Journal of Orthopaedic Trauma最新文献

Objectives: This study investigates whether the intra-operative administration of intravenous tranexamic acid (TXA), known for its hemostatic and potential anti-inflammatory properties, affects the incidence of heterotopic ossification (HO) following surgery for elbow fracture-dislocations.

Methods: Design: Prospective, randomized clinical trial.

Setting: Hand and Upper Extremity Surgery Unit.

Patient selection criteria: Patients aged 18 to 75 years with acute traumatic elbow fracture-dislocations requiring surgical management from June 1, 2016, to October 31, 2022, were eligible. Inclusion criteria included traumatic non-pathological elbow fracture-dislocations. Patients were randomized 1:1 to receive either intraoperative TXA or no additional treatment.

Outcome measures and comparisons: The primary outcome was the occurrence of heterotopic ossification (HO), defined by new bone formation observed in radiographic exams during postoperative follow-ups. Secondary outcomes included the presence of clinically relevant HO, reoperation rate due to symptomatic HO, and time to HO reoperation. Compared were patients who received TXA with controls.

Objectives: While rates of post-traumatic osteoarthritis after acetabulum fracture have been thoroughly studied, there has been less emphasis on hip osteoarthritis after pelvic ring injuries. The objective of this study was to determine the frequency of post-traumatic hip osteoarthritis in pelvic ring injury patients. It was hypothesized that more severe pelvic ring injuries would be associated with greater rates of post-traumatic hip osteoarthritis.

Methods: Design : Retrospective Cohort.

Setting: Urban/Suburban Academic Level I Trauma Center.

Patient selection criteria: Subjects were identified using a retrospective search for AO/OTA type A, B, and C pelvic ring injuries. Patients were included if they were age 18 or greater, had a pelvic ring injury, and one year or more of radiographic follow-up. Patients were excluded if they had prior total or hemi-arthroplasty of either hip, femoral neck fracture, acetabulum fracture, femoral head fracture, or inadequate radiographic follow-up.

Outcome measures and comparisons: Both hips were graded using the Tönnis classification at the time of injury and available follow-up pelvis films. Comparison of rate of osteoarthritis progression was made between stable (LC I injuries stable on examination under anesthesia, all APC I injuries) and unstable (APC II, APC III, LC II, LC III, LC I injuries unstable on examination under anesthesia) pelvic ring injury patients, as well as severity of injury using the Young-Burgess classification.

Results: Two hundred and eleven patients were included for final analysis. Average age was 58.8 years (SD 28.1 years, range 18-100 years). Eighty-eight patients (41.7%) were male. 127 patients underwent non-operative management, and 84 underwent surgical stabilization. 34.5% (29/84) of patients with unstable pelvic ring injuries and 6.2% (8/127) of patients with stable pelvic ring injuries demonstrated progression of osteoarthritis on the ipsilateral side of their injury (p < 0.001). More severe pelvic ring injury patterns had a greater rate of post-traumatic osteoarthritis (PTOA) based on the Young-Burgess injury classification (44.4% of LC III versus 11.1% of LC I pelvic ring injury patients, p < 0.001).

Conclusions: A significant frequency of post-traumatic osteoarthritis after pelvic ring injuries was identified. A higher rate of preogression to PTOA was found with unstable injuries compared with stable pelvic injuries.

Level of evidence: III, Retrospective Cohort Study.

Objectives: To identify the rate of fixation failure following femoral neck fracture (FNF) fixation in young adults within a national database.

Methods: Design: Retrospective cohort study.

Setting: National all-payer claims database.

Patient selection criteria: Adults between 18 and 49 years of age who underwent operative fixation for FNF (AO/OTA 31-B) between January 2010 and April 2019 were identified.

Outcome measures and comparisons: The primary outcome measure was five-year risk of revision surgery for fixation failure following operative management of FNF. Additional data variables included rate of fixation failure following open versus closed reduction techniques and the rate of revision fixation, intertrochanteric osteotomy for nonunion or malunion, and conversion to arthroplasty.

Results: A total of 3,534 young adults underwent operative fixation of a FNF during the study period. The mean age of the study population was 41.1 +/- 3.91 years (18-49) and a majority were male (52.6%). The five-year revision-free survival of young adults who underwent operative fixation for FNF was 86.1% (95% CI 85.5-89.1%). Four-hundred ninety-two patients (13.9%) required revision surgical intervention for fixation failure, including 210 (5.9%) revision fixation procedures and 21 (0.6%) intertrochanteric osteotomies; two hundred sixty-one (7.4%) patients underwent conversion to arthroplasty. There was no significant difference in rate of fixation failure when comparing open (n=392, 14.9%) and closed (n=100, 13.3%) reduction techniques (p=0.351).

Conclusions: Following operative management of FNF in young adults, fixation failure due to avascular necrosis, nonunion/malunion, or posttraumatic arthritis occurred at a rate of 13.9%. There was no difference in the rate of treatment failure between open and closed reduction.

Level of evidence: Therapeutic Level IV.

Objectives: The 22-modifier in the Current Procedural Terminology (CPT) system indicates increased surgical procedure complexity, aiming to secure greater reimbursement for surgeons. This study investigated the 22-modifier on reimbursement amounts after acetabular fracture fixation.

Methods: Design: Retrospective cohort study.

Setting: Academic Level I Trauma Center.

Patient selection criteria: Included were patients with third party reimbursement for acute acetabular fracture (AO/OTA 62A-C) fixation through an open approach from 2005 to 2021 as identified using CPT codes 27226, 27227 and 27228.

Outcome measures and comparisons: Chart review identified procedures where the 22-modifier for obesity or fracture complexity was applied. A cohort without the 22-modifier matched by diagnosis, primary CPT code and insurance carrier was made for comparison. The primary outcome measure was the difference in financial reimbursement when the 22-modifier was used. Secondary outcomes were the difference in billed charges and operative time.

Results: A total of 785 cases were initially identified with 747 meeting the inclusion criteria, and 73 having the 22-modifier applied. After removing surgeries that did not receive compensation from their insurance, 52 of these patients were compared to 52 matched cases without a 22-modifier. The 22-modifier group and the non-modifier group had no significant difference in reimbursed amounts ($4,112.71 USD vs. $3,851.00, p = 0.644). However, patients in the 22-modifier group had significantly greater billed charges ($8,007.35 vs. $7,120.94 USD; p = 0.0096), longer operative times (301.7 vs. 240.2 minutes, p < 0.001) and greater body mass index (BMI) (43.1 vs 29.3 kg/m2; p < 0.001).

Conclusions: Despite increased complexity and greater billed charges, the use of a 22-modifier in acetabular fracture cases did not result in improved collected reimbursements, and reimbursement is equal to when the 22-modifier is not used. Policymakers and insurers should revise reimbursement structures to better align reimbursements for acetabular fixation with surgical complexity.

Level of evidence: Level III.

Objectives: To describe and enumerate surgeries for patients who underwent reconstruction or amputation after severe distal tibia, ankle, and mid to hindfoot injuries.

Methods: Design: Secondary analysis of a multicenter prospective observational study.

Setting: 31 U.S. level-I trauma centers and 3 military treatment facilities.

Patient selection criteria: Participants aged 18 to 60 with Gustilo type-III pilon (OTA 43B or 43C), IIIB or C ankle fracture (OTA 44A, 44B, or 44C), type-III talar or calcaneal fracture (OTA 81B, 82B, or 82C), or open or closed crush or blast injuries to the hindfoot or midfoot who underwent limb reconstruction or amputation from 2012 to 2017.

Outcome measurements and comparisons: Number of temporizing, definitive, and complication surgeries were compared by treatment and injury.

Results: 574 participants with 221 ankle and pilon, 140 talus and calcaneal, and 213 other foot injuries were followed for 18 months. The mean age was 38 (range 8-64) and 33% were female. Participants underwent reconstruction (n=472), primary amputation (n=76), and failed reconstruction followed by amputation (n=26). 841 temporizing, 958 definitive, and 501 complication surgeries were performed. The number of surgeries was highest for those who underwent failed reconstruction (mean 5.8, 95% CI: 4.9-6.8, range 3-13) compared to reconstruction (mean 3.8, 95% CI: 3.5-4.0, range 1-21), and primary amputation (mean 4.9, 95% CI: 4.3-5.5, range 2-14) (p<0.01). Those with ankle and pilon injuries required more surgeries (4.7, 95% CI: 4.3-5.1, range 1-21) than hindfoot (3.4, 95% CI: 3.0-3.7, range 1-10), and other foot injuries (3.7, 95% CI: 3.4-4.0, range 1-14) (p<0.01). The average participant would complete definitive treatment 23 days after their injury, and those who required surgery for a complication spent 41 days in the complication phase of treatment.

Conclusions: Patients with high-energy lower extremity trauma underwent nearly 4 surgeries over 3 weeks until completion of definitive treatment, regardless of whether they underwent limb reconstruction or amputation. Those with ankle or pilon injuries and failed reconstruction attempts experienced the most operations, and those with complications required over an additional month of surgical care. These data may inform a shared decision-making process around limb optimization.

Level of evidence: Therapeutic Level II.

Objectives: To evaluate the effect of perioperative variables including PT and walking distance on length of stay (LOS) in hip fracture patients.

Methods: Design: A retrospective review.

Setting: Single level I trauma center.

Patient selection criteria: Patients ≥ 65 years of age with hip fractures (OTA/AO 31-A and 31-B) between 2017-2020 were included. Patients were excluded if they were treated nonoperatively, suffered periprosthetic fracture or were not admitted under the hip fracture protocol.

Outcome measures and comparisons: Admission and perioperative variables including time to surgery and number of postoperative days (PODs) without a documented PT session during the first three PODs were assessed for correlation with increased total hospital length of stay and postoperative length of stay.

Results: There were 301 patients included (234 (77.7%) female) with an average age of 84.4 years (± 8.1 years). Median total LOS was 5 [IQR, 3-7] days and 4 [IQR 3-6] days after surgical fixation. 37% of hip fractures had a delay in discharge. 95% of patients were discharged to a rehabilitation facility. The highest percentage of days with no PT session occurred on Saturdays and Sundays with 43% and 34% on POD#1 respectively; 40% and 33% on POD#2 and 26% and 30% POD#3; p = 0.0004. In multivariate analysis longer total LOS was associated with time to surgery greater than 24 hours (AOR 5.6; 95% CI, 1.8-17.4; p<0.0030), major complication (AOR 8.26; 95% CI, 2.8-20.0; p<0.0014), discharge to subacute rehab (AOR 5.6; 95% CI, 3.0-10.5; p<0.0001) and walking less than five feet or not receiving PT (among patients with no assistance required as pre-hospital ambulatory status) (AOR 6.0; 95% CI, 2.3-15.3; p<0.02). Longer LOS after surgery was associated with major complication (AOR 11.2; 95% CI, 3.1-39.8; p<0.0002), discharge to subacute rehab (AOR 5.0; 95% CI, 2.7-9.1; p<0.0001) and walking less than five feet or no PT (AOR 4.8; 95% CI, 2.0-11.5; p<0.01).

Conclusions: Emphasis should be placed on minimizing complications while maximizing postoperative PT and early ambulation in the acute postoperative period given the demonstrated association between inadequate mobilization and delayed disposition, especially if surgical fixation occurs surrounding the weekend or holiday.

Level of evidence: Level III.

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.