Journal of Orthopaedic Trauma最新文献

Objective: To compare rates of fracture-related infection (FRI) and acute kidney injury (AKI) in patients with open fractures treated with ceftriaxone (CTX) monotherapy or piperacillin-tazobactam (PIP-TAZ) monotherapy.

Methods: Design: Retrospective cohort study.

Setting: Single Level I Trauma Center (2020-2023).

Patient selection criteria: Adults who sustained an open fracture of the femur, tibia, humerus, radius/ulna, and foot fractures (metatarsals, calcaneus, talus), and underwent operative irrigation and debridement. Exclusion criteria were less than 6 months of follow-up, hospital transfers, primary amputation, receipt of vancomycin within the first 48 hours in addition to CTX or PIP-TAZ, and cases requiring vascular bypass, rotational or free flaps, or full-thickness skin grafts.

Outcome measures and comparisons: Primary outcomes were rates FRI and AKI. Outcomes were compared between patients receiving prophylactic CTX versus PIP-TAZ monotherapy.

Results: A total of 156 patients with open fractures were identified, of which 136 met inclusion criteria: 67 treated with CTX monotherapy and 69 with PIP-TAZ monotherapy. The mean age was 46.2 years (range: 18-86) in the CTX cohort and 41.6 years (range: 19-83) in the PIP-TAZ cohort, and males comprised 56.7% and 72.3% of each group, respectively. Differences between groups were limited to a longer mean follow-up duration in the PIP-TAZ cohort (p < 0.001) and a higher prevalence of soil contamination in the CTX cohort (11.9% vs 1.4%, p = 0.015). There were no statistically significant differences in rates of FRI (25.4% CTX vs. 29.0% PIP-TAZ, p = 0.501) or AKI (11.9% vs. 15.9%, p = 0.636) between groups. On multivariate analysis, diabetes (OR 6.62, p = 0.003) was independently associated with increased FRI risk, while soil contamination (OR 3.42, p = 0.180) and external fixation (OR 1.92, p = 0.163) demonstrated non-significant trends toward higher risk.

Conclusion: In this retrospective cohort of patients with open fractures, ceftriaxone and piperacillin-tazobactam demonstrated comparable outcomes in both fracture-related infection and acute kidney injury. Diabetes was found to be a statistically significant risk factor for FRI.

Level of evidence: III.

Objectives: To evaluate trends in pain medication prescriptions following pilon fracture open reduction and internal fixation (ORIF) in the context of recent initiatives to reduce opioid use and promote multimodal pain management.

Methods: Design: Retrospective database study.

Setting: US national administrative dataset (PearlDiver M170Ortho database).

Patient selection criteria: Included were patients undergoing pilon fracture (AO-OTA 43A/B/C) ORIF from 2010-2021 without history of pre-injury narcotic use, polytrauma, substance abuse, or neoplasm.

Outcome measures and comparisons: This study captured prescriptions for pain medications within 90 days postoperatively after definitive pilon fracture fixation, categorized by drug category. Annual prescriptions and morphine milligram equivalents (MMEs) per 1,000 surgeries were trended over the study interval. Timing of opioid prescriptions postoperatively was determined. Multivariable analysis was performed to determine factors independently associated with opioid prescriptions.

Results: Included were 13,108 pilon fracture ORIF patients of which the average age was 50 years (range 18-84 year, (49.9%) female). Discretely billed outpatient opioid prescriptions decreased from 434.1 per 1,000 surgeries in 2010 to 165.7 in 2021 (-61.8%). Prescriptions of other pain management drugs on aggregate decreased less drastically from 276.6 in 2010 to 195.3 in 2021 (-29.4%). The proportion of all analgesics prescribed postoperatively that were opioids decreased from 60.3% in 2010 to 45.9% in 2021. Among patients who received opioids within 90-days postoperatively, MMEs prescribed per 1,000 pilon fracture ORIF surgeries decreased from 589,486 in 2010 to 59,795 in 2021 (-91.3%). 97% of opioids were prescribed in the first two weeks postoperatively. Predictors of postoperative opioid prescriptions by multivariate analysis included younger age (OR 1.29 per decade decrease), male sex (OR 1.54), lower ECI (OR 1.28) (p<0.0001 for all). Patients who had repair of tibia and fibula fractures did not have greater odds of postoperative opioid prescriptions than those who had repair of the tibia alone.

Conclusions: Opioid prescriptions following pilon fracture ORIF decreased substantially from 2010 to 2021. Prescriptions for non-opioid analgesics also decreased but to a lesser extent. Younger age, male sex, and lower comorbidity burden were associated with higher post-operative opioid prescribing.

Level of evidence: III.

Objectives: To determine if use of a mini C-arm increased emergency department efficiency and decreased patient radiation exposure and the frequency of repeat closed reductions, as compared to traditional post-reduction radiographs in isolated distal radius and ankle fracture patients.

Methods: Design: Retrospective chart review.

Setting: Academic Level 1 Trauma Center.

Patient selection criteria: Adult patients with an isolated distal radius (OTA/AO 2R3A2), bimalleolar or trimalleolar ankle (OTA/AO 44B1) fractures requiring closed reduction by the orthopaedic surgery team in an academic level 1 trauma center emergency department (ED) from 2013-2023 were included. Patients with pathologic fractures were excluded.

Outcome measures and comparisons: Closed reductions in which mini C-arm imaging was utilized were compared to those that utilized traditional post-reduction radiographs. Total radiation exposure to the patient during the encounter (mGy), closed reduction radiation exposure (mGy), the number of repeated reductions in the ED requiring an additional analgesic/anesthetic event and splint application, orthopaedic consult time, doctor visit to discharge time, and time under sedation (conscious or unconscious) were compared between the mini C-arm group and the traditional post-reduction radiographs group.

Results: 199 subjects met inclusion criteria (81 ankle fractures and 118 distal radius fractures). For the mini C-arm group, the mean age was 59 years (range 25-93) and 58% of the patients were female (n = 14). For the traditional post-reduction radiographs group, the mean age was 58 years (range 21-90) and 55% of the patients were female (n = 96). Use of a mini C-arm (16 ankle fractures and 8 distal radius fractures) versus traditional post-reduction radiographs (65 ankle fractures and 110 distal radius fractures) resulted in significantly lower total radiation exposure, 0.9 mGy versus 0.4 mGy (p<0.001), and closed reduction radiation exposure, 0.5 versus 0.1 mGy (p<0.001); fewer repeated reductions,65 versus 0 repeated reductions (p<0.001); and shorter time from doctor visit to discharge, 6.2 versus 3.8 hours (p<0.001), orthopaedic consult time, 4.0 versus 1.7 hours (p<0.001), and time under sedation, 37 versus 26 minutes (p=0.046).

Conclusions: This study found that the use of a mini C-arm compared to traditional post-reduction radiographs for distal radius and ankle fracture closed reductions improved ED efficiency and decreased patient radiation exposure and repeated closed reductions.

Level of evidence: Level III.

Objectives: To determine if initial vertical fracture displacement affects postoperative outcomes following operative treatment of patella fractures.

Methods: Design: Prognostic retrospective study.

Setting: Single multi-site urban academic institution.

Patient selection criteria: Included were patients aged ≥18 years who underwent open reduction internal fixation of a patella fracture (AO/OTA 34A-C) with minimum 6-month follow-up, and complete trauma knee x-ray series. Vertical fractures and those without significant vertical displacement (<2mm) were excluded.

Outcome measures and comparisons: Initial vertical fracture displacement was recorded. Follow-up data included knee range-of-motion and post-operative complications: nonunion, fracture related infection (FRI), hardware failure, suspected FRI, knee contracture, inferior sleeve displacement, and venous thromboembolism events. Comparisons were made between the initial amount of displacement and postoperative complications.

Results: 229 patients with a median follow-up duration of 12 months (IQR: 6-14) were included. The mean age was 61.2 ± 15.1 years, BMI was 25.4 ± 4.7 kg/m2, and 69.0% (n = 158) were female. OTA fracture classification was: 35.4% C1, 32.3% C3, 17.9% C2, and 14.4% A1. Fixation methods included 63.8% tension band wiring, 17.9% suture repair, 13.5% plate and screws, and 4.8% screws with suture. 33 (14.4%) patients sustained complications. The mean displacement was significantly higher in patients who developed complications (21.6 mm ± 15.0 mm vs. 14.8 mm ± 10.1 mm, p=0.018), particularly for nonunion (29.8 mm ± 13.5 mm vs. 15.1 mm ± 10.6 mm, p<0.001) and hardware failure (30.8 mm ± 12.0 mm vs 15.4 mm ± 10.9 mm, p<0.001). Suture-only and screw-with-suture fixation had higher nonunion rates (p=0.004, p=0.005) than other fixation methods independent of displacement. Initial displacement predicted nonunion and hardware failure (AUROCs=0.818 and 0.838). Youden Index thresholds of >26.6mm and >21.7mm identified patients at increased risk for nonunion and hardware failure. Each millimeter increase in displacement raised nonunion and hardware failure risk by 14.9% (OR=1.1, p=0.003) and 14.6% (OR=1.1, p=0.003).

Conclusions: This study supports the future use of initial vertical fracture displacement as a prognostic tool for nonunion and hardware failure after patella ORIF. Displacement >2cm placed patients at high risk for these complications. Nonunion rates were higher in both suture only and screw-with-suture fixation when compared to other fixation constructs.

Level of evidence: III.

Objectives: To evaluate the clinical performance, screw placement accuracy, and complication profile of intraoperative computed tomography (CT) -guided anterior subcutaneous internal fixation (INFIX) for unstable anterior pelvic ring fractures.

Methods: Design: Retrospective study.

Setting: Single tertiary emergency medical center, equivalent to a Level I Trauma Center.

Patient selection criteria: A retrospective review was performed of skeletally mature patients with unstable anterior pelvic ring injuries (OTA/AO type 61) treated with CT-navigated INFIX fixation between December 2020 and December 2024. Patients with incomplete imaging or follow-up were excluded.

Outcome measures and comparisons: Primary outcomes included operative time, intraoperative blood loss, screw placement accuracy (axial angle and skin-to-head distance), and functional outcomes using a modified Majeed score (excluding work and sexual activity domains). Complications were recorded and compared by fixation construct.

Results: A total of 41 patients were included, with mean age 50.7 ± 24.0 years. Mean operative time was 121.0 ± 61.8 minutes and mean intraoperative blood loss was 86.8 ± 113.0 mL. Temporary external fixation was used in 48.8% of cases. The normalized modified Majeed score averaged 87.5 ± 12.7, and 65.9% of patients achieved "excellent" outcomes. The most frequent complication was lateral femoral cutaneous nerve (LFCN) injury (26.8%). No screw displacement occurred in cases with additional posterior fixation. Postoperative CT demonstrated consistent screw placement (mean axial angle, 27.0°; mean skin-to-head distance, 15.3 mm), and no major neurovascular complications were observed.

Conclusions: CT-guided INFIX allowed accurate screw placement with a low rate of major complications. Early functional outcomes were favorable when assessed with a modified score tailored to the study population. Combined anterior-posterior constructs enhanced fixation stability. Prospective comparative studies were warranted to clarify long-term outcomes.

Level of evidence: Level IV.

Objective: To investigate the relationship of avascular necrosis (AVN) of the talus with postoperative outcomes and to assess the utility of the Hawkins sign and its ability to predict talar vitality following talar fracture or dislocation.

Methods: Design: Retrospective cohort study.

Setting: Single center, academic, Level I Trauma center.

Patient selection criteria: Patients with talus injuries (AO/OTA 81-A, 81-B, 81-C) treated from 2007-2017 were included.Outcome measures and comparisons: Variables analyzed included anatomic location, fracture classification, timing of surgery, reduction quality, and the presence or absence of Hawkins' sign. Outcomes measured included development of AVN, degree of collapse, union, posttraumatic arthritis, prognotistic reliability of the Hawkins's sign and secondary reconstructive surgery (SRS). Data were analyzed using binary logistic regressions.

Results: Seventy-nine patients were reviewed, 65% of which were male, with mean age of 37.7 years (range 18-83). Patients were followed for average of 32.5 months post-surgery. Of the 79 patients, 30 developed AVN (38%) and 20 of the 79 required SRS (25%). Of the 20 SRS cases, AVN was an indication for 6 cases (30%). Of the 30 AVN cases, 27 (90%) demonstrated less than 25% collapse of the talar dome, with 3 demonstrating more than 25% collapse. Age at time of surgery and a higher number of incisions were associated with AVN (B=0.051 p=0.01 and B=2.173 p=0.001). Timing of surgery (<24hrs), and anatomic reduction were not associated with the development of AVN (B=0.602 p=0.286 and B=0.641 p=0.491). Non-anatomic reduction was associated with higher rates of SRS (B=-1.777 p=0.033).

Conclusion: Radiographic evidence of AVN was common after fractures and dislocations of the talus, with 38% of patients in this study developing AVN. However, the development of AVN did not influence the rate of SRS at follow up. This may be explained by the fact that most AVN patients (90%) had less than 25% collapse. Factors associated with AVN development included increased age at surgery and an increase in the number of incisions. The development of AVN had no detrimental clinical impact in this study.

Level of evidence: III.

Objectives: To compare the outcomes of intramedullary fixation of intertrochanteric femur fractures treated with a single lag screw (Gamma3) and a dual integrated screw design (Intertan), including outcomes depending on the mode of proximal lag screw fixation (static or dynamic).

Methods: Design. A pragmatic, single-blinded RCT with a three-arm parallel group design.

Setting: A multicentre PRCT, with a Level 1 academic trauma centre and a second linked smaller level 2 hospital.

Patient selection criteria: Patients aged over 60 undergoing intramedullary screw fixation of a standard obliquity intertrochanteric femur fracture (AO/OTA 31A1 or A2) were randomized into three groups: single lag screw (dynamically locked); dual integrated lag screw (dynamically locked) and dual integrated lag screw (statically locked).

Outcome measures and comparisons: The primary outcome measure was radiographic failure of the device by 6 months, judged by any one of cut-out requiring re-operation, a change in tip-apex distance of more than 10mm, or breakage of the metal. Pairwise comparisons were performed between the 3 study groups. Secondary outcomes included all cause re-operation rates, and degree of secondary collapse.

Results: 477 patients were randomised. 27 patients were excluded after randomisation and 95 died prior to 6 months. 226 had full follow up to the primary outcome point of 6 months: (80 Gamma, mean age 83 (range 60 -101), 60% female; 72 Intertan dynamic, mean age 80 (range 60 - 101), 63% female; 74 Intertan static, mean age 82 (range 61 - 97), 72% female). A further 129 had clinical follow-up but no radiographs. No difference was seen in radiographic failure by 6 months between the Gamma nail (single lag screw) and the Intertan Dynamic (dual lag screw) groups (11.3% vs 9.7%, p=0.74); Initial tip-apex distance remained statistically the most significant independent predictor of failure (Mean TAD of 15.7mm in non-failure group, 23mm in failure group, p<0.001 ). The Intertan group with a statically locked proximal lag screw had a lower (non-statistically significant) radiological failure rate (1.4%) than either dynamically locked group (Gamma 11.3%, Intertan dynamic 9.7%, p=0.05). Re-operation rates were similar for all groups (Intertan static 2%, Gamma 3.3%, Intertan dynamic 5.3%, p=0.42).

Conclusions: In patients over 60 undergoing intramedullary fixation of standard obliquity intertrochanteric fractures, the failure rate was not higher when using the Intertan nail in the proximally locked mode, when compared with either the Intertan nail or Gamma nail used in the dynamic proximal locking mode.

Level of evidence: Therapeutic Level I.

Objectives: To compare deep infection rates from ballistic ilium fractures in which the trajectory traversed the bowel before entering bone versus those that enter the bone before bowel, and to identify factors associated with deep infection of the bony pelvis.

Methods: Design: Retrospective cohort study.

Setting: Eight Level I trauma centers.

Patient selection criteria: Patients 18 years or older with ballistic ilium fractures (OTA/AO 61) and minimum 6-months of radiographic and clinical follow-up from January 2019 to December 2024.

Outcome measures and comparisons: The primary study outcome was the rate of secondary deep pelvic bony infection requiring subsequent surgical irrigation and debridement. Associations between ballistic trajectory (traversing bowel before entering bone [Bowel] versus bone before entering the abdomen [Bone]) were determined from computed tomography images; concomitant associated injuries, patient characteristics, and other interventions with the primary outcome were assessed using multivariable logistic regression.

Results: A total of 201 patients with ballistic ilium fractures were included; 88.6% were male, and the average age was 32.9 ± 12.3 years. Of these, 83 (41%) sustained ballistic injuries that traversed the bowel before entering bone (Bowel), 69 (34%) entered the bone before the bowel (Bone), and 49 (24%) had an indeterminate trajectory. The Bowel cohort had a higher average injury severity score (20.2 versus 12.5, p<0.001), lower prevalence of other drug use (39.8% versus 56.5%, p=0.025), and greater incidence of exploratory laparotomy (90.4% versus 36.2%, <0.001). Bowel patients experienced higher rates of deep infection requiring surgical debridement (10.8% versus 1.4%, p=0.017). On multivariate analysis, deep infection requiring surgical bony debridement was significantly associated with bullet trajectory traversing the bowel before entering the bone (odds ratio 14.6, 95% confidence interval 1.3-160.8, p=0.021).

Conclusions: Ballistic ilium fractures that traverse the bowel before entering bone were associated with higher rates of deep infection requiring bony debridement. The role of acute bony irrigation and debridement in these patients warrants further investigation.

Level of evidence: Prognostic Level III.

Objective: To define a CT-derived zone-of-injury metric, incorporating normalized soft-tissue air extent and BMI and secondly to determine if this metric was associated with adverse outcomes following an open OTA 42A-C tibia fractures.

Methods: Design: Retrospective cohort study.

Setting: Level I trauma center.

Patient selection criteria: A retrospective review of patients in a tibia fracture registry (2012-2024) meeting inclusion criteria (age ≥18 years old, open OTA 42A-C fractures, preoperative full length tibia CT imaging, ≥6-month follow-up) was performed.Outcome Measures and Comparisons: The CT-based ZOI was measured as the longitudinal extent of soft-tissue air (mm) normalized to tibial length (mm) (ZOIsoft/Tibial Length). The primary outcome was composite complications including fracture related infection, amputation, or nonunion. A logistic regression model using ZOIsoft/Tibial Length and BMI generated predicted probabilities for composite complications. Model discrimination was assessed via area under receiver operating characteristic (AUROC) analysis and compared to Gustilo-Anderson classification using the DeLong test. An optimal probability threshold was derived statistically (Youden Index) for dichotomizing patients into high- and low-risk cohorts.

Results: Fifty-five patients (58 fractures) met inclusion criteria (mean age 40.0 ± 15.1 years; 81.0% male; mean follow-up 16.9 ± 9.5 months). Soft-tissue ZOI and BMI were the significant predictors of composite complications (p = 0.006, 0.061). The CT-based ZOI model (log(p/1-p) = 0.601 + (3.343 × soft-tissue ZOI/Tibial Length) + (-0.106 × BMI) demonstrated superior discrimination (AUROC = 0.752) compared to Gustilo-Anderson (AUROC = 0.581, p = 0.042). Patients above the derived threshold (0.403) had significantly worse outcomes: composite complication rate 64.0% vs. 18.2% (p < 0.001) and nonunion (52.0% vs. 9.1%, p < 0.001). Amputation (20.0 vs 3.0%, p = 0.075) and fracture-related infection (32.0% vs. 15.2%, p = 0.203) were not significant.

Conclusions: A novel CT-based ZOI metric integrating soft-tissue injury extent as measured by soft-tissue air and BMI independently predicted overall complications risk. This newly described CT-based ZOIsoft metric provided superior prognostic accuracy compared to Gustilo-Anderson classification and may enhance early risk stratification in open tibia fractures.

Level of evidence: Prognostic Level III.