The rate of arterial injury in trauma patients with pelvic ring fractures has been cited as high as 15%. Addressing this source of hemorrhage is essential in the management of these patients as mortality rates are reported as 50%. Percutaneous techniques to control arterial bleeding, such as embolization and REBOA, are being employed with increasing frequency due to their assumed lower morbidity and invasiveness than open exploration or cross clamping of the aorta.

There are promising results with regards to the mortality benefits of angioembolization. However, there are concerns with regards to morbidity associated with embolization of the internal iliac vessels and its branches including surgical wound infection, gluteal muscle necrosis, nerve injury, bowel infarction, and thigh / buttock claudication.

The primary aim of this study is to determine whether pelvic arterial embolization is associated with surgical site infection (SSI) in trauma patients undergoing pelvic ring fixation.

This observational cohort study was conducted using US trauma registry data from the American College of Surgeons (ACS) National Trauma Database for the year of 2018. Patients over the age of 18 who were transported through emergency health services to an ACS Level 1 or 2 trauma hospital and sustained a pelvic ring fracture treated with surgical fixation were included. Patients who were transferred between facilities, presented to the emergency department with no signs of life, presented with isolated penetrating trauma, and pregnant patients were excluded from the study.

The primary study outcome was surgical site infection. Multivariable logistic regression was performed to estimate treatment effects of angioembolization of pelvic vessels on surgical site infection, adjusting for known risk factors for infection.

Study analysis included 6562 trauma patients, of which 508 (7.7%) of patients underwent pelvic angioembolization. Overall, 148 (2.2%) of patients had a surgical site infection, with a higher risk (7.1%) in patients undergoing angioembolization (unadjusted odds ratio (OR) 4.0; 95% CI 2.7, 6.0; p < 0 .0001). Controlling for potential confounding, including patient demographics, vitals on hospital arrival, open fracture, ISS, and select patient comorbidities, pelvic angioembolization was still significantly associated with increased odds for surgical site infection (adjusted OR 2.0; 95% CI 1.3, 3.2; p=0.003).

This study demonstrates that trauma patients who undergo pelvic angioembolization and operative fixation of pelvic ring injuries have a higher surgical site infection risk. As the use of percutaneous hemorrhage control techniques increase, it is important to remain judicious in patient selection.

Aims

The aim of this study was to determine the trajectory of recovery following fixation of tibial plateau fractures up to five-year follow-up, including simple (Schatzker I-IV) versus complex (Schatzker V-VI) fractures.

The effect of early surgery on hip fracture outcomes has received considerable study and although it has been suggested that early surgical treatment of these fractures leads to better patient outcomes, the findings are inconclusive. The American College of Surgeon's (ACS) National Surgical Quality Improvement Project (NSQIP) prospectively collects blinded, risk-adjusted patient-level data on surgical patients in over 600 participating hospitals worldwide. The primary objective of this study was to determine the proportion of ACS-NSQIP hospital patients that are currently being treated within the UK's National Institute for Health and Care Excellence (NICE) time to hip fracture surgery benchmark. The secondary objectives were to identify risk factors for missing the benchmark, and determine if the benchmark is associated with improved 30-day patient outcomes.

Patients that underwent hip fracture surgery between 2005–2013 and entered in the ACS-NSQIP database were included in the study. Counts and proportions were used to determine how frequently the NICE benchmark was met. Multivariate regression analysis was used to identify significant predictors of missing the NICE benchmark and determine if missing the benchmark was associated with 30-day mortality/complications rates.

26,006 patients met the study enrolment criteria. 71.4% of patients were treated within the NICE benchmark and 89.4% were treated by post-admission day two. Gender, dyspnea, infectious illness, bleeding disorders, preoperative hematocrit, preoperative platelet count, arthroplasty procedure type, race other than White, and hip fracture diagnosis were all statistically significant predictors of missing the benchmark (p<0.01). Meeting the NICE benchmark was not associated with reductions in major complications (OR=0.93, CI=0.83–1.05, p=0.23), nor a clinically significant difference in postoperative length of stay (LOS) (parameter estimate=0.77, p<0.01); however, it was associated with a decreased 30-day mortality (OR=0.88, CI=0.78–0.99, p=0.03) and the likelihood of minor complications (OR=0.92, CI=0.84–0.995, p=0.04).

ACS-NSQIP hospitals are currently compatible with the NICE benchmark. However, data from the ACS-NSQIP database suggests that surgical treatment within the NICE benchmark may be unnecessarily narrow. Extending the benchmark to post-operative day two did not significantly increase the risk of 30-day mortality and minor complications; nor did it extend the average LOS. Neither the NICE benchmark, nor the extended two-day standard, was associated with reductions in major complications. The findings highlight the importance of further prospective investigation to monitor the effect of time to surgery benchmarks.

Purpose: Minimally invasive surgery (MIS) knee replacement surgery has experienced a recent surge in popularity, driven by the patient concerns of a faster recovery time and a shorter, more cosmetic scar. However the evaluation of any new medical therapy must include a detailed evaluation of both efficacy and safety outcomes. The primary objective of our meta-analysis was to compare the incidence of complications between minimally invasive(MIS) and standard total knee replacement (TKR) approaches.

Method: We reviewed randomized controlled trials comparing minimally invasive TKR to standard TKR. After testing for publication bias and heterogeneity, the data were aggregated by random-effects modeling. Our primary outcome was the number of complications. Our secondary outcomes were alignment outliers, Knee Society Function Scores, and Knee Society Knee Scores.

Results: We had a total of 9 studies evaluating our primary outcome. Average follow up time ranged from 3 to 28 months. There was no significant publication bias in our study.

The combined odds ratios for complications for the MIS group and alignment outliers were 1.58 (95% CI: 1.01 to 2.47) p< 0.05 and 0.79 (95% CI: 0.34 to 1.82) p=0.58 respectively. The standard difference in means for Knee Society scores was no different between groups.

Conclusion: The results of this meta-analysis demonstrate a statistically significant increase in complication rates with MIS TKR when compared to standard TKR. There were no significant differences in postoperative alignment or KSS at 3 months between the two groups. MIS knee surgery should be approached with caution.

Purpose: To evaluate the effect of the presence of femur fracture on mortality, pulmonary complications, and ARDS in trauma patients. In addition, we aim to compare the effects of other major musculoskeletal injuries to femur fractures on these outcomes.

Method: We retrospectively reviewed the trauma registry of two tertiary level trauma centers for a period of 12 years (1995–2007). We evaluated data points on all patients: gender, age, AIS scores, GCS, SBP, and ICD-9 codes for femur fractures and other major orthopaedic injuries. Outcome measures were death in hospital and occurrence of a pulmonary complication (Adult respiratory distress syndrome, fat embolism syndrome, pneumonia and respiratory failure) and ARDS as a sub-group. Logistic regression was used to evaluate the effect of these variables and the presence of femur fracture on the three outcomes (death, pulmonary complications, and ARDS). The effect of other major orthopaedic injuries in these models was also compared to the effect of femur fractures.

Results: There were 83, 349 patients, with 3, 433 deaths, evaluated in the initial regression models. Gender, GCS < 8, age> 60, blood pressure < 90, 4 AIS scores and femur fracture were all independent predictors of mortality. The strongest predictors of mortality were GCS < 8 (OR 16.976, 95% CI 15.176–18.990) and SBP < 90 (OR 6.835, 95% CI 6.046– 7.726). Femur fracture was an independent predictor of mortality (OR 1.480 95% CI 1.135 – 1.929). The presence of femur fracture was not a statistically significant independent predictor of pulmonary complication (OR 1.29, 95% CI 0.911–1.766) while gender, GCS, and 5 of 6 AIS scores were. Other musculoskeletal injuries were significant predictors, including pelvic ring fractures and spinal fractures. In the ARDS regression model, femur fractures were not an independent predictor (OR 1.127, 95% 0.636–1.999).

Conclusion: The risk of mortality and pulmonary complications is multifactorial; most affected by age, GCS at presentation, SBP at presentation, gender and injury severity. In this study, the presence of a femur fracture does independently increase the risk of death, but not ARDS or other pulmonary complications. There are other musculoskeletal injuries that have a greater effect on mortality and pulmonary complications.

Purpose: To provide a CT-based description of the anatomic specifics of LC-1 pelvic ring disruptionsand to describe injury severity to other body systems, and their correlation with fracture anatomy.

Method: We identified a consecutive series of 100 patients with Young and Burgess LC-1 pelvic ring disruptions. The CT scan was reviewed for each patient. Sixteen categories were reviewed for each patient. Sacral fractures were graded based on severity. The age, ISS, and six categories of AIS were recorded for each patient. A statistical analysis was performed to test the associations between fracture characteristics and injury severity.

Results: All patients but three had one or more rami fractures, and all but two had a sacral fracture. Of the 98 anterior sacral injuries, there were nine (9.2%) buckles, 39 (39.8%) simple fractures, and 50 (51.0%) comminuted fractures. Of these 98 anterior sacral injuries, 47 (48.0%) were complete, passing through the sacrum and exiting the posterior cortex. Increasing severity of anterior sacrum fracture was associated with the presence of a complete sacral fracture (p value < 0.0001). Of the 98 sacral fractures, 50 (50.0%) were Denis type I, 41 (41.8%) Denis type II, and 7 (7.1%) Denis type III. Higher Denis types had higher likelihood of complete fractures of the sacrum (p value < 0.0001). There was a significant association between the presence of a comminuted rami fracture and a complete sacrum injury (p = 0.003), and a trend to higher rates in Nakatani two superior rami fractures (p = 0.169). There was a trend to higher mean ISS scores (p = 0.2287), and significantly higher abdominal AIS scores (p = 0.0014), in those with a complete sacral fracture. Those with comminuted and complete sacral fractures were more likely to be symptomatic and require posterior ring stabilization (p-value 0.003 and 0.043 respectively).

Conclusion: LC-1 fractures of the pelvic ring represent a spectrum of injuries, with a large proportion having complete disruption of the sacrum. This complete injury of the sacrum is predicted by Denis type, severity of anterior ring disruption, Abdominal AIS, and potentially location of rami fracture and ISS. CT scanning best defines these injuries.

Purpose: To describe operative experience and reductions of pelvic ring fractures treated with a novel pelvic reduction frame.

Method: All patients with displaced pelvic ring disruptions treated with the pelvic reduction frame were included. The series includes 35 patients, with 34 acute fractures and one malunion. Pre-operative and immediate post-operative radiographs were reviewed, and maximal displacement measured using two reproducible methods. Procedure and injury data were also recorded.

Results: In our series of 35 patients, we had 19 vertical shear fractures and 16 compression injuries. Mean age was 33.5 + 2.4, and mean delay to surgery was 4.7 + 0.6 days. Mean operative time in isolated procedures was 103.4 + 6.5 minutes. All but one patient had iliosacral screws placed, 18 had anterior column screws, six had symphysis plates and 12 had anterior external fixators. Maximum horizontal or vertical displacement was improved from 30.8 + 2.7 mm to 7.1 + 0.7 mm. Diameter asymmetry as measured on the AP view was improved form 26.4 + 2.7 mm to 5.2 + 0.7 mm. Very good, good or fair reduction was obtained in all acute cases. There was no statistically significant impact of obesity, fracture type or delay to surgery on quality of reduction (p> 0.05).

Conclusion: This novel pelvic reduction frame is a powerful tool in the effective reduction and fixation of displaced acute pelvic ring disruptions.

Purpose: Acetabular fractures in elderly patients are difficult problems with various treatment options. Our institution treats many of these patients with percutaneous acetabular fixation. We reviewed medical records and contacted patients to determine the rate of conversion to total hip arthroplasty.

Method: Our institutional trauma database was searched for all patients age 60 and older who had been treated with percutaneous screw fixation for an acetabular fracture. Seventy-nine consecutive patients (80 fractures) were identified. Medical records were examined to obtain peri-operative and follow-up information regarding the hospital course and conversion to total hip arthroplasty. A survivorship anaylsis was created with conversion to total hip arthroplasty as the censored event, and standard Kaplan-Meier curves were constructed. Five categorical variables were used to test for differences in survival of the native hip: age, sex, simple versus complex fracture pattern, closed versus limited open reduction, and occurrence of a medical complication.

Results: Seventy-five fractures had adequate clinical follow-up with a mean of 3.9 years (range 0.5 – 11.9 years). Average blood loss was 69 cc and there were no postoperative infections. 19/75 (25%) were converted to total hip arthroplasty at a mean time of 1.4 years after the index procedure. Survivorship analysis demonstrated a cumulative survival of 65% at 11.9 years of follow-up. There were no conversions to arthroplasty beyond 4.7 post-operatively. There were no statistically significant associations between conversion to arthroplasty and age, sex, closed versus limited open reduction, simple versus complex fracture pattern, and occurrence of a medical complication.

Conclusion: Percutaneous fixation is a viable treatment option for patients age 60 or greater with acetabular fractures. Rates of conversion to total hip arthroplasty are comparable to other treatment methods and if conversion is required, soft tissues are preserved for future surgery.

Fifty-six patients, with a median fourteen years follow-up of isolated tibial shaft fracture treated with an IM nailing, underwent functional evaluation with SMFA and SF-36 questionnaires, as well as an injury specific questionnaire. Thirty-three also underwent clinical and radiological evaluation.

Overall, SF-36 scores (PCS 49.9, MCS 52.0) were near normal. Five (15.2%) had physical findings of venous stasis, while a third reported symptoms A third had at least mild OA on radiographs (knee-seven, ankle-eleven). A third of patients had a loss in ankle dorsiflexion, and more than half reported knee pain that was limiting to at least one activity.

We conducted a study to evaluate the long term functional outcomes and disabilities of patients with an isolated tibial shaft fracture treated with intramedullary nailing.

We identified two hundred and fifty eligible patients from the VGH Orthopaedic Trauma database between 1987 and 1992. A total of fifty-six patients agreed to participate. All were evaluated with the SF-36 and SMFA functional questionnaires, as well as an injury specific questionnaire focusing on knee pain, and symptoms of venous insufficiency. A sub-group of thirty-three patients were evaluated radiographically and by physical examination. We had a median follow-up of fourteen years, with a range from twelve to seventeen years.

The SF-36 scores (PCS 49.9, MCS 52.0) were comparable to population norms. Of the questionnaire group (n=56), fifteen denied knee pain with any activity, while twenty-nine had knee pain that was limiting to at least one type of activity. With respect to swelling, eighteen reported asymmetrical swelling affecting the injured limb. However, in the examination group, only five had objective evidence of venous stasis. Knee range of motion was essentially equivalent to the unaffected side, while thirteen patients had a restricted range of motion of the ankle. Radiographically, seven patients had at least mild OA of at least one knee compartment, while eleven had at least mild OA of the tibio-talar joint, despite near anatomic fracture healing.

At a median fourteen years following tibial nailing of isolated tibial fractures, patients function very well, but objective and subjective evaluation shows not insignificant sequellae.