Introduction
The cortical thickness index (CTI) is a radiological measure and correlates with diminishing local bone quality in the proximal femur. The aim of this study was to evaluate if a lower CTI is associated with a higher rate of peri- and postoperative surgical complications.
Material & Methods
A total of 228 prospectively enrolled patients treated with endomedullary nailing for trochanteric fracture (TFx) (AO/OTA 31A1.1 - 31A2.3) (n = 99) and hemi-/total hip arthroplasty für femoral neck fracture (AO/OTA 31B1-B3) (FNFx) (n = 129) with a mean age of 82 9.9 (50 - 99) years were reviewed. These cases were evaluated after a mean follow-up of 83 106 (1 - 450) days for surgery-related complications. Eighteen cases (7.9%) of complications undergoing revision surgery were identified. Patient demographics and radiographic measurements of these groups were compared to the cases without complications (n = 210) and statistically analysed.
Results
Of the 18 patients undergoing revision surgery, ten (55.6 %) demonstrated a biomechanical complication. Eight cases were revised due to infection (n = 4), seroma/hematoma (n = 3) or a running wound (n = 1). In the FNFx group no intraoperative fracture but two traumatic periprosthetic fractures occurred after a fall 59 and 36 days postoperatively. In the TFx group five cut - ins/outs of the helical blade. Among all analyzed variables, including age, body mass index and hemoglobin level, merely the CTI of the unaffected side in the TFx group was significantly lower in the complications as well as the biomechanical complications group (0.51 ±0.09, 0.58 ±0.05, 0.58 ±0.05; p = 0.029).
Conclusion
Poor local bone quality, indicated by a low CTI, is not associated with increased complication rates following surgically managed proximal femoral fractures. Other factors such as inadequate fracture reduction, improper blade positioning, and technical errors appear to be the primary contributors to biomechanical complications.
Background: Sepsis is a leading cause of mortality in polytrauma patients, especially beyond the first week, and its management is vital for reducing multiorgan failure and improving survival rates. This is particularly critical in geriatric polytrauma patients due to factors such as age-related physiological alterations and weakened immune systems. This study aimed to investigate various clinical and laboratory parameters associated with sepsis in polytrauma patients aged < 65 years and ≥ 65 years, with the secondary objective of comparing sources of infection in these patient groups.
Methods: A retrospective cohort study was conducted at the University Hospital Zurich from August 1996 to December 2012. Participants included trauma patients aged ≥ 16 years with an Injury Severity Score (ISS) ≥ 16 who were diagnosed with sepsis within 31 days of admission. Patients in the age groups < 65 and ≥ 65 years were compared in terms of sepsis development. The parameters examined included patient and clinical data as well as laboratory values. The statistical methods encompassed group comparisons with Welch’s t-test and logistic regression.
Results: A total of 3059 polytrauma patients were included in the final study. The median age in the group < 65 years was 37 years, with a median ISS of 28. In the patient group ≥ 65 years, the median age was 75 years, with a median ISS of 27. Blunt trauma mechanism, ISS, leucocytosis at admission, and anaemia at admission were associated with sepsis in younger patients but not in geriatric patients, whereas sex, pH at admission, lactate at admission, and Quick values at admission were not significantly linked with sepsis in either age group. Pneumonia was the most common cause of sepsis in both age groups.
Discussion: Various parameters linked to sepsis in younger polytrauma patients do not necessarily correlate with sepsis in geriatric individuals with polytrauma. Hence, it becomes critical to recognize imminent danger, particularly in geriatric patients. In this context, the principle of "HIT HARD and HIT EARLY" is highly important as a proactive approach to effectively address sepsis in the geriatric trauma population, including the preclinical setting.
INTRODUCTION
(Periprosthetic) acetabular fractures are increasingly common in the elderly population. While stable, undisplaced fractures are usually treated non-operatively, unstable and displaced fractures may require surgery. If fracture morphology and/or poor bone quality do not allow for a stable, anatomical reconstruction, a combined approach with internal fixation and total hip arthroplasty (THA) is indicated to ensure stable fixation of the cup. To minimize the surgical burden and to allow immediate full weight bearing, navigated percutaneous screw fixation of the anterior and posterior columns combined with THA (npSFTHA) was introduced at our institution in 2020. For periprosthetic fractures, column screw fixation was combined with revision THA. The aim of our study was to evaluate PROMs and the radiological outcomes.
METHODS
Retrospective single-centre study including all patients ≥60 years treated with npSFTHA between January 2020 and December 2023. Full weight bearing was encouraged in all patients immediately after surgery. ASA score, intraoperative blood loss, complications, and re-interventions were recorded. Analysis also included PROMs, walking abilities, the level of independence and radiographs. Data are presented as median values and range.
RESULTS
Forty-one patients (age 84 years (61-95) were eligible for inclusion. ASA score ≥3 was recorded in 36 patients (88%). Intraoperative blood loss was 600 mL (200-2700). Thirty-day mortality was 5%. One patient (2%) had a large seroma evacuated after 1 month, 2 other patients (5%) had revision for periprosthetic infections ≥10 months after the initial surgery. PROMs were available for 21 patients (51%) at a follow-up of 11 months (2-49). Death precluded data collection in 8 (20%), while cognitive impairment affected 11 patients (27%). One patient could not be contacted. EQ-5D-5L Index was 0.91 (0.22-1.00). EQ-VAS was 80 (0-100). FJS was 93 (2-100). Thirty-three patients (81%) returned to the same level of independence after surgery, with 32 patients (78%) still living at home. Pre-injury levels of walking abilities were regained by 32 patients (78%). Radiographic follow-up was available for 32 patients (78%) after 6 months (2-25) demonstrating a stable cup in 30 cases (94%) whereas loosening was observed in 2 patients (6%).
CONCLUSION
NpSFTHA was successful in the vast majority of our study group, with good restoration of walking abilities, quality of life, and of the level of independence.
Introduction
Minimal-invasive placement of a trans-sacral screw represents an increasingly popular method of fixation for Fragility Fractures of the Pelvis (FFP), with variable upper sacral anatomy representing the main challenge. Little is known about the variability of sacral anatomy in the geriatric population and the potential effect of osteoporosis on the upper sacral anatomy and thus S1 corridor morphology. Our aim was to examine the eligibility ( > 12 mm) of the S1 corridor for the trans-sacral screw placement in a geriatric population and to analyse what pelvic dysmorphism signs might serve as predictors for an ineligible S1 corridor.
Methods
We analysed S1 corridor in pelvic CT scans of 107 geriatric patients without history of fracture or other pelvic pathology. First, the eligibility for the trans-sacral screw placement was determined by measuring the width and the height of the central portion of the S1 corridor. Then, pelvises were examined for signs of dysmorphism. The correlation of these signs with the ineligible S1 corridor was analysed.
Results
In our geriatric population with average age of 79,55 ± 8.79 years (male:female 0.88) 44% of S1 corridors were not eligible for a trans-sacral screw. In this ineligible group the height was shown to be a more significant limiting dimension (90,9%), compared to the width in 68,2% (p < 0.05). Mamillary processes, not recessed sacrum and dysmorphic sacral foramina were present in 38,3%, 34,6%, and 26,2% respectively, with not recessed sacrum demonstrating a significant correlation with a too narrow S1 corridor (p < 0.05).
Conclusion
The analysed geriatric population demonstrates a high prevalence of a too narrow S1 corridor, which makes a placement of a trans-sacral screw risky or even impossible. The height of the S1 corridor represents the main limiting factor with a dysmorphism sign of a not recessed sacrum being a significant predictor for the ineligible S1 corridor.
Objectives: To investigate the usefulness of the routinely planned six week outpatient visit and X-ray in patients treated surgically for the most common upper extremity fractures including clavicula, proximal hu-merus, humerus shaft, olecranon, radial shaft and distal radius.
Method: This was a retrospective snapshot study of all patients treated surgically for the most common upper extremity fractures between 2019 and 2022 in a level 1 trauma center. The first outcome of interest was the incidence of abnormalities found on the X-ray made at the 6-weeks outpatient visit. Ab-normalities were defined as all differences between the intra-operative (or direct postoperative) and 6-weeks X-ray. In case an abnormality was detected, the hospital records were screened to deter-mine its clinical consequence. The clinical consequences were categorized into requiring either addi-tional diagnostics, additional interventions, change of standard postoperative immobilization, weightbearing or allowed range of motion (ROM). The second outcome of interest was the inci-dence of deviations from the local standard post operative treatment and follow-up protocol based on the 6-weeks outpatient visit as a whole. Deviations were also categorized into either requiring additional diagnostics, additional interventions, change of standard postoperative immobilization, weightbearing or allowed range of motion.
Results; A total of 267 patients were included. Abnormalities on X-ray at 6-weeks were found in only 10 (3.7%) patients of which only 4 (1.5%) had clinical implications (in three patients extra imaging was required and in one patient it was necessary to deviate from standard weightbearing/ROM limita-tion regime). The clinical/radiological findings during the 6-weeks outpatient visit led to a deviation from standard in only 8 (3.0%) patients. Notably, the majority of these patients experienced symp-toms suggestive for complications.
Conclusion; The routine 6-weeks outpatient visit and X-ray, after surgery for common upper extremity fractures, rarely has clinical consequences. It should be questioned whether these routine visits are necessary and whether a more selective approach should be considered.
Introduction
Percutaneous sacroiliac screw placement is a challenging procedure in patients with pelvic fractures. To overcome these challenges, navigated techniques have emerged as an alternative to conventional 2D fluoroscopy for guiding screw placement. However, it remains to be seen whether navigated techniques truly have a beneficial effect on accuracy, radiation exposure and occurrence of complications. Therefore, a meta-analysis was performed to investigate these aspects.
Methods
The electronic databases were searched for both randomized clinical trials and observational studies comparing percutaneous sacroiliac screw fixation with 2D fluoroscopy to new navigated techniques. Effects were pooled and presented as odds ratio, mean difference and standardized mean difference with corresponding 95% confidence interval.
Results
In total 18 studies were included. New navigated techniques had a higher accuracy (OR 2.39, 95% CI 1.49;3.83). Also, fluoroscopy time (MD 72.13 seconds, 95% CI 7.73;92.91) and fluoroscopy frequency (MD 17.22 images in total, 95% CI 7.73;26.70) were lower for new navigated techniques. Radiation dose was higher for new navigated techniques (SMD 0.50, 95% CI 0.01;0.99). Surgery duration showed no significant difference. Similar results were found among in vitro studies. Complications were rare in both groups.
Conclusion
This meta-analysis demonstrated a higher accuracy of screw positioning, lower fluoroscopic frequency and time for navigated percutaneous sacroiliac screw fixation compared to conventional 2D fluoroscopy. Complications are acceptably low for both groups. Future studies should focus on which of the navigated techniques is the best and whether the implementation costs of a new technique outweigh its benefits.
Introduction: Trochanteric fractures are one of the most frequent fractures, affecting especially geriatric patients. Despite well-established treatment standards, complication rates remain high, not only due to general medical reasons, but also due to implant-related reasons. This retrospective study was set up to compare the complication rates of two different cephalomedullary nails (CMN) of the same manufacturer.
Methods: Patient identification was done through a keyword search of the electronic patient file database of a single institution, using the ICD-10 codes S72.XX between January 2017 and July 2021. The cases thus identified were then screened manually for the use of CMN. The study population was than separated in two groups using either the PFN-A or the TFN-A. Outcome parameters were all kind of reoperations, conversion to total hip arthroplasty (THA), and patient survival. Reoperations were differentiated as minor reoperation (any reoperation without exchange of any components, minor revision (exchange of cervical blade/screw only, definitive implant removal) or major revision (reosteosynthesis, conversion to THA). Furthermore, patient demographics, implant specifications and reasons for reoperation were collected. Fractures were classified according to the AO/ASIF classification. Quality of reduction and fixation were classified using the Baumgartner criteria, the Cleveland zones and the tip-apex-distance.
Results: In total 475 cases of CMN were detected, in 248 cases the PFN-A and in 244 the TFN-A was used. There were no differences between both groups regarding demographics, quality of reduction and fixation, and AO/ASIF classification. Reoperation and revision occurred mainly early, within less than a year. Overall, 75 (15,24%) reoperations were recorded with 33 (13.31%) in the PFN-A group and 42 (17.21%) in the TFN-A group. Higher rates of major revisions (2.02% vs. 7.38%) and implant failure were detected for the TFN-A group. Concerning nail specifications, the standard caput-collum-diaphyseal (CCD) was 130° in the TFN-A, whereas it was 125° in the PFN-A. The TFN-A was made of titanium, whereas the PFN-A was made of stainless steel.
Discussion: Reoperations, respectively conversion to THA were necessary mainly during the first month after internal fixation with CMN. In this cohort, the newer TFN-A seems to have a higher rate of major complications, such as nail breakage and cut-through/out/in, compared to the older PFN-A.
Background: Treatment of humeral greater tuberosity fractures is controversial. Besides a potentially altered function of the attached tendons, impingement of the dislocated fragment with the acromion potentially affects the shoulder's range of motion. CT-based 3D shoulder motion simulation could help predict potential impingement and facilitate choosing an appropriate treatment strategy.
Material and Methods: Shoulder CT scans of 27 patients suffering from greater tuberosity fractures were evaluated retrospectively. Mean age was 47 years, 66% of all patients were male, and nine patients underwent surgery. Bone segmentation was performed to generate patient-specific 3D models. Osseous shoulder motion simulations using the 3D models were generated. Osseus contact points (impingement location) were evaluated and compared to a control group with intact bones. Fracture displacement was measured on conventional plain film radiographs with three established methods and correlated to the shoulder motion simulations.
Results: Bone Segmentation and shoulder motion simulation were feasible for all analyzed cases. Nine patients with displaced GT fractures had significantly (p < 0.001) decreased simulated abduction (76°) compared to controls (96°). In these cases, subacromial impingement of the displaced GT fragment was noted in 5 of 9 patients (compared to none in the control group). Of the established conventional measurement techniques, only superior fragment displacement correlated with limited abduction (p = 0.01).
Discussion: Shoulder motion simulation using CT-based 3D models is feasible and allows visualizing the anatomical location of the bony impingement. In our dataset, established measurement techniques correlated with limited abduction. 3D shoulder motion simulations might facilitate decision-making for treating greater tuberosity fractures.
ABSTRACT
Background: Optimal treatment (i.e. nonoperative or operative) for patients with multiple rib fractures remains debated. Studies that compare treatments are rationalized by the alleged poor outcomes of nonoperative treatment.
Methods: The aim of this prospective international multicenter cohort study (between January 2018 and March 2021) with one-year follow-up, was to report contemporary outcomes of nonoperatively treated patients with multiple rib fractures. Including 845 patients with three or more rib fractures. Primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay (HLOS), (pulmonary) complications, and quality of life.
Results: Mean age was 57.7 ±17.0 years, median Injury Severity Score was 17 (13-22) and the median number of rib fractures was 6 (4-8). In-hospital mortality rate was 1.5% (n=13), 112 (13.3%) patients had pneumonia and four (0.5%) patients developed a symptomatic non-union. The median HLOS was 7 (4-13) days, and median intensive care unit length of stay was 2 (1-5) days. Mean EQ-5D-5L index value was 0.83 ±0.18 one year after trauma. Polytrauma patients had a median HLOS of 10 (6-18) days, a pneumonia rate of 17.6% (n=77) and mortality rate of 1.7% (n=7). Elderly patients (65 years) had a median HLOS of 9 (5-15) days, a pneumonia rate of 19.7% (n=57) and mortality rate of 4.1% (n=12).
Conclusions: Overall, nonoperative treatment of patients with multiple rib fractures shows low mortality and morbidity rate and good quality of life after one year. Future studies evaluating the benefit of operative stabilisation should use contemporary outcomes to establish the therapeutic margin of rib fixation.
Level of evidence: Level III, Therapeutic/Care Management.
Keywords: Multiple rib fractures; conservative treatment; nonoperative treatment; quality of life; mortality; pneumonia rate
Triaging is pivotal in the treatment of polytrauma patients. The Watson Trauma Pathway Explorer ® is an outcome prediction tool invented by the University Hospital of Zurich (European Level 1 Trauma Centre) in collaboration with IBM®, representing an artificial intelligence application to predict the most adverse outcome scenarios in polytrauma patients: Systemic Inflammatory Respiratory Syndrome (SIRS), sepsis and death within 21 days.
The question was how the early values of pH, Base excess (BE) and lactate would be associated with the incidence of death.
Data from 3653 patients in an internal database, with ongoing implementation, served for analysis. Patients were split in two groups according to the occurrence of death within 21 days.
pH, BE and lactate values were measured at formerly defined time points up until 48h after admission for both groups. Differences between groups were analyzed. The three laboratory parameters were tested as independent predictors for death at each time point, corrected for age, gender and ISS. The level of significance was set at p < 0.05.
The mortality rate was 26.9% (n = 981), with 9.9% (n = 361) of all patients dying within < 24h after admission to the trauma bay.
Group differences existed for the first 4h for pH, and continuously for BE and lactate. pH and BE at 4h were independent predictors for mortality (p = 0.037, respectively). For Lactate, this was true at 48h (p = 0.023).
The insights reporting very early, time-dependent differences in common laboratory parameters may be helpful in risk estimation of polytrauma patients, which could affect the decision on the extent of surgical treatment.
Introduction
Vascular compromise due to arterial injury is a rare but serious complication following proximal humerus fracture (PHF). We aimed to establish its incidence in a large urban population, and to identify clinical and radiographic predictors for this complication. We also evaluated the results of our protocol for treatment of these injuries.
Methods
A total of 3,515 adult patients (mean age 70 years, 72% female) with PHF were managed between 2015 and 2022 in a single tertiary trauma centre. We compared the demographics, clinical features and fracture configuration of patients with PHFs complicated by vascular compromise, with the remainder of the fracture population. The incidence of this complication was calculated from national population data and predictive factors for its occurrence were identified using multivariable regression analysis.
Results
During the study period, 18 patients (0.5%) sustained PHF with clinical evidence of vascular compromise giving an annual population incidence of 0.31 per 100,000. Their mean age was 68.7 (45-92) years and 10 (56%) were females. Multivariable analysis identified complete separation of the proximal shaft from the head with medial displacement (p < 0.001, OR 91.6)) and evidence of mixed pattern neurological deficit (brachial plexus palsy) (p =< 0.001, OR 683.8) as strong independent predictors of vascular compromise. Male gender was also more weakly associated with an increased risk of this complication (p = 0.04, OR 5.9). A policy of fracture reduction and reconstruction prior to any vascular surgical intervention was associated with favourable post-operative outcomes and the absence of vascular sequelae.
Conclusion
The classic signs of distal limb ischaemia are often absent in patients with proximal major vessel injury. Our study identified specific clinical and radiographic “red flags” which, when used in combination, it should increase the suspicion of a fracture with associated vascular injury and facilitate early diagnosis and intervention.
Introduction
Acetabular fractures in patients over 60 years-old are being increasingly observed. Postoperative weight-bearing protocols, such as non-weight bearing (NWB), partial weight bearing (PWB), or full weight bearing (FWB) are commonly selected after acetabular fractures open reduction and internal fixation (ORIF). NWB and PWB can increase post-operative complications as venous thromboembolism or infections, and are difficult to respect by elderly patients. FWB can theoretically displace the reduction. This study aims to compare outcomes among elderly patients undergoing acetabular fractures ORIF based on three distinct immediate postoperative weight-bearing protocols.
Method
Fifty-nine patients, aged 60 years and above, who underwent surgical treatment by ORIF for acetabular fractures, were retrospectively reviewed. Patients were categorized into three groups according to their postoperative weight-bearing protocol: FWB group (N=12; 20.4%), NWB group (N=11; 18.6%) and PWB group (N=36; 61%). Patient characteristics, clinical outcomes, and complications were assessed using medical records. Radiological outcomes were evaluated on preoperative and postoperative CT scans, as well as postoperative radiographs obtained during follow-up.
Results
The mean age of the cohort was 81 years (range: 60-95), with 47 males (70.1%). Charlson comorbidity index (CCI) and ASA score were slightly higher in FWB group. Associated fracture patterns, according to Letournel classification, were identified in 91.7% (N=11), 54.5% (N=5) and 77.8% (N=28) for FWB, NWB and PWB groups, respectively. There was no significant difference observed in terms of postoperative medical complications (42%, 45% and 46%, respectively). However, severe postoperative complications were slightly higher in the PWB group (14%; N=5) compared to the FWB group and NWB group (8% and 9%, respectively). There was no secondary displacement during follow-up assessments in the FWB group. Secondary THA procedure, due to symptomatic secondary hip arthritis, were performed in 8.1% for FWB group, 41.6% for NWB group and 13.9% for PWB group.
Conclusions
These results suggest that implementing an immediate postoperative full weight-bearing protocol may provide favorable outcomes in terms of medical complication rates and secondary THA requirements compared to partial weight-bearing, in particularly in elderly patients sustaining acetabular ORIF fractures.
Purpose: The pararectus approach is used more and more frequently, especially due to the increase of fractures of the acetabulum in old age concerning the anterior pillar as well as the quadrilateral surface. Coagulation of the iliolumbar vessels results in significantly reduced blood loss, but their morphology is highly variable and poorly studied lateral to the obturator nerve.
Material and Methods: Twelve body halves below L5 of six cadavers were examined. An extraperitoneal approach anterior to the psoas muscle to the sacroiliac joint (SIJ) was chosen. Here, the iliolumbar vessels lateral to the obturator nerve at the level of the SIJ were dissected and their position in relation to the anterior margin of the sacrum was measured. Afterwards, a dissection was performed further laterally between the psoas muscle and the iliac muscle; here, too, the iliolumbar vessels were dissected and their position in relation to the anterior margin of the sacrum was measured.
Results: A median of 4 iliolumbar vessels (range 3-5) were found at the level of the SIJ lateral to the obturator nerve, from 0 - 52 mm (mean 24mm) cranial to the anterior ala of the sacrum. A median of two iliolumbar vessel were found between the psoas and iliac muscles (range 1 - 4), at an average height of 21.4mm cranial to the anterior sacrum (range 5 - 42 mm).
Conclusions: The anatomic location and number of iliolumbar vessels in pararectus approach are highly variable and must be considered in its dissection.
Introduction
Distal clavicle fractures are typically classified according to their location relative to the coracoclavicular ligaments, on anteroposterior (AP) and 30° cephalic tilt radiographic views. Surgical intervention is advised for unstable or displaced fractures. However, reported consensus among clinicians using these views remains poor. The aim of this study was to assess the potential benefits of panorama, axial, and Alexander views in enhancing consensus among clinicians when evaluating distal clavicle fractures.
Methods
Thirty cases of distal clavicle fractures were evaluated by six observers, including two fellowship-trained shoulder surgeons, two fellowship-trained trauma surgeons, and two orthopedic residents. On AP and 30° cephalic tilt radiographs, evaluators categorized the fractures according to the Neer and AO classifications and evaluated displacement. On the panorama view, measurements focused on coracoclavicular distance (CCD), fracture angle (FA), and assessment of displacement. Axial view measurements included posterior displacement (PD), displacement ratio (PDR), fracture angle (FAA), and displacement assessment. Evaluation of the Alexander view involved dynamic displacement (DD) inspired by circle measurement and displacement assessment. Weighted kappa (k) and intraclass correlation coefficient (ICC) were used to quantify agreement among observers.
Results
Interrater agreement was substantial for Neer classification (k=0.78, p < 0.003) and moderate for AO classification (k=0.57, p=0.004). ICC were strong for CCD (0.87, p < 0.001), moderate for FA (0.69, p < 0.001), moderate for PD (0.64, p < 0.001), moderate for PDR (0.47, p < 0.001), weak for FAA (0.11, p=0.02) and strong for DD (0.71, p < 0.001). Interrater agreement for displacement were substantial on standard view (k=0.68, p < 0.001) and panorama view (k=0.73, p > 0.001), fair on axial view (k=0.38, p=0.23) and moderate for Alexander view (k=0.53, p=0.19).
Conclusion
The panorama view showed superior interobserver agreement for interpreting displacement compared to AP and 30° cephalic tilt X-rays, making it a valuable addition to standard radiographic work-up. Conversely, due to only fair to moderate agreement on axial and Alexander views, we do not recommend their systematic use when evaluating distal clavicle fractures.