Journal of Orthopaedic Trauma最新文献

Objectives: To evaluate differences in opioid use and length of stay (LOS) in patients treated with Fascia Iliaca (FI) blocks for a hip fracture compared to patients not receiving an FI block.

Methods: Design: Retrospective Cohort Study.

Setting: Nine University and Community Hospitals.

Patient selection criteria: Included were adults who underwent intramedullary nailing for hip fractures (OTA/AO 31A or OTA/AO 32) between January 2022 - October 2023 who either received a fascia iliaca block or did not prior to fixation.

Main outcome measures: Primary outcomes of the study are Morphine milligram equivalents (MMEs) during admission and postoperative days (POD) 1-3; hospital length of stay (LOS) in days. Outcomes were compared between patients receiving FI blocks and those who did not.

Results: There were 610 patients (179 males, 431 females) included in the study. Patients receiving an FI block (N=273) were significantly older (83.1 ± 9.7 years vs. 81.0 ± 10.2 years, Range = 60-105 years, P = 0.023) and had lower American Society of Anesthesiologists (ASA) classifications (P = 0.001). Univariate analysis showed significantly less opioid use for the FI block group during overall admission (3.75 MMEs vs 11.25 MMEs, P = 0.046),but showed no differences from POD 1-3 (0 MMEs vs 0 MMEs, P = 0.187) or in LOS (5.08 days vs 4.84 days, P = 0.287). After adjusting for age and ASA classification, multivariate regression revealed no significant association between FI blocks and decreased opioid consumption on POD 1 (Partial Eta Squared (η2) = 0.002, P = 0.243), POD 1-3 (η2 = 0.002, P = 0.284), or during overall admission (η2 = 0.004, P = 0.122).

Conclusions: Receiving a preoperative FI block did not decrease postoperative opioid consumption during hospitalization or LOS for older hip fracture patients when controlling for age and ASA classification.

Level of evidence: Level III Evidence.

Objectives: To evaluate the relationship between soft tissue envelope thickness and progression to union for humeral shaft fractures treated with functional bracing.

Methods: Design: Retrospective cohort study.

Setting: Single academic institution.

Patient selection criteria: Patients with humeral shaft fractures (OTA/AO 12) who underwent at least 6 weeks of functional brace treatment.

Outcome measures and comparisons: Demographics, injury characteristics, and treatment outcomes were collected. Failure of nonoperative management was defined as continued fracture site motion after 6 weeks with accompanying lack of progressive callus formation. Soft tissue envelope, including the relative thickness of muscle and fat, was measured at the surgical neck of the humerus and deltoid tuberosity using post-reduction radiographs and those taken at the two-, four-, and six-week follow-up visits. Compared were patients who achieved union with bracing to those who did not.

Results: Fifty-eight patients met inclusion criteria, of which 29 (50%) were female. Median age was 46.4 years (range 19.9-89.6). Thirty-five (60.3%) progressed to union with functional brace treatment, whereas 23 (39.7%) underwent surgery for failure of progressive union or had nonunion as their final outcome. Current smoking status was significantly associated with nonunion (43.5% versus 17.1%, p=0.028). Union outcome was not significantly associated with age, sex, body mass index (BMI), endocrine disease, injury mechanism, or AO/OTA classification (all p>0.05).Patients who progressed to union had less muscle at the deltoid tuberosity four weeks after injury (median 12.8mm (IQR 10.3-17.9)) versus those who did not progress to union (median 22.5mm (18.6-23.7); p=0.015). Union outcome was not associated with soft tissue measurements at any other time point (all p>0.05).

Conclusions: Four weeks post-injury, patients who progressed to union had 1cm less muscle at the deltoid tuberosity compared to those who failed nonoperative management. However, no association was found at other time points, suggesting the efficacy of functional brace treatment does not reliably depend on soft tissue thickness around the humerus.

Level of evidence: III.

Objectives: To compare infection rates after external fixation removal, comparing pin sites that were primary closed with those left open to heal by secondary intention.

Methods:

Design: Retrospective review.

Setting: Multicenter study.

Patient selection criteria: All adult patients (18 years and older) who underwent removal of external fixator that was used for extremity fractures from 2007 to 2023 with at least 30 days follow-up. Patients were stratified into 2 cohorts: (1) external fixator pin sites primarily closed after external fixator removal and (2) pin sites left open to heal with secondary intention after external fixator removal.

Outcome measures and comparisons: Patient characteristics, fracture characteristics, and details of the external fixator removal surgery were recorded. Comparison of the rate of surgical site infection (SSI) of pin site after external fixation removal were performed between the 2 groups (pin sites that were closed primarily and those left open after external fixator removal).

Results: A total of 412 patients were included, with a mean follow-up of 259 days. There were 254 patients in the closed pin site after pin removal group (mean age 53 years, range 18-95, 39% female) and 158 in the pin sites left open after pin removal group (mean age 54 years, range 18-93, 49.4% female). The median duration of external fixator in the closed group was 11 days and 19 days in the open group ( P < 0.05). Multivariate analysis demonstrated increased odds of SSI of pin site after pin removal if the pin site was left open (odds ratio = 3.2; 95% confidence interval, 1.44-7.19, P < 0.01) and with tibial plateau fractures (odds ratio = 4.45; 95% confidence interval, 1.92-10.32, P < 0.001).

Conclusions: After external fixation removal, closure of pin sites was associated with lower risk of pin site SSI after pin removal compared with leaving them open when external fixation duration was less than 2 weeks. External fixation is a common procedure, and this study can help change practice and decrease the risk of SSI of pin site after pin removal.

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

Objectives: To compare whether femoral version more closely mirrors the contralateral femur or a population norm estimate of 15 degrees of anteversion.

Methods:

Design: Radiologic observational study.

Setting: Level I Trauma Center.

Patient selection criteria: Patients with no history of anatomy-altering femoral injury who underwent bilateral lower extremity computed tomography scans.

Outcome measures and comparisons: Computed tomographies were analyzed to measure femoral version on each side. The asymmetry in femoral version between left and right in each patient (interfemoral rotational variance [IRV]) was recorded. The difference of each femur's version from a proposed population mean of 15 degrees of anteversion was also recorded.

Results: A total of 219 patients with a mean femoral version of 14.9 degrees ± 10.5 degrees of anteversion were included. Mean IRV was 5.3 degrees, compared with 8.2 degrees of mean variation from the population norm of 15 degrees of anteversion ( P < 0.001). Five percent of patients had IRV >15 degrees compared with 15% that had femoral rotation >15 degrees from the population mean of 15 degrees ( P < 0.001).

Conclusions: In the setting of a comminuted diaphyseal femur fracture, knowledge of the appropriate target for restoration of rotational alignment is critical. This radiologic cohort study found that on average, femoral version more closely mirrors an individual patient's contralateral femur as opposed to a population norm of 15 degrees of anteversion.

Objectives: To describe the injury characteristics, treatment methods, and maternal and fetal perioperative outcomes among pregnant patients with pelvic ring and acetabular fractures.

Methods: Design: Multisite retrospective cohort study.

Setting: Nine Level I trauma centers.

Patient selection criteria: Adult pregnant patients who presented with pelvic ring or acetabular fractures (AO/OTA 61A-C and/or 62A-C) were included. Patients with trace amounts of hCG due to recent miscarriages or deliveries were excluded.

Outcome measures and comparisons: Demographics, concomitant injuries, treatment methods, and perioperative clinical outcomes for both mother and fetus were abstracted and described. Comparisons were made between patients who presented with intrauterine fetal demise (IUFD) and those who did not, as well as between patients treated operatively and nonoperatively.

Results: Seventy-eight female patients were identified, with 68% having pelvic ring fractures, 22% acetabular fractures, and 10% combined fractures. Median age was 25.4 (range 18-40). The median Injury Severity Score (ISS) was 22. Patients' gravid status was evenly distributed by viability (51.3% viable). A third of the patients arrived with IUFD (n=25/78), and those with IUFD had higher ISS (median ISS 30.5 in IUFD group, 16.9 in non-IUFD group). Of the remaining 53 patients, 64% were indicated for surgery, and 36% were treated nonoperatively. Maternal complications occurred in 8% of patients (n=1/19, 5.3% nonoperative; n=2/19, 10.5% operative). Among patients who did not arrive with IUFD or deliver their baby prior to orthopaedic management, fetal complications (premature delivery, miscarriage, and neonatal death) occurred in 28.9% (n=11/38). Fetal complications were lower in the group treated operatively (n=4/19, 21.1%) as compared to the nonoperative group (n=7/19, 36.8%). Miscarriages specifically were similar between these groups (n=3, 15.8% nonoperative; n=2, 10.5% operative).

Conclusions: Fractures of the pelvic ring/acetabulum in pregnant patients frequently result in IUFD at presentation or during the hospital stay. Surgical management added minimal additional risk to the fetus. Miscarriage rates were similar among patients treated surgically and those managed nonoperatively.

Level of evidence: III.

Objectives: To evaluate soft tissue complications and the incidence of neurovascular bundle (NVB) injury following the modified posteromedial approach (moPMA) for posterior malleolar (PM) fractures, and to describe its indications in clinical practice.

Methods: Design: Retrospective, observational case-series study.

Setting: Single center with a dedicated foot and ankle trauma unit.

Patient selection criteria: Consecutive adult patients who underwent open reduction and internal fixation (ORIF) of PM fractures (AO/OTA 44 or 43) using the moPMA between 2014 and 2024. Exclusion criteria were open or pathological fractures, prior surgery at other institutions, or incomplete clinical records.

Outcome measures: Primary outcomes were incidence of soft tissue complications and NVB injuries, graded according to the modified Clavien-Dindo classification for foot and ankle surgery. Secondary outcomes included fracture classification according to AO/OTA and Bartoníček-Rammelt, associated procedures and approaches, surgical staging, fixation type, follow up, and use of intraoperative imaging.

Results: The mean age was 47 years (range 18-83 years), there were 14 male and 40 female patients. The mean time from injury to surgery was 5.9 days. According to the Bartoníček-Rammelt classification, 51.9% were type C, 31.5% type B, and 14.8% type D. Most cases (77.8%) were AO/OTA 44B3. The moPMA was used in the first surgical stage in 77.8% of cases. A second approach was required in 90.7%, most commonly for fibular fixation through a lateral approach (70.4%). Associated procedures were performed in 92.6%, with fibular osteosynthesis being the most frequent (66.7%). Fixation was plate-based in 92.5%. The mean follow-up was 63.1 ± 31.4 months. Hardware removal of the posterior fixation was performed in 37.1%. Soft tissue complications occurred in 4 patients (7.4%), all classified as grade IA. No NVB injuries or tibialis posterior tendon contractures were reported.

Conclusions: The modified posteromedial approach for fixation of posterior malleolar fractures demonstrated low complication rates and no neurovascular injuries, supporting its use in a wide range of posterior malleolar fractures.

Level of evidence: Level IV. Retrospective observational case-series study.

Objectives: To compare the effectiveness and safety of aspirin versus low-molecular-weight heparin (LMWH) for thromboprophylaxis in 11 high-risk or fracture location subpopulations.

Methods: Design: A post-hoc secondary analysis of the published PREVENT CLOT trial.

Setting: 21 trauma centers.

Patient selection criteria: Adult patients with an operatively treated extremity fracture or any pelvic or acetabular fracture were enrolled from April 2017 through August 2021. Patients with only hand or foot fractures, presenting >48 hours after injury, or with a history of VTE within 6 months of injury were excluded. The 11 subpopulations included i) a head injury, ii) an abdominal injury, iii) a spinal injury, iv) a thoracic injury, v) multiply injured patients, vi) obesity, vii) previous VTE ≥ 6 months, viii) isolated upper extremity fracture, ix) isolated lower extremity fracture, x) isolated pelvic or acetabular fracture, and xi) geriatric femur fracture.

Outcome measures and comparisons: The primary outcome was 90-day all-cause mortality. Secondary outcomes included non-fatal pulmonary embolism, proximal deep vein thrombosis (DVT), distal DVT, and bleeding events. Outcomes were assessed using Kaplan-Meier estimators and Cox proportional hazards models comparing 81 mg of aspirin versus 30 mg of LMWH twice daily. The threshold for statistical significance was a Bonferroni-corrected alpha of 0.001 to account for multiple comparisons.

Results: The largest subpopulations were isolated lower extremity fractures (n=6,289), obesity (n=4,234), and polytrauma with Injury Severity Score (ISS) >16 (n=1,596). No comparison of aspirin vs LMWH within the 11 subpopulations for the 5 outcomes reached the corrected threshold for statistical significance of P < 0.001. However, 5 comparisons of aspirin vs LMWH were less than the conventional P-value of 0.05. Specifically, the aspirin group demonstrated lower mortality in patients with a head injury (difference, -3.2%; 95% CI -6.1% to -0.3%; P = 0.03) or a spine injury (difference, -6.0%; 95% CI -11.7% to -0.3%; P = 0.04) than the LMWH group. The LMWH group demonstrated a lower rate of distal DVTs for patients with a head injury (difference, 4.4%; 95% CI, 0.8% to 8.1%; P = 0.03), thoracic injury (difference, 1.5%; 95% CI, 0.0% to 2.9%; P=0.034) or with ISS >16 (difference, 1.7%; 95% CI, 0.2% to 3.3; P = 0.03) than the aspirin group.

Conclusions: Within 11 high-risk or fracture location-specific subpopulations, there were no statistically significant differences between aspirin or LMWH in the 90-day rates of all-cause mortality, non-fatal PE, proximal DVT, distal DVT, or bleeding complications at a threshold corrected for multiple comparisons (P < 0.001).

Level of evidence: Therapeutic Level I.

Objectives: To investigate the occurrence and risk factors for breakage of 2.7 mm variable angle (VA) locking screws from Depuy - Synthes during removal.

Methods: Design: Retrospective cohort study.

Setting: Two urban tertiary care hospitals in India.

Patient selection criteria: Patients from 2018 to 2024, undergoing removal of VA locked implants after healing of distal humerus (AO/OTA 13 - A2,3 and 13 - C1,2,3) and distal tibia fractures (AO/ OTA 43 - A1,2,3 and C2,3).Outcome measures and comparisons: The primary outcome measure was breakage of 2.7 mm VA locked screws. Difference in breakage between titanium and stainless-steel screws were examined. Age, gender, bone quality (measured in Hounsfield units using preoperative computerised tomography), body mass index, screw length, and time between surgery and implant removal were analysed for association with screw breakage.

Results: Of 28 patients included, 16 patients underwent removal of titanium implants from the distal humerus and 12 patients underwent removal of stainless-steel implants from the distal tibia. There were 16 males and 12 females with mean age of 41years (range 20-20, SD 15). 95 out of 254 VA locking screws were reported broken during removal. 46 out of 105 (43.8%) stainless steel screws broke compared to 49 out of 149 (32.8%) titanium screws. This difference was not statistically significant (p = 0.234). Younger age (β = -0.48, SE = 0.2, p = 0.022), longer screw length (β = 0.21, SE = 0.23, p = 0.038) and a longer interval between surgery and removal (β = 0.43, SE = 0.42, p = 0.002) were associated with a higher incidence of screw breakage.

Conclusions: A high incidence of breakage was observed during removal of 2.7 mm VA titanium and stainless-steel locking screws. Younger patients, longer screws and late removal were associated with more risk for breakage. It is important for patients undergoing removal of these implants to be adequately informed and surgeons should be prepared to address this challenge intraoperatively.

Level of evidence: IV Retrospective cohort study.