Polytomous Rasch Analyses of Surgeons' Decision-Making on Choice of Procedure in Endoscopic Lumbar Spinal Stenosis Decompression Surgeries

BACKGROUND

With the growing prevalence of lumbar spinal stenosis, endoscopic surgery, which incorporates techniques such as transforaminal, interlaminar, and unilateral biportal (UBE) endoscopy, is increasingly considered. However, the patient selection criteria are debated among spine surgeons.

OBJECTIVE

This study used a polytomous Rasch analysis to evaluate the factors influencing surgeon decision-making in selecting patients for endoscopic surgical treatment of lumbar spinal stenosis.

METHODS

A comprehensive survey was distributed to a representative sample of 296 spine surgeons. Questions encompassed various patient-related and clinical factors, and responses were captured on a logit scale graphically displaying person-item maps and category probability curves for each test item. Using a Rasch analysis, the data were subsequently analyzed to determine the latent traits influencing decision-making.

RESULTS

The Rasch analysis revealed that surgeons' preferences for transforaminal, interlaminar, and UBE techniques were easily influenced by comfort level and experience with the endoscopic procedure and patient-related factors. Harder-to-agree items included technological aspects, favorable clinical outcomes, and postoperative functional recovery and rehabilitation. Descriptive statistics suggested interlaminar as the best endoscopic spinal stenosis decompression technique. However, logit person-item analysis integral to the Rasch methodology showed highest intensity for transforaminal followed by interlaminar endoscopic lumbar stenosis decompression. The UBE technique was the hardest to agree on with a disordered person-item analysis and thresholds in category probability curve plots.

CONCLUSION

Surgeon decision-making in selecting patients for endoscopic surgery for lumbar spinal stenosis is multifaceted. While the framework of clinical guidelines remains paramount, on-the-ground experience-based factors significantly influence surgeons' selection of patients for endoscopic lumbar spinal stenosis surgeries. The Rasch methodology allows for a more granular psychometric evaluation of surgeon decision-making and accounts better for years-long experience that may be lost in standardized clinical guideline development. This new approach to assessing spine surgeons' thought processes may improve the implementation of evidence-based protocol change dictated by technological advances was endorsed by the Interamerican Society for Minimally Invasive Spine Surgery (SICCMI), the International Society for Minimal Intervention in Spinal Surgery (ISMISS), the Mexican Spine Society (AMCICO), the Brazilian Spine Society (SBC), the Society for Minimally Invasive Spine Surgery (SMISS), the Korean Minimally Invasive Spine Society (KOMISS), and the International Society for the Advancement of Spine Surgery (ISASS).

Stand-Alone Anchored Spacer vs Anterior Plate Construct in the Management of Adjacent Segment Disease after Anterior Cervical Discectomy and Fusion: A Systematic Review and Meta-Analysis of Comparative Studies

STUDY DESIGN

Systematic Review and Meta-Analysis.

OBJECTIVES

This study aimed to evaluate the clinical and radiological outcomes of surgically treated adjacent segment disease (ASDis) following ACDF with either anterior plate construct (APC) or stand-alone anchored spacers (SAAS).

METHOD

Multiple databases were searched until December 2022 for pertinent studies. The primary outcome was health-related quality of life outcomes [JOA, NDI, and VAS], whereas, the secondary outcomes included operative characteristics [estimated blood loss (EBL) and operative time (OT)], radiological outcomes [C2-C7 Cobb angle, disc height index (DHI) changes, fusion rate], and complications.

RESULTS

A total of 5 studies were included, comprising 210 patients who had been surgically treated for cervical ASDis. Among them, 113 received APC, and 97 received SAAS. Postoperative dysphagia was significantly higher in the APC group [47% vs 11%, OR = 7.7, 95% CI = 3.1-18.9, P < .05]. Similarly, operative time and blood loss were higher in the APC group compared to the SAAS group; [MD = 16.96, 95% CI = 7.87-26.06, P < .05] and [MD = 5.22, 95% CI = .35 - 10.09, P < .05], respectively. However, there was no difference in the rate of prolonged dysphagia and clinical outcomes in terms of JOA, NDI, and VAS. Furthermore, there was no difference in the radiological parameters including the C2-7 Cobb angle and DHI as well as the fusion rate.

CONCLUSION

Our meta-analysis demonstrated that both surgical techniques (APC and SAAS) are effective in treating ASDis. However, with low certainty of the evidence, considering patients are at high risk of dysphagia following revision cervical spine surgery SAAS may be the preferred choice.

Disability-adjusted life years from bone and joint infections associated with antimicrobial resistance: an insight from the 2019 Global Burden of Disease Study

PURPOSE

Bone and joint infections, complicated by the burgeoning challenge of antimicrobial resistance (AMR), pose significant public health threats by amplifying the disease burden globally. We leveraged results from the 2019 Global Burden of Disease Study (GBD) to explore the impact of AMR attributed to bone and joint infections in terms of disability-adjusted life years (DALYs), elucidating the contemporary status and temporal trends.

METHODS

Utilizing GBD 2019 data, we summarized the burden of bone and joint infections attributed to AMR across 195 countries and territories in the 30 years from 1990 to 2019. We review the epidemiology of AMR in terms of age-standardized rates, the estimated DALYs, comprising years of life lost (YLLs) and years lived with disability (YLDs), as well as associations between DALYs and socio-demographic indices.

RESULTS

The GBD revealed that DALYs attributed to bone and joint infections associated with AMR have risen discernibly between 1990 and 2019 globally. Significant geographical disparities and a positive correlation with socio-demographic indicators were observed. Staphylococcus aureus infections, Group A Streptococcus, Group B Streptococcus, Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Enterobacter-related bone and joint infections were associated with the highest DALYs because of a high proportion of antimicrobial resistance. Countries with limited access to healthcare, suboptimal sanitary conditions, and inconsistent antibiotic stewardship were markedly impacted.

CONCLUSIONS

The GBD underscores the escalating burden of bone and joint infections exacerbated by AMR, necessitating urgent, multi-faceted interventions. Strategies to mitigate the progression and impact of AMR should emphasize prudent antimicrobial usage and robust infection prevention and control measures, coupled with advancements in diagnostic and therapeutic modalities.

The Outcomes of Revision Anterior Cervical Decompression and Fusion Using a Stand-Alone Implant Versus Traditional Interbody Polyetheretherketone Cage, Titanium Plate, and Screw Instrumentation

INTRODUCTION

Anterior cervical decompression and fusion (ACDF) is the standard surgical procedure for cervical radiculopathy and myelopathy, although ACDF includes risks of adjacent segment disease (ASD) and subsequent revision procedures. Various interbody cage, plate, and screw options can be utilized. Stand-alone devices were designed to overcome undesired complications of hardware prominence and associated dysphagia, soft tissue violation, and adjacent level encroachment. Implants include biomechanical structural support (cage) composed of various materials (polyetheretherketone (PEEK)/titanium) and integral fixation (screws/blades). The purpose was to compare intraoperative, short- and long-term outcomes of revision ACDF using a stand-alone implant (ACDF-ZP group) versus traditional interbody PEEK cage, titanium plate, and screw instrumentation (ACDF-CP group).

METHODS

This was a retrospective, cohort study reviewing charts of patients who underwent revision ACDF. The primary outcome measure was the incidence of postoperative dysphagia. Secondary outcomes included intraoperative, short-term, and long-term outcomes and complications.

RESULTS

Sixty-one patients were included (ACDF-ZP group = 50; ACDF-CP group = 11). In-hospital incidence of dysphagia was significantly less in the ACDF-CP group (P = 0.041). Thrity-one (62.0%) of the ACDF-ZP group reported dysphagia postoperatively, half resolved by 6 weeks, and two persisted for more than 6 months. Five (45.5%) of the ACDF-CP group reported dysphagia with most resolving within 6 weeks. There were no statistically significant differences between groups in short- or long-term complications, dysphonia, or reoperation rates. No statistical significance was seen in blood loss, operative time, hospital stay, local and global alignment, or cage subsidence.

CONCLUSION

Rates of dysphagia were comparable between groups at short and long-term follow-up, despite a greater incidence of postoperative dysphagia in the ACDF-ZP group. All complications and occurrences of cage subsidence were observed in the ACDF-ZP group, which may be attributed to the larger sample size. Given these findings, zero-profile stand-alone implants and traditional interbody PEEK cage, titanium plate, and screw instrumentation appear to be both safe and effective options for revision ACDF.

Open and closed reduction methods for intramedullary nailing of femoral shaft fractures: A systematic review and meta-analysis of comparative studies

Introduction

Closed reduction and intramedullary nailing is the preferred surgical intervention for femoral shaft fractures. Open reduction involves opening the fracture site and is performed in various circumstances. Comparative studies of the approaches have conflicting results. We sought to compare the outcomes and complications of open and closed reduction for intramedullary nailing of femoral shaft fractures.

Materials and methods

Following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, a systematic review of comparative studies included the databases and registers PubMed (Medline), Embase, Scopus, and Cochrane Central (PROSPERO registration ID: CRD42022325382). Additional studies were identified through hand and citation searching. Two reviewers independently extracted data. The standardized mean difference and 95% confidence intervals were determined for continuous variables, whereas odds ratios and 95% confidence intervals were assessed for dichotomous variables.

Results

Closed reduction had a higher pooled union rate (93.93%, 92.02%), an increased odds ratio for union (OR = 1.624 [95% CI: 1.004, 2.624]; p = .048), and a faster time to union (SMD = -0.292 [95% CI: -0.549, -0.0.035]; p = .026). There were no differences in operative time (SMD = 0.128 [95% CI: -0.700, 0.956] p = .762) or overall complication rate (OR = 1.314 [95% CI: 0.966, 1.787] p = .082).

Conclusions

Closed reduction has the advantage of higher union rates, quicker time to union, and lower overall infection compared to open reduction for intramedullary nailing of femoral shaft fractures. Open reduction remains a reasonable alternative with acceptable union rates when closed reduction is not feasible.

The Impact of Prior Bariatric Surgery on Outcomes After Spine Surgery: A Systematic Review and meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

To compare outcomes and complication rates in patients undergoing bariatric surgery (BS) prior to spine surgery.

METHODS

A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines comparing the outcomes of spine surgery between subjects with prior bariatric surgery to those who were considered obese with no prior bariatric surgery.

RESULTS

A total of 183, 570 patients were included in the 4 studies meeting inclusion criteria. The mean patient age was 52.9 years, and the majority were female (68%). The two groups consisted of a total of 36, 876 patients with prior BS and 146, 694 obese patients without prior BS. The overall rate of complications in the prior BS group was 6.4% (4.5%-38.7%) compared to 11.9% (11.2%-55.4%) in the non-prior BS obese group with a statistically significant difference between the two groups. The prior BS group had lower rates of renal, neurological, and thromboembolic complications, with a lower mortality and readmission rate. In a subgroup undergoing cervical spine surgery, patients with prior BS had fewer cardiac, GI, and total complications. For patients undergoing thoracolumbar spine surgery, patients with prior BS had fewer thromboembolic and total complications.

CONCLUSION

Patients undergoing bariatric surgery prior to spine surgery had fewer renal, neurological, and thromboembolic complications as well as a decreased mortality and readmission rate.

The Reliability of Postoperative Radiographic Matta Grading for Quality of Reduction of Acetabular Fractures

OBJECTIVES

To assess the reliability of the postoperative radiographic Matta grading for quality of reduction of acetabular fractures.

DESIGN

An inter-reliability and intrareliability study.

SETTING

Level I trauma center.

PARTICIPANTS

15 independent observers of different levels of experience who evaluated 115 sets of postoperative acetabulum radiographs in 35 consecutive patients with displaced acetabular fractures between January 2017 and January 2019.

MAIN OUTCOME MEASUREMENTS

To assess the interobserver and intraobserver reliability of Matta radiographic grading for postoperative quality of reduction of acetabular fractures.

RESULTS

The overall interobserver agreement was excellent among all groups with an average absolute intraclass correlation coefficient (ICC) of 0.91 (95% CI 0.93-0.97). When stratifying the agreement based on experience, the orthopaedic trauma fellow subgroup had the highest rate with an ICC of 0.92. The overall intraobserver agreement was good with an ICC of 0.81 (95% CI 0.74-0.85).

CONCLUSION

The Matta radiographic grading was a reliable tool for the evaluation of quality of reduction after surgical fixation of acetabular fractures with excellent interobserver and good intraobserver reliabilities among different levels of observers.

Minimally Invasive Scoliosis Surgery Is a Feasible Option for Management of Idiopathic Scoliosis and Has Equivalent Outcomes to Open Surgery: A Meta-Analysis

STUDY DESIGN

Meta-analysis.

OBJECTIVE

To compare outcomes between minimally invasive scoliosis surgery (MISS) and traditional posterior instrumentation and fusion in the correction of adolescent idiopathic scoliosis (AIS).

METHODS

A literature search was performed using MEDLINE, PubMed, EMBASE, Google scholar and Cochrane databases, including studies reporting outcomes for both MISS and open correction of AIS. Study details, demographics, and outcomes, including curve correction, estimated blood loss (EBL), operative time, postoperative pain, length of stay (LOS), and complications, were collected and analyzed.

RESULTS

A total of 4 studies met the selection criteria and were included in the analysis, totaling 107 patients (42 MIS and 65 open) with a mean age of 16 years. Overall there was no difference in curve correction between MISS (73.2%) and open (76.7%) cohorts. EBL was significantly lower in the MISS (271 ml) compared to the open (527 ml) group, but operative time was significantly longer (380 min for MISS versus 302 min for open). There were no significant differences between the approaches in pain, LOS, complications, or reoperations.

CONCLUSION

MISS was associated with less blood loss but longer operative times compared to traditional open fusion for AIS. There was no difference in curve correction, postoperative pain, LOS, or complications/reoperations. While MISS has emerged as a feasible option for the surgical management of AIS, further research is warranted to compare these 2 approaches.

Impact of leg numbness on patient satisfaction following decompression surgery for lumbar spinal stenosis

Decompression surgery is the most common surgical treatment for lumbar spinal stenosis (LSS). Relatively low satisfaction rate was reported. Patients often complaint of residual numbness despite significant pain relief. We hypothesized that numbness had a significant impact on patient satisfaction, but had not been evaluated, which is associated with low satisfaction rate. This study aimed to examine how much numbness is associated with patient satisfaction. We retrospectively reviewed prospectively collected data from consecutive patients who underwent decompression without fusion for LSS. We evaluated the Numeric Rating Scale (NRS) scores of low back pain (LBP), leg pain, and leg numbness preoperatively and at the final follow-up visit. Improvement was evaluated using minimum clinically important differences (MCIDs). Patient satisfaction was evaluated using the question, "How satisfied are you with the overall result of your back operation?". There are four possible answers consisting of "very satisfied (4-point)", "somewhat satisfied (3-point)", "somewhat dissatisfied (2-point)", or "very dissatisfied (1-point)". Spearman correlation was used to evaluate the association between patient satisfaction and reaching MCIDs. A total of 116 patients were included. All three components had correlation with patient satisfaction with the correlation efficient of 0.30 in LBP, 0.22 in leg pain, and 0.33 in numbness. Numbness had greatest correlation efficient value. We showed that numbness has a greater impact than leg/back pain on patient satisfaction in patients undergoing decompression for LSS. We suggest not only LBP and leg pain but also numbness should be evaluated pre- and postoperatively.

Return to Play and Fracture Union After the Surgical Management of Jones Fractures in Athletes: A Systematic Review and Meta-analysis

BACKGROUND

Proximal fifth metatarsal fractures are among the most common forefoot injuries in athletes. The management of this injury can be challenging because of delayed union and refractures. Intramedullary (IM) screw fixation rather than nonoperative management has been recommended in the athletic population.

PURPOSE

To provide an updated summary of the return-to-play (RTP) rate and time to RTP after Jones fractures in athletes with regard to their management, whether operative or nonoperative, and to explore the union rate and time to union as well as the rate of complications such as refractures.

STUDY DESIGN

Meta-analysis.

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases including PubMed, MEDLINE, Embase, Google Scholar, Web of Science, Cochrane Library, and ClinicalTrials.gov through November 2019 to identify studies reporting on Jones fractures of the fifth metatarsal exclusively in athletes. The primary outcomes were the RTP rate and time to RTP, whereas the secondary outcomes were the number of games missed, time to union, and union rate as well as the rates of nonunion, delayed union, and refractures.

RESULTS

Of 168 studies identified, 22 studies were eligible for meta-analysis with a total of 646 Jones fractures. The overall RTP rate was 98.4% (95% CI, 97.3%-99.4%) in 626 of 646 Jones fractures. The RTP rate with IM screw fixation only was 98.8% (95% CI, 97.8%-99.7%), with other surgical fixation methods (plate, Minifix) was 98.4% (95% CI, 95.8%-100.0%), and with nonoperative management was 71.6% (95% CI, 45.6%-97.6%). There were 3 studies directly comparing RTP rates with surgical versus nonoperative management, which showed significant superiority in favor of surgery (odds ratio, 0.033 [95% CI, 0.005-0.215]; P < .001). The RTP rate according to type of sport was 99.0% (95% CI, 97.5%-100.0%) in football, 91.1% (95% CI, 82.2%-99.4%) in basketball, and 96.6% (95% CI, 92.6%-100.0%) in soccer. The overall time to RTP was 9.6 weeks (95% CI, 8.5-10.7 weeks). The time to RTP in the surgical group (IM screw fixation) was 9.6 weeks (95% CI, 8.3-10.9 weeks), which was significantly less than that in the nonoperative group of 13.1 weeks (95% CI, 8.2-18.0 weeks). The pooled union rate in the operative group (excluding refractures) was 97.3% (95% CI, 95.1%-99.4%), whereas the pooled union rate in the nonoperative group was 71.4% (95% CI, 49.1%-93.7%). The overall time to union was 9.1 weeks (95% CI, 7.7-10.4 weeks). The time to union with IM screw fixation (8.2 weeks [95% CI, 7.5-9.0 weeks]) was shorter than that with nonoperative treatment (13.7 weeks [95% CI, 12.7-14.6 weeks]). The rate of delayed union was 2.5% (95% CI, 1.2%-3.7%), and the overall refracture rate was 10.2% (95% CI, 5.9%-14.5%).

CONCLUSION

The RTP rate and time to RTP after the surgical management of Jones fractures in athletes were excellent, regardless of the implant used and type of sport. IM screw fixation was superior to nonoperative management, as it led to a higher rate of RTP, shorter time to RTP, higher rate of union, shorter time to union, and improved functional outcomes. We recommend surgical fixation for all Jones fractures in athletes.

Clinical characteristics, injury pattern and management of pediatric pelvic fracture: An observational retrospective study from a level I trauma center

Background

Pediatric pelvic fractures (PPF) are uncommon among children requiring hospitalization after blunt trauma. The present study explored our experience for the prevalence, patients demographics, clinical characteristics, injury pattern and management of pediatric pelvic fractures in a level I trauma center.

Methods

This is a retrospective review of prospectively collected data obtained from trauma registry database for all pediatrics trauma patients of age ≤18 years. Data were analyzed according to different aspects relevant to the clinical applications such as Torode classification for pelvic ring fracture (Type I–IV), open versus closed triradiate cartilage, and surgical versus non-surgical management.

Results

During the study period (3 and half years), a total of 119 PPF cases were admitted at the trauma center (11% of total pediatric admissions); the majority had pelvic ring fractures (91.6%) and 8.4% had an acetabular fracture. The mean age of patients was 11.5 ± 5.7, and the majority were males (78.2%). One hundred and four fractures were classified as type I (5.8%), type II (13.5%), type III (68.3%) and type IV (12.5%). Patients in the surgical group were more likely to have higher pelvis AIS (p = 0.001), type IV fractures, acetabular fractures and closed triradiate cartilage as compared to the conservative group. Type III fractures and open triradiate cartilage were significantly higher in the conservative group (p < 0.05). Patients with closed triradiate cartilage frequently sustained spine, head injuries, acetabular fracture and had higher mean ISS and pelvis AIS (p < 0.01) than the open group. However, the rate of in-hospital complications and mortality were comparable among different groups. The overall mortality rate was 2.5%.

Conclusion

PPF are uncommon and mainly caused by high-impact trauma associated with multisystem injuries. The majority of PPF are stable, despite the underlying high-energy mechanism. Management of PPF depends on the severity of fracture as patients with higher grade fractures require surgical intervention. Furthermore, larger prospective study is needed to understand the age-related pattern and management of PPF.

Return to Play After Low-Energy Lisfranc Injuries in High-Demand Individuals: A Systematic Review and Meta-Analysis of Athletes and Active Military Personnel

Background

Although studies are available on high-energy Lisfranc injuries, the evidence for increasingly reported low-energy Lisfranc injuries in active individuals, including athletes and military personnel, remains scarce and mostly retrospective.

Purpose

This meta-analysis aimed to review the return-to-play (RTP) and return-to-duty (RTD) rates with regard to the anatomic type and the management of low-energy Lisfranc injuries in a high-demand, active population.

Study Design

Systematic review; Level of evidence, 4.

Methods

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched the MEDLINE (PubMed), EMBASE, Google Scholar, and Cochrane databases through June 2019 to identify studies on low-energy Lisfranc injuries in athletes and military personnel. The primary outcomes were RTP/RTD rates and time to RTP/RTD, and the secondary outcomes were time missed from practice, games missed, time to full recovery, midfoot arthritis rate, and reoperation rate.

Results

Overall, 15 studies (N = 441 patients) were included in the meta-analysis. Of these, 6 studies were of level 3 evidence, 8 studies were level 4 (case series), and 1 study was level 5. Of the 441 subjects, 380 (86.17%) were able to RTP and RTD. There was no statistically significant difference in RTP rates for operative versus nonoperative treatment, ORIF versus PA, or bony versus ligamentous injuries. The mean time missed from practice/duty for operative versus nonoperative treatment was 58.02 days (95% CI, 13.6-102.4 days; I ² = 98.03%) and 116.4 days (95% CI, 62.4-170.4 days; I ² = 99.45%), respectively. The mean time missed from practice/duty for bony versus ligamentous injury was 98.9 days (95% CI, 6.1-191.7 days; I ² = 99.82%) and 76.5 days (95% CI, 37.9-115.02 days; I ² = 99.83%), respectively, with no statistically significant differences (standardized mean difference = 3.62 days [95% CI: -5.7 to 13 days]; I ² = 83.17%).

Conclusion

This review indicated an overall excellent RTP/RTD rate for low-energy Lisfranc injuries in high-demand individuals. The time missed from athletic participation/military duty was not affected by injury treatment type, the bony versus ligamentous nature of the injury, or athlete player position. However, the low evidence levels and significant heterogeneity of the included studies precludes making conclusions regarding length of time missed or optimal management. Higher-quality studies on low-energy Lisfranc injuries are needed.

Early Outcomes of Pelvic Trauma Patients - Complications, ICU Stay and Treatment Concepts in Two ATLS Compliant Trauma Centers: Germany and Qatar

PURPOSE OF THE STUDY Pelvic trauma causes severe threats especially to polytraumatized patients. Not only it is in itself a possible cause for significant bleeding, but it also indicates a high risk for intra-abdominal injuries. The initial treatment of patients with pelvic trauma follows the ATLS principles of priority-oriented treatment. To examine the value of this highly standardized concept and to evaluate the effect of different patient collectives on early outcome parameters, two large collectives from Germany and Qatar were analyzed regarding injury parameters and early outcomes. MATERIAL AND METHODS Patients were recruited in Hamad General Hospital, Doha, Qatar (HGH) and BG Trauma Center Ludwigshafen, Germany (BG). All patients that were treated with a pelvic fracture between 2013 and 2016 were included in this retrospective analysis. Demographic parameters were collected as well as type of injury and the frequency of complication parameters as pneumonia, acute kidney failure, ARDS, sepsis and amount of blood transfusion. 1436 patients with pelvic fracture (645 from BG and 791 from HGH) were recruited. The mean age was 57.4 years in the BG and 33.6 years in the HGH group (p<0.000). The mean ISS was 17.81 in the BG and 15.88 in the HGH group (p=0.009). The mean pelvic AIS was 2.65 in the BG and 2.25 in the HGH group (p<0.000). RESULTS The mean frequency of complications was 9.3% in the BG and 9.9% in the HGH group (p=0.128). The mean frequency of ARDS was significantly higher in the BG group than in the HGH group (5.6% vs. 1.8%, p<0.000). The mean frequency of blood transfusion was significantly lower in the BG group than in the HGH group (28.8% vs. 39.2%, p<0.000). CONCLUSIONS Despite significant differences in the two collectives, this analysis shows comparable results regarding early outcome parameters in patients with pelvic injuries. In total, pelvic injuries are accompanied by a relatively high complication risk and need to be evaluated and treated according to priority-based algorithms. Key words: ATLS®, pelvic injury, complications, polytrauma.

The Effect of Different Doses of Intravenous Dexmedetomidine on the Properties of Subarachnoid Blockade: A Systematic Review and Meta-Analysis

Background

Dexmedetomidine is a sedative and analgesic medication which has gained an increased usage as an adjuvant to both general and regional anaesthesia in recent years. In this systematic review and meta-analysis, we examined the changes to the characteristics of subarachnoid block when accompanied with intravenous dexmedetomidine. Our aim is to evaluate the effects of different doses of intravenous dexmedetomidine on the sensory and motor blockade duration of a single shot spinal anaesthetic and the incidence of any associated side effects.

Methods

We searched published randomized clinical trials (RCTs) from January 1992 to April 2019 that investigated the use of IV dexmedetomidine with spinal anaesthesia. After considering our inclusion and exclusion criteria, we included 15 RCTs with 985 patients. We analyzed the duration of sensory and motor blockade and the related adverse effects in relation to different doses of IV dexmedetomidine.

Results

Intravenous dexmedetomidine, with loading dose of 1 mcg/kg, prolonged the sensory blockade duration of spinal anaesthesia by a mean difference of 49.6 min, P<0.001, and motor blockade duration by a mean difference of 44.7 min, P<0.001, while a loading dose of 0.5 mcg/kg prolonged the sensory blockade by a mean difference of 43.06 min, P<0.001, and motor blockade duration by a mean difference of 29.09 min, P<0.001. Dexmedetomidine-related side effects were higher in patients receiving larger doses; the incidence of bradycardia was higher (OR=3.53, P<0.001) and incidence of hypotension showed a 1.29 fold increase when compared to the control group (P=0.065).

Conclusion

The administration of intravenous dexmedetomidine in conjunction with spinal anaesthesia can significantly prolong the duration of both sensory and motor blockade. The use of larger loading doses of dexmedetomidine was associated with a larger side-effect profile with minimal beneficial changes when compared to lower loading doses.

The Orthopedic Residency Program at Hamad Medical Corporation During COVID-19 Crisis: an Evolving Educational Strategy

The COVID-19 pandemic has changed the strategies of most of the teaching hospitals worldwide, affecting the educational process in residency programs. The System Wide Incident Command Committee in the state of Qatar has set the country's medical response to the crisis. In line with command committee directives, the orthopedic surgery residency program planned an educational strategy keeping the trainees' wellbeing and education a priority and taking advantage of the pandemic as a tool of personal and professional growth.

Patterns, management, and outcomes of traumatic pelvic fracture: insights from a multicenter study

Background

Traumatic pelvic fracture (TPF) is a significant injury that results from high energy impact and has a high morbidity and mortality.

Purpose

We aimed to describe the epidemiology, incidence, patterns, management, and outcomes of TPF in multinational level 1 trauma centers.

Methods

We conducted a retrospective analysis of all patients with TPF between 2010 and 2016 at two trauma centers in Qatar and Germany.

Results

A total of 2112 patients presented with traumatic pelvic injuries, of which 1814 (85.9%) sustained TPF, males dominated (76.5%) with a mean age of 41 ± 21 years. In unstable pelvic fracture, the frequent mechanism of injury was motor vehicle crash (41%) followed by falls (35%) and pedestrian hit by vehicle (24%). Apart from both extremities, the chest (37.3%) was the most commonly associated injured region. The mean injury severity score (ISS) of 16.5 ± 13.3. Hemodynamic instability was observed in 44%. Blood transfusion was needed in one third while massive transfusion and intensive care admission were required in a tenth and a quarter of cases, respectively. Tile classification was possible in 1228 patients (type A in 60%, B in 30%, and C in 10%). Patients with type C fractures had higher rates of associated injuries, higher ISS, greater pelvis abbreviated injury score (AIS), massive transfusion protocol activation, prolonged hospital stay, complications, and mortality (p value < 0.001). Two-thirds of patients were managed conservatively while a third needed surgical fixation. The median length of hospital and intensive care stays were 15 and 5 days, respectively. The overall mortality rate was 4.7% (86 patients).

Conclusion

TPF is a common injury among polytrauma patients. It needs a careful, systematic management approach to address the associated complexities and the polytrauma nature.

Minimally Invasive Spine Lumbar Surgery in Obese Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Transforaminal lumbar interbody fusion (TLIF) is the treatment of choice for lumbar spinal stenosis and spondylolisthesis. The procedure can be performed through a traditional open approach (O-TLIF) or through minimally invasive techniques (MI-TLIF). Spinal surgeries in obese patients can pose risks, including increased rates of infection and thromboembolic events.

QUESTIONS/PURPOSES

We sought to systematically review the literature on the differences between MI-TLIF and O-TLIF in the obese patient in terms of complication rate, functional outcomes, blood loss, and length of hospital stay.

METHODS

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to systematically search PubMed, Embase, Web of Science, and the Cochrane Library for studies published through February 2019 and identified those comparing the outcomes of O-TLIF and MI-TLIF in obese patients. The primary outcome was complication rate (total, infections, dural tears); secondary outcomes were blood loss, length of hospital stay, and functional scores. Two authors independently reviewed the studies using the Newcastle-Ottawa Scale, and data were pooled using the Mantel-Haenszel random-effects model.

RESULTS

In the sample of 430 patients, the average age was 53.5 years, there were 153 men and 203 women, and the average body mass index was 33.6. Complications were significantly higher in O-TLIF than in MI-TLIF (OR = 0.420 [95% CI: 0.199, 0.887]; I ² = 45.20%). No difference was detected between the two groups for visual analog scale back pain scores and Oswestry Disability Index scores between the pre-operative and last follow-up visits (SMD = -0.034 [95% CI -0.695, 0.627]; I ² = 62.14% and SMD = 0.617 [95% CI: -1.082, 2.316]; I ² = 25%, respectively). Blood loss was significantly lower in MI-TLIF compared to O-TLIF (SMD = -426.736 [95% CI: -490.720, -362.752]; I ² = 70.53%), as was the duration of hospital stay (SMD = -1.079 [95% CI: -1.591, -0.208]; I ² = 84.3%).

CONCLUSION

MI-TLIF has equivalent efficacy to O-TLIF in obese patients at long-term follow-up. In addition, complication rate, blood loss, and length of hospital stay were lower in MI-TLIF than in O-TLIF.

Outcome of primary deltoid ligament repair in acute ankle fractures: a meta-analysis of comparative studies

PURPOSE

The indications of deltoid ligament repair in ankle injuries with widened medial clear space in the absence of medial malleolus fracture remain controversial. Many authors reported no difference in long-term functional outcomes, while others stated that persistent medial clear space widening and malreduction are higher when deltoid ligaments went without repair. This meta-analysis aims to report the current published evidence about the outcomes of deltoid ligament repair in ankle fractures.

METHODS

Several databases were searched through May 2018 for comparative studies. The primary outcome was the medial clear space correction, while secondary outcomes included maintenance of medial clear space reduction, pain scores, functional outcome, and total complications if any. Three comparative studies met the inclusion criteria for the meta-analysis. The analysis included a total of 192 patients, 81 in the deltoid ligament repair group and 111 in the non-repair group.

RESULTS

The medial clear space correction and maintenance of the said correction on final follow-up radiographs were superior in the deltoid ligament repair group. Although the pain scores were better in the repair group at the final follow-up, this did not result in a better functional outcome, with similar total complication rates.

CONCLUSION

In conclusion, those who had their deltoid ligament repaired had superior early and late radiological correction of the medial clear space, an indicator of the quality of ankle reduction with better pain scores. However, no differences in the functional outcome and complications rate were reported.

Prognostic Role of Shock Index in Traumatic Pelvic Fracture: A Retrospective Analysis

BACKGROUND

We aimed to validate the utility of shock index (SI) in predicting the need of blood transfusion and outcomes in patients with traumatic pelvic fracture (TPF).

MATERIALS AND METHODS

We conducted a retrospective analysis for patients who sustained TPF between 2012 and 2016 in a level 1 trauma center. Patients were categorized into patients with low versus high SI based on the cutoff obtained from the receiver operating characteristic curves to predict mortality.

RESULTS

A total of 966 patients sustained TPF (28.5% had SI ≥ 0.9 based on receiver operating characteristic curves) with a median age of 33 (IQR 25-47) y. Type B and C pelvic fractures significantly had higher SI. The frequency of blood transfusion use was greater in patients with high SI (P = 0.001). SI correlated significantly with Injury Severity Score (r = 0.32), Revised Trauma Score (r = -0.40), and transfused blood units (r = 0.35). Patients with high SI had prolonged hospital length of stay and higher mortality (P = 0.001). SI ≥ 0.9 showed high sensitivity and negative predictive value to identify the need of massive blood transfusion (77% and 86%, respectively) and mortality (73.5% and 98.1%, respectively). For hospital mortality, high SI had a sensitivity of 73.5%, specificity 74%, negative predictive value 98%, and negative likelihood ratio of 0.36. After adjustment for age, sex, Injury Severity Score, Glasgow Coma Scale, pelvis Abbreviated Injury Scale, blood transfusion, and Tile classification, the multivariate analysis models showed that high SI was an independent predictor of blood transfusion (odd ratio 5.6) and mortality (odd ratio 3.63).

CONCLUSIONS

SI is a potentially useful instant tool for the prediction of massive transfusion and mortality in patients with TPF. Further prospective studies are warranted to support our findings.

Functional and Radiological Outcomes of Combined Anterior-Posterior Approach Versus Posterior Alone in Management of Isthmic Spondylolisthesis. A Systematic Review and Meta-Analysis

Background

Lumbar isthmic spondylolisthesis (IS) in adults is defined as the forward slippage of a vertebra onto the top of the vertebra, resulting from a defect in the pars intraarticular, and can be low grade or high grade. Persistent back pain or neurological deficit are indications for surgical intervention. Surgery can be done from back, front, or both, with or without fusion, instrumentation, or decompression, and short or long segment.

Methods

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, several databases were searched through August 2017 for any observational or experimental studies that evaluated combined anterior-posterior approach versus posterior alone in management of IS. Primary outcome was fusion rate, whereas secondary outcomes included functional outcomes (Visual Analogue Scale [VAS] and Oswestry Disability Index [ODI] score), complication rate (infection, neurological), and reoperation rate. Descriptive, quantitative, and qualitative data were extracted. Most of the cases were low-grade IS.

Results

Of the 645 articles identified, 6 studies were eligible for the meta-analysis, with a total of 397 patients with IS, 198 in the combined (anterior interbody fusion [ALIF] + postero-lateral fusion [PLF]) group and 199 in the posterior (transformational interbody fusion [TLIF]/ postero-lateral interbody fusion [PLIF] + PLF) group, average age of 47.2 years, and 185:212 male : female ratio. Although the fusion rate reached 100% in some studies, the pooled odds ratio (OR) of fusion rate (OR = 1.02, 95% confidence interval [CI]: 0.294, 3.552, P = .972) did not reach statistical significance between (ALIF + PLF) versus (TLIF/PLIF + PLF). The estimated pooled standardized mean difference (SMD) showed less blood loss in the anterior approach compared to the posterior approach (SMD = -0.528, 95% CI: -0.777, -0.278, P < .001), with no difference in operative time and length of hospital stay. Despite both groups showing significant improvement in pain and functional scores at final follow up, ODI and VAS were not significantly different between groups with ODI (SMD = -0.644, 95% CI: -1.948, 0.621, P = .311) and VAS (SMD = 0.113, 95% CI: -0.173, 0.400, P = .439). The complication rate for the anterior approach was higher than the posterior, whereas reoperation rate was higher in the posterior approach than the anterior.

Conclusions

No significant difference between anterior and posterior approaches was found in the global assessment of fusion rate and clinical outcomes, despite a higher rate of complications using the anterior approach.

Level of Evidence

3.

Clinical Relevance

Both anterior and posterior approach are a valid option for treatment of isthemic spondylolisthesis.

External fixation for primary and definitive management of open long bone fractures: the Syrian war experience

AIMS

To report on the experience of one field hospital in using external fixation as a primary and definitive treatment for open long bone fractures during the Syrian war.

METHODS

A total of 955 patients with open long bone fractures (femur, tibia, humerus) who were operated and followed up at a field hospital in Aleppo, Syria, from 2011 to 2016, were retrospectively reviewed. Different types of uniplanar and some multiplanar external fixators were used solely as a primary and definitive tool until bone union was achieved. Union rate and infection rate were reported in association with age, gender, Gustilo/Anderson classification, type of fixator, and presence of neurovascular injuries.

RESULTS

Out of 955 patients, 404 (42.3%) continued to follow up until bone union or until removal of the external fixator. The average age was 27.5 ± 11 years, with 91.6% males and 8.2% females. The overall union rate was 68.3% (276/404), with 60.9% (95/156) in open femur, 70.3% (137/195) in open tibia, and 83% (44/53) in open humerus fractures. The overall infection rate was 16.7% (67/401), with 18.6% in open femur, 18.1% in open tibia, and 5.8% in open humerus fractures.

CONCLUSION

The use of external fixation for definitive treatment of open long bone shaft fractures caused by high energy trauma during times of wars or conflicts is reliable and should be used in early frontline intervention and in areas with limited access to resources.

Impact of Screw Type on Kyphotic Deformity Correction after Spine Fracture Fixation: Cannulated versus Solid Pedicle Screw

Study Design

Retrospective review.

Purpose

To detect the effect of cannulated (poly-axial head) and solid (mono-axial head) screws on the local kyphotic angle, vertebral body height, and superior and inferior angles between the screw and the rod in the surgical management of thoracolumbar fractures.

Overview of Literature

Biomechanics studies showed that the ultimate load, yield strength, and cycles to failure were significantly lower with cannulated (poly-axial head) pedicle comparing to solid core (mono-axial head).

Methods

The medical charts of patients with thoracolumbar fractures who underwent pedicle screw fixation with cannulated or solid pedicle screws were retrospectively reviewed; the subjects were followed up from January 2011 to December 2015.

Results

Total 178 patients (average age, 36.1±12.4 years; men, 142 [84.3%]; women, 28 [15.7%]) with thoracolumbar fractures who underwent surgery and were followed up at Hamad Medical Corporation were classified, based on the screw type as those with cannulated screws and those with solid screws. The most commonly affected level was L1, followed by L2 and D12. Surgical correction of the local kyphotic angle was significantly different in the groups; however, there was no significant difference in the loss of correction of the local kyphotic angle of the groups. Surgical correction of the reduction in the vertebral body height showed statistical significance, while the average loss of correction in the reduction of the vertebral body height was not significantly different. The measurement of the angles made by the screws on the rods was not significantly different between the cannulated (poly-axial head) and solid (mono-axial head) screw groups.

Conclusions

Solid screws were superior in terms of providing increased correction of the kyphotic angle and height of the fractured vertebra than the cannulated screws; however, no difference was noted between the screws in the maintenance of the superior and inferior angles of the screw with the rod.

Prevalence of Peroneal Tendon Instability in Calcaneus Fractures: A Systematic Review and Meta-Analysis

Peroneal tendon instability associated with an intraarticular calcaneal fracture is a common injury that still often passes undiscovered by both radiologists and orthopedic surgeons. Timely identification of this injury will guide the choice of surgical technique used and treatment of patients. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, several databases were searched through June 2017 for any observational or experimental studies that reported the prevalence/incidence of peroneal tendon subluxation/dislocation with a calcaneus fracture with regard to fracture classifications and the significance of the fleck sign. Nine studies were included, with 1027 patients and 1050 calcaneus fractures. The overall prevalence of peroneal instability (PI) in association with a calcaneus fracture was 29.3%. An increasing prevalence of PI increased the severity of the calcaneus fractures, 5.4% in Sanders I, 19% in Sanders II, 39.4% in Sanders III, and 49.5% in Sanders IV. The presence of a fleck sign is a strong indicator of PI, with a prevalence of 54.7%. The computed tomography findings can overestimate the presence of PI compared with the intraoperative findings. The global reported prevalence of peroneal tendon instability associated with intraarticular calcaneal fractures is high and increases with increasing severity of the calcaneus fracture.

Surgical versus Conservative Management of Weber B Fibular Fractures

Category:

Trauma

Introduction/Purpose:

Fibular fractures are one of the most common traumatic injuries treated by orthopaedic surgeons. These fractures range from stable to unstable, and accordingly may be treated conservatively with immobilization or operatively with open reduction and internal fixation. Unstable Weber classification type B fibula fractures are at the level of the syndesmosis. When stressed, they show an increased medial clear space widening. Recent studies have suggested these fractures may be treated non-operatively. The purpose of this study was to systematically review the literature to determine whether operative and non-operative management of Weber B fractures exhibit any difference in functional outcomes.

Methods:

For this study, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIMSA) guidelines were followed. A systematic review of the literature was performed on the Medline (PubMed), Ovid, and Embase databases in May 2017. Only studies analyzing surgical and non-surgical management of Weber B fibular fractures were included. A meta-analysis was performed to pool difference of the mean for functional outcome scores (Olerud Molander Ankle [OMA] score, American Orthopaedic Foot and Ankle Score [AOFAS], Visual Analogue Scale [VAS], and Short-form 36 [SF36] questionnaire) of the ankles of patients who underwent surgical and non-surgical management. Descriptive, quantitative, and qualitative data were extracted and analyzed using Comprehensive meta-analysis software and SPSS 21. Random effect model used to pool the difference of the mean of the outcomes and I2 to assess the heterogeneity.

Results:

Of the 823 articles identified, four studies met inclusion criteria for the meta-analysis. A total of 383 unstable Weber type B fibular fractures were identified, with 198 treated operatively and 161 treated non-operatively. There were 158 (41.2%) male and 225 (58.8%) female patients, who averaged 45.6 years of age (Table). Mean follow up was 27.3 months. The pooled mean difference (SMD) for OMA functional score did not show any statistically significant difference between surgical and non-surgical management (SMD = 12.364 [95% CI: -4.684, 29.413]; I2 = 91.93%), although each single paper highlighted the superiority of non-surgical management. Other functional scores could not be pooled because they were not consistently reported within the included studies.

Conclusion:

The early literature suggests that there is no difference in the clinical outcomes of unstable Weber B fractures, whether they are treated operatively or non-operatively. Longer-term studies are warranted to examine the clinical outcomes of patients managed non-operatively.

Prevalence of Peroneal Tendon Instability in Calcaneus Fractures

Category:

Trauma

Introduction/Purpose:

Peroneal tendon instability (PI) associated with intraarticular calcaneal fractures is a significant and commonly missed injury. It has been proposed that the peroneal tendon dislocates with the occurrence of a calcaneal fracture because the axial force transmitted blows out the lateral wall causing either impingement of the peroneal tendon or avulsion of the superficial peroneal retinaculum from the distal fibula, allowing the peroneal tendons to dislocate anteriorly. To date, peroneal tendon instability with a calcaneal fracture has often passed undiagnosed by both radiologists and orthopedic surgeons. The present review aimed to determine the global reported prevalence of peroneal instability associated with calcaneus fractures according to the severity of the calcaneus fracture classification and the significance of a fleck sign as an indicator of PI.

Methods:

An electronic search of MEDLINE, Scopus, and Google Scholar was conducted until June 2017 without a date restriction and for English-language reports only in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Database searching was augmented by manual searches of common journals in the field (JBS, Foot and Ankle International, Foot and Ankle Surgery, Journal of Orthopedic Trauma). The reference lists from the identified studies were also scrutinized for any additional reports.The studies that reported the prevalence/incidence of peroneal tendon subluxation/ dislocation in association with a calcaneus fracture were included whereas patients with calcaneus fractures combined with other fractures, extraarticular calcaneus fractures, and old calcaneus fractures were excluded.The data analysis was performed using a comprehensive meta-analysis with a random effects model.

Results:

Of 31 initial studies, 9 were included, contain 1027 patients/1050 calcaneus fractures.Most of the patients were male, with an average age of 42.03 (range 18 to 79) years.Of the 1050 calcaneus fractures, PI was found in association with 305.The pooled odds ratio of the prevalence of PI with calcaneus fractures was 29.3%(95% CI 25.9%-32.9%; p < .001).The prevalence of PI increased with an increased fracture severity using the Sanders classification, with a prevalence of 5.4% with Sanders I,19% with Sanders II, 39.4% in Sanders III, and 49.5% with Sanders IV. The prevalence of PI in the tongue type fracture using the Essex-Lopresti classification was 19%, and for joint depression, was 30.8% (p < .001). The prevalence of the fleck sign as an indicator of PI was 54.7%.

Conclusion:

The global reported prevalence of peroneal tendon dislocation associated with intraarticular calcaneal fractures was 29.3% and that the prevalence of PI increases with increased severity of the calcaneus fracture. Such a high prevalence should raise suspicions in both radiologists and orthopedic surgeons about this injury. The assessment should begin with a careful review of preoperative radiographs to search for the fleck sign and CT scans for a dislocated tendon, followed later by intraoperative assessment of superior peroneal retinaculum integrity.

Surgical versus non surgical management of Geriatrics ankle fractures. A Systematic Review and Meta-analysis

Category:

Trauma

Introduction/Purpose:

Ankle fractures are common orthopedics injuries especially in elderly. Bone quality, activity, and other comorbidities play a role in the management of ankle fracture in older age group. Conservative treatment by casting with or without reduction consider valid option whereas the open reduction and internal fixation still the stander of care for all age groups. This review aims to provide evidence-based difference between surgical and non-surgical management of geriatrics ankle fracture in regards to healing, complication and functional outcome.

Methods:

Relevant comparative studies in English literature were identified up to October 2017 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Electronic-based search on MEDLINE (PubMed), EMBASE, Google Scholar and Cochrane databases, and hand searching of abstracts in orthopedics, trauma and foot and ankle journals. The research team systematically reviewed published studies according to the following criteria:(1) subjects whom sustained ankle fractures with age above 50 years;(2) the intervention was done through surgical management (open reduction and internal fixation) or conservative management (closed reduction and casting or casting alone) (3) the study reported at least one desirable outcome(non-union/mal-union rate, hospital stay, period on cast, mortality, re-admission rate, functional outcome, complication rate)(4) followed up at least one year after surgical /conservative management. The data analysis was done by Comprehensive meta-analysis software using a random-effect model and SPSS 22. Statistical heterogeneity across the studies was tested using I2.

Results:

The non-union rate in surgical group was significantly less than conservative group, (OR: 0.127, 95% CI: [0.055, 0.292], [P <0.001])and the mal-union was similarly less in surgical group (OR: 0.128, 95% CI: [0.063, 0.262], [P <0.001]). No difference in the hospital stays detected between two groups and similarly in re-admission rate. No difference in the period in cast reported between two groups. The return to pre-injury level was better in surgery group comparing to surgical one, whereas no difference in patient satisfaction was reported between two group. The mortality rate was less in the surgical group. The total number of skin complication was more in the conservative group.No difference in the incidence of DVT between two groups whereas the PE was in the surgical group.

Conclusion:

Geriatrics ankle fractures are challenging injury. The surgical management of such injuries showed superior results comparing to conservative management in terms of non-union /mal-union rate and return to pre-injury level with less mortality rate, whereas no difference in complications rate, hospital stay and patient satisfaction.

A Systematic Review and Meta-Analysis of Procalcitonin as a Marker of Postoperative Orthopedic Infections

Procalcitonin is a serologic marker that increases in response to inflammatory stimuli, especially those of bacterial origin. Postoperative orthopedic periprosthetic infections are often difficult to diagnose. This study systematically reviewed the literature to evaluate the statistical measures of performance of procalcitonin as a marker of postoperative orthopedic infection. This study showed that procalcitonin has a weighted pooled sensitivity of 67.3%, specificity of 69.4%, positive likelihood ratio of 1.778, negative likelihood ratio of 0.423, and diagnostic odds ratio of 5.770. These results illustrate that procalcitonin is an effective serologic marker for postoperative bacterial infections. [Orthopedics. 2018; 41(3):e303-e309.].

The influence of vitamin C on the outcome of ankle fractures. A protocol of double-blind RCT

Category:

Ankle, Trauma

Introduction/Purpose:

Ankle fracture is one of the most common orthopedics injuries. Poor functional outcome, residual pain and discomfort is a major burden to the patients daily activities Complex regional pain syndrome (CRPS) is one of serious complication after orthopedics injuries .The incidence of CRPS is 0.3% after foot and ankle surgery. CRPS is well studied in wrist fracture. Vitamin C has been proposed to improve outcomes after a distal radius fracture by promotion of bone and soft-tissue healing and reducing the prevalence of complex regional pain syndrome (CRPS). We aim to detect the effect of vitamin C on the functional outcome, post op pain, incidence of CRPS, wound healing and fracture healing after an ankle fracture

Methods:

Prospective, Double blind, Randomized control study of 110 subjects (55 subjects in each group). Subjects in study group will receive 500 mg vitamin C for 50 days and standard of care, whereas control group will receive the stander of care alone. Subjects with age from 18-50 years old, with ankle fracture which treated surgically will be recruited, whereas open fracture, Peripheral vascular disease, Allergy to Vitamin C will be excluded. Subjects will be followed up in regular basis for one year. Primary end point will be diagnosis of CRPS and secondary end point will be failure of initial management

Results:

Although CRPS is more common in wrist injuries comparing to ankle injuries, subclinical of CRPS is more common after ankle fracture. Vitamin C showed promising results in decrease the incidence of CRPS in distal radius fracture. Literature lack of studies looking for CRPS and foot and ankle fracture without high evidence of effect of vitamin C on the functional outcome and post op pain after ankle fractures.

Conclusion:

We assume that vitamin C will improve functional outcome, decrease post op pain, decrease the incidence of CRPS and improve wound and fracture healing.

Bilateral asymmetrical hip dislocation with one side obturator intra-pelvic dislocation. Case report

•

Hip dislocation is considered an orthopedic emergency and should be reduced as soon as possible to decrease rate of complications.

•

Bilateral hip dislocation is very rare and usually results from high energy trauma mostly motor vehicle collisions.

•

Asymmetrical bilateral simultaneous hip dislocation with one hip dislocated intra-pelvic through the obturator foramen is rare.

•

Complex dislocation might better be reduced in the theatre.

Introduction

Hip dislocations usually occur as a result of motor vehicle accidents and require high energy trauma. Bilateral hip dislocations are rare compared to unilateral ones. Most reported cases are asymmetrical simultaneous bilateral anterior and posterior dislocations.

Case presentation

This case report describes a 32years female passenger who was involved in road traffic accident and had bilateral asymmetrical hip dislocations with one side posterior and the other side obturator intra-pelvic dislocation. Concentric reduction was achieved by closed reduction of both sides under general anesthesia but the patient required skeletal traction applied to the unstable side for three weeks.

Discussion

Hip dislocation is considered an orthopedic emergency and should be reduced as soon as possible to decrease rate of complications. Since hip dislocation usually occurs with high energy trauma so looking for associated injuries is of paramount importance and assessing such patients should be done according to advanced trauma life support.

Conclusion

Obturator intra-pelvic hip dislocation is challenging case and can be treated by closed reduction.