Risk Factor of Proximal Lag Screw Cut-Out After Cephalomedullary Nail Fixation in Trochanteric Femoral Fractures: A Retrospective Analytic Study

Objective: A cephalomedullary nail is the treatment of choice for trochanteric fractures; however, a lag screw cutout is one of the most devastating complications. The lag screw cut-out rate was reported to be around 2.5%–8.3%. This study aimed to evaluate the prevalence of lag screw cut-outs and identify the associated risk factors. Materials and Methods: A retrospective review of 267 trochanteric fracture patients treated with cephalomedullary nail fixation from January 2007 to December 2017 was conducted. The demographic variables were documented, comprising age, gender, fracture pattern, and AO/OTA classification. Immediate postoperative radiographs were assessed for quality of reduction and implant position. Lag screw cut-outs or radiographic union were determined using the final follow-up radiograph. Prognostic factors associated with lag screw cut-out were determined using univariate and multivariate logistic regression analyses. Results: Of the 175 patients, 154 were successfully treated, and 21 had a lag screw cut-out. There were no significant differences in mean ages or genders of the union and cut-out groups. No lag screw cut-outs were observed in patients with AO/OTA 31-A1. Patients with AO/OTA 31-B2.1 had a higher rate of screw cut-out (OR 10.5, [3.22, 34.25] p < .001). The disintegration of basicervical fragments was significantly associated with lag screw cut-out (OR 5.51, [2.01, 15.12] p = .001). The highest cut-out rate was found in the superoanterior and superoposterior positions of the lag screw. However, the screw position did not reach the significance level in a multivariate analysis (p = .094). Conclusion: The prevalence of lag screw cut-out after cephalomedullary nail fixation for trochanteric fractures was 12%. A simple, two-part, basicervical trochanteric fracture hads a significantly higher risk of lag screw cut-out

Removal of a Broken Cannulated Femoral Nail: A Novel Retrograde Impaction Technique

This report presents a surgical technique to remove a broken cannulated nail from the femur. A Harrington rod was modified for retrograde impaction of the retained fragment. The broken implant was finally removed without complication. This particular procedure was safe, simple, and promising

Evaluation of the implementation of multidisciplinary fast-track program for acute geriatric hip fractures at a University Hospital in resource-limited settings

Abstract Background Hip fractures are common among frail, older people and associated with multiple adverse outcomes, including death. Timely and appropriate care by a multidisciplinary team may improve outcomes. Implementing a team to jointly deliver the service in resource-limited settings is challenging, particularly on the effectiveness of patient outcomes. Methods A retrospective cohort study to compare outcomes of hip fracture patients aged 65 or older admitted at Siriraj hospital before and after implementation of the Fast-track program for Acute Geriatric Hip Fractures. The primary outcome was the incidence of medical complications. The secondary outcomes were time to surgery, factors related to the occurrence of various complications, in-hospital mortality, and mortality at month 3, month 6 and month 12 after the operation. Results Three hundred two patients were enrolled from the Siriraj hospital’s database from October 2016 to October 2018; 151 patients in each group with a mean age of 80 years were analyzed. Clinical parameters were similar between groups except the Fast-track group comprising more patients with dementia (37.1% VS 23.8%, p &lt; 0.012). In the Fast-track group, there was a significantly higher proportion of patients underwent surgery within 72-h (80.3% VS 44.7%, p &lt; 0.001) and the length of stay was significantly shorter (11 days (8–17) VS 13 days (9–18), p = 0.017). There was no significant difference in medical complications. Stratified analysis by dementia status showed a trend in delirium reduction in both patients with dementia and without dementia groups, and a pressure injury reduction among patients with dementia after the program was implemented but without statistical significance. There was no significant difference in mortality. Conclusions The implementation of a multidisciplinary team for hip fracture patients is feasible in resource-limited setting. In the Fast-track program, time to surgery was reduced and the length of stay was shortened. Other outcome benefits were not shown, which may be due to incomplete uptake of all involved disciplines. </jats:sec

Evaluation of the Implementation of a Multidisciplinary Fast Track Program for Geriatric Acute Hip Fracture Patients at a University Hospital in Resource-Limited Settings

Abstract Background: Hip fractures are common among frail, older people and associated with multiple adverse outcomes, including death. Timely and appropriate care by a multidisciplinary team may improve outcomes. Implementing a team to jointly deliver the service in resource-limited settings is challenging, particularly on the effectiveness of patient outcomes. Methods: A retrospective cohort study to compare outcomes of hip fracture patients aged 65 or older admitted at Siriraj hospital pre- and post-implementation of the Fast-track program. The primary outcome was the incidence of medical complications. The secondary outcomes were time to surgery, factors related to the occurrence of various complications, in-hospital mortality, and mortality at month 3, month 6 and month 12 after the operation. Results: 302 patients were enrolled from the Siriraj hospital’s database between October 2016 and October 2018; 151 patients in each group with a mean age of 80 years were analyzed. Clinical parameters were similar between groups except the Fast-track group comprising more patients with dementia (37.1% VS 23.8%, p&lt;0.012). In the Fast-track group, there was a significantly higher proportion of patients underwent surgery within 72-hours (80.3% VS 44.7%, p&lt;0.001) and the length of stay was significantly shorter (11 days (8-17) VS 13 days (9-18), p=0.017). There was no significant difference in medical complications and mortality. Stratified analysis by dementia status showed a trend in delirium reduction in both demented and non-demented groups, and a pressure injury reduction among patients with dementia after the program was implemented but there was no statistical significance.Conclusions: The implementation of a multidisciplinary team for hip fracture patients is feasible in resource-limited settings. In the Fast-track system, time to surgery was reduced and the length of stay was shortened. Other outcome benefits were not shown, which may be due to incomplete uptake of all involved disciplines.</jats:p

Time to Diagnosis and Treatment of Surgical Site Infections in Foot and Ankle Surgery

Background: The time at which patients typically present with surgical site infections (SSI) following foot and ankle surgery has not been characterized. The primary aim of this study was to quantify the time to definitive treatment of SSIs. Methods: We performed a retrospective review of 1933 foot and ankle procedures in 1632 patients from 2011 through 2015. Demographic and surgical data were collected. Time to presentation in cases diagnosed with postoperative wound complications or SSIs was analyzed. Wound complications were defined as any case with concerning wound appearance that subsequently resolved with antibiotic therapy alone. SSIs were defined as cases requiring operative irrigation and debridement (I&amp;D) for successful definitive management. Results: A total of 1569 procedures met inclusion criteria, with 17 SSIs (1.1%) and 63 wound complications (4.0%). Time between surgery and definitive treatment in the SSI group was significantly greater than in the wound complication group (28.2 ± 9.1 vs 13.4 ± 4.7 days, P &lt; .00001). Eleven (64.7%) cases in the SSI group failed a trial of antibiotics prior to I&amp;D, and 6 (35.3%) cases did not receive antibiotics prior to I&amp;D. Antibiotic treatment prior to I&amp;D did not significantly decrease the yield of intraoperative wound cultures (70% vs 100%, P = .51). Conclusion: In our cohort of patients, the time to diagnosis and treatment of SSIs was longer than that of wound complications. SSIs requiring operative intervention did not present until an average of 4 weeks after surgery. These data are of some benefit in trying to define and understand SSI. Level of Evidence: Level III, retrospective cohort study. </jats:sec

Sleep Quality, Pain Catastrophization, and Orthopedic Health Literacy

Category: Ankle Introduction/Purpose: Evidence increasingly indicates the importance of orthopedic health literacy, sleep quality, and a propensity for pain catastrophization in orthopedic patient outcomes. Using previously validated questionnaires including the Literacy in Musculoskeletal Problems (LiMP), Pain Catastrophization Scale (PCS), and the Pittsburgh Sleep Quality Index (PSQI), this study investigated the relationship between these factors and common functional outcome instruments including the Disability of Arm, Shoulder, and Hand (DASH) and the Foot and Ankle Outcome Score (FAOS). Methods: 245 patients in outpatient clinics of one foot and ankle surgeon and three hand surgeons were approached. Inclusion criteria required age greater than 18, English proficiency, and a newly presenting chief complaint. Enrolled patients completed a demographics form, LiMP, PCS, PSQI, and the DASH or FAOS based on extremity. Clinical history was reviewed retrospectively. DASH and FAOS scores were normalized to the same scale (0 – 100, best to worst) and termed “functional survey” (FS). Correlations were calculated between FS scores, subjective questionnaires, and demographic/clinical information. For the variables of race and education level, one-way ANOVA analysis was conducted to determine if FS scores differed based on these variables. Variables that were significantly correlated with FS score were entered into a multivariate linear regression analysis to assess their effect on FS score. Results: 231 patients (131 hand/wrist, 100 foot/ankle) were enrolled and completed all questionnaires. ANOVA analysis found that there were no significant differences in FS scores based on education or race (p > 0.05). Multivariate regression analysis was conducted with FS score as the dependent variable, and factors that were significantly correlated with FS score, including PCS, PSQI Global Score, visit type (trauma vs. non-trauma), and insurance type (private vs. public) as the independent variables. Health literacy was not significantly correlated with OS score. Results from this analysis can be found in Table 1. The model significantly (p < 0.05) accounted for 19.2% of variation in OS score. Conclusion: There is a strong correlation between tendency to catastrophize pain, sleep quality, and FS score. Every 1 unit increase in the PSQI/PCS corresponds with a 1.8/0.38 point increase in FS score; indicating higher functional disability. Given the strong correlation at baseline, such factors as poorly controlled tendency to catastrophize pain may confound functional outcomes. No significant correlation was noted between health literacy and FS scores. This suggests that an increased level of orthopedic knowledge does not affect perception of functional disability. However, our results show that sleep quality and catastrophic thinking may confound functional outcome scores