Journal of Orthopaedic Trauma最新文献

Objectives: To compare the outcomes of comminuted patella fractures fixed with a new patella-specific 2.7mm variable angle (VA) locking plate in isolation versus when augmentation of fracture fixation is applied with the plate.

Methods: Design:Retrospective.

Setting: Academic Level I Trauma Center.

Patient selection criteria: All acute comminuted patella fractures (AO/OTA 34-C3; complete displaced or undisplaced articular, frontal/coronal multifragmentary fractures) in adult patients primarily treated with a new patella-specific 2.7 mm VA locking plate (Synthes, Paoli, PA) between January 2021 and February 2024 at a single academic center were reviewed and divided in those fixed with the patella plate alone and those with additional bony and/or soft tissue augmentation. Excluded were those with < 90 follow-up, set a priori, unless complications occurred <90 days.

Outcome measures and comparisons: Comparison of patient age, sex, BMI, ASA, FRAX score, open fracture, polytrauma involvement, length of follow-up and post-operative protocols was made between groups. The primary outcome measure was loss of fixation. Secondary outcomes were mode of failure and other surgical complications.

Results: There were a total of 38 included patients, with no lack of or loss of follow-up, with 20 grouped into patella plate alone, and 18 into patella plate plus augmentation. The plate only group had a higher mean age (63.7 vs. 46.9, p=0.024), with no between-group differences in sex (65% vs. 44% female, p=0.20), BMI (p=0.51), 10-year fracture risk (FRAX) (p=0.06), open fractures (p=0.30), polytrauma involvement (p=0.97), or postoperative weight-bearing (p=0.76) or range of motion (p=0.06) protocols. There were eight failures (40.0%) in the plate-only group, and two failures in the plate with augmentation group (11.1%); (p=0.043). When controlling for known risk factors for osteoporosis and poor bone quality using the FRAX 10-year fracture risk on multivariable regression analysis, plate fixation with fracture augmentation was associated with a lower risk of fixation failure (OR=0.14, 95% CI 0.02-0.75; p=0.036). The plate-only group failed by loss of distal (62.5%, n=5) and proximal fixation (37.5%, n=3). Each of the two failures in the plate plus augmentation group had loss of distal fixation.

Conclusions: Treatment of comminuted patella fractures with a new patella-specific 2.7mm VA locking plate has a high failure rate when used in isolation. Augmenting fracture fixation with soft-tissue repair and/or independent fracture fragment fixation may significantly decrease failure rates. In particular, augmentation of the tendon avulsion component to restore the extensor mechanism appears critical.

Level of evidence: Therapeutic Level 3.

Objectives: To compare blood loss and transfusion rates in geriatric hip fracture patients on direct oral anticoagulants undergoing surgery ≤ 24 hours from admission (Expedited group) versus 24-72 hours from admission (Delayed group).

Methods: Design: Retrospective cohort study.

Setting: Level I Trauma Center.

Patient selection criteria: Patients aged ≥ 65 with a femoral neck, intertrochanteric, or subtrochanteric fracture (AO/OTA 31A, 31B, and 32) on factor Xa inhibitors (apixaban or rivaroxaban) prior to admission from April 2014 to April 2024 were included.Outcome Measures and Comparisons: Primary outcomes were preoperative blood loss (difference between admission hemoglobin (Hgb) and lowest preoperative Hgb), overall blood loss (difference between admission Hgb and lowest postoperative Hgb within four days postop), and transfusion rates. Secondary outcomes were length of stay (LOS) and 90-day complication (cerebrovascular accident, myocardial infarction, deep venous thrombosis, pulmonary embolism, urinary tract infection, gastrointestinal bleed, pneumonia, acute kidney failure, surgical site infection), readmission, reoperation, and mortality rates.

Results: The Expedited group (n=67) and Delayed group (n=183) were similar in age (85.2±6.8 years (67-97) vs. 84.4±7.5 years (65-101), p=0.405) and sex (50.7% vs. 37.2% male, p=0.084). The Delayed group had higher preoperative blood loss (1.2±1.3 g/dL vs. 0.80±1.0 g/dL, p=0.003) with no differences in overall blood loss (2.9±.1.7 g/dL vs. 2.9±1.7 g/dL, p=0.881) and transfusion rates (28.4% vs. 25.4%, p=0.634). The Expedited group had a shorter LOS (6.0±5.6 days vs. 7.1±3.3 days, p<0.001). The Delayed group had a higher 90-day complication rate (41.5% vs. 19.4%, p=0.001). The Expedited group did not have higher rates of 90-day readmission (22.4% vs. 25.7%, p=0.593), reoperation (4.5% vs. 3.8%, p=0.730), or mortality (9.0% vs 6.6%, p=0.581).

Conclusions: For geriatric hip fracture patients on factor Xa inhibitors, surgery ≤ 24 hours from admission reduced preoperative blood loss without increasing risk for overall bleeding, transfusion, or 90-day complication.

Level of evidence: Therapeutic Level III.

Objective: To determine if anterior internal or definitive external fixation combined with posterior internal fixation of unstable pelvic fractures was associated with frequency of discharge to home.

Methods: Design: Retrospective cohort study.

Setting: Two Level 1 Trauma Centers and one academic tertiary referral center.

Patient selection criteria: Patients aged ≥16 years with unstable OTA/AO 61B/C pelvis fractures treated with operative fixation of the anterior and posterior pelvic ring by three fellowship-trained orthopaedic trauma surgeons from October 2020 to November 2022.

Outcome measures and comparisons: The primary outcome was the adjusted odds of discharge to home with internal fixation compared with definitive external fixation of the anterior pelvic ring on multivariable analysis considering patient, injury, and treatment characteristics. Secondary outcomes included bivariable associations between anterior fixation type and intensive care unit (ICU) days, ventilator days, hospital length of stay, and hospital charges.

Results: Seventy-nine patients (65%) who were treated with internal fixation presented with higher mean Glasgow Coma Scale scores (13.5±3.6 vs 10.5±5.4, p<0.01) than 43 patients treated with definitive external fixation, but were otherwise similar to with regard to age (mean 48.1±19.9 vs 41.2±15.8, range (16-96) vs (19-77), p=0.07), sex (36.7% vs 44.2% female, p=0.42193), mean, body mass index (28.4±6.2 vs 28.7±7.4 kg/m2, p=0.93), any medical comorbidities (50.6% vs 44.2%, p=0.62), substance use ((13.9% vs 27.9%, p=0.09884), insurance type (p=0.97), mean Injury Severity Score (24.8±12.0 vs 29.5±14.0, range 5-57 vs 10-57, p=0.14), pelvis fracture pattern (p=0.12187), and preinjury living environment(p=0.67695). On multivariable analysis, patients treated with internal fixation were more frequently discharged to home (53.2% vs 27.9%, odds ratio 3.39, 95% confidence interval 1.29-9.84, p=0.0198). Patients treated with anterior internal fixation also experienced fewer mean ICU days (6.0±8.8 vs 9.8±16.3, p=0.0213), ventilator days (3.5±8.2 vs 6.9±15.9, p<0.0081), and hospital days (18.7±16.2 vs 31.2±26.7, p<0.01); and incurred less hospital charges ($278,563.29±$261,602.35 vs $580,625.98±$503,067.98, p<0.01).

Conclusions: Patients who received anterior and posterior internal fixation of their unstable pelvis fractures were more likely to discharge to home than patients treated with anterior definitive external fixation and posterior internal fixation. Anterior internal fixation was also associated with fewer ICU, ventilator, and hospital days, as well as less hospital charges.

Level of evidence: Therapeutic Level III.

Objectives: To determine whether suprapatellar or infrapatellar approach makes a difference in the rate of rotational malalignment in tibial diaphyseal fractures treated with intramedullary nailing.

Methods: Design: Non inferiority, randomized controlled trial, with 2 arms (Suprapatellar and Infrapatellar approach).

Setting: Single centre trial at a Level I trauma centre in South India.

Patient selection criteria: Adults presenting with tibial diaphyseal fractures (OTA/AO 42A, B and C, 43A) planned for intramedullary nailing between September 2021 to July 2022.

Outcome measures and comparisons: The primary outcome compared was the degree of rotational malignment in patients undergoing tibia nailing with Suprapatellar and Infrapatellar approaches. This was done using CT scan in the immediate post-operative period. Secondary outcomes included across the 2 groups were post-operative entry site pain, anterior knee pain (Kujala score), functional scores and union rates.

Results: 50 patients, 25 in each arm were included and followed up to a period of 1 year. The mean age was 34 (16-67) years (68% male) in the suprapatellar group and 45 (16-72) years (72% male) in the infrapatellar group. The rate of rotational malalignment was 34% with 8 (32%) in the suprapatellar group and 9 (36%) in the infrapatellar group and was independent of approach (P=0.76). The rotational malalignment had no association with knee functional scores (P=0.24). Factors such as location of fracture (P=0.81), mechanism of injury (P=0.76), type of injury (P=0.24) and surgeon seniority (P=0.2) had no association with malrotation. Suprapatellar and infrapatellar groups were similar in terms of knee function (P=0.52), knee (P=0.31) and ankle P=0.23) range of movement and union rates (P=0.84). Entry site pain was found to be significantly less (P=0.021) in the suprapatellar group (6/25) as compared to the infrapatellar group (14/25).This difference persisted at 1 year.

Conclusions: Rotational malalignment in tibial diaphyseal fractures treated by intramedullary nailing was independent of the approach used. Entry site pain was less common with suprapatellar approach.

Level of evidence: Level I.

Objectives: To compare the results of anterior to posterior screws (AP screws) versus posterior buttress plating in the fixation of posterior columns fractures in pilon injuries, regarding the 1) functional and 2) radiological outcomes and 3) the incidence of complications.

Methods: Design: Prospective, randomized clinical trial.

Setting: Single Center, Level 1 trauma Center.

Patient selection criteria: All patients with two, three and four column fracture according to the four-column classification (OTA/AO 43-C1 and 43-C2) during the study period were eligible for inclusion. Patients were randomized into two groups: direct reduction and fixation by posterior buttress plating (group A) and indirect reduction with fixation by AP screws (group B). Exclusion criteria included pediatric age group with open physis, pathological fractures, open fractures and fractures with neurovascular injuries. The minimum follow up period was 24 months.

Outcome measures and comparisons: The primary outcome was the quality of reduction as evaluated using postoperative plain radiographs and computed tomography (CT). Secondary outcomes included the functional American Orthopaedic Foot and Ankle Society (AOFAS) score and the incidence of complications.

Results: 30 patients were included, 15 patients were randomized to group A (mean age 42.3 (range 19-65) and 15 patients in group B (mean age 38.0 in group B (range 23-58). The mean follow up was 32 months (24-45 months). Anatomical reduction was achieved in 80% and 26.7% of group A and group B respectively. AOFAS score was significantly higher in group A compared to group B (p=0.03). There was no statistically significant difference between the two groups regarding the time to union and the complication rates (p>0.05).

Conclusions: A higher percentage of anatomical reduction was associated with direct reduction and posterior buttress plating compared to indirect reduction and anterior to posterior screws. This was reflected by a significantly higher AOFAS score.

Objectives: This study aimed to assess the relationship between postoperative alignment and nonunion in patients with tibial shaft fractures treated with intramedullary nailing.

Methods:

Design: Retrospective case-control study.

Setting: Single academic trauma center.

Patients selection criteria: Adult patients with closed or open tibial shaft fractures (42A-C) treated with intramedullary nailing from 2007 to 2018.

Outcomes measures and comparisons: Case patients with nonunion were compared with control patients with radiographic evidence of healing in terms of the postoperative tibial alignment measured in the coronal and sagittal planes.

Results: Of the 192 included patients (median age, 38 years; 76% male), 51 patients had a nonunion, and 141 patients had united fractures and served as the control group. A strong association between postoperative tibial malalignment in 1 plane and nonunion (odds ratio, 3.0; 95% confidence interval, 1.1-8.3; P = 0.03) was demonstrated. This association was even greater for malalignment in both coronal and sagittal planes (odds ratio, 5.7; 95% confidence interval, 2.1-16.1; P < 0.001) after controlling for confounders.

Conclusions: After controlling for confounding factors, postoperative malalignment in the coronal or sagittal plane was associated with significantly increased odds of tibial shaft nonunion after intramedullary nailing.

Level of evidence: Prognostic, Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To determine the top 100 cited authors and the top 20 articles in the Journal of Orthopaedic Trauma (JOT) and compare its impact factor to orthopaedic and non-orthopaedic surgery literature.

Design: Review.

Methods: The Web of Science database was used to determine the top 100 cited authors and top 20 cited articles that originated in JOT from 1995 to the present. The total number of citations for each article and author in first, last, and any author position for publications in JOT, and the location of training and current place of work for each author were gathered. Each author's total number of citations as first author was tallied to determine the top 100 JOT first authors. The Journal Citation Reports database was searched to determine the impact factor (IF) of multiple orthopaedic and non-orthopaedic journals from 1997 to 2023. Yearly IF and yearly IF percent growth were calculated.

Results: The number of citations for the top 20 cited articles in JOT ranged from 302 to 787. Of the top 100 JOT first authors by citation number, 93 were orthopaedic surgeons. 65% of these completed a residency in the United States, 61% worked in the United States, and of the authors that work in the United States, 70.5% practice in an academic setting. From 1997 to 2023, JOT's mean yearly IF was 1.6, and the mean yearly IF percent growth was 6.1%. The mean IF for included comparison orthopaedic subspecialty journals was 2.3, with 5.6% mean yearly IF percent growth. JOT's median IF was 1.8 and was second to Injury (IF 1.9) within orthopaedic trauma journals evaluated.

Conclusions: This bibliometric analysis shows that JOT's most cited authors are primarily U.S.-trained orthopaedic surgeons in academic environments. JOT has consistently experienced annual growth in its impact factor throughout its almost 30-year history and has one of the highest impact factors of measured orthopaedic trauma journals.

Level of evidence: IV.