Journal of Orthopaedic Trauma

Feed Category: 

Two-Stage Combined Ortho-Plastic Management of Type IIIB Open Diaphyseal Tibial Fractures Requiring Flap Coverage: Is the Timing of Debridement and Coverage Associated With Outcomes?

imageObjective:
To delineate whether timing to initial debridement and definitive treatment had an effect on patient outcomes in those undergoing 2-stage ortho-plastic management of Gustilo–Anderson type IIIB open tibial diaphyseal fractures.
Design:
Retrospective comparative cohort study over a 2-year period.
Setting:
Level 1 trauma center.
Patients/Participants:
A total of 148 patients were identified. After exclusion of ankle fractures, nondiaphyseal fractures and those who did not undergo 2-stage ortho-plastic management, 45 patients were eligible for final analysis.
Intervention:
Time to initial debridement and definitive management.
Main Outcome Measurement:
Deep infection. Secondary outcomes being nonunion and flap failure. Multiple linear regression was used for outcomes. We assumed a priori that P values of less than 0.05 were significant.
Results:
Mean age was 54 years (SD 23.0), with 28 men and 17 women. Over a mean 2-year follow-up, there were 4 (4/45) deep infections, 2 infection-associated flap failures, and 1 vascular flap failure. All patients progressed to union. The mean time to initial debridement for the whole cohort was 19 hours (SD 12.3), and the mean time to definitive reconstruction was 65 hours (SD 51.7). Longer time to both initial debridement and definitive reconstruction was not found to be significantly associated with deep infection, infected flap failure, or nonunion.
Conclusions:
Using a 2-stage ortho-plastic operative algorithm, timing to initial debridement and definitive fixation with soft-tissue coverage was not associated with negative outcomes.
Level of Evidence:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Feed Item Url: 
https://journals.lww.com/jorthotrauma/Fulltext/2019/12000/Two_Stage_Combined_Ortho_Plastic_Management_of.1.aspx

The Far Side Opposite the Surgeon is Most Prone to Contamination From the C-Arm

imageObjective:
Fluoroscopy is used in many orthopaedic procedures. The C-Arm drape is known to be easily contaminated during orthogonal imaging. However, it is unknown if one area of the operative field is more prone to contamination than another. The purpose of this study was to determine if secondary transfer of contaminate from the undraped portion of the C-Arm occurs.
Methods:
A C-Arm was utilized with standardized draping in a simulated operating room. We used a simulated contaminant: a fluorescent powder that phosphoresces under ultraviolet light. The powder was placed over nonsterile portions. A darkened room with a black light, and a camera was used. C-Arm movements were simulated by cycling through lateral to Anteroposterior imaging. Images were taken before (control) and after cycles of orthogonal imaging. The change in light intensity was quantified at each time point over each area as a percentage of change.
Results:
Contamination of the surgical field was observed in all areas after 15 cycles, with the area adjacent to the C-Arm being most pronounced. A linear increase in intensity with increased cycles was observed (R2 = 0.297; P = 0.036), with the mean increase in intensity of 5% after 15 cycles (95% confidence interval, 1.97–7.86). The remaining areas (closest to surgeon and middle) showed an increase as well but were not significant (P > 0.05).
Conclusions:
Secondary contamination of the surgical field from the C-Arm occurs. The area most prone to contamination is the area immediately adjacent to the fluoroscopy unit, usually opposite the surgeon.

Feed Item Url: 
https://journals.lww.com/jorthotrauma/Fulltext/2019/12000/The_Far_Side_Opposite_the_Surgeon_is_Most_Prone_to.17.aspx

Osteomyelitis Risk Factors Related to Combat Trauma Open Upper Extremity Fractures: A Case–Control Analysis

imageObjective:
To determine risk factors for osteomyelitis in US military personnel with combat-related, extremity long bone (humerus, radius, and ulna) open fractures.
Design:
Retrospective observational case–control study.
Setting:
US military regional hospital in Germany and tertiary care military hospitals in the United States (2003–2009).
Patients/Participants:
Sixty-four patients with open upper extremity fractures who met diagnostic osteomyelitis criteria (medical record review verification) were classified as cases. Ninety-six patients with open upper extremity fractures who did not meet osteomyelitis diagnostic criteria were included as controls.
Intervention:
Not applicable.
Main Outcome Measurements:
Multivariable odds ratios (ORs; 95% confidence interval [CI]).
Results:
Among patients with surgical implants, osteomyelitis cases had longer time to definitive orthopaedic surgery compared with controls (median: 26 vs. 11 days; P < 0.001); however, there was no significant difference with timing of radiographic union. Being injured between 2003 and 2006, use of antibiotic beads, Gustilo–Anderson [GA] fracture classification (highest with GA-IIIb: [OR: 22.20; CI: 3.60–136.95]), and Orthopaedic Trauma Association Open Fracture Classification skin variable (highest with extensive degloving [OR: 15.61; CI: 3.25–74.86]) were independently associated with osteomyelitis risk. Initial stabilization occurring outside of the combat zone was associated with reduced risk of osteomyelitis.
Conclusions:
Open upper extremity fractures with severe soft-tissue damage have the highest risk of developing osteomyelitis. The associations with injuries sustained 2003–2006 and location of initial stabilization are likely from evolving trauma system recommendations and practice patterns during the timeframe.
Level of Evidence:
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Feed Item Url: 
https://journals.lww.com/jorthotrauma/Fulltext/2019/12000/Osteomyelitis_Risk_Factors_Related_to_Combat.18.aspx

In Response

No abstract available

Feed Item Url: 
https://journals.lww.com/jorthotrauma/Fulltext/2019/12000/In_Response.3.aspx

Association Between Frailty Status and Odontoid Fractures After Traumatic Falls: Investigation of Varying Injury Mechanisms Among 70 Elderly Odontoid Fracture Patients

imageObjectives:
To determine significant associations between patient frailty status and odontoid fractures across common traumatic mechanisms of injuries (MOIs) in the elderly.
Design:
Retrospective review.
Setting:
Single, academic-affiliated hospital with full surgical services.
Patients/Participants:
Patients 65 years or older with traumatic odontoid fractures were included.
Intervention:
Nonoperative management (soft/hard collar, halo, traction tongs, and Minerva) and/or operative fixation.
Main Outcome Measurements:
Modified frailty index (mFI), MOI, concurrent injuries, inpatient length of stay (LOS), reoperation, and mortality rates.
Results:
Seventy patients were included (80.6 ± 8.5 years, 60% F, 88% European, 10% Maori/Pacific, 1.4% Asian, Charlson Comorbidity Index 5.3 ± 2.2, mFI 0.21 ± 0.15). The most common MOIs were falls (74.3%), high-speed motor vehicle accidents (MVAs) (17.1%), low-speed MVAs (5.7%), and pedestrian versus car (2.9%). Patients with traumatic falls exhibited significantly higher mFI scores (0.25) compared with low-speed MVAs (0.16), high-speed MVAs (0.08), and pedestrian versus car (0.01) (P = 0.003). Twenty-seven patients with odontoid fractures were frail, 33 were prefrail, and 10 were robust. Ninety-two percent of frail patients had a traumatic fall as their MOI, as opposed to 73% of prefrail and 30% of robust patients (P < 0.001). Prefrail and frail patients were 4.3 times more likely than robust patients to present with odontoid fractures through traumatic fall [odds ratio (OR): 4.33 (1.47–12.75), P = 0.008], and frailty increased likelihood of reoperation [OR: 4.2 (1.2–14.75), P = 0.025] and extended LOS [OR: 5.71 (1.05–10.37), P = 0.017]. Frail patients had the highest 30-day (P = 0.017) and 1-year mortality (P < 0.001) compared with other groups.
Conclusion:
Patients with traumatic odontoid fractures from falls were significantly more frail in comparison with any other MOIs, with worse short- and long-term outcomes.
Level of Evidence:
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Feed Item Url: 
https://journals.lww.com/jorthotrauma/Fulltext/2019/12000/Association_Between_Frailty_Status_and_Odontoid.19.aspx

Preperitoneal Pelvic Packing Is Not Associated With an Increased Risk of Surgical Site Infections After Internal Anterior Pelvic Ring Fixation

imageObjective:
To investigate the risk of postoperative surgical site infections after plate fixation of the anterior pelvic ring subsequent to preperitoneal pelvic packing (PPP).
Design:
Retrospective observational cohort study.
Setting:
Level I academic trauma center.
Patients:
Adult trauma patients with unstable pelvic ring injuries requiring surgical fixation of the anterior pelvic ring.
Intervention:
Pelvic plate fixation was performed as a staged procedure after external fixation and PPP/depacking (PPP group; n = 25) or as a single-stage primary internal fixation (control group; n = 87).
Main Outcome Measure:
Incidence of postoperative surgical site infections of the pelvic space.
Results:
Anterior pelvic plate fixation was performed in 112 patients during a 5-year study period. The PPP group had higher injury severity scores and transfused packed red blood cells than the control group (injury severity score: 46 ± 12.2 vs. 29 ± 1.5; packed red blood cells: 13 ± 10 vs. 5 ± 2; P < 0.05). The mean time until pelvic depacking was 1.7 ± 0.6 days (range: 1–3 days) and 3.4 ± 3.7 days (range: 0–15 days) from depacking until pelvic fracture fixation. Two patients in the PPP group and 8 patients in the control group developed a postoperative infection requiring a surgical revision (8.0% vs. 9.2%; n.s.). Both PPP patients with a pelvic space infection had undergone anterior plate fixation for associated acetabular fractures.
Conclusions:
These data support the safety of the PPP protocol for bleeding pelvic ring injuries due to the lack of increased infection rates after fracture fixation. Caution should be applied when considering PPP in patients with associated acetabular fractures.
Level of Evidence:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Feed Item Url: 
https://journals.lww.com/jorthotrauma/Fulltext/2019/12000/Preperitoneal_Pelvic_Packing_Is_Not_Associated.4.aspx

The Longitudinal Short-, Medium-, and Long-Term Functional Recovery After Unstable Pelvic Ring Injuries

imageObjectives:
Describe the trajectory of functional recovery for patients with surgically treated unstable pelvic ring injuries from baseline to 5 years.
Design:
Prospective cohort study.
Setting:
Level I Trauma Center.
Patients/Participants:
One hundred eight adult patients with surgically treated pelvic fractures (72% OTA/AO 61 B1-B3 and 28% OTA/AO 61 C1-C3) were enrolled into the institutions orthopaedic trauma database between 2004 and 2015. The cohort was 78% men with a mean age of 44.9 years and injury severity score of 16.9.
Intervention:
Surgical pelvic stabilization.
Main Outcome Measurements:
Function was measured at baseline and prospectively at 6 months, 1, and 5 years postoperatively using the Short Form–36 Physical Component Score (SF-36 PCS). The trajectory was mapped, and the proportion of patients achieving a minimal clinically important difference (MCID) between time points was determined.
Results:
The mean SF-36 PCS improved for the entire group between 6 and 12 months (P = 0.001) and between 1 and 5 years (P = 0.02), but did not return to baseline at 5 years (P < 0.0001). The proportion of patients achieving a MCID between 6 and 12 months and 1 and 5 years was 75% and 60%, respectively. The functional level was similar between type B and C groups at baseline (P = 0.5) and 6 months (P = 0.2); however, the type B cohort reported higher scores at 1 year (P = 0.01) and 5 years (P = 0.01). Neither group regained their baseline function (P < 0.0001).
Conclusions:
Functional recovery for patients with surgically treated pelvic fractures is characterized by an initial decline in function, followed by sharp improvement between 6 and 12 months, and continued steady improvement between 1 and 5 years. Type B injuries show better early recovery than type C and reach a higher level of function at the final follow-up. Despite the proportion of patients achieving MCID, patients do not regain the preinjury level of function.
Level of Evidence:
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Feed Item Url: 
https://journals.lww.com/jorthotrauma/Fulltext/2019/12000/The_Longitudinal_Short_,_Medium_,_and_Long_Term.5.aspx

Does Operative Intervention Provide Early Pain Relief for Patients With Unilateral Sacral Fractures and Minimal or No Displacement?

imageObjectives:
To compare pain after operative versus nonoperative pelvic ring injuries with unilateral sacral fractures.
Design:
Prospective, multicenter, observational.
Setting:
Sixteen trauma centers.
Patients/Participants:
Skeletally mature patients with pelvic ring injury and minimally displaced unilateral zone 1 or 2 sacral fractures and without anteroposterior compression injuries.
Main Outcome Measurements:
Pelvic displacement was documented on injury plain radiographs and computed tomography scans; a 10 point Visual Analog Scale (VAS) was used to evaluate pain was obtained in the anterior and posterior pelvic ring during the time of union (12 weeks).
Results:
One hundred ninety-four patients with unilateral sacral fractures displaced less than 5 mm, mean age of 38.7, and mean Injury Severity Score of 14.5 were included. Ninety-nine percent had lateral compression injuries, and 62% were in zone 1. Seventy-four percent were treated nonoperatively. Nonoperative patients had more zone 1 fractures (71%, P = 0.004). Nonoperative patients reported mean VAS 2.7 points higher in the posterior pelvis (P = 0.01) and 1.9 points higher anteriorly (P = 0.11) 24 hours after injury compared with patients treated operatively. After 3 months, nonoperative patients reported higher VAS scores than operative patients: 4.0 versus 2.9 posteriorly (P = 0.019) and 3.2 versus 2.3 anteriorly (P = 0.035).
Conclusions:
For sacrum fractures with minimal or no displacement, slight differences in the VAS were noted within 24 hours after injury or surgery, but limited differences were seen at 3 months for either operatively treated minimally or undisplaced sacrum fractures. It is unknown whether this represents clinical relevance. These differences were below the minimally important clinical difference for VAS scores for other orthopaedic conditions.
Level of Evidence:
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Feed Item Url: 
https://journals.lww.com/jorthotrauma/Fulltext/2019/12000/Does_Operative_Intervention_Provide_Early_Pain.6.aspx

Surgery for Unilateral Sacral Fractures: Are the Indications Clear?

imageObjectives:
To evaluate unilateral sacral fractures and compare those treated operatively versus nonoperatively to determine indications for surgery.
Design:
Prospective, multicenter, observational study.
Setting:
Sixteen trauma centers.
Patients/Participants:
Skeletally mature patients with pelvic ring injury and unilateral zone 1 or 2 sacral fractures and without anteroposterior compression injuries.
Main Outcome Measurements:
Injury plain anteroposterior, inlet, and outlet radiographs and computed tomography scans of the pelvis were evaluated for fracture displacement.
Results:
Three hundred thirty-three patients with unilateral sacral fractures and a mean age of 41 years with a mean Injury Severity Score of 15 were included. Ninety-two percent sustained lateral compression injuries, and 63% of all fractures were in zone 1. Thirty-three percent of patients were treated operatively, including all without lateral compression patterns. Operative patients were more likely to have zone 2 fractures (54%) and to have posterior cortical displacement (29% vs. 6.2%), both with P < 0.001. Over 60% of all patients had no posterior displacement. Mean rotational displacements comparing the injured side versus the intact side were no different for patients treated operatively compared with those treated nonoperatively.
Conclusions:
Most unilateral sacral fractures are minimally or nondisplaced. Many patients with radiographically similar fractures were treated operatively and nonoperatively by different surgeons. This suggests an opportunity to develop consistent indications for treatment.
Level of Evidence:
Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Feed Item Url: 
https://journals.lww.com/jorthotrauma/Fulltext/2019/12000/Surgery_for_Unilateral_Sacral_Fractures__Are_the.7.aspx

Pages