The effect of body mass index on posttraumatic transfusion after pelvic trauma.

The impact of body mass index (BMI) on posttraumatic blood transfusion after pelvic trauma is not well known. We conducted a retrospective review of trauma registry data over a 5-year period. Patients were stratified by BMI as normal: less than 25 kg/m(2), overweight: 25 to 29.9 kg/m(2), obese: 30 to 39.9 kg/m(2), and morbidly obese: 40 kg/m(2) or greater. Fractures were identified as "likely to receive transfusion" based on literature. Multivariable logistic regression modeling evaluated the relationship between BMI and initial posttraumatic transfusion. A second regression model was created to test the effect of BMI after adjusting for fractures "less likely to receive transfusion." Sixty-six of 244 patients (27.3%) received transfusion (mean: 1.1 ± 2.3 units). Morbid obesity was associated with transfusion (less than 55.6 vs 24.8%; P < 0.05) and units of total blood transfused (2.2 ± 2.9 vs 1.0 ± 2.2 mL; P < 0.05). The average age of patients who received a blood transfusion was significantly older compared with patients who did not receive a transfusion (45.4 ± 18.8 vs 36.1 ± 16.1 years; P < 0.05). After adjusting for potential confounders, morbid obesity was a significant risk factor for transfusion (odds ratio [OR], 4.1; 95% confidence interval [CI], 1.4 to 12.0). Adjusting by age and fracture patterns "less likely to receive transfusion," morbid obesity remained a risk factor for transfusion (OR, 4.5; 95% CI, 1.5 to 12.9). Morbid obesity represented a significant risk factor for posttraumatic transfusion in isolated pelvic trauma, even for fracture patterns "less likely to receive transfusion."

External fixation versus ORIF for distal intra-articular tibia fractures.

Tibia plafond fractures have historically demonstrated high complication rates. The purpose of this study was to assess the outcomes of tibia plafond fractures following treatment with definitive external fixation vs delayed open reduction and internal fixation (ORIF). Sixty patients were enrolled in a prospective cohort trial at 1 Level I trauma center. No differences were noted between the 2 treatment groups in terms of age, smoking history, presence of comorbidities, mechanism of injury, incidence of open fractures, or Orthopaedic Trauma Association fracture classification. Complete 12-month follow-up was available for 18 patients in the definitive external fixation group and 27 patients in the ORIF group. No difference was noted in articular reduction between the groups at 6 and 12 months postoperatively. Delayed union or non-union occurred in 4 (22.2%) of 18 patients in the external fixation group and 1 (3.7%) of 27 patients in the ORIF group (P=.05). Deep infection was equally likely in either group (P=.33). The ORIF group had improved Iowa Ankle Scores at 6 (23.6 ± 12.1 vs 11.1 ± 7.7; P<.05) and 12 months (5.5 ± 2.2 vs 3.1 ± 1.7; P<.05) postopertively and improved Short Form-36 Physical Function scores at 6 months (49.7 ± 30.1 vs 25.5 ± 8.0; P<.05) postoperatively compared with the external fixation group.External fixation and ORIF can attain bony union with adequate articular reduction and similar infection rates. Patients treated with ORIF appeared to have improved union rates and early outcomes with ankle function and Short Form-36 Physical Function scores.

Preoperative skeletal versus cutaneous traction for femoral shaft fractures treated within 24 hours.

OBJECTIVES: To compare the advantages and disadvantages of preoperative cutaneous traction versus skeletal traction in adults with diaphyseal femur fractures amenable to fixation within 24 hours. DESIGN: Randomized prospective trial. SETTING: Level I trauma center in a major metropolitan area. PATIENTS: Sixty-five patients with 66 femur fractures were prospectively enrolled and randomized to a traction group from July 2009 to July 2010. MAIN OUTCOME MEASUREMENTS: Time of application for on call physicians/practitioners, pain relief after application of traction; time of reduction in the operating room theater, and evaluation of pain medication consumption before stabilization. RESULTS: Thirty-seven patients received cutaneous femoral traction, whereas 29 patients received skeletal traction. There was a significant reduction in time of application for the cutaneous traction (24.30 ± 24.74 minutes) compared with skeletal traction (57.10 ± 33.60 minutes) (P ≤ 0.001). There was no statistically significant difference in visual analog scale (VAS) scores when compared with pretraction application pain assessment and posttraction pain assessment between the cutaneous and skeletal traction groups with a decrease in the VAS of (0.56 ± 3.73 and 0.54 ± 2.76), respectively (P = 0.99). There was no difference in pain medication requirements between groups (0.12 ± 0.17 mg/kg for cutaneous versus 0.09 ± 0.14 mg/kg for skeletal, P = 0.39). There was no significant difference in reduction time of the fracture (skin incision or opening reamer to guide wire passage) in the operating room between cutaneous traction versus skeletal traction (P = 0.59). CONCLUSIONS: Use of cutaneous traction for diaphyseal femur fractures when compared with skeletal traction results in a statistically significant reduction in time of application to the on call practitioner with no complications or detrimental change in operative time and no difference in VAS pain scores or narcotic usage.

Bone morphogenetic protein-2 compared to autologous iliac crest bone graft in the treatment of long bone nonunion.

This retrospective study investigated the effect of recombinant human bone morphogenetic protein-2 (rhBMP-2) mixed with cancellous allograft on fracture healing compared to iliac crest autograft in the treatment of long bone nonunion. Eighty-nine patients with 93 established long bone nonunions treated between January 2002 and June 2004 at a single academic Level I trauma center were evaluated. Patients with clinical and radiographic evidence of failed fracture union underwent nonunion debridement, revision of fixation, and implantation at the nonunion site of either rhBMP-2 or the standard treatment autologous iliac crest bone graft. Union rate, operative time, estimated intraoperative blood loss, hospital length of stay, and postoperative infections were recorded. Nineteen nonunions received rhBMP-2 on a specialized carrier matrix (an absorbable collagen sponge) mixed with cancellous allograft, and 74 nonunions were treated with autologous iliac crest bone graft. There was no statistical difference in the rate of healing between treatment groups (68.4% vs 85.1%, respectively; P=.09). Incidence of postoperative infection was 16.2% after autologous iliac crest bone graft and 5.3% after rhBMP-2/absorbable collagen sponge (P=.22). Iliac crest autograft was associated with longer operative procedures (257.9±93.0 vs 168.9±86.5 minutes; P=.0007) and greater intraoperative blood loss (554.6±447.8 vs 331.6±357.2 mL; P=.01). These outcomes suggest that rhBMP-2 may provide a suitable alternative to autologous iliac bone graft, with the possible advantages of shorter operative time and reduced intraoperative blood loss, and may be considered as part of the orthopedic surgeon's treatment options.

Delayed presentation of metastatic melanoma of the cervical spine.

A 54-year-old woman presented with neck pain and bilateral shoulder pain. The pain was of varying intensity and was present with activity as well as at night and at rest. She had weakness of her triceps and finger intrinsic muscles. Her past medical history included stage IV melanoma for which she underwent an excision from the right flank area 25 years ago. She was cleared from any disease 5 years after the excision. Magnetic resonance imaging of the cervical spine revealed increased signal intensity in the C7 vertebral body with soft tissue extension into the epidural space. Two weeks after initial presentation the patient underwent a C7 corpectomy and fusion. The C7 vertebral body was grossly pathologic and tissue samples revealed metastatic malignant melanoma. During the 2 weeks following the fusion the patient developed increasing pain and generalized weakness. Repeat MRI of the cervical spine revealed a large soft tissue intensity extending in the spinal canal from C6 to T2. Several days later the patient developed an acute onset of lower extremity weakness as well as urinary incontinence. The patient opted to pursue hospice care, and she died 3 weeks later, 8 weeks after the initial presentation.

Predicting blood loss in isolated pelvic and acetabular high-energy trauma.

OBJECTIVE: To quantify transfusion requirements in patients with isolated acetabular or pelvic fractures and correlate these requirements with fracture classification. DESIGN: Retrospective review of 382 patients with isolated pelvic and/or acetabular fractures. SETTING: Academic Level I Trauma Center. PATIENTS/PARTICIPANTS: Patients were identified from a trauma registry. Appropriate radiographs and complete transfusion data were obtained for 289 (75%) of 382 eligible patients between January 1, 1998 and December 31, 2003. INTERVENTION: Classification of pelvic fracture by Young and Burgess type and acetabular fractures by Letournel type. MAIN OUTCOME MEASUREMENT: Number of units of blood transfused in the first 24 hours after admission to the trauma center. RESULTS: Patients with isolated pelvic fractures with major ligament disruption (APC II or III, LC III, vertical shear, or combined mechanisms) were more likely to receive a blood transfusion (44%) than other fracture types (8.5 %) (P < 0.0005). Transfusion amounts were greatest in APC III (12.6 units) and vertical shear (4.6 units) injuries. Fractures classified as both column, anterior column, anterior column posterior hemi-transverse, or T type were more likely to receive a blood transfusion (56%) than other fracture types (28%) (P = 0.003). Of these fracture types, both column (8.8 units) and anterior column posterior hemi-transverse (6.4 units) received the largest transfusions. CONCLUSIONS: Patients with isolated acetabular fractures are as likely as those with isolated pelvic fractures to receive blood transfusions within the first 24 hours of admission. Higher energy pelvic ring fractures classified as APC II or III, LC III, vertical shear, or combined mechanism require more frequent transfusion than other pelvic fractures. Acetabular fractures involving the anterior column as well as T-type fractures require more frequent blood transfusions than other acetabular fractures.