The use of cannulated screws for femoral neck fractures is often limited by concerns of avascular necrosis (AVN) occurring, historically seen in 10–20% of fixed intracapsular fractures. The aim of this study was to investigate the rate of AVN with current surgical techniques within our unit. A single centre retrospective review was performed. Operative records between 1st July 2014 and 31st May 2019 were manually searched for patients with an intracapsular neck of femur fracture fixed with cannulated screws, with minimum one year follow up. Patient records and radiographs were reviewed for clinical and radiographic diagnoses of AVN and/or non-union. Fracture pattern and displacement, screw configuration and reduction techniques were recorded, with radiographs independently analysed by five orthopaedic surgeons.Abstract
Objectives
Methods
Intracapsular neck of femur fractures may be treated with fixation or arthroplasty, depending on fracture characteristics and patient factors. Two common methods of fixation are the sliding hip screw, with or without a de-rotation screw, and cannulated screws. Each has its merits, and to date there is controversy around which method is superior, with either method thought to risk avascular necrosis of the femoral head (AVN) rates in the region of 10–20%. Fixation with cannulated screws may be performed in various ways, with current paucity of evidence to show an optimum technique. There are a multitude of factors which are likely to affect patient outcomes: technique, screw configuration, fracture characteristics and patient factors. We present a retrospective case series analysis of 65 patients who underwent cannulated screw fixation of a hip fracture. Electronic operative records were searched from July 2014 until July 2019 for all patients with a neck of femur fracture fixed with cannulated screws: 68 were found. Three patients were excluded on the basis of them having a pathological fracture secondary to malignancy, cases were followed up for 2 years post-operatively. Electronic patient records and X-rays were reviewed for all included patients. All X-rays were examined by each team member twice, with a time interval of two weeks to improve inter-observer reliability. 65 patients were included with 2:1 female to male ratio and average age of 72 years. 36 patients sustained displaced fractures and 29 undisplaced. Ten patients sustained a high-energy injury, none of which developed AVN. Average time to surgery was 40 hours and 57 patients mobilised on day one post-operatively. All cases used either 7 or 7.3mm partially threaded screws in the following configurations: 2 in triangle apex superior, 39 triangle apex inferior, 22 rhomboid and 2 other, with 9 cases using washers. All reductions were performed closed. Five (8%) of our patients were lost to follow-up as they moved out of area, 48 (74%) had no surgical complications, seven (11%) had mild complications, three (5%) moderate and two (3%) developed AVN. Both of these sustained displaced fractures with low mechanism of injury, were female, ASA 2 and both ex-smokers. One received three screws in apex inferior configuration and one rhomboid, neither fixed with washers. Our AVN rate following intracapsular hip fracture fixation with cannulated screws is much lower than widely accepted. This study is under-powered to comment on factors which may contribute to the development of AVN. However, we can confidently say that our practice has led to low rates of AVN. This may be due to our method of fixation; we use three screws in an apex inferior triangle or four screws in a rhomboid, our consultant-led operations, closed reduction of all fractures, or our operative technique. We pass a short thread cannulated screw across the least comminuted aspect of the fracture first in order to achieve compression, followed by two or three more screws (depending on individual anatomy) to form a stable construct. Our series shows that fixation of intracapsular hip fractures with cannulated screws as we have outlined remains an excellent option. Patients retain their native hip, have a low rate of AVN, and avoid the risks of open reduction.
Europe has found itself at the epicentre of the COVID-19 pandemic. Naturally, this has placed added strain onto healthcare systems internationally. It was feared that the impact of the COVID-19 pandemic could overrun the Irish healthcare system. As such, the Irish government opted to introduce a national lockdown on the 27 March 2020 in an attempt to stem the flow of admissions to hospitals. Similar lockdowns in the UK and New Zealand have resulted in reduced emergency department presentations and trauma admissions. The aim of this study is to assess the effect of the national lockdown on trauma presentations to a model-3 hospital in Dublin, Ireland. A retrospective study was conducted. All emergency department presentations between 27 March 2019 to 27 April 2020 and 27 March 2020 to 27 April 2020 were cross-referenced against the National Integrated Medical Imaging System-Picture Archiving Communication System (NIMIS-PACS) radiology system to identify those with radiologically proven skeletal trauma. These patients were grouped according to sex, age, discharge outcome, mechanism of injury, and injury location.Aims
Methods
Antegrade K wiring of the fifth metacarpal for treatment of displaced metacarpal neck fractures is a well recognized surgical procedure. However it is not without complication and injury to the dorsal cutaneous branch of the ulnar nerve has been reported in up to 15% of cases. We performed a cadaver study to determine the proximity of this nerve to the K wire insertion point at the base of the fifth metacarpal. K wires were percutaneously inserted under image intensification in sixteen cadaver hands and advanced into the head of the metacarpal. Wires were then cut and bent outside the skin. This was then followed by meticulous dissection of the ulnar nerve from proximal to distal. A number of measurements were taken to identify the distance from the insertion point of the K wire to each branch of this nerve.Introduction
Methods
The process of femoral impaction grafting requires vigorous impaction to obtain adequate stability but the force of impaction has not been determined. This process has been reported to result in femoral fractures with rates reaching 16%. The aims of this study were to determine the threshold force required for femoral impaction grafting, to determine the affect cortical thickness, canal diameter and bone mineral density (BMD) have on this threshold force and to measure subsidence of an Exeter prosthesis following impaction at the threshold force. Adult sow femurs were prepared and placed through a DEXA scanner and the BMD and canal diameter measured. Thirty five femurs were impacted with morsellised bone chips and an increasing force of 0.5kN was applied until the femur fractured. Using callipers the cortical thickness of the bone was measured along the fracture line. Once the threshold force was determined 5 femurs were impacted to this threshold force and an Exeter stem was cemented into the neomedullary canal and a 28mm Exeter head attached. Axial cyclic loading was performed between 440N (swing phase of gait) and 1320N (stance phase of gait) for 150,000 cycles at a frequency of 3Hz. The position sensor of the hydraulic testing machine measured the subsidence. 29 tests were successfully completed. The threshold force was found to be 4kN. There was no significant correlation between the load at fracture and the cortex: canal ratio or the bone mineral density. Following impaction with the maximum force of 4kN the average subsidence for the 5 femurs was 0.276mm (range 0.235 – 0.325mm). In this animal study the threshold force was 4kN. Minimal axial subsidence of the implant occurred when impacting the graft with this threshold force. We therefore achieved a stable construct without fracture which is the ultimate goal for the revision hip surgeon.
We aimed to perform a randomized prospective study to determine the outcome of Buried versus Exposed K wire placement.
Patient details were collected and follow up was performed at 2 and 6 weeks post op. Infection at pin sites was measured on a 0 to 6 point scale. Superficial radial nerve was assessed with light touch and 2 point discrimination. EPL tendon was also assessed for damage.
No damage to EPL tendon was recorded in either group at 6/52 follow up. There was a slight increased rate of superficial infection at exposed pin sites noted at 2/52 follow up however this was not seen at the 6/52 follow up. Superficial radial nerve damage was noted in one case only. This was in the buried k wire group and occurred following removal of the radial wire.
We aimed to perform a randomized prospective study to determine the outcome of Buried versus Exposed K wire placement.
Patient details were collected and follow up was performed at 2 and 6 weeks post op. Infection at pin sites was measured on a 0 to 6 point scale. Superficial radial nerve was assessed with light touch and 2 point discrimination. EPL tendon was also assessed for damage.
No damage to EPL tendon was recorded in either group at 6/52 follow up. There was a slight increased rate of superficial infection at exposed pin sites noted at 2/52 follow up however this was not seen at the 6/52 follow up. Superficial radial nerve damage was noted in one case only. This was in the buried k wire group and occurred following removal of the radial wire.
Thus it would appear that leaving k wires exposed is the safer and more convenient method of K wiring the displaced distal radius fracture.
In a prospective randomized trial, we divided a group of patients with a clinically suspicious, although radiographically normal, acute fracture of the scaphoid into 2 groups, 1 treated with a cast (group I), the other with a splint (group II). There were 14 patients in group I, and 18 in group II. Patients were reviewed at 2,6, and 12 weeks for range of movement, grip strength, pain and satisfaction rating. Work disability costs were also calculated for both groups. Patients in group II had better range of movement and grip strength at 2 weeks, although complained of more pain. There was no difference in range of movement, grip strength, or pain at 6 or 12 weeks. Group II was more satisfied at 2 weeks, although not at 6 or 12 weeks. Group I required more time off work, and disability costs were significantly higher [€15,209 per person compared to €3,317 per person]. We recommend that all patients, with only a clinical suspicion of a fractured scaphoid, should have a short period of splint immobilization until symptoms resolve, or until further investigations reveal a fracture which can be appropriately treated. This policy is cost efficient and improves the short term outcome.
There was no significant difference between both groups for range of movement and grip strength. There was also no difference between the patient’s perception of pain and function which was assessed using the patient rated wrist evaluation (PRWE). Radiologically, the k-wire stabilisation group averaged better volar tilt compared with the ORIF group. For radial height and inclination the outcome was similar.
