Open fixation of the posterior malleolus increases the morbidity of trimalleolar ankle fracture fixation

PURPOSE

To assess the morbidity of open reduction internal fixation (ORIF) of posterior malleolus fractures (PMFs) in the setting of trimalleolar ankle fractures.

METHODS

A retrospective review of 79 trimalleolar ankle fractures was performed to identify need for syndesmotic fixation, blood loss, operative/tourniquet time, complications, and reoperations. Patients with PMF ORIF (n = 38) were compared to those with no fixation (n = 41). A subanalysis of patients with small PMFs (< 25%) was performed.

RESULTS

The PMF ORIF group required less syndesmosis fixation (proportional difference (PD) - 44.6%, 95% confidence interval (CI) - 61.8 to - 23.0%), had more blood loss (MD 20 ml, CI 0-40), longer operative times (MD 53.0 min, CI 35.9-70.1), longer tourniquet times (MD 26 min, CI 4-33), and had no difference in postoperative joint step-off or concentrically reduced joints. The PMF ORIF group had more postoperative complications (PD 26.9%, CI 6.3-44.8%) and a trend for more reoperations (PD 13.6%, CI -3.4 to 29.6%). Wound complications were more common in the PMF ORIF group (PD 26.5%, CI 6.9-43.6%), resulting in 5 (16.1%) irrigation and debridement procedures. On analysis of patients with small PMFs (n = 42), PMF ORIF (n = 15) resulted in longer operative/tourniquet times and had no observed difference in postoperative joint step-off, concentrically reduced joints, need for syndesmotic fixation, blood loss, or complications/reoperations.

CONCLUSION

PMF ORIF in the setting of trimalleolar ankle fractures was associated with increased operative/tourniquet times, blood loss, wound complications, and did not eliminate the need for syndesmosis fixation.

Antegrade versus retrograde nailing of proximal femur fractures: A cortical diameter based study

Background

Retrograde nailing of proximal femoral shaft fractures is controversial. The purpose of this study was to compare patients with proximal femur fractures undergoing antegrade versus retrograde intramedullary nailing (AIMN vs RIMN) and determine the safety and efficacy of RIMN.

Methods

A retrospective review was performed on 54 patients undergoing femoral IMN for proximal femoral shaft fractures at an urban level one trauma institution between January 2016 and July 2021.Fracture distance from the lesser trochanter (LT) was recorded and used to calculate the number of cortical diameters (NCD) from the LT. Proximal femur fractures were defined as < 3 NCD. AIMN and RIMN fixation was utilized in 31 (57.4%) and 23 (42.6%) patients, respectively. Outcomes measures included pre-/postoperative true translational and angular displacement (TTD and TAD), operative time, estimated blood loss (EBL), union rate, time to union, complications, and reoperations.

Results

AIMN and RIMN groups were similar in terms of age, sex, BMI, tobacco use, diabetes, ASA classification >2, AO/OTA classification, preoperative TTD or TAD, open fractures, or ballistic fractures. The AIMN group, had a shorter measured distance from the LT (47.0 vs. 66.1 mm, p = 0.04) but the difference in NCD was not significant (1.4 vs. 2.0, p = 0.07). Among patients with isolated IMN procedures, the RIMN group had shorter operative times (142.3 vs. 178.5 min, p = 0.01) and less EBL (100 vs. 250 mL, p = 0.008). There was no observed intergroup difference in terms of postoperative TTD/TAD, union rate, time to union, complications, or reoperations.

Conclusion

RIMN is a viable treatment option for proximal femoral shaft fractures that results in less operative time, less blood loss, and no detectable differences in union, reoperations, or complications.

Level of evidence

Level III, Retrospective cohort study.

Native tibia valga: a potential source of varus malreduction during intramedullary tibial nail fixation of tibial shaft fractures

PURPOSE

To determine the effect of native tibia valga on intramedullary nail (IMN) fixation of tibial shaft fractures.

METHODS

Retrospective comparative cohort analysis of 110 consecutive patients with tibial shaft fractures undergoing IMN fixation at an urban level one trauma centre was performed. Medical records and radiographs were reviewed for demographics, tibia centre of rotation of angulation (CORA), nail starting point, incidence of varus malreduction, and nail/canal proportional fit.

RESULTS

Tibia valga (CORA of ≥ 3 degrees) was present in 37 (33.6%) patients. The anatomic nail starting point distance (in relation to the lateral tibial spine) was significantly greater in the tibia valga group (12.0 mm vs. 5.0 mm, mean difference: 7.1 mm, 95% CI: 5.8 to 8.3 mm, p < 0.0001). Varus malreduction was more common in the tibia valga group (10.8% vs. 1.4%, proportional difference: 9.4%, 95% CI: - 1.0 to 21.3%, p = 0.04). Varus malreduction in the tibia valga group was associated with a decreased nail width/inner canal width proportion on multivariate analysis (OR = 0.683, 95% CI: 0.468 to 0.995, p = 0.0004).

CONCLUSION

Native tibia valga is common, and the use of a standard coronal IMN starting point with poor nail fit can lead to iatrogenic varus malreduction. In patients with tibia valga, maximizing nail fit or utilization of a medial starting point should be considered.

Unstable minimally displaced lateral compression type 1 (LC1) pelvic ring injuries have a similar hospital course as intertrochanteric femur fractures

INTRODUCTION

The purpose of this study was to evaluate how the hospital course of minimally displaced LC1 fractures, with and without occult instability, compares with that of intertrochanteric femur fractures.

PATIENTS AND METHODS

Retrospective comparative cohort analysis at an urban level one trauma center of 40 consecutive patients with an isolated LC1 pelvic ring injury and 40 age/sex matched patients with an isolated intertrochanteric femur fracture was performed. Medical records and radiographs were reviewed for patient and injury characteristics, including demographics, displacement, time to surgery, ambulation, physical therapy (PT) clearance, hospital length of stay (LOS), and inpatient morphine milligram equivalents (MME).

RESULTS

The LC1 pelvic ring injury group included 26 (65%) patients with ≥ 10 mm of displacement on lateral stress radiographs. The unstable LC1 group, compared to the stable LC1 group, had a greater LOS (median difference (MD): 2 days, 95% confidence interval (CI): 1 to 4, p = 0.0004), longer time to ambulate 15 feet (MD: 1 day, CI: 1 to 2, p = 0.0002), longer time to clear PT (MD: 2 days, CI: 1 to 3, p = 0.0003), and more inpatient MMEs (MD: 386 MME, CI: 225.8 to 546.7, p = 0.0002). The unstable LC1 and intertrochanteric fracture groups had no detectable differences in LOS (p = 0.24), days to ambulate 15 feet (p = 0.46), days to clear PT (p = 0.95), and inpatient MMEs (p = 0.06).

CONCLUSION

Patients with minimally displaced unstable LC1 injuries had worse hospital courses than stable LC1 injuries and similar hospital courses as intertrochanteric femur fractures. These findings emphasize the associated morbidity of unstable LC1 injuries.

LEVEL OF EVIDENCE

Level III, Retrospective cohort study.

Outcomes of orthopaedic trauma patients undergoing surgery during the peak period of COVID-19 infection at a UK major trauma centre

Background

To review the clinical outcomes of all patients undergoing emergency orthopaedic trauma surgery at a UK major trauma centre during the first 6 weeks of the COVID-19 related lockdown.

Methods

A retrospective review was performed of all patients who underwent emergency orthopaedic trauma surgery at a single urban major trauma centre over the first six-week period of national lockdown. Demographics, co-morbidities, injuries, injury severity scores, surgery, COVID-19 status, complications and mortalities were analysed.

Results

A total of 76 patients were included for review who underwent multiple procedures. Significant co-morbidity was present in 72%. The overall COVID-19 infection rate of the study population at any time was 22%. Sub-group analysis indicated 13% had active COVID-19 at the time of surgery. Only 4% of patients developed COVID-19 post surgery with no mortalities in this sub-group. The overall mortality rate was 4%. The overall complication rate was 14%. However mortality and complications rates were higher if the patients had active COVID-19 at surgery, if they were over 70 years and had sustained life-threatening injuries.

Conclusion

The overall survival rate for patients undergoing emergency orthopaedic trauma surgery during the COVID-19 peak was 96%. The rate of any complication was more significant in those presenting with active COVID-19 infections who had sustained potentially life threatening injuries and were over 70 years of age. Conversely those without active COVID-19 infection and who lacked significant co-morbidities experienced a lower complication and mortality rate.

Crisis change management during COVID-19 in the elective orthopaedic hospital: Easing the trauma burden of acute hospitals

Introduction

With the emergence of the 2019 novel coronavirus and its resulting pandemic status in March 2020 all routine elective orthopaedic surgery was cancelled in our institution. The developing picture in Italy, of acute hospitals becoming overwhelmed with treating patients suffering with severe and life-threatening symptoms from the disease, prompted the orthopaedic surgeons to formulate a plan to transfer trauma patients requiring surgery to the elective hospital to unburden the acute hospital system.

Methods

Under the threat of this pandemic; protocols and algorithms were established for referral, acceptance and care of trauma patients from acute hospitals in the region. Each day, as new guidance on COVID-19 emerged, our process and algorithms were adjusted to reflect pertinent change.

Results

The screening of all patients referred, worked well in keeping our hospital “COVID-free” with respect to patients undergoing operations. An upward trend in cases referred reflected the decreased capacity in the acute hospitals due to rising cases of COVID-19 within the hospital network. During the first 7 weeks of the pandemic 308 operations were performed, (31.1% upper limb, 33.4% lower limb, 4.1% spine, 14.1% urgent elective, 17.4% plastic surgery cases). Regular review and audit of the activity in the hospital as well as communication with the referring teams enabled appropriate planning to accommodate the increase in case-mix as the need arose.

Discussion

This paper details the steps that were taken in planning for such a change in management specific to the orthopaedic surgery setting and the lessons learnt during this process. The success of the development of this pathway was facilitated by clear communication channels, flexibility to adapt to changing process and feedback from all stakeholders. The implementation of this pathway allowed the unburdening of acute hospitals dealing with the pandemic that was steadily reducing access to operating theatres and anaesthetic resources.

Reducing routine laboratory tests in patients with isolated extremity fractures: a prospective safety and feasibility study in 246 patients

Background

Daily routine laboratory testing is unnecessary in most admitted patients. The opportunity to reduce daily laboratory testing in orthopaedic trauma patients has not been previously investigated.

Methods

A prospective observational study was performed based on a new laboratory testing reduction protocol for 12 months at two tertiary care trauma centers. Admitted patients with surgically treated isolated upper or lower extremity fractures were included (n = 246). The testing protocol consisted of a complete blood count (CBC) and basic metabolic panel (BMP) on postoperative day 2. Thereafter, tests were obtained at individual providers' discretion. Patients were followed for 30 days postoperatively. The primary outcome was number of laboratory tests reduced. Secondary outcomes included provider protocol compliance, and adverse patient outcomes. Chi-squared tests were used to compare differences in categorical variables among the cohorts. Analysis of variance tests were used for continuous variables. The relative reductions in testing utilization were calculated using our division's standard-of-care before program implementation (1 CBC and 1 BMP per patient per inpatient day). Significance was defined as P < 0.05.

Results

Of the 246 patients, there were 45 protocol fall outs due to provider deviation (n = 24) or medically justified necessity for additional testing (n = 21). Across all groups, a total of 778 CBC or BMP tests were avoided, amounting to a 69% reduction in testing compared to the pre-implementation baseline. Ninety-five percent of protocol group patients were safely discharged either without laboratory testing or with one set of tests obtained on postoperative day 2. There were no 30-day readmissions or reported complications associated with the new laboratory testing protocol.

Conclusions

In patients with surgically treated fractures about the elbow and knee, obtaining a single set of laboratory tests on postoperative day 2 is safe and efficacious in terms of reducing inappropriate resource utilization.

Trial registration

retrospectively registered.