Journal of Orthopaedic Trauma最新文献

Objectives: To explore outcomes after tibial rigid intramedullary nailing (RIMN) in skeletally immature patients, with a focus on post-operative complications and iatrogenic changes in tibial slope due to anterior physeal arrest.

Methods: Design: Retrospective case series.

Setting: A large, tertiary care health system in the rural Mid-Atlantic United States, including two Level 1 trauma centers and one Level 2 trauma center.

Patient selection criteria: Included were skeletally immature patients within 2 years of skeletal maturity undergoing tibial RIMN for OTA/AO 42 A to C fractures between March 2009 and January 2024 with post-operative follow-up more than 1-year.

Outcome measures and comparisons: The primary outcome was change in tibial slope after RIMN. Secondary outcomes included post-operative weight-bearing status and complications.

Results: Thirty-seven skeletally immature patients were included (mean age 15.2 ± 1.3 years, 76% male). For 22 patients with minimum 6-month post-operative radiographs (mean 18.4 ± 12.7 months), there was no significant change from pre- to post-operative tibial slope (80.0 ± 1.9° vs 80.1 ± 1.6°, p=0.86). Time to achievement of full weightbearing across the series averaged 45.4 ± 35.6 days. Five (14%) of patients necessitated hardware removal, and 89% of patients reported they had returned to "normal" activity at latest follow-up (mean 56.2 ± 42.5 months).

Conclusions: This study demonstrated that RIMN for tibial shaft fractures in skeletally immature pediatric patients within 2 years of maturity was not associated with iatrogenic physeal injury and resultant changes in tibial slope. Additional favorable clinical outcomes, the potential for early weight-bearing, and few associated post-operative complications, indicate that RIMN is a safe option for skeletally immature patients with tibial shaft fractures. Caution should be exercised when extrapolating these results to younger pediatric patients with >2 years of skeletal growth remaining.

Level of evidence: IV.

Objective: To evaluate mechanical failure rates of retrograde femoral nails in the treatment of distal femur fractures.

Methods: Design: Retrospective chart review.

Setting: Urban Academic Level 1 Trauma Center.

Patient selection criteria: Included were adult patients who sustained a distal femur fracture (AO/OTA 33) who were treated with a retrograde intramedullary nail from August 2021 through September 2022.

Outcome measures and comparisons: The primary outcome was the rate of mechanical failure of the intramedullary nail defined as deformation and/or breakage of the intramedullary nail. The rate of mechanical failure was compared amongst retrograde femoral nails used at the same institution during the same time period.

Results: One hundred and twenty distal femur fractures were identified (77 native distal femur, 43 periprosthetic) that were treated with a retrograde intramedullary nail. Average patient age was 67 years (SD 15.1, range 18-96 years). Eighty-three (69.2%) of patients were female. Four mechanical nail failures (deformation and/or breakage of the intramedullary nail) were observed within six months of surgery, two in patients with native distal femur fractures, and two in patients with periprosthetic distal femur fractures. All failures occurred among forty-nine fractures treated with a newly released retrograde femoral nail, the T2 Alpha Retrograde Femoral Nail (Stryker, Mahwah, NJ). This represents an 8.2% mechanical failure rate of distal femur fractures treated with this new nail compared to no failures observed with any other nail (p=0.03).

Conclusions: Mechanical nail failures, within six months of surgery for distal femur fracture, of a new retrograde femoral nail were observed to be higher than seen with other nails. Further evaluation is needed to determine if this experience represents factors related to patient, injury, or surgical characteristics, an anomaly, or a safety signal.

Level of evidence: Therapeutic Level III. See instructions for authors for a complete description of levels of evidence.

Objectives: To report the frequency of patients with pre- and post-reduction computed tomography (CT) scans associated with acetabular fracture-dislocations and the change of associated intra-articular fragments occurring with joint reduction.

Methods: Design: Retrospective case series.

Setting: Regional Level 1 trauma center.

Patient selection criteria: Patients who sustained an OTA/AO 62A1 and 62B1 posterior wall or transverse posterior wall acetabular fracture-dislocations with pre- and post-reduction CT imaging from February 2020 until July 2023.

Outcome measures and comparisons: Intra-articular fragments were identified and change in position (fossa to cranial, intra-articular to extra-articular, etc.) noted from pre- to post-reduction scans. Operative reports and post-operative CT scans were reviewed to determine the frequency of fragment retrieval.

Results: 119 out of 394 (30.2%) patients meeting fracture pattern inclusion received a CT scan prior to hip reduction. Of the 394 patients, 100 (25.9%) had pre- and post-reduction CT scans and were studied (average age of 35.5 years (range 16 - 87 years), 59 male). 45 of 100 patients (45%) had pre-reduction CT imaging demonstrating the presence of intra-articular fragment(s). 30 of 45 patients with a pre-reduction intra-articular fragment (66.7%) had an intra-articular fragment location change during the reduction. Of the 55 patients who did not have an intra-articular fragment on pre-reduction imaging, 28 of 55 (50.9%) had at least 1 intra-articular fragment on the post-reduction CT. Complete fragment retrieval was performed in 71.4% of patients.

Conclusions: The study demonstrated 30.2% of patients with posterior wall and transverse posterior wall acetabular fracture-dislocations received a CT scan prior to hip reduction. It was common to find intra-articular fragments on the post-reduction CT in patients who did not have them on the pre-reduction CT. Obtaining and scrutinizing the post-reduction CT scan provided accurate knowledge of the location of all osseous fragments associated with the fracture-dislocations which facilitated thorough preoperative planning, intraoperative implementation, and hopeful long-term patient outcomes.

Level of evidence: Prognostic Level IV.

Objective: To determine whether bone transport or Masquelet results in higher rates of major unplanned reoperations for the treatment of segmental tibial bone defects ≥4 cm in length.

Methods: Design: Retrospective cohort.

Setting: Level I trauma center.

Patient selection criteria: Adult patients with segmental tibial defects (OTA/AO 41,42,43) ≥4 cm who underwent surgical treatment with ring fixator bone transport or Masquelet between 2011-2022 with a minimum 1-year follow-up were included.

Outcome measures and comparisons: The primary outcome was a major unplanned reoperation after corticotomy (bone transport) or autografting (Masquelet), including below knee amputation, surgical debridement for deep infection, or surgical intervention for nonunion. Ring fixator bone transport and Masquelet were compared using multivariable logistic regression, adjusting for defect size as a potential confounder.

Results: 24 patients treated with bone transport (mean age 40yo (18-66), 100% male) and 22 patients treated with Masquelet (mean age 42yo (22-71), 91% male) were included. Defect etiology was identified as acute traumatic in 25 patients (54%) and post-infectious in 21 patients (46%) (P = 0.23). The median defect size was 7.2 cm (IQR 6.1-10.1) for transport and 5.8 cm for Masquelet (IQR 4.7-8.0) (P = 0.08). Bone transport was associated with an 85% reduction in the odds of a major unplanned reoperation compared to treatment with the Masquelet technique (OR, 0.15; 95% CI, 0.03-0.58; P = 0.01). Bone transport patients underwent a mean of 0.38 major unplanned reoperations compared to 0.91 in the Masquelet group. Reoperation for deep infection occurred significantly less in the bone transport group (21%) compared to the Masquelet group (46%) (OR, 0.18; 95% CI, 0.03-0.76; P = 0.03).

Conclusion: Bone transport was associated with a reduction in major reoperations compared to Masquelet for segmental tibial bone defects. This finding may have been driven by fewer surgeries for infection in the bone transport group.

Level of evidence: Therapeutic Level III.

Objectives: To identify clinical, demographic, and patient-reported outcomes (PROs) associated with return to work after lower extremity traumatic injury requiring amputation or limb salvage.

Methods: Design: Cross-sectional study.

Setting: Multi-center across 25 countries.

Patient selection criteria: Working patients who sustained lower extremity trauma requiring soft-tissue reconstruction or amputation.

Outcome measures and comparisons: The main outcome measurements were LIMB-Q scores. Regression analyses were performed to evaluate associations between functional and quality of life outcomes by return to work status.

Results: Responses were received from 258 participants with 66% males (n=173) and a mean age of 40 years old (IQR: 19-78) . Of respondents that worked prior to injury, 67% (n=173) returned to work after a mean 16 months (SD 39). Divorced or widowed status [p=0.006; OR 0.107 (95% CI 0.022-0.531)], bilateral injuries [p=0.004; OR 0.093 (95% CI 0.019-0.471)], and having a manual labor job [p=0.002; OR 0.191 (95% CI 0.027-0.395)] were negatively associated with return to work. Increased time since injury [p=0.036, OR 1.08 (95% 1.02, 1.16)] and higher educational status [p=0.024; OR 5.12 (95% CI 1.24, 21.0)] were positively associated with return to work status. Reconstruction or amputation was not associated with return to work [p=0.087, OR (95% CI 0.190-1.11)]. LIMB-Q Function (p=0.033; 95% CI [-11.3, -0.49]), and LIMB-Q Life Impact (p=0.008; 95% CI [-13.5, -2.01]) scores were significantly increased in patients that returned to work after injury.

Conclusions: Patients who returned to work after lower extremity injury reported higher levels of function and overall return to normalcy in their lives. Returning to work may improve quality of life in patients following lower extremity trauma.

Level of evidence: Prognostic Level III.

Objectives: This study aimed to identify the rate at which the anterolateral tibial plafond is affected in comminuted suprasyndesmotic ankle fractures (AO/OTA 44C2) and to assess how its involvement affects clinical outcomes.

Methods: Design: Retrospective review.

Setting: Level 1 Trauma Center.

Patient selection criteria: Patients with a pre-operative computed tomography (CT) treated surgically for AO/OTA 44C2 fractures from January 2005 to December 2021.

Outcome measures and comparisons: The primary outcome measure was the prevalence of anterolateral plafond impaction or a displaced Tillaux-Chaput fracture. Secondary outcome measures included reoperation rate (excluding hardware removal), rate of new-onset ankle osteoarthritis, rate of ankle osteoarthritis progression, Single Assessment Numeric Evaluation (SANE) score, and the Olerud Molander Ankle Score (OMAS).

Results: Fifty-three patients met inclusion criteria. The average age was 50 years (range 18-100), and 53% were female. The anterolateral plafond was involved in 26 patients (49%), with anterolateral plafond impaction in 11 patients (21%) and a displaced Tillaux-Chaput fragment in 15 patients (28%). Five patients (19%) received independent fixation of the anterolateral plafond, and three of these patients had anterolateral plafond impaction addressed. Thirty-eight patients (72%) had clinical follow-up of at least 6 months. Patients with anterolateral plafond impaction had a higher rate of reoperation (excluding hardware removal) compared to those without any anterolateral plafond involvement (HR = 8.3, 95% CI: 1.4-15.3, p=0.022) as well as a higher rate of new-onset ankle osteoarthritis (83% vs 23%, p=0.013). There was no difference in the rate of reoperation (11% vs 9%, p=0.748) or new-onset osteoarthritis (63% vs 23%, p=0.078 when comparing those with a displaced Tillaux-Chaput fracture to those without anterolateral plafond involvement. There were no differences in SANE (75% vs. 78% vs. 85%, p = 0.661) or OMAS (70 points vs. 69 points vs. 81 points, p=0.517) scores when comparing those with anterolateral plafond impaction, those with Tillaux-Chaput fragments, and those with no anterolateral plafond involvement.

Conclusion: CT evaluation is recommended in patients with comminuted suprasyndesmotic fibula fractures (AO/OTA 44C2) given their high association with anterolateral plafond impaction and Tillaux-Chaput fracture. Patients with anterolateral plafond impaction have a higher reoperation rate and new-onset ankle osteoarthritis compared to those without anterolateral plafond involvement.

Level of evidence: Level IV.

Introduction: Acute fracture-related infections are challenging problems, affecting up to 20% of orthopaedic trauma patients. High recurrence rates, secondary surgeries, and rehospitalizations lead to increased healthcare costs and are major burdens to patients. Bacteriophage therapy offers a potential alternative treatment option to address these challenges. In previous studies, it has been shown to be effective against biofilm and bacterial clearance on orthopaedic implants, however, their effects on fracture healing are poorly understood. The aim of this study was to determine if bacteriophages are as good as antibiotic therapy for the treatment of fracture related infection.

Methods: A canine model was used for this preclinical study examining bacteriophages specifically cultivated against S. aureus (OJ1). Based on sample size calculations and ethical care and use of animals, bilateral 1 cm ulnar defects (n=32; 16 dogs) were created and stabilized using plate and screw fixation. Implants were incubated in a suspension of biofilm-producing Staphylococcus aureus (OJ1). After 3 weeks, bone samples from fracture sites were cultured and surgical sites underwent irrigation and debridement (I&D) with retention of hardware, followed by 1 of 4 treatments (n=8/group): no additional treatment, 6 weeks of parenteral antibiotics, 7 days of bacteriophage therapy, or combination antibiotic/bacteriophage therapy. At 11 weeks, dogs were humanely euthanatized and bacterial load, callus formation, and histomorphometry for callus maturity and biofilm formation were assessed using quantitative microbial bone cultures, radiography and semi-quantitative histomorphometry.

Results: At 3 weeks, all surgical sites/ulnae had confirmed infections . At 11 weeks, fractures that received bacteriophage therapy (542 ± 204 CFU/g) had statistically significantly less CFU/g when compared to those (45,065 ± 4,409 CFU/g) that did not receive bacteriophage (p=0.033). Fractures treated with bacteriophages had statistically significantly (p<0.0001) more robust callus formation on radiographs at 11 weeks (77.7% ± 9% vs 52.5% ± 14%), as well as decreased biofilm formation (median = 1 vs 2; p=0.049) and statistically significant (p=0.035) increase in bone formation on histology/histomorphometry when compared to fractures that did not receive bacteriophages (20.7 ± 6 vs 15.7 ± 7).

Conclusion: Seven days of bacteriophage therapy was at least as good as 6 weeks of antibiotic therapy in terms of clearance of acute fracture-related infections. It was superior in terms of reduction in CFU/g, better callus formation, and biofilm clearance.

Objectives: To determine the most common reason for 30-day readmission following hospitalization for hip fractures.

Methods: Design: A retrospective review.

Setting: Single academic medical center that includes a Level 1 Trauma Center.

Patient selection criteria: Included were all patients operatively treated for hip fractures (OTA 31) between October 2014 and November 2023. Patients that died during their initial admission were excluded.

Outcome measures and comparisons: Patient demographics, hospital quality measures, outcomes and readmission within 30-days following discharge for each patient were reviewed. 30-day readmission reason was recorded and correlation analysis was performed.

Results: A total of 3,032 patients were identified with a mean age of 82.1 years and 70.5% of patients being female. The 30-day readmission cohort was 2.6 years older (p<0.001) and 8.8% more male patients (p=0.027), had 0.5 higher CCI (p<0.001), 0.3 higher ASA class (p<0.001) and were 9.2% less independent at the time of admission (p= 0.003). Hemiarthroplasty procedure (32.7% vs. 24.1%) was associated with higher 30-day readmission compared to closed percutaneous screw fixation (4.5% vs. 8.8%) and cephalomedullary nail fixation (52.2% vs. 54.4%, p<0.001). Those readmitted by 30-days developed more major (16.7% vs. 8.0%) (p<0.001) and minor (50.5% vs. 36.4%) (p<0.001) complications during their initial hospitalization and had a 1.5 day longer LOS during their first admission (p<0.001). Those discharged home were less likely to be readmitted within 30-days (20.7% vs. 27.6%, (p=0.008). Multivariate regression revealed increasing ASA class (O.R. 1.47, p=0.002) and pre-injury ambulatory status (O.R. 1.42, p=0.007) were most associated with increased 30-day readmission. The most common reason for readmission was pulmonary complications (17.1% of complications) including acute respiratory failure, COPD exacerbation and pneumonia.

Conclusion: Thirty-day readmission following hip fracture was associated with older, sicker patients with decreased pre-injury ambulation status. Hemiarthroplasty for femoral neck fracture was also associated with readmission. The most common reason for 30-day readmission following hip fracture was pulmonary complications.

Level of evidence: Prognostic Level III.

Objective: Traditional training and teaching have advised against mixing varying metal types to avoid the potential for in vivo galvanization and corrosion. The objective of this study was to retrospectively analyze patients who have undergone operative reconstruction with mixed metal (MM) constructs to report any related complications.

Methods: Design: Retrospective case series.

Setting: Single Level II Trauma Center.

Patient selection criteria: Patients that underwent trauma and/or arthroplasty surgery at a single level II trauma center between 2017-2022 with 'mixed' fixation defined as contact and proximity within the bone (≤10mm) with complete radiographs and medical records and minimum 1 year follow-up was eligible for study inclusion.

Outcome measures and comparisons: The primary outcome measure were incidence of corrosion directly related to hardware related complications causing unplanned reoperation.

Results: The final analysis included 56 patients (67.9% female), with a mean age of 62.0±16.6 years, mean BMI of 28.9±8.4 kg/m2, and mean Charlson Comorbidity Index (CCI) of 2.5±1.8. Seventy-three percent of the MM implants had direct metal on metal contact, and the average distance between non contacting metals was 0.32±0.28cm. The most common combination of metals was titanium+stainless steel (69.6%). At an average postoperative follow-up of 25.9±19.6 months, hardware-related complications were observed in 15 (26.8%) of patients, with reoperation due to hardware-complications in 12 (21.4%) within 18.5±15.8 months. No evidence of metal-on metal galvanic corrosion was observed on radiographic evaluation at an average of 25.9±19.6 months.

Conclusion: Patients who received mixed metal implants showed no radiographic or clinical signs of corrosion. While theoretical concerns exist regarding use of mixed metal implants, these findings suggest that the consequence of such combinations in clinical practice may not be as significant.

Level of evidence: IV, Retrospective case series.

Objectives: To determine if there is a correlation between time to surgery (TTS) and outcomes following repair of elbow fractures.

Methods: Design: Retrospective comparative study.

Setting: A single, urban hospital system.

Patient selection criteria: Patients from March 2011 to September 2022 who sustained an isolated fracture about the elbow joint (AO/OTA 13-A, B, and C and 21-A, B, and C), underwent surgical repair, and had at least 6 months of post-operative follow up identified from an Institutional Review Board-approved database.

Outcome measures and comparisons: Time to surgery, in days, was recorded. Radiographic and clinical follow up was obtained at all visits and a Mayo Elbow Performance Index (MEPI) was calculated based on the latest follow up. Complications recorded: elbow contracture, infection, early hardware failure, reoperation, and fracture nonunion. Multivariable regression and Spearman correlation analysis were used to determine any significant outcome differences based on time to surgery.

Results: 351 patients included with a mean age of 54.8 (range: 18 - 86) years with 217 females (61.8%) and 134 males (38.2%). Eighty-two patients (23.4%) developed at least one complication while 269 patients (76.6%) did not. As a continuous variable, TTS was not correlated with arc of motion at any follow up visit nor with the latest recorded MEPI score (p > 0.05). Mean TTS for patients who did and did not experience a complication was 6 (range: 0-24) and 10 (range: 0-38) days, respectively, and this was not significantly different (p = 0.217). Complication rate and any of the individual complications were not associated with TTS following a multivariable analysis controlling for age, sex, injury mechanism, open fracture, Charlson Comorbidity Index, and AO/OTA classification (p > 0.05 for all).

Conclusions: Timing of surgery following OTA 13 A-C and 21 A-C elbow fractures was not associated with differences in post-operative complications or range of elbow motion.

Level of evidence: Level III.