Fractures in Patients With Diabetes Mellitus: Findings From a 20-year Registry at a Single Level 1 Trauma Center.

INTRODUCTION: Diabetes mellitus (DM) is a risk factor of infection. Although DM has been associated with worse functional outcomes after acetabular fracture, literature regarding the effect of DM on surgical site infection and other early complications is lacking. METHODS: A 20-year registry from a level 1 trauma center was queried to identify 134 patients with DM and 345 nondiabetic patients with acetabular fractures. RESULTS: The diabetic patient population was older (57.2 versus 43.2; P < 0.001) and had higher average body mass index (33.6 versus 29.5; P < 0.001). Eighty-three patients with DM and 270 nondiabetics were treated surgically (62% versus 78%; P < 0.001). Diabetic patients who were younger (54.6 versus 61.4; P = 0.01) with fewer comorbidities (1.7 versus 2.2; P = 0.04) were more frequently managed surgically. On univariate analysis, patients with DM more commonly developed any early infection (28.4% versus 21%; P = 0.049) but were no more likely to develop surgical site infection, or other postoperative complications. Older patient age, length of stay, baseline pulmonary disease, and concurrent abdominal injury were independent predictors of postoperative infection other than surgical site infection. Diabetics that developed infection had more comorbidities (2.4 versus 1.5; P < 0.001) and higher Injury Severity Score (24.1 versus 15.8; P = 0.003), and were more frequently insulin-dependent (72.7% versus 41%; P = 0.01). DISCUSSION: Independent of management strategy, diabetic patients were more likely to develop an infection after acetabular fracture. Insulin dependence was associated with postoperative infection on univariate analysis. Optimal selection of surgical candidates among patients with DM may limit postoperative infections.

Associations of musculoskeletal dysfunction, time to brake, and patient reported outcomes following lower extremity trauma.

INTRODUCTION: Inability to drive a motor vehicle due to lower extremity injury is a major inconvenience. Timing of safe return to driving has not been much studied. Objective measurements such as time to brake (TTB) have been proposed; however, utility and concordance of functional outcome measurements have not been previously evaluated. The purpose of this project is to measure these parameters and to assess for associations with ability to safely return to driving, improving the ability of clinicians to assess for measurements of driving readiness without specifically measuring TTB. METHODS: A prospective, cohort study of 232 patients with complex lower extremity injuries to the pelvis, acetabulum, hip, femur, knee, tibia, ankle, and foot was performed. Time to brake (TTB) was measured once weightbearing was allowed. Function was assessed by the Musculoskeletal Function Assessment (MFA) questionnaire, and pain, mobility, and physical functions, via patient reported outcome measurement information system (PROMIS) surveys. RESULTS: Patients with longer TTB had significantly elevated MFA scores indicating increased musculoskeletal dysfunction post-injury. As the MFA score increased by 1 point, TTB increased by 0.013 s (p<0.001). PROMIS metrics were also significantly associated with patients experiencing more pain and worse mobility as TTB increased. DISCUSSION: Many patients continue to exhibit musculoskeletal dysfunction several months post-treatment for complex lower extremity injuries. Patients with better PROMIS metrics and MFA scores, and shorter TTB are more appropriate to return to driving. Surgeons may be better informed about safe driving ability by considering these measurements. LEVEL OF EVIDENCE: II.

Postmobilization Plain Radiography After Lateral Compression Type 1 Pelvic Ring Injury Does Not Affect Treatment.

INTRODUCTION: The purpose of this study was to describe the practice of postmobilization radiography after lateral compression type 1 pelvis ring injury. We hypothesized that postmobilization radiographs would be more frequent over time and would not influence treatment. METHODS: Displacement of pelvis ring injury on initial and final plain radiographs was measured. Frequency of postmobilization radiography was determined, and the impact on treatment and final radiographical outcome were assessed. RESULTS: Of the 156 patients reviewed, 98 (62.8%) were women and mean age was 60.1 years. Thirty-three of 156 patients (21.2%) had a postmobilization radiograph. Over 5 years, radiographs increased to 67% of presenting patients. None of the patients who received postmobilization plain radiographs (n = 33) had any change in clinical plan afterward; all continued with nonsurgical care. Initial fracture characteristics and alignment were no different for patients with postmobilization radiographs. Final alignment was unchanged in nearly 70%. Overall, 74% of all nonsurgical patients experienced no change in alignment, with similar rates among the patients with postmobilization radiographs. DISCUSSION: Patients with an lateral compression type 1 fracture demonstrated no changes in care after receiving postmobilization radiographs. However, the frequency of postmobilization radiographs increased over time, denoting opportunities to reduce costs and to improve efficiency and safety.

Trauma recidivism is reduced with engagement in psychosocial programming following orthopaedic trauma.

INTRODUCTION: Recidivism is common following injury. Interventions to enhance patient engagement may reduce trauma recidivism. Education, counseling, peer mentorship, and other resources are known as Trauma Recovery Services (TRS). The authors hypothesized that TRS use would reduce trauma recidivism. METHODS: Over five years at a level 1 trauma center, 954 adults treated operatively for pelvic, spine, and femoral fractures were reviewed. Recidivism was defined as return to trauma center for new injury within 30-months. All patients were offered TRS. Multivariate logistic regression statistical analysis was used to identify predictors of recidivism. RESULTS: Three hundred and ninety-seven of all patients (42 %) utilized TRS, including educational materials (n = 293), peer visits (n = 360), coaching (n = 284), posttraumatic stress disorder (PTSD) screening (n = 74), and other services. Within the entire sample, 136 patients (14 %) returned to the emergency department for an unrelated trauma event after mean 21 months. 13 % of TRS users became recidivists. Overall, 49 % of recidivists had history of pre-existing mental illness. High rates of TRS engagement between recidivists and non-recidivists were seen (75 %); however, non-recidivists were more likely to use multiple types of recovery services (49 % vs 34 %, p = 0.002), and were more likely to engage with trauma peer mentors (former trauma survivors) more than once (91 % vs 81 %, p = 0.03). After multivariable analysis, patients using multiple different recovery services had a lower risk of recidivism (p = 0.04, OR 0.42, 95 % CI [0.19-0.96]). CONCLUSIONS: Multifaceted engagement with recovery programming is associated with less recidivism following trauma. Future study of resultant reductions in healthcare costs are warranted. LEVEL OF EVIDENCE: Level II; Prognostic.

Education via a mobile application improves health literacy after orthopaedic trauma.

OBJECTIVES: Health literacy is often poor among trauma patients. We introduced an educational mobile application to newly injured patients. We hypothesized that patients who utilized the app would be more informed about their injury and treatment recommendations, and that app users would demonstrate greater adherence to treatment recommendations. DESIGN: Prospective, cohort study. SETTING: Level 1 trauma centerPatients/participants: Adult patients with acute orthopaedic injury. INTERVENTION: App with educational information about injuries, treatment, and recovery. bit.ly/traumaapp. MAIN OUTCOME MEASUREMENTS: Survey regarding knowledge about injury and treatment, and adherence to recommendations. RESULTS: 339 patients were enrolled: 187 received information about the app; 105 of them used the app. Another 234 patients had no prior knowledge about the app. App users were more often female (56.2% vs. 37.6%, p=0.002). App users were more likely to have completed college (34.3% vs. 13.7%, p<0.0001). Better health literacy was noted among app users in all measurements, including knowledge of: fracture location (69% vs. 39%, p<0.0001), treatment (100% vs. 93%, p=0.002), weightbearing status (96% vs. 88%, p=0.001), estimated healing time (63% vs. 26%, p<0.0001), and DVT prophylaxis (93% vs. 81%, p=0.003). CONCLUSIONS: Patients who used the app were more likely to have accurate knowledge in all assessed categories, with over 99% reporting adherence to weightbearing recommendations. It is probable that this level of knowledge and engagement will enhance various outcomes after injury. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Recidivism after orthopaedic trauma has diminished over time.

PURPOSE: The purpose was to analyze our trauma population during two periods to assess for predictors of recidivism. METHODS: Prior (2007-2011, n = 879) and recent (2014-2019, n = 954) orthopaedic trauma patients were reviewed. Recidivists were those returning with an unrelated injury. Recidivism rates were compared, and factors associated with recidivism were identified. RESULTS: Recidivism decreased: 18.7% to 14.3% (p = 0.01). Mean age and sex of the two cohorts were not different. Recent recidivists were more likely to sustain gunshot wound (GSW) injuries (22.1% vs 18.9%, p = 0.09), and mental illness was more common (56.6% vs 28.1%, p < 0.0001). The recent recidivist population was less often married (12.9% vs 23.8%, p = 0.03), and both recidivist groups were often underinsured (Medicaid or uninsured: (60.6% vs 67.0%)). CONCLUSION: Recidivism diminished, although more GSW and mental illness were seen. Recidivists are likely to be underinsured. The changing profile of recidivists may be attributed to socioeconomic trends and new programs to improve outcomes after trauma.

Prolonged Time to Brake Following Lower Extremity Injuries.

INTRODUCTION: No guidelines exist for recommending return to driving. This study will examine time to brake (TTB) after lower extremity injuries versus in uninjured people. The potential effect of various types of lower extremity injuries on TTB will be measured. METHODS: Patients with injuries to the pelvis, hip, femur, knee, tibia, ankle, and foot underwent testing using a driving simulator to assess TTB. Comparison was with a control group of uninjured people. RESULTS: Two-hundred thirty-two patients with lower extremity injuries participated. The majority were in the tibia and ankle regions (47%). Mean TTB for control subjects was 0.74 seconds, compared with 0.83 for injured patients, noting a 0.09-second difference (P = 0.017). Left-sided injuries averaged TTB of 0.80 seconds, right-sided injuries averaged TTB of 0.86 seconds, and bilateral injuries averaged TTB of 0.83 seconds, all prolonged versus control subjects. The longest TTB was exhibited after ankle and foot injuries (0.89 seconds) while the shortest was after tibial shaft fractures (0.76 seconds). DISCUSSION: Any lower extremity injury caused a prolonged TTB compared with control patients. Left, right, and bilateral injuries all had longer TTB. Ankle and foot injuries experienced the longest TTB. Additional investigation is warranted to develop safe guidelines for return to driving.

Trauma recidivism is pervasive and is associated with mental and social health opportunities.

INTRODUCTION: Recidivism after orthopedic trauma results in greater morbidity and costs. Prior studies explored the effects of social and medical factors affecting the frequency of return to the hospital with new, unrelated injury. Identification of mental, social and other risk factors for trauma recidivism may provide opportunities for mitigation. The purposes of this study are to determine the rates of subsequent, unrelated injury noted among orthopedic trauma patients at a large urban trauma center and to evaluate what patient and injury features are associated with greater rates of trauma recidivism. We hypothesize higher rates of new injuries will be related to ballistic trauma and other forms of assault, alcohol and recreational drug use, unemployment, and unmarried status among our trauma patients. METHODS: A series of 954 skeletally mature patients at a level 1 trauma center over a 5 year period were included in the study. All were treated operatively for thoracolumbar, pelvic ring, acetabulum, and/or proximal or shaft femoral fractures from a high energy mechanism. Retrospective review of demographic, injury, medical, and social factors, and subsequent care was performed. Trauma recidivism was defined as returning to the emergency department for treatment of any new injury. A backward stepwise logistic regression statistical analysis was used to identify independent predictors of recidivism. RESULTS: Mean age of all patients was 41.2 years, and 73.2% were male. 136 patients (14.3%) returned with a new injury within a mean of 21 months. These trauma recidivists were more likely to sustain a GSW (22.1% vs 11.4%, p = 0.001). They had higher rates of substance use, including tobacco (57.4% vs 41.8%, p = 0.001) and recreational drugs (50.7% vs 34.4%, p = 0.001), and were less likely to be married (10% vs 25.9%, p<0.001). Mental illness was pervasive, noted in 56.6% of patients with new injury (vs 32.8%, p<0.001). Medicaid insurance was most common in the trauma recidivist population (58.1% vs 35.0%, p = 0.001), and 12.5% were uninsured. Completing high school or more education was protective (93% non-recidivist (vs 79%, p = 0.001). Sixty-nine patients (50.7%) were repeat trauma recidivists within the study period. Independent predictors of new injury included recreational drug use (OR 1.64, p = 0.05) and history of assault due to GSW or other means (OR 1.67, p = 0.05). History of pre-existing mental illness represented the greatest risk factor for trauma recidivism (OR 2.55, p<0.001). DISCUSSION: New injuries resulting in emergency department presentation after prior orthopedic trauma occurred in 14.3% and were associated with history of assault, lower education, Medicaid insurance, tobacco smoking and recreational drug use. Mental illness was the greatest risk factor. Over half of patients with these additional injuries were repeat trauma recidivists, returning for another new injury within less than 2 years. Awareness of risk factors may promote focused education and other interventions to mitigate this burden. LEVEL OF EVIDENCE: Level 3 retrospective, prognostic.

Functional outcomes more than 5 years following acetabulum fracture.

OBJECTIVES: The purposes of this project were to evaluate functional outcomes more than 5 years after acetabulum fracture and to determine factors related to function. METHODS: This retrospective study consisted of 205 adult patients treated for acetabulum fracture who completed the Musculoskeletal Function Assessment (MFA) a minimum of 5 years following injury. The MFA includes survey of daily activities, gross and fine mobility, social and work function, sleeping, and mood. Higher scores indicate worse function. RESULTS: Two hundred five patients with 210 fractures, 69.3% of whom were male, with mean age of 45.7 and mean body mass index 30.1 were included after mean 128 months follow-up. Fracture patterns included OTA/AO 62A (37.1%), 62B (40.5%), or 62C (22.4%), and 80.0% were treated surgically. Late complications were noted in 35.2%, including posttraumatic arthrosis (PTA: 19.5%), osteonecrosis and/or heterotopic ossification. Mean MFA of all patients was 31.4, indicating substantial residual dysfunction. Worse MFA scores were associated with morbid obesity (body mass index >40: 42.3, P>.09), and current tobacco smoking history vs former smoker vs nonsmoker (45.2 vs 36.1 vs 23.0, P < .002). Patients with late complications had worse mean MFA scores (38.7 vs 27.7, P = .001); PTA was the most common late complication, occurring in 19.5%. CONCLUSIONS: More than 5 years following acetabulum fracture, substantial residual dysfunction was noted, as demonstrated by mean MFA. Worse outcomes were associated with late complications and tobacco smoking. While fracture pattern was not associated with outcome, those patients who had late complications, mostly PTA, had worse outcomes.

Surgical Versus Nonsurgical Management of Acetabular Fractures With Associated Patterns in Elderly Patients: Factors Affecting Outcomes.

INTRODUCTION: Among elderly patients, anterior column posterior hemitransverse (ACPHT) and associated both column (ABC) are common acetabular fracture patterns after low-energy mechanisms. Given the paucity of outcomes data in this cohort, the goal of this study was to determine the favorability of results with surgical versus nonsurgical management. Secondarily, factors linked with poor functional outcomes were assessed. METHODS: Over a 16-year period, 81 patients aged ≥60 years with 82 ACPHT and ABC acetabular fractures were evaluated. Retrospectively, patient demographics, injury details, and early and late complications were collected. Functional outcomes were assessed with the Musculoskeletal Function Assessment (MFA) after a minimum of 12 months of follow-up. RESULTS: During the study period, 81 patients sustained 82 ACPHT (n = 35, 43%) or ABC (n = 47) fractures, most secondary to low-energy falls (71%). Patients managed surgically were younger, had higher-energy mechanisms, and more often had an associated hip dislocation or marginal impaction (all P < 0.05). Of note, 42.3% and 18.5% of patients had early and late complications, respectively, with no differences between surgical and nonsurgical groups. Posttraumatic arthrosis (PTA) was noted in 27% overall (36% surgical versus 16% nonsurgical, P = 0.10). The mean MFA score was 25.2 after 59 months. Better outcomes were associated with high-energy mechanisms, multiple injuries, and surgical management (all P < 0.05). The worst MFA outcomes were among patients with PTA (40.2) and those requiring a secondary procedure (45.7), both P < 0.05. DISCUSSION: Nonsurgical management had a low rate of PTA. Mitigating PTA and decreasing the rate of secondary surgeries seem crucial achieving satisfactory outcomes. Higher-energy injuries benefit from open reduction and internal fixation, as indicated by better MFA scores.

Survivorship of the Hip Joint After Acetabulum Fracture.

PURPOSE: The purposes of this study were to determine the rate of failure of the hip joint after acetabulum fracture and to identify risk factors. METHODS: Acetabulum fractures treated over 17 years at a level-1 trauma center were reviewed. Patient, injury, and treatment factors were assessed regarding possible association with failure of the hip joint: end-stage arthrosis and/or total hip arthroplasty (THA). RESULTS: Seventy percent were treated with primary open reduction and internal fixation (ORIF). Seventy-two (12.5%) of 575 fractures underwent THA; 64 were after initial ORIF. The mean follow-up was 80 months, and the median time to THA was 14 months (range 10-200 months). Age, body mass index, fracture type, marginal impaction, and hip dislocations were independent predictors of hip joint failure. The mean injured age of THA patients was 53 versus 43 (P < 0.001). T-type fractures were most likely to fail (21% within 2 years, 45% within 10 years, P = 0.001). Other injury features: marginal impaction and posterior hip dislocation were associated with failure with odds ratios 2.79 and 1.73, respectively (P < 0.001). CONCLUSION: Eighty-five percent of native hips survived; the median time to THA was 14 months. Most who had THA had initial posterior fracture-dislocations. Older age, elevated body mass index, T-type pattern, marginal impaction, and hip dislocation increase the likelihood of hip joint failure.

Factors influencing functional outcomes following open reduction internal fixation of acetabular fractures.

INTRODUCTION: Recent large series of patient-reported outcomes after acetabulum fracture are limited, and potentially modifiable risk factors may be unidentified. The goal of this study was to describe patient and injury factors which negatively influence functional outcomes following operative management of acetabular fractures. METHODS: 699 patients with acetabular fractures were treated with open reduction and internal fixation (ORIF). Musculoskeletal Function Assessment (MFA) questionnaire was completed after a minimum 12 months post-injury by 283 adults. MFA scores range from 1 to 100 and higher scores represent greater dysfunction. Factors were assessed for potential association with MFA scores, and univariate and multiple linear regression analyses were performed. RESULTS: Survey respondents were more severely injured than non-respondents, with more chest injury (38% vs 22%, p<0.001) and higher Injury Severity Score (19.3 vs 16.8, p=0.003). Patients were 69% male with mean age 44.0 years. Approximately one-third were smokers (31%), while 14% had comorbid diabetes mellitus type II. The majority of injuries occurred during a motor vehicle collision (65%); low-energy mechanisms were rare (4.2%). The most common fracture pattern was isolated posterior wall (23%), followed by transverse/posterior wall (21%). Heterotopic ossification (HO) was noted in 22%: Brooker 1: 29.5%, 2: 23.0%, 3: 32.8%, and 4: 14.8%. Tobacco use (ß = 18.4, p<0.001), obesity (ß = 0.39, p=0.009), diabetes (ß = 8.2, p=0.029), post-traumatic arthrosis (PTA) (ß = 5.94 p=0.035), and increasing HO severity (ß = 8.93, p<0.001) were independently associated with worse MFA scores. Tobacco use had the strongest association, followed by the severity of HO. CONCLUSION: In a large series of patient-reported functional outcomes following fixation of acetabular fractures, tobacco use, obesity, comorbid diabetes, PTA, and HO were associated with worse MFA scores. Further study to mitigate HO should be considered. LEVEL OF EVIDENCE: III.

Nerve Injury With Acetabulum Fractures: Incidence and Factors Affecting Recovery.

OBJECTIVES: To determine factors associated with nerve injury after acetabulum fracture and to evaluate recovery and outcomes. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS AND PARTICIPANTS: Nine hundred seventy-five skeletally mature patients with acetabulum fracture. INTERVENTION: Operative and nonoperative management. MAIN OUTCOME MEASUREMENTS: Nerve injuries, categorized as traumatic or iatrogenic, recovery (none, partial, or complete), and patient-reported functional outcomes with the Musculoskeletal Function Assessment (n = 353, 36.2%). RESULTS: Thirty-two patients (3.3%) experienced nerve injury with 24 (78%) resulting from trauma and 23 with an associated posterior hip dislocation. Eight injuries (25%) were iatrogenic. Thirty-one (97%) occurred in patients with operative fractures (n = 738). The most common fracture pattern associated with nerve injury was transverse posterior wall (31% of injuries). Obesity was more common in patients with nerve injuries (59% vs. 30% in those without nerve injury (P = 0.001), but was not related to age or sex. Sixty-five percent of sciatic nerve injuries were to the common peroneal division only, while none were isolated to the tibial division. All iatrogenic injuries occurred after the ilioinguinal approach (P < 0.001). Overall, 50% experienced partial nerve recovery and 22% had complete recovery. However, 24% of patients with sciatic or common peroneal injuries had no recovery. Thirty-three percent of tobacco smokers experienced no recovery (vs. 26% of nonsmokers). Average Musculoskeletal Function Assessment scores for patients with nerve injuries was 32, similar to those without (33). CONCLUSIONS: Posterior acetabulum fracture dislocations are associated with traumatic nerve injury, although 25% of nerve injuries were iatrogenic. Nerve injuries are more common in obese patients. More than one-quarter of patients had no recorded nerve recovery. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.