Trauma

Delay to surgery in hip fracture

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Much progress has been made in the care of hip fracture patients over the last decade, but there may be more to do. While this is admittedly a retrospective study, these Danish surgeons (Copenhagen, Denmark) have looked again at the confusing topic of delay to surgery for hip fracture patients.¹ This retrospective analysis of 3517 patients accessed from the Danish Fracture Database was designed to examine if the outcomes of hip fracture surgery were dependent on timing of surgery following injury. The overall mortality in this cohort was in line with other contemporary studies, with 380 deaths at 30 days (10.8%) and 90-day mortality was 17.4%. The authors established that, in their study at least, the risk of 30-day mortality increased with surgical delay of more than 12 hours (OR 1.45). Also associated with increased mortality were: having a trainee surgeon perform the procedure, being a male patient, and having a higher ASA. Although these results make intuitive sense, there does not appear to really be an appropriate level of adjustment for confounders in this group and it may be that all this is reporting is selection bias.

Hexapod fixators in the management of hypertrophic tibial nonunions

Nonunion is more common in the tibia than in many other bones due to a combination of patterns of injury (usually high-energy) and poor blood supply. Treatment of nonunion in the tibia represents a significant health economic burden, requiring specialist surgeons and lengthy, complex operations. An option that potentially reduces the morbidity associated with tibial nonunion is the application of a frame distractor to adjust the fracture biomechanics and thereby achieve union. Although only really suitable for hypertrophic nonunions, this does represent an attractive option with a single surgery and little delay. This consecutive series of 46 tibial fracture nonunions is reported using treatment with closed frame distraction (KwaZulu Natal, South Africa).² Bony union was achieved in this series in 89% of patients after a single surgery, with length and alignment corrected within an average of 23 weeks. The authors highlight that all the patients they treated had stiff, hypertrophic nonunions, and it is their experience that frame distraction works well in such patients. The paper confirms this view and highlights the hexapod as a choice in the treatment of such nonunions.

Thromboembolism after nailing pathological fractures

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An increasingly common problem in general trauma is that of pathologic deposits. As survivals are increasing for solid organ tumours, so are numbers of patients who may present with metastases. These patients are rather challenging to treat as quality of life is paramount, they often have complex medical problems and are at higher risk of a range of complications including thromboembolism. Researchers in Philadelphia (USA) undertook a retrospective review describing their experience with 336 pathological long bone fractures.³ The overall incidence of symptomatic venous thromboembolic events in their series was surprisingly high, affecting 7.1% of patients. These break down into 3.9% pulmonary embolism and 3.3 % deep vein thrombosis. This was despite thromboprophylaxis for all patients. In terms of risk factors, lung cancer as the pathology was significantly associated with both forms of event, however, the method of thromboprophylaxis didn’t appear to make a difference. There was also a higher (but non-significant) rate of thromboembolic events in patients who had undergone radiotherapy. Clearly, one should interpret the study in the context of personal views regarding thromboprophylaxis and its effectiveness and safety in orthopaedic surgery, however, quantification of the significant increases in baseline rates of thromboembolism, even when thromboprophylaxis is administered, is valuable information.

Tibial plateau fracture patterns under the spotlight

The venerable Schatzker classification is universally taught and used, but we would all admit it has significant limitations in describing more complex fracture patterns. The original classification was made purely on the AP radiograph, and only really addresses coronal plane fractures. The classification doesn’t really address posterior and medial elements which are poorly described, particularly with respect to determination of treatment. This study from Amsterdam (The Netherlands) reviews the CT scans of 127 patients suffering a proximal tibial fracture and aims to describe the injuries in a more anatomic way using cross-sectional imaging, as has been described for the pilon.⁴ Review of all of the scans identified four frequent characteristics in the fracture patterns: 75% had a lateral split fragment, 43% had a posteromedial fragment, 28% had a zone of comminution centrally including the spines and extending into the lateral plateau, and 16% had a tibial tubercle fragment. None of these characteristics has previously been described in formal terms of incidence. Understanding the presence, in particular, of the posteromedial fragment, its size and orientation, will aid approach and fixation strategies. Although the authors do not propose a new classification or attempt to relate their findings to treatment outcomes or strategies, they may well form the basis for future studies.

The health economic effects of long bone nonunion

Having a nonunion following a long bone fracture is widely known to have a significant impact on patients’ quality of life. While much work has been conducted establishing the consequences of tibial nonunion and long bone infection, there is surprisingly little in the way of comparative information. A study group from Houston (USA) have attempted to quantify this effect by comparing utility scores.⁵ The study team used the ‘time trade off’ (TTO) approach, a form of utility score methodology which, while flawed, does give an indication of comparative health utility. The methodology involves asking patients how many years of remaining life they would give up in return for a full state of health for the remainder. This was administered to 832 consecutive patients, all with nonunions, whose TTO scores were identified. The overall TTO score was 0.68, although there were significant differences between nonunion site (forearm 0.54, clavicle 0.59, femur 0.68, and tibia 0.68). Forearm nonunions had the lowest utility score and so the worst patient impact, with the mean scores poorer than that for diabetes, stroke or HIV, indicating the profound quality of life impact such nonunions have for patients. Early recognition and treatment of nonunions, whatever the cause, is clearly essential.

Adverse outcomes in trauma

Researchers from Vanderbilt University, Nashville (USA) compared the risk of complications using the very large database of the American College of Surgeons National Surgical Quality Improvement Program.⁶ The analysis was designed to identify the adverse event rates for orthopaedic trauma patients, and go on to stratify these risks by anatomic region and patient risk factors. The study cohort consisted of 146 773 orthopaedic patients, including

22 361 with trauma diagnoses. After controlling for the risk factors available in the dataset, the investigators established that trauma patients were twice as likely as general orthopaedic patients to sustain complications (11.4 % vs 4.1 %). Patients with hip and pelvic injuries were four times more likely to develop a peri-operative complication compared with patients with upper extremity injuries, and patients with lower limb injuries were three times more likely to develop a peri-operative complication than those with upper extremity injuries. While it stands to reason that in the less controlled environment of trauma, the risks and complications of healthcare provision are likely to be higher, this is the first paper we have come across here at 360 to quantify in sufficient numbers the size of the problem.

The sacral screw in children

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Sacral fractures in the growing pelvis can be tricky both to diagnose and to treat. Given their rarity they are often treated in tandem with adult and paediatric consultants, and adult algorithms and treatment strategies are frequently used for operative stabilisation. In short, there is a lot we don’t know about how best to treat these rare injuries. In one of the few reports on treatment, surgeons in El Paso (USA) have focused on the sacral fracture and specifically the use of the iliosacral screw.⁷ As perhaps might be expected, the authors were able to assemble a very small series of just 11 paediatric patients presenting with sacral injury. They were all treated with one or more iliosacral screws, with ten of the 11 patients achieving stable fixation and healing. The technique in this series was feasible in children as young as six years old, with overall good stability and minimal complication rates.

Treating the contralateral SUFE

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Opinion still remains very divided about whether to treat the asymptomatic hip in patients who present with a slipped capital femoral epiphysis for the first time. Presenting often as part of the general trauma ‘take’, it is difficult to know what proportion of patients are acute, chronic, or acute-on-chronic. A retrospective study (Edinburgh, UK) reviewing 86 patients treated over a ten-year period considered outcome and cost in two groups of patients treated in different ways.⁸ Prophylactic contralateral fixation was performed in 36 cases, and the results of these were analysed for cost effectiveness against a larger group where no procedure was performed initially (n = 50). If no prophylactic fixation was undertaken, the rate of secondary slip was 46%, giving an overall cost of the quality-adjusted life year QALY gained at £1431 for prophylactic fixation. This is clearly on the side of cost effectiveness and has resulted in significantly fewer complications, better health measure scores (SF-12) and, in longer-term follow-up, no visible radiographic cam lesions. It certainly seems that the evidence is accumulating in favour of prophylactic pinning.