Increased rates of wound complications with locking plates in distal fibular fractures

Introduction: There is a growing use of locking compression plates in fracture surgery. The current study was undertaken to investigate the wound complication rates of locking versus non-locking plates in distal fibular fractures. Patients and methods: During a 6-year study period all consecutive, closed distal fibular fractures treated with either a locking or a non-locking plate were included and retrospectively analysed for complication related to the fibula. Results: A total of 165 patients received a one-third tubular plate and 40 patients were treated with a locking plate. The two groups were comparable with respect to patient characteristics (age, gender, smokers and diabetics), injury characteristics (affected side, fracture dislocations, number of fractured malleoli and classification) and operation characteristics (surgical delay and duration, use of a tourniquet and plate length). The wound complication rate was 5.5% in the conventional plating group, and 17.5% in the locking plate group (p = 0.019). This difference was largely due to an increase in major complications, for which removal of the plate was necessary (p = 0.008). Conclusion: There is a significant increase in wound complications in distal fibular fractures treated with a locking compression plate. In light of the current study, we would caution against the application of the currently used locking compression plates in the treatment of distal fibular fractures

The timing of ankle fracture surgery and the effect on infectious complications; A case series and systematic review of the literature

Purpose: Information about the influence of delayed surgery on infectious wound complications is ambiguous. A clinical audit was performed to test the hypothesis that early surgery lowers the rate of infectious wound complications. Secondly we looked at the influence of surgical delay and complications on patient reported functional outcome. Methods: All consecutive, closed distal fibular fractures treated surgically with a plate were included and retrospectively analysed for the delay in operation and wound complications. In a second cohort of patients with a AO-Weber B-type ankle fracture outcome was measured using the Olerud-Molander ankle score (OMAS), the American Orthopaedic Foot and Ankle Society score (AOFAS) and a visual analog score (VAS) for overall satisfaction. Results: Patients treated within one day experienced no wound complications (zero out of 60), whereas in the delayed group 11 % (16/145) did (p = 0.004). A similar significant difference was found for the patients treated within one week (2/98) versus after one week (14/107). A systematic review of the literature showed a difference in wound complications of 3.6 % (early) versus 12.9 % (late) (p < 0.0001). After 43 months, the median AOFAS was 11.5 points lower in the complication group, the OMAS 10 points, and the VAS 0.5 points, with all differences being statistically significant. Conclusions: Every effort should be made to operate on closed ankle fractures as soon as reasonably possible. A delay in surgery is associated with a significant rise in infectious wound complications, which significantly lowers outcome and patient satisfaction. These fractures should preferably be treated within the first day

Discriminating between simple and perforated appendicitis

Background: Several studies have been performed in order to diagnose an acute appendicitis using history taking and laboratory investigations. The aim of this study was to create a model for the identification of a perforated appendicitis. Methods: All consecutive patients who have undergone an appendectomy in the Reinier de Graaf hospital between January 1, 2007 and July 31, 2009, were included in a retrospective cohort study. Baseline patient characteristics, history and laboratory data were collected. Variables discriminating perforated from non-perforated appendicitis were identified using univariate and multivariable analyses. Results: A total of 498 patients were included in the study. In the univariate analysis leukocyte count, C-Reactive Protein levels, Erythrocyte Sedimentation Rate levels, days of symptoms and temperature were identified as predictors of perforated appendicitis. The predicted probability (P) of a perforated appendicitis can be calculated from the following model: (P) = 1/(1 + e(-(-2.788 + 0.012 CRP+0.207days with complaints))). Conclusions: Perforation of appendicitis can be predicted from the CRP level and the duration of abdominal pain. These findings might influence th

Complications of syndesmotic screw removal

Background: Currently, the metallic syndesmotic screw is the gold standard in the treatment of syndesmotic disruption. Whether or not this screw needs to be removed remains debatable. The aim of the current study was to determine the complications which occur following routine removal of the syndesmotic screw following operative treatment of unstable ankle fractures. Methods: This was a retrospective study with consecutive cases in a Level-2 Trauma center. All patients with routine removal of a syndesmotic screw, following the treatment of an unstable ankle fracture, between January 1, 2004 and November 30, 2010 were included. Complications recorded were: 1) minor or major wound infection following removal of the syndesmotic screw, 2) recurrent syndesmotic diastasis, and 3) unnecessary removal of a broken screw, not recognized during preoperative planning prior to surgery. Results: A total of 76 patients were included. A wound infection occurred in 9.2% (N=7) of which 2.6% (N=2) were deep infections requiring reoperation. Recurrent syndesmotic diastasis was found in 6.6% (N=5) of patients, and in 6.6% (N=5) screws were broken at the time of implant removal. In the group with recurrent diastasis the screws were removed significantly earlier compared with the group without recurrent diastasis (Mann- Whitney U-test; p = 0.011) and the group with screw breakage had their screws significantly longer in place compared with the group without breakage (p = 0.038). Conclusion: A total of 22.4% complications occurred upon routine removal of the syndesmotic screw. Removal might therefore be considered only in selected c

No Higher Risk of CRPS After External Fixation of Distal Radial Fractures – Subgroup Analysis Under Randomised Vitamin C Prophylaxis§

Operative and conservative treatment of wrist fractures might lead to complex regional pain syndrome (CRPS) type I

The effective dose due to scattered radiation at patients during primary osteosynthesis; a multicenter prospective observational study

Objectives: During osteosynthesis of a fracture patients are exposed to the primary radiation of an X-ray image and scattered (secondary) radiation. The primary objective was to measure the amount of scattered radiation at the thyroid, breast tissue, and gonads of patients undergoing primary osteosynthesis of acute fractures. The secondary objective was to calculate the effective dose caused by scattered radiation. Methods: In this multicenter prospective observational case series patients undergoing a primary osteosynthesis of an acute fracture of hand/wrist, shoulder, ankle, knee, or hip were included. Three dosimeters were attached to the patient at the level of the thyroid, breast and gonads. Scattered radiation doses were corrected for the average background radiation per hospital per day. Results: A total of 205 patients were included between March 6, 2017 and June 18, 2018; 49 (24%) had a hand/wrist fracture, 37 (18%) a shoulder fracture, 47 (23%) an ankle fracture, 35 (17%) a knee fracture, and 37 (18%) a hip fracture. In 32–39% of all patients undergoing primary osteosynthesis effective scattered doses was detected. The highest measured median effective dose was 60.43 µSv (P25–P75 33.84–100.76) at the gonads during hip osteosynthesis. Conclusions: The results of this study show that scattered radiation is detectable in a third of patients undergoing an osteosynthesis. However, both effective doses due to direct radiation and scattered radiation are low. Advances in knowledge: This is the first study that presents that no radiation protection for patients undergoing an osteosynthesis is necessary

Demographics and Functional Outcome of Toe Fractures

Toe fractures are common; however, there are few data on demographics and functional outcome. We studied outcomes in 339 consecutive patients with toe fractures treated between January 2006 and September 2008. Two hundred and sixty-four patients, aged 16 to 75, were mailed an outcome questionnaire, and overall subjective satisfaction with the outcome of treatment was measured using a visual analog scale (VAS). Most frequently affected were the first (38%) and fifth (30%) toes, and most (75.6%) of the fractures were caused by stubbing or crush injury. More than 95% of the fractures were displaced less than 2 mm, and all of the fractures were treated conservatively. The questionnaire was returned by 141 (53%) patients with a median follow-up of 27 months. Respondents were female in 57.4% of cases and had a median age of 45 years. The median AOFAS score was 100 (P25, P75= 93,100) points; the median VAS was 10 (P25, P75= 8, 10) points. Univariate regression analysis revealed no statistically significant associations between outcome and the particular toe or phalanx involved, number of fractured toes, fracture type and location, articular involvement, gender, age, body mass index, smoking habits, and the presence of diabetes mellitus. Satisfaction VAS was dependent on age (P = .047) and gender (P = .049) in the multivariate analysis. The AOFAS midfoot score was not influenced by any of the covariates. This is the first epidemiological investigation using 2 outcome-scoring systems to determine function and satisfaction following treatment of toe fractures

Chronic Obstructive Pulmonary Disease Is Not Associated with KRAS Mutations in Non-Small Cell Lung Cancer

Mutations in epithelial growth factor receptor (EGFR), as well as in the EGFR downstream target KRAS are frequently observed in non-small cell lung cancer (NSCLC). Chronic obstructive pulmonary disease (COPD), an independent risk factor for developing NSCLC, is associated with an increased activation of EGFR. In this study we determined presence of EGFR and KRAS hotspot mutations in 325 consecutive NSCLC patients subjected to EGFR and KRAS mutation analysis in the diagnostic setting and for whom the pulmonary function has been determined at time of NSCLC diagnosis. Information about age at diagnosis, sex, smoking status, forced vital capacity (FVC) and forced expiratory volume in 1 sec (FEV1) was collected. Chronic obstructive pulmonary disease(COPD) was defined according to 2013 GOLD criteria. Chi-Square, student t-test and multivariate logistic regression were used to analyze the data. A total of 325 NSCLC patients were included, 193 with COPD and 132 without COPD. COPD was not associated with presence of KRAS hotspot mutations, while EGFR mutations were significantly higher in non-COPD NSCLC patients. Both female gender (HR 2.61; 95% CI: 1.56-4.39; pT and G>C transversions were significantly more frequent in females (86.2%) than in males (61.5%) (p = 0.008). The exon 19del mutation was more frequent in non-smokers (90%) compared to current or past smokers (36.8%). In conclusion, KRAS mutations are more common in females and smokers, but are not associated with COPD-status in NSCLC patients. EGFR mutations are more common in non-smoking NSCLC patients

HUMeral Shaft Fractures: MEasuring Recovery after Operative versus Non-operative Treatment (HUMMER): A multicenter comparative observational study

Background: Fractures of the humeral shaft are associated with a profound temporary (and in the elderly sometimes even permanent) impairment of independence and quality of life. These fractures can be treated operatively or non-operatively, but the optimal tailored treatment is an unresolved problem. As no high-quality comparative randomized or observational studies are available, a recent Cochrane review concluded there is no evidence of sufficient scientific quality available to inform the decision to operate or not. Since randomized controlled trials for this injury have shown feasibility issues, this study is designed to provide the best achievable evidence to answer this unresolved problem. The primary aim of this study is to evaluate functional recovery after operative versus non-operative treatment in adult patients who sustained a humeral shaft fracture. Secondary aims include the effect of treatment on pain, complications, generic health-related quality of life, time to resumption of activities of daily living and work, and cost-effectiveness. The main hypothesis is that operative treatment will result in faster recovery. Methods/design. The design of the study will be a multicenter prospective observational study of 400 patients who have sustained a humeral shaft fracture, AO type 12A or 12B. Treatment decision (i.e., operative or non-operative) will be left to the discretion of the treating surgeon. Critical elements of treatment will be registered and outcome will be monitored at regular intervals over the subsequent 12 months. The primary outcome measure is the Disabilities of the Arm, Shoulder, and Hand score. Secondary outcome measures are the Constant score, pain level at both sides, range of motion of the elbow and shoulder joint at both sides, radiographic healing, rate of complications and (secondary) interventions, health-related quality of life (Short-Form 36 and EuroQol-5D), time to resumption of ADL/work, and cost-effectiveness. Data will be analyzed using univariate and multivariable analyses (including mixed effects regression analysis). The cost-effectiveness analysis will be performed from a societal perspective. Discussion. Successful completion of this trial will provide evidence on the effectiveness of operative versus non-operative treatment of patients with a humeral shaft fracture. Trial registration. The trial is registered at the Netherlands Trial Register (NTR3617)