High-energy trauma patients with pelvic fractures: Management trends in Ontario, Canada.

INTRODUCTION: Although fractures of the pelvic ring account for only 2-3% of all fractures, they are present in approximately 7-20% of patients with high-energy polytrauma. High-energy pelvic fractures are life-threatening injuries, with mortality estimates ranging from 6 to 35%. The purpose of this study was to examine trends in the incidence, diagnosis, treatment, and mortality rates of high-energy pelvic fractures in Ontario, Canada over a 10-year period. METHODS: A cohort of 3915 patients who sustained a high-energy pelvic fracture in Ontario between 01 April 2005 and 31 March 2015 was identified using the Ontario Trauma Registry and administrative healthcare data linked by the Institute for Clinical Evaluative Science (ICES). Severely injured patients (defined as having an Injury Severity Score (ISS) of ≥16) with pelvic fractures following high-velocity mechanisms of injury were identified using applicable ICD-10 codes. Trends were assessed statistically using the Poisson and the Cochrane-Armitage tests for trend. Modified Poisson regression was used to model the adjusted risk ratio of mortality by pelvic fracture treatment. RESULTS: The incidence of pelvic fracture remained constant at approximately 4.6 cases per 100,000 population annually between 2005 and 2011. From 2012, there was a decrease in patients with ISS ≥ 16 due to changes in the calculation of the ISS. The proportion of patients presenting with ISS > 50 increased from 8.2% to 14.1% (p = 0.008) over the study period. Automobile collisions or pedestrians struck by vehicles accounted for over half of injuries. Approximately 6% of patients underwent angioembolisation. Treatment with external fixation (15.5%-20.2%) or no surgical intervention (46.2%-61.3%) increased from 2005 to 2015. Mortality remained constant (11% at 30 days), and laparotomy was the only major intervention not associated with decreased risk of death. CONCLUSIONS: Stable mortality despite increasing injury severity suggests that the quality of care provided to patients with high-energy pelvic fractures has improved over time. However, unchanged incidence suggests the need for ongoing efforts aimed towards injury prevention. ISS at presentation was the most significant predictor of mortality in this patient population.

Length of stay, wait time to surgery and 30-day mortality for patients with hip fractures after the opening of a dedicated orthopedic weekend trauma room.

BACKGROUND: In September 2011, Kingston General Hospital (KGH) opened a dedicated orthopedic weekend trauma room. Previously, 1 weekend operating room (OR) was used by all surgical services. We assessed the impact this dedicated weekend trauma room had on hospital length of stay (LOS), time to surgery and 30-day mortality for patients with hip fractures. METHODS: Patients admitted between Oct. 1, 2009, and Sept. 30, 2012, were identified through our trauma registry, representing the 2 years before and 1 year after the opening of the orthopedic weekend trauma room. We documented type of fracture, mode of fixation, age, sex, American Society of Anesthesiologists (ASA) score, time to OR, LOS, discharge disposition and 30-day mortality. We excluded patients with multiple fractures, open fractures and those requiring trauma team activation. RESULTS: Our study included 609 patients (405 pre- and 204 post-trauma room opening). Mean LOS decreased from 11.6 to 9.4 days (p = 0.005) and there was a decreasing trend in mean time to OR from 31.5 to 28.5 hours (p = 0.16). There was no difference in 30-day mortality (p = 0.24). The LOS decreased by an average of 2 days following opening of the weekend trauma room (p = 0.031) and by an average of 2.2 additional days if the patient was admitted on the weekend versus during the week (p = 0.024). CONCLUSION: The weekend trauma OR at KGH significantly decreased the LOS and appears to have decreased wait times to surgery. Further analysis is needed to assess the cost-effectiveness of the current strategy, the long-term outcome of this patient population and the impact the additional orthopedic weekend trauma room has had on other surgical services (i.e., general surgery) and their patients.

CONTEXTE: En septembre 2011, l'Hôpital général de Kingston (HGK) a rendu disponible la fin de semaine une salle d'opération consacrée exclusivement aux traumas orthopédiques. Auparavant, une seule salle d'opération était ouverte la fin de semaine, et tous les services de chirurgie se la partageaient. Nous avons évalué l'incidence de la disponibilité de cette nouvelle salle sur la durée de séjour, la durée de l'intervention et le taux de mortalité dans les 30 premiers jours des patients ayant une fracture de la hanche. MÉTHODES: Nous avons recensé dans nos registres de traumatismes les patients hospitalisés entre le 1er octobre 2009 et le 30 septembre 2012, ce qui correspond à 2 années avant et 1 année après l'ouverture de la salle de fin de semaine. Nous avons noté le type de fracture, le mode de fixation, l'âge, le sexe, le score ASA (de l'American Society of Anesthesiologists), le délai avant l'entrée en salle d'opération, la durée de séjour, l'état à la sortie et le taux de mortalité dans les 30 premiers jours. Nous avons exclu les patients ayant subi de multiples fractures ou des fractures ouvertes et ceux ayant nécessité l'activation de l'équipe de trauma. RÉSULTATS: L'étude portait sur 609 patients (405 avant et 204 après l'ouverture de la salle). La durée de séjour moyenne a diminué après l'ouverture, passant de 11,6 à 9,4 jours (p = 0,005), tout comme le délai moyen avant l'entrée en salle d'opération, qui est passé de 31,5 à 28,5 heures (p = 0,16). Aucune différence n'a été relevée pour ce qui est du taux de mortalité dans les 30 premiers jours (p = 0,24). La diminution moyenne de la durée de séjour après l'ouverture de la salle était de 2 jours (p = 0,031), et de 2,2 jours additionnels si le patient avait été hospitalisé durant la fin de semaine (p = 0,024). CONCLUSION: L'ouverture durant la fin de semaine d'une salle d'opération réservée aux traumas à l'HGK a entraîné une baisse significative de la durée de séjour, et semble avoir entraîné une diminution du temps d'attente avant l'intervention. D'autres recherches seront nécessaires pour évaluer l'efficacité de la stratégie actuelle en fonction du coût, les résultats à long terme chez cette population de patients et l'incidence de l'ajout de cette salle sur les autres services de chirurgie (chirurgie générale) et leurs patients.

The Kingston periacetabular osteotomy utilizing computer enhancement: a new technique.

OBJECTIVE: To develop a new periacetabular osteotomy technique that can be performed safely and reliably using computer-enhanced technology. MATERIALS AND METHODS: This technique uses a modified posterior approach with a trochanteric osteotomy. A 3D surface model is generated from CT data. The osteotomy is planned using custom software developed by our team. A dynamic reference body is fixed to the iliac crest and the pelvis is registered using an optically tracked probe (Optotrak, Northern Digital, Ontario, Canada). A tracked probe is used to mark the osteotomies in three dimensions. The posterior column is osteotomized between the sciatic notch and hip joint. The pubic ramus is osteotomized under fluoroscopic guidance. The acetabular fragment is rotated into a more appropriate position and fixed with pelvic reconstruction plates. Subjective and objective data are collected pre- and postoperatively. RESULTS: This procedure has been performed on eight patients. Average center-edge angle correction has been 17 degrees. The computer and optical guidance system has provided accurate information in seven of eight cases, and there have been no complications. CONCLUSIONS: This technique has enabled us to perform periacetabular osteotomies with safety and predictability. Using this computer-enhanced technique, periacetabular osteotomy may become a more common procedure in the practice of hip reconstruction surgeons.

Long-term outcome of anterior decompression and spinal fixation after placement of the Wellesley Wedge for thoracic and lumbar spinal metastasis.

OBJECT: The authors assessed the long-term results of anterior decompressive and vertebral body reconstructive surgery in which the Wellesley Wedge was applied in patients with metastatic spinal lesions over the life span of these individuals. METHODS: The authors performed a retrospective review of the outcome of 27 consecutively treated patients who underwent surgery for thoracic or lumbar spine metastases. Decompressive surgery was performed via an anterior thoracotomy and/or retroperitoneal approach depending on the level of the lesion. The spine was reconstructed using a U-shaped plate with an interposed methylmethacrylate strut known as the Wellesley Wedge. RESULTS: Thirty percent of patients suffered medical complications whereas 22% experienced postoperative improvement, as reflected by an improved Frankel grade. Used in patients with a variety of primary tumor types, a spectrum of ages and neurological status, and extensive preoperative osseous spinal involvement and deformity, the Wellesley Wedge resulted in spinal stability for the duration of patients' lives in 92%. CONCLUSIONS: In this series the patient selection process for surgery was a challenge yet to be solved; however, considering the durability of the Wellesley Wedge itself, the authors will continue to use it in selected patients.