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Venous thromboembolism (VTE) is a notable contributor to the morbidity and mortality of patients with orthopaedic trauma. Several associations have published guidelines on VTE prophylaxis, with a strong predilection toward low-molecular-weight heparin for chemoprophylaxis. However, previous recommendations may be revisited because recent high-level evidence demonstrated aspirin to be noninferior to low-molecular-weight heparin in preventing serious complications of VTE. Direct oral anticoagulants are emerging as safe alternatives to injectable medication and may offer improved patient compliance. There is no consensus on postinjury duration of chemoprophylaxis as an outpatient. Mechanical prophylaxis remains an important adjunctive VTE preventive measure for inpatients with pelvis and extremity fractures. Proteomics and novel laboratory measurements may be able to predict high-risk patients and detect early thrombus formation. Despite high-quality prospective research over the past decade, we still have much to learn about patient- and injury-specific risk factors.
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The immune system plays an integral role in the regulation of cellular processes responsible for fracture healing. Local and systemic influences on fracture healing correlate in many ways with fracture-related outcomes, including soft tissue healing quality and fracture union rates. Impaired soft tissue healing, restricted perfusion of a fracture site, and infection also in turn affect the immune response to fracture injury. Modern techniques used to investigate the relationship between immune system function and fracture healing include precision medicine, using vast quantities of data to interpret broad patterns of inflammatory response. Early data from the PRECISE trial have demonstrated distinct patterns of inflammatory response in polytrauma patients, which thereby directly and indirectly regulate the fracture healing response. The clearly demonstrated linkage between immune function and fracture healing suggests that modulation of immune function has significant potential as a therapeutic target that can be used to enhance fracture healing.
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OBJECTIVES: Isolated femoral shaft fractures can be treated preoperatively with skeletal traction (TXN) or maintenance of a position of comfort (COMF). The goal of this retrospective review was to determine whether preoperative opioid consumption differs significantly between these forms of treatment. DESIGN: Case-control retrospective study. SETTING: Two academic Level 1 trauma centers. PATIENT SELECTION CRITERIA: Patients presenting to the emergency department with isolated OTA/AO 32A-C femoral shaft fractures from 2017 to 2020. OUTCOME MEASURES AND COMPARISONS: The primary outcome was preoperative opioid consumption (morphine milligram equivalents) comparing patients treated with application of TXN or placed in a position of COMF. RESULTS: Two hundred and twenty patients were studied (COMF n = 167, TXN n = 53). Multivariate regression analysis revealed significantly greater preoperative opioid consumption in the emergency department for the TXN group compared with COMF (2.6 more morphine milligram equivalents [confidence interval, 0.23-4.96], P = 0.031). There was no difference in preoperative opioid consumption between groups on the hospital floor ( P = 0.811) nor during the entire preoperative course ( P = 0.486). The total preoperative rate of opioid consumption (morphine milligram equivalents/hour) did not differ ( P = 0.825). CONCLUSIONS: Patients with isolated femoral shaft fractures treated preoperatively with skeletal traction consumed more opioids in the emergency department compared with patients treated in a position of comfort, but no difference in opioid consumption was observed between groups for the entire preoperative course. A position of comfort may be considered as an acceptable alternative to skeletal traction for patients with isolated femur fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Analgésicos Opioides , Fracturas del Fémur , Tracción , Humanos , Tracción/métodos , Fracturas del Fémur/cirugía , Femenino , Masculino , Estudios Retrospectivos , Analgésicos Opioides/uso terapéutico , Analgésicos Opioides/administración & dosificación , Estudios de Casos y Controles , Persona de Mediana Edad , Adulto , Cuidados Preoperatorios/métodos , AncianoRESUMEN
OBJECTIVES: To determine whether the timing of acetabular fracture fixation through an anterior approach influences estimated and calculated perioperative blood loss. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center from 2013 to 2021. PATIENT SELECTION CRITERIA: Patients aged ≥18 years treated with acetabular fracture fixation through an anterior-based approach. OUTCOME MEASURES AND COMPARISONS: The primary outcome was calculated blood loss (CBL). Secondary outcomes were estimated blood loss reported by surgeon and anesthesia, and blood transfusion requirements. Comparisons of blood loss were made at discrete postinjury time thresholds (24, 36, and 48 hours) and on a continuous basis. RESULTS: One hundred eight patients were studied. The mean age was 65 years, and 73% of patients were male. Earlier fixation of acetabular fractures resulted in greater CBL and estimated blood loss (surgeon and anesthesia) compared with later fixation when analyzed on a continuum and at specific time points (24, 36, and 48 hours). Mean CBL in patients treated earlier (<48 hours, 2539 ± 1194 mL) was significantly greater than those treated later (≥48 hours, 1625 ± 909 mL; P < 0.001). Fracture repair before 48 hours postinjury was associated with a 3 times greater risk of >2000 mL of CBL ( P = 0.006). This did not result in differences in transfusion rates between groups at 24 hours ( P = 0.518), 36 hours ( P = 1.000), or 48 hours ( P = 0.779). CONCLUSIONS: Delaying fixation of acetabular fractures treated through an anterior approach for 48 hours postinjury may significantly reduce perioperative blood loss. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Fracturas Óseas , Fracturas de Cadera , Fracturas de la Columna Vertebral , Humanos , Masculino , Adolescente , Adulto , Anciano , Femenino , Pérdida de Sangre Quirúrgica/prevención & control , Acetábulo/cirugía , Acetábulo/lesiones , Estudios Retrospectivos , Resultado del Tratamiento , Fracturas Óseas/terapia , Fracturas de Cadera/complicaciones , Fracturas de la Columna Vertebral/complicaciones , Fijación Interna de Fracturas/efectos adversos , Fijación Interna de Fracturas/métodosRESUMEN
OBJECTIVE: To determine whether intrawound vancomycin changes the bacteriology of surgical site infection pathogens and investigate the emergence of antibiotic-resistant pathogens. DESIGN: Secondary analysis of phase III, prospective, randomized clinical trial. SETTING: Thirty-six US trauma centers. PATIENT SELECTION CRITERIA: Patients who became infected after fixation of tibial plateau or pilon fracture. OUTCOME MEASURES AND COMPARISONS: Pathogen types and bacterial susceptibilities as determined from routine clinical culture in the operating room. RESULTS: Seventy-four patients were studied who were 67.5% male with a mean age of 48.6 years. A lower proportion of gram-positive cocci was observed in the vancomycin powder compared with the standard-of-care group (3.7% vs. 8.0%, P = 0.01). Methicillin-resistant Staphylococcus aureus infection incidence was comparable in both the vancomycin powder and the standard-of-care groups, but rates of methicillin-susceptible S. aureus infections were lower in the treatment group (1.4% vs. 4.8%, P = 0.01). The incidence of coagulase-negative Staphylococci and gram-negative rod infections were similar in both groups. There was no significant difference in susceptibilities between groups in rates of vancomycin-resistant enterococcus. CONCLUSIONS: Topical vancomycin powder decreases the likelihood of gram-positive infections consistent with the biologic activity of vancomycin. Fewer methicillin-susceptible S. aureus and coagulase-negative Staphylococci infections were observed in the group treated with vancomycin powder. An effect of vancomycin powder on methicillin-resistant S. aureus infection risk was not detected given the low incidence in both the intrawound vancomycin and the standard-of-care groups. There was no emergence of gram-negative rod infections or increased resistance patterns observed. Use of topical vancomycin powder does not seem to produce infections in these patients with greater antibiotic resistance than would have occurred without its use. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Bacteriología , Staphylococcus aureus Resistente a Meticilina , Infecciones Estafilocócicas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Antibacterianos , Coagulasa/farmacología , Coagulasa/uso terapéutico , Meticilina/farmacología , Meticilina/uso terapéutico , Polvos/farmacología , Estudios Prospectivos , Infecciones Estafilocócicas/microbiología , Staphylococcus aureus , Infección de la Herida Quirúrgica/tratamiento farmacológico , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/prevención & control , VancomicinaRESUMEN
BACKGROUND: Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture). METHODS: In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications. RESULTS: A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups. CONCLUSIONS: Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).
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Antiinfecciosos Locales , Clorhexidina , Fijación de Fractura , Fracturas Óseas , Yodo , Infección de la Herida Quirúrgica , Humanos , 2-Propanol/administración & dosificación , 2-Propanol/efectos adversos , 2-Propanol/uso terapéutico , Antiinfecciosos Locales/administración & dosificación , Antiinfecciosos Locales/efectos adversos , Antiinfecciosos Locales/uso terapéutico , Antisepsia/métodos , Canadá , Clorhexidina/administración & dosificación , Clorhexidina/efectos adversos , Clorhexidina/uso terapéutico , Etanol , Extremidades/lesiones , Extremidades/microbiología , Extremidades/cirugía , Yodo/administración & dosificación , Yodo/efectos adversos , Yodo/uso terapéutico , Cuidados Preoperatorios/efectos adversos , Cuidados Preoperatorios/métodos , Piel/microbiología , Infección de la Herida Quirúrgica/etiología , Infección de la Herida Quirúrgica/prevención & control , Fracturas Óseas/cirugía , Estudios Cruzados , Estados UnidosRESUMEN
BACKGROUND: The PREVENT CLOT trial concluded that thromboprophylaxis with aspirin was noninferior to low-molecular-weight heparin (LMWH) in preventing death after orthopedic trauma. However, it was unclear if these results applied to patients at highest risk of thrombosis. Therefore, we assessed if the effect of aspirin versus LMWH differed based on patients' baseline risk of venous thromboembolism (VTE). METHODS: The PREVENT CLOT trial enrolled 12,211 adult patients with fractures. This secondary analysis stratified the study population into VTE risk quartiles: low (<1%) to high (>10%) using the Caprini score. We assessed stratum-specific treatment effects using the win ratio method, in which each patient assigned to aspirin was paired with each assigned to LMWH. In each pair, we compared outcomes hierarchically, starting with death, then pulmonary embolism, deep vein thrombosis, and bleeding. The secondary outcome added patients' medication satisfaction as a fifth composite component. RESULTS: In the high-risk quartile (n = 3052), 80% had femur fracture, pelvic, or acetabular fractures. Thoracic (47%) and head (37%) injuries were also common. In the low risk quartile (n = 3053), most patients had a tibia fracture (67%), 5% had a thoracic injury, and less than 1% had head or spinal injuries. Among high risk patients, thromboembolic events did not differ statistically between aspirin and LMWH (win ratio, 0.94; 95% confidence interval [CI], 0.82-1.08, p = 0.42). This result was consistent in the low (win ratio, 1.15; 95% CI, 0.90-1.47, p = 0.27), low-medium (win ratio, 1.05; 95% CI, 0.85-1.29, p = 0.68), and medium-high risk quartiles (win ratio, 0.94; 95% CI, 0.80-1.11, p = 0.48). When medication satisfaction was considered, favorable outcomes were 68% more likely with aspirin (win ratio, 1.68; 95% CI, 1.60-1.77; p < 0.001). CONCLUSION: Thromboembolic outcomes were similar with aspirin or LMWH, even among patients at highest risk of VTE. Aspirin was favored if medication satisfaction was also considered. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.
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Embolia Pulmonar , Tromboembolia Venosa , Adulto , Humanos , Heparina de Bajo-Peso-Molecular/uso terapéutico , Anticoagulantes/uso terapéutico , Aspirina/uso terapéutico , Tromboembolia Venosa/etiología , Tromboembolia Venosa/prevención & control , Hemorragia/tratamiento farmacológico , Embolia Pulmonar/etiología , Embolia Pulmonar/prevención & control , Embolia Pulmonar/tratamiento farmacológico , Heparina/uso terapéuticoRESUMEN
OBJECTIVE: To quantify work impairment and economic losses due to lost employment, lost work time (absenteeism), and lost productivity while working (presenteeism) after a lateral compression pelvic ring fracture. Secondarily, productivity loss of patients treated with surgical fixation versus nonoperative management was compared. DESIGN: Secondary analysis of a prospective, multicenter trial. SETTING: Two level I academic trauma centers. PATIENT SELECTION CRITERIA: Adult patients with a lateral compression pelvic fracture (OTA/AO 61-B1/B2) with a complete posterior pelvic ring fracture and less than 10 mm of initial displacement. Excluded were patients who were not working or non-ambulatory before their pelvis fracture or who had a concomitant spinal cord injury. OUTCOME MEASURES AND COMPARISONS: Work impairment, including hours lost to unemployment, absenteeism, and presenteeism, measured by Work Productivity and Activity Impairment assessments in the year after injury. Results after non-operative and operative treatment were compared. RESULTS: Of the 64 included patients, forty-seven percent (30/64) were treated with surgical fixation, and 53% (30/64) with nonoperative management. 63% returned to work within 1 year of injury. Workers lost an average of 67% of a 2080-hour average work year, corresponding with $56,276 in lost economic productivity. Of the 1395 total hours lost, 87% was due to unemployment, 3% to absenteeism, and 10% to presenteeism. Surgical fixation was associated with 27% fewer lost hours (1155 vs. 1583, P = 0.005) and prevented $17,266 in average lost economic productivity per patient compared with nonoperative management. CONCLUSIONS: Lateral compression pelvic fractures are associated with a substantial economic impact on patients and society. Surgical fixation reduces work impairment and the corresponding economic burden. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Fracturas Óseas , Fracturas por Compresión , Huesos Pélvicos , Adulto , Humanos , Estudios Prospectivos , Fracturas Óseas/complicaciones , Fracturas Óseas/cirugía , Huesos Pélvicos/lesiones , Pelvis , EmpleoRESUMEN
Objectives: Patient engagement in the design and implementation of clinical trials is necessary to ensure that the research is relevant and responsive to patients. The PREP-IT trials, which include 2 pragmatic trials that evaluate different surgical preparation solutions in orthopaedic trauma patients, followed the patient-centered outcomes research (PCOR) methodology throughout the design, implementation, and conduct. We conducted a substudy within the PREP-IT trials to explore participants' experiences with trial participation. Methods: At the final follow-up visit (12 months after their fracture), patients participating in the PREP-IT trials were invited to participate in the substudy. After providing informed consent, participants completed a questionnaire that asked about their experience and satisfaction with participating in the PREP-IT trials. Descriptive statistics are used to report the findings. Results: Four hundred two participants participated in the substudy. Most participants (394 [98%]) reported a positive experience, and 376 (94%) participants felt their contributions were appreciated. The primary reasons for participation were helping future patients with fracture (279 [69%]) and to contribute to science (223 [56%]). Two hundred seventeen (46%) participants indicated that their decision to participate was influenced by the minimal time commitment. Conclusions: Most participants reported a positive experience with participating in the PREP-IT trials. Altruism was the largest motivator for participating in this research. Approximately half of the participants indicated that the pragmatic, low-participant burden design of the trial influenced their decision to participate. Meaningful patient engagement, a pragmatic, and low-burden protocol led to high levels of participant satisfaction.
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OBJECTIVES: To evaluate the rate of reoperation in patients without sagittal plane malalignment who underwent percutaneous screw fixation of a valgus-impacted femoral neck fracture. DESIGN: Retrospective case series. SETTING: Two Level 1 academic trauma centers. PATIENTS AND INTERVENTION: Two hundred seven patients >50 years of age with valgus-impacted femoral neck fractures treated with at least 3 large-diameter (>6.5 mm) cancellous screws from 2013 to 2019. Patients were excluded if there was a sagittal plane fracture deformity. MAIN OUTCOME MEASUREMENTS: The primary outcome was reoperation. Secondary outcomes considered "major complications" included: avascular necrosis, varus collapse or implant cutout, nonunion, deep infection, and hematoma requiring reoperation. Surgical fixation strategies (screw configuration, aim) and implant type (partial vs. fully threaded cancellous screws) were secondarily compared. RESULTS: Average patient age was 77 years, and median clinical follow-up was 658 days. Thirty-one patients (15%) required reoperation, and the major complication rate was 17.3% (36 complications in 33 patients). Logistic regression analysis demonstrated a higher risk of reoperation with constructs consisting of all partially threaded screws (17.0%) compared with the use of at least 1 fully threaded screw (7.5%) when an inverted triangle configuration was used (odds ratio, 2.50; 95% CI, 0.81-7.77). CONCLUSIONS: This study demonstrated a relatively high rate of reoperation and major complications in patients with valgus-impacted femoral neck fractures without sagittal malalignment treated with in situ percutaneous screw fixation. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Fracturas del Cuello Femoral , Fijación Interna de Fracturas , Humanos , Anciano , Estudios Retrospectivos , Fijación Interna de Fracturas/efectos adversos , Fracturas del Cuello Femoral/cirugía , Tornillos Óseos/efectos adversos , Reoperación , Resultado del TratamientoRESUMEN
Intramedullary nailing (IMN) of periarticular distal tibia fractures may offer advantages compared to plating. This study aims to report on the outcomes of select periarticular distal tibia fractures treated with IMN. Patients over 17 years of age that underwent IMN for extraarticular distal tibia fractures (Osteosynthesefragen/Orthopaedic Trauma Association [AO/OTA] 43-A), partial articular with associated segmental shaft component (43-B), and simple intraarticular (43-C1/2) at a Level I trauma center were included. The primary outcome was physical function (PF) and pain interference (PI) assessed via Patient-Reported Outcomes Measurement Information System (PROMIS). Secondary outcomes included reoperation, nonunion, infection, and malalignment. Eighty-four patients with > 12 months follow up were included. Mean PROMIS PI and PF scores were 55.5 and 45.0, respectively. The rate of nonunion and deep infection each were 8%. Eighty-four percent of patients achieved normal alignment. There were no differences detected in clinical outcomes between patients with intraarticular injuries compared with those with extraarticular fractures. Satisfactory clinical, radiographic, and patient-reported outcomes can be expected following treatment of extraarticular and simple intraarticular distal tibia fractures with IMN. (Journal of Surgical Orthopaedic Advances 32(4):246-251, 2023).
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Fracturas de Tobillo , Fijación Intramedular de Fracturas , Fracturas de la Tibia , Humanos , Tibia/cirugía , Curación de Fractura , Fracturas de la Tibia/cirugía , Fijación Interna de Fracturas , Resultado del Tratamiento , Estudios Retrospectivos , Clavos OrtopédicosRESUMEN
Background: At the initiation of the COVID-19 pandemic, restrictions forced researchers to decide whether to continue their ongoing clinical trials. The PREPARE (Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities) trial is a pragmatic cluster-randomized crossover trial in patients with open and closed fractures. PREPARE was enrolling over 200 participants per month at the initiation of the pandemic. We aim to describe how the COVID-19 research restrictions affected participant enrollment. Methods: The PREPARE protocol permitted telephone consent, however, sites were obtaining consent in-person. To continue enrollment after the initiation of the restrictions participating sites obtained ethics approval for telephone consent scripts and the waiver of a signature on the consent form. We recorded the number of sites that switched to telephone consent, paused enrollment, and the length of the pause. We used t-tests to compare the differences in monthly enrollment between July 2019 and November 2020. Results: All 19 sites quickly implement telephone consent. Fourteen out of nineteen (73.6%) sites paused enrollment due to COVID-19 restrictions. The median length of enrollment pause was 46.5 days (range, 7-121 days; interquartile range, 61 days). The months immediately following the implementation of restrictions had significantly lower enrollment. Conclusion: A pragmatic design allowed sites to quickly adapt their procedures for obtaining informed consent via telephone and allowed for minimal interruptions to enrollment during the pandemic.
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Background: With a rising number of periprosthetic femur fractures (PPFFs) each year, the primary objective of our study was to quantify risk factors that predict complications following operative treatment of PPFFs. Methods: A retrospective cohort study of 231 patients with a periprosthetic femur fracture was conducted at an Academic, Level 1 Trauma Center. The main outcome measurement of interest was complications, as defined by the ACS-NSQIP, within 30 days of surgery. Results: 56 patients had 96 complications. Bivariate analyses revealed ASA score, preoperative ambulatory status, length of stay, discharge disposition, time from admission to surgery, length of surgery, perioperative change in hemoglobin, Charlson comorbidity index, cerebral vascular accident/transient ischemic attack, chronic obstructive pulmonary disease, diabetes mellitus, and receipt of a blood transfusion were associated with development of a complication (p < 0.1). Multivariate logistic regression showed length of stay (OR 1.11, 95% CI 1.03-1.19; p = 0.006), receipt of a blood transfusion (OR 2.48, 95% CI 1.14-5.42; p = 0.02), and diabetes mellitus (OR 2.17, 95% CI 1.03-4.56; p = 0.04) remained independently predictive of complication. Conclusions: Length of stay, receipt of a blood transfusion, and diabetes were associated with increased perioperative risk for developing a complication following operative treatment of periprosthetic femur fractures. Methods to decrease length of stay or transfusion rates may mitigate complication risk in these patients. Level of Evidence: Prognostic, Level III.
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OBJECTIVES: To compare retrograde intramedullary nail (RIMN) and open reduction internal fixation (ORIF) in very distal periprosthetic distal femur fractures (PDFFs) to determine whether RIMN is an acceptable option for these fractures that are often considered too distal for IMN due to limited bone stock. DESIGN: Retrospective comparative series. SETTING: Level 1 trauma center. PATIENTS: Patients were treated with fracture fixation for a very distal PDFF, defined as the fracture extending to the anterior flange of the implant or distal. Fifty-six patients met inclusion criteria, with 8 excluded for less than 12 months of follow-up. INTERVENTION: The intervention involved fracture fixation with RIMN or ORIF. MAIN OUTCOME MEASUREMENTS: The primary outcome was unplanned return to surgery. Secondary outcomes included fracture union, radiographic alignment, visual analog score, and Patient-Reported Outcome Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference. RESULTS: The mean follow-up period was 27 months. Twelve patients were treated with ORIF and 36 with RIMN. Twenty-one fractures were at the flange, and 27 extended distal to the flange. There were no differences between fixation methods for reoperation, deep infection, nonunion, malunion, visual analog score pain score, and PROMIS Pain Interference score. The mean PROMIS PF score was higher in the RIMN group compared with that in the ORIF group. There were 5 reoperations in the RIMN group (14%) and 3 in the ORIF group (25%). CONCLUSIONS: This is the largest series, to the best of our knowledge, of a subset of very distal PDFFs. The results suggest that RIMN may be an acceptable treatment option for these very difficult fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Fracturas del Fémur , Fracturas Periprotésicas , Placas Óseas , Fracturas del Fémur/diagnóstico por imagen , Fracturas del Fémur/cirugía , Fémur , Fijación Interna de Fracturas/métodos , Humanos , Reducción Abierta/métodos , Dolor , Fracturas Periprotésicas/diagnóstico por imagen , Fracturas Periprotésicas/cirugía , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
SUMMARY: Optimal timing and procedure selection that define staged treatment strategies can affect outcomes dramatically and remain an area of major debate in the treatment of multiply injured orthopaedic trauma patients. Decisions regarding timing and choice of orthopaedic procedure(s) are currently based on the physiologic condition of the patient, resource availability, and the expected magnitude of the intervention. Surgical decision-making algorithms rarely rely on precision-type data that account for demographics, magnitude of injury, and the physiologic/immunologic response to injury on a patient-specific basis. This study is a multicenter prospective investigation that will work toward developing a precision medicine approach to managing multiply injured patients by incorporating patient-specific indices that quantify (1) mechanical tissue damage volume; (2) cumulative hypoperfusion; (3) immunologic response; and (4) demographics. These indices will formulate a precision injury signature, unique to each patient, which will be explored for correspondence to outcomes and response to surgical interventions. The impact of the timing and magnitude of initial and staged surgical interventions on patient-specific physiologic and immunologic responses will be evaluated and described. The primary goal of the study will be the development of data-driven models that will inform clinical decision-making tools that can be used to predict outcomes and guide intervention decisions.
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Traumatismo Múltiple , Procedimientos Ortopédicos , Ortopedia , Humanos , Traumatismo Múltiple/cirugía , Medicina de Precisión , Estudios ProspectivosRESUMEN
In this article we report data collected to evaluate the pathomechanistic effect of acute anaerobic metabolism in the polytraumatized patient and its subsequent effect on fracture nonunion; see "Base Deficit ≥6 within 24 Hours of Injury is a Risk Factor for Fracture Nonunion in the Polytraumatized Patient" (Sardesai et al., 2021) [1]. Data was collected on patients age ≥16 with an Injury Severity Score (ISS) >16 that presented between 2013-2018 who sustained a fracture of the tibia or femur distal to the femoral neck. Patients presenting to our institution greater than 24 hours post-injury and those with less than three months follow-up were excluded. Medical charts were reviewed to collect patient demographic information and known nonunion risk-factors, including smoking, alcohol use, and diabetes. In addition, detailed injury characteristics to quantify injury magnitude including ISS, Glasgow Coma Scale (GCS) at admission, and ICU length of stay were recorded. ISS values were obtained from our institutional trauma database where they are entered by individuals trained in ISS calculations. Associated fracture-related features including fracture location, soft-tissue injury (open vs. closed fracture), vascular injury, and compartment syndrome were recorded. Finally, vital signs, base deficit (BD), and blood transfusions over 24 hours from admission were recorded. We routinely measure BD and less consistently measure serum lactate in trauma patients at the time of presentation or during resuscitation. BD values are automatically produced by our laboratory with any arterial blood gas order, and we recorded BD values from the medical record. Clinical notes and radiographs were reviewed to confirm fracture union versus nonunion and assess for deep infection at the fracture site. Patients were categorized as having a deep infection if they were treated operatively for the infection prior to fracture healing or classification as a nonunion. Nonunion was defined by failure of progressive healing on sequential radiographs and/or surgical treatment for nonunion repair at least six months post-injury.
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OBJECTIVE: To compare the early pain and functional outcomes of operative fixation versus nonoperative management for minimally displaced complete lateral compression (LC; OTA/AO 61-B1/B2) pelvic fractures. DESIGN: Prospective clinical trial. SETTING: Two academic trauma centers. PATIENTS: Forty-eight adult patients with LC pelvic ring injuries with <10 mm of displacement were treated nonoperatively and 47 with surgical fixation. Sixty percent of participants were randomized. Seventy-three percent of the fractures were displaced <5 mm, and 71% were LC-1 patterns. INTERVENTION: Operative fixation versus nonoperative management. MAIN OUTCOME MEASUREMENTS: The primary outcome was patient-reported pain using the 10-point Brief Pain Inventory. Functional outcome was measured using the Majeed pelvic score. Outcomes were analyzed using hierarchical Bayesian models to compare the average treatment effect from injury to 12 and 52 weeks postinjury. The probability of the mean treatment benefit exceeding a clinically important difference was determined. RESULTS: The 3-month average treatment effect of surgery compared with nonoperative management was a 1.2-point reduction in pain [95% credible interval (CrI): 0.4-1.9] and an 8% absolute improvement in the Majeed score (95% CrI: 3%-14%). Similar results persisted to 1 year. Patients with initial fracture displacement ≥5 mm experienced a larger reduction in pain (2.2, 95% CrI: 0.9-3.5) compared with those patients with less initial displacement (0.9, 95% CrI: 0.1-1.8). CONCLUSION: On average, surgical fixation likely provides a small improvement in pain and functional outcome for up to 12 months. Patients with ≥5 mm of posterior pelvic ring displacement are more likely to experience clinically important improvements in pain. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Fracturas Óseas , Fracturas por Compresión , Adulto , Teorema de Bayes , Fijación Interna de Fracturas , Fracturas Óseas/cirugía , Humanos , Pelvis , Estudios Prospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Polytrauma patients are at risk for fracture nonunion, but the reasons are poorly understood. Increased base deficit (BD) is associated with hypovolemic shock. Although shock delays bone healing in animal models, there have been no clinical studies evaluating the impact of BD on nonunion risk. MATERIALS AND METHODS: Patients age ≥ 16 with injury severity score > 16 that presented to an academic Level One trauma center with an operative femur or tibia fracture were reviewed. Clinical notes and radiographs were assessed to determine fracture healing status. Patient demographics, injury characteristics, BD, and number of packed red blood cell transfusions were recorded. Bivariate and multivariate analyses of multiple risk factors associated with nonunion were conducted to investigate the association of BD with nonunion. RESULTS: The union group was comprised of 243 fractures; there were 36 fractures in the nonunion group. The following predictors were associated with nonunion: smoking (p = 0.009), alcohol use (p < 0.001), open fracture (p < 0.001), and treatment for deep infection at fracture site (p = 0.016). Additionally, worst BD over 24 h ≥ 6 (p = 0.031) was significant for nonunion development. A multivariate logistic regression analysis revealed worst BD ≥6 over 24 h remained significantly associated with the development of nonunion (odds ratio 3.02, p = 0.011) when adjusting for other risk factors. CONCLUSIONS: A BD ≥ 6 within 24 h of admission was associated with a significantly increased risk of developing lower extremity fracture nonunion in polytrauma patients, even after adjusting for multiple other risk factors. Acute post-traumatic acidosis may have effects on long-term fracture healing.
Asunto(s)
Fracturas no Consolidadas , Fracturas de la Tibia , Curación de Fractura , Fracturas no Consolidadas/diagnóstico por imagen , Humanos , Estudios Retrospectivos , Factores de Riesgo , Fracturas de la Tibia/complicaciones , Fracturas de la Tibia/diagnóstico por imagen , Fracturas de la Tibia/cirugía , Resultado del TratamientoRESUMEN
Recent studies suggest advantages to intramedullary nailing (IMN) of extra-articular proximal tibia fractures compared to plating. To our knowledge, no studies have evaluated IMN treatment of proximal tibia fractures with simple articular extension. We sought to compare rate of reoperation, malalignment, and patient-reported outcomes in patients with intra-articular versus extra-articular proximal tibia fractures treated via IMN. This retrospective cohort study compared patients that underwent IMN of extra-articular proximal tibia fractures (AO/OTA 41A2 and A3; n = 33) to simple intra-articular fractures (AO/OTA 41C1 and C2; n = 20) with minimum 12-month follow-up. With the numbers available, no significant differences were detected between the extra- and intra-articular groups for unplanned reoperation (9/33 vs. 2/20, p = 0.18), infection (4/33 vs. 1/20, p = 0.64), nonunion (4/33 vs. 2/20, p > 0.99), or malunion (5/30 vs. 3/19, p > 0.99). IMN of simple intra-articular proximal tibial fractures is a reasonable treatment strategy that may be desirable in certain clinical situations. (Journal of Surgical Orthopaedic Advances 30(1):055-060, 2021).
Asunto(s)
Fijación Intramedular de Fracturas , Fracturas de la Tibia , Clavos Ortopédicos , Placas Óseas , Curación de Fractura , Humanos , Estudios Retrospectivos , Tibia , Fracturas de la Tibia/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND: Trauma elicits a complex inflammatory response that, among multiple presenting factors, is greatly impacted by the magnitude of injury severity. Herein, we compared the changes in circulating levels of mediators with known proinflammatory roles to those with known protective/reparative actions as a function of injury severity in injured humans. METHODS: Clinical and biobank data were obtained from 472 (trauma database-1 (TD-1), University of Pittsburgh) and 89 (trauma database-2 (TD-2), Indiana University) trauma patients admitted to the intensive care unit (ICU) and who survived to discharge. Injury severity was estimated based on the Injury Severity Score (ISS), and this was used as both a continuous variable and for the purpose of grouping patients into severity-based cohorts. Samples within the first 24 hours were obtained from all patients and then daily up to day 7 postinjury in TD-1. Sixteen cytokines were assayed using Luminex and were analyzed using two-way analysis of variance (p<0.05). RESULTS: Patients with higher ISSs had longer ICU and hospital stays, days on mechanical ventilation and higher rates of nosocomial infection when compared with the mild and moderate groups. Time course analysis and correlations with ISS showed that 11 inflammatory mediators correlated positively with injury severity, consistent with previous reports. However, five mediators (interleukin (IL)-9, IL-21, IL-22, IL-23 and IL-17E/25) were suppressed in patients with high ISS and inversely correlated with ISS. DISCUSSION: These findings suggest that severe injury is associated with a suppression of a subset of cytokines known to be involved in tissue protection and regeneration (IL-9, IL-22 and IL-17E/25) and lymphocyte differentiation (IL-21 and IL-23), which in turn correlates with adverse clinical outcomes. Thus, patterns of proinflammatory versus protective/reparative mediators diverge with increasing ISS.