Trauma

Hip fractures and postoperative weight-bearing restrictions

Acetabular fracture surgery: mind the step

Early reoperation after operative treatment of acetabular fractures

In the second paper on acetabular fractures in this issue of 360, a group from Baltimore, Maryland (USA) have turned their attention to the risk factors for early reoperation.³ Rather than focusing on the quality of reduction and the longer-term risk of conversion to a total hip arthroplasty (THA), this paper deals with the causes of early secondary intervention. In one of the largest series of its kind, comprising 791 patients with displaced acetabular fractures, the authors examined risk factors that might be associated with early reoperation following operative fixation of the acetabulum. For the purposes of their study, they defined early reintervention as further operation occurring within three months, with the intention of capturing early infections, metalwork failure, and early conversion to THA. In their series, 7% of patients (n = 56) underwent debridement and washout of an acutely infected fixation or wound complications. Risk factors for this complication, in this series, included length of stay in the intensive care unit, having had a pelvic embolization, increased operative time, and time delay between injury and surgical fixation. Whilst some of these factors are self-evident or have been previously identified, supporting these previous findings in a large series is important. Some risk factors are clearly modifiable, such as operative time and timings to surgery, whilst others, such as pelvic embolization, may not be. The message should perhaps be that patients who are likely to have a prolonged stay in the intensive care unit, and who have required pelvic embolization, should be emergently operated on by an experienced, high-volume acetabular surgeon in order to minimize complications. Of the 8% of patients (n = 62) who underwent early revision surgery, the majority were revised to an arthroplasty (n = 45), whilst ten patients underwent early revision fixation for loss of reduction and six patients underwent removal of metalwork for likely joint penetration. Revision was more likely with hip dislocation, articular comminution, femoral head or neck fracture, and advancing age.

Quantitative histology and fracture-related infection

Single- versus double-column fixation in transverse fractures of the acetabulum

There are precious few randomized trials in trauma, let alone in rarer diagnoses such as acetabular fractures. Whilst there are some obvious methodological problems with this study from Cairo (Egypt), which involves just 30 patients and is therefore clearly underpowered, it is notable for its inclusion only of patients with a double-column acetabular fracture.⁵ These patients were randomized to receive either a single-column fixation (posterior) or a posterior column plating with an additional anterior column screw. The authors aimed to establish which approach was superior in the treatment of patients with a transverse fracture of the acetabulum, either with or without a posterior wall element. Outcomes were assessed using the Matta radiological criteria, roof arc angle, and femoral head offset. The patients had a variable follow-up period, with a mean follow-up of 19 months (minimum 12 months). In terms of initial treatment, the authors identified no differences in the quality of postoperative reduction, blood loss, and hospital stay. They were unable to establish any differences in functional scores (Merle d’Aubigné–Postel score). However, there was a difference in operative timing, as would be expected, with the double-column fixation group taking significantly longer on average (130 minutes vs 104 minutes). Despite the robust radiological outcome measures, there were no differences seen in terms of loss of reduction observed in the two groups. This trial is worthy of mention, given the difficulties in achieving such a study in a rare diagnosis, as well as the logistical issues associated with recruiting and randomizing patients to a complex intervention. Nevertheless, here at 360, we can’t help but view this trial as a pilot study demonstrating that this can be achieved. Not every transverse fracture is suitable for an anterior column screw, and nor is every fracture suitable for posterior fixation alone. The small numbers of patients reported here essentially make any ‘negative’ finding irrelevant, as the effect size it is powered to detect is extremely large and it is unlikely that any differences will be seen, clinically relevant or otherwise.

Treatment of type B and C pelvic fractures

The method of treatment for unstable pelvic fractures that involve the obturator ring is still very much a matter for debate. In the absence of any robust trial data, large case series have become the mainstay of research to underpin clinical decision making. However, there are now some large trauma registries that include high-quality information on patient diagnoses, allowing certain inferences to be drawn from their results. We were delighted to see this article from Freiburg (Germany) that reports on the outcomes of type B and type C pelvic fractures.⁶ The authors compared patients undergoing conservative management and surgical treatment, including posterior stabilization alone with isolated posterior osteosynthesis, anterior fixation, and combined fixation. The series consisted of 3739 fractures, including 2394 conservatively managed patients and 1345 patients who underwent surgical treatment. The authors undertook an evaluation of outcomes, including adjustment for recorded confounders. According to their analysis, operative stabilization reduced mortality by 36% but doubled the observed incidence of complications. Interestingly, there were no differences in mortality and the incidence of neurological deficits at discharge between isolated posterior or combined anteroposterior fixation. However, the odds of surgical and general complications were over twice as high in the group with the more extensive surgery. This observational series confirms the benefits of what has become standard practice in the majority of centres, in terms of open reduction and internal fixation of patients with unstable pelvic fractures. The assessment of complications is useful in that it addresses the question of risks and benefits in those patients with stable injuries, who would run the risk of a significant increase in major complications if surgery were undertaken for social or convenience reasons.

Plasma during air medical transport

There have been great strides made over the last 40 years in improving outcomes for the severely injured, thanks in part to the rationalization of trauma services, addition of transfer protocols, formal recognition of levels of trauma care, and nationalized and regionalized models of care. The prospects for the average trauma victim injured and managed within a modern trauma network are many times better than they would have been in previous decades, and are also better than they would be outside of a formalized trauma network. The formalization of these networks and coordination between Helimed and trauma centres have also allowed for changes in front-line care. One of these changes, pre-hospital plasma resuscitation, is the focus of this randomized trial led by researchers in Pittsburgh, Pennsylvania (USA).⁷ The authors trialled their standard resuscitation protocol against the addition of pre-hospital administration of thawed plasma. This was a safety-and-efficacy trial that included injured patients who were at risk of haemorrhagic shock. The trial reports on the outcomes of 501 patients, of whom 230 patients received plasma and 271 received standard care. The primary outcome was mortality at 30 days, as the trial was designed to assess the effects of early plasma administration on downstream haemorrhage. In terms of the primary outcome measure, there was a superior rate of survival in the plasma group (33.0% vs 23.2% in the standard-care group); this was also seen in the nine pre-specified subgroups. When explored with Kaplan–Meier analysis, the treatment effect appeared to begin at three hours post-injury, and was maintained until the 30-day follow-up. In terms of possible explanations for the observed effect, there was a lower average prothrombin-time ratio (1.2 vs 1.3) in the intervention group. There are no significant differences in the other common causes of death or expected serious adverse events with regard to multi-organ failure, acute lung injury and acute respiratory distress syndrome, nosocomial infections, or allergic or transfusion-related reactions. Quicker blood products in haemorrhagic shock leads to reduced mortality. Whilst there are some potential difficulties with access and logistics here, early access to blood ambulances or helicopters would seem to be a sensible approach where possible. The study was funded by the military, which makes it clear where one application of this protocol will be.

Discharged but not dissatisfied: the Edinburgh Trauma Triage Clinic

In state-funded systems and those with bundled payments, there is an incentive to reduce the number of patients moving through clinics, whilst in other systems there may be incentive to keep the number of patients high for funding reasons. In some parts of the world, telemedicine, Skype consultations, and other types of ‘virtual’ clinic have become very fashionable, whereas in others, triage approaches have become very common. In one of the few papers looking at these changes in detail, the Edinburgh (UK) trauma service report on how their changes in protocol were effective in streamlining the clinic experience for their patients.⁸ The Edinburgh approach involves the implementation of consultant-led ‘virtual’ triage of referrals combined with the direct discharge of minor fractures from the Emergency Department. The authors then compared the patient outcomes for simple fractures of the radial head, little finger metacarpal, and fifth metatarsal before and after the implementation of the Edinburgh Trauma Triage Clinic (TTC). The authors report on a consecutive series of 628 patients, all of whom had sustained these simple upper limb injuries over a one-year period. Two patients were subsequently excluded due to death and incarceration, respectively. During the study period, there were 337 patients in the pre-TTC group and 289 in the post-TTC group. This paper reports on the clinical scores in terms of Disabilities of the Arm, Shoulder and Hand Score (QuickDASH) or Foot and Ankle Disability Index (FADI), EuroQol-5D (EQ-5D), visual analogue scale (VAS) pain score, satisfaction rates, and return to work/sport at six months post-injury. The patients were not directly seen; however, their electronic records were evaluated at three years post-injury in an attempt to exclude late complication. A cost analysis was performed. Overall, patient-reported outcomes were equivalent between the two groups, although at three years, the pre-TTC group required a total of 496 fracture clinic appointments compared with 61 in the post-TTC group. Mean cost per patient was nearly four times less after the commencement of the TTC. There is certainly some food for thought here, and appropriate use of expensive resources (such as face-to-face fracture clinic time) is clearly important. It is worth noting that the system reported on here is an enhanced triage rather than a ‘telephone clinic’ approach, and that data related to the former should not be used to support the implementation of the latter.