RESUMO
Objectives: This study aimed to report the complication rate associated with open reduction and internal fixation (ORIF) of mandibular condyle fractures in Oman. Methods: This retrospective cohort study was conducted among patients who underwent ORIF of mandibular condyle fractures at Al-Nahdha Hospital and the Sultan Qaboos University Hospital in Muscat, Oman, from January 2008 to December 2020. Data collected included patient demographics, fracture aetiology, fracture side and type, surgical approach and recorded complications and outcomes. Results: A total of 68 patients (59 males and 9 females; mean age of 30.1 years) with 83 mandibular condyle fractures underwent ORIF during the study period. Subcondylar fractures were the most common type, occurring in 62.7% of patients, while bilateral fractures were observed in 21 (30.8%) patients. The most common surgical approach was retromandibular, used in 42.2% of patients. The overall complication rate was 42.6%, with the most frequently reported complications being transient facial nerve palsy (18.1%), malocclusion (14.7%) and restricted mouth opening (10.3%). Subsequent surgical interventions to correct malocclusion were performed in 6 cases. There was no statistically significant association between the overall complication rate and the patients' clinical characteristics. Conclusion: Although ORIF of mandibular condyle fractures generally offers favourable outcomes, it carries a risk of complications.
Assuntos
Fixação Interna de Fraturas , Côndilo Mandibular , Fraturas Mandibulares , Redução Aberta , Complicações Pós-Operatórias , Humanos , Omã/epidemiologia , Masculino , Feminino , Fraturas Mandibulares/cirurgia , Fraturas Mandibulares/epidemiologia , Estudos Retrospectivos , Adulto , Fixação Interna de Fraturas/métodos , Fixação Interna de Fraturas/estatística & dados numéricos , Fixação Interna de Fraturas/efeitos adversos , Côndilo Mandibular/lesões , Côndilo Mandibular/cirurgia , Redução Aberta/métodos , Redução Aberta/estatística & dados numéricos , Redução Aberta/efeitos adversos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Adolescente , Adulto Jovem , Estudos de CoortesRESUMO
Background: The nonunion rate for atypical femoral fractures (AFF) is known to be higher than that for typical fractures of the femur. We performed a meta-analysis to determine the incidence of nonunion necessitating reoperation following fixation for AFF and compare the rates according to the fracture site (subtrochanter or midshaft). Methods: A total of 742 AFFs from 29 studies were included. A proportion meta-analysis utilizing a random-effects model was conducted to estimate the prevalence of nonunion. The outcomes were the incidence of reoperations that included osteosynthesis. To determine the association of nonunion with patient mean age or average duration of bisphosphonate use, meta-regression analysis was done. Results: In proportion meta-analysis, the estimated pooled prevalence of nonunion was 7% (95% confidence interval [CI], 5%-10%) from all studies. There was a significant difference in nonunion rate between the 2 groups (I2 = 34.4%, p = 0.02); the estimated prevalence of nonunion was 15% (95% CI, 10%-20%) in subtrochanteric AFFs and 4% (95% CI, 2%-6%) in midshaft AFFs. From meta-regression analysis, significant correlations were identified between nonunion rate and patient mean age (coefficient: -0.0071, p = 0.010), but not in the average duration of bisphosphonate use (coefficient: -0.0024, p = 0.744). Conclusions: A notable disparity existed in the nonunion rate among subtrochanteric AFFs and midshaft AFFs group. Therefore, it is critical for orthopedic surgeons to consider the complexity and challenges associated with AFF and to estimate the proper possibility of nonunion according to the fracture site.
Assuntos
Fraturas do Fêmur , Fraturas não Consolidadas , Humanos , Fraturas não Consolidadas/epidemiologia , Fraturas não Consolidadas/cirurgia , Fraturas do Fêmur/cirurgia , Fraturas do Fêmur/epidemiologia , Reoperação/estatística & dados numéricos , Fixação Interna de Fraturas/métodos , Fixação Interna de Fraturas/estatística & dados numéricosRESUMO
INTRODUCTION: Hip fracture treatment should be as standardized and effective as possible, with emphasis on fast recovery and avoidance of complications, especially those leading to reoperations. There is accumulating evidence regarding the optimal treatment of hip fractures but reports of whether this has influenced treatment in the clinical setting are sparse. The objective of this study was to determine the trends of hip fracture incidence and treatment in Finland, with special regard to how we treat older patients compared to younger ones. MATERIALS AND METHODS: All operatively treated hip fractures in Finland between 1997 and 2018 were identified from a national administrative register. The incidence of these fractures and operations performed to treat them were calculated based on the adult population size. RESULTS: Apart from a decline in the elderly age groups during the first half of the study period, the incidence of hip fractures remained relatively constant. However, the incidences of different operations changed significantly. In treatment of femoral neck fractures from 1997 to 2018, the incidence of cemented hemiarthroplasty (HA) increased from 41.1 to 59.9 per 100,000 person-years (105) and hybrid total hip arthroplasty (THA) from 0.56 to 5.93 per 105, while the incidence of internal fixation (IF) decreased, for instance screw fixation from 12.5 to 2.7 per 105. The incidence of cementless HA decreased from 13.3 to 1.2 per 105. These changes were much more pronounced in the elderly population and there was a statistically significant difference in the proportion of patients aged > 59 treated with cemented HA and IF in 1997 compared to 2018. For trochanteric and subtrochanteric fractures, treatment with intramedullary nails replaced extramedullary devices as the most common treatment method. CONCLUSIONS: The changes in treatment methods in Finland correspond to the increasing knowledge available about the optimal treatment of hip fractures and global treatment trends.
Assuntos
Fixação Interna de Fraturas , Fraturas do Quadril , Humanos , Finlândia/epidemiologia , Idoso , Fraturas do Quadril/cirurgia , Fraturas do Quadril/epidemiologia , Masculino , Feminino , Idoso de 80 Anos ou mais , Pessoa de Meia-Idade , Incidência , Fixação Interna de Fraturas/estatística & dados numéricos , Fixação Interna de Fraturas/métodos , Artroplastia de Quadril/estatística & dados numéricos , Hemiartroplastia/estatística & dados numéricos , Fraturas do Colo Femoral/cirurgia , Fraturas do Colo Femoral/epidemiologia , Adulto , Sistema de RegistrosRESUMO
BACKGROUND: Femoral neck fractures (FNF) in young and middle-aged adults are primarily caused by high-energy injuries in traffic accidents. Surgical delays often occur due to transportation issues, preoperative evaluations, and economic burdens. METHODS: A retrospective analysis was conducted on young and middle-aged FNF patients undergoing reduction and internal fixation surgeries from 2010 to 2019 with the use of the National Inpatient Sample database. Logistic regression analysis was used to assess the relationship between surgical delays and complications, and the independent risk factors contributing to delays. Categorical variables were investigated via a chi-square test, while continuous variables including Elixhauser Comorbidity Index (ECI) scores, length of hospital stay (LOS), and total medical costs were analyzed via t-test or rank-sum test. RESULTS: 9,204 patients undergoing reduction and internal fixation surgeries were included. In the delayed group, patients had higher ECI scores, longer hospital stays, higher expenses, and increased inpatient mortality (1.61% vs. 0.28 %, P < 0.0001). Longer surgical delays were associated with higher risks of complications, including femoral head osteonecrosis, internal fixation loosening and breakage, and respiratory complications. Fluid and electrolyte disorders, metastatic cancer, pulmonary circulation disorders, and renal failure were identified as independent risk factors for surgical delays. Except for anemia (OR=2.37, P < 0.0001), no significant differences in early postoperative complications were found between open-reduction and closed-reduction internal fixation (ORIF/CRIF) surgeries. CONCLUSION: Early surgical intervention, within a 2-days period after injury, seems to be crucial for young adults with FNF. If CRIF is challenging in some cases, ORIF can be another choice.
Assuntos
Bases de Dados Factuais , Fraturas do Colo Femoral , Fixação Interna de Fraturas , Tempo de Internação , Complicações Pós-Operatórias , Tempo para o Tratamento , Humanos , Feminino , Masculino , Complicações Pós-Operatórias/epidemiologia , Pessoa de Meia-Idade , Fraturas do Colo Femoral/cirurgia , Estudos Retrospectivos , Adulto , Tempo de Internação/estatística & dados numéricos , Fixação Interna de Fraturas/estatística & dados numéricos , Fatores de Risco , Tempo para o Tratamento/estatística & dados numéricos , Estados Unidos/epidemiologia , Adulto Jovem , Mortalidade HospitalarRESUMO
BACKGROUND: Distal radius fractures are common injuries. Open reduction and internal fixation with volar locking plates is the most common approach for surgical fixation. This study investigated the association between time to surgery and health care utilization, income, and functional outcomes among patients undergoing open reduction and internal fixation for distal radius fracture. METHODS: We conducted a retrospective review of patients who underwent open reduction and internal fixation for isolated acute distal radius fracture between 2009 and 2019. Time to surgery was grouped as early (≤ 14 d) and delayed (> 14 d). We performed χ2 (or Fisher exact) and Wilcoxon rank sum (or Kruskal-Wallis) tests to provide statistical comparison of time to surgery by health care utilization and functional outcomes. Univariable and multivariable logistic regression analyses were performed to identify factors significantly associated with time to surgery. We included all significant univariables in the multivariable logistic regression model, which identified factors based on significant adjusted odds ratios (95% confidence intervals excluding the null) after we adjusted for confounding variables. RESULTS: We included 106 patients, with 36 (34.0%) in the group receiving early treatment and 70 (66.0%) in the group receiving delayed treatment. Patients in the delayed-treatment group attended significantly more clinic visits and postoperative hand therapy sessions. The group with delayed treatment demonstrated significantly lower degrees of wrist flexion at the first follow-up, but this difference did not persist. Patients with higher estimated income (> $39 405 per annum) had lower odds of delayed surgery than those with lower estimated income (≤ $39 405). CONCLUSION: Delayed time to surgery was associated with greater health care utilization and lower degrees of early wrist flexion. Access to care for lower-income patients warrants further evaluation.
Assuntos
Fixação Interna de Fraturas , Aceitação pelo Paciente de Cuidados de Saúde , Fraturas do Rádio , Tempo para o Tratamento , Humanos , Fraturas do Rádio/cirurgia , Masculino , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Tempo para o Tratamento/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Fixação Interna de Fraturas/estatística & dados numéricos , Idoso , Adulto , Resultado do Tratamento , Redução Aberta/estatística & dados numéricos , Recuperação de Função Fisiológica , Fraturas do PunhoRESUMO
BACKGROUND: Periprosthetic fractures can be devastating complications after total joint arthroplasty (TJA). The management of periprosthetic fractures is complex, spanning expertise in arthroplasty and trauma. The purpose of this study was to examine and project trends in the operative treatment of periprosthetic fractures in the United States. METHODS: A large, public and private payer database was queried to capture all International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes for periprosthetic femoral and tibial fractures. Statistical models were created to assess trends in treatment for periprosthetic fractures and to predict future surgical rates. An alpha value of 0.05 was used to assess significance. A Bonferroni correction was applied where applicable to account for multiple comparisons. RESULTS: In this study, from 2016 to 2021, 121,298 patients underwent surgical treatment for periprosthetic fractures. There was a significant increase in the total number of periprosthetic fractures. The incidence of periprosthetic hip fractures rose by 38% and that for periprosthetic knee fractures rose by 73%. The number of periprosthetic fractures is predicted to rise 212% from 2016 to 2032. There was a relative increase in open reduction and internal fixation (ORIF) compared with revision arthroplasty for both periprosthetic hip fractures and periprosthetic knee fractures. CONCLUSIONS: Periprosthetic fractures are anticipated to impose a substantial health-care burden in the coming decades. Periprosthetic knee fractures are predominantly treated with ORIF rather than revision total knee arthroplasty (TKA), whereas periprosthetic hip fractures are predominantly treated with revision total hip arthroplasty (THA) rather than ORIF. Both periprosthetic knee fractures and periprosthetic hip fractures demonstrated increasing trends in this study. The proportion of periprosthetic hip fractures treated with ORIF relative to revision THA has been increasing. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Fraturas Periprotéticas , Reoperação , Humanos , Fraturas Periprotéticas/epidemiologia , Fraturas Periprotéticas/cirurgia , Fraturas Periprotéticas/etiologia , Estados Unidos/epidemiologia , Reoperação/estatística & dados numéricos , Feminino , Fixação Interna de Fraturas/tendências , Fixação Interna de Fraturas/métodos , Fixação Interna de Fraturas/estatística & dados numéricos , Masculino , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/estatística & dados numéricos , Artroplastia de Quadril/tendências , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/estatística & dados numéricos , Idoso , Incidência , Pessoa de Meia-Idade , Fraturas do Fêmur/cirurgia , Fraturas do Fêmur/epidemiologia , Fraturas do Fêmur/etiologia , Fraturas da Tíbia/cirurgia , Fraturas da Tíbia/epidemiologiaRESUMO
Introduction: Basicervical femoral neck fracture (FNF) is an uncommon type of femoral neck fracture and is associated with an increased risk of fixation failure due to its inherent instability. The purpose of this study was to compare the surgical parameters and reoperation rate between the use of a multiple cannulated screw (MCS) and fixed angle device (FAD) in treating basicervical FNFs. Methods: We retrospectively reviewed the records of 885 patients who underwent internal fixation between May 2004 and August 2019 to determine basicervical FNF with at least 12 months of follow-up. Among the identified 77 patients with basicervical FNF, 17 patients who underwent multiple cannulated screw (MCS) fixation and 36 patients who underwent fixed angle device (FAD) fixation were included. We compared the rates of fracture-site collapse and reoperations according to the fixation device. Results: Among the 53 patients with basicervical FNF, 13 patients (24.5%) sustained surgical complications (8 collapses of fracture site and 5 reoperations). The reoperation rate in the MCS group was significantly higher than that in the FAD group (23.5% vs. 2.8%, p = 0.016), without any significant difference in the collapse of the fracture site (11.8% vs. 16.7%, p = 0.642). Conclusions: Although basicervical FNF was rare among hip fractures, fracture site collapse was prevalent and prone to fixation failure. Surgeons should keep this in mind, and consider FAD for basicervical FNF.
Assuntos
Parafusos Ósseos , Fraturas do Colo Femoral , Fixação Interna de Fraturas , Humanos , Fraturas do Colo Femoral/cirurgia , Feminino , Masculino , Estudos Retrospectivos , Fixação Interna de Fraturas/métodos , Fixação Interna de Fraturas/instrumentação , Fixação Interna de Fraturas/estatística & dados numéricos , Idoso , Pessoa de Meia-Idade , Resultado do Tratamento , Reoperação/estatística & dados numéricos , Idoso de 80 Anos ou mais , Complicações Pós-Operatórias/epidemiologiaRESUMO
BACKGROUND: Ankle fracture is a common injury and often requires operative treatment. This study investigated short-term (≤4 months) and long-term (>4 months) complications after ankle fracture surgery in a 23-year period with use of data from a comprehensive, nationwide, individual-level register. METHODS: Data regarding patients who underwent operative treatment for ankle fracture were collected from the Finnish Care Register for Health Care and analyzed with use of logistic and Cox regression. RESULTS: A total of 83,666 ankle fractures were operatively treated between 1998 and 2020. Of these, 36% were lateral malleolar fractures, 7% were medial malleolar fractures, 52% were bimalleolar or trimalleolar fractures, and 5% were other types of fractures. Fifty-one percent of the fractures were in female patients. The overall rate of short-term complications was 7.2%. Specifically, infection occurred in 4.4% of cases; thromboembolic complications,1.6% of cases; mechanical complications, 0.4% of cases; and other complications, 0.9% of cases. An age of >75 years was associated with a higher rate of short-term complications than an age of 51 to 75 years, with an odds ratio of 1.53 in the multivariable analysis (95% confidence interval, 1.39 to 1.67; p < 0.001). Short-term complications were also more prevalent in patients with diabetes (with or without associated complications); chronic pulmonary, kidney, or liver disease; or peripheral vascular disease. Mortality during the first 4 months after the ankle fracture operation was 0.6%. The most common reason for reoperation in the long term (>4 months after the index procedure) was fixation device removal, with a cumulative incidence of 17% within the first 3 years postoperatively. The risk of implant removal increased in younger patients and patients with bimalleolar or trimalleolar fractures. The cumulative incidence of ankle arthrodesis and arthroplasty was low. CONCLUSIONS: Although postoperative complications are relatively rare, their treatment can lead to considerable morbidity. The findings of this study allow us to identify patients who are prone to complications or reoperations after undergoing operative treatment for ankle fracture. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Fraturas do Tornozelo , Complicações Pós-Operatórias , Humanos , Fraturas do Tornozelo/cirurgia , Fraturas do Tornozelo/epidemiologia , Finlândia/epidemiologia , Feminino , Pessoa de Meia-Idade , Masculino , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Idoso , Adulto , Sistema de Registros , Fixação Interna de Fraturas/efeitos adversos , Fixação Interna de Fraturas/estatística & dados numéricos , Fixação Interna de Fraturas/métodos , Adulto Jovem , Adolescente , Idoso de 80 Anos ou maisRESUMO
BACKGROUND: Proximal humeral fractures are a common injury accounting for a significant workload across orthopaedic departments. Though often managed non-operatively, surgical management is indicated for a proportion of patients. AIMS: The aim of this study is to examine the trends in the management of proximal humeral fractures within Ireland over the past 13 years. METHODS: A retrospective review of Irish Hospital In-Patient Enquiry (HIPE) data was performed between January 2009 and December 2022. Information regarding demographics including age and gender, along with procedure type were collated after patients with proximal humerus fractures, were identified using relevant ICD 10 codes. RESULTS: Demographic details remained stable with females and those within the 55-69 year age bracket accounting for the highest proportion of patients. The mean annual number of procedures performed across the study period was 365 (273-508), with an increase from 288 cases in 2009 to 441 in 2022. Open reduction and internal fixation were the most common procedures accounting for 76.4% of cases. There has been a rising usage of total shoulder arthroplasty for fixation with an increase from < 5 cases in 2016 to 84 in 2022. A decrease in the usage of hemiarthroplasty and closed reduction internal fixation was also observed. CONCLUSIONS: There has been an increasing volume of operatively managed proximal humeral fractures in Ireland, which sustained despite the 2015 publication of the highly publicised PROPHER trial. The increasing utilisation of total shoulder arthroplasty in acute trauma management is notable and necessitates appropriate training for trauma theatre personnel.
Assuntos
Artroplastia do Ombro , Fraturas do Ombro , Humanos , Irlanda , Feminino , Masculino , Pessoa de Meia-Idade , Fraturas do Ombro/cirurgia , Idoso , Estudos Retrospectivos , Artroplastia do Ombro/estatística & dados numéricos , Fixação Interna de Fraturas/estatística & dados numéricos , Fixação Interna de Fraturas/tendências , Fixação Interna de Fraturas/métodos , Idoso de 80 Anos ou mais , Hemiartroplastia/estatística & dados numéricos , Hemiartroplastia/tendências , Adulto , Redução Aberta/estatística & dados numéricosRESUMO
Memory alloy patella claws for treating patella fractures have been used for more than 30 years with many desirable features including fast healing, quick recovery, and avoidance of top abrasion of Kirschner wires and other complications. However, there are many models and it is difficult to choose the accurate claw for the patient. In this study, a finite element model of the butterfly-shaped patellar claw made of shape memory alloy was established, its mechanical structure was analyzed, and its clinical application was monitored. We used Solidworks Simulation software for modeling and mainly analyzed the force of the compression ring of the butterfly-shaped patellar claw. Clinically, we chose a closed fresh patella fracture case. After finite element analysis, the maximum stress that the compression ring of the butterfly-shaped patellar claw can withstand is 568.1 MPa. In this range, it always has elastic deformation resistance. The butterfly-shaped patella claw is fixed on the patella and will not break when subjected to a maximum force of 150 N on the encircling arm, and at the same time, there will be no pressure failure due to plastic deformation. A total of 27 cases were clinically used for the assessment of the clinical efficacy of the newly designed butterfly-shaped patella claws. The average follow-up time was 15.5 months, and the average fracture healing time was 8-12 weeks. All patients can get out of bed with crutches within 2 to 3 days after surgery. Among them, there were 15 cases with excellent functional ratings, 10 cases with good ratings, 2 cases with acceptable ratings, and no cases with poor ratings. The designed butterfly-shaped patella claws can provide an effective method for the treatment of patella fractures.
Assuntos
Fixação Interna de Fraturas/instrumentação , Fixadores Internos , Fraturas Intra-Articulares/cirurgia , Patela/lesões , Patela/cirurgia , Adolescente , Adulto , Fenômenos Biomecânicos , Biologia Computacional , Simulação por Computador , Desenho Assistido por Computador/estatística & dados numéricos , Módulo de Elasticidade , Feminino , Análise de Elementos Finitos , Fixação Interna de Fraturas/estatística & dados numéricos , Humanos , Fixadores Internos/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Níquel , Desenho de Prótese , Ligas de Memória da Forma , Software , Estresse Mecânico , Resistência à Tração , Titânio , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Identifying and treating patients with fragility fractures may be effective in prevention of subsequent fractures because a first fragility fracture often predicts a second fracture. OBJECTIVES: To evaluate a multidisciplinary anti-osteoporotic clinic for patients with prior distal radius fragility fractures (DRFF). To assess whether addressing this early fracture may prevent a second fracture. METHODS: A retrospective case-control study was performed. Cases included patients treated surgically for DRFF who were assessed at a tertiary, multidisciplinary, fracture-prevention clinic. Controls were a series of similarly treated patients who did not attend the clinic. The primary outcome measure was a second fracture. RESULTS: Average follow-up was 42 months for the treated group and 85 months for the untreated group. The treated group received more treatment for osteoporosis than controls; however, despite one new fracture in the treated group and six new fractures in the control group, there was no significant difference in fracture occurrence. CONCLUSIONS: This pilot study supports the effectiveness of our multidisciplinary anti-osteoporotic clinic in treating osteoporosis but not in reducing subsequent fractures. Further study with larger cohorts and longer follow-up is needed to improve our ability to implement effective prevention of fragility fractures.
Assuntos
Fixação Interna de Fraturas , Osteoporose , Fraturas por Osteoporose , Equipe de Assistência ao Paciente , Fraturas do Rádio , Prevenção Secundária/métodos , Idoso , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Densidade Óssea , Estudos de Casos e Controles , Técnicas de Diagnóstico Endócrino/estatística & dados numéricos , Feminino , Fixação Interna de Fraturas/efeitos adversos , Fixação Interna de Fraturas/métodos , Fixação Interna de Fraturas/estatística & dados numéricos , Humanos , Masculino , Osteoporose/complicações , Osteoporose/diagnóstico , Osteoporose/metabolismo , Fraturas por Osteoporose/epidemiologia , Fraturas por Osteoporose/prevenção & controle , Fraturas por Osteoporose/cirurgia , Projetos Piloto , Fraturas do Rádio/epidemiologia , Fraturas do Rádio/prevenção & controle , Fraturas do Rádio/cirurgia , Recidiva , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Resultado do TratamentoRESUMO
BACKGROUND: Emerging evidences supported that the surgeon case volume significantly affected post-operative complications or outcomes following a range of elective or non-elective orthopaedic surgery; no data has been available for surgically treated tibial plateau fractures. We aimed to investigate the relationship between surgeon volume and the risk of deep surgical site infection (DSSI) following open reduction and internal fixation (ORIF) of closed tibial plateau fracture. METHODS: This was a further analysis of the prospectively collected data. Adult patients undergoing ORIF procedure for closed tibial plateau fracture between January 2016 and December 2019 were included. Surgeon volume was defined as the number of surgically treated tibial fractures in the preceding 12 months and dichotomized on the basis of the optimal cut-off value determined by the receiver operating characteristic (ROC) curve. The outcome was DSSI within one year post-operatively. Multiple multivariate logistic models were constructed for "drilling down" adjustment of confounders. Sensitivity and subgroup analyses were performed to assess the robustness of outcome and identify the "optimal" subgroups. RESULTS: Among 742 patients, 20 (2.7%) had a DSSI and 17 experienced re-operations. The optimal cut-off value for case volume was nine, and the low-volume surgeon was independently associated with 2.9-fold (OR, 2.9; 95%CI, 1.1 to 7.5) increased risk of DSSI in the totally adjusted multivariate model. The sensitivity analyses restricted to patients with original BMI data or those operated within 14 days after injury did not alter the outcomes (OR, 2.937, and 95%CI, 1.133 to 7.615; OR, 2.658, and 95%CI, 1.018 to 7.959, respectively). The subgroup analyses showed a trend to higher risk of DSSI for type I-IV fractures (OR, 4.6; 95%CI, 0.9 to 27.8) classified as Schatzker classification and substantially higher risk in patients with concurrent fractures (OR, 6.1; 95%CI, 1.0 to 36.5). CONCLUSION: The surgeon volume is independently associated with the rate of DSSI, and a number of ≥ nine cases/year are necessarily kept for reducing DSSIs; patients with concurrent fractures should be preferentially operated on by high-volume surgeons.
Assuntos
Fixação Interna de Fraturas , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Redução Aberta , Cirurgiões , Fraturas da Tíbia , Adulto , Fixação Interna de Fraturas/efeitos adversos , Fixação Interna de Fraturas/estatística & dados numéricos , Humanos , Redução Aberta/efeitos adversos , Redução Aberta/estatística & dados numéricos , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/etiologia , Fraturas da Tíbia/complicações , Fraturas da Tíbia/cirurgiaRESUMO
Tibial pilon fractures are polymorphic fractures posing therapeutic and prognostic challenges. The purpose of this study is to examine the epidemiological profile of these fractures and to assess our findings from an anatomical and functional point of view. We collected data fom 50 medical records of patients treated for tibial pilon fractures and monitored over the period 2004-2013 at the Orthopedic-Trauma Department of the Habib Bourguiba University Hospital in Sfax. Functional outcomes were assessed using the Ankle-Hindfoot score. Radiological findings were used to determine fracture healing. Treatment was based on internal osteosynthesis in 30 cases, external fixation in 11 cases and on a combination of both techniques in 9 cases. At the end of this study, functional outcomes were good and very good in 36 cases. Thirty cases of fracture healing were reported, with 18 cases of vicious callus and two cases of pseudosteoarthritis. Therapeutic management of tibial pilon fractures is difficult in some cases. Solid osteosynthesis with anatomical reduction is the only therapeutic option to secure a satisfactory functional outcome.
Assuntos
Fixação Interna de Fraturas/estatística & dados numéricos , Fixação de Fratura/métodos , Consolidação da Fratura , Fraturas da Tíbia/cirurgia , Adulto , Fixadores Externos , Feminino , Hospitais Universitários , Humanos , Masculino , Estudos Retrospectivos , TunísiaRESUMO
ABSTRACT: To summarize the surgical technique and clinical effects of the extended anterolateral approach for the treatment of Schatzker type II and Schatzker type V/VI involving the posterolateral column tibial plateau.From January 2015 through December 2018, 28 patients with tibial plateau fractures involving the posterolateral column were included in the study. Among them, 16 patients were Schatzker type II treated using an extended anterolateral approach with lateral tibial locking compression plate fixation. Twelve patients were Schatzker type V or VI treated using an extended anterolateral combined with a medial approach using lateral tibial locking compression plate plus medial locking compression plate fixation. All cases were followed up for 15 to 31âmonths, with an average follow-up of 22.5â±â3.7âmonths. During the follow-up, the tibial plateau angle (TPA), lateral posterior angle (PA) and Rasmussen radiological criteria were used to evaluate the effect of fracture reduction and fixation; the Hospital for Special Knee Surgery score and the range of motion were used to evaluate knee function. Additionally, the Lachman and knee Valgus (Varus) stress tests were used to evaluate anteroposterior and lateral stability of the knee.All fractures healed. At the 12-month follow-up, the Schatzker type II group revealed a mean TPA of 86.38â±â3.92°, a mean PA of 7.43â±â2.68°, and a mean Rasmussen radiological score of 16.00â±â2.06 points. The Schatzker type V/VI group showed a mean TPA of 84.91â±â3.51°, a mean PA of 9.68â±â4.01°, and a mean Rasmussen radiological score of 15.33â±â2.99 points. During the 1-year follow-up, when the postoperative PA was re-measured, the TPA and Rasmussen score of the 2 groups did not change significantly (Pâ>â.05). At the last follow-up, the Schatzker type II group showed a knee flexion angle of 110° to 135° and a mean HHS score of 88.37â±â10.01 points. The Schatzker type V/VI group revealed a knee flexion angle of 100° to 130° and a mean HHS score of 82.17â±â10.76 points. Additionally, up to the last follow-up, the Lachman and knee Valgus (Varus) stress test results of the 2 groups were negative. No complications were found.The extended anterolateral approach is a good choice to treat tibial plateau fractures involving the posterolateral column.
Assuntos
Fixação Interna de Fraturas/métodos , Traumatismos do Joelho/cirurgia , Fraturas da Tíbia/cirurgia , Adulto , Idoso , Feminino , Fixação Interna de Fraturas/estatística & dados numéricos , Humanos , Traumatismos do Joelho/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Radiografia , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fraturas da Tíbia/diagnóstico por imagemRESUMO
BACKGROUND: Subcondylar fractures represent 25 to 35 percent of all mandibular fractures, yet the treatment paradigm has remained controversial. Closed treatment relies on the plasticity of the condyle head during recovery, whereas open treatment is challenging and risks facial nerve injury. Perioperative, functional, and patient-reported outcomes were measured to compare methods of open versus closed treatment of subcondylar fractures. METHODS: Selected displaced subcondylar fracture cases with open (open reduction and internal fixation of subcondylar fracture with maxillomandibular fixation) versus closed (maxillomandibular fixation) treatment were compared (n = 60). Demographics, perioperative data, complications, persistent symptoms, chin deviation, malocclusion, change in mouth opening, functional scores, and FACE-Q patient satisfaction were recorded. RESULTS: Open versus closed groups had similar demographics and perioperative data, except the open group had longer operating room time (76.39 minutes versus 56.15 minutes). In long-term follow-up, open-treated patients had fewer symptoms (9 percent versus 67 percent), less chin deviation (0 percent versus 40 percent), a less restricted mouth opening (3mm versus 5mm), and better functional scores (1.92 versus 0.861). Transient facial nerve weakness was seen in 6 percent of open cases. CONCLUSION: For selected subcondylar fracture patients, open treatment with endoscopic assistance, nerve monitoring, and specialized plates provides superior long-term results compared to closed treatment when considering symptoms and functional parameters. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.
Assuntos
Endoscopia/métodos , Fixação Interna de Fraturas/métodos , Fraturas Mandibulares/cirurgia , Redução Aberta/métodos , Complicações Pós-Operatórias/epidemiologia , Adulto , Placas Ósseas , Endoscopia/instrumentação , Endoscopia/estatística & dados numéricos , Feminino , Seguimentos , Fixação Interna de Fraturas/efeitos adversos , Fixação Interna de Fraturas/instrumentação , Fixação Interna de Fraturas/estatística & dados numéricos , Humanos , Masculino , Côndilo Mandibular/diagnóstico por imagem , Côndilo Mandibular/lesões , Côndilo Mandibular/cirurgia , Pessoa de Meia-Idade , Redução Aberta/efeitos adversos , Redução Aberta/instrumentação , Redução Aberta/estatística & dados numéricos , Medidas de Resultados Relatados pelo Paciente , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: The aim of this study was to compare the cost-effectiveness and cost-utility between plaster cast immobilization and volar plate fixation for acceptably reduced intra-articular distal radial fractures. METHODS: A cost-effectiveness analysis was conducted as part of a randomized controlled trial comparing operative (volar plate fixation) with nonoperative (plaster cast immobilization) treatment in patients between 18 and 75 years old with an acceptably reduced intra-articular distal radial fracture. Health-care utilization and use of resources per patient were documented prospectively and included direct medical costs, direct non-medical costs, and indirect costs. All analyses were performed according to the intention-to-treat principle. RESULTS: The mean total cost per patient was $291 (95% bias-corrected and accelerated confidence interval [bcaCI] = -$1,286 to $1,572) higher in the operative group compared with the nonoperative group. The mean total number of quality-adjusted life-years (QALYs) gained at 12 months was significantly higher in the operative group than in the nonoperative group (mean difference = 0.15; 95% bcaCI = 0.056 to 0.243). The difference in the cost per QALY (incremental cost-effectiveness ratio [ICER]) was $2,008 (95% bcaCI = -$9,608 to $18,222) for the operative group compared with the nonoperative group, which means that operative treatment is more effective but also more expensive. Subgroup analysis including only patients with a paid job showed that the ICER was -$3,500 per QALY for the operative group with a paid job compared with the nonoperative group with a paid job, meaning that operative treatment is more effective and less expensive for patients with a paid job. CONCLUSIONS: The difference in QALYs gained for the operatively treated group was equivalent to an additional 55 days of perfect health per year. In adult patients with an acceptably reduced intra-articular distal radial fracture, operative treatment is a cost-effective intervention, especially in patients with paid employment. Operative treatment is slightly more expensive than nonoperative treatment but provides better functional results and a better quality of life. LEVEL OF EVIDENCE: Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Moldes Cirúrgicos/economia , Fixação Interna de Fraturas/economia , Fraturas Intra-Articulares/terapia , Fraturas do Rádio/terapia , Traumatismos do Punho/terapia , Adolescente , Adulto , Idoso , Placas Ósseas/economia , Moldes Cirúrgicos/estatística & dados numéricos , Análise Custo-Benefício , Feminino , Seguimentos , Fixação Interna de Fraturas/estatística & dados numéricos , Força da Mão/fisiologia , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Fraturas Intra-Articulares/diagnóstico , Fraturas Intra-Articulares/economia , Fraturas Intra-Articulares/fisiopatologia , Masculino , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Estudos Prospectivos , Anos de Vida Ajustados por Qualidade de Vida , Fraturas do Rádio/diagnóstico , Fraturas do Rádio/economia , Fraturas do Rádio/fisiopatologia , Amplitude de Movimento Articular , Resultado do Tratamento , Traumatismos do Punho/diagnóstico , Traumatismos do Punho/economia , Traumatismos do Punho/fisiopatologia , Articulação do Punho/diagnóstico por imagem , Adulto JovemRESUMO
BACKGROUND: Distal radius fractures (DRFs) are one of the most common major fractures. Despite their frequency, the tradeoffs in different outcomes after casting or surgery for closed extraarticular DRFs in older adults are unknown. QUESTIONS/PURPOSES: (1) For adults older than 60 years with closed extraarticular DRFs, what are the tradeoffs in outcomes for choosing casting versus surgery? (2) In what settings would surgery be preferred over casting? METHOD: This is a secondary analysis of data from the Wrist and Radius Injury Surgical Trial (WRIST), a randomized, multicenter clinical trial that enrolled patients from April 10, 2012 to December 31, 2016. For WRIST, researchers recruited patients older than 60 years who sustained closed extraarticular distal radius fractures from 24 sites in the United States, Canada, and Singapore. We conducted a secondary analysis using data from WRIST, which had longitudinal data from a robust collection of covariates for patients who underwent surgery and casting. Among the 296 patients recruited in the WRIST study, 59% (174) of patients (mean age 71 ± 9 years) with complete sociodemographic data and 12-month follow-up for each primary outcome were included in the main analysis. More patients underwent surgery than casting (72% [126 of 174] versus 28% [48 of 174]). Most sociodemographic variables were similar between the surgery and casting groups, except for age and volar tilt. The surgical cohort was composed of patients randomized to external fixation, closed reduction percutaneous pinning, or volar locking plate internal fixation. The casting cohort consisted of patients who elected to be treated with closed reduction and casting. A tree-based reinforcement statistical learning method was used to determine the best treatment, either surgery or casting, to maximize functional and esthetic outcomes while minimizing pain. Tree-based reinforcement learning is a statistical learning method to build an unsupervised decision tree within a causal inference framework that will identify useful variables and their cutoff values to tailor treatment assignment accordingly to achieve the best health outcome desired. The primary outcome was minimization of pain (12-month Michigan Hand Outcomes Questionnaire pain subdomain score), maximization of grip strength, total ROM (supination and wrist arc of motion), and esthetics (12-month Michigan Hand Outcomes Questionnaire esthetics subdomain score). RESULTS: Casting was the best treatment to reduce pain and maximize esthetics, whereas surgery maximized grip strength and ROM. When the patient favored gaining ROM over pain reduction (more than 80:20), surgery was the preferred treatment. When the patient prioritized the importance of grip strength over pain reduction (more than 70:30), surgery was also the preferred treatment. CONCLUSION: There are tradeoffs in outcomes after treating patients older than 60 years with closed extraarticular distal radius fractures with casting or surgery. When patients are attempting to balance minimizing pain and improving functional outcomes, unless they desire maximal functional recovery, casting may be the better treatment. Surgery may be beneficial if patients want to regain as much grip strength and ROM as possible, even with the possibility of having residual pain. These findings can be referenced for more concrete preoperative counseling and patient expectation management before treatment selection. LEVEL OF EVIDENCE: Level III, therapeutic study.
Assuntos
Moldes Cirúrgicos/estatística & dados numéricos , Redução Fechada/estatística & dados numéricos , Fixação Interna de Fraturas/estatística & dados numéricos , Modelos Estatísticos , Fraturas do Rádio/terapia , Idoso , Idoso de 80 Anos ou mais , Feminino , Força da Mão , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Romosozumab is a humanized, anti-sclerostin monoclonal antibody used to treat osteoporosis, which increases bone formation and decreases bone resorption. It enhances fracture healing and systemic romosozumab administration may have therapeutic potentials for accelerating bone healing of even nonunion. Herein, a 61-year-old heavy smoker male with distal radius nonunion who achieved successful bone union by combination therapy of romosozumab and spanning distraction plate fixation with bone graft substitutes was presented. Through the dorsal approach, atrophic comminuted nonunion of the distal radius was sufficiently debrided. Reduction of the distal radius was performed using indirect ligamentotaxis, and a 14-hole locking plate was fixed from the third metacarpal to the radial shaft. A beta (ß) tricalcium phosphate block was mainly packed into the substantial metaphyseal bone defect with additional bone graft from the resected ulnar head. Postoperatively, systemic administration of monthly romosozumab was continued for six months. Complete bone union was achieved 20 weeks postoperatively and the plate was, then, removed. Wrist extension and flexion improved to 75o and 55o, respectively, without pain, and grip strength increased 52 weeks postoperatively from 5.5 kg to 22.4 kg. During romosozumab treatment, bone formation marker levels increased rapidly and finally returned to baseline, and bone resorption marker levels remained low. In conclusion, combination of systemic romosozumab administration and grafting ß-tricalcium phosphate with bridge plating provides an effective treatment option for difficult cases of comminuted distal radius nonunion with risk factors such as smoking, diabetes, and fragility.
Assuntos
Anticorpos Monoclonais/uso terapêutico , Fixação Interna de Fraturas/estatística & dados numéricos , Fraturas do Rádio/cirurgia , Humanos , Japão , Masculino , Pessoa de Meia-IdadeRESUMO
OBJECTIVE: This meta-analysis study aims to determine the efficacy and safety of surgical and conservative treatments for distal radius fractures (DRFs) in adults. METHODS: Reports of randomized controlled trials were retrieved from the Web of Science, Pubmed, Google Scholar, EMBASE, Cochrane Library, Medline, Ovid, and BIOSIS for studies that met the eligibility criteria. The search was limited to human subjects and had no language limits. The search strategy was check by two independent reviewers. If there was any dispute, a third reviewer was consulted. Primary outcomes were: (1) the active wrist range of motion including flexion, extension, pronation, supination, radial, and ulnar deviation; (2) the Disabilities of the Arm, Shoulder, and Hand (DASH) score; and (3) radiological outcomes including radial inclination and ulnar variance. Secondary outcomes were the number of complications including non-infectious and infectious. Quality assessment was performed using the Cochrane Risk of Bias Tool provided by the Cochrane Review Manager 5.3. RESULTS: A total of 10 randomized controlled trials were included. The meta-analysis detected no statistically significant difference in pooled data for complications not included infection (MD 0.64, CI: 0.33 to 1.23, Z=1.34, p=0.18). Surgical treatment achieved a better range of motion (MD 3.76, CI: 1.58 to 5.95, Z=3.37, p=0.0007), DASH score (MD -6.57, CI: -9.08 to -4.06, Z=5.12, p<0.00001), and radiographic outcomes (MD 3.75, CI: 2.75 to 4.74, Z=7.37, p<0.00001) compared with conservative treatment. In contrast, the conservative treatment achieved less infection rate compared with surgical treatment (MD 4.09, CI: 1.18 to 14.21, Z=2.21, p=0.03). CONCLUSION: Findings of this study reveal that when compared with conservative treatment, surgical treatment can ensure better clinical and radiological results for the treatment of DRFs in adults. Although similar complication rates can be encountered with both treatment modalities, it should be taken into account that the rate of infection may be higher in surgical treatment. LEVEL OF EVIDENCE: Level I, Therapeutic Study.
Assuntos
Tratamento Conservador , Fixação Interna de Fraturas , Fraturas do Rádio , Adulto , Tratamento Conservador/métodos , Tratamento Conservador/estatística & dados numéricos , Fixação Interna de Fraturas/métodos , Fixação Interna de Fraturas/estatística & dados numéricos , Humanos , Avaliação de Resultados em Cuidados de Saúde , Fraturas do Rádio/cirurgia , Fraturas do Rádio/terapia , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
BACKGROUND: Randomized controlled trials have demonstrated that surgical stabilization of rib fractures (SSRF) in selected trauma patients is associated with potential benefits. This study evaluates the real-world outcomes of SSRF since its implementation at Westmead Hospital, Australia. We hypothesize these outcomes to be similar to that reported by best-evidence in the literature. MATERIALS AND METHODS: A retrospective analysis of data on all consecutive SSRF performed between January 2013 to December 2018 was completed. RESULTS: Sixty-three patients (54 male; average age 55.9 ± 14.1 y) with median ISS 24 (IQR 17;30) underwent SSRF. Thirty-seven patients were admitted to Intensive Care Unit (ICU), with median ICU length of stay (LOS) 10.0 (5.0-17.0) d. Median hospital LOS was 15.5 (10.0-24.8) d. Fifty-five (87.3%) patients did not have any surgery-specific complications. The highest observed surgical morbidity was wound infection (n = 4, 4.7%). There was one mortality after rib fixation that was not related to surgery. SSRF within 3 d of hospital presentation in ventilated patients with flail chest was associated with significantly reduced median ICU LOS (3.0 [2.0;4.0] versus 10.0 [9.3;13.0] d; P = 0.03). Early (2013-2015) versus late (2015-2018) phase SSRF implementation demonstrated no significant difference in outcome variables. CONCLUSION: Experience with SSRF demonstrates early outcomes similar to best-evidence in the existing literature. As a quality assurance tool, ongoing evaluation of real-world data is needed to ensure that outcomes remain consistent with benchmarks available from best-evidence.