Causes and associations with mortality in patients with pelvic ring injuries with haemorrhagic shock.

BACKGROUND: High energy pelvic ring injuries are associated with significant morbidity and mortality and can be accompanied by haemorrhagic shock following associated vascular injury. This study evaluated the causes and predictors of mortality in haemodynamically unstable pelvic fractures. METHODS: This retrospective observational study at a Major Trauma Centre reviewed 938 consecutive adult patients (≥ 18yrs) with pelvic ring injuries between December 2014 and November 2018. Patients with features of haemorrhagic shock were included, defined as: arrival Systolic BP < 90 mmHg, Base Deficit ≥ 6.0 mmol/l, or transfusion of ≥ 4 units of packed red blood cells within 24 h. RESULTS: Of the 102 patients included, all sustained injuries from high energy trauma, and 47.1% underwent a haemorrhage control intervention (Resuscitative Endovascular Balloon Occlusion of the Aorta-REBOA, Interventional Radiology-IR, or Laparotomy). These were more often required following vertical shear injuries (OR 10.7, p = 0.036). Overall, 33 patients (32.4%) died; 16 due to a head injury, and only 2 directly from acute pelvic exsanguination (6.1%). Multivariable logistic regression demonstrated that increasing age, Injury Severity Score, Abbreviated Injury Scale (AIS) Head ≥ 3 and open pelvic fracture were all independent predictors of mortality, and IR was associated with reduced mortality. Lateral Compression III (LC3) injuries were associated with mortality due to multiple organ dysfunction syndrome (MODS). CONCLUSION: Haemodynamically unstable patients with pelvic ring injuries have a high mortality rate, but death is usually attributed to other injuries or later complications, and not from acute exsanguination. This reflects improvements in resuscitative care, transfusion protocols, and haemorrhage control techniques.

Two-stage revision surgery for infected total knee replacements: reasonable function and high success rate with the use of primary knee replacement implants as temporary spacers.

Two-stage revision surgery for infected total knee replacements remains the gold standard treatment. Articulating spacers are preferred to static spacers for improved functional outcome. Articulating spacers made of cement can be prone to fracture, may not be suitable for full weight bearing, create abrasion debris and necessitate second-stage revision surgery. An alternative is the use of primary knee replacement implants as temporary spacers. With this technique, implants are loosely cemented into place at time of revision, allow the patient reasonable mobility and an ability to fully weight bear and can obviate the need for second-stage surgery. A retrospective review of all patients undergoing revision for infection over two years was conducted. Patients were clinically assigned to single- or two-stage revision. Patients who had a temporary knee replacement, that is, a primary knee replacement used as an articulating spacer, were identified and contacted to complete an Oxford Knee Score. Time to second stage and recurrence was identified from the notes 23 patients received temporary knee replacements. Of these, one patient died, 13 proceeded to a second-stage revision and nine remain in situ. Median time to second-stage revision was 19 weeks [range 11-27]. No patients had re-infection. Median follow-up for ongoing temporary knee replacements was 43 weeks [range 24-90]. Four temporary implants had survived for longer than 1 year. Median Oxford Knee Score was 26 [23-32] and satisfaction score was 8 out of 10 [8-8]. These early results show that knee replacement implants used as spacers provide a good alternative to cement-based articulating spacers with low re-infection rates. Their additional cost when compared with cement spacers is offset by the fact that many patients achieve adequate function and frail patients can avoid a revision procedure. Level of evidence Case series, Level IV.

Shoulder dystocia and associated manoeuvres as risk factors for perineal trauma.

INTRODUCTION AND HYPOTHESIS: Shoulder dystocia (SD) is an obstetric emergency that can be associated with serious neonatal morbidity and mortality. The aim of this study was to identify the incidence and risk factors for obstetric anal sphincter injuries (OASIS) in women who sustained SD at birth. METHODS: This was a retrospective observational study over a 5-year period whereby 403 cases of SD were identified. The primary outcome measure was to identify the incidence of OASIS in women with SD. We also evaluated the role of the manoeuvres used for the management of SD and aimed to identify possible correlations between specific manoeuvres and OASIS by univariate and multivariate regression analysis. RESULTS: Shoulder dystocia was associated with a three-fold increase in the risk of OASIS in our population. The use of internal manoeuvres (OR 2.182: 95 % CI 1.173-4.059), an increased number of manoeuvres ≥ 4 (OR 4.667: 95 % CI 1.846-11.795), Woods' screw manoeuvre (OR 3.096: 95 % CI 1.554-6.169), reverse Woods' screw manoeuvre (OR 4.848: 95 % CI 1.647-14.277) and removal of the posterior arm (OR 2.222: 95 % CI 1.117-4.421) were all associated with a significant increase in the likelihood of OASIS. CONCLUSIONS: In our study, instrumental deliveries, the use of internal manoeuvres (Woods' screw and reverse Woods' screw) and four or more manoeuvres for the management of SD were independently associated with a higher incidence of OASIS. To effectively manage shoulder dystocia with lower risks of perineal trauma, these factors could be considered when designing further prospective studies and developing management protocols.

Fetal Scoliosis: Natural History and Outcomes.

INTRODUCTION: Scoliosis can be detected on prenatal ultrasonography and may be associated with structural and syndromic abnormalities. Associations and pregnancy outcomes related to the prenatal diagnosis of scoliosis are poorly understood. METHODS: A retrospective cohort study was undertaken at a tertiary referral center in London. Referred cases with spinal deformities between 1997 and 2021 were identified from the prenatal ultrasonography database. Outcomes were ascertained from the database and electronic notes. RESULTS: One hundred twenty-three cases of fetal spinal deformities (scoliosis, kyphosis, or kyphoscoliosis) were identified from a referral population of 660,000 pregnancies, giving an incidence of approximately 0.2 per 1000 fetuses. Fifty-eight live births (47.2%) and 65 cases (52.8%) of fetal or neonatal demise or termination were observed. Most live births were isolated spinal deformities with a good postnatal outcome (n = 35, 60.3%). The commonest syndromic diagnosis in this group was VACTERL association (n = 7, 12.1%). Most cases of fetal loss were associated with severe malformations, most commonly spina bifida, body stalk anomaly and amniotic band sequence, or chromosomal abnormalities, except in 2 cases (3.1%). CONCLUSIONS: This is the largest reported cases series to date of prenatally diagnosed fetal spinal deformity. This confirms that fetal scoliosis and associated vertebral abnormalities are underdiagnosed prenatally, with the reported incidence (0.2 per 1000) lower than the recognized incidence of congenital scoliosis (1 in 1,000). The concurrent finding of severe malformations was strongly associated with fetal loss. When an isolated finding, most fetal spinal deformities had a good postnatal outcome, while 1:8 live births were diagnosed with VACTERL association.

The feasibility, acceptability, safety, and effects of early weight bearing in humeral fractures - a scoping review.

PURPOSE: Non-weight bearing is often recommended after humeral fractures. This review aims to summarise the extent and nature of the evidence for the feasibility, acceptability, safety, and effects of early weight bearing (EWB) in people with humeral fractures, treated operatively or non-operatively. . METHODS: Data sources identified published (PUBMED, EMBASE, CINAHL) and unpublished (ClinicalTrials.gov, CENTRAL, NIHR Open Research, OpenGrey) literature. Independent data extraction was conducted by two reviewers. RESULTS: 13 901 records were retrieved. Ten studies, involving 515 post-operative patients and 351 healthcare professionals, were included. EWB was found to be feasible in nine studies. There was limited evidence regarding adherence to EWB. Trauma and orthopaedic surgeons reported that EWB was acceptable. This depended on surgery type and whether it was a post-operative polytrauma case. No acceptability data was reported from patients' perspectives. Only one study reported two patients who developed unsatisfactory outcomes from excessive post-operative EWB. Positive effects of EWB were reported on disability level, pain, shoulder and elbow motion, and union. CONCLUSION: There is some evidence for the feasibility, safety, and effectiveness of post-operative EWB after humeral fractures. There was limited data on the acceptability of EWB. Heterogeneous study designs, and variations in EWB protocols limit conclusions.

There is some evidence to support the feasibility, safety, and effectiveness of early weight bearing following operative management of humeral fractures.Early weight bearing after some humeral fractures is acceptable to some subspecialities of orthopaedic surgeons but is not universally accepted.Rehabilitation professionals should discuss the option of early weight bearing after operative management of humeral fracture with patients and their multidisciplinary team.

Fracture-related infections.

Fracture-related infection is a serious complication which can occur following musculoskeletal injury and is associated with significant morbidity. These complications can be challenging to recognise, and experts have provided a clearer definition of fracture-related infection to help with the diagnosis and detection of these infections. This system includes clinical, radiological and laboratory-based diagnostic features which are either confirmatory or suggestive of fracture-related infection. Treatment requires a multifaceted approach with multidisciplinary involvement, and generally a combination of surgical techniques and prolonged antibiotics, the timing and choice of which should be optimised. This article provides an evidence-based review of the British Orthopaedic Association Standards for Trauma for the diagnosis and management of fracture-related infections.

Short-Term Hip Fracture Outcomes during the COVID-19 Pandemic.

Introduction Despite many significant changes as a result of the coronavirus disease 2019 (COVID-19) pandemic, and reductions in overall trauma workload, patients with fragility hip fractures continued to present to hospital. As we plan for ongoing service provision during future waves of the pandemic, valuable lessons can be learned from patients that have been treated surgically during the "first wave." Methods All patients admitted to our center (a busy District General Hospital in London, United Kingdom) with a hip fracture during a 13-week period representing the initial rise ("United Kingdom first wave") in COVID-19 cases, from February 17 th to May 17 th , 2020 (study group) were compared with hip fracture patients from the equivalent 13-week period in February to May 2019 (control group). The primary outcome was 30-day mortality, and additional information was collected in terms of length of stay (LOS), SARS-CoV-2 antigen testing, and cause of death. Results During the COVID-19 study period, 69 patients were admitted with a hip fracture, compared with 70 patients in the control group ( p = 0.949). There was no significant difference in 30-day mortality between the two groups (5.8 vs. 7.1%, p = 0.747). Mean LOS was shorter in the COVID-19 period compared with the control group (11.6 vs. 19.6 days, p <0.001, effect size 0.572). Forty-six patients (66.7%) had a SARS-CoV-2 antigen swab test, as testing was not available in the early period, and 10 patients (14.5%) tested positive. None of the patients, who presented before the antigen testing was available, had clinical suspicion of COVID-19 retrospectively. Two "COVID-19 positive" patients (20%) died within 30 days of admission. Conclusion We report reassuring short-term results demonstrating no statistically significant difference in the 30-day mortality rate of hip fracture patients admitted during the United Kingdom's first wave of the COVID-19 pandemic compared to the equivalent period in the previous year. Hip fracture incidence remained stable, and LOS was reduced, likely due to recent departmental changes as well as a drive to discharge patients quickly during the pandemic. We agree with existing reports that elderly hip fracture patients with COVID-19 have a higher risk of perioperative mortality, however, our results suggest that overall mortality for the whole hip fracture population was similar to the previous year, in which deaths were more commonly attributed to respiratory infections associated with other pathogens. Further work may be needed to evaluate the outcomes during subsequent waves of the pandemic as mutations in the virus and conditions may affect outcomes.

Epidemiology of pelvic and acetabular fractures across 12-mo at a level-1 trauma centre.

BACKGROUND: Despite motor-vehicle safety advancements and increasingly rigorous workplace safety regulations, trauma/suicide remains the leading cause of death under the age of 45 in the United Kingdom. To promote centralisation of care and optimisation of major trauma outcomes, in 2012 the National Health Service introduced the Trauma Network System. To our knowledge, this is the first study to analyse the epidemiology of pelvic and acetabular trauma over a one-year period at a level-1 trauma centre in the United Kingdom, since nationwide introduction of the Trauma Network System. AIM: To characterize the epidemiology of high-energy pelvic and acetabular fractures over a one-year period at a level-1 trauma centre, and explore both resources required to care for these patients and opportunities for future research and injury prevention initiatives. METHODS: 227 consecutive patients at a level-1 trauma centre with pelvic and acetabular fractures were analysed between December 2017-December 2018. Paediatric patients (< 18 years) and fragility fractures were excluded, leaving 175 patients for inclusion in the study. Statistical analysis was performed using Fisher's exact test for categorical variables. RESULTS: 72% of pelvic and acetabular fractures occurred in male patients at a median age of 45 years. 15% were the result of a suicide attempt. 48% of patients required pelvic or acetabular surgery, with 38% undergoing further surgery for additional orthopaedic injuries. 43% of patients were admitted to intensive care. The median inpatient stay was 13 days, and the 30- day mortality was 5%. Pelvic ring trauma was more commonly associated with abdominal injury (P = 0.01) and spine fractures (P < 0.001) than acetabular fractures. Vertical shear pelvic ring fractures were associated with falls (P = 0.03) while lateral compression fractures were associated with road traffic accidents (P = 0.01). CONCLUSION: High energy pelvic and acetabular fractures are associated with concomitant orthopaedic fractures (most commonly spine and lower limb), intensive care admission and prolonged inpatient stays. Most pelvic ring injuries secondary to road traffic accidents are lateral compression type, demonstrating the need for future research to drive advancements in lateral impact vehicle safety along with mental health surveillance for those deemed to be potential suicide risks.

Lesson of the month 2: When steroids stop working - infective endocarditis, the great mimicker.

A 63-year-old man with an extensive travel history to South East Asia presented with generalised malaise, temporal headaches and high inflammatory markers. He was treated with corticosteroids for presumed giant cell arteritis. Unsuccessful attempts to wean him from prednisolone prompted further investigations by rheumatology, haematology and finally ophthalmology. Roth spots were identified which prompted blood cultures to be taken. All three sets grew Streptococcus sinensis, an alpha-haemolytic Streptococcus reported as an emerging cause of endocarditis worldwide. The patient had signs of severe aortic regurgitation, confirmed on transthoracic echo. A transoesophageal echo demonstrated large aortic valve vegetations. He underwent an aortic valve replacement and completed 6 weeks of intravenous antibiotics with resolution of his symptoms.This case illustrates the importance of challenging a previous diagnosis, including repeat examination, when a patient's condition does not evolve as expected. Endocarditis is recognised as a great imitator and the diagnosis remains challenging.

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.

Fracture liaison services: improving outcomes for patients with osteoporosis.

Fragility fractures are sentinels of osteoporosis, and as such all patients with low-trauma fractures should be considered for further investigation for osteoporosis and, if confirmed, started on osteoporosis medication. Fracture liaison services (FLSs) with varying models of care are in place to take responsibility for this investigative and treatment process. This review aims to describe outcomes for patients with osteoporotic fragility fractures as part of FLSs. The most intensive service that includes identification, assessment and treatment of patients appears to deliver the best outcomes. This FLS model is associated with reduction in re-fracture risk (hazard ratio [HR] 0.18-0.67 over 2-4 years), reduced mortality (HR 0.65 over 2 years), increased assessment of bone mineral density (relative risk [RR] 2-3), increased treatment initiation (RR 1.5-4.25) and adherence to treatment (65%-88% at 1 year) and is cost-effective. In response to this evidence, key organizations and stakeholders have published guidance and framework to ensure that best practice in FLSs is delivered.

A mathematical theory for identifying and measuring severity of episodes of care.

OBJECTIVES: We propose and test a method for constructing episodes of care from data within administrative databases and electronic health records. SUBJECTS: We created a measure for severity of episodes of illness for 565 randomly chosen developmentally delayed children who were enrolled in the Medicaid program. DESIGN: Regression analysis was conducted to test the percentage of variance explained by our proposed mathematical model in cost of care. DATA COLLECTION: Data included both hospitalizations and clinic visits obtained from Medicaid programs from one southeastern state. METHODS: For each patient, the likelihood that two diagnoses are part of the same episode is proportional to the similarity of the two diagnoses and to the short time interval between them. When this likelihood exceeds a preset cutoff, then the two diagnoses are part of the same episode. The cutoff is estimated by selecting number of days before two very similar diagnoses are considered to be part of separate episodes. The similarity between two diagnoses is assumed to be proportional to co-occurrence of the two diagnoses within a fixed period (usually 30 days). The severity of an episode was calculated using a Muliplicative Multiattribute Utility model, where severity of each diagnosis is aggregated to estimate the overall severity of the episode. Severity of each diagnosis was assumed to be proportional to average cost of a diagnosis-if patients do not die before care is delivered. The article includes an algorithm that can classify a patient's diagnosis into episodes of care and measure severity of the episodes from date of diagnoses, code for the diagnoses, and charges for the visit. To facilitate integration with existing database, the article includes a Standard Query Language computer program. To evaluate the method of constructing episodes of care, we regressed cost of care on the patient's number of episodes of care within the year, average severity of the episodes within the year, and the interaction between number and average severity of the episodes. RESULTS: The number of episodes (alpha = .001), the average severity of the episodes (alpha = .001), and the product of the two (alpha = .001) had statistically significant relationships to the average cost of the case. The 3 variables together explained 53% of variation in yearly cost of care. CONCLUSIONS: These data suggest that our proposed mathematical approach is reasonable and produces severity scores that are predictive of objective criteria such as cost of care.

The Prevalence of Frailty in Patients Admitted to Hospital with Vertebral Fragility Fractures.

INTRODUCTION: Vertebral fragility fractures are the most common fragility fracture. A significant proportion of patients still present to hospital for treatment due to their underlying older age and frailty syndrome. We aim to describe the prevalence of frailty within a cohort of hospitalised patients with vertebral fragility fracture using clinical frailty scales and comparing this group of patients with those that have a fragility fracture of the hip, a well-recognised frail group of patients. METHOD: As part of a service improvement project, a prospective case series of all patients ≥50years admitted to hospital with a vertebral fragility fracture over a 6 week period (n=24) were screened for frailty. This was done using recognised clinical scales for frailty assessment (PRISMA-7, Groningen Frailty Index(GFI) and Edmonton Frail Scale (EFS)). Data was collected on patients' mobility (timed-up-and-go test), activities of daily living (Barthel Index) and cognition (abbreviated mental test). Secondly, we performed a cross-sectional analysis of patient characteristics of those ≥50years admitted to hospital with a fragility fracture of the hip (n=30) and those with a vertebral fragility fracture using data from our local clinical service registries. RESULTS: In the first study, frailty was identified in 70.8% of vertebral fracture patients using PRISMA-7 tool; 66.7% with the GFI; and 33.3% with the EFS. A further 20.8% were considered vulnerable to frailty on the EFS. Almost 30% were considered frail on all the three scales. Three quarters had a timed-up-and-go of >20seconds. Median Barthel Index was 18 (range 6-20); and the median abbreviated mental test was 9 (range 2-10), which suggests a cohort that is mostly independent with personal activities of daily living with good levels of cognition. In the second study, compared to patients with hip fracture, patients with vertebral fractures were younger; more likely to be living independently; less likely to have fallen in the last year; were taking more medication; and had equal number of co-morbidities as patients with hip fractures Conclusion: Frailty is prevalent in those admitted to hospital with a vertebral fragility fracture. Treatment of their acute fracture will need to include addressing their frailty issues.

Demonstrating value: registries and beyond.

Patient registries have evolved to support goals within medical specialties that have traditionally fallen outside their core missions. Quality measurement and reporting can support payor advocacy, meet federal and state requirements, evolve practices into novel care environments, and facilitate coordination among multiple health care providers. Registries can additionally be of use in safety and event monitoring, and supporting comparative effectiveness research. Through integration with electronic health records, registries also serve as a vehicle for the delivery of guidelines and the implementation of decision support and care pathways.