Journal of Orthopaedic Trauma最新文献

Objectives: To determine the prevalence and surgical relevance of asymmetry in patients with sacral dysmorphism.

Methods: Design: Retrospective Review.

Setting: Level one academic trauma center.

Patient selection criteria: Included were patients between 16-85 years old with an operative pelvic ring injury (OTA/AO 61A-C) and a thin-cut pelvis CT (≤2.0mm) with 3D reformats. Sacral dysmorphism was defined by the inability to place a transiliac-transsacral screw in the upper sacral segment.Outcome Measures and Comparisons: Asymmetry was assessed by evaluating side-to-side differences in neuroforaminal height, upper sacral segment pathway obliquity, and anterior-posterior pathway width.

Results: The group of patients with asymmetric sacral dysmorphism was 52.9% female while the group with symmetric sacral dysmorphism and without sacral dysmorphism was 36.3% female and 44.3% female, respectively. The average age of the patients with asymmetric, symmetric, and no sacral dysmorphism was 43.0 years (range 16-89), 42.9 years (range 18-94), and 47.5 years (range 33-89), respectively. Of the 220 patients evaluated, there were 114 (51.8%) patients that demonstrated sacral dysmorphism. Among dysmorphic patients, 34 (29.8%) exhibited at least one feature of asymmetry. Asymmetric features included differences in neuroforaminal height, upper sacral segment pathway obliquity, and pathway width.

Conclusion: Nearly 30% of patients with sacral dysmorphism demonstrated asymmetric features, which can impact surgical planning. Recognition of asymmetric sacral dysmorphism is important for proper execution of posterior pelvic fixation.

Level of evidence: Level IV.

Objectives: To compare the incidence and severity of patellofemoral chondromalacia and its correlation with anterior knee pain following suprapatellar (SP) versus infrapatellar (IP) approaches for tibial intramedullary nailing.

Methods: Design: Prospective, randomized controlled trial.

Setting: Single-center study at a Level I Trauma Center.

Patient selection criteria: Patients aged between 18-45 years who presented with AO/OTA type 42 fractures from September 2020 to March 2024 were randomized into Suprapatellar (SP) and Infrapatellar (IP) groups. MRI at six months post-surgery assessed cartilage damage using the Modified Outerbridge Classification. Diagnostic knee arthroscopy was offered for further evaluation.

Outcome measures and comparisons: The primary outcome was frequency and severity of chondromalacia assessed via MRI (Modified Outerbridge Classification) and diagnostic knee arthroscopy at six months. Secondary outcomes were correlation of MRI findings with knee pain (VAS score) and comparison of time taken for nail insertion with cartilage damage in the SP group.

Results: Both groups had 30 patients each. In SP group, mean age was 33.7 years (range 18-45 years) and 83.3% were male while IP group had a mean age of 29.3 years (range 18-45 years) and 83.3% were male. 57 underwent MRI knee (SP: 28, IP: 29) and 16 underwent diagnostic knee arthroscopy (SP: 9, IP: 7). MRI detected chondromalacia in 46.4% in the SP group and 44.8% patients in the IP group; there was no significant difference (p-value 0.9). Arthroscopy revealed chondromalacia in all 9 (100%) patients who underwent diagnostic arthroscopy in the SP group as compared to 2 of 7 (28.6%) patients in the IP group (p-value 0.003). Correlation between chondromalacia grading on MRI and VAS scores at 6 months follow-up was significant (r=0.4, p-value 0.006). Time taken for nail insertion weakly correlated with presence of chondromalacia on MRI in the SP group but was not statistically significant (r=0.2, p-value 0.5).

Conclusions: No differences were found in the occurrence of patellofemoral chondromalacia seen on MRI between SP or IP nailing techniques. The SP approach demonstrated a higher frequency of patellofemoral chondromalacia on arthroscopic evaluation.

Level of evidence: Therapeutic Level I.

Objectives: To evaluate whether the use of intraoperative 3D fluoroscopy during acetabular fracture fixation reduces the rate of unplanned returns to the operating room and improves radiographic quality of reduction without increasing operative time or blood loss.

Methods: Design : Retrospective comparative study.

Setting: Single urban Level I trauma center.

Patient selection criteria: Patients with operatively treated acetabular fractures (OTA/AO 62) between 2017 and 2025. Patients were divided into two cohorts: those treated before and after the implementation of intraoperative 3D fluoroscopy (Cios Spin, Siemens, Germany).Outcome Measures and Comparisons : Primary outcome was the rate of unplanned return to the operating room. Secondary outcomes included postoperative residual joint gap, presence of intra-articular loose bodies, implant malposition, operative time, and estimated blood loss (EBL). These outcomes were compared between the two cohorts.

Results: 177 patients were included between 2017 and 2025, 148 patients treated before (control group) and 29 after the implementation of intraoperative 3D fluoroscopy (3D fluoro group). The mean age was 41.1 ±17.4 years old in the control group with 117 men (79%) vs 42.8 ±18.1 years old (p=0.55) in the 3D fluoro group, with 20 men (68.9%, p=0.34). The rate of unplanned return to the operating room was significantly lower in the 3D fluoroscopy group (0%) compared to the control group (15.5%) (p = 0.01). Postoperative CT scan (obtained in 148/148 in the control group and 22/29 in the 3D fluoroscopy group) demonstrated better fracture reduction in the 3D fluoroscopy group (mean residual gap: 3.4 ± 1.9 mm vs 4.5 ± 2.4 mm; p = 0.03). There were no significant differences in operative time (200.6 ±99.8 vs 221.2 ±114.4; p=0.49) or EBL (641.6 ±637.1 vs 674 ±572; p=0.67) between groups. Intraoperative findings seen on the 3D fluoroscopy such as malreduction, loose bodies or misplaced hardware led to modification of the surgical plan in 29% of cases where the 3D fluoroscopy was used.

Conclusions: The use of intraoperative 3D fluoroscopy allowed intraoperative identification and correction of malreductions, implant malposition and removal of loose bodies, reducing the need for revision surgery and improving quality of reduction in acetabular fracture fixation. Its use did not increase operative time or blood loss, suggesting clinical and potentially economic benefits that may support broader adoption.

Level of evidence: Therapeutic Level III.

Objectives: To determine if the presence of intra-articular air on computed tomography (CT) correlates with hip joint instability following posterior wall acetabular fractures.

Methods: Design: Retrospective chart and radiographic review.

Setting: Two academic level 1 trauma centers.

Patient selection criteria: Skeletally mature patients with posterior wall acetabulum fractures (AO/OTA 62A1) that underwent stress examination under anesthesia (EUA) from 2014 to 2024.

Outcome measures and comparisons: Patients with positive and negative EUAs were compared with regards to history of dislocation, presence of intra-articular air on CT scan, amount of fracture displacement, sagittal angle measurement, and fracture size.

Results: There were 38 positive (unstable) and 33 negative (stable) EUAs for posterior wall acetabulum fractures. Demographics were similar between positive (mean age 28 years (range (18-58 years), 34% female) and negative (mean age 36 years (range (18-61 years), 30% female) groups. Patients with a positive EUA had a significantly higher incidence of intra-articular air (82% vs 9%, P < 0.001), fracture displacement greater than 5 millimeters (76% vs 33%, P < 0.001), sagittal angle measurement greater than 70° (74 vs 21%, P < 0.001), and hip dislocation on injury radiograph (61 vs 18%, P < 0.001). In 43 patients who presented without a history of hip dislocation, intra-articular air was present significantly more often in the positive EUA group (n = 16) compared to the negative EUA group (n = 27) (75 vs 7%, P < 0.001).

Conclusions: Hip joint instability following posterior wall acetabulum fracture was significantly higher in patients with intra-articular air on CT scan - regardless of a history for hip dislocation. Fracture displacement greater than 5 millimeters and sagittal angle measurement greater than 70° were also found to be predictors of positive EUA. When these characteristics are found on injury imaging, an EUA should be considered to rule out hip joint instability.

Level of evidence: Diagnostic Level III.

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.

Objectives: To compare the quality of syndesmotic reduction with and without deltoid ligament repair (DLR).

Methods: Ten cadaveric ankle specimens underwent baseline computed tomography (CT) imaging in neutral plantarflexion. A fellowship-trained orthopaedic trauma surgeon disrupted the syndesmosis and deltoid ligament of each specimen. The syndesmosis was reduced in neutral plantarflexion by manual hand pressure under direct visualization through an anterolateral approach and stabilized with two 0.062-inch K-wires placed lateral-to-medial in a quadricortical fashion. Postreduction CT imaging was then obtained. K-wires were removed, and DLR was performed using suture anchor fixation. The syndesmosis was again reduced and stabilized using the same technique, followed by a second postreduction CT scan. Four validated measurements were used to evaluate the quality of syndesmotic reduction. All postreduction CT scans were compared to baseline using mixed-effects linear regression to account for the nesting of ankles within donors.

Results: Ten cadaveric ankle specimens were obtained from five donors (mean age: 76.8 years [range: 70-83 years], 3 female and 2 male). Postreduction CT imaging demonstrated mean anterior translation of the fibula, both with DLR compared to baseline (6.4±1.1 mm vs. 7.7±1.5 mm, P=0.001) and without DLR compared to baseline (6.4±1.9 mm vs. 7.7±1.5 mm, P<0.001). The fibula was internally rotated following DLR when compared to baseline when evaluating mean rotation ratio (0.3±0.1 vs. 0.4±0.2, P=0.04) but not mean rotation angle (15.4±3.9 degrees vs. 13.3±3.2 degrees, P=0.12). No differences were observed in mean lateral translation with or without DLR compared to baseline (P>0.05). Direct comparison of reductions with and without DLR showed no differences in measures of mean reduction quality (P>0.05).

Conclusions: In this cadaveric study, DLR did not significantly improve syndesmotic reduction quality compared to reductions performed without DLR. Relative internal rotation of the fibula was observed after DLR, perhaps due to prevention of talar external rotation and tensioning of the medial side during syndesmotic reduction.