Age-based differences in the disability of extremity injuries in pediatric and adult occupants.

Objective: The objective was to develop a disability-based metric for motor vehicle crash (MVC) upper and lower extremity injuries and compare functional outcomes between children and adults.Methods: Disability risk (DR) was quantified using Functional Independence Measure (FIM) scores within the National Trauma Data Bank-Research Data System for the top 95% most frequently occurring Abbreviated Injury Scale (AIS) 3 extremity injuries (22 unique injuries). Pediatric (7-18 years), young adult (19-45 years), middle-aged (46-65 years), and older adult (66+ years) MVC occupants with an FIM score and at least one of the 22 extremity injuries were included. DR was calculated for each injury as the proportion of occupants who were disabled of those sustaining the injury. A maximum AIS-adjusted disability risk (DRMAIS) was also calculated for each injury, excluding occupants with AIS 4+ co-injuries.Results: Locomotion impairment was the most frequent disability type across all ages. DR and DRMAIS of the extremity injuries ranged from 0.06 to 1.00 (6%-100% disability risk). Disability risk increased with age, with DRMAIS increasing from 25.9% ± 8.6% (mean ± SD) in pediatric subjects to 30.4% ± 6.3% in young adults, 39.5% ± 6.6% in middle-aged adults, and 60.5 ± 13.3% in older adults. DRMAIS for upper extremity fractures differed significantly between age groups, with higher disability in older adults, followed by middle-aged adults. DRMAIS for pelvis, hip, shaft, knee, and other lower extremity fractures differed significantly between age groups, with older adult DRMAIS being significantly higher for each fracture type. DRMAIS for hip and lower extremity shaft fractures was also significantly higher in middle-aged occupants compared to pediatric and young adult occupants. The maximum AIS-adjusted mortality risk (MRMAIS, proportion of fatalities among occupants sustaining an MAIS 3 injury) was not correlated with DRMAIS for extremity injuries in pediatric, young adult, middle-aged, and older adult occupants (all R2 < 0.01). Disability associated with each extremity injury was higher than mortality risk.Conclusions: Older adults had significantly greater disability for MVC extremity injuries. Lower disability rates in children may stem from their increased physiological capacity for bone healing and relative lack of bone disease. The disability metrics developed can supplement AIS and other severity-based metrics by accounting for the age-specific functional implications of MVC extremity injuries.

Patella fractures are not associated with an increased risk of mortality in elderly patients.

INTRODUCTION: The modern literature includes only limited information regarding mortality rates and cumulative survival following patella fractures. The aim was to report the 30-day, six-month, and one-year mortality of patients with patella fractures and compare this to the mortality of a matched reference population. METHODS: All patients who sustained a patella fracture in Denmark between 1996 and 2000 were included in the study. The survival status of these patients was monitored until 2015. We compare the mortality with a ten-fold reference population matched on age and gender without a prior patella fracture. RESULTS: 6096 patients were treated for 6114 patella fractures. The mean age of patients was 48.9 years. The overall mortality rates at 30 days, six months, and one year were 0.7%, 1.8%, and 2.8%. The mortality rates for patients > 65 years at 30 days, six months, and one year were 1.3%, 3.9%, and 6.2%. The mortality rates for patients at ≤ 65 years at 30 days, six months, and one year were 0.4%, 0.9%, and 1.3%. Compared to the matched reference population, the relative risk of mortality in patients > 65 years at 30 days, six months, and one year were 1.9 (95% CI 1.2-2.9), 1.0 (95% CI 0.8-1.3), and 0.9 (95% CI 0.7-1.1). CONCLUSION: The overall one-year mortality rate of patella fractures was 2.8% and this was increased to 6.2% in patients older than 65 years. In elderly patients above 65 years, the relative risk of death was 0.9, indicating that patella fractures in elderly patients were not associated with an increased mortality rate.

[Traumatology in the elderly : Multimodal prevention of delirium and use of augmentation techniques]. / Alterstraumatologie : Multimodale Delirprävention und Verwendung von Augmentationstechniken.

Recent data show that 20-80% of surgery patients are affected by delirium during inpatient clinical treatment. The medical consequences are often dramatic and include a 20 times higher mortality and treatment expenses of the medical unit increase considerably. At the University Hospital of Münster a multimodal and interdisciplinary concept for prevention and management of delirium was developed: all patients older than 65 years admitted for surgery are screened by a specialized team for the risk of developing delirium and treated by members of the team if there is a risk of delirium. Studies proved that by this multimodal approach the incidence of delirium was lowered and therefore the quality of medical care improved.When surgical treatment of fractures in the elderly is required, limited bone quality as well as pre-existing implants can complicate the procedure. Secondary loss of reduction after osteosynthesis and avulsion of the implant in particular must be prevented. Augmentation of the osteosynthetic implant with bone cement can increase the bone-implant interface and therefore stability can be improved. Additional intraoperative 3D imaging can be necessary depending on the localization of the fracture. In biomechanical studies we could prove greater stability in the osteosynthesis of osteoporotic fractures of the distal femur when using additional bone cement; therefore, the use of bone cement is an important tool, which helps to prevent complications in the surgical treatment of fractures in the elderly. Nevertheless, special implants and technical skills are required and some safety aspects should be considered.

Fifteen-Year Survival of Endoscopic Anterior Cruciate Ligament Reconstruction in Patients Aged 18 Years and Younger.

BACKGROUND: The current body of literature surrounding anterior cruciate ligament (ACL) survival and the variables contributing to further ACL injuries after primary ACL reconstruction in children and adolescents is limited, with no long-term evidence examining the incidence and contributing factors of further ACL injuries in this younger patient population. PURPOSE: To determine the long-term survival of the ACL graft and the contralateral ACL (CACL) after primary reconstruction in patients aged ≤18 years and to identify the factors that increase the odds of subsequent ACL injuries. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients having undergone primary ACL reconstruction at age ≤18 years between 1993 and 1998 who were included in a prospective database by a single surgeon were considered for this study. Single-incision endoscopic ACL reconstruction was performed with either an autologous bone-patellar tendon-bone graft or a hamstring tendon graft. At a minimum of 15 years after ACL reconstruction, patients completed a subjective survey involving the International Knee Documentation Committee (IKDC) questionnaire in addition to questions regarding current symptoms, further ACL injuries, family history of ACL injury, and current level of activity. RESULTS: A total of 288 adolescents (age range, 13-18 years) met the inclusion criteria, of whom 242 (84%) were reviewed at a mean of 16 years and 6 months after ACL reconstruction. Of these patients, 75 (31%) sustained a further ACL injury: 27 (11.2%) suffered an ACL graft rupture, 33 suffered a CACL injury (13.6%), and 15 sustained both an ACL graft rupture and a CACL injury (6.2%) over 15 years. Survival of the ACL graft was 95%, 92%, 88%, 85%, and 83% at 1, 2, 5, 10, and 15 years, respectively, and survival of the CACL was 99%, 98%, 90%, 83%, and 81%, respectively. Survival of the ACL graft was less favorable in those with a family history of ACL injury than in those without a family history (69% vs 90%, respectively; hazard ratio [HR], 3.6; P = .001). Survival of the CACL was less favorable in male patients than in female patients (75% vs 88%, respectively; HR, 2.1; P = .03) and in those who returned to competitive team ball sports than in those who did not (78% vs 89%, respectively; HR, 2.3; P = .05). CONCLUSION: After ACL reconstruction in patients aged ≤18 years, a further ACL injury occurred in 1 in 3 patients over 15 years. The 15-year survival rate of the ACL graft was 83%, and the 15-year survival rate of the CACL was 81%. The ACL graft and CACL were most vulnerable within the first 5 years after index surgery. A family history of ACL rupture significantly increased the risk for ACL graft ruptures, and a CACL injury was more common in male patients and those who returned to team ball sports. High IKDC scores and continued participation in sports were maintained over the long term after ACL reconstruction in the adolescent population.

Risk factors for reoperation and mortality after the operative treatment of tibial plateau fractures in Ontario, 1996-2009.

OBJECTIVE: To define the rates and risk factors for reoperation and early mortality after open reduction and internal fixation (ORIF) of a tibial plateau fracture (AO type 41A-C) with or without concomitant tibial shaft fractures. DESIGN: Retrospective cohort study of administrative health data (prognostic level II). SETTING: Ontario, Canada. PATIENTS/PARTICIPANTS: Eight thousand four hundred twenty-six patients who underwent unilateral tibial plateau ORIF between 1996 and 2009. INTERVENTION: ORIF of the tibial plateau. MAIN OUTCOME MEASURES: Reoperation included irrigation and debridement, compartment syndrome release, amputation, knee fusion, implant removal, and repeat ORIF within 1 year of the index surgery and 90-day mortality. Outcomes were fit to a multivariate logistic regression model that included patient demographics, surgical factors, and provider factors as covariates. RESULTS: The median cohort age was 48 years, with 51.5% male sex. Of all included plateau fractures, 27.9% were bicondylar fractures and 4.8% were open fractures. The odds of undergoing a repeat ORIF were increased significantly by the presence of an open fracture [odds ratio (OR) = 1.8, 1.3-25], bicondylar fracture (OR = 1.4, 1.2-1.7), an associated tibial shaft fracture (OR = 1.8, 1.3-2.5), surgery performed during the evening/weekend (OR = 1.24, 1.05-1.47), or surgery performed after midnight (OR = 2.08, 1.42-3.06). The odds of requiring an irrigation and debridement were also increased significantly by open fractures, bicondylar fractures, use of a temporizing external fixator, and an associated tibial shaft fracture [OR = 3.2 (2.2-4.6), 2.7 (2.1-3.5), 1.97 (1.09-3.56), and 3.2 (2.2-4.6), respectively]. The odds of repeat ORIF were significantly lower [0.8 (0.7-0.9)] when the index operation was performed in an academic center. Ninety-day mortality was 0.85% overall but 8.2% in patients older than 80 years. CONCLUSIONS: Markers of higher energy injury are associated with higher reoperation rates and 90-day mortality after ORIF of the tibial plateau. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

A pilot study of conically graded chitosan-gelatin hydrogel/PLGA scaffold with dual-delivery of TGF-ß1 and BMP-2 for regeneration of cartilage-bone interface.

Repair of cartilage-bone interface tissue remains challenging, because it combines different cell types and gradients of composition and properties. To enable simultaneous regeneration of bone, cartilage, and especially their interface, a conically graded scaffold of chitosan-gelatin hydrogel/poly(l-lactide-co-glycolide) (PLGA) was facilely prepared in the study. The chitosan-gelatin hydrogel containing transforming growth factor ß1 (TGF-ß1) was used for chondrogenesis, while the PLGA scaffold loading bone morphogenetic protein-2 (BMP-2) for osteogenesis. The conically graded transition from the hydrogel to PLGA scaffold and graded variation in amount of growth factors from TGF-ß1 to BMP-2 benefited the cartilage-bone interface reconstruction. The graded scaffold exhibited spatio-temporal delivery of TGF-ß1 and BMP-2. Preliminary results of in vitro cell culture demonstrated that the hydrogel and PLGA phases could promote bone marrow mesenchymal stem cells toward chondrogenic and osteogenic differentiation, respectively. From the result of the pilot in vivo experiment, it showed that the regenerated hyaline-like cartilage surface and subchondral bone excellently integrated with the native tissues were found by using the TGF-ß1 and BMP-2 double-loaded hydrogel/PLGA graded scaffold via H&E and immunohistochemical stainings of collagen I, collagen II, and osteocalcin at 2 months. The obtained preliminary experiment results showed that the hydrogel/PLGA graded scaffold combining multiphasic composition and spatial dual growth-factor delivery would be useful for cartilage-bone interface tissue defect repair.

Floating knee injuries: a high complication rate.

Floating knee injuries are usually associated with complications and mortality, regardless of the treatment regimen. Orthopedic surgeons typically recommend various treatment regimens, especially aggressive and early stabilization of both femoral and tibial fractures. Some authors have reported that the complication and mortality rates remain high regardless of the treatment regimen used. The purpose of this retrospective study was to review the long-term results of treatments for floating knee injuries performed at our institution, and also to calculate the distribution of fracture types within patient age groups and the association with complications related to floating knee injury. We retrospectively reviewed medical records and radiographs of 419 floating knee injuries treated for postoperative complications from November 1987 to April 2003. Of the 419 patients with floating knee injuries, 104 (24.8%) developed complications. The result showed that the complication rate was associated with fracture type (open fracture [32.2%; P<.001], Fraser type IIc [36.8%; P<.001], tibial plateau [28.6%; P=.037], and distal tibia [28.6%; P=.035]). This study revealed that the complication rate associated with floating knee injuries remained high, regardless of the treatment regimen used. Surgeons should focus on reducing complications while treating floating knee injuries.

Custom made Ilizarov ring fixator for fracture care in morbidly obese patients.

BACKGROUND: Fracture care in obese patients is becoming an everyday problem because the prevalence of obesity in European countries has tripled since the last 20 years. PATIENTS AND METHOD: With the use of a custom made Ilizarov ring fixator with a ring diameter of 300 to 340 mm, fracture stabilization in three morbidly obese patients was performed. The patients' body mass index (BMI) ranged from 59 to 89. There were one proximal tibia fracture and two pilon fractures. The tibia fracture was stabilized with a 340-mm frame and the pilon fractures were stabilized by primary ankle arthrodesis with 300-mm frames. Primary ankle arthrodesis was performed because polyneuropathy and Charcot arthropathy were present in one patient and in the other patient because time from injury to referral was too long for reconstruction. RESULTS: All patients were able to fully weight bear. Frame removal after fracture correction and consolidation was performed only in the patient with the tibial fracture (patient BMI 89). The other patients died during the treatment because of decompensated comorbidities. CONCLUSION: The Ilizarov technique is a good fixation modality for stabilizing fractures of the lower limb in morbidly obese patients. Associated medical comorbidities are the limitations of successful fracture care.

Revision total knee arthroplasty with modular components inserted with metaphyseal cement and stems without cement.

The clinical and radiographic outcomes of 50 consecutive revision total knee arthroplasties in 47 patients, placed with metaphyseal cemented femoral and tibial components with press-fit cementless stems, were reviewed at 36-month average follow-up. Revision was performed for aseptic loosening (11/50), infection (17/50), periprosthetic fracture (8/50), component failure (6/50), instability (6/50), and malalignment (2/50). The press-fit cementless stems were 80 to 160 mm in length and tightly contacted the endosteum of the metadiaphyseal areas. Four (9%) knees were re-revised for infection, zero for aseptic loosening. The average modified Hospital for Special Surgery knee score improved from 49 to 87. One patient (2%) reported thigh pain, and 1 reported leg pain. Metaphyseal cemented revision total knee components with press-fit cementless femoral and tibial stems were not associated with significant thigh and leg pain.

Total knee arthroplasty for salvage of failed internal fixation or nonunion of the distal femur.

Seventeen patients with a mean age of 66 years had total knee arthroplasty (TKA) performed to salvage failed internal fixation or nonunion of the distal femur. Two patients died at less than 2 years, both of whom were unrevised. The remaining 15 were followed for a mean of 5 years. Three arthroplasties failed, 1 by infection and 2 by mechanical failure. The 5-year survivorship free of revision for aseptic failure was 91% (72%-100%). There were 5 intraoperative complications (29%) and 5 postoperative complications (29%). The mean Knee Society pain score improved from 2 (range, 0-10) to 89 (range, 63-97), and the mean functional score improved from 2 (range, 0-25) to 45 (range, 10-90). TKA provided reliable pain relief and functional improvement for the great majority of patients. Functional scores and prosthesis survivorship, however, were inferior to those reported for primary TKA. The surgeries were difficult, and intraoperative and postoperative complications were common.

Factors related to additional knee injuries after anterior cruciate ligament injury.

PURPOSE: We reviewed 1,375 consecutive patients to determine whether patient gender, age at injury, or activity level at injury were related to the risk of additional knee injuries over time following anterior cruciate ligament (ACL) injury. TYPE OF STUDY: Retrospective case series. METHODS: Survival analysis was used to analyze the effect of each factor while statistically controlling for the effect of time from ACL injury to reconstruction. RESULTS: The risk of meniscus injury was significantly higher among male subjects (odds ratio [OR] = 1.5, P < .001). When undergoing ACL reconstruction more than 6 months after injury, the risk of meniscus injury increased by 1.5 times for male subjects (P = .021) but increased by 3.4 times for female subjects (P < .001). The risk of meniscus injuries was significantly higher among patients undergoing ACL reconstruction more than 6 months after injury when compared with patients undergoing reconstruction within 2 weeks of injury (OR = 2.2, P < .001). The risk of articular cartilage lesions was significantly higher among patients undergoing ACL reconstruction more than 1 year after injury when compared with patients undergoing reconstruction within 2 weeks of injury (OR = 2.1, P < .001). CONCLUSIONS: Men had a consistently higher occurrence rate of meniscus injuries than did women. The risk of meniscus injuries increased at a higher rate over time among women. The risk of meniscus injuries increases when ACL reconstruction is performed more than 6 months after injury. The risk of articular cartilage lesions increases when ACL reconstruction is performed more than 1 year after injury. LEVEL OF EVIDENCE: Level IV, Case Series.

The Lubinus patellofemoral arthroplasty. A five- to ten-year prospective study.

We present a prospective review of the outcome of 76 Lubinus patellofemoral arthroplasties carried out in 59 patients between 1989 and 1995. At a mean follow-up of 7.5 years, 62 knees in the 48 patients were reviewed; 11 patients (14 knees) had died. None was lost to follow-up. The clinical outcome using the Bristol Knee Scoring system was satisfactory in 45% of the cases. Maltracking of the patella, resulting in lateral tilt, subluxation and polyethylene wear, was the most common complication (32%). Revision surgery was carried out in 21 knees (28%) giving a cumulative survival rate of 65% (confidence interval (CI) 49 to 77) at eight years. The survival rate for revision and moderate pain was 48% (CI 36 to 59) at six years. Progression of arthritis was seen in seven cases (9%). In five of these (6.5%), the symptoms were severe enough to need revision surgery. Due to the high proportion of unsatisfactory results, we have discontinued the use of this prosthesis.

Injury risk factors among telemark skiers.

We performed a population survey of telemark skiers over two ski seasons to determine specific risk factors for injury. The survey inquired about the skier's sex, experience, equipment used, injuries, and number of days skied in each season. The respondents completed the surveys whether or not they were injured while skiing. We received 677 responses from telemark skiing clubs, with 19,962 skier-days of data. The number of self-reported injuries was 178, for an overall self-reported injury rate of 8.9 per 1000 skier-days. Knee injuries (N = 48) were the most common injury (27%), followed by thumb (N = 32, 18%) and shoulder (N = 21, 12%) injuries. Specific risk factors for injury were identified with multivariate regression and survival analysis. The skill level of the skier had a significant injury-sparing effect, as did the use of plastic telemark boots. The protective effect of the plastic boots was likely due to the increased stability they provided compared with traditional leather boots. There were fewer knee injuries with the recently available releasable bindings for telemark skis. Sex and age had no significant impact on injury rates in this study population. As all reported deaths associated with telemark sking were due to environmental hazards, skiers must continue to pay close attention to these hazards in the backcountry.