Thoracic Injuries in Pediatric Polytraumatized Patients: Epidemiology, Treatment and Outcome.

PURPOSE: The purpose of the present study was to assess the influence and contribution, epidemiology, treatment and outcome of thoracic injuries in a cohort of pediatric and adolescent polytraumatized patients. MATERIAL AND METHODS: All pediatric and adolescent (age < 18 years) polytraumatized patients with associated thoracic injuries were included in this study. Demographic data, mechanism of injury (MOI), injury severity score (ISS), Glasgow Coma Scale (GCS), hemodynamic parameters and pupillary response at ED admission, site of major injury (SOMI), associated chest and non-chest related injuries, length of hospital stay (LOS), procedures performed at the ED as well as outcome variables including mortality and cause of death. Stepwise logistic regression analysis was used to identify risk factors for a poor prognosis and outcome. RESULTS: The logistic regression found the following variables decreasing the odds for a "bad outcome": lack of a hemodynamically unstable condition (p = 0.009) and the absence of a pathological pupillary response (p < 0.001). CONCLUSIONS: The present study suggests that the severity of concomitant chest injuries in polytraumatized pediatric and adolescent patients contributes substantially to morbidity and mortality. Due to the anatomic features of the immature pediatric bones, careful attention should be drawn to possible severe chest injuries even in the absence of rib fractures. LEVEL OF EVIDENCE: A retrospective study (level - IV study).

The use of the LARS system in the treatment of AC joint instability - Long-term results after a mean of 7.4 years.

BACKGROUND: The acromioclavicular (AC) joint is of great importance for shoulder stability and one of the most frequently injured regions of the shoulder. HYPOTHESIS: AC joint reconstruction with the ligament augmentation & reconstruction system (LARS™) leads to a good-to-excellent outcome at long-term follow-up. PATIENTS AND METHODS: This study was performed as a retrospective single-centre data analysis of a level-I trauma centre. All patients treated operatively for an acute AC dislocation with the LARS™ between 2003 and 2013 were included. RESULTS: The study group consisted of three female (6%) and 44 male patients (94%) with an average age of 37 years and a minimum follow-up of two years. The overall mean clinical outcomes at latest follow-up were: Constant 93, DASH 2.64, ASES 96, SST 97, UCLA 34 and VAS 0.4-representing a good-to-excellent outcome in all patients. Overall, 45 patients (96%) reported to be very satisfied with the achieved result at latest follow-up. In five patients, (11%) complications occurred during the follow-up period, requiring surgical revision in four of the five patients (80%). CONCLUSION: AC joint reconstruction with the LARS™ achieves good-to-excellent clinical and functional outcomes at long-term follow-up with a surgical revision rate of 8.5%. LEVEL OF EVIDENCE: Retrospective follow-up study, case series, level IV.

Secondary femur shaft fracture following treatment with cephalomedullary nail: a retrospective single-center experience.

AIM: Secondary femur fracture subsequent to treatment of trochanteric fractures with cephalomedullary nailing (i.e., a periprosthetic fracture related to the cephalomedullary nail) is a rare but very severe complication. As such, the aim of this study was to assess the impact of revision surgery and general state of health on mortality and functional outcomes in patients suffering femur fractures following treatment with cephalomedullary nails. MATERIALS AND METHODS: Between 2000 and 2015, 3549 patients presenting with OTA/AO 31A1-3 femur fractures were admitted to our department and subsequently treated with either a Gamma® Nail or PFNA®. Out of this sample population, 42 patients suffered 43 secondary femur shaft fractures (1.2%). The mean follow-up time was 26 ± 9.7 months. Fractures were classified according to the AO classification and the modified Vancouver classification. Treatment options included ORIF, removing the cephalomedullary nail and fixation with a long nail with or without cerclage wires. General health status was defined according to the ASA Score. Mortality, pre- and postoperative mobility, hospital stay and complications were assessed retrospectively. RESULTS: A total of 14.3% patients died within 90 days following surgery. At least 16.6% patients died due to medical complications strongly related to the surgery. The average time to secondary fracture following initial surgery for trochanteric fracture was 122.7 ± 32 weeks. The most common fracture types were AO 32A1 (53.5%) and AO 32B1 (23.3), as well as Vancouver C and B1. A time-to-secondary-fracture of less than or longer than 6 months following surgery for trochanteric fracture and ASA Score all had no significant influence on mortality, complications, duration of surgery and postoperative mobility. CONCLUSION: Femoral shaft facture subsequent to fixation of trochanteric fracture with cephalomedullary nails is a severe complication. It leads to prolonged hospital stays and delayed recovery. Postoperative hospital stay mortality rates may be as high as 16.6%.

Does an additional antirotation U-Blade (RC) lag screw improve treatment of AO/OTA 31 A1-3 fractures with gamma 3 nail?

INTRODUCTION: Poor bone quality and unstable fractures increase the cut-out rate in implants with gliding lag screws. The U-Blade (RC) lag screw for the Gamma3® nail was introduced to provide monoaxial rotational stability of the femoral head and neck fragment. The purpose of this study was to evaluate whether the use of the U-Blade (RC) lag screw is associated with reduced cut-out in patients with OTA/AO 31A1-3 fractures. MATERIAL & METHODS: Between 2009 and 2014, 751 patients with OTA/AO 31A1-3 fractures were treated with a Gamma3® nail at our institution. Out of this sample 199 patients were treated with U-blade (RC) lag screws. A total of 135 patients (117 female, 18 male) with standard lag screw (treatment group A) were matched equally regarding age (±4 years) sex, fracture type and location to 135 patients with U-blade (RC) lag screw (treatment group B). Within a mean follow up of 9.2 months (range 6-18 months) we assessed the cut-out rate, the calTAD, lag screw migration, the Parker's mobility score and the Parker's ratio at postoperatively, six and 12 months following surgery. Furthermore we recorded all complications, ASA-Score, hospital stay and duration of surgery retrospectively. RESULTS: The most common fracture among group B with a cut-out of the lag screw were AO/OTA 2.3 and 3.2 fractures whereas in group A cut-out was most commonly seen in AO/OTA 2.1, 2.2 and 2.3 fractures, there was no significant reduction of the cut-out rate in group B 2.2% (n=3) compared to group A 3.7% (n=5). The duration of surgery was significantly shorter in group A (p<0.05). There was no significant difference in lag screw placement, the Parker's ratio and mobilization. CONCLUSION: In our study the U-Blade (RC) lag screw did not reduce the cut-out in treatment of OTA/AO 31A1-3 fractures at all. Considering the longer duration of surgery and the higher costs of the U-Blade (RC) lag screw, our results do not justify its use. However, further prospective randomized studies will be necessary.

A comparison of anterior screw fixation and halo immobilisation of type II odontoid fractures in elderly patients at increased risk from anaesthesia.

AIMS: We performed a retrospective, comparative study of elderly patients with an increased risk from anaesthesia who had undergone either anterior screw fixation (ASF) or halo vest immobilisation (HVI) for a type II odontoid fracture. PATIENTS AND METHODS: A total of 80 patients aged 65 years or more who had undergone either ASF or HVI for a type II odontoid fracture between 1988 and 2013 were reviewed. There were 47 women and 33 men with a mean age of 73 (65 to 96; standard deviation 7). All had an American Society of Anesthesiologists score of 2 or more. RESULTS: Patients who underwent ASF had a significantly better outcome than those who were treated by HVI. There was a rate of nonunion of 10% after ASF and 23% after HVI. Failure of reduction or fixation occurred in 11 patients (15%) but there was no significant difference between the two groups. Mortality rates were also similar: 9% (n = 3) after ASF and 8% (n = 4) after HVI. CONCLUSION: We conclude that ASF is the preferred method of treatment in this group of elderly patients, having a significantly higher rate of fusion, better clinical outcome and a similar rate of general and treatment-related complications. Cite this article: Bone Joint J 2016;98-B:1222-6.