A comprehensive analysis of intraoperative factors associated with acute-on-chronic kidney injury in elderly trauma patients: blood loss as a key predictor.

BACKGROUND: Postoperative acute kidney injury (AKI) is a critical issue in geriatric patients with pre-existing chronic kidney disease (CKD) undergoing orthopedic trauma surgery. The goal of this study was to investigate modifiable intraoperative risk factors for AKI. METHODS: A retrospective study was conducted on 206 geriatric patients with CKD, who underwent orthopedic trauma surgery. Several variables, including intraoperative blood loss, postoperative hypoalbuminemia, intraoperative blood pressure and long-term use of potentially nephrotoxic drugs, were analyzed. RESULTS: Postoperative AKI (KIDGO) was observed in 25.2% of the patients. The 1-year mortality rate increased significantly from 26.7% to 30.8% in patients who developed AKI. Primary risk factors for AKI were blood loss (p < 0.001), postoperative hypoalbuminemia (p = 0.050), and potentially nephrotoxic drugs prior to admission (angiotensin-converting enzyme inhibitors, angiotensin-II receptor antagonists, diuretics, antibiotics, NSAIDs) (p = 0.003). Furthermore, the AKI stage negatively correlated with propofol dose per body weight (p = 0.001) and there was a significant association between AKI and the use of cement (p = 0.027). No significant association between intraoperative hypotension and AKI was observed in any statistical test. Femur fracture surgeries showed the greatest blood loss (524mL ± 357mL, p = 0.005), particularly intramedullary nailing at the proximal femur (598mL ± 395mL) and revision surgery (769mL ± 436mL). CONCLUSION: In geriatric trauma patients with pre-existing CKD, intraoperative blood loss, postoperative hypoalbuminemia, and pre-admission use of potentially nephrotoxic drugs are associated with postoperative AKI. The findings highlight the necessity to mitigate intraoperative blood loss and promote ortho-geriatric co-management to reduce the incidence and subsequent mortality in this high-risk population.

Are pre- and postoperative true translational and angular displacement predictive of nonunion after intramedullary nail fixation of tibial shaft fractures?

PURPOSE: To determine if there is an association between pre-/postoperative translational and angular displacement with nonunion after intramedullary nail (IMN) fixation of tibial shaft fractures. METHODS: Retrospective review of 120 patients with tibial shaft fractures undergoing IMN at an urban level-one trauma center was performed. Demographics, injury characteristics, and pre-/postoperative translational and angular fracture displacement in the coronal and sagittal planes were recorded. True fracture translational and angular displacement (TTD and TAD) were calculated by combining sagittal and coronal displacement utilizing the Pythagorean theorem. RESULTS: 10.8% of patients (n = 13) developed nonunion with remaining patients serving as the control. Groups were similar across age, sex, and BMI. Univariate analysis revealed no difference in pre-/postoperative TAD between nonunion and union groups and an increased preoperative TTD (median difference (MD): 6.2 mm, CI: 1.4-10.8 mm) and postoperative TTD (MD: 1.8 mm, CI: 0-3.7 mm) in the nonunion group. On multivariate analysis, however, only tobacco use and type 2 or 3 open fractures were associated with nonunion (OR: 5.1, CI: 1.2-22.8 and OR: 4.9, CI: 1.2-19.2, respectively). CONCLUSION: True translational and angular displacement of tibial shaft fractures before and after IMN fixation were not independently associated with nonunion. Tobacco use and type 2 or 3 open fracture are independent factors for nonunion.

Pelvic ring injuries after alpine ski and snowboard accidents.

PURPOSE: The purpose of this study was to analyze the patient/injury characteristics and associated hospital course of patients sustaining traumatic pelvic ring injuries after alpine ski and snowboard accidents at a level one trauma center in the Rocky Mountain region. METHODS: Patient/injury characteristics were obtained from patients presenting with pelvic ring injuries after alpine ski (n = 55) and snowboard (n = 9) accidents. Characteristics and outcomes analyzed included mechanism of injury, pelvic ring classification (Young-Burgess and Tile), hospital admission, physical therapy (PT) clearance, ambulation, length of stay, inpatient morphine milligram equivalents (MME), and discharges to rehabilitation facility. RESULTS: Snowboarders were more often younger, male, tobacco/substance users, and more likely to be injured by a fall from height than skiers. There were no differences in injury classification or hospital course outcomes between alpine sports. Most common injuries included lateral compression type 1 (LC1) injuries (37.5%), isolated pubic ramus fractures (31.3%), and isolated iliac wing fractures (15.6%). LC1 injuries were unstable in 50% of cases and associated with increased admissions (proportional difference: 47.5%, CI: 23.8-64.5%, p = 0.0002), longer time to PT clearance (median difference(MD): 1.0 day, CI: 0-2.0, p = 0.03), longer LOS (MD: 2.0, CI: 0-2.0, p = 0.02), and increased inpatient MMEs (MD: 197.9 MME, CI: 30.0-420.0, p = 0.02), as compared to other pelvic ring injuries. CONCLUSION: The majority of pelvic ring injuries from alpine ski and snowboard accidents were LC1 injuries, half of which were unstable, resulting in longer hospital stays, time to PT clearance/ambulation, and opioid use.

Experimental and virtual testing of bone-implant systems equipped with the AO Fracture Monitor with regard to interfragmentary movement.

Introduction: The management of fractured bones is a key domain within orthopedic trauma surgery, with the prevention of delayed healing and non-unions forming a core challenge. This study evaluates the efficacy of the AO Fracture Monitor in conjunction with biomechanical simulations to better understand the local mechanics of fracture gaps, which is crucial for comprehending mechanotransduction, a key factor in bone healing. Through a series of experiments and corresponding simulations, the study tests four hypotheses to determine the relationship between physical measurements and the predictive power of biomechanical models. Methods: Employing the AO Fracture Monitor and Digital Image Correlation techniques, the study demonstrates a significant correlation between the surface strain of implants and interfragmentary movements. This provides a foundation for utilizing one-dimensional AO Fracture Monitor measurements to predict three-dimensional fracture behavior, thereby linking mechanical loading with fracture gap dynamics. Moreover, the research establishes that finite element simulations of bone-implant systems can be effectively validated using experimental data, underpinning the accuracy of simulations in replicating physical behaviors. Results and Discussion: The findings endorse the combined use of monitoring technologies and simulations to infer the local mechanical conditions at the fracture site, offering a potential leap in personalized therapy for bone healing. Clinically, this approach can enhance treatment outcomes by refining the assessment precision in trauma trials, fostering the early detection of healing disturbances, and guiding improvements in future implant design. Ultimately, this study paves the way for more sophisticated patient monitoring and tailored interventions, promising to elevate the standard of care in orthopedic trauma surgery.

Artificial intelligence and CT-based 3D statistical modeling to assess transsacral corridors and plan implant positioning.

Transsacral corridors at levels S1 and S2 represent complex osseous spaces allowing percutaneous fixation of non- or minimally-displaced fragility fractures of the sacrum. To safely place transsacral implants, they must be completely intraosseous. However, standard radiographs and CT do not properly demonstrate the corridor's intricate configuration. Our goal was to facilitate the three-dimensional assessment of transsacral corridors using artificial intelligence and the planning of transsacral implant positioning. In total, 100 pelvic CTs (49 women, mean age: 58.6 ± SD 14.8 years; 51 men, mean age: 60.7 ± SD 13 years) were used to compute a 3D statistical model of the pelvic ring. On the basis of morphologic features (=predictors) and principal components scores (=response), regression learners were interactively trained, validated, and tuned to predict/sample personalized 3D pelvic models. They were matched via thin-plate spline transformation to a series of 20 pelvic CTs with fragility fractures of the sacrum (18 women and 2 men, age: 69-9.5 years, mean age: 78.65 ± SD 8.4 years). These models demonstrated the availability, dimension, cross-section, and symmetry of transsacral corridors S1 and S2, as well as the planned implant position, dimension, axes, and entry and exit points. The complete intraosseous pathway was controlled in CT reconstructions. We succeeded to establish a workflow determining transsacral corridors S1 and S2 using artificial intelligence and 3D statistical modeling.

The role of virtual and augmented reality in orthopedic trauma surgery: From diagnosis to rehabilitation.

Virtual and augmented reality have been used to assist and improve human capabilities in many fields. Most recent advances allow the usage of these technologies for personal and professional purposes. In particular, they have been progressively introduced in many medical procedures since the last century. Thanks to immersive training systems and a better comprehension of the ongoing procedure, their main objectives are to increase patient safety and decrease recovery time. The current and future possibilities of virtual and augmented reality in the context of bone fracture reduction are the main focus of this review. This medical procedure requires meticulous planning and a complex intervention in many cases, hence becoming a promising candidate to be benefited from this kind of technology. In this paper, we exhaustively analyze the impact of virtual and augmented reality to bone fracture healing, detailing each task from diagnosis to rehabilitation. Our primary goal is to introduce novel researchers to current trends applied to orthopedic trauma surgery, proposing new lines of research. To that end, we propose and evaluate a set of qualitative metrics to highlight the most promising challenges of virtual and augmented reality technologies in this context.

Variability in Trauma Case Volume in Orthopedic Surgery Residents.

Orthopedic trauma surgery is a critical component of resident education. Surgical case logs obtained from the Accreditation Council of Graduate Medical Students from 2009 to 2013 for orthopedic surgery residents were examined for variability between the 90th and 10th percentiles in regards to the volume of cases performed. There was an upward trend in the mean number of cases performed by senior residents from 484.4 in 2009 to 534.5 in 2013, representing a 10.3% increase. There was a statistically significant increase in the number of cases performed for humerus/elbow, forearm/wrist, and pelvis/hip during this period (P<0.05). Although the difference between the 10th and 90th percentile case volumes narrowed over the study period, the difference between these groups remained significant in 2013 (P=0.02). In 2013, all categories of trauma cases had a greater than 2.2-fold difference between the 10th and 90th percentile of residents for numbers of trauma cases performed. Although case volume is not the sole determinant of residency education and competency, evidence suggests that case volume plays a crucial role in surgeon confidence and efficiency in performing surgery. Further studies are needed to better understand the effect of this variability seen among residents performing orthopedic trauma surgery.