Aims

Acetabular fractures are associated with long-term morbidity. Our prospective cohort study sought to understand the recovery trajectory of this injury over five years.

Purpose

The measurement of functional outcomes in pelvic fracture patients remains difficult for authors. We aimed to test the construct validity, respondent burden, and patient perception of three previously published pelvic outcome questionnaires.

Purpose: Problem: Tibia plateau fractures may lead to end-stage post-traumatic arthritis that requires reconstructive surgery. The incidence of this problem is unknown but has been estimated at 20–40% by studies that were limited by small sample sizes, potential follow-up bias, and the limitations of using radiographic arthritis as a chosen outcome (not correlated to function). The use of administrative data bases to follow the care of a large number patients for robust end points such as surgery, offers an opportunity to address these limitations. Purpose: to determine the minimum ten year incidence of post-traumatic arthritis necessitating reconstructive surgery following tibia plateau fractures.

Method: We queried our prospectively collected Orthopedic Trauma Data base to identify operatively treated patients with tibia plateau fractures. These cases were cross-referenced with the data from our Province’s administrative health database and tracked over time for the performance of reconstructive knee surgery. Each individual’s exposure/follow-up period was limited by end of health plan coverage on record or date of death from vital statistics data. The minimum follow-up was ten years.

Results: Between 1987 and 1994, 378 patients with a tibia plateau fracture were treated at our institution. The average age was 46 years (sd=18, range 14–87), while 56% of patients were males. Seventeen out-of-Province residents were excluded, along with forty-six others whose “Medical Services Plan” numbers could not be identified. Of which seven were WCB patients and one who was affiliated with the military. The study cohort therefore consisted of 311 patients with 314 tibia plateau fractures. Four individuals (1.3%) we treated tibia plateau fractures have required reconstructive knee surgery for end-stage post-traumatic knee arthritis at 10 years. Of these 3 of 4 were type VI fractures and 1 of 4 was open.

Conclusion: Patients who require surgical treatment of tibia plateau fractures may be counseled on their long-term risk of requiring reconstructive knee surgery for endstage knee arthritis based on a clinical study. Based on our findings, the proportion of those who have required a total knee surgery, ten years following their injury, is lower than previously published.

Purpose: Femoral and tibial shaft malunion may predispose to knee osteoarthritis but may also pose a problem for knee reconstruction; malposition of total knee prostheses being a known cause of early failure. Limb realignment may prove to be beneficial prior to proceeding with arthroplasty. The purpose of this study was to evaluate the outcome and effect of shaft osteotomy prior to total knee arthroplasty (TKA).

Method: A search of the trauma database between 1987 and 2006 was conducted. Twenty-two osteotomies were performed on 21 patients with femoral or tibial shaft malunion who had been considered for TKA. Mean age at osteotomy was 54 years and mean follow-up 86 months. Time intervals between surgical procedures and Knee Society scores were calculated. Patients were surveyed regarding pain relief and functional improvement.

Results: Femoral osteotomy improved mean Knee Society knee scores from 47 to 76 and function scores from 34 to 61. Tibial osteotomy improved knee scores from 53 to 82 and function scores from 28 to 50. Four osteotomies were complicated by nonunion and required further intervention. Osteotomy subjectively improved pain and function for a mean of 56 months. Femoral and tibial shaft osteotomy delayed TKA in 45% (10 cases) for a mean period of just over 6.5 years (89 and 73 months for femoral and tibial osteotomy respectively). Pre and post Knee society scores were: Femur: knee 56 to 88, function 41 to 72; Tibia: knee 65 to 85, function 25 to 57. One TKA was revised after 11 months due to valgus malalignment and was complicated by a wound infection. There were no other infections or wound complications. The procedure additionally relieved pain and improved function in the remaining 12 joints, not yet requiring arthroplasty.

Conclusion: Femoral and tibial shaft osteotomy may delay and possibly avoid TKA, relieve pain and improve function in patients who present with malunion and end-stage knee arthritis. The complication rate and clinical results of TKA following shaft osteotomy appear to be similar to primary TKA. This treatment strategy should be considered in younger patients with post traumatic osteoarthritis where significant femoral or tibial deformity is present.

Purpose: We aimed to determine the effect of delay to surgery in hip fracture patients, including in hospital mortality, major complications, minor complications and length of hospital stay.

Method: We identified 615 eligible patients from the VGH Orthopaedic Trauma database between 1998 and 2002. A thorough chart review was performed. Age, gender, time from admission to surgery, pre-existing medical comorbidity, length of acute care hospital stay, major medical complications, minor medical complications and in hospital death were recorded and categorized. Patients were categorized into three risk groups for pre-existing comorbidity, and three groups for delay to surgery (48 hours). Chi-squared tests were performed to determine the association of delay to surgery to death, major complications, minor complications and length of stay, as a categorical variable. Multivariate logistic regression analysis was used to evaluate these associations, while adjusting for age, gender, and pre-existing medical comorbidity. Anvoa test was used to evaluate the association between length of stay, as a continuous variable, and delay to surgery.

Results There were 471 female patients, and 141 male patients. We identified 52 deaths (8.5%), 72 major complications (11.7%) and 238 minor complications (38.7%). The delay to surgery was < 24 hours in 346 patients (56.3%), 24–48 hours in 216 (35.1%), and > 48 hours in 50 (8.1%). The mean length of hospital stay was 23.4 days. Chi squared test showed no statistically significant association between delay to surgery and in hospital death (p= 0.787), despite a trend to increasing death (< 24 hours 8.1%, 24–48 hours 8.3%, > 48 hours 12.2%). There was no statistically significant association between delay and minor complications. Statistically significant associations between delay to OR and length of hospital stay (p= 0.0026), and the occurrence of a major complication (p=0.0085) were found. Regression analysis of major complications revealed an odds ratio of 1.47 for the > 48 hour group compared to the < 24 hour group, with a confidence interval of 1.15–1.87. Regression analysis did not show a statistically significant odds ratio for either death or minor complications.

Conclusion: There is a trend to increasing mortality and minor complications with a delay to surgery in hip fractures. A statistically significant increase in major medical complications and length of hospital stay with delay to surgery was found in our group. Regression analysis including age, gender and pre-existing medical comorbidity supported the significance of the increased risk of major medical complications with delay, adjusted for age, gender, and pre-existing medical comorbidity.

Our aim was to determine the effect of delay to surgery on the time to discharge, in-hospital death, the presence of major and minor medical complications and the incidence of pressure sores in patients with a fracture of the hip. All patients admitted to Vancouver General Hospital with this injury between 1998 and 2001 inclusive were identified from our trauma registry. A review of the case notes was performed to determine the delay in time from admission to surgery, age, gender, type of fracture and medical comorbidities. A time-to-event analysis was performed for length of stay. Additionally, a Cox proportional hazards model was used to determine the effect of delay to surgery on the length of stay while controlling for other pertinent confounding factors. Using logistical regression we determined the effect of delay to surgery on in-hospital death, medical complications and the presence of pressure sores, while controlling for confounding factors.

Delay to surgery (p = 0.0255), comorbidity (p < 0.0001), age (p < 0.0001) and type of fracture (p = 0.0004) were all significant in the Cox proportional hazards model for increased time to discharge. Delay to surgery was not a significant predictor of in-hospital mortality. However, a delay of more than 24 hours was a significant predictor of a minor medical complication (odds ratio (OR) 1.53, 95% confidence interval (CI) 1.05 to 2.22), while a delay of more than 48 hours was associated with an increased risk of a major medical complication (OR 2.21, 95% CI 1.01 to 4.34), a minor medical complication (OR 2.27, 95% CI 1.38 to 3.72) and of pressure sores (OR 2.29, 95% CI 1.19 to 4.40).

Patients with a fracture of the hip should have surgery early to lessen the time to acute-care hospital discharge and to minimise the risk of complications.

The purpose of the study was to ascertain whether there were benefits from surgical treatment of acetabular fractures within 3 days of injury, as opposed to within a 2–3 week time period as stated in the current literature.

This is a matched-pair, retrospective study, using prospectively entered data from 2 trauma units’ databases, of patients with acetabular fractures treated operatively between 1991 and 1996. Patients were matched for age, acetabular fracture pattern and associated injuries. One group of patients had surgery within 3 days of injury (median time to surgery 1. 5 days), the other group had surgery at 4 or more days post-injury (median 8 days, range 4–19 days). There were 128 patients, 64 per group.

The proportion of patients with complications was higher in the later surgery group (relative risk 2. 1, CI 0. 24–0. 87). Median lengths of stay were significantly shorter in the early surgery group, 11 days compared to 22 days (p< 0. 001 Mann-Whitney-U test). The rate of HO in the early surgery group was 2% compared with 14% in the later surgery group. The rate of good or excellent results was 81% in patients with earlier surgery, and 72% in the later surgery group, in those with median follow-up time of 24 months.

Surgery for acetabular fractures can and should be undertaken as soon as possible. In the setting of our Trauma Units, this seems to confer lower risks of early and late complications, shorter inpatient stay and may improve long-term outcome.