Lumbopelvic fixation in the treatment of spinopelvic dissociation: union, complications, and neurologic outcomes of a multicenter case series

PURPOSE

To review outcomes of spinopelvic dissociation treated with open lumbopelvic fixation.

METHODS

We reviewed all cases of spinopelvic dissociation treated at three Level-I trauma centers with open lumbopelvic fixation, including those with adjunctive percutaneous fixation. We collected demographic data, associated injuries, pre- and postoperative neurologic status, pre- and postoperative kyphosis, and Roy-Camille classification. Outcomes included presence of union, reoperation rates, and complications involving hardware or wound.

RESULTS

From an initial cohort of 260 patients with spinopelvic dissociation, forty patients fulfilled inclusion criteria with a median follow-up of 351 days. Ten patients (25%) had a combination of percutaneous iliosacral and open lumbopelvic repair. Average pre- and postoperative kyphosis was 30 degrees and 26 degrees, respectively. Twenty patients (50%) had neurologic deficit preoperatively, and eight (20%) were unknown or unable to be assessed. All patients presenting with bowel or bladder dysfunction (n = 12) underwent laminectomy at time of surgery, with 3 patients (25%) having continued dysfunction at final follow-up. Surgical site infection occurred in four cases (10%) and wound complications in two (5%). All cases (100%) went on to union and five patients (13%) required hardware removal.

CONCLUSION

Open lumbopelvic fixation resulted in a high union rate in the treatment of spinopelvic dissociation. Approximately 1 in 6 patients had a wound complication, the majority of which were surgical site infections. Bowel and bladder dysfunction at presentation were common with the majority of cases resolving by final follow-up when spinopelvic dissociation had been treated with decompression and stable fixation.

Percutaneous Posterior Pelvic Fixation of Spinopelvic Dissociation: A Multicenter Series of Displaced Patterns

OBJECTIVE

To characterize the success and complications of percutaneous posterior pelvic fixation in the treatment of displaced spinopelvic dissociation patterns.Design: Retrospective cohort study.Setting: Three Level I trauma centers.Patients: Fifty-three patients with displaced spinopelvic patterns.Intervention: Percutaneous iliosacral screw fixation.Main outcome measures: Incidence of union, fixation failure and soft tissue complications.

RESULTS

All patients had displaced, unstable patterns with a mean pre-operative kyphosis of 29.7 ± 15.4 degrees (range, 0-70). The majority of patients treated were neurologically intact (72%) or had an unknown exam at the time of fixation (15%). The median follow-up was 254 days (Interquartile range, 141-531).The union rate was 98%. Radiographic and clinical follow-up demonstrated one case (2%) of nonunion. Two patients (4%) had radiographic evidence of screw loosening at final follow-up, both of whom had fixation with a single sacroiliac style screw placed bilaterally and went on to uneventful union. Neurologic recovery occurred at an average of 195 ± 114 days (range, 82-363 days). When present, long-term neurologic sequelae most commonly consisted of radicular pain and paresthesias at final follow-up (n=3, 6%).

CONCLUSIONS

Percutaneous posterior pelvic fixation of select displaced spinopelvic dissociation appears to be safe with a low complication rate and reliable union. In a cohort of displaced fractures that were fixed in situ, we found a 2% rate of fixation failure/nonunion. While rare, radicular pain and paresthesias were the most common long-term neurologic sequela.

Neurologic injury after spinopelvic dissociation: Incidence, outcome, and predictors

BACKGROUND

Traumatic spinopelvic dissociation is a rare injury pattern resulting in discontinuity between the spine and bony pelvis. This injury is associated with a known risk of neurologic compromise which can impact the clinical outcome of these patients. We sought to determine incidence and characteristics of neurologic injury, outcomes following treatment, and predictive factors for neurologic recovery.

METHODS

We reviewed the clinical documentation and imaging of 270 patients with spinopelvic dissociation from three Level-1 trauma centers treated over a 20-year period. From this cohort, 137 patients fulfilled inclusion criteria with appropriate follow-up. Details surrounding patient presentation, incidence of neurologic injury, and outcome variables were collected for each injury. Neurologic injuries were categorized using the Gibbons criteria. Multivariate analysis was performed to assess for patient and injury factors predictive of neurologic injury and recovery.

RESULTS

The overall incidence of neurologic injury in spinopelvic dissociation injuries was 33% (45/137), with bowel and/or bladder dysfunction (n=16) being the most common presentation. Complete neurologic recovery was seen in 26 cases (58%) and two patients (4%) improved at least one Gibbon stage in clinical follow-up. The most common long-term neurologic sequela at final follow-up was radiculopathy (n=12, 9%). Increased kyphosis was found to be associated with neurologic injury (p=0.002), while location of transverse limb and Roy-Camille type were not predictive of neurologic injury (p=0.31 and p=0.07, respectively). There were no factors found to be predictive of neurologic recovery in this cohort.

CONCLUSION

Neurologic injury is commonly seen in patients with spinopelvic dissociation and complete neurologic recovery was seen in the majority of patients at final follow-up. When present, long term neurologic dysfunction is most commonly characterized by radiculopathy. While increasing kyphosis was shown to be associated with neurologic injury, no patient or injury factors were predictive of neurologic recovery.

Single dose IV Antibiotic for Low-Energy Extremity Gunshot Wounds: A Prospective Protocol

Objective

To prospectively determine infection rate following low-energy extremity GSWs with a single dose IV antibiotic protocol.

Summary Background Data

Previous work suggests that a single IV antibiotic dose, without formal surgical debridement, mitigates infection risk.

Methods

Over 35 months 530 adults with low-energy GSWs to the extremities were included. Three hundred fifty-two patients (66%) had ≥30 days follow-up. Patients were administered a single dose of first-generation IV cephalosporin antibiotics, and those with operative fractures received 24-hour perioperative antibiotics. Injury characteristics, treatment, protocol adherence, and outcomes (infection) were assessed between the protocol group (single-dose antibiotics) and the non-protocol group (no antibiotics or extra doses of antibiotics).

Results

Compliance with the single-dose protocol occurred in 66.8%, while 33.2% received additional antibiotics or no antibiotics. The deep infection rate requiring surgical debridement was 0.8%, while the combined rate of all infections was 11.1%. Age, sex, injury location, multiple injuries, fracture presence, and type of surgery did not affect infection rate. Adherence to the antibiotic protocol was associated with a reduction in infection risk (odds ratio = 0.39, 95% confidence interval 0.19-0.83, P = 0.01). Receipt of additional antibiotics outside of our single-dose protocol did not predict further reduction in rate of infection (P = 0.64).

Conclusions

A standardized protocol of single-dose IV antibiotic appears effective in minimizing infection after low-energy GSW to the extremities.

Level of Evidence

Therapeutic Level II.

Costs of Care for Low-Energy Extremity Gunshot Injuries are Reduced With Standardized Treatment

OBJECTIVES

(1) To determine the overall treatment costs associated with isolated low-energy gunshot wounds (GSWs) to the extremity and (2) to estimate cost savings associated with a single-dose IV antibiotic strategy administered in the emergency room for patients with simple GSWs.

DESIGN

Retrospective review.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Patients (N = 380) with extremity-only GSW injuries from 2010 to 2015 were retrospectively reviewed. Treatment was recorded including type and duration of antibiotics, admission, and surgical intervention.

MAIN OUTCOME MEASURES

Costs were calculated including facility services in the operating room and hospital.

RESULTS

There were 460 GSWs in 380 patients with a mean age of 30 years old. There were 309 admissions, 273 operations performed, and 1010 days of antibiotics prescribed. The total inpatient facility cost to treat all patients was $1,701,154. Among 179 patients who could be treated by the single-dose antibiotic care pathway for simple GSWs, 132 patients (73%) received additional treatment with 108 hospital admissions, 26 debridement surgeries, and 322 days of additional oral and/or IV antibiotics. The single-dose antibiotic care pathway would have saved an average of $1436 per patient with simple GSWs in actual facility expenses.

CONCLUSIONS

The overall cost associated with isolated low-energy GSWs to the extremity is high. Limiting antibiotics to a single IV dose in the emergency room can reduce treatment expenses substantially for patients with simple GSWs.

LEVEL OF EVIDENCE

Economic Level IV. See instructions for authors for a complete description of levels of evidence.

A Novel USMLE Step 1 Projection Model Using a Single Comprehensive Basic Science Self-Assessment Taken During a Brief Intense Study Period

BACKGROUND

Comprehensive Basic Science Self-Assessments (CBSSAs) offered by the National Board of Medical Examiners (NBME) are used by students to gauge preparedness for the United States Medical Licensing (USMLE) Step 1. Because residency programs value Step 1 scores, students expend many resources attempting to score highly on this exam. We sought to generate a predicted Step 1 score from a single CBSSA taken several days out from a planned exam date to inform student testing and study plans.

METHODS

2016 and 2017 Step 1 test takers at one US medical school were surveyed. The average daily score improvement from CBSSA to Step 1 during the 2016 study period was calculated and used to generate a predicted Step 1 score as well as mean absolute prediction errors (MAPEs). The predictive model was validated on 2017 data.

RESULTS

In total, 43 of 61 respondents totaling 141 CBSSAs in 2016 and 37 of 43 respondents totaling 122 CBSSAs in 2017 were included. The final prediction model was [Predicted Step 1 = 292 - (292 - CBSSA score) * 0.987527 ^ (number of days out)]. In 2016, the average difference between predicted and actual scores was -0.81 (10.2) and the MAPE was 7.8. In 2017, 88 (72.1%) and 118 (96.7%) of true Step 1 scores fell within one and two standard deviations of a student's predicted score. There was a MAPE of 7.7. Practice form used (p = 0.19, 0.07) and how far out from actual Step 1 it was taken (p = 0.82, 0.38) were not significant in either year of study.

CONCLUSION

This projection model is reasonable for students to use to gauge their readiness for Step 1 while it remains a scored exam and provides a framework for future predictive model generation as the landscape of standardized testing changes in medical education.

Infection and Complications After Low-velocity Intra-articular Gunshot Injuries

OBJECTIVES

The purpose of this study is to characterize the demographics, interventions, infection rates, and other complications after intra-articular (IA) gunshot wounds.

DESIGN

Retrospective review.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Fifty-three patients with 55 civilian low-velocity IA gunshot injuries with a minimum of 4 weeks follow-up were included in the study. Seven patients had associated vascular injuries.

INTERVENTIONS

Most patients (84.9%) received antibiotic prophylaxis, consisting most often of cefazolin (93.3%). Based on injury pattern and surgeon preference, joint injuries were either treated nonoperatively (43.6%), with surgical debridement only (20.0%), with surgical debridement plus fracture fixation and/or neurovascular repair (32.7%), or with percutaneous fracture fixation without debridement (3.6%).

MAIN OUTCOME MEASURES

Incidence of deep infection.

RESULTS

Two joints (3.6%) developed deep infections. Both had associated vascular injuries. Patients with vascular injuries were at higher risk of infection compared with those without vascular injury (28.6% vs. 0.0%, P = 0.02). Two of 24 (8.3%) injuries that were originally managed nonoperatively required delayed surgical procedures, 1 for bullet removal and 1 for ulnar nerve allograft. No patient treated nonoperatively developed an infection.

CONCLUSIONS

The incidence of infection after IA gunshot injuries is low with the routine use of antibiotic prophylaxis. In the absence of IA pathology, IA gunshot injuries do not appear to necessitate surgical debridement to decrease the risk of infection. Patients with vascular injury deserve special attention, as they are at higher risk of infection.

LEVEL OF EVIDENCE

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

Leaving the Skin Incision Open May Not Be as Beneficial as We Have Been Taught

BACKGROUND

Currently, various methods of skin closures are used in contaminated and dirty abdominal wounds without solid, evidence-based guidance. This study investigates whether closure methods affect surgical site infection (SSI) and other incisional complications. We hypothesize that open management of the skin would have the lowest complications, including SSI.

PATIENTS AND METHODS

Patients age ≥18 who underwent trauma laparotomy (TL) or damage control laparotomy (DCL) from 2008-2013 and had class III/IV wounds were included. Demographic, injury, treatment, and outcome variables were compared based on skin closure methods: Primary closure, intermittently stapled with wicks, or open management. Subgroup analyses for TL, DCL, and high-risk patients with stomach, colon, or rectal injuries were performed. Bivariable and multivariable logistic regression (MLR) analyses were performed to identify risk factors for superficial/deep SSI and surgical incision complications.

RESULTS

A total of 348 patients were included. The median age was 47 years; 14% were female; 21% had blunt injuries. Overall SSI was highest for open incisions (p < 0.05), but there was no difference in superficial/deep SSI. Primary closures healed a median of 20 days, compared with 68 and 71 days for the intermittently stapled and open groups, respectively (p < 0.001). Primary closure in TL and high-risk patients also had the lowest SSI rates (all p < 0.05), but there were no differences in superficial/deep SSI in any subgroup. In TL patients, diabetes mellitus and colon injuries were independently associated with the development of superficial/deep SSI and surgical incision complications; however, skin closure method was not.

CONCLUSION

In class III and IV wounds, primary closure was associated with the lowest SSI, shortest length of stay and healing time. Method of skin closure, however, did not have an independent effect on the development of superficial/deep SSI or surgical incision complications. These suggest that primary skin closure in contaminated and dirty abdominal wounds may be performed more safely than commonly perceived.