SURGERY & ANAETHESIA
Please find below the presentation abstracts for this session's theme.
Is a Single Plate Enough? Primary Surgical Fixation Methods for Distal Femoral Fractures
Hannah Blades | University of Warwick
Distal femoral fractures are notoriously complex to surgically fix. Currently, the majority are fixed using a single locking plate. However, surgeons at the major trauma centre of University Hospital Coventry and Warwickshire (UHCW) have observed a large number of single locking plates failing, resulting in a revision surgery with alternative or supplementary fixation being required. This projects aim was to establish the complication and revision rates of single locking plates and to compare outcomes with double locking plates used in primary surgical fixation of distal femoral fractures at UHCW.
Patients were identified using operating procedure codes matching surgical fixation of distal femoral fractures between June 2016 and June 2019. Retrospective analysis of clinic letters, theatre notes and x-rays for 53 patients with single locking plates and 13 patients with double locking plates was performed.
12 patients (32%) with single locking plates suffered complications, with 9 (24%) requiring a revision surgery. This compares to only 2 patients (15%) within the double locking plate group. The most common complication of single locking plates was plate breakage before union (21%). Periprosthetic fractures and increasing age reduced the success rate of single locking plates.
1 in 3 single locking plates suffered complications compared to 1 in 7 double locking plates, meaning single locking plates are 2.6x more likely to fail. This rises to 3.7x in those with a periprosthetic fracture. Therefore, double plates should be adopted as the primary fixation method for distal femoral fractures, especially with periprosthetic fractures.
Temporomandibular Joint Dysfunction following use of a Supraglottic Airway Device in General Anaesthesia
Serkan Cakir | University of Warwick
Supraglottic airway devices (SADs) are used for securing the airway in over 50% of general anaesthetics in the UK. Although considered relatively safe devices, there are several potential complications. These include temporomandibular joint (TMJ) dysfunction, which has been reported in isolated cases but not well-characterised in clinical studies to date. This study investigated TMJ dysfunction following the use of a SAD during general anaesthesia.
Fifty adult surgical patients scheduled to receive a SAD were recruited. Pre-operatively, patients were asked to complete a 12-item questionnaire (to assess subjective TMJ function at baseline) and objective measurements of the jaw (inter-incisor distance, forward and lateral jaw movements) were taken. The questionnaire and objective measurements were then repeated two-to-24 hours after the operation.
There was no statistically significant difference in mean inter-incisor distance, forward jaw protrusion and right lateral jaw movement post-operatively versus pre-operatively (p= 0.588, p=0.135 and p= 0.372 respectively). Mean left lateral jaw movements were significantly reduced post-operatively (p=0.029). Subjective: 90% of patients reported no changes post-operatively in any of the parameters questioned. New post-operative symptoms included jaw joint pain (4% of recruits), jaw muscle pain (4%), jaw grinding (2%), jaw locking (1%), and difficulty chewing (1%).
There was a low incidence of subjective TMJ discomfort following SAD use. Objective measures were generally not statistically significant. If shown to be consistent in future studies, these results can help reassurance patients during the anaesthetic consenting pre-operatively, particularly for those worried about having an airway device inserted.
Endoprosthetic Reconstruction & Intramedullary Nailing for Pathological Fractures of the Proximal Femur: a Systematic Review and Meta-Analysis of Survival and Complications
Sallu Dawo | University of Warwick
Up to 50% of new cases of cancer diagnosed eventually metastasise to bone. The femur and humerus are common sites for metastases to the bone. Pathological fractures of the femur can lead to impaired mobility, severe pain, morbidity and reduced quality of life. This review compares survival and complication rate following endoprosthetic reconstruction (EPR) and intramedullary nailing (IMN) for impending and complete pathological fractures of the proximal femur associated with metastatic bone disease.
A systematic review of the literature was performed searching Medline, Cochrane, Web of Science and EMBASE databases for articles published within the last 40 years reporting outcomes for surgical treatment of metastatic lesions in the proximal femur. Twenty-eight studies with 2631 patients treated for 2657 lesions were included. Meta-analysis was performed to compare pooled estimates and 95% confidence intervals for IMN and EPR.
EPR provides a greater 1-year survival rate than IMN (39% vs 33.2%, p > 0.05). Systemic complications were lower in patients treated with EPR than IMN (3% vs 7.9%). Rate of tumour progression was lower in EPR than IMN (0.9% vs 2%). Patients treated with EPR were less likely to experience implant failure or dislocation than the IMN group (3.6% vs 5.8%). Pooled deep infection rate was higher in patients treated with EPR than in the IMN group. Significant heterogeneity (p < 0.05) was present in studies reporting on both treatment modalities.
Survival, complication and reoperation rates are comparable between EPR and IMN. EPR provides a greater 1-year survival rate than IMN. EPR also lasts the lifetime of the patient and provides a greater protection against local recurrence. Risk of systemic complications is lower in patients treated with EPR, but they are more susceptible to deep infections than patients treated with IMN.
Comparing Outcomes of Plate versus Screw Osteosynthesis of Scaphoid Non-union: A Systematic Review and Meta-Analysis
Mary Rose Harvey & Rosie Hall | University of Warwick
Scaphoid nonunion is commonly treated with open reduction and internal fixation with a headless compression screw. The use of variable-angle buttress plates has also been described, although this has been considered a salvage procedure. The aim of this systematic review is to compare plate and screw osteosynthesis of scaphoid nonunion to determine whether either has preferable outcomes.
A database and hand search was performed, and included studies were critically appraised using NIH Quality Assessment Tools. Meta-analyses or narrative syntheses were performed for relevant data.
Twelve studies met the eligibility criteria for inclusion. The evidence suggests that there are no significant differences between plate and screw interventions for the outcomes of Disabilities of the Arm Shoulder and Hand, Modified Mayo Wrist Score and grip strength. Range of motion demonstrated incidences of improvement in extension, flexion, ulnar deviation and radial deviation for both interventions. However, there was considerable variety in reporting methods, making statistical comparison difficult.
Plate osteosynthesis of scaphoid nonunion is a viable alternative to screw osteosynthesis in terms of outcomes. Surgeons may choose to use this method of fixation based on preference or clinical need. There is a need for consistent reporting standards in order to draw valuable inferences from research.
Case series studies can lead to significant advancements in medicine, but this systematic review must be interpreted with caution due to inherent biases in such study designs. Randomised controlled trials with well-established comparators and standardised reporting techniques will provide a higher level of evidence.
Evaluating the Reporting and Implications of Troponin Measurement in Paediatric Cardiac Surgery: a Systematic Review
Caleb Johnson | University of Warwick
Troponin is a biomarker of myocardial injury in paediatric cardiac surgery. There are inconsistencies in the way cardiac biomarkers are measured and reported due to a lack of standardised protocols. This systematic review aims to highlight these comprehensively by evaluating the current evidence base.
The following databases were searched: MEDLINE, CENTRAL, EMBASE, and LILACS/IBECS. Inclusion criteria included paediatric patients undergoing cardiac surgery and explicit measurement and reporting of troponin. There were no restrictions on study design, aim, year, or language. The protocol was prospectively registered with PROSPERO.
There were 125 studies of mixed design and aim. The most frequent aim was risk factors/prognostic value for post-operative course (28, 22.4%) followed by cardioplegia (27, 21.6%). Cardiac troponin I was the most reported assay (93, 74.4%). There were 116 different time points for measurement collection. Preoperative baseline was the most frequent (79, 63.2%) followed by 24-hour post-operatively (43, 34.4%). Forty-nine (39.2%) studies only represented values graphically. Twenty-six (20.8%) studies reported reference ranges. Fifty-seven (45.6%) studies reported other cardiac biomarkers with CK-MB being most frequent in 32 studies. The most frequent clinical variables were aortic cross-clamp time (97, 77.6%) and cardiopulmonary bypass time (95, 76%).
The current literature highlights variations in troponin measurement and reporting. These include differences in assays, time points, normal ranges, clinical outcomes, alongside uncertainty regarding other cardiac biomarkers and a lack of reporting numerical values. These findings outline inconsistencies due to a lack of standardised protocols and implicate that further exploration is needed.