Journal of Orthopaedic Trauma最新文献

Objectives: To evaluate the effectiveness of intramedullary nailing combining with iliac or fibular autograft for the treatment of adult forearm nonunions.

Methods: Design: Retrospective case series.

Setting: Two academic trauma referral center.

Patient selection criteria: Adult patients who sustained surgical treatment for forearm fracture (OTA/AO 2R2-2U2) nonunion with intramedullary nailing and grafting from May 2005 to January 2023 were included.

Outcome measures and comparisons: The primary outcome was to determine the bone union rates after nounion surgery with intramedullary nail and grafting. Secondary outcomes were to assess functional scores including The Visual Analog Score (VAS), the shortened version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire, Grace-Eversmann evaluation criteria.

Results: The study included 24 patients comprising 19 males and 5 females (7 radius, 14 ulna, 3 both bone) with an average age at the time of surgery of 40.5 ± 11.2 years (range, 23 to 61 years) and union was achieved for 24 out of 27 bones (88.8 %) in 22 out of 24 patients. The mean (average) preoperative and postoperative QuickDASH scores were found 64.5 ± 18.2 and 15.3 ± 18.9, respectively. The functional improvement was found statistically significant (p < 0,001).The mean (average) preoperative and postoperative VAS was found to be 7.2 ± 2.1 and 1.52 ± 1.5, respectively. The difference was found statistically significant (p < 0.001). Two cases of radius nonunion healed with 10° and 15° of angulation and shortening, while nonunion persisted in two patients. All remaining cases healed without deformity. Excellent to acceptable results were obtained for 83.3% of patients according to Grace-Eversmann criteria.

Concluson: Intramedullary nailing with autologous grafting is a viable option for the treatment of adult forearm nonunions.

Level of evdence: Therapeutic Level IV.

Objectives: The aim of this study was to investigate the relationship between preoperative marijuana use and complications following tibia shaft fracture fixation.

Methods: Design: Retrospective cohort study.

Setting: Two academic Level I trauma centers.

Patient selection criteria: Adults age ≥18 years who underwent tibia shaft fracture (OTA/AO 42) fixation from 2014-2022 and had a minimum 3-months postoperative follow-up were included. Patients were considered marijuana users if they had current self-reported marijuana use or a urine toxicology screen positive for cannabinoids documented at initial presentation.

Outcome measures and comparisons: Bivariate statistics and multivariate regression were used to evaluate the effect of marijuana use on 90-day postoperative thromboembolic and surgical complications, unplanned readmissions, and emergency department (ED) visits. Complications related to fracture union were evaluated in patients with ≥ 6 months follow-up. Multivariate analysis controlled for tobacco use, open fracture, and American Society of Anesthesiologist class ≥ 3.

Results: Among 388 patients included in the study, the mean age was 37.6 years (range, 18-90), and most patients were men (66.5%). Ninety-six patients (25%) were identified as marijuana users. Marijuana users were significantly younger (30.5 years vs 40 years, P < .001) and more likely to be male (79% vs 62%, P = .002) and use tobacco currently (73% vs 31%, P < .001) than non-users. Marijuana users experienced higher rates of 90-day surgical complications (11.5% vs 4.8%, P = .030) and deep infection (8.3% vs 2.1%, P = .008) compared with non-users. No significant difference was observed between groups in the rates of thromboembolic complications, nonunion, or delayed union (P > .05). On multivariate analysis, marijuana use was not associated with odds of developing any 90-day surgical complication (OR 2.01; 95% CI 0.83-4.84) or deep infection (OR 2.97; 95% CI 0.95-9.25).

Conclusions: Preoperative marijuana use was not found to be associated with risk of thromboembolic, surgical, or fracture union-related complications in patients undergoing tibia shaft fracture fixation.

Level of evidence: Prognostic Level III.

Objectives: The objective of this study was to compare clinical outcomes between in situ fixation and fixation after closed reduction (CR) in patients aged 50 and above with valgus impacted femoral neck fractures using data from multiple centers.

Methods: Design: Retrospective multicenter cohort study.

Setting: Five tertiary-care university hospitals.

Patient selection criteria: Patients aged 50 and above, treated with operative fixation of valgus impacted femoral neck fractures using multiple cannulated screws from 2003 to 2019.

Outcome measures and comparisons: Complications such as fixation failure, osteonecrosis of femoral head (ONFH), and reoperation were compared between the groups (in situ fixation group and fixation after CR group). Postoperative EuroQol-5 Dimension (EQ-5D), Harris Hip Score (HHS), and Koval's grade were compared.

Results: The mean age of the 206 patients (161 in situ fixation group, 45 in fixation after CR group) who met the inclusion criteria was 68.9 ± 10.9 years (range, 50 to 95 years). There were 39 men and 167 women. Fixation failure occurred in 11.2% (6.8% of in situ fixation group vs 26.7% of fixation after CR group, p = 0.002). Reoperation was required for 10.2% (7.5% of in situ fixation group vs 20% of fixation after CR group, p = 0.023). Fixation failure and reoperation rates were significantly higher in the fixation after CR group than in the in-situ fixation group (odds ratio = 4.757, p = 0.002 and odds ratio = 3.104, p = 0.023, respectively). At the two-year follow-up, ONFH occurred in 5.8% (9 out of 161, in situ fixation group vs 3 out of 45, fixation after CR group). There was no significant difference in the occurrence of ONFH between the two groups (p = 0.727). The Koval's grade at 6 and 12 months demonstrated better results in the in-situ group (p = 0.027, 0.044, respectively). Postoperative EQ-5D and HHS scores showed no statistically significant differences between the two groups.

Conclusion: In patients aged 50 years or older with valgus impacted femoral neck fractures, when fixation was done after reduction, the reoperation rate was higher due to fixation failure compared to in-situ fixation. There was no significant difference in the incidence of ONFH in valgus impacted femoral neck fractures regardless of whether reduction was performed.

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

Objective: To compare outcomes after ankle fracture fixation between those receiving formal physical therapy (PT) vs. no formal PT and those with high vs. low PROMIS anxiety score (AS), and to evaluate the effect of PT in the setting of PROMIS AS scores.

Methods:

Design: Retrospective cohort study.

Setting: Level 1 trauma center.

Patient selection criteria: Patients aged > 18 undergoing isolated ankle fracture (OTA/AO 44A, 44B, 44C) fixation with documented PROMIS scores postoperatively.Outcome Measures and Comparisons: The post-operative PROMIS physical function (PF) and pain interference (PI) were compared between patients receiving formal PT vs. no PT and those with baseline high vs. low PROMIS AS scores. A sub-analysis was performed between patients with low anxiety and no PT (LANP) vs. low anxiety with PT (LAP) vs. high anxiety and no PT (HANP), and high anxiety with PT (HAP).

Results: A total of 161 patients, 111 females (68.9%), with an average age of 46 years (range: 72), were included in this study: 127 PT, 34 no PT, 88 low anxiety, and 73 high anxiety. PT did not yield any significant differences in PROMIS PF (44.9 PT vs 42.6 no PT, p=0.180) or PI (53.5 PT vs 54.4 no PT, p=0.656) at final follow-up. At final follow-up, high anxiety patients had similar PROMIS PF (43.0) vs. low anxiety patients (45.5, p=0.088), but significantly worse PROMIS PI scores (51.5 vs. 56.7, respectively; p=0.001). Univariate analysis demonstrated a significant difference in age between high and low anxiety patients and was thus selected as a control variable in the analysis of HANP, HAP, LANP, and LAP. After controlling for age, pairwise comparisons of estimated PROMIS PF scores at final follow-up were significantly lower for HANP (39.0) than HAP (43.9, p=0.05), LANP (45.1, p=0.05), and LAP patients (45.9, p=0.04). Final PROMIS PI scores were significantly worse for HANP (59.1) and HAP (56.5) when compared to LANP (51.3, p=0.021 vs HANP, p=0.049 vs HAP) and LAP (51.3, p=0.005 vs HANP, p=0.004 vs HAP) groups .

Conclusion: Patients with high anxiety who undergo isolated ankle fracture fixation perform worse regarding PROMIS PI irrespective of PT status. However, some patients with high anxiety may benefit from formal PT referral to maximize their functional outcomes.

Level of evidence: Level III, Prognostic.

Objectives: To determine sources of frustration for surgeons and how they might affect job satisfaction within the orthopaedic trauma community.

Methods: A 25-question survey regarding potential common causes of frustration, operating room (OR) utilization, and career satisfaction was electronically distributed to the Orthopaedic Trauma Association (OTA) membership.

Results: Four hundred seventy-one surgeons participated in the survey (response rate 27.5%). The highest ranked source of frustration was OR turnover time, followed by staff turnover, and OR scheduling. Most reported they were very satisfied with their career (n=240, 51.0%). The top three strategies to increase career satisfaction from most to least effective were increased compensation, case delay reduction, and decreased work hours. The majority of surgeons reported that if their number one frustration was solved, they would feel a higher level of career satisfaction (very satisfied: n=344, 73.1%). Most felt their cases did not start on time (n=273, 58.0%), with the majority of respondents reporting that their cases were delayed on average between 15-60 minutes (n=222, 81.9%). The number one ranked reason for case start delays was OR turnover and case setup, followed by the anesthesia team.

Conclusions: Many surgeons within the orthopaedic trauma community reported concern with OR turnover time and staff turnover. Addressing these sources of frustration is crucial to maintaining surgeon well-being and can aid in optimizing delivery of patient care. Future studies should seek out institutions that have successfully addressed these common frustrations and identify potential strategies in order to improve the delivery of orthopaedic trauma care across North America.

Level of evidence: Level V.

Summary: As the operative management of acute, chest wall, skeletal injury escalates throughout the world, it has become commonplace for patients with posttraumatic conditions to present with clinical reconstructive challenges as well. In addition, it is becoming clear that rib nonunions are not rare, likely more than 5% of rib fractures. No subspecialty is better equipped to address such painful conditions than orthopaedic surgery. Likewise, there are a plethora of other posttraumatic problems that patients face, from intercostal neuralgia, pleural herniation, rib synostosis, and costal margin and sternal injuries that do not heal properly, which require treatment solutions. This emerging new field of surgery is optimized by an interdisciplinary approach, between general and orthopaedic trauma surgeons, and between thoracic, anesthesia, and rehabilitation specialists. This article emphasizes the workup and operative treatment of painful rib and sternal nonunions, in particular, and familiarizes the orthopaedist with other cold skeletal trauma in general. From the distinctive history and physical examination of the patient with a rib psuedoarthrosis to proper diagnostic studies, the surgeon is led through a principled approach to nonunion surgery, inclusive of autogenous graft harvest to provide both biologic and mechanical variables to bear in the successful treatment of this condition.

Summary: Although nonoperative management is the mainstay for rib fracture treatment, surgical stabilization of rib fractures is becoming more common. Recently, the number of high-quality studies on management of rib fractures has also increased. The primary purpose of this review is to analyze the currently available prospective randomized studies on the management of rib fractures. In addition, we will summarize both short-term and long-term outcomes of patients with rib fractures.

Summary: Achieving satisfactory alignment during intramedullary nailing of periarticular fractures can be technically challenging due to a combination of deforming forces and the lack of cortical contact by the nail in the articular segment metaphysis allowing malreduction to persist during nail passage. Although blocking screws are described to facilitate reduction, they risk impeding subsequent implant fixation. This article introduces an innovative Temporary Reduction Assisting Corridor Constraint Wires (TRACC-wires) technique to safely correct multiplanar deformities without limiting fixation options. A retrospective case series of 22 patients showed that TRACC-wires effectively facilitated anatomic alignment intraoperatively that was maintained after wire removal. Compared with other methods, advantages include (1) the ability to easily redirect, reposition, or remove (given instant access to the blocking device), (2) malleability of the wires during nail insertion, (3) small bony footprint, and (4) versatility for patient-specific correction. Outcomes support TRACC-wires as a valuable tool for trauma surgeons managing complex periarticular fractures.