Treatment of Lower Extremity Fractures in Chronic Spinal Cord Injury: A Systematic Review of the Literature

Management of Femoral and Tibial Shaft Fractures in Patients With Chronic Spinal Cord Injury

OBJECTIVES

To compare outcomes and complications between nonoperative and operative management of femur and tibia fractures in patients with paraplegia or quadriplegia from chronic spinal cord injury (SCI).

METHODS

DESIGN

Retrospective cohort study.

SETTING

Three Level-1 Trauma centers.

PATIENT SELECTION CRITERIA

All adult patients with paraplegia or quadriplegia due to a chronic SCI with operative or nonoperative treatment of a femoral or tibial shaft fracture from January 1, 2009 through December 31, 2019 were included.

OUTCOME MEASURES AND COMPARISONS

Outcomes collected included range of motion, pain, return to baseline activity, extent of malunion, and treatment complications (infection, pressure ulcers, nonunion, deep vein thrombosis/pulmonary emobolus, stroke, amputation, death). Comparison between operative and nonoperative treatment were made for each outcome.

RESULTS

Fifty-nine patients with acute lower extremity fracture in the setting of chronic SCI fulfilled inclusion criteria with a median age of 46 years in the operative group and 47 years in the nonoperative group. Twelve patients (70.6%) in the nonoperative group were male with 32 (76.2%) male patients in the operative group. Forty-six patients (78%) presented as low energy trauma. Differences were seen between operative and nonoperative management for pressure ulcers (19% vs. 52.9%, P = 0.009) and mean Visual Analog Scale pain score at first follow-up (1.19 vs. 3.3, P = 0.03). No difference was seen for rates of infection, nonunion, deep vein thrombosis/pulmonary emobolus, stroke, amputation, death, return to baseline activity, and range of motion.

CONCLUSIONS

Tibial and femoral shaft fractures commonly resulted from low energy mechanisms in patients with chronic SCI. Operative treatment seemed to decrease morbidity in these patients via lowered rates of pressure ulcers and decreased pain compared with nonoperative management.

LEVEL OF EVIDENCE

Therapeutic, Level III. See Instructions for Authors for a complete description of levels of evidence.

Malunions following lower extremity fractures in veterans with a spinal cord injury/disorder

BACKGROUND

Nearly 50% of all persons with a spinal cord injury/disorder (SCI/D) will sustain an osteoporotic fracture sometime in their life, with lower extremity fractures being the most common. There are a number of complications that can occur post fracture, including fracture malunion. To date, there have been no dedicated investigations of malunions among persons with SCI/D.

OBJECTIVES

The primary objective of this study was to identify risk factors associated with fracture malunion among fracture-related (type of fracture, fracture location, initial fracture treatment) and SCI/D-related factors. Secondary objectives were to describe treatment of fracture malunions and complications following these malunions.

METHODS

Veterans with SCI/D with an incident lower extremity fracture and subsequent malunion from Fiscal Year (FY) 2005-2015 were selected from the Veteran Health Administration (VHA) databases using International Classification of Diseases, 9th edition (ICD-9) codes for lower extremity fractures and malunion. These fracture malunion cases underwent electronic health record (EHR) review to abstract information on potential risk factors, treatments and complications for malunion. Twenty-nine cases were identified with a fracture malunion with 28 of them successfully matched with Veterans with a lower extremity fracture during FY2005-FY2014 without a malunion (matched 1:4) based on having an outpatient utilization date of care within 30 days of the fracture case. There was trend towards more nonsurgical treatment in the malunion group (n = 27, 96.43%) compared to the control group (n = 101, 90.18%) (P = 0.05), though fracture treatment proved not to be not associated with developing a malunion in univariate logistic regression analyses (OR = 0.30; 95% CI: 0.08-1.09). In multivariate analyses, Veterans with tetraplegia were significantly less likely (approximately 3-fold) to have a fracture malunion (OR = 0.38; 95% CI: 0.14-0.93) compared to those with paraplegia. Fracture malunion was significantly less likely to occur for fractures of the ankle (OR = 0.02; 95% CI: 0-0.13) or the hip (OR = 0.15; 95% CI: 0.03-0.56) compared to femur fractures. Fracture malunions were rarely treated. The most common complications following malunions were pressure injuries (56.3%) followed by osteomyelitis (25.0%).

CONCLUSIONS

Persons with tetraplegia as well as fractures of the ankle and hip (compared to the femur) were less likely to develop a fracture malunion. Attention to prevention of avoidable pressure injuries following a fracture malunion is important.

Appendicular fracture and polytrauma correlate with outcome of spinal cord injury (SCI): A TRACK-SCI study

Spinal cord injuries (SCIs) frequently occur in combination with other major organ injuries, such as traumatic brain injury (TBI) and injuries to the chest, abdomen, and musculoskeletal system (e.g., extremity, pelvic, and spine fractures). However, the effects of appendicular fractures on SCI recovery are poorly understood. We investigated whether the presence of SCI-concurrent appendicular fractures is predictive of a less robust SCI recovery. Patients enrolled in the Transforming Research And Clinical Knowledge in SCI (TRACK-SCI) prospective cohort study were identified and included in this secondary analysis study. Inclusion criteria resulted in 147 patients consisting of 120 isolated SCIs and 27 with concomitant appendicular fracture. The primary outcome was ASIA Impairment Scale (AIS) neurological grades at hospital discharge. Secondary outcomes included hospital length of stay, ICU length of stay, and AIS grade improvement during hospitalization. Multivariable binomial logistic regression analyses assessed whether SCI-concomitant appendicular fractures associate with SCI function and secondary outcomes. These analyses were adjusted for age, gender, injury severity, and non-fracture polytrauma. Appendicular fractures were associated with more severe AIS grades at hospital discharge, though covariate adjustments diminished statistical significance of this effect. Notably, non-fracture injuries to the chest and abdomen were influential covariates. Secondary analyses suggested that appendicular fractures also increased hospital length of stay. Our study indicated that SCI-associated polytrauma is important for predicting SCI functional outcomes. Further statistical evaluation is required to disentangle the effects of appendicular fractures, non-fracture solid organ injury, and SCI physiology to improve health outcomes amongst SCI patients.

The improvement of the lower limb exoskeletons on the gait of patients with spinal cord injury: A protocol for systematic review and meta-analysis

BACKGROUND

Spinal Cord Injury is a severely disabling disease. In the process of Spinal Cord Injury rehabilitation treatment, improving patients' walking ability, improving their self-care ability, and enhancing patients' self-esteem is an important aspect of their return to society, which can also reduce the cost of patients, so the rehabilitation of lower limbs is very important. The lower limb exoskeleton robot is a bionic robot designed according to the principles of robotics, mechanism, bionics, control theory, communication technology, and information processing technology, which can be worn on the lower limb of the human body and complete specific tasks under the user's control. The purpose of this study was to evaluate the effect of the lower limb exoskeleton on the improvement of gait function in patients with spinal cord injury.

METHODS

The following electronic databases will be searched from inception to January 2022: PubMed, the Cochrane Library, Embase, Scopus, EBSCO, Web of Science, China National Knowledge Infrastructure, WanFang Data, Weipu Electronics. In addition, reference lists of the included studies were manually searched to identify additional relevant studies. Randomized controlled trials were collected to examine the effect of lower limb exoskeletons on lower limb functional recovery in spinal cord injury patients. We will consider inclusion, select high-quality articles for data extraction and analysis, and summarize the intervention effect of lower limb exoskeletons on the upper limb function of spinal cord injury patients. Two reviewers will screen titles, abstracts, and full texts independently according to inclusion criteria; Data extraction and risk of bias assessment were performed in the included studies. We will use a hierarchy of recommended assessment, development, and assessment methods to assess the overall certainty of the evidence and report findings accordingly. Endnote X8 will be applied in selecting the study, Review Manager 5.3 will be applied in analyzing and synthesizing.

RESULTS

The results will provide evidence for judging whether lower limb exoskeletons are effective and safe in improving lower limb function in patients with spinal cord injury.

CONCLUSION

Our study will provide reliable evidence for the effect of lower limb exoskeletons on the improvement of lower limb function in spinal cord injury patients.

INPLASY REGISTRATION NUMBER

INPLASY202180095.