Early Results of Orthopaedic Trauma and Anemia: Conservative Versus Liberal Transfusion Strategy.

INTRODUCTION: The purpose of this study was to determine whether it is safe to use a conservative packed red blood cell transfusion hemoglobin threshold (5.5 g/dL) compared with a liberal transfusion threshold (7.0 g/dL) for asymptomatic patients with musculoskeletal-injured trauma out of the initial resuscitative period. METHODS: This was a multicenter, prospective, nonblinded, randomized study done at three level 1 trauma centers. One hundred patients were enrolled. One patient was inappropriately enrolled, withdrawn from the study, and excluded from analysis leaving 99 patients (49 liberal and 50 conservative) with 30-day follow-up. After initial resuscitation, patients were enrolled and randomized to either a liberal or a conservative transfusion strategy. This strategy was followed throughout the index hospitalization. The primary outcome of the study was infection. Superficial infection was defined as clinical diagnosis of cellulitis or other superficial infection treated with oral antibiotics only. Deep infection was defined as clinical diagnosis of fracture-related infection requiring IV antibiotics and/or surgical débridement. RESULTS: Ninety-nine patients were successfully followed for 30 days with 100% follow-up during this time. Seven infections (14%) occurred in the liberal group and none in the conservative group ( P < 0.01). Five deep infections (10%) occurred in the liberal group and none in the conservative group ( P = 0.03). Three superficial infections (6%) occurred in the liberal and none in the conservative group, which was not a significant difference ( P = 0.1). No difference was observed in length of stay between groups. DISCUSSION: Transfusing young healthy asymptomatic patients with orthopaedic trauma for hemoglobin <7.0 g/dL increases the risk of infection. No increased risk of anemia-related complications was identified with a conservative transfusion threshold of 5.5 g/dL. DATA AVAILABILITY AND TRIAL REGISTRATION NUMBERS: Data are available on request. IRB protocol number is 1402557771. This study was registered with Clinicaltrials.gov identifier NCT02972593. LEVEL OF EVIDENCE: Level 2, unblinded prospective randomized multicenter study.

Orthopaedic Trauma and Anemia: Conservative versus Liberal Transfusion Strategy: A Prospective Randomized Study.

OBJECTIVES: To determine whether it is safe to use a conservative packed red blood cell transfusion hemoglobin (Hgb) threshold (5.5 g/dL) compared with a liberal transfusion threshold (7.0 g/dL) for asymptomatic musculoskeletal injured trauma patients who are no longer in the initial resuscitative period. METHODS: Design: Prospective, randomized, multicenter trial. SETTING: Three level 1 trauma centers. PATIENT SELECTION CRITERIA: Patients aged 18-50 with an associated musculoskeletal injury with Hgb less than 9 g/dL or expected drop below 9 g/dL with planned surgery who were stable and no longer being actively resuscitated were randomized once their Hgb dropped below 7 g/dL to a conservative transfusion threshold of 5.5 g/dL versus a liberal threshold of 7.0 g/dL. OUTCOME MEASURES AND COMPARISONS: Postoperative infection, other post-operative complications and Musculoskeletal Functional Assessment scores obtained at baseline, 6 months, and 1 year were compared for liberal and conservative transfusion thresholds. RESULTS: Sixty-five patients completed 1 year follow-up. There was a significant association between a liberal transfusion strategy and higher rate of infection (P = 0.01), with no difference in functional outcomes at 6 months or 1 year. This study was adequately powered at 92% to detect a difference in superficial infection (7% for liberal group, 0% for conservative, P < 0.01) but underpowered to detect a difference for deep infection (14% for liberal group, 6% for conservative group, P = 0.2). CONCLUSIONS: A conservative transfusion threshold of 5.5 g/dL in an asymptomatic young trauma patient with associated musculoskeletal injuries leads to a lower infection rate without an increase in adverse outcomes and no difference in functional outcomes at 6 months or 1 year. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Illicit drug and alcohol use and measures of musculoskeletal function and mental health in orthopaedic trauma patients.

Objectives: The objective of this study was to describe the relationship between positive toxicology screens and measures of preinjury mental health and physical function in an orthopaedic trauma population. Design: This was a cross-sectional study. Setting: Urban Level 1 trauma center. Patients: A total of 125 trauma patients gave written consent for this study. Main Outcome Measurements: Questionnaires such as, Patient Health Questionnaire-9, General Anxiety Disorder-7, PCL-5, and Short Musculoskeletal Function Assessment, were used to survey patients after surgical intervention. Results: Patient Health Questionnaire-9 (P = 0.05) and PCL-5 (P = 0.04) were not found to have significant differences between positive and negative toxicology screens. Both General Anxiety Disorder-7 (P = 0.004) and Short Musculoskeletal Function Assessment function (P = 0.006) were significantly higher in patients with positive toxicology screens. Conclusions: Positive toxicology seems to be associated with preinjury anxiety. Patient reported preinjury function was not adversely affected by the presence of illicit substances or alcohol, nor were levels of post-traumatic stress disorder and depression found to be higher in patients with positive toxicology screens. Level of Evidence: Level IV Cross-Sectional Study.

Anterior Intrapelvic Plating of the Sacroiliac Joint-A Cadaveric Quantification of Visualized Area with Case Series.

SUMMARY: The objective of this study was to quantitatively describe the area available on the sacrum for reduction and plating using the Anterior Intrapelvic approach and describe its use clinically in a case series. The area available for plate and screw placement on 5 cadavers was on average 1007 ± 231 mm3. The cranial/caudal dimension at greatest length was 39.78 ± 6.91 mm, and the greatest length medial to the sacroiliac joint was 30.91 ± 3.43 mm. The major anatomic restraints to visualization were the S1 nerve root and the external and internal iliac vessels. Large fragment plates had an area overlying the sacrum of 360 mm3, and all sacrum had an area for at least two plates. The exposure was succesfully used for reduction, fixation and direct inspection of neural elements in 4 patients, demonstrating the anterior intrapelvic approach can be expanded to the lateral sacrum.

Intraoperative monitoring of femoral head perfusion in adult femoral neck fractures.

OBJECTIVES: To validate a novel intraoperative method of quantifying femoral head perfusion in adult patients with femoral neck fractures and to determine whether the lack of a perfusion waveform correlates with the development of osteonecrosis, nonunion, or reoperation. DESIGN: Prospective cohort. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Nineteen patients with 20 acute femoral neck fractures treated with hip-preserving surgical fixation. All patients underwent intraoperative quantification of femoral head perfusion. INTERVENTION: Intraoperative quantification of femoral head perfusion pressure and waveform utilizing an intracranial pressure monitor. MAIN OUTCOME MEASUREMENTS: Radiographic union, avascular necrosis, revision surgery. RESULTS: Nineteen patients (8 male, 11 female, average age 56 ±â€Š21 years) with 20 femoral neck fractures were enrolled. Eight fractures were stable (Garden 1-2/OTA B1.1-1.3) and 12 were unstable (Garden 3-4/OTAB2.1-3.3). A waveform was present in 12 of 20 cases. The average pressures were systolic 36.8 mm Hg, diastolic 30.8 mm Hg, pulse pressure 6.0 mm Hg. A perfusion waveform was significantly associated with advanced age (P = 0.02) and accompanied by trend toward stable fracture patterns. There were 4 deaths during the 1-year follow-up period (20%), and there were 5 conversions to total hip arthroplasty (25%). There was no significant association between revision surgery or death with the absence of a waveform. CONCLUSIONS: Our study demonstrated the feasibility of a relatively low cost, minimally invasive, technique to quantify femoral head perfusion. In our limited sample, the absence of perfusion did not correlate with our main outcomes; however, the trend toward correlation with increased fracture displacement was as expected. A larger cohort of patients will be needed to detect a significant difference between those with and without a perfusion waveform with regards to our primary outcomes. Further study is needed to delineate the role such data may play in medical decision making at the time of index surgery. LEVEL OF EVIDENCE: Prognostic Level II.

Quantification and Comparison of Talar Exposure Utilizing a Posteromedial Approach and Medial Malleolar Osteotomy.

BACKGROUND: Fractures of the talus are a rare but challenging injury. This study sought to quantify the area of osseous exposure afforded by a posteromedial approach to the talus and medial malleolar osteotomy. METHODS: Five fresh-frozen cadaveric lower extremities were dissected using a posteromedial approach and medial malleolar osteotomy respectively. Following exposure, the talar surfaces directedly visualized were marked and captured using a calibrated digital image. The digital images were then analyzed using ImageJ software (National Institutes of Health) to calculate the surface area of the exposure. RESULTS: The average square area of talus exposed using the posteromedial approach was 9.70 cm2 (SD = 2.20, range 7.20-12.46). The average quantity of talar exposure expressed as a percentage was 9% (SD = 1.58, range 7.03-10.40). The average square area of talus exposed using a medial malleolar osteotomy was 14.32 cm2 (SD = 2.00, range 11.26-16.66). The average quantity of talar exposure expressed as a percentage was 12.94% (SD = 1.79, range 9.97-14.73). The posteromedial approach provided superior visualization of the posterior talus, whereas the medial malleolar osteotomy offered greater access to the medial body. CONCLUSION: The posteromedial approach and medial malleolar osteotomy allow for significant exposure of the talus, yielding 9.70 and 14.32 cm2, respectively. Given the differing portions of the talus exposed, surgeons may prefer to use the posteromedial approach for operative fixation of posterior process fractures and elect to use a medial malleolar osteotomy in cases requiring more extensive medial and distal exposure for neck or neck/body fractures. LEVEL OF EVIDENCE: Level IV.

Skeletal surveys lack efficacy in obtunded polytrauma patients.

OBJECTIVES: To evaluate if a skeletal survey protocol initiated after 48 hours of intubation will decrease time to diagnosis and the treatment of occult fractures in the obtunded polytrauma patient. DESIGN: Prospective cohort trial with a retrospective cohort comparison arm. SETTING: A single level 1 trauma center. PATIENTS: Forty-seven patients were identified prospectively for the skeletal survey protocol to screen for occult fractures. The results of the new protocol were compared to a retrospective comparison arm of 46 patients who would have met the same criteria. INTERVENTION: A skeletal survey protocol using 2-view x-rays of the patients' extremities to evaluate for any occult injuries after 48 hours of intubation in trauma patients with altered mental status and an unreliable tertiary examination. MAIN OUTCOME MEASURE: Time to diagnosis of delayed fractures and surgical intervention from date of admission. RESULTS: The average time to fracture diagnosis and time to surgical intervention in days was not statistically significant between the retrospective and prospective groups [fracture diagnosis: 1.6 ±â€Š5.1 (retrospective) versus 0.5 ±â€Š0.9 (prospective) (P = .159); time to initial surgery: 2.7 ±â€Š5.6 (retrospective) versus 1.1 ±â€Š1.7 (prospective) (P = .064); time to final surgery: 5.3 ±â€Š8.5 (retrospective) versus 2.4 ±â€Š3.0 (prospective) (P = .029)]. In addition, only 24% (4/17) of patients with a delayed fracture diagnosis required surgical intervention making most nonoperative. CONCLUSIONS: Given the inability to have a clinically or statistically significant impact on time to fracture diagnosis or subsequent treatment, we cannot advocate for the routine use of a skeletal survey protocol in obtunded polytrauma patients.Level of Evidence: Level III.