To determine whether it is safe to use a conservative packed red blood cell transfusion hemoglobin (Hgb) threshold (5.5 g/dL) compared with a liberal transfusion threshold (7.0 g/dL) for asymptomatic ...musculoskeletal injured trauma patients who are no longer in the initial resuscitative period.
Design: Prospective, randomized, multicenter trial.
Three level 1 trauma centers.
Patients aged 18-50 with an associated musculoskeletal injury with Hgb less than 9 g/dL or expected drop below 9 g/dL with planned surgery who were stable and no longer being actively resuscitated were randomized once their Hgb dropped below 7 g/dL to a conservative transfusion threshold of 5.5 g/dL versus a liberal threshold of 7.0 g/dL.
Postoperative infection, other post-operative complications and Musculoskeletal Functional Assessment scores obtained at baseline, 6 months, and 1 year were compared for liberal and conservative transfusion thresholds.
Sixty-five patients completed 1 year follow-up. There was a significant association between a liberal transfusion strategy and higher rate of infection (P = 0.01), with no difference in functional outcomes at 6 months or 1 year. This study was adequately powered at 92% to detect a difference in superficial infection (7% for liberal group, 0% for conservative, P < 0.01) but underpowered to detect a difference for deep infection (14% for liberal group, 6% for conservative group, P = 0.2).
A conservative transfusion threshold of 5.5 g/dL in an asymptomatic young trauma patient with associated musculoskeletal injuries leads to a lower infection rate without an increase in adverse outcomes and no difference in functional outcomes at 6 months or 1 year.
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
The purpose of this study was to determine whether it is safe to use a conservative packed red blood cell transfusion hemoglobin threshold (5.5 g/dL) compared with a liberal transfusion threshold ...(7.0 g/dL) for asymptomatic patients with musculoskeletal-injured trauma out of the initial resuscitative period.
This was a multicenter, prospective, nonblinded, randomized study done at three level 1 trauma centers. One hundred patients were enrolled. One patient was inappropriately enrolled, withdrawn from the study, and excluded from analysis leaving 99 patients (49 liberal and 50 conservative) with 30-day follow-up. After initial resuscitation, patients were enrolled and randomized to either a liberal or a conservative transfusion strategy. This strategy was followed throughout the index hospitalization. The primary outcome of the study was infection. Superficial infection was defined as clinical diagnosis of cellulitis or other superficial infection treated with oral antibiotics only. Deep infection was defined as clinical diagnosis of fracture-related infection requiring IV antibiotics and/or surgical débridement.
Ninety-nine patients were successfully followed for 30 days with 100% follow-up during this time. Seven infections (14%) occurred in the liberal group and none in the conservative group ( P < 0.01). Five deep infections (10%) occurred in the liberal group and none in the conservative group ( P = 0.03). Three superficial infections (6%) occurred in the liberal and none in the conservative group, which was not a significant difference ( P = 0.1). No difference was observed in length of stay between groups.
Transfusing young healthy asymptomatic patients with orthopaedic trauma for hemoglobin <7.0 g/dL increases the risk of infection. No increased risk of anemia-related complications was identified with a conservative transfusion threshold of 5.5 g/dL.
Data are available on request. IRB protocol number is 1402557771. This study was registered with Clinicaltrials.gov identifier NCT02972593.
Level 2, unblinded prospective randomized multicenter study.
OBJECTIVE:To report the rate of peroneal nerve palsy after routine use of intraoperative distraction during open reduction internal fixation (ORIF) for lateral unicondylar and bicondylar tibial ...plateau fracture (TPF) repairs.
DESIGN:Retrospective chart review.
SETTING:Level I trauma center.
PATIENTS:Patients with traumatic TPF treated with ORIF between 2007 and 2017.
INTERVENTION:ORIF for lateral unicondylar and bicondylar TPF.
MAIN OUTCOME MEASUREMENT:Presence and resolution of neurovascular injury.
RESULTS:There were a total of 21 lateral unicondylar and 40 bicondylar TPFs repaired through ORIF in 60 patients identified during the study period with 1-year follow-up and complete records for review. Thirty-six patients had staged external fixation before ORIF while 24 were treated with ORIF initially. Of the staged patients, 9 of 36 (25%) developed nerve palsy while those undergoing initial ORIF (not staged) developed palsy in only one case (1 of 24, or 4%). Of the patients who developed nerve palsy, 9 of 10 (90%) were staged with an initial external fixator before ORIF. The incidence of iatrogenic peroneal nerve palsy secondary to intraoperative distraction was 16.4% (10 of 61). Only 60% (6 of 10) of peroneal nerve palsies recovered clinically with a mean recovery time of approximately 14 weeks. Comparison of demographics in patients with peroneal nerve palsy versus those without yielded no significant difference by sex (P = 0.08), age (P = 0.27), fracture type (P = 0.29), tobacco use (P = 0.44), or alcohol use (P = 0.78).
CONCLUSIONS:Peroneal nerve palsy is a common sequela of ORIF for TPFs involving the lateral compartment using an intraoperative distractor. Staged external fixation followed by definitive ORIF using intraoperative distraction was associated with significant risk for developing nerve palsy (9/10). Many patients (40%) who develop peroneal nerve palsies do not recover, leading to permanent loss of motor and/or sensory function for 7% of patients studied. None of the epidemiologic variables evaluated yielded predictive value for development of peroneal nerve palsy or subsequent resolution. Caution should be exercised in avoiding overdistraction when using intraoperative distraction, especially in those cases that had staged fixation, most notably bicondylar injuries.
LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
The objective of this study was to determine whether time from hospital admission to surgery for acetabular fractures using an anterior intrapelvic (AIP) approach affected blood loss.
Retrospective ...review.
Three level 1 trauma centers at 2 academic institutions.
Adult (18 years or older) patients with no pre-existing coagulopathy treated for an acetabular fracture via an AIP approach. Excluded were those with other significant same day procedures (irrigation and debridement and external fixation were the only other allowed procedures).
Multiple methods for evaluating blood loss were investigated, including estimated blood loss (EBL), calculated blood loss (CBL) by Gross and Hgb balance methods, and packed red blood cell (PRBC) transfusion requirement. Outcomes were evaluated based on time to surgery.
195 patients were studied. On continuous linear analysis, increasing time from admission to surgery was significantly associated with decreasing CBL at 24 hours (-1.45 mL per hour by Gross method, P = 0.003; -0.440 g of Hgb per hour by Hgb balance method, P = 0.003) and 3 days (-1.69 mL per hour by Gross method, P = 0.013; -0.497 g of Hgb per hour by Hgb balance method, P = 0.010) postoperative, but not EBL or PRBC transfusion. Using 48 hours from admission to surgery to define early versus delayed surgery, CBL was significantly greater in the early group compared to the delayed group (453 IQR 277-733 mL early versus 364 IQR 160-661 delayed by Gross method, P = 0.017; 165 IQR 99-249 g of Hgb early versus 143 IQR 55-238 g Hgb delayed by Hgb balance method, P = 0.035), but not EBL or PRBC transfusion. In addition, in multivariate linear regression, neither giving tranexamic acid nor administering prophylactic anticoagulation for venous thromboembolism on the morning of surgery affected blood loss at 24 hours or 3 days postoperative ( P > 0.05).
There was higher blood loss with early surgery using an AIP approach, but early surgery did not affect PRBC transfusion and may not be clinically relevant.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
OBJECTIVES: Evaluate if nonoperative or operative treatment of displaced clavicle fractures delivers reduced rates of nonunion and improved Disability of the Arm, Shoulder, and Hand (DASH) scores. ...METHODS: Design: Multicenter, prospective, observational. Setting: Seven Level 1 Trauma Centers in the United States. Patient Selection Criteria: Adults with closed, displaced (100% displacement/shortened >1.5 cm) midshaft clavicle fractures (Orthopaedic Trauma Association 15.2) were treated nonoperatively, with plates and screw fixation, or with intramedullary fixation from 2003 to 2018. Outcome Measures and Comparisons: DASH scores (2, 6 weeks, 3, 6, 12, and 24 months), reoperation, and nonunion were compared between the nonoperative, plate fixation, and intramedullary fixation groups. RESULTS: Four hundred twelve patients were enrolled, with 203 undergoing plate fixation, 26 receiving intramedullary fixation, and 183 treated nonoperatively. The average age of the nonoperative group was 40.1 (range 18–79) years versus 35.8 (range 18–74) in the plate group and 39.3 (range 19–56) in the intramedullary fixation group ( P = 0.06). One hundred forty (76.5%) patients in the nonoperative group were male compared with 154 (75.9%) in the plate group and 18 (69.2%) in the intramedullary fixation group ( P = 0.69). All groups showed similar DASH scores at 2 weeks, 12 months, and 24 months ( P > 0.05). Plate fixation demonstrated better DASH scores (median = 20.8) than nonoperative (median = 28.3) at 6 weeks ( P = 0.04). Intramedullary fixation had poorer DASH scores at 6 weeks, 3 months, and 6 months than plate fixation and worse DASH scores than nonoperative at 6 months ( P < 0.05). The nonunion rate for nonoperative treatment (14.6%) was significantly higher than the plate group (0%) ( P < 0.001). CONCLUSIONS: Operative treatment of displaced clavicle fractures provided lower rates of nonunion than nonoperative treatment. Except at 6 weeks, no difference was observed in DASH scores between plate fixation and nonoperative treatment. Intramedullary fixation resulted in worse DASH scores than plate fixation at 6 weeks, 3 months, and 6 months and worse DASH scores than nonoperative at 6 months. Implant removal was the leading reason for reoperation in the plate and intramedullary fixation groups, whereas surgery for nonunion was the primary reason for surgery in the nonoperative group. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
The objective of this study was to determine factors that may affect transfusion rates for patients requiring an anterior intrapelvic (AIP) approach for an acetabulum fracture.
This was a multicenter ...retrospective comparison study (3 trauma centers at two urban academic centers). Patients who had an AIP approach for an acetabulum fracture without other notable same-day procedures (irrigation and débridement and/or external fixation were only other allowed procedures) were included. One hundred ninety-five adult (18 and older) patients had adequate records to complete analysis with no preexisting coagulopathy. The main outcome evaluated was the number of units transfused at the time of surgery and up to 7 days after surgery.
Factors that were found to affect intraoperative transfusion rates were older age, lower preoperative hematocrit, longer surgery duration, and requiring increased intraoperative intravenous fluids. Factors that did not affect transfusion rate included sex, body mass index, hip dislocation at the time of injury, fracture pattern, AIP approach alone or with lateral window ± distal extension, Injury Severity Score, preoperative platelet count, use of tranexamic acid, and venous thromboembolism prophylaxis received morning of surgery. When followed out through the remainder of a week after surgery, the results for any factor did not change.
In this large multicenter retrospective study of patients requiring an AIP approach, tranexamic acid and use of venous thromboembolism prophylaxis (or holding it the morning of surgery) did not affect transfusion rates either during surgery or up to a week after surgery. Older age, lower preoperative hematocrit level, longer surgery time, and increased intraoperative intravenous fluids were associated with higher transfusion rates.
Data are available on request.
Level 3, retrospective case-control study.
User-friendly resource presents state-of-the-art management of orthopaedic trauma
Orthopaedic trauma spans the full spectrum of injury, from simple fractures to life-threatening accidents with ...multiple broken bones. As such, these incidents are a common reason patients visit emergency departments and receive treatment from orthopaedic surgeons. Synopsis of Orthopaedic Trauma Management by nationally recognized experts Brian Mullis, Greg Gaski, and esteemed contributors fills a gap in the literature by providing a concise yet comprehensive reference for evaluating these conditions and initiating immediate treatment.
The text provides a well-rounded perspective on the surgical and nonsurgical management of trauma in adult and pediatric patients. The opening section lays a solid foundation, with chapters covering physiology, open and closed fracture management, imaging, biomechanics, complications, and other core topics. Subsequent chapters address a full compendium of orthopaedic procedures to treat traumatic conditions of the upper and lower extremities, pelvis, and spine.
Key Features
*Bulleted format provides quick and authoritative navigation of essential information needed for effective treatment
*A wealth of high-quality illustrations, radiographic images, and tables supplement concise text
*Uniformly organized chapters include up-to-date, clinically relevant statistics and suggestions for further reading
*Videos by renowned experts enhance understanding of specific fractures and orthopaedic surgery approaches
*This is a must-have resource for providers who treat orthopaedic trauma patients, including general and orthopaedic surgeons, residents, ER physicians, nurse practitioners, physician assistants, nurses, medical students, and others on call. It also provides a robust review for orthopaedic residents prepping for the boards.
This book includes complimentary access to a digital copy on https://medone.thieme.com.
To report functional outcomes of unilateral sacral fractures treated both operatively and nonoperatively.
Prospective, multicenter, observational study.
Sixteen Level 1 trauma centers.
Skeletally ...mature patients with unilateral zone 1 or 2 sacral fractures categorized as displaced nonoperative (DN), displaced operative (DO), nondisplaced nonoperative (NN), and nondisplaced operative (NO).
Pelvic displacement was documented on injury plain radiographs. Short Musculoskeletal Function Assessment (SMFA) scores were obtained at baseline and at 3, 6, 12, and 24 months after injury. Displacement was defined as greater than 5 mm in any plane at the time of injury.
Two hundred eighty-six patients with unilateral sacral fractures were initially enrolled, with a mean age of 40 years and mean injury severity score of 16. One hundred twenty-three patients completed the 2-year follow-up as follows: 29 DN, 30 DO, 47 NN, and 17 NO with 56% loss to follow-up at 2 years. Highest dysfunction was seen at 3 months for all groups with mean SMFA dysfunction scores: 25 DN, 28 DO, 27 NN, and 31 NO. The mean SMFA scores at 2 years for all groups were 13 DN, 12 DO, 17 NN, and 17 NO.
All groups (operative/nonoperative and displaced/nondisplaced) reported worst function 3 months after injury, and all but (DN) continued to recover for 2 years after injury, with peak recovery for DN seen at 1 year. No functional benefit was seen with operative intervention for either displaced or nondisplaced injuries at any time point.
Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Purpose
The purpose of this study was to determine whether anterior plating is better tolerated than superior plating for midshaft clavicle fractures.
Methods
This was a prospective non-randomized ...observational cohort study following operative vs. non-operative management of clavicle fractures from 2003 to 2018 at 7 level 1 academic trauma centers in the USA. The subset of patients treated with plate and screws is the basis for this comparative study. Adults aged 18–85 with closed clavicle fractures displaced over 100% or shortened by more than 1.5 cm were eligible for enrollment. Patients were followed for 2 years following enrollment. Allowable fixation methods at the discretion of the surgeon consisted of anterior–inferior or superior plating. A total of 412 patients were enrolled. Of these, 192 patients received either superior or anterior plating for a displaced clavicle fracture with complete documented prospective research forms capturing type of plating technique. The primary outcome measure was hardware removal (HWR). Secondary outcomes were Disability of the Arm Shoulder and Hand (DASH) score and Visual Analog Pain (VAP) score, and satisfaction score (1 = high satisfaction; 5 = low satisfaction).
Results
There was no difference in HWR rates (7.1% superior 9/127; 6.2% anterior 4/65,
p
= 0.81), VAP score (mean 1.5 SD 1.0 superior; mean 1.7 SD 0.6 anterior,
p
= 0.21), DASH score (mean 7.5 SD 12.4 superior; mean 5.2 SD 15.2 anterior;
p
= 0.18) or satisfaction score (mean 1.6 SD 1.0 superior; mean 1.7 SD 0.60 anterior,
p
= 0.18).
Conclusion
There is no difference in HWR rates or functional outcomes when using a superior vs. anterior plating technique.
Hip Dislocation: Evaluation and Management Foulk, David M; Mullis, Brian H
Journal of the American Academy of Orthopaedic Surgeons,
04/2010, Letnik:
18, Številka:
4
Journal Article
Recenzirano
A simple hip dislocation is one without fracture of the proximal femur or acetabulum. Complex fracture-dislocations involve the acetabulum, femoral head, or femoral neck. The incidence of ...posttraumatic arthritis is much lower in simple dislocations than in fracture-dislocations. The most common mechanism of injury is a high-energy motor vehicle accident, which is usually associated with other systemic and musculoskeletal injuries. The hip should be reduced emergently in an atraumatic fashion. For acetabular fracture, intraoperative stress views may be necessary to evaluate for instability and to determine whether surgical fixation is required. The appearance of a concentric reduction on plain radiographs and CT does not rule out intra-articular hip pathology; such injury may contribute to long-term degenerative changes. Other complications of hip dislocation include osteoarthritis, osteonecrosis, and sciatic nerve injury. Indications for surgical management include nonconcentric reduction, associated proximal femur fracture (including hip, femoral neck, and femoral head), and associated acetabular fracture producing instability. Surgical management ranges from formal open arthrotomy to minimally invasive hip arthroscopy. Hip arthroscopy has become popular for treating intra-articular hip pathology, including loose bodies, chondral defects, and labral tears.
PDF
