Journal of Orthopaedic Trauma最新文献

Objective: To determine whether 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 or older 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 regarding age [mean 48.1 ± 19.9 vs. 41.2 ± 15.8, range (16-96) versus (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/m 2 , 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. See Instructions for Autho

Objectives: To compare blood loss and transfusion rates in geriatric patients with hip fracture 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 years with a femoral neck, intertrochanteric, or subtrochanteric fracture (AO/OTA 31A, 31B, and 32) on factor Xa inhibitors (apixaban or rivaroxaban) before 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 4 days postoperation), and transfusion rates. Secondary outcomes were length of stay 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) versus 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 ± 0.1.7 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 length of stay (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 patients with hip fracture 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. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To compare the results of anterior to posterior screws (AP screws) versus posterior buttress plating in the fixation of posterior column 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 2-, 3-, and 4-column fracture according to the 4-column classification (orthopedic trauma association/Arbeitsgemeinschaft für Osteosynthesefragen 43-C1 and 43-C2) during the study period were eligible for inclusion. Patients were randomized into 2 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. Secondary outcomes included the functional American Orthopaedic Foot and Ankle Society (AOFAS) score and the incidence of complications.

Results: Thirty 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. The AOFAS score was significantly higher in group A compared with group B ( P = 0.03). There was no statistically significant difference between the 2 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 with indirect reduction and AP screws. This was reflected by a significantly higher AOFAS score.Clinical Trials Registration Number: NCT05303389.

Level of evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Lateral compression pelvic fractures represent a spectrum of injuries with a range instability. Dynamic pelvic stress examinations (DPSE) including exam under anesthesia and lateral stress radiographs offer the potential advantage of more accurately identifying patients who may benefit from surgery to decrease malunion and improve clinical outcomes. This article examines the current literature on DPSE and critically analyzes the validity of its role in indicating patients for surgery. In addition, recommendations on the use of DPSE in clinical practice based on the current literature and surgeon experience are provided.

Objectives: "Rescue screws" are used to address screw stripping during fracture fixation. Bone screw fasteners (BSF; Osteocentric Technologies) have a thread pattern that may enhance purchase. This study compared maximum compressive forces of traditional buttress screws (TBS; Stryker) and BSF in rescue/lag modes using synthetic models of osteoporotic and normal bone.

Methods: 2.7-mm TBS screws were placed in lag mode and the maximum compression force prior to stripping was measured. Rescue screws, varied by screw type and diameter, were placed in lag mode through previously stripped lag holes, using appropriate glide holes in the proximal cortex and the maximum compression force prior to stripping was measured. Force differences were compared between the stripped 2.7-mm TBS screws, and each rescue screws (3.5-mm TBS, 2.7-mm BSF, and 3.5-mm BSF). Trials were conducted on two synthetic-layered biomechanical models, a synthetic 20-10 pound-per-cubic-foot (PCF) osteoporotic model and a 40-30 PCF normal bone density model.

Results: 2.7-mm rescue BSF produced similar compression to the original 2.7-mm TBS lag screw (BSF-501.0 N vs TBS-577.0 N, p=0.441) in normal bone, but lower compression in osteoporotic bone (61.0 N vs 104.0 N, p=0.001). 3.5-mm TBS and BSF rescue screws increased the amount of compression in osteoporotic bone (3.5-mm TBS vs 2.7-mm BSF: 136.0 N (16.4) vs 61.0 N (14.5); 3.5mm BSF vs 2.7-mm BSF: 198.4 N (4.2) vs 61.0 N (14.5) p<0.001) and in normal bone (3.5-mm TBS vs 2.7-mm BSF: 968.0 N (30.3) vs 501.0 N (197.7); 3.5-mm BSF vs 2.7-mm BSF: 1136.0 N (51.2) vs 501.0 N (197.7) p<0.001) versus 2.7-mm rescue screws.3.5-mm rescue BSF produced more compression than 3.5-mm TBS (198.4 N (4.2) vs 136.0 N (16.3), p<0.001) in osteoporotic bone, but not in normal bone (1136.0 N (51.2) vs 968.0 N (30.3), p=0.106).

Conclusions: After stripping of a 2.7-mm Traditional Buttress Screw (TBS), 3.5-mm rescue TBS and Bone screw fasteners (BSF) generated more compressive force than the original lag screws in both normal and osteoporotic surrogate bone. 2.7-mm rescue BSF provided similar compression as the original lag screw in normal bone, but not osteoporotic bone. Depending on bone quality, surgeons can use different rescue screws to obtain similar or more fracture compression and construct stability.

Objectives: To assess the incidence of and risk factors for conversion to total knee arthroplasty after bicondylar tibial plateau fractures.

Methods: Design: Retrospective, prognostic study.

Setting: Tertiary-referral, single-center, Level I trauma center.

Patient selection criteria: From 2008-2021, patients were included if they had an operative 41C1-C3 tibial plateau fractures and had ≥2 years of follow-up.

Outcome measures and comparisons: Age, sex, BMI, smoking status, injury mechanism, medical history, surgical details (meniscal repair, external fixation, time to fixation), and radiographic data (Kellgren-Lawrence grade, reduction quality (defined as gap <2 mm after reduction), medial proximal tibial angle (MPTA), posterior proximal tibial angle (PPTA)) were collected and compared between patients that went onto require total knee arthroplasty (TKA) and those that did not.

Results: 243 patients were included with mean age of 49.7 (19-89) years and 58.8% were male. Mean follow-up was 5.2±2.6 years. 13.6% (33) required total knee arthroplasty (TKA) after an average of 23.4 months. TKA patients were older (54.0 vs. 49.0 years, p=0.042) and had larger fracture gaps (2.9 vs. 1.7 mm, p=0.024). They also had less satisfactory reductions in fracture gap (42.4% vs. 62.9% achieving reduction with a gap of <2mm, p=0.026) and PPTA (33.3% vs. 61.9%, p=0.002). Risk factors for TKA included fracture gap >2.45 mm after fixation, age >50.5, and PPTA >15°.

Conclusions: Sagittal malalignment, age, and poor fracture gap reduction increased the risk of TKA conversion after OTA41C1-C3 fracture fixation.

Level of evidence: III, prognostic.