Surgical treatment of sacral nonunions Arthur, Rodney Y.; Johnson, Joey P.
Injury,
July 2023, 2023-Jul, 2023-07-00, 20230701, Letnik:
54, Številka:
7
Journal Article
Recenzirano
Sacral fractures are complex injuries that follow a bimodal distribution, typically involving acute high energy trauma in young adults and low energy trauma in older adults (> 65 years old). Nonunion ...is a rare but debilitating potential complication of undiagnosed or improperly managed sacral fractures. Various surgical techniques, including open reduction and internal fixation, sacroplasty, and percutaneous screw fixation, have been used to manage these fracture nonunions. In addition to reviewing the initial management of sacral fractures and the risk factors for fracture nonunion, this article describes techniques, specific cases and outcomes of these treatment strategies.
High-energy Femoral Neck Fractures in Young Patients Rajfer, Rebecca A; Carlson, Bradley A; Johnson, Joey P
Journal of the American Academy of Orthopaedic Surgeons,
2024-Apr-01, Letnik:
32, Številka:
7
Journal Article
Recenzirano
Femoral neck fractures in physiologically young patients typically occur from high-energy axial loading forces through the thigh with the hip in an abducted position. These fractures have a high rate ...of associated head, chest, abdominal, and musculoskeletal injuries. High-energy hip fractures differ from traditional geriatric hip fractures regarding incidence, mechanism, management algorithms, and complications. After adequate resuscitation, goals of treatment include anatomic reduction and stable fixation while maintaining vascularity of the femoral head, which can be achieved through a variety of different techniques. Prompt recognition and treatment of these fractures is crucial to achieve a successful outcome because these injuries are often associated with complications such as osteonecrosis, fixation failure, and nonunion.
Pelvic Ring Injuries: Stable or Not? Elsissy, Joseph G; Ruckle, David E; LeBrun, Christopher ...
Journal of the American Academy of Orthopaedic Surgeons,
2024-Feb-01, Letnik:
32, Številka:
3
Journal Article
Recenzirano
Pelvic ring injuries occur in varying severity and in vastly different patient demographics. Knowledge regarding which of these injuries require surgical intervention and which can be managed ...nonsurgically continues to evolve. Previous studies have shown validated criteria for sacral fractures and the posterior ring, explored the role of examination under anesthesia, and other forms of dynamic imaging. Although there is substantial information available, a comprehensive synthesis of this information is lacking. This article provides a comprehensive review of radiographic markers suggestive of stability, discusses treatment strategies, and proposes a treatment algorithm that is easily understood and applicable to not only those with a trauma background but also the general orthopaedic surgeon who will see these injuries frequently while on call.
The goal of this study is to establish radiographic features and characteristics of patient injury in cases of femoral shaft fractures that predict the presence of ipsilateral femoral neck fractures ...(IFNFs).
Patient data was retrospectively assessed from a single level I trauma center through the electronic health record using (Current Procedural Terminology) CPT codes for both isolated and combined ipsilateral femoral shaft and neck fractures. Demographic information, injury characteristics, and independently reviewed radiographic features were collected and compared against the same information from a group of isolated femoral shaft fractures. Multivariable logistic regression was performed to identify risk factors for concomitant IFNFs and their respective odds ratios. A probability algorithm for assessing ipsilateral femoral neck fractures based on independent multivariate predictors was constructed and used.
A total of 113 patients with either isolated femoral shaft fractures or combined femoral shaft and IFNF (n = 33) met inclusion criteria and were identified for this study. Fracture displacement was most strongly associated with increased risk of combined injury with an aOR of 25.64 (95 %CI = 5.96–110.28) for every 100 % displacement. Motorcycle crash (MCC) was the mechanism associated with the highest risk of combined injury, with an aOR of 9.85 (95 % CI = 1.99–48.74). Combined injury was also correlated with lower Winquist score and presentation with a closed fracture, with aORs of 0.38 (95 %CI = 0.21 - 0.68) and 11.61 (95 %CI = 1.93–69.94), respectively. Presence of at least 3 of the statistically significant variables produced a positive predictive value (PPV) of ≥ 89 % for combined femoral shaft and IFNF.
Identification of combined femoral shaft and IFNF is of critical importance when caring for orthopedic trauma patients. While diagnosis remains a challenging task, MCC mechanism, >100 % fracture displacement, and lower Winquist classification were found to be associated with combined injuries. The combination of these variables might assist in predicting the probability of combined injury and potentially guide decision making on the appropriateness of obtaining single sequence MRI or implementing prophylactic femoral neck fixation.
Level III
DVT is a common complication following lower extremity surgery, occurring in up to 60% of patients undergoing hip fracture surgery without postoperative anticoagulation. The risk of fatal PE ...continues well-beyond two weeks postoperatively, thus extended DVT prophylaxis beyond 14 days may be warranted. This investigation sought to examine the association between prescription of extended DVT prophylaxis and 30-day postoperative complications following hip fracture surgery.
This study utilized the ACS NSQIP Hip Fracture Procedure Targeted dataset, a newly available set of patient variables for 2016. The outcome measures were death, occurrence of any postoperative complication, complication subtype, readmission or reoperation within 30-days postoperatively, and length of stay. The primary independent variable was medical DVT prophylaxis continued 28-days postoperatively (“extended DVT prophylaxis”). The control group contains both patients receiving no prophylaxis and those receiving short-duration prophylaxis. Multivariate stepwise logistic regression was employed to control for potential demographic, comorbidity, and procedural/medical confounding factors.
In total, 7533 surgically treated hip fracture patients treated in 2016 were analyzed. Overall, 57.8% of patients (n = 4354) were prescribed extended DVT prophylaxis. On bivariate analysis, prescription of extended DVT prophylaxis was associated with significantly lower incidence of death (7.7% without vs. 2.7% with, p < 0.0001) and stroke/CVA (1.4% vs. 0.6%, p = 0.0016). In multivariate analysis, prescription of extended DVT prophylaxis was significantly associated with lower odds of death (OR 0.33, p < 0.0001), stroke/CVA (OR 0.44, p = 0.0010), and acute kidney injury (AKI) (OR 0.31, p = 0.0010).
This retrospective cohort study of the 2016 ACS NSQIP found that hip fracture surgery patients prescribed ≥28 days of postoperative DVT prophylaxis exhibited 67% lower odds of death and significantly lower rates of AKI and stroke/CVA as compared to those prescribed short-duration prophylaxis. Given the retrospective and uncontrolled nature of this analysis, these results should be interpreted with caution, and additional prospective randomized controlled trials examining the association between extended DVT prophylaxis and postoperative outcomes are warranted. If these observations accurately reflect real-world experience, these data suggest that ≥28 days of DVT prophylaxis following hip fracture surgery should be strongly considered for patients without explicit contraindications.
The purpose of this study is to evaluate the predictive ability of the Orthopedic Trauma-Open Fracture Classification (OTA-OFC) system in regards to short-term (90 days) outcomes of amputation, ...infection necessitating intravenous antibiotics, and wound healing in clinical practice across multiple centers.
Prospective observational study.
Academic and private practice.
Patients with open fractures.
None.
OTA-OFC, amputations, IV antibiotics, and wound healing.
Three hundred seventy-three patients with a total of 419 open fractures were enrolled. Logistic regression to predict amputation demonstrated that arterial and skin injury were statistically significant contributors to the prediction of amputation. Bone loss and muscle injury were significant contributors to the prediction of readmission for IV antibiotics. None of the variables in the OTA-OFC were significant predictors of unhealed wounds.
Our study demonstrates the predictive value of the OTA-OFC regarding the short-term (90 days) outcomes of amputation and infection necessitating IV antibiotics and is another step towards the validation of the OTA-OFC in widespread clinical practice.
Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.
Management of open pelvic ring injuries Roszman, Alexander D; John, Devin Q; Patch, David A ...
Injury,
April 2023, 2023-Apr, 2023-04-00, 20230401, Letnik:
54, Številka:
4
Journal Article
Recenzirano
•Open pelvic ring injuries are rare devastating injuries that require multidisciplinary care.•Outcomes of open pelvic ring injuries have improved due to advancements in trauma protocols.•Early ...mortality is due to exsanguinating hemorrhage, and late mortality is due to wound sepsis and multiorgan system failure.•Treatment includes initial resuscitation, diagnosis of associated injuries, prevention of wound sepsis, and delayed definitive fixation.
Open pelvic ring injuries are rare clinical entities that require multidisciplinary care. Due to the scarcity of this injury, there is no well-defined treatment algorithm. As a result, conflicting evidence surrounding various aspects of care including wound management and fecal diversion remain. Previous studies have shown mortality reaching 50% in open pelvic ring injuries, nearly five times higher than closed pelvic ring injuries. Early mortality is due to exsanguinating hemorrhage, while late mortality is due to wound sepsis and multiorgan system failure. With advancements in trauma care and ATLS protocols, there has been an improved survival rate reported in published case series. Major considerations when treating these injuries include aggressive resuscitation with hemorrhage control, diagnosis of associated injuries, prevention of wound sepsis with early surgical management, and definitive skeletal fixation. Classification systems for categorization and management of bony and soft tissue injury related to pelvic ring injuries have been established. Fecal diversion has been proposed to decrease rates of sepsis and late mortality. While clear indications are lacking due to limited studies, previous studies have reported benefits. Further large-scale studies are necessary for adequate evaluation of treatment protocols of open pelvic ring injuries. Understanding the role of fecal diversion, avoidance of primary closure in open pelvic ring injuries, and importance of well-coordinated care amongst surgical teams can optimize patient outcomes.
Bone augmentation: Is it really needed? Johnson, Joey P.; Norris, Grayson; Giannoudis, Peter V.
Injury,
August 2018, 2018-08-00, 20180801, Letnik:
49, Številka:
8
Journal Article
Proximal humerus fractures (PHFs) are managed with open reduction and internal fixation (ORIF), hemiarthroplasty (HA), reverse shoulder arthroplasty (RSA), or nonoperatively. Given the mixed results ...in the literature, the optimal treatment is unclear to surgeons. The purpose of this study was to survey orthopedic shoulder and trauma surgeons to identify the patient- and fracture-related characteristics that influence surgical decision-making.
We distributed a 23-question closed-response email survey to members of the American Shoulder and Elbow Surgeons and Orthopaedic Trauma Association. Questions posed to respondents included demographics, surgical planning, indications for ORIF and arthroplasty, and the use of surgical augmentation with ORIF. Numerical and multiple-choice responses were compared between shoulder and trauma surgeons using unpaired t-tests and χ2 tests, respectively.
Respondents included 172 shoulder and 78 trauma surgeons. When surgery is indicated, most shoulder and trauma surgeons treat 2-part (69%) and 3-part (53%) PHFs with ORIF. Indications for managing PHFs with arthroplasty instead of ORIF include an intra-articular fracture (82%), bone quality (76%), age (72%), and previous rotator cuff dysfunction (70%). In patients older than 50 years, 90% of respondents cited a head-split fracture as an indication for arthroplasty. Both shoulder and trauma surgeons preferred RSA for treating PHFs presenting with a head-split fracture in an elderly patient (94%), pre-existing rotator cuff tear (84%), and pre-existing glenohumeral arthritis with an intact cuff (75%). Similarly, both groups preferred ORIF for PHFs in young patients with a fracture dislocation (94%). In contrast, although most trauma surgeons preferred to manage PHFs in low functioning patients with a significantly displaced fracture or nonreconstructable injury nonoperatively (84% and 86%, respectively), shoulder surgeons preferred either RSA (44% and 46%, respectively) or nonoperative treatment (54% and 49%, respectively) (P < .001). Similarly, although trauma surgeons preferred to manage PHFs in young patients with a head-split fracture or limited humeral head subchondral bone with ORIF (98% and 87%, respectively), shoulder surgeons preferred either ORIF (54% and 62%, respectively) or HA (43% and 34%, respectively) (P < .001).
ORIF and HA are preferred for treating simple PHFs in young patients with good bone quality or fracture dislocations, whereas RSA and nonoperative management are preferred for complex fractures in elderly patients with poor bone quality, rotator cuff dysfunction, or osteoarthritis. The preferred management differed between shoulder and trauma surgeons for half of the common PHF presentations, highlighting the need for future research.
