Volume 22 · Issue 06 · 2019

To study the effect of early restrictive fluid resuscitation (EFR) on inflammatory and immune factors in patients with severe pelvic fracture (SPF ).

A total of 174 SPF patients in the Department of Orthopaedics, the First Affiliated Hospital of Chengdu Medical College from July 2015 to June 2018 were involved in this study and divided into EFR group (n = 87) and control group (n = 87) using the random number table method. Conventional fluid resuscitation (CFR) was performed in control group, and EFR was performed in EFR group. The incidences of acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS) during rescue, successful rescue rate, blood transfusion volume, fluid input, and resuscitation time were compared between the two groups. The parameters including prothrombin time (PT), hematocrit (HCT), platelet (PLT) and blood lactate (BL) at the 4th hour after fluid resuscitation were recorded. The levels of inflammatory factors (TNF-α, IL-6, CRP) and immune factors (CD3^＋, CD4^＋, CD8^＋, CD4＋/CD8＋) were compared between the two groups before treatment and 7 days after treatment. The revised acute physiologic and chronic health evaluation system and the sequential organ failure assessment scores were adopted for evaluation before treatment and 7 days after treatment.

The incidences of ARDS and MODS during rescue in EFR group were significantly lower than those in control group (p=0.015 and 0.010 respectively), and the successful rescue rate in EFR group was significantly higher than that in control group (p = 0.011). The blood transfusion volume, fluid input, resuscitation time in EFR group were significantly lower than those in control group (p = 0.016, 0.002 and 0.001 respectively). At the 4th hour after fluid resuscitation, PT and BL in EFR group were significantly lower than those in control group (p = 0.021 and 0.003 respectively), while HCT and PLT in EFR group were significantly higher than those in control group (p = 0.016 and 0.021 respectively). On day 7 after treatment, TNF-α, IL-6, CRP and CD8^＋ in EFR group were significantly lower than those in control group (p = 0.003, 0.004, 0.007 and 0.003 respectively), while CD3^＋, CD4^＋ and CD4＋/CD8＋in EFR group were significantly higher than those in control group (p = 0.004, 0.000, 0.007 respectively). On day 7 after treatment, the revised acute physiologic and chronic health evaluation (APACHE) system and the sequential organ failure assessment (SOFA) scores in EFR group were significantly lower than those in control group.

EFR can effectively eliminate inflammatory factors, improve immune function, maintain the stability of blood components, reduce the incidences of ARDS and MODS, and elevate the successful rescue rate in patients with SPF.

Sepsis is a common acute life-threatening condition that emergency physicians routinely face. Diagnostic options within the Emergency Department (ED) are limited due to lack of infrastructure, consequently limiting the use of invasive hemodynamic monitoring or imaging tests. The mortality rate due to sepsis can be assessed via multiple scoring systems, for example, mortality in emergency department sepsis (MEDS) score and sepsis patient evaluation in the emergency department (SPEED) score, both of which quantify the variation of mortality rates according to clinical findings, laboratory data, or therapeutic interventions. This study aims to improve the management processes of sepsis patients by comparing SPEED score and MEDS score for predicting the 28-day mortality in cases of emergency sepsis.

The study is a cross-sectional, prospective study including 61 sepsis patients in ED in Suez Canal University Hospital, Egypt, from August 2017 to June 2018. Patients were selected by two steps: (1) suspected septic patients presenting with at least one of the following abnormal clinical findings: (a) body temperature higher than 38℃ or lower than 36℃, (b) heart rate higher than 90 beats/min, (c) hyperventilation evidenced by respiratory rate higher than 20 breaths/min or PaCO₂ lower than 32 mmHg, and (d) white blood cell count higher than 12,000/μL or lower than 4000/μL; (2) confirmed septic patients with at least a 2-point increase from the baseline total sequential organ failure assessment (SOFA) score following infection. Other inclusion criteria included adult patients with an age ≥18 years regardless of gender and those who had either systemic inflammatory response syndrome or suspected/confirmed infection. Patients were shortly follow-up for the 28-day mortality. Each patient was subject to SPEED score and MEDS score and then the results were compared to detect which of them was more effective in predicting outcome. The receiver operating characteristic curves were also done for MEDS and SPEED scores.

Among the 61 patients, 41 died with the mortality rate of 67.2%. The mortality rate increased with a higher SPEED and MEDS scores. Both SPEED and MEDS scores revealed significant difference between the survivors and nonsurvivors (p = 0.004 and p < 0.001, respectively), indicating that both the two systems are effective in predicting the 28-day mortality of sepsis patients. Thereafter, the receiver operating characteristic curves were plotted, which showed that SPEED was better than the MEDS score when applied to the complete study population with an area under the curve being 0.87 (0.788-0.963) as compared with 0.75 (0.634-0.876) for MEDS. Logistic regression analysis revealed that the best fitting predictor of 28-day mortality for sepsis patients was the SPEED scoring system. For every one unit increase in SPEED score, the odds of 28-day mortality increased by 37%.

SPEED score is more useful and accurate than MEDS score in predicting the 28-day mortality among sepsis patients. Therefore SPEED rather than MEDS should be more widely used in the ED for sepsis patients.

Trauma may lead to serious complications in children patients. The purpose of this study was to investigate prognosis in children with traumatic injuries.

This cross-sectional study was conducted on all of the children (<18 years old) who had suffered traumatic injuries and transferred to the emergency department of Imam Hussein Hospital by emergency medical services. After selecting the children, a checklist including information such as demographic characteristics, trauma type, consciousness level, and final outcome was recorded. Finally, the data were analyzed using t-test, Chi-square test and ANOVA.

In total of 564 children were investigated. Among them, 70% were males, and 33.2% were in the age range of 5-12 years. The mechanism of injuries in 97.9% of the cases was blunt trauma. The most common chief complaint among the affected children was nausea. The majority of them had stable vital signs and normal neurological tests results. However, 1.06% of them died during hospitalization. The results indicated that the final outcome in the children affected by traumatic injuries is significantly related to the type of trauma, the location of traumatic event, the vehicle used to transport them to emergency departments and their Glasgow coma scale score (p < 0.05).

Considering the young age of the child patients and over half of trauma happened at home, it is important to raise parents' awareness about the risky places and activities, which were likely to result in traumatic injuries for children.

Distal femoral fracture is one of the most common lower limb injuries and accounts for less than 1% of all fractures. Open fracture takes 5%-10% of the all distal femoral fractures, which is at an increased risk of complications. There were limited studies which documented the outcomes of such cases. The present study aims to evaluate the outcome and complications in these fractures using primary definitive fixation with condylar locking plate and antibiotic impregnated collagen sheet secondary to aggressive debridement.

This is a prospective study conducted in a tertiary care orthopaedic hospital in northern India. Thirty patients of open distal femoral fractures were managed by primary definitive fixation with condylar locking plate and antibiotic impregnated collagen sheet secondary to aggressive debridement. They were followed for minimum of six months. Patients were followed up monthly for first four months, at six months and one year after surgery. Clinical and radiological signs of healing, any complications, time to union, and functional outcome were assessed.

The mean age of patients was 44.33 years (range 20-82 years) with male predominance of 66.7%. According to Gustilo-Anderson classification, there were 5, 15 and 10 patients with open grade I, II and IIIA distal femoral fractures respectively. According to orthopaedic trauma association (OTA) classification, majority of patients in our study were of C3 type. The mean time to bony union was 5.6 months (range 4-9 months). Average postoperative knee range of motion (ROM) at the latest follow-up was 98° (range 70°-120°). Lysholm knee scoring scale showed excellent score in 11 patients, good in 9 patients, fair and poor in 5 patients each; however, there was no significant correlation with fracture pattern types (p < 0.05). Knee stiffness was the major complications encountered in the study. The knee ROM was <90° in 5 patients and 90°-120° in rest of the patients, while 1 patient had extensor lag of 10°. One patient had implant failure and lost to follow-up; 3 patients had deep infection.

An approach of primary definitive fixation with condylar locking plate and antibiotic impregnated collagen sheet secondary to early aggressive debridement in open distal femur fractures shows significant results in terms of functional and radiological outcomes with minimal complications.

Thalamic hemorrhage breaking into ventricles (THBIV) is a devastating disease with high morbidity and mortality rates. Endoscopic surgery (ES) may improve outcomes, although there is no consensus on its superiority. We investigated the efficacy and safety of ES and compared the outcomes of different management strategies by ES, hematoma puncture and drainage (HPD), and external ventricular drainage (EVD) in patients with THBIV.

We retrospectively analyzed patients with THBIV treated by ES, HPD, or EVD at our hospital from June 2015 to June 2018. Patients were categorized into anteromedial and posterolateral groups based on THBIV location, and then the two groups were further divided into ES, HPD, and EVD subgroups. Individualized surgical approach was adopted according to the location of the hematoma in the ES subgroups. Patient characteristics and surgical outcomes were investigated.

We analyzed 211 consecutive patients. There were no significant differences in clinical characteristics or incidence of perioperative procedure-related complications (postoperative rebleeding and intracranial infection) in either anteromedial or posterolateral groups. Compared with other therapeutic methods, the ES subgroups had the highest hematoma evacuation rate, shortest drainage time, and lowest incidence of chronic ventricular dilatation (all p < 0.05). Among the three anteromedial subgroups, ES subgroup had the best clinical outcomes which was assessed by the modified Rankin Scale, followed by HPD and EVD subgroups (p < 0.01); while in the posterolateral subgroups, clinical outcomes in the ES and HPD subgroups were similar and better than that in the EVD subgroup (p = 0.037).

Individualized surgical ES approach for removal of thalamic and ventricular hematomas is a minimally invasive, safe, and effective strategy for the treatment of THBIV with a thalamic hematoma volume of 10-30 mL.

Fractures of distal radius are one of the common orthopaedic injuries. Placing the plate on volar surface requires release of underlying pronator quadratus (PQ) muscle. No consensus is present in the literature about the repair or not of the PQ. The purpose of this study was to evaluate the influence of PQ repair on functional outcome and complications.

Retrospectively 83 patients of distal radius fractures managed with volar plating between 2014 and 2016 were evaluated. Demographic data, operative notes and physical therapy records were retrieved. Patients were divided into group A where PQ repair was done and group B where no repair was done. Functional data such as range of motion (ROM), grip strength, visual analogue scale (VAS) score and disabilities of arm, shoulder and hand (DASH) score at 4 weeks, 3 months, 6 months and finial follow-up were retrieved.

Totally 63 patients (n = 29 in group A and n = 34 in group B) with the mean age of 51.64 years were examined. Patients were followed up for a mean of 35.2 months (range 27.2-47.1 months) in group A and 38.6 months (range 28.6-51.0 months) in group B. Though functional outcome of the affected limb was not significantly different between two groups after 3 months, PQ repair did affect the recovery at an early stage. Repair group had significantly better ROM (p = 0.0383) and VAS score at 4 weeks (p = 0.017) while grip strength (p = 0.014) was significantly better at 3 months.

Repair of PQ may provide pain relief and increased ROM in early postoperative period and hence every attempt should be made to achieve the repair.

The technology of 3D printing (3DP) exists for quite some time, but it is still not utilized to its full potential in the field of orthopaedics and traumatology, such as underestimating its worth in virtual preoperative planning (VPP) and designing various models, templates, and jigs. It can be a significant tool in the reduction of surgical morbidity and better surgical outcome avoiding various associated complications.

An observational study was done including 91 cases of complex trauma presented in our institution requiring operative fixation. Virtual preoperative planning and 3DP were used in the management of these fractures. Surgeons managing these cases were given a set of questionnaire and responses were recorded and assessed as a quantitative data.

In all the 91 cases, where VPP and 3DP were used, the surgeons were satisfied with the outcome which they got intraoperatively and postoperatively. Surgical time was reduced, with a better outcome. Three dimensional models of complex fracture were helpful in understanding the anatomy and sketching out the plans for optimum reduction and fixation. The average score of the questionnaire was 4.5, out of a maximum of 6, suggesting a positive role of 3DP in orthopaedics.

3DP is useful in complex trauma management by accurate reduction and placement of implants, reduction of surgical time and with a better outcome. Although there is an initial learning curve to understand and execute the VPP and 3DP, these become easier with practice and experience.

To investigate the utility and complications of paratricipital 2 window approach for complex intra articular distal humerus fractures (AO/OTA type C).

Between December 2012 and September 2016, 27 patients (male-14, female-13) having mean age of 39 years (range, 22-62 years) with closed intra articular fracture (AO/OTA 13 type C) were surgically managed using paratricipital 2 window approach. Fractures were fixed as per AO principles. All patients were followed up for 21 months (range, 12-28 months) prospectively. Functional outcome was measured using Mayo Elbow Performance Score (MEPS) and complications were observed. Student ttest, Pearson co-relation coefficient and Kruskal Wallis test used for statistical evaluation.

All cases unite by the end of 3 months. Mean flexion achieved was 120° and extension lag was 10°. Mean arc of motion was 111°. Mean pronation and supination was 70° and 77° respectively. MEPS and motion arc were weak negatively co-related with surgical delay and advancement in age. Postoperative transient ulnar nerve palsy and heterotrophic ossification (HO) was noted in 3.7% cases and infection occurred in 7.4% cases. Hardware prominence noted in 11.1% cases. Mean MEPS was 82. MEPS was excellent in 18.5%, good in 62.9%, fair in 11.1% and poor in 7.4% cases.

Paratricipital 2 window approach for these fractures had good functional outcome with fewer complications. We advocate paratricipital 2 window approach when dealing with these complex fractures particularly, in type C1 and type C2.

During fracture fixation, the size of tibial nail is a vital factor affecting the outcomes and thus preoperative estimation of tibial nail length is very important. This study aims to find out whether "olecranon to 5th metacarpal head" (O-MH) measurement can be used to reliably predict the tibial nail length.

This was a cross sectional study involving 100 volunteers. Measurements were done and recorded by two observers on two separate occasions. Tibial nail length estimation measurement was done from highest point of tibial tuberosity to the tip of the medial malleolus (TT-MM). O-MH measurement was taken from tip of olecranon to the tip of 5th metacarpal head with wrist in neutral position and hand clenched. Statistical analysis was done to find out correlation between two measurements and influence of age, gender and body mass index on them.

Paired t-test showed no systematic error between the readings. Intraclass correlation coefficient showed strong agreement in inter and intra observer settings. Strong correlation was found between the TT-MM & O-MH measurements using Pearson's correlation coefficient test (r = 0.966). Hierarchical regression analysis showed age, gender and BMI have no statistically significant bearings on these measurements and their correlations.

O-MH measurement is a useful and accurate means of estimating tibial nail length preoperatively.

To investigate the characteristics of the onset and treatment of radial head subluxation (RHS) in pediatric clinics and emergency departments.

A retrospective study was performed on 11, 404 RHS cases in 9827 children who visited pediatric clinics and emergency departments from January 2015 to December 2018. The patients who with history of trauma and fracture of the affected limb were excluded. The following factors were examined: the mechanisms of RHS, the type of manual reduction, the attending physician's clinical background (emergency surgeon, junior pediatric orthopedic surgeon or senior pediatric orthopedic surgeon), and the epidemiological features (gender, age, climate and location) of the injury.

The mean age of the patients was 27.93 ± 17.94 months (range 0.93-214.53 months), with a peak incidence of 10.73-44.53 months. Approximately two-thirds of RHS cases occurred in cold weather from January to March and from September to December. Females accounted for 53.81% (n = 6137) of the cases, and left injuries were predominant (56.87%, n = 6485) in all cases. Mechanisms of injury were classified as "pull" (90.57%, n =10, 339), "fall" (1.56%, n = 178), "hit" (0.75%, n = 86) and "unknown" (7.02%, n = 801). The overall success rate of manual reduction was 99.47%, and the success rate of reduction was higher for senior pediatric orthopedic surgeons than for emergency surgeons and junior pediatric orthopedic surgeons (p < 0.05). However, there was still a recurrence rate of 12.16% in the 9827 patients.

Younger children are predisposed to RHS, and there is a possibility of recurrence. Trained emergency doctors can handle it well, but it is essential to refer patients to specialists when manual reduction failed.

A below knee amputation (BKA) requires sufficient stump length for the fitting of a modern prosthesis. In cases of trauma where the levels of injury are unpredictable, achieving sufficient stump length can be a challenge. We described a case report of using the Ilizarov technique for bone lengthening at the residual BKA stump for a patient who sustained a mangled limb following a road traffic accident. Using this technique, we have successfully lengthened the tibial stump adequately for a functioning prosthesis. As shown in this case, we believe that this technique could attain an excellent outcome for a selected group of patients with short residual BKA stump.

Upper cervical schwannoma is rare, and belongs to benign tumors that is usually asymptomatic. It accounted for only ten percent of schwannomas cases and mostly occurs in 40-50 years old patients. Aggressive and total resection is the treatment of choice for this tumor. Preoperative diagnosis is difficult, relying on clinical suspicion, and confirmed by surgical pathology. We report a 54-year-old male patient with chief complain of progressive weakness and numbness of his right arm for four months. He had a history of lymph node tumor in 2007 and excised in 2011. Neurological decrease was found on the right arm. The radiographic examination showed lytic lesion on the second, third, and fourth cervical spine. Computed tomography scan showed destruction extending to the first cervical vertebra. Capsulated extradural and extramedullary mass and compression to the spinal cord was found from the magnetic resonance imaging. Two-stage operation was performed. The first stage was posterior decompression with occipitocervical fusion and instrumentation, while the second was anterior decompression and iliac strut graft. Both operations performed using the surgical ultrasonic dissector. During three months' follow-up, it showed neurological improving. Neurological deficit appears when there is compression on the spinal cord. Total resection is the treatment of choice for these tumors. Preoperative imaging should be performed to exclude malignant tumor and found tumor extension.