Plate-Assisted Intramedullary Nailing of Distal Tibia Fractures.

The combination of plate and intramedullary nailing has been established as the treatment of proximal tibial fractures. Nevertheless, at the distal end of the tibia, the application of the plate-assisted intramedullary nailing is rarely applied as a therapeutic technique. This technical note demonstrates the use of the reduction plating technique for nail insertion as the management of distal tibia fractures.

Epidemiology of Paediatric Trauma During National Lockdown: A Retrospective Study With 12 Months of Follow-Up.

Introduction The COVID-19 pandemic and its associated preventative measures such as national lockdown dramatically changed the daily activities of children. This paper aims to compare the epidemiology of paediatric orthopaedic trauma presentation, management and outcomes during the school closure period with the matched pre-pandemic period in 2019. Methods This was a retrospective cohort study of data collected from the West Yorkshire Trauma Network, comprising a major trauma centre, Leeds General Infirmary, and five peripheral trauma units. All patients aged 0-18 years who required trauma unit management during the school closure period (18 March 2020-25 May 2020) were included. Cases for the matched period in 2019 were analysed for baseline comparison. Patient demographics, mechanism and anatomical location of injury, management and follow-up were assessed. Results In the 2020 and 2019 cohorts, 286 and 575 injuries were observed, respectively. In the 2020 cohort, we observed a 50.3% (n=289) fall in paediatric trauma presentation and a significant proportional reduction in referrals from the emergency department (22% (n=63) versus 53% (n=305); p<0.001). There was also a significant reduction in the average age at presentation by more than one year (p<0.001). Sports-related injuries decreased significantly (n=16 (5.6%) versus n=127 (22.1%); p<0.001). While the proportion of ride-on injuries increased significantly, overall numbers remained similar (n=63 (22%) versus n=61 (10.6%); p<0.0001). Non-accidental injury (NAI) concerns rose significantly (n=9 (3.1%) versus n=4 (0.7%); p=0.01), but the absolute number of confirmed NAI cases stayed the same (n=2). There was a proportional increase in upper limb injuries (64.3% (n=184) versus 58.4% (n=336); p>0.05) and a proportional reduction in lower limb injuries (32.1% (n=92) versus 35.5% (n=204); p>0.05). However, the rate of tibial shaft injuries rose significantly (10.1% (n=29) versus 5.2% (n=30); p=0.02). The use of conservative management increased with a significant delay in average time to surgery from the date of injury (8.5 days versus 3.1 days; p=0.01). Patients who were only followed up with a telephone consultation rose significantly (23% (n= 66) versus 6% (n=35); p<0.001). Re-presentation rate increased significantly (1.4% (n=4) versus 0.2% (n=12); p=0.04). Conclusion Our study showed a reduction in paediatric trauma presentations during the pandemic and a significant reduction in the average age at presentation. This change has been accompanied by a shift in the mechanism and anatomical location of injury, management and subsequent follow-up.

Computed tomography micromotion analysis in the follow-up of patients with surgically treated pelvic fractures: a prospective clinical study.

PURPOSE: High-energy pelvic fractures are complex injuries often requiring surgical treatment. Different radiological methods exist to evaluate the reduction and healing process postoperatively but with certain limitations. The aim of this study was to evaluate Computed Tomography Micromotion Analysis (CTMA) in a clinical setting for follow-up of surgically treated pelvic fracture patients. METHODS: 10 patients surgically treated for a pelvic fracture were included and prospectively followed with Computed Tomography (CT) at 0, 6, 12 and 52 weeks postoperatively. CTMA was used to measure postoperative translation and rotation of the pelvic fracture during the 52 weeks follow-up. Clinical outcomes were collected through the questionnaires EQ-5D index score and Majeed score. RESULTS: 10 patients were included with mean age (± SD, min-max) 52 (16, 31-80) years and 70% (n = 7) were males. The median (IQR, min-max) global translation from 0 to 52 weeks was 6.0 (4.6, 1.4-12.6) millimeters and median global rotation was 2.6 (2.4, 0.7-4.7) degrees. The general trend was a larger translation between 0 and 6 weeks postoperatively compared to 6-12 and 12-52 weeks. For the clinical outcomes, the general trend was that all patients started from high scores which decreased in the first postoperative follow-up and recovered to different extent during the study period. CONCLUSION: CTMA was successfully used in the follow-up of surgically treated pelvic fracture patients. Movement in the pelvic fractures after surgical fixation was largest between 0 and 6 weeks.

Blood loss and transfusion rates following total hip arthroplasty: a multivariate analysis.

This study aimed to identify factors that inde- pendently predict increased rates of transfusion following total hip arthroplasty (THA) surgery. A retrospective analysis of all patients undergoing THA surgery over 12 months was performed. Electronic operative records were analysed to determine the following patient factors: American Society of Anesthesiologists (ASA) grade, body mass index (BMI), co-morbidities, indication for surgery, surgical technique, type of implant used, haematological markers, hospital length of stay (LOS) and complications. A total of 244 patients were included. There were 141 females (58%) and 103 males (42%). The median age was 65±12. The median pre-operative blood volume was 4500mls (IQR; 4000-5200). The median blood loss was 1069mls (IQR; 775-1390). The total number of patients requiring transfusion was 28 (11%), with a median of two units being transfused. Pre-operative haemoglobin (p<0.001) level, haematocrit (p<0.001) level and weight (p=0.016) were found to be predictive of transfusion requirement as well as ASA grade (p=0.005). Application of an intra-operative surgical drain was associated with higher rates of transfusion (p<0.001). Our study strengthens the evidence that pre-operative haemoglobin and haematocrit levels are valuable predictors of patients requiring transfusion. Additionally, ASA grade may be viewed as a helpful factor in predicting risk of transfusion. A strategy incorporating pre-operative optimisation of modifiable factors may reduce rates of transfusion requirement.

A novel technique to assess rotational deformities in lower extremities using CT-based motion analysis.

Rotational deformities following intramedullary (IM) nailing of tibia has a reported incidence of as high as 20%. Common techniques to measure deformities following IM nailing of tibia are either based on clinical assessment, plain X-rays or Computed Tomography (CT) comparing the treated leg with the uninjured contralateral side. All these techniques are based on examiners manual calculation inherently subject to bias. Following our previous rigorous motion analysis and symmetry studies on hemi pelvises, femurs and orthopaedic implants, we aimed to introduce a novel fully digital technique to measure rotational deformities in the lower legs. Following formal institutional approval from the Imperial College, CT images of 10 pairs of human lower legs were retrieved. Images were anonymized and uploaded to a research server. Three dimensional CT images of the lower legs were bilaterally reconstructed. CT-based motion analysis (CTMA) was used and the mirrored images of the left side were merged with the right side proximally as stationary and distally as moving objects. Discrepancies in translation and rotation were automatically calculated. Our study population had a mean age of 54 ± 20 years. There were six males and four females. We observed a greater variation in translation (mm) of Centre of Mass (COM) in sagittal plane (95% CI - 2.959-.292) which was also presented as rotational difference alongside the antero-posterior direction or Y axis (95% CI .370-1.035). In other word the right lower legs in our study were more likely to be in varus compared to the left side. However, there were no statistically significant differences in coronal or axial planes. Using our proposed fully digital technique we found that lower legs of the human adults were symmetrical in axial and coronal plane. We found sagittal plane differences which need further addressing in future using bigger sample size. Our novel recommended technique is fully digital and commercially available. This new technique can be useful in clinical practice addressing rotational deformities following orthopaedic surgical intervention. This new technique can substitute the previously introduced techniques.

A review of preclinical absorbable inferior vena cava filters.

OBJECTIVE: Absorbable inferior vena cava filters (IVCFs) could be more effective and safer than standard IVCFs in theory, as they will self-resorb over time, thus rendering the need for filter retrieval and the risks associated with it unnecessary. This scoping review aims to evaluate the design of current absorbable IVCFs, review the development phase of the absorbable IVCFs, assess the efficacy of the absorbable IVCFs and their complications, and discuss the limitations and areas for future research. METHODS: MEDLINE, PubMed, and Embase databases were electronically searched and citations of relevant studies manually searched. Study selection and data extraction were performed by two independent reviewers using predetermined criteria and stored on premade proforma, respectively. The risk of bias (RoB) for both in vitro and in vivo studies were performed using established RoB tools. RESULTS: Eight studies were suitable for inclusion in this scoping review; five were in vivo and three were in vitro studies. No clinical trials were found. The RoB varied from moderate to high for in vivo studies and from low to moderate for in vitro studies. Overall, there was evidence from both in vivo and in vitro studies that absorbable IVCFs were effective in clot capturing and self-resorption and could decrease complications associated with standard IVCFs. However, there was a broad lack of statistical analyses and control groups to determine the significance of these findings. CONCLUSIONS: Absorbable IVCFs have shown promising features and results in preclinical models. However, significant research needs to be further performed to achieve the ideal characteristics of an absorbable IVCF before the first human trial can be conducted safely.

A novel 3D technique to assess symmetry of hemi pelvises.

Anatomical reconstruction of pelvic fractures has been shown to affect functional outcome. Using the contra lateral side of the extremities to create a template for an ipsilateral reconstruction is common practice in orthopedic surgery. We aimed to assess whether hemi pelvises are symmetrical in terms of translation and rotation using 3D reconstruction, point to point mirroring and merging of the 3D created volumes, a method with previous proven high precision and accuracy. CT images of ten randomly selected patients were used. The DICOM images were converted to STL files. Three dimensional images of left hemi pelvis were reversed and merged with the right side. The posterior aspect of the pelvises was considered static and the anterior aspect as moving. Differences in translation and rotation were measured. There were no statistically significant differences between right and left hemi pelvis. The 95% confidence interval (CI) for all mean angular differences between right hemi pelvis and mirrored left hemi pelvis were - 2° to 1.5°. The 95% CI for all mean translational differences between these two objects were - 2.3 to 2.9 mm. Differences between the right hemi pelvis and the mirrored images of the left hemi pelvis for any patient greater than 3 mm or 2 degrees could be excluded with a 95% confidence. The left and right hemi pelvis of healthy adults are symmetrical enough. The pre-operative planning based on a healthy contra lateral side seems reasonable.

Higher Risk of Mortality in Intentional Traumatic Injuries; A Multivariate Regression Analysis of a Trauma Registry.

OBJECTIVES: To assess whether intentional traumatic injuries are associated with higher mortality rate when compared to unintentional injuries. METHODS: Data from SweTrau (Swedish National Trauma Registry). Information regarding age, gender, injury severity score (ISS), new injury severity score (NISS), Glasgow coma scale (GCS), systolic blood pressure, and respiratory rate were collected via "SweTrau". "Mortality within 30 days of injury" was defined as having been registered as dead within 30 days following the injury. Intentional injuries compared to non-intentional injuries. Multivariate regression analysis was conducted. Stepwise forward and backward regression was conducted. RESULTS: A total number of 3875 patients were included. There were 3613 (93%) non-intentional and 262 (7%) intentional patients. The 30-day mortality rate was higher in the intentional group compared to non-intentional group, 10% vs. 4% (p<0.001). Patients in the intentional group were younger than the non-intentional group, at 39±18 vs. 47±21 years old (p<0.001). In both, the forward and backward tests injury intention remained statistically significant with OR 2 (CI 1.1-3.7). Shock (OR 4.7, CI 2.9-7.8), Severe Head Injury (OR 8.9, CI 5.3-14.7), Age ≥ 60 (OR 6.7, CI 4.1-10.8), ISS ≥16 (OR 10.8, CI 6.9-16.9) and ASA (OR 3.5, CI 2.2-5.7) were other factors affecting mortality. CONCLUSION: Injury intention was an independent factor contributing to mortality in our study. This particular cohort needs further attention during trauma management with a holistic insight to improve their survival.

Volume fusion of CT images to measure femoral symmetricity.

PURPOSE: Pre-operative planning is widely used in orthopaedic surgery. In case of trauma with fracture or previous injury with malunion, the contralateral extremity is used as a surrogate for planning with an assumption of symmetry between sides. The aim of this study was to investigate femoral symmetricity in human adults. METHODS: Ten randomly selected lower extremity computerized tomography (CT) images were analyzed for femur symmetry using 3D Trauma and CT motion analysis (CTMA). Mirrored images of the left femur were created using the right as a template. The 3D images from each side were merged, and translational and rotational differences reported. RESULTS: There were no statistically significant differences between mirrored images of the left and right femurs. Differences in rotation and translation of bony segmentation showed a greater variation in internal and external rotation of the distal femur (CI - 0.7° to 4.9°) compared to varus/valgus (CI - 1.3° to 0.8°) or flexion/extension (CI - 0.5° to 0.6°), though none of these differences were significant. CONCLUSION: The left and right femurs of healthy adults are symmetrical. Pre-operative templating relying on the contralateral healthy femur is encouraged.

Three Dimensional Quality Assessments of Applied Pelvic Binders.

OBJECTIVE: To assess the quality of applied pelvic binders using three dimensional computer tomography (3D CT). METHODS: A local trauma registry was used to identify patients with pelvic fractures after high-energy trauma during 2011-2015. A 3D CT reconstruction was made from the initial trauma computer tomography images to assess the level of application, symmetricity of the binder and achieved fracture reduction. An acceptable application of the pelvic binder was deemed if it was at the trochanteric level, symmetric and minimized residual displacement. RESULTS: We found 73 patients with a pelvic fracture and a pelvic binder on the initial trauma CT-scan. The mean (±SD) age of the patients was 46±17 years and 40% (n=29) were females. The median ISS score was 38 (IQR;29-50), the mean systolic blood pressure on arrival was 106±46 mmHg and the median GCS on arrival was 14 (IQR;7-15). We found that 59% (n=43) of the binders were correctly applied (symmetric at the trochanteric level, symmetrical and with acceptable residual displacement of the fracture). The 30-day mortality was higher in patients with non-correct application 17% (n=5/30) compared to patients with correct application of the pelvic binder 9.3% (n=4/43) however this was not statistically significant (p=0.562). CONCLUSION: A substantial number of patients had non-correct application of pelvic binders. Future studies using 3D technique are encouraged to further investigate clinical impacts of non-appropriate application of pelvic binders.

Experience and Availability of Pelvic Binders at Swedish Trauma Units; A Nationwide Survey.

OBJECTIVE: To assess availability, experience, and knowledge about the Pelvic Circumferential Compression Device (PCCD) in Sweden. METHODS: A telephone interview with the current on-call trauma doctors at all trauma units in Sweden was conducted. After a short presentation and oral consent, the doctors were asked to answer four short questions. We asked the doctors to answer whether they knew if they had PCCDs available in their emergency room, how many times had they applied a PCCD, which is the correct level of application for a PCCD, and if a PCCD can stop arterial bleeding. RESULTS: The on-call trauma doctors at the nine University hospitals, twenty-two General hospitals and twenty-one District General hospitals, with response rate of 100%, were interviewed. Availability of PCCD was 85 % and there was no difference between hospital types (p=0.546). In all hospitals 29/52 (56%) of those interviewed had used a PCCD at least once. There were significantly more doctors that had used a PCCD at least once in the University hospitals (8/9), compared to General hospitals (13/22) and District General hospitals (8/21) (p=0.034). A total of 43/52 (83 %) doctors defined the greater trochanters as the correct level of application for a PCCD. No difference was found when comparing hospitals (p=0.208). Only 22/52 (42 %) of doctors answered that a PCCD could not stop an arterial bleeding. No difference was found between hospitals (p=0.665). CONCLUSION: Less than half of the doctors knew that a PCCD cannot stop arterial bleeding, while the majority knew the correct level of application of a PCCD.

The pelvic fracture - Indicator of injury severity or lethal fracture?

BACKGROUND: Presence of pelvic fractures in trauma patients has previously been related to high mortality. However, there are controversies on whether pelvic fractures are the underlying cause of death or if it is rather an indicator of injury severity. We aimed to assess whether the presence of pelvic fracture increased mortality among a cohort of trauma patients or if it was simply an indicator of severe injury. MATERIAL AND METHODS: Karolinska University Hospital is the largest trauma centre in Sweden. The hospital is linked to the Swedish National Trauma Registry, "SweTrau". Registry data was collected for the period January 2013 until December 2015 with a one year further follow-up regarding mortality. Patients in the pelvic fracture group were compared to the non-pelvic fracture group and regression analysis was performed adjusting for factors that could possibly affect mortality. RESULTS: Univariable analysis showed that pelvic fracture was associated with an increased mortality, OR 2.4 (CI 1.3-3.4). Multivariable analysis showed that the presence of a pelvic fracture was not associated with an increased 30-day mortality (OR 0.5, CI 0.2-0.9), while factors as Shock (OR 7.1, CI 4.6-10.9), GCS < 9 (OR 6.2, CI 3.9-9.8), ISS > 15 (OR 12.4, CI 8.1-18.9), Age >60 (OR 3.2, CI 2.1-4,9) and ASA 3-4 (OR 4.7, CI 3.1-7.3) were associated with an increased 30-day mortality. Factors affecting 1-year mortality was analysed in the same way and the results were similar. CONCLUSION: Presence of pelvic fractures in trauma patients is not correlated to increased mortality when adjusted for Age, ISS, ASA, GCS and Shock.

Factors affecting mortality and reoperations in high-energy pelvic fractures.

AIM: Factors affecting mortality during the first year following high-energy pelvic fractures has not been reported previously. Nor has surgical complications leading to reoperations been reported in a cohort with only high-energy pelvic trauma patients. OBJECTIVES: The aim of this study was to report and analyse factors affecting outcome, in terms of mortality and reoperations, up to 1 year after the injury in patients with a traumatic pelvic ring injury due to a high-energy trauma. MATERIALS AND METHODS: Data from the SweTrau (Swedish National Trauma Registry) on patients admitted to the Trauma Centre Karolinska in Stockholm, Sweden, were collected. Inclusion criteria were adults (age ≥ 18), trauma with a high-energy mechanism, alive on arrival, Swedish personal identification number, reported pelvic fracture on CT scan. Patient records and radiographies were reviewed. The study period was 2011-2015 with 1-year follow-up time. Univariate and regression analysis on factors affecting mortality was performed. Risk of reoperation was analysed using univariate and case-by-case analysis. RESULTS: We included 385 cases with mean age 47.5 ± 20.6 years (38% females): 317 pelvic fractures, 48 acetabular fractures and 20 combined injuries. Thirty-day mortality was 8% (30/385), and 1-year mortality was 9% (36/385). The main cause of death at 1 year was traumatic brain injury (14/36) followed by high age (> 70) with extensive comorbidities (8/36). Intentional fall from high altitude (OR 6, CI 2-17), GCS < 8 (OR 12, CI 5-33) and age > 70 (OR 17, CI 6-51) were factors predicting mortality. Thirty patients (22%, 30/134) were further reoperated due to hardware-related (n = 18) or non-hardware-related complications (n = 12). Hardware-related complications included: mal-placed screws (n = 7), mal-placed plate (n = 1), implant failure (n = 6), or mechanical irritation from the implant (n = 4). Non-hardware-related reasons for reoperations were: infection (n = 10), skin necrosis (n = 1), or THR due to post-traumatic osteoarthritis (n = 1). CONCLUSION: Non-survivors in our study died mainly because of traumatic brain injury or high age with extensive comorbidities. Most of the mortalities occurred early. Intentional injuries and especially intentional falls from high altitude had high mortality rate. Reoperation frequency was high, and several of the hardware-related complications could potentially have been avoided.

Effectiveness of non invasive external pelvic compression: a systematic review of the literature.

INTRODUCTION: Pelvic fractures might carry a significant risk of bleeding. A wide variety of pelvic binders together with pelvic sheets are available and offer an adjunct to the initial management of poly-trauma patients with pelvic injuries. These devices are collectively referred to as pelvic circumferential compression devices (PCCDs). The aim of this study was to review the literature for evidence pertinent to the efficacy and safety of PCCDs. METHODS: Using the PRISMA guidelines a systematic search on PubMed, Web of Science, CINAHL, Embase and Scopus was carried out. Articles included were in English language and published between 1999 and 2015. Studies included were appraised with narrative data synthesis. RESULTS: Seven articles addressed mechanical properties of non-invasive external mechanical devices, six articles focused on physiological aspects, and three studies evaluated the pressure characteristics of these devices. We found 4 case reports regarding adverse effects. None of the studies identified addressed the cost effectiveness or pain relief issues related to the use of PCCDs. CONCLUSIONS: Based on available literature, PCCDs are widely used in the initial management of patients with suspected pelvic bleeding. There is evidence to suggest that external compression reduces disrupted pelvic rings. There are some complications reported following application of PCCDs. Hemorrhagic source and physiological effectiveness of PCCDs needs to be addressed in future studies. In the meantime judicious application of PCCDs will continue to be recommended.