Does Routine Postoperative Computerized Tomography After Acetabular Fracture Fixation Affect Management?

INTRODUCTION AND AIMS: The use of routine postoperative computerized tomography (CT) scan after acetabular fracture reconstruction remains controversial. CT scan may provide more accurate detail regarding metalwork position, retained intra-articular fragments, and quality of reduction but does expose the patient to additional radiation dosage and incurs increased cost. The aim of this study was to evaluate a protocol of routine postoperative CT scan for all acetabular fractures after surgical fixation and assess the effect this has on patient management. PATIENTS AND METHODS: The perioperative fluoroscopic images and postoperative plain radiographs of 122 patients who underwent surgical stabilization of a displaced acetabular fracture were reviewed and categorized into 3 groups: (1) safe, when there was no suspicion of metalwork malposition or intra-articular fragments; (2) inconclusive, when it was not possible to exclude malposition; or (3) definite malposition or intra-articular penetration of implants. The findings were compared with postoperative CT scans. The quality of reduction of the acetabular fracture was graded on plain radiographs using the Matta criteria and compared with the CT scan using a standardized technique. RESULTS: Fractures that were categorized as safe on plain radiographs were confirmed to have no metalwork malposition on CT scan in 94% of the cases, with the other 6% having insignificant findings that did not require revision surgery. When plain radiographs were inconclusive (n = 17), 4 patients had metalwork malposition documented on CT scan and 2 of these required revision surgery. There was an increased risk of implant malposition with use of spring plates for posterior wall stabilization. There was significant variation between the quality of reduction when assessed with plain radiographs as compared with CT scans (P < 0.001). In 42% of the patients who were thought to have anatomic reduction on plain radiographic assessment, the reduction was either imperfect or poor based on CT assessment. CONCLUSIONS: CT scans were more accurate than plain radiographs in detecting metalwork malposition and in assessing quality of reduction of the acetabular fracture. The use of postoperative CT scans may be restricted to a group of fractures that have inconclusive or definite malpositioning of implants on perioperative or postoperative radiographs, especially with use of spring pates or to those patients in whom quality of reduction needs more accurate assessment for quality assurance or prognostic reasons. LEVEL OF EVIDENCE: Level IV; Diagnostic -Investigating a diagnostic test.

Routine Postoperative Computed Tomography Scans After Pelvic Fracture Fixation: A Necessity or a Luxury?

INTRODUCTION: There is no consensus regarding the postoperative radiology imaging protocol after pelvic fracture surgery. Some institutes routinely scan all patients after their surgery, others do not. The aim of this study was to assess the value of routine use of computed tomography (CT) scans after pelvic fracture surgery and to determine the sensitivity of conventional plain radiographs and intraoperative fluoroscopy in detecting metalwork malposition. PATIENTS AND METHODS: The radiographs and clinical notes of patients undergoing pelvic fracture surgery in the period between January 2010 and December 2015 were reviewed. Patients were categorized into 2 main groups: group A-patients whose fixation entailed the use of a sacroiliac (SI) screws and group B-patients whose fixation did not require an SI screw. Furthermore, the patients were classified according to the position of metalwork in their postoperative plain radiographs and perioperative fluoroscopy into 3 groups: (1) Safe: When there was no suspicion of metalwork malposition. (2) Suspicious: When there was some suspicion of malposition but radiographs were inconclusive. (3) Definite: When plain imaging showed a definite malposition. RESULTS: One hundred ninety-eight patients were included in this study (161 in group A and 37 in group B). In group A, 148 (92%) were classified as safe, 10 were suspicious (6%), and 3 (2%) showed definite malposition. Of the fractures that were believed to be safe on plain radiographs, 78% were confirmed to be safe on CT scans, whereas 22% showed malpositioned metalwork, and 7 patients (4%) required a revision surgery. Plain radiographs showed a sensitivity of 27% in detecting metalwork malposition and a specificity of 99%. Increasing the number of screws significantly increased the risk of malposition and reoperation (P = 0.006 and 0.002 respectively). The plain images of group B were all classified as safe. The CT scans detected 2 cases with long metalwork protruding into the soft tissues, none of which required a revision surgery. CONCLUSION: Perioperative fluoroscopy and plain postoperative radiographs have a low sensitivity in detecting the metalwork malposition after pelvic fracture surgery. We recommend the use of routine postoperative CT scans in patients whose fixation entails the use of SI screws. In this series, routine scanning of patients who did not have SI screws added no significant clinical value. LEVEL OF EVIDENCE: Level IV Diagnostic. See Instructions for Authors for a complete description of levels of evidence.

Close Contact Casting vs Surgery for Initial Treatment of Unstable Ankle Fractures in Older Adults: A Randomized Clinical Trial.

Importance: Ankle fractures cause substantial morbidity in older persons. Surgical fixation is the contemporary intervention but is associated with infection and other healing complications. Objective: To determine whether initial fracture treatment with close contact casting, a molded below-knee cast with minimal padding, offers outcome equivalent to that with immediate surgery, with fewer complications and less health resource use. Design, Setting, and Participants: This was a pragmatic, equivalence, randomized clinical trial with blinded outcome assessors. A pilot study commenced in May 2004, followed by multicenter recruitment from July 2010 to November 2013; follow-up was completed May 2014. Recruitment was from 24 UK major trauma centers and general hospitals. Participants were 620 adults older than 60 years with acute, overtly unstable ankle fracture. Exclusions were serious limb or concomitant disease or substantial cognitive impairment. Interventions: Participants were randomly assigned to surgery (n = 309) or casting (n = 311). Casts were applied in the operating room under general or spinal anesthesia by a trained surgeon. Main Outcomes and Measures: The primary 6-month, per-protocol outcome was the Olerud-Molander Ankle Score at 6 months (OMAS; range, 0-100; higher scores indicate better outcomes and fewer symptoms), equivalence prespecified as ±6 points. Secondary outcomes were quality of life, pain, ankle motion, mobility, complications, health resource use, and patient satisfaction. Results: Among 620 adults (mean age, 71 years; 460 [74%] women) who were randomized, 593 (96%) completed the study. Nearly all participants (579/620; 93%) received allocated treatment; 52 of 275 (19%) who initially received casting later converted to surgery, which was allowable in the casting treatment pathway to manage early loss of fracture reduction. At 6 months, casting resulted in ankle function equivalent to that with surgery (OMAS score, 66.0 [95% CI, 63.6-68.5] for surgery vs 64.5 [95% CI, 61.8-67.2] for casting; mean difference, -0.6 [95% CI, -3.9 to 2.6]; P for equivalence = .001). Infection and wound breakdown were more common with surgery (29/298 [10%] vs 4/275 [1%]; odds ratio [OR], 7.3 [95% CI, 2.6-20.2]), as were additional operating room procedures (18/298 [6%] for surgery and 3/275 [1%] for casting; OR, 5.8 [95% CI, 1.8-18.7]). Radiologic malunion was more common in the casting group (38/249 [15%] vs 8/274 [3%] for surgery; OR, 6.0 [95% CI, 2.8-12.9]). Casting required less operating room time compared with surgery (mean difference [minutes/participant], -54 [95% CI, -58 to -50]). There were no significant differences in other secondary outcomes: quality of life, pain, ankle motion, mobility, and patient satisfaction. Conclusions and Relevance: Among older adults with unstable ankle fracture, the use of close contact casting compared with surgery resulted in similar functional outcomes at 6 months. Close contact casting may be an appropriate treatment for such patients. Trial Registration: isrctn.com Identifier: ISRCTN04180738.

A comparison of the long gamma nail with the sliding hip screw for the treatment of AO/OTA 31-A2 fractures of the proximal part of the femur: a prospective randomized trial.

BACKGROUND: Controversy exists with regard to whether to treat AO/OTA 31-A2 fractures of the proximal part of the femur with an intramedullary device or an extramedullary device. A prospective, randomized, controlled trial was performed to compare the outcome of treatment of these unstable fractures of the proximal part of the femur with either a sliding hip screw or a long gamma nail. METHODS: Two hundred and ten patients presenting with an AO/OTA 31-A2 fracture of the proximal part of the femur were randomized, at the time of admission, to fixation with use of either a long gamma nail or a sliding hip screw. The primary outcome measure was reoperation within the first postoperative year. Secondary measures included mortality, length of hospital stay, transfusion rate, change in mobility and residence, and quality of life as measured with the EuroQol 5D outcome score. RESULTS: There was no significant difference between the reoperation rates for the two groups. In total, five patients (three from the long-gamma-nail group and two from the sliding-hip-screw group) underwent revision surgery because of cut-out. Tip-apex distance was found to correlate with the implant cut-out rate. There was no significant difference between the two groups in terms of the EuroQol 5D outcome scores, the mortality rates after correction for the mini-mental score, or any of the secondary outcome measures. CONCLUSIONS: When compared with the long gamma nail, the sliding hip screw should remain the gold standard for the treatment of AO/OTA 31-A2 fractures of the proximal part of the femur because it is associated with similar outcomes with less expense.