Pelvic trauma: What are the predictors of mortality and cardiac, venous thrombo-embolic and infectious complications following injury?

Tobacco smoking portends worse functional outcomes after acetabular fracture

INTRODUCTION

Modifiable patient-related factors contribute to morbidity and functional outcomes after acetabular fracture. This study will investigate the relationship between tobacco smoking and patient-reported functional outcomes after acetabular fracture.

MATERIALS AND METHODS

A retrospective cohort study of 770 patients with 782 acetabulum fractures was performed following operative (n = 535, 68%) or non-operative (n = 247, 32%) management. Musculoskeletal Function Assessment (MFA) scores were assessed a minimum of 12-months after injury in 37.5% of patients.

RESULTS

Tobacco smoking was pervasive with 44% current users and 14% former users. Current tobacco smokers had higher associated MFA scores, when compared to former and never smokers (42.7 vs. 36.5 and 26, p < 0.001). On linear regression analysis, history of tobacco smoking (current or former) was a risk factor for higher, worse outcomes on the MFA (B = 9.86, p = 0.02).

CONCLUSIONS

Current or former tobacco smoking was predictive of worse patient-reported functional outcomes scores after acetabular fracture.

LEVEL OF EVIDENCE

Level III, Prognostic.

Machine learning-based prediction of mortality in pediatric trauma patients

Background

This study aimed to develop a predictive model for mortality outcomes among pediatric trauma patients using machine learning (ML) algorithms.

Methods

We extracted data on a cohort of pediatric trauma patients (18 years and younger) from the National Trauma Data Bank (NTDB). The main aim was to identify clinical and physiologic variables that could serve as predictors for pediatric trauma mortality. Data was split into a development cohort (70%) to build four ML models and then tested in a validation cohort (30%). The area under the receiver operating characteristic curve (AUC) was used to assess each model's performance.

Results

In 510,381 children, the gross mortality rate was 1.6% (n = 8,250). Most subjects were male (67%, n = 342,571) and white (62%, n = 315,178). The AUCs of the four models ranged from 92.7 to 97.7 with XGBoost demonstrating the highest AUC. XGBoost demonstrated the highest accuracy of 97.7%.

Conclusion

Machine learning algorithms can be effectively utilized to build an accurate pediatric mortality prediction model that leverages variables easily obtained upon trauma admission.

The Role of Screening for Venous Thromboembolism in Pelvic Trauma Patients: A Single-Centre Retrospective Study

Background: Venous thromboembolism (VTE) is a severe complication following pelvic trauma. Thromboprophylaxis has reduced the risk of VTE in the pelvic trauma population; nevertheless, the risk remains high. A substantial pulmonary embolism has emerged as the unexpected cause of death among patients presenting with 'minor pelvic fractures'. The purpose of this study was to analyse the single-centre experience with a surveillance protocol. We hypothesised that DVT surveillance with VUS and CTPA may reduce the perioperative mortality-morbidity rate in the subpopulation of patients with pelvic or acetabular fractures. Methods: This is a retrospective analysis of patients admitted with pelvic or acetabular fractures between January 2001 and December 2021. In April 2013, a screening protocol for VTE was introduced. This protocol included venous ultrasound and CTPA for patients with chest injuries. Patients from two groups-one screened for VTE and one without screening-were compared. Results: Of the 3186 patients with pelvic and/or acetabular fractures who were admitted, 1975 were not screened for VTE and 1211 underwent screening. There were more VTE cases in the screening group (5.62% vs. 0.86%, p < 0.001). Nine (0.46%) cases of sudden death occurred in the non-screening group, and all of them died with symptoms of acute PE. Since the screening was introduced, we have not encountered any deaths in the perioperative period (0.46 vs. 0, p = 0.02). Conclusions: The combined use of VUS and CTPA in chest-injured patients is a trustworthy means of screening for VTE, resulting in decreased mortality rates for those with pelvic and acetabular fractures by accurately diagnosing VTE during the perioperative phase.

Acetabular fractures in elderly patients are associated with high rates of complications during the initial admission

Background

Acetabular fractures among the elderly are common. Identification of risk factors predisposing elderly patients to in-hospital complications is critical to mitigating morbidity and mortality.

Methods

A retrospective cohort study was performed including 195 patients ≥60 years old who sustained acetabulum fractures treated at a single level 1 trauma center. Operative (n=110, 56.4%) or non-operative management was undertaken, and complications during the index hospitalization were defined.

Results

Seventy-three patients (37%) developed a complication during their hospitalization. Most common complications were acute respiratory failure: 13.3%, pneumonia: 10.3%, urinary tract infection: 10.3%, cardiac dysrhythmia: 9.7%, and acute kidney injury: 6.2%. On multivariable analysis, factors associated with in-hospital complications were increased age (adjusted OR (AOR): 1.06, 95% CI: 1.01 to 1.11, p=0.013), more comorbidities (AOR: 1.69, 95% CI: 1.07 to 2.65, p=0.024), operative management (AOR: 0.3, 95% CI: 0.12 to 0.76, p=0.011), and increased length of stay (AOR: 1.34, 95% CI: 1.2 to 1.51, p<0.001).

Conclusions

Acetabular fractures in the elderly are associated with high rates of in-hospital complications. Advanced age, more medical comorbidities and longer lengths of stay predicted higher risk of developing complications. Whereas operative management was associated with lower risk of developing complications during the initial admission, it is important to note the selection bias in which healthier patients with improved baseline functionality may be more likely to undergo operative management.

Level of evidence

Level III therapeutic.

Perioperative management of acetabular and pelvic fractures: evidence-based recommendations

PURPOSE

The American Academy of Orthopaedic Surgeons does not currently provide clinical practice guidelines for management of PAF. Accordingly, this article aims to review and consolidate the relevant historical and recent literature in important topics pertaining to perioperative management of PAF.

METHODS

A thorough literature review using PubMed, Cochrane and Embase databases was performed to assess preoperative, intraoperative and postoperative management of PAF fracture. Topics reviewed included: time from injury to definitive fixation, the role of inferior vena cava filters (IVCF), tranexamic acid (TXA) use, intraopoperative cell salvage, incisional negative pressure wound therapy (NPWT), intraoperative antibiotic powder use, heterotopic ossification prophylaxis, and pre- and postoperative venous thromboembolism (VTE) prophylaxis.

RESULTS

A total of 126 articles pertaining to the preoperative, intraoperative and postoperative management of PAF were reviewed. Articles reviewed by topic include 13 articles pertaining to time to fixation, 23 on IVCF use, 14 on VTE prophylaxis, 20 on TXA use, 10 on cell salvage, 10 on iNPWT 14 on intraoperative antibiotic powder and 20 on HO prophylaxis. An additional eight articles were reviewed to describe background information. Five articles provided information for two or more treatment modalities and were therefore included in multiple categories when tabulating the number of articles reviewed per topic.

CONCLUSION

The literature supports the use of radiation therapy for HO prophylaxis, early (< 5 days from injury) surgical intervention and the routine use of intraoperative TXA. The literature does not support the routine use of iNPWT or IVCF. There is inadequate information to make a recommendation regarding the use of cell salvage and wound infiltration with antibiotic powder. While the routine use of chemical VTE prophylaxis is recommended, there is insufficient evidence to recommend the optimal agent and duration of therapy.

Patients of Obese Representation Require Longer Operative Times: An Evaluation of Acetabular and Pelvic Ring Operative Duration

Recent literature has determined that operative times for the obese population are greater for both elective and nonelective orthopedic procedures. If time allotted for a given surgical procedure is used as a measure of procedural difficulty, then consideration can be given for using an additional coding modifier (i.e., Modifier 22) for the increased skill and effort associated with longer procedures. A retrospective chart review was conducted on all patients who underwent surgical treatment for an acute fracture about the pelvis at an urban level-1 trauma center from October 1, 2010 through October 31, 2018. After allowing for both inclusion and exclusion criteria, 102 patients with acetabular fractures and 55 patients with pelvic ring injuries were included in this investigation. The obese population within the acetabular fracture cohort demonstrated significantly longer mean times for the duration of surgery, total time in spent in the operating room, and duration under anesthesia (P values of 0.038, 0.05 and 0.035, respectively). Similar results were observed with the pelvic ring injury cohort, with significantly longer procedural times (P = 0.019), total time in the operating room (P = 0.034), and total duration under anesthesia (P = 0.0395). A trend towards a greater risk of infection was found in obese patients (7%) when compared with nonobese patients (1.6%) within the acetabular fracture subset (P = 0.093). Operative duration for acetabular fractures and pelvic ring injuries is significantly longer in the obese population. Furthermore, this indicates that a Modifier 22 may be justified for the surgical treatment of these injuries in the obese and morbidly obese patient populations.

Incidence and risk factors of preoperative deep venous thrombosis following pelvic and acetabular fractures: a retrospective case–control study

The objective of this study was to investigate the prevalence of preoperative deep venous thrombosis (DVT) in the pelvic cavity and lower extremities following pelvic and acetabular fractures and to identify the risk factors of the occurrence of DVT. Duplex ultrasound (DUS) screening and blood tests were conducted in patients admitted from June 2012 to December 2020 for surgical treatment of pelvic and acetabular fractures. Univariate analyses were performed on data of demographics, comorbidities, time from injury to surgery, injury mechanism, accompanied injury, and laboratory results. The optimal cutoff values of continuous variables with statistical significance were obtained by using the receiver operating characteristic (ROC) curve. A multivariate logistic regression analysis was then employed to examine the independent values in terms of predicting preoperative DVT. A total of 607 patients with pelvic and acetabular fractures were included, among whom 82 (13.5%) patients sustained preoperative DVTs. Specifically, 31.7% (26/82) were diagnosed with proximal DVTs. Fifty-two (63.4%) patients had DVT within 7 days after injury, and 67 (81.7%) patients within 10 days. The multivariate logistic regression analysis identified 6 factors independently associated with the presence of preoperative DVT, including age > 46 years (odds ratio [OR] = 2.94), BMI > 26.73 kg/m2 (OR = 3.91), time from injury to surgery > 9 days (OR = 5.39), associated injury (OR = 7.85), ALB < 32.8 g/L (OR = 2.71) and FIB > 3.095 g/L (OR = 3.34). Despite the modern prophylactic regimen, the preoperative DVT in patients with pelvic and acetabular fractures still draws the attention of orthopaedic surgeons. Better understanding these risk factors can help surgeons refine the risk stratification profile and perform early interdisciplinary management for patients at high risk of DVT.

Risk Factors for Mortality Associated With Pelvic Fractures at a Level I Trauma Center

Pelvic bone fractures are usually caused by high-energy trauma and are often accompanied by organ injuries. For hemodynamically unstable patients with pelvic bone fractures, knowing the anatomic type of fracture-whether it is a pelvic ring injury or an acetabular fracture-might be helpful in prioritizing treatment. A total of 302 patients with pelvic bone fractures who received treatment at the authors' level I trauma center between March 1, 2015, and February 28, 2017, were included in this study. Patients with pelvic bone fractures were enrolled in the Korea Trauma Data Bank and classified by anatomic type of pelvic bone fracture: pelvic ring injury, acetabular fracture, or combined fractures. The authors used t tests to analyze survival and death groups and multivariate regression to analyze mortality factors. Different types of pelvic bone fractures had significantly different mortality rates (P<.001). Forty-four (22.6%) of 195 patients with pelvic ring injuries and 6 (18.8%) of 32 patients with combined fractures died. Meanwhile, only 1 of 75 patients with isolated acetabular fractures died (1.3%). The mortality rate was lowest for type A pelvic ring injuries (8.2%) and highest for type C pelvic ring injuries (68.2%). The difference was statistically significant (P<.001). It is commonly acknowledged that age, combined injuries, higher Injury Severity Score, and lower initial systolic blood pressure are risk factors for mortality, but research has shown that classification and anatomic type of pelvic bone fracture are also highly related. [Orthopedics. 2021;44(6):e724-e728.].

Six-year national study of damage control laparotomy and the effect of repeat re-exploration on rate of infectious complications

BACKGROUND

Damage control laparotomy (DCL) is a life-saving procedure in patients with abdominal hemorrhage. After DCL, patients are sometimes left with an open abdomen (OA) so they may undergo multiple exploratory laparotomies (EXLAP), or re-explorations. Patients with OA are at increased risk of infectious complications (ICs). The association between number of re-explorations after DCL and the number of ICs is not clear. We hypothesized that each additional re-exploration increases the risk of developing IC.

METHODS

This 6-year retrospective cohort study included patients aged ≥16 years from the NTDB who had DCL defined as EXLAP within 2 hours of arrival (ICD-9: 54.11, 54.12, 54.19) with at least one re-exploration. The primary outcome was IC (ie, superficial surgical site infection (SSI), organ space SSI, deep SSI, sepsis, pneumonia, or catheter-related bloodstream infection), examined dichotomously (present/absent) and ordinally as the number of ICs. Multivariate Poisson regression was used to assess the association between number of re-explorations and number of ICs. Significance was assigned at p<0.01.

RESULTS

There were 7431 patients who underwent DCL; 2509 (34%) patients developed at least one IC. The rate of IC was lowest in patients who were closed during the first re-exploration (27%) and significantly increased with each re-exploration to 59% in patients who had five or more re-explorations (Cochran-Armitage trend p<0.001). After adjustment, there was 14% increased risk of an additional IC with each re-exploration (p<0.001).

DISCUSSION

For patients requiring DCL, each re-exploration of the abdomen is associated with increased rate of ICs.

LEVEL OF EVIDENCE

III, retrospective epidemiological study.

Is Obesity Associated With an Increased Risk of Complications After Surgical Management of Acetabulum and Pelvis Fractures? A Systematic Review

Background:

When considering surgical fixation of acetabulum and pelvis fractures in patients with obesity, a thorough understanding of the risks of potential complications is important. We performed a systematic review to evaluate whether obesity is associated with an increased risk of complications after surgical management of acetabulum and pelvis fractures.

Methods:

We searched PubMed/MEDLINE, EMBASE, and the Cochrane Library for studies published through December 2020 that reported the effect of increased body mass index (BMI) or obesity on the risk of complications after surgical treatment of acetabulum and pelvis fractures.

Results:

Fifteen studies were included. Eight of the 11 studies that included infection or wound complication as end points found that increased BMI or some degree of obesity was a significant risk factor for these complications. Two studies found that obesity was significantly associated with loss of reduction. Other complications that were assessed in a few studies each included venous thromboembolism, nerve palsy, heterotopic ossification, general systemic complications, and revision surgery, but obesity was not clearly associated with those outcomes.

Conclusions:

Obesity (or elevated BMI) was associated with an increased risk of complications—infection being the most commonly reported—after surgical management of acetabulum and pelvis fractures, which suggests the need for increased perioperative vigilance.

Age and traumatic brain injury as prognostic factors for late-phase mortality in patients defined as polytrauma according to the New Berlin Definition: experiences from a level I trauma center

BACKGROUND

The rationale of this study was to identify independent prognostic factors influencing the late-phase survival of polytraumatized patients defined according to the New Berlin Definition.

METHODS

Retrospective data analysis on 173 consecutively polytraumatized patients treated at a level I trauma center between January 2012 and December 2015. Patients were classified into two groups: severely injured patients (ISS > 16) and polytraumatized patients (patients who met the diagnostic criteria for the New Berlin Definition).

RESULTS

Polytraumatized patients showed significantly lower late-phase and overall survival rates. The presence of traumatic brain injury (TBI) and age > 55 years had a significant influence on the late-phase survival in polytraumatized patients but not in severely injured patients. Despite the percentage of severe TBI being nearly identical in both groups, severe TBI was identified as main cause of death in polytraumatized patients. Furthermore, severe TBI remains the main cause of death in polytraumatized patients > 55 years of age, whereas younger polytraumatized patients (< 55 years of age) tend to die more often due to the acute trauma.

CONCLUSION

Our results suggest that age beyond 55 years and concomitant (severe) TBI remain as most important influencing risk factor for the late-phase survival of polytraumatized patients but not in severely injured patients.

LEVEL OF EVIDENCE

Prognostic study, level III.

Guidelines for the prevention of venous thromboembolism in hospitalized patients with pelvi-acetabular trauma

BACKGROUND

Venous thromboembolism is a dreaded complication leading to increased morbidity and mortality in patients having pelvi-acetabular fractures.

OBJECTIVES

These evidence based guidelines aim to provide the decision making ability in the prevention of venous thromboembolism in patients with pelvi-acetabular trauma planned for operative or non operative treatment.

METHODS

The patients were subclassified into 5 categories. The PICO framework was used to devise research questions in each category. The systematic reviews were performed for each research question. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess outcomes of critical interest. The guideline panel consisting of expert members of different subspecialties, analyzed the evidence and made recommendations.

RESULTS

The guideline panel proposed 21 recommendations. There are five recommendations in category 1 to 3, two recommendations in category 4 and four recommendations in category 5.

CONCLUSION

In pelvi-acetabular fractures there is strong evidence to suggest that thromboprophylaxis should be given. It should be initiated as early as possible after control of hemorrhage. The chemical prophylaxis is the preferred mode and LMWH is the preferred agent of choice. The mechanical methods can be used as an adjunct. The routine prophylactic use of IVC filters is not recommended. However, the use of retrievable IVC filters in high risk patients with established VTE in preoperative period can be considered. The use of newer directly acting oral anticoagulants is gaining importance.

The Effect of an Abnormal BMI on Orthopaedic Trauma Patients: A Systematic Review and Meta-Analysis

Aims: The aim of this systemic review is to identify the complications that arise in operating on orthopaedic trauma patients with an abnormal body mass index (BMI). Materials and Methods: Systematic literature search using a combination of MESH subject headings and free text searching of Medline, Embase, SCOPUS and Cochrane databases in August 2019. Any orthopaedic injury requiring surgery was included. Papers were reviewed and quality assessed by two independent reviewers to select for inclusion. Where sufficiently homogenous, meta-analysis was performed. Results: A total of 26 articles (379,333 patients) were selected for inclusion. All complications were more common in those with a high BMI (>30). The odds ratio (OR) for high BMI patients sustaining post-operative complication of any type was 2.32 with a 23% overall complication rate in the BMI > 30 group, vs. 14% in the normal BMI group (p < 0.05). The OR for mortality was 3.5. The OR for infection was 2.28. The OR for non-union in tibial fractures was 2.57. Thrombotic events were also more likely in the obese group. Low BMI (<18.5) was associated with a higher risk of cardiac complications than either those with a normal or high BMI (OR 1.56). Conclusion: Almost all complications are more common in trauma patients with a raised BMI. This should be made clear during the consent process, and strategies developed to reduce these risks where possible. Unlike in elective surgery, BMI is a non-modifiable risk factor in the trauma context, but an awareness of the complications should inform clinicians and patients alike. Underweight patients have a higher risk of developing cardiac complications than either high or normal BMI patient groups, but as few studies exist, further research into this group is recommended.

Risk factors for complications and in-hospital mortality: An analysis of 19,834 open pelvic ring fractures

BACKGROUND

Open pelvic fractures are rare injuries, associated with high patient morbidity and mortality. Few studies have investigated the impact of patient demographics, comorbidities, and injury related factors on complication and mortality rates. The purpose of this study was to: (1) identify the overall incidence of complications and mortality after open pelvic fractures, (2) compare patient factors between those who did and did not develop complications, (3) identify perioperative independent risk factors for complications and mortality.

METHODS

A query was performed for patients with open pelvic fractures between 2007 and 2017 using the American College of Surgeons National Trauma Data Bank. Patient and injury specific variables were collected and complications were identified using International Classification of Disease Ninth and Tenth edition Codes. Patient demographic and perioperative data was compared using Fisher's exact test and chi-square test for categorical variables, and Welch's t-test for continuous variables. Using pooled data from multiple imputations, logistic regressions were used to calculate odds ratios and confidence intervals of independent risk factors for complications.

RESULTS

A total of 19,834 open pelvic fracture cases were identified, with 9622 patients (48.5%) developing at least one complication. Patients who developed complications were older (35.0 vs 38.1 years), and had higher Injury Severity Scores (17.7 vs 26.5), lower Glasgow Coma Scores (14.2 vs 11.7), and a larger proportion presenting with hypotension (21% vs 6.9%). After pooled regression involving 19 factors, these were the strongest independent predictors of inpatient complication and mortality.

CONCLUSION

We report a mortality rate of 14%, with an inclusive complication rate of 48.5%. Evaluating risk factors for morbidity and mortality for this devastating orthopaedic injury provides knowledge of an inherently sparse population.

LEVEL OF EVIDENCE

Level II, Retrospective study.

Predictors of mortality after pelvic fractures: a retrospective cohort study from a level one trauma centre in Upper Egypt

PURPOSE

The primary objective was to identify the predictors of in-hospital mortality after pelvic ring injuries. Secondary objectives were to analyze the differences between adults and children and to analyze the causes and timing of death.

METHODS

A retrospective cohort study from the pelvic registry of Assiut University Trauma Unit (AUTU), a level 1 trauma centre in Upper Egypt, was carried out. A total of 1188 consecutive patients with pelvic ring fractures treated from January 2010 to December 2013 were eligible for analysis. Potential predictors were identified using standard statistical tests: univariable and multivariable regression analysis.

RESULTS

Nine hundred fifty-one were adults (above 16 years) and 237 were children. According to Tile's classification, fractures type A, B, and C were 31.8%, 25.1%, and 43.1%, respectively. About a third of patients had fractures with soft tissue injury. Abdominopelvic collection as diagnosed by Focused Assessment with Sonography for Trauma (FAST) was positive in 11%. Associated injuries were present in 67.3% with abdominal-urogenital injuries being the most prevalent (66.3%). Median hospital stay was five days. Fifty-two patients (4.4%) were admitted to the ICU. One hundred three patients died (8.7%) within two peaks: first 24 hours and between 48 hours and one week. Multivariable logistic regression analysis identified increasing age, fractures with soft tissue injury, associated head injury, positive FAST examination, and admission to an ICU as significant predictors of in-hospital mortality.

CONCLUSIONS

The first 24 hours were confirmed to be critical for survival in pelvic fracture patients. Advancing age, associated soft tissue injury, associated head injury, admission to ICU, and positive FAST examination can serve as reliable predictors for an elevated mortality risk in such patients.

Incidence and Risk Factors of Deep Vein Thrombosis in Patients With Pelvic and Acetabular Fractures

This study aimed to investigate the incidence and risk factors for deep vein thrombosis (DVT) in patients with pelvic and acetabular fractures. Patients with pelvic or acetabular fractures were included. Demographic data, fracture classification, time to surgery, and d-dimer levels at admission and one day after surgical intervention were recorded. Duplex ultrasonography was performed in the lower extremities for DVT evaluation. All patients received mechanical and chemical thromboprophylaxis. One hundred ten patients with a mean age of 44.2 ± 13.8 years were included. There were 48 patients with pelvic fractures and 62 patients with acetabular fractures. Thirty-two (29.09%) patients sustained DVT; 21 (19.09%) patients exhibited proximal thrombosis, and 3 patients suffered pulmonary embolism. The incidence of DVT in patients with acetabular fractures was significantly higher than that of patients with pelvic fractures (χ² = 4.42, P = .04). The incidence of proximal DVT was significantly higher in patients with complex acetabular fractures than in patients with simple acetabular fractures (χ² = 6.65, P = .01). Multivariate analysis showed that age older than 60 years, associated injuries, and the time to surgery longer than 2 weeks were independent risk factors (P < .05). Despite mechanical and chemical thromboprophylaxis, the risk of DVT in patients with pelvic and acetabular fractures is still very high, and most of the thromboses were localized proximally. The risk of DVT is higher in patients older than 60 years, in those with associated injuries, and when the time from injury to operation is more than 2 weeks.

Significant Reduction of Pulmonary Embolism in Orthopaedic Trauma Patients

OBJECTIVES

To report results of a protocol to lessen incidence of pulmonary embolism (PE) among orthopaedic trauma patients.

DESIGN

Retrospective review.

SETTING

Level 1 trauma center.

PATIENT/PARTICIPANTS

Orthopaedic trauma inpatients were included in the study.

INTERVENTION

On arrival, an orthopaedic trauma patient's PE risk is calculated using a previously developed tool. If possible, patients at high risk are given their first dose of enoxaparin before leaving the emergency room. If other injuries preclude enoxaparin, then chemoprophylaxis is held for 24 hours. Twenty-four hours after arrival, the patient's ability to receive enoxaparin is reassessed. If possible, enoxaparin is started, with dosing twice a day. If enoxaparin is still contraindicated, a removable inferior vena cava filter is placed. Adequacy of enoxaparin dosing is tested using anti-factor Xa assay, drawn 4 hours after the third dose of enoxaparin. If the anti-factor Xa result is less than 0.2 IU/mL, a removable inferior vena cava filter is placed. If the result is 0.2-0.5 IU/mL, enoxaparin dosing is continued. If greater than 0.5 IU/mL, the dose of enoxaparin is reduced.

OUTCOME MEASURE

The main outcome measure was rate of PE.

RESULTS

From September 1, 2015 to December 31, 2015, our hospital admitted 420 orthopaedic trauma patients. Fifty-one patients were classed as high risk for PE. In September through December 2015, 9 sustained PE, 1 of which was fatal. From September 1, 2016 to December 31, 2016, our hospital admitted 368 orthopaedic trauma patients with comparable age and Injury Severity Score to 2015. Forty patients were at high risk for PE, 1 sustained a nonfatal PE. PE incidence from September to December 2016 was significantly lower than in 2015 (P = 0.02). Overall, 26 patients managed under the new protocol had IVCFs placed, 21 had their filters removed, and 3 died with filters in place. There were no complications during filter placement or removal. One patient had hemorrhage felt to be attributable to enoxaparin.

CONCLUSIONS

Our protocol emphasizes more robust enoxaparin dosing, and more frequent use of IVCF, but only among those at high risk. We lessened the incidence of PE, with a low complication rate.

LEVEL OF EVIDENCE

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

Early management of severe pelvic injury (first 24 hours)

OBJECTIVE

Pelvic fractures represent 5% of all traumatic fractures and 30% are isolated pelvic fractures. Pelvic fractures are found in 10 to 20% of severe trauma patients and their presence is highly correlated to increasing trauma severity scores. The high mortality of pelvic trauma, about 8 to 15%, is related to actively bleeding pelvic injuries and/or associated injuries to the head, abdomen or chest. Regardless of the severity of pelvic trauma, diagnosis and treatment must proceed according to a strategy that does not delay the management of the most severely injured patients. To date, in France, there are no guidelines issued by healthcare authorities or professional societies that address this subject.

DESIGN

A consensus committee of 22 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et de Réanimation; SFAR) and the French Society of Emergency Medicine (Société Française de Médecine d'Urgence; SFMU) in collaboration with the French Society of Radiology (Société Française de Radiologie; SFR), French Defence Health Service (Service de Santé des Armées; SSA), French Society of Urology (Association Française d'Urologie; AFU), the French Society of Orthopaedic and Trauma Surgery (Société Française de Chirurgie Orthopédique et Traumatologique; SOCFCOT), and the French Society of Digestive Surgery (Société Française de Chirurgie digestive; SFCD) was convened. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently from any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised.

METHODS

Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the recommendations were then conducted according to the GRADE^® methodology.

RESULTS

The SFAR Guideline panel provided 22 statements on prehospital and hospital management of the unstable patient with pelvic fracture. After three rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, 11 have a high level of evidence (Grade 1 ± ), 11 have a low level of evidence (Grade 2 ± ).

CONCLUSIONS

Substantial agreement exists among experts regarding many strong recommendations for management of the unstable patient with pelvic fracture.

[Changes in age distribution and frequency of comorbidities in patients in the occupational insurance association treatment process]

BACKGROUND

Due to the demographic development the proportion of older patients has increased. These show at least a higher rate of comorbidities, which affects the length of inpatient hospital stay. Until now no uniform recording exists for such comorbidities within the occupational insurance association system even if the clinical relevance is beyond dispute. Adaptations within the system with increased interdisciplinary treatment are necessary.

OBJECTIVE

The aim of this study was to analyze changes in the age distribution and the frequency of comorbidities in patients in the occupational insurance association system.

METHODS

The study was a retrospective analysis of age distribution and comorbidities of all operatively treated occupational insurance association patients in 2005 (n = 631), 2010 (n = 1180) and 2015/2016 (n = 2315). A comparison of the age groups ≤29 years, 30-49 years, 50-65 years and ≥66 years was performed.

RESULTS

The proportion of patients aged 50-65 years showed a significant increase: 2005 (26.5%), 2010 (30.5%) and 2015/2016 (37.3%) (p < 0.001) and an increased proportion of patients with at least 1 comorbidity: 2005 (38.7%), 2010 (52.5%) and 2015/2016 (52.9%) (p = 0.01). This was statistically significant (p < 0.001, p = 0.005) within the age group 30-49 years (2005: 31.1%, 2015/2016: 49.0%) and the age group 50-65 years (2005: 55.7%, 2015/2016: 67.1%). Significant changes were found for arterial hypertension, morbid obesity, thyroid and respiratory diseases. In addition, there was an increase in multimorbid patients.

DISCUSSION

A changing age distribution with a tendency to an increased number of older patients and an increased frequency of comorbidities could be determined. In the present documentation system of the occupational insurance association treatment procedure these comorbidities are insufficiently recorded and considered, even though their clinical relevance is indisputable. Adaptations with respect to intensified interdisciplinary cooperation are necessary.

Mortality After High-Energy Pelvic Fractures in Patients of Age 65 Years or Older

OBJECTIVES

To document in-hospital and 1-year mortality rates after high-energy pelvic fracture in patients 65 years of age or older as compared to a younger cohort.

DESIGN

Retrospective review.

SETTING

Urban Level 1 academic trauma center.

PATIENTS

Seventy consecutive patients 65 years of age and older treated for pelvic fracture resulting from high-energy mechanism from 2008 to 2011. A total of 140 patients 18-64 years of age were matched to the study population based on mechanism of injury and OTA Code 61 subtype for comparison.

INTERVENTION

Review of demographics, injury characteristics, hospital management, and mortality.

MAIN OUTCOME MEASUREMENTS

Mortality.

RESULTS

The overall inpatient mortality rate was 10%. The older cohort exhibited an inpatient mortality rate 3 times higher than the younger cohort (18.6% vs. 5.7%, P = 0.003). There was no difference in mortality 1 year post discharge (5.3% vs. 3.8%, P = 0.699). No significant differences in initial Glasgow Coma Scale or Injury Severity Score were identified (GCS 12.9 vs. 12.4, P = 0.363; ISS 24.7 vs. 23.4, P = 0.479). Multivariate analysis identified the Charlson Comorbidity Index (CCI) (P = 0.012) and Abbreviated Injury Scale (AIS)-chest (P = 0.005) as independent predictors of in-hospital mortality, and CCI (0.005) and AIS-abdomen (0.012) for 1-year mortality.

CONCLUSIONS

After controlling for mechanism of injury and pelvic fracture classification, we found that adults ≥65 and those with multiple comorbidities were more likely to die in the hospital than younger adults. However, mortality within 1-year postdischarge was low and did not differ between groups. This is in sharp contrast to the high rates of postdischarge mortality observed in elderly patients with a hip fracture.

LEVEL OF EVIDENCE

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

Outcome Determinants of Patients with Traumatic Pelvic Fractures: A Cohort Study in a Level I Trauma Center in Southern Iran

Pelvic fracture is a result of devastating injuries and is usually encountered in conjunction with other life-threatening injuries. The aim of the current study was to determine the outcome determinants of patients with pelvic fractures referred to a large trauma center in southern Iran. This retrospective cross-sectional study was conducted in a level I trauma center over a period of three years from 2012 to 2015. We included all patients with pelvic fractures whose medical records had sufficient data. Data were compared between good condition and poor conditions. A total of 327 patients with mean age of 40.1 ± 19.7 years were included. Poor condition was defined as being associated with higher heart rate (p=0.002), lower systolic blood pressure (p<0.001), lower diastolic blood pressure (p=0.002) lower Glasgow Coma Scale (GCS) on admission (p<0.001) and higher Injury Severity Score (ISS) (p<0.001). Those with poor conditions had significantly higher admission to ICU (p<0.001), higher rate of surgical interventions (p<0.001) and higher mortality (p<0.001). The hospital length of stay (p<0.001) and ICU length of stay (p=0.025) were also longer in those with poor condition. Lower hemoglobin, lower pH, higher heart rate, lower systolic blood pressure, lower GCS on admission and higher ISS were important outcome determinants of traumatic pelvic fractures.

Independent early predictors of mortality in polytrauma patients: a prospective, observational, longitudinal study

OBJECTIVES:

Trauma is an important public health issue and associated with substantial socioeconomic impacts and major adverse clinical outcomes. No single study has previously investigated the predictors of mortality across all stages of care (pre-hospital, emergency room, surgical center and intensive care unit) in a general trauma population. This study was designed to identify early predictors of mortality in severely injured polytrauma patients across all stages of care to provide a better understanding of the physiologic changes and mechanisms by which to improve care in this population.

METHODS:

A longitudinal, prospective, observational study was conducted between 2010 and 2013 in São Paulo, Brazil. Patients submitted to high-energy trauma were included. Exclusion criteria were as follows: injury severity score <16, <18 years old or insufficient data. Clinical and laboratory data were collected at four time points: pre-hospital, emergency room, and 3 and 24 hours after hospital admission. The primary outcome assessed was mortality within 30 days. Data were analyzed using tests of association as appropriate, nonparametric analysis of variance and generalized estimating equation analysis (p<0.05). ClinicalTrials.gov: NCT01669577.

RESULTS:

Two hundred patients were included. Independent early predictors of mortality were as follows: arterial hemoglobin oxygen saturation (p<0.001), diastolic blood pressure (p<0.001), lactate level (p<0.001), Glasgow Coma Scale score (p<0.001), infused crystalloid volume (p<0.015) and presence of traumatic brain injury (p<0.001).

CONCLUSION:

Our results suggest that arterial hemoglobin oxygen saturation, diastolic blood pressure, lactate level, Glasgow Coma Scale, infused crystalloid volume and presence of traumatic brain injury are independent early mortality predictors.

Predictors of Inpatient Mortality and Systemic Complications in Acetabular Fractures Requiring Operative Treatment

Patient demographics, physiologic variables, and injury characteristics predictive of mortality and major systemic complications following operative fixation of acetabulum fractures were identified using the National Sample Program of the National Trauma Data Bank. Age older than 60 years, obesity, and Injury Severity Score greater than 15 portended a statistically significant increase in mortality and major systemic complications (P≤.05). Systolic blood pressure less than 90 mm Hg and Glasgow Coma Scale score less than 8 were also significant predictors of mortality and major systemic complications (P<.0001). Time to surgery and hospital length of stay did not affect mortality. The most common potentially modifiable risk factors were smoking (22.3%) and obesity (body mass index ≥30 kg/m²) (9.1%). Increasing age, Injury Severity Score, and obesity independently predicted a statistically significant increase in both mortality and major systemic complications. A better understanding of the associated risk factors and unique complication profile will provide orthopedic surgeons with a basis on which to effectively counsel and care for patients. [Orthopedics. 2017; 40(2):e223-e228.].

Shoulder Arthroscopy in Adults 60 or Older: Risk Factors That Correlate With Postoperative Complications in the First 30 Days

PURPOSE

To investigate the 30-day postoperative adverse event (AE) rates of adults 60 years or older after shoulder arthroscopy and identify risk factors for complications in this patient population.

METHODS

Patients aged 60 or more who underwent shoulder arthroscopy were identified in the American College of Surgeons National Surgery Quality Improvement Program database from 2006 to 2013 using 12 Current Procedural Terminology codes related to shoulder arthroscopy. Complications were categorized as severe AEs, minor AEs, and infectious AEs for separate analyses. Pearson's χ² tests were used to identify associations between patient characteristics and AE occurrence and binary logistic regression for multivariate analysis of independent risk factors.

RESULTS

In total, 7,867 patients were included for analysis. Overall, 1.6% (n = 127) of the older adults experienced at least one AE with 1.1% (n = 90) severe AEs, 0.6% (n = 46) minor AEs, and 0.4% (n = 28) infectious complications. Multivariate analysis revealed that age 80 years or older (odds ratio [OR] = 2.2, 95% confidence interval [CI] = 1.2-2.7, P = .01), body mass index greater than 35 (OR = 1.8, 95% CI = 1.1-2.7, P = .01), functionally dependent status (OR = 2.9, 95% CI = 1.3-6.8, P = .01), American Society of Anesthesiologists class greater than 2 (OR = 1.5, 95% CI = 1.0-2.2, P = .04), congestive heart failure (OR = 6.1, 95% CI = 1.8-21.2, P = .03), disseminated cancer (OR = 7.9, 95% CI = 1.4-43.9, P = .02), and existence of an open wound at the time of surgery (OR = 4.0, 95% CI = 1.1-14.6, P = .03) were independently associated with the occurrence of an AE. Nineteen of the patients included in the study required readmission to the hospital within the 30-day period for an overall readmission rate of 0.2%.

CONCLUSIONS

Patients 60 years or older who underwent shoulder arthroscopy for a variety of indications have a low overall 30-day postoperative complication rate of 1.6%. Although low, this is a higher rate than previously reported for the overall shoulder arthroscopy population. Independent patient characteristics associated with increased risk of AE occurrence included age 80 years or older, body mass index greater than 35, functional dependent status, American Society of Anesthesiologists score of 3 or 4, congestive heart failure, disseminated cancer, and existence of an open wound.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Predictors of early versus late mortality in pelvic trauma patients

Background

Risks of predicting time-related in-hospital mortality varies in pelvic trauma patients. We aim to identify potential independent risks predictive of time-related (early versus late) mortality among pelvic trauma patients.

Methods

Local trauma registry data from 2004 through 2013 were reviewed. Mortality causes and timing of death were investigated. Multivariate logistic regression identified independent risks predictive of early versus late mortality in pelvic trauma patients while adjusting for patient demographics (age, sex, race), clinical variables (initial vital signs, mental status, injury severity, associated injuries, comorbidities), and hospital outcomes (surgical interventions, crystalloid resuscitations, blood transfusions).

Results

We retrospectively collected data on 1566 pelvic trauma patients with a mortality rate of 9.96 % (156/1566). Approximately 74 % of patients died from massive hemorrhage within the first 24 h of hospitalization (early mortality). Revised trauma score (RTS), injury severity score (ISS), initial hemoglobin, direct transfer to operating room, and blood transfusion administration in the Emergency Department were considered independent risk factors predictive of early mortality. Age, ISS, and Glasgow Coma Scale (GCS) were deemed risk factors predictive of death after 24 h (late mortality).

Discussion

Given the fact of a substantial number of patients died within the first 24 h of hospital arrival, it is reasonable to consider the first 24 h of hospitalization as the appropriate window within which early mortality may be expected to occur in pelvic trauma patients. The risk factors associated with massive hemorrhage were strong predictors of early mortality, whereas late mortality predictors were more closely linked with comorbidities or in-hospital complications.

Conclusions

While risk factors predictive of early versus late mortality vary, ISS seems to predict both early and late mortality accurately in pelvic trauma patients.

Predictors of mortality among initially stable adult pelvic trauma patients in the US: Data analysis from the National Trauma Data Bank

OBJECTIVES

Pelvic fractures are associated with increased risk of death among trauma patients. Studies show independent risks predicting mortality among patients with pelvic fractures vary across different geographic regions. This study analyses national data to determine predictors of mortality in initially stable adult pelvic trauma patients in the US.

METHODS

This study is a retrospective analysis of the US National Trauma Data Bank from January 2003 to December 2010 among trauma patients ≥18 years of age with pelvic fractures (including acetabulum). Over 150 variables were reviewed and analysed. The primary outcome was all-cause in-hospital mortality. Logistic regression analysis was used to determine independent risk factors predictive of in-hospital mortality in stable pelvic fracture patients.

RESULTS

30,800 patients were included in the final analysis. Overall in-hospital mortality rate was 2.7%. Mortality increased twofold in middle aged patients (age 55-70), and increased nearly fourfold in patients with advanced age ≥70. We found patients with advanced age, higher severity of injury, Glasgow Coma Scale (GCS) <8, GCS between 9 and 12, prolonged mechanical ventilation, and/or in-hospital blood product administration experienced higher mortality. Patients transported to level 1 or level 2 trauma centres experienced lower mortality while concomitantly experiencing higher associated internal injuries.

CONCLUSIONS

Geriatric and middle aged pelvic fracture patients experience higher mortality. Predictors of mortality in initially stable pelvic fracture patients are advanced age, injury severity, mental status, prolonged mechanical ventilation, and/or in-hospital blood product administration. These patients might benefit from transport to local level 1 or level 2 trauma centres.

Methods and Guidelines for Venous Thromboembolism Prevention in Polytrauma Patients with Pelvic and Acetabular Fractures

Sequential compression devices and chemical prophylaxis are the standard venous thromboembolism (VTE) prevention for trauma patients with acetabular and pelvic fractures. Current chemical pharmacological contemplates the use of heparins or fondaparinux. Other anticoagulants include coumarins and aspirin, however these oral agents can be challenging to administer and may need monitoring. When contraindications to anticoagulation in high-risk patients are present, prophylactic inferior vena cava filters can be an option to prevent pulmonary emboli. Unfortunately strong evidence about the most effective method, and the timing of their commencement, in patients with pelvic and acetabular fractures remains controversial.

Treatment of pelvic fractures - a national survey

INTRODUCTION

This survey was conducted during the 38(th) Brazilian Congress of Orthopaedics and Traumatology to identify the opinion of Brazilian orthopaedic surgeons on the standard treatment of pelvic fractures.

MATERIALS AND METHODS

Participants were randomly selected and invited to voluntarily answer a questionnaire of 10 multiple choice questions addressing the main aspects of the treatment of pelvic fractures: classification, fixation methods in unstable patients, optimal surgical timing in stable patients, and fixation methods in different types of anterior and posterior pelvic injuries.

RESULTS/CONCLUSION

Three hundred and fifty-two questionnaires were completed, and the following main observations were made: most orthopaedists prefer to use an external fixator in the iliac crest for the emergency stabilisation of pelvic injuries in haemodynamically unstable patients (79.5%); they consider a period of up to one week as optimal for fixation in stable patients (55.1%); they use a plate for the fixation of fractures of the iliopubic rami through a Pfannenstiel or ilio-inguinal approach (53.9%); and they use reconstruction plates for the fixation of fractures of the iliac wing (63.1%). Regarding other studied aspects, there was no predominance of more than 50% of the choices among respondents.