Orthopaedic Trauma Association Research Articles

IDCRP Combat-Related Extremity Wound Infection Research.

Extremity trauma is the most common battlefield injury, resulting in a high frequency of combat-related extremity wound infections (CEWIs). As these infections are associated with substantial morbidity and may impact wounded warriors long after initial hospitalization, CEWIs have been a focus of the Infectious Disease Clinical Research Program (IDCRP). Herein, we review findings of CEWI research conducted through the IDCRP and discuss future and ongoing analyses. Military personnel with deployment-related trauma sustained between 2009 and 2014 were examined in retrospective analyses through the observational Trauma Infectious Disease Outcomes Study (TIDOS). Characteristics of wounded warriors with ≥1 open extremity wound were assessed, focusing on injury patterns and infection risk factors. Through a separate trauma-associated osteomyelitis study, military personnel with combat-related open fractures of the long bones (tibia, femur, and upper extremity) sustained between 2003 and 2009 were examined to identify osteomyelitis risk factors. Among 1,271 wounded warriors with ≥1 open extremity wound, 16% were diagnosed with a CEWI. When assessed by their most severe extremity injury (i.e., amputation, open fracture, or open soft-tissue wound), patients with amputations had the highest proportion of infections (47% of 212 patients with traumatic amputations). Factors related to injury pattern, mechanism, and severity were independent predictors of CEWIs during initial hospitalization. Having a non-extremity infection at least 4 days before CEWI diagnosis was associated with reduced likelihood of CEWI development. After hospital discharge, 28% of patients with extremity trauma had a new or recurrent CEWI during follow-up. Risk factors for the development of CEWIs during follow-up included injury pattern, having either a CEWI or other infection during initial hospitalization, and receipt of antipseudomonal penicillin for ≥7 days. A reduced likelihood for CEWIs during follow-up was associated with a hospitalization duration of 15-30 days. Under the retrospective osteomyelitis risk factor analysis, patients developing osteomyelitis had higher open fracture severity based on Gustilo-Anderson (GA) and the Orthopaedic Trauma Association classification schemes and more frequent traumatic amputations compared to open fracture patients without osteomyelitis. Recurrence of osteomyelitis was also common (28% of patients with open tibia fractures had a recurrent episode). Although osteomyelitis risk factors differed between the tibia, femur, and upper extremity groups, sustaining an amputation, use of antibiotic beads, and being injured in the earlier years of the study (before significant practice pattern changes) were consistent predictors. Other risk factors included GA fracture severity ≥IIIb, blast injuries, foreign body at fracture site (with/without orthopedic implant), moderate/severe muscle damage and/or necrosis, and moderate/severe skin/soft-tissue damage. For upper extremity open fractures, initial stabilization following evacuation from the combat zone was associated with a reduced likelihood of osteomyelitis. Forthcoming studies will examine the effectiveness of common antibiotic regimens for managing extremity deep soft-tissue infections to improve clinical outcomes of combat casualties and support development of clinical practice guidelines for CEWI treatment. The long-term impact of extremity trauma and resultant infections will be further investigated through both Department of Defense and Veterans Affairs follow-up, as well as examination of the impact on comorbidities and mental health/social factors.

Understanding postoperative rehabilitation preferences in operatively managed proximal humerus fractures: do trauma and shoulder surgeons differ?

Proximal humerus fractures (PHFs) are common, and their incidence is increasing as the population ages. Despite this, postoperative rehabilitation remains unstandardized and little is known about surgeon preferences. The aim of this study was to assess differences in postoperative rehabilitation preferences and patient education between orthopedic trauma and shoulder surgeons. An electronic survey was distributed to members of the Orthopaedic Trauma Association and the American Shoulder and Elbow Surgeons to assess differences in postoperative rehabilitation preferences and patient counseling. Descriptive statistics were reported for all respondents, trauma surgeons, and shoulder surgeons. Chi-square and unpaired 2-sample t tests were used to compare responses. Multinomial regression was used to further elucidate the influence of fellowship training independent of confounding characteristics. A total of 293 surgeons completed the survey, including 172 shoulder and 78 trauma surgeons. A greater proportion of trauma surgeons preferred an immediate weightbearing status after arthroplasty compared to shoulder surgeons (45% vs. 19%, P=.003), but not after open reduction and internal fixation (ORIF) (62% vs. 75%, P=.412). A greater proportion of shoulder surgeons preferred home exercise therapy taught by the physician or using a handout following reverse shoulder arthroplasty (RSA) (21% vs. 2%, P=.009). A greater proportion of trauma surgeons began passive range of motion (ROM) <2 weeks after 2-part fractures (70% vs. 41%, P<.001). Conversely, a greater proportion of shoulder surgeons began passive ROM between 2 and 6 weeks for 2-part (57% vs. 24%, P<.001) and 4-part fractures (65% vs. 43%, P=.020). On multinomial regression analysis, fellowship training in shoulder surgery was associated with preference for a nonweightbearing duration of >12 weeks vs. 6-12 weeks after ORIF. Similarly, fellowship training in shoulder surgery was associated with increased odds of preferring a nonweightbearing duration of <6 weeks vs. no restrictions and >12 weeks vs. 6-12 weeks after arthroplasty. Training in shoulder surgery was associated with greater odds of preferring a nonweightbearing duration prior to beginning passive ROM of 2-6 weeks vs. <2 weeks or >6 weeks for 2-part fractures, but not 4-part fractures. Trauma surgeons have a more aggressive approach to rehabilitation following operative PHF repair compared to shoulder surgeons regarding time to weightbearing status and passive ROM. Given the increasing incidence of PHFs and substantial variations in reported treatment outcomes, differences in rehabilitation after PHF treatment should be further evaluated to determine the role it may play in the outcomes of treatment studies.

Adaptation of the Centers for Disease Control Surgical Wound Classification System for Orthopaedic Trauma Surgery.

To evaluate a proposed orthopaedic-specific surgical wound classification system (SWCS) and the current Centers for Disease Control (CDC) system in a series of detailed clinical vignettes and to identify the degree of satisfaction with CDC SWCS and desire for institution of an orthopaedic-specific SWCS. Forty-five clinical vignettes and a 5-question survey were distributed to current and past members of the Orthopaedic Trauma Association's Classification Committee. Respondents were asked to provide wound class for each vignette using the CDC system and orthopaedic-specific SWCS. The orthopaedic-specific and CDC SWCS had interclass correlations of 0.95 and 0.91, respectively. When the systems were compared, in 34% of cases, there was no grade change; in 63% of cases, the wound was graded higher using the orthopaedic-specific SWCS. When only the procedure was changed between vignettes, wound classification was infrequently affected. There was near universal dissatisfaction with the CDC SWCS and desire for an orthopaedic-specific system. Both the CDC SWCS and orthopaedic-specific SWCS have excellent interobserver reliability. Incorporation of orthopaedic-specific language affects wound classification. There is low satisfaction with the current CDC SWCS and a desire exists for further development and validation of an orthopaedic-specific SWCS.

Keyhole Sliding Hip Screw Fixation for Stable Intertrochanteric Hip Fractures: A Novel Technique.

Intertrochanteric hip fractures are common orthopaedic injuries and the incidence is growing with increasing life expectancy. Several randomized controlled studies have shown the advantages of intramedullary devices over hip screw fixation in unstable intertrochanteric fractures. However, the proven advantage of the intramedullary device in stable intertrochanteric fractures, OTA (Orthopaedic Trauma Association) classification 31-A1 and some 31-A2 fractures are in less blood loss compared with standard hip screw fixation. In the current technical note, we describe a novel minimally invasive technique of hip screw fixation that use a keyhole size incision to fix stable intertrochanteric fractures using sliding hip screw. The less invasive nature and potentially reduced blood loss makes this technique an attractive option for stabilizing stable intertrochanteric hip fractures.

H-Index Predicts Academic Rank Among Full-time Academic Orthopaedic Trauma Surgeons Affiliated with Fellowship Programs

Objectives: The purpose was to investigate the association between Hirsch index (H-index) and academic rank among orthopaedic trauma surgeons affiliated with Orthopaedic Trauma Association (OTA) and Accreditation Council for Graduate Medical Education (ACGME) fellowship programs with academic appointments. Additional variables investigated included total number of publications and training program affiliation. Design: Database review. Participants: Orthopaedic trauma surgery faculty members at OTA and ACGME orthopaedic trauma surgery fellowship. Main outcome measurement: H-index, total number of publications, academic rank, and fellowship training pedigree. Results: The H-indices of 273 orthopaedic traumatologists from 57 fellowship programs were organized and calculated. There are strong correlations among total number of publications, citations, and H-index. Overall, there is a strong association with number of publications, number of citations, and H-index with higher academic rank. Overall, H-index was a stronger predictor of academic rank than total number of publications and citations. Appointment to the same program as an individual’s fellowship training program and orthopaedic subspeciality fellowship outside of traumatology were not associated with academic rank. Level of Evidence: IV, case series Key words: trauma, fellowship, academic rank, H-index

The Orthopaedic Trauma Association's international relations: an expanding initiative

The Orthopaedic Trauma Association's international relations: an expanding initiative

The intra- and interobserver reliability of five commonly used intertrochanteric femur fracture classification systems.

Objectives This study aims to evaluate the effect of surgical experience on reliability for Boyd-Griffin, Evans/Jensen, Evans, Orthopaedic Trauma Association (main and subgroups), and Tronzo classification systems.Patients and methods Between January 2013 and December 2014, radiological images of a total of 60 patients (13 males, 47 females; mean age: 78.9±21.9 years; range, 61 to 96 years) with the diagnosis of intertrochanteric femur fracture were analyzed. Radiographs were evaluated and classified by five residents and five orthopedics and traumatology surgeons according to the Evans, Boyd-Griffin, Evans/Jensen, OTA, and Tronzo classification systems. Intraand interobserver reliability were calculated using the kappa statistics.Results The worst intraobserver compatibility among the residents was the classification system with OTA subgroups (κ=0.516), while the classification system with the best intraobserver fit was found to be OTA main groups (κ=0.744). The worst agreement among surgeons was in the Evans classification system (κ=0.456). However, the best intraobserver agreement was in the OTA main groups (κ=0.741). The best interobserver agreement was observed regarding the OTA main groups (κ=0.699).Conclusion The classification that has the best harmony both among residents and surgeons, and between residents and surgeons is the OTA main group classification.

Percutaneous minimally invasive treatment of transverse patellar fracture using cannulated screws combined with high-strength sutures and Nice knots: a retrospective study.

Patella fractures treated with traditional open approach and tension band fixation are associated with a significant rate of soft tissues complications, including hardware irritation, postoperative adhesions and non-cosmetic scar. An alternative is to utilize cannulated screws and high-strength sutures by the minimally invasive technique. This retrospective study comprised 48 patients who had been treated for unilateral closed transverse patellar fracture, type 34C1 according to the AO Foundation and Orthopaedic Trauma Association (AO/OTA) classification, between June 2018 to June 2020. All patients were treated either by closed reduction and internal fixation using cannulated screws combined with high-strength sutures and Nice knots (the CRIF-NK group, n=24), or traditional open reduction and internal fixation using cannulated screws and tension band wiring (the ORIF-TBW group, n=24). The operative time and intraoperative blood loss for each patient were recorded. All the patients were underwent a regularly clinical and radiological follow-up. The clinical evaluation was performed using the Böstman scale and the Visual Analogue Scale (VAS) for pain. Average follow up was 21.9 months (range, 16-29 months). The mean intraoperative blood loss of the CRIF-NK group (35.21±6.16 mL) was significantly less than that of the ORIF-TBW group (75.42±7.92 mL; P<0.001). The mean VAS scores at 4 and 8 weeks and the mean Böstman scale score at 8 weeks after surgery were significantly better in the CRIF-NK group (3.52±0.42, 1.47±0.40 and 28.13±0.94, respectively) than the ORIF-TBW group (5.16±0.68, 3.14±0.72 and 26.33±1.00, respectively; all P<0.001). No significant differences were observed between the two groups in terms of operative time, Böstman scale score at 1-year follow-up, or fracture healing time. The union rate was 100% (24/24) in both groups. One patient (1/24) in the CRIF-NK group, and all patients (24/24) in the ORIF-TBW group required internal fixation removal. The percutaneous minimally invasive technique using cannulated screws combined with high-strength sutures and Nice knots exhibited some superiority to traditional open reduction with cannulated screws and tension band wiring for treatment of transverse patellar fractures in terms of efficacy and safety by reducing soft-tissue stimulating complications and promoting functional recovery.

Utility and Associated Charge of Anteroposterior Radiographs in Rotational Ankle Fractures During Postoperative Follow-Up: The Results of an Orthopaedic Trauma Association Survey.

To evaluate the perceived utility and associated charges of the anteroposterior (AP) radiograph during rotational ankle fracture postoperative follow-up. Survey study with charge analysis using published data at 50 orthopaedic hospitals in the United States. Not Applicable. Orthopaedic Trauma Association Members with an active email address who were invited and interested in answering a survey. Ninety-four percent of respondents stated that they did routinely obtain an AP radiograph during rotational ankle fracture follow-up. However, 57% thought that the AP view should be eliminated from standard follow-up and only 51% found this view useful after initial treatment. The mean difference between a 2-view and 3-view ankle radiograph series was $102.00. Using this value and the assumption that each patient with a rotational ankle fracture gets 3 follow-up radiographs, there is the potential for a charge reduction of $306 per patient. Assuming over 134,000 rotational ankle fractures, a charge reduction of 41 million US dollars (USD) per year is possible if the AP image is routinely removed. Actual savings are likely to be less based on agreed on payer rates. Although less easy to quantify, there is also a potential reduction of radiation exposure, radiologists' interpretation time, and data storage. Routine AP radiographs should potentially be eliminated from routine postoperative ankle x-ray protocols based on this survey of experienced orthopaedic surgeons. If this specific radiograph is ordered on a case-by-case basis, then significant savings may occur.

Weightbearing after combined medial and lateral plate fixation of AO/OTA 41-C2 bicondylar tibial plateau fractures: a biomechanical study

BackgroundCombined medial and lateral plate fixation is recommended for complex tibial plateau fractures with medial fragments or no cortical bone contact. Although such fixation is adequate to resist forces during range of motion, it may be insufficient to support immediate postoperative weightbearing. Here, we analyzed displacement, stiffness, and fixation failure during simulated full weightbearing of bicondylar tibial plateau fractures treated with combined medial and lateral locking plate fixation.MethodsWe used 10 fresh-frozen adult human cadaveric tibias and mated femurs. Osteotomies were performed with an oscillating saw and cutting template to simulate an AO Foundation and Orthopaedic Trauma Association (AO/OTA) 41-C2 fracture (simple articular, multifragmentary metaphyseal fracture). Specimens were anatomically reduced and stabilized with combined medial and lateral locking plates (AxSOS, Stryker, Mahwah, NJ). Specimens were loaded axially to simulate 4 weeks of walking in a person weighing 70 kg. The specimens were cyclically loaded from 200 N to a maximum of 2800 N. Then, if no failure, loading continued for 200,000 cycles. We measured displacement of each bone fragment and defined fixation failure as ≥5 mm of displacement. Construct stiffness and load at failure were calculated. Categorical and continuous data were analyzed using Chi-squared and unpaired t-tests, respectively.ResultsMean total displacement values after 10,000 loading cycles were as follows: lateral, 0.4 ± 0.8 mm; proximal medial, 0.3 ± 0.7 mm; distal medial, 0.3 ± 0.6 mm; and central 0.4 ± 0.5 mm. Mean stiffness of the construct was 562 ± 164 N/mm. Fixation failure occurred in 6 of 10 specimens that reached 5 mm of plastic deformation before test completion. In the failure group, the mean load at failure was 2467 ± 532 N, and the mean number of cycles before failure was 53,155. After test completion, the greatest displacement was found at the distal medial fracture site (2.3 ± 1.4 mm) and lateral fracture site (2.2 ± 1.7 mm).ConclusionsAlthough combined medial and lateral plate fixation of complex tibial plateau fractures provides adequate stability to allow early range of motion, immediate full weightbearing is not recommended.

Weight Bearing as Tolerated After Intramedullary Nailing of the Femur: A Retrospective Analysis of Clinical and Radiographic Outcomes.

Intramedullary nailing of femur fractures has become the standard of care, with high union rates. Few high-level studies have discussed the effect that early weight bearing has on the healing of these fractures, regardless of nail size or fracture pattern. The goal of this study was to determine the clinical and radiographic outcomes of femoral shaft fractures for patients allowed immediate weight bearing after intramedullary nailing. We performed a retrospective review of 341 femoral shaft fractures, with 131 allowed immediate weight bearing, 99 allowed partial weight bearing, and 111 kept non-weight bearing. Demographic, intraoperative, and postoperative variables were collected and analyzed. Increased fracture complexity was associated with higher likelihood of delayed weight bearing. No significant difference was found for nail size or rate of failure with different nail sizes. A total of 50 nonunions were noted (14.7%), with no difference in nonunion rates between weight bearing cohorts. The only significant predictor of nonunion was Orthopaedic Trauma Association (OTA) classification of OTA32B fractures (P=.02), which were 2 times and 4 times as likely to occur compared with OTA32A and OTA32C fractures, respectively. Failure of interlocking screws occurred among 15 patients (4.4%) and was more common with older patients, osteoporotic bone, and larger diameter nails. In summary, unilateral intramedullary nailing of adult femoral shaft fractures does not show a difference in fracture union rates or implant failure with unrestricted, immediate weight bearing, regardless of nail characteristics. [Orthopedics. 2022;45(3):e148-e153.].

Good functional outcomes after open reduction and internal fixation for AO/OTA type 13-C2 and-C3 acute distal humeral fractures in patients aged over 45 years.

The purpose of this study was to report the functional outcomes and complications after open reduction and internal fixation (ORIF) for Arbeitsgemeinschaft für Osteosynthesefragen (AO)/Orthopaedic Trauma Association (OTA) type 13-C2 and -C3 acute distal humeral fractures with minimum 2-year follow-up. Our hypothesis was that ORIF would provide functional outcomes that are comparable to those of total elbow arthroplasty and elbow hemiarthroplasty reported in the literature. During a 6-year period, 23 patients aged > 45 years were treated with double plating for AO/OTA type 13-C2 or -C3 fractures. The mean age was 62 years (range, 46-80 years). The Oxford Elbow Score was used as the primary outcome; the Mayo Elbow Performance Score, pain severity score (on a visual analog scale), range of motion, reoperations, and complications were used as secondary outcomes. The median Oxford Elbow Score was 42 (range, 25-48), where a score of 48 represents a normal elbow; 20 patients achieved good to excellent outcomes, and 3 achieved fair outcomes. The median Mayo Elbow Performance Score was 85 (range, 60-100), where a score of 100 represents a normal elbow; 18 patients achieved good to excellent outcomes, and 5 achieved fair outcomes. The median visual analog scale score was 2 (range, 0-5). The median flexion-extension and supination-pronation arcs were 120° (range, 70°-155°) and 160° (range, 75°-170°), respectively. Eight complications were recorded in 7 patients; 4 of them required reoperation because of fracture pseudarthrosis or elbow stiffness. Ten patients were working at the time of trauma, and nine of them returned to the same occupation. Our results are comparable to the results of previously published studies regarding the outcome of ORIF, elbow hemiarthroplasty, or total elbow arthroplasty for AO/OTA type 13-C fractures. ORIF is a reliable treatment option for AO/OTA type 13-C2 and -C3 acute distal humeral fractures in middle-aged and elderly patients, despite the considerable rate of complications. Good to excellent results can be obtained in most patients.

Reduction Quality of Open vs Percutaneous Techniques for the Posterior Malleolus

Category:Ankle; TraumaIntroduction/Purpose:Ankle fractures with posterior malleolar involvement are common. Fixation of the posterior malleolus (PM) in these injuries remains controversial & currently, there is no evidence to guide operative decision making for the PM. This study compares radiographic & clinical outcomes between percutaneous & open fixation techniques of the PM.Methods:All ankle fractures between 01/2010 & 01/2018 with surgical stabilization of the PM were reviewed from a level 1 trauma center. High-energy (i.e. pilon), open & pathologic fractures were excluded. Orthopaedic Trauma Association (AO/OTA) fracture pattern, PM articular surface comminution, incarcerated fragments & loose bodies were recorded based on pre-operative CT scans. Patients were either treated with direct reduction (DR) or percutaneous reduction (PR). Intra-operative & serial post- operative radiographs were used to measure PM articular reduction & graded as satisfactory (<2mm articular step-off) or poor (>2mm articular step-off). Medical records were reviewed for fixation technique & complications. Patient-reported outcomes measurement information system (PROMIS) scores were used to compare clinical outcomes. Univariate methods including x2, Fischer exact test, One-way ANOVA were used & a multivariate nominal logistic regression model was constructed to evaluate predictors of a satisfactory reduction.Results:A total of 120 patients (ages 19-84) were included. DR through an open approach was performed in 91 patients & PR in 29. The DR cohort had a higher rate of satisfactory reduction (92.3% vs 75.9%, p=0.04). Articular comminution was identified in 65 (50.4%) & this morphology had a higher rate of satisfactory reduction with ORIF (94% vs 66.6%, p=0.04). There was no difference in reduction quality for non-comminuted fractures treated open or percutaneously (90.2% vs 83.3%, p=0.64). Incarcerated fragments or loose bodies were identified in 58 (48.3%) of fractures. There was a trend for improved reduction quality in the DR group for this morphology (p=0.08). Multivariate analysis identified that open approach is associated with a satisfactory reduction (p=0.02). No difference in complication rate between groups or PROMIS scores (p>0.05) for 64 patients with average final follow up of 19 months (range 6-60 months) were found.Conclusion:This study demonstrates that DR of the PM via an open approach in low energy ankle fractures leads to improved radiographic outcomes compared to percutaneous techniques without a difference in complication rate. This study also highlights the utility of a pre-operative CT scan to better assess the morphology of the posterior malleolus as articular comminution, interposed fragments or loose bodies were common findings that are difficult to assess on plain radiographs & may alter surgical plan if present. However, no difference in PROMIS scores were seen between direct and percutaneous reduction techiniques.

Surgical treatment strategies and their radiological potential for correction of proximal radius fractures in children and adolescents

The isolated proximal radius fracture in children is a quite rare injury. In difference to adults a conservative treatment is often possible. But in case of increasing dislocation the indication for surgery is given. Options for an operative treatment are "closed reduction", "percutaneous reduction", "intramedullary nailing", "open reduction" with and without fixation. Aim of this study is to compare these procedures with each other. This was aretrospective investigation and 82patients who underwent surgery after an isolated proximal radius fracture were included. Fracture types were classified according to the AO (working group for osteosynthesis questions)/OTA (Orthopedic Trauma Association) classification. The preoperative and postoperative degrees of axis deviation were compared and were considered to be a measure of the quality of treatment. The lowest degree of axis deviation resulted by open reduction and implantation of K‑wires (15,8°) and implantation of headless compression screws (HCS, 16°). Closed reduction without any fixation resulted in 19°, with implantation of an TEN (titan elastic nail) in 20° and the open reduction without any fixation resulted in 21° of axis deviation. No correlation was observed concerning the fracture type and the postoperative axis deviation. The study shows that the postoperative result does not depend on the fracture type (according to the AO/OTA classification) but on the surgical procedure. Despite the good radiological results in open reduction and internal fixation this procedure should be reserved for difficult situations in which less invasive surgical procedures fail, to avoid aseptic bone necrosis.

A meta-analysis of union rate after proximal scaphoid fractures: terminology matters

Heterogeneity in the anatomical definition of ‘proximal’ affects the comparison of outcomes of these scaphoid fractures. This study aims to review published outcomes of all variants to determine both, differences in terminology, and union rate based upon definition. A literature search was conducted to identify articles that reported descriptions and union rate of all acute (<8 weeks of injury) proximal scaphoid fractures in adult patients (>16 years old). Proximal fractures were grouped as reported (‘third’, ‘pole’, ‘fifth’ or ‘undefined’). The data were pooled using a fixed-effects method, and a meta-analysis was conducted to compare relative risk (RR) of non-union against non-proximal fractures. Qualitative analysis of 12 articles included three main definitions: ‘proximal’ (1 article), ‘proximal third’ (3 articles), and ‘proximal pole’ (8 articles). Only 6 articles adopted a specific anatomical or ratio description. In a pooled meta-analysis of union rates (15 articles), 'proximal third' and 'proximal pole' fractures demonstrated a relative risk (RR) of non-union of 2.3 and 3.4 in comparison to non-proximal fractures, respectively. Operative management yielded lower non-union rates than non-operative for all fracture types (6% vs. 18%). In conclusion, non-union risk varies depending on definition, with non-standardised classifications adding heterogeneity to reported outcomes. We recommend an approach utilizing fixed anatomical landmarks on plain radiographs (referencing scaphoid length and scapho-capitate joint) to standardise reporting of proximal fracture union in future studies. Abbreviations: CI: confidence intervals; CT: computer tomography; Df: degrees of freedom; DL: dersimonian and laird estimator; MRI: magnetic resonance imaging; NICE: national institute for health and care excellence; OTA: orthopaedic trauma association; PA: posterior-anterior; PRISMA: preferred reporting items for systematic reviews and meta analyses; RCT: randomised controlled trial; RR: relative risk; SNAC: scaphoid non-union advanced collapse; UK: United Kingdom

From Bench to Bedside: Our Patients Want to Move, So Why Are We Slowing Them Down?

Both TKA and THA, which were once managed with inpatient admission of days to more than one week, have been safely transitioned to outpatient or overnight procedures [9]. This is but one example of the benefits of accelerated rehabilitation. Compelling evidence exists that early motion is less restrictive and generally leads to the same or often better outcomes following elbow injuries and surgery [13], Achilles’ tendon ruptures treated either operatively or nonoperatively [1, 2], and proximal humerus fractures [5]. The obvious retort or rebuttal is that early motion may lead to complications, implying that we, as surgeons, would rather treat (or more commonly ignore and write off to a natural sequelae) a stiff, healed injury than a reinjury or treatment complication. But is it really true that early motion leads to increased complications? The answer seems simply to be “no.” While this is not an all-encompassing review article, there are many (many) studies demonstrating that early motion is beneficial, whereas I did not find any recent articles suggesting that early motion was harmful or associated with inferior outcomes. The same can be said for early, permissive weightbearing on many fractures. Early weightbearing appears to be safe, resulting in no increase in complications such as loss of fixation or articular collapse, and yield equivalent or better patient-reported outcomes for everything from ankle fractures [11], to tibial plateau fractures [3], to geriatric hip fractures [7, 8]. Taking a closer look at the latter case of hip fractures, patients older than 65 years of age generally have worse mobility scores in the setting of (attempted) weightbearing restrictions [8], worse outcomes (including mortality) without early mobilization and weightbearing [7], and are unable to follow weightbearing restrictions even when they are imposed or recommended [4, 8]. All of this raises the question: If our patients want to move and are better for it, why are we so slow to adapt and let them? There is evidence suggesting that is exactly what we are doing for both motion and weightbearing. One survey study noted that nearly 40% of low-volume surgeons (and over 20% of high-volume surgeons) still delayed weightbearing after ACL reconstruction, with very similar proportions for delays in permitting full ROM [6]. Another survey of 702 surgeons from both the Orthopaedic Trauma Association and American Orthopaedic Foot & Ankle Society reported wide ranges in time to full weightbearing following ankle fractures [12]. And Ottesen et al. [7] reported that at least 25% of patients with hip fractures were placed on restricted weightbearing status after surgery. I am not at all criticizing the flood of recent studies seeking to demonstrate the equivalence or benefit of early mobilization and/or weightbearing. Rather, I would argue that we need more of them. The ankle fracture survey cited above concluded that there was “reluctance of many practicing surgeons to adopt some of the more aggressive mobilization protocols,” but conceded “there is very little objective guidance for what is most appropriate” [12], although the latter situation has since improved [11]. And one systematic review of pelvic fractures concluded: “A review of postoperative weightbearing regimens reveals a nonexistent scientific evidence base from which to make recommendations” [10]. Still, we can infer a lot from recently published studies and at the very least adapt our own clinical practices to match the existing evidence. Next, (as I am fond of explaining to my patients) making a patient “permissive weightbearing” or “weightbearing as tolerated” does not mean those patients will be able to immediately tolerate full weightbearing. On the contrary, there is evidence that patients will auto-regulate and adapt their weightbearing to match their injury and healing, such as patients with more severe tibial plateau fractures taking longer to achieve full weightbearing than their less severe counterparts [3]. But discrepancies such as this should make us more, not less, comfortable letting our patients attempt do more, sooner. Finally, there are certainly injuries, such as articular, osteoporotic lower extremity fractures in patients with diabetes or neuropathic joints of the ankle and hindfoot, for which surgeons are understandably hesitant to be too aggressive and for which (surprise!) there is to my knowledge no evidence in favor of immediate mobilization and unrestricted weightbearing. And then there are injuries, such as pelvic fractures, for which there is, indeed, a dearth of evidence to guide as and requiring further study. So it seems like we need more research to guide us and help us migrate away from the AO’s “magical 10 to 12 week” timeline for healing, as my colleague Robert O’Toole MD sarcastically likes to call it. But for many injuries, orthopaedic procedures, and fractures, we need to heed the evidence that already exists. Our patients want to move and we have demonstrated that they are better for it when they do. Let’s move with them.

Which general functional outcome measure does a better job of capturing change in clinical status in pelvic and acetabular fracture patients? An analysis of responsiveness over the first year of recovery.

Objective:To compare the responsiveness of the Short Form-36 (SF-36) physical component score (PCS) to the Short Musculoskeletal Function Assessment (SMFA) dysfunction index (DI) in pelvic and acetabular fracture patients over multiple time points in the first year of recovery.Design:Prospective cohort study.Setting:Level 1 trauma center.Patients/Participants:Four hundred seventy-three patients with surgically treated pelvic and acetabular fractures (Orthopaedic Trauma Association B or C-type pelvic ring disruption or acetabular fracture) were enrolled into the center's prospective orthopaedic trauma database between January 2005 and February 2015. Functional outcome data were collected at baseline, 6 months, and 12 months.Main outcome measurements:Evaluation was performed using the SF-36 Survey and Short Musculoskeletal Function Assessment. Responsiveness was assessed by calculating the standard response mean (SRM), the minimal clinically important difference (MCID), and floor and ceiling effects.Results:Three hundred five patients had complete data for both outcome scores. SF-36 PCS and SMFA DI scores showed strong correlation for all time intervals (r = −0.55 at baseline, r = −0.78 at 6 months, and r = −0.85 at 12 months). The SRM of the SF-36 PCS was greater in magnitude than the SRM of SMFA DI at all time points; this was statistically significant between baseline and 6 months (P < .001), but not between 6 and 12 months (P = .29). Similarly, the proportion of patients achieving MCID in SF-36 PCS was significantly greater than the proportion achieving MCID in SMFA DI between baseline and 6 months (84.6% vs 69.8%, P < .001), and between 6 and 12 months (48.5% vs 35.7%, P = .01). There were no ceiling or floor effects found for SF-36 PCS at any time intervals. However, 16.1% of patients achieved the highest level of functioning detectable by the SMFA DI at baseline, along with smaller ceiling effects at 6 months (1.3%) and 12 months (3.3%).Conclusions:SF-36 PCS is a more responsive measure of functional outcome than the SFMA DI over the first year of recovery in patients who sustain a pelvic ring disruption or acetabular fracture. This superiority was found in using the SRM, proportion of patients meeting MCID, and ceiling effects. Furthermore, the SF-36 PCS correlated with the more disease-specific SMFA DI.Level of evidence:Prognostic Level II.

MP04-06 SEXUAL DYSFUNCTION ON QUALITY OF LIFE AFTER PELVIC FRACTURE

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: External Genitalia Reconstruction and Urotrauma (including transgender surgery) I (MP04)1 Sep 2021MP04-06 SEXUAL DYSFUNCTION ON QUALITY OF LIFE AFTER PELVIC FRACTURE Alice Wang, Monica Vavilala, Frederick Rivara, and Niels Johnsen Alice WangAlice Wang More articles by this author , Monica VavilalaMonica Vavilala More articles by this author , Frederick RivaraFrederick Rivara More articles by this author , and Niels JohnsenNiels Johnsen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001971.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pelvic trauma disproportionately affects a younger population and has the potential to cause long-term sexual dysfunction. We hypothesized that the presence of sexual dysfunction after traumatic pelvic fracture negatively impacts health-related quality of life in men. METHODS: 228 patients with traumatic pelvic fractures treated at a level 1 trauma center between 2012 and 2017 completed a survey that evaluated post-injury health-related quality of life and sexual function. Inverse probability weighting was utilized to adjust for survey non-response. Pelvic fracture characteristics were classified based on the Orthopaedic Trauma Association (OTA) classification system. Sexual function was evaluated utilizing the International Index of Erectile Function (IIEF) and health-related quality of life (HrQOL) was evaluated utilizing the EuroQol 5 Dimensions Questionnaire (EQ-5D). Quality-adjusted life years were determined based on calculated EQ-5D utility indices. Multiple regression models were created to evaluate the association between sexual health and HrQOL. RESULTS: After inverse probability weighting and adjustment for potential confounders, a decrease in IIEF was associated with a decline in overall HrQOL as measured by the EQ-5D visual analog scale (ß=0.28, p=0.02). No association was identified between OTA pelvic fracture configuration and risk of post-injury erectile dysfunction (ED) (p=0.99). 53.3% of men reported persistent ED at a median of 42.6 months (IQR 28.0, 63.3) following injury. The presence of ED was independently associated with a decrease in HrQOL (ß=10.92, p<0.001). This difference equates to a loss of 1.6 quality-adjusted life years per 10-years for men with ED following pelvic fracture relative to those without. CONCLUSIONS: Sexual dysfunction is an independent risk factor for decreased HrQOL in pelvic trauma survivors. Further work is needed to create appropriate patient-centered survivorship care pathways that incorporate sexual health evaluation. Source of Funding: 2018 Sexual Medicine Society of North America Pfizer Research Fellowship in Men's Health © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e69-e69 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alice Wang More articles by this author Monica Vavilala More articles by this author Frederick Rivara More articles by this author Niels Johnsen More articles by this author Expand All Advertisement Loading ...

Review of pediatric functional outcomes measures used to evaluate surgical management in pediatric patients with an upper extremity fracture.

For two decades, many scores, questionnaires, and rating systems have been used to evaluate the functional outcome of children with an upper extremity fracture (UEF). However, only a few of these were created specifically for children, and many assess only elbow function. In the absence of any published review on this topic, we set out to identify and categorize different scores used to evaluate the clinical and functional outcomes of surgically treated pediatric UEFs. A literature search was performed, and 38 studies were identified. The scores used more often were the shortened version of the Disability of the Arm, Shoulder and Hand questionnaire and the Mayo Elbow Performance Score/Index. In a lower number of studies, authors used other scoring systems, including the Mayo Wrist Score, the Patient-Rated Wrist Evaluation, the Patient-Rated Elbow Evaluation, the Métaizeau functional scoring system, the Oxford Elbow Score, the Price and Flynn criteria, the Hardacre Functional Score, the Neer Shoulder Score, the Constant-Murley Shoulder Score, the Modified Orthopedic Trauma Association Score, the Medical Outcomes Study Short Form-36, and the Pediatric Outcomes Data Collection Instrument. Some specific pediatric scoring systems to evaluate the functional outcome of children with a UEF have been suggested, but a single tool that is valid and reliable for skeletally immature patients of all ages is not yet available. Further studies are needed to identify specific pediatric measurements to increase validity, responsiveness, sensitivity, and interpretability of upper limb functional outcome scores in common clinical practice.

CORR Insights®: Institutional Experience and Orthoplastic Collaboration Associated with Improved Flap-based Limb Salvage Outcomes.

CORR Insights®: Institutional Experience and Orthoplastic Collaboration Associated with Improved Flap-based Limb Salvage Outcomes.