Heather A. Vallier

A New Look at the Hawkins Classification for Talar Neck Fractures: Which Features of Injury and Treatment Are Predictive of Osteonecrosis?

BACKGROUNDnOsteonecrosis and posttraumatic arthritis are common after talar neck fracture. We hypothesized that delay of definitive fixation would not increase the rate of osteonecrosis, but that the amount of initial fracture displacement, including subtalar and/or tibiotalar dislocations, would be predictive. We investigated the possibility of dividing the Hawkins type-II classification into subluxated (type-IIA) and dislocated (type-IIB) subtalar joint subtypes.nnnMETHODSnThe cases of eighty patients with eighty-one talar neck and/or body fractures who had a mean age of 36.7 years were reviewed. The fractures included two Hawkins type-I, forty-four type-II (twenty-one type-IIA and twenty-three type-IIB), thirty-two type-III, and three type-IV fractures. Open fractures occurred in twenty-four patients (30%).nnnRESULTSnOne deep infection, two nonunions, and two malunions occurred. After a mean of thirty months of follow-up, sixteen of sixty-five fractures developed osteonecrosis, but 44% of them revascularized without collapse. Osteonecrosis never occurred in fractures without subtalar dislocation (Hawkins type I and IIA), but 25% of Hawkins type-IIB patterns developed osteonecrosis (p = 0.03), and 41% of Hawkins type-III fractures developed osteonecrosis (p = 0.004). Osteonecrosis occurred after 30% of open fractures versus 21% of closed fractures (p = 0.55). Forty-six fractures were treated with urgent open reduction and internal fixation (ORIF) at a mean of 10.1 hours, primarily for open fractures or irreducible dislocations. With the numbers studied, the timing of reduction was not related to the development of osteonecrosis. Thirty-five patients had delayed ORIF (mean, 10.6 days), including ten with Hawkins type-IIB and ten with Hawkins type-III fractures initially reduced by closed methods, and one (5%) of the twenty developed osteonecrosis. Thirty-five patients (54%) developed posttraumatic arthritis, including 83% of those with an associated talar body fracture (p < 0.0001) and 59% of those with Hawkins type-III injuries (p < 0.01).nnnCONCLUSIONSnFollowing talar neck fracture, osteonecrosis of the talar body is associated with the amount of the initial fracture displacement, and separating Hawkins type-II fractures into those without (type IIA) and those with (type-IIB) subtalar dislocation helps to predict the development of osteonecrosis as in this series. It never occurred when the subtalar joint was not dislocated. When it does develop, osteonecrosis often revascularizes without talar dome collapse. Delaying reduction and definitive internal fixation does not increase the risk of developing osteonecrosis.

Analysis of anatomic periarticular tibial plate fit on normal adults.

Implant manufacturers are producing anatomically contoured periarticular plates to improve the treatment of proximal tibia fractures. We assessed the accuracy of the designation anatomic. We applied eight-hole medial and lateral anatomically contoured periarticular plates to 101 cadaveric tibiae. The tibiae and the plate fits were mapped, quantified, and analyzed using a MicroScribe® G2LX digi tizer, Rhinoceros® software, and MATLAB® software. By corresponding the clinical appearance of good fit with our digital findings, we created numerical criteria for plate fit in three planes: coronal (volume of free space between the plate and bone), sagittal (alignment with the tibial plateau and shaft), and axial (match in curvature between the proximal horizontal part of the plate and the tibial plateau). An anatomic fit should mirror the shape of the tibia in all three planes, and only four medial and four lateral plate fits qualified. Recognizing and understanding the substantial variations in fit that exist between anatomically contoured plates and the tibia may help lead to a more stable fixation and prevent malreduction of the fracture and/or soft tissue impingement.

Complications are reduced with a protocol to standardize timing of fixation based on response to resuscitation

BackgroundOur group developed a protocol, entitled Early Appropriate Care (EAC), to determine timing of definitive fracture fixation based on presence and severity of metabolic acidosis. We hypothesized that utilization of EAC would result in fewer complications than a historical cohort and that EAC patients with definitive fixation within 36xa0h would have fewer complications than those treated at a later time.MethodsThree hundred thirty-five patients with mean age 39.2xa0years and mean Injury Severity Score (ISS) 26.9 and 380 fractures of the femur (nu2009=u2009173), pelvic ring (nu2009=u200971), acetabulum (nu2009=u200957), and/or spine (nu2009=u200979) were prospectively evaluated. The EAC protocol recommended definitive fixation within 36xa0h if lactate <4.0xa0mmol/L, pH ≥7.25, or base excess (BE) ≥−5.5xa0mmol/L. Complications including infections, sepsis, DVT, organ failure, pneumonia, acute respiratory distress syndrome (ARDS), and pulmonary embolism (PE) were identified and compared for early and delayed patients and with a historical cohort.ResultsAll 335 patients achieved the desired level of resuscitation within 36xa0h of injury. Two hundred sixty-nine (80xa0%) were treated within 36xa0h, and 66 had protocol violations, treated on a delayed basis, due to surgeon choice in 71xa0%. Complications occurred in 16.3xa0% of patients fixed within 36xa0h and in 33.3xa0% of delayed patients (pu2009=u20090.0009). Hospital and ICU stays were shorter in the early group: 9.5 versus 17.3xa0days and 4.4 versus 11.6xa0days, respectively, both pu2009<u20090.0001. This group of patients when compared with a historical cohort of 1443 similar patients with 1745 fractures had fewer complications (16.3 versus 22.1xa0%, pu2009=u20090.017) and shorter length of stay (LOS) (pu2009=u20090.018).ConclusionsOur EAC protocol recommends definitive fixation within 36xa0h in resuscitated patients. Early fixation was associated with fewer complications and shorter LOS. The EAC recommendations are safe and effective for the majority of severely injured patients with mechanically unstable femur, pelvis, acetabular, or spine fractures requiring fixation.

Teamwork in Trauma: System Adjustment to a Protocol for the Management of Multiply Injured Patients.

Objectives: We developed a protocol to determine the timing of definitive fracture care based on the adequacy of resuscitation. Inception of this project required a multidisciplinary group, including physicians from anesthesiology, general trauma and critical care, neurosurgery, orthopaedic spine, and orthopaedic trauma. The purposes of this study were to review our initial experience with adherence to protocol recommendations and to assess barriers to implementation. Design: Prospective. Setting: Level 1 trauma center. Intervention: Definitive fixation of pelvis, acetabulum, spine, and femur fractures within 36 hours of injury, based on laboratory parameters for acidosis. Main Outcome Measurements: Three hundred five consecutive skeletally mature patients with Injury Severity Score ≥16 (mean, 26.4) and 346 fractures of the proximal or diaphyseal femur (n = 152), pelvic ring (n = 56), acetabulum (n = 44), and/or spine (n = 94) were treated surgically. Adherence to the protocol was defined as definitive fixation within 36 hours of injury in resuscitated patients. All patients were adequately resuscitated within that time. Patient demographic and injury characteristics, date and time of presentation, and reasons for delay were recorded. Results: Two hundred fifty-one patients (82%) with 287 fractures were treated according to the protocol, whereas 54 patients (18%) with 59 fractures were definitively stabilized on a delayed basis (mean, 90 hours). Delay was not related to patient age, Injury Severity Score, day of week, or time of presentation. Before implementation of this protocol, 76% were treated on a delayed basis, demonstrating improvement for each fracture type: spine (79% of previous patients with delay), pelvis (57%), acetabulum (72%), and femur (22%); all P < 0.0001 for more frequently delayed surgery before the protocol. Surgeon choice to delay the procedure accounted for 67% of reasons for delay. Other reasons included intensivist choice (13%), operating room availability (7.4%), patient choice (3.7%), severe head injury (5.6%), or cardiac issues (3.7%). Our trauma center and surgeons became more accustomed to the protocol and had fewer delays over time; 10% were delayed 2 years after implementation. Conclusions: Management of trauma patients with injury to multiple systems requires teamwork among providers from related specialties and hospital support, in terms of operating room access, with appropriate ancillary personnel and equipment. Our system adjusted quickly to the protocol. Surgeon preference was the most common reason for delayed fixation, but within 24 months, only 10% of fractures were treated on a delayed basis, as long as patients were resuscitated. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Psychiatric Illness Is Common Among Patients with Orthopaedic Polytrauma and Is Linked with Poor Outcomes.

BACKGROUNDnPsychiatric disorders are common, and their functional consequences may be underappreciated by non-mental health-care providers. There exist limited data regarding the frequency of psychiatric illness in patients who sustain orthopaedic polytrauma. The purpose of this study was to describe the prevalence of psychiatric illness in patients with orthopaedic polytrauma, to determine whether psychiatric illnesses were identified and were accommodated by trauma providers, and, finally, to investigate any associations between postoperative complications and psychiatric illness.nnnMETHODSnThree hundred and thirty-two skeletally mature patients with surgically treated axial and/or femoral fractures and injuries to other body systems (Injury Severity Score of ≥ 16 points) were identified from a database at a Level-I trauma center. These included 238 men and ninety-four women with a mean value (and standard deviation) of 39 ± 16 years for age and 27 ± 12 points for the Injury Severity Score. Records were reviewed for preexisting diagnoses of psychiatric disorders. The inpatient courses and discharge recommendations regarding treatment of psychiatric illness were analyzed. Complications in the six-month postoperative period were determined by an independent committee.nnnRESULTSnPreexisting psychiatric disorders were identified in 130 patients (39.2%), including depression in seventy-four patients (22.3%) and substance abuse in fifty-six patients (16.9%). Patients managed by an orthopaedic surgery service were less likely to receive their home psychiatric medications while hospitalized (p = 0.001) and were less likely to receive instructions for psychiatric follow-up at discharge (p = 0.087). Postoperative complications occurred in sixty-six patients (19.9%) overall; depression was an independent predictor of increased complications, with an odds ratio of 2.956 (95% confidence interval, 1.502 to 5.816).nnnCONCLUSIONSnPsychiatric illness was common among individuals who sustained orthopaedic polytrauma, and patients with depression had more complications. This study highlights the need for greater attention to mental health disorders in this population.

Prolonged resuscitation of metabolic acidosis after trauma is associated with more complications.

BackgroundOptimal patterns for fluid management are controversial in the resuscitation of major trauma. Similarly, appropriate surgical timing is often unclear in orthopedic polytrauma. Early appropriate care (EAC) has recently been introduced as an objective model to determine readiness for surgery based on the resuscitation of metabolic acidosis. EAC is an objective treatment algorithm that recommends fracture fixation within 36xa0h when either lactate <4.0xa0mmol/L, pHu2009≥u20097.25, or base excess (BE) ≥−5.5xa0mmol/L. The aim of this study is to better characterize the relationship between post-operative complications and the time required for resuscitation of metabolic acidosis using EAC.MethodsAt an adult level 1 trauma center, 332 patients with major trauma (Injury Severity Score (ISS) ≥16) were prospectively treated with EAC. The time from injury to EAC resuscitation was determined in all patients. Age, race, gender, ISS, American Society of Anesthesiologists score (ASA), body mass index (BMI), outside hospital transfer status, number of fractures, and the specific fractures were also reviewed. Complications in the 6-month post-operative period were adjudicated by an independent multidisciplinary committee of trauma physicians and included infection, sepsis, pulmonary embolism, deep venous thrombosis, renal failure, multiorgan failure, pneumonia, and acute respiratory distress syndrome. Univariate analysis and binomial logistic regression analysis were used to compare complications between groups.ResultsSixty-six patients developed complications, which was less than a historical cohort of 1,441 patients (19.9xa0% vs. 22.1xa0%). ISS (pu2009<u20090.0005) and time to EAC resuscitation (pu2009=u20090.041) were independent predictors of complication rate. A 2.7-h increase in time to resuscitation had odds for sustaining a complication equivalent to a 1-unit increase on the ISS.ConclusionsEAC guidelines were safe, effective, and practically implemented in a level 1 trauma center. During the resuscitation course, increased exposure to acidosis was associated with a higher complication rate. Identifying the innate differences in the response, regulation, and resolution of acidosis in these critically injured patients is an important area for trauma research.Level of evidenceLevel 1: prognostic study.

Is Early Appropriate Care of axial and femoral fractures appropriate in multiply-injured elderly trauma patients?

BackgroundPrevious work established resuscitation parameters that minimize complications with early fracture management. This Early Appropriate Care (EAC) protocol was applied to patients with advanced age to determine if they require unique parameters to mitigate complications.MethodsBetween October 2010 and March 2013, 376 consecutive skeletally mature patients with unstable fractures of the pelvis, acetabulum, thoracolumbar spine, and/or proximal or diaphyseal femur fractures were treated at a level I trauma center and were prospectively studied. Patients aged ≤30xa0years (nu2009=u2009114), 30 to 60xa0years (nu2009=u2009184), and ≥60xa0years (nu2009=u200937) with Injury Severity Scores (ISS) ≥16 and unstable fractures of the pelvis, acetabulum, spine, and/or diaphyseal femur were treated within 36xa0h, provided they showed evidence of adequate resuscitation. ISS, Glasgow Coma Scale (GCS), and American Society of Anesthesiologists (ASA) classification were determined. Lactate, pH, and base excess (BE) were measured at 8-h intervals. Complications included pneumonia, pulmonary embolism (PE), acute renal failure, acute respiratory distress syndrome (ARDS), multiple organ failure (MOF), deep vein thrombosis, infection, sepsis, and death.ResultsPatients ≤30xa0years old (y/o) were more likely to sustain gunshot wounds (pu2009=u20090.039), while those ≥60xa0y/o were more likely to fall from a height (pu2009=u20090.002). Complications occurred at similar rates for patients ≤30xa0y/o, 30 to 60xa0y/o, and ≥60xa0y/o. There were no differences in lactate, pH, or BE at the time of surgery. For patients ≤30xa0y/o, there were increased overall complications if pH was <7.30 (pu2009=u20090.042) or BE <−6.0 (pu2009=u20090.049); patients ≥60xa0y/o demonstrated more sepsis if BE was <−6.0 (pu2009=u20090.046).ConclusionsEAC aims to definitively manage axial and femoral shaft fractures once patients have been adequately resuscitated to minimize complications. EAC is associated with comparable complication rates in young and elderly patients. Further study is warranted with a larger sample to further validate EAC in elderly patients. Level of evidence: level II prospective, comparative study.

Noncontiguous and open fractures of the lower extremity: Epidemiology, complications, and unplanned procedures.

INTRODUCTIONnIsolated fractures of the lower extremity are relatively common injuries while multifocal injuries resulting from high-energy trauma are less frequently encountered. Our objectives are to characterise patients who sustained multiple noncontiguous fractures and open fractures of the lower extremity, report the incidence of major complications, and identify factors that may contribute to complications and unplanned re-operations.nnnPATIENTS AND METHODSnA retrospective review of patients was performed at a Level 1 trauma centre from 2000 to 2013. Patients who sustained two or more noncontiguous operative fractures in an ipsilateral lower extremity, with at least one open fracture were included. Noncontiguous was defined as fractures in the same lower limb that were not in continuity on preoperative radiographs or intra-operatively. Demographic, injury characteristics, and hospitalisation data were collected. Primary outcomes included non-union, deep infection, and the need for unplanned surgeries.nnnRESULTSn257 patients sustained a total of 876 lower extremity fractures with an average of 1.7 open and 2.7 operative fractures in the qualifying limb. Ninety-nine patients (38.5%) sustained bilateral lower extremity injuries. Following their initial stay, 22.6% of patients had planned procedures (definitive fixation, skin, or planned bone grafting). Nearly half (45.9%) required one or more unplanned re-operation. Complications included deep infections (19.5%), non-unions (19.5%), and mal-unions (2.7%). 17.5% of the patients had at least one procedure for removal of painful implants. A deep infection was predictive of having a non-union (odds ratio, OR 7.5). The presence of a Gustilo-type IIIB/IIIC (OR 24.6/16.0) fracture was predictive of having a deep infection. After excluding painful implant removal, a type IIIB fracture was associated with an unplanned procedure (OR 13.8).nnnCONCLUSIONSnPatients with multiple non-contiguous lower extremity injuries associated with open fractures can expect complications including non-unions, deep infections, and painful implants. Nearly half of the patients will need further operative treatment.

Improving pain management and long-term outcomes following high-energy orthopaedic trauma (pain study)

Poor pain control after orthopaedic trauma is a predictor of physical disability and numerous negative long-term outcomes. Despite increased awareness of the negative consequences of poorly controlled pain, analgesic therapy among hospitalized patients after orthopaedic trauma remains inconsistent and often inadequate. The Pain study is a 3 armed, prospective, double-blind, multicenter randomized trial designed to evaluate the effect of standard pain management versus standard pain management plus perioperative nonsteroidal anti-inflammatory drugs or pregabalin in patients of ages 18-85 with extremity fractures. The primary outcomes are chronic pain, opioid utilization during the 48 hours after definitive fixation and surgery for nonunion in the year after fixation. Secondary outcomes include preoperative and postoperative pain intensity, adverse events and complications, physical function, depression, and post-traumatic stress disorder. One year treatment costs are also compared between the groups.

Variation in treatment of low energy gunshot injuries – A survey of OTA members

The purpose of this study was to determine current practice patterns in the treatment of low energy gunshot wounds involving bones and joints. One hundred seventy-three Orthopaedic Trauma Association (OTA) members completed a web-based survey. The survey included practices for antibiotic therapy and operative treatment for different types of low-energy gunshot injuries. Six different scenarios of soft tissue injury, intra-articular injury, and fractures were described. Several permutations of antibiotic therapy and operative or non-operative management options were given as choices on the survey. Survey responses had a high degree of heterogeneity with only two treatment options receiving more than 50% agreement among responders: 54% agreed on joint exploration with perioperative antibiotics for gunshot wounds (GSWs) traversing a joint and 55% agreed on treating operative tibial shaft fractures from GSWs with fixation, along with debridement and irrigation of the GSW tract, and perioperative antibiotics. The majority of participants (69%) were either not aware of or not sure of an established protocol for treatment of GSW to bones and joints at their institution. Moreover, there is still wide variation in treatments among 31% of the participants who reported a protocol in place at their institutions. We conclude there is wide variation among orthopaedic surgeons in the antimicrobial prophylaxis and treatment of GSWs. Opportunity exists to develop standardized practices to minimize related infections, other complications, and costs.