The purpose of this study was to review the rates of adverse healing outcomes following surgical fixation of lower extremity fractures in diabetic patients and matched controls.
Searches of PubMed, ...MEDLINE, CINAHL and Embase were performed for studies published between the date of database inception and July 6, 2015. Patient characteristics and the incidence of adverse healing outcomes (nonunion, malunion, delayed union, infection and reoperation) were extracted from each study. The occurrence of each fracture healing complication was pooled and analyzed for comparisons between diabetic and non-diabetic patients. An odds ratio with a 95% confidence interval for each healing outcome was calculated between the diabetic and non-diabetic groups.
Diabetes was found to significantly increase rates of malunion, infection and reoperation in patients with surgically treated lower extremity fractures. In addition, when only peripheral lower extremity fractures (i.e. below the knee) were examined, diabetes significantly increased the rates of nonunion.
Diabetes substantially alters bone metabolism and soft tissue healing, posing a risk of adverse fracture healing and other complications. This systematic review provides evidence that the presence of diabetes significantly increases the risks of infection, malunion, nonunion and re-operation across a wide variety of surgically treated lower extremity fractures. This study provides prognostic information for clinicians and may aid in guiding treatment for this population.
Fracture healing is a complex process requiring mechanical stability, an osteoconductive matrix, and osteoinductive and osteogenic biology. This intricate process is easily disrupted by various ...patient factors such as chronic disease and lifestyle. As the medical complexity and age of patients with fractures continue to increase, the importance of developing relevant experimental models is becoming paramount in preclinical research. The objective of this review is to describe the most common small animal models of systemically impaired fracture healing used in the orthopedic literature including osteoporosis, diabetes mellitus, smoking, alcohol use, obesity, and ageing. This review will provide orthopedic researchers with a summary of current models of systemically impaired fracture healing used in small animals and present an overview of the methods of induction for each condition.
There is a paucity of research regarding the relationship between anemia and postoperative morbidity and mortality among geriatric patients presenting with hip fracture. The objective of this study ...was to determine the effect of anemia at presentation on 30-day morbidity and mortality among geriatric patients with hip fracture.
The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all hip fracture patients ≥60 years old from 2011 to 2016. Included were all emergency unilateral, nonpathological hip fractures (femoral neck, intertrochanteric, or subtrochanteric) treated with arthroplasty, intramedullary nailing, or open reduction and internal fixation. Anemia was classified as a hematocrit (HCT) level of <0.41 and <0.36 for male and female patients, respectively. Age, body mass index (BMI), race, comorbidities, smoking status, American Society of Anesthesiologists (ASA) class, baseline functional status, time to surgery, operative time, anesthesia type, need for transfusion, fixation method, length of stay (LOS), and discharge destination were collected. Our primary outcome of interest was 30-day postoperative mortality, with all-cause readmission and any postoperative ischemic events (cerebrovascular accident CVA and myocardial infarction MI) analyzed as secondary outcomes. A multivariable regression analysis was performed and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated while controlling for confounding variables.
Of 34,805 patients identified, 22,469 (65%) were anemic at presentation (63% female; mean age, 80 ± 8 years), while 12,336 (35%) were non-anemic (85% female; mean age, 79 ± 8 years). Anemia at presentation was independently associated with higher odds of mortality (OR,1.3 95% CI, 1.1 to 1.5) and readmission (OR, 1.2 95% CI, 1.1 to 1.3), while no relationship was observed for MI (OR, 1.1 95% CI, 0.9 to 1.4) or CVA (OR, 0.8 95% CI, 0.6 to 1.1).
Our findings suggest that anemia at presentation is associated with greater 30-day postoperative morbidity and mortality in geriatric hip fracture patients. Additional research should focus on elucidating this modifiable risk factor and advancing the preoperative optimization of hip fracture patients.
Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Purpose To determine the interobserver reliability of the International Cartilage Repair Society (ICRS) grading system of chondral lesions in cadavers, to determine the intraobserver reliability of ...the ICRS grading system comparing arthroscopy and video assessment, and to compare the arthroscopic ICRS grading system with histological grading of lesion depth. Methods Eighteen lesions in 5 cadaveric knee specimens were arthroscopically graded by 7 fellowship-trained arthroscopic surgeons using the ICRS classification system. The arthroscopic video of each lesion was sent to the surgeons 6 weeks later for repeat grading and determination of intraobserver reliability. Lesions were biopsied, and the depth of the cartilage lesion was assessed. Reliability was calculated using intraclass correlations. Results The interobserver reliability was 0.67 (95% confidence interval, 0.5-0.89) for the arthroscopic grading, and the intraobserver reliability with the video grading was 0.8 (95% confidence interval, 0.67-0.9). A high correlation was seen between the arthroscopic grading of depth and the histological grading of depth (0.91); on average, surgeons graded lesions using arthroscopy a mean of 0.37 (range, 0-0.86) deeper than the histological grade. Conclusions The arthroscopic ICRS classification system has good interobserver and intraobserver reliability. A high correlation with histological assessment of depth provides evidence of validity for this classification system. Clinical Relevance As cartilage lesions are treated on the basis of the arthroscopic ICRS classification, it is important to ascertain the reliability and validity of this method.
•Symptoms of depression, anxiety and PTSD are common in orthopaedic trauma patients.•Patients with higher levels of psychological dysfunction have shown increased levels of pain and dysfunction ...post-operatively.•The implementation of effective screening programs and subsequent intervention programs are highly desirable.
Recent research has identified a high prevalence of psychological illnesses in patients who have sustained orthopaedic trauma. Depressive symptoms in this patient population have been reported to range from 13% to as high as 56%. Moreover, symptoms of depression, catastrophic thinking, and post-traumatic stress disorder (PTSD), have been consistently shown to negatively impact patient outcomes following treatment for their traumatic injuries. Specifically, patients with higher levels of psychosocial dysfunction have shown increased levels of pain, disability, and complications throughout their recovery. However, current research in orthopaedic trauma continues to be substantially focused on the physical and technical factors involved in the treatment of orthopaedic injuries. More research which applies the “biopsychosocial model” of health and evaluates the significant impact of psychological and social factors on recovery from trauma is needed. In particular, investigation which evaluates effective screening strategies and interventions to treat psychosocial dysfunction during recovery from trauma is highly desirable. This article reviews the current state of knowledge in this area and suggests future directions for research.
The optimal entry point for antegrade intramedullary nailing of femoral shaft fractures remains controversial. The purpose of this systematic review was to determine whether there is a difference in ...operative parameters, healing, and functional outcome when comparing the greater trochanter (GT) and piriformis fossa (PF) entry points. A systematic search of multiple databases and 3 major orthopedic meetings (American Academy of Orthopaedic Surgeons, Canadian Orthopaedic Association, and Orthopaedic Trauma Association) was conducted. Four studies (570 patients) met the inclusion criteria. Mean patient age was 34.5 years, and 60.4% were male. The GT entry point was associated with significantly shorter operative (mean difference MD, -20.05 minutes 95% confidence interval (CI), -23.09 to -17.02; P<.00001) and fluoroscopy times (MD, -24.55 seconds 95% CI, -43.23 to -5.86; P=.01). There was no significant difference in nonunion (risk ratio RR, 0.74 95% CI, 0.35 to 1.58; P=.44) and delayed union rates (RR, 0.94 95% CI, 0.41 to 2.14; P=.88) between the 2 entry points. Heterogeneity in outcome measures reported prevented pooled analysis of functional outcomes. This review supports the use of the GT entry point during antegrade nailing of femoral shaft fractures over the PF entry point, with regard to shorter operative and fluoroscopy times. Healing and complication rates were not related to the entry point. Further study is required to determine the effect of each entry point on the surrounding soft tissue structures and ultimately its impact on postoperative function.
Distal femur fractures are challenging injuries to manage, and complication rates remain high. This article summarizes the international and basic science perspectives regarding distal femoral ...fractures that were presented at the 2022 Orthopaedic Trauma Association Annual Meeting. We review a number of critical concepts that can be considered to optimize the treatment of these difficult fractures. These include biomechanical considerations for distal femur fixation constructs, emerging treatments to prevent post-traumatic arthritis, both systemic and local biologic treatments to optimize nonunion management, the relative advantages and disadvantages of plate versus nail versus dual-implant constructs, and finally important factors which determine outcomes. A robust understanding of these principles can significantly improve success rates and minimize complications in the treatment of these challenging injuries.
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