European Journal of Trauma and Emergency Surgery最新文献

Purpose: Surgical stabilization of posterior rib fractures involving the costotransverse joint is debated, with most patients managed non-operatively. However, surgery may be indicated for respiratory failure due to altered mechanics or severe pain leading to functional limitations. Long-term outcomes related to quality of life and pulmonary function in these patients are underreported. This study aimed to describe our unique experience with the surgical stabilization of posterior rib fractures involving the costotransverse joint and to report the associated outpatient clinical outcomes.

Methods: An observational descriptive study was conducted at a tertiary care institution in Colombia during 2020-2024. Patients with posterior rib fractures involving the costotransverse joint who underwent surgery were included. Data collected included demographics, trauma severity, and complication rates. Primary outcomeswere mortality, postoperative complications, and implant failure.

Results: Eleven patients were included, with a median age of 42 years (interquartile range [IQR] 35-53). The median Injury Severity Score was 26 [IQR 21-35]. The median hospital length of stay was 13 days [IQR 10-17], Intensive care unit stay was 7 days [IQR 4-10], and invasive mechanical ventilation duration was 4 days [IQR 3-4]. One patient (9.1%) experienced a postoperative surgical site infection. Pulmonary function tests revealed a median forced vital capacity at 66% of the predicted value [IQR: 63-73%] and a median forced expiratory volume in the first second at 65% of the predicted value [IQR: 64-70%]. Quality of life assessments indicated acceptable outcomes, with a median score of 60 points [IQR 50-75].

Conclusion: Surgical stabilization of posterior rib fractures involving the costotransverse joint is feasible and yields favorable outcomes, overcoming many technical hurdles. Larger studies with standardized follow-up are needed to validate these findings and establish definitive management guidelines.

Purpose: We aimed to demonstrate which side should be taken care of when fixating an intramedullary nail with a lag screw for an intertrochanteric fracture under the influence of clockwise torque.

Methods: From 2021 to 2023, 63 patients who underwent surgery for intertrochanteric fractures were divided into two groups: Group A (45 patients with left-side fractures) and Group B (18 patients with right-side fractures). We evaluated intraoperative images before fixation and postoperative radiographs to assess anteromedial cortical support. Clinically, the time to union and union rate were evaluated, and the complications, reoperation, and Koval score at one year were reviewed.

Results: Pre-fixation reduction quality showed no significant difference between groups. However, in terms of postoperative reduction quality on the lateral view, Group A had the highest incidence of neutral anterior cortical support (ACS) (62%), whereas Group B had the highest incidence of negative ACS (78%) (p < 0.001). Bone union occurred in 98% of Group A cases and 78% of Group B cases (p = 0.021). The mean time to union was shorter in Group A (5.2 months) compared to Group B (5.8 months) (p = 0.004). The mean Koval score was also better in Group A (2.4 vs. 2.0, p = 0.031).

Conclusion: When fixating intertrochanteric fractures with an intramedullary nail using a lag screw, right-sided fractures tended to exhibit negative ACS on lateral radiographs by clockwise torque. Therefore, particular attention should be paid to maintaining proper reduction while fixating right-sided intertrochanteric fractures.

Purpose: Frailty has gained recognition as a crucial determinant of patient outcomes following traumatic spinal injury (TSI), particularly due to its increasing incidence in elderly populations. The aim of the current investigation was therefore to compare the ability of several frailty scores to predict adverse outcomes in surgically managed isolated TSI patients without spinal cord injury.

Methods: All adult patients (18 years or older) who suffered an isolated TSI due to blunt trauma, and required surgical management, were extracted from the 2013-2021 Trauma Quality Improvement Program database. The ability of the Orthopedic Frailty Score (OFS), the Hospital Frailty Risk Score (HFRS), the 11-factor (11-mFI) and 5-factor (5-mFI) modified frailty index, as well as the Johns Hopkins Frailty Indicator to predict adverse outcomes was compared based on the area under the receiver-operating characteristic curve (AUC). Subgroup analyses were also performed on patients who were ≥ 65 years old and those who were injured due to a ground-level fall (GLF).

Results: A total of 39,449 patients were selected from the TQIP database. The 5-mFI and 11-mFI outperformed all other frailty scores when predicting in-hospital mortality (5-mFI AUC: 0.73) (11-mFI AUC: 0.73), any complication (5-mFI AUC: 0.65) (11-mFI AUC: 0.65), and FTR (5-mFI AUC: 0.75) (11-mFI AUC: 0.75). Among the 14,257 geriatric patients, however, the OFS demonstrated the highest predictive ability for in-hospital mortality (AUC: 0.65). The OFS (AUC: 0.64) also performed on the same level as both the 5-mFI (AUC: 0.63) and the 11-mFI (AUC: 0.63) when predicting FTR in this population. Among the 9616 patients who were injured due to a GLF, the OFS performed on par with the 5-mFI and 11-mFI when predicting in-hospital mortality and FTR.

Conclusion: Simpler scores like the 5-factor modified Frailty Index and Orthopedic Frailty Score outperform or perform on par with more complicated frailty scores when predicting mortality, complications, and failure-to-rescue in surgically managed isolated traumatic spinal injury patients without spinal cord injury, particularly among geriatric patients and those injured in a GLF.

Purpose: The repair of bony non-unions remains challenging and often requires graft material due to limited availability of autologous bone. The aim of this study was to investigate the potency of a stand-alone pedicled periosteal flap (PF) versus a ligated periosteal flap (PFx), an empty defect and a crossover group in terms of newly formed bone in a 5 mm critical-sized defect in the rat femur diaphysis.

Methods: The following 4 treatment groups were formed out of a total of 36 male Sprague Dawley rats: Pedicled periosteal flap, ligated periosteal flap, crossover (each n = 10) and empty defect group (n = 6). A prospective randomized plate osteosynthesis was performed. The periosteal flap was dissected along with the supplying vessel from the medial femoral condyle with the aid of magnifying glasses and fixed to the plate and to the defect with a suture. Regular radiographic and µ-CT examinations were performed to determine bone volume inside the defect, as well as descriptive histological examinations.

Results: Newly formed bone tissue was measured by Bone Volume / Tissue Volume. The significant highest ratio to the control group was detected in the PF group after 10 weeks (18.77%) compared to the crossover- (11.28%; p = 0.0436), the PFx- (10.98%; p = 0.0411), and the control group (10.47%; p = 0.0293). No relevant differences were found in the descriptive histological examination.

Conclusion: According to the observed results, bony healing of non-union defects can be supported with a pedicled periosteal flap. The superiority of the pedicled compared to the ligated periosteal flap suggests that the improved blood flow within the defect area is an essential component of the healing phase itself.

Purpose: Biological matrices have been used to reinforce large rotator cuff tear repairs. However, rapid resorption and initial immune reactions presented challenges in clinical practice. This study evaluates whether a resorbable synthetic matrix (scaffold), used alone or with platelet-rich plasma (PRP), impacts repair processes at microscopic, ultrasound, and biomechanical levels in a rabbit model of induced tendon-bone interface injury.

Methods: An experimental study was performed on 24 rabbits. Two experimental groups (n = 12 each) and a control group (n = 24) were defined. In the first group (BioP), the internal gastrocnemius tendon was sectioned and repaired to bone using double-row sutures, reinforced with a PLC (poly-L-lactic-co-ε-caprolactone) and PLA (polylactic acid) scaffold. In the second group (BioP + PRP), autologous PRP was added to the repair. The control group received no scaffold or PRP. Euthanasia was performed at 8 weeks, followed by microscopic, ultrasound, and biomechanical evaluations.

Results: Microscopically, a granulomatous reaction limited to the foreign body was observed in both scaffold groups. The healing process was not altered in any group, showing good biocompatibility of the scaffold. Echographically, a greater sagittal diameter was observed in the group without PRP compared to the other groups. Biomechanically, no significant differences in rupture zones were found across groups, but the scaffold-only group required a higher maximum applied force before rupture.

Conclusions: At 8 weeks, using a degradable synthetic PLC and PLA scaffold as support at the bone-tendon interface did not significantly alter the normal repair process, showed echographic and biomechanical benefits, and PRP did not show additional benefits in our experimental model.

Purpose: To describe the epidemiology of myocardial injury in trauma patients, in doing so informing design for future multicentre prospective studies.

Method: A one-year retrospective study ending on 31/08/2023 was conducted at a Level-1 Trauma Centre. All adult trauma resuscitation patients with elevated Troponin serum concentration were included. Patient demographics, medical history, mechanism, injury severity, laboratory data, cardiac investigations, LOS, ICU admission and mortality were collected. Patients were categorised into three pragmatic groups based on the timing of their Troponin peak (Group1:<12 h; Group2:12-24 h; Group3:>24 h).

Results: From 1408 admissions, 97(7%) patients [Age:57(35,80); Male:71%; ISS:18(9-33); LOS:9(4,16.5); ICU:66%; Mortality:16.5%] had elevated Troponin. Group 1 [n = 37; Age:47(24,70); Male:76%; ISS:9(4,22); LOS:7(3,14); ICU:51%; Mortaliy:5.4%]; Group 2 [n = 32; Age:53.5(26,74); Male:78%; ISS:27(12.5,53.5); LOS:10(5,17); ICU:84%; Mortaliy:25%] and Group 3 [n = 28; Age:78(62,84); Male:57%; ISS:19(9.5,47.5); LOS:12.5(6,19.5); ICU:64%; Mortaliy:21%]. 64% of patients had thoracic injuries, which was consistent among the three groups. Group 3 had most frequent ECG (61%) and echocardiography (25%) findings.

Conclusion: Troponin elevation occurs in 7% of all trauma admissions and it identifies the seriously injured high-risk cohort. The timing of the maximum Troponin concentration seems to describe three distinct phenotypes. "Hyperacute" with most favourable outcomes, "Subacute" with severe trauma and tissue injury requiring major resource utilisation and associated with the highest mortality rate, and "Late" characterised by ECG and ECHO changes suggesting primary ischaemic cardiac pathology.

Introduction: Rib fractures are prevalent and clinically significant injuries, often associated with thoracic trauma. Despite their frequency, the precise distribution and characteristics of rib shaft fractures remain underexplored. This study investigates the distribution, location, and classification of lateral rib fractures using the AO/OTA classification, focusing on fracture patterns and the relationship to neighbored ribs.

Methods: The study retrospectively analyzed 116 patients with 617 isolated rib fractures treated at a Level 1 trauma center over seven years. Using CT scans, fractures between the tubercle and osteochondral junction of the rib shaft were examined. Fracture type, dislocation, and location were categorized according to AO standards. The 116 patients underwent detailed statistical analysis to identify distribution patterns and correlations between fracture characteristics.

Results: The fractures predominantly occurred between the fifth and seventh ribs, with a focus in the anterolateral to lateral region (40°-69°). Type A fractures were more anteriorly located, while type B fractures and dislocations shifted posteriorly. A regression analysis confirmed the significance of fracture type and dislocation in determining fracture position. Moreover, fractures showed clustering patterns, with adjacent ribs more likely to be injured. A caudal shift in fracture density and localization from the cranial to the caudal thorax was also observed.

Discussion and conclusion: The findings validate the AO/OTA classification for rib fractures, highlighting the need for refined subsegmental divisions within the rib shaft for more precise clinical application. The study underscores the relationship between fracture location, type, and associated injuries, advocating for multicenter studies and a comprehensive classification system for thoracic trauma. This could enhance our understanding of injury patterns and inform treatment strategies.

Purpose: Removal of symptomatic hardware after fracture fixation is common, especially in patients with clavicle fracture. Yet, refracture after hardware removal is a relatively common complication in those patients. The aim of this study was to identify risk factors for clavicle refractures that could be influenced by the surgical treatment provided.

Methods: All patients from a level one trauma center from 2017 to 2022 were screened for eligibility. Inclusion criteria included hardware removal after plate osteosynthesis of the clavicle, age ≥ 18 years, and signed informed consent. Groups were stratified according to occurrence of refracture: no-refracture (NR) vs. refracture (R). Nearest-neighbor matching in a ratio of 5:1 was performed. Parameter investigated included baseline demographics, fracture characteristics and surgical treatment details. A subgroup analysis of only clavicle shaft fractures was performed.

Results: Sixty patients were included with 50 patients in Group NR and 10 in Group R. Baseline characteristics were comparable between the groups. A subgroup analysis on shaft fractures revealed that a significantly larger working length (number of empty screw holes adjacent to the fracture site) in Group NR (1.94 ± 0.85) compared to the refracture group (1.20 ± 0.92) (p = 0.042). Logistic regression yielded an inverse correlation with the number of empty screw holes to the fracture site and the occurrence of refractures (OR 0.369, 95% CI 0.132-0.873; p = 0.035). Time in situ, lag screw application, plate positioning and the total amount of screws did not affect either of the groups.

Conclusion: An increased working length in patients with clavicle shaft fractures might be a protective measure for occurrence of refractures after hardware removal.

Purpose: The application of artificial intelligence (AI) in healthcare has seen widespread implementation, with numerous studies highlighting the development of robust algorithms. However, limited attention has been given to the secure utilization of raw data for medical model training, and its subsequent impact on clinical decision-making and real-world applications. This study aims to assess the feasibility and effectiveness of an advanced diagnostic model that integrates blockchain technology and AI for the identification of tibial plateau fractures (TPFs) in emergency settings.

Method: In this study, blockchain technology was utilized to construct a distributed database for trauma orthopedics, images collected from three independent hospitals for model training, testing, and internal validation. Then, a distributed network combining blockchain and deep learning was developed for the detection of TPFs, with model parameters aggregated across multiple nodes to enhance accuracy. The model's performance was comprehensively evaluated using metrics including accuracy, sensitivity, specificity, F1 score, and the area under the receiver operating characteristic curve (AUC). In addition, the performance of the centralized model, the distributed AI model, clinical orthopedic attending physicians, and AI-assisted attending physicians was tested on an external validation dataset.

Results: In the testing set, the accuracy of our distributed model was 0.9603 [95% CI (0.9598, 0.9605)] and the AUC was 0.9911 [95% CI (0.9893, 0.9915)] for TPF detection. In the external validation set, the accuracy reached 0.9636 [95% CI (0.9388, 0.9762)], was slightly higher than that of the centralized YOLOv8n model at 0.9632 [95% CI (0.9387, 0.9755)] (p > 0.05), and exceeded the orthopedic physician at 0.9291 [95% CI (0.9002, 0.9482)] and radiology attending physician at 0.9175 [95% CI (0.8891, 0.9393)], with a statistically significant difference (p < 0.05). Additionally, the centralized model (4.99 ± 0.01 min) had shorter diagnosis times compared to the orthopedic attending physician (25.45 ± 1.92 min) and the radiology attending physician (26.21 ± 1.20 min), with a statistically significant difference (p < 0.05).

Conclusion: The model based on the integration of blockchain technology and AI can realize safe, collaborative, and convenient assisted diagnosis of TPF. Through the aggregation of training parameters by decentralized algorithms, it can achieve model construction without data leaving the hospital and may exert clinical application value in the emergency settings.