Anaemia Is Associated with an Increased Risk of Fractures, a Systematic Review, and Meta-Analysis.

BACKGROUND: Anaemia and osteoporotic fractures are both major health problems among older adults worldwide. OBJECTIVES: Previous studies suggest that anaemia may be associated with elevated fracture risk among older adults; however, the exact relationship between them is unknown. We aimed to investigate the association between anaemia and fracture risk. METHODS: A comprehensive literature search was performed in four medical databases. We included articles that were published from inception to February 18, 2021. Odds ratios (ORs), hazard ratios (HRs) with 95% confidence intervals (CIs), and original raw incidences from studies comparing fracture rates in anaemic versus non-anaemic patients were extracted and pooled with the random-effects model. I2 test was used to assess heterogeneity. Risk of bias assessment was performed using the Quality of Prognostic Studies tool. PROSPERO: CRD42021241109. RESULTS: A total of 13 studies were identified; 8 of them were included in the quantitative synthesis. Anaemia was found to be a risk factor for fracture compared to non-anaemia. Anaemia increased hip fracture risk in both older men (HR = 1.71; CI: 1.46-2.00, p< 0.001, I2 = 83.2%) and women (HR = 1.31; CI: 1.13-1.52, p< 0.001), but the fracture risk was more increased among men. There was also an increased chance of hip fracture in the presence of anaemia in populations, including both older men and women (OR = 1.64; CI: 1.35-2.01, p< 0.001, I2 = 61.1%). Anaemia was also associated with increased vertebral (HR = 1.21; CI: 1.04-1.40, p = 0.012) and all-type (HR = 1.49; CI: 1.19-1.86, p< 0.001) fracture risk in older men. CONCLUSION: Our results suggest that there is a significant relationship between anaemia and fracture risk in older adults. This association is stronger among older men than women and differs in the different types of fractures.

Differences between proximal bone remodeling in femoral revisions for aseptic loosening and periprosthetic fractures using the Wagner SL stem.

BACKGROUND: Monoblock taper fluted stems have been reliably used to treat proximal femoral periprosthetic fractures (PFF) and femoral aseptic loosening (AL). Although proximal femoral remodeling has been observed around the Wagner Self-Locking (SL) stem, the exact characteristics of this process are yet to be established. Our aim was to compare the remodeling that takes place after femoral revisions for PFF and AL. METHODS: Consecutive patients between January 2015 and December 2017 undergoing femoral revision using the Wagner SL stem for PFF or AL without an extended trochanteric osteotomy (ETO) or bone grafting were selected from our database. Radiological follow-up was performed using plain antero-posterior hip radiographs taken postoperatively and at 3, 6, 12 months and at 24 months. The Global Radiological Score (GRxS) was utilized by four blinded observers. Intra and interobserver variability was calculated. Secondary outcome measures included the Oxford Hip Score and the Visual Analog Scale for pain. RESULTS: We identified 20 patients from our database, 10 PFF and 10 AL cases. The severity of AL was Paprosky 2 in 2 cases, Paprosky 3A in 2 cases and Paprosky 3B in 6. PFF were classified as Vancouver B2 in 7 cases and Vancouver B3 in 3 cases. Patients undergoing femoral revision for PFF regained 89% (GRxS: 17.7/20) of their bone stock by 6 months, whilst patients with AL, required almost 2 years to achieve similar reconstitution of proximal femoral bony architecture 86% (GRxS: 17.1/20). Inter-observer reproducibility for numerical GRxS values showed a "good" correlation with 0.68, whilst the intra-observer agreement was "very good" with 0.89. Except immediate after the revision, we found a significant difference between the GRxS results of the two groups at each timepoint with pair-wise comparisons. Functional results were similar in the two groups. We were not able to show a correlation between GRxS and functional results. CONCLUSIONS: Proximal femoral bone stock reconstitutes much quicker around PFF, than in the cases of AL, where revision is performed without an ETO. The accuracy of GRxS measurements on plain radiographs showed good reproducibility, making it suitable for everyday use in a revision arthroplasty practice.

Comparison of minor bleeding complications using dabigatran or enoxaparin after cemented total hip arthroplasty.

BACKGROUND: Orally administered chemical thromboprophylactic agents for total hip replacement (THR) have become popular in recent years. Certain clinical trials suggest that the efficacy and the risk of major bleeding after administration of direct thrombin inhibitor dabigatran etexilate are equivalent to the clinical trial comparator, subcutaneous low-molecular-weight heparin enoxaparin. Our aim was to compare and evaluate the incidence of minor haemorrhagic and soft-tissue adverse effects of enoxaparin and dabigatran. MATERIALS AND METHODS: 122 patients who were treated by elective cemented primary THR were enrolled in our quasi-randomised study. Two groups were formed according to which perioperative thromboprophylactic agent was used: 61 patients in enoxaparin group versus 61 patients in dabigatran group. Thigh volume changes, calculated perioperative blood loss, area of haematoma, wound bleeding, duration of wound discharge and intensity of serous wound discharge on postoperative day 3 and day 7 were recorded. RESULTS: The duration and intensity of serous wound discharge differed significantly between the two groups. Duration of wound discharge after drain removal was 2.2 (±2.7) days in the dabigatran group and 1.2 (±1.9) days in the enoxaparin group (p < 0.05). Significant increase in serous discharge was found in the dabigatran group (p < 0.05) on third and seventh postoperative days compared to the enoxaparin group. CONCLUSION: Both thromboprophylactic agents were found to have appropriate antithrombotic effects after THR. However, dabigatran was associated with an increased incidence of prolonged serous wound discharge, which might cause longer hospitalization and might instigate the use of prolonged antibiotic prophylaxis.

Percutaneous fixation of acetabular fractures: computer-assisted determination of safe zones, angles and lengths for screw insertion.

INTRODUCTION: Percutaneous retrograde screw fixation for acetabular fractures is a demanding procedure due to the complex anatomy of the pelvis and the varying narrow safe bony corridors. Limited information is available on optimal screw placement and the geometry of safe zones for screw insertion in the pelvis. METHODS: Three-dimensional reconstructions of 50 consecutive CT scans of polytrauma patients (35 males, 15 females) were used to introduce three virtual CAD bolts (representing screws) into the anterior column (superior ramus of the pubic bone), posterior column (the ischial bone) and the supraacetabular region, as performed during percutaneous screw fixation. The three-dimensional (3D) position of these screws was evaluated with a computer software (MIMICS) after virtual optimal insertion. The 3D position, the narrowest zone and the distance to the hip joint of the two columns and the supraacetabular region were defined. RESULTS: The mean maximal screw length for the three virtual screws measured between 107.4 and 148 ± 18.7 mm. The narrowest zone of the pelvic bone (superior pubic ramus) had a width of 9.2 ± 2.4 mm. The average distances between the bolts and the hip joint were 3.9 and 19.4 ± 7.4 mm. For the anterior column (superior pubic ramus) screw, the mean lateral angle to the sagittal midline plane was 39.0 ± 3.2° and the mean posterior angle to the transversal midline plane was 15.1 ± 4.0°. The mean supraacetabular screw angles measured 22.4 ± 3.4° (medial), 35.3 ± 4.6° (cranial) and the mean angles for the ischial screw were 12.0 ± 5.4° (posterior) and 18.4 ± 4.0° (lateral). CONCLUSIONS: The zones for safe screw positioning are very narrow, making percutaneous screw fixation of the acetabulum a challenging procedure. The predefined angles for the most frequently positioned percutaneous screws may aid in preoperative planning, decrease operative and radiation times and help to increase safe insertion of screws.

Pathological femoral neck fracture caused by an echinococcus cyst of the vastus lateralis--case report.

BACKGROUND: Musculoskeletal hydatid cysts are rare, but being locally invasive, can potentially cause significant deformity or pathological fracture. CASE PRESENTATION: A 39 y.o. male presented to our orthopaedic outpatient clinic complaining of severe right hip pain, and inability to ambulate. Symptoms were not preceded by trauma. Subsequent imaging confirmed a large, 17 × 3 × 5 cm echinococcus cyst in the vastus lateralis, causing erosion of the proximal metaphysis of the femur. As a consequence the patient suffered a non-traumatic pathological intertrochanteric femur fracture. The patient was treated with an en-bloc excision of the lesion - the affected soft tissue envelope containing the large cyst - and as a second surgical step a cemented total hip replacement (THR) was implanted under the same anaesthetic. The manuscript reviews the literature regarding musculoskeletal hydatid disease.

Biomechanical comparison of three cemented stem removal techniques in revision hip surgery.

BACKGROUND: There are various techniques available to remove a cemented femoral component and distal cement in the case of septic or aseptic loosening, periprosthetic or component fracture. The present study describes the mechanical effects of three techniques: the transfemoral approach (TFA), the distal fenestration technique (DF) and the retrograde stem removal technique (RSR). An experiment on cadaveric femora was performed to establish if there are any differences in the resistance to fracture in and between the various groups. METHODS: Twenty-two paired femora were recovered from human cadavers and were frozen. These were later subdivided into three groups to provide similar specimens in each group (TFA, DF, RSR). The femora were tested using an Instron 8874 biaxial testing system. The torque required to fracture was measured. Intra- and intergroup statistical analysis was performed. RESULTS: In the TFA group, the force required till fracture was significantly less than in controls. (p = 0.018). Similar results were found in the DF group (p = 0.048). There was no difference in the RSR group (p = 1). Intergroup analysis showed the following: Femora in the TFA group required significantly less force to fracture than specimens in the DF group (p = 0.018) or the RSR group (p = 0.0055). Femora in the DF group required significantly less force to fracture than specimens in the RSR (p = 0.037). CONCLUSIONS: The TFA technique decreases the mechanical resistance of human cadaveric femora very significantly against rotational forces. The DF technique in the same setup also significantly decreases the resistance of bone, whilst no significant change is seen with the RSR technique.

Successful treatment of late Salmonella infections in total hip replacement - report of two cases.

BACKGROUND: Salmonella species can be rarely isolated from periprosthetic joint infections, however when present, are usually part of a severe septic clinical picture. CASE PRESENTATIONS: Two patients presented with late infected hip replacements to our institution. The first patient with multiple comorbidities had a confirmed Salmonella Enteridis infection with an abscess in the groin, with loosening of both components. He underwent a successful one stage cemented revision hip replacement, followed by 6 weeks of antibiotic therapy (ciprofloxacin). He had no recurrence or complications. The second patient was admitted in a septic condition with ARDS to the Intensive Care Unit 7 years following an uncemented total hip replacement. From an ultrasound guided hip aspirate Salmonella cholerae-suis was isolated. He underwent a successful a two-stage revision hip replacement. CONCLUSIONS: Successful treatment of such potentially life threatening infections is achievable using modern orthopaedic techniques and close collaboration with the infectious diseases specialists.

Novel dynamic stabilization method for medial instability of the first metatarsophalangeal joint.

Medial collateral ligament injury of the first metatarsophalangeal (MTP) joint is rare. If it is missed, chronic instability and traumatic hallux valgus develop, requiring surgical treatment. Different methods have been reported in the limited available literature aiming to restore the balance between the lateral and medial stabilizers by tightening the medial joint capsule with or without additional tendon graft. Our described method utilizes a suture button device (Mini TightRope, Arthrex, Naples, Florida) for reconstruction. This device applies tension to hold the hallux in the correct position, providing stability. Relevant diagnostic regimen, surgical technique, and postoperative care are described, along with a case of a handball player who underwent this procedure. He continues to perform at the same level 38 months postoperatively. Mini TightRope fixation for chronic medial first MTP instability has not been reported. It does not require postoperative immobilization and allows faster return to sport, so it seems superior to other methods when treating athletes.

The DePuy Proxima™ short stem for total hip arthroplasty - Excellent outcome at a minimum of 7 years.

PURPOSE: Metaphyseal, proximally anchored uncemented stems for total hip arthroplasty provide bone preservation and decrease the incidence of proximal stress shielding and thigh pain. Our study investigated the clinical and radiological outcome of the DePuy Proxima™ short stem at a minimum of 7 years. METHODS: Eighty-one consecutive patients (86 procedures) under the age of 70 undergoing primary total hip replacement at two arthroplasty centres were enrolled. Follow-up was clinical (Harris Hip Score (HHS), thigh pain and satisfaction) and radiological (subsidence, malalignment and loosening) at 6 months and yearly thereafter. RESULTS: Average age was 50 (range 32-65) with 79% (68 of 86) being male. Preoperative diagnosis included primary osteoarthritis (OA) 36%, avascular necrosis of femoral head 51%, dysplasia 9% and post-traumatic OA 4%. HHS improved 51 points at latest follow-up (from 40 to 91). We had 3.5% (3 of 86) periprosthetic fractures, one requiring revision. We had one dislocation, no infections and no thigh pain. Malalignment rate (≥5° off neutral) was 12% (10 of 86), not affecting clinical results. CONCLUSION: Overall stem survival was over 97% at 7 years. The DePuy Proxima provides excellent clinical results at a minimum of 7 years post-operatively.

[Effect of tranexamic acid on blood loss and soft-tissue swelling following cemented total hip replacement]. / A tranexámsav vérvesztést és kis vérzéses szövodményeket befolyásoló hatása cementes csípoprotézis beültetése után.

INTRODUCTION: Tranexamic acid (TXA) is widely used during elective joint replacement to reduce blood loss and decrease the transfusion requirement. AIM: This study assessed the efficacy of tranexamic acid in reducing minor bleeding complications following primary cemented total hip replacement, when rivaroxaban is used as thromboprophylaxis, the complicated wound healing effect of which has been published recently. METHOD: Consecutive patients undergoing hip replacement were studied. Patients receiving tranexamic acid perioperatively between January 2014 and November 2014 were designated as the TXA-group. We compared these data with those of a group of patients who underwent the same procedure between February 2012 and December 2012 (control group), before the introduction of tranexamic acid. The authors investigated the effect of tranexamic acid on surgical wound bleeding and discharge, area of hematoma on the skin surface, thigh volume changes, calculated perioperative blood loss and transfusion requirement. RESULTS: 168 patients, 81 in the TXA-group and 87 in the control group were included. The extent of postoperative thigh swelling was significantly less in the TXA-group, 270.3 mL (129.1-449.0) as compared with the control group, 539.8 mL (350.0-864.8, p<0.001). Tranexamic acid significantly reduced wound bleeding during the first 24 hours postoperatively (p<0.001). The amount of calculated blood loss was significantly less in the TXA-group (1150 mL [780-1496] versus 1579 mL [1313-2074] in the control group, p<0.001). Transfusion requirement was remarkably lower in the TXA-group than in the control group (15% versus 39%). CONCLUSIONS: Tranexamic acid reduces postoperative thigh volume, wound bleeding and area of hematoma on the skin surface when rivaroxaban is used as the anticoagulant. Further large scale studies could help establish the clinical relevance and long-term outcome of minor bleeding complications. Orv Hetil. 2019; 160(12): 456-463.

A preoperative education class reduces length of stay for total knee replacement patients identified at risk of an extended length of stay.

OBJECTIVE: To establish whether attendance at an education class prior to total hip or knee replacement surgery as part of an enhanced recovery after surgery pathway could decrease length of hospital stay. METHODS: A single-site, retrospective cohort study comparing length of stay in hospital for patients who attended and did not attend an education class prior to hip or knee replacement surgery. Patients were stratified into 3 groups according to the predicted likelihood of an extended inpatient hospital stay using the Risk Assessment Predictor Tool. RESULTS: Mean length of stay reduced by 0.37 days for patients who received hip replacement (n = 590) (95% confidence interval (95% CI) -0.74, -0.01, p = 0.05) and by 0.77 days for patients who underwent knee replacement (n = 643) (95% CI -1.23, -0.31, p = 0.001) following attendance at a preoperative education class. Patients undergoing knee replacement who were considered at high risk of an extended hospital stay stayed, on average, 2.59 days less in hospital after attending the class (mean length of stay: 4.52 (standard deviation (SD) 1.26) vs 7.11 (SD 4.18) days (95% CI -4.62, -0.54, p < 0.02). CONCLUSION: This study supports the inclusion of a preoperative education session in this context for both hip and knee replacement procedures, and indicates that this may be most beneficial for patients undergoing knee replacement who are at risk of an extended length of stay.

Supporting shoulder rehabilitation - designing simple devices aiding physiotherapy.

The authors present simple devices which can facilitate and improve shoulder rehabilitation following various conditions. These commercially available and easily assembled functional aids improve patient experience and allow the bulk of the rehabilitation to take place in the patients' home environment.

The definition of polytrauma: variable interrater versus intrarater agreement--a prospective international study among trauma surgeons.

BACKGROUND: The international trauma community has recognized the lack of a validated consensus definition of "polytrauma." We hypothesized that using a subjective definition, trauma surgeons will not have substantial agreement; thus, an objective definition is needed. METHODS: A prospective observational study was conducted between December 2010 and June 2011 (John Hunter Hospital, Level I trauma center). Inclusion criteria were all trauma call patients with subsequent intensive care unit admission. The study was composed of four stages as follows: (1) four trauma surgeons assessed patients until 24 hours, then coded as either "yes" or "no" for polytrauma, and results compared for agreement; (2) eight trauma surgeons representing the United States, Germany, and the Netherlands graded the same prospectively assessed patients and coded as either "yes" or "no" for polytrauma; (3) 12 months later, the original four trauma surgeons repeated assessment via data sheets to test intrarater variability; and (4) individual subjective definitions were compared with three anatomic scores, namely, (a) Injury Severity Score (ISS) of greater than 15, (b) ISS of greater 17, and (c) Abbreviated Injury Scale (AIS) score of greater than 2 in at least two ISS body regions. RESULTS: A total of 52 trauma patients were included. Results for each stage were as follows: (1) κ score of 0.50, moderate agreement; (2) κ score of 0.41, moderate agreement; (3) Rater 1 had moderate intrarater agreement (κ score, 0.59), while Raters 2, 3, 4 had substantial intrarater agreement (κ scores, 0.75, 0.66, and 0.71, respectively); and (4) none had most agreement with ISS of greater than 15 (κ score, 0.16), while both definitions ISS greater than 17 and Abbreviated Injury Scale (AIS) score of greater than 2 in at least two ISS body regions had on average fair agreement (κ scores, 0.27 and 0.39, respectively). CONCLUSION: Based on subjective assessments, trauma surgeons do not agree on the definition of polytrauma, with the subjective definition differing both within and across institutions.

Tissue oxygen saturation changes during intramedullary nailing of lower-limb fractures.

BACKGROUND: The systemic complications of acute intramedullary nailing (IMN) in trauma patients are well known. There are no reliable methods available to predict these adverse outcomes. Noninvasive near-infrared spectroscopy (NIRS) allows measurement of oxygen saturation within muscle tissue (StO2) and quantification of the potential metabolic and microcirculatory effects of IMN in real time. The aim of this study was to characterize tissue oxygenation changes occurring during reamed IMN. METHODS: Patients undergoing reamed IMN for fixation of a tibia or femur fracture and patients having an open reduction and internal fixation of the ankle (to control for potential effects of anesthesia) had a noninvasive NIRS probe attached to the thenar eminence of the hand. Tissue oxygenation was monitored continuously throughout the operation and digitally recorded for later analysis. Vascular occlusion tests, an established technique with the NIRS device, were performed before canal opening and after nail insertion (at equivalent times in the control group), to establish the presence and nature of changes in systemic microcirculation occurring during the duration of the operation. RESULTS: Tissue oxygenation data were collected on 23 patients undergoing 26 IMN. (mean [SD] age, 36 [19] years; median Injury Severity Score [ISS], 9; interquartile range, 9-12). The control group consisted of 19 patients (mean [SD] age, 41 [18] years; ISS, 4). Remote muscle tissue desaturated significantly faster after IMN compared with the control operation (mean [SD] difference in IMN desaturation rate, 1.8% per minute [2.6% per minute]; mean [SD] difference in control group desaturation rate, -0.6% per minute [1.5% per minute]; p = 0.014). Near infrared-derived muscle oxygen consumption (NIR VO(2)) was significantly increased during the course of IMN compared with the control (mean [SD] difference in IMN NIR VO(2), 19.9 [32.1]; mean [SD] difference in control NIR VO(2), -4.2 [17.9]; p = 0.041). CONCLUSION: IMN causes significant remote microcirculatory changes. The responsiveness of the microcirculation could be a predictor of secondary organ dysfunction. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Acute transfusion practice during trauma resuscitation: who, when, where and why?

BACKGROUND: Early transfusion (ET=within 24h) has been shown to be required in approximately 5% of trauma patients. Critical care transfusion guidelines control transfusion triggers by evidence based cut-offs. Empirical guidelines influence decision making for ET in trauma. AIM: to describe the patterns, indications and timing of ET at level 1 trauma centre. METHODS: A 12-month prospective study was performed on all trauma admissions requiring ET. Demographics, mechanism, injury severity (ISS) were collected. Timing, location, volume, the clinician initiating first unit of transfusion, reason for transfusion was recorded, with corresponding blood gas results and physiological parameters. Mortality, ICU admission, length of stay, need for emergent surgery were outcomes. RESULTS: From 965 trauma admissions 91 (9%) required ET (76% male, median age: 38 (10-88, IQR: 22-59), blunt mechanism: 87%, ISS: 25 (4-66, IQR: 16-34). 43% (39/91) had massive transfusion protocol (MTP) activation. ET was initiated in ED (52%), OR (38%) or ICU (10%). MTP transfusions were started at a median of 0.5h (0.5-4, IQR: 0.5-1.5), whilst non-MTP transfusions were initiated at a median 3h (0.5-23, IQR: 2-9). The first unit of ET was initiated by trauma surgeon (35%), anaesthetist (30%), ED (19%), ICU (13%) and general surgeon (3%). Transfusions triggers at the first unit of transfusion were 'expected or ongoing bleeding' 29%, dropping haemoglobin 26%, haemorrhagic shock 24%, hypotension 10%, tachycardia 8%. Median systolic blood pressure was 90 (45-125, IQR: 80-100), heart rate was 100 (53-163, IQR: 80-120), haemoglobin was 96 (50-166, IQR: 85-114)g/l and base excess was -4.2(-22.1 to 2.7, IQR: -7.2 to 2.4)mmol/l at the time of transfusion. Emergency surgery was required in 86% (78/91). ICU admission rate was 69% (63/91). Mortality was 14%. Low volume transfusion (1-2 units) was more likely to lead to overtransfusion (Hb>110 g/l). CONCLUSION: The prospective evaluation of acutely transfused trauma patients showed a distinct pattern of transfusion triggers as the patient passes from ED to the OT and arrives to the ICU. The conventional transfusion trigger (haemoglobin level) is not appropriate in ET as early transfusion triggers are based on vital signs, blood gas results, injury patterns and anticipated major bleeding.

Epidemiology of acute transfusions in major orthopaedic trauma.

OBJECTIVES: The orthopaedic trauma-related blood product usage is largely unknown. Aim of this study was to describe the epidemiology of early (<24 hours of arrival) blood component use in major orthopaedic trauma. DESIGN: 12-month prospective observational study. SETTING: John Hunter Hospital, Level 1 Trauma Center, New South Wales, Australia. PATIENTS: 64 consecutive trauma admissions identified, who had an orthopaedic injury and required at least 1 unit of packed red blood cells (PRBC) <24 hours of arrival. INTERVENTION: Epidemiological study. MAIN OUTCOME MEASURES: Demographics, orthopaedic injury type, procedure type, injury severity score, timing, place of first unit of transfusion, and blood component volumes were collected. Activation of the massive transfusion protocol was recorded. Primary outcome measures were intensive care unit admission and mortality. RESULTS: From 965 major trauma admissions, 64 had one or more orthopaedic injuries and were transfused <24 hours. Forty-eight percent (31/64) required massive transfusion protocol activation. Average age was 41 ± 21 years, 73% (47/64) men. Eighty-four percent (54/64) required emergent orthopaedic intervention, 41% (22/54) having multiple procedures. Overall mortality was 13% (8/64). Twenty-five percent (16/64) required ≥10 units of PRBC. Average PRBC use was 7.2 ± 6.6 units and fresh frozen plasma use 4.3 ± 5.2 units. Thirty-nine percent (25/64) had a pelvic ring injury or acetabular fracture. Thirty-seven percent (24/64) had at least one femoral shaft fracture. Twenty patients had a total of 23 tibia fractures. CONCLUSIONS: Orthopaedic trauma patients consume the majority of the blood products <24 hours among blunt trauma patients. This resource-intensive group requires frequent urgent surgical interventions and intensive care unit admission. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Population-based epidemiology of femur shaft fractures.

BACKGROUND: The management of patients with femoral shaft fractures (FSFs) is often a decision making dilemma (damage-control orthopedics vs. early total care), with equivocal evidence. The comprehensive, population-based epidemiology of patients with FSF is unknown. The purpose of this prospective study was to describe the epidemiology of patients with FSF, with special focus on patient physiology and timing of surgery. METHODS: A 12-month prospective population-based study was performed on consecutive patients with FSF in an area with 850,000 population including all ages and prehospital deaths. Patient demographics, mechanism, Injury Severity Score (ISS), shock parameters (systolic blood pressure, base deficit and lactate), transfusion requirement, fracture type [Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association classification (OA/OTA)], comorbidities, procedures, and outcomes were recorded. Patients hemodynamic status was described as stable, borderline, unstable, and "in extremis." RESULTS: A total of 126 patients (21 per 100,000 per year) with 136 femur fractures (62% male; age, 38 [28] years; ISS, 20 [19]; 51% multiple injuries) were identified in the region. Sixty patients (48.4%) sustained a high-energy injury with 19 (31.1%) of these being polytrauma patients (ISS, 28 [12]; systolic blood pressure, 98 [39]; base deficit, 6.5 [5.8]; lactate 4 [2]).Fifteen polytrauma patients (94%) required massive transfusion (12 [12] U of packed red blood cells, 8 [5] fresh frozen plasma, 1 [0.4] platelet, 13 [8] cryoprecipitate). Twenty-one patients (16.7%) died at the prehospital setting (3.5 per 100,000 per year). From the 105 hospital admissions, 68.3% was stable (14.3 per 100,000 per year), 8.7% was borderline (1.8 per 100,000 per year), 4.0% was unstable (0.8 per 100,000 per year) and 2.4% (0.5 per 100,000 per year) was in extremis. Six patients (5.7%) died. The length of stay (LOS) was 18 (15) days, and the intensive care unit LOS was 5 (6) days. Fourty-five patients sustained a low-energy injury that had in 85% of cases multiple comorbidities. Eight low-energy patients needed 3 (1) transfusions, and none of the patients died. The LOS was 15 (11) days. CONCLUSION: Patients with low-energy FSF have a hospital admission rate similar to the patients with high-energy FSF. Sixty-eight percent of patients with FSF are complicated (open, compromised physiology, multiple injuries, bilateral, elderly with comorbidities, etc.), requiring major resources and highly specialized care. LEVEL OF EVIDENCE: Epidemiology study, level III.

Time to computed tomography scanning for major trauma patients: the Australian reality.

BACKGROUND: Computed tomography (CT) can facilitate the diagnosis of life-threatening injuries in polytrauma patients. Reported times to imaging vary widely, but it has been suggested that rapid whole body scanning improves mortality rates. The aim of this study was to determine the time to CT for severe polytrauma patients presenting to a level I trauma centre in Australia. METHODS: Retrospective audit of prospectively collected trauma registry data combined with electronic medical records. Inclusion criteria were trauma patients with injury severity score ≥16 who underwent CT scanning over a 12-month period. Exclusion criteria were scans performed at regional centres or greater than 5 h after arrival. Time to commencement of CT was defined as time from arrival to the first CT image being recorded, and time to completion of CT as the time from arrival to recording the final CT image. Time in CT was defined as minutes between acquisition of the first and final images. RESULTS: Two hundred thirty-three eligible patients were admitted over the study period. CT acquisition times were median 76 min (interquartile range (IQR) 52-115) to commencement, 93 min (IQR 71-129) to completion and time in CT 14 min (IQR 6-24). Time to completion was faster for isolated head scans, abbreviated injury scale head >3, intubated patients and those with subsequent fatal outcome. CONCLUSIONS: Although 93 min to completion of trauma CT scans is comparable with some international reports, it falls well behind centres who have demonstrated improved outcomes with CT scanning. Our results serve as a baseline to our and potentially other Australasian trauma centres to improve on this surrogate measure of trauma team efficacy.