Journal of Orthopaedic Trauma最新文献

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.

Objective: To compare rates of nail breakage of three common cephalomedullary nails (CMNs) for the treatment of AO/OTA 31A1-3 femur fractures.

Methods: Design: multi-center retrospective study.

Setting: 13 Level I trauma centers.

Patient selection criteria: Adult patients with AO/OTA 31A1-3 femur fractures treated between 2014 and 2021with the Trochanteric Fixation Nail-Advanced (TFNA), Gamma3, or Trigen InterTAN were included.

Outcome measurements and comparisons: The primary outcome was implant (nail or head element) breakage. The secondary outcomes included nonunion, cut-out/cut-through and overall reoperation rate. Univariate and multivariable analyses were performed to compare breakage rates between implants while controlling for age, sex, AO/OTA 31A1-2 vs 31A3 fracture patterns, low vs high-energy mechanisms and post-operative neck shaft angle (NSA).

Results: 2,130 patients were included: 770 (36.2%) TFNA, 1,073 (50.4%) Gamma3 and 287 (13.5%) InterTAN. The InterTAN group had younger patients (median age: InterTan: 74, TFNA: 77, Gamma3: 80, p<0.001), more high-energy mechanisms (InterTan: 23%, TFNA: 14%, Gamma3: 10%, p=0.001), and more varus malreductions (NSA<128.5: InterTan: 46%, Gamma3: 39%, TFNA: 34%, p=0.001). The TFNA group was more likely to have an AO/OTA 31A3 fracture pattern than the Gamma3 (TFNA: 17.3%, InterTAN: 14.3%, Gamma3: 12.1%, p=0.002). The overall rate of implant breakage was 1.4% in the InterTAN group, 1.2% in the TFNA group, and 0% in the Gamma3 group. All breakages occurred in the presence of a nonunion or delayed union. Only two of the 31A3 fracture patterns resulted in breakage, both in the TFNA group, while the remainder occurred in 31A1-2 fracture patterns (p = 1.0). After controlling for confounding factors listed above, the TFNA and InterTAN groups were associated with a marginally increased odds of implant breakage compared to the Gamma3 (TFNA vs Gamma3: OR 0.04, 95% CI <0.01-0.5, p=0.034; InterTAN vs Gamma3: OR 0.04, 95% CI <0.01-0.5, p=0.037), while there was no difference between the TFNA and InterTAN (p=0.991). Post-operative neck shaft angle was not independently predictive of breakage (p = 0.55).

Conclusions: This study suggests that the TFNA may be slightly more prone to breakage than the Gamma3 when used for extracapsular proximal femur fractures. However, breakage is a rare event after cephalomedullary nailing with all implants evaluated, is always associated with nonunion or delayed union, and the magnitude of this difference may not be clinically relevant.

Level of evidence: III.

Objectives: To report the injury profile of gunshot wounds (GSWs) to the humerus along with treatment, fracture related infection (FRI), and nonunion.

Methods:

Design: Retrospective review.

Setting: Multicenter, 12 academic hospitals.

Patient selection criteria: All patients ≥18 years old who presented to the emergency room with GSW-related humerus fractures (OTA classifications 11-13, types A-C) were included from January 2016 to October 2021. Patients were compared based on surgical management (SM) and nonsurgical management (NoSM).

Outcome measures and comparisons: Data on patient demographics, injury presentation, treatment received, and outcomes including FRI and nonunion were collected. FRI was split into confirmatory and suggestive diagnoses. Multivariable logistic regression evaluated differences between the SM and NoSM groups in FRI after controlling for indicators of injury severity.

Results: Six hundred fifty-four patients were included with a mean age of 31 years (range: 18 to 74 years). Five hundred seventy-five patients (88%) were male, and 512 (79%) were Black or African American. Intra-articular fractures were more likely to be managed surgically (SM: 33.4%, NoSM: 17%, p < 0.0001). The rate of vascular injury was significantly higher in SM patients (SM: 16.8%, NoSM: 5.4%, p < 0.001); this was also true for nerve injury (SM: 45.6%, NoSM: 23.9%, p < 0.0001). Among all 654 patients, there was a significant difference in confirmatory FRI (SM: 5.4%, NoSM: 0.4%, p = 0.004) and suggestive FRI (SM: 19.9%, NoSM: 4.4%, p<0.0001). In the subgroup of 307 patients with at least 90 days of follow-up, a significant difference was observed in suggestive FRI (SM: 22.5%, NoSM: 2.4%, p <0.0001), but not in confirmatory FRI (SM: 6.8%, NoSM: 1.2%, p = 0.080). The rate of nonunion did not differ significantly between groups in the full cohort (SM: 8.4%; NoSM: 5.3%, p=0.148) and subgroup with at least 90 days of follow-up (SM: 14.4%; NoSM: 12.9%, p = 0.739). After controlling for indicators of injury severity, the SM group had a significantly higher odds of suggestive FRI than the NoSM group both in the overall cohort (adjusted odds ratio [aOR] = 2.54; 95% CI: 1.14-5.64; p = 0.023) and among patients with at least 90 days of follow-up (aOR = 5.62; 95% CI: 1.22-25.8; p = 0.027).

Conclusions: In this study, humerus GSWs managed with surgery were associated with a higher prevalence of suggestive FRI, vascular injury, and nerve injury than GSWs managed without surgery; management (surgery versus no surgery) was not associated with risk of nonunion.

Level of evidence: Level III.

Objective: To examine the association between debridement timing and infection, readmission, and reoperation in open upper-limb fractures.

Methods: Design: Retrospective cohort study.

Setting: Academic Level 1 Trauma Center.

Patient selection criteria: All patients with open upper limb fractures involving the humerus (AO/OTA 1), radius or ulna (AO/OTA 2), scapula (AO/OTA 14), or clavicle (AO/OTA 15) treated at a single academic Level I trauma center between 2014 and 2023 were included. Exclusions were isolated hand injuries, primary amputation, death before surgery, and incomplete records.

Outcome measures and comparisons: Patients were grouped based on time to debridement: ≤24 hours, 24-48 hours, and >48 hours. Multivariable logistic regression models adjusted for ASA grade, Gustilo-Anderson classification, and ISS evaluated the association between timing and 30-day readmission, 90-day readmission, one-year reoperation, and infection.

Results: The study included 297 patients (mean age 44.7 years [SD 22.5]; 66.9% male). Baseline demographics were similar across time-to-debridement groups (≤24 h, n=154; 24-48 h, n=83; >48 h, n=60) with no significant differences in age, sex, or ISS (all p>0.05). Debridement within 24 hours occurred in 154/297 (51.9%), and 60/297 (20.2%) experienced delays >48 hours. Outcome rates were: 30-day readmission 18/297 (6.1%), 90-day readmission 21/297 (7.1%), reoperation within one year 44/297 (14.8%), and postoperative infection 13/297 (4.4%). No statistically significant association was observed between debridement timing and 30-day readmission (p=0.72), 90-day readmission (p=0.83), one-year reoperation (p=0.11), or infection (p=0.39).

Conclusions: Within the studied intervals (≤24, 24-48, and >48 hours), debridement timing up to and including delays >48 hours was not significantly associated with readmission, reoperation within one year, or postoperative infection in open upper limb fractures.

Level of evidence: Therapeutic Level III - Retrospective cohort study.

Objectives: To compare surgical complication rates between delayed arthroplasty after failed nonoperative management and acute arthroplasty for valgus-impacted geriatric femoral neck fractures.

Methods: Design: Retrospective review.

Setting: Single academic Level I trauma center.

Patient selection criteria: Patients over 65 with valgus-impacted femoral neck fractures (AO/OTA 31-B1) from 2005-2024 treated with acute or delayed arthroplasty were retrospectively reviewed. Arthroplasty was considered delayed on or after day 7 of attempted nonoperative management.Outcome Measures and Comparisons: Postoperative complication rates, reoperations, and failure to return to baseline ambulatory status at final follow-up were assessed. Differences in patient demographics and outcomes between acute and delayed arthroplasty patients were assessed with chi-squared, Fisher's exact, and independent samples t-tests (α=0.05).

Results: There were 47 patients treated with acute arthroplasty [35 (74.5%) female, age 83.5± 2 years, CCI: 6.0, 40% independent weight-bearing, follow-up: 8.5 months] and 21 treated with delayed arthroplasty [16 (76.2%) female, age 82.1±4 years, CCI: 6.1, 60% independent weight-bearing, follow-up: 10.1 months]. Rates of medical [acute: 12 (25.5%), delayed: 3 (14.3%); p = 0.361] and surgical [acute: 5 (10.6%), delayed: 2 (9.5%); p = 0.999] complications did not differ between groups. The proportion of patients who did not return to baseline ambulatory status [acute: 14 (32.6%), delayed: 5 (26.3%); p = 0.847] and reoperation rates [acute: 2 (4.3%), delayed: 0 (0%); p = 0.999] were similar between groups. The postoperative mortality rate was 19.1% among the patients treated with acute arthroplasty and 19.0% among those treated with delayed arthroplasty, with no difference between groups (p = 0.999).

Conclusions: There were no differences in postoperative complications, reoperations, failure of return to baseline ambulatory status, or mortality for geriatric patients who underwent delayed versus acute arthroplasty for valgus-impacted femoral neck fractures. There was no evidence of increased surgical morbidity in geriatric valgus-impacted femoral neck fractures after failed nonoperative management compared to patients treated with acute arthroplasty.

Level of evidence: Level III.

Objectives: To determine whether 6-12 week modified Radiographic Union Score for Tibial fractures (mRUST) scores following lateral locked plating (LLP) of distal femur fractures were associated with nonunion versus healing.

Methods: Design: Retrospective case-control study.

Setting: Two Level 1 Trauma Centers.

Patient selection criteria: Included were adult patients with distal femur fractures (OTA/AO 33A/C) treated with LLP between 2006-2024 and with available postoperative radiographs between 6-12 weeks. Nonunion cases were defined as patients undergoing reoperation for nonunion after 12 weeks and were randomly matched 1:2 to controls, defined as those not undergoing reoperation for nonunion and with documented healing or an mRUST score of ≥12 at final follow-up.Outcome Measures and Comparisons: Total mRUST (scale:4-16) and combined medial and posterior (scale:2-8) mRUST scores were compared between nonunion cases and controls. Associations of mRUST scores with nonunion versus healing were estimated using logistic regression with adjustment for sampling distribution and time from surgery to mRUST assessment.

Results: Thirty distal femur nonunion cases and 60 controls were included (median ages 58 and 63 years; with 70% and 67% females, respectively). The median total mRUST score was 6 (IQR 6-7) for nonunion cases and 10 (IQR 8-11) for controls (p<0.001). Each 1-point increase in mRUST score was associated with a 57% reduction in odds of nonunion (OR: 0.43, 95%CI: 0.24-0.66; AUC 0.91). For the combined medial and posterior cortex scores, each 1-point increase was associated with a 70% reduction in odds of nonunion (OR: 0.30, 95%CI: 0.12-0.61; AUC 0.84).

Conclusions: mRUST scores between 6-12 weeks demonstrated strong association with nonunion versus healing following LLP of distal femur fractures. This was consistent in analysis limited to medial and posterior cortices, although wide confidence intervals suggest imprecision in the effect estimate. Early mRUST assessment may serve as a helpful adjunct to support clinical decision-making and patient counseling following LLP of distal femur fractures.

Objectives: To investigate the association between proton pump inhibitor (PPI) use and fracture nonunion risk across different anatomical fracture locations and patient age groups.

Methods: Design: Retrospective cohort study utilizing propensity score matching to control for confounding variables.

Setting: Multicenter database analysis (TriNetX).

Patient selection criteria: This study included patients who underwent operative fixation of a fracture of the humerus, radius/ulna, femur, or tibia/fibula corresponding to OTA/AO fracture types 11-13, 21-23, 31-33, and 41-43, respectively. Fractures that occurred between 2015 and 2023 were identified using ICD and CPT codes. Propensity matching balanced cohorts by age, sex, race/ethnicity, comorbidities (e.g., obesity, chronic kidney disease, hypertension), bone health conditions (osteoporosis, osteopenia), and medication use affecting fracture healing (NSAIDs, Denosumab, Alendronate, Vitamin D).

Outcome measures and comparisons: The primary outcome was rate of fracture nonunion. Comparisons included anatomical fracture site (humerus, radius/ulna, femur, tibia/fibula), and patient age groups (18-44, 45-64, ≥65 years).

Results: 410,433 patients were analyzed, with balanced cohorts of PPI users and non-users. PPI use significantly increased nonunion risk in tibia/fibula (4.44% vs 2.21%; HR: 2.08, 95% CI: 1.86-2.31, p<0.0001) and radius/ulna fractures (3.36% vs. 1.88%; HR: 1.85, 95% CI: 1.56-2.20, p<0.0001). The highest vulnerability was among younger patients (ages 18-44) with tibia/fibula fractures (HR: 10.87, 95% CI: 6.95-16.99). Nonunion rates were higher, though not statistically significant for femur (4.34% vs. 3.88%; HR: 1.11, 95% CI: 0.97-1.27, p=0.0958) and humerus fractures (6.06% vs. 5.21%; HR: 1.21, 95% CI: 1.01-1.44, p=0.0802).

Conclusions: Proton pump inhibitor (PPI) use was associated with increased nonunion risk, particularly in tibia/fibula and radius/ulna fractures. Younger patients demonstrated greater susceptibility to PPI-associated nonunion. The findings indicated that PPI exposure may have adversely affected fracture healing in specific anatomical or demographic subgroups and warranted further investigation.

Level of evidence: Level III.