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.

Proximal humerus fractures are a common fragility fracture in older adults. A variety of treatment options exist, yet longer term outcomes of newer surgical treatments have not been extensively researched. Additionally, intermediate term outcomes following both surgical and non-surgical initial treatment of these injuries have not been evaluated at a population level. The purpose of this study was to utilise administrative data from Ontario, Canada to evaluate intermediate term outcomes following initial treatment of proximal humerus fractures.

We used data from the Canadian Institute for Health Information to identify all patients aged 50 and older who presented to an ambulatory care facility with a “main diagnosis” of proximal humerus fracture from April 1, 2004 to March 31, 2013. Intervention codes from the Discharge Abstract Database were used to categorise patients into fixation, replacement, reduction or non-surgically treated groups. We used intervention codes to identify instances of complication-related operations following initial treatment (including fixation, replacement, hardware removal, rotator cuff repair and irrigation and debridement [I&D]) at one year post initial treatment.

The majority of patients (28,369, 86.6%, 95% confidence interval [95% CI] 86.2–87.0%) were initially treated non-surgically, while 2835 (8.7%, 95% CI 8.4–9.0%) underwent initial fixation, 1280 (3.9%, 95% CI 3.7–4.1%) received primary joint replacement, and 276 (0.8%, 95% CI 0.8–1.0%) were initially treated with a reduction procedure. In the year following the initial treatment period, 127 (0.4%, 95%CI 0.4–0.5%) non-surgically treated patients underwent a replacement surgery, 292 (1.0%, 95%CI 0.9–1.2%) underwent fixation, and 12 (0.04%, 95% CI 0.02–0.07%) underwent a reduction procedure. Of the 2835 patients who received initial fixation, 57 (2.0%, 95% CI 1.6–2.6%) returned for a shoulder replacement, 80 received secondary fixation (2.8%, 95% CI 2.3–3.5%), 57 (2.0%, 95%CI 1.6–2.6%) underwent rotator cuff repair, 300 (10.6%, 95% CI 9.5–11.8%) had their implants removed, and 16 (0.6%, 95% CI 0.4–0.9%) returned for I&D. Of the 1280 patients who underwent initial replacement surgeries, 30 (2.3%, 95% CI 1.7–3.3%) returned for a secondary replacement, nine (0.7%, 95% CI 0.4–1.3%) underwent rotator cuff repair, and seven (0.6%, 95% CI 0.3–1.1%) had their implant removed. In the group who received initial reduction, eight (2.9%, 95% CI 1.5–5.6%) underwent a fixation procedure, six (2.2%, 95% CI 1.0–4.7%) received replacement surgeries, and five (1.8%, 95% CI 0.8–4.2%) each received rotator cuff repair and I&D in the year following initial treatment.

The majority of proximal humerus fractures in patients 50 and older in Ontario, Canada are treated non-surgically. Complication-related operations in the year following initial non-operative treatment are relatively low. The most commonly observed procedure following initial fixation surgery is hardware removal.

Proximal femur fractures are increasing in prevalence, with femoral neck (FN) and intertrochanteric (IT) fractures representing the majority of these injuries. The salvage procedure for failed open reduction internal fixation (ORIF) is often a conversion to total hip arthroplasty (THA). The use of THA for failed ORIF improves pain and function, however the procedure is more challenging. The aim of this study was to investigate the clinical and radiographic outcomes in patients who have undergone THA after ORIF.

This retrospective case-control study compared patients who underwent THA after failed ORIF to a matched cohort undergoing primary THA for non-traumatic osteoarthritis. From 2004 to 2014, 40 patients were identified. The matched cohort was matched for date of operation, age, gender, and type of implant. Preoperative, intraoperative, and postoperative data were collected and statistical analysis was performed.

The cohort of patients with a salvage THA included 18 male and 22 female patients with a mean age of 73 years and mean follow up of 3.1 years. Those with failed fixation included 12 IT fractures and 28 FN fractures. The mean time between ORIF and THA was 2.1 years for IT fractures and 8.5 years for FN fractures (p=0.03). The failed fixation group had longer procedures, greater drop in hemoglobin, and greater blood transfusion rate (p<0.05). There was one revision and one dislocation in the failed fixation group with no revisions or dislocations in the primary THA group. Length of admission, medical complications, and functional outcome as assessed with a standardised hip score and were found not to be statistically different between the groups.

Salvage THA for failed initial fixation of proximal femur fractures yields comparable clinical results to primary THA with an increased operative time, blood loss, and blood transfusion rate.

Introduction:

One method of femoral head preservation following avascular necrosis (AVN) is core decompression and Tantalum Rod insertion. There is, however, a published failure rate of up to 32% at 4 years. The purpose of the present study was to document the clinical and radiological outcome following Total Hip Arthroplasty (THA) subsequent to failed Tantalum Rod insertion.