RESUMO
BACKGROUND: Hip fractures are associated with high morbidity, mortality, and cost. Implants used for hip fracture fixation can fail for many reasons including lag screw cut-out. Tip-apex distance (TAD) is indicative of the position and depth of a screw in the femoral head and has been shown to be associated with cut-out failure. We conducted a systematic review of the published literature to quantify the association between TAD and cut-out failure for patients undergoing hip fracture fixation surgery. METHODS: We performed a search of the Medline, Embase, and Cochrane databases. We performed abstract and full text reviews independently and in duplicate. We used a random effects model to combine, in duplicate, the incidence of cut-out for patients who had TAD <25 mm and TAD >25 mm. We also combined mean TAD values for patients who had cut-out failure and those who did not. RESULTS: Seventeen studies were eligible for this review, four of which were included in combined analysis of dichotomous outcomes and seven in combined analysis of continuous outcomes. Patients with TAD >25 mm had a significantly greater risk of cut-out than patients with TAD <25 mm (RR = 12.71). Patients who experienced implant cut-out had significantly higher TAD scores than those who did not (mean difference = 6.54 mm). CONCLUSION: Tip-apex distance is an important concept in relation to cut-out failure of hip fracture fixation surgery. Surgeons should understand and apply the concept of TAD to improve outcomes for their patients.
Assuntos
Fixação Interna de Fraturas , Fraturas do Quadril/diagnóstico por imagem , Fraturas do Quadril/cirurgia , Parafusos Ósseos , Humanos , RadiografiaRESUMO
OBJECTIVES: among patients undergoing noncardiac surgery, our objectives were to: (1) determine the feasibility of undertaking a large international cohort study; (2) estimate the current incidence of major perioperative vascular events; (3) compare the observed event rates to the expected event rates according to the Revised Cardiac Risk Index (RCRI); and (4) provide an estimate of the proportion of myocardial infarctions without ischemic symptoms that may go undetected without perioperative troponin monitoring. DESIGN: An international prospective cohort pilot study. PARTICIPANTS: Patients undergoing noncardiac surgery who were >45 years of age, receiving a general or regional anesthetic, and requiring hospital admission. MEASUREMENTS: Patients had a Roche fourth-generation Elecsys troponin T measurement collected 6 to 12 hours postoperatively and on the first, second, and third days after surgery. Our primary outcome was major vascular events (a composite of vascular death [i.e., death from vascular causes], nonfatal myocardial infarction, nonfatal cardiac arrest, and nonfatal stroke) at 30 days after surgery. Our definition for perioperative myocardial infarction included: (1) an elevated troponin T measurement with at least one of the following defining features: ischemic symptoms, development of pathologic Q waves, ischemic electrocardiogram changes, coronary artery intervention, or cardiac imaging evidence of myocardial infarction; or (2) autopsy findings of acute or healing myocardial infarction. RESULTS: We recruited 432 patients across 5 hospitals in Canada, China, Italy, Colombia, and Brazil. During the first 30 days after surgery, 6.3% (99% confidence interval 3.9-10.0) of the patients suffered a major vascular event (10 vascular deaths, 16 nonfatal myocardial infarctions, and 1 nonfatal stroke). The observed event rate was increased 6-fold compared with the event rate expected from the RCRI. Of the 18 patients who suffered a myocardial infarction, 12 (66.7%) had no ischemic symptoms to suggest myocardial infarction. CONCLUSIONS: This study suggests that major perioperative vascular events are common, that the RCRI underestimates risk, and that monitoring troponins after surgery can assist physicians to avoid missing myocardial infarction. These results underscore the need for a large international prospective cohort study.