Causes and associations with mortality in patients with pelvic ring injuries with haemorrhagic shock.

BACKGROUND: High energy pelvic ring injuries are associated with significant morbidity and mortality and can be accompanied by haemorrhagic shock following associated vascular injury. This study evaluated the causes and predictors of mortality in haemodynamically unstable pelvic fractures. METHODS: This retrospective observational study at a Major Trauma Centre reviewed 938 consecutive adult patients (≥ 18yrs) with pelvic ring injuries between December 2014 and November 2018. Patients with features of haemorrhagic shock were included, defined as: arrival Systolic BP < 90 mmHg, Base Deficit ≥ 6.0 mmol/l, or transfusion of ≥ 4 units of packed red blood cells within 24 h. RESULTS: Of the 102 patients included, all sustained injuries from high energy trauma, and 47.1% underwent a haemorrhage control intervention (Resuscitative Endovascular Balloon Occlusion of the Aorta-REBOA, Interventional Radiology-IR, or Laparotomy). These were more often required following vertical shear injuries (OR 10.7, p = 0.036). Overall, 33 patients (32.4%) died; 16 due to a head injury, and only 2 directly from acute pelvic exsanguination (6.1%). Multivariable logistic regression demonstrated that increasing age, Injury Severity Score, Abbreviated Injury Scale (AIS) Head ≥ 3 and open pelvic fracture were all independent predictors of mortality, and IR was associated with reduced mortality. Lateral Compression III (LC3) injuries were associated with mortality due to multiple organ dysfunction syndrome (MODS). CONCLUSION: Haemodynamically unstable patients with pelvic ring injuries have a high mortality rate, but death is usually attributed to other injuries or later complications, and not from acute exsanguination. This reflects improvements in resuscitative care, transfusion protocols, and haemorrhage control techniques.

Acute versus delayed total hip arthroplasty after acetabular fracture fixation: a systematic review and meta-analysis.

BACKGROUND: Post-traumatic osteoarthritis (PTOA) is a disabling complication of open reduction and internal fixation (ORIF) for acetabular fractures. There is a trend towards acute total hip arthroplasty (THA), 'fix-and-replace', in patients considered to have a poor prognosis and likelihood of PTOA. Controversy remains between early fix-and-replace, versus delayed THA as required after initial ORIF. This systematic review included studies comparing functional and clinical outcomes between acute versus delayed THA after displaced acetabular fractures. METHODS: Comprehensive searches following the PRISMA guideline were performed on six databases for articles in English published anytime up to 29 March 2021. Two authors screened articles and discrepancies were resolved by consensus. Patient demographics, fracture classification, functional and clinical outcomes were compiled and analysed. RESULTS: The search yielded 2770 unique studies, of which five retrospective studies were identified with a total of 255 patients. Of them, 138 (54.1%) were treated with acute and 117 (45.9%) treated with delayed THA. Delayed THA group represented a younger cohort compared to the acute group (mean age, 64.3 vs 73.3). The mean follow-up time for the acute and delayed group was 23 and 50 months, respectively. There was no difference in functional outcomes between the two study groups. Complication and mortality rates were comparable. Delayed THA had a higher revision rate compared to the acute group (17.1 vs 4.3%; p = 0.002). CONCLUSION: Fix-and-replace had functional outcomes and complication rates similar to ORIF and delayed THA, but lower revision rates. Although the quality of studies was mixed, sufficient equipoise now exists to justify randomised studies in this area. PROSPERO registration: CRD42021235730.

Epidemiology of pelvic and acetabular fractures across 12-mo at a level-1 trauma centre.

BACKGROUND: Despite motor-vehicle safety advancements and increasingly rigorous workplace safety regulations, trauma/suicide remains the leading cause of death under the age of 45 in the United Kingdom. To promote centralisation of care and optimisation of major trauma outcomes, in 2012 the National Health Service introduced the Trauma Network System. To our knowledge, this is the first study to analyse the epidemiology of pelvic and acetabular trauma over a one-year period at a level-1 trauma centre in the United Kingdom, since nationwide introduction of the Trauma Network System. AIM: To characterize the epidemiology of high-energy pelvic and acetabular fractures over a one-year period at a level-1 trauma centre, and explore both resources required to care for these patients and opportunities for future research and injury prevention initiatives. METHODS: 227 consecutive patients at a level-1 trauma centre with pelvic and acetabular fractures were analysed between December 2017-December 2018. Paediatric patients (< 18 years) and fragility fractures were excluded, leaving 175 patients for inclusion in the study. Statistical analysis was performed using Fisher's exact test for categorical variables. RESULTS: 72% of pelvic and acetabular fractures occurred in male patients at a median age of 45 years. 15% were the result of a suicide attempt. 48% of patients required pelvic or acetabular surgery, with 38% undergoing further surgery for additional orthopaedic injuries. 43% of patients were admitted to intensive care. The median inpatient stay was 13 days, and the 30- day mortality was 5%. Pelvic ring trauma was more commonly associated with abdominal injury (P = 0.01) and spine fractures (P < 0.001) than acetabular fractures. Vertical shear pelvic ring fractures were associated with falls (P = 0.03) while lateral compression fractures were associated with road traffic accidents (P = 0.01). CONCLUSION: High energy pelvic and acetabular fractures are associated with concomitant orthopaedic fractures (most commonly spine and lower limb), intensive care admission and prolonged inpatient stays. Most pelvic ring injuries secondary to road traffic accidents are lateral compression type, demonstrating the need for future research to drive advancements in lateral impact vehicle safety along with mental health surveillance for those deemed to be potential suicide risks.

Removal of iliosacral screws: the washer problem.

Iliosacral screw removal is an infrequent surgery, and when needed, removal of the washer can be surprisingly difficult. Different forceps, clamps and other non-specific instruments are frequently used to this end, many a time without success, or at the expense of tissue damage, blood loss and radiation exposure. After trying all the tricks in the book, we devised this neat little surgical tactic that ensures easy and reliable retrieval of the washer when removing iliosacral screws percutaneously, with no increased morbidity.

Spinopelvic Dissociation: A Retrospective Case Study and Review of Treatment Controversies.

INTRODUCTION: Spinopelvic dissociation is a rare injury resulting in discontinuity between the spine and pelvis. We review the English- language literature and discuss critical treatment controversies. We present a series of spinopelvic dissociation cases from a level I trauma center. METHODS: In this retrospective review of 18 consecutive cases treated surgically over a period of 4 years, we collected patient, injury, and surgical demographics and clinical and radiographic outcome measures. RESULTS: Twelve patients had associated injuries, five were intubated on arrival, and six had neurologic deficits at presentation. No patient had spinal decompression, and all patients underwent closed reduction and percutaneous fixation. There were no cases of iatrogenic nerve injury, despite the use of partially threaded sacroiliac screws and closed reduction techniques. Five patients showed progressive neurologic improvement postoperatively. After reduction, eight patients (44%) had radiographic loss of the sacrococcygeal angle at the latest follow-up, but correction of fracture translation was preserved in all. DISCUSSION: Spinopelvic dissociation represents a heterogeneous group of injuries often in the context of polytraumatized patients with other injuries. Our closed reduction and fixation technique resulted in satisfactory outcomes. We present a treatment algorithm for these rare injuries.

Are patient-reported outcome measures in orthopaedics easily read by patients?

BACKGROUND: Patient-reported outcome measures (PROMs) are commonly used by healthcare providers as means of assessing health-related quality of life and function at any given time. The complexity of PROMs can differ and when combined with varying degrees of adult literacy, error can be introduced if patients fail to understand questions. With an average adult literacy level of 11-year-old students in the United Kingdom, it is unclear to what degree PROMs can be read and understood by most patients (readability); to our knowledge, this has not been evaluated. QUESTIONS/PURPOSES: We wished to determine the readability of commonly used PROMs in orthopaedic surgery, as assessed by a validated tool that measures the complexity of the language in these surveys. METHODS: We performed a MEDLINE search to identify the most-commonly reported PROMs in orthopaedic research. One hundred twenty-one PROMs were identified and reviewed by 19 attending orthopaedic surgeons at our institution. Fifty-nine were selected as the most commonly used in our department. Of these, 52 (78%) were disease specific and included: 12 (20%) knee, 10 (17%) shoulder, seven (12%) spine, six (10%) hip, five (8%) foot and ankle, four (7%) elbow, three (5%) pelvis, three (5%) hand and wrist, and two (3%) lower limb. The remaining seven (12%) PROMs were general health questionnaires. The Flesch Reading Ease Score is a validated readability tool measuring average sentence length and syllables per word. It is expressed on a scale from 0 to 100 with higher scores indicating easier reading. We extracted the text from each PROM and inserted it in the same online Flesch Reading Ease Score calculator to generate a score. RESULTS: The mean readability score was 55 (range, 0-93), corresponding to text best understood by 16- to 18-year-old students (11th-12th grades). Twenty-nine PROMs (49%) scored less than 60, classifying them as at least fairly difficult to read. Eight (14%) scored less than 30, best understood by university graduates. Only seven of 59 PROMs analyzed scored greater than 79, corresponding to text that can be understood by the average UK adult. CONCLUSIONS: The majority of PROMs analyzed are written at a level that is incomprehensible to the average UK adult. CLINICAL RELEVANCE: This issue needs to be addressed if we are to continue basing our research conclusions on outcome scores. The information obtained is useful for patients to understand their musculoskeletal health, governmental agencies allocating healthcare resources, provision of management guidelines, and as a link to other data sets, such as hospital episodes statistics. Accurate and reliable data can be obtained only if patients who complete these evaluations are able to read and understand the questions asked.

Pre-operative Waterlow score: Predicts risk of post-operative infection in patients with neck of femur fractures.

INTRODUCTION: Nursing staff prospectively collect Waterlow scores (Ws) on all inpatients across most NHS hospitals, identifying patients at risk of pressure ulcers. This bedside score has not been applied in predicting other negative outcomes in patients with neck of femur (NOF) fractures. OBJECTIVES: To investigate the relationship between increasing Waterlow score and 30-day post-operative infection in patients with NOF fracture. PATIENTS AND METHODS: Pre-operative Ws and 30-day clinical outcome data were collected on 97 consecutive operatively treated NOF fracture patients at our institution (level one trauma centre). RESULTS: 30-day infection rate was 36%, which manifested as hospital acquired pneumonia (66%) and urinary tract infection (34%). For every one point increase in Ws, the odds of having an infection increased by 1.68 times (95% CI 1.37-2.08). The relationship between Ws and 30-day infection was similar when adjusted for potential confounders: patient demographics (age and gender), number of medical comorbidities, ASA grade, and days to surgery. For our data, the Ws predictive of infection was ≥17. This has a sensitivity of 84.9% (95% CI 68.1-94.9%) and a specificity of 84.1% (95% CI 74.7-92.1%). The area under the curve was 0.89 (95% CI 0.82-0.96). CONCLUSION: Our study demonstrates a strong relationship between increasing Ws and post-operative infection risk. This raises the interesting yet controversial question of using Ws to identify patients at high-risk of developing post-operative infections and the potential benefit of an extended period of antibiotic prophylaxis.

Thromboprophylaxis in patients with pelvic and acetabular fractures: A short review and recommendations.

The management of thromboprophylaxis in patients with pelvic and acetabular fractures remains a highly controversial topic within the trauma community. Despite anticoagulation, venous thromboembolism (VTE) remains the most common cause of surgical morbidity and mortality in this high-risk patient group. Although various thromboprophylactic regimes are employed, evidence relating to the most effective method remains unclear. Controversies surrounding screening, the use of prophylactic inferior vena cava filters (IVCF) and chemothromboprophylaxis in polytraumatised patients, particularly those with pelvic and acetabular fractures, form the basis of considerable debate. With the absence of a well-designed clinical trial and the presence of ongoing controversies within the literature, this review will explore current treatment options available to trauma surgeons and highlight differing scientific opinions, providing an update on the role of screening and current available preventative measures. We cover existing as well as recent advances in chemical thromboprophylactic agents and discuss external mechanical compression devices, the usefulness of serial duplex ultrasonography and the role of extended chemothromboprophylaxis on discharge. The evidence behind prophylactic IVCF is also considered, along with reported complication profiles. We conclude with a proposed protocol for use in major trauma centres, which can form the basis of local policy for the prevention of VTE in trauma patients with pelvic and acetabular fractures.

Ankle replacement versus arthrodesis: a comparative gait analysis study.

BACKGROUND: The improving survivorship of ankle replacements is making this an increasingly popular option in the treatment of ankle arthritis, rather than the established option of ankle fusion. The potential benefits of restoring movement, improving gait and protecting adjacent joints are persuasive arguments in favor of replacing rather than fusing the ankle joint. METHODS: Gait analysis was performed before and after ankle arthroplasty on 12 patients, and compared to 12 patients with a successful ankle arthrodesis and to a healthy control group of 12 people. RESULTS: Important differences between the arthrodesis and ankle replacement groups were demonstrated although neither restored normal movement or walking speed. Ankle arthrodesis resulted in a faster gait with a longer step length compared to replacement, although the timing of gait demonstrated greater asymmetry. The ankle replacement group had greater movement at the ankle, a symmetrical timing of gait and restored ground reaction force pattern. CONCLUSION: The improved timing of gait would support the observation of a reduction in limp with ankle replacement though the gait is significantly slower. Longer term results are necessary to determine whether the improved movement and force transmission persists with time and protects adjacent articulations.