Locating an iliac cortical window for reduction of an acetabular dome impaction: A computed tomography and cadaveric study.

This study aimed to determine the optimal location of the iliac cortical window (ICW) for the direct reduction of acetabular dome impactions using a reference bony landmark. Methods: In the first part of the study, computed tomography scans of 10 normal acetabula, the femoral head weight bearing area, were projected through the superior iliac cortical surface perpendicular to the plane of the true pelvis to show the area that corresponds to the acetabular dome. A line connecting each pair of anterior inferior iliac spines (AIIS) was drawn then reflected in the superior surface of the acetabulum and a reference point (RP) was marked on the line halfway between the AIIS and the pelvic brim. A 12-point 1-cm interval grid with horizontal and vertical axes labeled A, B, C and 1 to 4, respectively, overlying the acetabular surface projection was created to identify the location of the acetabular dome. In the second part of the study, the 12-point grid was marked on eight fresh cadavers (16 acetabula) and the same acetabular dome reference point was identified. K-wires were drilled into the acetabula using a parallel drill guide at each of the twelve grid points. An arthrotomy was carried out and the locations of the K-wires which penetrated the acetabular dome were recorded. Results: The average distance from the AIIS to the medial pelvic brim in the CT scans and cadaveric study were 47.7 and 45.9 mm, respectively. The K-wires at grid points B2 and C1 had a 100% correlation to the dome area. The A2, B1, and C2 grid points had a correlation with the dome area of >80%. The remaining grid points had joint penetrations ranging from 6.25% to 62.5%. Conclusion: The proposed RP, which can be easily identified intraoperatively, and the area 1 cm2 around the RP (except in the posterior direction) can be used as reliable reference landmarks and for identification of the location of the ICW for the reduction of an acetabular dome impaction.

Cost-effectiveness analysis of the Geriatric Fracture Center (GFC) concept: a prospective multicentre cohort study.

INTRODUCTION: Geriatric Fracture Centers (GFCs) are dedicated treatment units where care is tailored towards elderly patients who have suffered fragility fractures. The primary objective of this economic analysis was to determine the cost-utility of GFCs compared with usual care centres. METHODS: The primary analysis was a cost-utility analysis that measured the cost per incremental quality-adjusted life-year gained from treatment of hip fracture in GFCs compared with treatment in usual care centres from the societal perspective over a 1-year time horizon. The secondary analysis was a cost-utility analysis from a societal perspective over a lifetime time horizon. We evaluated these outcomes using a cost-utility analysis using data from a large multicentre prospective cohort study comparing GFCs versus usual care centres that took place in Austria, Spain, the USA, the Netherlands, Thailand and Singapore. RESULTS: GFCs may be cost-effective in the long term, while providing a more comprehensive care plan. Patients in usual care centre group were slightly older and had fewer comorbidities. For the 1-year analysis, the costs per patient were slightly lower in the GFC group (-$646.42), while the quality-adjusted life-years were higher in the usual care centre group (+0.034). The incremental cost-effectiveness ratio was $18 863.34 (US$/quality-adjusted life-year). The lifetime horizon analysis found that the costs per patient were lower in the GFC group (-$7210.35), while the quality-adjusted life-years were higher in the usual care centre group (+0.02). The incremental cost-effectiveness ratio was $320 678.77 (US$/quality-adjusted life-year). CONCLUSIONS: This analysis found that GFCs were associated with lower costs compared with usual care centres. The cost-savings were greater when the lifetime time horizon was considered. This comprehensive cost-effectiveness analysis, using data from an international prospective cohort study, found that GFC may be cost-effective in the long term, while providing a more comprehensive care plan. A greater number of major adverse events were reported at GFC, nevertheless a lower mortality rate associated with these adverse events at GFC. Due to the minor utility benefits, which may be a result of greater adverse event detection within the GFC group and much greater costs of usual care centres, the GFC may be cost-effective due to the large cost-savings it demonstrated over the lifetime time horizon, while potentially identifying and treating adverse events more effectively. These findings suggest that the GFC may be a cost-effective option over the lifetime of a geriatric patient with hip fracture, although future research is needed to further validate these findings. LEVEL OF EVIDENCE: Economic, level 2. TRIAL REGISTRATION NUMBER: NCT02297581.

Real-World Evidence on the Efficacy and Tolerability of Tramadol/Dexketoprofen (TRAM/DKP) Fixed-Dose Combination for the Management of Acute Non-surgical Pain in Asian Patients: A Multicentre Retrospective Case Series.

INTRODUCTION: Multimodal analgesia is key in the effective management of acute pain. Previous clinical trials have demonstrated good results with the use of a fixed-dose combination (FDC) of tramadol 75 mg and dexketoprofen 25 mg (TRAM/DKP) in acute pain management. However, there is a dearth of real-world evidence on the efficacy and safety of this combination in the management of acute non-surgical pain, especially among Asian patients. The case series reported herein investigates the real-world experiences of physicians and Asian patients with the use of TRAM/DKP FDC in the management of acute non-surgical pain. METHODS: Data were collected retrospectively on 11 Asian patients across multiple hospitals who had received a short course of TRAM/DKP FDC for acute non-surgical orthopaedic and non-orthopaedic pain. Data on baseline characteristics, medical history, treatment regimen, clinical outcomes, and patient satisfaction were compiled and shared at a peer-to-peer expert meeting in October 2022. RESULTS: All patients experienced a reduction in pain intensity and were very satisfied with pain management, with a mean satisfaction score of 4.3/5. Five patients (range: 63-74 years) experienced mild adverse events, including nausea, vomiting, and dizziness, which resolved with no need for additional treatment in the majority of cases. No serious adverse events were recorded. CONCLUSION: Asian patients with acute non-surgical orthopaedic and non-orthopaedic pain achieved good pain control with TRAM/DKP FDC. The regimen was well tolerated, and patients reported high levels of satisfaction with the outcomes, indicating that TRAM/DKP FDC is an effective choice for the control of acute non-surgical pain in Asian patients.

3D printing in fracture treatment : Current practice and best practice consensus.

The use of 3D printing in orthopedic trauma is supported by clinical evidence. Existing computed tomography (CT) data are exploited for better stereotactic identification of morphological features of the fracture and enhanced surgical planning. Due to complex logistic, technical and resource constraints, deployment of 3D printing is not straightforward from the hospital management perspective. As a result not all trauma surgeons are able to confidently integrate 3D printing into the daily practice. We carried out an expert panel survey on six trauma units which utilized 3D printing routinely. The most frequent indications are acetabular and articular fractures and malalignments. Infrastructure and manpower structure varied between units. The installation of industrial grade machines and dedicated software as well as the use of trained personnel can enhance the capacity and reliability of fracture treatment. Setting up interdisciplinary jointly used 3d printing departments with sound financial and management structures may improve sustainability. The sometimes substantial logistic and technical barriers which impede the rapid delivery of 3D printed models are discussed.

[3D printing in fracture treatment : Current practice and best practice consensus]. / 3D-Druck in der Frakturversorgung : Aktuelle Praxis und "Best-practice"-Konsens.

The use of 3D printing in orthopedic trauma is supported by clinical evidence. Existing computed tomography (CT) data are exploited for better stereotactic identification of morphological features of the fracture and enhanced surgical planning. Due to complex logistic, technical and resource constraints, deployment of 3D printing is not straightforward from the hospital management perspective. As a result not all trauma surgeons are able to confidently integrate 3D printing into the daily practice. We carried out an expert panel survey on six trauma units which utilized 3D printing routinely. The most frequent indications are acetabular and articular fractures and malalignments. Infrastructure and manpower structure varied between units. The installation of industrial grade machines and dedicated software as well as the use of trained personnel can enhance the capacity and reliability of fracture treatment. Setting up interdisciplinary jointly used 3d printing departments with sound financial and management structures may improve sustainability. The sometimes substantial logistic and technical barriers which impede the rapid delivery of 3D printed models are discussed.

Geriatric fracture centre vs usual care after proximal femur fracture in older patients: what are the benefits? Results of a large international prospective multicentre study.

OBJECTIVE: The aim of this study was to determine the effect of treatment in geriatric fracture centres (GFC) on the incidence of major adverse events (MAEs) in patients with hip fractures compared with usual care centres (UCC). Secondary objectives included hospital-workflow and mobility-related outcomes. DESIGN: Cohort study recruiting patients between June 2015 and January 2017. Follow-up was 1 year. SETTING: International (six countries, three continents) multicentre study. PARTICIPANTS: 281 patients aged ≥70 with operatively treated proximal femur fractures. INTERVENTIONS: Treatment in UCCs (n=139) or GFCs (n=142), that is, interdisciplinary treatment including regular geriatric consultation and daily physiotherapy. OUTCOME MEASURES: Primary outcome was occurrence of prespecified MAEs, including delirium. Secondary outcomes included any other adverse events, time to surgery, time in acute ward, 1-year mortality, mobility, and quality of life. RESULTS: Patients treated in GFCs (n=142) had a mean age of 81.9 (SD, 6.6) years versus 83.9 (SD 6.9) years in patients (n=139) treated in UCCs (p=0.013) and a higher mean Charlson Comorbidity Index of 2.0 (SD, 2.1) versus 1.2 (SD, 1.5) in UCCs (p=0.001). More patients in GFCs (28.2%) experienced an MAE during the first year after surgery compared with UCCs (7.9%) with an OR of 4.56 (95% CI 2.23 to 9.34, p<0.001). Analysing individual MAEs, this was significant for pneumonia (GFC: 9.2%; UCC: 2.9%; OR, 3.40 (95% CI 1.08 to 10.70), p=0.027) and delirium (GFC: 11.3%; UCC: 2.2%, OR, 5.76 (95% CI 1.64 to 20.23), p=0.002). CONCLUSIONS: Contrary to our study hypothesis, the rate of MAEs was higher in GFCs than in UCCs. Delirium was revealed as a main contributor. Most likely, this was based on improved detection rather than a truly elevated incidence, which we interpret as positive effect of geriatric comanagement. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov: NCT02297581.