The 2023 WSES guidelines on the management of trauma in elderly and frail patients.

BACKGROUND: The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures. METHODS: Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023. RESULTS: The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared. CONCLUSIONS: The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.

Access to an Educational Video Preoperatively Has No Effect on Postoperative Opioid Use After Arthroscopic Partial Meniscectomy of the Knee: A Prospective Cohort Study.

Purpose: To determine whether access to a website with an educational video would decrease postoperative opioid use in patients undergoing arthroscopic partial meniscectomy. Methods: Enrolled patients who underwent arthroscopic partial meniscectomy at a single center were randomized to either the intervention or control group prior to surgery. The intervention group received a card with access to an online educational video regarding opioids with their postoperative instructions; the control group did not. The online video was just over 5 minutes long and contained general information about the dangers of opioid use, how to safely dispose of unused opioids, and local support contact information. Data were collected by telephone 10 to 14 days postoperatively and analyzed with GraphPad Prism version 9.5.0. Patient characteristics including age, sex, body mass index, allergies, smoking, depression, alcohol abuse, American Society of Anesthesiologists level, diagnosis of chronic obstructive pulmonary disease, hypertension, diabetes, substance abuse, employment status, workers' compensation, and sports participation were analyzed and correlated with postoperative opioid use. Results: A total of 166 patients were included in this study, with 78 in the control group and 88 in the intervention group. Mean number of pills consumed was 3 in the control group and 2.2 in the intervention group. This difference did not reach statistical significance. Patients who were obese, smokers, or diagnosed with depression both consumed more opioids and were less likely to take no narcotics postoperatively. Patients who participated in sports consumed fewer total opioids on average than those who did not. Subgroup analysis of patients with higher risk factors did not show a difference between the control and intervention groups in the average amount of opioid used or the likelihood of using no narcotics. Among all patients, 82 (49%) used no narcotics postoperatively and 90% used 8 or fewer tablets. Conclusions: Directing patients to an educational website and video is not an effective tool in decreasing opioid consumption. Patients undergoing arthroscopic meniscectomy who are obese, active smokers, and clinically depressed or do not participate in sports are likely to use more postoperative narcotics. Regardless of access to the online educational video, half of patients used no narcotics. Level of Evidence: Level II, prospective cohort.

Robotic emergency liver resection of ruptured hepatocellular carcinoma.

BACKGROUND: The spontaneous rupture of hepatocellular carcinoma (HCC) is a rare complication. The management of this complication needs a stepwise, multidisciplinary approach which considers first of all clinical conditions of the patient and also the possibility of the best curative treatment. METHODS: We report our experience of an emergency robotic liver resection for a ruptured HCC in an elderly patient. Minimally invasive liver resection is currently recognised as a safe and feasible approach to the treatment of HCC in elderly patients. RESULTS: Our patient presented haemodynamic stability, which allows us to perform a robotic resection of segment 3. To our knowledge, this is the first report of the application of a robotic platform in an emergency setting for liver resection. CONCLUSIONS: Rupture of HCC is an uncommon complication, burdened by a high rate of mortality. Its management still remains controversial. Treatment should be individualised taking into consideration the clinical status of the patient, tumour features and possibility of centre therapeutic strategy.

Acute abdomen in the immunocompromised patient: WSES, SIS-E, WSIS, AAST, and GAIS guidelines.

Immunocompromised patients are a heterogeneous and diffuse category frequently presenting to the emergency department with acute surgical diseases. Diagnosis and treatment in immunocompromised patients are often complex and must be multidisciplinary. Misdiagnosis of an acute surgical disease may be followed by increased morbidity and mortality. Delayed diagnosis and treatment of surgical disease occur; these patients may seek medical assistance late because their symptoms are often ambiguous. Also, they develop unique surgical problems that do not affect the general population. Management of this population must be multidisciplinary.This paper presents the World Society of Emergency Surgery (WSES), Surgical Infection Society Europe (SIS-E), World Surgical Infection Society (WSIS), American Association for the Surgery of Trauma (AAST), and Global Alliance for Infection in Surgery (GAIS) joined guidelines about the management of acute abdomen in immunocompromised patients.

Liver trauma: WSES 2020 guidelines.

Liver injuries represent one of the most frequent life-threatening injuries in trauma patients. In determining the optimal management strategy, the anatomic injury, the hemodynamic status, and the associated injuries should be taken into consideration. Liver trauma approach may require non-operative or operative management with the intent to restore the homeostasis and the normal physiology. The management of liver trauma should be multidisciplinary including trauma surgeons, interventional radiologists, and emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) liver trauma management guidelines.

Evaluation of sterilization methods following contamination of hamstring autograft during anterior cruciate ligament reconstruction.

PURPOSE: Inadvertent contamination of the hamstring autograft during ACL reconstruction is infrequent, but can result in significant complications. The purpose of this study is to evaluate bacterial contamination of hamstring autografts dropped onto the operating room floor and methods of graft decontamination. METHODS: Hamstring tendons were harvested from patients. Excess tendon not used in the ACL procedure was divided into 6 segments. Segments were assigned to 6 groups (A through F, N = 30 in each group): group A: uncontaminated graft immediately postharvest (control), group B: graft dropped onto the floor (5 s), group C: graft dropped onto the floor (15 s). grafts in groups D to F were dropped onto floor for 15 s then rinsed with saline (group D), bacitracin solution (group E) or chlorhexidine 4 % solution (group F) for 3 min. All grafts were sent to the microbiology laboratory for anaerobic and aerobic cultures. RESULTS: Cultures were positive in 23 % of graft segments from group A (7/30), 33 % of grafts from group B (10/30), 23 % from group C (7/30), 30 % from group D (9/30) and 3 % from both group E (1/30) and group F (1/30). Sixteen unique organisms were identified, with Staphylococcus aureus as the most common isolate. Grafts rinsed in either bacitracin solution or 4 % chlorhexidine solutions were significantly less likely to be culture positive when compared to control graft segments (p < 0.05). However, there was no significant difference between uncontaminated grafts retrieved in <5 versus 15 s from the floor. CONCLUSION: This study supports the practice of decontaminating a dropped ACL hamstring autograft using either 4 % chlorhexidine or bacitracin solution. Specimens should be retrieved sterilely and washed for at least 3 min. This study also demonstrates no advantage in retrieval time of less than 5 s as compared to 15 s for uncontaminated graft. Hamstring harvest in ACL reconstruction may result in positive cultures, thus routine soaking of the hamstring autograft in either bacitracin or 4 % chlorhexidine solution is recommended. In addition, dropped hamstring autograft can be effectively sterilized with bacitracin or 4 % chlorhexidine solution. LEVEL OF EVIDENCE: II.

Three-part head-splitting proximal humerus fracture through a unicameral bone cyst.

Unicameral bone cysts are rare in adults and are most often found incidentally on radiographs. However, they can persist from the adolescent period and may be present in locations that predispose to or exacerbate fractures.This article describes a case of a healthy 40-year-old woman who sustained a proximal humerus trauma that involved a large unicameral bone cyst, resulting in a 3-part head-splitting fracture. The epiphyseal location of the cyst contributed to the severity and extent of the fracture that resulted from a simple fall. Given the age of the patient, open reduction and internal fixation with a locking plate and lag screws was performed. The patient chose open reduction and internal fixation to preserve a hemiarthroplasty procedure in case of future revision. Successful humeral head reconstruction was achieved, and the patient fully recovered. One year postoperatively, the patient underwent arthroscopic debridement to alleviate subjective stiffness and decreased range of motion.Multipart head-splitting fractures require complex repair strategies. The gold standard for the treatment of these injuries is hemiarthroplasty. However, the decision process is difficult in a young patient given the average survival of autoplastic prostheses and the added difficulty of later revision. The current case demonstrates the complexity of decision making resulting from a rare injury in a young, healthy patient and shows that open reduction and internal fixation can provide acceptable reconstruction in such situations.

Relationship between anthropometric measurements and hamstring autograft diameter in anterior cruciate ligament reconstruction.

The role of anthropometric measurements in the prediction of hamstring autograft size remains unclear. In this internal review board - approved study, we evaluated medical records for patients receiving anterior cruciate ligament (ACL) reconstruction with hamstring autograft at our institution between 2006 and 2008. One hundred and thirty-two patients received hamstring autografts. Correlation coefficients and step-wise multiple linear regression analysis were used to determine the relationships between sex, age, height, body mass index (BMI), and hamstring graft diameter. Women had significantly smaller grafts than men (P < .00001). Twenty-four patients had grafts less than 7 mm in diameter and 18 of those patients were female. Age and BMI did not correlate with graft diameter in women. Height correlated to graft diameter in women (P = .002, R(2) = 0.14). Women shorter than 65 in had significantly smaller graft diameters (mean [SD], 6.94 [0.45] mm), than those women 65 in and taller (mean [SD], 7.20 0.49] mm; (P = .03). Age and height did not correlate with graft size in men. BMI greater than 25 kg/m(2) correlated with larger graft diameter, but BMI less than 18 kg/m(2) did not predict graft sizes less than 7 mm. Therefore, alternative graft options should be considered in women less than 65 in tall.

Treatment of distal biceps tendon ruptures using a single-incision technique and a Bio-Tenodesis screw.

No consensus exists in the literature on the optimal operative treatment method for distal biceps tendon ruptures. It is our hypothesis that a single-incision technique with a poly-L-lactide Bio-Tenodesis screw (Arthrex, Inc, Naples, Florida) is a safe and effective method for operative management of distal biceps tendon ruptures, with success and complication rates comparable to previous reports in the literature. This article describes a prospective case series of 29 consecutive patients (30 operations) managed by the same surgeon over 34 months. Average follow-up was 19.6 months. Two patients were lost to follow-up. Elbow range of motion (ROM) and strength; Disabilities of the Arm, Shoulder, and Hand (DASH) score; and SF-12 score were measured at various time points up to 2 years. All patients had full extension and supination. Supination and flexion strength was at least 4/5 in all patients. Mean DASH, SF-12 Physical Component (PCS), and SF-12 Mental Component (MCS) scores were 5.86 (range, 0-16.67), 50.35 (range, 30.4-60.1), and 57.15 (range, 41.7-64.4), respectively. These scores are comparable to normative values reported by the American Academy of Orthopaedic Surgeons. Complication rates were similar to those previously reported in the literature. This type of fixation allowed for early mobilization of the operative arm. Our study demonstrates that use of a tenodesis screw for distal biceps repair results in DASH and SF-12 scores comparable to the norm for the general population with complications similar to those seen in past studies. In addition, biomechanical studies suggest that the repair is strong enough to allow early ROM, and the fixation technique may allow for more anatomic positioning of the distal biceps along the ulnar border of the bicipital tuberosity.

Management of type II superior labrum anterior posterior lesions: a review of the literature.

Superior labrum anterior and posterior lesions were first described in 1985 by Andrews et al. and later classified into four types by Synder et al. The most prevalent is type II which is fraying of the superior glenoid labrum with detachment of the biceps anchor. Superior labrum anterior posterior (SLAP) lesions can also be associated with other shoulder pathology. Both MRI and MRA can be utilized in making the diagnosis with the coronal images being the most sensitive. The mechanism of injury can be either repetitive stress or acute trauma with the superior labrum most vulnerable to injury during the late cocking phase of throwing. A combination of the modified dynamic labral shear and O'Brien test can be used clinically in making the diagnosis of SLAP lesion. However, the most sensitive and specific test used to diagnosis specifically a type II SLAP lesion is the Biceps Load Test II. The management of type II SLAP lesions is controversial and dependent on patient characteristics. In the young high demanding overhead athlete, repair of the type II lesion is recommended to prevent glenohumeral instability. In middle-aged patients (age 25-45), repair of the type II SLAP lesion with concomitant treatment of other shoulder pathology resulted in better functional outcomes and patient satisfaction. Furthermore, patients who had a distinct traumatic event resulting in the type II SLAP tear did better functionally than patients who did not have the traumatic event when the lesion was repaired. In the older patient population (age over 45 years), minimum intervention (debridement, biceps tenodesis/tenotomy) to the type II SLAP lesion results in excellent patient satisfaction and outcomes.

Congenital instability of the shoulder joint: assessment and treatment options.

UNLABELLED: Congenital instability of the shoulder is a form of multidirectional instability not caused by a traumatic event. It is believed that excess laxity may be responsible for an overly elastic capsule and, therefore, can contribute to multidirectional instability. Minor microtraumatic events can progressively lead to the development of pain and lead to instability. The current preferred treatment is largely nonoperative with extensive rehabilitation of the dynamic restraints of the shoulder complex. In recalcitrant cases, operative intervention to restore stability may be necessary. It is of paramount importance to notice the directions of instability and to address each of them. Surgical procedures include open capsular shift, as well as arthroscopic capsular plication. Because multidirectional instability can be difficult to diagnose, this article will attempt to provide the clinician with a better understanding of the pathophysiology involved in this condition, the necessary steps for diagnosis, and considerations for treatment. A comprehensive guide to both nonoperative and operative treatment is reviewed in this article, as well as the surgical techniques used to decrease the capsular volume. LEVEL OF EVIDENCE: Level 5.

The proximal biceps tendon: tricks and pearls.

The diagnosis and treatment of proximal biceps tendon injuries continue to be a challenge. The difficulty lies on determining if there is isolated biceps pathology versus concomitant rotator cuff tears or instability. Imaging modalities, such as magnetic resonance imaging, continue to provide us with the extra tool to help us confirm our suspicion of additional pathology. Symptomatic biceps tendon tears can undergo debridement, tenotomy, or tenodesis if nonoperative measures fail to provide relief. Reports from performing a biceps tenotomy often give similar functional outcomes compared with tenodesis. Cosmetic deformity on the lateral arm may be noted with tenodesis and initial fatigue. Tenodesis may subject the patient to a longer rehabilitation process and increased pain. The decision of which one should be performed lies between the physician and the patient's expectations.

Use of the trauma pelvic orthotic device (T-POD) for provisional stabilisation of anterior-posterior compression type pelvic fractures: a cadaveric study.

OBJECTIVE: To demonstrate that a commercially available pelvic binder the trauma pelvic orthotic device (T-POD) is an effective way to provisionally stabilise anterior-posterior compression type pelvic injuries. METHODS: Rotationally unstable pelvic injuries were created in 12 non-embalmed human cadaveric specimens. Each pelvis was then stabilised first with a standard bed sheet wrapped circumferentially around the pelvis and held in place with a clamp. After recreating the symphyseal diastasis, the pelvis was stabilised with the T-POD. Reduction of the symphyseal diastasis was assessed by comparing measurements obtained via pre- and post-stabilisation AP radiographs. RESULTS: The mean symphyseal diastasis was reduced from 39.3mm (95% CI 30.95-47.55) to 17.4mm (95% CI -0.14 to 34.98) with the bed sheet, and to 7.1mm (95% CI -2.19 to 16.35) with the T-POD. CONCLUSIONS: Although both a circumferential sheet and the T-POD were able to decrease symphyseal diastasis consistently, only the T-POD showed a statistically significant improvement in diastasis when compared to injury measurements. In 75% of the cadaveric specimens (9 of 12), the T-POD was able to reduce the symphysis to normal (<10mm diastasis). Both a circumferential sheet and the T-POD are effective in provisionally stabilising Burgess and Young anterior-posterior compression II type pelvic injuries, but the T-POD is more effective in reducing symphyseal diastasis.

Understanding the superior clear space in the adult ankle.

BACKGROUND: The width of the medial clear space often is used to determine the integrity of the deltoid ligament, the primary medial stabilizer of the ankle joint. The normal clinical relationship of the superior clear space to the medial clear space is not well described. This investigation sought to determine if the superior clear space constitutes an accurate point of comparison for the medial clear space and a means for assessing ligamentous stability in an adult ankle. METHODS: A retrospective review of consecutive ankle radiographs for a 4-month period of time was completed using a university-based radiology database. Using a digitally calibrated ruler, the widths of the medial and superior clear spaces were measured on the mortise view. These values were compared using a Student's t-test. RESULTS: Digital radiographs of 564 consecutive ankles were reviewed retrospectively and 94 cases were without evidence of trauma, surgery, or degenerative disease. The medial and superior clear spaces were measured on the mortise view and found to be 2.7 mm (standard deviation 0.5; range 1.3 mm to 4.3 mm; 95% confidence interval 1.7 mm to 3.8 mm) and 3.6 mm (standard deviation 0.6; 2.0 to 5.3; CI 2.4 mm to 4.7 mm), respectively. The average absolute difference was 0.9 mm (standard deviation 0.5; -0.7 to 1.5; CI -0.1 mm to 1.8 mm) and in 92 of 94 ankles (98%), the superior clear space was greater than or equal to the medial clear space. CONCLUSIONS: Understanding the normal radiographic relationship of the superior and medial clear spaces may help in the diagnosis of ligamentous instability in the ankle and may obviate the need for additional diagnostic tests.

Does medial tenderness predict deep deltoid ligament incompetence in supination-external rotation type ankle fractures?

OBJECTIVE: To identify whether medial tenderness is a predictor of deep deltoid ligament incompetence in supination-external rotation ankle fractures. DESIGN: All Weber B lateral malleolar fractures with normal medial clear space over a 9 month period were prospectively included in the study. Fracture patterns not consistent with a supination-external rotation mechanism were excluded. SETTING: High-volume tertiary care referral center and Level I trauma center. PATIENTS/PARTICIPANTS: Fifty-five skeletally mature patients with a Weber B lateral malleolar fracture and normal medial clear space presenting to our institution were included. INTERVENTION: All study patients had ankle anteroposterior, lateral, and mortise radiographs. Each patient was seen and evaluated by an orthopedic specialist and the mechanism of injury was recorded. Each patient was assessed for tenderness to palpation in the region of the deltoid ligament and then had an external rotation stress mortise radiograph. MAIN OUTCOME MEASURE: Correlating medial tenderness with deep deltoid competence as measured by stress radiographs. RESULTS: Thirteen patients (23.6%) were tender medially and had a positive external rotation stress radiograph. Thirteen patients (23.6%) were tender medially and had a negative external rotation stress radiograph. Nineteen patients (34.5%) were nontender medially and had a negative external rotation stress radiograph. Ten patients (18.2%) were nontender medially and had a positive external rotation stress radiograph. We calculated a chi statistic of 2.37 as well as the associated P value of 0.12. Medial tenderness as a measure of deep deltoid ligament incompetence had a sensitivity of 57%, a specificity of 59%, a positive predictive value of 50%, a negative predictive value of 66%, and an accuracy of 42%. CONCLUSION: There was no statistical significance between the presence of medial tenderness and deep deltoid ligament incompetence. There is a 25% chance of the fracture in question with medial tenderness having a positive external rotation stress and a 25% chance the fracture with no medial tenderness having a positive stress test. Medial tenderness in a Weber B lateral ankle fracture with a normal clear space on standard plain radiographs does not ensure the presence of a positive external rotation stress test.

Anatomy of the superficial peroneal nerve in relation to fixation of tibia fractures with the less invasive stabilization system.

OBJECTIVE: To examine the danger to the superficial peroneal nerve during percutaneous screw placement in the distal holes of the 13-hole proximal tibia Less Invasive Stabilization System plate in a cadaver. DESIGN: Anatomic study. SETTING: Medical school anatomy laboratory. INTERVENTIONS: Fourteen adult cadaveric lower extremities were used. A 13-hole proximal tibia Less Invasive Stabilization System plate was placed as described by the manufacturer. Dissection of the superficial peroneal nerve was performed following localization of screw holes 7 through 13 using insertion sleeves, centering sleeves, and 2.0-mm Kirschner wires passed through the insertion guide. RESULTS: The average distance from the superficial peroneal nerve to the center of holes 11, 12, and 13 was 10.0 mm (range 0-21, standard deviation 5.6), 6.8 mm (range 0-16, standard deviation 4.3), and 2.7 mm (0-11, standard deviation 3.7), respectively. In 12 of 14 legs (86%), the superficial peroneal nerve was 5.0 mm or less from the center of hole 13. The nerve was touching the guide wire at hole 11 in 1 specimen (7%), at hole 12 in 2 specimens (14%), and at hole 13 in 6 specimens (43%). In 1 specimen (7%), the guide wire pierced the superficial peroneal nerve at hole 13. CONCLUSION: These findings suggest that the superficial peroneal nerve is at significant risk during percutaneous screw placement in holes 11 through 13 of the 13-hole proximal tibia Less Invasive Stabilization System plate. Use of a larger incision and careful dissection down to the plate in this region may minimize the risk of damage to the nerve.

Assessment and differential diagnosis of the painful hip.

Hip pain is a common problem seen by orthopaedic surgeons. The current authors provide an approach to the patient with hip pain, including important information to be gained from the history and physical examination and relevant radiographic studies and laboratory tests. A differential diagnosis for patients presenting with the complaint of hip pain and indications for hip arthroscopy are provided.

Hip arthroscopy in the pediatric population.

Hip arthroscopy has obvious advantages over arthrotomy in the pediatric population. Hip arthroscopy, used as a diagnostic or therapeutic tool, is significantly less invasive than arthrotomy and allows for quicker recovery and return to activities. In addition, arthroscopy avoids dislocation of the femoral head and the corresponding risk of osteonecrosis. Current indications for hip arthroscopy in pediatric patients include septic arthritis, labral disorders, slipped capital femoral epiphysis, and Legg-Calvé-Perthes disease. The role of hip arthroscopy in the pediatric population will continue to expand because of its attractiveness as a less invasive option for evaluating the hip.