A novel "pelvic ring augmentation construct" for lumbo-pelvic reconstruction in tumour surgery.

AIM: Reconstructing or augmenting the lumbo-pelvic junction after resection of L5 and part of the sacrum is challenging. Numerous lumbo-pelvic reconstruction methods based on posterior construct and anterior cages have been proposed for cases involving total sacrectomy and lumbar vertebrectomy. These constructs create long lever arms and generate high cantilever forces across the lumbo-sacral junction, resulting in implant failure or breakage. Biomechanical studies have shown that placing implants anterior to lumbo-sacral pivot point provides a more effective moment arm to resist flexion force and improves the ultimate strength of the construct. We present here a novel method to augment a lumbo-pelvic construction using a pelvic ring construct. METHODS: A 69-year-old lady presented with implant failure of her two previous posterior lumbo-pelvic reconstructions performed by the authors. She initially presented, two and a half years previously with 6 months history of back pain with normal neurological function. MRI scans of her whole spine showed isolated secondaries in the lumbar spine (L4, L5) and sacrum (S1). An abdominal CT scan revealed a primary tumour in her right kidney. Briefly, the first surgery involved a single-stage removal of posterior elements of L4 and L5 and posterior stabilisation from L2 to pelvis, anterior resection of L4 and L5 and partially S1 with implantation of an expandable Synex II cage. The cage was replaced with an anterior rod construct from L2 and L3 to a trans-sacral screw a week later as it had dislodged. The second revision, 9 months later, involved removal of two posterior broken rods which were replaced and converted into a modified four-rod construct. While monitoring her progress, it was subsequently noted that the trans-sacral rod had broken. Therefore, it was decided to augment her lumbo-pelvic construct to prevent eventual catastrophic posterior construct failure. From a posterior approach, contoured rods were passed bilaterally along the inner table of the pelvis under the iliacus muscle up to the anterior border of the pelvis. Using T-connectors, the rods were connected to the posterior lumbo-pelvic construct. Thereafter, two anterior supra-acetabular pelvic screws were connected to a subcutaneously placed rod matched to the shape of the anterior abdominal wall. The pelvic ring construct was completed on connecting this rod with T-connectors to the free ends of the contoured iliac rods. RESULTS AND CONCLUSION: There were no intra-operative complications. At the end of 12 months, she was mobilising with a frame, with no radiological evidence of failure of the construct. However, she died due to disease progression at the end of 15 months. Experience from one clinical case shows that such a construct is feasible and adds a technical option to the difficult reconstruction of lumbo-pelvic junction after tumour surgery.

Surgical fixation of rib fractures improves 30-day survival after significant chest injury : an analysis of ten years of prospective registry data from England and Wales.

AIMS: The last decade has seen a marked increase in surgical rib fracture fixation (SRF). The evidence to support this comes largely from retrospective cohorts, and adjusting for the effect of other injuries sustained at the same time is challenging. This study aims to assess the impact of SRF after blunt chest trauma using national prospective registry data, while controlling for other comorbidities and injuries. METHODS: A ten-year extract from the Trauma Audit and Research Network formed the study sample. Patients who underwent SRF were compared with those who received supportive care alone. The analysis was performed first for the entire eligible cohort, and then for patients with a serious (thoracic Abbreviated Injury Scale (AIS) ≥ 3) or minor (thoracic AIS < 3) chest injury without significant polytrauma. Multivariable logistic regression was performed to identify predictors of mortality. Kaplan-Meier estimators and multivariable Cox regression were performed to adjust for the effects of concomitant injuries and other comorbidities. Outcomes assessed were 30-day mortality, length of stay (LoS), and need for tracheostomy. RESULTS: A total of 86,838 cases were analyzed. The rate of SRF was 1.2%. SRF significantly reduced risk of mortality (odds ratio (OR) 0.27 (95 confidence interval (CI) 0.128 to 0.273); p < 0.001) and need for tracheostomy (OR 0.22 (95% CI 0.191 to 0.319); p < 0.001) after adjustment for other covariables across the whole cohort. SRF remained protective in patients with a serious chest injury (hazard ratio (HR) 0.24 (95% CI 0.13 to 0.45); p < 0.001). The benefit in more minor chest injury was less clear. Mean LoS for patients who survived was longer in the SRF group (24.29 days (SD 26.54) vs 16.60 days (SD 26.35); p < 0.001). CONCLUSION: SRF reduces mortality after significant chest trauma associated with both major and minor polytrauma. The rate of fixation in the UK is low and potentially underused as a treatment for severe chest wall injury. Cite this article: Bone Joint J 2022;104-B(6):729-735.

Surgical Stabilization Improves 30-day Mortality in Patients With Traumatic Flail Chest: A Comparative Case Series at a Major Trauma Center.

OBJECTIVES: To evaluate the outcomes including early mortality after surgical rib fixation using a locking plate system as part of a newly introduced chest trauma pathway. DESIGN: Prospective cohort study with retrospective case-controlled matching with a minimum of 1-year follow-up. SETTING: Regional Level 1 trauma center. PATIENTS/PARTICIPANTS: Consecutive patients undergoing surgical rib fixation were prospectively recruited over a 3-year period (56 patients) and matched to similar patients managed nonoperatively (89 patients) using our local trauma registry. Matching was based on injury severity scores and patient demographics. INTERVENTION: Surgical rib fixation with locking plates. MAIN OUTCOME MEASUREMENTS: The primary outcome measure was 30-day mortality with secondary outcomes of hospital length of stay, intensive care unit length of stay, and patient-reported outcome measures including quality of life (EuroQol-EQ-5D-5L). Official causes of death were obtained from the coroner including postmortem results. RESULTS: There was a significant reduction in 30-day mortality in the fixed patients with 1.8% (1/56) compared to 12.4% (11/89) of the nonfixed patients (P = 0.03). This difference remained significant after further exclusion of other nonsurvivable injuries (P = 0.046). Although hospital length of stay was significantly longer in the fixed group, there was no difference on multivariable analysis. Other secondary outcomes were comparable between the groups with no significant differences in any patient-reported measures. CONCLUSIONS: Mortality was significantly lower in patients who underwent rib stabilization. Quality of life and other patient-reported measures were similar, demonstrating no evidence of detrimental longer-term effects of rib stabilization. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Improving core surgical training in a major trauma centre.

INTRODUCTION: English Major Trauma Centres (MTCs) were established in April 2012. Increased case volume and complexity has influenced trauma and orthopaedic (T&O) core surgical training in these centres. OBJECTIVES: To determine if T&O core surgical training in MTCs meets Joint Committee on Surgical Training (JCST) quality indicators including performance of T&O operative procedures and consultant supervised session attendance. METHODS: An audit cycle assessing the impact of a weekly departmental core surgical trainee rota. The rota included allocated timetabled sessions that optimised clinical and surgical learning opportunities. Intercollegiate Surgical Curriculum Programme (ISCP) records for T&O core surgical trainees at a single MTC were analysed for 8 months pre and post rota introduction. Outcome measures were electronic surgical logbook evidence of leading T&O operative procedures and consultant validated work-based assessments (WBAs). RESULTS: Nine core surgical trainees completed a 4 month MTC placement pre and post introduction of the core surgical trainee rota. Introduction of core surgical trainee rota significantly increased the mean number of T&O operative procedures led by a core surgical trainee during a 4 month MTC placement from 20.2 to 34.0 (p<0.05). The mean number of hip hemiarthroplasty procedures led by a core surgical trainee during a 4 month MTC placement was significantly increased (0.3 vs 2.4 [p=0.04]). Those of dynamic hip screw fixation (2.3 vs 3.6) and ankle fracture fixation (0.7 vs 1.6) were not. Introduction of a core surgical trainee rota significantly increased the mean number of consultant validated WBAs completed by a core surgical trainee during a 4 month MTC placement from 1.7 to 6.6 (p<0.0001). CONCLUSIONS: Introduction of a departmental core surgical trainee rota utilising a 'problem-based' model can significantly improve T&O core surgical training in MTCs.

Anatomy, classification and treatment of intracapsular hip fractures.

Hip fractures are increasingly common, given the increasing ageing, osteoporotic population with significant medical comorbidities. This review summarizes the anatomy of the proximal femur, reviews classification systems and gives recommendations for use of each treatment modality.

Postero-medial approach for complex tibial plateau injuries with a postero-medial or postero-lateral shear fragment.

This study demonstrates the utility of a modified postero-medial surgical approach to the knee in treating a series of patients with complex tibial plateau injuries with associated postero-medial and postero-lateral shear fractures. Posterior coronal shear fractures are underappreciated and their clinical relevance has recently been characterised. Less-invasive surgery and indirect reduction techniques are inadequate for treating these coronal plane fractures. Our approach includes an inverted 'L'-shaped incision situated within the posterior flexor knee crease, followed by the retraction or incision of the medial head of the gastrocnemius tendon, while protecting the neurovascular structures. This provides a more extensile exposure, as far as the postero-lateral corner, than previously described. Our case series included eight females and eight males. The average age was 53 years. The majority of these injuries were sustained through high-energy trauma. All patients' fractures were classified as Schatzker grade 4, or above, with a postero-medial split depression. Eight patients had associated postero-lateral corner fractures. Two were open, two had vascular compromise and one had neurological injury. The average time to surgery was 6.4 days (range 0-12), operative time 142 min (range 76-300) and length of stay 17 days (range 7-46). A total of 11 patients were treated using the postero-medial approach alone and in five the treatment was combined with an antero-lateral approach. Two patients suffered a reduced range of movement requiring manipulation and physiotherapy, and three patients had a 5-degree fixed flexion deformity. Two patients developed superficial wound infections treated with antibiotics alone. Anatomical reduction and fracture union was achieved in 15 patients. These are complex fractures to treat, and our modified posterior approach allows direct reduction and optimal positioning of plates to act as buttress devices. It can be extended across the midline to the postero-lateral corner and also allows excellent exposure of the popliteal vessels should concurrent vascular repair be required.

Evolution of the hip fracture population: time to consider the future? A retrospective observational analysis.

OBJECTIVE: To examine how the population with fractured neck of femur has changed over the last decade and determine whether they have evolved to become a more physically and socially dependent cohort. DESIGN: Retrospective cohort study of prospectively collected Standardised Audit of Hip Fractures of Europe data entered on to an institutional hip fracture registry. PARTICIPANTS: 10 044 consecutive hip fracture admissions (2000-2012). SETTING: A major trauma centre in the UK. RESULTS: There was a generalised increase in the number of admissions between 2000 (n=740) and 2012 (n=810). This increase was non-linear and best described by a quadratic curve. Assuming no change in the prevalence of hip fracture over the next 20 years, our hospital is projected to treat 871 cases in 2020 and 925 in 2030. This represents an approximate year-on-year increase of just over 1%. There was an increase in the proportion of male admissions over the study period (2000: 174 of 740 admissions (23.5%); 2012: 249 of 810 admissions (30.7%)). This mirrored national census changes within the geographical area during the same period. During the study period there were significant increases in the numbers of patients admitted from their own home, the proportion of patients requiring assistance to mobilise, and the proportion of patients requiring help with basic activities of daily living (all p<0.001). There was also a twofold to fourfold increase in the proportion of patients admitted with a diagnosis of cardiovascular disease, renal disease, diabetes and polypharmacy (use of >4 prescribed medications; all p<0.001). CONCLUSIONS: The expanding hip fracture population has increasingly complex medical, social and rehabilitation care needs. This needs to be recognised so that appropriate healthcare strategies and service planning can be implemented. This epidemiological analysis allows projections of future service need in terms of patient numbers and dependency.

The effect of intravenous iron on postoperative transfusion requirements in hip fracture patients: study protocol for a randomized controlled trial.

BACKGROUND: Anaemia following hip fracture is common. Approximately 30 to 45% of patients have haemoglobin concentrations below population norms on admission, and around 10% are severely anaemic. Anaemia on admission, and in the postoperative period, is associated with poor outcomes with regard to mobility, postoperative mortality and readmission. There is currently no clear consensus on the optimal method of managing perioperative anaemia in this group of frail patients with frequent comorbidity. Liberal red cell transfusion in the postoperative period does not appear to improve outcome, whereas tranexamic acid appears to reduce transfusion rate at the expense of increased cardiovascular morbidity. There are encouraging results from one centre with the use of agents to stimulate red cell production, including intravenous iron and erythropoietin. UK practice differs significantly from these patients and these studies, and it is not clear whether these promising results will translate to the UK population. METHODS/DESIGN: This is a single-centre randomized controlled parallel group trial, in a British university hospital.Randomization is achieved using a website and computer-generated concealed tables. Participants are 80 patients 70 years or over with acute hip fracture undergoing operative repair. The intervention group receive three daily infusions of 200 mg iron sucrose, starting within 24 hours of admission. The control group receive standard hospital care at the discretion of the clinical team. Red cell transfusions for each group are given in accordance with standard clinical triggers. The primary outcome is an increase in mean reticulocyte count in the intervention group at day 7. Secondary outcome measures include haemoglobin concentrations, early and late transfusion rates, infectious and cardiovascular complications, mobility and 30-day mortality. DISCUSSION: This is a pilot study to demonstrate haematopoietic efficacy of intravenous iron in this setting. Hence, we have chosen to measure change in reticulocyte count rather than the more clinically relevant differences in haemoglobin concentration or transfusion rate. If our results are positive, the study will provide the necessary information for development of a full-scale trial of intravenous iron. TRIAL REGISTRATION: Current Controlled Trials ISRCTN76424792; UK Medicines and Healthcare products Regulatory Authority (EuDRACT: 2011-003233-34).

Surgical treatment of distal radial fractures with a volar locking plate versus conventional percutaneous methods: a randomized controlled trial.

BACKGROUND: The aim of this study was to compare the outcomes of displaced distal radial fractures treated with a volar locking plate with the results of such fractures treated with a conventional method of closed reduction and percutaneous wire fixation with supplemental bridging external fixation when required. Our aim was to ascertain whether the use of a volar locking plate improves functional outcomes. METHODS: A single-center, pragmatic, randomized controlled trial was conducted in a tertiary care institution. One hundred and thirty patients (eighteen to seventy-three years of age) who had a displaced distal radial fracture were randomized to treatment with either a volar locking plate (n = 66) or a conventional percutaneous fixation method (n = 64). Outcome assessments were conducted at six weeks, twelve weeks, and one year. Outcomes were measured on the basis of scores on the Patient Evaluation Measure (PEM) and QuickDASH questionnaire (a shortened version of the Disabilities of the Arm, Shoulder and Hand, or DASH, Outcome Measure), EuroQol-5D (EQ-5D) scores, wrist range of motion, grip strength, and radiographic parameters. RESULTS: The rate of follow-up at one year was 95%. Patients in the volar locking-plate group had significantly better PEM and QuickDASH scores and range of motion at six weeks compared with patients in the conventional-treatment group, but there were no significant differences between the two groups at twelve weeks or one year. Grip strength was better in the plate group at all time points. The volar locking plate was better at restoring palmar tilt and radial height. Significantly more patients in the plate group were driving at the end of six weeks, but this did not translate to a significant difference between groups in terms of those returning to work by that time. CONCLUSIONS: Use of a volar locking plate resulted in a faster early recovery of function compared with use of conventional methods. However, no functional advantage was demonstrated at or beyond twelve weeks. Use of the volar locking plate resulted in better anatomical reduction and grip strength, but there was no significant difference in function between the groups at twelve weeks or one year. The earlier recovery of function may be of advantage to some patients. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

A biomechanical comparison of a locking plate, a nail, and a 95° angled blade plate for fixation of subtrochanteric femoral fractures.

OBJECTIVE: To compare the biomechanical performance of a cephalomedullary nail (CMN), a proximal femoral locking plate, and a 95° angled blade plate in a comminuted subtrochanteric fracture model. METHODS: A comminuted subtrochanteric femoral fracture model was created with a 2-cm gap below the lesser trochanter in 15 pairs of human cadaveric femora confirmed to be nonosteoporotic. The femora were randomized to treatment with one of the previously mentioned 3 devices. Each was tested under incrementally increasing cyclic load up to 90,000 cycles from 50% to 250% of body weight to simulate progressive weight bearing during 3 months of an average 700-N (approximately, 70 kg or 150 lb) person. Force, number of cycles, and total load sustained to reach 10 mm of displacement were compared. Failure modes were also noted. RESULTS: The CMN construct withstood significantly more cycles, failed at a significantly higher force, and withstood a significantly greater load than either of the plate constructs (P < 0.001). Varus collapse was significantly lower in the CMN construct (P < 0.0001). Modes of failure differed among implant-bone constructs with damage to the femoral head through implant cutout in 5 of 10 blade plate specimens and 2 of 10 CMN specimens, whereas no damage to the femoral head bone was observed in any of the locking plate constructs. CONCLUSIONS: The CMN construct was biomechanically superior to either the locking plate or 95° blade plate constructs. The locking plate construct was biomechanically equivalent to the blade plate construct.

Does 2.5 cm of symphyseal widening differentiate anteroposterior compression I from anteroposterior compression II pelvic ring injuries?

OBJECTIVE: It has been proposed that 2.5 cm of diastasis of the symphysis pubis corresponds with injury to the anterior sacroiliac ligament and differentiates Young-Burgess anteroposterior compression Type I and II pelvic ring injuries. We hypothesized that if a pelvis has greater than 2.5 cm of symphysis pubis diastasis, the anterior sacroiliac ligaments are disrupted and the pelvic floor has failed. METHODS: Pure torsional moment was applied to cadaveric human pelves with the hemipelvis either unconstrained (n = 10) or constrained to move only in the plane of rotation (n = 10). We recorded displacement of the symphysis pubis and sacroiliac joint and the applied torque that corresponded with failure of the anterior sacroiliac ligaments. RESULTS: Average symphysis pubis diastasis at the point of anterior sacroiliac ligament failure was 2.2 cm (n = 20; range, 1-4.5 cm); however, 80% of the values were outside the range of 2 to 3 cm. Symphysis pubis diastasis in male specimens averaged 2.5 cm and in female specimens, 1.8 cm (P = 0.06). The sacrospinous and sacrotuberous ligaments that make up the pelvic floor were not injured in unconstrained testing (zero of 10 specimens) but were at least attenuated in constrained testing (10 of 10 specimens), either simultaneously or after anterior sacroiliac ligament failure. CONCLUSIONS: We were not able to confirm 2.5 cm of symphysis pubis diastasis as a valid differentiation point between anteroposterior compression I and II injuries because significant morphologic variation seems to exist. Our data support that anterior sacroiliac ligament disruption is likely for displacement greater than 4.5 cm and unlikely for values less than 1.8 cm. Our study suggests that sacrospinous and sacrotuberous ligaments might not rupture at the same time as the anterior sacroiliac ligament.

Biomechanical comparison of proximal locking plates and blade plates for the treatment of comminuted subtrochanteric femoral fractures.

OBJECTIVES: The 95 degrees angled blade plate is an accepted standard for plating subtrochanteric femoral fractures but can be technically demanding and often requires extensive soft tissue exposure. Proximal femoral locking plates (PFLPs) have been developed for subtrochanteric and pertrochanteric fractures and are potentially easier to apply with less soft tissue dissection. Clinical experience has raised concerns regarding the strength of the PFLP. The purpose of our study was to compare the relative stability of two designs of PFLP with the 95 degrees angled blade plate under loads simulating the first 3 months of progressive weight bearing after fracture fixation. METHODS: A comminuted subtrochanteric femoral fracture model was created with a 2-cm gap below the lesser trochanter in 15 synthetic femora. Fracture fixation of three plates (95 degrees angled blade plate [blade plate], the original version of the PFLP [O-PFLP], and the newest version of the PFLP [N-PFLP]), all manufactured by Synthes, Inc., Paoli, PA, was tested under progressive cyclic loading to reproduce progressive weight bearing during 3 months after fracture fixation. The force and number of cycles to reach 5 mm of displacement of the femoral head or failure of the implant were compared for each implant. RESULTS: N-PFLPs were significantly stiffer than blade plates and O-PFLPs (P = 0.01) and had a trend toward withstanding more cycles before failure (P = 0.06). All five O-PFLPs demonstrated catastrophic fatigue failure before completion of the protocol. One each of the blade plates and the N-PFLPs failed to complete the protocol (P = 0.04). CONCLUSIONS: In the model studied, N-PFLPs were shown to have biomechanical properties that were at least equivalent to those of the blade plate. The fatigue failures of O-PFLPs mirrored our clinical experience. Use of the N-PFLP might be a viable alternative fixation method for comminuted subtrochanteric femoral fractures that currently are treated with blade plates.

Intercarpal ligament injuries associated with fractures of the distal part of the radius.

BACKGROUND: Soft-tissue injuries of the wrist are often not recognized in patients with distal radial fractures, yet scapholunate injuries have been reported to occur in association with as many as 54% of distal radial fractures. The true prevalence and natural history of intercarpal ligament injury are not known. METHODS: This prospective observational study assessed the prevalence and one-year outcome of intercarpal ligament injuries in non-osteoporotic patients with displaced fractures of the distal part of the radius. The study group consisted of fifty-one patients (twenty-seven women and twenty-four men) with a median age of forty-one years (range, twenty to fifty-seven years). Patients underwent standard fracture treatment and, in addition, wrist arthroscopy was performed to identify associated carpal injuries. No ligamentous injuries were treated. Patients were reviewed at one year and underwent physical and radiographic evaluation. Patients were analyzed according to the status of the scapholunate ligament at the time of the injury and were graded with use of a modification of the Geissler classification system: Group I consisted of ten patients with a grade-3 scapholunate ligament injury, and Group II consisted of forty-one patients with a grade-0, 1, or 2 injury. RESULTS: Patients with an increase in ulnar variance of >2 mm at the time of the injury had a fourfold increase in the risk of sustaining a grade-3 scapholunate ligament injury (p = 0.01). Radiographically, at one year, patients in Group I (grade-3 injuries) had a greater amount of static and dynamic scapholunate dissociation and a significantly greater increase in the scapholunate angle in comparison with the uninjured wrist (p = 0.006) than did those in Group II. Intra-articular fractures were associated with a twofold increase in the prevalence of scapholunate dissociation as seen radiographically at one year. The prevalence of subjective pain on examination was significantly greater in Group I than in Group II (p = 0.009). There were no significant differences between the two groups with respect to objective outcome according to range of motion and hand grip and tip pinch strengths. Lunotriquetral injuries were uncommon and did not correlate with the scapholunate injuries, fracture grade, or configuration. CONCLUSIONS: Grade-3 scapholunate ligament tears can be associated with ulnar positive variance at the time of initial presentation of a distal radial fracture and can be associated with more scapholunate joint pain at one year. These injuries could lead to scapholunate dissociation at the time of follow-up, particularly in patients with intraarticular fractures.