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Locking plates in the management of peri-prosthetic fractures of the distal femur
118
Abstracts / Injury Extra 43 (2013) 71–127
with deficient bone stock. In the case of the latter, they often require extended osteotomies to avoid intra operative fractures, but even so intra operative fractures are common. The Cannulok revision hip prosthesis has been advocated to treat periprosthetic fractures and allow early mobilisation. We describe 5 cases in which although the prosthesis gave a good initial result it subsequently failed at a later stage. Methods: 5 patients who initially mobilised well without pain but subsequently had failure of the Cannulok revision hip prosthesis requiring revision were identified from the theatre logbook in a retrospective case series study. Results: 5 patients were identified with this mode of failure out of 50 procedures performed. There were 3 men and 2 women with a mean age of 73.2. All presented over 1 year post surgery with recent onset of thigh pain. X-rays revealed broken distal interlocking screws in all these cases. Bone scans and arthrograms performed on the patients were not helpful in diagnosing loosening of the prosthesis. Thigh pain in the presence of broken distal interlocking screws even with minimal sinkage and fracture healing seems to be diagnostic of loosening even if the prosthesis seems to be in a stable position on consecutive films. 5 Cannulok hip prosthesis have been successfully revised to a long CPT cemented hip revision prosthesis and the Cannulok stems were all found to be loose at surgery. Discussion/Conclusions: Periprosthetic fractures and failed hip replacements with deficient proximal bone can be treated with the Cannulok prosthesis as it provides distal fixation. However, a small number of patients present later with thigh pain and broken distal screws. We postulate that in these cases, lack of osseo-integration eventually resulted in the failure of the distal locking screws and the prosthesis hence loosened and caused thigh pain. The lack of osseo-integration may well result from the fact that this prosthesis relies on distal fixation and with significant proximal bone loss there is poor bone contact and therefore osseointegration can be deficient proximally. We would advise caution in using this prosthesis with deficient proximal bone stock or lack of proximal bone contact. http://dx.doi.org/10.1016/j.injury.2012.07.335 [P 14.1] Lateral X-ray view of the hip in fracture of proximal femur: Is it necessary? W.Y. Leong ∗ , Y.M. Koay, D. Haughton, S. Blanckley, J.D. Moorehead Aintree University Hospital, United Kingdom Introduction: The standard practice for X-ray investigation of fracture of proximal femur remains an AP and Lateral view in many hospitals. The aim of this study was to identify if a lateral view provides any further information that would influence a consultant’s management plan in addition to the standard AP Pelvis X-ray. Methods: We identified the first 25 patients admitted with fracture of proximal femur in 2010 from our hospital hip fracture database. The X-rays taken on admission were obtained and presented to all consultants during a directorate meeting. The management plan was first recorded after only seeing the AP view. The consultants were then asked to record any changes in management plan after being shown the lateral X-rays, as well as the reasons for it. Results: Out of the 25 cases, there were 16 intracapsular and 9 extracapsular fractures. There were a total of 225 management decisions with 9 consultants reviewing 25 X-rays. There was no change in management plan with the addition of lateral view in 221 cases (98.2%). 4 out of 9 consultants made one change in management plan after reviewing the lateral view in one of the patients
with Gardens III intracapsular fracture. They changed from cannulated screws to Total Hip Replacement (THR). The remaining consultants chose THR after only seeing the AP X-ray. Discussion: We traditionally use two views in X-ray examination of a fracture. However, lateral view of the hip causes tremendous amount of pain to patients with proximal femur fracture. Our study showed that the lateral X-ray does not make any difference in 98.2% of the cases. Hence, we believe the pain “cost” of a lateral view far out-weighs its “benefits”. Thus, we recommend that only standard AP pelvis should be routinely undertaken for these patients. http://dx.doi.org/10.1016/j.injury.2012.07.336 [P 14.3] Levels of inaccuracy in fluid management for patients with a fractured neck of femur E.A.O. Lindisfarne ∗ , E.J.C. Dawe, M. Patel, P.M. Stott Brighton & Sussex University Hospitals, United Kingdom Aim: This study aims to assess the discrepancy between the fluid prescribed and fluid given to elderly patients with a fractured neck of femur. Methods: This is a longitudinal cohort study of 30 patients who sustained a displaced intracapsular fracture of the femoral neck. The case notes of each patient were reviewed and assessed for the presence of a fluid chart, volume of fluid prescribed and volume given. These measurements were repeated for the first three days after admission. Results: Twenty eight percent (SD 1.7) of prescribed fluid was not administered on day one. This had reduced to 19.8% (SD 1.4) by day two and to 18.1% (SD 2.5) by day 3. On the first day of admission only two patients had a dedicated fluid balance chart. This had risen to 16/30 (53%) by day 3. Patients with renal or cardiac failure were not more likely to have a fluid balance chart than those without (P = 0.300). Patients with fractured neck of femur represent a diverse group with a multitude of comorbidities. Such patients may often have very poor oral fluid intake because of pain or altered mental state. Hence the clinician is reliant upon clinical assessment of volume status and the delivery of intravenous fluids to maintain adequate hydration prior to surgery. Suboptimal perioperative fluid management could result in poorer outcomes after surgery. Intravenous fluid delivery is commonly interrupted by delays in prescription, difficulty with intravenous access or slow delivery of fluids. This data suggests that these problems are greatest in the first day after admission. Conclusion: One third of intravenous fluid prescribed to patients with a fractured neck of femur in the first 24 h of their admission is not given. http://dx.doi.org/10.1016/j.injury.2012.07.337 [P 15.1] Locking plates in the management of peri-prosthetic fractures of the distal femur K. Kneale ∗ , E. Nagy, S. Deo Great Western Hospital, Swindon, United Kingdom Aim: To evaluate the short term outcome of the use of locking plates in the fixation of peri-prosthetic femoral fractures. Subjects and methods: This is a retrospective, observational study of patients admitted with a peri-prosthetic femoral fracture over a four year period, who underwent fracture fixation with a 5 mm
Abstracts / Injury Extra 43 (2013) 71–127
AxSOS (Stryker, Newbury, UK) peri-articular locking plate, in terms of demographics, time to surgery, post operative morbidity and mortality. Patient notes & radiographs were used to create the database. Conclusions: We feel the use of large fragment peri-articular locking plates provides safe, satisfactory stability, and is therefore an acceptable treatment option in the management of difficult fractures around joint replacements, in often very high risk surgical patients. Introduction: Acute peri-prosthetic fractures (PPF) are becoming increasingly prevalent due to the combination of an ageing population and the increasing number of patients with joint replacements in that population. There are a number of possible treatment options. With the increased use of periarticalur plates with minimally invasive techniques, this has become an established treatment option for PPF in our Unit. We have present our review of the results do date. Results: Our cohort comprises of 24 patients with a mean age of 79 years (range 50–97). There were 19 females. The majority (96%) had more than 2 co-morbidities. 14 patients underwent early fixation, within 72 h of admission. The others underwent operation within 5 days after admission, with a mean time of 2.4 days. The early, less than 6 week, local complication rate was nil. The early general major complication rate was nil. There were 2 plate fractures (8.3%), which required (successful) replating and 1 (4%) non-union. Three patients died within a year of surgery, none directly rated to surgical complications, giving a 1 year mortality of 12.5%. http://dx.doi.org/10.1016/j.injury.2012.07.338 [P 15.2] Modified Lautenbach technique in the treatment of an open infected non union of the clavicle B. Johnson ∗ , P. Thomas, D. McClelland University Hospital North Staffordshire, United Kingdom Purposes of the study: The clavicle is one of the most commonly fractured bones. Malunion resulting from non-operative management of such fractures has been shown to be problematic in patients with significant fracture shortening. There is therefore a move toward operative fixation of displaced fractures of the clavicle. Deep infection of the clavicle will therefore become an increasingly common complication. Infection after internal fixation of clavicle fractures is associated with a poor rate of union and poor functional outcome. We aimed to identify a safe and effective method of achieving union in patients with infected non unions of the clavicle following internal fixation. Methods and results: External fixators have been used in the treatment of clavicle fractures for many years and the main indications for their use are open fracture or infected non-unions. In 1986 Lautenbach described a continuous local antibiotic delivery system for the treatment of infected total hip replacements. Its use has also been described in the treatment of post traumatic osteomyelitis. The Lautenbach system involves the use of a closed double lumen tube delivering antibiotics locally followed by suction. The suction element of the system allows the microbiology, volume and appearance of the drainage fluid to be checked. It also allows obliteration of the dead space created by soft tissue and bone debridement. The Lautenbach technique has never previously been used in the management of infected non unions of the clavicle. We describe how a modified Lautenbach technique in conjunction with external fixation was successfully used in the management of an
119
open infected non-union of the clavicle following open reduction and internal fixation. Conclusion: We believe the modified use of a Lautenbach system in conjunction with external fixation in the management of infected clavicle non-unions is to be recommended as a safe and effective means of achieving union. http://dx.doi.org/10.1016/j.injury.2012.07.339 [P 15.3] Multimedia extended matching questions (EMQs) in undergraduate musculoskeletal education D.J. Bryson ∗ , A.J. Batchelder, S.C. Williams Leicester Royal Infirmary, Leicester UK/University of Leicester Medical School, United Kingdom Introduction: Extended matching questions (EMQs) are commonly used to assess knowledge and problem-solving ability in both undergraduate and postgraduate medical education. Musculoskeletal practice makes extensive use of dynamic clinical evaluation and interpretation of imaging. Assessment of students in this discipline necessarily requires testing such areas. Here we describe the development and evaluation of multimedia EMQs as an assessment tool in undergraduate musculoskeletal education. Methods: Key themes in the musculoskeletal curriculum were identified and 20 EMQs written by a collaboration of clinicians. Each EMQ had 5 stems and 12 items. These included an admixture of case vignettes, plain radiographs and high-quality photographs of clinical signs. Multimedia elements were collated on a PowerPoint presentation and the examination undertaken with each student at a computer workstation. Data were reviewed to identify common errors to guide future delivery of the curriculum. Item analysis was conducted with calculation of reliability co-efficients (Cronbach’s alpha) and discrimination indices for each stem. Results: The assessment was undertaken by 193 fourth-year medical students at the end of a 7-week clinical musculoskeletal placement. The range of scores was 24–71% (mean 51%, standard deviation 8.2%). Topic areas where students performed poorly included recognition of radiological changes associated with common arthropathies, selection of appropriate antimicrobial therapy in orthopaedic patients and identification of paediatric fractures. Conclusion: EMQS are gaining increasing prominence as an assessment tool in undergraduate and post-graduate education. Here we have described how the benefits this of this format may be effectively utilised in the context of undergraduate orthopaedic examinations. This unique admixture of case vignettes and multimedia images allows assessment of clinical and interpretive skills routinely employed in the practice of trauma and orthopaedics. Multimedia EMQs are easy to generate and provide a viable alternative to the short-answer and multiple-choice assessment formats commonly employed in undergraduate musculoskeletal medical education. http://dx.doi.org/10.1016/j.injury.2012.07.340
Abstracts / Injury Extra 43 (2013) 71–127
with deficient bone stock. In the case of the latter, they often require extended osteotomies to avoid intra operative fractures, but even so intra operative fractures are common. The Cannulok revision hip prosthesis has been advocated to treat periprosthetic fractures and allow early mobilisation. We describe 5 cases in which although the prosthesis gave a good initial result it subsequently failed at a later stage. Methods: 5 patients who initially mobilised well without pain but subsequently had failure of the Cannulok revision hip prosthesis requiring revision were identified from the theatre logbook in a retrospective case series study. Results: 5 patients were identified with this mode of failure out of 50 procedures performed. There were 3 men and 2 women with a mean age of 73.2. All presented over 1 year post surgery with recent onset of thigh pain. X-rays revealed broken distal interlocking screws in all these cases. Bone scans and arthrograms performed on the patients were not helpful in diagnosing loosening of the prosthesis. Thigh pain in the presence of broken distal interlocking screws even with minimal sinkage and fracture healing seems to be diagnostic of loosening even if the prosthesis seems to be in a stable position on consecutive films. 5 Cannulok hip prosthesis have been successfully revised to a long CPT cemented hip revision prosthesis and the Cannulok stems were all found to be loose at surgery. Discussion/Conclusions: Periprosthetic fractures and failed hip replacements with deficient proximal bone can be treated with the Cannulok prosthesis as it provides distal fixation. However, a small number of patients present later with thigh pain and broken distal screws. We postulate that in these cases, lack of osseo-integration eventually resulted in the failure of the distal locking screws and the prosthesis hence loosened and caused thigh pain. The lack of osseo-integration may well result from the fact that this prosthesis relies on distal fixation and with significant proximal bone loss there is poor bone contact and therefore osseointegration can be deficient proximally. We would advise caution in using this prosthesis with deficient proximal bone stock or lack of proximal bone contact. http://dx.doi.org/10.1016/j.injury.2012.07.335 [P 14.1] Lateral X-ray view of the hip in fracture of proximal femur: Is it necessary? W.Y. Leong ∗ , Y.M. Koay, D. Haughton, S. Blanckley, J.D. Moorehead Aintree University Hospital, United Kingdom Introduction: The standard practice for X-ray investigation of fracture of proximal femur remains an AP and Lateral view in many hospitals. The aim of this study was to identify if a lateral view provides any further information that would influence a consultant’s management plan in addition to the standard AP Pelvis X-ray. Methods: We identified the first 25 patients admitted with fracture of proximal femur in 2010 from our hospital hip fracture database. The X-rays taken on admission were obtained and presented to all consultants during a directorate meeting. The management plan was first recorded after only seeing the AP view. The consultants were then asked to record any changes in management plan after being shown the lateral X-rays, as well as the reasons for it. Results: Out of the 25 cases, there were 16 intracapsular and 9 extracapsular fractures. There were a total of 225 management decisions with 9 consultants reviewing 25 X-rays. There was no change in management plan with the addition of lateral view in 221 cases (98.2%). 4 out of 9 consultants made one change in management plan after reviewing the lateral view in one of the patients
with Gardens III intracapsular fracture. They changed from cannulated screws to Total Hip Replacement (THR). The remaining consultants chose THR after only seeing the AP X-ray. Discussion: We traditionally use two views in X-ray examination of a fracture. However, lateral view of the hip causes tremendous amount of pain to patients with proximal femur fracture. Our study showed that the lateral X-ray does not make any difference in 98.2% of the cases. Hence, we believe the pain “cost” of a lateral view far out-weighs its “benefits”. Thus, we recommend that only standard AP pelvis should be routinely undertaken for these patients. http://dx.doi.org/10.1016/j.injury.2012.07.336 [P 14.3] Levels of inaccuracy in fluid management for patients with a fractured neck of femur E.A.O. Lindisfarne ∗ , E.J.C. Dawe, M. Patel, P.M. Stott Brighton & Sussex University Hospitals, United Kingdom Aim: This study aims to assess the discrepancy between the fluid prescribed and fluid given to elderly patients with a fractured neck of femur. Methods: This is a longitudinal cohort study of 30 patients who sustained a displaced intracapsular fracture of the femoral neck. The case notes of each patient were reviewed and assessed for the presence of a fluid chart, volume of fluid prescribed and volume given. These measurements were repeated for the first three days after admission. Results: Twenty eight percent (SD 1.7) of prescribed fluid was not administered on day one. This had reduced to 19.8% (SD 1.4) by day two and to 18.1% (SD 2.5) by day 3. On the first day of admission only two patients had a dedicated fluid balance chart. This had risen to 16/30 (53%) by day 3. Patients with renal or cardiac failure were not more likely to have a fluid balance chart than those without (P = 0.300). Patients with fractured neck of femur represent a diverse group with a multitude of comorbidities. Such patients may often have very poor oral fluid intake because of pain or altered mental state. Hence the clinician is reliant upon clinical assessment of volume status and the delivery of intravenous fluids to maintain adequate hydration prior to surgery. Suboptimal perioperative fluid management could result in poorer outcomes after surgery. Intravenous fluid delivery is commonly interrupted by delays in prescription, difficulty with intravenous access or slow delivery of fluids. This data suggests that these problems are greatest in the first day after admission. Conclusion: One third of intravenous fluid prescribed to patients with a fractured neck of femur in the first 24 h of their admission is not given. http://dx.doi.org/10.1016/j.injury.2012.07.337 [P 15.1] Locking plates in the management of peri-prosthetic fractures of the distal femur K. Kneale ∗ , E. Nagy, S. Deo Great Western Hospital, Swindon, United Kingdom Aim: To evaluate the short term outcome of the use of locking plates in the fixation of peri-prosthetic femoral fractures. Subjects and methods: This is a retrospective, observational study of patients admitted with a peri-prosthetic femoral fracture over a four year period, who underwent fracture fixation with a 5 mm
Abstracts / Injury Extra 43 (2013) 71–127
AxSOS (Stryker, Newbury, UK) peri-articular locking plate, in terms of demographics, time to surgery, post operative morbidity and mortality. Patient notes & radiographs were used to create the database. Conclusions: We feel the use of large fragment peri-articular locking plates provides safe, satisfactory stability, and is therefore an acceptable treatment option in the management of difficult fractures around joint replacements, in often very high risk surgical patients. Introduction: Acute peri-prosthetic fractures (PPF) are becoming increasingly prevalent due to the combination of an ageing population and the increasing number of patients with joint replacements in that population. There are a number of possible treatment options. With the increased use of periarticalur plates with minimally invasive techniques, this has become an established treatment option for PPF in our Unit. We have present our review of the results do date. Results: Our cohort comprises of 24 patients with a mean age of 79 years (range 50–97). There were 19 females. The majority (96%) had more than 2 co-morbidities. 14 patients underwent early fixation, within 72 h of admission. The others underwent operation within 5 days after admission, with a mean time of 2.4 days. The early, less than 6 week, local complication rate was nil. The early general major complication rate was nil. There were 2 plate fractures (8.3%), which required (successful) replating and 1 (4%) non-union. Three patients died within a year of surgery, none directly rated to surgical complications, giving a 1 year mortality of 12.5%. http://dx.doi.org/10.1016/j.injury.2012.07.338 [P 15.2] Modified Lautenbach technique in the treatment of an open infected non union of the clavicle B. Johnson ∗ , P. Thomas, D. McClelland University Hospital North Staffordshire, United Kingdom Purposes of the study: The clavicle is one of the most commonly fractured bones. Malunion resulting from non-operative management of such fractures has been shown to be problematic in patients with significant fracture shortening. There is therefore a move toward operative fixation of displaced fractures of the clavicle. Deep infection of the clavicle will therefore become an increasingly common complication. Infection after internal fixation of clavicle fractures is associated with a poor rate of union and poor functional outcome. We aimed to identify a safe and effective method of achieving union in patients with infected non unions of the clavicle following internal fixation. Methods and results: External fixators have been used in the treatment of clavicle fractures for many years and the main indications for their use are open fracture or infected non-unions. In 1986 Lautenbach described a continuous local antibiotic delivery system for the treatment of infected total hip replacements. Its use has also been described in the treatment of post traumatic osteomyelitis. The Lautenbach system involves the use of a closed double lumen tube delivering antibiotics locally followed by suction. The suction element of the system allows the microbiology, volume and appearance of the drainage fluid to be checked. It also allows obliteration of the dead space created by soft tissue and bone debridement. The Lautenbach technique has never previously been used in the management of infected non unions of the clavicle. We describe how a modified Lautenbach technique in conjunction with external fixation was successfully used in the management of an
119
open infected non-union of the clavicle following open reduction and internal fixation. Conclusion: We believe the modified use of a Lautenbach system in conjunction with external fixation in the management of infected clavicle non-unions is to be recommended as a safe and effective means of achieving union. http://dx.doi.org/10.1016/j.injury.2012.07.339 [P 15.3] Multimedia extended matching questions (EMQs) in undergraduate musculoskeletal education D.J. Bryson ∗ , A.J. Batchelder, S.C. Williams Leicester Royal Infirmary, Leicester UK/University of Leicester Medical School, United Kingdom Introduction: Extended matching questions (EMQs) are commonly used to assess knowledge and problem-solving ability in both undergraduate and postgraduate medical education. Musculoskeletal practice makes extensive use of dynamic clinical evaluation and interpretation of imaging. Assessment of students in this discipline necessarily requires testing such areas. Here we describe the development and evaluation of multimedia EMQs as an assessment tool in undergraduate musculoskeletal education. Methods: Key themes in the musculoskeletal curriculum were identified and 20 EMQs written by a collaboration of clinicians. Each EMQ had 5 stems and 12 items. These included an admixture of case vignettes, plain radiographs and high-quality photographs of clinical signs. Multimedia elements were collated on a PowerPoint presentation and the examination undertaken with each student at a computer workstation. Data were reviewed to identify common errors to guide future delivery of the curriculum. Item analysis was conducted with calculation of reliability co-efficients (Cronbach’s alpha) and discrimination indices for each stem. Results: The assessment was undertaken by 193 fourth-year medical students at the end of a 7-week clinical musculoskeletal placement. The range of scores was 24–71% (mean 51%, standard deviation 8.2%). Topic areas where students performed poorly included recognition of radiological changes associated with common arthropathies, selection of appropriate antimicrobial therapy in orthopaedic patients and identification of paediatric fractures. Conclusion: EMQS are gaining increasing prominence as an assessment tool in undergraduate and post-graduate education. Here we have described how the benefits this of this format may be effectively utilised in the context of undergraduate orthopaedic examinations. This unique admixture of case vignettes and multimedia images allows assessment of clinical and interpretive skills routinely employed in the practice of trauma and orthopaedics. Multimedia EMQs are easy to generate and provide a viable alternative to the short-answer and multiple-choice assessment formats commonly employed in undergraduate musculoskeletal medical education. http://dx.doi.org/10.1016/j.injury.2012.07.340