A clinical evaluation of the effect of MRI scan to bring about a change in surgical management of elderly patients who present with hip fracture with no history of trauma or a suspicious looking lesion on x-rays. Many of these patients present with or without history of previous malignancy or bone disorder. We evaluated that if the delay in treatment within 36 hours as per national guide lines is justified to benefit patients. A clinical review of six hundred hip fracture patients where one hundred and four patients who had MRI scan of hip for fracture with either no history of trauma or a fracture with suspected pathological features with or without history of malignancy or bone disorder. The final outcome of hundred patients who had MRI scans 32 male and 68 female with median age of 65 years. Four patients were excluded as were unable to tolerate the MRI scan. Statistical analysis software SAS/STAT® was used to conduct data collation and analyses. A further radiological analysis of MRI scans with positive lesion to the plain X-rays to correlate the finding of a lesion on femoral side on MRI scan to a lesion on acetabular side. Out of hundred patients who had MRI scan for a suspected metastatic or pathological lesion only 12 showed a metastatic lesion despite the fact 31 had previous history of malignancy, CI 4.03; 101.91, P < 0.0003. No primary lesion detected in any patient. We also found if the acetabular side was not seen to be involved on pain x-ray, MRI scan did not detect any acetabular lesion, contingency coefficient 0.5632, P < .0001.Methods
Results
It is recommended that the ankle be held in dorsiflexion at the time of placement of syndesmosis screw. We assessed the validity of this recommendation. A two-part roentgenographic and computerised analysis of distal tibiofibular syndesmosis. The first part involved recruitment of 30 healthy adult volunteers. The second part involved 15 ankle fractures with syndesmotic injury requiring syndesmosis screw placement. In the first part individuals maximally dorsiflexed and plantarflexed their ankles in a specialised jig for standardisation. Mortice views were taken and intermalleolar distance measured. In the second part mortice views were taken in plantarflexion and dorsiflexion before and after the placement of syndesmosis screw in theatre. The intermalleolar distance was then measured.Introduction
Materials and methods
Manoli and Schaeffer in 1987, showed that fixation by antiglide plate demonstrated superior static biomechanical properties compared to lateral plating. However there are some shortcomings in their study and hence we decided to perform our biomechanical study. The shortcomings of the Manoli study are. They did not use an interfragmentary lag screw for lateral plate fixation. It was a cadaveric study where the bone does not accurately represent the live bone. The quality of the bone ranging from normal to osteoporotic bone varies from cadaver to cadaver and hence there is no uniformity between the samples.
These bones were custom made for the experiment. We used two sets of bones, one representative of normal bone (Set A n=10) and the other of osteoporotic bone quality (Set B n=10). Each of the sets A &
B will have two types of fixations for artificially created Weber B Fractures.
Lateral plate with interfragmentary lag screw. Antiglide plate with interfragmentary lag screw. The strength of the fixation was measured by restressing the bone until the fixation failed using an Instron machine which simultaneously applied torque and compressive forces to the fibular construct. The resulting data was analysed on a computer and statistical analysis was performed.
The concept of tension band wiring is based on the fact that the distractive force applied to one surface of the bone will result in compression on the opposite articular surface. Clinical outcomes of TBW are not equivocal. It is associated with significant morbidity such as non union, failure of fixation, especially in osteoporotic bone and infection which sometimes leads to amputation. Often a second procedure for removal of prominent metal work is required. In our biomechanical study we investigated this concept as we believe that the forces generated by TBW construct do not generate significant compressive forces required for healing of fracture.
The advantage of using 4th generation composite bone model is that it provides uniformity which is not achievable in cadaveric studies. Two different bone models representative of Olecranon and patella were used. Transverse fractures were created in the bones and fixed with TBW technique as described in A.O. manual. Two 0.062-inch Kirschner wires and figure of eight configuration of 18G Stainless steel wire with single knot technique was used. Micro motion transducers (DVRT: MicroStrain, Williston, Vermont) with an accuracy of ± 1μm were placed across the fracture site both anteriorly and posteriorly. Continuous information regarding fracture distraction and compression, as determined by the transducers was recorded from both sites simultaneously during the experiment. The tension band wire construct was loaded up to a maximum force of 4000 Newtons for patella and 500 for the olecranon. The fractures were subjected to cyclic loading at 1Hz using a servo hydraulic materials-testing system (model 8500; Instron, Canton, Massachusetts). The results were analysed on a computer and statistical analysis performed.
51 male and 49 female. Average age of 48.0 (25.3–63.8IQR) 45 Simple, 46 comminuted and 9 pathological fractures. 70 were isolated and 10 were part of multiple trauma fractures. 91 closed and 9 open fractures. 52 fractures due to simple falls, 30 road traffic accident,9 pathological fracture,8 work related and 1 unknow cause. Out of 100 nails, 90 were statically locked while 9 were locked proximally and 1 was locked only distally. The outcomes were assessed clinically, radiologically and using the Disability of Arm Shoulder and Hand (DASH) function scoring system. Statistically Cronbach’s alphas were calculated for the three scales of the DASH instrument. These scales were the function/symptom scale consisting of 30 items, sports/music module containing 4 items, and work module comprising 4 items. Medians (interquartile ranges) and ranges are presented for numerical variables. Mann-Whitney U tests (two-tailed) and Univariate and multivariate regression analysis were used.
The DASH function scale scores was categorised into good 71 patients 85.5% (Score 0-<
25), Medium 4 patients 4.8% (Score 25-<
40) and Poor 8 patients 9.6% (Score 40+). Univariate and multivariate regression analysis showed, Increasing age (adjusted OR=0.96,95%CI 0.93–0.99,P<
0.01) and communited compared to simple fractures (adjusted OR=0.12,95%CI 0.03–0.45,P<
0.01) were associated with reduced likelihood of attaining full range of motion. Male patients (unadjusted OR=2.37,95%CI 0.90–6.25,P=0.08) and patients involved in RTA compared to falls (unadjusted OR=4.5,95%CI 0.96–21.07,P=0.06) were associated with higher likelihood of attaining full range of motion. 85 % had no complication, while 15 % had complications. One nerve palsy and one case of infection. Seven patients required nail removal and 3 required removal of proximal locking screw.
A further study was undertaken to verify the results on composite material with biomechanical properties similar to human bone.
Statistical analysis was performed on the data collected through DASH questionnaires along with multivariate and univariate analysis and t-tests.
48 % of patients showed a rise in DASH scores after the fracture healing, indicating decrease shoulder function. This was statistically analysed and failed to reach any significance p=0.867. There was no difference between the two techniques in terms of complications and union rates.
Patients were matched for age, gender, pathology, weight, implant type, pre operative haemoglobin and senior operator in all three groups. We assessed intra-operative and total blood loss, transfusions requirements, postoperative wound complication, regaining of the range of motion, incidence of systemic effects of tourniquet and duration of hospital stay. We also looked at the effects of NSAIDS on blood loss and compared the validity of various factors reported in the literature to be predictive of future transfusion after the surgery. Statistical analysis used were, student’s t-test, univariate and multivariate analysis and regression statistical analysis.