Journal of Orthopaedic Trauma最新文献

Objectives: To examine the impact of frailty on 30-day outcomes of ORIF alone or ORIF+THA (fix-and-replace) for the treatment of acetabular fractures.

Methods: Design: Retrospective Cohort.

Setting: 700 hospitals in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

Patient selection criteria: Included were patients aged 60 years or older undergoing ORIF+/-THA for OTA/AO type 62 A-C fractures from 2015-2020.

Outcome measures and comparisons: Preoperative frailty was assessed by the revised Risk Analysis Index (Not frail: <21, pre-frail: 21-30, frail: 31-40, severely frail: >40) and the 5-Item Modified Frailty Index (mFI-5) factor. All outcome measures were in-hospital or within 30 days postoperatively, including the 'favorable outcome', defined as: no readmission, length of stay

Results: There were 585 patients included [ORIF (88%): mean age - 70.5 ± 14.2, sex - 41.4% female; ORIF+THA (12%): mean age - 77.0 ± 13.4; sex - 65.7% female]. Frail patients (n=353, 65.5%) were more likely to experience a complication (OR: 3.31, CI: [1.83-5.96]) and mortality (3.7% vs. 0.0%). ORIF+THA had higher association with postoperative transfusion (OR: 2.70, CI: [1.63-4.48]) but lower association with length of stay >3 days (OR: 0.41, CI: [0.24-0.72]) and non-home discharge (OR: 0.52, CI: [0.27-0.98]) than ORIF. Pre-Frail and Frail patients undergoing ORIF+THA were more likely to achieve favorable outcomes than those non-frail or severely frail (OR: 9.69, [3.40-27.57]).

Conclusions: Surgical intervention for acetabular fractures carried a 30-day complication risk of 12-19% for frail patients. Frailty had similar predictability to age for early morbidity following surgery to treat acetabular fractures. Open reduction and internal fixation with the addition of an acute total hip arthroplasty was associated with a higher rate of blood transfusion and shorter hospital length of stay in frail patients with acetabular fractures.

Level of evidence: III.

Objectives: To determine the rate of successful humeral shaft nonunion repair in patients with no prior surgery on the humerus (failed nonoperative management), compared with patients with a history of surgery on the humerus (initial operative treatment complicated by nonunion, or prior attempted nonunion repair after failed nonoperative management).

Methods:

Design: Retrospective.

Setting: Two academic trauma centers (1 level 1 and 1 level 2).

Patient selection criteria: All skeletally mature patients undergoing nonunion repair of a presumed aseptic humeral shaft nonunion (AO/OTA 11A, 11B, 11C, 12A, 12B, 12C) were eligible for inclusion.

Outcome measures and comparisons: The primary outcome was osseous union. Univariate analysis was used to examine patient, injury, and treatment factors associated with recalcitrant nonunion between those with and without prior surgery.

Results: One hundred fifty-nine patients were included. Eighty-two patients had a history of operative treatment. The group with prior operative treatment was significantly younger (47 vs. 52, P = 0.047) and had fewer comorbidities (average Charlson comorbidity score 1.3 vs. 1.9, P = 0.015). There were 34 men in the group with prior operative treatment, compared with 37 in the group without prior operative treatment ( P = 0.493). For patients with prior operative treatment, 17 of 82 (21%) patients developed a recalcitrant nonunion, versus 2 of 79 (3%) patients with no prior operative treatment ( P < 0.001). The number of prior operations on the arm was significantly associated with increased risk of recalcitrant nonunion (3% risk if no prior surgeries, 19% risk with 1 prior surgery, 25% risk with 2 prior surgeries, 33% risk with 3 prior surgeries, P = 0.004). No demographic factors were associated with development of a recalcitrant nonunion ( P > 0.05 for all). Nine patients had unexpected positive cultures, but this was not associated with increased risk of recalcitrant nonunion (22% in patients with infection vs. 26% in those without infection, P = 0.907).

Conclusions: Patients undergoing nonunion repair after prior operative treatment of a humeral shaft fracture had a 1 in 5 rate of recalcitrant nonunion, while patients undergoing initial nonunion repair after failed nonoperative management had a 3 in 100 rate of recalcitrant nonunion. Increased risk of persistent nonunion stemmed not from initial treatment strategy for the acute fracture, but rather from the presence of any prior surgery.

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

Objective: To determine whether the occurrence of short-term postoperative altered mental status (AMS) was lower in geriatric patients undergoing operative repair of hip fractures with Monitored Anesthesia Care and Soft Tissue Infiltration with Local Anesthesia (MAC-STILA) when compared with those undergoing operative repair of hip fractures with general anesthesia (GA).

Design: Retrospective cohort study.

Setting: Two US hospitals within a single academic medical center.

Patient selection criteria: Geriatric patients with hip fractures (AO/OTA 31A and 31B) undergoing operative repair were identified. Propensity matching was performed in a 1:2 ratio to minimize selection bias (age, sex, body mass index, American Society of Anesthesiology class, fracture pattern, fixation construct, preinjury ambulatory status, and assistive device use).

Outcome measures: Patients who underwent surgical fixation with MAC-STILA were compared with those who underwent surgical fixation with GA. Primary outcome was postoperative AMS, defined as missing ≥1 items on the alert and oriented assessment (person, place, and time) at any point from postoperative days 0-3.

Results: After matching, 228 patients (76 MAC-STILA: 152 GA) were included in the analysis. The average age of patients in both groups was 83 years. In the MAC-STILA group, 62% were women and 33% had baseline dementia, while in the GA group 66% were women and 29% had baseline dementia. Treating patients with MAC-STILA was associated with 72% lower odds of having AMS than treating patients with GA, controlling for baseline comorbidity and dementia (odds ratio: 0.28. 95% confidence interval: 0.09-0.075, P = 0.016). Among patients with baseline dementia, the rate of AMS was lower in patients treated with MAC-STILA than in patients treated with GA (64.0% vs. 95.3%, P = 0.001).

Conclusions: MAC-STILA was associated with lower odds of short-term postoperative AMS than GA in patients with hip fracture undergoing operative repair. Given the high rate of postoperative AMS and complications associated with a geriatric patient with hip fracture, MAC-STILA should be considered for use in patients with increased risk of postoperative AMS, particularly in the setting of preoperative dementia.

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

Objectives: To evaluate if operative irrigation and debridement (I&D) is necessary for the treatment of pediatric traumatic arthrotomies (TAs) secondary to gunshot wounds (GSWs) to prevent joint infections.

Methods: Design: Retrospective cohort study.

Setting: US Academic Level I Trauma Center.

Patient selection criteria: Pediatric patients (age 0-17) with TAs secondary to GSW between 2016-2023 with at least 1-month follow-up were included. Arthrotomies included shoulder, elbow, wrist, hand, sacroiliac, hip, knee, ankle, or foot joints.

Outcome measures and comparisons: The primary outcome was rate of joint infection between those who received acute operative I&D vs. nonoperative management. A sub analysis was completed only comparing "major joints". Within the cohorts, length of antibiotic treatment was compared.

Results: 57 cases of ballistic TA (50 subjects, 82% male, mean age 14.6) were included. 31/57 joints (54.4%) underwent formal operative I&D with or without fixation, while 26 joints (45.6%) did not. In the operative I&D cohort, 85% were male with a mean age 14.8 versus 79% male with mean age of 14.3 in the nonoperative group. Mean follow-up duration was 10.8 months (range 1-56 months) for both cohorts. No joint infections were documented between either group, regardless of treatment (p=1.0). 38 TAs were major joints: 23/38 (60.5%) received I&D while 15/38 (39.5%) did not. All joints received at least one dose of intravenous antibiotics. Among the operative group, 54.8% of joints received ≤ 72 hours of intravenous antibiotics (45.2% received > 72 hours), compared with 46.2% of joints in the nonoperative group (53.8% received > 72 hours).

Conclusions: Formal operative I&D was not found to be necessary to prevent joint infection after TA secondary to GSW. Prolonged antibiotic use did not affect rates of infection.

Level of evidence: Level III.

Objectives: To evaluate whether ballistic (gunshot) injuries increase the rate of severity of heterotopic ossification (HO) compared to blunt trauma in patients with peri-articular elbow fractures.

Methods: Design: Retrospective Cohort.

Setting: Single Level 1 Trauma Center.

Patient selection criteria: Study inclusion required; patients of mature skeletal age diagnosed with a peri-articular elbow fracture (OTA/AO 13A-C) with a minimum of 6-weeks radiographic follow-up between 2018-2024.

Outcome measures and comparisons: Data on demographics, injury characteristics, and surgical management were collected for the ballistic trauma cohort and blunt trauma cohort. HO was assessed using the Hastings/Brooker Classification. Secondary outcomes included post-injury stiffness defined as a flexion/extension arc of motion < 100°, revision surgery, and complications. Descriptive statistics were used to compare frequencies of categorical outcome variables between blunt and ballistic cohorts, and multivariable logistic regressions were used to identify risk factors for elbow HO occurrence and severity as well as all secondary outcomes.

Results: A total of 171 patients met inclusion criteria including 65 GSW-related fractures (38%). GSW patients were younger (29.2 [Range: 18-62] vs. 43.8 years [Range: 18-93]) and more often male (84.6% vs 51.9%). Overall HO occurrence was 61.4%. GSW was not significantly associated with HO (63.1% vs. 60.4%, p=0.607). Distal humerus fractures were associated with increased HO risk (OR 2.15) and severity (OR 2.63) compared to proximal radius/ulna injuries. Stiffness occurred in 73.7% of patients and was more common in distal humerus injuries than proximal radius/ulna fractures (OR 2.50; p = 0.030). No significant differences were found in stiffness, revision surgery, or complication rates between GSW and non-GSW groups (OR 1.36; 95% CI: 0.537-3.455; p =0.51).

Conclusions: Ballistic injury did not significantly increase heterotopic ossification risk or stiffness compared to blunt trauma in a civilian population. Consistent with prior literature, fracture location, specifically distal humerus fractures compared to proximal radius/ulna injuries, appears to be an important driver for heterotopic ossification prevalence and severity. Identifying heterotopic ossification risk factors after peri-articular elbow trauma can help clinicians stratify patient risk and guide preventive strategies for managing these complex injuries.

Level of evidence: Level III.

Objectives: To estimate the academic quality of Orthopaedic Trauma Association (OTA) annual meetings by analyzing acceptance rates and publication characteristics among featured abstracts.

Methods: Featured abstracts found in the finalized 2017-2021 OTA annual meeting programs were reviewed. Abstracts published with altered methodology, dissimilar results, or lacking the original first author were excluded. Variables such as annual acceptance rates, publication status, study type, level of evidence, journal impact factor (JIF), and more were analyzed.

Results: The OTA annual meeting abstract acceptance rate averaged 23±4% (range 17.5%-28.1%). Among 1001 accepted abstracts, 691 (69.0%) were published in peer-reviewed journals. Fifty-six (8.1%) abstracts were published prior to their respective annual meeting, 248 (35.9%) were published within 12 months after the meeting, and 544 (78.7%) were published within 36 months after the meeting. The JIF of publications averaged 3.2±5.0 without significant variation between years. Featured abstracts were most commonly retrospective (n=436; 63.1%). Podium presentations were published at a significantly higher rate than posters (77.4% versus 64.9%, p<0.001) and averaged higher JIFs (4.1±7.9 versus 2.7±1.3, p=0.001). A total of 122 unique journals published abstracts, with the Journal of Orthopaedic Trauma publishing the highest proportion of articles (n=232, 33.6%).

Conclusions: Abstracts featured in recent OTA annual meetings boast high rates of subsequent publication in high impact journals. These findings imply the OTA annual meeting offers strong educational value. When compared to posters, podium presentations were more often published and appeared in higher impact journals. However, the increasing prevalence of publication among both podium and poster presentations is encouraging for authors looking to substantiate the educational value of their research.

Level of evidence: IV, retrospective epidemiological study.