High-energy skeletal trauma in the elderly

The total number of patients with any of four major fragility fractures decreased during the first wave of the COVID-19 epidemic in Japan, commencing before the state of emergency declaration, which was not as enforceable as lockdown

Durin g the first wave of the COVID-19 epidemic, the total number of patients with any of the four major fragility fractures, including both inpatients and first-visit outpatients, began to decline shortly before the state of emergency was declared, rather than immediately after it was declared.

PURPOSE

This study aimed to investigate the impact of public health measures in the first wave of the COVID-19 epidemic on the occurrence of major fragility fractures (MFFs).

METHODS

Patients aged 50 years or older who were hospitalized or had an initial visit as an outpatient for an MFF, defined as a proximal femoral fracture (PFF), vertebral fragility fracture (VFF), distal radius fracture (DRF), or a proximal humeral fracture (PHF), were included in this study. Three-phase interrupted time-series analyses were performed to evaluate the impact of the voluntary event cancellation request in late February 2020 and the emergency declaration in early April 2020 on changes in the total number of patients, including inpatients and first-visit outpatients.

RESULTS

A total of 166,560 patients with MFFs were included (92,767 PFFs, 26,158 VFFs, 33,869 DRFs, and 13,766 PHFs). From the end of February, in seven prefectures with high proportions of urbanization, decreasing trends were estimated for level changes and slope changes in the total number of patients with any of the four MFFs (level change: PFF; point estimate; - 13.5 (95% CI; - 43.4, 16.5), VFF; - 15.3 (- 32.2, 1.5), DRF; - 16.1 (- 39.9, 7.6), PHF; - 1.9 (- 13.6, 9.8), slope change: PFF; - 4.8 (- 14.0, 4.4), VFF; - 3.0 (- 8.1, 2.2), DRF; - 0.6 (- 7.9, 6.7), PHF; - 2.4 (- 6.0, 1.2)).

CONCLUSION

The findings suggested that the total number of patients with any of the four MFFs did not begin to decline from early April 2020 after the state of emergency was declared but earlier, in late February 2020.

Retrograde tibiotalocalcaneal nailing for the treatment of acute ankle fractures in the elderly: a systematic review and meta-analysis

Introduction

Methods

Results

Conclusion

Factors Influencing Geriatric Orthopaedic Trauma Mortality

INTRODUCTION

This study aimed to: (1) evaluate the independent risk factors related to survival and mortality and (2) predict survival in geriatric orthopaedic trauma patients admitted to our institution's ICU as a Level 1 or 2 trauma activation.

METHODS

A retrospective review was performed on patients age >60, over a 10 year period, who were involved in a multi-trauma with orthopaedic injuries. Variables evaluated include: sex, age, Injury Severity Score (ISS), mechanism of injury, number and type of orthopaedic injury, anticoagulant use, comorbidities, length of stay in intensive care unit (ICU), type of ICU, ventilator use, vasopressors use, incidence of multiple organ dysfunction syndrome (MODS), number of surgeries, and 1-month and 6-month mortality. A Kaplan-Meier estimator and Cox proportional hazards analysis were used to predict and assess survival probability.

RESULTS

174 patients were included, with an average mortality of 47.7%. Deceased patients had a significantly greater age, ISS, vasopressor usage, ICU stay, incidence of MODF, incidence of genitourinary disease, anticoagulant usage, ventilator usage, number of orthopaedic surgeries, and orthopaedic injuries. The relative risk for mortality within the first month was significantly associated with increased age, ISS, high-energy trauma, length of ICU stay, MODS, psychiatric disease, and anticoagulant use. Patients with an ISS ≤30 were significantly more likely to survive than patients with an ISS of >30. Greater age, ISS, length of ICU stay, incidence of MODS, anticoagulant, and ventilator use were significantly predictive of lower survival rates. Mechanism of injury, number of orthopaedic surgeries and orthopaedic injuries, and type of orthopaedic injury were not found to be predictive of survival.

CONCLUSIONS

An ISS >30 at admission is strongly predictive of a lower probability of survival. Genitourinary disease was associated with increased mortality. Low age, ISS, length of stay in ICU, incidence of MODS, anticoagulant use, and ventilator use, are significantly predictive of survival. Number of orthopaedic surgeries, orthopaedic injuries, and type of orthopaedic injury were not found to be predictive of survival. These indications help us to better understand factors predictive of death among geriatric orthopaedic trauma patients, and improve the way we can diagnose and care for them.

Challenges in the PREHOSPITAL emergency management of geriatric trauma patients - a scoping review

BACKGROUND

Despite a widely acknowledged increase in older people presenting with traumatic injury in western populations there remains a lack of research into the optimal prehospital management of this vulnerable patient group. Research into this cohort faces many uniqu1e challenges, such as inconsistent definitions, variable physiology, non-linear presentation and multi-morbidity. This scoping review sought to summarise the main challenges in providing prehospital care to older trauma patients to improve the care for this vulnerable group.

METHODS AND FINDINGS

A scoping review was performed searching Google Scholar, PubMed and Medline from 2000 until 2020 for literature in English addressing the management of older trauma patients in both the prehospital arena and Emergency Department. A thematic analysis and narrative synthesis was conducted on the included 131 studies. Age-threshold was confirmed by a descriptive analysis from all included studies. The majority of the studies assessed triage and found that recognition and undertriage presented a significant challenge, with adverse effects on mortality. We identified six key challenges in the prehospital field that were summarised in this review.

CONCLUSIONS

Trauma in older people is common and challenges prehospital care providers in numerous ways that are difficult to address. Undertriage and the potential for age bias remain prevalent. In this Scoping Review, we identified and discussed six major challenges that are unique to the prehospital environment. More high-quality evidence is needed to investigate this issue further.

National trends in extremity fracture hospitalizations among older adults between 2003 and 2017

BACKGROUND

Fractures in late life are highly consequential for health, services use, and spending. Little is known about trends in extremity fracture hospitalizations among older adults in the United States.

DESIGN

Retrospective longitudinal cohort study.

SETTING

The 2003-2017 National Inpatient Sample (NIS), a representative sample of U.S. community hospitals.

PARTICIPANTS

Hospitalized adults aged 65 and older with a diagnosis of upper or lower extremity fracture.

MEASUREMENTS

Incidence of extremity fracture hospitalization and mortality, using NIS discharge and trend weights, and population denominators derived from the U.S. Census Bureau. Incidence was reported separately for men and women by age, fracture diagnosis, and injury mechanism. Weighted linear regression was used to test for significant trends over time.

RESULTS

Incidence of extremity fracture hospitalizations declined in both women (15.7%, p trend < 0.001) and men (3.2%, p trend < 0.001) between 2003 and 2017. This trend was primarily attributed to a decline in low energy femur fractures which accounted for 65% of all fracture hospitalizations. Among older adults with an extremity fracture hospitalization, mortality declined from 5.1% in 2003 to 3.3% in 2017 in men, and from 2.6% to 1.9% in women (p trend < 0.001). High energy fractures were due to falls (53%), motor vehicle accidents (34%), and other high impact injuries (13%). Overall, 12% of extremity fracture hospitalizations were attributed to high-energy injuries: increases were observed among men ages 65-74 (20%; p trend < 0.001) and 75-84 (10%; p trend = 0.013), but not among women of any age.

CONCLUSION

Observed declines in the incidence of extremity fracture hospitalizations and related mortality are encouraging. However, increasing incidence of fracture hospitalization from high energy injuries among men suggests that older adults with complex injuries will be seen with more prevalence in the future.

[Trends in the surgical treatment of fractures of the pelvic ring : A nationwide analysis of operations and procedures code (OPS) data between 2005 and 2017]

AIM

The aim of this study was to analyze the epidemiological trends and incidences in inpatient pelvic surgery in the period from 2005 to 2007.

METHOD

Approximately 194 million anonymized diagnosis-related groups (DRG) inpatient records were collected by the German Federal Statistical Office between 2005 and 2017. These data were screened for pelvic procedures, gender and age of the patients. Statistical testing was performed using the χ²-test and Mann-Whitney U-test (p < 0.05).

RESULTS

Between 2005 and 2017 the number of closed reduction and internal fixation of the pelvic ring with screw fixation increased by +1116%. The use of screw fixation for closed reduction and internal fixation of the sacroiliac joint increased by +800%. The number of cases of open reduction and internal fixation of fractures of the pelvic ring and pelvic rim increased by +185% and reposition with external fixator increased by +188%. In 2005 more surgical procedures were undertaken in male inpatients, whereas more surgical procedures were undertaken in female inpatients in 2017. In general, a large increase in the number of pelvic procedures was observed in the group of patients >50 years old.

CONCLUSION

There was an increase in the number of all analyzed pelvic procedures between 2005 and 2017. Especially the use of screw fixation increased. The introduction of new techniques (e.g. screw fixation of the sacroiliac joint) and progress and innovation in the field of three-dimensional navigation techniques, the demographic trend, greater mobility and higher demands on functionality of older patients might explain this increase in pelvic procedures.

Treatment of fragility ankle fractures using hindfoot nail, systemic review

With an aging population, the prevalence of fragility ankle fractures is rising. The surgical management of these injuries is challenging and associated with high rates of complications. An extensive literature review (inception of data until September 2019) was undertaken to locate previous studies that have addressed the same topic. Seven studies met the inclusion criteria. The post-operative Olerud and Molander scores were comparable/slightly lower than pre-injury scores. Bony union was achieved in 90.3%-100% of cases. Hindfoot nails, when used to treat fragility ankle fractures, can facilitate early rehabilitation and restoration of function among elderly osteoporotic patients.

[Polytrauma in old age-Knowledge from the TraumaRegister DGU®]

The geriatric fracture patient is becoming more and more in the forefront due to the demographic development. It is expected that the number of polytraumatized geriatric patients in the coming years will rise in line with demographic trends. The TraumaRegister DGU® of the German Trauma Society (DGU) provides interesting insights into the age structure and patient outcome. In 2017 in total 26.2% of the patients included were over 70 years old. Geriatric polytraumatized patients show significant differences in the injury patterns as well as in the treatment strategy compared to younger patients. This is often due to the pre-existing diseases and various drugs that alter the physiology. With respect to the injury patterns an increase in severe head injuries and a decrease in severe abdominal injuries can be seen with increasing age. Hospitals and professional societies are currently dealing with numerous challenges. The implementation of the General Data Protection Regulation leads to conflicts and uncertainties. The further development of the TraumaRegister DGU® is important in order to collect more outcome-relevant data from patients because more than ever the objective should be the survival of an accident with a high quality of life. To measure this, a structured survey of patients is necessary. The TraumaRegister DGU® is one of the most important tools to make treatment comparable and to measure structural changes.

A Survey of High- and Low-Energy Acetabular Fractures in Elderly Patients

INTRODUCTION

Geriatric patients represent 14% of acetabular fractures and are the fastest growing subset of patients affected by this injury in the US. Treatment outcomes have been reported as inferior to those achieved in younger patients after high-energy (HE) acetabular trauma. This study aimed to compare detailed demographic characteristics and clinical outcomes in elderly patients (≥65 years of age) treated in a tertiary North American trauma center for acetabular fractures after both high- and low-energy mechanisms of injury.

METHODS

Patients (≥65 years of age) diagnosed with an acetabular fracture were identified over a 7-year period. Patient and injury characteristics were extracted from our institutional trauma database. Length of stay, intervention, operative details, disposition, complications, readmissions, and mortality were analyzed.

RESULTS

One hundred nine patients were identified for inclusion. Low-energy mechanisms (simple falls) were found in 64 (58.7%) and HE mechanisms in 45 (41.3%) patients. The HE cohort was younger (74.6 vs 80.7 years; P < .001), had a higher male predominance (76% vs 56%; P = .10), a lower Charlson comorbidity index (1.29 ± 1.49 vs 2.16 ± 1.76; P = .01), and a higher injury severity score (19.90 ± 15.33 vs 6.46 ± 3.57; P < .001). Fracture patterns, described according to the Letournel-Judet classification, were similar between the 2 groups. Thirty-day mortality was significantly higher in the HE group (26.7% vs 3.1%; P < .001); however, the 1-year mortality rates were not statistically different (31.1% vs 25.0%; P = .20).

DISCUSSION

Patients with acetabular fractures sustained due to HE accidents demonstrate significantly higher 30-day mortality rate than patients with low-energy fractures, but similar mortality 1 year after the injury, despite having a much lower mean age and fewer comorbidities.

CONCLUSION

Medical efforts made during initial hospital admission may have the biggest impact on survivorship following acetabular fracture.

Epidemiology of traumatic brain injury in the elderly over a 25 year period

OBJECTIVE

To identify the changes in the epidemiology of traumatic brain injury (TBI) in a cohort of patients older than 65 years old admitted in the Intensive care unit of a third-level hospital over a 25 year period.

MATERIAL AND METHODS

A retrospective cohort study conducted on patients over 65 years-old admitted with the diagnosis of TBI into an intensive care unit of a Spanish university hospital. The demographic, clinical variables were collected at the time of admission, including comorbidities, injury mechanisms, and injuries presented, and days of stay in ICU. A statistical analysis was carried out by five-year periods.

RESULTS

A total of 446 TBI in patients over 65 years were included. In the analysis, an increase was observed in the proportion of patients presenting with epidural haematoma (1.39% in the period 1990-1995 vs. 9.46% in 2010-2015), with a significant linear tendency (P=.018). Falls from own height have increased from 8.33% (1991-1995) to currently more than 70% (2011-2015), P<.001. The percentage of traffic accidents declined from 26.39% to 3.95% in the last period, P<.001.

CONCLUSIONS

In the last 25 years there seems to be evidence of a change in the origins of TBI in the elderly in our field.

Have outcomes improved in trauma patients age 90 years and older over the past decade: Experience at a level II trauma center

INTRODUCTION

Managing trauma in the elderly is challenging and requires a multidisciplinary team approach. The aim of this study is to characterize and compare outcomes in patients 90 years and older in the last two decades.

METHODS

Retrospective review of trauma patients 90 years and older admitted from 1996 to 2015. The patients were divided into two groups: Early Decade (ED) and Late Decade (LD).

RESULTS

A total of 1697 patients were recorded, 551 (ED) and 1146 (LD). The mean age was 92.92 ± 8(90-108)[ED] and 92.9 ± 2.7(90-105)[LD] years. The most common mechanism and type of injury was falls and extremity trauma. Hospital length of stay (LOS) was shorter in the LD. There was no significant difference in in-hospital mortality or ICU LOS.

CONCLUSION

Trauma admission has increased in the last decade. However, in-hospital mortality remains low. It is important for multidisciplinary teams to allocate resources to treat this elderly population.

Ten-Year Incidence of High-Energy Geriatric Trauma at a Level 1 Trauma Center

OBJECTIVES

To examine the characteristics of high-energy geriatric trauma over time.

DESIGN

Retrospective chart review.

SETTING

Level 1 trauma center.

PATIENTS

Demographic, injury, and clinical characteristics were compared between 34,017 patients with geriatric and nongeriatric high-energy trauma from 2005 to 2014 using t test, χ analysis, and negative binomial regression for annual trend in injuries.

RESULTS

Geriatric high-energy trauma composed 11.2% of all trauma activations. Patients with geriatric high-energy trauma nearly doubled from the study period of 2005-2014 to previous 10 years (P = 0.0004). Compared with patients with nongeriatric trauma, geriatric high-energy traumas were twice as likely to be due to a fall from height (P < 0.0001), had higher Injury Severity Scores (P < 0.0001), fewer abdominal injuries (P = 0.0011), and have head trauma (P < 0.0001). Fracture patterns were similar between groups. Mortality was higher for all geriatric patients (odds ratio [OR], 4.76; 95% confidence interval [CI], 4.00-5.67), and high-energy mechanisms (OR, 4.71; 95% CI, 3.90-5.68) compared with low-energy mechanisms (OR, 3.00; 95% CI, 2.48-3.62).

CONCLUSION

The number of geriatric high-energy traumas has doubled over 10 years. Patients with geriatric trauma are sicker on presentation, based on the Injury Severity Score, and high-energy geriatrics have a 4-fold increase in mortality.

LEVEL OF EVIDENCE

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

Base excess, a useful marker in the prognosis of chest trauma in the geriatric population

OBJECTIVE

To determine the usefulness of the determination of base excess in a cohort of elderly patients admitted to an intensive care unit (ICU) with a diagnosis of chest trauma.

MATERIAL AND METHOD

Two hundred and forty-nine patients were included aged 65 years and over with a diagnosis of thoracic trauma who required admission to the ICU. We made a statistical analysis in order to determine the association of the first base excess levels with mortality during the unit stay.

RESULTS

Two hundred and forty-nine patients, with a mean APACHE II score of 16.21±7.87 and 24.45±14.16 ISS. Mean ICU stay was 12.74±16.85 days and the mean hospital stay was 26.55±30.1 days. Statistical analysis showed an association with mortality in patients whose blood pressure was lower than 110mmHg on admission, with an OR=4.11 (95% CI 1.91 to 8.85) compared to patients with blood pressure between 110 and 140mmHg. Those patients who had base excess levels on admission of less than -6mmol/L also showed increased mortality compared to patients with higher levels, with an OR=3.12 (95% CI 1.51 to 6.42).

CONCLUSIONS

The presence of a base excess level of less than -6 is associated with increased mortality in elderly patients with initial blood pressure between 110 and 140mmHg, diagnosed with thoracic trauma and who require admission to ICU. Routine measurement of this parameter in this population may show the clinical usefulness of assessing possible hidden hypoperfusion.

Is Early Appropriate Care of axial and femoral fractures appropriate in multiply-injured elderly trauma patients?

BACKGROUND

Previous work established resuscitation parameters that minimize complications with early fracture management. This Early Appropriate Care (EAC) protocol was applied to patients with advanced age to determine if they require unique parameters to mitigate complications.

METHODS

Between October 2010 and March 2013, 376 consecutive skeletally mature patients with unstable fractures of the pelvis, acetabulum, thoracolumbar spine, and/or proximal or diaphyseal femur fractures were treated at a level I trauma center and were prospectively studied. Patients aged ≤30 years (n = 114), 30 to 60 years (n = 184), and ≥60 years (n = 37) with Injury Severity Scores (ISS) ≥16 and unstable fractures of the pelvis, acetabulum, spine, and/or diaphyseal femur were treated within 36 h, provided they showed evidence of adequate resuscitation. ISS, Glasgow Coma Scale (GCS), and American Society of Anesthesiologists (ASA) classification were determined. Lactate, pH, and base excess (BE) were measured at 8-h intervals. Complications included pneumonia, pulmonary embolism (PE), acute renal failure, acute respiratory distress syndrome (ARDS), multiple organ failure (MOF), deep vein thrombosis, infection, sepsis, and death.

RESULTS

Patients ≤30 years old (y/o) were more likely to sustain gunshot wounds (p = 0.039), while those ≥60 y/o were more likely to fall from a height (p = 0.002). Complications occurred at similar rates for patients ≤30 y/o, 30 to 60 y/o, and ≥60 y/o. There were no differences in lactate, pH, or BE at the time of surgery. For patients ≤30 y/o, there were increased overall complications if pH was <7.30 (p = 0.042) or BE <-6.0 (p = 0.049); patients ≥60 y/o demonstrated more sepsis if BE was <-6.0 (p = 0.046).

CONCLUSIONS

EAC aims to definitively manage axial and femoral shaft fractures once patients have been adequately resuscitated to minimize complications. EAC is associated with comparable complication rates in young and elderly patients. Further study is warranted with a larger sample to further validate EAC in elderly patients.

LEVEL OF EVIDENCE

level II prospective, comparative study.

[Evolution of mortality in severe chest trauma in the elderly patient]

INTRODUCTION

Persons older than 65 years represent about 30% of all cases requiring care for traumatic injury, and is the fifth leading cause of death. Thus, it is considered important to search for epidemiological parameters that can identify this population group.

PATIENTS AND METHOD

A retrospective, observational, and comparative study was conducted on patients aged 65 years and over admitted to the Intensive Care Unit of tertiary hospital with a primary diagnosis of severe chest trauma between January 1992 and January 2012. A logistic regression was performed to determine the probability of hospital death in relation to the year of hospitalisation.

RESULTS

The cohort included 235 patients. Univariate logistic regression analysis showed a gradual decrease in the probability of death over the years, with an OR of 0.95 [95% CI; 0.90 to 0.99] for each year of admission after 1992 (P=.029). The multivariate model showed an association of mortality with patient age (OR: 1.08 for year over 65), the score on the scale APACHE II (OR: 1.1 for each point obtained), and need for mechanical ventilation (OR: 5.36).

CONCLUSIONS

This study shows a decrease in mortality over the years, with an association that remained after adjustment for different confounding parameters.

The Effects of a Hospitalist Comanagement Model for Joint Arthroplasty Patients in a Teaching Facility

BACKGROUND

The goal of this study was to compare postoperative medical comanagement of total hip arthroplasty and total knee arthroplasty patients using a hospitalist (H) and nonhospitalist (NH) model at a single teaching institution to determine the clinical and economic impact of the hospitalist comanagement.

METHODS

We retrospectively reviewed the records of 1656 patients who received hospitalist comanagement with 1319 patients who did not. The NH and H cohorts were compared at baseline via chi-square test for the American Society of Anesthesiologists classification, the t test for age, and the Wilcoxon test for the unadjusted Charlson Comorbidity Index score and the age-adjusted Charlson Comorbidity Index score. Chi-square test was used to compare the postoperative length of stay, readmission rate at 30 days after surgery, diagnoses present on admission, new diagnoses during admission, tests ordered postoperatively, total direct cost, and discharge location.

RESULTS

The H cohort gained more new diagnoses (P < .001), had more studies ordered (P < .001), had a higher cost of hospitalization (P = .002), and were more likely to be discharged to a skilled nursing facility (P < .001). The H cohort also had a lower length of stay (P < .001), but we believe evolving techniques in both pain control and blood management likely influenced this. There was no significant difference in readmissions.

CONCLUSION

Any potential benefit of a hospitalist comanagement model for this patient population may be outweighed by increased cost.

Isolated sacral injuries: Postoperative length of stay, complications, and readmission

AIM: To investigate inpatient length of stay (LOS), complication rates, and readmission rates for sacral fracture patients based on operative approach.

METHODS: All patients who presented to a large tertiary care center with isolated sacral fractures in an 11-year period were included in a retrospective chart review. Operative approach (open reduction internal fixation vs percutaneous) was noted, as well as age, gender, race, and American Society of Anesthesiologists’ score. Complications included infection, nonunion and malunion, deep venous thrombosis, and hardware problems; 90-d readmissions were broken down into infection, surgical revision of the sacral fracture, and medical complications. LOS was collected for the initial admission and readmission visits if applicable. Fisher’s exact and non-parametric t-tests (Mann-Whitney U tests) were employed to compare LOS, complications, and readmissions between open and percutaneous approaches.

RESULTS: Ninety-four patients with isolated sacral fractures were identified: 31 (30.4%) who underwent open reduction and internal fixation (ORIF) vs 63 (67.0%) who underwent percutaneous fixation. There was a significant difference in LOS based on operative approach: 9.1 d for ORIF patients vs 6.1 d for percutaneous patients (P = 0.043), amounting to a difference in cost of $13590. Ten patients in the study developed complications, with no significant difference in complication rates or reasons for complications between the two groups (19.4% for ORIF patients vs 6.3% for percutaneous patients). Eight patients were readmitted, with no significant difference in readmission rates or reasons for readmission between the two groups (9.5% percutaneous vs 6.5% ORIF).

CONCLUSION: There is a significant difference in LOS based on operative approach for sacral fracture patients. Given similar complications and readmission rates, we recommend a percutaneous approach.

Open Reduction and Internal Fixation of Scapula Fractures in a Geriatric Series

The purpose of this small descriptive series was to report patient and injury characteristics, as well as, surgical and functional outcomes in patients aged 70 years or older, with operative scapular fracture. A retrospective review of 214 scapula fractures identified 6 consecutive geriatric patients aged 70 years or older and formed the basis for this study. Outcomes reported include surgical complications; disabilities of the arm, shoulder, and hand (DASH); range of motion (ROM); and strength assessment at the 6-month postoperative interval and final follow-up. All patients were community ambulators and 5 of the 6 patients routinely performed recreational activities that required shoulder strength and/or motion. Outcomes were attained on all patients at greater than 1 year with a mean of 23.2 months. There were no surgical complications and all fractures united. The mean ROM expressed as a percentage of contralateral ROM ranged from 82% to 100% at both 6-month and final follow-up. The mean strength expressed as a percentage of contralateral strength ranged from 63% to 82% at the 6-month follow-up and 94% to 100% at the final follow-up. The mean DASH score was 12.3 at final follow-up. Our conclusion is that operative treatment for displaced scapula fractures appears to be safe and can yield good functional results in patients aged 70 years and older.

Geriatric High-Energy Polytrauma With Orthopedic Injuries: Clinical Predictors of Mortality

Background:

The impact of orthopedic injuries in the elderly patient with multi-trauma and the effect of operative fixation on these injuries have not been thoroughly evaluated.

Methods:

We reviewed geriatric patients (aged 65 and older) between 2004 and 2010 at a level 1 trauma center who sustained high-energy polytrauma (injury and severity score [ISS] ≥ 16) with associated orthopedic injuries. Patients were excluded if they had severe head and spine injuries, died on arrival, or had low-energy mechanisms of injury. Logistic regression was conducted to identify factors that predict mortality.

Results:

There were 154 patients who comprised our study group with an average age of 76 years and an ISS of 23. There were 96 males and 58 females. Overall, 52 patients died within 1 year of their admission: 21 patients during their initial hospital stay and 31 patients within 1 year following admission. In all, 64 (42%) patients underwent operative stabilization of their orthopedic injuries. Increased mortality was seen (P < .05) in female patients, those with lower admission Glasgow coma score, and those who underwent orthopedic surgery. Patients had worse outcomes if they sustained femur (P = .014), clavicle, or scapular fractures (P = .027). Other factures associated with higher mortality included pelvic/acetabular injury requiring surgery (P = .019) or spine fractures treated nonoperatively (P = .014).

Conclusion:

The effect of orthopedic injuries on this geriatric polytrauma group contribute to worse outcomes when they included clavicle, scapula, and femur fractures. We also found that pelvic/acetabular fractures treated operatively and nonoperative spine fractures were associated with higher mortality rates. Risk/benefit consideration is suggested when contemplating operative intervention in these patients.

A growing problem: acetabular fractures in the elderly and the combined hip procedure

Acetabular fractures in the elderly are most frequently the result of low-energy trauma and present unique management challenges to orthopedic surgeons. Evaluation and treatment should be performed in a multidisciplinary fashion with early involvement of internal medicine subspecialists and geriatricians. Distinct fracture patterns and pre-existing osteoarthritis and osteoporosis necessitate careful preoperative planning. The role of total hip arthroplasty should also be considered when surgical treatment is indicated. The outcomes of acetabular fractures in the elderly have improved, but complications remain higher and results less satisfactory than in younger individuals. The lack of randomized controlled trials has limited the ability to establish an evidence-based treatment algorithm.

Surgery in vertebral fracture: epidemiology and functional and radiological results in a prospective series of 518 patients at 1 year's follow-up

INTRODUCTION

Recent epidemiological data for spinal trauma in France are sparse. However, increased knowledge of sagittal balance and the development of minimally invasive techniques have greatly improved surgical management.

OBJECTIVES

To describe the epidemiology and management of traumatic vertebral fracture, and to analyze evolution and risk factors for poor functional outcome at 1 year's follow-up.

MATERIALS AND METHODS

A prospective multicenter French cohort study was performed over a 6-month period in 2011, including all cases of vertebral fracture surgery. Data were collected by online questionnaire over the Internet. Demographic characteristics, lesion type and surgical procedures were collected. Clinical, functional and radiological assessment was carried out at 1 year.

RESULTS

Five hundred and eighteen patients, with a mean age of 47 years, were included. Sixty-seven percent of fractures involved the thoracic or lumbar segment. Thirty percent of patients had multiple fractures and 28% neurological impairment. A minimally invasive technique was performed in 20% of cases and neurological decompression in 25%. Dural tear was observed in 42 patients (8%). Seventy percent of patients were followed up at 1 year. Functionally, SF-36 scores decreased on all dimensions, significantly associated with age, persistent neurological deficit and previous spine imbalance. Thirty-eight percent of working patients had returned to work. Radiologically, sagittal balance was good in 74% of cases, with fracture consolidation in 70%.

DISCUSSION

Despite progress in management, spinal trauma was still a source of significant morbidity in 2011, with pronounced decrease in quality of life. Conserved sagittal balance appeared to be associated with better functional outcome.

Management in high-risk patients

Injuries to the foot and ankle are often missed or underestimated in patients with polytrauma and are a source of long-term limitations. Injures below the knee are among the highest causes for unemployment, longer sick leave, more pain, more follow-up appointments, and decreased overall outcome. As mortalities decrease for patients with polytrauma a greater emphasis on timely diagnosis and treatment of foot and ankle injuries is indicated. Geriatric patients represent nearly one-quarter of trauma admissions in the United States. This article discusses perioperative management and complications associated with foot and ankle injuries in polytrauma, and in diabetic and geriatric patients.

Inducible nitric oxide synthase drives mTOR pathway activation and proliferation of human melanoma by reversible nitrosylation of TSC2

Melanoma is one of the cancers of fastest-rising incidence in the world. Inducible nitric oxide synthase (iNOS) is overexpressed in melanoma and other cancers, and previous data suggest that iNOS and nitric oxide (NO) drive survival and proliferation of human melanoma cells. However, specific mechanisms through which this occurs are poorly defined. One candidate is the PI3K-AKT-mTOR pathway, which plays a major role in proliferation, angiogenesis, and metastasis of melanoma and other cancers. We used the chick embryo chorioallantoic membrane (CAM) assay to test the hypothesis that melanoma growth is regulated by iNOS-dependent mTOR pathway activation. Both pharmacologic inhibition and siRNA-mediated gene silencing of iNOS suppressed melanoma proliferation and in vivo growth on the CAM in human melanoma models. This was associated with strong downregulation of mTOR pathway activation by Western blot analysis of p-mTOR, p70 ribosomal S6 kinase (p-P70S6K), p-S6RP, and p-4EBP1. iNOS expression and NO were associated with reversible nitrosylation of tuberous sclerosis complex (TSC) 2, and inhibited dimerization of TSC2 with its inhibitory partner TSC1, enhancing GTPase activity of its target Ras homolog enriched in brain (Rheb), a critical activator of mTOR signaling. Immunohistochemical analysis of tumor specimens from stage III melanoma patients showed a significant correlation between iNOS expression levels and expression of the mTOR pathway members. Exogenously supplied NO was also sufficient to reverse the mTOR pathway inhibition by the B-Raf inhibitor vemurafenib. In summary, covalent modification of TSC2 by iNOS-derived NO is associated with impaired TSC2/TSC1 dimerization, mTOR pathway activation, and proliferation of human melanoma. This model is consistent with the known association of iNOS overexpression and poor prognosis in melanoma and other cancers.