Accuracy Analysis of 3D Bone Fracture Models: Effects of Computed Tomography (CT) Imaging and Image Segmentation.

The introduction of three-dimensional (3D) printed anatomical models has garnered interest in pre-operative planning, especially in orthopedic and trauma surgery. Identifying potential error sources and quantifying their effect on the model dimensional accuracy are crucial for the applicability and reliability of such models. In this study, twenty radii were extracted from anatomic forearm specimens and subjected to osteotomy to simulate a defined fracture of the distal radius (Colles' fracture). Various factors, including two different computed tomography (CT) technologies (energy-integrating detector (EID) and photon-counting detector (PCD)), four different CT scanners, two scan protocols (i.e., routine and high dosage), two different scan orientations, as well as two segmentation algorithms were considered to determine their effect on 3D model accuracy. Ground truth was established using 3D reconstructions of surface scans of the physical specimens. Results indicated that all investigated variables significantly impacted the 3D model accuracy (p < 0.001). However, the mean absolute deviation fell within the range of 0.03 ± 0.20 to 0.32 ± 0.23 mm, well below the 0.5 mm threshold necessary for pre-operative planning. Intra- and inter-operator variability demonstrated fair to excellent agreement for 3D model accuracy, with an intra-class correlation (ICC) of 0.43 to 0.92. This systematic investigation displayed dimensional deviations in the magnitude of sub-voxel imaging resolution for all variables. Major pitfalls included missed or overestimated bone regions during the segmentation process, necessitating additional manual editing of 3D models. In conclusion, this study demonstrates that 3D bone fracture models can be obtained with clinical routine scanners and scan protocols, utilizing a simple global segmentation threshold, thereby providing an accurate and reliable tool for pre-operative planning.

The Epidemiological Transition of Surgically Treated Proximal Hip Fractures in Austria over the Course of the Pandemic-Back to Normal or a New Normal?

BACKGROUND: The COVID-19 pandemic has had a significant impact on the treatment protocols of orthopedic and trauma departments, but its specific effect on the mortality of hip fracture patients due to possible delays in surgery remains uncertain. This study aimed to investigate whether the COVID-19 pandemic worsened the mortality of patients with hip fractures. MATERIALS AND METHODS: This study included 246 prospectively enrolled patients who suffered from hip fractures during the Austrian State of Emergency period between 1 March and 30 June 2020 and 2021 and were admitted to a tertiary care trauma center. This cohort was compared with a retrospective control group of 494 patients admitted for hip fractures during the same timeframe in 2017, 2018, and 2019. These groups were compared to a prospective recruited "post-COVID-19 collective consisting of the years 2022 and 2023 including 313 patients. RESULTS: This study found a 22% reduction in admissions during the COVID-19 period compared to the pre-COVID period (p = 0.018), as well as significant changes in gender (p = 0.013) and place of accident (p = 0.049). No other changes in demographic variables were observed. The 30-day mortality rate was 14.67% in the pre-COVID period, compared to 15.18% during the COVID-19 period (p = 0.381). No differences were observed in surgical complication rates or in the relationship between comorbidity burden and survival. CONCLUSION: This study did not show a higher perioperative mortality rate due to COVID-19. However, under current circumstances, with potentially reduced surgical and hospital bed capacities, it is expected that this condition might require a high degree of resources in times when resources are potentially scarce, such as during an ongoing pandemic. LEVEL OF EVIDENCE: Level III.

Predictive Validity of Mortality after Surgically Treated Proximal Femur Fractures Based on Four Nutrition Scores-A Retrospective Data Analysis.

BACKGROUND: Hip fractures are becoming a growing concern due to an aging population. The high costs to the healthcare system and far-reaching consequences for those affected, including a loss of independence and increased mortality rates, make this issue important. Poor nutritional status is a common problem among geriatric patients and is associated with a worse prognosis. Nutritional screening tools can help identify high-risk patients and enable individualized care to improve survival rates. MATERIAL AND METHODS: This retrospective study investigates four nutritional scores and laboratory parameters' predictive significance concerning postoperative mortality after surgical treatment of proximal femur fractures at 1, 3, 6, and 12 month/s for patients over 60 years using the chi-square test, Cox regression analysis, and receiver operating characteristics (ROC). The European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines were used as part of the screening of the respective nutritional status of the patients, in particular to filter out malnutrition. RESULTS: A total of 1080 patients were included in this study, whereas 8.05% suffered from malnutrition, defined as a body mass index (BMI) below 18.5 kg/m2. The Mini Nutritional Assessment (MNA) screening tool identified the highest proportion of malnourished patients at 14.54%. A total of 36.39% of patients were at risk of malnutrition according to three nutrition scores, with MNA providing the most significant proportion at 41.20%. Patients identified as malnourished had a higher mortality rate, and MNA screening was the only tool to show a significant correlation with postoperative mortality in all survey intervals. The MNA presented the best predictive significance among the screening tools, with a maximum area under the curve (AUC) of 0.7 at 12 month postoperatively. CONCLUSIONS: MNA screening has a solid correlation and predictive significance regarding postoperative mortality-therefore routine implementation of this screening in orthopedic/traumatology wards is recommended. Moreover, nutritional substitution therapy can offer a relatively inexpensive and easy-to-implement measure. The Graz malnutrition screening (GMS) shows moderate predictive power and could be considered as an alternative for patients under 60 years of age. A higher albumin level is associated with improved survival probability, but cannot be indicative of nutritional status.

Feasibility of aluminum phantom radiography for osteoporosis detection in postmenopausal women with a fragility fracture of the distal radius compared to DXA and HR-pQCT.

Recently, promising results have been reported for detection of osteoporosis with use of an aluminum phantom. Therefore, the aim of this study was to evaluate the feasibility of radiography-based bone mineral density (BMD) measurement using a graded aluminum phantom. This study included 27 postmenopausal women with a distal radius fracture. Aluminum phantom radiography of the healthy radius was conducted as well as high-resolution peripheral quantitative computed tomography (HR-pQCT) measurement of the ultradistal radius and dual energy X-ray absorptiometry (DXA) of the radius, spine, and hip. A strong correlation was observed between aluminum phantom radiography-based mean gray value (mGV) and DXA-derived BMD, especially for the ultradistal radius (ρ = 0.75; p < 0.001). A moderate correlation for the femoral neck (ρ = 0.61 and p < 0.001) between modalities was found. Radius mGV and HR-pQCT-derived BMD only showed a moderate correlation (ρ = 0.48; p < 0.09). Aluminum phantom radiography might serve as a cost efficient, highly available, low-radiation dose screening, and diagnostic method for osteoporosis additively to DXA measurements. Especially, an application in areas with constrained DXA availability and such as preoperative trauma settings would be beneficial. However, further investigation and assessment of specificity and sensitivity is needed.

Mortality and Epidemiological Changes in Proximal Hip Fractures in the Course of a Pandemic.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has had an immense impact on the treatment protocols of orthopedic and trauma departments, yet its specific effect on mortality in patients with hip fractures due to possible surgical delays is still unclear. The purpose of this paper was to investigate whether the COVID-19 pandemic worsened the mortality rate of hip fracture patients. PATIENTS AND METHODS: This study comprised 175 prospectively included patients who (1) suffered from hip fractures, (2) presented during the Austrian state of emergency period from 15 March 2020 to 30 May 2021, and (3) were admitted to a level I trauma center. This cohort was compared with a retrospective control group of 339 patients admitted for hip fractures during the same timeframe in 2017, 2018, and 2019. RESULTS: An admission reduction of 22% in the COVID period compared with the pre-COVID period was evident (p = 0.018). The 30-day mortality rate was 14.67% (pre-COVID) compared with 15.18% (p = 0.381). No differences in surgical complication rates or relationships between comorbidity burden and survival were observed. There were no significant changes in demographic variables, except for admission rate, gender (p = 0.013), and place of accident (p = 0.049). CONCLUSION: Surgeons should be reassured to take COVID-19 precautions, as this study did not show higher perioperative mortality due to COVID-19 measures. Under the current circumstances, with possibly reduced surgical and hospital bed capacities, it is expected that hip fractures may continue to require a high degree of resources.

Predicting 30-Day and 180-Day Mortality in Elderly Proximal Hip Fracture Patients: Evaluation of 4 Risk Prediction Scores at a Level I Trauma Center.

This study evaluated the use of risk prediction models in estimating short- and mid-term mortality following proximal hip fracture in an elderly Austrian population. Data from 1101 patients who sustained a proximal hip fracture were retrospectively analyzed and applied to four models of interest: Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM), Charlson Comorbidity Index, Portsmouth-POSSUM and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP®) Risk Score. The performance of these models according to the risk prediction of short- and mid-term mortality was assessed with a receiver operating characteristic curve (ROC). The median age of participants was 83 years, and 69% were women. Six point one percent of patients were deceased by 30 days and 15.2% by 180 days postoperatively. There was no significant difference between the models; the ACS-NSQIP had the largest area under the receiver operating characteristic curve for within 30-day and 180-day mortality. Age, male gender, and hemoglobin (Hb) levels at admission <12.0 g/dL were identified as significant risk factors associated with a shorter time to death at 30 and 180 days postoperative (p < 0.001). Among the four scores, the ACS-NSQIP score could be best-suited clinically and showed the highest discriminative performance, although it was not specifically designed for the hip fracture population.

Impact of lockdown during the COVID-19 pandemic on number of patients and patterns of injuries at a level I trauma center.

OBJECTIVE: The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) and its associated illness, coronavirus disease 2019 (COVID-19), has led to a global health crisis burdening frontline emergency departments, including orthopedic and trauma units. The aim of this study was to provide an overview of the impact of the lockdown secondary to the pandemic on patient numbers and pattern of injuries at the department of traumatology of the Medical University of Vienna. METHODS: This retrospective, descriptive study identified all patients admitted and enrolled onto the trauma registry at a level I trauma center, between 15 March 2020 and 30 April 2020 (lockdown) and compared them to those between 15 March 2019 and 30 April 2019 (baseline). Variables collected included patient age, sex, reason for hospital admission, place of injury, death, injury severity score (ISS), as well as American Society of Anaesthesiologists (ASA) score. RESULTS: A total of 10,938 patient visits to the trauma emergency department were analyzed, 8353 presentations during the baseline period and 2585 during lockdown. Only 1869 acutely injured and 716 follow-up patients presented during lockdown, compared to 6178 and 2175, respectively, during baseline. Throughout the COVID-19 lockdown there were significant reductions in both workplace and traffic accidents, sports injuries, number of hospitalized patients, and overall visits to the trauma emergency department; however, the number of major traumas and hip fractures remained similar. Furthermore, there was a significant increase in the frequency of injuries at home as well as hospital admissions due to attempted suicide. CONCLUSION: Despite the reduction in total number of patients, trauma departments should continue to provide adequate service during lockdown considering that severe injuries showed no change. Conditions such as breakdown of social networks and limited access to mental health care and support might account for the significant rise in hospital admissions due to suicides. We recommend that more attention and effort should be made to prevent this excess of suicide deaths.

Outcome of Surgical Treated Isolated Pronator Teres Syndromes-A Retrospective Cohort Study and Complete Review of the Literature.

PURPOSE: This study aims to elucidate the occurrence of postoperative carpal tunnel syndrome (CTS), the functional outcome of patients with primary pronator teres syndrome (PTS), and review complete literature regarding this topic. MATERIAL AND METHODS: A retrospective chart review was conducted in patients with PTS at a single center. In all patients, a numeric Visual Analog Scale (VAS) score, Pinch-Test, Jamar hand dynamometer test (JAMAR), and the Disabilities of the Arm Shoulder and Hand (DASH) score were analyzed preoperatively and at final follow-up to assess outcome. Additionally, a complete review of the literature was performed, including all data dealing with pronator teres syndrome. RESULTS: Ten female and two male patients were included with a mean age of 49 years. Significant improvement in DASH and numeric VAS was detected at latest postoperative follow-up. In three patients, clinical signs of CTS pathology were detected during the follow-up period. One patient needed to be treated surgically, and in the other two patients, a conservative management was possible. In one patient (8%), a PTS recurrence was detected. All patients presented satisfied at latest follow-up. CONCLUSION: In one-fourth of our patients, a CTS occurred during the follow-up period. Therefore, focusing on double-crush syndrome in unclear or mixed symptoms is necessary to avoid multiple operations. Furthermore, it seems that assessment with NCV is not enough for diagnosing PTS; therefore, further research is needed to clarify this problem.

Acromioclavicular joint dislocation treated with Bosworth screw and additional K-wiring: results after 7.8 years - still an adequate procedure?

BACKGROUND: The acromioclavicular (AC) joint dislocation is a major reason for shoulder instability. Different concepts of treatment and surgical methods are described in the literature. Thus, the purpose of this study was to present our data of long-term follow-up of patients having undergone treatment of acromioclavicular (AC) joint dislocation using the Bosworth Screw with additional K-wiring. METHODS: This study was conducted as a retrospective single centre data analysis. All patients treated operatively for AC joint dislocation with a Bosworth screw and additional K-wire fixation at our Department were asked to participate in this study. RESULTS: The study population consisted of 22 patients, 20 male and 2 female, with a mean age of 40 years ±15.6 years. Three grade-II lesions, 13 grade-III lesions, four grade-IV lesions and two grade-V lesions according to the Rockwood classification were found. The overall mean clinical outcome at the latest follow up was: Constant 95, DASH 6.4, ASES 94.6, SST 99.02, UCLA 33.1, ACJI 91.82 and VAS 0.29 - representing a good-to-excellent long-term outcome in all patients after at least 2 years follow-up (range; 2 - 19 years). Overall, 19 patients (86%) reported to be very satisfied with the achieved result, 15 patients (68%) reported to be able to participate in every sports activity and 16 patients (73%) reported to be able to perform their daily work without limitations. Overall, complications occurred in three patients (14%). Only one patient remained unsatisfied with the achieved result. CONCLUSION: Summarizing, our reported results showed that surgical fixation of acute AC joint dislocation with a Bosworth screw and additional K-wire fixation leads to good-to-excellent functional outcome and highly satisfactory results in the majority of patients. Despite its complications, in accordance with our results, Bosworth screw fixation with additional K-wiring in AC joint dislocation represents an adequate surgical procedure. LEVEL OF EVIDENCE: Level IV, retrospective study.

Incidence, characteristics, and long-term follow-up of sternoclavicular injuries: An epidemiologic analysis of 92 cases.

BACKGROUND: The majority of published studies concerning sternoclavicular injuries are case series or systematic reviews. Prospective studies on the subject are hindered by the low incidence of these lesions. The aims of the present study were to provide an overview of this rare entity compared with those described in the literature and to present the long-term clinical outcome. METHODS: We performed a retrospective data analysis of all sternoclavicular injuries treated at a single Level I trauma center from 1992 to 2011. Long-term clinical outcome was assessed using the ASES [American Shoulder and Elbow Surgeons], SST [Simple Shoulder Test], UCLA [University of California-Los Angeles] Shoulder Scale, and VAS [Visual Analog Scale] at latest follow-up. RESULTS: We detected an overall incidence of 0.9% of sternoclavicular injuries related to all shoulder-girdle lesions. Ninety-two patients (52 males and 40 females) with a mean (SD) age of 39.2 (19.5) years (median, 41 years; range, 4-92 years) were included in this study. The main trauma mechanism was fall. Classification was performed according to Allman, the time point of treatment after initial trauma, and the direction of the dislocation. Nine patients of the 15 Grade III lesions were treated conservatively by closed reduction and immobilization, while four patients were treated surgically by open reduction and internal fixation. Forty-nine percent of the patients were available for long-term follow-up at a median of 11.3 years (range, 5.3-22.6 years) with a mean ASES score of 96.21, SST score of 11.69, UCLA score of 31.89, and VAS score of 0.47. CONCLUSION: We found an overall incidence of 0.9% of sternoclavicular joint injuries related to all shoulder-girdle lesions and of 1.1% related to all dislocations, which is slightly lower compared with those described in the literature. Furthermore, we observed a high number of physeal sternoclavicular injuries with a percentage of 16% and overall good-to-excellent results at long-term follow-up. LEVEL OF EVIDENCE: Epidemiologic study, level IV.