Fixation Of Open Fractures Research Articles

Clinical outcome of conversion from external fixation to definitive internal fixation for open fracture of the lower limb

IntroductionFew reports have examined the outcomes and complications of temporary bridging external fixation (EF) in open fracture of the lower limb followed by conversion to open reduction internal fixation (ORIF). The purpose of this study was to evaluate healing rates and complications in patients treated with conversion from external fixation to definitive internal fixation for open fracture of the lower limb. MethodPatients who underwent temporary bridging EF and subsequent conversion to internal fixation (IF) for open fracture of the lower limb, with follow-up period ≥12 months were included in this study. Demographic data, Gustilo-Anderson classification, fracture type, duration to definitive surgery, surgical procedure, perioperative complications, and additional procedures for cases with complications were obtained. ResultsIn total, 58 patients (43 males, 15 females), 63 fractures were included in this study. Four fractures (6.3%) were Gustilo grade I, 11 fractures (17.5%) were grade II, 34 fractures (54.0%) were grade IIIa, 12 fractures (19.0%) were grade IIIb, and two fractures (3.2%) were grade IIIc. Mean duration of the application of EF was 12.4 days (range, 3–45 days) until conversion to definitive IF. Rates of deep infection and nonunion were both 9.5%, with two cases showing concomitant infection and nonunion. Rates of infection were 8.8% (3/34) in grade IIIa and 25% (3/12) in grade IIIb. Rates of nonunion were 9.1% (1/11) in grade II, 2.9% (1/34) in grade IIIa and 33% (4/12) in grade IIIb. ConclusionTemporary EF for open fracture of the lower limb followed by conversion to IF, as early as soft tissue and general condition permit, may be a safe and effective procedure for patients with lower-limb open fracture of Gustilo grade IIIa or less. Level of evidenceLevel IV, Case series.

The Pediatric Floating Elbow

The pediatric floating elbow involves fractures of the humerus and forearm. Majority of these injuries include supracondylar humerus fractures with ipsilateral forearm fractures. These fractures should be managed with great caution as they often result from higher energy injuries and have increased risks of nerve palsies, open fractures, loss of forearm fracture reduction, and compartment syndrome. Previous literature has advocated for operative fixation of ipsilateral forearm fractures in addition to stabilization of the supracondylar humerus fracture, to allow for noncircumferential immobilization to decrease the risk of compartment syndrome. However, recent studies have questioned the universal need for forearm fixation in patients with these injuries. This paper will discuss the pediatric floating elbow, review the available literature, and describe our technique for managing these injuries.

Naša iskustva u liječenju preloma dijafize potkoljenice spoljnom fiksacijom

Introduction. Lower leg fractures are most frequent of all fractures of long bones because a lower leg is very exposed part of a leg, especially it is anteromedial side of tibia, located immediately under skin. Aim of this paper is to analyse results of teatment of open and closed diaphysial tibial fractures using method of external fixation. Patients and methods. We analyzed the results of treatment of open and closed diaphysial tibial fractures using method of external fixation at Department of Ortopedics od Doboj hospital in period from 2005 until 2009. All patients with open fractures been treated first with surgical treatment of the wound up to 8 hours and with installation of external fixator. Patients with closed fractures which did not have satisfactory reposition have been installed external fixator which was worn from 4 to 8 weeks and then taken off, they have been applied a closed lower leg walking cast which was worn pending fracture healing verified by a clinical and xray examination. Patients in wich there was no healing process have undergone a subseqent surgical treatment which in all cases was positive. After surgical treatment all patients were sent for physical therapy. Results. Out of 124 patients with diaphysial tibial fractures, 56 (45,2%) were with open fractures and 68 of them (54,8%) were with closed fractures. After a primary treatment, there were 49 (87,5%) open fractures and 39 (57,4%) closed fractures with complications. Conclusion. Treatment of closed and open diaphysial tibial fractures by means of external fixation in open fractures as standard and selected closed fractures have shown good results with a small number of complications which were removed by a second surgical teatment. This method of treatment fractures is recommendable method in a primary as well as in final treatment of these fractures due to a positive treatment outcome.

A Retrospective Review on Atypical Femoral Fracture: Operative Outcomes and the Risk Factors for Failure.

Background:Atypical femoral fractures have been demonstrated to have high risks of reoperation and nonunion. The aim of this study is to evaluate whether the quality of reduction following operative fixation of atypical femoral fracture predicts failure.Methods:This is a 6.5-year retrospective review of atypical femoral fractures from 2 centers in a high-income region. A total of 56 patients with 66 fractures met our inclusion criteria. The quality of reduction was evaluated from postoperative films according to Hoskins’ modification of Baumgartner criteria for subtrochanteric fractures. Our primary outcome measure was failure of treatment, defined as either reoperation or nonunion at 12 months.Results:There were a total of 8 reoperations (12% of all fractures) and 8 nonunion (12% of all fractures), affecting a total of 12 fractures (18%) in 12 patients (21%). Closed reduction (P = .04) and poor quality of reduction (P = .0227 Fisher exact test) are statistically significant risk factors for failure.Conclusions:An aim for anatomical reduction with both <4 mm maximal cortical displacement and <10° angulation can improve the operative outcome of atypical femoral fractures. The addition of open reduction may be beneficial.

Early results of proximally inserted minimally invasive plate osteosynthesis for distal fibular fractures in unfavorable skin conditions: A case series

Background: Operative fixation of fractures of the lateral malleolus may be complicated by skin complications and wound infection, especially in patients with an unfavorable skin condition or soft-tissue injury. The goal of this study was to assess a technique of minimally invasive, proximally inserted plate fixation for distal fibular fractures in unfavorable skin conditions, including superficial abrasions, blisters, and contusions. Methods: This prospective case series study included 20 patients with syndesmotic and suprasyndesmotic fractures of the distal fibula, with unfavorable skin conditions, presenting to the emergency department of a major trauma center between May, 2015 and May, 2016. All patients were followed for an average of 1 yr (range, 6 mo-2 yr). Results: All fractures united at an average of 9.4 wk (range, 8-12 wk). Functional assessment according to the American Orthopaedic Foot And Ankle Society Scoring system was 93.9 (range, 78-100). None of the cases was complicated by wound dehiscence or deep infection. Conclusions: Minimally invasive, proximally inserted plate fixation is a viable and safe technique that can avoid an incision over the skin of the distal fibula in patients with unfavorable skin conditions. Level of Evidence: Level IV.

Perioperative nutrition assessment in musculoskeletal trauma patients: Dietitian evaluation is superior to serum chemistries or modified screening questionnaire for risk stratification

Malnutrition is a potentially modifiable risk factor associated with increased hospital charges, major wound complication, and fracture non-union after orthopaedic surgery. The goal of thisstudy was to examine the relationship between three nutrition screening tools and postoperative complications in patients undergoing acute fracture fixation. Patients aged 18 or older undergoing acute operative fracture fixation at a Level I academic trauma center were screened upon admission using a malnutrition screening questionnaire (MSQ), and classified as low-, moderate- or high risk. Patients at moderate-to-high risk were assessed for clinical malnutrition by dietitian. Serum albumin, transferrin, total lymphocyte count, and 25(OH) Vitamin D were measured preoperatively. Primary outcome measures included twelve-month postoperative surgical and medical complications obtained by retrospective chart review. Of 373 patients, 17% were moderate-to-high risk of malnutrition by MSQ. Clinical malnutrition was diagnosed by dietitian in 4.3% of patients assessed. Nearly half of all subjects had deficiency in one or more serum biomarkers. Cost of biomarker assays was $624 per patient. Medical or surgical complications occurred in 19% of patients. Dietitian diagnosed malnutrition (clinical malnutrition) was the strongest predictor of complication (OR 3.49, p=0.017). Hypoalbuminemia was also associated with increased complication risk (OR 1.79, p=0.045). MSQ score was not correlated with postoperative complication. Among the examined malnutrition screening tools, clinical malnutrition had the strongest association with postoperative complication. Hypoalbuminemia was associated with increased odds of complication, however there was a large false positive rate with all tested serum chemistries and high associated hospital charges compared to dietitian assessment. MSQ was a poor predictor of malnutrition and clinical outcome. Dietetic assessment is advised for orthopaedic trauma patients.

Management of Unstable Distal Radius Fractures: A Survey of Hand Surgeons.

Background Length of immobilization after operative fixation of unstable distal radius fractures and management in elderly patients is an area of debate. Purpose The purpose of this study is to delineate common practices of fellowship-trained hand surgeons and how they compare with current evidence-based protocols. Methods Surveys were distributed to American Society for Surgery of the Hand members on preferred methods of fixation, postoperative immobilization, and variations in treatment of elderly patients with unstable distal radius fractures. Responses were analyzed in comparison to a literature review. Subgroups were compared with regard to training, practice type, and years in practice. Results Four-hundred eighty-five surveys were analyzed. Volar fixed-angle plating was the most common choice of fixation (84.7%). Patients are most often immobilized for 1 to 2 weeks (40.0%) with range of motion (ROM) therapy begun most commonly between 1 and 4 weeks (47.2%). The majority of surgeons do not treat fractures differently in patients more than 65 years old. Physicians with more than 20 years of experience were significantly more likely to begin wrist ROM sooner with volar plating versus other fixation techniques compared with physicians with less than 20 years of experience (40.7% vs. 34.2%, respectively). Also, physicians in academic-only practices were more likely to immobilize patients for a shorter time after volar plating compared with those in privademics. Conclusion Volar fixed-angle plating is the dominant fixation method for unstable distal radius fractures among fellowship-trained hand surgeons. Elderly patients are not treated more conservatively and rigid immobilization after operative fixation remains the treatment of choice despite current evidence-based protocols.

Assessment of Capacity to Meet Lancet Commission on Global Surgery Indicators in the Federal Capital Territory, Abuja, Nigeria.

This is a baseline assessment of surgical capacity in the Federal Capital Territory (FCT), in preparation for the creation of a National Surgical, Obstetric, Anesthesia, and Nursing Plan. In October 2017, all 10 of the 11 secondary hospitals in FCT that provide surgical and/or obstetric care were surveyed using a modified World Health Organization Hospital Assessment Tool and a qualitative semi-structured hospital interview tool of the medical Director (MdD). This project received approval from the Nigeria Federal Ministry of Health and the FCT Department of Health and Human Services. The number of inpatient beds ranged from 35 to 140, and the number of admissions ranged from 1200 to 6400 patients per year. The mean number of surgeries performed in 2016 by these hospitals was 783 (range 235-1601). Cesarean section was the most common surgical procedure at each hospital. Only five hospitals regularly performed laparotomies. Only three hospitals regularly performed fixation of open fractures. Of 152 surgical, obstetric, and anesthesia providers, all hospitals had at least one consultant obstetrician, but only four hospitals had a general surgeon and three hospitals had a consultant anesthesiologist. Deficient physical space for inpatient admissions was the most common concern of MdDs. The FCT reaches the target for 2-h access, with 80% of patients (on average) reaching the hospital within 2h. However, SAO provider density, surgical volume, and tracking of the perioperative mortality rate were low. Data were lacking to comment on protection against impoverishing and catastrophic expenditures.

Rib fixation versus non-operative treatment for flail chest and multiple rib fractures after blunt thoracic trauma: a multicenter cohort study

BackgroundOver the years, a trend has evolved towards operative treatment of flail chest although evidence is limited. Furthermore, little is known about operative treatment for patients with multiple rib fractures without a flail chest. The aim of this study was to compare rib fixation based on a clinical treatment algorithm with nonoperative treatment for both patients with a flail chest or multiple rib fractures.MethodsAll patients with ≥ 3 rib fractures admitted to one of the two contributing hospitals between January 2014 and January 2017 were retrospectively included in this multicenter cohort study. One hospital treated all patients nonoperatively and the other hospital treated patients with rib fixation according to a clinical treatment algorithm. Primary outcome measures were intensive care length of stay and hospital length of stay for patients with a flail chest and patients with multiple rib fractures, respectively. To control for potential confounding, propensity score matching was applied.ResultsA total of 332 patients were treated according to protocol and available for analysis. The mean age was 56 (SD 17) years old and 257 (77%) patients were male. The overall mean Injury Severity Score was 23 (SD 11) and the average number of rib fractures was 8 (SD 4). There were 92 patients with a flail chest, 37 (40%) had rib fixation and 55 (60%) had non-operative treatment. There were 240 patients with multiple rib fractures, 28 (12%) had rib fixation and 212 (88%) had non-operative treatment. For both patient groups, after propensity score matching, rib fixation was not associated with intensive care unit length of stay (for flail chest patients) nor with hospital length of stay (for multiple rib fracture patients), nor with the secondary outcome measures.ConclusionNo advantage could be demonstrated for operative fixation of rib fractures. Future studies are needed before rib fixation is embedded or abandoned in clinical practice.

Effectiveness of wide fascial and doubly vascularized pedicle posterior cnemis flap in repair of soft tissue defect of forefoot

To investigate the effectiveness of wide fascial and doubly vascularized pedicle posterior cnemis flap in repair of the soft tissue defect of forefoot. Between March 2011 and March 2017, 18 cases with severe soft tissue defects of forefeet were repaired with the wide fascial and doubly vascularized pedicle posterior cnemis flaps. There were 13 males and 5 females with an average age of 33 years (range, 11-49 years). Of 18 cases, the defects were caused by trauma in 16 cases with an average disease duration of 15 hours (range, 3-72 hours), by infection after correction of spastic clubfoot in 1 case, and by infection after open fracture fixation in 1 case. The defects were on the planta of forefoot in 11 cases and on the dorsum of forefoot in 7 cases. The size of soft tissue defects ranged from 6 cm×4 cm to 15 cm×9 cm. All defects combined with the bone, joint, and tendon exposures and 4 defects combined with fractures. The size of flaps ranged from 8 cm×5 cm to 17 cm×10 cm. All wounds of donor sites were repaired by skin grafting. The operation time was 100-190 minutes (mean, 140 minutes). Seventeen flaps survived and wounds healed by first intention. One flap had partial necrosis and cured after dressing change. Seventeen cases were followed up 5-24 months (mean, 16 months). Both the color and texture of the flaps were satisfactory. But the pedicles of flaps were swollen. The functions of foot and ankle returned to normal. The wide fascial and doubly vascularized pedicle posterior cnemis flap has reliable blood supply and sufficient venous reflux to ensure its survive, which can be used to repair severe soft tissue defect of forefoot.

Prevalence and Epidemiology of Injuries Among Elite Cyclists in the Tour de France.

Background:Cycling injuries are increasing, particularly among elite athletes during major events such as the Tour de France. Many athletes miss considerable time from sport and require surgical intervention. Little is known about the epidemiology of injuries to guide practice participation strategies, return-to-competition expectations, and injury prevention protocols.Purpose:To evaluate the injury epidemiology, operative incidence, and return-to-competition timeline among all elite cyclists participating in the 21-stage Tour de France race over a span of 8 years.Study Design:Descriptive epidemiological study.Methods:All injuries sustained during 1584 unique rides by cyclists participating in the Tour de France from 2010 to 2017 were evaluated. In the absence of an established Tour de France injury database, demographic, injury, surgical, and return-to-competition details from all athletes who withdrew because of a traumatic injury were retrospectively compiled using publicly available data, which were cross-referenced for validity. The inclusion criterion consisted of any cyclist who withdrew from the Tour de France because of an injury; cyclists who withdrew for noninjury reasons were excluded. Independent variables included injury demographics, missed days, and whether the injury required surgery. Injury prevalence, relative frequency distributions, and sample proportions were dependent metrics for this investigation.Results:Among the 1584 cycling entries evaluated over the 8-year study period, there were 259 cyclists (16%) who withdrew (17 cyclists/year). A total of 138 withdrawals were caused by acute trauma, 49% of which were fractures (n = 67), which represented the most common reason for withdrawal. A total of 29 (43%) cyclists with fractures underwent surgery. The most commonly fractured bones were the clavicle (n = 21), followed by the wrist (n = 6), hand (n = 5), femur (n = 5), humerus (n = 5), and ribs (n = 5). Cyclists who underwent operative fracture fixation had a longer time between the injury and their next race compared with those who did not undergo surgery (77 vs 44 days, respectively; P = .065).Conclusion:The most common injury leading to withdrawal from the Tour de France over the study period was acute fracture, comprising 49% of all injuries. Almost half of the cyclists with fractures underwent surgery. The clavicle was the most commonly fractured bone. For cyclists who underwent operative treatment of their fractures, return to competition was more than 1 month longer than for those who did not. A prospective database is warranted to catalog injuries among these elite cyclists.

Staged conversion from temporary external fixation to internal fixation for open fractures of tibial shaft

Objective To evaluate the clinical efficacy and safety of planed conversion from temporary external fixation to internal fixation for open fractures of tibial shaft. Methods We retrospectively reviewed 31 patients with high-energy open fracture of tibial shaft who had been treated from October 2008 to October 2016 at Department of Orthopaedics, in our hospital. They were 20 males and 11 females, with an average age of 38.7 years (from 15 to 79 years). By the Gustilo classification, 2 cases were type I, 9 type II, 17 type ⅢA and 3 type ⅢB; by the AO/OTA classification, 3 cases were type 42A, 10 type 42B, and 18 type 42C. External fixation was temporally applied for the fracture ends after thorough debridement to recover the tibial length and alignment. The wounds were closed directly in 23 cases and covered with vacuum sealing drainage in 8. The external fixators were removed after their systemic condition and/or local condition of soft tissue recovered. After plaster casts were maintained for 4 to 7 days to allow for healing of the pin tracts, conversion into secondary definite internal fixation started. Plating was applied in 24 patients and intramedullary nailing in 7 patients. Results The 31 patients gained fellow-up from 13 to 61 months (mean, 22.3 months). All fractures gained bony union after an average of 18.7 weeks (from 14 to 31 weeks). No wound complication or infection was observed. According to the Johner-Wruh’s criteria, 24 cases were rated as excellent, 4 as good and 3 as fair, giving an excellent to good rate of 90.3%. Conclusion The staged conversion from temporary external fixation to internal fixation is effective and safe for open fractures of tibial shaft, leading to limited complications of soft-tissue and a high rate of fracture union. Key words: Tibial fractures; External fixator; Fracture fixation, internal; Fractures, open; Damage control

Early Surgical Stabilization of Complex Chest Wall Injuries Improves Short-Term Patient Outcomes.

This study aimed to assess the outcome of patients undergoing internal fixation of complex rib fractures in a U.K. major trauma center. A retrospective analysis was performed on all patients undergoing operative fixation of rib fractures from March 2014 to May 2016. Outcome measures included hospital length of stay, intensive care unit (ICU) admission, mechanical ventilation, infection, and mortality. One hundred and two patients (66 male patients and 36 female patients, with a median age of 62 years) underwent rib fracture fixation during the study period. The causes of trauma were road traffic accidents in 39 patients (38%), a fall from a substantial height in 38 patients (37%), and a fall down stairs in 21 patients (21%). Thirty-eight patients (37%) had isolated chest trauma, and 64 patients (63%) had additional injuries. Fifty-three patients (52%) required ICU admission with a mean ICU stay of 4.7 days (range, 1 to 34 days). The median hospital length of stay was 10.6 days (range, 3 to 51 days). Patients with additional injuries (p = 0.01) and those requiring mechanical ventilation (p < 0.0001) stayed significantly longer. Sixty-five patients (64%) underwent rib fixation within 48 hours of the injury, and 37 patients (36%) underwent the surgical procedure after 48 hours. A surgical procedure within 48 hours resulted in a shorter ICU stay (p = 0.01), fewer cases of pneumonia (p = 0.001), reduced duration of mechanical ventilation (p = 0.03) and fewer tracheostomies (p = 0.02), and shorter hospital length of stay (11.5 compared with 17.3 days; p = 0.008). Surgical stabilization of multiple rib fractures may improve the outcome in patients with multiple injuries and isolated chest wall trauma. Early surgical fixation leads to shorter length of stay and better outcomes. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes Following Posterior and Posterolateral Plating of Distal Fibula Fractures.

Ankle fractures are common orthopaedic injuries often requiring open reduction and internal fixation. A variety of positions for plate placement exist for surgical fixation of distal fibula fractures, including direct lateral, posterior, or posterolateral. Direct lateral is more common, despite evidence that posterior and posterolateral placement is mechanically superior. However, concern for peroneal tendon injury from posterior plating remains. Our study investigates clinical and functional outcomes of patients who underwent operative fixation of distal fibula fractures with posterior or posterolateral plating over a 3-year period. Analyses were performed on 59 patients with at least 2 years of follow-up. Questionnaires were used to obtain demographic data, in addition to information regarding the presence of ankle pain, subsequent hardware removal, and Foot and Ankle Outcome Scores (FAOS). In patients with at least 2 years of follow-up (average 39.6 ± 10.6 months), 37.2% reported ongoing ankle pain; 11 patients underwent hardware removal (18.6%), with 8 patients undergoing removal because of hardware-related pain (13.6%). FAOS scores (n = 51) were as follows: pain (79.9 ± 22.3), activities of daily living (84.2 ± 22.6), symptoms (75.7 ± 23.5), sports (69.4 ± 31.6), and quality of life (58.3 ± 30.5). Posterior and posterolateral plating achieved good clinical and high functional outcomes across our study population. The percentage of hardware removal in our study was either equivalent to, or less than, historical controls for any type of fibular fixation, and removal may be helpful for those patients whose postoperative ankle pain is subjectively related to the hardware. Levels of Evidence: Therapeutic, Level IV: Retrospective.

Functional outcomes in early vs delayed operative fixation of extra-articular ankle fractures

Functional outcomes in early vs delayed operative fixation of extra-articular ankle fractures

Risk Factors for Early Reoperation After Operative Treatment of Acetabular Fractures.

To identify the risk factors for early reoperation after operative fixation of acetabular fractures. Retrospective evaluation. Level I Trauma Center. Seven hundred ninety-one patients with displaced acetabular fractures treated with open reduction and internal fixation (ORIF) from 2006 to 2015. Average follow-up was 52 weeks. Early reoperation after acetabular ORIF, defined as secondary procedure for infection or revision within 3 years of initial operation. Fifty-six (7%) patients underwent irrigation and debridement for infection and wound complications. Four associated risk factors identified were length of stay in the intensive care unit, pelvic embolization, operative time, and time delay between injury and surgical fixation. Sixty-two (8%) patients underwent early revision, including 45 conversions to total hip arthroplasty, 10 revision ORIF, 6 fixation device removals because of concern for joint penetration (2 acutely and 4 > 6 months after surgery), and 1 stabilization procedure. Three risk factors associated with early revision were hip dislocation, articular comminution, and concomitant femoral head or neck injury. Combined injuries to the pelvic ring and acetabulum, fracture pattern, marginal impaction, and body mass index had no significant effect on early revision surgery. Risk factors for early reoperation after operative fixation of acetabular fractures differed based on the reason for return to the operating room. Infection was more likely to occur in patients who had prolonged stays in the intensive care unit, had prolonged operative times, were embolized, or experienced delay in time to fixation. Revision was more likely with hip dislocation, articular comminution, femoral head or neck fracture, and advancing age. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

External Fixation in the Emergency Department Is Equally Efficacious to Placement in the Operating Room

Category: Trauma Introduction/Purpose: Pilon and unstable ankle fractures are often treated initially with an external fixator (ex-fix) due to soft tissue concerns. Typically, the second stage involves open reduction internal fixation of the fracture as the definitive management. Ex-fix application in the emergency department (ED) has been described previously. We aimed to determine if an ex-fix applied in the ED would have any difference in rate of ex-fix revision, deep infection, and hospital length of stay when compared to an ex-fix that is applied in the operating room (OR). Methods: This is a retroscpective, case-cohort study performed at an urban, level-1 trauma center. Using CPT codes in our billing database, we identified all patients from 2011-2015 who had operative fixation of pilon (AO classification 43B or 43C) or unstable ankle fractures (AO classification 44C) and had application of an ex-fix (either ED or OR) prior to definitive fixation. Patients with open injury, those placed in ex-fix at outside institutions and those treated definitively with ex-fix were excluded. Results: Ninety-six patients met the inclusion criteria. Average age was 47 years and 54 (56%) were male. Thirty-three patients had ex-fix placed in the OR and 63 patients had ex-fix placed in the ED. Post-surgical complications (prominent implant, nonunion, deep infection, DVT, loss of reduction) were seen in 6/33 in the ED and 8/63 in the OR group (χ2=0.44, p=0.51). Deep infections occurred in 2/33 OR ex-fix and 5/63 ED ex-fix patients (χ2=0.137, p=0.71, OR= 1.4 [95% CI = 0.25 to 7.5]). Revision ex-fix for loss of reduction was performed 4/33 in the OR group and 10/63 in the ED ex-fix group (χ2=0.296, p=0.59). Mean length of stay was 14 days for the OR and 13 days for the ED group (p=0.35). Conclusion: We found no significant difference in post-surgical complications (surgical or infectious) or ex-fix revision rates for an ex-fix placed in ED compared to one placed in the OR. Total hospital days were similar in both groups. Prospective studies are needed to validate this method of provisional stabilization in the ED; however, these results indicate that the ED ex-fix is equally efficacious to an OR ex-fix.

Ankle Fracture Complications in the Elderly

Category: Trauma Introduction/Purpose: In the geriatric patient population, pre-existing medical conditions and poor bone quality often make operative fixation of unstable ankle fractures and fracture-dislocations more challenging. The objective of this study was to characterize the complications that occurred following operative fixation of these injuries at our institution and to determine whether complication rates were higher in our geriatric patient population (65 years and older) as compared to our younger patient population. We hypothesized that complication rates in the geriatric population would be significantly higher relative to complication rates in the younger population. We also hypothesized that in elderly patients, the soft tissue envelope would be less forgiving and require significantly more time for swelling to decrease to a level considered appropriate for definitive surgical fixation to occur. Methods: With IRB approval, a review of medical records for patients diagnosed with ankle fractures or fracture-dislocations and operated on between January of 2015 and December of 2016 was performed. Major complications were defined as any adverse outcomes requiring further surgical intervention such as irrigation and debridement for infection or exposed hardware, nonunion, major hardware failure, or amputation. Minor complications included other adverse outcomes which did not require further surgical intervention such as wound dehiscence, loss of reduction, or delayed union. Data were compared for statistically significant (p&lt;0.05) differences. Results: Medical record review produced 110 patients meeting criteria for inclusion with a mean follow-up of 179 days (range, 0 to 601 days). No significant (p&gt;0.08) differences were noted in rates of major, minor, or total complications between geriatric and younger patients treated at our institution (Fig. 1). An analysis of patient characteristics, demonstrated a significantly (p=0.035) higher proportion of trimalleolar ankle fractures within the geriatric population, but the proportions of other injury types were not significantly (p&gt;0.198) different between age groups. Prevalence of tobacco use, alcohol use, illicit drug use, or diabetes mellitus was not found to be significantly different (p&gt;0.058) between age groups. No significant (p=0.12) difference was found in time from injury to definitive surgical treatment between age groups. Conclusion: Complication rates following operative treatment of ankle fractures and fracture-dislocations were not significantly higher in our geriatric patient population, although the incidence of minor complications in the geriatric population was markedly increased relative to the younger population. A lack of significant difference in time from injury to definitive surgical treatment between age groups suggests that geriatric patients may not require a prolonged time for soft tissue swelling to decrease prior to surgery. Further study with a larger sample size is needed to determine if these findings are clinically significant.

Impact of Psychiatric Illness on Outcomes After Operatively Managed Tibial Plateau Fractures (OTA-41).

To assess the role self-reported treatment for a psychiatric diagnosis may play in long-term functional outcomes after operatively managed tibial plateau fractures. Prospective cohort study. Academic medical center. Over an 11-year period, patients were screened and identified on presentation to the emergency department or in the clinical office for inclusion in an IRB-approved registry. A total of 245 patients were included in the study. Twenty-one patients reported treatment for a psychiatric diagnosis. Surgical repair of tibial plateau fractures. Patients were divided into 2 cohorts; 1 cohort being those who self-reported receiving treatment of a psychiatric diagnosis (PI); the other group being those who did not self-report receiving treatment of a psychiatric diagnosis (NPI). Three-month, 6-month, and long-term outcomes (mean = 18 months) were evaluated using the Short Musculoskeletal Function Assessment (SMFA), pain scores, and postoperative complications (infection, VTE, nonunion, and necessity for secondary operations). Pain scores were higher in patients who self-reported receiving treatment for a psychiatric diagnosis (P = 0.012). Long-term functional outcomes as measured by the SFMA were demonstrated to be worse in patients who self-reported treatment for a psychiatric diagnosis (P = 0.034). No differences existed between groups in regards to postoperative complications. Multiple linear regression analysis revealed that being treated for diagnosis of a mental health illness was an independent predictor of worse functional outcomes at long-term follow-up [B = 8.874, 95% confidence interval (CI) = 0.354-17.394, P = 0.041]. Mental health plays a crucial role in long-term outcomes after operative fixation of tibial plateau fractures. Patients who have been diagnosed with a mental health illness have significantly worse outcomes at long-term follow-up. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predictors of lower health-related quality of life after operative repair of diaphyseal femur fractures in a low-resource setting

BackgroundLittle data exists on the negative impact of orthopaedic trauma on quality of life (QOL) in low- and middle-income countries (LMICs). The goal of this study is to investigate the factors associated with lower QOL after operative fixation of femoral shaft fractures in adult patients in a low-resource setting. MethodsThis prospective cohort study followed 272 factures in adults undergoing operative fixation for diaphyseal femur fractures at Tanzania. Patient demographics, injury characteristics, treatment modalities, and functional outcomes up to 1-year post-operatively were evaluated for association with 1-year post-operative EQ-5D QOL scores via univariate linear regression analysis. ResultsEQ-5D values were significantly lower at 1 year than at baseline (0.941 vs 0.991, p < 0.0005). ConclusionsOperative fixation of femoral shaft fractures in LMICs results in return to near baseline QOL. Demographic and treatment factors were not significantly associated with EQ-5D. and several markers of recovery were associated with lower 1 year QOL, including pain, knee stiffness, delayed radiographic healing, complications requiring reoperation. Efforts to reduce perioperative complications may help improve post-operative QOL.