Unstable pelvic fractures in women: implications on obstetric outcome.

PURPOSE: Obstetric outcomes in women following pelvic injuries requiring surgical fixation is not thoroughly known. We aimed to evaluate if radiographic measurements (RMs) can be used to provide information on delivery methods outcome after these injuries, and to evaluate if metal work removal is required prior to delivery. METHOD: A retrospective study in a level 1 trauma centre of female patients with pelvic fractures treated operatively, aged 16-45 at the time of injury. Participants completed a questionnaire regarding their obstetric history. RM evaluating pelvic symmetry, displacement, and pelvimetry were conducted on postoperative radiographs and CT scans. Patients who gave birth after the injury were divided to two groups according to the delivery method: vaginal delivery (VD) and caesarean section (CS). These two groups RM were compared. RESULTS: Forty-four patients were included, comparison of the RM of patients who delivered by CS (9) and patients who had only VD (11) showed no significant difference between the groups. Two patients underwent a trial of VD who subsequently underwent urgent CS due to prolonged labour, their RM were below the average and their pelvimetry measurements were above the cut-off for CS recommendation. Eleven patients had uncomplicated VD, all had retained sacroiliac screws at the time of delivery and one patient had an anterior pubic plate. CONCLUSION: Postoperative RM did not show an effect on delivery method of women after pelvic fracture fixation. A relatively high number of patients who underwent normal vaginal delivery had retained sacroiliac screws. These findings can form the foundation for larger cohort studies.

Failure of Fixation in Trochanteric Hip Fractures: Does Nail Design Matter?

OBJECTIVE: The objective of this study was to compare clinical outcomes of patients with trochanteric hip fractures treated with specific different cephalomedullary nail (CMN) designs. METHODS: A scoping review of the English literature was performed. Inclusion criteria were studies comparing perioperative and postoperative outcomes of trochanteric hip fractures fixated by CMNs for one of the following CMN designs: short versus long nails, blade versus screw fixation, dual versus single lag screw fixation, and application of cement augmentation. Inclusion criteria consisted of human comparative clinical trials (randomized and observational). Exclusion criteria included noncomparative studies, studies comparing CMN with non-CMN devices or with arthroplasty, studies with less than 3 months follow-up, studies that did not provide relevant clinical outcome measures, biomechanical, finite element analyses, animal, or in vitro publications. Data regarding reoperations, peri-implant fractures, mechanical failure, nonunion, infection rates, and functional outcomes were reviewed. RESULTS: Twenty-two studies met the inclusion criteria and formed the basis of this study. Failure of fixation rates and reoperation rates for each of the nail designs selected for evaluation is presented, in addition to specific outcome measures relevant to that nail design which was explored: peri-implant fracture-short versus long nails, and specific mechanism of failure-blade versus plate. CONCLUSIONS: Decreased failure of fixation and reoperations rates were found for integrated dual lag screw fixation. Similar fixation failure and reoperation rates were found for the long versus short nails and for blade versus screw fixation. LEVEL OF EVIDENCE: Diagnostic, Level IV.

Cost Analysis of a Fracture Liaison Service: A Randomized Controlled Trial for the Secondary Prevention After Fragility Fractures of the Hip.

OBJECTIVE: Fracture liaison services (FLSs) have proven to be effective for secondary fracture prevention. In this study, we evaluated the essential factors in determining whether the FLS saves or loses more than it costs. METHODS: A randomized controlled trial was performed in patients with hip fragility fractures using a hospital-based FLS program in parallel with a cost analysis. Data were generated from a cohort of patients using actual data for FLS effectiveness, individual costs of hip fracture treatment, and medication costs based on an accepted treatment algorithm. RESULTS: A total of 200 patients were randomized, and 180 were analyzed for costs. The FLS program had an overall cost despite the savings in reducing secondary fractures. Medication was 89% of the costs and was the main factor for the FLS costs exceeding the savings. Specifically, using the medication algorithm in this study, the overall cost per patient enrolled in the FLS was $1189 for a 2-year period. If intravenous zoledronic acid had been used, then the overall cost would have been $489. If only oral bisphosphonates had been used, then the FLS would have cost $159 per patient for a 2-year period. CONCLUSION: The present analysis shows that medication cost is the critical component in cost-effectiveness of an FLS program. The FLS program costs would be significantly lower if patients are prescribed less expensive drugs to treat osteoporosis. Additional work needs to be performed refining the medication algorithm considering medication costs but individualized to patient needs based on fracture risk.

Automated computation of radiographic parameters of distal radial metaphyseal fractures in forearm X-rays.

PURPOSE: Radiographic parameters (RPs) provide objective support for effective decision making in determining clinical treatment of distal radius fractures (DRFs). This paper presents a novel automatic RP computation pipeline for computing the six anatomical RPs associated with DRFs in anteroposterior (AP) and lateral (LAT) forearm radiographs. METHODS: The pipeline consists of: (1) segmentation of the distal radius and ulna bones with six 2D Dynamic U-Net deep learning models; (2) landmark points detection and distal radius axis computation from the segmentations with geometric methods; (3) RP computation and generation of a quantitative DRF report and composite AP and LAT radiograph images. This hybrid approach combines the advantages of deep learning and model-based methods. RESULTS: The pipeline was evaluated on 90 AP and 93 LAT radiographs for which ground truth distal radius and ulna segmentations and RP landmarks were manually obtained by expert clinicians. It achieves an accuracy of 94 and 86% on the AP and LAT RPs, within the observer variability, and an RP measurement difference of 1.4 ± 1.2° for the radial angle, 0.5 ± 0.6 mm for the radial length, 0.9 ± 0.7 mm for the radial shift, 0.7 ± 0.5 mm for the ulnar variance, 2.9 ± 3.3° for the palmar tilt and 1.2 ± 1.0 mm for the dorsal shift. CONCLUSION: Our pipeline is the first fully automatic method that accurately and robustly computes the RPs for a wide variety of clinical forearm radiographs from different sources, hand orientations, with and without cast. The computed accurate and reliable RF measurements may support fracture severity assessment and clinical management.

New Versus Old-How Reliable Is the New OTA/AO Classification for Trochanteric Hip Fractures?

OBJECTIVE: To evaluate the intraobserver and interobserver reliability of the 2018 OTA/AO trochanteric hip fracture (THF) classification compared with the 1983 OTA/AO Muller classification system. To further delineate the reliability of classifying stable and unstable THF using the 2 classification systems. DESIGN: Radiographic observational study. SETTING: Multicenter, one Level 1 and one Level 2 trauma centers. PARTICIPANTS/PATIENTS: Seventy-three radiographic series of patients treated operatively for THF were evaluated by 6 orthopaedic surgeons. INTERVENTION: The OTA/AO THF classification system was applied by each surgeon to 73 cases in 2 independent assessments performed 4 weeks apart: once by the old classification followed by the new 2018 OTA/AO classification. Each radiographic series included lateral hip and anteroposterior initial radiographs. Eight random cases were duplicated in each of the surveys to evaluate the intraobserver reliability. MAIN OUTCOME MEASUREMENTS: Intraobserver and interobserver of the group, subgroup and fracture stability classification determined by the interclass coefficient (ICC) and Cohen kappa values. RESULTS: The interobserver reliability for the group classification (31A1/A2/A3) was moderate using the new classification, whereas substantial agreement was shown using the old classification (0.49 and 0.69, respectively). The reliability of the fracture stability classification was higher using the old classification (0.70 vs. 0.52). Subgroup classifications interobserver agreement was fair for both classification systems, although lower reliability was shown in the old classification (0.34 vs. 0.31). CONCLUSIONS: The new OTA/AO classification has a lower interobserver reliability for THF classification when compared with the old one.

Computer-Generated Radiographic Measurements of Distal Radius Fractures: Does It Help With Decision Making?

PURPOSE: Operative management of distal radius fractures (DRFs) has become increasingly common. Age, activity levels, and comorbid conditions are major factors influencing the treatment decision, although operative indications are still controversial. Radiographic parameters (RPs), such as radial inclination, dorsal tilt, and articular step-off, can provide objective support for effective decision making. However, manual measurement of RPs may be imprecise and subject to inconsistency. To address this problem, we developed custom software of an algorithm to automatically detect and compute 6 common RPs associated with DRF in anteroposterior and lateral radiographs. The aim in this study was to assess the effect of this software on radiographic interobserver variability among orthopedic surgeons. Our hypothesis was that precise and consistent measurement of RPs will improve radiographic interpretation variability among surgeons and, consequently, may aid in clinical decision making. METHODS: Thirty-five radiograph series of DRFs were presented to 9 fellowship-trained hand and orthopedic trauma surgeons. Each case was presented with basic clinical information, together with plain anteroposterior and lateral radiographs. One of the 2 possible treatment options was selected: casting or open reduction with a locking plate. The survey was repeated 3 weeks later, this time with computer-generated RP measurements. Data were analyzed for interobserver and intraobserver variability for both surveys, and the interclass coefficient, kappa value, was calculated. RESULTS: The interobserver reliability (interclass coefficient value) improved from poor to moderate, 0.35 to 0.50, with the provided RP. The average intraobserver interclass coefficient was 0.68. When participants were assessed separately according to their subspecialties (trauma and hand), improved interobserver variability was found as well. CONCLUSIONS: Providing computed RPs to orthopedic surgeons may improve the consistency of the radiographic judgment and influence their clinical decision for the treatment of DRFs. CLINICAL RELEVANCE: Orthopedic surgeons' consistency in the radiographic judgment of DRFs slightly improved by providing automatically calculated radiographic measurements to them.

Neck of femur fractures treated with the femoral neck system: outcomes of one hundred and two patients and literature review.

INTRODUCTION: The recently developed femoral neck system (FNS) for treatment of femoral neck fractures (FNF), comprises theoretical biomechanical advantages compared to other implants. The aim of this study was to validate the safety and to report outcomes of patients treated with the FNS. METHOD: A retrospective multicentric analysis of patients treated by FNS with a minimum of three months of follow-up. Details analysed from three medical centres were operative duration, estimated blood loss, initial hospitalisation duration, fixation quality as well as complications and reoperation rate. Patients who had revision surgery were compared to all other patients to identify risk factors for failure. In addition, a literature review was performed to analyse data on FNS clinical implementation and patient's outcomes. The two data sets were combined and analysed. RESULTS: One-hundred and two patients were included in this study cohort with an average follow-up of seven months (range 3-27). Ten papers were included in the literature review, reporting data on 278 patients. Overall, 380 patients were analysed. Average age was 62.6 years, 52% of the fractures were classified as Gardens 1-2. Overall, the revision rate was 9.2% (14 patients diagnosed with cut-out of implant, 10 with AVN, 8 with non-union and 8 with hardware removal). For the 102 patients in the cohort risk factors for reoperation included patients age, surgeon seniority and inadequate placement of the implant. CONCLUSION: This study shows that FNS is a safe treatment option for FNF. Intra-operative parameters and failure rates are comparable to previously reported rates for this implant and other frequently used implants.

Initial definitive treatment of open femoral shaft fractures with retrograde nailing - is it safe? A retrospective analysis comparing antegrade to retrograde nailing.

INTRODUCTION: Treatment of severe open femoral fractures with retrograde intramedullary nailing, raises concerns of septic arthritis of the knee due to its intra-articular entrance point. There is little evidence concerning the safety of retrograde femoral nailing (RFN) usage in these cases, and what evidence there is does not necessarily include severe open fractures. Furthermore, the outcome of ballistic injuries treated in this manner and a comparison with antegrade femoral nailing (AFN), is yet to be established. The aim of this study was to examine the outcome of primary retrograde femoral nailing in high-grade open fractures and compare our results with similar fractures treated with AFN. PATIENTS AND METHODS: A retrospective analysis of treated high-grade open femoral fractures, was performed at an academic level one trauma centre between 2006 and 2016. Included were all open femur shaft fractures treated with either RFN or AFN as primary fixation. We analysed both patient groups and compared outcomes including the infection rate, non-union rate and secondary interventions. Presence of knee pain and long-term function, was evaluated using the Short-Form 12 (SF-12) questionnaire. RESULTS: Forty-nine patients with open femoral shaft fractures whose primary treatment was intramedullary nailing (IMN), were included in the cohort. Thirty patients were treated with RFN and 19 with AFN. No septic arthritis of the knee was detected in either group. One patient in the RFN group and two in the AFN had a deep surgical wound infection. Excluding reoperations for locking screw removal due to local irritation, the reoperation rate was 22% with two patients treated for non-union in the RFN group and two in the AFN. When comparing outcome measures, including SF-12 scores and the reported knee pain rates of AFN and RFN groups, no significant differences were observed. CONCLUSION: Our study showed that retrograde femoral nailing as initial definitive treatment in high-grade open femoral shaft fractures, resulted neither in septic arthritis of the knee nor in an unacceptable infection rate. General outcomes regarding complications and reoperations, was similar to antegrade femoral nailing performed in our centre for similar injuries.

Recommendations for Orthopedic Surgeons during the COVID-19 Pandemic.

BACKGROUND: Toward the end of 2019, the coronavirus disease-2019 (COVID-19) pandemic began to create turmoil for global health organizations. The illness, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), spreads by droplets and fomites and can rapidly lead to life-threatening lung disease, especially for the old and those with health co-morbidities. Treating orthopedic patients, who presented with COVID-19 while avoiding nosocomial transmission, became of paramount importance. OBJECTIVES: To present relevant methods for pandemic control and hospital accommodation with emphasis on orthopedic surgery. METHODS: We searched search PubMed and Google Scholar electronic databases using the following keywords: COVID-19, SARS-CoV-2, screening tools, personal protective equipment, and surgery triage. RESULTS: We included 25 records in our analysis. The recommendations from these records were divided into the following categories: COVID-19 disease, managing orthopedic surgery in the COVID-19 era, general institution precautions, triage of orthopedic surgeries, preoperative assessment, surgical room setting, personal protection equipment, anesthesia, orthopedic surgery technical precautions, and department stay and rehabilitation. CONCLUSIONS: Special accommodations tailored for each medical facility, based on disease burden and available resources can improve patient and staff safety and reduce elective surgery cancellations. This article will assist orthopedic surgeons during the COVID-19 medical crisis, and possibly for future pandemics.

Evolution of treatment of femoral shaft fracture in polytrauma: Did damage control orthopaedics improve the outcome? A retrospective study.

BACKGROUND: Treatment of polytrauma patients with femoral shaft fracture has changed considerably during the past few decades. A transition from early total care (ETC) to "Damage Control" Orthopaedics (DCO) in selected patients was proposed in order to decrease mortality. The aim of the study was to investigate whether this policy change resulted in improved patient outcome. METHODS: We present a retrospective, comparative study, held in a Level I trauma center in Jerusalem, Israel. Polytrauma patients with Injury Severity Score higher than 16 with femoral shaft fracture were included. Data was extracted from our institute's electronic trauma registry. The study examines two time periods: Between the years 1996 and 2006 patients were treated according to the ETC protocol, with immediate intramedullary nailing (IMN) within 12 h. From 2007 until 2019 a DCO policy was adopted, implementing temporary external fixator for high risk patients, according to the "Hannover" criteria. Following resolution of the acute phase, these were converted to IMN. Patients eligible for DCO were matched to controls who received ETC during the earlier period. RESULTS: A total of ninety-six patients were included (DCO n = 44, ETC n = 52). The groups were comparable in terms of age, gender, mechanism of injury, injury to surgery time and Injury severity score (DCO median 31.5, ETC median 29). No statistical difference was found between the groups in terms of mortality (P = 0.757), acute respiratory distress syndrome (P = 0.534), sepsis (P = 0.519) and hospital stay (DCO median 24 days, ETC median 21.5 days) or ICU stay (Median 7 days in both groups). CONCLUSIONS: This pilot study did not demonstrate better outcome by implementing DCO concepts in the polytrauma patient. LEVEL OF EVIDENCE: III prognostic.

Effects of Covid-19 on orthopaedic trauma services: early experiences in South Africa and Israel.

South Africa and Israel have significantly different health systems. As South Africa is geographically 500 times as large and has a population nearly 7 times as large as the state of Israel, major differences in the challenges and subsequent handling of the pandemic between these countries were to be expected. South Africa's challenges included being under-resourced, particularly related to trauma, and severe and radical measures had to be undertaken that included extended strict lockdowns, bans on alcohol sales, and cancellation of the majority of the elective surgery during this initial period of the pandemic. Although Israel is much smaller and thereby theoretically easier to control, a complex political situation created difficulties and delays in controlling the pandemic after the initial response, leading to a second wave and additional lockdown. Although massively engaged initially, the Israeli trauma systems had continued functioning almost normally throughout the COVID-19 crisis.