Journal of Orthopaedic Trauma最新文献

Summary: Pain after amputation is often managed by target muscle reinnervation (TMR) with the added benefit that TMR also provides improved myoelectric terminal device control. However, as TMR takes several months for the recipient muscles to reliably reinnervate, this technique does not address pain within the subacute postoperative period during which pain chronification, sensitization, and opioid dependence and misuse may occur. Cryoneurolysis, described herein, uses focused, extreme temperatures to essentially "freeze" the nerve, blocking nociception, and improving pain in treated nerves potentially reducing the chances of pain chronification, sensitization, and substance dependence or abuse.

Objectives: To analyze the relationship between patient resilience and patient-reported outcomes after orthopaedic trauma.

Methods:

Design: Retrospective analysis of prospectively collected data.

Setting: Single Level 1 Trauma Center.

Patient selection criteria: Patients were selected based on completion of the Patient-Reported Outcomes Measurement Information System (PROMIS) and Brief Resilience Scale (BRS) surveys 6 months after undergoing operative fracture fixation following orthopaedic trauma. Patients were excluded if they did not complete all PROMIS and BRS surveys.

Outcome measures and comparisons: Resilience, measured by the BRS, was analyzed for its effect on patient-reported outcomes, measured by PROMIS Global Physical Health, Physical Function, Pain Interference, Global Mental Health, Depression, and Anxiety. Variables collected were demographics (age, gender, race, body mass index), injury severity score, and postoperative complications (nonunion, infection). All variables were analyzed with univariate for effect on all PROMIS scores. Variables with significance were included in multivariate analysis. Patients were then separated into high resilience (BRS >4.3) and low resilience (BRS <3.0) groups for additional analysis.

Results: A total of 99 patients were included in the analysis. Most patients were male (53%) with an average age of 47 years. Postoperative BRS scores significantly correlated with PROMIS Global Physical Health, Pain Interference, Physical Function, Global Mental Health, Depression, and Anxiety ( P ≤ 0.001 for all scores) at 6 months after injury on both univariate and multivariate analyses. The high resilience group had significantly higher PROMIS Global Physical Health, Physical Function, and Global Mental Health scores and significantly lower PROMIS Pain Interference, Depression, and Anxiety scores ( P ≤ 0.001 for all scores).

Conclusions: Resilience in orthopaedic trauma has a positive association with patient outcomes at 6 months postoperatively. Patients with higher resilience report higher scores in all PROMIS categories regardless of injury severity. Future studies directed at increasing resilience may improve outcomes in patients who experience orthopaedic trauma.

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

Objectives: To compare cost, hospital-related outcomes, and mortality between angioembolization (AE) and preperitoneal pelvic packing (PPP) in the setting of pelvic ring or acetabulum fractures.

Methods: .

Design: Retrospective database review.

Setting: National Inpatient Sample, years 2016-2020.

Patient selection criteria: Hospitalized adult patients who underwent AE or PPP in the setting of a pelvic ring or acetabulum fracture.

Outcome measures and comparisons: Mortality and hospital-associated outcomes, including total charges, following AE versus PPP in the setting of pelvic ring or acetabulum fractures.

Results: A total of 3780 patients, 3620 undergoing AE and 160 undergoing PPP, were included. No significant differences in mortality, length of stay, time to procedure, or discharge disposition were found ( P > 0.05); however, PPP was associated with significantly greater charges than AE ( P = 0.04). Patients who underwent AE had a mean total charge of $250,062.88 while those undergoing PPP had a mean total charge of $369,137.16.

Conclusions: Despite equivalent clinical efficacy in terms of mortality and hospital-related outcomes, PPP was associated with significantly greater charges than AE in the setting of pelvic ring or acetabulum fractures. This data information can inform clinical management of these patients and assist trauma centers in resource allocation.

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

Objectives: To determine the postoperative trajectory and recovery of patients who undergo Lisfranc open reduction and internal fixation using Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI).

Methods:

Design: Retrospective cohort study.

Setting: Level 1 trauma center.

Patient selection criteria: Patients who underwent Lisfranc open reduction and internal fixation between January 2002 and December 2022 with documented PROMIS PF and/or PI scores after surgery.

Outcome measures and comparisons: PROMIS PF and PI were mapped over time up to 1 year after surgery. A subanalysis was performed to compare recovery trajectories between high-energy and low-energy injuries.

Results: A total of 182 patients were included with average age of 38.7 (SD 15.9) years (59 high-energy and 122 low-energy injuries). PROMIS PF scores at 0, 6, 12, 24, and 48 weeks were 30.2, 31.4, 39.2, 43.9, and 46.7, respectively. There was significant improvement in PROMIS PF between 6 and 12 weeks ( P < 0.001), 12-24 weeks ( P < 0.001), and 24-48 weeks ( P = 0.022). A significant difference in PROMIS PF between high and low-energy injuries was seen at 0 week (28.4 vs. 31.4, P = 0.010). PROMIS PI scores at 0, 6, 12, 24, and 48 weeks were 62.2, 58.5, 56.6, 55.7, and 55.6, respectively. There was significant improvement in PROMIS PI 0-6 weeks ( P = 0.016). A significant difference in PROMIS PI between high-energy and low-energy injuries was seen at 48 weeks with scores of (58.6 vs. 54.2, P = 0.044).

Conclusions: After Lisfranc open reduction and internal fixation, patients can expect improvement in PF up to 1 year after surgery, with the biggest improvement in PROMIS PF scores between 6 and 12 weeks and PROMIS PI scores between 0 and 6 weeks after surgery. Regardless the energy type, Lisfranc injuries seem to regain comparable PF by 6-12 months after surgery. However, patients with higher energy Lisfranc injuries should be counseled that these injuries may lead to worse PI at 1 year after surgery as compared with lower energy injuries.

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

Objectives: To compare three fluoroscopic methods for determining femoral rotation.

Methods: Native femoral version was measured by computed tomography in 20 intact femurs from 10 cadaveric specimens. Two Steinmann pins were placed into each left femur above and below a planned transverse osteotomy which was completed through the diaphysis. Four surgeons utilized the true lateral (TL), neck-horizontal angle (NH), and lesser trochanter profile (LTP) techniques to correct the injured femur's rotation using the intact right femur as reference, yielding 120 measurements. Accuracy was assessed by comparing the angle subtended by the two Steinmann pins before and after manipulation and comparing against version measurements of the right femur.

Results: Absolute mean rotational error in the fractured femur compared to its uninjured state was 6.0° (95% CI, 4.6-7.5), 6.6° (95% CI, 5.0-8.2), and 8.5° (95% CI, 6.5-10.6) for the TL, NH, and LTP techniques, respectively, without significant difference between techniques ( p = 0.100). Compared to the right femur, absolute mean rotational error was 6.6° (95% CI, 1.0-12.2), 6.4° (95% CI, 0.1-12.6), and 8.9° (95% CI, 0.8-17.0) for the TL, NH, and LTP techniques, respectively, without significant difference ( p = 0.180). Significantly more femurs were malrotated by >15° using the LTP method compared to the TL and NH methods (20.0% vs 2.5% and 5.0%, p = 0.030). Absolute mean error in estimating femoral rotation of the intact femur using the TL and NH methods compared to CT was 6.6° (95% confidence interval [CI], 5.1-8.2) and 4.4° (95% CI, 3.4-5.4), respectively, with significant difference between the two methods ( p = 0.020).

Conclusions: The true lateral (TL), neck-horizontal angle (NH), and the lesser trochanter profile (LTP) techniques performed similarly in correcting rotation of the fractured femur, but significantly more femurs were malrotated by >15° using the LTP technique. This supports preferential use of the TL or NH methods for determining femoral version intraoperatively.

Objectives: To investigate femoral intramedullary (IM) pressures during reamed antegrade nailing and to determine whether fracture level and/or complexity affect peak pressures.

Methods:

Design: Prospective, nonrandomized observational cohort.

Setting: Single level I trauma center.

Patient selection criteria: Patients presenting with femur fractures (OTA/AO 31A3; 32A; 32B; 32C; 33A2; 33A3), requiring antegrade IM nail fixation, were included in this study. Excluded were minors and patients presenting with hemodynamic instability, a reduced level of consciousness and intoxication. Femurs were divided into thirds based on preoperative radiological measurements and allocated to 3 groups based on fracture location: Proximal (A), middle (B), and distal (C) third femur fractures. Fracture complexity was also documented.

Outcome measures and comparisons: Peak IM pressures of proximal, middle, and distal third femoral fractures were compared during antegrade femoral IM nail fixation.

Results: Twenty-two fractures in 21 patients were enrolled and treated over a 4-month period with a distribution of fracture locations of group A = 12, group B = 6, and group C = 4. Measured mean resting distal IM pressures were significantly higher ( P < 0.05) in proximal fractures (group A: 52.5 mm Hg) than in middle and distal third fractures (group B: 36.6 mm Hg and group C: 27.5 mm Hg). Greatest peak pressures were generated during the first ream in groups A and B, occurring distal to the fracture in all cases. Group A averaged 363.8 mm Hg (300-420), group B 174.2 mm Hg (160-200), and group C 98.8 mm Hg (90-100). There was a significant difference comparing group A with B and C combined ( P < 0.01) and group A with B ( P < 0.05) and C ( P < 0.05]) individually. Group A consisted of 6 comminuted and 6 simple fracture configurations. Mean peak pressures in these subgroups differed significantly: 329 mm Hg (300-370) versus 398 mm Hg (370-430), respectively ( P < 0.05). Complex fractures in study groups B and C did not have significantly different peak pressures compared with simple fractures ( P > 0.05).

Conclusions: Both the fracture location and comminution affect peak IM pressures during reamed antegrade femoral nailing. Proximal, simple fracture configurations resulted in significantly higher pressures when compared with more distal and comminuted fracture configurations.

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