Orthopaedic Trauma Surgery Research Articles

Is it safe to restart elective day-case surgery? Lessons learned from upper limb ambulatory trauma during the COVID-19 pandemic

BackgroundThe COVID-19 pandemic has impacted on the provision of elective and trauma orthopaedic surgery worldwide with millions of operations cancelled. The risk of patients developing COVID-19 after undergoing ambulatory procedures in hospitals is unknown. This paper aims to investigate the risk of developing COVID-19 from day-case and overnight stay upper limb procedures during the peak of the pandemic in London, and to discuss the implications for the safe management of elective hand and upper limb patients in the coming months. Methods56 patients underwent emergency trauma upper limb procedures as a day case or with a single overnight stay from 1st March to May 31, 2020 at two central London hospitals that were also key players in the pan-London COVID response. Data was collected retrospectively from clinical and theatre records. Patients were contacted post-operatively and answered a structured questionnaire, including whether patients had experienced any of the symptoms suggestive of COVID-19 in the 14 days prior or 30 days following surgery. ResultsOf 56 patients, one patient reported COVID-19 symptoms, which were minor and did not require hospitalisation. Five patients experienced minor post-operative complications such as stiffness and scar hypersensitivity; one patient had a superficial wound infection. The mean age was 46 years (20–90) with 68% patients ASA I, 25% ASA II and 4% ASA III. 9% had LA, 30% a regional block and 61% had a GA. The most common operation was a distal radius open reduction and internal fixation. The average time spent in hospital was 11 h (3–34 h) and 12 patients required an overnight stay. The median length of face-to-face follow up was 38.5 days. ConclusionOur study suggests that, with appropriate precautions, elective upper limb ambulatory surgery can be safely restarted with a low risk of contracting COVID-19 or its complications.

Peer reviewing in foot and ankle surgery: is there a limit to scientific altruism?

IntroductionComplex foot and ankle trauma surgery is a super-specialization of orthopedic trauma surgery. This topic is gaining in interest, both clinically and in research. The peer review process is the cornerstone of the current scientific model of evaluation of research papers. The burden of peer review activity in foot and ankle trauma surgery is currently unknown. Material and methodA comprehensive Microsoft Outlook® analysis of over seven years’ worth of review invites from one surgical Foot & Ankle specialist working at a Level-1 trauma center was evaluated. The topic of each paper was recorded. Whether or not the journal was specifically foot ankle, orthopedic, general medicine or predatory of origin was noted. In addition, it was recorded if the journal was indexed in Pubmed, Medline, or Scopus. The topic of the paper was scored as being foot and ankle related, and more specifically foot and ankle trauma related. Review of revisions were scored as invites as well. ResultsFrom January 2013 to December 2019 a total of 467 review invites were received. The number of peer review invitations rose from 14 in 2013 to 127 in 2019. The percentage of foot and ankle specific journals was 27.4%. The number of requests from non-indexed (predatory) journals rose from 3.7% in 2014 to 36.2% in 2019, with a decrease in article topics related to the authors subspecialty. The annual absolute number of performed reviews stayed approximately the same throughout the study period (34 on average in the last 5 years). ConclusionThe number of review requests in foot and ankle surgery has increased about 5-fold over the 5 year period evaluated. There is a need for more reviewers to spread the burden. Therefore, foot and ankle specialists who are prepared to publish, should also be prepared to provide peer reviews to maintain a high level of quality in foot and ankle research.

Bilateral Pulmonary Embolism After Reverse Total Shoulder Arthroplasty: A Case Report

Venous thromboembolism is a rare surgical complication after shoulder replacement surgery. Most common seen for those who underwent for lower limb reconstruction such as: total hip or knee arthroplasty as well as orthopaedic trauma surgery in general. we report one case of 56-year-old male known to have diabetes mellitus and hypertension who had an isolated proximal humerus fracture. He underwent for reverse shoulder arthroplasty and the patient had an uneventful day of surgery. On postoperative day 2, patient started to have lightheadedness with decreased oxygen saturation. He denied any history of chest pain or shortness of breath. Patient was put on 2L oxygen face mask. Patient was evaluated by the medical team. CT spiral was done and it revealed bilateral small filling defects involving the right lower pulmonary artery and the left upper lobar pulmonary artery. Patient was started on anticoagulant therapy with improvement in his condition.

Multi-body 3D–2D registration for image-guided reduction of pelvic dislocation in orthopaedic trauma surgery

Surgical reduction of pelvic dislocation is a challenging procedure with poor long-term prognosis if reduction does not accurately restore natural morphology. The procedure often requires long fluoroscopic exposure times and trial-and-error to achieve accurate reduction. We report a method to automatically compute the target pose of dislocated bones in preoperative CT and provide 3D guidance of reduction using routine 2D fluoroscopy. A pelvic statistical shape model (SSM) and a statistical pose model (SPM) were formed from an atlas of 40 pelvic CT images. Multi-body bone segmentation was achieved by mapping the SSM to a preoperative CT via an active shape model. The target reduction pose for the dislocated bone is estimated by fitting the poses of undislocated bones to the SPM. Intraoperatively, multiple bones are registered to fluoroscopy images via 3D–2D registration to obtain 3D pose estimates from 2D images. The method was examined in three studies: (1) a simulation study of 40 CT images simulating a range of dislocation patterns; (2) a pelvic phantom study with controlled dislocation of the left innominate bone; (3) a clinical case study investigating feasibility in images acquired during pelvic reduction surgery. Experiments investigated the accuracy of registration as a function of initialization error (capture range), image quality (radiation dose and image noise), and field of view (FOV) size. The simulation study achieved target pose estimation with translational error of median 2.3 mm (1.4 mm interquartile range, IQR) and rotational error of 2.1° (1.3° IQR). 3D–2D registration yielded 0.3 mm (0.2 mm IQR) in-plane and 0.3 mm (0.2 mm IQR) out-of-plane translational error, with in-plane capture range of ±50 mm and out-of-plane capture range of ±120 mm. The phantom study demonstrated 3D–2D target registration error of 2.5 mm (1.5 mm IQR), and the method was robust over a large dose range, down to 5 Gy/frame (an order of magnitude lower than the nominal fluoroscopic dose). The clinical feasibility study demonstrated accurate registration with both preoperative and intraoperative radiographs, yielding 3.1 mm (1.0 mm IQR) projection distance error with robust performance for FOV ranging from 340 × 340 mm2 to 170 × 170 mm2 (at the image plane). The method demonstrated accurate estimation of the target reduction pose in simulation, phantom, and a clinical feasibility study for a broad range of dislocation patterns, initialization error, dose levels, and FOV size. The system provides a novel means of guidance and assessment of pelvic reduction from routinely acquired preoperative CT and intraoperative fluoroscopy. The method has the potential to reduce radiation dose by minimizing trial-and-error and to improve outcomes by guiding more accurate reduction of joint dislocations.

The Association between High Body Mass Index and Early Clinical Outcomes in Patients with Proximal Femur Fractures.

Background: Fractures of the proximal femur constitute daily work in orthopedic trauma surgery. With the continuous increase of obesity in the general population, surgeons face several known technical challenges. The aim of this study was to investigate the association of high body mass index (BMI) in patients with proximal femur fractures with intra- and postoperative adverse events, as well as with functional outcomes after successful surgery. Methods: In this retrospective, single-center cohort study, 950 patients who sustained a fracture of the proximal femur (femoral neck fracture or trochanteric fracture) and underwent surgical treatment at our level I trauma center between 2003 and 2015 were included. Patient-specific data were obtained in regard to demographics, comorbidities, and fracture morphology. In-hospital postoperative complications (i.e., need for revision surgery, wound site infection, pneumonia, urinary tract infection, necessary transfusion, and deep-vein thrombosis) were analyzed, along with the length of hospitalization and overall mortality rate. Functional outcome was assessed using the Barthel index and the patient’s ability to walk on crutches. Mortality rate and need for revision surgery were assessed over a two-year time period. Any adverse event was correlated to one of the four WHO’s BMI groups. Results: The cohort included 80 (8.4%) underweight patients, 570 (60.0%) normal weight patients, 241 (25.4%) overweight patients, and 59 (6.2%) obese patients. We found more femoral neck fractures (506, or 53%) than trochanteric fractures (444, or 47%). In bivariate analysis, no significant difference was found in regard to overall mortality or postoperative complications. Hospitalization time (LOS) differed between the underweight (12.3 ± 4.8 days), normal (13.6 ± 7.8 days), overweight (14.2 ± 11.7 days), and obese patients (16.0 ± 9.7 days) (p = 0.040). Operation time increased stepwise with increasing BMI: underweight = 85.3 ± 42.9 min; normal weight = 90.2 ± 38.2 min; overweight = 99.9 ± 39.9 min; obese = 117.2 ± 61.5 min (p < 0.001). No significant difference was found by analyzing functional outcomes. However, patients with intermediate BMI levels (18.5–30 kg/m2) tended to achieve the best results, as represented by a higher Barthel index score and the patient’s ability to walk on crutches. Conclusion: Increased BMI in patients with proximal femur fractures is associated with both longer operation time and length of hospitalization (LOS). Postoperative mobilization and functional outcomes appear to follow a reversed J-curve distribution (with overweight patients showing the best functional results), whereas both obese and underweight patients have associated poorer function.

Finding NEEMO: towards organizing smart digital solutions in orthopaedic trauma surgery.

There are many digital solutions which assist the orthopaedic trauma surgeon. This already broad field is rapidly expanding, making a complete overview of the existing solutions difficult.The AO Foundation has established a task force to address the need for an overview of digital solutions in the field of orthopaedic trauma surgery.Areas of new technology which will help the surgeon gain a greater understanding of these possible solutions are reviewed.We propose a categorization of the current needs in orthopaedic trauma surgery matched with available or potential digital solutions, and provide a narrative overview of this broad topic, including the needs, solutions and basic rules to ensure adequate use in orthopaedic trauma surgery. We seek to make this field more accessible, allowing for technological solutions to be clearly matched to trauma surgeons’ needs.Cite this article: EFORT Open Rev 2020;5:408-420. DOI: 10.1302/2058-5241.5.200021

Pioneering orthopaedic trauma surgery in Turkey: Burhaneddin Toker (1890-1951), the stormy 1930s, and refugees running from Nazism.

Orthopedic surgery, the medical discipline that deals with diseases and injuries of the musculoskeletal system has been considered a distinct medical discipline in the west since the beginning of the twentieth century. However, in Turkey, the acceptance of musculoskeletal traumatology as an integral part of orthopedic surgery actualized as late as 1961. Previously, orthopedic trauma patients were usually treated in general surgery departments. Dr. Burhaneddin Toker, a true pioneer, changed this conduct of the time in Turkey. He transformed Cerrahpaşa Hospital, then a municipality hospital today the well-known Cerrahpaşa Medical School of Istanbul University, to a trauma center. He pioneered systematic surgery of the musculoskeletal injuries, created a separate service for musculoskeletal traumatology, trained many surgeons in this field, wrote textbooks, and reported his clinical experience in scientific publications. This study examines the biography of Burhaneddin Toker and how he was able to further medical training in Turkey with a focus on Turkey in the stormy 1930s, the way the young republican government under Atatürk's leadership handled educational issues, and the refugee scientists who found a safe haven in Turkey fleeing Nazism.

Fracture reduction and screw position after 3D-navigated and conventional fluoroscopy-assisted percutaneous management of acetabular fractures: a retrospective comparative study.

Navigational techniques in orthopaedic trauma surgery have developed over the last years leaving the question of really improving quality of treatment. Especially in marginal surgical indications, their benefit has to be evident. The aim of this study was to compare reduction and screw position following 3D-navigated and conventional percutaneous screw fixation of acetabular fractures. The study hypothesis postulated that better fracture reduction and better screw position are obtained with 3D navigation. Preoperative and postoperative CT scans of 37 acetabular fractures treated by percutaneous screw fixation (24 3D-navigated, 13 conventional) were evaluated. Differences in pre- and postoperative fracture gaps and steps were compared in all reconstructions as well as the screw position relative to the joint and the fracture. The differences in fracture gaps and fracture steps with and without 3D navigation were not significantly different. Distance of the screw from the joint line, angle difference between screw and ideal angle relative to the fracture line, length of the possible corridor used and position of the screw thread did not show any significant differences. Comparison of 3D-navigated and conventional percutaneous surgery of acetabular fractures on the basis of pre- and postoperative CTs revealed no significant differences in terms of fracture reduction and screw position.

In Memory of Mark Shirtliff, PhD: Modern Concepts in Diagnosis, Treatment, Prevention, and Cost of Infection After Fracture Surgery

This issue in Techniques in Orthopaedics is dedicated to our friend and colleague Mark Shirtliff, PhD. Dr Shirtliff had a remarkable career that was cut short tragically at the age of 49 during a rafting accident. Mark’s professional accomplishments were many (see details of his life and career at: https://markshirtliffbiofilmfoundation.org), and he certainly will have a long-lasting effect on our field. His contributions included important discoveries and developments in the field of biofilm-mediated infection, as well as the selfless role he played as a mentor to so many other researchers. The sheer size and breadth of support for him shown at his memorial service speak to what an important influence he had on the many who had the pleasure of working with him. Although Mark’s professional accomplishments were impressive, in many ways he was even more memorable for the type of person he was. He was one of the most charismatic, entertaining, and fascinating people that you could ever meet. Mark was the rare person who was able to give a basic science talk to clinicians that was simultaneously hilarious and thought-provoking. Most importantly he was a talented communicator who could convey complex information in a manner that even a clinician could understand. Any small meeting with Mark inevitably involved a lot of laughter and many outrageous comments—all part of the fun we had in working with him. His tremendous intelligence, creativity, and passion for science were wrapped up with his charm, lightning-quick wit, and self-deprecating modesty. As Mark dedicated much of his professional life to a better understanding of biofilm-related infections, such as those observed after fracture surgery, we hope that this issue serves as an appropriate tribute to his career. Many of the authors of these articles worked closely with Dr Shirtliff for many years and his influence on our lives has been important to us. The 6 articles in this symposium discuss many of the important issues pertaining to current approaches for prevention, diagnosis, and treatment of infections after orthopedic trauma surgery. Clinicians are well aware of the societal importance of the all too common deep infections after fracture surgery. Unfortunately, this is nowhere close to a solved problem,1 and much progress is needed. Dr Johnson and colleagues lead off the symposium with a detailed discussion of the problems that are endemic to timely and accurate diagnosis in the clinical management of patients with infection after fracture fixation. Dr Natoli and colleagues next lay out modern diagnostic techniques, such as those that were of particular interest to Dr Shirtliff, and their potential to help us with the problems the first article identified. The third article, led by Dr Wise, details the current evidence for risk factors associated with infection, followed by Dr Joshi who provides a comprehensive look at clinical measures that can be used for infection prevention. Dr Costales and colleagues detail the approach to treating infections after tibia fracture fixation, an issue that continues to plague fracture surgeons. The issue ends with Dr Levy and colleagues’ sophisticated look at the costs of infection after fracture-related surgeries. Taken together this body of work summarizes important issues and identifies areas for future work. The authors are grateful of the journal for giving us the opportunity to present this information to the readers, and we hope that it serves as a small tribute to Mark Shirtliff.

Will My Fracture Surgery Get Infected? Evidence-based Risk Factors

Postoperative surgical site infection (SSI) is a growing problem in orthopedic trauma surgery. Consequently, emphasis on identifying risk factors has increased. We present a narrative review of the literature to facilitate evidence-based risk stratification for patients undergoing fracture fixation. Risk factors, including diabetes, hyperglycemia, end-stage renal disease requiring hemodialysis, human immunodeficiency virus, acquired immunodeficiency syndrome, hepatitis C, and alcohol abuse, have consistently been shown to increase infection risk in orthopedic surgery. Other risk factors, including smoking, obesity, and the use of immunomodulatory medications, have been shown to have varying direct impact on postoperative SSI depending on the study and the specific fractures examined. Factors such as increasing age, male sex, and ballistic injuries have very limited data implicating them in increasing risk of postoperative SSI. Fracture characteristics, including fracture region, open injury, compartment syndrome, and the need for flap coverage, increase the risk of SSI to varying degrees. Interventions such as blood transfusion and angioembolization can also increase the risk of infection. Although data on many of the risk factors for infection in orthopedic trauma are conflicting and larger scale studies are needed, an understanding of the available research is helpful to guide clinicians as they inform patients and attempt to optimize care.

Postoperative fever in the time of COVID-19.

Postoperative fever is common following orthopedic trauma surgery. As the prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection increases in the community, migration into the acute care hospital setting intensifies, creating confusion when fever develops postoperatively. The transmission dynamics of SARS-CoV-2 make it difficult to adequately gauge and pinpoint risk groups with questionnaires at the time of hospital admission. This is particularly problematic when asymptomatic or presymptomatic patients infected with SARS-CoV-2 require urgent surgery and cannot be screened effectively. One approach is to treat every patient as though they were SARS-CoV-2-positive in preparation for surgery, but doing so could exacerbate shortages of personal protective equipment and staffing limitations. Uncertainty regarding the etiology of postoperative fever could be significantly reduced by universal SARS-CoV-2 testing of all surgical patients at the time of hospital admission in addition to routine screening, but testing capacity and a rapid turnaround time would be required.

Dresdener Network Osteoporosis.

On a global scale the main focus of traumatological therapy lies in the treatment of unintentional injuries or victims of violence. People of all ages and through all economic groups can be affected. Due to demographic change in Western industrial countries, however, this focus increasingly shifts towards fragility fractures. In Europe osteoporosis is the most common bone disease in advanced age. Secondary prevention programs like the Fracture Liaison Service (FLS) are becoming increasingly prevalent, especially in Anglo-American health care systems. In German orthopedic and trauma wards and hospitals, however, the FLS is still relatively uncommon. This article will examine the question whether secondary prevention programs like FLS need to be established in the German health care system. This study aims at finding out, whether in the area of a medium sized German city there is a difference regarding the initiation of osteoporosis diagnosis and therapy between the regular aftercare by the general practitioner or the orthopedic surgeon and the aftercare by a specialist trained in osteology (Osteologe). For the open, randomized prospective study 70 patients with low energy fractures were recruited, who were older than 60 years and have been treated in our department. 58 out of 70 patients have completed the study, which amounts to a follow-up of 82.9%. Limited mobility and a high degree of organizational effort were the main reasons for early termination of the study. While in the group with regular aftercare, only 2 out of 29 patients received a specific osteoporosis treatment, in group who were directly transferred to a specialist trained in osteology 17 out of 29 patients received specific treatment. After re-evaluation of group with regular aftercare in 21 out of 29 cases a specific osteoporosis treatment was recommended. It could be established that there is a significant diagnosis and treatment gap regarding the aftercare of patients with fractures caused by osteoporosis between general practitioners or orthopedic surgeons on the one hand and the specialists trained in osteology on the other hand. To improve the aftercare of fracture patients, cross sectoral networks with a background in geriatrics and orthopedic-trauma surgery like a FLS need to be established in the German healthcare system.

Treatment-process analysis of orthopaedic trauma surgery patients at an outpatient setting in a university hospital

The cost pressure in acompetitive environment forces hospitals and physicians to optimize clinical processes. In order to secure competitive advantages, a continuous evaluation of relevant processes is necessary. Administrative and medical processes in a university outpatient department for orthopedics and traumatology were evaluated using the lean method in order to reduce patient waiting times. Over aperiod of 2 weeks all patients who were treated in the department for orthopedic and trauma surgery on an outpatient basis were included in the assessment of the process. Personnel in the policlinic were prepared and trained to record times for appointments made by telephone, arrival time at the hospital, first contact, administrative procedure, first contact with the doctor, length of stay in the radiology and anesthesiology departments and completion of treatment. In addition, potential inefficiencies were identified through patient flow analysis and personal interviews with personnel in the administration and outpatient departments as well as residents and senior physicians. A total of 126 patients were enrolled in the study. The average length of stay of patients in the outpatient clinic was 144 min (range 30-371 min). A necessary imaging examination increased the length of stay by an average of 53 min and a necessary premedication by an average of 78 min compared to patients with no further consultations. By analyzing the pathways and times of patients, various reasons for waiting times in the university outpatient clinic could be shown. This study shows that astructured application of lean management and adedicated analysis create added value for patients by reducing waiting times.

Simulation of life-like distal humerus and olecranon fractures in fresh frozen human cadaveric specimens

Abstract Background Economic burden and personnel shortages lead to a reduction in the time spent on surgical training of young resident physicians. This underlines the importance of courses for learning and optimizing surgical skills. Particularly for orthopaedic trauma surgery, training on fractured cadaveric specimens has proven highly useful. The present study investigates a method to induce realistic fracture patterns in fresh frozen elbow specimens, leaving the skin and soft tissue envelope intact. Methods For fracture simulation, 10 human cadaveric specimens with intact soft tissue envelopes were placed in 90° flexion in a custom-made high-impact test bench and compressed by an impactor. The fractures were subsequently classified using conventional x‑rays. Results Of the 10 specimens, 6 could be classified as distal humerus fractures and 4 as olecranon fractures. The fractures of the distal humerus were mainly type C according to Arbeitsgemeinschaft Osteosynthesefragen (AO) criteria, the olecranon fractures were mainly type IIB according to the Mayo classification. Subsequently, all 10 specimens would have been appropriate for use in musculoskeletal trauma courses. Conclusion With the given setup it was possible to induce realistic fracture patterns in fresh frozen cadaveric specimens. The advantage of the presented technique lies in the preservation of soft tissue. With their intact soft tissue envelopes, these pre-fractured preparations could be used in courses to precisely train resident physicians directly on human cadaver preparations. Further research should focus on finding reliable predictors to improve the precision of fracture induction in specimens.

Minimising aerosol generation during orthopaedic surgical procedures- Current practice to protect theatre staff during Covid-19 pandemic

Covid-19 pandemic is the largest health care crisis of this century. A large number of health care workers have succumbed to this virus. Orthopaedic trauma surgery has changed during the pandemic, by generally treating more patients conservatively. Emergency Orthopaedic surgeries and fracture neck of femur patients still need to be treated operatively for a better outcome. Our paper aims to give an insight into our current practice to minimise aerosol generation during these procedures, thereby reducing the risk of infection to the surgical and anaesthetic team.

Image-Guided Robotic K-Wire Placement for Orthopaedic Trauma Surgery.

We report the initial development of an image-based solution for robotic assistance of pelvic fracture fixation. The approach uses intraoperative radiographs, preoperative CT, and an end effector of known design to align the robot with target trajectories in CT. The method extends previous work to solve the robot-to-patient registration from a single radiographic view (without C-arm rotation) and addresses the workflow challenges associated with integrating robotic assistance in orthopaedic trauma surgery in a form that could be broadly applicable to isocentric or non-isocentric C-arms. The proposed method uses 3D-2D known-component registration to localize a robot end effector with respect to the patient by: (1) exploiting the extended size and complex features of pelvic anatomy to register the patient; and (2) capturing multiple end effector poses using precise robotic manipulation. These transformations, along with an offline hand-eye calibration of the end effector, are used to calculate target robot poses that align the end effector with planned trajectories in the patient CT. Geometric accuracy of the registrations was independently evaluated for the patient and the robot in phantom studies. The resulting translational difference between the ground truth and patient registrations of a pelvis phantom using a single (AP) view was 1.3 mm, compared to 0.4 mm using dual (AP+Lat) views. Registration of the robot in air (i.e., no background anatomy) with five unique end effector poses achieved mean translational difference ~1.4 mm for K-wire placement in the pelvis, comparable to tracker-based margins of error (commonly ~2 mm). The proposed approach is feasible based on the accuracy of the patient and robot registrations and is a preliminary step in developing an image-guided robotic guidance system that more naturally fits the workflow of fluoroscopically guided orthopaedic trauma surgery. Future work will involve end-to-end development of the proposed guidance system and assessment of the system with delivery of K-wires in cadaver studies.

Seasonal effect on the incidence of post-operative wound complications after trauma-related surgery of the foot, ankle and lower leg

IntroductionPost-operative wound complications remain among the most common complications of orthopedic (trauma) surgery. Recently, studies have suggested environmental factors such as season to be of influence on wound complications. Patients operated in summer are reported to have more wound complications, compared to other seasons. The aim of this study was to identify if “seasonality” was a significant predictor for wound complications in this cohort of trauma-related foot/ankle procedures.Materials and methodsThis retrospective cohort study included all patients undergoing trauma-related surgery (e.g. fracture fixation, arthrodesis, implant removal) of the foot, ankle or lower leg. Procedures were performed at a Level 1 Trauma Center between September 2015 until March 2019. Potential risk factors/confounders were identified using univariate analysis. Procedures were divided into two groups: (1) performed in summer (June, July or August), (2) other seasons (September–May). The number of surgical wound complications (FRIs, SSIs or wound dehiscence) was compared between the two groups, corrected for confounders, using multivariate regression.ResultsA total of 599 procedures were included, mostly performed in the hindfoot (47.6%). Patients were on average 46 years old, and mostly male (60.8%). The total number of wound complications was 43 (7.2%). Age, alcohol abuse, open fracture and no tourniquet use were independent predicting factors. No difference in wound complications was found between summer and other seasons, neither in univariate analysis [4 (3.2%) vs 39 (8.2%), p = 0.086] nor when corrected for predicting factors as confounders (p = 0.096).ConclusionsNo seasonality could be identified in the rate of wound complications after trauma surgery of the lower leg, ankle and foot in this cohort. This lack of effect might result from the temperate climate of this cohort. Larger temperature and precipitation differences may influence wound complications to a larger extent. However, previous studies suggesting seasonality in wound complications might also be based on coincidence.

Prevalence of posttraumatic stress disorder in acute trauma patients.

Objective:To determine the prevalence of positive screening for posttraumatic stress disorder (PTSD) amongst trauma patients.Design:Prospective, longitudinal study.Setting:Single urban US level 1 trauma center.Patients and methods:Four hundred fifty-two adult trauma patients were administered the PTSD checklist for DSM-V (PCL-5) survey upon posthospital outpatient clinic visit. This included 300 men (66%) and 152 women with mean age 43.8 years and mean Injury Severity Score (ISS) 11.3, with 83% having fractures of the pelvis and/or extremities. Medical and injury related variables were recorded. Multivariate logistic regression analysis was performed to identify factors predictive of screening positive for PTSD.Main outcome measurement:Prevalence and risk factors for screening positive for PTSD amongst the trauma patient population.Results:Twenty-six percent of trauma patients screened positive for PTSD after mean 86 days following injury. These patients were younger (35 vs 46 years old, P < 0.001) and more commonly African American (56% vs 43% Caucasian, P < 0.001). Pedestrians struck by motor vehicles (OR 4.70, P = 0.040) and victims of crime (OR 4.12, P = 0.013) were more likely to screen positive. Psychiatric history, injury severity (ISS), and injury type did not predict positive screening.Conclusion:One-in-four patients suffering traumatic injuries screened positive for PTSD suggesting the prevalence of PTSD among trauma patients far exceeds that of the general population. Predictive factors included victims of crime and pedestrians struck by motor vehicles. Screening measures are needed in orthopaedic trauma surgery clinics to refer these at-risk patients for proper evaluation and treatment.Level of evidence:Prognostic; Level II

Primary or secondary wound healing of the pin sites after removal of the external fixator: study protocol for a prospective, randomized controlled, monocenter trial

BackgroundTemporary fixation with an external fixator is used for numerous indications in orthopedic trauma surgery. It is unclear whether primary wound healing or secondary open-wound healing after removal of the external fixator should be advocated for the pin site. This study compares primary wound closure with secondary wound healing for the pin site. The primary aim is to compare pin-site infection rates. The secondary aim is to compare time to wound healing and esthetic outcome. The hypothesis was that primary wound closure does not lead to more infections than secondary wound healing.Methods and designThis is a prospective, randomized controlled, blinded, monocenter study based on a non-inferiority design. To obtain an equal patient population and groups, all pin-entry sites of the patients are treated alternately at the time of removal of the external fixator with primary wound closure and secondary wound healing. Patients are randomized according to whether the proximal pin-entry site is treated with wound closure or by secondary open-wound healing, from which the further sequence develops. The pre- and postoperative protocol is standardized for all pin-entry sites. A photo documentation of the pin-entry sites takes place 2 and 52 weeks postoperatively during the routine clinical follow-up visits. Further controls take place at 6, 12 and 26 weeks after pin removal.The primary outcome was to demonstrate the non-inferiority of primary wound closure compared to secondary wound healing in terms of postoperative wound infections according to the Center of Disease Control and Prevention (CDC) definitions.The secondary outcomes are time to complete wound healing (days) and esthetical outcome (subjective preference of patients and Vancouver Scar Scale score).DiscussionThis study aims to answer how to deal with the pin site after removal of the external fixator. To date, no routine and generally accepted protocol exists for the management of pin sites after removal of the external fixator. This prospective, randomized controlled, blinded monocenter trial should determine whether primary wound closure or secondary wound healing should be advocated after removal of the external fixator.Trial registrationClinicalTrials.gov, ID: NCT03842956. Registered retrospectively on 13 February 2019.

Readmissions Are Not What They Seem: Incidence and Classification of 30-Day Readmissions After Orthopedic Trauma Surgery.

To evaluate the causes of 30-day readmissions after orthopedic trauma surgery and classify them based on their relation to the index admission. Retrospective chart review. One large, academic, medical center. Patients admitted to a large, academic, medical center for a traumatic fracture injury over a 9-year period. Assignment of readmission classification. Readmissions within 30 days of discharge were identified and classified into orthopedic complications, medical complications, and noncomplications. A χ test was performed to assess any difference in the proportion of readmissions between the hospital-reported readmission rate and the orthopedic complication readmission rate. One thousand nine hundred fifty-five patients who were admitted between 2011 and 2018 for an acute orthopedic trauma fracture injury were identified. Eighty-nine patients were readmitted within 30 days of discharge with an overall readmission rate of 4.55%. Within the 30-day readmission cohort, 30 (33.7%) were the direct result of orthopedic treatment complications, 36 (40.4%) were unrelated medical conditions, and 23 (25.8%) were noncomplications. Thus, the readmission rate directly due to orthopedic treatment complications was 1.53%. A χ test of homogeneity revealed a statistically significant difference between the hospital-reported readmission rate and the orthopedic-treatment complication readmission rate (P < 0.0005). The use of 30-day readmissions as a measure of hospital quality of care overreports the number of preventable readmissions and penalizes surgeons and hospitals for caring for patients with less optimal health. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.