Systematic review on the outcomes of poller screw augmentation in intramedullary nailing of long bone fracture.

Various technical tips have been described on the placement of poller screws during intramedullary (IM) nailing; however studies reporting outcomes are limited. Overall there is no consistent conclusion about whether intramedullary nailing alone, or intramedullary nails augmented with poller screws is more advantageous.We conducted a systematic review of PubMed, EMBASE, and Cochrane databases. Seventy-five records were identified, of which 13 met our inclusion criteria. In a systematic review we asked: (1) What is the proportion of nonunions with poller screw usage? (2) What is the proportion of malalignment, infection and secondary surgical procedures with poller screw usage? The overall outcome proportion across the studies was computed using the inverse variance method for pooling.Thirteen studies with a total of 371 participants and 376 fractures were included. Mean follow-up time was 21.1 months. Mean age of included patients was 40.0 years. Seven studies had heterogenous populations of nonunions and acute fractures. Four studies included only acute fractures and two studies examined nonunions only.The results of the present systematic review show a low complication rate of IM nailing augmented with poller screws in terms of nonunion (4%, CI: 0.03-0.07), coronal plane malunion (5%, CI: 0.03-0.08), deep (5%, CI: 0.03-0.11) and superficial (6%, CI: 0.03-0.11) infections, and secondary procedures (8%, CI: 0.04-0.18).When compared with the existing literature our review suggests intramedullary nailing with poller screws has lower rates of nonunion and coronal malalignment when compared with nailing alone. Prospective randomized control trial is necessary to fully determine outcome benefits. Cite this article: EFORT Open Rev 2020;5:189-203. DOI: 10.1302/2058-5241.5.190040

Bone transport with magnetic intramedullary nails in long bone defects.

BACKGROUND: This study describes the outcomes of internal bone transport with magnetic nails in five cases of traumatic segmental femoral bone defects. METHODS: Five patients with open fracture of the femur and diaphyseal bone loss were included between May 2018 and August 2020. The mean femoral defect was 8.7 cm (range 5.6-16.0). INTERVENTION: We used plate-assisted bone segment transport (PABST) with PRECICE magnetic nails. RESULTS: All five patients have fully consolidated. The mean consolidation time and index were 7.5 months and 0.8 mo/cm, respectively. The mean follow-up was 21.3 months. The main complications were reduced knee ROM, mild varus deformity and plate bending. Post-operative SF-36, Oxford Knee scores and ED-5Q-5L scores were also compiled for four of five patients. SF-36 and Oxford Knee scores were reported without pre-injury data for comparison. ED-5Q-5L index and VAS were compared UK population norm and were both found to be statistically insignificant (p = 0.071 and p = 0.068, respectively). CONCLUSION: Bone transport with magnetic nails has the capacity to obtain good functional recovery in long bone defects despite variable outcome pictures. In response to variable outcome reporting in the literature, we propose a standard reporting template for future studies to facilitate more rigorous analyses

Management of chronic osteomyelitis of the femur and tibia: a scoping review.

Osteomyelitis refers to an inflammatory process causing bone destruction and necrosis. Managing such a persistent disease is complex, with a number of authors reporting different techniques. This scoping review aims to map and summarize the literature on treatment of chronic femoral and tibial osteomyelitis, in order to improve the reader's understanding of potential treatments and identify areas of further research.The methodological framework of the Joanna Briggs Institute was followed. A computer-based search was conducted in PubMed, EMBASE, MEDLINE, EMCARE and CINAHL, for articles reporting treatment of chronic tibial/femoral osteomyelitis. Two reviewers independently performed title/abstract and full-text screening according to pre-defined criteria.A total of 1230 articles were identified, with 40 finally included. A range of treatments are reported, with the core principles being removal of infected tissue, dead-space management and antibiotic therapy. The majority (84.5%) of patients presented with stage III or IV disease according to the Cierny-Mader classification, and Staphylococcus aureus was the most commonly isolated organism. The proportion of patients achieving remission with no recurrence during follow-up varies from 67.7-100.0%.The majority of studies report excellent outcomes in terms of infection remission and lack of recurrence. However, identifying specific patient or treatment-related factors which may affect outcomes is currently challenging due to the nature of the included studies and unclear reporting of treatment outcomes. It is now important to address this issue and identify such factors using further high-level research methods such as randomized controlled trials and comparative cohort studies. Cite this article: EFORT Open Rev 2021;6:704-715. DOI: 10.1302/2058-5241.6.200136

Measuring Paranoid Beliefs in Adolescents:A Comparison of the Revised-Green et al.’s Paranoid Thoughts Scale (R-GPTS) and the Bird Checklist of Adolescent Paranoia (B-CAP)

Research on paranoid beliefs in adolescents is in its infancy. Valid and reliable assessments are essential to advancing the field, yet there is no current consensus as to which are optimal to use in this population. This study compared the psychometric properties of two measures of paranoia in a general population adolescent sample. A cross-sectional study with quota sampling (gender and age) recruited adolescents (14-17 years) from the UK (n=262) and USA (n=200), who completed the Revised Green et al. Paranoid Thoughts Scale (R-GPTS) and the Bird Checklist for Adolescent Paranoia (B-CAP). We assessed factor structures, intercorrelations, overlap of participants identified as at-risk for paranoid thoughts via both scales, convergent validity (scales with one another) and discriminant validity (distress, wellbeing, bullying and discrimination). Both scales performed equally well in terms of factorial validity. Intercorrelations between the subscales and with general distress were high for both measures. However, a substantial percentage of participants were identified as having paranoid beliefs according to the R-GPTS but not the B-CAP. Furthermore, the B-CAP showed a very high correlations (0.69≤r≤0.79) with self-reported bullying experiences, which bordered on multicollinearity. Findings highlight the possibility that B-CAP may risk confounding paranoid beliefs with exposure to bullying more so than R-GPTS, and that B-CAP may miss instances of elevated paranoia that are captured by the R-GPTS. Future research needs to further explore this by validating both scales with an external (e.g., interview-based) criterion for paranoia

A retrospective analysis of the definitive management of open talus fractures at a major trauma centre, comparing ORIF to FUSION: cohort study and audit of BOAST 4 guidelines.

PURPOSE: Open talus fractures are notoriously difficult to manage, and they are commonly associated with a high level of complications including non-union, avascular necrosis and infection. Currently, the management of such injuries is based upon BOAST 4 guidelines although there is no suggested definitive management, and thus, definitive management is based upon surgeon preference. The key principles of open talus fracture management which do not vary between surgeons are early debridement, orthoplastic wound care, anatomic reduction and definitive fixation whenever possible. However, there is much debate over whether the talus should be preserved or removed after open talus fracture/dislocation and proceeded to tibiocalcaneal fusion. METHODS: A review of electronic hospital records for open talus fractures from 2014 to 2021 returned fourteen patients with fifteen open talus fractures. Seven cases were initially managed with ORIF, and five cases were definitively managed with FUSION, while the others were managed with alternative methods. We collected patient's age, gender, surgical complications, surgical risk factors and post-treatment functional ability and pain and compliance with BOAST guidelines. The average follow-up of the cohort was 4 years and one month. EQ-5D-5L and FAAM-ADL/Sports score was used as a patient reported outcome measure. Data were analysed using the software PRISM. RESULTS: Comparison between FUSION and ORIF groups showed no statistically significant difference in EQ-5D-5L score (P = 0.13), FAAM-ADL (P = 0.20), FAAM-Sport (P = 0.34), infection rate (P = 0.55), surgical times (P = 0.91) and time to weight bearing (P = 0.39), despite a higher proportion of polytrauma and Hawkins III and IV fractures in the FUSION group. CONCLUSION: FUSION is typically used as second line to ORIF or failed ORIF. However, there is a lack of studies that directly compared outcome in open talus fracture patients definitively managed with FUSION or ORIF. Our results demonstrate for the first time that FUSION may not be inferior to ORIF in terms of patient functional outcome, infection rate and quality of life, in the management of patients with open talus fracture patients. Of note, as open talus fractures have increased risks of complications such as osteonecrosis and non-union, FUSION should be considered as a viable option to mitigate these potential complications in these patients

A health economic analysis of the management of open lower limb fractures in the elderly.

AIM: The aim of this study was to investigate the financial implications of the inpatient management of open lower limb fractures in adults over 65 years old. Further, the study compares the calculated cost to the income received by the hospital for these patients and to the existing body of literature. METHODS: This study employed direct inpatient costing analysis to estimate the cost of treating the open lower limb fractures incurred by 58 patients over the age of 65 years treated in our centre (Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust) between March 2014 and March 2019. RESULTS: The median cost of inpatient care calculated in this study was £20,398 per patient, resulting in a financial loss to the hospital of £5113 per patient. When the results were disaggregated by sex, the median cost for an open lower limb fracture in a male patient was £20,886 compared to £19,304 in a female patient. Data were also disaggregated by the site of injury, which produced a median cost for an open femur fracture of £23,949, and £24,549 and £15,362 for open tibia and ankle fractures, respectively. CONCLUSION: This study provides a valuable estimate of the expense of treating open lower limb fractures in patients over the age of 65 years in a Major Trauma Centre in England. The study highlights the large losses incurred by hospitals in treating these cases, and supports revision of the remuneration structures in the National Health Service to adequately cover their cost

A health economic analysis of the management of open lower limb fractures in the elderly.

AIM: The aim of this study was to investigate the financial implications of the inpatient management of open lower limb fractures in adults over 65 years old. Further, the study compares the calculated cost to the income received by the hospital for these patients and to the existing body of literature. METHODS: This study employed direct inpatient costing analysis to estimate the cost of treating the open lower limb fractures incurred by 58 patients over the age of 65 years treated in our centre (Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust) between March 2014 and March 2019. RESULTS: The median cost of inpatient care calculated in this study was £20,398 per patient, resulting in a financial loss to the hospital of £5113 per patient. When the results were disaggregated by sex, the median cost for an open lower limb fracture in a male patient was £20,886 compared to £19,304 in a female patient. Data were also disaggregated by the site of injury, which produced a median cost for an open femur fracture of £23,949, and £24,549 and £15,362 for open tibia and ankle fractures, respectively. CONCLUSION: This study provides a valuable estimate of the expense of treating open lower limb fractures in patients over the age of 65 years in a Major Trauma Centre in England. The study highlights the large losses incurred by hospitals in treating these cases, and supports revision of the remuneration structures in the National Health Service to adequately cover their cost

Charcot knee — presentation, diagnosis, management — a scoping review

Abstract: Background: Charcot arthropathy is a progressive, non-infectious, destructive inflammatory process. Charcot arthropathy of the knee (CK) is rare and diagnosis is often delayed, resulting in detrimental outcomes. This scoping review aims to investigate the literature on CK, present the pathognomonic features of CK to aid early diagnosis, and suggest gaps in the literature for future research. Methods: A systematic search of PubMed, EMBASE, Web of Science for literature relevant to CK was performed. Primary studies such as case reports, case series, retrospective studies were included. Review articles and animal studies were excluded. Results: Of the 513 results, 58 were included in qualitative synthesis. Average time from symptom onset to CK diagnosis was 50.5 months. Eighteen and twenty-one studies included patients who had diabetes mellitus and syphilis, respectively. Twenty-one studies reported pain as a presenting complaint, but the degree of pain didn’t correspond with the level of destruction. Oedema and joint effusion were noticed in 34 studies. Twenty-nine studies reported lower limb hypoesthesia and 17 studies reported decreased tendon reflex. Twenty-eight studies reported initial conservative treatment, often in a knee brace with minimal weight bearing, 9 of which needed subsequent surgical management. Twelve studies utilised arthrodesis, with fracture at the intramedullary nail entry site being the most common complication. Twenty-four studies utilised TKA. Conclusion: The literature on CK remains sparse, with most publications being case reports. Given that CK dramatically reduces quality of life, increases morbidity of patients, there is need for more literature on evidence-based options for early diagnoses and management

Dynamic hip screw fixation of subtrochanteric femoral fractures.

INTRODUCTION: A subtrochanteric proximal femur fracture occurs in the 5 cm of bone immediately distal to the lesser trochanter. UK national guidelines advise that adults with subtrochanteric fractures should be treated with an intramedullary nail (IMN). This study aims to compare peri-operative outcome measures of patients with subtrochanteric fractures treated with either an IMN or a dynamic hip screw (DHS) construct. MATERIALS AND METHODS: We retrospectively reviewed subtrochanteric fractures presenting at our institution over 4.5 years (October 2014-May 2019), classifying them into two treatment groups; IMN and DHS. These groups were compared on outcome measures including surgical time, blood loss, radiation dose area product (DAP), length of stay, re-operation rate and mortality. RESULTS: During the time period studied, 86 patients presented with a subtrochanteric fracture of the femur; with 74 patients (86%) receiving an IMN and 12 (14%) receiving a DHS. The comparative outcome measures reaching statistical significance were blood loss and radiation DAP. The DHS group showed a significantly lower mean blood loss of 776 ml compared to 1029 ml in the IMN group. Also, the DHS group showed a significantly lower mean DAP of 150.30 mGy cm2 compared to 288.86 mGy cm2 in the IMN group. CONCLUSION: Although UK national guidelines recommend treating all subtrochanteric fractures with an IMN; the outcome measures assessed in our study did not show use of an IMN to be superior to a DHS. The DHS group showed a lower estimated blood loss and a reduced DAP. This, along with the reduced financial cost associated with a DHS, may support the use of DHS over IMN for certain subtrochanteric fractures of the femur. There may not be a single favourable implant for the treatment of subtrochanteric fractures as a whole; instead different subtypes of fracture may be amenable to a number of fixation devices. Choice of implant should be determined locally and based on existing and future clinical and health economic research