Improved Intraoperative Fluoroscopy for Pelvic and Acetabular Surgery.

Over the past 3 decades, the evolution of pelvic and acetabular surgery has been supported by the advances in intraoperative pelvic fluoroscopic imaging technology. The new Ziehm RFD 3D C-arm unit provides routine fluoroscopic pelvic imaging but also offers rapid and high-quality real-time axial, sagittal, and coronal intraoperative imaging. This technology allows the surgeon to accurately assess fracture reduction, loose body removal, and implant locations while the patient is still under anesthesia. In this way, any necessary corrections can be performed before the patient leaves the operating room. Essentially, this technology should eliminate the need for revision surgeries. In this report, we present our initial experience using this new device.

Scapulothoracic Dissociation: Evaluation and Management.

Scapulothoracic dissociation is a rare, potentially limb- and life-threatening injury of the shoulder girdle. The injury is characterized by lateral displacement of the scapula resulting from traumatic disruption of the scapulothoracic articulation. The typical physical examination findings consist of substantial swelling of the shoulder girdle, along with weakness, numbness, and pulselessness in the ipsilateral upper extremity. Radiographic evaluation includes measurement of the scapular index on a nonrotated chest radiograph and assessment for either a distracted clavicle fracture or a disrupted acromioclavicular or sternoclavicular joint. Although vascular injury occurs in most patients, emergent surgery is performed only in patients with either limb-threatening ischemia or active arterial hemorrhage. Management of neurologic injury can be delayed if necessary. The location and severity of neurologic injury determine whether observation, nerve grafting, nerve transfer, or above-elbow amputation is performed. Skeletal stabilization procedures include plate fixation of clavicle fractures and reduction of distracted acromioclavicular or sternoclavicular joints. The extent of neurologic injury determines clinical outcomes. Medical Outcomes Study 36-Item Short Form scores are significantly lower in patients with complete brachial plexus avulsion injury than in patients with postganglionic injury.

Assessment of pelvic fractures resulting from the 2010 Haiti earthquake: opportunities for improved care.

BACKGROUND: On January 12, 2010, a catastrophic 7.0 magnitude earthquake shook the Haitian capital of Port-au-Prince. Because of their sudden and destructive nature, earthquakes can result in unfamiliar mass casualty situations accompanied by devastating orthopedic injuries. Evaluation of the pelvic fractures resulting from this earthquake revealed several factors that we hope will facilitate optimal preparation and planning for future disaster situations. METHODS: A cohort of patients with earthquake-related pelvic ring fractures who were treated aboard the USNS Comfort was retrospectively analyzed. Anteroposterior radiographs of the pelvis were evaluated and categorized according to the Young-Burgess classification system. RESULTS: Sixty-eight patients were included in the cohort. The mean (SD) age was 29.6 (14.4) years. Nineteen patients (29.7%) were male, and 49 (70.3%) were female. Pelvic fractures were categorized as anteroposterior compression in 7 patients, lateral compression (LC) in 47 patients, vertical shear (VS) in 8 patients, and combination of pelvic ring/acetabulum in 6 patients. Among the 23 patients treated operatively, the mean (SD) delay from injury to surgery was 19.2 (7.4) days. CONCLUSION: Patients showed predominance toward LC injuries (69.1%), consistent with crush under rubble. Thirty-one percent of the fractures were considered unstable (anteroposterior compression Type III, LC Type III, VS, and combination of pelvic ring/acetabulum). The VS injuries observed (11.8%) may be the result of a previously unidentified injury mechanism, an upright individual being struck by falling rubble, violently applying a downward force to the body over an extended lower extremity. A substantial delay in the treatment observed in this series may lead to an underestimation of both quantity and severity of pelvic fractures as critically ill patients may have perished before evaluation and treatment. In addition, the application of pelvic sheeting techniques may be a lifesaving intervention for interval pelvic stabilization following earthquakes in which medical resources are scarce. LEVEL OF EVIDENCE: Epidemiologic study, level III; therapeutic study, level V.

Are we delivering two standards of care for pelvic trauma? Availability of angioembolization after hours and on weekends increases time to therapeutic intervention.

BACKGROUND: We hypothesized that patients with pelvic fractures and hemorrhage admitted during daytime hours were undergoing interventional radiology (IR) earlier than those admitted at night and on weekends, thereby establishing two standards of time to hemorrhage control. METHODS: The trauma registry (January 2008 to December 2011) was reviewed for patients admitted with pelvic fractures, hemorrhagic shock, and transfusion of at least 1 U of blood. The control group (DAY) was admitted from 7:30 AM to 5:30 PM Monday to Friday, while the study group (after hours [AHR]) was admitted from 5:30 PM to 7:30 AM, on weekends or holidays. RESULTS: A total of 191 patients met the criteria (45 DAY, 146 AHR); 103 died less than 24 hours and without undergoing IR (29% DAY group vs. 62% AHR, p < 0.001). Sixteen patients (all in AHR group) died while awaiting IR (p = 0.032). Eighty-eight patients (32 DAY, 56 AHR) survived to receive IR. Among these, the AHR group were younger (median, 30 years vs. 54 years; p = 0.007), more tachycardic (median pulse, 119 beats/min vs. 90 beats/min; p = 0.001), and had more profound shock (median base, -10 vs. -6; p = 0.006) on arrival. Time from admission to IR (median, 301 minutes vs. 193 minutes; p < 0.001) and computed tomographic scan to IR (176 minutes vs. 87 minutes, p = 0.011) were longer in the AHR group. There was no difference in the 30-day mortality by univariate analysis. However, after controlling for age, arrival physiology, injury severity, and degree of shock, the AHR group had a 94% increased risk of mortality. CONCLUSION: The current study demonstrated that patients admitted at night and on weekends have a significant increase in time to angioembolization compared with those arriving during the daytime and during the week. Multivariate regression noted that AHR management was associated with an almost 100% increase in mortality. While this is a single-center study and retrospective in nature, it suggests that we are currently delivering two standards of care for pelvic trauma, depending on the day and time of admission. LEVEL OF EVIDENCE: Therapeutic study, level II.

Early femur fracture fixation is associated with a reduction in pulmonary complications and hospital charges: a decade of experience with 1,376 diaphyseal femur fractures.

BACKGROUND: Early fixation (<24 hour) of femur fractures with an intramedullary nail (IMN) has been associated with a decreased incidence of pulmonary complication (PC) in stable trauma patients. Early fixation is in accordance with the "two-hit" hypothesis, that is, an increase in proinflammatory markers during Days 3 to 5 after injury, increases the risk of developing a PC. We hypothesized that early IMN fixation of femur fractures would be associated with a decreased incidence of PC, hospital stay, and overall charges. METHODS: A retrospective review of all trauma patients with diaphyseal femur fractures was performed from January 2000 through December 2010 at an academic Level 1 trauma center. The cohort was divided into those who underwent early fixation (<24 hours) and delayed fixation (≥24 hours). Multivariable logistic regression modeling was used to adjust for the anatomic (Injury Severity Score [ISS]) and physiologic (Revised Trauma Score [RTS]) severity of injury. The primary outcome of interest was PC, defined as the presence of pneumonia (PNA), pulmonary embolism, or adult respiratory distress syndrome. Continuous variables are expressed as mean (SD). The analysis was repeated for patients with an ISS of greater than 15 and an ISS of greater than 25. RESULTS: During the study period, 1,755 patients were admitted with a diaphyseal femur fracture, of whom 1,376 patients underwent primary IMN. A total of 1,032 (75%) underwent early fixation (median, 7.4 hours; interquartile range [IQR], 3.7-12.9 hours), and 344 (25%) underwent delayed fixation (median, 40.9 hours; IQR, 31.0-64.9 hours). The early fixation group had lower ISS (median [IQR], 10 [10-19] vs. 17.5 [10-27]; p < 0.001) and a higher RTS (median [IQR], 7.84 [7.84-7.84] vs. 7.84 [7.84-7.84]; p < 0.001). PC were reduced in the early fixation group, (3.9% vs. 13.4%, p < 0.001). Specifically, there was a decreased incidence of PNA (2% vs. 11%, p < 0.001), pulmonary embolism (2% vs. 4%, p < 0.21), and adult respiratory distress syndrome (0.002% vs. 0.02%, p < 0.001). After adjustment for anatomic (ISS) and physiologic (RTS) indices of injury severity, early fixation was independently associated with a reduction in PC (odds ratio, 0.43; 95% confidence interval, 0.25-0.72; p = 0.002). The early fixation group also had a decrease in hospital length of stay (median [IQR], 6 [4-11] vs. 10 [6-17]; p < 0.001), ventilator days (median [IQR], 0 [0-0] vs. 0 [0-4]; p < 0.001), and hospital charges (median [IQR], $59,561 [$38,618-$106,780] vs. $97,018 [48,249-205,570]; p < 0.001). Mortality was low in both groups (0.4% vs. 1.7%, p < 0.01). Similar results were seen in patients with an ISS of greater than 15 and ISS of greater than 25. CONCLUSION: Controlling for anatomic and physiologic severity of injury, early femoral IMN was associated with an almost 60% reduction in odds of developing PCs. Early fixation was also associated with a reduction ventilator days, hospital length of stay, and overall hospital charges. As the list of "never events" continues to expand and improving quality of care while reducing costs is emphasized, early (<24 hours) definitive operative intervention seems to decrease complications, achieve early hospital discharge, and reduce hospital charges. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Health-care costs associated with amputation or reconstruction of a limb-threatening injury.

BACKGROUND: Recent reports have suggested that functional outcomes are similar following either amputation or reconstruction of a severely injured lower extremity. The goal of this study was to compare two-year direct health-care costs and projected lifetime health-care costs associated with these two treatment pathways. METHODS: Two-year health-care costs were estimated for 545 patients with a unilateral limb-threatening lower-extremity injury treated at one of eight level-I trauma centers. Included in the calculation were costs related to (1) the initial hospitalization, (2) all rehospitalizations for acute care related to the limb injury, (3) inpatient rehabilitation, (4) outpatient doctor visits, (5) outpatient physical and occupational therapy, and (6) purchase and maintenance of prosthetic devices. All dollar figures were inflated to constant 2002 dollars with use of the medical service Consumer Price Index. To estimate projected lifetime costs, the number of expected life years was multiplied by an estimate of future annual health-care costs and added to an estimate of future costs associated with the purchase and maintenance of prosthetic devices. RESULTS: When costs associated with rehospitalizations and post-acute care were added to the cost of the initial hospitalization, the two-year costs for reconstruction and amputation were similar. When prosthesis-related costs were added, there was a substantial difference between the two groups ($81,316 for patients treated with reconstruction and $91,106 for patients treated with amputation). The projected lifetime health-care cost for the patients who had undergone amputation was three times higher than that for those treated with reconstruction ($509,275 and $163,282, respectively). CONCLUSIONS: These estimates add support to previous conclusions that efforts to improve the rate of successful reconstructions have merit. Not only is reconstruction a reasonable goal at an experienced level-I trauma center, it results in lower lifetime costs.

Early predictors of long-term work disability after major limb trauma.

BACKGROUND: A better understanding of the factors influencing return to work (RTW) after major limb trauma is essential in reducing the high costs associated with these injuries. METHODS: Patients (n = 423) who underwent amputation or reconstruction after limb threatening lower extremity trauma and who were working before the injury were prospectively evaluated at 3, 6, 12, 24, and 84 months. Time to first RTW was assessed. For individuals working at 84 months, the percentage of time limited in performance at work was estimated using the Work Limitations Questionnaire. RESULTS: Estimates of the cumulative proportion returning to work at 3, 6, 12, 24, and 84 months were 0.12, 0.28, 0.42, 0.51, and 0.58. Patients working at 84 months were, on average, limited in their ability to perform the demands of their job 20 to 25% of the time. In the context of a Cox proportional hazards model, differences in RTW outcomes by treatment (amputation versus reconstruction) were not statistically significant. Factors that were significantly associated (p < 0.05) with higher rates of RTW include younger age, being White, higher education, being a nonsmoker, average to high self efficacy, preinjury job tenure, higher job involvement, and no litigation. Early (3 month) assessments of pain and physical functioning were significant predictors of RTW. CONCLUSIONS: Return to work after severe lower extremity trauma remains a challenge. Although the causal pathway from injury to impairment and work disability is complex, this study points to several factors that influence RTW that suggest strategies for intervention.

Long-term persistence of disability following severe lower-limb trauma. Results of a seven-year follow-up.

BACKGROUND: A recent study demonstrated that patients treated with amputation and those treated with reconstruction had comparable functional outcomes at two years following limb-threatening trauma. The present study was designed to determine whether those outcomes improved after two years, and whether differences according to the type of treatment emerged. METHODS: Three hundred and ninety-seven patients who had undergone amputation or reconstruction of the lower extremity were interviewed by telephone at an average of eighty-four months after the injury. Functional outcomes were assessed with use of the physical and psychosocial subscores of the Sickness Impact Profile (SIP) and were compared with similar scores obtained at twenty-four months. RESULTS: On the average, physical and psychosocial functioning deteriorated between twenty-four and eighty-four months after the injury. At eighty-four months, one-half of the patients had a physical SIP subscore of > or = 10 points, which is indicative of substantial disability, and only 34.5% had a score typical of a general population of similar age and gender. There were few significant differences in the outcomes according to the type of treatment, with two exceptions. Compared with patients treated with reconstruction for a tibial shaft fracture, those with only a severe soft-tissue injury of the leg were 3.1 times more likely to have a physical SIP subscore of 5 points (p < 0.05) and those treated with a through-the-knee amputation were 11.5 times more likely to have a physical subscore of 5 points (p < 0.05). There were no significant differences in the psychosocial outcomes according to treatment group. Patient characteristics that were significantly associated with poorer outcomes included older age, female gender, nonwhite race, lower education level, living in a poor household, current or previous smoking, low self-efficacy, poor self-reported health status before the injury, and involvement with the legal system in an effort to obtain disability payments. Except for age, predictors of poor outcome were similar at twenty-four and eighty-four months after the injury. CONCLUSIONS: The results confirm previous conclusions that reconstruction for the treatment of injuries below the distal part of the femur typically results in functional outcomes equivalent to those of amputation. Regardless of the treatment option, however, long-term functional outcomes are poor. Priority should be given to efforts to improve post-acute-care services that address secondary conditions that compromise optimal recovery.

Functional outcomes following trauma-related lower-extremity amputation.

BACKGROUND: The principal aims of this study were to examine functional outcomes following trauma-related lower-extremity amputation and to compare outcomes according to the amputation levels. We hypothesized that above-the-knee amputations would result in less favorable outcomes than would through-the-knee or below-the-knee amputations. A secondary aim was to examine the factors, in addition to amputation level, that influence outcome, including the type of soft-tissue coverage, selected patient characteristics, and the technological sophistication of the prosthetic device. METHODS: A cohort of 161 patients who had undergone an above-the-ankle amputation at a trauma center within three months following the injury was followed prospectively at three, six, twelve, and twenty-four months after the injury. The Sickness Impact Profile, a self-reported measure of functional status, was used as the principal measure of outcome. Secondary outcomes included pain; degree of independence in transfers, walking, and climbing stairs; self-selected walking speed; and the physician's satisfaction with the clinical, functional, and cosmetic recovery of the limb. Longitudinal multivariate regression techniques were used to determine whether outcomes differed according to the level of amputation after we controlled for covariates. RESULTS: There was no significant difference in the scores on the Sickness Impact Profile between the patients treated with above-the-knee and those treated with below-the-knee amputation. However, patients with a below-the-knee amputation performed better than did patients with an above-the-knee amputation on the timed test for walking speed (p = 0.04). Patients with a through-the-knee amputation had worse regression-adjusted Sickness Impact Profile scores (p = 0.05) and slower self-selected walking speeds (p = 0.004) than did patients with either a below-the-knee or an above-the-knee amputation. Differences according to the level of amputation were most pronounced for physical function. In general, physicians were less satisfied with the clinical, cosmetic, and functional recovery of the patients with a through-the-knee amputation. Except for problems encountered with insufficient gastrocnemius coverage of the stump in many patients with a through-the-knee amputation, neither the soft-tissue coverage nor the technological sophistication of the prosthesis correlated with outcome. CONCLUSIONS: Severe disability accompanies above-the-ankle lower-extremity amputation following trauma, regardless of the level of amputation. Clinicians should critically evaluate the need for a through-the-knee amputation in patients with a traumatic injury. The results of this study also underscore the need for controlled studies that examine the relationship between the type and fit of prosthetic devices and functional outcomes.

An analysis of outcomes of reconstruction or amputation after leg-threatening injuries.

BACKGROUND: Limb salvage for severe trauma has replaced amputation as the primary treatment in many trauma centers. However, long-term outcomes after limb reconstruction or amputation have not been fully evaluated. METHODS: We performed a multicenter, prospective, observational study to determine the functional outcomes of 569 patients with severe leg injuries resulting in reconstruction or amputation. The principal outcome measure was the Sickness Impact Profile, a multidimensional measure of self-reported health status (scores range from 0 to 100; scores for the general population average 2 to 3, and scores greater than 10 represent severe disability). Secondary outcomes included limb status and the presence or absence of major complications resulting in rehospitalization. RESULTS: At two years, there was no significant difference in scores for the Sickness Impact Profile between the amputation and reconstruction groups (12.6 vs. 11.8, P=0.53). After adjustment for the characteristics of the patients and their injuries, patients who underwent amputation had functional outcomes that were similar to those of patients who underwent reconstruction. Predictors of a poorer score for the Sickness Impact Profile included rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), smoking, and involvement in disability-compensation litigation. Patients who underwent reconstruction were more likely to be rehospitalized than those who underwent amputation (47.6 percent vs. 33.9 percent, P=0.002). Similar proportions of patients who underwent amputation and patients who underwent reconstruction had returned to work by two years (53.0 percent and 49.4 percent, respectively). CONCLUSIONS: Patients with limbs at high risk for amputation can be advised that reconstruction typically results in two-year outcomes equivalent to those of amputation.

Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma.

BACKGROUND: Factors thought to influence the decision for limb salvage include injury severity, physiologic reserve of the patient, and characteristics of the patient and their support system. METHODS: Eligible patients were between the ages of 16 and 69 with Gustilo type IIIB and IIIC tibial fractures, dysvascular limbs resulting from trauma, type IIIB ankle fractures, or severe open midfoot or hindfoot injuries. Data collected at enrollment relevant to the decision-making process included injury characteristics and its treatment, and the nature and severity of other injuries. Logistic regression and stepwise modeling were used to determine the effect of each covariate on the variable salvage/ amputation. RESULTS: Of 527 patients included in the analysis, 408 left the hospital with a salvaged limb. Of the 119 amputations performed, 55 were immediate and 64 were delayed. The multivariate analysis confirmed the bivariate analysis: all injury characteristics remained significant predictors of limb status with the exception of bone loss; and soft tissue injury and absence of plantar sensation were the most important factors in accounting for model validity. CONCLUSION: Soft tissue injury severity has the greatest impact on decision making regarding limb salvage versus amputation.