Orthopaedic Fracture Research Articles

Risk Factors For Deep Surgical Site Infections Following Orthopaedic Trauma Surgery

Background: Surgical site infections (SSIs) represent a major concern in orthopedic surgery, leading to prolonged hospital stays, increased healthcare costs, and potentially life-threatening complications. SSIs are particularly common in patients with severe fractures, such as those classified by the Cauchoix grading system, where the risk of infection is heightened due to the complexity of the injury and the surgical intervention required. Factors such as nutritional status, diabetes, smoking, and the use of external fixators contribute to the development of SSIs. This study, conducted at Bacha Khan Medical Complex, Mardan, seeks to identify the clinical and laboratory markers that can predict SSIs in patients undergoing orthopedic fracture management, thereby helping to reduce the incidence and severity of these infections. Method: This prospective cohort study was conducted from January 2024 to December 2024 at the orthopedic ward of Bacha Khan Medical Complex, Mardan. A total of 207 patients who underwent surgery for fractures were included in the study. Inclusion criteria were patients over the age of 18 years undergoing orthopedic fracture surgery. Exclusion criteria included patients with pre-existing infections, immunocompromised conditions, or those who underwent emergency surgeries. Data was collected on patient demographics, fracture grade (Cauchoix classification), laboratory markers (hemoglobin, lactate levels, creatinine, glycemia, and arterial oxygen levels), and the use of external fixators. Statistical analysis was performed using SPSS, and predictive models for SSI development were created based on these parameters. Result: Fractures classified as Cauchoix grade 3 were associated with a higher incidence of SSIs (47%). Polymicrobial infections were found in 64% of the SSI cases, with gram-positive cocci, including Staphylococcus aureus, being the most common pathogens (72%). A predictive model with an AUC of 0.80 and a negative predictive value of 95.9% was developed. The significant risk factors for SSI development included low hemoglobin, maximum lactate levels, minimum arterial oxygen levels, and high glycemia levels. The use of external fixators was linked to a higher risk of infection in 38% of the SSI cases. Conclusion: Cauchoix grade 3, and laboratory markers such as lactate levels and glycemia were strongly associated with an increased risk of infection. The developed predictive model with high sensitivity and specificity could aid in early identification of at-risk patients, allowing for targeted preventive measures and potentially reducing the incidence of SSIs in orthopedic trauma care. Future research should focus on refining this model and assessing the effectiveness of preventive strategies based on these predictive factors.

Dexmedetomidine-associated hypothermia in critical trauma: A case report and literature analysis.

Hypothermia, defined as a core body temperature below 35°C, is a common and serious complication in severe trauma patients, often worsened by hemorrhage and medical interventions. Dexmedetomidine, an α2-adrenergic agonist used for sedation in intensive care units, has known thermoregulatory effects; however, its association with hypothermia in trauma patients remains insufficiently explored. A 40-year-old male with severe polytrauma from a motor vehicle accident presented in distress, with hypotension, tachycardia, and a baseline temperature of 35.8°C. Despite effective management, he developed profound hypothermia, with a recorded temperature dropping below 34.0°C after switching from midazolam to dexmedetomidine for sedation. The patient had multiple bilateral rib fractures, a right-sided pneumothorax, and grade 3 liver and grade 5 splenic injuries, along with orthopedic fractures. His Injury Severity Score signified critical trauma, increasing the risk of complications like hypothermia. Following stabilization, dexmedetomidine was administered for sedation. Continuous warming interventions were initiated to address hypothermia; however, the temperature continued to decline. Suspecting dexmedetomidine's contribution, its administration was discontinued. After stopping dexmedetomidine, the patient's temperature gradually recovered to 36.8°C within 5 hours. He demonstrated improved consciousness and stable vital signs, subsequently undergoing 2 successful orthopedic surgeries and discharging without further hypothermia-related issues. This case highlights dexmedetomidine's potential to induce hypothermia in critically ill trauma patients. It stresses the importance of careful temperature monitoring and proactive thermoregulation during sedative administration in intensive care. Further research is needed to explore the prevalence and mechanisms of dexmedetomidine-associated hypothermia in trauma populations.

An algorithm for identifying causes of reoperations after orthopedic fracture surgery in health administrative data: a diagnostic accuracy study using the Danish National Patient Register.

Disease- or procedure-specific registers offer valuable information but are costly and often inaccurate regarding outcome measures. Alternatively, automatically collected data from administrative systems could be a solution, given their high completeness. Our primary aim was to validate a method for identifying secondary surgical procedures (reoperations) in the Danish National Patient Register (DNPR) within the first year following primary fracture surgery. The secondary aim was to evaluate the accuracy of the diagnosis and procedure codes used to determine the causes of these reoperations. Finally, we developed algorithms to enhance precision in identifying the reasons for reoperations. In a national cohort of 11,551 patients with primary fracture surgery, reoperations were identified through subsequent surgical procedure codes in the DNPR. Each patient record was reviewed to confirm the reoperations and causes. To improve accuracy, a stepwise algorithm was developed for each cause. We identified 2,347 possible reoperations; 2,212 were validated as true reoperations by review of patient record, i.e., a 94% positive predictive value (PPV). However, the coding for the causes of these reoperations was inaccurate. Our algorithm identified major reoperations with a sensitivity/PPV of 89/77%, minor reoperations 99%/89%, infections 77/85%, nonunion 82/56%, early re-osteosynthesis 90/75%, and secondary arthroplasties 95/87%. While the overall reported reoperations in the DNPR had a high PPV, the predefined diagnosis and procedure codes alone were not sufficient to accurately determine the causes of these reoperations. An algorithm was developed for this purpose, yielding acceptable results for all causes except nonunion.

Impact of Weather and Holidays on Orthopedic Emergency Room Crowding, Fractures, and Polytraumas in a Third-Level Referral Trauma Center in Europe.

Background: Orthopedic trauma is a significant component of emergency department workloads worldwide. The relationship between weather conditions and injury rates is controversial in modern literature. Even less has been written to investigate bank holidays' influence on contusions, dislocations, fractures, and even polytrauma. Our study aimed to assess whether meteorological factors and national holidays could vary the workloads in the orthopedic ER of a European third-level trauma center. Materials and Methods: Our study consisted of a review of all the patients who underwent orthopedic evaluations in our institution's orthopedic emergency room between 2019 and 2023. Days were divided depending on weather (cloudy or sunny vs. rainy or stormy), day type (regular working days vs. national public holidays vs. Saturdays and Sundays), and presence or absence of COVID-19 restrictions. We also recorded the temperatures of each day. Cases were subdivided into three groups: cases without significant injuries (Group A), cases with isolated bone fractures, major tears or articular dislocations (Group B1), and polytrauma (Group B2). Results: Higher temperatures were associated with a significant increase in overall ER visits, isolated injuries, and polytrauma. Sunny or cloudy days had a significantly higher number of patients with all injury types compared to rainy or stormy days. Weekends saw a significant decrease in overall admissions and isolated injuries but a higher rate of polytrauma compared to weekdays. National holidays had a significantly lower number of admissions for all injury types compared to weekdays. Restrictions due to the pandemic significantly reduced overall ER visits. Conclusion: Temperatures, meteorological factors, and national holidays could vary the workloads in the orthopedic ER of a European third-level trauma center.

Fat embolism syndrome caused by fracture or liposuction: a retrospective case series of nine patients

Background Fat embolism syndrome (FES) is a rare and potentially fatal complication commonly observed after liposuction or fractures. Patients with FES often have an acute onset and a rapid course of disease. However, there is a paucity of research summarizing the clinical features of FES caused by simultaneous fracture or liposuction. Methods A comprehensive analysis was conducted to enhance understanding of patients with FES associated with either fractures or liposuction procedures. Results Nine patients who were diagnosed with FES were included in our study, of whom two were male. Six patients underwent liposuction, while three sustained multiple orthopaedic fractures. Postoperative liposuction complications occurred rapidly (average 1.8 h) after surgery, whereas patients with fractures experienced symptoms approximately 24 h after injury. All patients presented with respiratory insufficiency, six patients had cerebral involvement, and four patients had petechial haemorrhage. Laboratory tests revealed that six patients had leucocytosis, five patients had elevated neutrophil counts and eight patients had increased D-dimer concentrations. Seven patients exhibited decreased partial pressure of oxygen (7/9), six presented with decreased haemoglobin (6/9) and four had thrombocytopenia (4/9). Chest computed tomography (CT) revealed pneumonia with symmetrically diffuse ground glass opacities and patchy exudates in both lungs, which are the most common radiographic findings (8/9). Brain CT of five patients revealed multiple cerebral infarctions, and CT angiograms of the head and neck demonstrated corresponding vessel occlusions in one patient. All patients received supportive care, including six who received noninvasive ventilation and three who received mechanical ventilation. Additionally, seven patients were treated with corticosteroids. Eight patients survived, while one died of sustained cerebral embolism and ischaemia during treatment. Conclusions A patient’s medical history is critical for the diagnosis of FES. Early diagnosis and timely treatment can reduce mortality, while supportive care is important, and corticosteroid therapy may be effective for early treatment.

Incidence of venous thromboembolism in fracture below the knee with and without chemical thromboprophylaxis: a systematic review and meta-analysis.

Low rates of venous thromboembolism (VTE) have been found in patients with isolated orthopaedic trauma below the knee. Many surgeons routinely provide chemical thromboprophylaxis in these injuries, however. This is not without inherent risks, and this remains a controversial topic in perioperative care in orthopaedic trauma. This systematic review and meta-analysis was performed to look at rates of VTE in patients with isolated orthopaedic fractures below the knee, grouped by whether they received chemical prophylaxis versus no chemical prophylaxis. A systematic review was performed comparing VTE with and without chemical thromboprophylaxis following isolated orthopaedic fracture below the knee. A chi-square analysis was then performed on data including patients who received chemical prophylaxis versus those who did not from all 25 included articles. The articles were grouped according to type of study, such as observational versus randomized controlled trial (RCT), and then further subdivided according to surgical intervention status, and whether routine screening for thromboembolism was utilized to diagnose. Risk of bias assessment was performed using the ROBINS-I criteria for cohort studies and the Cochrane RoB 2 tool for randomized controlled trials. A random effects pooled logistic regression and Fisher's exact tests were then performed. 222,188 patients were found from 25 articles. Chemical prophylaxis was given to 8,666 patients, and VTE was reported in 347 cases (4.0%). 213,522 patients did not receive chemical prophylaxis, and VTE was reported in 2,185 (1.02%) (χ2 (1, n = 222,188) = 656.8, p < .00001). Pooled logistic regression revealed that patients receiving prophylaxis were 0.5 times less likely to develop VTE. With a calculated population baseline risk of 1.5% for developing VTE, the number needed to treat (NNT) with chemical prophylaxis is 134 to prevent 1 VTE after fracture below the knee. In patients with isolated orthopaedic trauma below the knee, indiscriminate use of chemical VTE prophylaxis is not recommended due to the lack of significant benefit and high NNT. Level III.

A multi-domain computational framework investigating the short- and long-term viability of bioabsorbable magnesium fixation for tibial fractures

This study presents a multi-domain computational framework to investigate the long-term performance of permanent and bioabsorbable magnesium fixation devices in orthopaedic fracture applications. The framework integrates a coupled model for bone fracture healing and remodeling, with an enhanced surface-based corrosion model to predict the performance of bioabsorbable magnesium devices. It was found that plated fracture fixation enabled fracture healing outcomes compare to non-plated models by facilitating direct fracture healing. During the fracture healing phase, it was found that the stiff titanium plate provided a better healing response compared to the less stiff bioabsorbable magnesium plates. However, in the longer-term remodeling phase, the titanium plate showed evidence of stress-shielding and inhibited bone remodeling. On the other hand, the magnesium plates showed that there was continued remodeling, which meant that the bone tissue gradually returned to the pre-fracture stress state. While the corrosion rate and pit severity heavily influenced the mechanical support provided by the corroding magnesium fixator, the results showed that fixation was only required to provide mechanical stability to the fracture region for approximately the first 30 days for successful fracture union to occur. This coupled computational framework provides a platform to investigate the role of a wide range of magnesium fixation devices and their design and optimisation in orthopaedic applications.

Hounsfield unit values are useful for predicting early outcomes after acetabular fractures: a retrospective study.

Acetabular fractures are among the most challenging orthopaedic fractures, and a high total hip arthroplasty (THA) conversion rate has been reported in older patients with acetabular fractures. Bone quality is a poor prognostic factor after acetabular fracture fixation and has been assessed using computed tomography (CT). However, the relationship between Hounsfield unit (HU) values measured using CT and early acetabular fracture outcomes remains unknown. This study aimed to elucidate the effect of HUs on early acetabular fracture outcomes. 50 consecutive patients who underwent open reduction and internal fixation for acetabular fractures were included. The mean follow-up duration was 24 months. 27 hips had elementary fractures and 23 had associated fractures. The reduction quality assessed using CT was as follows: anatomical, 13 hips; imperfect, 10 hips; and poor, 27 hips. Secondary hip osteoarthritis was observed in 5 patients (10%), and the surgery was converted to THA in 1 patient (2%). The HU values of the fifth vertebral body and the unaffected side of the femoral head were measured. The fracture type, radiological secondary hip osteoarthritis, conversion to THA, and postoperative displacement gap were recorded. The unaffected femoral head HU values in elementary fractures (250.5 ± 50.5) were significantly higher than those in associated fractures (221.5 ± 48) (p < 0.047). The HU values of the fifth vertebral body and the unaffected femoral head were significantly correlated with the postoperative residual displacement gap and were significantly lower in those with secondary osteoarthritis than in those without it. The cut-off value for predicting early osteoarthritic change after an acetabular fracture was approximately 180. The HU values were correlated with the fracture type, postoperative displacement gap, and early osteoarthritic change after acetabular fractures and are clinically useful prognostic factors for early acetabular fracture outcomes.

Assessing Chat Generative Pre-training Transformer’s Proficiency in Identifying, Diagnosing, and Managing Orthopedic Fractures

Abstract Background: The exploration of Chat generative pre-training transformer’s (GPT’s) applications in medicine is gaining momentum, with artificial intelligence, particularly ChatGPT, showing promise in enhancing orthopedic care. ChatGPT can assist clinicians by providing relevant information based on patient symptoms, medical history, and radiological findings, aiding in differential diagnosis, and suggesting appropriate imaging modalities. This study focuses on evaluating the effectiveness of ChatGPT-4 in diagnosing and managing common orthopedic fractures. Methods: This study involved inputting a diverse set of fracture images into the ChatGPT-4 model. The process commenced by prompting ChatGPT with four questions: “What does the radiograph show?” The second prompt instructed ChatGPT with the actual diagnosis, followed by inquiries on how a clinician should manage the condition and potential complications. All generated responses underwent grading by two authors (musculoskeletal radiologist and orthopedic trainee), utilizing a 5-point Likert scale. Intraclass correlation coefficient (ICC) analysis measurements were performed to assess inter-rater reliability. Descriptive statistical analysis was then employed to provide a comprehensive summary of the study’s findings. Results: ChatGPT demonstrated limitations in identifying diagnoses based on inputted X-ray images. However, it excelled in providing comprehensive information about fracture management and potential complications. There was excellent interobserver reliability with a kappa of 0.9. Conclusion: Our study underscores the utility of ChatGPT as a valuable tool for aiding in the management of common fractures, offering a comprehensive overview of diagnosis, management, and potential complications. The findings highlight its potential role as a supplementary resource in orthopedic practice.

There is no correlation between differences in adverse events and differences in patient-reported outcome measures in orthopaedic trauma randomized controlled trials: A systematic review

IntroductionA recovery without adverse events is a top priority of orthopaedic trauma patients, however many randomized controlled trials (RCTs) are only powered to detect a difference in patient-reported outcome measures (PROMs). While it may be assumed that differences in major adverse event rates between treatment groups will result in differences in PROMs, this has not been established. The purpose of this study was to perform a systematic review of RCTs to evaluate if differences in these outcomes were correlated. MethodsA systematic search was conducted of online databases to identify RCTs in orthopaedic trauma fracture management that reported both major adverse events and PROMs. Adverse events included secondary surgeries or complications that could negatively affect long-term outcomes (nonunion, chronic regional pain syndrome, etc.). The correlation between a difference (p < 0.05) in adverse events and a difference in PROMs was assessed. ResultsThe systematic review yielded 30 RCTs involving 6,769 patients. The primary outcome was a continuous PROM in 70.0 % (21/30). A difference in major adverse events was reported in 23.3 % (7/30) and a difference in PROMs was reported in 6.7 % (2/30). Studies reporting a difference in adverse events, compared to those that did not, were not more likely to report a difference in PROMs (14.3 % (1/7) vs. 4.3 % (1/23); p = 0.42). ConclusionsThere was no correlation between differences in adverse event rates and differences in PROMs in orthopaedic trauma RCTs. Investigators should consider powering studies to detect differences in the major adverse events that both patients and surgeons wish to avoid. Level of evidenceLevel I

Orthopedic pelvic and extremity injuries increase overall hospital length of stay but not in-hospital complications or mortality in trauma ICU patients: Orthopedic Injuries in Trauma ICU Patients

BackgroundThe purpose of this study was to compare the ICU length of stay (LOS), overall hospital LOS, in-hospital complications, and mortality rate between trauma ICU patients with orthopedic injuries versus those without. MethodsThis was a retrospective cohort study in which the trauma registry of a single level 1 trauma center was queried over a 6-year period for patients admitted to the ICU during hospitalization. Patients were stratified based on the presence/absence of an orthopedic fracture. Negative binomial regression was used to evaluate the effect of orthopedic injury on overall hospital and ICU LOS while controlling for confounding factors. Secondary outcomes included group differences with respect to in-hospital complications, mortality, and discharge disposition. ResultsA total of 1,785 trauma patients were admitted to the ICU and included. Among all trauma ICU patients, 61.1 % (n = 1,091) had no associated orthopedic injuries whereas 38.9 % (n = 694) had at least one. Patients with orthopedic injuries had higher odds of being severely injured (ISS ≥ 16: OR [CI] =1.47 [1.2–1.8]; p < 0.001) despite presenting with a higher level of consciousness than those without orthopedic injuries (mean GCS: 13.3 ± 3.5 vs 12.5 ± 4.1, p < 0.001). Multivariable models demonstrated having an orthopedic injury did not moderate ICU LOS (IRR [CI] = 0.93 [0.9–1.0]; p = 0.110) but did contribute significantly to increasing hospital LOS (IRR [CI] = 1.23 [1.1–1.3]; p < 0.001). There was no evidence to suggest that orthopedic injury increases the risk of in-hospital complication or in-hospital mortality. Orthopedically injured trauma ICU patients were less likely to be discharged home than those without orthopedic injuries. ConclusionsTrauma ICU patients with an associated orthopedic injury have significantly longer hospital stays compared to those without an orthopedic injury, despite no evidence to suggest that the orthopedic injury affects the duration of ICU stay or in-hospital complications. Level of evidenceIII, Retrospective cohort study

Fracture Lines and Patterns in Intra-articular Distal Femur Fractures.

Distal femur fractures are complex injuries that often present with multiple fragments, posing notable challenges to fixation. This study aimed to (1) use preoperative CT scans to graphically display fracture lines in intra-articular distal femur fractures and (2) identify common fracture patterns in these injuries. All skeletally mature patients that underwent surgical fixation of Orthopaedic Trauma Association type 33C distal femur fractures between 2012 and 2022 were identified across two level 1 trauma centers (n = 63). Preoperative axial, sagittal, and coronal computed tomography scans were obtained. Fracture lines in each plane were traced out and superimposed on standardized distal femur cross-sections, generating a fracture map for each plane. Injury and fracture characteristics were summarized and compared between fracture patterns. On axial scans, 59 of 63 fractures contained a central intercondylar split from the intercondylar notch to the trochlea. On coronal scans, fracture lines originated at the notch and exited laterally and medially in the supracondylar region, creating a Y-shape. One-third of all fractures contained coronal fracture lines, with most involving the lateral condyle. Based on fracture line orientation and location, fractures were divided into four main fracture pattern types. Type 4 fractures (central split and medial coronal fracture line) were associated with lower average medial fracture height and a lower rate of medial metaphyseal comminution. We found that C-type distal femur fractures can present with four main fracture patterns. Most fractures contain a central sagittal intercondylar split, and a high proportion of fractures contain either medial or lateral coronal fracture lines. Fracture pattern was associated with mechanism of injury, presence of medial comminution, and medial fracture line height. Future studies should focus on clinical outcomes and surgical management of these distinct fracture patterns. IV.

Significant Interaction between Melatonin and Titanium Bone Implants: Available Evidence and Future Research Directions.

The trend in the incidence rate of bone fractures has been upward and as a result, the burden associated with orthopedic fractures has increased significantly. Titanium (Ti) implants are considered a preferred method of managing long bone fractures. However, no benefit comes without some downside, and using Ti implants is associated with several complications. In this respect, it was observed that in bones, Ti can disrupt the bone healing process by disturbing the balance of osteoclast and osteoblast activation and also increasing the production of inflammatory cytokines. Melatonin is a widely-acting molecule that possesses strong anti-oxidant features. This molecule reinforces mineral density and improves bone formation processes. In this review, we focused on the protective effect of melatonin in mitigating the Ti-related complications.

Volar Locking Plate Fixation of Distal Radius Fractures: A Surgical Technique

Distal radius fractures are one of the most common upper extremity fractures in orthopaedics. Unstable distal radius fractures are often managed with volar locking plates (VLP). However, fragment-specific fixation may be more appropriate for fractures of the dorsal rim, dorsal ulnar corner, isolated radial styloid, and small volar ulnar corner fragments. While the volar approach is most common, the surgeon should also be familiar with dorsal, radial, and extensile volar approaches. This article discusses a contemporary surgical technique for open reduction and internal fixation of distal radius fractures using VLP via the flexor carpi radialis approach.

Fixation of Sacral Ala Fracture Using a Midfoot Mesh Plate as a Cannulated Screw Washer: A Case Report

Introduction: Sacral fractures are rare but are increasing in incidence among trauma patients. They are associated with a wide variety of complications, most commonly neurologic defects. Case Report: A 59-year old woman initially underwent open reduction internal fixation (ORIF) for a sacral fracture, after which the patient developed an infection, wound complications, and hardware failure. The revision of the iliosacral screws proved challenging in that the standard screw and washer could not achieve sufficient compression of the fracture. Therefore, a modified midfoot mesh plate was cut to size and used as a washer to gain more surface area, achieving fixation. The plate was applied laterally and cut to cover as much surface area as possible without unnecessary bony overhang. A trans-iliac trans-sacral screw was then inserted in the standard fashion, thus allowing the plate to act as a washer. This resulted in an excellent outcome with appropriate fracture healing. Conclusion: We describe the case of an iliosacral screw revision in which a modified midfoot mesh plate was used as a washer. This resulted in appropriate fixation in the revision settings. The principles described to achieve this fixation can be broadly applied in the setting of orthopedic fractures.

What influences post-operative opioid requirements for tibial fractures?

Currently there are few opioid prescribing guidelines for orthopaedic fractures. Long-term post-surgical analgesia requirements, understandably, vary between orthopaedic cases. Our study aims to provide detailed information to clinicians and policy makers, on the opioid requirement associations for patients sustaining tibial fractures. This study reviewed all patients sustaining an isolated tibial fracture at a major trauma centre that were operated on within 1month of injury, from 2015 to 2022. The total opioid dosage used each month in morphine milligrams equivalents (MME) and the number of days opioids were used each month, within the first-year post-surgery were collected, representing the strength and coverage of opioid analgesia in the post-operative stage, respectively. We compared opioid strength and coverage requirements with types of definitive fracture fixations, location, fracture type and concurrent patient medical comorbidities to assess for any trends. A total of 1814 patients sustaining a combined of 1970 fractures were included in the study. Tibial plateau fractures had the highest opioid strength and coverage requirements in each month and the entire year (p < .05). Across all fracture locations, Ex Fix frame showed higher opioid strength and coverage requirements compared to both IM nailing and plate ORIF. With regard to opioid coverage in the presence of specific comorbidities, only chronic kidney disease (quotient: 1.37, 95% Confidence interval [95%CI] = 1.19-1.55, p = .002) and hypertension (quotient: 1.34, 95%CI = 1.14-1.53, p = .009) showed significance at the 1-year overall level. For opioid strength, Chronic Kidney Disease (quotient: 1.72, 95%CI = 1.41-2.03 p = .005) and COPD (quotient: 1.90, 95%CI = 1.44-2.36, p = .014), show significance at the 1-year overall level. Our study details opioid requirements post-surgery amongst tibial fractures with subgroup analysis assessing opioid needs amongst specific fracture locations, types, surgical techniques and medical comorbidities. This framework aids clinicians in anticipating rehabilitation and assists in risk stratifying patients at injury onset.

Safety and Depth of Sedation With Ketamine Alone Versus Ketamine With Midazolam in Pediatric Fracture Reduction: A Retrospective Chart Review.

Pediatric patients with extremity fractures often require sedation for fracture reduction in the pediatric emergency department (PED). Although orthopedic literature suggests combination sedation regimens may be more effective for fracture reduction, some pediatric literature suggests adverse events are more frequent. The primary objective of this study is to determine the comparable depth of sedation and incidence of adverse events when intravenous ketamine is used alone versus with midazolam for pediatric procedural sedation and orthopedic fracture reduction. This is a retrospective cohort study of pediatric patients 2-18 years old who underwent sedation for fracture reduction in the PED at a single level 1 trauma center over a 2-year period. Medical records were reviewed, and occurrence of adverse events, depth of sedation (Ramsey score), midazolam dose, total ketamine administration, opiate administration, total sedation time, and time to PED discharge were compared in patients who received ketamine alone versus those who received ketamine with midazolam. Logistic regression models were adjusted to evaluate for potential confounders. There was a statistically significant increase in the occurrence of hypoxia with coadministration of midazolam (5% vs 0%). When hypoxia occurred, it was mild and resolved with repositioning or administration of supplemental oxygen. Length of sedation was increased in sedations with coadministration of benzodiazepines by approximately 3.5 minutes. Time to PED discharge was not significantly different. There was no significant difference in depth of sedation, ketamine dose administered, end-tidal CO 2 measurements, administration of positive pressure ventilation, vomiting, agitation, or overall occurrence of adverse events. No patients developed apnea or laryngospasm. This study showed a low rate of adverse events in pediatric sedation for orthopedic reduction with ketamine alone or ketamine with midazolam. There was an increased occurrence of hypoxia with coadministration of midazolam and an increase in the length of sedation. This study showed no difference in depth of sedation based on Ramsay scores when midazolam was coadministered. Information on the orthopedic reduction and provider satisfaction was not collected.

Shots fired: evaluation of vascular injury, compartment syndrome, and transfusion rates among civilian ballistic orthopaedic fracture patients presenting to two Level I trauma centres.

This study investigates baseline patient demographics and predictors of vascular injury, blood transfusion, and compartment syndrome in patients with orthopaedic fractures secondary to GSWs at two high-volume Level I trauma centres. A retrospective chart review of all GSW-related trauma patients at two Level I trauma centres between July 2019 and September 2021 was conducted. Chi-squared and two-tailed independent t tests were used for data analysis, and logistic regression with odds ratios (OR) determined predictors of primary outcomes. Among 478 GSW patients, 94 (19.7%) sustained 130 orthopaedic fractures, most commonly at the lower extremity (77.7%). Orthopaedic fracture patients showed significantly higher rates of vascular injury (29.8 vs. 4.7%, p < 0.001), transfusion (27.7 vs. 12.8%, p = 0.006), and compartment syndrome (3.2 vs. 0.3%, p = 0.011) compared to non-orthopaedic injury patients. Univariable analysis identified ankle (OR = 47.50, p < 0.001) and hip/femur fractures (OR = 5.31, p < 0.001) as predictors of vascular injury. Multivariable logistic regression revealed lower extremity vascular injury (OR = 54.69, p = 0.006) and anatomic fracture sites of the humerus (OR = 15.17, p = 0.008), clavicle/scapula (OR = 11.30, p = 0.009), and acetabulum/pelvis (OR = 7.17, p = 0.025) as predictors of blood transfusion. Univariable analysis showed lower extremity vascular injury (OR = 30.14, p = 0.007) as a predictor of compartment syndrome. These findings underscore the importance of diagnosing and managing vascular injuries and compartment syndrome in GSW-related orthopaedic fractures, emphasizing the necessity for targeted transfusion strategies in such cases.

Characterization of patient population receiving bioactive glass bone graft substitute as intraoperative treatment for orthopaedic trauma fractures

BackgroundBioactive glass synthetic bone grafts are used to treat osseous defects in orthopaedic surgery. Characterization of the clinical scenarios associated with bioactive glass use in the context of orthopaedic trauma, are not well established. This study aims to characterize population demographics, operative variables, as well as postoperative variables, for patients who required bone grafting for treatment of traumatic orthopaedic injuries and received a bioactive glass bone substitute intraoperatively. MethodsThe electronic medical record at a large Level I trauma center was queried for fracture patients between January 1st, 2019, and April 30th, 2022. Our retrospective cohort included fracture patients who received Fibergraft Matrix or Fibergraft Putty intraoperatively, and their respective control groups. This study ascertained patient demographic variables, operative variables, and postoperative variables. Differences in categorical variables were tested with Fischer's Exact Tests, while differences in continuous variables were tested with ANOVA. Statistical significance was determined as P < 0.05. If the overall Group model was significant for a given variable, post-hoc Fischer's Exact or Tukey HSD tests were used to assess pairwise significance between individual Group pairs. ResultsA total of four categories across our analysis of demographic, operative, and postoperative variables displayed significant differences amongst subject Groups (P ≤ 0.03). Individual groups were compared such that significant differences between subject groups could be appreciated for a specific variable. FM subjects had greater length of surgery, billable costs, and vitamin D supplementation at the time of surgery compared to FM controls. Similarly, FP subjects had greater length of surgery, billable cost, and implants used intraoperatively compared to FP controls. ConclusionThis analysis revealed Fibergraft patients to have greater length of surgery and billable cost, with respect to their matched controls. These data suggest that Fibergraft patients had more severe orthopaedic fractures compared to matched controls.

Three-year follow-up of a novel orthopedic ward fracture liaison services (OWFLS) model.

We established an orthopedic ward fracture liaison services (OWFLS) model and evaluated its role in improving detection rates of bone metabolic markers, treatment rates, and long-term treatability. This observational retrospective cohort study included 120 patients aged >50 years hospitalized for primary osteoporotic fracture from January 2018 to January 2019 (group A: not included in OWFLS). Group B (included in OWFLS) comprised 120 patients from February 2019 to February 2020. We compared rates of bone metabolic index testing, treatment, and adherence; symptomatic improvement; and recurrent fracture between groups. Rates of bone metabolism index testing (50% vs. 0%) and medication use (94.2% vs. 64.2%) were significantly higher after OWFLS implementation. There was no significant difference in adherence rates at 3 months between groups (97.3% vs. 93.5%). Adherence rates at 1 and 3 years were better in group B than A (73.5% vs. 51.9%; 57.5% vs. 26%, respectively). Recurrence of bone pain at 1 and 3 years was significantly lower in group B than A (20.4% vs. 46.8%; 45.1% vs. 76.6%, respectively). OWFLS improved the detection rate of bone metabolism indicators, treatment rate, and patient adherence and reduced recurrence of bone pain. OWFLS may be suitable for settings lacking human resources.