Journal of Orthopaedic Trauma最新文献

Objectives: Healing remains a clinical challenge in non-operatively treated fragility fractures of the pelvis (FFPs). Modifying gut microbiota has been found to impact cytokine pathways involved in bone formation and resorption. This study examined the impact of probiotic treatment pre- and post-unilateral pubic rami fracture on bone microstructure and load-to-failure of healing fractured and intact (unfractured) contralateral hemi-pelvises.

Methods: Twenty-one 6-month-old female Sprague Dawley rats were bilaterally ovariectomized and housed for 3 months to establish an osteoporotic phenotype. At 9-months old, stable unilateral fractures of the superior and inferior pubic rami of the left hemi-pelvis (Type 1a FFP) were created. Prior to fracture creation, rats were randomly separated into control (phosphate buffered saline (PBS) administered for 12-weeks), pre-fracture treatment (probiotics administered for 12-weeks starting 6-weeks pre-fracture), and post-fracture treatment (probiotics administered for 6-weeks post-fracture) groups. At 6-weeks post-fracture, rats were sacrificed, and their pelvises were harvested, µCT imaged, and evaluated via microstructural analysis and biomechanical testing.

Results: On the intact hemi-pelvises, the pre-fracture treatment group (n=5) had significantly higher bone volume (BV) (p=0.050), bone volume fraction (BV/TV) (p=0.019), bone mineral density (BMD) (p=0.019), and tissue mineral density (TMD) (p=0.014) when compared to those in the post-fracture treatment group (n=7). The intact hemi-pelvises of the pre-fracture treatment group also had significantly increased trabecular thickness (TbTh) (p=0.021) when compared to those in the control group (n=6). On the fractured hemi-pelvises, the pre-fracture group had increased total volume (TV) (p=0.020), BV (p=0.011), and BV/TV (p=0.026) when compared to the control group (n=4). While load-to-failure was correlated with microstructural parameters (BV/TV (r=0.42, p=0.015), trabecular number (TbN) (r=0.42, p=0.014), BMD (r=0.55, p=0.0008), TMD (r=0.40, p=0.019) and trabecular spacing (TbS) (r=-0.58, p=0.0003), no significant differences in bone strength were found between groups.

Conclusions: Probiotic treatment was shown to improve bone microstructure in osteoporotic rats, however, efficacy was related to treatment timing and duration. Administration of probiotics for 12-weeks beginning 6-weeks pre-fracture significantly enhanced bone quality in both the healing fractured and intact contralateral hemi-pelvises. This suggests a critical timing threshold exists for probiotic therapy to impact the gut microbiome, facilitating an alteration of the immune response post-fracture and producing positive structural changes in osteoporotic pelvic bone.

Objective: To develop a stratification tool to identify patients with hip fracture at risk for second contralateral hip fracture and mortality within 5 years of an index fracture, and to assess the cost-effectiveness of prophylactic fixation in high fracture risk/low mortality risk patients.

Methods:

Design: Retrospective prognostic cohort study.

Setting: Single academic system with 2 Level 1 Trauma Centers, 1 orthopedic specialty hospital, and 1 tertiary care hospital.

Patient selection criteria: Patients who were 60 years or older with OTA 31A/B hip fractures from low-energy mechanisms between 11/1/2014 and 11/31/2023 with ≥5-year follow-up or until death were included.

Outcome measures and comparisons: The study included 4 phases: (1) identifying factors associated with second hip fracture within 5 years; (2) using multivariate logistic regression to generate models predicting 5-year second hip fracture (vs. FRAX) and mortality risk; (3) creating a "risk matrix" to identify candidates for prophylactic fixation using Youden Index, which determined cutoff points encompassing the maximum sensitivity and specificity for each risk equation and were used to define a value-based target group; and (4) cost analysis comparing standard versus prophylactic care in high fracture risk/low mortality risk patients.

Results: Of 426 patients (mean age 80.25 years, 73.4% female), 78 sustained second hip fractures (mean interval: 594 days). Predictors included higher FRAX score ( P = 0.004), dementia ( P < 0.001), ICU stay ( P = 0.014), discharge to subacute care ( P < 0.001), and 90-day readmission ( P = 0.011). Logistic regression predicted 5-year second fracture risk (AUC 0.742 vs. FRAX 0.617, P = 0.012) and 5-year mortality (AUC 0.723). The risk matrix used cutoff points of 18.2% (mortality) and 38.2% (second fracture) to define a value-based target group (n = 26; 13 experienced second fracture). Cost analysis showed that prophylactic fixation of all 26 patients ($781,508) would save $353,067 compared with treating the 13 who fractured again ($1,134,575).

Conclusions: A novel matrix was developed that accurately predicted 5-year second hip fracture and mortality risk. Prophylactic fixation in low mortality, high fracture risk patients may reduce costs and prevent future fractures [Tool available: https://sttgmacom.wpcomstaging.com/predicting-risk-of-second-hip-fractures/ ].

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

Summary: Tibia pilon fractures are complex injuries associated with ankle articular cartilage damage and soft tissue compromise. Modern circular external fixation methods are useful in their surgical management, especially for open fractures, severe soft tissue injury, fracture patterns with bone loss or compromise, severe cartilage loss, and certain patient factors. Surgical techniques involve ring block concepts, strategic distal tibia wire placements, hexapod fixators with software-guided bone alignment, and other uses of circular external fixation including ankle joint distraction, augmentation of internal fixation to create integrated constructs, intentional limb deformation for soft tissue defects, bone transport, and primary arthrodesis. Circular external fixation has comparable and sometimes favorable outcomes versus all internal fixation techniques and can be the treatment of choice for certain complex pilon cases.

Objectives: To estimate representative outcomes of patients who underwent distal femur replacement (DFR) for distal femur fractures (DFFs).

Methods:

Design: Retrospective Cohort Study.

Setting: Twelve academic trauma centers in the United States.

Patient selection criteria: Adult patients who underwent DFR for native or periprosthetic DFF (OTA/AO 33A1.1-33C3.3) from 2010 to 2022 were included. Patients who underwent DFR for infectious, oncologic, and/or other indications besides fracture fixation were excluded.

Outcome measures and comparisons: The primary outcome was periprosthetic joint infection (PJI). Secondary outcomes included reoperation, 1-year mortality, and function. Outcomes were estimated using proportions and Kaplan-Meier curves with 95% confidence intervals (CI) and stratified by periprosthetic fracture with Fisher exact testing.

Results: One hundred seventy-three patients were included, with 130 (75%) having a periprosthetic DFF. The median age was 77 [interquartile range, 70-84] and the median final follow-up was 6 months [interquartile range, 2-14], with 146 women (84%) and several medical comorbidities (63% American Society of Anesthesiologists class III and 24% American Society of Anesthesiologists class IV). The rate of PJI was 5.8% (95% CI, 3.1%-10.5%). PJI was 2.3% for native compared with 6.9% for periprosthetic DFF ( P = 0.45). The reoperation rate was 16.6% (95% CI, 11.7%-23.0%), and the 1-year mortality was 27% (95% CI, 20%-35%). Fifty-five percent of patients returned to their baseline function (95% CI, 46.9%-62.1%).

Conclusions: DFR for native and periprosthetic DFF was associated with a PJI rate of 5.8%. The 1-year mortality rate was 27.0%, and the reoperation rate was 16.6%. Fifty-five percent of patients returned to their baseline function. DFR can be considered as an option in cases of complex native and periprosthetic DFF, although surgeons should continue to counsel patients on the considerable risks associated with DFR when assessing treatment options.

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

Objectives: To evaluate the clinical outcomes of a standardized postoperative protocol permitting removal of postoperative dressings, showering, and cleansing of incisional wounds 3 days after fracture surgery.

Methods:

Design: Retrospective review.

Setting: Tertiary orthopaedic center.

Patient selection criteria: All adult patients, aged 18 years or older, operatively treated for fracture or other musculoskeletal trauma from September 2017 to September 2023 were screened for study eligibility. Patients with open fractures, revision surgery through surgical incisions created <6 weeks before the index procedure, immobilization (eg, splints) precluding surgical wound access, known prior infection, acute traumatic local skin abrasions or lacerations, were excluded because these patients were not treated with the early showering protocol. Also excluded were patients with <3-month follow-up.

Outcome measures and comparisons: Outcome measures were reoperation within 3 months for wound or infectious complications and superficial surgical site infection treated with oral antibiotics.

Results: A total of 1067 surgical cases were performed during the included time frame. Six hundred and two cases were excluded based on eligibility criteria, leaving 465 surgeries in 444 patients with a mean age of 59 years (range 18-95; 65% female). Mean follow-up was 11.7 months (SD 12.3; range 3.0-73.0). Reoperation for a wound or infectious complication occurred in 1.1% (5/465) of patients and superficial surgical site infection requiring antibiotic treatment occurred in an additional 1.1% of patients (5/465).

Conclusions: A protocol of dressing removal and showering at 3 days postoperatively for acute uncomplicated surgical wounds was associated with reoperation for deep infection in 1.1% of patients and superficial infection in 1.1% of patients supporting the safety of an early showering protocol.

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

Objectives: To investigate the impact of diabetic neuropathy on operative bimalleolar or trimalleolar ankle fracture outcomes when compared with both patients who are nondiabetic and patients who are diabetic without neuropathy.

Methods: .

Design: Retrospective comparative study.

Setting: TriNetX research network, a global health-collaborative clinical research platform comprising deidentified electronic health records from health care organizations across the United States.

Patient selection criteria: The TriNetX research network was queried for all patients with an operative bimalleolar or trimalleolar ankle fracture (OTA/AO 44) from 2005 to 2022. From this population, subgroups were formed based on diabetes status and the presence of diabetic neuropathy.

Outcome measures and comparisons: Patients with diabetic neuropathy were compared with both patients who are nondiabetic and patients with diabetes. Propensity score matching (1:1) was performed to match patients based on demographics and comorbidities across groups, including severity of diabetes by A1C. After matching, logistic regression was performed to calculate risk ratios and assess differences in postoperative medical and surgical complications between patients who are neuropathic and patients who are nondiabetic, and between patients who are neuropathic and patients who are diabetic.

Results: Included were 115,162 patients with ankle fracture; 94,111 (81.7%) patients without diabetes, 13,741 (12%) patients with diabetes but without diabetic neuropathy, and 7310 (6.3%) patients with diabetic neuropathy. When compared with patients without diabetes, patients with diabetic neuropathy had increased risk of 2-year malunion/nonunion (RR 1.79; P < 0.001), implant infection (RR 2.12; P < 0.001), and amputation (RR 8.01; P < 0.001). When compared with patients with diabetes, but without neuropathy, patients with diabetic neuropathy again had significantly higher odds of implant failure (RR 2.00; P < 0.001), malunion/nonunion (RR 2.35; P < 0.001), and infection (RR 2.25; P < 0.001).

Conclusions: This study found that patients with diabetic neuropathy had higher odds of postoperative complications, such as malunion/nonunion, infection, and amputation, after surgical fixation of ankle fractures than patients who are nondiabetic and patients who are diabetic without neuropathy.

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

Objectives: To compare outcomes and complications of retrograde intramedullary nailing (rIMN), plating, and combined rIMN + plate constructs for native distal femur fractures.

Methods:

Design: Retrospective review of operative distal femur fractures, 2018-2022.

Setting: Urban level 1 trauma center.

Patient selection criteria: Included were patients >18 years old with AO/OTA 33A or 33C distal femur fractures and ≥6 months follow-up.

Outcome measures and comparisons: Demog r aphics, fracture type, operative time, estimated blood loss (EBL), changes in radiographic alignment, union rates (mRUST ≥10), reoperations, complications, and return to weightbearing were collected and compared between the 3 fixation constructs.

Results: One hundred thirty-seven patients were included (71 rIMN, 27 plate, 39 rIMN + plate). Median age was older for rIMN + plate than for rIMN (61 vs. 54 years, P = 0.015) and similar between rIMN + plate and plate groups (61 years for both, P = 0.68). There were no other differences in demographics among groups ( P > 0.05). The rIMN + plate group had longer operative time (256 minutes) and higher EBL (250cc) than rIMN alone (150 minutes, P = 0.0006 and 200cc, P = 0.023) and similar operative time and EBL compared with plate alone (168 minutes, P = 0.071 and 250cc, P = 0.73) There were no differences in final coronal or sagittal alignment ( P = 0.78, P = 0.87, respectively) or reoperation rates ( P = 0.74) among groups. The rIMN + plate group showed a higher rate of radiographic union (66.7%) than the rIMN (42.3%) and plate (44.4%) groups ( P = 0.042). When controlling for patient age, time to weightbearing was similar among the groups ( P = 0.79).

Conclusions: Although the rIMN + plate combination led to higher rates of union, it did not decrease time to weightbearing or reoperation rates compared with rIMN alone, and was associated with longer operative time and greater blood loss.

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

Objectives: To compare hemiarthroplasty (HA) outcomes for low-energy femoral neck fracture (FNF) among a direct anterior approach (DAA), direct lateral approach (DLA), and posterior approach (PA).

Methods:

Design: Retrospective review.

Setting: Nine level-1 tertiary academic centers.

Patient selection criteria: All patients from January 2010 through December 2019 undergoing HA for a low-energy FNF (AO/OTA 31B1-3). Exclusion criteria were pathologic fractures, concomitant acetabular fractures, and high-energy mechanisms.

Outcome measure and comparisons: Multivariable regression models were constructed for outcomes among DAA and DLA compared with PA including mortality, revision, and infection. It was hypothesized that anterior approaches would be independently associated with fewer postoperative complications including infection, dislocation, and mortality.

Results: A total of 956 consecutive patients with FNF treated with HA using DAA (n = 71; 7.4%; mean (SD) age 82.6 (8.5) years), DLA [n = 252; 26.4%; mean (SD) age 81.3 (10.8) years] or PA [n = 633; 66.2%; mean (SD) age 79.2 (10.9) years] were included. There were no differences in sex among groups ( P = 0.83). The DAA was independently associated with higher periprosthetic joint infection rates at 90 days [Odd's Ratio (OR), 7.295; 95% confidence interval (CI), 2.35‒22.61; P < 0.001] and 1-year (OR, 5.769; 95% CI, 1.93‒17.22; P = 0.002), as was the DLA at 90 days (OR, 2.952; 95% CI, 1.29‒6.74; P = 0.010) and 1-year (OR, 3.047; 95% CI, 1.43‒6.50; P = 0.004). The DLA was associated with lower 90-day dislocation (OR, 0.129; 95% CI, 0.03‒0.60; P = 0.009), 1-year dislocation (OR, 0.175; 95% CI, 0.05‒0.63; P = 0.008), and greater independent ambulation at discharge (OR, 3.273; 95% CI, 2.00‒5.37; P < 0.001).

Conclusions: Among HA for low-energy femoral neck fracture, the lateral approach was associated with decreased dislocation postoperatively and greater independent ambulation at discharge, but with decreased ambulatory distance compared to a posterior approach. Furthermore, the anterior and lateral approaches were associated with increased infection versus a posterior approach.

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