Acetabular Peri-Prosthetic Fractures-A Narrative Review.

Acetabular peri-prosthetic fractures are rare but their incidence is rising due to the increased prevalence of total hip arthroplasty, the increasing life expectancy and the growing functional demand of an ageing population, the incidence of primary total hip arthroplasty is increasing. They are either intra-operative or post-operative and have various aetiologies. Several factors such as implant stability, bone loss, remaining bone stock, fracture pattern, timing, age and co-morbidities of the patients must be considered for adequate treatment. To date, the literature on this subject has been sparse and no universally recognized treatment algorithm exists. Their rarity makes them a little-known entity and their surgical management represents a challenge for most orthopaedic surgeons. This review aims to present an update on epidemiology, the diagnostic work up, existing classification systems, surgical approaches and therapeutic options for acetabular peri-prosthetic fractures.

Operatively treated ankle fractures in Switzerland, 2002-2012: epidemiology and associations between baseline characteristics and fracture types.

BACKGROUND: Ankle fractures are common, and their incidence has been increasing. Previous epidemiological studies have been conducted in the US, Scandinavia, and Scotland. Our objectives were to provide a current epidemiological overview of operatively treated ankle fractures and to evaluate the influence of age, sex, lifestyle factors, and comorbidities on fracture types. METHODS: We performed a population-based epidemiological study of all ankle fractures treated operatively in a 10- year period from 2002 to 2012. RESULTS: Two thousand forty-five ankle fractures were operated upon. Men and women differed significantly in age (median 41 vs. 57 years old), obesity (16% vs. 23%), diabetes (5% vs. 10%), smoking (45% vs. 24%), and accident type (daily activities 48% vs. 79%, transportation 24% vs. 9%, sports 21% vs. 8%) respectively. Overall, there were 2% Weber A, 77% Weber B, and 21% Weber C fractures; 54% were uni-, 25% bi-, and 21% trimalleolar; 7.5% of all fractures were open. Weber C fractures were much more frequent among men and with higher BMI (lowest vs. highest category: 14% vs. 32%), but slightly less frequent with older age and among current smokers. Trimalleolar fractures were twice as frequent in women and increased with age. CONCLUSION: Men and women differed substantially in age, lifestyle factors, comorbidities, accident type, and type of ankle fracture. Male sex and higher BMI were more frequently associated with Weber C fractures, whereas female sex and older age were associated with trimalleolar fracture. The risk for severe fracture increased linearly with the degree of obesity.

Incidence rate and topography of intra-pelvic arterial lesions associated with high-energy blunt pelvic ring injuries: a retrospective cohort study.

BACKGROUND: The aim of this study was to determine the rate and topography of intra-pelvic arterial lesions associated with high-energy blunt pelvic ring injuries (PRI). METHODS: This retrospective cohort study was conducted in a level I trauma center serving 500,000 inhabitants. A total of 127 consecutive patients with high-energy blunt PRI were included between January 1st, 2014 and December 31st, 2017. Every patient had a total body or thoraco-abdominal computed tomography scan including contrast enhanced arterial sequences. A board-certified radiologist reviewed all the vascular images and precisely described every intra-pelvic arterial lesion in terms of localization. Complete pelvic series (standard radiographs and fine cut computed tomography images) were reviewed by three board-certified orthopedic surgeons experienced in PRI management, and Young and Burgess and AO/OTA classifications were determined. Demographic, clinical, therapeutic and outcome data were extracted from the institutional severely injured patients' registry. RESULTS: Patients' mean age was 45.3 years and 58.3% were males. Fifteen (11.8%) had a total of 21 intra-pelvic arterial lesions: seven lesions of the obturator artery, four of the superior gluteal artery, three of the inferior gluteal artery, two of the vesical artery, and one of each of the following arteries: internal iliac, internal pudendal, fifth lumbar, lateral sacral, ilio-lumbar. These lesions occurred in 8.6% of lateral compression injuries, 33.3% of anteroposterior compression injuries and 23.5% of vertical shear and combined mechanism injuries (Young and Burgess classification, p = 0.003); and in 0% of type A injuries, 9.9% of type B injuries and 35% of type C injuries (AO/OTA classification, p = 0.001). Patients with an intra-pelvic arterial lesion were more likely to present with pre-hospital hemodynamic instability (p = 0.046) and to need packed red blood cells transfusion within the first 24 h (p = 0.023; they needed a mean of 7.53 units vs. 1.88, p = 0.0016); however, they did not have a worst outcome in terms of complications or mortality. CONCLUSIONS: This systematic study found an 11.8% rate of intra-pelvic arterial lesion related to high-energy blunt PRI. The obturator, superior gluteal and inferior gluteal arteries were most often injured. These findings are important for the aggressive management of high-energy blunt PRI.

Clinical and radiographic predictors of acute compartment syndrome in the treatment of tibial shaft fractures: a retrospective cohort study.

BACKGROUND: The purpose of this study was to evaluate the association between epidemiological, clinical and radiographic factors of patients with tibial shaft fractures and the occurrence of acute compartment syndrome. METHODS: 270 consecutive adult patients sustaining 273 tibial shaft fractures between January 2005 and December 2009 were included in this retrospective cohort study. The outcome measure was acute compartment syndrome. Patient-related (age, sex), fracture-related (high- vs. low-energy injury, isolated trauma vs. polytrauma, closed vs. open fracture) and radiological parameters (AO/OTA classification, presence or absence of a noncontiguous tibial plateau or pilon fracture, distance from the centre of the tibial fracture to the talar dome, distance between tibial and fibular fracture if associated, and angulation, translation and over-riding of main tibial fragments) were evaluated regarding their potential association with acute compartment syndrome. Univariate analysis was performed and each covariate was adjusted for age and sex. Finally, a multivariable logistic regression model was built, and odds ratios and 95% confidence intervals were obtained. Statistical significance was defined as p < 0.05. RESULTS: Acute compartment syndrome developed in 31 (11.4%) cases. In the multivariable regression model, four covariates remained statistically significantly associated with acute compartment syndrome: polytrauma, closed fracture, associated tibial plateau or pilon fracture and distance from the centre of the tibial fracture to the talar dome ≥15 cm. CONCLUSIONS: One radiological parameter related to the occurrence of acute compartment syndrome has been highlighted in this study, namely a longer distance from the centre of the tibial fracture to the talar dome, meaning a more proximal fracture. This observation may be useful when clinical findings are difficult to assess (doubtful clinical signs, obtunded, sedated or intubated patients). However, larger studies are mandatory to confirm and refine the prediction of acute compartment syndrome occurrence. Radiographic signs of significant displacement were not found to be correlated to acute compartment syndrome development. Finally, the higher rate of acute compartment syndrome occurring in tibial shaft fractures associated to other musculoskeletal, thoraco-abdominal or cranio-cerebral injuries must raise the level of suspicion of any surgeon managing multiply injured patients.

A case report depicting patient's installation on the fracture table when an ankle spanning external fixator is already in place.

BACKGROUND: Fractures of the proximal and diaphyseal femur are frequently internally fixed using a fracture table. Moreover, some femoral neck fractures may be treated with total hip arthroplasty using a direct anterior approach and a traction table. Fracture and traction tables both use a boot tightly fitted to the patient's foot in order to: 1) obtain fracture reduction by traction and adequate rotation exerted on the slightly abducted or adducted extremity; or 2) adequately expose the hip joint using traction, rotation and extension to implant total hip arthroplasty components. In some instances, multiply injured patients may present with both a proximal or diaphyseal femur fracture and a diaphyseal or distal tibia or ankle fracture necessitating an ankle spanning external fixator on the same limb. Frequently, the tibia or ankle fracture has to be treated first, and standard use of the fracture or traction table may be thereafter difficult due to the external fixator construct preventing tight fitting of the boot to the patient's foot. CASE PRESENTATION: In order to address this situation, the authors describe a simple technique allowing rigid fixation of the limb with an ankle spanning external fixator to the traction or fracture table, providing accurate control of the position of the lower limb in all planes for adequate fracture reduction and fixation or total hip arthroplasty. The technique is exemplified with a clinical case. CONCLUSIONS: This technique allows an efficient way to: 1) timely stabilize diaphyseal or distal tibia or ankle fractures; and 2) subsequently use all the advantages of a fracture or traction table to adequately reduce and fix proximal or diaphyseal femur fractures, or optimally expose femoral neck fractures for total hip arthroplasty using a direct anterior approach.

Radiation exposure using the O-arm® surgical imaging system.

PURPOSE: This study was conducted to characterise the O-arm® surgical imaging system in terms of patient organ doses and medical staff occupational exposure during three-dimensional thoracic spine and pelvic examinations. METHODS: An anthropomorphic phantom was used to evaluate absorbed organ doses during a three-dimensional thoracic spine scan and a three-dimensional pelvic scan with the O-arm®. Staff occupational exposure was evaluated by constructing an ambient dose cartography of the operating theatre during a three-dimensional pelvic scan as well as using an anthropomorphic phantom to simulate the O-arm® operator. RESULTS: Patient organ doses ranged from 30 ± 4 µGy to 20.0 ± 3.0 mGy and 4 ± 1 µGy to 6.7 ± 1.0 mGy for a three-dimensional thoracic spine and pelvic examination, respectively. For a single three-dimensional acquisition, the maximum ambient equivalent dose at 2 m from the iso-centre was 11 ± 1 µSv. CONCLUSION: Doses delivered to the patient during a three-dimensional thoracic spine image acquisition were found to be significant with the O-arm®, but lower than those observed with a standard computed tomography examination. The detailed dose cartography allows for the optimisation of medical staff positioning within the operating theatre while imaging with the O-arm®.

Clinical and radiographic predictors of acute compartment syndrome in the treatment of tibial plateau fractures: a retrospective cohort study.

BACKGROUND: The aim of the study was to evaluate the relation between demographic, injury-related, clinical and radiological factors of patients with tibial plateau fractures and the development of acute compartment syndrome. METHODS: All consecutive adult patients with intra-articular tibial plateau fractures admitted in our urban academic medical centre between January 2005 and December 2009 were included in this retrospective cohort study. The main outcome measurement was the development of acute compartment syndrome. RESULTS: The charts of 265 patients (mean age 48.6 years) sustaining 269 intra-articular tibial plateau fractures were retrospectively reviewed. Acute compartment syndrome occurred in 28 fractures (10.4%). Four patients presented bilateral tibial plateau fractures; of them, 2 had unilateral, but none had bilateral acute compartment syndrome. Non-contiguous tibia fracture or knee dislocation and higher AO/OTA classification (type 41-C) were statistically significantly associated with the development of acute compartment syndrome in multivariable regression analysis, while younger age (<45 years), male sex, higher Schatzker grade (IV-V-VI), higher tibial widening ratio (≥1.05) and higher femoral displacement ratio (≥0.08) were significantly associated in the analysis adjusted for age and sex. CONCLUSIONS: Two parameters related to the occurrence of ACS in tibial plateau fractures were highlighted in this study: the presence of a non-contiguous tibia fracture or knee dislocation, and higher AO/OTA classification. They may be especially useful when clinical findings are difficult to assess (doubtful clinical signs, obtunded, sedated or intubated patients), and should rise the suspicion level of the treating surgeon. In these cases, regular clinical examinations and/or intra-compartmental pressure measurements should be performed before and after surgery, even if acute compartment syndrome seemed unlikely during initial assessment. However, larger studies are mandatory to confirm and refine both factors in predicting the occurrence of acute compartment syndrome.

Primary open anterior shoulder stabilization: a long-term, retrospective cohort study on the impact of subscapularis muscle alterations on recurrence.

BACKGROUND: Post-traumatic anterior shoulder instability patients may present histopathologic lesions within the subscapularis muscle compatible with a scarring process associated with disuse atrophy. We hypothesized that such lesions identified on intraoperative biopsy at the time of primary anterior shoulder stabilization would predict a higher risk of postoperative instability recurrence. METHODS: Of 52 eligible patients (52 shoulders) who had undergone subscapularis muscle biopsy during primary anterior open labral repair and capsulorrhaphy, 35 (mean age at surgery, 27.2 years; male sex, 71.4%) were retrospectively evaluated (mean follow-up, 12.9 years; range, 10.9-14.5 years). Primary outcome was shoulder instability recurrence. Secondary outcomes included shoulder range of motion, functional scores, and radiological analysis of glenohumeral joint degenerative changes. RESULTS: Overall five patients (14.3%) presented shoulder instability recurrence. Twelve patients with histopathologic lesions had significantly more instability recurrence than 23 without histopathologic changes (33.3% vs. 4.3%; risk difference, 29% [95% CI 1; 57]; p = 0.038). Patients without histopathologic changes had significantly reduced external rotation with arm at side (ER1; -11.9°; p = 0.001) and with shoulder abducted to 90° (ER2; -14.9°; p = 0.001) on the operated side when compared to the contralateral side. Patients with histopathologic lesions had only ER2 significantly reduced (-8.9°; p = 0.031). There was no substantial difference regarding functional and quantitative radiological scores between both patients' groups. CONCLUSIONS: Histopathologic changes within the subscapularis muscle at the time of primary open labral repair and capsulorrhaphy were associated with an increased risk of shoulder instability recurrence. Further investigations are needed to assess the impact of dedicated postoperative rehabilitation programs for patients presenting these lesions. Their recognition on preoperative magnetic resonance imaging should also be investigated; non-anatomical repairs could be an option in these cases.

Pathogen-driven decision for implant retention in the management of infected total knee prostheses.

PURPOSE: In prosthetic joint infections (PJIs) of the knee, debridement with implant retention is associated with a high risk of recurrence. METHODS: A single-centre cohort study was performed with extensive analysis of the literature covering 1980-2012. RESULTS: In 21 patients (mean age 80.4 years, 19 immunosuppressed), in association with 1.5-three months of antibiotic treatment, an attempt was made to salvage the prosthesis by open (11 patients) or arthroscopic (ten patients) debridement. After a mean follow-up of seven years (range four-20 years), patients were in remission in seven cases (33 %). Remission was achieved in 0 % of all methicillin-resistant Staphylococcus aureus (MRSA) infections (zero/three), in 0 % (zero/three) of methicillin-resistant coagulase-negative staphylococcal infections, in 29 % (two/seven) of methicillin-sensitive S. aureus infections and in 75 % (three/four) of infections due to streptococci. The literature review focused on implant preserving approaches yielded 599 cases with an overall success rate of 47 % (284/599) and significantly more remissions in streptococcal vs staphylococcal knee PJIs (43/54 vs 144/324; p < 0.01, odds ratio 4.9, 95 % confidence interval 2.4-10.9). CONCLUSIONS: In addition to established indications for explantation such as implant loosening, sinus tract or methicillin resistance, the decision for debridement and retention of knee PJIs should also depend on the pathogen. Implant preservation is futile with methicillin-resistant staphylococci, but seems to be a valid option for streptococcal PJIs.

No need for broad-spectrum empirical antibiotic coverage after surgical drainage of orthopaedic implant infections.

PURPOSE: Empirical broad-spectrum antibiotic treatment for orthopaedic implant infections after surgical lavage is common practice while awaiting microbiological results, but lacks evidence. METHODS: This was a single-centre cohort study from 1996 to 2010 with a follow-up of two years. RESULTS: We retrieved 342 implant infections and followed them up for a median of 3.5 years (61 recurred, 18%). Infected implants were arthroplasties (n = 186), different plates, nails or other osteosyntheses. The main pathogens were S. aureus (163, 49 methicillin-resistant) and coagulase-negative staphylococci (60, 45 methicillin-resistant). Median duration of empirical antibiotic coverage after surgical drainage was three days before switching to targeted therapy. Vancomycin was the most frequent initial empirical agent (147), followed by intravenous co-amoxiclav (44). Most empirical antibiotic regimens (269, 79%) proved sensitive to the causative pathogen, but were too broad in 111 episodes (32%). Cephalosporins and penicillins were used only in 44 and ten cases, respectively, although they would have covered 59% of causative pathogens identified later. Multivariate Cox regression analysis showed that neither susceptible antibiotic coverage (compared to non-susceptible; hazard ratio 0.7, 95% confidence interval 0.4-1.2) nor broad-spectrum use (hazard ratio 1.1, 0.8-1.5) changed remission rates. CONCLUSIONS: Provided that surgical drainage is performed, broad-spectrum antibiotic coverage does not enhance remission of orthopaedic implant infections during the first three days. If empirical agents are prescribed from the first day of infection, narrow-spectrum penicillins or cephalosporins can be considered to avoid unnecessary broad-spectrum antibiotic use.

Clinical and radiological risk factors associated with the occurrence of acute compartment syndrome in tibial fractures: a systematic review of the literature.

Introduction: Acute compartment syndrome (ACS) is an orthopedic emergency that may lead to devastating sequelae. Diagnosis may be difficult. The aim of this systematic review is to identify clinical and radiological risk factors for ACS occurrence in tibial fractures. Methods: PubMed® database was searched in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Additional articles were found by a manual research of selected references and authors' known articles. Results: The identification process individualized 2758 via database and 30 via other methods. After screening and eligibility assessment, 29 articles were included. Age, gender, occupation, comorbidities, medications, habits, polytrauma, multiple injuries, mechanism, sports, site, open vs closed, contiguous lesion, classification, and pattern were found to be related to ACS occurrence. Conclusions: Younger age and male gender are strong independent risk factors in tibial plateau and shaft fractures. High-energy fractures, polytrauma, more proximal fractures and fractures with contiguous skeletal lesions are aggravating risk factors; higher AO/OTA and Schatzker classification types, increased displacement of the tibia relative to the femur, and increased tibial joint surface width are associated risk factors in tibial plateau fractures; higher AO Foundation/Orthopaedic Trauma Association classification types and subgroups and more proximal fractures within the diaphysis are associated risk factors in tibial shaft fracture. Open fractures do not prevent ACS occurrence. Increased fracture length is the only factor suggesting a higher risk of ACS in tibial pilon fractures. The presence of each independent predictor may have a cumulative effect increasing the risk of ACS occurrence.

Epidemiology of high-energy blunt pelvic ring injuries: A three-year retrospective case series in a level-I trauma center.

BACKGROUND: High-energy pelvic ring injuries (PRI) represent a heavy burden for institutions treating severely injured patients. Epidemiological data knowledge may help to provide them appropriate management. Only two epidemiologic studies about high-energy PRI were published during last decade. This study aimed to determine the gender-specific and global incidences of high-energy blunt AO/OTA type B or C PRI and their frequency among high-energy blunt trauma. It further reports the spectrum of these injuries and compares their characteristics and outcomes to high-energy blunt trauma without type B or C PRI. HYPOTHESIS: Type B or C PRI incidence isn't gender specific and approximates 5/100,000/year. PATIENTS AND METHODS: A prospective database of a level-I trauma center serving approximately 500,000 inhabitants was retrospectively queried for all high-energy trauma patients injured between 01.01.2014 and 12.31.2016. Inclusion criteria were: alive emergency department delivery; entire acute treatment at the authors' institution; age >16. Exclusion criteria were: penetrating, blast, burn and electrical injuries; drownings; low-energy trauma; patients living outside the institution's catchment area. Three authors performed PRI classifications. Clinical data were extracted from the database. RESULTS: We analyzed 434 patients. High-energy blunt type B or C PRI incidence was 3.8/100,000/year without gender disparity (p=0.6697). High-energy blunt trauma incidence was lower in women than in men (20.5 vs. 51.6/100,000/year, p<0.001). Type B or C PRI frequency during high-energy blunt trauma was higher in women than in men (17.6% vs. 7.9%, p=0.003). Type B or C PRI patients were more severely injured and needed more treatment resources than other high-energy blunt trauma patients but didn't present higher complication or death rates. DISCUSSION: The incidence of high-energy blunt type B or C PRI was comparable to previously published data. Women were less likely to sustain a high-energy blunt trauma, but when they sustained one, they were more likely to have a type B or C PRI. Despite higher injury severity score and resource requirements, complication and death rates weren't different between type B or C PRI patients and other high-energy blunt trauma patients. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

High-energy blunt pelvic ring injury incidence and polytrauma caseload in a single level I trauma center during COVID-19 related pseudo-lockdown measures: a retrospective cohort study based on a prospective registry.

BACKGROUND: Pelvic ring injuries are potentially lethal lesions associated with polytrauma patients and need an efficient trauma team for their management. The purpose of this study was to evaluate the incidence of high-energy blunt pelvic ring injuries and the absolute number of polytrauma patients in a single level I trauma center during the 2020 pseudo-lockdown period related to the Coronavirus pandemic, and to compare it with corresponding periods in 2014-2019 in order to better understand the need of organized and dedicated personnel and infrastructures. METHODS: This retrospective cohort study was based on data prospectively recorded into the institutional Severely Injured Patients' Registry. Data were obtained for each year period (January 1st to December 31st) and corresponding pseudo-lockdown period (March 16th to June 19th). High-energy blunt pelvic ring injuries inclusion criteria were: (1) Registry entry between January 1st, 2014 and December 31st, 2020; (2) age ≥ 16 years old; and (3) pelvic ring injury presence. Corresponding exclusion criteria were: (1) death before admission; (2) transfer from another institution > 24 h after trauma; (3) penetrating, blast, burn and electrical injuries, drownings; (4) patients living outside the defined institution's catchment area; and (5) any document attesting the patient's will to not participate in any study. Polytrauma patients inclusion criteria were: (1) Registry entry between January 1st, 2014 and December 31st, 2020; (2) age ≥ 16 years old; and (3) Injury Severity Score ≥ 16. Corresponding exclusion criteria were: (1) death before admission; (2) transfer from another institution > 24 h after trauma; and (3) any document attesting the patient's will to not participate in any study. Categorical variables were reported using proportions and continuous variables using medians and interquartile ranges. Because data were exhaustive for the authors' level I trauma center, no inferential statistics were computed. RESULTS: The incidence of high-energy blunt pelvic ring injuries and the absolute number of polytrauma patients remained within range of previous years despite pseudo-lockdown measures. CONCLUSIONS: These observations bring better knowledge about pseudo-lockdown's impact on trauma and may help for future health strategy planning by pointing out the importance of maintaining the activity of level I trauma centers in terms of personnel and infrastructures.

Postfasciotomy Classification System for Acute Compartment Syndrome of the Leg.

OBJECTIVE: Acute compartment syndrome (ACS) is a true emergency. Even with urgent fasciotomy, there is often muscle damage and need for further surgery. Although ACS is not uncommon, no validated classification system exists to aid in efficient and clear communication. The aim of this study was to establish and validate a classification system for the consequences of ACS treated with fasciotomy. METHODS: Using a modified Delphi method, an international panel of ACS experts was assembled to establish a grading scheme for the disease and then validate the classification system. The goal was to articulate discrete grades of ACS related to fasciotomy findings and associated costs. A pilot analysis was used to determine questions that were clear to the respondents. Discussion of this analysis resulted in another round of cases used for 24 other raters. The 24 individuals implemented the classification system 2 separate times to compare outcomes for 32 clinical cases. The accuracy and reproducibility of the classification system were subsequently calculated based on the providers' responses. RESULTS: The Fleiss Kappa of all raters was at 0.711, showing a strong agreement between the 24 raters. Secondary validation was performed for paired 276 raters and correlation was tested using the Kendall coefficient. The median correlation coefficient was 0.855. All 276 pairs had statistically significant correlation. Correlation coefficient between the first and second rating sessions was strong with the median pair scoring at 0.867. All surgeons had statistically significant internal consistency. CONCLUSION: This new ACS classification system may be applied to better understand the impact of ACS on patient outcomes and economic costs for leg ACS.

Chronic osteomyelitis.

Chronic osteomyelitis is a multifaceted bacterial infection with common features. It absolutely requires surgery for remission. The duration and form of concomitant administration of antibiotic agents for adult patients is still based on expert opinion. The traditional recommendation of 6-12 weeks of antibiotic therapy, where, for at least the first 2-6 weeks, antibiotics should be administered intravenously, is more and more challenged in favor of an oral antibiotic treatment with selected agents from the start. There is no evidence that the total duration of antibiotic therapy for more than 4-6 weeks improves outcome, when compared with shorter regimens. Hopefully, the future will show randomized trials in the adult population, allowing optimal timing of surgical and medical therapy and sparing of unnecessary prescription, with concomitant development of antibiotic resistance. External advice from an expert team with combined surgeons and infectious disease physicians may help to reduce antibiotic consumption in a cost-effective way.

Conditions found among pediatric survivors during the early response to natural disaster: a prospective case study.

BACKGROUND: Major natural disasters may provoke a mass casualty situation, and children tend to represent an important proportion of the victims. The purpose of this study was to prospectively record medical conditions presented by pediatric survivors of a major natural disaster to determine the type of medical specialists most needed during the acute phase of relief response. METHODS: After the 2010 Haiti earthquake, age, sex, date of presentation, diagnosis, and treatment provided were prospectively recorded for all patients less than 18 years old treated by a medical relief team. Patients were then allocated to 1 of the 2 groups: surgical (traumatism or surgical disorder) and medical (medical disorder). Medical activity lasted for 43 days. RESULTS: Four hundred seventy-one of the 796 treated patients were less than 18 years old. Two hundred forty-four (52%) were assigned to the surgical group and 227 (48%) to the medical group. As there was a substantial decrease in the number of new surgical patients registered on day 11 of activity, we arbitrarily defined an early period (until day 10 of activity) and a late period (beginning on day 11 of activity). Data obtained from the 147 new patients registered during the early period revealed 134 (91%) surgical patients and 13 (9%) medical patients. Eighty-eight percent of patients needed specialized care for traumatic orthopaedic lesions, and procedures under anesthesia or sedation were mainly (98%) performed for traumatic conditions. Data obtained for the 324 new patients registered during the late period revealed 110 (34%) surgical patients and 214 (66%) medical patients. There was a switch from high surgical needs to more routine medical and surgical care, with less procedures (88%) for the treatment of traumatic lesions. CONCLUSIONS: Pediatric orthopaedic surgeons have a major role to play in the acute phase of relief response to potentially minimize long-term physical and psychosocial disability associated with these complex injuries in growing patients. LEVEL OF EVIDENCE: Economic or decision analyses, level II.

Management of high-energy blunt pelvic ring injuries: A retrospective cohort study evaluating an institutional protocol.

INTRODUCTION: High-energy blunt pelvic ring injuries with hemodynamic instability are complicated by a high mortality rate (up to 32%). There is no consensus on the best management strategy for these injuries. The aim of this study was to evaluate the high-energy blunt pelvic ring injury management protocol implemented in the authors' institution. PATIENTS AND METHODS: This retrospective cohort study was performed in an academic level I trauma center. The institutional protocol incorporates urgent pelvic mechanical stabilization of hemodynamically unstable patients not responding to a pelvic belt, fluids, and transfusions. If hemodynamic instability persists, angiography ± embolization is performed. Adult patients sustaining a high-energy blunt pelvic ring injury between 2014.01.01 and 2019.12.31 were included in the study. The primary outcome was mortality at 1, 2, 30 and 60 days. The secondary outcomes were the number of packed red blood cell units transfused during the first 24 h, intensive care unit stay, and total hospitalization length of stay. RESULTS: 192 high-energy blunt pelvic ring injury patients were analyzed. Of these, 71 (37%) were hemodynamically unstable, and 121 (63%) were stable. The overall in-hospital mortality of the hemodynamically unstable and stable groups was 20/71 (28.2%) and 4/121 (3.3%) respectively (p<0.001). Cumulative mortality rates for hemodynamically unstable patients were 15.5% at day 1, 16.9% at day 2, 26.8% at day 30 and 28.2% at day 60, and for hemodynamically stable patients, rates were 0% at day 1 and 2, 2.5% at day 30 and 3.3% at day 60. Unstable patients required a higher number of packed red blood cell units than stable patients during the first 24 h (5.1 vs. 0.1; p<0.001). Intensive care unit length of stay and total hospitalization duration was 11.25 and 37.4 days for unstable patients and 1.9 and 20.9 days for stable patients (p<0.001). CONCLUSIONS: For both hemodynamically unstable and stable patients, the institutional protocol showed favorable mortality rates when compared to available literature. Comparative studies are needed to determine the management strategies with the best clinical outcome and survival.

High-energy blunt pelvic ring injury: dataset of patients and injury characteristics from a severely injured patients' registry.

Since mid-2013, data on high-energy trauma patients admitted to the Emergency Department of the University Hospitals of Geneva, Switzerland, are prospectively recorded in a dedicated registry. This includes data on patients with high-energy blunt pelvic ring injuries (PRI), defined as closed fracture of the pelvic ring following falls from a height >1 m, road traffic accidents, sport, crush, farm and industrial injuries. The registry was screened for patients aged ≥16 years with high-energy blunt PRI admitted to the aforementioned academic level I trauma center between 2014.01.01 et 2019.12.31, to assess the outcome of the institutional PRI management protocol. Data on 195 patients were collected and analyzed for this purpose [1]. The dataset "patients' demographic and injury characteristics" provides the raw demographics and Abbreviated Injury Scale (AIS) of these 195 patients. These data can contribute to the knowledge of patients' demographics and injury characteristics of high-energy blunt PRI patients.

Association between open tibia fractures and acute compartment syndrome: A retrospective cohort study.

BACKGROUND: Studies on the association of open tibia fractures and acute compartment syndrome (ACS) show confusing results, with some papers highlighting a positive association, and others failing to do so. The aim of this study was to determine if an open tibia fracture is at increased risk of ACS occurrence, when compared to a closed fracture. HYPOTHESIS: Skin injury in the setting of an open tibia fracture does not prevent from ACS occurrence, because the energy transmitted to the limb during trauma may lead to soft tissue lesions, including skin lacerations and ACS. PATIENTS AND METHODS: In total, 711 consecutive adult patients (mean age 44.6 years; 65.8% males) sustaining 725 tibia fractures between 01.01.2005 and 31.12.2009 were included in this retrospective study. The outcome measure was ACS. The following variables were assessed: soft tissue condition, age, sex, low- vs. high-energy injury, type of fracture, associated contiguous skeletal injury. A logistic regression model was used and adjustment was performed for age and sex. RESULTS: ACS occurred in 10.4% of proximal intra-articular fractures, 10.4% of extra-articular fractures and 3.3% of distal intra-articular fractures, and in 8.7% of closed fractures, 7.8% of open Gustilo 1 fractures and 13.3% of open Gustilo 2 and 3 fractures. Open lesions were not associated with ACS when tibia fractures were considered as a whole. When stratifying by types of fractures, open Gustilo 2 and 3 lesions were associated with ACS in proximal intra-articular fractures (p=0.048). There was no association with closed or any type of open lesions for extra-articular fractures. There were not enough ACS cases among distal intra-articular fractures to draw conclusions. DISCUSSION: As ACS may occur with any type of open tibia fractures, clinicians should not be wrongly reassured by an open fracture, assuming that the wound would relieve the pressure inside the muscle compartments. There is a weak association between open Gustilo 2 and 3 lesions and ACS in proximal intra-articular fractures only. These findings are important for surgeons treating these injuries, especially by intubated, sedated or obtunded patients. LEVEL OF EVIDENCE: III; retrospective diagnostic study.

The Intraseptal Course of the Superficial Peroneal Nerve: An Anatomic Study.

BACKGROUND: Anatomic and clinical studies show many variants of the superficial peroneal nerve (SPN) course and branching within the compartments and at the suprafascial layer. The anatomy of the transition zone from the compartment to the subcutaneous layer has been occasionally described in the literature, mainly in studies reporting the intraseptal SPN variant in 6.6% to 13.6% of patients affected by the SPN entrapment syndrome. Despite the little evidence available, the knowledge of the transition zone is relevant to avoid iatrogenic lesions to the SPN during fasciotomy, open approaches to the leg and ankle, and SPN decompression. Our anatomic study aimed to describe the SPN transition site and to evaluate the occurrence of a peroneal tunnel and of an intraseptal SPN variant. METHODS: According to the institutional ethics committee requirements, 15 fresh-frozen lower limbs were dissected to study the SPN course and its branching, focusing on the transition site to the suprafascial layer. RESULTS: The SPN was located in the anterior compartment in 2 cases and in the lateral in 13. An intraseptal tunnel was present in 10 legs (66%), at a mean distance of 10.67 cm from the lateral malleolus. Its mean length was 2.63 cm. The tunnel allowed the passage of the main SPN in 8 cases and of its branches in two. In the remaining 5 legs (33%), the SPN pierced a crural fascia window. CONCLUSION: In our sample a higher rate than expected of intraseptal SPN variants was found. CLINICAL RELEVANCE: The knowledge of the anatomy of the SPN course and intraseptal variant is relevant to avoid iatrogenic lesions during operative dissection. Further studies are needed to evaluate the effective prevalence of an intraseptal tunnel, independently from the SPN entrapment syndrome, and how to avoid associated iatrogenic complications.