Suture-Button Versus Syndesmotic Screw Fixation of Ankle Fractures: A Comparative Retrospective Review Over One Year

Background Syndesmotic fixation is essential in the management of unstable ankle fractures with syndesmotic disruption. It can be achieved either by rigid fixation with screws or dynamic fixation with suture-button devices. Syndesmosis screws are considered the gold standard for the stabilisation and fixation of distal tibiofibular syndesmotic injuries. We use both types of devices in our unit for the stabilisation of syndesmotic injuries. In our department, Arthrex TightRope® (Arthrex, Naples, FL) is the preferred suture-button device for the dynamic fixation of distal tibiofibular syndesmosis. Some studies have reported better outcomes with the use of suture-button devices. In this study, we aim to compare the outcomes with the use of both these devices. Methodology This retrospective cohort study was conducted from 1 June 2019 until 31 May 2020 which included all patients who underwent syndesmotic fixation. Data were collected from the Northern Ireland Electronic Care Record and the Northern Ireland Picture Archiving and Communication System. Primary outcomes included reoperation rates due to failure of syndesmotic hardware. Secondary outcomes included the comparison of complications (e.g. infection, wound problems, or loss of reduction) radiographic fixation/stability, duration of follow-up, and significant ongoing symptoms at the time of discharge from the clinic. Results A total of 53 patients underwent syndesmotic stabilisation during this period. In total, 34 patients underwent fixation with TightRope and 19 underwent syndesmotic screw fixation. Three patients (9%) had reoperation due to any cause in the TightRope group compared to four patients (21%) in the syndesmotic screw group. All four patients in the syndesmotic screws group underwent implant removal due to failure or symptoms due to implant. Only one patient (3%) in the TightRope group underwent implant removal due to ongoing pain [the other two (6%) patients included one with lateral ankle abscess and one with long distal fibula screws, both unrelated to the use of TightRope and TightRope left in situ at reoperation]. Rediastasis was reported in one (5.2%) patient with syndesmotic screws. The median duration of follow-up was 82 days in the syndesmotic screw group compared to 77.5 days in the TightRope group. Conclusions Based on our data, we report a lower incidence of implant-related problems and the need for implant removal with the use of TightRope. Quicker return to weight-bearing and slightly better radiographic stabilisation were noted as well. Our study has its limitations in terms of a small number of patients and the absence of functional outcomes as these were not routinely recorded at the time of discharge from the clinic.

The association of hypotension during non-cardiac surgery, before and after skin incision, with postoperative acute kidney injury: a retrospective cohort analysis

Intra-operative hypotension is associated with acute postoperative kidney injury. It is unclear how much hypotension occurs before skin incision compared with after, or whether hypotension in these two periods is similarly associated with postoperative kidney injury. We analysed the association of mean arterial pressure < 65 mmHg with postoperative kidney injury in 42,825 patients who were anaesthetised for elective non-cardiac surgery. Intra-operative hypotension occurred in 30,423 (71%) patients: 22,569 (53%) patients before skin incision; and 24,102 (56%) patients after incision. Anaesthetised patients who were hypotensive had mean arterial pressures < 65 mmHg for a median (IQR [range]) of 5.5 (0.0-14.7 [0.0-60.0]) min.h^-1 before skin incision, compared with 1.7 [0.3-5.1 [0.0-57.5]) min.h^-1 after incision: a median (IQR [range]) of 36% (0%-84% [0%-100%]) of hypotensive readings were before incision. We diagnosed postoperative kidney injury in 2328 (5%) patients. The odds ratio (95%CI) for acute kidney injury was 1.05 (1.02-1.07) for each doubling of the duration of hypotension, p < 0.001. Postoperative kidney injury was associated with the product of hypotension duration and severity, that is, area under the curve, before skin incision and after, odds ratio (95%CI): 1.02 (1.01-1.04), p = 0.004; and 1.02 (1.00-1.04), p = 0.016, respectively. A substantial fraction of all hypotension happened before surgical incision and was thus completely due to anaesthetic management. We recommend that anaesthetists should avoid mean arterial pressure < 65 mmHg during surgery, especially after induction, assuming that its association with postoperative kidney injury is, at least in part, causal.

Treatment of acute fractures of the femoral shaft with reamed intramedullary interlocking AO nails

OBJECTIVE

To review and audit our experience with closed intramedullary interlocking nailing for acute femoral shaft fractures.

METHODS

All patients admitted to The Aga Khan University Hospital, over the last six years and with a minimum follow-up of twelve months, with acute fractures of the femoral shaft were included in the study. All patients treated for established non-unions and infections or with pathological fractures were excluded from the study.

RESULTS

There were 89 fractures, 74% of whom were closed and 50% were associated with other orthopedic injuries. Most of these were younger patients involved in high velocity road traffic accidents. The union rate was 88% with 4.4% of fractures going into non-union. The remaining 8% of the fractures went into a phase of delayed union, but ultimately united, making the overall success rate to be 95.6%. The mean time for union was 11.5 weeks. At the final clinical follow-up, 4% of the patients had minor pain, 7% had limp, 4% had leg length discrepancy of more than 2 cm and 4% had decreased range of motion at the hip or knee joints. We had a 4% rate of superficial infection. There were 3 cases of pudendal nerve neuropraxia and 2 cases of deep vein thrombosis.

CONCLUSION

Intramedullary Interlocking nailing is a safe and effective treatment modality for acute fractures of the femoral shaft. Proper surgical decision making regarding static versus dynamic mode of locking can avoid problems of delayed union.