Ebrahim Paryavi

Effect of surgical treatment on mortality after acetabular fracture in the elderly: a multicenter study of 454 patients.

Objectives: Controversy exists regarding the effect of operative treatment on mortality after acetabular fracture in elderly patients. Our hypothesis was that operative treatment would confer a mortality benefit compared with nonoperative treatment even after adjusting for comorbidities associated with death. Design: Retrospective study. Setting: Three University Level I Trauma Centers. Patients/Participants: All patients aged 60 years and older with acetabular fractures treated from 2002 to 2009 were included in the study. Four hundred fifty-four patients were identified with an average age of 74 years. Sixty-seven percent of the study group was male and 33% female. Intervention: One of 4 treatments: nonoperative management with early mobilization, percutaneous reduction and fixation, open reduction and internal fixation, acute total hip arthroplasty. Main Outcome Measurements: Kaplan–Meier survival curves were created, and Cox proportional hazards models were used to calculate unadjusted and adjusted hazard ratios (HRs) for covariates of interest. Results: In contrast to previous smaller studies, the overall mortality was relatively low at 16% at 1 year [95% confidence interval (CI), 13–19]. Unadjusted survivorship curves suggested higher 1-year mortality rates for nonoperatively treated patients (21% vs. 13%, P < 0.001); however, nonoperative treatment was associated with other risk factors for higher mortality. By accounting for these patient risk factors, our final multivariate model of survival demonstrated no significant difference in hazard of death for nonoperative treatment (0.92, P = 0.6) nor for any of the 3 operative treatment subgroups (P range, 0.4–0.8). As expected, we did find a significantly increased hazard for factors such as the Charlson comorbidity index [HR, 1.25 per point (95% CI, 1.16–1.34)] and age [HR, 1.08 per year of age more than 70 years (95% CI, 1.05–1.11)]. In addition, associated fracture patterns (compared with elementary patterns) significantly increased the hazard of death with a ratio of 1.51 (95% CI, 1.10–2.06). Conclusions: The operative treatment of acetabular fractures does not increase or decrease mortality, once comorbidities are taken into account. The reasons for this are unknown. Regardless of the causes, the decision for operative versus nonoperative treatment of geriatric acetabular fractures should not be justified based on the concern for increased or decreased mortality alone. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Predictive model for surgical site infection risk after surgery for high-energy lower-extremity fractures: development of the risk of infection in orthopedic trauma surgery score.

BACKGROUND Current infection risk scores are not designed to predict the likelihood of surgical site infection after orthopedic fracture surgery. We hypothesized that the National Nosocomial Infections Surveillance (NNIS) System and the Study on the Efficacy of Nosocomial Infection Control (SENIC) scores are not predictive of infection after orthopedic fracture surgery and that risk factors for infection can be identified and a new score created (Emerg Infect Dis. 2003;9:196–203). METHODS We conducted a secondary analysis of data from a trial involving internal fixation of 235 tibial plateau, pilon, and calcaneus fractures treated between 2007 and 2010 at a Level I trauma center. The predictive value of the NNIS System and SENIC scores was evaluated based on areas under the receiver operating characteristic (ROC) curve. Bivariate and multiple logistic regression analyses were used to build an improved prediction model, creating the Risk of Infection in Orthopedic Trauma Surgery (RIOTS) score. The predictive value of the RIOTS score was evaluated via the ROC curve. RESULTS NNIS System and SENIC scores were not predictive of surgical site infection after orthopedic fracture surgery. In our final regression model, the relative odds of infection among patients with AO [Arbeitsgemeinschaft für Osteosynthesefragen] type C3 or Sanders type 4 fractures compared with fractures of lower classification was 5.40. American Society of Anesthesiologists class 3 or higher and body mass index less than 30 were also predictive of infection, with odds ratios of 2.87 and 3.49, respectively. The area under the ROC curve for the RIOTS score was 0.75, significantly higher than the areas for the NNIS System and SENIC scores. CONCLUSION The NNIS System and SENIC scores were not useful in predicting the risk of infection after fixation of fractures. We propose a new score that incorporates fracture classification, American Society of Anesthesiologists classification, and body mass index as predictors of infection. LEVEL OF EVIDENCE Prognostic study, level II.

Radiographic Predictors of Compartment Syndrome Occurring After Tibial Fracture.

Objectives: Compartment syndrome (CS) is a potentially devastating injury associated with tibial fractures. Few data exist regarding radiographic indicators of CS. We hypothesized that radiographic signs are associated with development of CS. Design: Retrospective review. Setting: Level I trauma center. Patients: Consecutive series of adult patients with tibial fractures with (n = 56) and without (n = 922) CS. Intervention: None. Outcomes: AO/OTA fracture classification, Schatzker type, fracture length, fibular fracture, CS diagnosis. Results: The odds of CS increased by 1.67 per 10% increase in the ratio of fracture length to tibial length when considering all fractures. CS was most likely to occur with plateau fractures at 12% (shaft fractures, 3%; pilon fractures, 2%). Schatzker VI fractures were more likely to develop CS than any other Schatzker type. Fibular fracture was predictive of CS with plateau fractures only. Segmental fractures (AO/OTA type 42-C2) were not more likely to develop CS than other shaft fractures. Conclusions: Several objective and easily reproducible radiographic indicators should raise suspicion for CS. CS was more likely in plateau fractures, especially when fracture length was >20% of the tibial length, in the presence of fibular fracture, and classified as Schatzker VI. Conversely, segmental tibial shaft fractures were not more likely than other shaft fractures to develop CS. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes Using Titanium Elastic Nails for Open and Closed Pediatric Tibia Fractures

The authors conducted a retrospective review at their level I trauma center to assess the outcomes of closed vs open pediatric tibial fractures treated with titanium elastic nails. The study group included 38 pediatric patients (median age, 12 years) treated with titanium elastic nails for tibial fractures during a 5-year period. Patient demographics, closed or open injury, Gustilo-Anderson type for open fractures, fracture location, skeletal maturity, time to union, hospital length of stay, number of procedures performed per patient, and complications were recorded. The main outcome measures were time to union and complications. Average follow-up duration was 13 months. Mean time to union was 4 months for closed and 9 months for open fractures (P<.001). Average time to union for type IIIA and IIIB fractures was significantly increased (11 and 12 months, respectively; P=.02). Delayed union (>6 months postoperatively) occurred in 1 (6%) of 17 closed fractures compared with 11 (52%) of 21 open fractures. The average number of surgical procedures for closed fractures was fewer than for open fractures (2 vs 3 procedures, respectively; P=.03). Mean hospital length of stay was shorter for closed than open fractures (3 vs 6 days, respectively; P=.03). Two infections occurred in the open fracture group. Closed and open pediatric tibial shaft fractures can be successfully treated with titanium elastic nails. Open fractures treated with titanium elastic nails have a significantly longer time to union, require additional operative procedures, and result in longer hospital stays.

Reliability and Effectiveness of Smartphone Technology for the Diagnosis and Treatment Planning of Pediatric Elbow Trauma.

Background: Mobile imaging, such as viewing radiographs as text messages, is increasingly prevalent in clinical settings. The purpose of this study was to determine whether remote diagnosis of pediatric elbow fractures using smartphone technology is reliable. In addition, this study aimed to determine whether the assessment regarding the decision for operative treatment is affected by evaluation of images on a mobile device as opposed to standard picture archiving and communication system (PACS). Methods: Standard anteroposterior and lateral radiographs of 50 pediatric elbow trauma cases were evaluated by 2 fellowship-trained pediatric orthopaedic surgeons and 2 senior orthopaedic residents. Raters were asked to classify the case as any of 6 diagnoses: supracondylar humerus, lateral condyle, medial epicondyle, radial neck fracture, positive posterior fat pad sign, or normal pediatric elbow. Raters were asked to choose operative or conservative treatment. After 1 week, photographs of the same images were taken from a standardized distance from a computer monitor with an iPhone 5 camera and transmitted by multimedia messaging to each rater. The same questions were again posed to raters. Interobserver and intraobserver reliabilities were calculated by Cohen &kgr;-statistics with bootstrapped 95% confidence intervals. Results: Intraobserver reliability of classification of injuries on PACS compared with smartphone images was excellent, with an overall &kgr; of 0.91. Treatment decision also demonstrated excellent intraobserver reliability (PACS vs. smartphones) with a &kgr; of 0.86 for all raters. Conclusions: Diagnosis of pediatric elbow injuries can be made equally reliably based on either PACS or transmitted multimedia messaging images taken with an iPhone camera from a computer screen and viewed on a smartphone. Treatment decisions can also be made reliably based on either image modality. Clinical Relevance: Using smartphones to transmit and display radiographs, which is common in current clinical practice, is effective and reliable for diagnosis and treatment planning of pediatric elbow injuries.

Is satisfaction among orthopaedic trauma patients predicted by depression and activation levels

Objectives: Among orthopaedic trauma patients, little is known regarding the relationship between patient satisfaction and patient levels of depression and “activation” (level of involvement of patient in his or her own care). Our hypothesis was that satisfaction is correlated to levels of depression and activation. Design: Patient questionnaires. Setting: Level 1 trauma center. Patients: One hundred twenty-four patients with at least one fracture. Intervention: Patients were evaluated at orthopaedic trauma clinics 6 weeks or longer after injury. Main Outcome Measures: Patient Satisfaction Questionnaire (PSQ), Patient Activation Measure, and Patient Health Questionnaire, a screening and evaluation tool for the presence and severity of depression. Spearman correlation coefficients assessed the relationship between activation level and depression severity with PSQ domains. Bivariate and multivariate linear regression models determined independent effects of depression and activation on general satisfaction. Results: Patient satisfaction was moderate to high in general (mean score, 4.17). Spearman correlation coefficients were high for patient activation and all PSQ domains (generally >0.3, P < 0.05). Correlation coefficients were weaker for depression and PSQ domains (rho range, 0.16–0.33). Final multivariate linear regression model indicated improvement in general satisfaction of 0.14 with increasing patient activation. A decrease in general satisfaction of −0.03 was noted with increasing Patient Health Questionnaire depression score. Conclusions: Patient satisfaction is strongly correlated with patient activation but less correlated with the presence of depression. Patient satisfaction after orthopaedic trauma might be improved by encouraging and coaching patients on how to be more involved in their own health care. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Use of 2 column screws to treat transcondylar distal humeral fractures in geriatric patients.

We describe fixation of transcondylar distal humeral fractures with column screws in geriatric patients and review our initial results. We conducted a retrospective review of a prospectively collected database at a Level I trauma center. Six patients met inclusion criteria of age older than 65 years and treatment of minimally or nondisplaced transcondylar distal humeral fracture with column screws only. All were closed fractures with no associated nerve injuries. One patient was lost to follow-up. The mechanism of injury was low-energy fall for the 5 remaining patients (average age, 74 y; age range, 70 to 83 y; average follow-up duration, 10.6 wk). One patient had a traumatic brain injury and a contralateral metacarpal fracture that was treated with internal fixation. The remaining 4 patients sustained isolated distal humeral fractures. No complications were noted, and all fractures healed at an average radiographic union time of 7.2 weeks. Average range of motion was 22 degrees extension [95% CI (−1.47, 45.47)], 114 degrees flexion [95% CI (89.4, 138.6)], and 92 degrees arc of motion [95% CI (58.68, 125.38)]. Treatment of select transcondylar distal humeral fractures with column screws in geriatric patients provides an option for stable fixation that allows early range of motion with minimal surgical morbidity.

Surgical site infection in tibial plateau fractures with ipsilateral compartment syndrome

AIM The aim of this study was to investigate the effects of compartment syndrome and timing of fasciotomy wound closure on surgical site infection (SSI) after surgical fixation of tibial plateau fractures. Our primary hypothesis was that SSI rate is increased for fractures with compartment syndrome versus those without, even accounting for confounders associated with infection. Our secondary hypothesis was that infection rates are unrelated to timing of fasciotomy closure or fixation. MATERIALS AND METHODS We conducted a retrospective cohort study of operative tibial plateau fractures with ipsilateral compartment syndrome (n=71) treated with fasciotomy at our level I trauma center from 2003 through 2011. A control group consisted of 602 patients with 625 operatively treated tibial plateau fractures without diagnosis of compartment syndrome. The primary outcome measure was deep SSI after ORIF. RESULTS Fractures with compartment syndrome had a higher rate of SSI (25% versus 8%, p<0.001). The difference remained significant in our multivariate model (odds ratio, 7.27; 95% confidence interval, 3.8-13.9). Delay in timing of fasciotomy closure was associated with a 7% increase per day in odds of infection (95% confidence interval, 0.2-13; p<0.05). CONCLUSIONS Tibial plateau fractures with ipsilateral compartment syndrome have a significant increase in rates of SSI compared with those without compartment syndrome (p<0.001). Delays in fasciotomy wound closure were also associated with increased odds of SSI (p<0.05).

Supplemental Perioperative Oxygen to Reduce Surgical Site Infection After High-Energy Fracture Surgery (OXYGEN Study).

Supplemental perioperative oxygen (SPO) therapy has been proposed as one approach for reducing the risk of surgical site infection (SSI). Current data are mixed regarding efficacy in decreasing SSI rates and hospital inpatient stays in general and few data exist for orthopaedic trauma patients. This study is a phase III, double-blind, prospective randomized clinical trial with a primary goal of assessing the efficacy of 2 different concentrations of perioperative oxygen in the prevention of SSIs in adults with tibial plateau, pilon (tibial plafond), or calcaneus fractures at higher risk of infection and definitively treated with plate and screw fixation. Patients are block randomized (within center) in a 1:1 ratio to either treatment group (FiO2 80%) or control group (FiO2 30%) and stratified by each study injury location. Secondary objectives of the study are to compare species and antibacterial sensitivities of the bacteria in patients who develop SSIs, to validate a previously developed risk prediction model for the development of SSI after fracture surgery, and to measure and compare resource utilization and cost associated with SSI in the 2 study groups. SPO is a low cost and readily available resource that could be easily disseminated to trauma centers across the country and the world if proved to be effective.

Upper extremity injuries in motorcyclists: implications for mortality and need for rehabilitation services

BACKGROUND Motorcycle crashes (MCCs) constitute a disproportionately high number of road accidents that result in mortality and injury, compared with other motor vehicle collisions. Distribution and characteristics of upper extremity injuries sustained by motorcyclists and their implications are not well established. We sought to determine the epidemiology of upper extremity injuries in motorcyclists and the independent effects of the injuries on mortality and need for rehabilitative services. METHODS All motorcyclist admissions at our Level I trauma center from 2006 through 2010 were retrospectively reviewed. We identified and categorized all upper extremity injuries. Demographic data, in-hospital mortality, disposition to a rehabilitation facility, and other potential confounding covariates were recorded. Propensity score–adjusted logistic regression models quantified the effects of upper limb injuries on mortality and transfer to rehabilitation facilities. RESULTS Thirty-five percent (759 of 2,151 patients) involved in MCCs sustained upper extremity injury. Shoulder girdle injuries were most common (n = 433), followed by forearm fractures (n = 272). Mortality rate was 4% (87 of 2,151 patients) for all MCC admissions. Propensity score–adjusted logistic regression models showed that injuries distal to the humerus had an independent odds ratio for mortality of 0.41 (95% confidence interval, 0.21–0.8). Odds of requiring rehabilitation after discharge were 1.82 times (95% confidence interval, 1.47–2.26) higher when any upper extremity injury was sustained. CONCLUSION Upper extremity injuries are common in MCCs. Distal injuries are associated with lower mortality rates possibly because of a “crumple zone effect” of distal upper extremities sparing the head and neck region from direct impact in head-first injuries. MCC patients with upper extremity injuries are more likely to require rehabilitation services. LEVEL OF EVIDENCE Epidemiologic study, level III.