High energy pelvic injury poses a challenging setting for the treating surgeon. Often multiple injuries are associated, which makes the measurement of short- and long-term functional outcomes a difficult task. The purpose of this study was to determine the incidence of pelvic dysfunction and late impacts of high energy pelvic ring fractures on pelvic floor function in women, with respect to urinary, sexual and musculoskeletal function. This was compared to a similar cohort of women with lower limb fractures without pelvis involvement.

The data in our study was prospectively gathered between 2010 and 2013 on 229 adult females who sustained injury between 1998 and 2012. Besides demographic and operative variables, the scores of three validated health assessment tools were tabulated: King's Health Questionnaire (KHQ), Female Sexual Function Index (FSFI) and the Short Musculoskeletal Functional Assessment (SMFA). A multivariate regression analysis was done to compare groups.

The incidence of sexual dysfunction was 80.8% in the pelvis and 59.4% in the lower extremity group. A Wilcoxon rank sum test showed a significant difference in KHQ-score (p<0.01) with the pelvis group being worse. When adjusting for age, follow-up and Injury Severity Score this difference was not significant (p=0.28), as was for FSFI and SMFA score. The mean FSFI scores of both groups met the criteria for female sexual dysfunction (<26). Patients with a Tile C fracture have better FSFI scores (16.98) compared to Tile B fractures (10.12; p=0.02). Logistic regression predicting FSFI larger than 26.5 showed that older age and pelvic fractures have a higher likelihood having a form of sexual dysfunction.

Sexual dysfunction after lower extremity trauma is found in patients regardless of pelvic ring involvement. Urinary function is more impaired after pelvic injuries, but more data is needed to confirm this. Older age and pelvic fracture are predictors for sexual dysfunction in women. This study is important as it could help counsel patients on the likelihood of sexual dysfunction, something that is probably under-reported and recognized during our patient follow up.

There has been a substantial increase in the surgical treatment of unstable chest wall injuries recently. While a variety of fixation methods exist, most surgeons have used plate and screw fixation. Rib-specific locking plate systems are available, however evidence supporting their use over less-expensive, conventional plate systems (such as pelvic reconstruction plates) is lacking. We sought to address this by comparing outcomes between locking plates and non-locking plates in a cohort of patients from a prior randomized trial who received surgical stabilization of their unstable chest wall injury.

We used data from the surgical group of a previous multi-centred, prospective, randomized controlled trial comparing surgical fixation of acute, unstable chest wall injuries to non-operative management. In this substudy, our primary outcome was hardware-related complications and re-operation. Secondary outcomes included ventilator free days (VFDs) in the first 28 days following injury, length of ICU and hospital stay, and general health outcomes (SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores). Categorical variables are reported as frequency counts and percentages and the two groups were compared using Fisher's Exact test. Continuous data are reported as median and interquartile range and the two groups were compared using the Wilcoxon rank-sum test.

From the original cohort of 207 patients, 108 had been treated surgically and had data available on the type of plate construct used. Fifty-nine patients (55%) had received fixation with non-locking plates (primarily 3.5 or 2.7 mm pelvic reconstruction plates) and 49 (45%) had received fixation with locking plates (primarily rib-specific locking plates). The two groups were similar in regard to baseline and injury characteristics. In the non-locking group, 15% of patients (9/59) had evidence of hardware loosening versus 4% (2/49 patients) in the locking group (p = 0.1). The rate of re-operation for hardware complications was 3% in the non-locking group versus 0% in the locking group (p = 0.5). No patients in either group required revision fixation for loss of reduction or nonunion. There were no differences between the groups with regard to VFDs (26.3 [19.6 – 28] vs. 27.3 [18.3 – 28], p = 0.83), length of ICU stay (6.5 [2.0 – 13.1] vs 4.1 [0 – 11], p = 0.12), length of hospital stay (17 [10 – 32] vs. 17 [10 – 24], p = 0.94) or SF-36 PCS (40.9 [33.6 – 51.0] vs 43.4 [34.1 – 49.6], p = 0.93) or MCS scores (47.8 [36.9 – 57.9] vs 46.9 [40.5 – 57.4], p = 0.95).

We found no statistically significant differences in outcomes between patients who received surgical stabilization of their unstable chest wall injury when comparing non-locking plates versus locking plates. However, the rate of hardware loosening was nearly 4 times higher in the non-locking plate group and trended towards statistical significance, although re-operation related to this was less frequent. This finding is not surprising, given the inherent challenges of rib fixation including thin bones, comminution, potential osteopenia and a post-operative environment of constant motion. We believe that the increased cost of locking plate fixation in this setting is likely justifiable given these findings.

Unstable chest wall injuries have high rates of mortality and morbidity. These injuries can lead to respiratory dysfunction, and are associated with high rates of pneumonia, sepsis, prolonged ICU stays, and increased health care costs. Numerous studies have demonstrated improved outcomes with surgical fixation compared to non-operative treatment. However, an adequately powered multi-centre randomized controlled study using modern fixation techniques has been lacking.

We present a multi-centred, prospective, randomized controlled trial comparing surgical fixation of acute, unstable chest wall injuries with the current standard of non-operative management. Patients aged 16–85 with a flail chest (3 or more consecutive, segmental, displaced rib fractures), or severe deformity of the chest wall, were recruited from multiple trauma centers across North America. Exclusion criteria included: severe pulmonary contusion, severe head trauma, randomization>72 hours from injury, inability to perform surgical fixation within 96 hours from injury (in those randomized to surgery), fractures of the floating ribs, or fractures adjacent to the spine not amendable to surgical fixation. Patients were seen in follow-up for one year. The primary outcome was days free from mechanical ventilation in the first 28 days following injury. Secondary outcomes were days in ICU, rates of pneumonia, sepsis, need for tracheostomy, mortality, general health outcomes, pulmonary function testing, and other complications of treatment. A sample size of 206 was required to detect a difference of 2 ventilator-free days between the two groups, using a 2-tailed alpha error of 0.05 and a power of 0.80.

A total of 207 patients were recruited from 15 sites across Canada and USA, from 2011–2018. Ninety-nine patients were randomized to non-operative treatment, and 108 were randomized to surgical fixation. Overall, the mean age was 53 years, and 75% of patients were male, with 25% females. The commonest mechanisms of injury were: motor vehicle collisions (34%), falls (20%), motorcycle collisions (14%), and pedestrian injuries (11%). The mean injury severity score (ISS) at admission was 26, and patients had a mean of 10 rib fractures. Eighty-nine percent of patients had pneumothorax, 76% had haemothorax, and 54% had pulmonary contusion. There were no differences between the two groups in terms of demographics. The final results will be available and presented at the COA meeting in Halifax.

This is the largest randomized controlled trial to date, comparing surgical fixation to non-operative treatment of unstable chest wall and flail chest injuries. The results of this study will shed light on the best treatment options for patients with such injuries, help understand outcomes, and guide treatment. The final results will be available and presented at the COA meeting in Halifax.

Echocardiography is commonly used in hip fracture patients to evaluate perioperative cardiac risk and identify cardiac abnormalities. However, echocardiography that delays surgical repair may be harmful. The objective of this study was to compare mortality, surgical wait times, length of stay (LOS), and health care costs for similar hip fracture patients managed with and without preoperative echocardiograms.

A population based, retrospective cohort study of all hip fracture patients (>age 45) in Ontario, Canada was conducted. The primary exposure was pre-operative echocardiography (between hospital admission and surgery). Patients receiving preoperative echocardiograms were matched to those without using a propensity score incorporating patient demographic information, comorbidity status, and provider information. Mortality rates, surgical wait times, post-operative length of stay (LOS), and medical costs (expressed as 2013$ CAN) up to 1-year post-operatively were assessed after matching.

There were 2354 (∼5.6%) of 42,230 eligible hip fracture patients that received a preoperative echocardiogram during the study period. After successfully matching 2298 (∼97.6%) patients, echocardiography was associated with significant increases in mortality at 90 days (20.1% vs. 16.8%, p=0.004) and 1 year (32.9% vs. 27.8%, p < 0 .001), but not 30-days (11.4% vs. 9.8%, p=0.084). Patients with echocardiography also had an increased (mean ± SD) delay (in hours) from presentation to surgery (68.80 ± 44.23 hours vs. 39.69 ± 27.09 hours, p < 0 .001) and only 38.1% of patients had surgery within 48 hours. Total LOS (in days) (mean 19.49 ± 25.39 days vs. 15.94 ± 22.48 days, p < 0 .001) and total healthcare costs at 1 year (mean: $51,714.69 ± 54,675.28 vs. $41,861.47 ± 50,854.12, p < 0 .001) were also increased. There was wide variability in echocardiography ordering practice in Ontario, with a range of 0% to 22.97% of hip fracture patients undergoing preoperative echocardiography at different hospital sites.

Preoperative echocardiography for hip fracture patients is associated with increased postoperative mortality. It is also associated with increased surgical delay, post-operative LOS, and total health care costs at 1 year. Echocardiography should be considered an urgent test when ordered to prevent additional surgical delay, and further research is necessary to clarify indications for this common preoperative investigation.

Echocardiography is commonly used in hip fracture patients to evaluate perioperative cardiac risk and identify cardiac abnormalities. However, echocardiography that delays surgical repair may be harmful. The objective of this study was to compare mortality, surgical wait times, length of stay (LOS), and health care costs for similar hip fracture patients managed with and without preoperative echocardiography.

A population based, retrospective cohort study of all hip fracture patients (>age 45) in Ontario, Canada was conducted. The primary exposure was pre-operative echocardiography (between hospital admission and surgery). Patients receiving preoperative echocardiography were matched to those without using a propensity score incorporating patient demographic information, comorbidity status, and provider information. Mortality rates, surgical wait times, post-operative length of stay (LOS), and medical costs (expressed as 2013$ CAN) up to one year post-operatively were assessed after matching.

There were 2354 (∼5.6%) of 42,230 eligible hip fracture patients that received preoperative echocardiograghy during the study period. After successfully matching 2298 (∼97.6%) patients, echocardiography was associated with significant increases in mortality at 90 days (20.1% vs. 16.8%, p=0.004) and one year (32.9% vs. 27.8%, p < 0 .001), but not 30-days (11.4% vs. 9.8%, p=0.084). Patients with echocardiography also had an increased (mean ± SD) delay (in hours) from presentation to surgery (68.80 ± 44.23 hours vs. 39.69 ± 27.09 hours, p < 0 .001) and only 38.1% of patients had surgery within 48 hours. Total LOS (in days) (mean 19.49 ± 25.39 days vs. 15.94 ± 22.48 days, p < 0 .001) and total healthcare costs at one year (mean: $51,714.69 ± 54,675.28 vs. $41,861.47 ± 50,854.12, p < 0 .001) were also increased. There was wide variability in echocardiography ordering practice in Ontario, with a range of 0% to 22.97% of hip fracture patients undergoing preoperative echocardiography at different hospital sites.

Preoperative echocardiography for hip fracture patients is associated with increased postoperative mortality. It is also associated with increased surgical delay, post-operative LOS, and total health care costs at one year. Echocardiography should be considered an urgent test when ordered to prevent additional surgical delay, and further research is necessary to clarify indications for this common preoperative investigation.

Although wait-times for hip fracture surgery have been linked to mortality and are being used as quality-of-care indicators worldwide, controversy exists about the duration of the wait that leads to complications. Our objective was to use new population-based wait-time data to emprically derive an optimal time window in which to conduct hip fracture surgery before the risk of complications increases.

We used health administrative data from Ontario, Canada to identify hip fracture patients between 2009 and 2014. The main exposure was the time from hospital arrival to surgery (in hours). The primary outcome was mortality within 30 days. Secondary outcomes included a composite of mortality or other medical complications (MI, DVT, PE, and pneumonia) also within 30 days. Risk-adjusted cubic splines modeled the probability of each complication according to wait-time. The inflection point (in hours) when complications began to increase was used to define ‘early’ and ‘delayed’ surgery. To evaluate the robustness of this definition, outcomes amongst propensity-score matched early and delayed patients were compared using percent absolute risk differences (% ARDs, with 95% confidence intervals [CIs]).

There were 42,230 patients who met entry criteria. Their mean age was 80.1 (±10.7) and the majority were female (70.5%). The risk of complications modeled by cubic splines consistently increased when wait-times were greater than 24 hours, irrespective of the complication considered. Compared to 13,731 propensity-score matched patients who received surgery earlier, 13,731 patients receiving surgery after 24 hours had a significantly higher risk of 30-day mortality (N=898 versus N=790, % ARD 0.79 [95% CI 0.23 to 1.35], p = .006) and the composite outcome (N=1,680 versus N=1,383, % ARD 2.16 [95% CI 1.43 to 2.89], p < .001). Overall, there were 14,174 patients (33.6%) who received surgery within 24 hours and 28,056 patients (66.4%) who received surgery after 24 hours.

Increased wait-time was associated with a greater risk for 30-day mortality and other complications. The finding that a wait-time of 24 hours represents a threshold defining higher risk may inform existing hip fracture guidelines. Since two-thirds of patients did not receive surgery within this timeframe, performance improvement efforts that reduce wait-times are warranted.

Over the last decade, there has been a growing body of level I evidence supporting non-operative management (focused on early range of motion and weight bearing) of acute Achilles tendon ruptures. Despite this emerging evidence, there have been very few studies evaluating its uptake. Our primary objective was to determine whether the findings from a landmark Canadian trial assessing the optimal management strategy for acute Achilles tendon ruptures influenced the practice patterns of orthopaedic surgeons in Ontario, Canada over a 12-year time period. As a second objective we examined whether patient and provider predictors of surgical repair utilisation differed before and after dissemination of the landmark trial results.

Using provincial health administrative databases, we identified Ontario residents 18 years of age and older with an acute Achilles tendon rupture from April 2002 to March 2014. The proportion of surgically repaired ruptures was calculated for each calendar quarter and year. A time-series analysis using an interventional autoregressive integrated moving average (ARIMA) model was used to determine whether changes in the proportion of surgically repaired ruptures were chronologically related to the dissemination of results from a landmark Canadian trial by Willits et al. (first quarter, 2009). Spline regression was then used to independently identify critical time-points of change in the surgical repair rate to confirm our findings. A multivariate logistic regression model was used to assess for differences in patient and provider predictors of surgical repair utilisation before and after the landmark trial.

From the second quarter of 2002 to the first quarter of 2010 the surgical repair rate remained constant at ∼21%, however, by the first quarter of 2014 it fell to 6.5%. A statistically significant decrease in the rate of surgical repair (P<0.001) was observed after the results from a landmark Canadian trial were presented at a major North American conference (February 2009). Both teaching and non-teaching hospitals demonstrated a decline in the surgical repair rate over the study period, however, only the decrease seen at non-teaching hospitals was found to be significantly associated with the dissemination of landmark trial results (P<0.001). All other predictors of surgical repair utilisation remained unchanged in the before-and-after analysis with the exception of patients 30 years of age and younger having a higher odds of undergoing surgical repair after the trial when compared to those 51 years of age and older.

The current study demonstrates that large, well-designed randomised trials, such as the one conducted by Willits et al. can significantly change the practice patterns of orthopaedic surgeons. Moreover, the decline in surgical repair rate observed at both teaching and non-teaching hospitals suggests both academic and non-academic surgeons readily incorporate high quality evidence in to their practice.

Purpose

Traditional recommendations suggest that open fractures require urgent surgical debridement to reduce infection. Although many papers comparing early vs late debridement have found no difference in infection rates, these papers have not taken into account important confounding factors. We attempt to answer whether delay between injury and surgical debridement in open fractures is associated with a higher infection rate after accounting for these important confounders.

Purpose

Hip fractures are the most common injury requiring hospitalization in both men and women over the age of 65. There is significant mortality associated with hip fracture and delay to surgical treatment increases this rate. We undertook an ethnographic study exploring organizational barriers to timely hip fracture surgery.

Background

Traditional recommendations suggest that open fractures require urgent surgical debridement to reduce infection. However, this has recently been challenged by a number of investigations. However, in many cases, these studies were not able to control for important confounding factors. The purpose of our study was to evaluate the relationship between delay to definitive surgical debridement while controlling for important confounders.

Purpose: To determine the effect of delay to surgery on functional outcome in patients with operatively-treated acetabular fractures.

Method: Two hundred and thirty-two patients with acetabular fractures were identified from a pelvic trauma database. Functional outcome data was assessed using the validated Musculoskeletal Functional Assessment (MFA) and the Short Form 36 (SF-36) surveys in 162 patients. After 1997, functional outcome scores were collected prospectively at 6 months, 1 year and 2 years (or greater) post-operatively. Functional outcome scores, quality of reduction, and risk of complications were modeled as a function of days of delay to surgery via multivariate regression analysis adjusting for age, gender, fracture type, and associated injuries.

Results: At 6 months post-operatively, functional outcome scores were significantly worse with increasing delay to surgery. A delay of between 7 and 13 days or 14 or more days decreased the SF-36 physical component (PCS) z-scores by 0.75 (95% CI: −1.41 to −0.09) and 1.5 standard deviations (95% CI: −2.43 to −0.56) respectively. Delay of 14 or more days was associated with a worsening of the lower extremity (Move) subsection of the MFA by 18.6 points (95% CI: 3.3 to 33.8). Delay to surgery was associated with a significantly higher risk of poor reduction among those with available radiographic follow-up (n=67). Delay 14 days or more was associated with a 5 times (95% CI?.04 to 23.99) greater risk of a post operative step or gap over 2 mm. Delay to surgery was associated with an increase in thrombotic complications. In those patients who were diagnosed with a pulmonary embolism(PE) the mean delay was 11.3 days versus 7.3 days for the rest of the cohort (p=0.01). For patients with a deep vein thrombosis (DVT) average delay was 14.1 days versus 7.1 days (p=0.01).

Conclusion: Delay to surgery is associated with worsening functional outcome scores after as little as 7 days of delay. After 14 days, functional outcomes deteriorate further and radiographic outcomes are negatively influenced. Increased delay also increases risk of thrombotic events. These conclusions underscore the importance of timely treatment for displaced acetabular fractures.

This study is designed to evaluate intra-operative stress testing on detection of syndesmosis injuries. We evaluated forty patients with ankle fractures requiring surgery. Their ankles were subjected to stress examinations after each stage of fixation. These were compared to the contralateral side. Biomechanical criteria were used to predict need for syndesmosis fixation. In 42% of the fractures, intra-operative fluoroscopy found an unpredicted syndesmosis injury. In 8% the syndesmosis was intact despite prediction. Medial malleolar fixation was not adequate for syndesmosis fixation as shown by stress testing. These findings may have implications for future diagnosis and treatment of syndesmosis injuries.

This study is designed to evaluate the utility of intra-operative fluoroscopic stress testing in diagnosing tibio-fibular syndesmotic injuries.

Forty skeletally mature patients with unilateral external rotation ankle fractures requiring open reduction and internal fixation were prospectively recruited. Intra-operatively the injured ankle was examined fluoroscopically using external rotation, valgus and anterior drawer stress tests, as well as static antero-posterior, mortise, and lateral ankle views. Stress testing was performed using a standardized force of 37.5 N. Stress testing was done after each stage of fixation (lateral, medial, and syndesmotic). The uninjured contralateral limb was examined as a control, and a 1 mm side to side difference was defined as a positive stress examination.

Intra-operative fluoroscopy detected unpredicted syndesmotic injuries in 42 % of ankle injuries. In all cases, fixation of the medial malleolus did not restore syndesmotic stability. In 8 % of ankle injuries, a syndesmotic injury was predicted but stress testing revealed the syndesmosis intact.

Intra-operative fluoroscopy is a more sensitive modality for detection of otherwise unpredicted syndesmotic injuries compared to criteria based upon static radiographs. Medial malleolar fixation did not add stability to syndesmotic injuries in this study.

Injuries involving the distal tibio-fibular syndesmosis are difficult to detect. Previously, the decision to stabilize the syndesmosis in ankle fractures was based upon biomechanical criteria and static radiography. This and other recent studies challenge this, suggesting fluoroscopic stress testing is a better diagnostic method for these poorly tolerated injuries.

Funding: Synthes Canada, Smith Nephew Richards Inc.

Purpose: Achieving accurate imaging in talus neck fracture management is important. Patient outcome relies on the ability to achieve and maintain anatomic reduction. The ability to visualize the reduction postoperatively using plain radiographs or computed tomography (CT) is limited. The purpose of this study is to assess the ability of radiostereometric analysis (RSA) to detect changes in talus fracture fragment alignment using an in-vitro model. This will be compared to the use of plain radiographs and CT.

Methods: Eight cadaveric human lower extremities were used as talus fracture models. Each talus was removed from the specimen and an osteotomy was created. RSA beads were inserted into the fragments. Anatomical reduction was achieved with two 3.5 mm cortical screws. A set of plain radiographs and RSA films was obtained. The fragments were displaced in a combined varus and supination direction. The degree of displacement was measured with a Vernier caliper and the rotation measured with a protractor. The imaging sequence was repeated in addition to obtaining CT scans with three dimension reconstruction. The RSA measurements were interpreted in a blinded fashion by an experienced researcher. Two independent blinded observers measured the displacement and rotation with plain films and CT. The results from each radiographic measurements were compared using ANOVA method to the experimental values.

Results: The average difference between the RSA measurements and the experimental measurements was 5.9mm while the difference between CT scan measurements and experimental values was 2.4mm (p=0.003). The average difference in rotation was not statistically significant between the three groups.

Conclusions: CT scan provides the most accurate assessment of talar neck malunion. Unfortunately, RSA is not a viable imaging technique for assessing talar neck displacement.

Funding : Other Education Grant

Funding Parties : Lawson Health Research Institute