The use of a 30-degree radiolucent triangle during surgery in distal avulsion fractures of the patella.

Avoiding patella baja or alta after the Krackow suture technique for distal avulsion fractures of the patella can be challenging. We aim to introduce a simple and reproducible technique using a 30-degree radiolucent triangle involving the contralateral knee to ensure the correct positioning of the patella intraoperatively. The radiolucent triangle is positioned under the contralateral knee before operating the injured knee. A strict lateral view is obtained using fluoroscopy as a reference before a Krackow technique is performed on the avulsion fracture of the patella. The triangle technique is straightforward and easily reproducible by surgeons of all levels. It allows the surgeon to correctly position the patella intraoperatively in avulsion fracture repair and modify tension on the patellar tendon. This method avoids millimetric mispositioning of the operated patella, thus improving the management intraoperatively and could decrease postoperative complications

Simultaneous Ipsilateral Quadriceps and Triceps Tendon Rupture in a Patient with End-Stage Renal Failure.

Quadriceps tendon ruptures (QTR) frequently occur in patients with end-stage renal failure, while triceps brachii tendon ruptures (TTR) are less common. This is the first properly documented report of a simultaneous ipsilateral traumatic rupture of both of these tendons. A 50-year-old patient, on hemodialysis for end-stage renal failure, fell on his right side. He presented with sudden right knee and elbow pain, with functional impairment of both joints. X-rays showed avulsion-like osseous lesions on the olecranon and patella with a low-riding patella. Ultrasound confirmed complete quadriceps and triceps avulsion ruptures. Both lesions were treated surgically. Fixation was performed with anchors using the Krackow suture technique for both tendons. Postoperative clinical and radiological results were satisfactory, and follow-up was uneventful. The patient regained his preinjury functional level with a complete range of motion of both his knee and elbow. Isolated QTR and TTR are frequent lesions in chronic renal failure patients treated with hemodialysis. Simultaneous ipsilateral rupture of both tendons however is extremely rare and should therefore not be overlooked. Surgical treatment is recommended for complete ruptures

Outcomes of combined hip procedure with dual mobility cup versus osteosynthesis for acetabular fractures in elderly patients: a retrospective observational cohort study of fifty one patients.

Acetabular fractures are more and more common in the elderly. Open reduction and internal fixation (ORIF) may lead to poor outcomes and high revision rates. Primary total hip arthroplasty (THA) combined with internal fixation, also known as the combined hip procedure (CHP), associated with dual mobility cup (DM-CHP) could be an efficient procedure in selected elderly patients. The aim of this study is to compare functional and radiological outcomes between ORIF and DM-CHP. Between 2007 and 2018, 51 patients older than 65 years were surgically treated for acetabular fractures. Twenty-six patients were treated by DM-CHP and 25 by ORIF. Each group was divided into two subgroups regarding a single or combined approach. Hospital stay, surgical time, intraoperative blood loss, and complications were documented. The Harris Hip Score (HHS) was used for measuring the functional outcome. Radiological analysis was used to assess the centre of rotation in the DM-CHP group. Median surgery time and intra-operative blood loss were higher in DM-CHP than those in ORIF. Early medical complication rate was higher for a combined approach as compared with a single posterior approach in DM-CHP (p = 0.003). Dislocation rate was 7.7% in DM-CHP. Revision rate was higher in ORIF (20% versus 7.7%). HHS was similar in both groups. DM-CHP leads to similar functional outcomes and less revision than ORIF. This study strengthens the practice of using only the posterior approach for primary THA in the elderly. Dual mobility is a valid therapeutic option for acetabular fractures in elderly patients

Clinical and radiological outcome of the Chimaera short nailing system in inter- and subtrochanteric fractures.

cephalomedullary devices are popular treatment for femoral intertrochanteric or subtrochanteric fractures. Various complications include post-surgical lateral thigh pain and cut-out. To prevent those complications, a new concept cephalomedullary device system was designed (Chimaera, Orthofix®). This study aimed to evaluate the clinical and radiological outcomes in patients with femoral intertrochanteric or subtrochanteric fractures treated with the proximal femoral cephalomedullary device system. A prospective cohort study involved consecutive patients with Arbeitsgemeinschaft für Osteosynthesefragen/ Orthopaedic Trauma Association type 31-A1, 2, 3 fractures treated with the Chimaera short cephalomedullary device system from October 2016 to September 2017 at our level 1 trauma center. The Parker and Palmer mobility score and Jensen social function scores and post-surgical lateral thigh pain were assessed at 3 months post-operatively and compared to before surgery. Radiologic assessment consisted of controlling the position of the cephalic screw by using the tip-apex distance (TAD) and Cleveland zone as well as union and cut-out rates. We included 99 patients (79 women; 100 hips; one bilateral fracture 3 months after a first trochanteric fracture) with a mean follow-up of 2 years. The Parker and Palmer mobility score decreased by 22% at 3 months post-operatively as compared with the pre-fracture score (42/99 patients showed a return to their pre-injury level). The Jensen social function score increased by 16.5% at 3 months post-operatively as compared with the pre-fracture score (68/99 patients showed a return to their pre-injury level). No major intra-operative complication was recorded. Nine TAD scores were > 25 mm. The mean TAD was 16.5 mm (range 5-36), and the lag screw position was well positioned in most (95%) hips according to Cleveland zones. Three patients required revision surgery (one for cut-out of the lag screw, one for hip osteoarthritis and one for gluteus medius insufficiency). All patients but the one with the cut-out showed fracture union. The Chimaera short cephalomedullary device exhibited good mid-term functional and radiological outcomes

Perioperative Contamination of Orthopaedic Polyethylene Implants, Targeting Devices and Arthroscopes. Experts' Decision Tree and Literature Review.

Introduction Sterility errors during orthopaedic procedures can be stressful for the surgeon or scrub nurse and lead to devastating infectious complications and liability issues. This paper aims to review orthopaedic surgeon practices and propose possible attitudes to adopt. Methods Out of 1023 questionnaires sent, 170 orthopaedic surgeons answered a Volunteer Feedback Template (multiple-choice test) by SurveyMonkey® (San Mateo, CA, USA) anonymously. The survey questioned surgeon's response to a sterility mistake during a standard total knee joint replacement, trauma surgery and arthroscopic procedure. Those "sterility mistake" situations occurred when there was contamination of 1) a sterile polyethylene (PE) 2) a sterile targeting device, and 3) an arthroscope. Results When the definitive PE is contaminated, and if a new definitive PE will only be available 2 hours later, 52% of surgeons would wait for the new definitive PE (p<0.001). In the same situation, if a new PE will only be available in 4 hours, the results showed a significant difference favoring two other options: "putting a definitive PE one size smaller or bigger with balance adjustment" (31%); and "leaving the provisional PE in the joint, closing the wound and re-operating the patient in the coming days when the definitive PE arrives" (29%) (p<0.001). When the new PE is only available 24 hours later results were 34% and 31%, respectively (p<0.001). In the case of a surgical procedure for a classic intertrochanteric fracture, if the carbon fiber targeting device is contaminated, most surgeons (50%) chose to put the nail without the targeting device and finish the surgery (p<0.001). When the arthroscope is desterilized, 39% of participants would wait until the arthroscope has been sterilized again (approximately 2 hours), while 24% would use another procedure (p<0.001). Sixty-two percent of surgeons would adapt their strategy. No clear trend could be identified in terms of antibiotic treatment following a sterility error. Conclusions There are no established guidelines on how to deal with sterility breaches during surgery and on the antibiotic strategy following the prolonged surgical time resulting from the delay for a new implant. The most common course of action chosen by participating surgeons is detailed in our expert decision tree - if another sterile component is not available within 2 hours - : insertion of another PE size, rescheduling the operation, adapting the surgical technique (for trauma procedures), or soaking the arthroscope in disinfectant solution. As instances of contamination cannot be avoided, it is recommended to have a minimum of two copies of sterile PE implants, arthroscopes or targeting devices readily available before surgery begins-

Association of pelvic fracture patterns, pelvic binder use and arterial angio-embolization with transfusion requirements and mortality rates; a 7-year retrospective cohort study.

Pelvic fractures are severe injuries with frequently associated multi-system trauma and a high mortality rate. The value of the pelvic fracture pattern for predicting transfusion requirements and mortality is not entirely clear. To address hemorrhage from pelvic injuries, the early application of pelvic binders is now recommended and arterial angio-embolization is widely used for controlling arterial bleeding. Our aim was to assess the association of the pelvic fracture pattern according to the Tile classification system with transfusion requirements and mortality rates, and to evaluate the correlation between the use of pelvic binders and arterial angio-embolization and the mortality of patients with pelvic fractures. Single-center retrospective cohort study including all consecutive patients with a pelvic fracture from January 2008 to June 2015. All radiological fracture patterns were independently reviewed and grouped according to the Tile classification system. Data on patient demographics, use of pelvic binders and arterial angio-embolization, transfusion requirements and mortality were extracted from the institutional trauma registry and analyzed. The present study included 228 patients. Median patient age was 43.5 years and 68.9% were male. The two independent observers identified 105 Tile C (46.1%), 71 Tile B (31.1%) and 52 Tile A (22.8%) fractures, with substantial to almost perfect interobserver agreement (Kappa 0.70-0.83). Tile C fractures were associated with a higher mortality rate (p = 0.001) and higher transfusion requirements (p < 0.0001) than Tile A or B fractures. Arterial angio-embolization for pelvic bleeding (p = 0.05) and prehospital pelvic binder placement (p = 0.5) were not associated with differences in mortality rates. Tile C pelvic fractures are associated with higher transfusion requirements and a higher mortality rate than Tile A or B fractures. No association between the use of pelvic binders or arterial angio-embolization and survival was observed in this cohort of patients with pelvic fractures

Between ‘entertainment medicine’ and professionalization of healthcare : an interview study of Belgian doctors

Background: Nowadays, digital self-tracking devices offer a plethora of possibilities to both healthy and chronically ill users who want to closely examine their body. This study suggests that self-tracking in a private setting will lead to shifting understandings in professional care. In order to provide more insight into these shifts, this paper seeks to lay bare the promises and challenges of self-tracking while staying close to the everyday professional experience of the physician. Objective: Our objective is twofold. First, to offer an analysis of how medical doctors evaluate self-tracking methods in their practice. Second, to explore the anticipated shifts that digital self-care will bring about in relation to our findings and those of other studies. Methods: Twelve in-depth semi-structured interviews with general practitioners (GPs) and cardiologists have been conducted in Flanders, Belgium, between November 2015 and November 2016. Thematic analysis was applied to examine the transcripts in an iterative process. Results: Four major themes arise in our body of data: (1) the patient as health manager; (2) health obsession and medicalization; (3) information management; and (4) shifting roles of the doctors and impact on healthcare organization. Our research findings show a nuanced understanding of the potentials and pitfalls of different forms of self-tracking. The necessity of contextualization of self-tracking data, and a professionalization of self-care through digital devices come to the fore as important overarching concepts. Conclusions: This interview study with Belgian doctors examines the potentials and challenges of self-monitoring, while focusing on the everyday professional experience of the physician. The dialogue between our dataset and the existing literature affords a fine-grained image of digital self-care and its current meaning in a medical-professional landscape

“Good patients manage their health”:: a critical conceptual analysis of the patient as health manager

This conceptual study builds further upon an interview study with general practitioners and cardiologists (N = 12) on their experience with and views on (digital) self-tracking in the clinical practice (Gabriels & Moerenhout, 2018). One of the key themes arising in our body of data is the concept of the patient as health manager. Both in medical literature and on a broader societal level, the patient as manager of his or her health and – if applicable – chronic illness is perceived to be a desirable and even necessary evolution to increase efficiency and to reduce costs (Topol, 2015 and De Block, 2016). The current surge in self-tracking technology is a strong facilitator of this type of patient empowerment through self-care.Drawing upon our previous empirical work, we present a critical conceptual analysis of the patient-manager. First, we explore the concepts behind this notion. In so doing, we focus on the specific interpretation of autonomy leading to an isolated and detached patient position and on the outcome of an increased patient responsibility. Second, we look at the role of self-tracking technology: data collection is no longer confined to the medical environment, but conducted in the private sphere of the patient. Digital self-tracking often lacks contextual awareness, preferably operating in a one-size-fits-all model. Overall, this analysis leads to the identification of several problems and pitfalls in the patient-manager. Alternatively, we suggest a different approach stemming from care ethics and relational autonomy (specifically focusing on Mol, 2008) that could lead to a better integration of self-tracking in the patient-doctor relationship and in a broader medical context

“Good patients manage their health”::a critical conceptual analysis of the patient as health manager

This conceptual study builds further upon an interview study with general practitioners and cardiologists (N = 12) on their experience with and views on (digital) self-tracking in the clinical practice (Gabriels & Moerenhout, 2018). One of the key themes arising in our body of data is the concept of the patient as health manager. Both in medical literature and on a broader societal level, the patient as manager of his or her health and – if applicable – chronic illness is perceived to be a desirable and even necessary evolution to increase efficiency and to reduce costs (Topol, 2015 and De Block, 2016). The current surge in self-tracking technology is a strong facilitator of this type of patient empowerment through self-care.Drawing upon our previous empirical work, we present a critical conceptual analysis of the patient-manager. First, we explore the concepts behind this notion. In so doing, we focus on the specific interpretation of autonomy leading to an isolated and detached patient position and on the outcome of an increased patient responsibility. Second, we look at the role of self-tracking technology: data collection is no longer confined to the medical environment, but conducted in the private sphere of the patient. Digital self-tracking often lacks contextual awareness, preferably operating in a one-size-fits-all model. Overall, this analysis leads to the identification of several problems and pitfalls in the patient-manager. Alternatively, we suggest a different approach stemming from care ethics and relational autonomy (specifically focusing on Mol, 2008) that could lead to a better integration of self-tracking in the patient-doctor relationship and in a broader medical context