Material and Methods: A retrospective study was conducted in our department from the data collected in the period between 1997 and 2010. There were 86 cases of infected non-union of the tibia, in patients of the age group 18 to 65 years, with a minimum two-year follow-up. Group A consisted of cases treated by ASRL (n=46), and Group B, of cases by IBT (n=40). The non-union following both open and closed fractures had been treated by plate osteosynthesis, intra-medullary nails and primary Ilizarov fixators. Radical debridement was done and fragments stabilised with ring fixators. The actual bone gap and limb length discrepancy were measured on the operating table after debridement. In ASRL acute docking was done for defects up to 3cm, and subacute docking for bigger gaps. Corticotomy was done once there was no infection and distraction started after a latency of seven days. Dynamisation was followed by the application of a patellar tendon bearing cast for one month after removal of the ring with the clinico-radiological union.
Results: The bone loss was 3 to 8cm (4.77±1.43) in Group A and 3 to 9cm (5.31± 1.28) in Group B after thorough debridement. Bony union, eradication of infection and primary soft- tissue healing was 100%, 85% and 78% in Group A and 95%, 60%, 36% in Group B respectively. Nonunion at docking site, equinus deformity, false aneurysm, interposition of soft-tissue, transient nerve palsies were seen only in cases treated by IBT.
Conclusion: IBT is an established method to manage gap non-union of the tibia. In our study, complications were significantly higher in cases where IBT was employed. We, therefore, recommend ASRL with an established protocol for better results in terms of significantly less lengthening index, eradication of infection, and primary soft tissue healing. ASRL is a useful method to bridge the bone gap by making soft tissue and bone reconstruction easier, eliminating the disadvantages of IBT.
METHODS: Electronic health records were linked to echocardiography data between 2015 and 2021 from patients in Tayside, Scotland (population~450 000). Incident HF diagnosis was classified into inpatient or outpatient and stratified by ejection fraction (EF). A non-HF comparator group with normal left ventricular function was also defined. The primary outcome was time to cardiovascular death or hHF within 12 months of diagnosis.
RESULTS: In total, 5223 individuals were identified, 4231 with HF (1115 heart failure with reduced ejection fraction (HFrEF), 666 heart failure with mildly reduced ejection fraction, 1402 heart failure with preserved ejection fraction and 1048 HF with unknown EF) and 992 with non-HF comparators. Of the 4231 HF patients, 2169 (51.3%) were diagnosed as inpatients. The primary outcome was observed in 1193 individuals with HF (28.1%) and 32 (3.2%) non-HF comparators and was significantly more likely to occur in individuals diagnosed as inpatients than outpatients (809 vs 384 events; adjusted HR: 1.62 (1.39-1.89), p<0.001), and this was consistent regardless of EF. For HFrEF patients first diagnosed as inpatients, those discharged on ≥2 GDMT had a reduced incidence of the primary outcome compared with those discharged on <2 GDMT (303 vs 175 events; adjusted HR: 0.72 (0.55-0.94), p=0.016).
CONCLUSIONS: Individuals whose first presentation was a HF hospitalisation had a significantly worse outcome than those who were diagnosed in the community. Among hospitalised individuals, higher use of GDMT was associated with improved outcomes. Our results highlight the importance of improving diagnostic pathways to allow for earlier identification and treatment of HF.