Injury August 2023

Injury 54 (2023) 110713
Contents lists available at ScienceDirect
Injury
journal homepage: www.elsevier.com/locate/injury
Anxiety and depression are associated with poor outcomes in open

elbow arthrolysis
Weitong Sun, Chen Chen, Xieyuan Jiang *, Kehan Hua, Yejun Zha, Maoqi Gong, Dan Xiao,
Xian Zhao
Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing 100035, China
A R T I C L E I N F O A B S T R A C T
Keywords: Background: Open elbow arthrolysis (OEA) is an established treatment for posttraumatic elbow stiffness (PTES);
Joint stiffness however, its efficacy is debatable for some patients. Poor surgical outcomes have been associated with anxiety
Elbow and depression in other orthopedic conditions, but no studies have examined this association in OEA. In this
Open elbow arthrolysis
study, we aimed to determine whether a high preoperative anxiety and depression score is associated with a
Anxiety
Depression
worse functional outcome in OEA for PTES.
Prognosis Methods: A retrospective review of prospectively collected data was carried out in patients undergoing OEA
between April 2021 and March 2022. Mental state evaluated by Hospital Anxiety and Depression Scale (HADS),
subjective elbow function valued by Disabilities of the Arm, Shoulder, and Hand (DASH) score, objective elbow
function valued by Mayo Elbow Performance Score (MEPS), pain score measured by visual analog scale (VAS)
and the flexion-extension range of motion (ROM) of the affected elbow were collected before and after surgery in
outpatient clinic follow-up at 3 months and 6 months. Patient satisfaction was only recorded 6 months post
operatively. All patients were divided into 2 groups based on the preoperative HADS score for analysis: Group A
was the nonanxiety-depression group, and Group B was the anxiety-depression group.
Results: A total of 49 patients were included. Both groups improved in DASH, MEPS and ROM at 3 months and at
6 months. The HADS score in Group B decreased significantly at 6 months, showing that the mental state of
patients in Group B improved after surgery. Group A had a lower DASH at 3 months and 6 months, larger 6-
month ROM and higher satisfaction rate than Group B. Comparing the differences between preoperative and
postoperative measurements, Group A improved more in ROM at 6 months. There was no significant difference
in other outcome measures between the two groups.
Conclusions: OEA is a safe and effective treatment for PTES, and can achieve good clinical outcomes in the short-
term follow-up, regardless of whether the patients suffer from anxiety or depression. Patients with a HADS score
≥11 before OEA, however, have worse outcomes than those with a HADS score <11.
Level of evidence: Level II; Retrospective Design; Prognosis Study
Introduction (OEA) is shown to be a reliable and effective intervention for PTES in

recent studies, with an aim of maximizing elbow motion and achieving a
Posttraumatic elbow stiffness (PTES), manifested as limited flexion pain-free, stable and functional joint. [7,8]
or extension, develops in approximately 5–15% of patients who undergo Psychological factors, especially anxiety and depression, are associ
elbow trauma. [1–3] PTES causes severe impairments in daily activities, ated with disability, pain, and a lower quality of life in a variety of
as a 50% reduction in elbow range of motion (ROM) would cause up to musculoskeletal disorders, [9–11] including elbow. [12] For orthopedic
80% loss of upper extremity function. [4–6] Open elbow arthrolysis surgery, current studies have also demonstrated that patients with
Abbreviations: BMI, Body Mass Index; DASH, Disabilities of the Arm, Shoulder, and Hand; HADS, Hospital Anxiety and Depression Scale; IQR, Interquartile Range;
MEPS, Mayo Elbow Performance Score; OEA, Open Elbow Arthrolysis; PTES, Posttraumatic Elbow Stiffness; ROM, Range Of Motion; TKA, Total Knee Arthroplasty;
VAS, Visual Analog Scale.
* Corresponding author.
E-mail address: jxytrauma@163.com (X. Jiang).
https://doi.org/10.1016/j.injury.2023.03.041
Accepted 31 March 2023
Available online 1 April 2023
0020-1383/© 2023 Published by Elsevier Ltd.
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W. Sun et al. Injury 54 (2023) 110713
anxiety and depression have lower satisfaction, worse functional out percentages, and their differences were compared using Fisher’s exact or
comes and increased postoperative complications compared with pa Pearson’s test. Normally distributed continuous data were presented as
tients without mental health disorders. [13–20] A randomized the mean ± standard deviation and were compared using a t-test, while
controlled clinical trial confirmed that psychological interventions abnormally distributed continuous data were expressed as the median
during the perioperative period in orthopedic surgery can improve pa (interquartile range [IQR]) and were analyzed using the Mann‒Whitney
tient satisfaction in patients with depression. [21] Surgeons have, U test. The Wilcoxon signed rank test for paired abnormally distributed
therefore, raised concerns about mental status in musculoskeletal dis data was used to assess the statistical significance between preoperative
eases during the past few years. and postoperative outcome measures. A p value of < 0.05 was consid
PTES has a tremendous negative impact on daily life, leading to a ered statistically significant.
range of psychological disorders. Our team has preliminarily investi No pilot study was performed on this original research; therefore, no
gated the comorbid anxiety of PTES, revealing a prevalence of 39.2% a priori analysis could be performed to determine the sample size. A post
and a higher anxiety level than patients with normal elbow function. hoc power analysis was performed using the final outcome measure
[22] Liu et al. [23] found a prevalence of 63.8% and 53.7% for ments for satisfaction rates at 6 months, and our sample size had a power
depression and anxiety, respectively, in patients with PTES. Clinically, of 94% at a 5% level of significance (2 tailed). Analysis using the same
we found that the efficacy of OEA was debatable in some patients, outcome measurements for satisfaction rates at 6 months for a power of
especially in those with possible psychological disorders. There have 80% and 5% level of significance (2 tailed) revealed that a total sample
been a large number of studies on the relationship between the preop size of 38 patients would be sufficient to conduct the study.
erative psychological disorders and outcomes of orthopedic surgeries,
and their conclusions have guided the perioperative management of Results
other orthopedic diseases and significantly improved the functional
outcomes [13–21]. However, there has been no research into the cor A total of 71 patients met the inclusion criteria and agreed to
relation between outcomes of OEA and preoperative anxiety and participate in this study. Six patients who underwent arthroscopic elbow
depression. If the relationship between the preoperative mental state arthrolysis were excluded. Sixteen patients failed to attend the 6-month
and the outcomes of OEA is established, perioperative management follow-up, and ultimately, data from 49 patients were included in the
strategies for PTES can be optimized to improve patient outcomes. In analysis (Fig. 1). There were 31 patients in Group A, with a mean age of
this study, we aimed to determine whether a high preoperative anxiety 39.8 ± 12.1 years (18 male, 13 female), while there were 18 patients in
and depression score is associated with a worse functional outcome in Group B, with a mean age of 38.4 ± 13.9 years (10 male, 8 female). The
OEA for PTES. basic demographic data of both groups were comparable (Table I).
Comparing preoperative to postoperative measurements, both
Materials and methods groups improved in DASH, MEPS and ROM at 3 months and at 6 months.
HADS was improved in Group B at 6 months. There was no significant
This study was approved by the institutional ethical review board of difference in VAS at 3 months or at 6 months (Table II, Fig. 2).
our hospital (JST-202104–17). A retrospective review of prospectively The 3-month HADS score of Group A was still significantly lower
collected data was carried out in patients undergoing OEA in our hos than that of Group B, but there was no significant difference in the 6-
pital between April 2021 and March 2022. Inclusion criteria were as month HADS score between the two groups. Group A had a lower
follows: (1) not regaining functional flexion-extension ROM after 6 DASH at 3 months and 6 months, larger 6-month ROM and higher
months of nonoperative treatment, and (2) patients (aged ≥18 years) satisfaction rate than Group B. The preoperative VAS of Group B was
with flexion-extension ROM of ≤100◦ who desire to improve their ROM. higher than that of Group A. There was no significant difference in other
[6] The exclusion criteria were as follows: (1) undergoing arthroscopic outcome measures between the two groups (Table II). Comparing the
elbow arthrolysis; (2) concomitant severe cognitive impairment; and (3) differences between preoperative and postoperative measurements be
known ipsilateral elbow or forearm deformity. Basic demographic data tween the two groups, Group A improved more than Group B in ROM at
were collected for each patient. Preoperative mental state evaluated by 6 months after OEA (Table III). Twenty cases of transient ulnar nerve
Hospital Anxiety and Depression Scale (HADS), patient-based subjective symptoms and 3 cases of wound infection were observed in the included
elbow function score valued by Disabilities of the Arm, Shoulder, and
Hand (DASH) score, surgeon-based objective elbow function score
valued by Mayo Elbow Performance Score (MEPS), pain score measured
by visual analog scale (VAS) and the flexion-extension range of motion
(ROM) of the affected elbow were collected one day before OEA. All
patients were divided into 2 groups based on the preoperative HADS
score (≥11 represents anxiety and depression). [13] Group A was the
nonanxiety-depression group (HADS <11), and Group B was the
anxiety-depression group (HADS≥11).
All procedures were performed following the standard OEA protocol
of our hospital. Postoperative rehabilitation of all patients was carried
out in our hospital. The surgeons, rehabilitation physicians and patients
were all blinded to the results of the preoperative questionnaire. Patients
were followed up in the clinic at 3 months and 6 months by the authors
of the study, and the HADS, DASH, MEPS, ROM and VAS scores were
collected again. Satisfaction of the patients was only recorded 6 months
postoperatively. We divided satisfaction into the following three levels:
satisfied, average and dissatisfied. The satisfaction rate was calculated
by dividing the number of satisfied patients by the total number of
patients.
Statistical analysis was performed using SPSS version 22.0 statistical
Fig. 1. Patient flowchart.
software (IBM, USA). All data were tested for normality using the Sha
piro‒Wilk test. The categorical variables were described as numbers and
W. Sun et al. Injury 54 (2023) 110713
Table I interventions in orthopedic surgery can improve patient satisfaction in

Patient demographics. patients with depression. [21] Cross-sectional studies [22,23] found that
Group A Group B Significance a large proportion of patients with PTES have either depression or
(HADS<11) (HADS≥11) anxiety symptoms. Therefore, determining whether anxiety and
Age, y 39.8 ± 12.1 38.4 ± 13.9 0.714 depression are associated with worse clinical outcomes after OEA is
Gender, M/F 18(58.1)/13(41.9) 10(55.6)/8(44.4) 0.864
crucially important. In this study, we found that preoperative anxiety
Dominant limb 18(58.1) 12(66.7) 0.551
BMI, kg/m2 25.2 ± 4.7 23.3 ± 4.0 0.163 and depression correlate with worse functional outcomes after OEA.
PTES patients with HADS ≥11 had worse patient-based subjective upper
Categorical variables are presented as number (%); continuous variables are
limb functional scores, smaller elbow flexion-extension ROM, and lower
presented as mean ± standard deviation. BMI, Body Mass Index.
satisfaction after surgery. We speculated that this might be related to the
poor compliance of patients with anxiety and depression with post
patients. There was no significant difference in post-operative compli operative rehabilitation. Rehabilitation is crucial for the final outcomes
cations between the two groups (Table II). of OEA, and studies [24–27] have shown that anxiety and depression are
associated with reduced treatment adherence in a variety of diseases.
Discussion Our results showed that OEA can significantly improve upper limb
function and elbow flexion-extension ROM in patients with PTES, which
Recent studies [13–20] have shown that anxiety and depression is proven to be a safe and effective treatment for PTES. The patient-based
correlate with worse clinical outcomes in various specialties, including subjective score, surgeon-based objective score and flexion-extension
shoulder surgery, total knee arthroplasty, total hip arthroplasty, lumbar ROM of both groups were significantly improved at 3 months after the
spinal stenosis surgery and surgical intervention for traumatic brachial operation and further slightly improved at 6 months. The HADS in the
plexus injury. It has been proven that perioperative psychological anxiety-depression group decreased significantly at 6 months,
Table II
Comparison of outcome measures.
Group A Significance Group B Significance Significance
(HADS<11) (preop vs. postop) (HADS≥11) (preop vs. postop) (A vs. B)
Preoperative HADS 4(3,8) – 15.5(13,21) – <0.001
3-month HADS 5(2,9) 0.952 13.5(4.5,21.3) 0.052 0.005
6-month HADS 3(1,7) 0.123 6.5(0.8,15.5) 0.002 0.128
Preoperative DASH 26.7(16.7,45.8) – 40(16.9,55.2) – 0.290
3-month DASH 16.7(10,25) <0.001 29.2(12.3,39.4) 0.037 0.044
6-month DASH 10.8(5,16.7) <0.001 16.3(9,34.2) 0.001 0.035
Preoperative MEPS 70(55,85) – 60(53.8,71.3) – 0.182
3-month MEPS 95(85,100) <0.001 85(73.8,100) 0.001 0.428
6-month MEPS 100(85,100) <0.001 90(83.8,100) <0.001 0.385
Preoperative ROM, ◦ 45(0,60) – 30(17.5,55) – 0.714
3-month ROM, ◦ 110(80,140) <0.001 105(57.5,125) <0.001 0.220
6-month ROM, ◦ 130(110,140) <0.001 110(75,132.5) <0.001 0.042
Preoperative VAS 0(0,1) – 2(0.8,3.3) – 0.002
3-month VAS 0(0,2) 0.884 0(0,2.5) 0.129 0.806
6-month VAS 0(0,1) 0.570 0(0,2.3) 0.072 0.454
6-month satisfaction 26(83.9) – 6(33.3) – <0.001
Complications 14(45.2) – 8(44.4) – 0.961
Categorical variables are presented as number (%); continuous variables are presented as median (interquartile range [IQR]). HADS, Hospital Anxiety and Depression
Scale; DASH, Disabilities of the Arm, Shoulder, and Hand score; MEPS, Mayo Elbow Performance Score; ROM, Range Of Motion; VAS, visual analog scale.
Fig. 2. Outcome measures. The white boxes represent patients in Group A; gray boxes represent patients in Group B. Box plot of median and interquartile range are
shown. HADS, Hospital Anxiety and Depression Scale; DASH, Disabilities of the Arm, Shoulder, and Hand score; MEPS, Mayo Elbow Performance Score; ROM, Range
Of Motion; VAS, visual analog scale.
W. Sun et al. Injury 54 (2023) 110713
Table III The overall complication rate of OEA in this study was 44.9% (22/
Comparison of differences between preoperative and postoperative outcome 49), including 20 cases of transient ulnar nerve symptoms and 3 cases of
measures. wound infection. All patients recovered after treatment. No one under
Difference Group A Group B Significance went a second operation. According to the data from this study, anxiety
(HADS<11) (HADS≥11) and depression were not associated with an increased incidence of
HADS (3-month - pre) 0(− 2,3) − 4(− 9.5,1.8) 0.025 postoperative complications after OEA. Numerous studies [16,18,20]
HADS (6-month - pre) − 1(− 3,1) − 7.5(− 13.5,− 1.8) 0.001
have shown that psychiatric disorders can significantly increase the
DASH (3-month - pre) − 10.9 − 12.1 0.717
(− 22.5,− 2.5) (− 17.7,− 1.7) incidence of complications after total knee arthroplasty (TKA), but this
DASH (6-month - pre) − 16.6 − 19.6 0.582 is not the case in OEA.
(− 31.6,− 5.9) (− 23.4,− 6.7) Our results need to be interpreted on the basis of the following
MEPS (3-month - pre) 25(5,35) 20(10,40) 0.610
limitations. First, this study was performed in a single center, which
MEPS (6-month - pre) 25(10,40) 27.5(13.8,41.3) 0.639
ROM (3-month - pre), 60(45,95) 45(30,82.5) 0.170 leads to the possibility that our results may not be suitable for other
ROM (6-month - pre), 70(60,110) 60(33.8,90) 0.045 institutions. However, the single-center study has its advantage, as it
VAS (3-month - pre) 0(− 1,1) − 1.5(− 3.3,0.3) 0.064 maintains the consistency of surgical protocols and perioperative man
VAS (6-month - pre) 0(0,0) − 1.5(− 3,0) 0.017 agement strategies. Second, there may be some self-reporting bias. Some
Continuous variables are presented as median (interquartile range [IQR]). important data were collected through questionnaires completed by
HADS, Hospital Anxiety and Depression Scale; DASH, Disabilities of the Arm, patients, which may lead to under/overreporting. Third, there was no
Shoulder, and Hand score; MEPS, Mayo Elbow Performance Score; ROM, Range power calculation to guide the sample size for this study, although post
Of Motion; VAS, visual analog scale. hoc analysis suggests that this study is adequately powered, given the
findings. Fourth, only PTES patients with limited flexion-extension ROM
suggesting that OEA can alleviate their anxiety and depression. How were included. Our findings are thus not suitable for patients with
ever, PTES patients with HADS ≥11 gained less flexion-extension ROM limited rotation ROM of the forearm and elbow stiffness caused by
after OEA at 6 months. Despite the overall worse outcome, OEA is still an degeneration and inflammatory diseases. Fifth, patients were only fol
effective treatment for the anxiety-depression group of patients. lowed up for 6 months after surgery, so whether preoperative anxiety
The HADS was developed as a simple screening tool for anxiety and and depression have a negative impact on patients’ long-term outcomes
depression by Zigmond and Snaith in 1983, [28] the validity of which remains unknown. Future studies with a long-term follow-up are
has been confirmed in many studies. [29–31] It consists of 14 items, needed.
seven of which rate anxiety level and seven of which rate depression
level. A score of >11 defines a case with possible anxiety and depression Conclusions
symptoms. It is not used to diagnose clinical anxiety and depression;
however, it provides a robust and simple means for quantitatively OEA is a safe and effective treatment for PTES, and can achieve good
evaluating the mental state of a patient. [13] The patient group was clinical outcomes in the short-term follow-up, regardless of whether the
defined according to HADS score, not by clinical diagnosis of anxiety or patients suffer from anxiety or depression. Patients with a HADS score
depression, because a score of 11 does not specifically indicate that any ≥11 before OEA, however, have worse outcomes than those with a
individual line of treatment is appropriate but rather that further HADS score <11. We suggest that the HADS questionnaire should be
investigation and treatment may be necessary, [13] which is more used to evaluate the mental state of patients before surgery. Since pa
relevant in this study. tients with a higher HADS score still significantly improve physically
Since anxiety and depression are frequently observed in patients and mentally, discussion with patients regarding preoperative psychi
suffering from chronic pain, [32–34] the VAS score of preoperative pain atric treatment is appropriate. Assessment and treatment of preoperative
in the anxiety-depression group was higher than that in the mental health is important in designing a comprehensive perioperative
nonanxiety-depression group in this study. No significant difference in management plan to optimize patient outcomes and satisfaction.
the VAS score of pain between the two groups existed after surgery.
Clinically, anxiety and depression often go hand in hand. Approximately Declaration of Competing Interest
85% of patients with depression have significant anxiety, and 90% of
patients with anxiety disorder have depression. [35] The purpose of this All authors of this study, their immediate family, and any research
study was to establish the relationship between preoperative mental foundation with which they are affiliated did not receive any financial
state and functional outcomes after OEA to lay a foundation for payments or other benefits from any commercial entity related to the
improving the efficacy of OEA through perioperative psychological subject of this article.
intervention. In general hospitals, preoperative mental assessment is
only used to screen patients with anxiety and depression who may need Financial biases
intervention, and more detailed differentiation, diagnosis and treatment
can be carried out in psychiatric clinics. Therefore, in this study, anxiety None.
and depression were not distinguished in the assessment of preoperative
mental state, but the HADS was used to evaluate both at the same time. IRB approval
Understanding the bidirectional interaction between physical and
psychiatric disorders could help improve patient outcomes. Based on the Beijing Jishuitan Hospital institutional review board (JST-
results of our study, we suggest preoperative screening using the HADS 202104–17).
questionnaire for PTES patients. Referring patients with a HADS score
≥11 to psychiatric clinics for further diagnosis and treatment may be Funding
helpful to improve the outcome of OEA, but this needs to be confirmed
by further clinical studies. Because patients suffering from anxiety and Project supported by Beijing JST Research Funding (code: QN-
depression still show an improvement at 6 months both physically and 202106).
mentally, we recommend it should be discussed with the patient and
consider whether preoperative psychiatric treatment is appropriate. Our Supplementary materials
study will help orthopedic surgeons educate PTES patients on proper
expectations of postoperative outcomes. Supplementary material associated with this article can be found, in
W. Sun et al. Injury 54 (2023) 110713
the online version, at doi:10.1016/j.injury.2023.03.041. arthroplasty: a propensity score-weighted retrospective analysis. J Am Acad
Orthop Surg 2021 Oct 15;29(20):873–84. https://doi.org/10.5435/JAAOS-D-20-
00721.
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primary total knee arthroplasty in the United States. J Arthroplasty 2019;34(10): [34] Kerckhove N, Boudieu L, Ourties G, Bourdier J, Daulhac L, Eschalier A, Mallet C.
2337–46. Epub 2019 May 28. Ethosuximide improves chronic pain-induced anxiety and depression-like
[17] Khatib Y, Madan A, Naylor JM, Harris IA. Do psychological factors predict poor behaviors. Eur Neuropsychopharmacol 2019;29(12):1419–32. https://doi.org/
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[18] Zalikha AK, Karabon P, Hajj Hussein I, El-Othmani MM. Anxiety and depression https://doi.org/10.5694/mja12.10628.
impact on inhospital complications and outcomes after total knee and hip
Injury 54 (2023) 110813
Injury
Effect of surgical delay on 30-day mortality in patients receiving direct oral

anticoagulants and admitted for hip fracture
Eric Noll a, *, Ludovic Keller a, Pierre Tran Ba Loc b, Philippe Adam c, Thomas Arat a,
Johanne Piotrowski d, Elliott Bennett-Guerrero d, Erik Sauleau b, Julien Pottecher a
a
Department of Anesthesiology and Intensive Care, Hautepierre Hospital, Strasbourg University Hospital, Service d’Anesthésie-Réanimation, 1 avenue Molière, Strasbourg
67200, France
b
Department of Public Health, Strasbourg University Hospital, France
c
Department of Orthopedic & Trauma Surgery, Hautepierre Hospital, Strasbourg University Hospital, France
d
Department of Anesthesiology, Stony-Brook Medicine, Stony-Brook University, New York, USA
Keywords: Background: Early hip fracture surgery is recommended to decrease mortality, however the impact of a delay in
Anticoagulants surgery due to previous treatment with direct oral anticoagulants (DOA) is unknown. Our objective was to
Perioperative medicine determine if early surgery, defined as surgery within 48 h of hospital admission is associated with decreased
Hip
postoperative mortality. We tested the hypothesis that early surgery was beneficial with regard for mortality in
Mortality
Surgery
patients treated with direct oral anticoagulants.
Methods: Retrospective cohort study in a French University Hospital including patient admitted for Hip fracture.
The main exposure was wait time for surgery defined as the total time, in hours, between hospital admission and
surgery. The main outcome was mortality within 30 days after hip fracture surgery.
Results: In 3429 patients, the overall 30-day mortality was 4.1% (95% CI 3.5%; 4.9%). In DOA + patients, the 30-
day mortality rates in the early and delayed surgery groups were 1.2% and 5.9%, respectively, with estimated
risk difference of -4.4 (with a 2% probability of this difference is > 0). In the DOA + group, early surgery tended
to be associated with a higher percentage receiving red-blood cells (64.6% vs 54.8%, respectively, estimated risk
difference of 9.9% with a 93% probability of this difference is > 0) and lower risk of pneumonia (1.2% vs 8.2%,
respectively; estimated difference of -6.7% with 0.3% probability of superiority).
Conclusion: Early hip fracture surgery was associated with improved survival in patients previously treated with
DOAs.
Introduction elderly and frail with multiple comorbidities [12]. A significant number
of these patients are treated with DOA for various indications, including
The annual incidence of hip fracture in the United States and the prevention of thromboembolic events due to non-valvular atrial
worldwide is approximately 300,000 and 4.5 million cases, respectively fibrillation and the treatment or secondary prophylaxis of venous
[1–3]. The mortality from this trauma can be as high as 10% at 1 month thromboembolism [13–16]. DOA-treated patients are at increased risk
[4,5] and 50% at 1 year [6], and is therefore a major health issue. for bleeding, especially in the perioperative period [17,18]. The time to
Among the modifiable risk factors for mortality is the duration between recover normal coagulation after DOA discontinuation depends on the
hospital admission and surgery [7,8]. Several National Guidelines, type of clearance pathway, the specific drug and dose, and patient’s
therefore, recommend performing surgery soon after hospital admis organ function needed for drug clearance. The infrequent use of anti
sion, ideally in less than 48 h [9–11]. dotes for DOA may contribute to the common delay between hospital
However, complying with this recommendation may be challenging admission and surgery observed in DOA-treated patients [19,20].
in patients previously treated with a Direct Oral Anticoagulant (DOA) Assessing risk-benefits for early surgery in DOA-treated patients
due to risk of bleeding. Patients experiencing hip fracture are frequently admitted for hip fracture is challenging given the limited available data.
E-mail address: eric.noll@chru-strasbourg.fr (E. Noll).
Accepted 10 May 2023
Available online 19 May 2023
0020-1383/© 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
E. Noll et al. Injury 54 (2023) 110813
Therefore, the goal of this study was to characterize the association database of deceased people in France, published by the French National
between surgical waiting time and clinical outcome in DOA-treated Institute of Statistics and Economical Studies (INSEE). This 30-day
patients admitted for hip fracture. We hypothesized that early surgery follow-up period is among the most common outcome criteria to
in DOA-treated patients, despite potential risk for more bleeding, would describe the association between wait-time and postoperative mortality
be associated with better outcome. after hip fracture surgery [8].
Secondary outcomes were 90-day mortality, medical complications
Methods during initial hospital length of stay including deep venous thrombosis,
pneumonia, myocardial infarction, and stroke. Medical complications
Setting and data sources during initial hospital length of stay were extracted from the PMSI
database using ICD-10 codes (supplemental Table 1). Red blood cell
This is a single center, retrospective, cohort study using institutional transfusions during the hospitalization were extracted from the EMR.
electronic medical records and a national health administrative data
base in Strasbourg University Hospital France. Statistics
The study protocol was approved by the French Society of Anes
thesiology Institutional Review Board on July 6, 2020 (IRB Patients were separated into DOA-treated (DOA +) vs. non DOA-
00010254–2020-150). As per French law [21], individual patient treated groups (DOA -). Patients receiving the following medication as
informed consent was not required for this retrospective cohort part of their home medication were considered DOA +: rivaroxaban,
research. The study was registered to the institutional Data Protection apixaban and dabigatran. Patients were also separated into early vs.
Officer registry (#20-042). The French National Uniform Hospital delayed surgery according to a wait time for surgery ≤ or > to 48 h after
Discharge Database (Programme de Médicalisation des Systèmes d’Infor hospital admission, respectively.
mation, PMSI), which includes medical and administrative data for every Statistical analyses included a descriptive step (number and fre
hospitalization, was screened to select eligible patients (see below). In quency for qualitative variables and mean and standard deviation for
the PMSI database, according to national coding rules, diagnoses are quantitative variables) and an inferential step using fully Bayesian
coded using the International Classification of Diseases, 10th Revision techniques (Markov chains and Monte Carlo integrations, McMC, with 3
(ICD-10), and procedures are coded according to the French Common chains, a burn-in of 25,000 and 75,000 more iterations with a thinning
Classification of Medical Acts (Classification Commune des Actes of 15 for building a total sample of 15,000 iterations). The summary of
Médicaux, CCAM). The flowchart of the screening process is shown in each posterior distribution is presented as median and symmetric 2.5th
supplemental Fig. 1. and 97.5th distribution quantiles. The probability of superiority of a
parameter was estimated by the frequency of values higher than a given
Patients value of interest (for example 0 for a difference) in the posterior sample.
This probability is similar to a p-value but its definition is the "proba
Adults (age ≥ 45 years) admitted for Hip fracture and discharged bility that the parameter in the population is greater than a given value".
either alive or dead from Strasbourg University Hospital between Eventually a threshold, such as 0.05, is the probability to decide on a
January 1, 2015 and December 31, 2019 were included. Exclusion clinically significant effect.
criteria included encoded associated severe trauma (« severe multiple For the 30-day mortality estimations we used Bayesian logistic
trauma » category of the diagnosis related group), not having undergone regression models with the delay of surgery as the explaining covariate.
hip fracture surgery during hospitalization, and not being a French Bayesian inference in the respect of an evolutionary epistemology con
citizen. sisted of combining prior known information on each parameter to be
estimated (for example from the literature) in the form of a mathemat
Main exposure ical distribution with the information contained in the data (likelihood
function) in order to determine posterior knowledge on each parameter,
The primary independent variable was the duration between usually by sampling in a distribution close to the true distribution of the
admission and surgery (ie entrance in operating theater) measured in parameters (technique of MCMC). When using Bayesian techniques it is
total hours [8]. This time was extracted from the electronic medical important to assess the effect of the prior distributions on the posterior
record (EMR). distributions, in order to judge the robustness of the results. Sensitivity
analyses were carried out by considering four scenarios with different
Covariates priors: a non-informative prior (e.g., Jeffreys’ prior), an informative
prior when available (e.g., 30-day mortality values [8]), an optimistic
The following patient characteristics previously associated with prior and a pessimistic prior. The consequences on the posterior distri
mortality after hip fracture were recorded [8]: age, sex and medical butions when changing prior are not shown in the results section
comorbidities including chronic obstructive pulmonary disease, heart because it turns out that the robustness of the models was confirmed.
failure (HF), and coronary artery disease. These comorbidities were During the reviewing process, we made a supplementary analysis to test
extracted from the PMSI database using the ICD-10 codes(supplemental for imbalance between the subgroups early and delayed surgery sub
Table 1). Surgery duration and preoperative DOA dosing were extracted groups of the DOA-treated patients. We used the Standardized Mean
from the EMR. Medications taken at home at admission were extracted Difference (SMD) approach as previously described [22]. We considered
from the EMR and the use of DOA was recorded (apixaban, rivaroxaban SMD of more than 0.1 or less than − 0.1 as significant.
or dabigatran). The administration of Fresh Frozen Plasma (FFP) or The study size was established on a pragmatic basis considering the
Prothrombin Complex Concentrate (PCC) during hospital stay was exposure time period to maximize sample size while minimizing chro
extracted from the EMR. The dispensation of idarucizumab during the nological bias.
study period was extracted from the hospital pharmacy charts and the For each analysis, patients with relevant missing data were excluded,
medical indications in the corresponding EMR were analyzed. so no imputation was performed. The analyses were carried out using
the R software (with ad hoc packages, e.g., R2jags).
Outcomes The study was carried out with institutional funding only.
The primary outcome was all-cause mortality within 30 days after

hip fracture surgery. This outcome was extracted from the open
Table 1
Patients demographics.
All All DOA DOA DOA SMD between All NON NON DOA NON DOA
patients treated treated treated DOA treated DOA treated treated
patients Early Delayed early and treated Early Delayed
Surgery Surgery delayed surgery patients Surgery Surgery
n¼ n ¼ 217 n ¼ 82 n ¼ 135 n ¼ 3212 n ¼ 2331 n ¼ 881
3429
Demographics Age, mean (SD), y 81.6 83.2 (9.1) 80.9 (11.1) 84.6 (7.4) 0.3914 81.4 (11.2) 80.8 (11.6) 83.2 (10.0)
(11.1)
Female, n (%) 2483 154 (71.0) 64 (78.1) 90 (66.7) − 0.2566 2329 (72.5) 1714 (73.5) 615 (69.8)
(72.4)
Fracture Characteristics
Femoral Neck, n (%) 1553 93 (42.9) 33 (40.2) 60 (44.4) 0.0851 1460 (45.5) 1015 (43.5) 445 (50.5)
(45.3)
Intertrochanteric, n 1724 112 (51.6) 49 (59.8) 63 (46.7) − 0.2646 1612 (50.2) 1195 (51.3) 417 (47.3)
(%) (50.3)
Subtrochanteric, n 182 (5.3) 13 (6.0) 1 (1.2) 12 (8.9) 0.3556 169 (5.26) 138 (5.9) 31 (3.5)
(%)
Associated diagnoses
Bone cancer, n(%) 0 (0) 0 (0) 0 (0) 0 (0) 0 0 (0) 0 (0) 0 (0)
Osteomyelitis, n(%) 0 (0) 0 (0) 0 (0) 0 (0) 0 0 (0) 0 (0) 0 (0)
Other associated 192 (5.6) 11 (5.1) 5 (6.1) 6 (4.4) − 0.0740 181 (5.6) 131 (5.6) 50 (5.7)
fracture, n(%)
Fixation
Osteosynthesis, n 2227 142 (65.4) 60 (73.2) 82 (60.7) − 0.2666 2085 (64.9) 1609 (69.0) 476 (54.0)
(%) (65.0)
Arthroplasty, n(%) 1202 75 (34.6) 22 (26.8) 53 (39.2) 0.2666 1127 (35.1) 722 31.0) 405 (46.0)
(35.1)
Comorbidites
Diabetes 593 43 (19.8) 12 (14.6) 31 (23.0) 0.2144 550 (17.1) 372 (16.0) 178 (20.2)
(17.3)
Hypertension 1701 129 (59.5) 47 (57.32) 82 (60.7) 0.0700 1572 (48.9) 1092 (46.9) 480 (54.5)
(49.6)
Chronic Obstructive 108 (3.2) 3 (1.4) 1 (1.2) 2 (1.5) 0.0227 105 (3.3) 77 (3.3) 28 (3.2)
Disease
Heart Failure 80 (2.3) 11 (5.1) 3 (3.7) 8 (5.9) 0.1063 69 (2.2) 37 (1.6) 32 (3.6)
Coronary artery 157 (4.6) 10 (4.6) 0 (0) 10 (7.4) 0.4000 147 (4.6) 84 (3.6) 63 (7.2)
Disease
Dementia 509 28 (12.9) 8 (9.8) 20 (14.8) 0.1546 481 (15.0) 350 (15.0) 131 (14.9)
(14.8)
Surgical delay
Duration from 42.9 64.8 (47.1) 36.0 (10.0) 82.3 (51.9) 34.7 (27.9) 27.9 (12.1) 77.3 (47.2)
admission to (36.1)
surgery, mean
(sd), h
Type of DOA
Rivaroxaban 78 (2.3) 78 (35.9) 23 (28.1) 55 (40.7) 0.2696 0(0) 0(0) 0(0)
Apixaban 120 (3.5) 120 (55.3) 52 (63.4) 68 (50.37) − 0.2657 0(0) 0(0) 0(0)
Dabigatran 19 (0.55) 19 (8.8) 7 (8.5) 12 (8.9) 0.0125 0(0) 0(0) 0(0)
Anti-Xa/IIa activity 131.1 86.4 (84.4) 158.2 0.5725 NA NA NA
dosing after (138.4) (156.8)
admission, ng/ml
Other antithrombotic treatments
Vit K Antagonsits 474 0 (0) 0 (0) 0 (0) 0 474 (14.8) 212 (9.1) 262 (29.7)
(13.8)
Antiplatelet therapy 908 9 (4.2) 5 (6.1) 4 (3.0) − 0.1512 899 (28.0) 669 (28.7) 230 (26.1)
(26.5)
Intrahospital Prothrombotic Therapy
FFP, n(%) 28 (0.8) 2 (0.9) 2 (2.4) 0 (0) − 0.2236 26 (0.8) 10 (0.4) 16 (1.8)
PCC, n(%) 17 (0.5) 1 (0.5) 0 (0) 1 (0.7) 0.1222 16 (0.5) 8 (0.3) 8 (0.9)
Year
2015 714 14 (6.5) 7 (8.5) 7 (5.2) − 0.1329 700 (21.8) 518 (22.2) 182 (20.7)
(20.8)
2016 677 27 (12.4) 9 (11.0) 18 (13.3) 0.0722 650 (20.2) 450 (19.3) 200 (22.7)
(19.7)
2017 668 33 (15.2) 13 (15.9) 20 (14.8) − 0.0288 635 (19.8) 195 (21.2) 140 (15.9)
(19.5)
2018 671 59 (27.2) 25 (30.5) 34 (25.2) − 0.1185 612 (19.1) 436 (18.7) 176 (20.0)
(19.6)
2019 699 84 (38.7) 28 (34.2) 56 (41.5) 0.1517 615 (19.2) 432 (18.5) 183 (21.0)
(20.4)
DOA: Direct Oral Anticoagulants.

FFP: Fresh Frozen Plasma.
PCC: Prothrombin Complex Concentrate.
SMD: Standardized Mean Difference.
Fig. 1. The relationship between hospital admission to surgery time-delay and 30-day mortality
The relationship between hospital admission to surgery time-delay and 30-day mortality, in Direct Oral Anticoagulants (DOA) + and DOA – groups. Red lines
represent the posterior median of calculated mortality from the Bayesian logistic regression model with increasing time as a covariate and black lines representing the
95% posterior credible interval.
Results Discussion
The flowchart of the screening process is represented in Supple -The main finding of our study is that in DOAtreated patients,
mental Fig. 1. Overall, 3429 admissions were included in the analysis. As delayed surgery, i.e., after more than 48 h after admission, was associ
some patients may have been admitted several times for hip fracture ated with increased 30-day mortality compared with surgery performed
surgery during the several year study period, these 3429 patients within 48 h. These results were observed despite the tendency to an
admission involved 3280 unique patients. Two-hundred seventeen increased risk of transfusion in the DOA+ early surgery. In DOA+ pa
(6.3%) patients were treated with a DOA at time of hospital admission tients, delayed surgery was associated with increased proportion of
(Table 1-). The percentage of DOAtreated patients in the years 2015, postoperative pneumoniae. The internal validity of our results is sup
2016, 2017, 2018 and 2019 were 2.0, 4.0, 5.0, 8.8 and 12.0%, respec ported by the tendency to a superior 90-day mortality in the delayed
tively. No hip fracture-related idarucizumab use was identified during DOA + surgery group. Pincus [8] described a positive relationship be
the study period. tween wait time and 30-day mortality following admission for hip
Overall, 2413 (70%) patients underwent early surgery. Early surgery fracture. The 30-day mortality rate in this paper (5.8% and 6.5% for wait
was performed in 82 (37.8%) and 2331 (72.6%) patients in the DOA + time less than or greater to 24 h) was similar to our mortality rate.
and DOA - groups, respectively (estimated difference of 34.8% [28.0; However, in clinical practice performing early surgery in patients
41.2] with a 99% probability that this difference is > 0%). The time treated with DOA may be challenging for several reasons. To reduce
delay (median [interquartile range]) between hospital admission and bleeding risk, some expert panel guidelines recommend, in the ideal
surgery was 55 [29] hours and 37 [28] hours in the DOA + and DOA - situation of elective surgery, DOA should be discontinued several days
groups, respectively (estimated difference of 23.4 h with a 99% proba before surgery to reduce the bleeding [17,23,24]. Performing hip frac
bility that this difference is > 0 min (Prdiff > 0)). The relationship be ture surgery in DOA+ patients early after admission could increase
tween duration from hospital admission to surgery and 30-day mortality bleeding risk. For hip fracture surgery the bleeding risk associated with
in DOA + and DOA – groups are shown in Fig. 1. the procedure may not always be classified as low, especially for open
The overall 30-day mortality was 4.1%. In DOA + patients, the 30- surgery like arthroplasty [25]. Our results tend to confirm this increased
day mortality rates in the early and delayed surgery groups were 1.2% bleeding risk as we showed a higher proportion of red blood cell
and 5.9%, respectively, with estimated risk difference of –4.4% (Prdiff transfusions in the early DOA + vs. the delayed DOA + surgery groups.
>0 = 0.02). According to the Bayesian paradigm, the probability that Second, expert panels recommend in non-elective surgery settings to
30-day mortality is higher in the group DOA+ delayed surgery than in perform DOA laboratory testing to assess plasma concentration of the
the group DOA+ early surgery is 98%. The 30-day mortality was 3.6% DOA before intervention [17,23,24]. However calibrated, DOA-specific
and 5.7% in the early and delayed DOA- surgery groups, respectively. testing is not universally available. Third, specific antidotes are not al
Secondary outcomes are represented in Table 2. In the DOA + group ways available for all DOA in current practice and increased bleeding
90-day mortality tended to be higher in the delayed surgery group (28.1 may only be partially antagonized with PCC, which are considered
vs 37.8%, respectively; estimated risk difference of − 9.7% PrDiff > 0 = non-definitive and non-selective antagonists [26]. During the study
0.07). According to the Bayesian paradigm, the probability that 90-day period, in our institution, only idarucizumab was available but was not
mortality is higher in the group DOA+ delayed surgery than in the group used in hip fracture surgery setting. Consistent with this, Schuetze et al.
DOA+ early surgery is 93%. In the DOA + group, early surgery tended to [18] reported in a retrospective study including 52 patients with DOA,
be associated with a higher percentage receiving a red blood cell that early hip fracture surgery was associated with a 3.4 risk ratio of
transfusion rate (64.6% vs 54.8%, respectively, estimated risk difference transfusion.
of 9.3% with PrDiff >0 = 93%) and lower risk of pneumonia (1.2% vs For all these reasons, we need to expand our knowledge concerning
8.2%, respectively; estimated difference of − 6.7% with PrDiff >0 = the risk-benefits ratio of performing early hip fracture surgery in DOA
0.3%). According to the Bayesian paradigm, the probability that pneu treated patients. In another example, Cafaro et al. studied in a retro
monia rate is higher in the group DOA+ delayed surgery than in the spective cohort study, time to surgery (TTS) in hip fracture patients. In
group DOA+ early surgery is 99% the 31 patients with DOA, TTS was longer compared to the control group
not treated with oral anticoagulants (median 61 h, IQR 42–77 versus 44

h, IQR 28–63 p = 0.003) [19]. In another cohort study, Hourston et al.
(diff>0)
<6.67
0.005
0.005
[20] studied the association between DOA treatment and TTS. They
10− 5
0.01
0.08
0.14
0.99
Pr
reported that DOA therapy was independently associated with increased

TTS beyond 36 h (p = 0.001).
− 6.0[− 8.0;− 4.1]
− 0.8 [− 1.6; 0.2]

− 0.3[− 1.0; 0.1]
− 0.2[− 0.8; 0.2]

Estimated Risk
Difference in%
Our study has several limitations. First, being retrospective, several

− 4.3 [− 8.0; -
5.2 [1.3; 9.1]

medical factors, other than DOA status, may contribute to one patient
− 0.7 [− 1.6;
being delayed for hip fracture surgery and therefore be confounding
− 0.2]
factors. We believe that our exploratory results will encourage further
0.6]
confirmation with other study designs addressing this limitation. Sec

ond, people admitted for hip fracture without surgery were not
considered in this study and therefore people that died awaiting for
NON DOA
338 (38.5)
475 (54.0)
surgery were not included. We did not believe we could correctly
Delayed
n ¼ 881
Surgery
79 (9.0)
10 (1.1)
treated
6 (0.7)
4 (0.5)
9 (1.0)
analyze/include patients with no indication for surgery and people who
died awaiting surgery. Third, as the study was retrospective, other fac
tors than surgical time delay may have contributed to the observed
difference in mortality. We observed some imbalances between early
treated Early
1379 (59.3)
and delayed surgery subgroups of the DOA-treated patients that may
NON DOA
n ¼ 2331
796 (34)
Surgery
70 (3.0)
represent potential cofounding factors. Finally, as a single center study

7 (0.3)
5 (0.2)
7 (0.3)
6 (0.3)
its results might not be generalizable to some other hospitals.
Our study however reveals several strengths. First, it included a large
population of more than 3000 patients including more than 200 treated
All non DOA
1134 (35.3)
1854 (57.7)
with DOA. Second, the primary exposure, time from hospital admission
n ¼ 3212
149 (4.6)
patients
13 (0.4)
17 (0.5)
15 (0.5)
treated
to surgery was based on the EMR, which allowed for a precision at the
9 (0.3)
level of hours and minutes. In contrast, in many administrative datasets

(PMSI for example), time from hospital admission to surgery is only
available with a precision at the level of days, not hours as in our study.
(diff>0)
0.003
Third, our study offers time specific epidemiologic description of the

0.07
0.70
0.67
0.66
0.93
0.09
Pr
increased prevalence of DOA in patients admitted for hip fracture sur

gery. We observed a gradual increase in DOA prevalence during the
− 6.7 [− 12.2; − 2.2]
− 9.7 [− 22.2; 2.9]
years 2015 to 2019 from 2 to 12%. These epidemiological data

− 0.4 [− 2.4; 0.3]
9.9 [− 3.4; 22.8]
0.01 [− 0.5; 0.5]
0.01 [− 0.6; 0.6]

Estimated Risk
Difference in%
0.4 [− 1.6; 3.3]
emphasize the need to improve our knowledge on the best therapeutical

options required for patients receiving DOA who are admitted for hip
[95% CI]
fracture surgery.
Conclusion
DOA treated
In our study, we show that in people admitted for hip fracture while
51 (37.8)
74 (54.8)
Delayed
n ¼ 135
Surgery
11 (8.2)
on DOA treatment, surgical treatment performed within 48 h was

1 (0.7)
1 (0.7)
0 (0)
0 (0)
associated with decreased mortality. There was a small tendency to an

increase in risk of blood transfusion in these patients. These results
DOA treated
suggest more research is needed on the optimal surgical timing in

DOAtreated patient presenting with hip fracture.
23 (28.1)
53 (64.6)
Surgery
n ¼ 82
1 (1.2)
1 (1.2)
DOA Direct Oral Anticoagulants; Pr(diff>0): probability of superiority to 0.

Early
0 (0)
0 (0)
0 (0)
Declaration of Competing Interest

127 (58.5)
EN and JP are local investigators for a research study promoted by

74 (34.1)
patients
n ¼ 217
All DOA
12 (5.5)
treated
2 (0.9)
1 (0.5)
TAKEDA Pharmaceutical (TAK-330–3001).

0 (0)
0 (0)
Supplementary materials
n ¼ 3429
161 (4.7)
patients
15 (0.4)
17 (0.5)
16 (0.5)
9 (0.3)
(57.8)
(35.2)
1981
1208
Supplementary material associated with this article can be found, in

All
the online version, at doi:10.1016/j.injury.2023.05.044.

90-day mortality, n
transfusion rate, n
Pneumonia, n (%)
thrombosis, n (%)
infarction, n (%)
embolism, n (%)
References
Red blood cell
Stroke, n (%)
Deep venous
Myocardial
Pulmonary
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Injury 54 (2023) 110817
Injury
Letter to the Editor
Pathological fracture in prior diagnosed malignancies: A dilemma
Malignancies are one of the commonest etiology of pathological a symptom-free interval in these cases. This would enable the treating
fractures [1]. These may be discovered incidentally when patient pre surgeon to anticipate as well as prognosticate the patient before
sents with a history of fracture due to any low velocity trauma. The rate embarking on the arduous journey of tissue diagnosis and definitive
of misdiagnosis of such cases varies from 10 to 100% [1]. In this setting, treatment, both for the fracture as well as the malignancy.
the study by Demiroz et al. titled “Evaluation of patients with patho
logical fractures treated by standard trauma principles but neglecting Funding
the underlying malign bone disease” was read with interest by us [2].
They concluded that when a pathological fracture is misdiagnosed and None.
managed as a simple fracture, the outcomes are devastating. They
opined that in such cases, the curative surgery is more extensive with CRediT authorship contribution statement
increased complication rates and a poor life expectancy. We congratu
late the authors for their series on this topic which is “not so rare” but Sitanshu Barik: Conceptualization, Formal analysis, Writing –
rarely deeply researched. original draft. Vikash Raj: Conceptualization, Formal analysis, Writing
The number of patients in the initial database, as reported by the – original draft. Vishal Kumar: Conceptualization, Formal analysis,
authors, is conflicting. In the results section, they have mentioned the Writing – original draft.
number of cases as 452 initially but later they mention that of the 432
cases, they pooled a total of six cases meeting the inclusion criteria for Declaration of Competing Interest
the present study. We would point out this discrepancy of 20 cases.
The details regarding the Patient 1 reported in the study is inter None.
esting. This patient had an earlier diagnosis of rectal adenocarcinoma
and had undergone rectum resection and adjuvant chemotherapy with a
References
disease-free period of five years prior to the femoral subtrochanteric
fracture. This patient had no trauma (getting out of bed) when he suf [1] Hu Y, Lun D, Wang H. Clinical features of neoplastic pathological fractures. Chin
fered the fracture. He was managed by a proximal femoral intra Med J 2012;125:3127–32.
medullary nailing. We would like to know more about the protocol that [2] Demiroz S, Oktem F, Celik A, Erdogan O, Ozkan K, Gurkan V. Evaluation of patients
with pathological fractures treated by standard trauma principles but neglecting the
the authors follow in such cases, if they present primarily to them. Is it underlying malign bone disease. Injury 2022;53:3736–41. https://doi.org/10.1016/
needed to do further imaging either in the form of a bone scintigraphy or j.injury.2022.08.052.
positron emission topography followed by a needle biopsy from the [3] Jayarangaiah A, Kemp AK, Theetha Kariyanna P. Bone metastasis. Treasure
IslandFL: StatPearls Publishing; 2022. StatPearls.
fractured bone before proceeding with a definite fixation? Does the [4] Anract P, Biau D, Boudou-Rouquette P. Metastatic fractures of long limb bones.
length of the disease-free period have any bearing on the management of Orthop Traumatol Surg Res 2017;103:S41–51. https://doi.org/10.1016/j.
such cases? It is estimated that the cumulative incidence of bone otsr.2016.11.001.
metastasis is 2.9% at 30 days, 4.8% at one year, 5.6% at two years, 6.9%
at five years and 8.4% at 10 years [3]. The interview of the patient, Sitanshu Barik*, Vikash Raj, Vishal Kumar
physical examination and the radiographic examination in a more Department of Orthopedics, All India Institute of Medical Sciences, Deoghar,
detailed manner in patients with low velocity trauma could help the India
surgeons in not missing a malignant pathological fracture [4].
*
A study including the prior diagnosed malignancies, either bony or Corresponding author.
systemic, presenting with pathological fractures would help in defining E-mail address: sitanshubarik@gmail.com (S. Barik).
0020-1383/© 2023 Elsevier Ltd. All rights reserved.
Injury 54 (2023) 110820
Injury
The effect of ultrasound on bone healing across a bone gap, an experimental

study of a delayed union model
Richard Neville Brueton a, *, Frederick William Heatley b, Murray Brookes b, #
a
St Thomas’ Hospital, London SE1 7EH
b
Guy’s Hospital, St Thomas Street, London SE1 9RT
Keywords: The aim of the study is to determine whether ultrasound accelerates bone repair across a bone gap. To replicate
Ultrasound the clinical situation of bone repair in a severe tibial fracture, such as Gustilo grade three, we designed an
Bone Healing experimental model to determine whether ultrasound can promote bone healing in the presence of a bone gap.
Delayed Union
The effect of ultrasound on bone healing of a tibial bone gap held in an external fixator was studied. 60 New
Histology
Densitometry
Zealand White rabbits were divided into four groups. In one group of 6 animals, a tibial osteotomy was closed or
Angiography compressed and studied at six weeks (Comparative Group). In 3 groups of 18 animals each, a tibial bone gap was
External Fixator maintained and was untreated, treated with ultrasound or mock ultrasound (Control Group). The repair of the
Osteotomy bone gaps was studied in 3 animals each at 2,4,6,8,10 and 12 weeks. Investigation was by histology, angiog
Radiology raphy, radiography and densitometry. Three of the 18 untreated group progressed to delayed union, compared
Bone Gap with 4 in the ultrasound and 3 in the mock ultrasound group (Control Group). Statistical analysis showed no
difference between the three groups. 5 of the 6 closed/compressed osteotomies (Comparative Group) united
faster at 6 weeks. The healing pattern of the bone gap groups were similar. We recommend this as a delayed
union model. We found no evidence that ultrasound accelerated bone healing, reduced the rate of delayed union
or increased callus formation in this model of delayed union. This study simulates delayed union following a
compound tibial fracture and has clinical relevance concerning treatment of a delay in union with ultrasound.
Introduction The aim of this study is to determine whether ultrasound accelerates

bone repair across a bone gap, held in an external fixator.
Ultrasound has been found to have a therapeutic effect on soft tissue Ethical Approval and Home Office Licence: This study was carried out
wound healing in both experimental [1] and clinical studies [2,3]. The at the Biological Research Facility, the Rayne Institute, Guys and St
effect of ultrasound on the repair of experimental osteotomies has been Thomas’ Hospital, under a Personal Licence (No. PL 9039). This had
studied in the dog [4], rat [5,6], rabbit [7] and horse [8]. The effect of been subjected to the Ethical Review Process and independently
ultrasound on bone formation in drill holes has also been studied in the approved by the local committee and the Home Office (Animal and
rat [9], mouse [10] and rabbit [11] as well as on stabilised rat femoral Scientific Procedures Act 1986). The experiments were carried out in an
osteotomies [12]. Sheep tibial osteotomies [13] held in an external ethical and humane fashion.
fixator and treated with an implanted ultrasound transducer have also
been reported. To replicate the clinical situation of bone repair in a se Methods
vere tibial fracture, such as Gustilo grade three, we designed an exper
imental model to determine whether ultrasound can promote bone The experimental model was an osteotomy in the tibia of the New
healing in the presence of a bone gap. We carried out an open tibial Zealand White rabbit, just distal to the natural synostosis of the fibula
osteotomy in a rabbit tibia and stabilised the osteotomy by means of a with the tibia. All animals were mature adults, weighing more than 2.5
specially designed external fixator. A bone gap was maintained and this Kgs.
resulted in bone healing with an incidence of delayed union. In a few The external fixator consisted of two incomplete Perspex C rings,
animals we closed the osteotomy gap and observed rapid bone repair. allowing full movement of both knee and ankle. These were connected
#
Deceased.
R.N. Brueton et al. Injury 54 (2023) 110820
Table 1
Experimental Design. Study Group Outline.
Study Group Total Animals at Start Numbers remaining in study
2 4 6 8 10 12
weeks weeks weeks weeks weeks weeks
1 (a) Bone Gap Closed 3 3 3 3 - - -

(b) Bone Gap Compressed 3 3 3 3 - - -
(Comparative Group)
2. Bone Gap Maintained 18 18 15 12 9 6 3
Untreated

Treated with
Ultrasound

Treated with
Mock Ultrasound
(Control Group)
Total Animals 60 60 51 42 27 18 9
Table 2
The Parameters of Treatment with Ultrasound.
Treatment Power Timing of Treatment Parameters of Treatment Coupling Sedation
Days Minutes Weeks Intensity Frequency Timing Agent
Ultrasound ON 5 days per 10 mins per day 4 weeks post 0.5 W/cm2 (S.A.T. 1.5 mHz. Pulsed 2 msec on 8 Geliperm Hypnorm
week op P) off
Mock OFF 5 days per 10 minutes per 4 weeks post 0.5 W/cm2 (S.A.T. 1.5 mHz. Pulsed 2 msec on 8 Geliperm Hypnorm
Ultrasound week day op P) off
Geliperm: a clear polyacrylamide sterile gel. This transmitted 95% of the incident ultrasound and is used clinically in the treatment of burns [2].
by four rigid longitudinal stainless-steel bars, allowing attachment of • Group 2. Bone Gap maintained but untreated.
compression springs. Four transverse Vitallium pins were passed
through the C rings across the tibia, together with anterior and posterior In this group of eighteen animals, an osteotomy gap was created at
half pins, offset at 20◦ avoiding the Achilles tendon. the time of the application of the fixator. The progress of repair of the
The fixator was applied to the left tibia under general anaesthesia. osteotomy was followed by the methods of investigation described
The anaesthetic agent used was the sedative Hypnorm, given by intra above. However, no treatment was given and this group demonstrated a
muscular injection. The left tibia was chosen as the asymmetrical cross base line of the repair of the osteotomy held by the fixator.
section of the left rabbit tibia was best suited to the asymmetry of the
fixator. The fixator could therefore be more easily applied to the left • Group 3. Bone Gap maintained and treated with Ultrasound.
tibia. Once the fixator had been applied to the intact left tibia, an
osteotomy was made with an oscillating saw, midway between the C In this group of eighteen animals, an osteotomy gap was created and
rings. The bone gap created was always the width of the saw blade, maintained as described above. The osteotomy was treated with ultra
1.5mm, in each animal and the bones ends were held rigidly apart by the sound using the parameters outlined in Table 2. Each treatment required
fixator. This was easily reproduced in each animal. The versatility of the sedation of the animal with Hypnorm. Treatment was daily for five days
fixator enabled the gap to be closed or compressed immediately after the per week, ten minutes per day and for the first four weeks post opera
osteotomy. Alternatively, the bone gap could be maintained throughout tively after application of the fixator.
repair.
Sixty animals were studied and divided into four groups (Table 1). • Group 4. Bone Gap maintained and treatment with Mock Ultrasound.
• Group 1. Comparative Group. This group of eighteen animals was the Control Group for the group 3
that was treated with ultrasound. Group four was treated exactly the
This group of six animals proved a comparative group against which same as group three except that the ultrasound machine was not
the other three groups could be compared. switched on. Groups three and four were treated exactly the same in the
In three animals, the bone gap was closed immediately after the administration of sedation, handling and feeding regime.
osteotomy had been carried out and while the animal was still sedated. The experimental design and study group outline is shown in Table 1.
The locking screws of the fixator were released enabling the osteotomy Parameters of Treatment with Ultrasound are shown in Table 2.
gap to be closed so that the bone ends touched and were in opposition. Ultrasound was administered using a Mettler model 705 ultrasound
The locking screws were then re-tightened. In a further three animals, therapy unit. This unit was the same as that used in clinical practice at
while the animal was still sedated, the locking screws were released the time. The animal required sedation by Hypnorm for each adminis
while two compression springs were applied to the longitudinal bars of tration of the ultrasound. The coupling agent chosen was sterile Gel
the fixator. In this way the now closed osteotomy was tightly com iperm. Geliperm is a clear polyacrylamide agar gel containing 96%
pressed and the locking screws were then re-tightened. These six animals water. It was available in its hydrated form in sterile packs as 3.3mm
provided a comparative group with no osteotomy gap and against which thick sheets. The properties of ultrasonic transmission of Geliperm were
the rate of healing of the other groups could be assessed. measured using a tethered flat radiometer [14]. Geliperm was found to
Fig. 1. Histological Scoring System. To reflect the process of remodelling, hard callus providing sound intracortical union was given a score of 128 (4x its score in
isolation). Adjacent endosteal or external hard callus, that had not yet been remodelled, was given a negative score of half its value (-16). In intermediate repair B, the
histology score can be obtained by two methods: 6×32 or 128×2 = 192 or 72% (192/264).
transmit 95% of the incident power [15]. The advantage of Geliperm limbs. After removal of the fixator, the tibia was fixed in 10% buffered
was that this was a sterile coupling agent that eliminated any infection of Formol Saline and decalcified for three weeks in 35% Formic Acid.
pin tracks and surgical wounds. The ultrasound regime was selected Medial and lateral surfaces were removed leaving the middle of the
specifically for this experimental model by Dr Mary Dyson, a specialist in whole decalcified tibia, 3mm thick. A localised 2.5 cm. segment in the
ultrasound [16]. sagittal plane was taken across the tibial osteotomy/bone gap. Histology
Methods of investigation were Radiology, Histology, Angiography, using a Hexachrome modification of the Movat stain [17], demonstrated
Radiology and Densitometry. the anterior and posterior cortices and medulla.
Radiology: Weekly antero-posterior and lateral radiographs of the Angiography: An x-ray of the longitudinal segment of the whole
whole tibiae were taken. The animals required sedation with Hypnorm decalcified tibia was taken on mammography film to study the vascu
on each occasion that radiology was carried out. larity of the whole tibia.
Histology: At the selected time postoperatively, the abdominal aorta Microradiography of the 2.5cm. decalcified localised osteotomy/
was cannulated, under general anaesthesia. Perfusion of intra-arterial bone gap segment was made using a Wild Heerbrugg Photomicroscope,
Hypaque and Heparin by hand enabled angiography of the lower before histology, demonstrating vascular repair.
Table 3
Histology scores with increasing Tissue Maturity.
Tissue Score
Medullary or Dead Amorphous Tissue 0
“Cystic” change 1
Blastemal Tissue 2
Fibrous Tissue 4
Fibrocartilage 6
Cartilage 8
Soft Callus
(many lacunae, thin trabeculae) 16
Hard Callus 32
(few lacunae, lamellar bone)
Hard Callus adjacent to intracortical hard callus union -16

Mature Osteotomy 128
(Intracortical Hard Callus Union after remodelling)
Tissues were scored in ascending maturity from blastema through fibrous tissue,
fibrocartilage, cartilage, and finally to soft and hard callus with cortical union.
Each specimen was given a histology score as a percentage of a mature healed
bone.
Histological sections and corresponding angiography of each tibial

osteotomy/bone gap segment were obtained.
Densitometry: Densitometry of each weekly antero-posterior radio
graph of each animal was performed by scanning using a Joyce-Loebel
microdensitometer.
A Histology Scoring System was devised to assess the healing across
each osteotomy/ bone gap at its end point. This new scoring system was
specifically related to the chosen experimental model that involved a
longitudinal histological section at the osteotomy site. Analysis was
based on the maturity of tissues present in six standardised zones at the
osteotomy [18] as shown in Fig. 1, carried out by one of the authors.
(Table 3).
Angiographic Analysis of the mammography films and microradio
graphs enabled the qualitative assessment of the vascular repair of the
osteotomy/bone gap [19].
A Radiology Scoring System was based on callus formation and cortical Fig. 2. Restoration of Density in the Bone Gap measured by Densitometry. (10c
union of the medial, lateral and posterior cortices at the osteotomy/bone in Table 6).
gap. The anterior cortex could not be assessed, as this was by chance
always obscured by one of the longitudinal bars of the fixator [20]. combined scores of the three groups in where a bone gap was main
Callus deposition in each cortical gap was classified as hazy, dense, tained. A healing rate analysis was made from the densitometry.
maturing and cortical reconstitution. Each osteotomy or bone gap was
given a radiology score as a percentage of a radiologically healed Results
specimen. Each series of x-rays were assessed blind by one of the
authors. 1 Tibial Osteotomy, Closed or Compressed (Comparative Group).
A Combined Score given for each osteotomy/bone gap consisted of the
average of the percentage Histology and Radiology Scores. Bone repair progressed rapidly. The results are seen in Table 4. At six
Densitometric Scanning of the weekly anteroposterior radiographs of weeks there was external callus union and an endosteal plug of callus in
each animal enabled the progression of healing of each tibial bone gap in two of the three closed osteotomies and all three of the compressed
each group to be assessed quantitively during the repair process [21]. osteotomies. Radiological union was present at six weeks with little
The proximal and distal Perspex C rings of each fixator provided refer periosteal callus. Primary bone union was seen in one specimen [23].
ence points of fixed density for each bone gap. The week at which the Vascular continuity was re-established in all six specimens at six weeks
density of the bone gap was restored to normal by callus deposition in [24].
the gap was determined (Fig. 2). This was expressed as the percentage of In this group of six Closed or Compressed tibial osteotomies, five of
all the bone gaps where density returned to normal for each time period. the six specimens showed bone union at six weeks. One was less
In one additional specimen, a Thermistor was implanted at the bone advanced, (b) (Table 4).
gap to measure temperature during ultrasound treatment.
Figs. 1 and 2 have been reproduced from the text of the doctorate 2 Tibial Bone Gap Maintained, Untreated.
thesis in which the results were first presented [22].
Statistical analysis was carried out of the histology, radiology and Bone repair began with soft posterolateral callus at two weeks
Table 4
Histology, Radiology and Combined Scores of Closed or Compressed Osteotomies at Six Weeks (Comparative Group).
Histology Average Histology Score (%) X-ray score Average X-ray Score (%) Combined Score (%) Average Combined Score (%)
Score (%) (%)
a) 73 50 61.5
Closed * b) 15.3 * 50 19.4* 39.8 17.3* 45
c) 60.6 50 55.3
d) 48.5 50 49.2
Compressed e) 43.9 48.46 50 66.6 49.2 57.5
f) 53.4 100 76.9
5 of 6 Closed or Compressed Osteotomies showed Bone Union at 6 weeks, while one showed less advanced healing (*).
with delayed union showed sclerosis on each side of the gap.

The initial Densitometric peak at the bone gap decreased. Density
was restored by deposition of endosteal and posterior callus masses and
cortical union.
Three of the eighteen specimens in the Untreated Group with a bone
gap progressed to delayed union, these being one at eight and two at
twelve weeks (Table 5). In all these delayed unions, there was intra
cortical fibrous tissue. In the delayed specimen at eight weeks, gap
density had not been restored (8b). In the two delayed twelve weeks
specimens (12a,12c), densitometry showed restoration of the gap den
sity, even in the presence of fibrous cortical union, from a residual
endosteal callus plug.
3 Tibial Bone Gap Maintained, treated with Ultrasound
The overall pattern of bone repair at gaps treated with ultrasound

was similar to the untreated group. The results are seen in Table 6. Four
of eighteen specimens with bone gaps progressed to delayed union with
intracortical fibrous tissue at the gap, these being two at six (6a, 6b), one
at eight (8c) and one at ten weeks (10b) (Table 6).
There was a Hypovascular Zone in one Delayed Specimen at 10
weeks (10b)
In the two delayed six and one eight-week specimens, the gap density
had not been restored. In the one delayed ten-week specimen, gap
density was restored at nine weeks, by an endosteal callus plug that had
not yet resorbed (10b).
4 Tibial Bone Gap Maintained, treated with Mock Ultrasound

(Control Group).
The group of eighteen specimens treated with Mock Ultrasound

showed a similar progression of bone repair to both the untreated group
and ultrasound group. The results are seen in Table 7. Three of eighteen
specimens with bone gaps progressed to delayed union with intra
Fig. 3. Histology of an Untreated Bone Gap at two weeks (2b in Table 5) – cortical fibrous tissue, at six (6c), eight (8a) and twelve weeks (12b).
longitudinal section at low power, proximal to the left. Angiography of this (Table 7).
specimen in Fig. 6 and Radiology in Fig. 7.
The gap density was restored in the twelve-week delayed specimen
from a residual endosteal callus plug (12b).
(Fig. 3). The results are seen in Table 5. An endosteal bone plug united Initially, ultrasound cream was used as a coupling agent but resulted
the fragments before later absorption. From eight weeks onwards, hard in pin track or wound infections in 14 of 60 cases (23%). Sterile Gel
callus united the cortices, with transversely orientated trabeculae in the iperm was then used. Each treatment was carried in sterile conditions,
cortical gap at ten weeks (Fig. 4). Cortical remodelling replaced the old eliminating wound infections.
cortex with islands of medullary tissue. In three specimens, There was no difference in soft tissue healing or healing of the sur
(8b,12a,12c), a mature band of fibrous tissue crossed the intercortical gical wounds between any of the groups, whether treated with ultra
gap showing delayed union (Fig. 5). sound or not.
The distal fragment was initially ischaemic at two weeks (Fig. 6). In Summary, five of the six closed or compressed osteotomies pro
Vascularisation progressed to vascular union of the posterior periosteal gressed to bone union by six weeks, providing the baseline for healing of
callus and cortices of the united specimens. A hypovascular zone was the experimental model (Comparative Group). With the other three
present across the gap of three delayed specimens (8b,12a,12c). This groups of animals, delayed union occurred in three of eighteen bone
was seen as an area on the microradiograph with reduced perfusion. gaps in the Untreated Group, four of eighteen in the Ultrasound and
Radiology showed the bone gap at two weeks (Fig. 7), progressing to three of eighteen in the Mock Ultrasound Groups (Control Group). Of
union initially via postero-lateral soft callus masses. By ten weeks, there fifty-four specimens in all groups where a bone gap was maintained, ten
was cortical union of the united specimens with remodelling and ab progressed to delayed union (18.5%), being evenly spread between the
sorption of external periosteal and endosteal callus. Three specimens three groups.
Table 5
Histology, Radiology, Combined Scores and Densitometry of Untreated Bone Gap.
Weeks post Histology score Average Radiology Average Radiology Combined Average Combined Densitometry
op (%) Histology Score Score (%) Score Score (%) Week Gap %
Score (%) (%) (%) Restored Gap
Restored
a) 6.4 0 3.2 -
2 b) 4.8 8.3 0 0 2.4 4.15 - 0
c) 13.7 0 6.8 -
a) 19.7 5.5 12.6 4
4 b) 22.3 16.6 0 1.83 11.2 9.23 - 26
c) 7.8 0 3.9 -
a) 34 5.5 19.7 -
6 b) 48.5 39.1 8.3 9.2 28.4 24.15 - 41
c) 34.8 13.8 24.3 4
a) 42 38.8 40.4 4
8*H b) 14.7*H 38.0 0* H 21.26 7.3* H 29.6 - 55
c) 57.5 25 41.2 6
a) 92.4 100 96.2 7
10 b) 91.7 89.63 66.6 88.86 79.1 89.23 9 66
c) 84.8 100 92.4 4
a) 26.1*H 11* H 18.5* H 12
12 * * M H b) 92.4 46.1 100 62 96.2 54.03 5 100
H
c)19.8*MH 75* M H
47.4* M H 11
3 of 18 Untreated Bone Gaps progressed to a Delay in Union, one at 8 weeks (*) and 2 at 12 weeks (**).
1 Mismatch (M) of Histology/Radiology scores in Delayed Specimen 12c.
3 Hypovascular Zones (H) in the 3 Delayed Specimens 8b,12a,12c.
Fig. 4. Bone Union of anterior cortex of an Untreated Bone Gap at Ten Weeks,
(10a in Table 5), high power.
Fig. 6. Angiography of an Untreated Bone Gap a Two Weeks of the specimen

shown in Figs. 3 and 7 (2b in Table 5).
Fig. 5. Mature Band of fibrous tissue in posterior cortical gap of an Untreated

Bone Gap at Twelve weeks, (12a in Table 5), high power.
12 weeks.
There were three outcomes of interest; histology, radiology and
combined scores, all of which were measured on a continuous scale
Linear regression was used to fit the change in score over time in each
of the three groups. The analysis involved fitting the relationship be
tween time and outcome in the three groups. For all outcomes the rate of
change of outcomes over time was not found to significantly vary be
tween groups
As the rate of change was similar in all groups, the difference in
scores between groups was assessed. The results for the group differ
ences suggested no strong evidence of an overall difference between the
three groups for histology or radiology scores.
There was no difference between groups for the radiology scores,
both when the data from week two is included and excluded.
There was some evidence of an overall difference in combined scores
between the three groups, although this was only of borderline signifi
cance (p=0.06). There was some evidence that scores were lower in the
Fig. 7. Anteroposterior and lateral radiographs of an Untreated Bone Gap at mock ultrasound and ultrasound groups, compared to the untreated
Two Weeks, of the specimen shown in figs. 3 and 6 (2b in Table 5). group.
A Healing Rate Analysis was made based on the densitometric
A Thermistor was implanted at the bone gap of one specimen treated findings. Kaplan-Meier methods were used to calculate the proportion of
with ultrasound. Temperature recording from the thermistor demon animals which had healed during the follow up periods. The time of
strated a rise of 1.6◦ C after five minutes of treatment. This plateau was healing in weeks was used to measure those animals which had healed.
maintained until treatment with ultrasound was discontinued, equili Animals that had not healed at the time of examination were censored at
brating after five minutes, confirming that ultrasound was working. this point. Kaplan-Meier methods were used to calculate the proportion
Results of the Scores. The Average Histology Scores (%) of the three of animals which had healed during the follow up periods.
animals at each two weekly time period for the Untreated, Ultrasound The log rank test was used to calculate healing rates between groups.
and Mock Ultrasound Groups with bone gaps are shown in Fig. 8, The results suggested no evidence of any differences in healing times
together with average histology scores of the Closed/Compressed at all between the three groups (p=0.99). This lack of difference was
osteotomies at six weeks. illustrated by the Kaplan-Meier plot which showed similar curves in the
The Average Combined Scores (%) of the three animals at each two three groups.
weekly time period for the Untreated, Ultrasound and Mock Ultrasound
Groups with bone gaps are shown in Fig. 9, together with average Discussion
combined scores of the Closed/Compressed osteotomies at six weeks.
The Restoration of Gap Density of bone gaps in the Untreated speci Two other studies have investigated the effect of ultrasound on bone
mens and those treated by Ultrasound and Mock Ultrasound is shown as repair using a gap healing experimental model of a rabbit tibial
the weekly percentage of restoration of the bone gap in Fig. 10. osteotomy in an external fixator. Shakouri et al 2010 [25] and Tobita et
A Statistical Analysis was carried out on the three groups of 18 al 2011 [26] used 3mm and 2mm gaps respectively. Their only method
animals, Untreated, treated with Mock Ultrasound and Ultrasound. The of investigation was multidetector computed tomography at 2,5 and 8
repair of the bone gaps was studied in 3 animals each at 2,4,6,8,10 and weeks by Shakouri et al (2010) and 3D quantitative microCT at 4,6 and 8
Table 6
Histology, Radiology, Combined Scores and Densitometry of Bone Gap treated with Ultrasound.
Weeks post Histology score Average Radiology Average Radiology Combined Average Combined Densitometry
op (%) Histology Score Score (%) Score Score (%) Week Gap %
Score (%) (%) (%) Restored Gap
Restored
a) 2.3 0 1.1 -
2 b) 5.9 3.6 0 0 2.9 1.76 - 0
c) 2.6 0 1.3 -
a) 34.8 M 0M 17.4 M -
M
4 b) 4.2 14.0 0 0 2.1 7.0 - 26
c) 3.0 0 1.5 -
a) 3.8* 0* 1.9 * -
6** b) 10.1* 12.2 0* 3.6 5.0 * 7.9 - 33
c) 22.7 11.0 16.8 6
a) 46.8 M 0M 23.4 M -
M
8* b) 72.7 43.0 22.2 12.0 47.4 27.52 5 66
c) 9.7 * 13.8 * 11.7 * -
a) 72.7 25 48.8 8
H
10* b) 27.0*H 54.3 11.0* H 25.86 19.0* H 40.06 9 100
c) 63.2 41.6 52.4 8
a) 84.8 66 75.4 7
12 b) 84.8 78.7 75 80.3 79.9 79.53 8 100
c) 66.6 100 83.3 4
4 of 18 Bone Gaps treated progressed to Delayed Union, 2 at 6 weeks (**), 1 at 8 weeks (*) and 1 at 10 weeks (*).
2 Mismatches (M) of Histology/Radiology Scores in specimens 4a,8a.
1 Hypovascular Zone (H) in Delayed Specimen 10b
Table 7
Histology, Radiology, Combined Scores and Densitometry of Bone Gap treated with Mock Ultrasound (Control Group).
Weeks post Histology score Average Histology Radiology Average Radiology Combined Average Combined
op (%) Score (%) Score Score (%) Score Score (%) Densitometry Densitometry
(%) (%) Week Gap % Gap
Restored Restored
a) 2.6 0 1.3 -
2 b) 2.0 2.2 0 0 1.0 1.1 - 0
c) 2.0 0 1.0 -
a) 17.8 0 8.9 -
4 b) 20.3 16.23 0 0 10.1 8.1 - 13
c) 10.6 0 5.3 -
a) 21.6 5.5 13.5 -
6* b) 33.6 22.7 13.8 7.33 23.7 15.0 5 50
c) 12.9 * 2.7 * 7.8 * -
a) 12.6 * 0* 6.3 * -
8* b) 78.8 56.23 50.0 33.3 64.4 44.76 4 66
c) 77.3 50.0 63.6 4
a) 65.9 M 13.8 M 39.8 M 6
M
10 b) 44.7 61.6 50.0 29.6 47.3 45.6 8 66
c) 74.2 25 49.6 -
a) 48.5 M 8.3 M 28.4 M 6
M
12* b) 27.3 * 48.5 5.5 * 20.33 16.4 * 34.4 12 100
c) 69.7 47.2 58.4 6
3 of 18 Bone Gaps progressed to a Delay in Union, 1 at 6 weeks (*), 1 at 8 weeks (*) and 1 at 12 weeks (*)
2 Mismatches (M) of Histology/Radiology Scores in specimens 10a and 12a.
weeks by Tobita et al (2011). Shakouri et al (2010) reported that There was a mismatch of Histology/Radiology Scores in one of the
low-intensity pulsed ultrasound enhanced callus mineral density. Tobita eleven delayed specimens and four of the remaining forty-nine speci
et al (2011) reported that low- intensity pulsed ultrasound could shorten mens (8.3%). This illustrates that a variety of different investigations
the time required for remodelling and enhanced the mineralisation of must be correlated to fully assess bone repair. Four of the ten delayed
callus. bone gap specimens showed a Hypovascular Zone on angiography.
Tobita et al (2011) noted a limitation of evaluation by micro-CT in In the presence of a bone gap, mechanical forces at the gap were
that analysis of the effect of ultrasound is only possible after healing has neutralised and bypassed through the longitudinal bars of the fixator.
progressed to callus mineralisation. This did not assess healing before 4 This controlled environment enabled the study of the biological factors
weeks. Interestingly, Shakouri et al (2010) noted that the major limi involved in repair of the bone gap, providing a model to test whether
tation of their study was a lack of histopathology. ultrasound would restore the healing rate of delayed union to normal.
We believe that unless the methods of investigation include histology Since our described animal study, the effect of ultrasound on the
and assessment of the vascular supply, it is difficult to draw conclusions. repair of fractures with delayed union has been reviewed in two clinical
Neither Tobita et al (2011) or Shakouri et al (2010) carried out an studies. Busse et al 2016 [29] in a randomised clinical trial of internally
untreated baseline control of repair of the bone gap of their experi fixed tibial fractures, concluded that low intensity pulsed ultrasound
mental models. Our study comprised three untreated groups, one with does not accelerate radiographic healing and fails to improve function.
the gap closed/compressed as a baseline of the experimental model Schandelmaier et al 2017 [30] carried out a systematic review and a
(Comparative Group). Second, the untreated series that assessed bone meta-analysis of randomised controlled clinical trials that has compared
repair of the bone gap. Third, the mock ultrasound group is the Control low intensity pulsed ultrasound with a sham device or no device in
Group, specifically related to treatment with ultrasound. patients with any fracture or osteotomy. They concluded that low in
The site of Periosteal Callus formation during repair of the tibial bone tensity pulsed ultrasound does not improve outcomes important to pa
gap was the same in all groups, situated postero-laterally, related to the tients and probably has no effect on radiographic bone healing. Our
blood supply provided by the calf muscle mass. Court-Brown (1985), experimental findings strongly support this clinical conclusion.
using a single bar fixator applied to the medial subcutaneous surface of Our model with a bone gap replicated the clinical situation of
the rabbit tibia, also noted that more periosteal callus was formed on the delayed bone union which may be treated with ultrasound. If treatment
lateral tibia than on the medial subcutaneous surface [27]. He attributed with ultrasound is to have clinical relevance, it must be shown to
this to the mechanical characteristics with one medially placed fixator accelerate repair of a delayed union model. Ultrasound must change the
bar. Our external fixator, incorporating two circular cut away rings, rate of healing from the Mock Ultrasound Group (Control Group) to
provided evenly distributed mechanical forces across the fracture site. wards the effect of closing the gap (Comparative Group). This was not
We concluded that the site of periosteal callus formation relates to the achieved in this experimental study.
blood supply of the tibia [28].
An analysis of the methods of investigation is shown in Table 8. Conclusion
All methods of investigation must be considered together. Densi
tometry may show that gap density has been restored, even in the In this study, we found no evidence that Ultrasound accelerated bone
presence of delayed intracortical fibrous union, if there is residual healing across the bone gap, reduced the rate of delayed union or
endosteal or periosteal callus. This emphasises the importance of his increased callus formation. This study simulates delayed union
tology to assess bone union in addition to the measurement of miner following a compound tibial fracture and has clinical relevance con
alisation by radiology or CT. Histology and angiography give cerning treatment of a delay in union with ultrasound.
information on bone healing before mineralisation is detectable radio
logically (see Figs. 3, 6 and 7).
Densitometry is an investigation of its time, but the densitometric Declaration of Competing Interest
results are still valid.
The authors have no conflict of interest to declare.
Fig. 8. Average Histology Scores (%) of Closed or Compressed Osteotomies and Bone Gaps treated with Ultrasound, Mock Ultrasound or Untreated.
Fig. 9. Average Combined Scores (%) of Closed or Compressed Osteotomies and Bone Gaps treated with Ultrasound, Mock Ultrasound or Untreated.
10
Fig. 10. Restoration of Gap Density of Bone Gaps treated with Ultrasound, Mock Ultrasound and Untreated.
Table 8
Analysis of the Methods of Investigation
Method of Investigation Zone of Interest Objectivity of Investigation Quality of Investigation Frequency of Investigation
Ant. Post. Med. Lat. Medulla Subjective Objective Qualitative Quantitative Weekly Once
Gap Gap Gap Gap
+ + - - + + - - + - +
Histology
- + + + + + - - + + -
Radiology
+ + - - + + - + - - +
Angiography
+ + - - + - + - + + -
Densitometry
11
Acknowledgments [13] Hantes ME, Mavrodontidis AN, Zalavras CG, Karantanas AH, Karachalios T,
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12
Injury 54 (2023) 110824
Injury
Increases in adolescent firearm injuries were associated with school

closures during COVID-19
John N. Bliton a, *, Jonathan Paul b, Alexis D. Smith c, Randall G. Duran d, Richard Sola Jr. e, f,
Sofia Chaudhary c, g, Kiesha Fraser Doh c, g, Deepika Koganti f, g, Goeto Dantes g,
Roberto C. Hernandez Irizarry f, g, Janice M. Bonsu f, Tommy T. Welch h, Roland A. Richard h,
Randi N. Smith f, g, i
a
Jamaica Hospital Medical Center, USA
b
WellStar Atlanta Medical Center, USA
c
Children’s Healthcare of Atlanta, USA
d
Ross University School of Medicine, USA
e
Morehouse School of Medicine, USA
f
Grady Memorial Hospital, USA
g
Emory University School of Medicine, USA
h
Gwinnett County Public Schools, USA
i
Emory University Rollins School of Public Health, USA
Keywords: Background: : Mitigation measures, including school closures, were enacted to protect the public during the
Adolescent firearm injuries COVID-19 pandemic. However, the negative effects of mitigation measures are not fully known. Adolescents are
Violence uniquely vulnerable to policy changes since many depend on schools for physical, mental, and/or nutritional
COVID-19
support. This study explores the statistical relationships between school closures and adolescent firearm injuries
Injury prevention
(AFI) during the pandemic.
Methods: : Data were drawn from a collaborative registry of 4 trauma centers in Atlanta, GA (2 adult and 2
pediatric). Firearm injuries affecting adolescents aged 11–21 years from 1/1/2016 to 6/30/2021 were evaluated.
Local economic and COVID data were obtained from the Bureau of Labor Statistics and the Georgia Department
of Health. Linear models of AFI were created based on COVID cases, school closure, unemployment, and wage
changes.
Results: : There were 1,330 AFI at Atlanta trauma centers during the study period, 1,130 of whom resided in the
10 metro counties. A significant spike in injuries was observed during Spring 2020. A season-adjusted time series
of AFI was found to be non- stationary (p = 0.60). After adjustment for unemployment, seasonal variation, wage
changes, county baseline injury rate, and county-level COVID incidence, each additional day of unplanned school
closure in Atlanta was associated with 0.69 (95% CI 0.34- 1.04, p < 0.001) additional AFIs across the city.
Conclusion: : AFI increased during the COVID pandemic. This rise in violence is statistically attributable in part to
school closures after adjustment for COVID cases, unemployment, and seasonal variation. These findings rein
force the need to consider the direct implications on public health and adolescent safety when implementing
public policy.
Background occurred in the US [2], included increased availability of firearms [3–5],

a rise in poverty [6], and unemployment [7]. The media has also sug
Firearm violence increased by 35% during the COVID-19 pandemic, gested that decreasing trust in law enforcement or generalized feelings
compounding the already devastating loss of life from the virus [1]. of social disorder may have contributed to the violence [8,9]. During
Potential contributors to this spike in violence, which primarily this increase, firearms became the single greatest cause of mortality
* Corresponding author at: Department of Surgery, 8900 Van Wyck Expressway, Queens, NY, 11418.
E-mail address: jbliton@jhmc.org (J.N. Bliton).
Available online 7 June 2023
J.N. Bliton et al. Injury 54 (2023) 110824
among children [10], with non-Hispanic black, urban adolescents being based on the Atlanta-wide, monthly data. The coefficient estimating the
most at risk [11]. relationship between days closed/remote and AFIs at the monthly, dis
Many children in these vulnerable demographic groups depend on trict level was used to estimate the overall, adjusted increase in AFIs per
school for social, emotional, physical [12], and even nutritional security day closed. A single sensitivity analysis was performed, with restriction
[13]. Furthermore, it has already been established that school closures of the population to age < 19.
during the early stages of COVID-19 disproportionately harmed the
mental health of urban, minority youth [14,15]. It is plausible that loss Results
of the support and physical safety provided schools contributed to the
societal increases in youth violence, but this question has not been In total, 1330 adolescents were evaluated for firearm injuries at the
studied in detail. trauma centers in Atlanta during the study period. 1130 resided in the
This study evaluates relationships between school closures and 10 metro Atlanta counties (approximated adolescent population
adolescent firearm injuries (AFI) during the pandemic. This study uses a 782,465) and were included in the analysis. Patients were mostly non-
registry developed by Atlanta level 1 and 2 trauma centers capturing Hispanic (94%, n = 1059), Black (89%, n = 1008) and male (87%, n
city-wide adolescent injuries. With adjustment for local economic, sea = 984), and the mean age was 18.1 (Table 1). More than half of patients
sonal, and COVID-related variables, we investigate the independent required surgical interventions in the OR (54%). The inpatient mortality
statistical relationships between district-level school closures and the rate was 13%, with 91% of deaths within the first 24 h of arrival.
increase in AFIs. On the time series, two spikes in AFI superimpose temporally over
the initial spikes in COVID rates and the initial phase of school closure
Materials and methods (Fig. 1). The mean AFI rates were higher than baseline for COVID era
unplanned closures (123% over baseline, 95% confidence interval [CI]
The current iteration of the Atlanta-based adolescent injury registry 66–181%) and COVID era remote teaching (73% over baseline, 95% CI
includes data from 4 trauma centers: a combined adult and pediatric 36–111%) (Fig. 2).
Level 1 center, a Level 1 adult center that treats adolescents aged 15 and Relationships between school policy and AFI persisted in multivari
older, an independent Level 1 pediatric center, and a separate Level 2 able models after adjustment for COVID infections, county baseline
pediatric center. The development of this study and the database were injury, seasonal variation, and economic factors (Table 2). A significant
approved by Institutional Review Boards at each institution. The difference was also observed between COVID era unplanned or remote
American Academy of Pediatrics definition of adolescents includes ages school policies and COVID era planned breaks (difference in AFI/100k/
11–21; this age range was used for inclusion. Firearm injuries were year = 11.98, 95% CI 0.47–23.49, p = 0.0413). Therefore, based on the
identified for dates 1/1/2020 to 6/30/2021. Injuries were connected to adolescent population in Atlanta, each additional day of unplanned
school district by patient county residence. Baseline county character
istics (total and adolescent population) were obtained from the Census
Bureau [16]. County baseline AFI rates per 100,000 adolescents were Table 1
calculated based on dates 1/1/16 to 2/28/20. Daily COVID-19 infection Descriptive statistics.
frequency was obtained from the Georgia Department of Health at the N Percent
zip-code level [17] and standardized to the county population on weekly Demographics Age 11 to 14 112 9.90%
and monthly bases to calculate rates. Monthly, Atlanta metro unem 15 to 18 454 40.20%
ployment rates and changes in wages were obtained from the Bureau of 19 to 21 564 49.90%
Labor Statistics [18]. Sex Female 984 87.10%
Male 138 12.20%
School closure data for 2016–2019 were obtained from calendars Unknown 8 0.70%
posted to district websites. Articles from the Atlanta Journal- Ethnicity Hispanic/Latino 49 4.30%
Constitution were used to supplement district calendars and press re Non-Hispanic 1065 94.20%
leases to establish the dates of planned closure, unplanned closure, and Unknown 16 1.40%
Race African 1008 89.20%
remote-only education in 2020–21. Where counties had two public
American/Black
school districts (3 of 10 counties), closure data from the more populous Asian 5 0.40%
district was used for analysis. Monthly school closure data was stan White 50 4.40%
dardized to the baseline proportion of injuries per district to create an Other 27 2.40%
Atlanta-wide estimate of the percent of at-risk children whose schools Unknown 40 3.50%
Injury Data Descriptive (site and pre- Neck/Skull 228 20.20%
were closed by month. On the district level, the monthly number of days hospital arrest) Face 154 13.60%
schools had planned closures, unplanned closures, or remote-only were Thorax 279 24.70%
calculated. Lastly, on a per-district and weekly level, weeks were clas Abdomen 262 23.20%
sified as having >2 days closed, <3 days closed, or fully open and by Extremities 532 47.10%
Superficial only 108 9.60%
closure type (planned or unplanned). A comprehensive list of school
Pre-hospital 106 9.40%
closure data sources is available in Appendix 1. This study used arrest
Strengthening the Reporting of Observational Studies in Epidemiology Unavailable 110 9.70%
guidelines to optimize reporting [19]. ISS 1 to 8 369 32.70%
Descriptive statistics were calculated for patient demographics, 9 to 15 386 34.20%
16 to 24 165 14.60%
injury types, Injury severity scores, surgical interventions, mortality >24 210 18.60%
before discharge and length of stay. Time series were organized to Outcomes Surgical intervention Yes 608 53.80%
visualize AFIs, COVID cases, school closure, seasonal variation, unem Unknown 110 9.70%
ployment, and wage changes over time. Dickey-Fuller Testing to eval Mortality before discharge 145 12.80%
Length of inpatient stay 0 to 1 341 30.20%
uate for stability of AFI over time. Mean changes from baseline COVID
(days) 2 to 4 301 26.60%
rates were calculated by school policy and COVID era. 4 to 7 136 12.00%
Three linear models were created: Atlanta-wide, monthly; district 8 to 14 139 12.30%
level, monthly; and district level, weekly. All models of AFI included >14 213 18.80%
variables for school policy, COVID-19 infection rates, wage changes, Length of stay if expired 0 to 1 132 91.00%
before discharge 13 9.00%
unemployment, and seasonal variation. R2 contributions were estimated
>1
Fig. 1. Time series. A: Injuries and COVID-19 Incidence. The monthly data is displayed according to the left Y axis, and the weekly data according to the right Y axis.
B: Seasonal variation (by month) and school closure. Covariates. C: Economic covariates. Wage changes are standardized to a yearly rate and averaged over 3 months.
Fig. 2. Unadjusted mean differences vs pre-COVID baseline rates under various conditions. This is based on weekly data and is standardized to district-level
adolescent populations.
Table 2 Discussion
Linear model coefficients: multivariable models of yearly AFIs/100k
adolescents. AFIs are associated with both unplanned school closures and remote-
Factors Coefficient: 95% P only teaching despite adjustment for COVID and societal factors. This
ΔAFI Rate per Confidence finding lends credence to the idea that school is among the safest places
ΔFactor Interval for children to be based on rates of violent crime [20], and that children
City-wide summary data, by month may depend on school for physical security [21]. Our study supports
Percent of adolescents affected 0.164/1% 0.074 0.25 0.0006 these findings with adolescent-specific, per-district and per-week pre
by school closure
cision, and estimates the magnitude of the increase in violence at 2 in
City COVID rate 0.344/1k 0.159 0.53 0.0005
By county, by month juries per every 3 days closed.
Days closed for COVID 1.06/day 0.52 1.6 <0.0001 Schools were closed during the first COVID waves for multiple, valid
Days remote for COVID 0.99/day 0.52 1.45 <0.0001 reasons. COVID-19 does pose a measurable threat to children; as of July
Planned days closed 0.23/day -0.1 0.55 0.1719 2022 in Georgia, 1720 children aged 10− 17 have been hospitalized, and
County-level District infection 0.561/1k -0.06 1.18 0.0765
21 have died due to the disease [17]. Another public health concern at
rate
By county, by week the time was related to transmission to family members [22,23]. Addi
Pre-COVID Open -13.15 (vs ref) -23.25 -3.1 0.0108 tional infections pose threats to both the afflicted and the broader
Long weekend -10.99 -22.2 0.24 0.0552 community in the context of limited hospital capacity by forcing oper
Planned closure -7.21 -17.5 3.07 0.1677
ating rooms to shut down [24–26]. Many teachers also lost their lives to
(>2 day)
COVID Planned closure 0 (reference) – – the complications of viral infection [27], although initial infections of
(>2 days) teachers at school were generally from other staff members, rather than
Open -6.95 -18.1 4.21 0.2226 students [28].
Long weekend -13.49 -30 3 0.1093 However, the costs borne by children are significant and long-lasting.
Remote (>2 11.72 -0.83 24.3 0.0673
Children have suffered blows to mental health [29], academic
days)
Unplanned 12.33 -0.93 25.6 0.0685 achievement [30], and social development [31] during the pandemic.
closure (>2 Our finding of additional violent injuries adds to this list of reasons to
days) avoid closure or remote-only school in the future. Furthermore, multiple
Unplanned 11.98 0.47 23.5 0.0413
studies have found that schools appear to be able to control at-school
closure or
remote
transmission with implementation of appropriate preventative strate
Sensitivity analysis: Only age <19 gies [32]. In future pandemics, elected officials and government
By county, Days closed for 0.70/day 0.19 1.21 0.0076 agencies will be responsible for weighing these priorities.
by month COVID This study has numerous limitations. Above all, a great number of
Days remote for 1.04/day 0.6 1.49
societal factors changed during the COVID-19 pandemic, but we were
<0.0001
COVID
By county, Unplanned 14.81 3.55 26.1 0.0099 only able to control for a small subset. Also, the assumed relationships
by week closure or between residence county and school district are likely to be affected by
remote inconsistencies between district and county borders, as well as private
schooling. Lastly, registry data is often affected by inaccuracies, and we
did not validate the registry data (specifically, the mechanism of injury)
school closure was associated with 0.69 (95% CI 0.34–1.04, p < 0.001)
with manual chart review. Further study is necessary to confirm our
additional AFIs. The largest contributors to model fit were COVID
findings, such as through qualitative interviews at the patient level.
infection rates and school policy, although there was considerable
overlap between these two contributions (Fig. 3). A spike in AFIs in
Conclusion
Spring of 2021 is not well-accounted for by the model (Fig. 4). The
sensitivity analysis, which included only ages <19, did not reveal any
Firearm injuries increased in relation to unplanned school closures
change in result (Table 2).
and remote schooling after adjustment for COVID incidence and socio
economic factors. Increased risk of injury should be considered in
addition to the other costs faced by adolescents when they lose access to
resources provided by school.
Funding
Adjusted R2 contribuons
Monthly, city-wide model. R2=0.685
This project is not funded by any grants.
Wage change, 0.011
Unemployment, Supplemental digital content
Variaon not 0.062
accounted
for, 0.315 School policy,
0.087
Appendix 1: Detailed references for closure dates and school
calendars
Season and COVID cases,
other shared, 0.090 CRediT authorship contribution statement
0.091
John N. Bliton: Conceptualization, Formal analysis, Methodology,

Project administration, Resources, Software, Visualization, Writing –
review & editing. Jonathan Paul: Writing – original draft, Writing –
School policy and COVID
(shared), 0.345
review & editing. Alexis D. Smith: Project administration, Resources,
Fig. 3. R2 contributions. This is based on Atlanta-wide, monthly data. The Writing – review & editing. Randall G. Duran: Writing – original draft,
shared contribution of school policy and COVID cases is calculated by observing Writing – review & editing. Richard Sola: Writing – review & editing.
the difference in R2 after removing both from the model. Sofia Chaudhary: Writing – review & editing. Kiesha Fraser Doh:
Linear Model: Adolescent Firearm Injuries, Jan 2016-Jun 2021

R2 = 0.68
50
45
40
35
AFIs per Month

30
25
20
15
10
5
0
Jan-16 Jul-16 Jan-17 Jul-17 Jan-18 Jul-18 Jan-19 Jul-19 Jan-20 Jul-20 Jan-21 Jul-21
Adolescent ﬁrearm injuries (le axis)
3 month moving average
Model based on unemployment, wages, school closure and COVID cases (le axis)
Fig. 4. Model fit. This model is based on Atlanta-wide, monthly data.
Writing – review & editing. Deepika Koganti: Writing – review & [13] McLoughlin GM, McCarthy JA, McGuirt JT, Singleton CR, Dunn CG, Gadhoke P.
Addressing food insecurity through a health equity lens: a case study of large urban
editing. Goeto Dantes: Writing – review & editing. Roberto C. Her
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nandez Irizarry: Writing – review & editing. Janice M. Bonsu: Writing 759–75.
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[15] Hawrilenko M, Kroshus E, Tandon P, Christakis D. The association between school
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editing. [16] United States Census Bureau. American Community Survey Microdata, 2020.
Accessed 2/15/2022. Available from: https://data.census.gov/mdat/#/search?ds
=ACSPUMS5Y2020.
Declaration of Competing Interest [17] Gerogia Department of Health. COVID-19 Status Report 2022. Accessed 2/15/
2022. Available from: https://dph.georgia.gov/covid-19-status-report.
[18] United States Bureau of Labor Statistics. Tables for Atlanta-Sandy Springs-Marietta,
The authors declare that they have no known competing financial GA. Accessed 2/15/2022. Available from: https://www.bls.gov/eag/eag.ga_atlant
interests or personal relationships that could have appeared to influence a_msa.htm.
[19] von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP,
the work reported in this paper.
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Injury 54 (2023) 110827
Injury
Evaluation of a 30-day-mortality risk calculator for patients undergoing

surgical fixation of fragility hip fractures
Eliza R Pelrine, Patrick J Dunne, John Burke, Harrison S Mahon, Max Hoggard, Wendy Novicoff,
Seth R Yarboro *
University of Virginia, Department of Orthopaedics, United States
A B S T R A C T
Introduction: Hip fractures often occur in medically complex patients and can be associated with high perioperative mortality. Mortality risk assessment tools that are
specific to hip fracture patients have not been extensively studied. The objective of this study is to evaluate a recently published 30-day mortality risk calculator (Hip
Fracture Estimator of Mortality Amsterdam [HEMA]) in a group of patients treated at a university health system.
Materials & Methods: 625 patients treated surgically for hip fractures between 2015 and 2020 at our institution were retrospectively reviewed. Patients younger than
age 65, periprosthetic fractures, revision procedures, and fractures treated non-operatively were excluded. Univariate and multivariate analyses were used to
determine significant relationships between variables and 30-day mortality after surgery. Additional patient-specific risk factors not included in the original risk
calculator were also evaluated.
Results: The observed 30-day mortality was 5.6%. HEMA score was significantly associated with 30-mortality, though our cohort had significantly lower mortality
rates in high-risk patients than expected based on the HEMA tool. In analyzing patient characteristics not included in HEMA score, history of dementia and elevated
troponin were significantly associated with 30-day mortality.
Discussion: The HEMA score reliably stratifies risk for 30-day mortality after hip fracture, though overestimates mortality in high-risk patients treated at a tertiary care
center with a multidisciplinary team. The HEMA score may be enhanced by considering additional variables, including troponin level and history of dementia.
Level of Evidence: IV
Introduction factors [6]. They include age greater than or equal to 85, in-hospital
fracture, signs of malnutrition, history of myocardial infarction,
Hip fractures represent a major burden to the US population and congestive heart failure, current pneumonia, end stage renal disease,
healthcare system with over 200,000 per year with that number ex malignancy within last 5 years, and serum urea greater than 9 mmol/L
pected to grow exponentially as the US population ages [1]. Hip fracture (or BUN greater than 25.2 mg/dL). Each of the risk factors is assigned a
portends a high degree of morbidity and mortality for patients with weighted point score based on its contribution to overall 30-day mor
1-year mortality rates as high as 21% [2], however, overall mortality tality risk. The score is then summed and each patient is assigned to low,
following hip fractures has been decreasing worldwide [3]. Hip fractures intermediate, or high-risk groups. The tool was effective in their popu
have a significant physical, psychiatric and economic burden for both lation and showed good results when assessed for discrimination, cali
patients and their families [4]. By controlling for an aging population, a bration, and goodness of fit.
longitudinal decrease in age adjusted incidence in hip fractures has The HEMA model was based on a data set from 2004 to 2010 in a
occurred since 2002, but the trend has plateaued since 2013 [5]. homogenous group of people in Amsterdam, so its external validity has
Risk calculators have been developed to help clinicians make de not been thoroughly evaluated. Our study has two major aims. First, it
cisions about surgical intervention, but few were created specifically for serves to evaluate the generalizability of the HEMA model in an uni
hip fracture patients. Karres et al. analyzed data for 1050 patients un versity level 1 trauma center with an orthogeriatric hip fracture service
dergoing surgery for hip fracture (including hemiarthroplasty, intra (2015–2020). Second, we aim to identify additional significant variables
medullary nailing, cannulated screws, or a dynamic hip screw) and that may be included in a revised version of the HEMA tool.
published a 30-day mortality risk prediction tool, which used two
separate cohorts to find and subsequently validate nine patient risk
E-mail address: sry2j@virginia.edu (S.R. Yarboro).
E.R. Pelrine et al. Injury 54 (2023) 110827
Patients and methods relationships between 30-day mortality and continuous variables, and
chi-square tests were done to assess univariate relationships between 30-
All patients aged 65 and older who were admitted to our institution day mortality and discrete variables. Both univariate and multivariate
between January 2015 and December 2020 with a hip fracture diagnosis odds ratios for all variables in the original HEMA score and additional
were initially identified. Periprosthetic fractures, pathologic fractures, continuous and discrete variables not in the original HEMA score were
revision procedures, and fractures treated non-operatively were calculated using binary logistic regression models. In addition, Fisher’s
excluded. Additionally, patients who did not have follow-up recorded in exact test was used to compare the expected 30-day mortality from each
the electronic medical record at least 30 days out from injury were HEMA risk category and the observed 30-day mortality after placing
excluded. For patients who did not have a follow-up at 30-days, we patients into their respective HEMA risk categories based on their
searched the public record for any evidence of them being alive or dead calculated HEMA scores. p-values less than 0.01 were considered sig
at 30-days. If one could be found, then they were included in the study. A nificant. All analyses were completed using SPSS Version 28.
total of 7 patients who met criteria had to be excluded due to no follow-
up data or public records being available. This resulted in 625 patients Results
being included in our analysis. The methods of surgical fixation included
hemiarthroplasty, total hip arthroplasty, intramedullary nail, sliding hip Among the 625 patients included in our analysis, 36 patients died
screw, percutaneous screw fixation, and other open reduction with in within 30 days after surgery (5.8%). There were 13 in-hospital deaths
ternal fixation. As in the original HEMA study, the primary outcome was (2.11%). The mean age in our cohort was 80.7 years with a mean HEMA
30-day mortality. score of 1.27. In a univariate analysis age, HEMA score, length of stay
The HEMA tool was applied to all patients in our cohort. This tool (LOS), creatinine, and Hgb on admission were all significantly associ
uses nine risk factors to classify patients into low, intermediate, and ated with 30-day mortality. When put through a multivariate analysis
high-risk groups. The nine factors include age >85, in-hospital frac only age and HEMA score were significant predictors (Table 2, p-value
ture, signs of malnutrition, history of myocardial infarction (MI), <0.01).
congestive heart failure (CHF resulting in Paroxysmal nocturnal dys Most patients in our cohort (56.5%) fell into the low-risk group, with
pnea, needing diuretics, or afterload reducing agents), current pneu a HEMA score between 0 and 1. The mean HEMA score of patients who
monia, end-stage renal disease (ESRD, requiring hemodialysis), died within 30 days after surgery was significantly higher than those
malignancy within last 5 years, and serum urea > 9 mmol/L. Each of the who survived (p = 0.001). Based on mean HEMA score, the expected 30-
factors are weighted according to their contribution to overall 30-day day mortality rate in the low risk group was 2.8%. We observed a
mortality risk. In-hospital fracture, signs of malnutrition, and current mortality rate of 2.56%. The intermediate risk group (22.7% of patients
pneumonia are two-point risk factors. Malignancy within last 5 years is a in our cohort) had an expected mortality rate of 9.8%, with an observed
1.5-point risk factor. Age ε 85, history of MI, CHF, and ESRD are one- mortality rate of 6.34%. The high-risk group (20.9% of patients in our
point risk factors. Serum urea > 9 mmol/L (or BUN > 25.2 mg/dL) is cohort) had an expected mortality rate of 33.2%, with an observed
a 0.5-point risk factor (Table 1). The points for each patient are totaled mortality rate of 13.7% (Table 3). There was a statistically significant
and each patient is then placed into low (0 to 1 points), intermediate (1.5 difference between observed 30-day mortality and the expected 30-day
to 2 points), or high risk (2.5 points or greater) groups. The formula to mortality calculated using the formula 100/[1 + e(3.823 – HEMA)], as
calculate percentage risk of 30-day mortality is 100/[1 + e(3.823 – described by Karres et al. [6]. (Table 3; p-value=0.001). However, no
HEMA)], as described by Karres et al. [6]. statistically significant difference was observed in the low and
In addition to the nine risk factors included in the HEMA tool, our intermediate-risk HEMA score categories (Table 3).
study evaluated several other independent risk factors. These included Univariate and multivariate analyses were used to evaluate indi
hemoglobin at the time of admission, serum creatinine, code status, vidual components of the HEMA score against 30-day mortality. Age
anesthesia type, ambulatory status, dementia, atrial fibrillation, chronic >85, history of MI, CHF, renal failure, and BUN >25.2 were all found to
obstructive pulmonary disease (COPD), elevated serum troponin, be significantly correlated with 30-day mortality. However, malignancy
abnormal coagulation lab value, anticoagulant use, home oxygen use, within last 5 years and signs of malnutrition were not found to be
recent hospital admission, preexisting narcotic use, smoking status, associated with 30-day mortality. When the HEMA components were
electrolytes, calcium, and serum glucose. These variables were selected put through multivariate analysis of odds ratios, only elevated BUN was
based on their relation to overall health status, evidence of significant found to be significant (Table 4, p-value <0.01).
physiologic insult, or previous correlation to mortality in elderly trauma Several independent risk factors not included in the HEMA score
patients. Additionally, patients were classified as independent living, or were also analyzed for association with 30-day mortality. When put
non-independent, which included, skilled nursing facilities, assisted through a univariate analysis, dementia, heart disease other than CHF,
living, and imprisoned. DNR status, and elevated troponins were found to be significant
Descriptives and frequencies were calculated for all variables. Two (Table 6, p-value <0.01). On multivariate analysis, only dementia and
sample t-tests and Mann-Whitney U tests were used to assess univariate elevated troponins were statistically significant. (Table 5, p-value
<0.01).
Table 1
HEMA risk factors and points according to weighted 30-day mortality risk. TABLE 2
Odds ratios (and 95% confidence intervals) for selected demographic variables.
Risk Factor HEMA points
Variable Univariate Odds Ratio (and Multivariate Odds Ratio (and
Age ≥ 85 1
95% CI) 95% CI)
In-hospital fracture 2
Signs of malnutrition 2 Age 1.05 (1.01–1.09)* 1.06 (1.01–1.11)*
Myocardial infarction 1 HEMA score 1.84 (1.44–2.35)* 1.68 (1.24–2.27)*
Congestive heart failure 1 LOS 1.07 (1.02–1.12)* 1.06 (0.99–1.12)
Renal Failure (dialysis dependent) 1 BMI 1.01 (0.96–1.07) 1.06 (1.00–1.11)
Malignancy within last 5 years 1.5 Hgb on 0.78 (0.67–0.90)* 0.87 (0.73–1.05)
BUN > 25.2 mg/dL 0.5 admission
Creatinine 1.41 (1.09–1.83)* 1.22 (0.86–1.75)
The nine HEMA risk factors and their weighted points as described by
*
Karres et al. For the purposes of this study, malnutrition was defined as a Significant odds ratio with p ≤ 0.01. Multivariate model used all variables
diagnosis of malnutrition in the EMR or a BMI <18. in table.
TABLE 3
HEMA score risk groups and association with 30-day mortality.
30-Day mortality No 30-Day mortality Total (%) Mean HEMA score Expected 30-Day mortality (%) Observed 30-Day mortality (%) p-
value
Low risk 9 337 57.9 0.39 3.14 2.60 0.821

HEMA 0 to 1
Intermediate Risk 9 133 22.9 1.68 10.46 6.34 0.286
HEMA 1.5 to 2
High Risk 18 112 19.2 3.19 34.71 13.85 0.001
HEMA ≥ 2.5
Overall 36 582 100 1.28 7.24 5.83 0.387
30-day mortality data for low, intermediate, and high risk HEMA score groups are shown. The majority of patients fell into the low-risk group. Expected and observed
30-day mortality also shown, with percent expected 30-day mortality calculated as 100/[1 + e(3.823-HEMA)]. p-values shown were obtained via Fisher’s Exact Test to
compare percent expected mortality with observed mortality for each risk category.
TABLE 4 TABLE 6
Odds ratios (and 95% confidence intervals) for HEMA score components. Multivariate odds ratios (and 95% confidence intervals) for variables that were
Variable Univariate Odds Ratio (and Multivariate Odds Ratio
significant (p<0.01) in univariate analysis.
95% CI) (and 95% CI) Characteristic Multivariate Odds Ratio (95% CI)
Age ≥ 85 2.37 (1.20–4.67)* 2.27 (1.09–4.69) Age 1.01 (0.91–1.11)
In-hospital fracture Not defined – no deaths Not defined – no deaths with LOS 1.09 (1.02–1.17)*
with this condition present this condition present HEMA score 1.31 (0.79–2.17)
Signs of malnutrition 2.16 (0.95–4.93) 2.35 (0.96–5.70) Hgb on admission 0.81 (0.64–1.02)
Myocardial 3.71 01.65–8.34)* 2.49 (1.02–6.10) Creatinine 0.53 (0.28–1.01)
infarction Dementia 4.40 (1.50–12.88)*
Congestive heart 3.80 (1.89–7.65)* 2.41 (1.12–5.17) Heart Disease other than CHF 1.66 (0.60–4.58)
failure DNR status – full code or not 0.91 (0.29–2.85)
Renal Failure 3.32 (1.19–9.20)* 2.55 (0.82–7.94) Elevated troponins 3.28 (1.31–8.20)*
(dialysis Age 85 and older 1.28 (0.25–6.53)
dependent) Myocardial infarction 1.97 (0.52–7.51)
Malignancy within 1.24 (0.47–3.30) 1.58 (0.56–4.41) Congestive heart failure 2.41 (0.79–7.31)
last 5 years Renal Failure (dialysis dependent) 10.39 (1.75–61.80)*
BUN > 25.2 mg/dL 4.59 (2.27–9.27)* 3.33 (1.57–7.06)* Malignancy within last 5 years 1.32 (0.31–5.69)
* BUN > 25.2 mg/dL 3.08 (1.17–8.12)
Significant odds ratio with p ≤ 0.01. Multivariate model used all variables
*
in the table. Significant odds ratio with p ≤ 0.01. Multivariate model used all variables
in the table.
TABLE 5 Discussion
Odds ratios (and 95% confidence intervals) for categorical patient variables.
Characteristic Univariate Odds Ratio Multivariate Odds Ratio The purpose of our study was to evaluate the HEMA score as a pre
(95% CI) (95% CI)
dictor of early mortality after hip fracture surgery, as well as other
Anesthesia type – general or 1.02 (0.35–2.99) 0.82 (0.21–3.27) possible independent predictors of 30-day mortality in an university
not trauma center. The results of our retrospective, observational cohort
Procedure type – 0.65 (0.32–1.30) 0.51 (0.20–1.28)
analysis show that HEMA score is significantly associated with 30-day
arthroplasty or not
Non-ambulatory 1.65 (0.77–3.52) 1.84 (0.70–4.86) mortality. We found our overall 30-day mortality to be 5.83%, which
Dementia 2.66 (1.30–5.42)* 3.62 (1.29–10.14)* was lower than the observed rates of 8.6% and 7.2% published in the
Heart Disease other than 2.62 (1.30–5.28)* 2.76 (1.09–6.99) original HEMA study, though not statistically significant. However, our
CHF
patients categorized as high-risk using the HEMA score did have a
COPD 2.04 (0.90–4.66) 0.51 (0.11–2.32)
Anticoagulant use 1.23 (0.56–2.68) 0.41 (0.11–1.47)
significantly lower observed 30-day mortality compared to the Karres
Home oxygen use 1.65 (0.37–7.37) 1.73 (0.15–19.54) cohort (34.7% vs 13.85%, p = 0.001). The observed mortality within our
Recent hospital admission 1.04 (0.39–2.76) 0.63 (0.18–2.22) low and intermediate-risk group was lower than expected by the HEMA
Preexisting narcotic use 0.87 (0.33–2.29) 0.94 (0.23–3.86) tool, however this was not statistically significant. Our mortality rate is
Smoker (past or present) 0.90 (0.46–1.77) 0.99 (0.39–2.50)
on par with other reported 30-day mortalities in hip fractures. The Iowa
DNR status – full code or 0.28 (0.13–0.58)* 0.65 (0.24–1.77)
not hip fracture risk calculator was developed from a study investigating
Time to surgery <48 hrs 1.84 (0.77–4.43) 1.98 (0.65–6.02) independent predictors of 30 day mortality in 4331 patients undergoing
Residence Non- 0.86 (0.38–1.95) 1.69 (0.56–5.13) surgery for hip fractures, with a reported 5.8% mortality rate [7]. They
Independent
identified patient age greater than 80 years, male gender, decreased
Elevated troponins 3.57 (1.64–7.75)* 4.02 (1.54–10.47)*
Coagulation abnormalities 1.73 (0.88–3.39) 1.59 (0.59–4.30)
functional status, an ASA class of 3 or 4, and a history of cancer as risk
*
factors [7]. The Nottingham Hip Fracture score was developed from a
Significant odds ratio with p ≤ 0.01. Multivariate model used all variables study investigating independent predictors of 30 day mortality in 4967
in the table.
patients undergoing surgery for hip fractures [8]. Data used to create the
Nottingham Hip Fracture Score reported an 8% mortality rate in those
We finally did a multivariate analysis comparing all the variables that had surgery [8]. They found age 66–85 years old and ≥86 years old,
that had been statistically significant in univariate analysis. In this, we male sex, presence of ≥2 co-morbidities, mini-mental test score ≤6 out
found that hospital length of stay, dementia, elevated troponins, and of 10, admission hemoglobin concentration ≤10 g dl− 1, living in an
dialysis-dependent renal failure were significantly associated with 30- institution, and presence of malignant disease to be risk factors for
day mortality after hip fracture. (Table 6, p-value <0.01). 30-day mortality [8]. An older study by Roche et al., reported a 30-day
mortality rate of 9% [9]. fracture surgery in a group of over 1800 patients (though was not an
The two most likely explanations for this observed difference would independent risk factor when adjusted for comorbidities) [11].
be differences in patient cohorts or differences in patient care. Our The other statistically significant variables had a trend to be related
cohort was slightly older than both HEMA cohorts, with an average age to cardiac and/or renal disease. Both of these factors have previously
of 80.6 years compared to 80 years in each of the HEMA cohorts. 35% of been shown to be associated with an increased risk of mortality after hip
our patients were 85 years old or older, compared to 32% in the HEMA fracture [12–16]. In contrast with existing studies, our study failed to
study. This is unlikely to explain that difference in observed 30-day show a significant relationship between COPD and early mortality after
mortality given the minimal age difference between cohorts. Average hip fractures, but is in agreement with literature describing cardiac
HEMA score of the original study is not available, but our cohort had disease and markers as predictors of early mortality after hip fracture
proportionally more high-risk patients and less low-risk patients than [17].
both HEMA cohorts. Presumably, the high-risk patients in our cohort Of the variables found to be significant in univariate analysis, hos
were more likely to be involved in family and medical team discussions pital length of stay, dementia, elevated troponins on admission, and
that may have deterred them from undergoing surgery. Additionally, all dialysis dependent renal failure were found to be associated with 30-day
hip fracture patients at our institution are managed by an interdisci mortality in a multivariate analysis. These results emphasize the
plinary team. This hip fracture program is certified by the International importance of considering renal, cardiac, and cognitive health when
Geriatric Fracture Society (IGFS) and requires sites to have above- assessing mortality risk in fragility hip fracture patients. The HEMA
average outcomes in time from admission until surgery, mortality score already accounts for renal and cardiac comorbidities but having a
rates, readmission rates, and general bone health care and education. A more objective measurement (like creatinine or troponin levels) may be
typical care team at our facility includes orthopedic surgeons, medicine simpler than relying on medical records or patient history to identify
doctors, physical and occupational therapists, nurses, care coordinators, these risk factors. In regard to dementia, no other commonly used hip
case managers, and social workers. It is unknown whether the original fracture scoring tool identifies it as a risk factor of mortality. Our data
Karres cohort was managed similarly, but the comprehensive pathway- highlights its importance in future conversations about mortality risks
driven approach at our institution could be a possible explanation for after fragility hip fractures.
our lower mortality rates. Our current data set cannot offer any specific changes to the HEMA
We did consider missing data and patients lost to follow up as a score due to statistical limitations. However, it does provide a list of
potential cause of skewed data. We made every effort to confirm variables that could be studied in another cohort of hip fractures patients
whether each hip fracture patient at our institution survived at the 30- to determine weighting and stratification (similar to the original study
day timepoint. However, 7 patients had to be excluded due to lack of by Karres et al.). We would suggest including all variables found to be
any follow-up data or public records. Potentially all 7 of the patients statistically significant in a univariate analysis to be included in this
could have died, which would have increased our mortality rate to 6.8% second validation cohort.
(compared to 5.8%). We were not missing HEMA score variables on any There are several limitations to both the original HEMA study and
patients included. However, some data is missing from the additional this validation of the HEMA risk prediction tool. Our analysis may have
variables studied. This is to be expected to some extent but could been limited by the relatively few 30-day mortalities in our cohort.
represent a source of error in our findings. Despite our cohort being older with proportionally more high-risk pa
Our study analyzed the individual HEMA score components in tients, the observed mortality rates in the intermediate and high-risk
addition to multiple patient risk factors which are not included in the groups were lower than expected. As previously mentioned, the multi
HEMA score. While the HEMA score itself was found to be a significant disciplinary care provided as part of our institution’s hip fracture
predictor of mortality, its individual components did not remain sig pathway may be a contributor to the low mortality rate. This finding is
nificant in a multivariate analysis. Elevated BUN was the only compo consistent with the meta-analysis by Patel et al. showing improved hip
nent found to be significant in the multivariate analysis. This suggests fracture outcomes when patients are managed by orthopedic/internist
that the HEMA score is “greater than the sum of its parts” in that it can hybrid teams or internist-led teams [18].
successfully stratify 30-day mortality risk, but individual components Additionally, a considerable number of hip fracture patients at our
are not strong predictors themselves. Thus, the HEMA score could likely institution were treated with total hip arthroplasty (THA). These pa
be improved with additional evaluation. tients were not excluded from the analysis as in the original HEMA
Malnutrition and malignancy were not significant predictors of 30- study. We performed a post-hoc analysis looking at procedure type,
day mortality in our cohort in either the univariate or multivariate an HEMA score, and 30-day mortality. Results of this showed a significant
alyses. Malnutrition was a subjective physician assessment in the orig relationship between 30-day mortality and type of surgical fixation (p =
inal HEMA validation study while we used a definition of BMI <18 or 0.02), with THA and closed reduction percutaneous pinning (CRPP)
diagnosis of malnutrition, which could explain our diverging results. having lower mortality. Patients treated with THA also had significantly
Regarding cancer diagnosis as a predictor of mortality, the literature
shows malignancy is associated with increased 30-day mortality [7–10].
In addition to its inclusion in the HEMA score, malignancy is also used as Table 7
a variable in the Nottingham Hip Fracture Score (NHFS) and was found – Post-Hoc Analysis, Procedure type vs 30-day mortality & HEMA score.
to be an independent predictor of 30-day mortality [8]. Our results did Procedure type Number of patients 30-day mortality Mean HEMA
not show significant association to confirm these findings. It is difficult (percent of total) (and mortality rate) score (SD)
to explain these results, as we used a similar definition of malignancy as Hemiarthroplasty 191 (30.9%) 13 (6.8%) 1.48 (1.21)
the other tools (any cancer excluding local skin cancers). The Notting Intramedullary 208 (33.7%) 18 (8.7%) 1.38 (1.25)
ham Hip Fracture Score only differs in that it included cancers diagnosed Nail
Sliding hip screw 84 (13.6%) 5 (6.0%) 1.16 (1.14)
within the previous 20 years.
Total Hip 93 (15.1%) 0 (0.0%) 0.77 (1.14)
Of the variables not currently included in the HEMA tool, we found Arthroplasty
the relationship between DNR status and 30-day mortality to be of CRPP 42 (6.8%) 0 (0.0%) 1.23 (1.11)
particular interest. For the purposes of this study, patients who were not Total 618 36 (5.8%) 1.28 (1.22)
listed as full code status were included as patients with DNR status, *THA patients had a significantly lower HEMA score than patients having IM
including all DNR subtypes. Our data showed that being full code was nails or hemiarthroplasty (p<0.001). No other comparisons were significant.
protective from mortality. Simons et al. also found that DNR status was There was a significant relationship between procedure type and 30-day mor
associated with a significantly increased risk of early mortality after hip tality (p = 0.020).
lower HEMA scores than hemiarthroplasty and intramedullary nailing [2] Schnell S, Friedman SM, Mendelson DA, et al. The 1-year mortality of patients
treated in a hip fracture program for elders. Geriatr Orthop Surg Rehabil 2010;1(1):
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Injury 54 (2023) 110826
Injury
Arterialization of plantar venous system via vein graft: A novel technique

for reconstruction of heel pad degloving injuries
Hokuto Morii a, *, Takahiro Inui b, Hiroki Shibayama c, Kazunori Oae d, Fumio Onishi e,
Takuya Hashimoto f, Koichi Inokuchi a, Makoto Sawano a
a
Department of Emergency and Critical Care Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
b
Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
c
Department of Orthopaedic Surgery, KKR Sapporo Medical Center, Hokkaido, Japan
d
Department of Orthopaedic Surgery, Hiroshima University School of Medicine, Hiroshima, Japan
e
Department of Plastic Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
f
Department of Vascular Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
Keywords: Background: Patients with heel pad degloving injury frequently develop ischemic necrosis of the area, necessi
Heel pad degloving injury tating soft-tissue reconstruction surgery. We have developed a technique for arterialization of the plantar venous
Venous arterialization system via vein graft (APV) as the primary revascularization treatment. The objective of this study was to clarify
Vascular reconstruction
both the utility of APV for the preservation of degloved heel pads and the impact of this preservation on clinical
Heel pad necrosis
Tissue reconstruction
outcomes.
Methods: Ten consecutive cases of degloving injury with devascularized heel pad were treated at a single trauma
center from 2008 to 2018. Five cases underwent APV and five underwent conventional primary suture (PS) as the
initial treatment. We evaluated the course according to the frequency of heel pad preservation, additional
intervention after heel pad necrosis, post-operative complications, and outcomes using the Foot and Ankle
Disability Index score (FADI) at the time of last follow-up.
Results: Among the five cases that underwent APV, the heel pad was preserved in three cases and flap surgery was
required in two cases. All cases that underwent PS developed necrosis of the heel pad, requiring skin graft in one
case and flap surgery in four. One skin graft case and one free flap case after PS developed plantar ulcers. The
three cases with preserved heel pads exhibited higher FADI than the seven cases that developed necrosis.
Conclusion: APV showed a relatively high frequency of heel pad preservation, which otherwise was uniformly
lacking. Functional outcomes were improved in cases with preserved heel pad compared to those that developed
necrosis and underwent additional tissue reconstruction.
Introduction paid to preserving the heel pad as much as possible. The soft tissue of the
weight-bearing surface has a special structure for withstanding walking
Automobile run-over trauma to the foot often involves heel pad on the ground, and the heel pad in particular is a shock-absorbing tissue
degloving injuries as well as bone fractures, ligamental injuries, and that cannot currently be replaced [4]. However, heel pad necrosis
joint dislocations. If the plantar soft tissue is not reconstructed, ambu gradually progresses in some cases of plantar run-over trauma and ex
lation is hindered by the sequelae [1]. Methods of bone and joint poses the bone [5,6]. Although the aim is to achieve a loadable limb by
reconstruction have improved with the development of new types of reconstructing the heel pad, results to date have been poor [7–9]. If the
implants and methods of ligament reconstruction [2,3]. On the other heel pad could be revascularized to some extent prior to the onset of
hand, a ‘gold standard’ for reconstructing soft tissues of the degloved irreversible necrosis, the chance of preservation may be improved.
plantar region is currently lacking. Because the perforating arteries in the degloved heel pad are severely
In the soft tissue of the plantar region, particular attention should be damaged, identifying and repairing these arteries is not always possible
* Corresponding author at: Department of Emergency and Critical Care Medicine, Saitama Medical University, 1981, Kamota, 350-8550, Kawagoe Saitama, Japan.
E-mail address: ho9101117@saitama-med.ac.jp (H. Morii).
0020-1383/© 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
H. Morii et al. Injury 54 (2023) 110826
[5,6]. Venous arterialization (VA) has been performed to achieve between the soft tissues posterior to the medial malleolus through which
anastomosis of arteries and veins for limb ischemia due to peripheral the MCBA passes [14] and the soft tissues posterior to the lateral mal
vascular disease in cases where arteries cannot be reconstructed [10]. leolus through which the CBCA passes [15]. In cases with uncertain
However, few reports have detailed the application of VA in the field of continuity of these soft tissues, angiography was performed, and APV
trauma medicine. The only two case series available have involved VAs was considered if the heel pad did not show contrast enhancement. The
via vein graft from the radial artery to veins in the hand performed for indications and contraindications of APV are listed in Table 1. APV was
three hands [11] and anastomoses of arteries and veins in the foot for considered when at least one of the indications was met and the
three feet [12] to treat soft-tissue degloving injuries. We performed contraindication was not present.
arterialization of the plantar venous system via vein graft (APV) for heel
pad degloving injuries with the aim of preserving the devascularized Surgical technique
heel pad.
Before surgery, ultrasonography of the great saphenous vein on the
Materials and methods unaffected side is performed, followed by marking. The great saphenous
vein often has a minimum vessel diameter 32 mm [16], whereas the
This single center, retrospective cohort study was approved by the diameter of the perforating vein of the foot is usually 0.9–1.8 mm [17].
ethics committee of our hospital (approval no. 2114). Due to this mismatch of vessel diameters, small branches of the great
Among cases with a diagnosis of plantar degloving injury transferred saphenous vein must be identified on ultrasound examination, and
to our hospital between January 1, 2008, and December 31, 2020, we blood vessels are then collected from a site at which multiple blood
enrolled those cases in which the heel pad was degloved just above the vessels can be selected. Surgery is performed with the patient in a supine
periosteum of the calcaneus and remained in continuity with the plantar position. After debridement, a suitable perforating vein identified in the
skin of the midfoot. Two cases presenting with lower leg amputation in adipose tissue of the heel pad tissue is clamped using a vein clip (Fig. 2).
the acute phase and one pediatric case were excluded from this series Next, the flexor retinaculum and fibrous sheath are incised partially to
(Fig. 1). expose the posterior tibial artery and vein. The great saphenous vein or
Until 2017, conventional primary suture (PS) was performed after its branch with a diameter closest to that of the anastomotic vein in the
irrigation and debridement for heel degloving. In cases of wound ne heel pad tissue is selected according to preoperative ultrasonography,
crosis, soft-tissue reconstruction was performed by skin grafting until then extracted from the lower leg or thigh. A reversed autogenous
2012, and flap surgery was performed from 2013 to 2017. Since the start saphenous vein graft is interposed between the posterior tibial artery
of 2018, APV has been used for early soft-tissue reconstruction of heel and the subcutaneous vein of the heel pad. Under microscopy,
degloving wounds. end-to-side anastomosis is performed between the distal end of the vein
In each case, the presence of main arterial injuries below the knee, graft and the posterior tibial artery initially, then the proximal end of the
the type and duration of antibiotics, method of fracture treatment, vein graft and the stump of the perforating vein in the heel pad are
method of first soft-tissue reconstruction, initial bleeding from heel pad, anastomosed (Fig. 2). After these procedures, blood flow drainage from
initial capillary refilling time (CRT) of heel pad, number of hours until the other subcutaneous veins of the heel pad and recovered CRT of the
first soft-tissue reconstruction, prognosis of the heel pad, presence and heel pad skin must be confirmed. Next, the subcutaneous vein around
method of additional soft-tissue reconstruction procedures, number of the ankle joint is identified and its suitability for anastomosis to a suit
days until additional soft-tissue reconstruction, postoperative compli able vein of the heel pad with good backflow is judged from the per
cations, Foot and Ankle Disability Index (FADI) score at the time of last spectives of location and diameter. If no suitable vein is found, the
follow-up, and follow-up period were evaluated. venous anastomosis is abandoned, and the affected limb is thoroughly
Due to the small number of cases, we did not use statistical methods raised to prevent postoperative congestion of the heel pad. If continuity
for comparisons, but have only provided descriptive data. between the anterior part of the heel pad skin and plantar skin is
maintained and no congestion of the heel pad skin is evident, venous
Indications for APV anastomosis is considered unnecessary. Due to the small diameter of the
blood vessels around the heel pad, all anastomoses are performed using
Blood flow to the heel pad is supplied via the medial calcaneal a simple interrupted suture technique.
branch of the posterior tibial artery (MCBA) and lateral calcaneal branch After suturing the wounded site of the plantar tissue, two 5.0 mm-
of the peroneal artery (LCBA) [13]. APV is therefore indicated in cases diameter self-tapping Schanz screws are inserted into the tibia along
where the heel pad is detached from the calcaneus and continuity is lost with one 4.0 mm-diameter self-tapping Schanz screw each into the
medial cuneiform bone and base of the 5th metatarsal to connect
external fixator rods for the purpose of halting movement of the ankle
joint to protect the anastomosis. Limb elevation is maintained using
external fixation in a manner similar to a kickstand to prevent
Table 1
The indications and contraindications of APV.
Arterialization of the plantar venous system via vein graft (APV) is considered
when at least one of the indications are met and the contraindication is not
present.
Indication
• The heel pad is totally detached from the calcaneus, but continuity is maintained
between the area anterior to the heel pad and the midfoot.
• The heel pad is partially detached from the calcaneus, and angiography shows a
contrast defect at that site.
• The heel pad is partially detached from the calcaneus, but the capillary refilling
time of the heel pad is significantly prolonged compared to the contralateral side.
Contraindication
• The heel pad is partially detached from the calcaneus, but the capillary refilling
time of the heel pad is indifferent from the contralateral side.
Fig. 1. Characteristics of the study cohort.
and osteosynthesis together with partial amputation in two patients

(Table 3). No major vascular injuries were present in any of the cases.
Bleeding from the heel pad in the pin-prick test was seen in nine cases
at first examination; one case was lacking data on this test result in the
medical record. CRT was recorded in six cases, showing delays in the
range of 3–10 s compared to the contralateral side.
Mean time to first soft tissue reconstruction was 13.1 h (range,
6.5–32.5 h) for patients who underwent APV and 3.8 h (range, 2–5 h) for
those who did not. In three of the five cases for which APV was per
formed as soft tissue reconstruction, the heel pad was able to be pre
served, whereas all five cases for which PS was performed showed total
necrosis of the heel pad within several weeks. Two APV cases developed
heel pad necrosis and both cases were reconstructed with a distal-based
sural artery flap. As additional soft tissue reconstruction, of the five
patients who underwent PS, three received free flaps, one received local
flaps, and one received a split-thickness skin graft. No ulcers in the
plantar soft tissue or heel pad were found in the three cases of successful
APV. Two cases after PS showed a plantar foot ulcer at the time of final
follow-up.
As of final follow-up, mean FADI score for the three cases in which
the heel pad was preserved by APV was 91.7 (individual scores: 87.5,
92.3, and 95.2). In the other cases in which the heel pad could not be
preserved, mean FADI score was 57.3 (range, 27.9–74).
Fig. 2. A reversed autogenous saphenous vein graft is interposed between the
posterior tibial artery and the subcutaneous vein of the heel pad. Case report
congestion [18]. To prevent postoperative embolization of recon Case 1 involved a 21-year-old man with no previous medical history.
structed blood vessels, heparin sodium and prostaglandin E1 prepara He was injured while driving a forklift indoors in a warehouse, after
tions are continuously infused intravenously for 1 week postoperatively. accidentally pinching his left foot between the wall and the forklift. He
Weight-bearing on the plantar surface is commenced from approxi was brought by ambulance to our hospital, arriving approximately 1 h
mately 1 month postoperatively, while continuing to monitor the con after injury. The patient presented with an open wound spanning from
dition of the soft tissues. the inside of the left Achilles tendon to the medial side of the calcaneus.
The heel pad was degloved on the plantar aponeurosis, and CRT for the
Results heel pad was 3–4 s. (Fig. 3). Because the heel pad was not yet completely
ischemic and the injury occurred during the night, we decided to
We enrolled ten of the 20 patients diagnosed with plantar degloving schedule the surgery for the next morning.
injury who were transferred to our hospital between January 1, 2008, The day after the injury, we performed reconstruction surgery for
and December 31, 2020 (Table 2). Six patients were male and mean age degloved heel pad. After debridement and irrigation, the saphenous vein
was 48.6 years (range, 21–71 years). with branches was collected from the unaffected lower leg for use in
There is an institutional protocol for prophylactic antibiotic admin APV. The distal end of the collected vein was anastomosed in end-to-side
istration to extremity trauma patients with open wounds, but a review of fashion to the posterior tibial artery, and the proximal stump was
medical records revealed that compliance with the protocols is not high. anastomosed to the vein in the heel pad (Fig. 4). CRT improved to
The type and duration of antibiotic administration varied from case to approximately 1–2 s and as we ascertained that suitable backflow from
case, depending on the degree of wound contamination. In all cases, another vein in the heel pad was present, end-to-end anastomosis was
antibiotics were started immediately after the patient’s arrival at the performed between that vein and another vein near the medial mal
hospital and continued until 2–10 days after the initial soft tissue leolus. The heel pad was not evident on angiography prior to revascu
reconstruction procedure. larization, but became visible after revascularization (Fig. 5). Finally,
Five patients underwent APV and five underwent conventional PS as Schanz screws were inserted into the tibia, first metatarsal, and calca
the initial treatment. Six of the injuries were caused by traffic accidents neus for connection to external fixator rods to immobilize the ankle and
and the other four were accidents occurring during work. Fractures were for use as a kickstand support (Fig. 6). Despite slight congestion at 2
involved in eight cases, and conservative treatment was performed in weeks postoperatively, the heel pad survived and no ulcers formed on
one case, osteosynthesis in four instances, toe amputation in one case, the sole of the foot. The capacity of the patient to ambulate
Table 2
Patient demographics.
Case Age (years)/Sex Mechanism of injury Comorbid factors Associated fractures Contralateral injury
1 21/M crush by forklift N/A N/A N/A

2 58/M auto-motorcycle N/A closed, forefoot N/A
3 63/F crush by forklift N/A open, Lisfranc joint fracture N/A
4 20/F crush by train schizophrenia open, all regions of foot N/A
5 39/M single-auto N/A open, hindfoot N/A
6 49/M crush by train N/A open, hindfoot BK amputation
7 63/F auto-pedestrian N/A closed, forefoot open tibial fracture
8 41/M crush by forklift N/A N/A N/A
9 71/F auto-pedestrian N/A open, hindfoot N/A
10 32/M auto-motorcycle depression N/A N/A
H. Morii et al.
Table 3
Results.
Case Fracture Antibiotics Duration of 1st intervention Initial Initial Time to 1st HP Additional Time to Postoperative FADI Follow-up
treatment antibiotic to HP degloving bleeding CRT of HP intervention (h) necrosis intervention additional complication period
administration from HP intervention (mo)
(days) (days)
1 N/A ABPC/SBT 2 APV + delayed 18 – – N/A minor infection 96.2 36

(2–3 s)
2 OS CTX 4 APV + delayed 10 – – N/A – 95.2 26
(4–5 s)
3 OS (Lisfranc CTX 3 APV + delayed 24.5 – LD (dorsal 21 deformity of 87.5 16
joint) (2–3 s) foot) Lisfranc joint
4 OS (medial CTX 10 APV + delayed 6.5 + LD (dorsal 14 / 48 HP necrosis after 27.9 8

column, (10 s) foot) APV
calcaneus)
4
amputation Scapula
(lateral (plantar)
column)
RSA (heel
pad)
5 OS (calcaneus) ABPC/SBT 3 APV + delayed 32.5 + RSA (heel 16 HP necrosis after 78.8 18
(2–3 s) pad) APV
6 OS CEZ, GM 7 PS N.I. N.I. 4 + STSG 51 ulcer, bleeding 53.8 105
7 OS CEZ 3 PS + N.I. 3.5 + TAP 17 – 57.7 68
8 N/A CEZ 3 PS + N.I. 4 + ALT 21 – 74 20
9 NOM CTX 3 PS + N.I. 5 + LD 28 ulcer 59.6 19
10 N/A CEZ 2 PS + delayed 2 + RSA (heel 47 – 68.3 10
(2–3 s) pad)
Abbreviations: ABPC, aminobenzylpenicillin; ALT, free anterolateral thigh perforator flap; APV, arterialization of plantar venous system; CEZ, cefazolin; CRT, capillary refilling time; CTX, cefotaxime; FADI, Foot and
Ankle Disability Index score; GM, gentamicin; HP, heel pad; LD, free latissimus dorsi flap; mo, months; N/A, not applicable; N.I., not indicated in medical record; NOM, non-operative management; OS, osteosynthesis; RSA,
reverse-flow sural artery flap; SBT, sulbactam; STSG, split-thickness skin graft; TAP, free thoracic artery perforator flap.
Injury 54 (2023) 110826

Fig. 3. Interior of the degloved laceration of the heel pad (a) and sole (b). Soft-
tissue continuity is maintained in the exterior of the heel pad and a portion of
the midfoot. Fig. 6. After APV, external fixation is performed to protect the transplanted
vessels and to keep the heel pad elevated to prevent congestion.
independently without assistance was restored as of final follow-up, 14

months postoperatively (Fig. 7).
Discussion
This retrospective study is the first to investigate the effectiveness of

APV by direct comparison of APV and PS as treatments for severe heel
degloving injuries. APV was performed in five of ten cases of degloving
injuries of the heel pad. In the five cases in which APV was not per
formed, heel pad necrosis progressed over time, resulting in complete
necrosis. Among the five cases in which APV was performed, heel pad
preservation was achieved in three, none of which developed post
operative ulcers. These patients also achieved good functional scores for
the lower limbs.
In some cases of heel degloving injuries, even though skin continuity
between the midfoot and heel pad is preserved and bleeding from the
Fig. 4. a, b) A suitable vein in the heel pad is located and secured (white arrow heel pad is seen, the heel pad eventually develops necrosis [5,6]. The
in b). c) The great saphenous vein (yellow arrow) is collected and reversed, fact that necrosis of the heel pad occurs in those cases is potentially due
with the distal end sutured to the posterior tibial artery and the proximal end to a dysfunctional choke vessel system between angiosomes. The heel
sutured to the vein in the heel pad. The vein in the heel pad with favorable pad receives inflow from two arteries: the calcaneal branch of the pos
backflow is sutured to the subcutaneous vein located at the margins of the terior tibial artery and the calcaneal branch of the peroneal artery [13].
medial malleolus. Since the choke vessel system links the angiosome of the plantar skin of
the midfoot with that of the heel skin, even if blood flow from both the
MCBA and LCBA is interrupted, the heel pad should theoretically be
spared from necrosis by the opening of the choke vessel [19]. However,
as shown in the five cases in which APV was not performed in this study,
the choke vessel system may not function in cases of heel pad degloving
injury and necrosis may develop over time.
To preserve the degloving heel pad, finding a healthy perforator vein
and using it as a drainage vessel appears easier than reconstructing the
calcaneal artery. Even in the fat of the damaged heel pad, several
perforator veins can generally be identified and an appropriate vein with
diameter similar to that of the grafted vein can be selected. The method
of re-vascularization and anastomosis of an artery to a vein has already
been performed as a venous flap [20] for soft tissue reconstruction or VA
[21,22] for salvage of ischemic limb caused by peripheral arterial
disease.
We believe that preservation of the heel pad by APV led to favorable
functional prognosis. In all cases of PS, the heel pads became necrotic.
Fig. 5. a) Angiography before surgery. Heel pad blood flow is disrupted (black
arrow: anterior tibial artery; yellow arrow: posterior tibial artery). b) Angiog With APV, the heel pad was preserved in three of five cases. Preservation
raphy after arterialization of the plantar venous system via vein graft (APV). of the heel pad would have prevented the plantar ulcers caused by
Blood flow is supplied from the transplanted great saphenous vein (red arrow). vulnerable skin grafts and sacrifice at the donor site for flap surgery,
The heel pad is now clearly visible. which may have contributed to good clinical outcomes. Ensuring pres
ervation of a soft part that is thick and deformable is important to allow
sufficient durability while retaining a compact nature such that the
patient can wear typical shoes [23]. In particular, the heel pad has a
unique structure in which the subcutaneous tissue is divided into a
Fig. 7. Postoperative course of the plantar laceration. a) Immediately postoperatively. b) Two weeks postoperatively. c) Seven months postoperatively. d–f) Fourteen
months postoperatively. Healing of the sole continues uneventfully, with no soft-tissue complications.
shallow stratum corneum comprising microchambers and a deep stra were needed in each group to show a statistically significant difference
tum corneum comprising macrochambers that absorb shock [4]. As in FADI between the groups. Since the study was a single-center retro
such, the tissue cannot be replaced with skin grafts or flaps. Recon spective study recruiting all cases of heel pad degloving for which re
struction procedures for skin grafts are simple and minimally invasive, cords were accessible, this discrepancy between the sample size of the
but should be avoided for reconstruction of volumetric defects of soft study and that indicated by the analysis is an inevitable limitation.
tissues in the plantar region, as such procedures carry a very high risk of Therefore, future studies, including multicenter studies that recruit
ulceration [23]. In fact, even a long time after reconstruction, one pa more patients with and without APV, are warranted to demonstrate the
tient who underwent skin grafting showed recurrent ulcers on the efficacy of the technique.
plantar surface. Reconstruction by flap surgery was achieved by
selecting a flap of certain thickness, durability, and stability. This Conclusions
method has been considered useful for plantar reconstruction [24,25],
representing a good option after the heel pad has become necrotic. In APV was performed using greater saphenous vein grafts to address
addition, reconstruction by flap surgery is unable to avoid the sacrifice three cases of heel pad degloving injuries, and the heel pads were pre
of the donor site, and reconstructed soft tissue in the plantar area will served in three cases. These three patients achieved much better func
unavoidably show inferior preservation of the heel pad from a cosmetic tional scores than the seven patients who underwent soft-tissue
perspective. Furthermore, from a functional perspective, cases in which reconstruction with flaps and skin grafts after heel pad necrosis.
flap surgery was performed exhibited lower functional prognosis scores If heel pad necrosis seems inevitable, APV may represent a good
than cases in which the heel pad was preserved. Based on these findings, treatment option for the purpose of heel pad preservation.
we believe that preservation of the heel pad by APV carries a much
greater chance of favorable clinical results. Ethical considerations
Study limitations This study was approved by the ethics committee of Saitama Medical
Center, Saitama Medical University (approval no. 2114).
Certain limitations to this study need to be considered when inter HM was the first and corresponding author and conducted the study
preting the findings. First, this study involved data from a single his as the principal investigator. HS, KO, HT and FO conducted the study
torical institutional cohort. The observed outcomes may not strictly focusing on the analysis and evaluation of the outcomes of the enrolled
represent the results of performing APV, but rather may also reflect patients. TI, KI, and MS supervised the design and general logical
accumulated improvements in outcomes due to non-APV activities, such structure of the study.
as increased case experience and advances in wound care. As no new All authors have no conflict of interest regarding this study.
treatment methods were introduced during the study period and
methods of wound protection have remained unchanged other than Declaration of Competing Interest
APV, we considered this limitation was unlikely to have had any sig
nificant impact. The authors declare that they have no conflict of interest.
Second, the definition of circumferential degloving injury to the heel
is ambiguous. As a retrospective study, appropriately standardizing re References
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Injury 54 (2023) 110830
Injury
Incidence of alpine skiing and snowboarding injuries

Moritz Wagner a, e, *, Michael Liebensteiner b, Dietmar Dammerer c, Johannes Neugebauer c,
Paul Nardelli d, Alexander Brunner a
a
Abteilung Orthopädie und Traumatologie BKH St. Johann in Tirol, Bahnhofstrasse 14, 6380, St. Johann in Tirol, Austria
b
Orthopädie, Knie & Fuß im Zentrum, Innrain 2, 6020 Innsbruck, Austria
c
Krems Donauuniversität Orthopädie und Traumatologie, Dr.-Karl-Dorrek-Straße 30, 3500 Krems an der Donau, Austria
d
Klinik für Orthopädie und Traumatologie Innsbruck, Anichstraße 42, 6020 Innsbruck, Austria
e
Paracelsus Medical University, Salzburg, Austria
Keywords: Background: The incidence of injuries on alpine ski slopes have been assessed using various methods. A decline in
Injury injury rate has been observed throughout the literature; however, the actual incidence remains unclear. The
Ski purpose of this study was therefore to evaluate the incidence of skiing and snowboarding injuries using large-
Rescue
sample data from an entire geographic state.
Benchmark
COVID-19
Methods: Data on alpine injuries over the course of five winter seasons between 2017 and 2022 were prospec
tively collected from the emergency service dispatch center of Tyrol (Austria). The incidence of injuries was
assessed in relation to the number of skier days, which was obtained from the chamber of commerce.
Results: A total of 43,283 cases were identified, and a total of 98.1 Mio skier days were registered during the
inclusion period of our study, resulting in an overall incidence of 0.44 injuries per 1,000 skier days. This is
significantly less than reported from previous studies. From 2017/18 to 2021/22 there was a slight increase in
injuries per 1000 skier days with an exception only for the COVID-19 related season 2020/21.
Conclusion: Our study showed a significant reduction in the incidence of alpine skiing and snowboarding injuries
in comparison with previous studies and should be considered a benchmark for future studies. Long-term studies
on the efficacy of safety gear, as well as the influence of ski patrol and air-borne rescues on patient outcome are
warranted.
Introduction least accurate.

To minimize the risk of recreational sport injuries, there is constant
The incidence of alpine skiing and snowboarding injuries has been improvement in the use of safety gear and the design of sport equipment,
described by multiple studies [1–6]. However, studies based on as exemplified by the development of modern ski bindings [11–13].
self-reported levels of injury are prone to recall bias, while data from Awareness and education on injury prevention among the general
tertiary care providers can be biased by patient selection [7]. A more population has likewise been increasing [14]. Indeed, a decline in injury
accurate depiction of the incidence of ski resort injuries is warranted, rate has been observed throughout the literature. However, given the
and may be gained by using prospectively collected data from injury varied methods of assessment, the actual incidence of such injuries re
registries, such as those from the ski resorts themselves, paramedical mains unclear.
organizations, or emergency service dispatch centers [8]. The purpose of this study was therefore to evaluate the incidence of
Currently, the incidence of injuries is most commonly reported as the skiing and snowboarding injuries using large-sample data from a single
number of injuries per 1000 winter sport days. Some studies reported geographic state during five peak winter tourist seasons to evaluate the
the incidence of injuries per 10,000 ski-lift runs. It is estimated in overall efficacy of recently implemented safety measures.
literature that 20 ski-lift ascends count as one skier day [9,10]. Another
method to describe the frequency of injuries is to count the days between
injuries [2]. This method is used in retrospective surveys and considered
* Corresponding author at: BKH St. Johann in Tirol, Abteilung für Orthopädie und Traumatologie, Bahnhofstrasse 14, 6380 St. Johann in Tirol, Austria.
E-mail address: moritz.wagner@khsj.at (M. Wagner).
M. Wagner et al. Injury 54 (2023) 110830
Patients and methods 2.7% (n = 246). The severity of injuries in patients was compared be
tween by ski-patrol or helicopter services, relative risks were calculated
Data on alpine rescues in the state of Tyrol, Austria between as odds ratios, those are summarized in Table 4.
November 2017 and April 2022 were prospectively collected. All pa
tients requiring emergency service assistance who were transferred from Discussion
the ski slopes to any medical facilities in the state were included. The
study period spanned five complete winter seasons. This study was Our study assessed the incidence of skiing and snowboarding injuries
approved by the ethical committee of the Medical University Innsbruck in the state of Tyrol, Austria, and found an incidence of 0.44 injuries per
(1244/2021). 1000 skier days within a span of five winter seasons, which is signifi
All injury-related data were obtained from the state emergency ser cantly lower than that reported in the literature [1,2,5,8,17–26]. The
vice dispatch center of Tyrol (Austria), where all rescue missions were general trend that injury risk decreases with modernization of ski gear
coordinated. Data such as patient age, mode of the rescue, date and time has been observed by multiple studies [2,16]. However, direct com
of the rescue, patient age, location of the patient, mechanism of injury, parison between studies remains impossible, given the heterogeneity in
type of injury, anatomical region of injury, and severity of injury were approaches to assessing the incidence of injuries. Studies that rely on
collected. Odds ratios were calculated to quantify the strength of asso data of a single medical institution in proximity to a ski resort may be
ciation between injury severity and mode of rescue. biased, given that patients may seek help at various other medical fa
The incidence of injuries was calculated in relation to the number of cilities, from first aid rooms and general practitioners to level 1 trauma
skier days, which was obtained from federal chamber of commerce. The centers. In contrast, questionnaire-based studies are prone to selection
number of skier days, and the number of patient transportation, are and recall bias.
recorded using a tracking system (Skidata GmbH; Grödig, Austria) in The incidence of alpine recreational sport injuries has been assessed
cooperation with the ski resorts of the state. by multiple studies, as summarized in Table 2. The previously largest
cohort study on skiing injuries involving a total of 24,340 cases was
Statistical analysis conducted in the eastern Sierra mountains of California [26]. Based on
reports from ski patrol first-aid rooms between 1983 and 1987, an
Descriptive statistics were used to summarize the dataset. Categori incidence of 2.7 injuries per 1000 skier days was observed. The second
cal values were expressed as absolute numbers and relative frequencies. largest study was conducted in Austria, with a reported sample size of
The incidence of injuries was described in terms of 1000 skier days, in 17,914 cases across two seasons between 1997 and 1998. Their reported
accordance with previous studies [1,3,11,15]. The one-sample t-test has incidence of injury was 1.43 per 1000 skier days [16]. To our knowl
been used to compare injury rates within this study and with other edge, our study represents the largest study on skiing and snowboarding
studies. All statistical analyses were performed using the SPSS software injuries, with a total of 43,283 cases. Altogether, our findings demon
(version 27.0; IBM Coorporation; Armonk, USA). strated a decline in the incidence of ski slope injuries in comparison with
previous studies conducted 10 to 50 years ago (Table 2).
Results The observed decline in incidence of alpine injuries may be caused
by multiple factors. Developments in safety measures implemented by
A total of 43,283 patients were identified from the database of the ski resorts, such as the grooming and preparation of ski slopes, and the
emergency service dispatch center with a mean age of 34.2 years (SD = installation of signs and markings for dangerous crossings and difficult
21.07). A total of 98.1 Mio skier days were registered during the in territories, may have contributed this [12,14]. Better emphasis on
clusion period of our study, resulting in an overall incidence of 0.44 awareness campaigns and injury prevention education, as well as on the
injuries per 1000 skier days. This is significantly less compared to importance of personal protective gear, may have further reduced the
incidence of injuries from 1997 to 1998 (0.44 vs. 1.43, p < 0.001) [16]. risk of injuries at an individual level. Furthermore, with the majority of
From 2017/18 to 2021/22 there was a slight increase in injuries per injuries being those of the knees, there has been wider use of modern ski
1000 skier days with an exception only for the COVID-19 related season bindings, which have been designed to protect the knee joint [11,27,28].
2020/21. The reduction in injury incidence during the season of the Our study period coincided with the COVID-19 pandemic, and a mild
COVID-19 outbreak was not statistically significant (0.38 vs. 0.44, p = reduction in the rate of injuries was observed. This may be attributable
0.11). The number of injuries and skier days per winter season is sum to the restrictions in tourism, and thus the lack of beginners on the ski
marized in Table 1 and compared with other studies in Table 2. Majority slopes.
of the rescues were performed by ski patrols (n = 33,229; 76.8%), while To our knowledge, this is the largest study on alpine skiing and
the remaining were by air ambulance (n = 10,054, 23.2%). snowboarding injuries, providing the most accurate depiction of the true
Data for details on the injured anatomic areas and injury severity was incidence on such injuries [25]. Injury-related data were gathered
available for 9103 of 43,283 cases (21.03%). The most injured anatomic electronically from the state emergency service dispatch center in a
region was the knee, in 29.1% (2950 of 10,143 cases). The number of standardized manner, while those on skier days were collected using
injuries in relation to the anatomic region and the age are summarized in electronic ticketing systems, which can be considered accurate. In
Table 3. Most of the injuries were classified as minor (n = 4121, 45.3%), addition, this study contributes to the limited literature on skiing in
only a very small proportion of patients suffered life-threatening injuries juries during the era of COVID-19, when only local residents were
allowed to visit alpine ski resorts [29].
There were several limitations in our study. Firstly, given the het
Table 1
Number of injuries and skier days per winter season in Tyrol, Austria.
erogeneity in assessing the incidence of injuries in the literature, direct
comparison of our findings with those of previous studies may be un
Winter season Number of skier Number of Injuries per 1000
feasible. Nonetheless, this study sets a benchmark for injuries that
Days (Mio.) injuries skier days
require emergency service assistance, which should be considered more
2017/18 25.5 10,320 0.40 clinically relevant, and should be applied in future studies to allow for
2018/19 26.2 10,718 0.41
2019/20 22.1 10,125 0.46
more accurate analysis of this topic. Further limitations include the lack
2020/21 4.4 1658 0.38 of differentiation between skiers and snowboarders, the lack of gender
(COVID-19) information and the lack of outcome assessment including mortality.
2021/22 19.9 10,462 0.53
Total 98.1 43,283 0.44
Table 2
Details of published studies assessing winter sport injuries.
Authors Time period Country Source of data Number of injuries Injuries per 1000 Skier Days
Wagner et al. (this study) 2016–2022 Austria State-wide emergency service dispatch center 43,283 0.44
Coury et al. [4] 1995–2000 and 2009–2010 USA Questionnaire 1196 n/a
Kim et al. [2] 1988–2006 USA Single hospital 9465 n/a
Stenroos and Handolin [1] 2006–2012 Finland Regional emergency dispatch center 2911 1.96
Davidson and Laiotis [26] 1983–1992 USA Ski patrol first-aid room documentation 24,340 2.6
Sulheim et al. [30] 2002 Norway Questionnaire 3277 n/a
Ruedl et al. [31] 2010–2011 Austria Federal Ministry of the Interior 2326 0.00079 (only fatalities)
Burtscher et al. [16] 1997–1998 Austria n/a 17,914 1.43
Burtscher et al. [32] 2002–2003 Austria Questionnaire 2433 n/a
Johnson et al. [33] 1991 USA Single hospital 5701 3.37
Johnson et al. [34] 1972–1978 USA Survey 1711 4.19
Table 3
Number of injuries according to anatomic regions and age.
Age (y) 1–3 4–5 6–12 13–17 18–29 30–49 50–69 70–89 n/a Total
Knee 2 11 216 319 598 1031 671 25 77 2950

Pelvis 0 1 6 25 39 53 78 12 6 220
Thoracic Spine 0 1 28 32 69 59 54 2 6 251
Thumb 0 0 1 0 7 6 1 0 2 17
Elbow 0 0 6 10 18 18 7 1 2 62
Heel 0 0 15 11 16 18 16 2 3 81
Foot 1 3 15 21 25 31 40 2 3 141
Hand 1 0 45 63 85 66 33 4 13 310
Head/Skull 1 6 76 93 163 246 268 50 25 928
Lumbar Spine 0 0 16 28 49 48 32 5 1 179
Upper Arm 0 0 9 25 32 47 54 8 6 181
Thigh 0 0 33 38 60 72 105 16 11 335
Rips 0 0 4 5 17 17 18 1 2 64
Shoulder 0 5 43 117 292 384 351 34 32 1258
Ankle Joint 0 0 15 19 24 29 28 2 2 119
Thorax 0 0 4 10 18 34 34 0 1 101
Forearm 0 1 31 57 52 77 42 3 11 274
Lower Leg 0 8 133 104 138 271 231 16 28 929
Collarbone 0 0 9 20 37 31 25 1 5 128
n/a 0 4 70 85 162 171 208 31 884 1249
Total 5 40 775 1082 1901 2709 2296 215 757 10,143
version.
Table 4 This manuscript has not been submitted to, nor is under review at,
Injury severity in patients rescued by ski-patrol and helicopter services.
another journal or other publishing venue.
Minor Intermediate Severe Life-threatening The authors have no affiliation with any organization with a direct or
Ski Patrol 3970 3411 460 123 indirect financial interest in the subject matter discussed in the
only manuscript.
% 43.8 5.1 5.1 1.4
OR 2.268 1.117 0.406 0.341
95% CI 1.524–3.376 0.785–1.588 0.235–0.702 0.137–0.849
Acknowledgements
p-value <0.05 0.539 <0.05 <0.05
Helicopter 151 508 357 123 We wish to thank the state emergency dispatch center (Leitstelle
% 11.5 38.6 27.1 9.4 Tirol gemeinnützige GmbH, Tirol, Österreich) for providing the data and
OR 0.136 0.753 24.500 162.438
supporting the authors.
95% CI 0.114–0.161 0.669–0.849 19.688–30.489 66.292–398.032
p-value <0.05 <0.05 <0.05 0.235
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Injury 54 (2023) 110833
Injury
Postoperative sepsis and septic shock after hip fracture surgery

Christian A Gonzalez a, *, Alana O’Mara b, Jacquelyn P Cruz c, Dylan Roth d,
Noelle L Van Rysselberghe c, Michael J Gardner c
a
University of Nevada, Reno School of Medicine, Reno, NV, USA
b
Stanford University School of Medicine, Stanford, CA, USA
c
Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
d
Indiana University School of Medicine, Indianapolis, IN, USA
Keywords: Introduction: There is a paucity of research in the rates for sepsis and septic shock in the hip fracture population
Hip fracture specifically, despite marked clinical and prognostic differences between these conditions. The purpose of this
Sepsis study was to determine the incidence, risk factors, and mortality rates for sepsis and septic shock as well as
Septic shock
evaluate potential infectious causes in the surgical hip fracture population.
Mortality
Methods: The ACS-NSQIP (2015–2019) was queried for patients who underwent hip fracture surgery. A backward
elimination multivariate regression model was used to identify risk factors for sepsis and septic shock. Multi
variate regression that controlled for preoperative variables and comorbidities was used to calculate the odds of
30-day mortality.
Results: Of 86,438 patients included, 871 (1.0%) developed sepsis and 490 (0.6%) developed septic shock. Risk
factors for both postoperative sepsis and septic shock were male gender, DM, COPD, dependent functional status,
ASA class ≥3, anemia, and hypoalbuminemia. Unique risk factors for septic shock were CHF and ventilator
dependence. The 30-day mortality rate was 4.8% in aseptic patients, 16.2% in patients with sepsis, and 40.8% in
patients who developed septic shock (p < 0.001). Patients with sepsis (OR 2.87 [95% CI 2.37–3.48], p < 0.001)
and septic shock (OR 11.27 [95% CI 9.26–13.72], p < 0.001) had increased odds of 30-day mortality compared
to patients without postoperative septicemia. Infections that preceded a diagnosis of sepsis or septic shock
included urinary tract infections (24.7%, 16.5%), pneumonia (17.6%, 30.8%), and surgical site infections (8.5%,
4.1%).
Conclusions: The incidence of sepsis and septic shock after hip fracture surgery was 1.0% and 0.6%, respectively.
The 30-day mortality rate was 16.2% in patients with sepsis and 40.8% in patients with septic shock. Potentially
modifiable risk factors for both sepsis and septic shock were anemia and hypoalbuminemia. Urinary tract in
fections, pneumonia, and surgical site infections preceded the majority of cases of sepsis and septic shock.
Prevention, early identification, and successful treatment of sepsis and septic shock are paramount to lowering
mortality after hip fracture surgery.
Introduction leads to circulatory, cellular, and metabolic abnormalities [3,6]. Causes

of sepsis are multifactorial, but can include postoperative urinary tract
Hip fractures carry high rates of morbidity and mortality, with a 7% infections, pneumonia, and surgical site infections [7]. Higher rates of
thirty day mortality rate and a 22% mortality rate in the first year sepsis and septic shock have been reported in orthopedic trauma pa
following treatment [1,2]. Sepsis, which is defined as organ dysfunction tients compared to nontraumatic patients [8]. However, no studies have
secondary to the body’s response to infection [3], affects approximately reported the rates for sepsis and septic shock in the hip fracture popu
1–2% of patients following hip fracture surgery and significantly in lation specifically, despite marked clinical and prognostic differences
creases postoperative mortality [4,5]. Severe sepsis may progress to between these conditions [3,6,9].
septic shock, in which the body’s inflammatory response to infection The purpose of this study was to determine the incidence, risk
* Corresponding author at: University of Nevada, Reno School of Medicine, 1664 N Virginia St Reno, NV, 89557, USA.
E-mail address: cagonzalez@med.unr.edu (C.A. Gonzalez).
C.A. Gonzalez et al. Injury 54 (2023) 110833
factors, and mortality rates for sepsis and septic shock after hip fracture dysfunction. Circulatory dysfunction was defined as hypotension and/or
surgery. We additionally sought to evaluate the relationship between the requirement of inotropic or vasopressor agents [10].
various infectious causes and their relationship with sepsis and septic The secondary outcome was 30-day mortality, surgical site infection
shock in the postoperative setting. We hypothesized that patients with (SSI), urinary tract infection (UTI) and pneumonia. The dates at which
sepsis and septic shock will have higher rates of early mortality with any of these complications were diagnosed were collected. SSIs were
increased mortality rates in those with septic shock compared to sepsis comprised of superficial, deep, and organ space. The NSQIP defines an
alone. organ space infection as an infection that involves any part of the
anatomy other than the incision, which was opened or manipulated
Methods during an operation [16]. Patients diagnosed with multiple SSIs were
classified as having only the more severe type of SSI infection with su
This investigation utilized data from the American College of Sur perficial being the least severe and organ space being the most severe. If
geons (ACS) National Surgical Quality Improvement Program (NSQIP) a UTI, pneumonia, or SSI was diagnosed within 3 days prior to or on the
collected from 2015–2019. This database consists of deidentified patient same day of the diagnosis of sepsis or septic shock, it was considered a
information collected by a trained surgical clinical reviewer, and sys potential cause.
tematic sampling process is utilized in order to prevent bias from case
selection [10]. The database includes patient demographics, surgical Statistical analysis
details, and outcomes within 30 days. In 2019, the database contained
more than a million surgical cases collected from over seven hundred Baseline characteristics were summarized using descriptive statis
different locations in a variety of healthcare settings [10]. The ACS tics. A Chi-squared test was used to analyze initial differences in out
implements audits to ensure data quality and these as well as previous comes. Missing laboratory data were treated using the missing-indicator
studies have demonstrated excellent reliability as well as interrater method, which creates a unique category for missing data in order to
agreement [10–12]. This study was deemed HIPAA-compliant and control for them in the multivariable analysis [13,14,17]. This approach
institutional review board-exempt. has been used in prior research with the NSQIP dataset and is supported
Data was filtered by orthopedic surgery cases and patients were then over alternative methods [13,14,17]. For the multivariable logistic
identified by using Current Procedural Terminology (CPT) codes regression model, a backward elimination approach was utilized where
representative of hip fractures including intramedullary nailing of all categorical preoperative and operative variables were initially
intertrochanteric, peritrochanteric, or subtrochanteric fractures included in the model, and variables with the highest p values were
(27245), hemiarthroplasty for femoral neck fracture (27236), open eliminated one by one until only variables with a p value less than 0.05
reduction and internal fixation of intertrochanteric fractures (27244) remained. Variables remaining in the model represented independent
[13]. Exclusion criteria included patients with preoperative sepsis or risk factors that were associated with an occurrence of sepsis or septic
septic shock. Patients with incomplete height, weight, ASA class, or shock. A second multivariable logistic regression that controlled for all
functional status data were additionally excluded. of the aforementioned preoperative variables was used to calculate the
Patient characteristics collected included sex, age, weight, height, odds ratio of 30-day mortality between patients with postoperative
and medical comorbidities. Patient height and weight were used to sepsis or septic shock and aseptic patients. P values less than 0.05 were
calculate body mass index (BMI). Comorbidities included smoking, considered significant. All statistical analyses were performed using IBM
chronic obstructive pulmonary disease (COPD), diabetes (DM), hyper SPSS v.28.0 (SPSS IBM, New York, USA).
tension (HTN), congestive heart failure (CHF), dialysis use, ventilator
dependence, chronic steroid use, functional status, and American Soci Results
ety of Anesthesiologists (ASA) class. A patient’s ability to perform the
activities of daily living was used to define functional status, which was After inclusion and exclusion criteria were applied, 86,438 patients
grouped as either dependent or independent [13]. Anesthesia types with hip fractures were included. The median age was 82 years (inter
collected included spinal, general, and monitored anesthesia care (MAC) quartile range (IQR) 73–88) and 68.9% of patients were female. In total,
with IV sedation. 871 patients (1.0%) developed sepsis and 490 (0.6%) developed septic
Anemia was defined as preoperative hematocrit less than 36% for shock. The median duration of time between surgery and diagnosis was
women or less than 39% for men. Preoperative white blood cell (WBC) 12 days (IQR 6–20) for sepsis and 10 days (IQR 4–18) for septic shock.
counts were collected and classified as leukocytosis for WBC counts A Chi-squared test was performed to assess the association of patient
greater than 11,000/μL, leukopenia for WBC counts less than 4000/μL, characteristics, comorbidities, preoperative laboratory values, and
and normal WBC count 4000 – 11,000/μL. Preoperative platelet counts operative variables with postoperative sepsis and septic shock. Variables
were collected and classified as thrombocytopenia for platelet counts that were associated with sepsis included male sex, medical comorbid
less than 150,000/μL, thrombocytosis for platelet counts greater than ities (HTN, DM, COPD, ventilator dependence, CHF, dialysis, chronic
400,000/μL, and normal platelet count 150,000 – 400,000/μL. Hypo steroid use, and dependent functional status) and hematologic de
albuminemia was defined as a preoperative serum albumin levels less rangements (anemia, platelet abnormalities, leukocytosis, and hypo
than 3.5 g/dL [14,15]. albuminemia). (Tables 1 and 2)
The primary outcomes were postoperative sepsis and septic shock.
Patients diagnosed with both sepsis and septic shock postoperatively Risk factors for sepsis and septic shock
were classified as having septic shock. The NSQIP defines sepsis as a
systemic inflammatory response with evidence of an infectious source. Multivariable logistic regression analysis of patient characteristics,
Systemic inflammatory response was defined as the presence of two or comorbidities, preoperative laboratory values, and operative variables
more of the following: temperature >38 ◦ C or <36 ◦ C, heart rate >90 revealed the following risk factors for sepsis after hip fracture surgery:
beats per minute, respiratory rate >20 breaths per minute, WBC male gender (OR 1.59 [95% CI 1.38–1.82], p < 0.001), diabetes (OR
>12,000 cell/mm3, <4000 cells/mm3, or >10% immature (band) forms. 1.24 [95% CI 1.06–1.45], p = 0.007), COPD (OR 1.44 [95% CI
Evidence of an infectious source includes a positive blood culture, 1.21–1.73], p < 0.001), chronic steroid use (OR 1.32 [95% CI
clinical documentation of purulence or positive culture from any site 1.03–1.69], p = 0.027), dependent functional status (OR 1.40 [95% CI
thought to be causative, or suspected pre-operative clinical condition of 1.21–1.63], p < 0.001), ASA ≥ 3 (OR 1.61 [95% CI 1.38–1.82], p <
infection which led to the surgical procedure. Septic shock is defined as 0.001), anemia (OR 1.44 [95% CI 1.24–1.67], p < 0.001), leukocytosis
sepsis with circulatory dysfunction and/or documented organ (OR 1.29 [95% CI 1.12–1.48], p < 0.001), and hypoalbuminemia (OR
Table 1 Table 3
Patient characteristics and comorbidities by sepsis and septic shock. Multivariable analysis of risk factors for sepsis and septic shock.
Sepsis P value Septic shock P value Sepsis Septic shock
OR (95% CI) P value OR (95% CI) P value
Age 0.725 0.362
< 65 97 (1.0%) 50 (0.5%) Male 1.59 < 1.80 <
≥ 65 774 (1.0%) 440 (0.6%) (1.38–1.82) 0.001 (1.50–2.16) 0.001
Gender < 0.001 < 0.001 ASA ≥ 3 1.61 < 1.57 0.009
Male 367 (1.4%) 261 (0.4%) (1.27–2.04) 0.001 (1.12–2.19)
Female 504 (0.8%) 229 (0.9%) Diabetes 1.24 0.007 1.41 <
Body Mass Index 0.354 0.009 (1.06–1.45) (1.15–1.72) 0.001
< 18.5 79 (1.1%) 30 (0.4%) COPD 1.44 < 1.81 <
18.5–30.0 635 (1.0%) 358 (0.6%) (1.21–1.73) 0.001 (1.45–2.25) 0.001
> 30.0 157 (1.1% 102 (0.7%) Congestive Heart Failure 1.65 0.002
Hypertension 620 (1.1%) < 0.001 368 (0.6%) < 0.001 (1.19–2.27)
Diabetes 212 (1.3%) < 0.001 138 (0.8%) < 0.001 Ventilator Dependence 4.88 <
Smoking 106 (1.0%) 0.545 80 (0.7%) 0.021 (2.44–9.76) 0.001
COPD 154 (1.6%) < 0.001 110 (1.1%) < 0.001 Chronic Steroid Use 1.32 0.027
Ventilator Dependence 5 (3.1%) 0.009 9 (5.6%) < 0.001 (1.03–1.69)
Congestive Heart Failure 52 (1.7%) < 0.001 44 (1.4%) < 0.001 Dependent Functional 1.40 < 1.24 0.037
Dialysis 26 (1.6%) 0.021 21 (1.3%) < 0.001 Status (1.21–1.63) 0.001 (1.01–1.52)
Chronic Steroid Use 72 (1.5%) < 0.001 43 (0.9%) 0.001 Anemia 1.44 < 1.30 0.008
Dependent Functional Status 252 (1.4%) < 0.001 134 (0.7%) < 0.001 (1.24–1.67) 0.001 (1.07–1.58)
Leukocytosis 1.29 <
COPD, Chronic Obstructive Pulmonary Disease. (1.12–1.48) 0.001
Hypoalbuminemia 1.27 0.004 1.72 <
(1.08–1.50) (1.38–2.14) 0.001
Table 2
OR, Odds Ratio; CI, Confidence Interval; COPD, Chronic Obstructive Pulmonary
Operative variables and laboratory values by sepsis and septic shock.
Disease; ASA, American Society of Anaesthesiologists.
Sepsis P value Septic shock P value
ASA < 0.001 < 0.001 mortality compared to patients without postoperative septicemia.
1–2 81 (0.5%) 40 (0.3%)
(Table 4)
≥3 790 (1.1%) 450 (0.6%)
Procedure 0.381 0.596
Intramedullary Nail 328 (1.1%) 164 (0.5%) Potential infectious causes of sepsis and septic shock
ORIF 96 (1.0%) 53 (0.6%)
Hemiarthroplasty 328 (1.1%) 164 (0.5%)
Within the three days prior to a sepsis diagnosis, 215 (24.7%) pa
Anesthesia Type 0.809 0.013
General 652 (1.0%) 392 (0.6%) tients were diagnosed with a UTI, 153 (17.6%) patients were diagnosed
Spinal 164 (1.0%) 70 (0.4%) with pneumonia, and 74 (8.5%) patients were diagnosed with SSIs (15
MAC/IV Sedation 47 (0.9%) 25 (0.5%) superficial, 17 deep, and 42 organ space). Within the three days prior to
Anemia 566 (1.2%) < 0.001 322 (0.7%) < 0.001 a septic shock diagnosis, 81 (16.5%) patients were diagnosed with a UTI,
Platelet Count < 0.001 < 0.001
Thrombocytopenia 215 (1.2%) 135 (0.8%)
151 (30.8%) patients were diagnosed with pneumonia, and 20 (4.1%)
Thrombocytosis 31 (1.6%) 18 (0.9%) patients were diagnosed with SSIs (4 superficial, 8 deep, and 8 organ
White Blood Cell Count 0.013 0.113 space).
Leukopenia 15 (1.2%) 8 (0.6%)
Leukocytosis 308 (1.2%) 170 (0.6%)
Discussion
Hypoalbuminemia 333 (1.4%) < 0.001 224 (0.9%) < 0.001
ASA, American Society of Anaesthesiologists; ORIF, Open Reduction Internal Hip fractures and sepsis are both common conditions that impose a
Fixation; MAC, Monitored Anesthesia Care. high risk of mortality [1,2,6]. As the incidence of hip fractures, sepsis,
and septic shock are all rising [18,19], it is important to study the risk
1.27 [95% CI 1.08–1.50], p = 0.004) (Table 3). factors associated with these life threatening infections that can occur
A similar multivariable analysis revealed the following risk factors after hip fracture surgery. While there is evidence that mortality rates in
for septic shock after hip fracture surgery: male gender (OR 1.80 [95% patients with sepsis have decreased over time, mortality rates in patients
CI 1.50–2.16], p < 0.001), diabetes (OR 1.41 [95% CI 1.15–1.72], p < with septic shock have not [6]. These findings highlight the importance
0.001), COPD (OR 1.81 [95% CI 1.45–2.25], p < 0.001), CHF (OR 1.65 of identifying patients at risk for developing sepsis and septic shock and
[95% CI 1.19–2.27], p = 0.002), ventilator dependence (OR 4.88 [95% taking proactive measures to prevent the progression to shock.
CI 2.44–9.76), p < 0.001), dependent functional status (OR 1.24 [95% CI This study utilized a large, nationally representative database and
1.01–1.52], p = 0.037), ASA ≥ 3 (OR 1.57 [95% CI 1.12–2.19], p < found that rates of postoperative sepsis and septic shock after surgery for
0.001), anemia (OR 1.30 [95% CI 1.07–1.58], p = 0.008), and hypo hip fractures were 1.0% and 0.6%, respectively. These rates are
albuminemia (OR 1.72 [95% CI 1.38–2.14], p < 0.001) (Table 3). consistent with the combined rate of sepsis and septic shock in all or
thopedic trauma patients (1.6%) and greater than rates in nontraumatic
Association of sepsis and septic shock with 30-Day mortality orthopedic patients (0.5%) [8]. After controlling for relevant
co-morbidities we found that, compared to patients without post
After surgical fixation of the hip, 30-day mortality rate was 4.8% in operative septicemia, sepsis in the hip fracture population was associ
patients who did not have postoperative septicemia compared to 16.2% ated with approximately three times the odds of 30-day mortality, while
(p < 0.001) in patients with postoperative sepsis and 40.8% (p < 0.001) septic shock was associated with more than eleven times the odds of
in patients with postoperative septic shock (Fig. 1). A multivariable 30-day mortality. Comparing these results to a recent systematic review
analysis that controlled for patient characteristics, comorbidities, pre and meta-analysis of a general medical population with sepsis, surgical
operative laboratory values, and operative variables found patients with hip fracture patients with sepsis have similar 30-day mortality rates
sepsis (OR 2.87 [95% CI 2.37–3.48], p < 0.001) and septic shock (OR (16.2% for hip fracture patients vs 19.6% for general medical popula
11.27 [95% CI 9.26–13.72], p < 0.001) had increased odds of 30-day tion), whereas those with septic shock have significantly higher rate of
Fig. 1. Rates of 30-day mortality after hip fracture surgery.
treatment, preventative measures should be taken to reduce the occur

Table 4
rence of these infections, which may help decrease the incidence of
Multivariable analysis of sepsis and septic shock with 30 day mortality.
postoperative septicemia and mortality in hip fracture patients [4]. To
Odds ratio (95% CI) P value reduce the incidence of urinary tract infections, guidelines suggest
Sepsis 2.87 (2.37–3.48) < 0.001 limiting the use of indwelling urinary catheters to 24 h after surgery
Septic Shock 11.27 (9.26–13.72) < 0.001 unless otherwise warranted [31]. Antibiotic prophylaxis, hair removal,
CI, Confidence Interval. and skin decontamination have all been reported to reduce the occur
rence of a SSI [32]. Implementing a standardized pneumonia prevention
30-day mortality (40.8% in hip fracture patients vs 33.7% in general program in the surgical ward has been found to reduce the incidence of
medical population) [6]. postoperative pneumonia by 81% [33]. These programs emphasize use
The risk factors for both sepsis and septic shock were similar and of an incentive spirometer, oral hygiene, head-of-bed elevation, sitting
predominantly related to non-modifiable factors such as male gender up for all meals, early ambulation, and staff and patient education
and chronic medical conditions such as diabetes, COPD, dependent [33–35].
functional status, and ASA ≥ 3. Unique risk factors for sepsis included To our knowledge, this is the first study to analyze postoperative
chronic steroid use and preoperative leukocytosis, whereas unique risk sepsis and septic shock separately in patients after surgical intervention
factors for septic shock included preoperative ventilator dependence, for hip fracture. This information will enable physicians to better
and CHF. Ventilator dependence increases the risk of ventilator associ counsel patients and their families with more definitive knowledge of
ated pneumonia, which has a high rate of progression to septic shock, the risk factors and mortality associated with sepsis and septic shock.
and CHF likely predisposes patients with sepsis to circulatory failure Additionally, our findings can direct physicians to the modifiable risk
[20–22]. factors and measures that could reduce inciting infections and hopefully
Due to the large sample size in this study, we were able to identify decrease the incidence of sepsis and progression to shock in the surgical
more risk factors compared to prior literature[5] and we identified two hip fracture population.
new and potentially modifiable risk factors: preoperative anemia and This research had the usual limitations that accompany retrospective
hypoalbuminemia. Prior literature has emphasized the importance of studies with large databases. Recording and measurement bias that goes
nutritional intervention in hip fracture patients to improve long term along with retrospective research were minimized by the standardized
outcomes, and preoperative supplementation has recently been associ collection process of the NSQIP. Only events within 30 days of surgery
ated with a decreased rate of postoperative complications [23,24]. In are included in the NSQIP database, which may falsely lower the inci
general, blood transfusions are given when hemoglobin levels are < 7 dence of postoperative sepsis and septic shock. The NSQIP database does
g/dL, however recent literature has recommended a restrictive red not collect certain measures that were taken perioperatively, such as
blood cell transfusion threshold of 8 g/dL for patients undergoing or fluid resuscitation and vasopressor use, which may limit our findings.
thopedic surgery [25,26]. Prior literature has found the use of erythro While only small portions of patient characteristics were missing, there
poietin and iron supplementation in hip fracture patients preoperatively were significant portions of preoperative laboratory values that were
to be safe and may be associated with a reduced hospital stay as well as missing. However, this was in part controlled for by using the missing-
improved recovery [27–30], however more research is needed to vali indicator method.
date these measures.
Potential infectious causes of sepsis and septic shock were identified Conclusion
in more than half of the cases in this study and included UTI, SSIs, and
pneumonia. UTIs and SSIs were diagnosed more frequently in patients Patients who underwent surgical intervention after hip fracture had
with sepsis, while pneumonia was more common in patients who pro a postoperative sepsis incidence of 1.0% and a postoperative septic
gressed to septic shock. In addition to prompt identification and shock incidence of 0.6%. The 30-day mortality rate in patients who
developed sepsis was 16.2% and was increased to 40.8% in those that [15] Bohl DD, Shen MR, Mayo BC, Modi K, Basques B, Singh K, et al. Malnutrition
predicts infectious and wound complications following posterior lumbar spinal
progressed to shock. Risk factors for both sepsis and septic shock were
fusion. Spine (Phila Pa 1976) 2016;41(21):1693–9. https://doi.org/10.1097/
similar and included male gender as well as chronic medical conditions BRS.0000000000001591.
such as diabetes, and chronic obstructive pulmonary disease. Unique [16] Wills BW, Sheppard ED, Smith WR, Stagger JR, Li P, Shah A, et al. Impact of
risk factors for septic shock were preoperative ventilator dependence, operative time on early joint infection and deep vein thrombosis in primary total
hip arthroplasty. Orthop Traumatol Surg Res 2018;104(4):445–8. https://doi.org/
and congestive heart failure. Potentially modifiable risk factors associ 10.1016/j.otsr.2018.02.008.
ated with sepsis and septic shock included anemia, and hypo [17] Greenblatt DY, Rajamanickam V, Mell MW. Predictors of surgical site infection
albuminemia. Urinary tract infections, pneumonia, and surgical site after open lower extremity revascularization. J Vasc Surg 2011;54(2):433–9.
https://doi.org/10.1016/j.jvs.2011.01.034.
infections were associated with more than half of the cases of sepsis and [18] Wu AM, Bisignano C, James SL, Abady G, Abedi A, Abu-Gharbieh E, et al. Global,
septic shock. Prevention, early identification, and successful treatment regional, and national burden of bone fractures in 204 countries and territories,
of sepsis and septic shock are paramount to lowering all-cause mortality 1990–2019: a systematic analysis from the Global Burden of Disease Study 2019.
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Funding Anaesthesiol 2021;34(2):71–6. https://doi.org/10.1097/
ACO.0000000000000958.
[20] Aydogdu M, Gursel G. Predictive factors for septic shock in patients with
No funding was received for this research. ventilator-associated pneumonia. South Med J 2008;101(12):1222–6. https://doi.
org/10.1097/SMJ.0b013e3181827891.
[21] Heredia-Rodríguez M, Peláez MT, Fierro I, Gómez-Sánchez E, Gómez-Pesquera E,
Lorenzo M, et al. Impact of ventilator-associated pneumonia on mortality and
epidemiological features of patients with secondary peritonitis. Ann Intensive Care
The other authors report no relevant conflicts of interest. 2016;6(1):34. https://doi.org/10.1186/s13613-016-0137-5.
[22] Vindhyal MR, Lu LK, Ranka S, Acharya P, Shah Z, Gupta K. Impact of underlying
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Injury 54 (2023) 110835
Injury
Ultrasonography-assisted assessment of the influence of the volar

prominence of the plate on the median nerve in distal radius fractures
Haoran Chen a, b, Jin Liang a, b, Cong He a, b, Xiaokun Gu a, Cheng Xu c, Aidong Deng a, *,
Gu Heng Wang a, *
a
Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong 226001, China
b
Medical School of Nantong University, Nantong 226001, China
c
Department of Medical Ultrasound, Affiliated Hospital of Nantong University, Nantong 226001, China
Keywords: Objective: The study aimed to explore the effect of differing volar locking plate (VLP) prominence on the median
Median nerve nerve (MN) in distal radius fracture (DRF) with ultrasound assistance to guide clinical treatment.
Ultrasound Methods: Forty-four patients who received VLP for DRF at our department were admitted and followed-up be
Distal radius fracture
tween January 2019 and May 2021. Different plate positions were graded using Soong classification; 13 were
Position
Grade 0, 18 were Grade 1, and 13 were Grade 2. The MN parameters at different wrist positions in patients with
Volar locking plate
different Soong grades were measured with ultrasound assistance, including the median nerve cross-sectional
area (MNCSA), diameter in the radial–ulnar direction (D1), and diameter in the dorsal–palmar direction (D2).
The sensation in the affected finger and grip strength were collected at follow-up, scored using the Disabilities of
the Arm, Shoulder, and Hand (DASH) scale to determine function, and statistically analysed.
Results: The MNCSA differed significantly across Soong grades. The MNCSA at the flexed, neutral, and extended
wrist positions was smallest at Grade 0 and largest at Grade 2 (P < 0.05), and that at the neutral position was not
significantly different between Grades 1 and 2 (P > 0.05). There was no significant interaction between the wrist
positions and Soong grade (P > 0.05). The differences in D1 and D2 among different Soong grades were not
statistically significant (P > 0.05). There were no statistical differences in grip strength, DASH, and sensation
among different Soong grades (P > 0.05).
Conclusions: Differing plate protrusions in DRF treatment did not cause clinical symptoms during follow-up;
however, excessive plate protrusion (Soong Grade 2) increased the cross-sectional area of the MN. We recom
mend placing the plate as proximal as possible during VLP treatment of DRFs to avoid excessive bulges affecting
the MN.
Type of study/level of evidence: Prognostic III. postoperative mobilization [4,6,7].

VLP treatment of DRFs can achieve good results; however, compli
Introduction cations such as tendon rupture, incision infection, and nerve compres
sion occasionally arise [8–10]. Tendon rupture has been found to be
Distal radius fracture (DRF) is common, accounting for 15–20% of all related to VLP prominence (different Soong grades) in most cases;
fractures, and its incidence is rising as the population ages [1,2]. Sur however, whether VLP prominence causes median nerve (MN)
gical treatment is often an option for patients with unstable DRFs or compression has not been reported [11–14]. Thus, we investigated (1)
when non-operative treatment fails [3]. Surgical methods for DRFs the influence of the MN between different Soong grades at different
include external fixator fixation, percutaneous Kirschner wire fixation, wrist positions after the volar plating of DRFs and (2) whether any
volar or dorsal plate fixation, and intramedullary nail fixation [4,5]. changes in the sensation of median innervation, grip strength, or hand
Among these methods, volar locking plate (VLP) fixation is widely used function are present across different Soong grades.
to treat DRFs because it provides stable fixation and allows early Magnetic resonance imaging, electromyography, and
* Corresponding authors at: No. 20, Xisi Road, Nantong, China.

E-mail addresses: aidong_deng@163.com (A. Deng), guhengwang@ntu.edu.cn (G.H. Wang).
H. Chen et al. Injury 54 (2023) 110835
ultrasonography are used to determine whether nerves are affected by a (the palmar cortex of the pisiform projects within the interval between
procedure [15–17]. Ultrasound is the most commonly used technique the palmar cortices of the distal scaphoid pole and the capitate head)
since it is cost-effective [17]. Additionally, ultrasound can be used to and classified as Soong Grades 0, 1, and 2 according to the relationship
measure the effect of the volar prominence of the plate on the MN in between the plate and the critical line [6] (Fig. 1). Thirteen patients
different wrist positions. were Grade 0, 18 were Grade 1, and 13 were Grade 2.
Therefore, we used ultrasound to understand the influence of
differing VLP prominence on the MN in different wrist positions and Content of follow-up visits
guide clinical treatment.
Ultrasonography
Materials and methods Ultrasound was performed with the wrist in three positions (neutral,
flexion, and extension). In the neutral position, the patient is seated
Participants opposite the examiner with the elbow slightly flexed, palm facing up
wards, and the affected wrist in one plane with the fingers slightly
This study was approved by the Institutional Review Board of Affil extended. Conventional ultrasound (ultrasound model: GE Logic E9;
iated Hospital of Nantong University. A total of 60 patients with DRFs probe: linear array probe 15 M HZ, musculoskeletal condition) was
with VLP were admitted to our department between January 2019 and performed using B-mode images, and the cross-sectional area (CSA), D1,
May 2021, and 53 met the inclusion criteria. Of these 53 patients, one and D2 were measured and recorded in the plane near the distal radial
experienced extensor tendon rupture, and the plate was removed 3 watershed (Fig. 2A). In detail, the examiner traced the MN along the
months postoperatively in combination with tendon repair; eight were hyperechogenic rim and quantified the median nerve cross-sectional
lost to follow-up. Thus, we obtained complete follow-up information for area (MNCSA) by tracing. Subsequently, the longest diameter in the
44 patients (Table 1). Eighteen of the patients were male (40%), 26 were radial–ulnar (D1) and dorsal–palmar (D2) directions were identified by
female (60%), and the mean age was 56.8 years. The inclusion criteria two perpendicular straight lines within the outlined MN (Fig. 2A).
were as follows: (1) VLP internal fixation for DRF; (2) age ≥ 18 years, Similarly, the D1, D2, and MNCSA values in the extreme flexion and
and (3) consented to the study and signed informed consent documen extension wrist positions were also measured using ultrasound (Fig. 2B
tation. The exclusion criteria were as follows: (1) patients with post and 2C).
operative deformity in the healing of DRFs; (2) patients with other
specific serious medical diseases and pathological fractures; (3) patients Sensations and functional outcomes
with bilateral DRFs or other fractures; (4) patients with a history of pre- MN sensory function in the index finger was determined using static
existing carpal tunnel syndrome, hand tumours, and gout, and (5) 2-point discrimination (S-2PD), moving 2-point discrimination (M-
ungradable patients with highly comminuted fractures and cumulative 2PD), and Semmes-Weinstein monofilament (SWM) tests. In addition,
anatomical landmarks. grip strength and the Disabilities of the Arm, Shoulder, and Hand
(DASH) scores were measured to determine hand function recovery
Surgical method [18–21]. During the follow-up, the patient was asked about and assessed
for nerve entrapment symptoms, such as finger numbness.
VA-LCP Two-Column Distal Radius Plates 2.4 (Synthes® GmbH,
Oberdorf, Switzerland) plates were used in this study with the palmar Statistical methods
Henry or flexor carpi radialis approach. No preventive carpal tunnel
release surgery was performed. SPSS 21.0 software (SPSS Inc. Chicago, IL, USA) was used to statis
tically analyze the follow-up measurement data. The measurement data
Postoperative management are expressed as mean ± standard deviation; the Kruskal–Wallis test and
an ANOVA were used to compare quantitative differences between the
Postoperatively, all patients were given temporary prophylactic an three groups. A two-factor ANOVA was used for comparisons across
tibiotics for one day and clean dressing changes until the incision was different positions and grades. P < 0.05 was considered to indicate
completely healed. Active functional fist clenching and finger extension significance.
exercises were performed on the first postoperative day. Functional
wrist flexion and extension and grip strength exercises were initiated 2 Results
weeks after surgery, resistance exercises for palm and finger pairs were
added in the third postoperative week, and wrist and palm support ex Effect of VLP prominence on MNCSA
ercises were gradually added 6–8 weeks after surgery.
MNCSA differences across Soong grades were statistically significant
Plate position determination (P < 0.01), and there was no significant interaction between different
wrist positions and Soong grade (P > 0.05).
Patients were assessed using standard lateral radiographs of the wrist In the flexed wrist position, the CSA of Soong Grade 0 (8.90 ± 0.75
mm2) was smaller than those of Grade 1 (10.10 ± 1.43 mm2) (P < 0.05)
and Grade 2 (11.19 ± 0.60 mm2) (P < 0.001). In addition, the CSA of
Table 1
Grade 1 (10.10 ± 1.43 mm2) was smaller than that of Grade 2 (11.19 ±
Characteristics of the participants (n = 44).
0.60 mm2) (P < 0.05) (Table 2).
Soong Age, yr Height, Weight, kg BMI, kg/ Follow-up,
In the neutral wrist position, the CSA of Soong Grade 0 (8.83 ± 0.80
Grade cm m2 mo
mm2) was smaller than those of Grade 1 (10.09 ± 1.50 mm2) (P < 0.05)
0 58.9 ± 164.4 ± 64.2 ± 23.7 ± 13.6 ± 2.7 and Grade 2 (11.03 ± 0.76 mm2) (P < 0.001). There was no difference in
8.1 7.3 12.0 3.5
1 52.8 ± 163.2 ± 69.1 ± 25.9 ± 13.9 ± 2.3
CSA between Grade 1 (10.09 ± 1.50 mm2) and Grade 2 (11.03 ± 0.76
13.7 8.1 11.4 2.9 mm2) (P > 0.05) (Table 2).
2 54.9 ± 162.7 ± 65.0 ± 24.4 ± 13.1 ± 1.9 In the extended wrist position, the CSA of Soong Grade 0 (9.02 ±
7.4 6.8 11.7 2.9 0.75 mm2) was smaller than those of Grade 1 (10.09 ± 1.42 mm2) (P <
P value > 0.05 > 0.05 > 0.05 > 0.05 > 0.05
0.05) and Grade 2 (11.19 ± 0.71 mm2) (P < 0.001). Similarly, the CSA
Data are presented as mean ± standard deviation. of Grade 1 (10.09 ± 1.42 mm2) was smaller than that of Grade 2 (11.19
Fig. 1. The green line passing through the palmar border of the cortical bone of the radial tuberosity is line b. The red line a passes through the palmar border of the
distal radius and runs parallel to the green line b. The red line a is the critical line. If the distal end of the plate is entirely dorsal to the red line, this is recorded as
Soong Grade 0 (Fig. 1A), if the distal end of the plate is entirely palmar to the red line, this is recorded as Soong Grade 2 (Fig. 1C), and if the distal end of the plate is
between these two conditions, this is recorded as Soong Grade 1 (Fig. 1B). (For interpretation of the references to colour in this figure legend, the reader is referred to
the web version of this article.)
Discussion
± 0.71 mm2) (P < 0.05) (Table 2).
VLP is widely used to treat DRFs because of its obvious advantages
Effect of VLP prominence on D1 and D2
[22–24]. Although the effect of the VLP approach is good, some com
plications remain, which have attracted scholars’ attention. The inci
In the flexed wrist position, the D1 values of Soong Grades 0, 1, and 2
dence of MN injury or compression is 0.5–14.6% [25–27]. MN injury
were 5.05 ± 0.53 mm, 5.17 ± 0.56 mm, and 5.27 ± 0.46 mm, respec
phenomena associated with VLP, including MN disorders and direct or
tively. The D2 values of Soong Grades 0, 1, and 2 were 2.28 ± 0.28 mm,
indirect compression, have been reported [26,28]. VLP prominence may
2.31 ± 0.23 mm, 2.37 ± 0.28 mm, respectively. The differences in D1
cause a volume change in the wrist and indirectly compress the MN.
and D2 values across different Soong grades in the flexed position were
Such compression can damage the local circulation to the MN and the
not statistically significant (P > 0.05) (Table 2).
blood–nerve barrier, increasing fluid pressure in the nerve and further
In neutral wrist position, the D1 values of Soong Grades 0, 1, and 2
aggravating MN swelling and other phenomena, potentially causing MN
were 5.32 ± 0.49 mm, 5.38 ± 0.52 mm, and 5.48 ± 0.44 mm, respec
injury-related symptoms [29].
tively. The D2 values of Soong Grades 0, 1, and 2 were 2.07 ± 0.25 mm,
In this study, the MNCSA was 8–11 mm2 in all patients, which is
2.16 ± 0.24 mm, and 2.18 ± 0.25 mm, respectively. The D1 and D2
consistent with the results of Pan et al. [30]. However, the influence of
differences across different Soong grades in the neutral position were not
the plate protrusion on the MNCSA has rarely been reported. VLP pro
statistically significant (P > 0.05) (Table 2).
trusions were divided into Grades 0, 1, and 2 following Soong classifi
In the extended wrist position, the D1 values of Soong Grades 0, 1,
cation. The CSA of the MN of those classified as Grade 2 was greater than
and 2 were 5.57 ± 0.51 mm, 5.61 ± 0.53 mm, and 5.63 ± 0.46 mm,
that of those classified as Grade 0 in the flexed, neutral, and extended
respectively. The D2 values of Soong Grades 0, 1, and 2 were 1.88 ±
wrist positions. Thus, the higher the plate protrusion is, the greater the
0.19 mm, 2.03 ± 0.22 mm, and 2.08 ± 0.26 mm, respectively. The D1
swelling of the MN near the carpal tunnel will be, increasing the CSA
and D2 differences across different Soong grades in the extended posi
and, consequently, the likelihood of MN injury symptoms [31].
tion were not statistically significant (P > 0.05) (Table 2).
We also measured D1 and D2, representing the longest diameter of
the MN in the radial–ulnar and dorsal–palmar directions, respectively.
Sensations and functional outcomes
The changes in D1 and D2 represent the deformation of the MN near the
entrance of the carpal tunnel. Studies have shown that changes in the
There were no statistical differences in the S-2PD, M-2PD, and SWM
carpal tunnel volume will deform D1 and D2 of the MN [32]. In our
(P > 0.05) with differing Soong classifications at follow-up (Table 3),
study, no statistical difference was found in D1 and D2 across different
and no statistical differences in the grip strength and DASH of different
Soong grades. The compression of the tendon led to irregular or no
Soong grades (P > 0.05) (Table 3). No patients had symptoms of MN
change pattern in the MN; thus, there were no differences in D1 and D2.
entrapment, such as numbness and abnormal sensation in the fingers at
We next measured the S-2PD, M-2PD, and SWM in the pulp of the
follow-up.
index finger, the grip strength, and the DASH of the affected hand; the
differences across the grades were not statistically significant. Studies
have shown that MN morphological changes often appear before clinical
symptoms or functional changes [33]. In addition, Koo et al. found that
Fig. 2. Fig. 2A. Neutral position, Fig. 2B Flexion position, Fig. 2C. Extension position. The white arrow P pointing to the plate position. Quantification of the median
nerve cross-sectional area (MNCSA), diameter in radial-ulnar direction (D1) and diameter in dorsal-palmar direction (D2).
complications may not occur until 6 years after VLP placement [34]. Our patient intended to have the plate removed within a year or had no MN
follow-up time was approximately 13 months, and whether increased symptoms at the time of surgery.
nerve CSA in Soong Grade 2 patients will cause clinical symptoms or The present study has some limitations. First, the displacement of the
functional changes over a longer period needs further investigation. flexor tendon of the fingers may cause morphological changes in the MN
Some scholars have suggested that preventive carpal tunnel release and may have affected the quantitative data regarding the MN. Second,
should be performed at the same time as DRF treatment [35]. None of different pressures applied to the ultrasonic probe during the examina
the patients in our study experienced MN symptoms in the 13 months tion may cause different degrees of nerve deformation [36]. Therefore,
after VLP fixation, and carpal tunnel release was unnecessary if the the same senior musculoskeletal sonographer performed all ultrasound
Table 2
Results of CSA, D1, and D2 of the median nerve in different grades at different wrist position.
Soong grade Flexion position Neutral position Extension position
CSA, mm2 D1, mm D2, mm CSA, mm2 D1, mm D2, mm CSA, mm2 D1, mm D2, mm
0 8.90 ± 0.75 5.05 ± 0.53 2.28 ± 0.28 8.83 ± 0.80 5.32 ± 0.49 2.07 ± 0.25 9.02 ± 0.75 5.57 ± 0.51 1.88 ± 0.19
1 10.10 ± 1.43a 5.17 ± 0.56 2.31 ± 0.23 10.09 ± 1.50a 5.38 ± 0.52 2.16 ± 0.24 10.09 ± 1.42a 5.61 ± 0.53 2.03 ± 0.22
2 11.19 ± 0.60ab 5.27 ± 0.46 2.37 ± 0.28 11.03 ± 0.76a 5.48 ± 0.44 2.18 ± 0.25 11.19 ± 0.71ab 5.63 ± 0.46 2.08 ± 0.26
a: P < 0.05 compared to 0, the difference is statistically significant. b: P < 0.05 compared to 1, the difference is statistically significant. Data are presented as mean ±
standard deviation.
Provincial Key Research and Development Program (BE2017681) and

Table 3
Science and Technology Project of Nantong City (MS22022110) for this
Comparative analysis of sensory and functional at different soong grades.
research.
Soong S-2PD, M-2PD, SWM Grip strength, DASH,
Grades mm mm kg points
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Injury 54 (2023) 110839
Injury
Adipose delivered stem cells protect liver after ischemia-reperfusion injury

by controlling autophagy
Bahar Kartal a, *, Ebru Alimoğulları a, Pınar Elçi b, Hazal Demir a
a
Ankara Yıldırım Beyazıt University, Medical Faculty, Department of Histology and Embryology, Ankara, Turkey
b
Health Sciences University, Gulhane Health Sciences Institute,Stem Cell Laboratory, Ankara, Turkey
Keywords: Objective: : Ischemia-reperfusion(I/R) injury is an unavoidable side effect of liver surgery and transplantation. A
Ischemia-reperfusion injury potentially useful tool for cellular therapy and tissue engineering is adipose-derived stem cells (ADSCs).The
Liver process of autophagy is used by the cell to break down inappropriate molecules.The study’s goal was to examine
Adipose-derived stem cells(ADSCs)
the impact of ADSCs on the autophagic pathway after rat hepatic ischemia-reperfusion injury.
Autophagy
Histopathology
Material and Methods: : Thirty male rats used in our study were divided into control, ADSC, ischemia, I/R, and I/
R+ ADSC groups (n = 6). Liver tissues were stained with hematoxylin-eosin and histological changes were
evaluated with Suzuki scoring. Immunoexpressions of transforming growth factor (TGF-β) and autophagy
markers LC3B, p62 were analyzed using the immunohistochemical method.
Results: : As a result of histological evaluation the ischemia and I/R groups displayed sinusoid congestion,
vacuolization, and necrosis in liver tissues. We showed that the immunostaining of LC3B and TGF- β were
elevated, and p62 decreased in the rat liver from ischemia and I/R groups when compared to the control group.
Conclusion: : ADSCs reduced the excessive level of autophagy and structural damage to hepatocytes and the
pathological alterations in the liver after ıschemia-reperfusion injury.
Introduction tissue structural regeneration and functional recovery [9,10].

Mesenchymal stem cells [MSCs) lower inflammatory and immune
The injury caused by hepatic ischemia-reperfusion (HIR) is a sign of reactions. They can be used as bio-therapeutic tools to treat inflamma
impending liver damage and failure [1]. Shock, trauma, hepatectomy, tory illnesses [11].MSCs can develop into cells that mimic hepatocytes,
liver transplantation, and other surgical operations all inevitably result protect the liver from injury, diminish liver fibrosis, promote liver
in HIR injury complications [2,3].Hepatic ischemia-reperfusion injury regeneration, and reduce inflammation [12,13].
causes liver damage mostly during the reperfusion phase when blood In tissue engineering, adipose-derived mesenchymal stem cells
reperfusion causes an innate immune response. Overproduction of (ADSCs), which serve as good progenitor cells for cell-based regenera
reactive oxygen species, activation of Kupffer cells and other inflam tive therapies, are often used [14].The benefits of adipose-derived
matory cells, and calcium overload all contribute to the pathophysio mesenchymal stem cells include plentiful supplies, simplicity of har
logical process of HIRI, which ultimately results in hepatocellular death vesting, less damaging fat storage for the body, low immunogenicity,
[4].The regeneration of the liver is harmed by IRI. Hepatocyte and strong in vitro proliferative capacity [15]. The kidney [16], liver
destruction will result from the ischemia-induced lack of nourishment [17], heart [18], and brain [19] can all be protected against
and oxygen in the early stages of liver IRI. The pathogenic processes of ischemia-reperfusion injury by ADSCs.
IRI have been widely researched [5,6,7] however the interactions be The cellular catabolic process known as autophagy is responsible for
tween the signaling pathways involved in IRI are extremely complicated removing primarily damaged molecules and organelles by transporting
and poorly understood. them to lysosomes for destruction. The balance between the production,
A promising method for tissue repair and regeneration is stem cell breakdown, and subsequent recycling of cellular products is maintained
treatment [8].Numerous studies have demonstrated that exogenous by autophagy [20].
stem cell injection or mobilization of endogenous stem cells can enhance The most popular marker for tracking autophagy is microtubule-
* Corresponding author at: Ankara Yıldırım Beyazıt University, Medical Faculty, Department of Histology and Embryology, Ankara, Turkey.
E-mail address: bahar.kartal@outlook.com (B. Kartal).
https://doi.org/10.1016/j.injury.2023.110839
B. Kartal et al. Injury 54 (2023) 110839
associated protein-1 light chain 3-B(LC3B).The exterior and inner They were observed and captured on camera using a light microscope
autophagosomal membranes are integrated with lipidated LC3B(LC3B- (LeicaDM4000, Wetzlar, Germany). The immunohistochemistry anal
II), allowing for the detection of various autophagic vesicle phases ysis was conducted using H-score calculations [27].
[21,22]. Numerous investigations have discovered that autophagy can
be very selective [23].P62, one of the best-studied autophagy receptors, Analyses of statistics
is involved in the autophagy-dependent removal of a variety of cargos,
including bacteria and ubiquitinated protein aggregates. P62 is Expressions of immunocytochemistry were evaluated using the
degraded by autophagy due to its interaction with LC3, and when GraphPad Prism (GraphPad, San Diego, CA). Through the use of ANOVA
autophagy is blocked, p62 positive aggregates form [24]. and Turkey’s multiple comparison tests, the significance of the data
Therefore, the study’s goal was to examine how ADSCs affected the between groups was investigated. The agreed point for statistical sig
autophagic process following hepatic ischemia/reperfusion. nificance was p < 0.05.
Materials and methods Results
Animals Histopathological results
30 Wistar albino rat (200–220 gr) were used. All animals were given To determine ADSCs’ protective effects in the rat liver IRI model,
seven days to adjust to the lab setting while having free access to water H&E staining was used to evaluate hepatocellular damage. The control
and regular laboratory food. Standard environmental conditions with a and ADSCs animals’ livers showed a typical lobular structure, a clean
12-hour light/dark cycle were used to house the animals. liver cord, and no indications of injury. The hepatic cell cord structure
was disrupted in the Ischemia and I/R group rats, which led to hepatic
Operative procedure sinus congestion, necrotic parenchyma, and hepatocyte vacuolization.
Additionally, the hepatic parenchyma of ischemia and I/R groups had
A ketamine cocktail consisting of ketamine (13 mg/mL), xylazine inflammatory cell influx. The ADSC -treated group following I/R,
(2.6 mg/mL), and acepromazine(0.15 mg/mL) in 0.9% NaCl was showed reduced liver histopathologic injury, including portal inflam
injected intraperitoneally into rats for anesthesia. Under anesthesia, all mation, hepatocyte edema, cytoplasm deformation, and coagulation.
surgical procedures were carried out.Midline incision was made to open (Fig. 1).
the abdomen, and the ligaments encircling each lobe were subsequently
removed.A microvessel clip applied to the portal vein, hepatic artery, Immunohistochemistry results
and bile duct supplying the liver’s midline and left lateral lobes resulted
in 70% partial liver ischemia. The vascular clip was loosened to start The immunoexpression of autophagic markers LC3B and p62 was
hepatic reperfusion after 40 min of partial hepatic ischemia.The ADSCs investigated. Apparent positive staining was observed in the ıschemia
(1 × 106 cells/kg) were injected into the liver parenchyma following 20 and I/R groups (Fig. 2D and E) and the I/R + ADSC group (Fig. 2F)
min of ischemia. Following the reperfusion, animals were sacrificed compared with the negative and positive control (Fig. 2A and B) and
[25]. ADSC groups (Fig. 2C). The number of LC3B positive cells was notably
decreased in I/R + ADSC (Fig. 2F) compared to those in the ischemia and
Histological examination I/R.
The expression of p62 tended to decline in the ischemia and I/R
Standard procedures were followed to prepare the liver tissues for groups(Fig. 3D and E).In contrast, ADSC therapy dramatically increased
histological investigation after they were fixed in 4%formaldehyde and P62 protein expression (Fig. 3F).
embedded in paraffin. 5 μm-thick of each paraffin block was removed, There was not any specific immunostaining of TGFβ in the negative
and hematoxylin-eosin (H&E) staining was carried out on them.Suzuki control, control, and ADSC groups (Fig. 4A, B, and C). The staining of
classification [26],which is based on sinusoidal congestion, vacuoliza TGFβ was increased in ıschemia (Fig. 4D) and ischemia-reperfusion
tion of hepatocyte cytoplasm, and parenchymal necrosis, was used to groups (Fig. 4E) and the staining intensity was decreased with the
grade hepatic IRI. The scores were 0: none, 1: minimal, 2: mild, 3: treatment of ADSC (Fig. 4F). The H-SCORE analysis of the immunoex
moderate, and 4: severe, and necrosis was 0: none, 1: < 10%, 2: 30%, 3: pression of LC3B,p62, and TGFβ was given in Fig. 5.
60%, and 4: >60%.
Discussion
Immunohistochemistry assay
Clinical trials have examined stem cell therapy as a potential treat
The liver sections were deparaffinized and rehydrated by using ment for a variety of inflammatory illnesses and liver disorders [28]. The
xylene and graduated alcohol. Antigen retrieval took place in a micro effectiveness and mechanism of MSCs in preventing hepatic I/R injury
wave for 10 min at 96 ◦ C (10 mM/L citrate buffer, pH: 6). Hydrogen were studied by Zheng et al. [29].The effects of MSCs were investigated
peroxide at 3% (v/v) was used to suppress endogenous peroxidase for utilizing a mouse liver injury/recovery model and a hypoxia/reoxyge
15 min, followed by phosphate-buffered saline washing (PBS). After nation model using L02 hepatocytes. These in vivo and in vitro
that, the slides were blocked with blocking serum (UltraV Block, ScyTek I/R-induced hepatocellular apoptosis models were used to study the
Laboratories, Utah, USA). The sections were treated with the primary potential pathways of MSCs. MSCs also showed an improvement in he
antibodies LC3B, p62, and TGF-β for an overnight period at 4 ◦ C. The patic damage and the capacity to control mitochondrial efficiency.
tissue sections were incubated with biotinylated anti-mouse secondary Restored ATP generation, enhanced mitophagy, decreased buildup of
antibodies (LabVision, TM-015-BN) for 10 min at room temperature fragmented mitochondria, and lower levels of excess mitochondrial
after followed by two PBS washes. Antigen-antibody complexes were reactive oxygen species served as proof of this.
fixed using a streptavidin-peroxidase complex (TP-060-HL; LabVision, Another study in the literature has investigated the function of the
Fremont, CA, USA) for 10 min after three PBS washes. DAB (3,3′ -dia secretome produced by ADSCs in liver regeneration in small pigs. Serum
minobenzidine) was used to treat the sections after they were stained and liver tissue samples were collected at 1, 3, and 7 days after surgery,
with Mayer’s hematoxylin (Merck). After drying, the sections were and changes in tissue pathology, inflammatory markers in the serum,
mounted with Entellan (Mounting Medium, LabVision, TA-060-UG). liver function, angiogenesis-related factors, and genes were evaluated.
Fig. 1. Histopathological modifications and liver score following IR.

Liver tissues with HE staining from the (A)control, (B) ADSC, (C) Ischemia, (D) I/R and (E) I/R+ADSCs groups. hemorrhage is indicated by a black arrow, hepatocyte
vacuolar degeneration by blue arrow, and inflammatory cell infiltration by a arrow head. (Magnification 400X) (F) Histopathology score.
Fig. 2. The immunochemistry staining of LC3B in rat liver tissue

A: Negative control; B: Control; C: ADSC; D: Ischemia; E: I/R; F: I/R+ADSC.
(Magnification 40X).
They discovered that ASC-secretome enhances liver regeneration and In the current study, liver histology reviewed that ischemia-
suppresses the inflammatory response induced by partial hepatectomy reperfusion caused hepatic sinusoid congestion,vacuolization,andnec
and ischemia-reperfusion in miniature pigs [30]. rosis. Adipose-derived stem cells could alleviate the histological changes
Fig. 3. The immunostaining of p62 in rat liver tissue

Fig. 4. The immunostaining of TGFβ in rat liver tissue

in the liver after I/R. vacuoles, which can result in cell death [33], in extreme circumstances,
The cytoplasmic elements are transported into lysosomes for such as acute organ injury or reperfusion injury [34]. These findings also
destruction by autophagy, an intracellular degradation system [31]. The point to a potential novel strategy for improving the effects of IRI, which
biological process that maintains cell viability and homeostasis is involves regulating the level of autophagy [34,35,36].
autophagy, which recycles and reuses energy [32].On the other hand, By lowering the degree of hepatocyte autophagy, recent in
uncontrolled autophagy can result in the build-up of autophagic vestigations have demonstrated that ADSCs transplantation can lessen
Fig. 5. The H-SCORE analyzes of immunoexpression of LC3B (A),p62 (B), and TGFβ (C).
The immunoexpression of LC3B and TGFβ was significantly increased whereas p62 decreased in I/R compared to control. p < 0.05.
the damage caused by HIRI paired with hepatectomy [34]. Additionally, The effect of IR-induced liver damage on the TGF/Smad3 signaling
uncontrolled autophagy causes an increase in autophagy-related pro pathway in vivo was examined by Li et al. [44].The findings showed that
teins, which causes hepatocytes to die in HIRI paired with hepatectomy TGF1, Smad3, and pSmad3 expression levels increased in the hepatic
injury [34,35]. tissue of WT mice after IR injury.
According to studies, LC3 is a particular protein marker of autophagy In the current study, we examined TGF-beta protein expression. After
that has been demonstrated to rise during ischemia-reperfusion damage. a hepatic I/R injury, TGF-β immunoexpression was enhanced in the
When autophagy is triggered, a ubiquitin-like enzyme combines LC3A liver, and therapy with ADSCs decreased the upregulation of TGF-β.
with phosphatidylethanolamine to form LC3B [37]. The removal of the Thus, we can conclude that ADSC therapy can protect the liver from
autophagic substrate requires two steps: first, the substrate must be damage caused by ischemia and reperfusion by lowering excessive
identified as one that needs to be degraded by autophagy, and second, it autophagy.
must be transported to the autophagosomes. Whether autologous flow
activation occurs or not depends on these two processes. The main Ethical approval
element in controlling these actions is p62 because it is a specific
autophagic receptor. This protein, which joins with ubiquitinated pro This study was approved by the Technical Universal Verification
teins to form the autophagosome and subsequently merges with lyso local ethic community (approved number: 0009/2022, Ankara, Turkey)
somes to produce autophagosomes to be eliminated, is a
ubiquitin-binding protein that is implicated in cell signaling, oxidative
Financial interests
stress, and autophagy [38]. As a regulator of the makeup of autopha
gosomes, p62 is destroyed during autophagy when it is connected to
The authors have no relevant financial or non-financial interests to
LC3B [39].
disclose.
Yansong Ge et al. has investigated the efficacy of ADSCs in a porcine
I/R model of laparoscopic hepatectomy [40]. It was found that the ADSC
treatment considerably reduced the serum levels of the enzymes Data availability statement
aspartate aminotransferase, alanine aminotransferase, total bilirubin,
and lactate dehydrogenase. Additionally, as critical autophagy markers, The datasets generated during and/or analyzed during the current
Beclin1, ATG5, ATG12, and LC3II all showed decreased expression study are available from the corresponding author on reasonable
during phagophore development whereas P62 showed an increase. request.
IR surgery was performed on rats to measure liver damage and
identify autophagy. Following ischemia and reperfusion, LC3B protein CRediT authorship contribution statement
expression was significantly increased, and p62 expression was
decreased according to immunohistochemical examination. The amount Bahar Kartal: Conceptualization, Supervision, Writing – review &
of hepatocyte autophagy was increased in the ıschemia and I/R groups editing. Ebru Alimoğulları: Data curation, Methodology, Software.
by downregulating LC3B and upregulating P62 expression. Therefore we Pınar Elçi: Visualization, Investigation. Hazal Demir: Software,
can say that ADSCs inhibit excessive hepatic autophagy. Validation.
Rats receiving ADSC therapy were guarded against hepatic IRI. In
line with earlier research, we found that ADSC–CM reduced hepatocyte
autophagy, which improved the pathological and morphological alter Declaration of Competing Interest
ations of the liver parenchyma in the porcine hepatic I/R combined with
the hepatectomy model. No potential competing interest was reported by the authors
The transforming growth factor-β (TGF-β) is a crucial myofibroblast-
activated mediator that causes stellate cells to release collagen fibers, Acknowledgements
which in turn causes liver fibrosis [41,42].TGF is the most potent fibrotic
and pro-inflammatory factor, and it can also aggravate IR injury [43]. This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
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Injury 54 (2023) 110841
Injury
Titanium alloy cannulated screws and biodegrade ceramic nails for

treatment of femoral neck fractures: A finite element analysis
Yang Liu a, Zhiyuan Ren a, Huifeng Shao b, c, Xueding Wang a, Yongsheng Ma a, Wenjie Song a,
Xiaogang Wu d, Xiangyu Zhang d, Pengcui Li a, Yong He c, Xiaochun Wei a, Wangping Duan a, *
a
Department of Orthopaedics, Second Hospital of Shanxi Medical University, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, Taiyuan, 030001, China
b
School of Mechanical Engineering, Hangzhou Dianzi University, Hangzhou, 310018, China
c
Key Laboratory of 3D Printing Process and Equipment of Zhejiang Province, School of Mechanical Engineering, Zhejiang University, Hangzhou, 310027, China
d
Institute of Biomedical Engineering, College of biomedical Engineering, Taiyuan University of Technology, Taiyuan, 030024, China
Keywords: Background: Our previous studies have demonstrated the mechanical effect of sclerosis around screw paths on the
Finite element analysis healing of femoral neck fractures (FNF) after internal fixation. Furthermore, we discussed the possibility of using
Femoral neck fracture bioceramic nails (BNs) to prevent sclerosis. However, all these studies were conducted under static conditions as
Biomaterial
the patient was standing on one leg, while the effect of the stress generated during movement is unknown. The
purpose of this study was to evaluate the stress and displacement under dynamic stress loading conditions.
Methods: Two types of internal fixation, namely cannulated screws and bioceramic nails, were utilized in
conjunction with various finite element models of the femur. These models included the femoral neck fracture
healing model, the femoral neck fracture model, and the sclerosis around screws model. The resulting stress and
displacement were analyzed by applying the contact forces associated with the most demanding activities during
gait, including walking, standing, and knee bending. The present study establishes a comprehensive framework
for investigating the biomechanical properties of internal fixation devices in the context of femoral fractures.
Results: The stress at the top of the femoral head in the sclerotic model was increased by roughly 15 MPa during
the knee bend and walking phases and by about 30 MPa during the standing phase compared to the healing
model. The area of high stress at the top of the femoral head was increased during the sclerotic model’s walking
and standing phases. Additionally, the stress distribution throughout the dynamic gait cycle was comparable
before and after the removal of internal fixations following the healing of the FNF. The overall stress distribution
of the entire fractured femoral model was lower and more evenly distributed in all combinations of internal
fixation. Furthermore, the internal fixation stress concentration was lower when more BNs were used. In the
fractured model with three cannulated screws (CSs), however, the majority of the stress was concentrated around
the ends of the fractures.The maximal stress in the healing model with one CS and two BNs was the highest at all
stages of gait over three combinations of internal fixation, and the stress was mainly carried by CS.
Conclusions: The presence of sclerosis around screw paths increases the risk of femoral head necrosis. Removal of
CS has little effect on the mechanics of the femur after healing of the FNF. BNs have several advantages over
conventional CSs after FNF. Replacing all internal fixations with BNs after the healing of FNF may solve the
problem of sclerosis formation around CSs to improve bone reconstruction owing to their bioactivity.
Introduction in young patients involves three partly threaded cannulated screws ar
ranged in an inverted triangle [3,4]. In young and middle-aged patients
Although femoral neck fractures (FNFs) represent a common form of with femoral neck fractures, early surgery and precise anatomical
trauma, they are rare in the general population and are typically induced reduction should be a priority in order to limit local blood supply
by incidences of high-energy trauma, such as car accidents [1,2]. The disruption to restore the blood circulation of the femoral head with high
typical traditional internal fixation technique for femoral neck fractures efficiency [5,6]. The fracture healing rate following internal fixation of
* Corresponding author at: Department of Orthopaedics, Second Hospital of Shanxi Medical University, No. 382, Wuyi Road, Taiyuan, Shanxi, 030001, China.
E-mail address: dwpsc2004121@163.com (W. Duan).
0020-1383/© 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
Y. Liu et al. Injury 54 (2023) 110841
Fig. 1. Stress of the femur and internal fixation in a sclerotic model with three CSs.
femoral neck fractures with cannulated screws has increased to over altered during stance. Due to insufficient mechanical stimulation, the
90% owing to advancements in imaging and internal fixation methods bone tissue may become osteoporotic in the later phases of fracture
[7,8]. However, despite these improvements, there is still a high repair and is thus commonly vulnerable to refracture [16–18]. The
(10.0–48.8%) need for reoperation, and this rate has not changed in the mechanical characteristics of the bone deteriorate as fixation lengthens.
last 30 years [9]. In search for the ideal course of treatment for FNF, the The frequency of implant removal and the selection criteria for candi
high reoperation rate has generated debate [10]. dates for removal are uncertain, and there is an ongoing debate con
Mechanical analyses have revealed that the mechanical loads are cerning the impact of the implant on stress distribution after healing
centered on the internal fixation material placed furing FNF repair using [19].
cannulated screws, which changes the bone mass and microstructure of In recent years, medical professionals have been looking for more
the femoral head [11–13]. The screw pathways of the femoral head may suitable surgical techniques [20]. The creation of a novel hip fracture
develop sclerosis after long-term retention of the internal fixation implant and a new surgical technique was motivated by the benefits and
implant following FNF surgery. Herein, we refer to this high-density drawbacks of each implant from both laboratory and biomechanical
distribution as sclerotic cancellous bone (SCB) [14]. Furthermore, as tests. Clinical bone implants composed of a variety of biomaterials, such
we found in a previous clinical study, no useful tissue filling forms as carbon fiber, titanium, and magnesium have been employed [21].
within the screw routes years after the removal of the internal fixation Although the biomaterials used to create implants offer sufficient me
material [15]. As a result, the osteogenic vascularization and mechani chanical support, several investigations have revealed that there is no
cal qualities of the entire femoral head are further reduced, accelerating direct osseointegration between these materials and the host bone;
necrosis of the femoral head. Owing to a lack of osteogenic vasculari instead, fibrous tissue is formed between the host bone and the material
zation along the screw path, efficient tissue filling and blood supply [22]. Biodegraded magnesium alloys have previously demonstrated
recovery are not possible at the latter stage, even after internal fixation strong mechanical characteristics and biosafety when employed in
had been removed during long-term retention. clinical settings for FNF, wrist fracture, and hallux vaglus [23]. Because
Internal fixation therapy aims to mimic the physiological transfer of its crucial involvement in osteoblast adhesion, differentiation, pro
that occurs in the original load femur from the femoral head to the liferation, and bone mineralization [24], magnesium is believed to have
metaphyseal cortex to prevent stress shielding. In order to heal the potential for use in skeletal tissue engineering. Furthermore, research
fracture, it is important to ensure that the bone has a stable mechanical has shown that it can promote the growth of new bone [25]. Hence, in
environment in the near term, while avoiding reinjury. To this end, order to balance their mechanical and biological qualities, we suggested
clinical treatment using cannulated screws (CSs) with high stiffness and using ionizing silicates. In the present study, we used a 3D printer and a
elastic modulus is recommended. However, there is a loss of bone mass sintering process to create degradable bioceramic nails (BNs) with
because the stiffness of the CS is higher than that of the bone tissue, improved hydroxyapatite (HA) layer deposition sedimentary capabil
while the stress distribution in the proximal femur is significantly ities. The rate of bone tissue regeneration was equal to the rate of
Y. Liu et al. Injury 54 (2023) 110841
Fig. 2. Stress of the femur and internal fixation in a healing model with three CSs.
and knee bending and to translate them into a loaded form for loading
Table 1 analysis in finite elements. The specific aims of this study were as follow:
Comparison of stress between the sclerotic and healing models. to examine how implants affect the distribution of femoral stress after
Maximum stress (MPa) Maximum stress at the top of the healing of the femoral neck fracture; to ascertain the connection
femoral head (MPa)* between the stress distribution in the proximal femur and osteosclerosis
Sclerotic Healing Sclerotic Healing surrounding the screws; to assess the mechanical efficacy of BN in
model model model model
treating unstable FNFs in comparison with traditional CS; and to show
Walking 1 85.5 84.3 42 23 the biomechanical stability of the combination implants in order to
Walking 2 128.9 127.5 50 35
define the theoretical underpinnings for the clinical use of novel BNs.
Standing 1 100.9 100.4 28 16
Standing 2 97.2 75.0 48 29
Knee bend 1 54.1 53.2 21 14 Methods
Knee bend 2 119.2 80.4 60 30
*
Because the stresses here are regional, the stress values shown are only The femoral heads were obtained from patients at our hospital who
approximate figures. underwent total hip arthroplasty and developed non-traumatic femoral
head necrosis, as well as those with femoral neck fractures. These
degradation of the BN. The expanded lateral holes and accelerated new samples, which had to be obtained from the operating table within half
bone formation was caused by the enhanced bilayer printing technique an hour, were transferred to an ice box and stored in a -80◦ refrigerator
[26]. This can prevent fracture complications by accelerating osteogenic in the shortest time possible so that the measurement of the modulus of
vascularization and restoring the mechanical properties of the femur in elasticity can be reliably completed within a week. All participants
advance if a new calcium-magnesium-silicate ceramic nail is implanted provided written informed consent to participate in this study, which
into the screw path following healing of FNF and before the formation of was approved by the .
an osteosclerotic area around screw paths. The advantages of these two The cannulated screw material is 00Cr18Ni14Mo3 stainless steel or
types of materials have been mentioned in a number of studies, but they titanium 6 aluminum 4 vanadium titanium alloy., an associate professor
have not received sufficient attention. In addition, a reliable finite from, used three-dimensional microstructure printing and sintering to
element experiment has not been conducted to compare the mechanical prepare the BNs used in this study. A bioceramic material suitable for
stability of the two materials. bone implantation was created by combining homogeneously indepen
In this study, we aimed to moniter the stress distribution and dently generated calcium magnesium silicate ceramic powder and
displacement conditions during physiological movements in order to hydrogel solution. The material was considered for the effects of
identify the six vulnerable to the stress (i.e., those that are likely to different sintering temperatures, scaffold porosity, and other parameters
sustain most harm due to internal fixation) during walking, standing, [27]. Controlled degradation experiments in Tris-HCl solution and
Y. Liu et al. Injury 54 (2023) 110841
Fig. 3. Stress and displacement of the femur in a healing model without three CSs.
Y. Liu et al. Injury 54 (2023) 110841
Fig. 4. Stress of the femur and internal fixation in a fracture model with three BNs.
defect repair experiments in vivo indicated that the scaffold materials [35], the two postures most detrimental to internal fixation, respec
had good osteogenic and osteoinductive properties as well as good tively, during walking, standing, and knee bending were converted to
biological activity. Osteogenic vascularization of scaffold materials in loading. All nodes on the distal femoral surface were restricted to 0 de
vivo can be considerably enhanced by optimizing the spatial organiza grees of freedom during the analysis to avoid rigid body motion. The
tion of the bioceramic scaffolds [28]. To prevent the implant from being model assumes that various materials are homogeneous and isotropic
pulled out, this material is frequently used in spinal diseases and has linear elastic [36,37]. The Von Mises stress and the implant and femur
excellent frictional properties [29]. displacements were measured.
A 31-year-old healthy male volunteer with no history of hip pa
thology or systemic illness was identified. The models of the CS (7.3 mm Result
diameter, 16 mm thread length, 85 mm total length) and BNs (7.3 mm
diameter, 85 mm total length) were created using the Solidworks soft 1. Sclerotic model and healing model with three CSs
ware based on engineering geometry data and clinical fixation pro
gramming [30]. In accordance with a previously described surgical The maximal Von mises stress in the healing model was at the second
technique [31], implants were designed using Solidworks software in time point of the knee bend, at 127.51 MPa. The minimum stress was at
the shape of an inverted triangle parallel to the longitudinal axis of the the first time point of stance at 53.237 MPa. The overall stress was
femur. After the screw model was created using the feature function mainly distributed in the femoral shaft. In contrast, the stress was mainly
command in the Solidworks, the previously created femoral model was distributed in the femur shaft, femoral neck, and top of the femoral head
placed into the assembly interface of Solidworks together with the screw during the second phase of walking and stance. In addition, the stress of
model; the screw was dragged to the specified position and then internal fixation was mainly distributed in the middle of cannulated
fine-tuned according to the placement requirements, resulting in a screws, and the maximal stress was at the second time point of stance, at
screw-placed femoral model. An FNF of the Pauwels type III (50◦ ) was 23.326 MPa, which tests the load-bearing capacity of internal fixation
used in this study. Finite element analysis was performed using ANSYS the most (Fig. 1).
17.0 after three models (sclerotic, healing, fracture) and four internal The maximal Von Mises stress in the sclerotic model was at the
fixations (A: three CS, B: three BN, C: two BN and one CS, D: one BN and second time point of the knee bend, at 128.86 MPa, and the minimal
two CS) were prepared. stress was at the first time point of stance (54.117 MPa). The overall
The Poisson’s ratio and elastic modulus of the materials [32,33] and stress was mainly distributed in the femoral shaft, femoral neck, and top
the friction coefficient [34] of the fracture ends were set up as in pre of the femoral head, while the stress was mainly distributed in the
vious static studies. According to the curve data in Bergman’s study femoral shaft during the first phase of walking. In addition, the stress of
Y. Liu et al. Injury 54 (2023) 110841
Fig. 5. Displacement of the femur and internal fixation in a fracture model with three BNs.
Y. Liu et al. Injury 54 (2023) 110841
Fig. 6. Stress of the femur and internal fixation in a fracture model with three CSs.
internal fixation was predominantly distributed in the middle of the second time point of knee bend. Displacement of both the femur and
cannulated screws, and the maximal stress was placed at the second time internal fixation was decreased from proximal to distal. The maximum
point of stance, at 25.85 MPa, which tests the load-bearing capacity of displacement of the fractured end was approximately 3.7 mm at the
internal fixation the most (Fig. 2). The results of this section are shown second time point of the knee bend (Fig. 5).
in Table 1. The maximal Von Mises stress was 332.83 MPa in the fractured
model with three CSs at the second time point of stance and the minimal
2. Healing models without three cannulated screws stress was 108.16 MPa at the first time point of stance. The overall stress
was mainly distributed in the femoral shaft and the lower part of the
The maximal Von Mises stress in the healing model without internal fracture ends. In addition, the stress of internal fixation was mainly
fixation was at the second time point of the knee bend, at 131.02 MPa, distributed in the corresponding position of the fracture, and the
and the minimal stress was 53.084 MPa at the first time point of stance. maximum stress was 635.51 MPa at the second time point of stance,
The overall stress was mainly distributed in the femoral shaft, while the which tests the load bearing capacity of internal fixation the most
stress was mainly distributed in the femoral shaft, femoral neck, and top (Fig. 6). (Because the stresses were mainly distributed in the CSs, the CSs
of the femoral head in the second phase of walking and stance (Fig. 3). were removed when showing the femoral stresses, not because the
model was without internal fixation at the time of analysis.)
3. Fracture model with three bioceramic nails and three cannulated The maximal displacement was 11.522 mm in the fracture model
screws with three CSs at the second time point of stance, and the minimal
displacement was 7.698 mm at the first time point of stance. The
The maximal Von Mises stress in the fracture model with three BNs maximum displacement of internal fixation was 10.486 mm at the sec
was at the second time point of stance, at 197.87 MPa, and the minimal ond time point of the knee bend. Displacement of both the femur and
stress was at the first time point of stance, at 116.66 MPa. The overall internal fixation was decreased from proximal to distal. The maximum
stress was mainly distributed in the femoral shaft, and the lower part of displacement of the fractured end was approximately 5.1 mm at the
the fracture ends. In addition, the stress of internal fixation was mainly second time point of stance (Fig. 7). The results of this section are
distributed in the corresponding position of the fracture, and the included in Table 2.
maximal stress was at the second time point of stance, at 105.99 MPa,
which tests the load bearing capacity of internal fixation the most 4. Fracture model with two CSs and one BN, fracture model with one CS
(Fig. 4). and two BNs
The maximal displacement in the fracture model with three BNs was
at the second time point of stance (6.0169 mm), and the minimal The maximal displacement was 6.5238 mm in the fracture model
displacement was at the first time point of stance (3.8284 mm). The with one CS and two BNs at the first walking point and the minimal
maximum displacement of the internal fixation was 5.6649 mm at the displacement was 4.53 mm at the first stance time point. The maximum
Y. Liu et al. Injury 54 (2023) 110841
Fig. 7. Displacement of the femur and internal fixation in a fracture model with three CSs.
which tests the load bearing capacity of internal fixation the most. The
Table 2 anterior and inferior internal fixations are stressed in the gait cycle
Comparison of the fracture models for each internal fixation modality. (Fig. 9).
Three CSs Three BNs Two CSs and One CSs and The maximum displacement was 6.795 mm in the fracture model
one BN two BN with two CSs and one BN at the first time point of walking, and the
A# B* A B A B A B minimum displacement was 4.8494 mm at the first time point of stance.
Walking 1 216.6 3.2 153.5 3.0 225.1 3.4 177.6 2.6 The maximum displacement of internal fixation was 6.3255 mm at the
Walking 2 259.3 4.8 165.3 3.3 240.0 3.7 194.2 3.5 first time point of the knee bend. Displacement of both the femur and
Standing 1 135.3 4.3 148.3 3.1 252.9 3.8 184.6 2.9 internal fixation decreased from proximal to distal. The maximum
Standing 2 245.4 3.9 164.1 1.7 275.7 2.2 239.2 2.3
Knee bend 1 108.2 3.4 116.7 1.7 222.8 2.2 140.5 2.0
displacement of the fractured end was approximately 3.7 mm at the
Knee bend 2 332.9 5.1 197.9 2.2 358.6 2.8 272.2 2.7 second time point of the knee bend (Fig. 10).
#
The maximal von mises stress was 358.63 MPa in the fractured model
Maximum stress (MPa).
* with two CSs and one BN at the second time point of stance, and the
Displacement of the fracture end (mm).
minimal stress was 222.83 MPa at the first time point of stance. The
overall stress was mainly distributed in the femoral shaft and the lower
displacement of internal fixation was 5.9724 mm at the first walking
part of the fracture ends. In addition, the stress of internal fixation was
time point. Displacement of both the femur and internal fixation was
mainly distributed in the corresponding position of the fracture, and the
decreased from proximal to distal. The maximum displacement of the
maximal stress was 320.59 MPa at the second time point of stance,
fractured end was approximately 3.5 mm at the second time point of the
which tests the load bearing capacity of internal fixation the most. The
knee bend (Fig. 8).
anterior and inferior internal fixations were more stressed in the gait
The maximal Von Mises stress was 272.21 MPa in the fractured
cycle (Fig. 11). These results are presented in Table 2.
model with one CS and two BNs at the second time point of stance, and
the minimal stress was 140.48 MPa at the first time point of stance. The
5. Healing models with three BNs, one CS and two BNs, and two CSs and
one BN
part of the fracture ends. In addition, the stress of internal fixation was
mainly distributed in the corresponding position of the fracture, and the
The maximum Von Mises stress was 126.95 MPa in the fractured
maximal stress was 200.85 MPa at the second time point of stance,
model with three BNs at the second time point of the knee bend, and the
Y. Liu et al. Injury 54 (2023) 110841
Fig. 8. Displacement of the femur and internal fixation in a fracture model with one CS and two BNs.
Y. Liu et al. Injury 54 (2023) 110841
Fig. 9. Stress of the femur and internal fixation in a fracture model with one CS and two BNs.
minimum stress was 53.451 MPa at the first time point of stance. The Discussion
part of the fracture ends. In addition, the stress of internal fixation was The healing of FNFs is a dynamic process of continuous remodeling
mainly distributed in the corresponding position of the fracture, and the of the bone trabeculae, regulated by mechanical load [12]. Under the
maximal stress was 37.866 MPa at the first time point of walking, which physical measure, the forces acting on femoral joint are altered ac
tests the load bearing capacity of internal fixation the most. The anterior cording to the posture during the dynamic cycles of knee bending,
and inferior internal fixations were stressed more in the gait cycle walking, and stance. Based on the data provided in the previous litera
(Fig. 12). ture, the two postures that created the strongest stresses were found
The maximal Von Mises stress was 131.08 MPa in the fractured from knee bend, walking and stance, respectively, which were the most
model with two CSs and one BN at the second time point of the knee unfavorable for internal fixation. The stability of the femur and internal
bend and the minimal stress was 53.288 MPa at the first time point of fixation was tested by converting this joint force to a loading form for
stance. The overall stress was mainly distributed in the femoral shaft and finite elements analysis. Evidence suggests that after surgery, the
the lower part of the fracture ends. In addition, the stress of internal femoral neck is mostly subjected to tensile, compressive, and shear
fixation was mainly distributed in the corresponding position of the stresses concentrated around the implants [12,38]. According to Zhang
fracture, and the maximal stress was 37.866 MPa at the first time point et al., mature rat cortical bones do not undergo bone construction under
of the knee bend, which tests the load bearing capacity of internal fix physiological circumstances. Nevertheless, after axial forelimb stress,
ation the most. The anterior and inferior internal fixations were stressed intracortical bone reconstruction occurs in the areas of bone micro
more in the gait cycle (Fig. 13). damage. When the same load is applied, but no bone microdamage is
The maximal Von Mises stress was 129.02 MPa in the fractured created, reconstruction does not occur, indicating that bone micro
model with one CS and two BNs at the second time point of the knee damage can initiate bone tissue reconstruction [39]. During revision
bend and the minimal stress was 53.259 MPa at the first time point of surgery for failed arthroplasty, a continuous bone section closest to the
stance. The overall stress was mainly distributed in the femoral shaft and implant’s surface was discovered [40]. The loose cement mantle and
the lower part of the fracture ends. In addition, the stress of internal implant produce a thicker, more continuous, and distinctly high
fixation was mainly distributed in the corresponding position of the persistence of formation activity because they are both in an unstable
fracture, and the maximal stress was 47.239 MPa at the first time point mechanical environment. Therefore, the following question is con
of the knee bend, which tests the load bearing capacity of internal fix cerned with how the sclerotic area around cannulated screws forms.
ation the most. The anterior and inferior internal fixations were more First, the implant’s micro-injury initiates the process of bone rebuilding.
stressed in the gait cycle (Fig. 14). These results are presented in Table 3. Stress concentrations around the cannulated screw and considerable
internal implant retraction provide unstable conditions for the produc
tion of sclerotic bone around the screw, allowing for gradual thickening
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Y. Liu et al. Injury 54 (2023) 110841
Fig. 10. Displacement of the femur and internal fixation in a fracture model with two CSs and one BN.
11
Y. Liu et al. Injury 54 (2023) 110841
Fig. 11. Stress of the femur and internal fixation in a fracture model with two CSs and one BN.
and growth of sclerosis. Finally, based on the computed tomography This method still uses CSs, which pose a risk of sclerosis around screw
(CT) image, a high-density shadow appears. The bone trabeculae dete paths owing to stress shielding of CS according to the mechanics of
riorate, absorb, and collapse if the remodeled structure cannot be uti sclerosis formation in the previous section.
lized in the new compressive stress and other biomechanical The most important aspect of this study is the time point of sclerosis,
environments [41]. that is, the sequence of healing of FNF and sclerosis around the screw
The difference between the middle values of the upper and lower paths. The trabecular bone has not yet begun to reconstruct in some
stress limits in the stress region at the top of the femoral head in the cases where fractures have not healed despite years of internal fixation
sclerotic models during the knee bend phase was approximately 15 MPa, treatment and the absence of high-density development surrounding the
while that in the standing phase was approximately 30 MPa. Addition screws. Fracture healing and trabecular bone sclerosis must be examined
ally, during the walking and standing phases of the sclerotic model, the jointly [42]. In this process, a hematoma forms, followed by an early
area of high stress at the top of the femoral head was expanded signif stage of inflammation, the creation of a soft callus, the construction of a
icantly (Figs. 1, 2). This implies that even if the FNF heals properly, hard callus, and finally, bone remodeling. Thus, fractures and bone
sclerosis around the implants may prevent partial stress from reaching defects often heal naturally. As a result, sclerotic bone formation and
the lateral femoral stem during the gait cycle and may result in femoral reconstruction of the bone trabeculae did not occur until the FNF was
head necrosis. Therefore, it is crucial to identify techniques to prevent healed. Therefore, the third method is to use BNs after healing of FNF.
the development of sclerosis. Moreover, after the healing of the FNF, the The maximal stress of the healing model with one CS and two BNs was
stress distributions before and after the removal of the internal fixations greatest at all stages of gait over the three combinations of internal
were similar during the dynamic gait cycle. This indicates that removing fixation, and the stress was mainly carried by CS, which reflects that this
the internal fixation at the right time in physiological gait and replacing condition led to the increased stress concentration of the combination of
CSs with BNs is mechanically safe. the two types of material. The magnitude and distribution of stress were
Of the three approaches of using the BNs to address sclerosis around similar for the three combinations of internal fixation, which also ver
screw paths, the first method of internal fixation with BNs directly after ifies the previous conclusion of internal fixation removal. Therefore, in
FNF results in lower displacement and lower stress on the model and dynamic gait, combining three BNs after healing of FNF ensures both
internal fixation. However, as BNs do not have the thread compression sufficient mechanical properties and accelerated osteogenic vasculari
effect of CSs, it is easy for BN to migrate backward, and there is still a risk zation of screw paths during dynamic gait. Therefore, it may be the best
of sclerosis. The second is a combination of the two types of internal method to prevent sclerosis around screw paths.
fixation in FNFs. In all combinations of internal fixation, the more BNs Ideally, following FNF, the fracture ends should attain anatomical
are used, the lower and the more even overall stress distribution is on the reduction (i.e., good alignment of the fracture and restoration of the
entire femoral model was observed, and the lower was the stress con original anatomical position). However, many surgeons choose not to
centration of internal fixation. In contrast, most of the stress was remove internal fixation is because they avoid cutting off the blood
concentrated around the fracture ends in the models with the three CSs. supply to femoral head, since this increases the risk of necrosis and
12
Y. Liu et al. Injury 54 (2023) 110841
Fig. 12. Stress of the femur and internal fixation in a healing model with three BNs.
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Y. Liu et al. Injury 54 (2023) 110841
Fig. 13. Stress of the femur and internal fixation in a healing model with two CSs and one BN.
14
Y. Liu et al. Injury 54 (2023) 110841
Fig. 14. Stress of the femur and internal fixation in a healing model with two CSs and one BN.
Conclusion
Table 3
Comparison of the fracture models for each internal fixation modality. The presence of sclerosis around the screw paths increases the risk of
Three BNs Two CSs and one BN One CS and two BNs femoral head necrosis. Removal of the internal fixation has little effect
A# B* A B A B on the mechanics of the femur after healing of femoral neck fracture.
Walking 1 86.5 37.2 83.3 34.7 87.2 47.2 Bioceramic nails offer greater advantages than conventional canulated
Walking 2 127.0 35.2 131.1 32.3 129.0 44.4 screws after femoral neck fractures. Replacing all internal fixations with
Standing 1 89.2 37.9 89.2 33.7 90.1 45.8
bioceramic nails after the healing of femoral neck fractures has a po
Standing 2 72.7 34.4 78.3 31.6 76.2 43.9
Knee bend 1 53.5 36.7 53.3 32.8 53.3 44.7
tential to solve the problem of sclerosis formation around the cannulated
Knee bend 2 83.6 33.9 84.1 31.0 81.7 43.3 screws and improve bone reconstruction owing to their bioactivity. The
# dynamic results showed that the magnitude and position of stress and
Maximum stress of the total model (MPa).
* displacement were constantly changing during the gait cycle and that
Maximum stress of internal fixation (MPa).
the different models experienced the maximum stress and maximum
displacement at different point of time. Overall, mechanical analysis of
collapse. The findings from the fracture models clearly illustrate that
internal fixation still needs to be carried out over the entire gait cycle.
traditional cannulated screw fixation has an unstable alignment of the
fracture end and a large displacement, which tends to disrupt the blood
supply to the femoral head. Regardless of whether BNs are used alone or Declaration of Competing Interest
in combination with CSs, the entire displacement was considerably
lower than that in the fracture model with three CSs. Therefore, it is The authors declare that they have no known competing financial
more advantageous to use BNs in a clinic setting than three CSs (Figs. 7, interests or personal relationships that could have appeared to influence
8, 10). the work reported in this paper.
There are some limitations in this study. The necrotic femoral head at
different time points after internal fixation should be analyzed using
micro-CT to observe the osteometric changes in the sclerotic bone Funding
around screw paths in the future. In addition, the molecular mechanisms
of sclerotic bone formation and femoral head necrosis need to be This study is supported by the Central Government Guides Local
analyzed using proteomics to support the results of the mechanical Science And Technology development funds (YDZJSX2022B011), the
studies in this study. Key R&D program of Shanxi Province (International Cooperation,
201903D421019) and National Natural Science Foundation of China
(51805475).
15
Y. Liu et al. Injury 54 (2023) 110841
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Injury 54 (2023) 110842
Injury
What makes vertical femoral neck fracture with posterior inferior

comminution different? An analysis of biomechanical features and optimal
internal fixation strategy
Dajun Jiang a, Shi Zhan a, Hu Hai a, Lingtian Wang a, Jinhui Zhao a, Ziyang Zhu a, Tao Wang b,
Weitao Jia a, 1, *
a
Department of Orthopedic Surgery and Orthopedic Biomechanical Laboratory, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of
Medicine, Shanghai 200233, PR China
b
Department of emergency trauma center, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
Keywords: Background and purpose: Fracture comminution occurs in 83.9%-94% of vertical femoral neck fractures (VFNFs),
Vertical femoral neck fractures the majority of which were located in posterior-inferior region, and poses a clinical challenge in fixation stability.
Posterior inferior comminution We conducted a subject-specific finite element analysis to determine the biomechanical features and optimal
Subject-specific finite element analysis
fixation selection for treating VFNF with posterior-inferior comminution.
Internal fixation
Patients and methods: Eighteen models with three fracture types (VFNF without comminution [NCOM], with
comminution [COM], with comminution + osteoporosis [COMOP]) and six internal fixation types (alpha [G-
ALP], buttress [G-BUT], rhomboid [G-RHO], dynamic hip screw [G-DHS], invert triangle [G-ITR], femoral
neck system (G-FNS)) were created based on the computed tomography data. By using the subject-specific finite
element analysis method, stiffness, implant stress, yielding rate (YR) were compared. Additionally, in order to
elucidate distinct biomechanical characters of different fracture types and fixation strategies, we calculated
interfragmentary movement (IFM), detached interfragmentary movement (DIM), shear interfragmentary
movement (SIM) of all fracture surface nodes.
Results: Generally, in comparison with NCOM, COM showed a 30.6% reduction of stiffness and 1.46-times higher
mean interfragmentary movement. Besides, COM had a 4.66-times (p = 0.002) higher DIM at the superior-middle
position, but similar SIM across fracture line, which presented as varus deformation. In COM and COMOP, among
all six fixation strategies, G-ALP had significantly the lowest IFM (p<0.001) and SIM (p<0.001). Although G-FNS
had significantly highest IFM and SIM (p<0.001), it had the highest stiffness and lowest DIM (p<0.001). In
COMOP, YR was the lowest in G-FNS (2.67%).
Conclusions: Posterior-inferior comminution primarily increases superior-middle detached interfragmentary
movement in VFNF, which results in varus deformation. For comminuted VFNF with or without osteoporosis,
alpha fixation has the best interfragmentary stability and anti-shear property among six current mainstream
fixation strategies, but a relatively weaker stiffness and anti-varus property compared to fixed-angle devices. FNS
is advantageous owing to stiffness, anti-varus property and bone yielding rate in osteoporosis cases, but is
insufficient in anti-shear property.
Introduction because of high complications including 11.3% non-union, 25.8%

avascular necrosis, and 23.7% reoperation rates [1]. This is attributed to
Femoral neck fractures in patients aged <60 years are frequently due their high-energy nature [2], general vulnerabilities in the vasculature
to high energy trauma, and present as vertically oriented types. Internal [3], and an unfavorable biomechanical environment. For these frac
fixation treatment for these patients is an unresolved clinical challenge, tures, anatomic reduction and stable fixation are the premises to
E-mail address: jiaweitao@shsmu.edu.cn (W. Jia).
1
Investigation performed at Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine.
nc-nd/4.0/).
D. Jiang et al. Injury 54 (2023) 110842
guarantee a satisfactory clinical outcome. inferior comminution (NCOM), with posterior-inferior comminution
Although various internal fixation strategies such as dynamic hip (COM), and with posterior-inferior comminution and osteoporosis
screw (DHS) [4], femoral neck system (FNS) [5–7], three or four parallel (COMOP). Posterior-inferior comminution was created with a posterior
screws [8], alpha fixation [1,9], and buttress plate technique [10,11] inferior 15◦ osteotomy in the proximal fragment in the middle of the
had been developed for treating VFNF, the optimal internal fixation femoral neck [19] (Fig. 1). Osteoporosis in COMOP was simulated by
strategy for treating VFNFs is still debatable. In most previous biome altering the bone density [20], which was detailed demonstrated in
chanical studies [4,9,12,13], a single vertical plane osteotomy was Finite element analysis part.
created in fracture models, which is quite different from the real-world Six different internal fixation strategies were applied in each fracture
fracture morphologies of VFNF. Recent studies [14,15] revealed that group (Fig. 2): (1) three cannulated screws with one off-axis screw ar
comminution presented in 83.9% - 94% cases of vertical femoral neck ranged in an ‘alpha’ configuration (G-ALP); (2) three cannulated screws
fractures and was proved to be a critical risk factor for treatment failure augmented with a buttress plate (G-BUT); (3) DHS with an anti-rotation
[16]. Morphological analysis [17,15] found that the majority of cannulated screw (G-DHS); (4) four parallel cannulated screws in a
comminution in VFNFs located in the posterior inferior quadrant of the ‘rhomboid’ configuration (G-RHO); (5) three parallel screws in an
femoral neck, resulting in a defect of bony buttress that makes inverted triangular construction (G-ITR); and (6) femoral neck system
anatomical reduction difficult and increases the likelihood of fracture (G-FNS). Fixation devices were all created in SolidWorks2017 (DS Sol
re-displacement under physiological load. Additionally, fracture idWorks Corp, Waltham, MA, USA) based on the parameters of 6.5-mm
comminution is frequently accompanied with poor bone quality [18], cannulated screws (Stryker, Mahwah, NJ, USA), 6-hole-2.7-mm AO
which results in a substantial decrease in fixation stability. However, the locking plate with 2.7-mm locking screws (Depuy-Synthes), and 125◦ -
detailed biomechanical features of this fracture type have not been DHS (Depuy-Synthes), 130◦ - FNS (Depuy-Synthes). The placement of
thoroughly investigated before. Further, owing to the unique challenges internal fixations in the present study was meticulously discussed and
presented by this fracture type, the requirement for biomechanical executed by two experienced orthopedic surgeons, following established
properties is more demanding, and the optimal internal fixation strategy criteria as reported in the literature [1,12]. In the event of any dis
needs further research. agreements or uncertainties, a third senior surgeon (the corresponding
The purpose of this study was to conduct a comprehensive biome author) provided expert judgment to resolve the issue.
chanical comparison of six internal fixation strategies to determine
biomechanical features and optimal fixation selection for treating VFNF Finite element analysis (FEA)
with posterior-inferior comminution in patients with or without
osteoporosis. All 3D models were meshed into 1-mm equal-sized facets according
to the suggestion of mesh convergence tests [21]. The quality of mesh
Material and methods was checked in Hypermesh 13.0 (Altair Engineering, Troy, MI, USA),
without any mesh that was deemed fair or bad. The models were then
Establishment of the study models converted to 4-node linear (C3D4) elements, which is proven to have a
similar accuracy with second-order tetrahedron (C3D10) elements in
Three-dimensional models of this study were established based on femoral simulation [9,22]. These models were imported into Abaqus
computed tomography (CT) images of one healthy, 45-year-old male 6.13 (Simulia Corp, Providence, RI, USA) as .inp format for FEA. All
volunteer. This volunteer had no history of hip fractures, osteopenia, models were assigned as linear elastic properties. The apparent density
and other general comorbidities. He underwent standard clinical pelvic (ρ), Young’s modulus (E), and Poisson’s ratio of each bone element was
CT scans with slice thickness <1.5 mm and an area including the whole assigned based on the Hu value in the CT images according to formula
femur. The study was approved by the local institutional ethics review (1) [23]. According to the formula, bone material was assigned ten
board (No. 2021-KY-71[K]). material groups for each of the cortical and cancellous bones in the FEA
The raw data of CT scans were imported into Mimics software as suggested by a previous study [24]. The density and elastic modulus
(materialize, Leuven, Belgium) in DICOM format for segmentation, of cortical bone ranged from 1.26 to 2.37 g/cm3 and 3718.5 to 28,098.7
retraction, and three-dimensional (3D) modeling. The model was then MPa, while those of cancellous bone ranged from 0.43 to 1.16 g/cm3 and
osteotomized in 3-Matics software (materialize). In this study, all 243.1 to 2920.2 MPa. To simulate models with osteoporosis, bone
models were created with a modified Pauwels angle of 70◦ , and further density was reduced to 75% the initial bone density according to a
divided into three fracture groups, namely VFNF without posterior- previous study protocol [20].
Fig. 1. The location of posterior inferior comminution in this study. Wedge osteotomy was performed in posterior inferior quadrant (180◦ –270◦ in the imaginary
clock face) (Fig. 1A). The fracture line was created with a modified Pauwels angle of 70◦ The wedge osteotomy is 15◦ and located in the middle of the femoral
neck (Fig. 1B).
Fig. 2. All vertical femoral neck fracture (VFNF) models analysed in this study. Fracture types included VFNF (1) without comminution (NCOM), (2) comminution
(COM), and (3) with comminution + osteoporosis (COMOP). To simulate models with osteoporosis in COMOP, bone density was reduced to 75% of the initial bone
density. Internal fixation strategies included (1) alpha fixation (G-ALP), (2) three cannulated screws augmented with a buttress plate (G-BUT); (3) dynamic hip screws
with an anti-rotation cannulated screw (G-DHS); (4) four parallel cannulated screws in an ‘rhomboid’ configuration (G-RHO); (5) three parallel screws in an invert
triangular construction (G-ITR); and the novel femoral neck system (G-FNS).
( / )
ρ g cm3 =/0.000968 ∗ HU + 0.5 Poisson’s ratio assigned as 110,000 MPa and 0.3, respectively [25]. The
If ρ < 1.2 g/cm3 , E = 2014 ρ2.5 (MPa), ν = 0.2 (1) interfaces of screw thread-bone, thread-plate, thread-bolt interfaces
If ρ > 1.2 g cm3 , E = 1763 ρ3.2 (MPa), ν = 0.32. were tied, while screw shaft-bone and fracture interfaces were assigned
as slide contact with a frictional coefficient [26] of 0.46 and 0.3,
All implants were made from titanium (Ti-6L-4 V) with E and
respectively. The region within 80 mm distal from the lesser trochanter
Fig. 3. Fig. 3a The algorithm of interfragmentary movement (IFM). In this algorithm, a local coordinate system was built based on the nodes of distal fracture
surface. Plane Y-Z represented fracture surface (shear direction), while axis X represented the direction perpendicular to the fracture surface (detached direction).
The initial distance vector between each pair of nodes is (→), while the final vector is ( →
′ ′
). The IFM of each pair of nodes was calculated using the vector’s delta
DP DP
value along each coordinate axis (IFMx, IFMy, IFMz). Fig. 3b Apart from the total IFM, the value in detached (Detached Interfragmentary Motion, DIM) and shear
directions (Shear Interfragmentary Motion, SIM) were also documented. DIM mainly represented varus deformation force, while SIM represented the shear force.
was constrained in all degrees of freedom. First, a 12.38 N/mm2 preload √̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅
⃒ ⃒2 ⃒ ⃒2̅
2 ⃒ ⃒ ⃒ ⃒
was applied to the middle of the cannulated and lag screw shaft ac ⃒
SIM = ⃒ → − → ⃒ ⃒
+ ⃒→ − → ⃒ (2)
′ ′⃒ ′ ′⃒
cording to previous protocols [9,12]. This simulated the dynamic DPy DP y
DP z D P z
compression force of the devices. Then, all models were subjected to

The peak implant stress and Von Mises stress distribution were
237.7% body weight [27] in line with the femoral mechanical axis,
analysed. Bone yielding element was determined as trabecular elements
which simulated the loading condition of walking status.
with minimal principal strain below -0.9% [20]. YR was calculated by
Parameters including stiffness, interfragmentary movement (IFM),
the number of yielding elements divided by the total number of elements
peek implant stress, and yielding rate (YR) were analysed and compared.
in the proximal femur.
Stiffness was calculated by dividing patient-specific load by the
The methodology of finite element modeling was previously vali
displacement of the applying node. To handle the ‘fixed point paradox’
dated using cadaver bone with a satisfactory relative coefficient (R =
illustrated in previous literature [28], the IFM of all paired nodes on the
0.78–0.94) [9] of strain distribution. Local comparison of IFM, DIM, and
fracture surface was calculated using the method of vector (formula 2) in
SIM of the superior, middle, and inferior nodes among the three fracture
Matlab software (MathWorks, Natick, MA, USA) (Fig. 3a) [29]. Paired
types were tested using randomized block one-way ANOVA. General
nodes were determined as two points with the smallest distance on the
comparison of IFM, DIM, and SIM of the nodes on the whole fracture
distal and proximal fracture surfaces. Apart from the resultant IFM, the
surface among the six internal fixation strategies were tested using
value in detached (Detached Interfragmentary Motion, DIM) and shear
Kruskal-Wallis ANOVA. For all statistical analyses, p<0.001 was
directions (Shear Interfragmentary Motion, SIM) were also documented
considered to indicate statistically significant differences.
(Fig. 3b). Furthermore, to fully describe the biomechanical effects of
posterior-inferior comminution and osteoporosis on interfragmentary
Results
stability, the SIM and DIM values of the same position at the superior,
middle, and inferior positions among the 18 models were documented in
Generally, in comparison with NCOM, COM had a 30.6% reduction
detail.
of stiffness, 1.46-times higher mean IFM, 1.15-times higher mean SIM,
√̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅
⃒
⃒
⃒2 ⃒
⃒ ⃒
⃒2
⃒ and 4.66-times higher mean DIM. Additionally, in comparison with
COM, COMOP exhibited a 55.1% decrease in stiffness, 1.60-times higher
2 2 ⃒→ − → ⃒ + ⃒→ − → ⃒
IFM = | → − → ′ ′
| + ⃒ ′ ′ ⃒ ⃒ ′ ′⃒
DPx DPy DPz
mean IFM, 1.59-times higher mean SIM, and 1.54-times higher mean
D P
x y DP z D P
⃒ ⃒ DIM than COM. Comparison between the NCOM and COM groups
⃒ ⃒
DIM = ⃒⃒ → − → ⃒ showed that posterior-inferior comminution primarily influences DIM
′ ′⃒
(p = 0.002) especially at the superior-middle positions (3.52–5.74 times
DPx D P x
Fig. 4. Comparison of mean shear interfragmentary movement (SIM) and detached interfragmentary movement (DIM) among the three fracture types at the su
perior, middle, and inferior positions of the fracture surface.
higher), presenting as varus form (Fig. 4), and had no significant [15]. It has been acknowledged [30] that vertically oriented fracture
(p>0.05) impact on SIM at all positions. Comparison between the COM line significantly increases shear displacement. The current study first
and COMOP groups showed that osteoporosis similarly (p<0.05) demonstrated that posterior-inferior comminution mainly causes
increased both DIM and SIM at all positions. superior-middle detached interfragmentary displacement, which results
Fig. 5 illustrates the comprehensive comparison of stiffness among in femoral head varus deformation. Consequently, the ideal internal
all fixation groups. For COM and COMOP, G-FNS (595.1, 274.0 N/mm) fixation device for comminuted VFNF must efficiently manage inter
and G-DHS (564.1, 260.6 N/mm) has the greatest stiffness. The fragmentary shear and varus deformity force simultaneously. This
comprehensive statistical comparison of IFM, SIM, and DIM among the enhanced biomechanical comprehension of fracture type opens the door
six internal fixations were depicted in detail in Fig. 6. Among six fixation for novel opinions on optimal internal fixation selection and innovate
strategies, IFM (max: 0.170–0.667 mm) and SIM (max: 0.136–0.249 device development.
mm) values were significantly (p<0.001) the lowest in G-ALP in all Fixed angle device and cannulated screws are the two main cate
fracture types. In COM and COMOP, DIM value was found to be the gories of internal fixation strategies used for VFNF [31]. Cannulated
lowest (p<0.001) in FNS (max: 0.302 mm). In general, implant stress screw is favoured by most orthopedic surgeons [32] owing to advan
was lowest in G-ALP and highest in G-BUT (Fig. 7). Fixed-angle devices tages of minimal invasiveness, easy handling, and dynamic compres
(G-DHS, G-FNS) had higher implant stress than the other three screw sion. Among the six fixation strategies, the current study found that
fixation strategies. Severe stress concentration was noticed in G-BUT in alpha fixation outperforms other fixation strategies in terms of inter
the first locking screw-plate junction. fragmentary stability and implant stress in comminuted VFNF with or
The location of yielding bone volume depicted in Fig. 8 showed that without osteoporosis. The most striking biomechanical advantage of
bone yielding is moderate in NCOM and COM but severe in COMOP. In Alpha fixation is anti-shear ability. This is attributed to the cross screw
COMOP models, YR (4.03 ± 0.92%) was 4.60 times higher than that in structure, the ability of neutralizing the sliding effect [33], a better
the COM (0.88%±0.31%) models. In the COMOP group, G-FNS (2.67%) screw purchase with surrounding bone [9], and an enhanced cortical
revealed the lowest YR in COMOP, while G-DHS exhibited the highest support [9]. In addition, in terms of anti-varus property, alpha fixation
YR (5.54%). performed better than any other multiple screw technique and was
second to fixed-angle devices when treating comminuted VFNF. Despite
Discussion these unique biomechanical advantages of alpha fixation, the clinical
performance of this technique in treating VFNF with posterior-inferior
In VFNF, fracture comminution is scientifically defined as the comminution remains to be clarified in further randomized clinical
occurrence of separate fragments measuring >1 cm in any dimension trials.
based on CT images, which was observed in as high as 83.9% - 94% cases FNS is a novel fixed-angle device in the treatment of VFNF, which has
[14,15]. The majority of experimental models used in previous biome a comparable mechanical property with DHS. In this study, apart from
chanical studies [4,9,12,13] were flawed, because they did not replicate the stress concentration in G-BUT, these two fixed-angle devices shared
comminuted fragments in VFNF and hence were unable to accurately the greatest implant stress among six fixation strategies. This is the
depict the complexity of the real fracture morphology. In the present reason why they could exhibit the highest construct stiffness for
study, VFNF models with posterior-inferior comminution were created comminuted VFNF in the current analysis and were called as ‘weight-
according to prior protocol [19]. The fragment was located in the pos bearing device’ in previous literature [12]. Additionally, it was firstly
terior inferior region, in accordance with recent morphology findings identified that the fixed-angle biomechanical property allows DHS and
Fig. 5. The comparison of stiffness among the five internal fixation strategies and three various fracture types. The dotted line represents the median values of
these parameters.
Fig. 6. Statistical comparison of IFM (A), SIM (B), DIM (C) among six internal fixations. The Violin diagram on the left showed value distribution in NCOM, COM and
COMOP fracture types. The results of statistical comparison between the most stable and the other fixation strategies was listed on the right, with the line in red
represented Adjusted-p value below 0.05.
FNS to function optimally in resisting varus force, as seen by the lowest study found that the stiffness of FNS is the lowest in non-comminuted
DIM value from the present FEA data. This indicated that the fixed-angle VFNF, which is comparable with those in previous studies [35,36]. In
device is theoretically promising in handling VFNF with large scale these studies, the neck-shaft angles of the femurs were all lower than
posterior-inferior comminution, a condition in which the varus defor those of FNS, which will cause the bolt to insert in a varus position and
mation force is severe. may compromise construct stiffness. As a result, the development of FNS
However, in the current study, fixed-angle devices were shown to be devices with NSA other than 130◦ is another imperative trend in the
insufficient in resisting shear force, as seen by the highest SIM value future.
across all fixation groups. In comparison with multiple screws fixation, In patients with comminuted VFNF, osteoporosis is a common
FNS and DHS, due to the ‘one/two-point’ fixation structure, were unable concomitant [18] scenario and treatment challenge. Severe osteoporosis
to obtain adequate triangular support base and area moment of inertia will diminish the holding power of cannulated screws [37], increase
[34] and could hence not provide the great resistance to axial motion. In bone yielding and result in clinical failure [38]. In comparison to pa
non-comminuted VFNF where SIM is dominant, interfragmentary sta tients with normal bone quality, internal fixation of comminuted VFNF
bilities of FNS and DHS were thus the lowest among all fixation strate in patients with osteoporosis had 4.60-times higher bone YR, 55.1%
gies. Consequently, addressing the weakness in anti-shear property is a lower stiffness, and 1.60-times higher interfragmentary movement. For
crucial objective in further improvement of these devices. Besides, our these patients in COMOP, it was found that FNS had the lowest bone YR
Fig. 7. von Mises stress distribution in devices of the models. On the contour plot, the values and locations of peak implant value were labelled.
Fig. 8. The comparison of yielding rate (YR) among the five internal fixation strategies and three various fracture types. Elements of cancellous bone with a minimal
primary strain of <− 0.9% were displaced in a solid pattern. The YR value of each fixation model is labelled below. The minimal YR value in each fracture group is
marked in red font. Note that, elements directly connected to the external applied load in femoral head surface was not included in the analysis.
among all fixation devices. This may be attributed to the crossed-screw fixation has the best interfragmentary stability and anti-shear property
structure across fracture surface, which can potentially minimize shear among six current mainstream fixation strategies, but a relatively
force and bone yielding at the bone-screw interface. Consequently, FNS weaker stiffness and anti-varus property compared to fixed-angle de
is also promising in comminuted VFNF patients with osteoporosis. vices. FNS is advantageous owing to stiffness, anti-varus property and
This study has some limitations. First, just as previous studies, all bone yielding rate in osteoporosis cases, but is insufficient in anti-shear
FEA models were also simulated as linear elastic materials. This meth property. Nevertheless, FNS still holds potential for further development
odology does not incorporate plastic deformation in the loading process, in the treatment of femoral neck fractures with large-scale comminution
which may introduce systematic errors between simulation results and or with osteoporosis.
clinical reality. Second, all models in the study were established from a
single volunteer, making our study subject-specific. Finally, the current Ethical review committee statement
study focused on the initial stability but not the situation during the
bone healing process. Our findings need further validation in dynamic CT scanning of participants was approved by Ethics Committee of
experiments or clinical trials. Shanghai Sixth People’s Hospital (Approval No. 2021-KY-71[K]) and a
Posterior-inferior comminution primarily increases superior-middle written consent was obtained from the participant.
detached interfragmentary movement in VFNF, which results in varus
deformation. For comminuted VFNF with or without osteoporosis, alpha
Funding analysis of 492 patients repaired at 26 north american trauma centers. J Orthop
Trauma 2022;36:271–9.
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Joint Funds of the National Natural Science Foundation of China comminution significantly influences torque to failure in vertically oriented
(U223010030), National Key Research and Development Project of femoral neck fractures: a biomechanical study. J Orthop Trauma 2020;34:644–9.
China (2022YFB3804504). [20] Goffin JM, Pankaj P, Simpson AH, Seil R, Gerich TG. Does bone compaction around
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Injury 54 (2023) 110843
Injury
Fluid-structure interaction analysis of amniotic fluid with fetus and

placenta inside uterus exposed to military blasts
Jonathan Arias a, Gregory Kurgansky a, Ong Chi Wei b, Rosalyn Chan-Akeley c, Milan Toma *, 1, a
a
New York Institute of Technology, College of Osteopathic Medicine, Old Westbury, 11568, New York, USA
b
Institute of High Performance Computing, 1 Fusionopolis Way #16-16 Connexis, Singapore, 138632, Singapore
c
Lang Research Center, NewYork-Presbyterian Queens, Flushing, 11355, New York, USA
Keywords: Introduction: Pregnancy-related trauma is one of the leading causes of morbidity and mortality in pregnant
Fluid-structure interaction women and fetuses. The fetal response to injury is largely dependent on the timing of fetal presentation and the
FSI underlying pathophysiology of the trauma. The optimal management of pregnant patients who have suffered an
Amniotic fluid
obstetric emergency depends on clinical assessment and understanding of the placental implantation process,
Fetus
Placenta
which can be difficult to perform during an emergency. Understanding the mechanisms of traumatic injuries to
the fetus is crucial for developing next-generation protective devices. Methods: This study aimed to investigate
the effect of amniotic fluid on mine blast on the uterus, fetus, and placenta via computational analysis. Finite
element models were developed to analyze the effects of explosion forces on the uterus, fetus, and placenta,
based on cadaveric data obtained from the literature. This study uses computational fluid-structure interaction
simulations to study the effect of external loading on the fetus submerged in amniotic fluid inside of the uterus.
Results: Computational fluid-structure interaction simulations are used to study the effect of external loading on
the fetus/placenta submerged in amniotic fluid inside the uterus. Cushioning function of the amniotic fluid on
the fetus and placenta is demonstrated. The mechanism of traumatic injuries to the fetus/placenta is shown.
Discussion: The intention of this research is to understand the cushioning function of the amniotic fluid on the
fetus. Further, it is important to make use of this knowledge in order to ensure the safety of pregnant women and
their fetuses.
Introduction though pregnancy-related trauma is uncommon, it is one of the leading

causes of morbidity and mortality in pregnant women and fetuses.
Trauma during pregnancy is the leading non-obstetric cause of Pathophysiology of trauma in pregnant patients presents an extra barrier
morbidity and mortality, and accounts for five per 1000 fetal deaths due to their unusual presentation and the management of two patients at
[23]. Blunt prenatal trauma is occasionally associated with intracranial once [17].
hemorrhages, the most frequent are the subarachnoid hematoma and The number of motor vehicle collisions is increasing worldwide [20].
intraparenchymal, scarcely ever the epidural hematoma. Treating these Motor vehicle collisions are predicted to become more prevalent prob
bleedings is challenging due to the ongoing pregnancy. Thus, the lem in the future. It is projected that motor vehicle collisions will be the
prognosis is often reserved, with a mortality rate of 43% and 25% of fifth most common cause of fatalities in the world [20]. A recent review
neurological sequelae [2]. A traumatic injury occurs during pregnancy of ‘traumatic injuries to the pregnant patient’ shows that a motor vehicle
in about 8% of all pregnant women [1]. Interestingly, when pregnant collision is the most common life-threatening injury for a pregnant
patients with injuries are treated in designated trauma hospitals, their woman [14]. In the United States, state-level studies have estimated the
birth outcomes are usually better than in non-trauma hospitals [1]. Even crash risk among pregnant front-seat passengers or drivers to be
Abbreviations: SPH, Smoothed-Particle Hydrodynamics.

E-mail addresses: jarias08@nyit.edu (J. Arias), gkurgans@nyit.edu (G. Kurgansky), Ong_Chi_Wei@ihpc.a-star.edu.sg (O.C. Wei), roc9166@nyp.org (R. Chan-
Akeley), tomamil@tomamil.com (M. Toma).
1
www.tomamil.com
J. Arias et al. Injury 54 (2023) 110843
Fig. 1. The model used in the computational simulations. The SPH fluid par
ticles are prescribed to fill the space between the uterus and fetus/
placenta/cord.
Fig. 3. The model is exposed to boundary and initial conditions typical for
scenarios in which the mother experiences an exposure to the blast underneath
a vehicle inside of which she is present. The measurements generated in such
scenario are experimental and collected by a private equity. Hence, the data is
classified as private and cannot be shared in this article.
similar to the ones discussed in this study. The existing computational

studies related to pregnant women and fetuses employ simplified
models, which fail to take into account important factors such as the
amniotic fluid surrounding the fetus within the uterus [12]. Addition
ally, these models rarely consider external loading conditions [19].
Further exploration through academic investigation is essential for
comprehensive understanding of fetal injury dynamics and how they can
be addressed effectively.
Methods
Three interconnected subsections are described as follows. The nu

merical method used is based on governing equations that solve the
deformations of both the solid and fluid phases and their interaction
Fig. 2. More detailed representation of the fetus with placenta (and umbilical with each other. The geometrical model is developed to preserve the
cord) inside the uterus, where dFL ⇔ U is the distance between the fetus’ frontal small-scale features of a realistic fetus surrounded by fluid domain inside
lobe (FL) and the nearest point of the uterus (U), dOL ⇔ U is the distance between the uterus [10]. Boundary and initial conditions are prescribed to expose
the fetus’ occipital lobe (OL) and uterus, dP ⇔ U is the distance between the the uterus to external loading.
placenta and uterus, and dLB ⇔ U is the distance between the fetus’ lower back
and uterus. The aforementioned distances will be measured in time for better
understanding of the relative motion between the fetus/placenta and Model
the uterus.
The model consists of multiple parts (see Figs. 1 and 2). Separate set
between 1.0% and 2.8% [7,18,34]. According to a retrospective longi of material properties is prescribed to each part according to data found
tudinal cohort analysis, it has been suggested that there could be a po in the literature. The fetus inside the uterus is surrounded by 16,731
tential link between motor vehicle crashes during pregnancy and an fluid particles that, under prescribed conditions, interact with the
escalated probability of cerebral palsy among preterm birth cases [16]. endometrium (i.e., the inner lining of uterus) and the fetus with cord and
Acute injuries to the abdominal area, which may occur in automobile placenta. Fluid motion and boundary interaction calculations are solved
collisions, have the potential to result in severe ruptures of the uterus with the IMPETUS Afea γSPH Solver (IMPETUS Afea AS, Norway), while
[35]. Other adverse outcomes in pregnancy after a blunt trauma to the large deformations in the solid parts are calculated with the IMPETUS
abdomen include placental abruption, preterm labor and preterm de Afea Solver.
livery, and pelvic fracture [4]. Timely identification of complications is
crucial in order to administer appropriate treatment and prevent Boundary and initial conditions
potentially lethal outcomes for both the pregnant individual and fetus
[24]. The model is subjected to initial and boundary conditions that are
This study uses a comprehensive fluid-structure interaction models representative of situations where a pregnant woman encounters an
of a pregnant woman with fetus exposed to specific loading conditions. explosion while being present inside a vehicle, as depicted in Fig. 3. The
Namely, the loading conditions prescribed to the model are typical for a measurements generated in such scenario are experimental and
mine blast that occurs underneath the vehicle in which the pregnant collected by a private equity. Hence, the raw data is classified as private
female is present at the time of the blast. Numerous results are extracted and cannot be shared in this article. However, the normalized acceler
from the simulations, e.g., the effect of amniotic fluid protecting the ation values are shown in Fig. 4. Succinctly, the blast survivability tests
placenta. There is a paucity of research that investigates fetal injuries were performed at the General Dynamics Land Systems (GDLS) Edge
field Test Center in South Carolina. Blast experiments were conducted
flow, with a high-order finite element method used to simulate the solid
domain deformations, is ideal for simulating FSI, especially when
complex geometries are included. Using SPH methods provides nu
merical stability because the contact between the solid and fluid do
mains is easily treated numerically. Moreover, SPH is highly
parallelizable. That being the case, it is possible to run FSI simulations
that are numerically stable, precise, parallelized on a standard GPU
workstation (as opposed to large supercomputers), which do not require
the use of simplified geometries and a runtime of hours or days rather
Fig. 5. Smoothed-Particle Hydrodynamics Kernel approximation. than weeks and months.
under very controlled and consistent procedures as the accuracy of the Results
blast data is used to validate the numerical models used [9,31].
Traditionally, most studies found in the literature do not account for
Smoothed-particle hydrodynamics the fluid-structure interaction processes occurring inside the uterus.
However, without a fluid-structure analysis, only structural results can
Smoothed-Particle Hydrodynamics (SPH) is a computational mesh be assessed. This study presents both structural (such as strain/stress,
free Lagrangian method developed by Gingold and Monaghan [3] and see Fig. 6) and fluid-related results (such as contact penetration and load
Lucy [11], initially for astrophysical problems. Since then, it has been angles, see Fig. 7). To concisely describe Fig. 6, stress denotes the
used for simulating the mechanics of continuum media, such as solid amount of pressure applied per unit area and strain refers to the corre
mechanics and fluid flows. It has been used in many fields outside as sponding physical alteration. Deviatoric principal stress is distinguished
trophysics, e.g. ballistics, volcanology, oceanography. Increasingly, it is by the variation between major principal stress and minor principal
being adopted by many with an interest in biomedical engineering [27]. stress, whereas effective stress reflects the transmission of pressure via
More detailed description including the formulation used can be found contact among elements forming the models. Nevertheless, deviatoric
in our prior publications, e.g., [30]. A graphical depiction is shown in principal stress yields outcomes similar to those obtained from effective
Fig. 5. stress assessments; henceforth, future research could exclusively employ
The combination of SPH methods, used to simulate the fluid domain deviatoric principal stress for investigations in this domain. In Fig. 7, the
Fig. 6. Results related to the structural parts of the model (fetus, cord, placenta). For the stress results: blue represents 0 Pa; red represents 10 GPa. Strain is a
dimensionless quantity. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
Fig. 7. Results related to the effect of the amniotic fluid on the structural parts of the model, i.e., these results are directly related to the fluid-structure interaction
processes inside the uterus and can only be acquired by fluid-structure analyses.
Fig. 8. The distances between various parts of the fetus/placenta and the uterus, where dFL ⇔ U is the distance between the fetus’ frontal lobe (FL) and the nearest
point of the uterus (U), dOL ⇔ U is the distance between the fetus’ occipital lobe (OL) and uterus, dP ⇔ U is the distance between the placenta and uterus, and dLB ⇔ U is
the distance between the fetus’ lower back and uterus. The corresponding acceleration values depicted in Fig. 4 are symbolized here by the gray lines. In contrast, the
alterations in distances exhibit less erratic patterns, thereby exhibiting the mitigating influence of amniotic fluid. This indicates that amniotic fluid serves as a
cushioning mechanism..
representation of contact penetration is demonstrated. It indicates

where fluid particles exerted pressure on the outermost layer of solid
domains (namely fetus, placenta and cord). During this process, as the
fluid particles alter the shape of solid models, they are (just computa
tionally within the algorithm) permitted to enter into their domain only
for extracting necessary information about how much deformation will
occur in that specific contact point. Once deformation has been estab
lished, these particles computationally retreat back outside the limits of
solid boundaries where they interact with other surrounding fluid par
ticles. The orientation or direction in which a fluid particle applies force
against its corresponding solid model within a fluid-structure interaction
system is determined by load angles.
The fluid results are directly related to the fluid-structure interaction
processes inside the uterus and can only be acquired by fluid-structure
analyses. It is worth noting that no one parameter should be assessed
without considering its meaning in the context of the other parameters
Fig. 4. The experimental acceleration values prescribed to the uterus.
available for analysis. Considering that, in the current framework, the
orientation of the fetus is cephalic (i.e., its head is facing downwards),
regions where the fluid particles made an effort to penetrate the fetus
and that the mine exploding is underneath the uterus, injuries to the
surface, but were ultimately repelled by the contact algorithm, are pri
head can be observed in the structural results. However, the maximum
marily visible on the posterior aspect of the fetus. These fluid-related
load angles between the fluid and structural domains are prominently
results together create a bigger picture about the flow of the amniotic
observable on both the placenta and the face of the fetus. Similarly, the
fluid when exposed to external loading. Additionally, in the interest of
brevity, only the results around the first peak in Fig. 4 are shown. and assumptions/equations used to build the models. For example, a
However, within a few milliseconds multiple peaks in the acceleration worldwide benchmark Food and Drug Administration (FDA) study, to
occur (Fig. 4). Hence, the resulting damage to the fetus and placenta standardize computational fluid dynamics techniques used to assess the
would be more substantive. safety of medical devices, shows that even results produced by experts
To be able to conceptualize the relative movement between various might not be reliable [22].
parts of the fetus/placenta and the uterus, Fig. 8 shows the distances In the next phase of these studies, it is planned to analyze the results
between them, where dFL ⇔ U is the distance between the fetus’ frontal of the fetus brain injury. The same methodology has been previously
lobe (FL) and the nearest point of the uterus (U), dOL ⇔ U is the distance utilized to study pediatric head trauma [29] and other head injuries
between the fetus’ occipital lobe (OL) and uterus, dP ⇔ U is the distance [28]. Case reports that show the evidence of fetal closed head injury by
between the placenta and uterus, and dLB ⇔ U is the distance between the both shear and tensile forces due to a maternal motor vehicle accident
fetus’ lower back and uterus. The aforementioned distances are scaled so will be utilized for the choice of boundary and initial conditions, e.g.,
they all start from 1. For example, it can be observed that the frontal [13]. The developing brain may be significantly impacted by fetal
lobe’s distance from the nearest point of the uterus grows after the first trauma during pregnancy. Skull fractures, intracranial hemorrhages,
acceleration peak whereas the distance between the occipital lobe and hypoxic-ischemic damage, and other intracranial diseases can all result
uterus decreases. Hence, relative to the uterus, the fetus was moving to from fetal trauma [15]. Other use of this model can include an investi
the left. gation of the restraining mechanical forces of worn seat belts on the
body and their effect on the fetus. While it is widely acknowledged that
Discussion and Conclusions the utilization of seat belts has resulted in decreased mortality rates for
pregnant individuals and their fetuses [6], conducting additional
Acknowledging that the external loading parameters employed in research may yield advantageous outcomes. Notably, pregnant drivers
this study to examine fetal and maternal injuries within uteri may who neglect to wear seat belts are at risk of experiencing severe or fatal
appear excessive, it is pertinent to note their relevance amidst current harm to their fetus even during low-velocity accidents [25].
military conflicts occurring in Eastern Europe and Middle East. With
documented cases of airstrikes targeting maternity hospitals, such
research holds significance. Nonetheless, the precise loading conditions
utilized are not the crucial aspect of this study. We simply aimed to
The authors declare that they have no known competing financial
illustrate the practicability of our model. This investigation employs an
interests or personal relationships that could have appeared to influence
elaborate 3D representation that incorporates genuine patient-specific
geometries of all constituents, including the placenta, uterus, fetus,
and umbilical cord. Additionally, fluid-structure interaction analysis is
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Injury 54 (2023) 110845
Injury
Mechanisms and weapons in physical elder abuse injuries: Findings from

legally adjudicated cases
Tony Rosen a, *, Brady Rippon b, Alyssa Elman a, Kriti Gogia a, Aisara Chansakul a,
E-Shien Chang c, David W. Hancock a, Elizabeth M. Bloemen d, Sunday Clark a,
Veronica M. LoFaso c
a
Department of Emergency Medicine, Weill Cornell Medical College / NewYork-Presbyterian Hospital, 525 East 68th Street, Room M130, New York, NY, 10065, USA
b
Department of Population Health Sciences, Weill Cornell Medicine, 402 E 67th Street, New York, NY, USA
c
Division of Geriatrics and Palliative Medicine, 525 East 68th Street, Baker 14, Weill Cornell Medical College / NewYork-Presbyterian Hospital, New York, NY, USA
d
Division of Geriatric Medicine, University of Colorado School of Medicine, 12631 East 17th Avenue, Aurora, CO, 80045, USA
Keywords: Introduction: Elder abuse is common, but many characteristics have not been well-described, including injury
Elder abuse mechanisms and weapons in physical abuse. Better understanding of these may improve identification of elder
Mechanisms of injury abuse among purportedly unintentional injuries. Our goal was to describe mechanisms of injury and weapons
Injury patterns
used and their relation to injury patterns.
Methods: We partnered with District Attorney’s offices in 3 counties and systematically examined medical, police,
and legal records from 164 successfully prosecuted physical abuse cases of victims aged ≥60 from 2001 to 2014.
Results: Victims sustained 680 injuries (mean 4.1, median 2.0, range 1–35). Most common mechanisms were:
blunt assault with hand/fist (44.5%), push/shove, fall during altercation (27.4%), and blunt assault with object
(15.2%). Perpetrators more commonly used body parts as weapons (72.6%) than objects (23.8%). Most
commonly used body parts were: open hands (55.5% of victims sustaining injuries from body parts), closed fists
(53.8%), and feet (16.0%). Most commonly used objects were: knives (35.9% of victims sustaining injuries from
objects) and telephones (10.3%). The most frequent mechanism/injury location pair was maxillofacial/dental/
neck injury by blunt assault with hand/fist (20.0% of all injuries). The most frequent mechanism/injury type pair
was bruising by blunt assault with hand/fist (15.1% of all injuries). Blunt assault with hand/fist injury was
positively associated with victim female sex (OR: 2.27, CI: [1.08 – 4.95]; p = 0.031), while blunt assault with
object mechanisms was inversely associated with victim female sex (OR: 0.32, CI: [0.12 - 0.81]; p = 0.017).
Conclusion: Physical elder abuse victims are more commonly assaulted with an abuser’s body part than an object,
and the mechanisms and weapons used impact patterns of injury.
Introduction frequently than some other types, with a reported prevalence of

0.2–2.1% [1,12–14], this violent mistreatment may be particularly
Elder abuse is common and has serious consequences, but it is under- dangerous for an older adult.
recognized. As many as 10% of community-dwelling U.S. older adults Physical elder abuse is poorly understood, with only limited existing
are victims of elder abuse each year [1–3]. Experiencing elder abuse is literature examining characteristics of the phenomenon, including
associated with adverse health outcomes including depression [4], injury patterns [15–19]. Better understanding of these may improve
exacerbation of chronic illnesses, hospitalization [5], nursing home identification of elder abuse among purportedly unintentional injuries, a
placement [6,7], and dramatically increased mortality [8–10]. This critical role of trauma professionals and all providers who care for
mistreatment may include physical abuse, sexual abuse, neglect, psy injured patients. Recognizing intentional injuries allows initiation of
chological abuse, or financial exploitation, and many victims suffer from interventions and prevention of more serious injury in the future. One
multiple types of abuse [1–3,11]. While physical abuse occurs less important aspect of physical elder abuse about which little is known is
* Corresponding author at: 525 East 68th Street, Room 130.

E-mail address: aer2006@med.cornell.edu (T. Rosen).
T. Rosen et al. Injury 54 (2023) 110845
which mechanisms are common, what weapons are typically used, and Mechanisms and weapons were grouped into categories by the
their effect on resulting injury patterns. Describing these in detail has research team via a consensus process based on existing family and
been helpful for researchers and clinicians examining other types of interpersonal violence literature [20–24,30] and the team’s extensive
family violence, including child abuse [20,21] and intimate partner experience with the phenomenon.
violence in younger adults [22–24]. To better understand the relationship between mechanisms,
In previous research, we partnered with a large, urban district at weapons, and injuries, we used two-dimensional heat maps comparing
torney’s office and examined medical, police, and legal records from both mechanisms and weapons to type of injury and body location
successfully prosecuted cases of physical elder abuse to describe typical injured. We also examined the impact of demographic characteristics of
injury patterns [19]. We expand on that work here, expanding the the older adult victim and abuser as well as whether alcohol or drugs
cohort of legally adjudicated cases to include two addition jurisdictions was involved in the abuse episode.
and focusing on mechanisms and weapons. The goal of our research was We performed analysis both at the level of the older adult victim as
to describe mechanisms of injury and weapons used and their relation to well as the individual injury. Results for mechanisms and weapons are
injury patterns in legally adjudicated cases of physical elder abuse. presented as a proportion of injuries. Marginal frequencies between
injury mechanisms/implements and injury location/type are reported as
Methods heat maps. Associations between injury mechanism and injury charac
teristics, including victim age/sex, abuser sex, victim-abuser relation
We partnered with District Attorney’s Offices in 3 counties: Kings ship, and abuser drug/alcohol use at the time of injury, are reported as
County (Brooklyn, New York), King County (Seattle, Washington), and odds ratios from multivariate logistic regression. Results are reported at
Westchester County (New York). Each maintains an Elder Abuse Unit, a an alpha = 0.05 significance level. Analysis was performed using
legal team devoted exclusively to the investigation of cases, prosecution Rv4.1.1.
of abusers, and protection of these vulnerable victims. We included in This project was reviewed and approved by the ____ Institutional
this analysis 225 physical abuse victims aged ≥60 with visible injuries Review Board. This work is reported based on STROBE guidelines [31].
from successfully prosecuted cases in which the perpetrator had been
convicted or pled guilty and the victim sustained visible injuries. All Results
cases had abuse initially identified between 2001 and 2016. We did not
include cases that were sealed by the court when the abuser elected to We examined the mechanisms of injury and weapons used to injure
enter and successfully completed a substance abuse or mental health 164 victims of physical elder abuse from King’s County, New York (78
treatment program. Previous research has suffered from challenges in victims, 47.6% of total), King County, Washington (74 victims, 45.1%),
identifying and confirming cases, with the most rigorous studies typi and Westchester County, New York (12 victims, 7.3%). Demographic
cally convening an “expert panel” to assess cases to determine that abuse characteristics of victims and perpetrators, circumstances surrounding
occurred [16,25,26]. Our approach represents a significant methodo abuse, and details of injuries suffered including mechanisms and
logic advance, allowing for the in-depth evaluation of a large number of weapons used are shown in Table 1. Among these victims, 43.3% were
legally adjudicated elder abuse cases in which the presence of abuse has treated in the Emergency Department (ED) for their injuries. Many of
been established by the criminal justice system, establishing a potential those who were not refused transport to the ED, with medical follow-up
new “gold standard” [19]. unknown for others. These victims had a total of 680 visible injuries
We used as the definition of physical abuse: “the non-accidental use (mean 4.1, median 2.0, inter-quartile range 1.0–5.3, range 1–35). The
of force that results in bodily injury, pain or impairment, including but body regions most commonly injured included: maxillofacial/dental/
not limited to, being slapped, burned, cut, bruised or improperly neck (63.4% of victims), upper extremities (50.0%), and chest/
restrained” by a person in a relationship with the victim with an abdomen/back (28.9%). Victims most commonly sustained bruises
expectation of trust. This is the text of New York State Social Services (64.6% of victims), abrasions (33.5%), and lacerations (29.3%). Mech
Law, Article 9B, Adult Protective Services, Section 473(6), which is anisms of injury were most commonly: blunt assault with hand/fist
remarkably similar to the consensus definition from National Research (44.5%), push/shove, fall during altercation (27.4%), and blunt assault
Council [11], which incorporates the content of statutes from different with object (15.2%), with 26.8% of victims having multiple mecha
U.S. states, and the definitions recently proposed in the Elder Justice nisms. Perpetrators more commonly used body parts as weapons
Roadmap [27] and by the Centers for Disease Control and Prevention (72.6%) than objects as weapons (23.8%), with both used on 7.9% of
[28]. victims. The most commonly used body parts were: open hands (55.5%
We used police, legal, and medical records, including photographs of victims sustaining injuries with body parts as weapons), closed fists
and victim statements, to gather detailed information about the mech (53.8%), and feet (16.0%), while the most commonly used objects were:
anisms, weapons, and injuries. We also recorded information from these knives (35.9% of victims sustaining injuries with objects as weapons)
cases about the victim, the abuser, and the circumstances surrounding and telephones (10.3%). A total of 19 different objects were used by
the physical abuse. We developed a novel classification system / tax abusers in these cases. The environment was used as a weapon on 15.2%
onomy to facilitate completely and accurately characterizing injuries of victims, with ground most common.
[29]. This taxonomy, which we have used in related work [19], employs Heat maps show, for individual injuries (n = 680), the relative fre
a 3-step process to fully describe and classify visible acute geriatric in quencies of mechanisms and weapons causing injuries to specific body
juries. It includes 9 unique types of visible injury and 7 characteristics regions and specific types of injuries among physical elder abuse injuries
common to all injury types, including 6 body regions. (Fig. 1). The most frequent mechanism/injury location pair was maxil
Records usually included specific, extensive information about the lofacial/dental/neck injury by blunt assault with hand/fist (20.0% of all
mechanisms and weapons used in the physical abuse. In cases where injuries). The most frequent mechanism/injury type pair was bruising
multiple mechanisms or weapons were reported, we included all of them by blunt assault with hand/fist (15.1% of all injuries).
as contributing to injuries. In victims with multiple injuries caused by We examined whether victim or abuser demographics, abuser rela
multiple mechanisms and/or weapons, we attempted to assign the tionship to victim, or the use of alcohol/drugs was associated with the
appropriate mechanism(s) and weapon(s) to each injury based on re mechanism of injury. Table 2 shows the odds ratios for the 3 most
cords. If this was unclear, all mechanisms and/or weapons reported for common mechanisms of injury. Blunt assault with hand/fist injury
the case were assigned to all injuries. Two members of the research team mechanisms was inversely associated with age of victim (OR: 0.95, CI:
independently evaluated descriptions of each injury and associated [0.91 - 0.99]; p = 0.026) and positively associated with victim female
mechanisms and weapons to ensure consistency and accuracy. sex (OR: 2.27, CI: [1.08 – 4.95]; p = 0.031). Blunt assault with object
a
Table 1 Other non-relative includes: acquaintance, current/former cohabitant,
Characteristics of physical elder abuse victims (n = 164) and their injuries, friend, neighbor, other non-relative.
b
including mechanisms and weapons. Other mechanism includes: biting, dragging through gravel, gouging with
fingers, hair pulling, headlock, holding against a wall, knocking to the ground,
% of Physical Elder Abuse Cases (n
= 164)
pouring lighter fluid, sexual assault, slammed door, snapping rubber bands onto
skin, spraying with chemicals.
Victim Age (median, IQR) 67.0, 62.9–75.2 c
Other object as weapon includes: baseball bat, broken glassware, broken
Victim Female sex 116 (70.7%)
plate, broom stick, chair, dumbbell weight, kitchen utensil, liquor bottle,
Abuser Female sex
necklace, pipe, purse strap, roach spray, suitcase.
Abuser’s relationship to victim d
Spouse / companion 42 (25.6%) Other type of injury includes: bite mark, broken/chipped teeth, burn, che
Current 38 (23.2%) mosis, collapsed lung, concussion, contusion, dislocation, hematoma, petechiae,
Former 4 (2.4%) puncture/stab wound, ruptured stitches, skin redness, subarachnoid hemor
Adult child 66 (40.2%) rhage, swelling, traumatic alopecia.
Son 35 (21.3%)
Daughter 8 (4.9%)
Unspecified 23 (14.0%)
mechanisms was inversely associated with victim female sex (OR: 0.32,
Other CI: [0.12 - 0.81]; p = 0.017). Both mechanism types of push/shove, fall
Grandchild 25 (15.2%) during altercation (OR: 2.39, CI: [1.14 – 5.09]; p = 0.021) and blunt
Other family 13 (7.9%) assault with object (OR: 0.25, CI: [0.07 - 0.74]; p = 0.010) were asso
Home attendant 3 (1.8%)
ciated with abuser drug/alcohol use at the time of incident. Abuser sex
Other non-relative a 15 (9.1%)
Abuser alcohol/drug use at time of incident 61 (37.2%) and abuser relationship to victim were not associated with the most
Presentation to Emergency Department after frequent injury mechanisms.
injuries
Yes 71 (43.3%)
Discussion
No 64 (39.0%)
Unknown 29 (17.7%)
Mechanism This represents, to our knowledge, the first detailed examination of
Blunt assault with hand/fist 73 (44.5%) mechanisms and weapons used in physical elder abuse. Recognizing,
Push/shove, fall during altercation 45 (27.4%) intervening on, and preventing intentional interpersonal violence and
Blunt assault with object 25 (15.2%)
related injuries is a core component of practice for all trauma health
Blunt assault with foot/knee 23 (14.0%)
Strangulation/suffocation 17 (10.4%) professionals and those who care for injured patients. This includes
Grabbing/twisting/pinching 22 (13.4%) trauma surgeons, Emergency Department providers, forensic nurse ex
Penetrating assault with object 16 (9.8%) aminers, members of the ED/hospital trauma team from other disci
Using body weight/sitting on victim 5 (3.0%) plines, and Emergency Medical Services providers. Recognizing this, in
Other mechanism b 22 (13.4%)
Unknown 30 (18.3%)
2019, the American College of Surgeons Committee on Trauma (ACS
Multiple mechanisms 44 (26.8%) COT) released Best Practice Guidelines for Trauma Center Recognition
Weapon(s) of Child Abuse, Elder Abuse, and Intimate Partner Violence. (https://
Body parts as weapons 119 (72.6%) www.facs.org/media/o0wdimys/abuse_guidelines.pdf). Beyond medi
Closed fist 64 (39.0%)
cal providers, improved understanding of injury patterns is critical for
Open hand 66 (40.2%)
Foot 19 (11.6%) professionals who investigate cases of alleged elder physical abuse,
Knee 3 (1.8%) including law enforcement and Adult Protective Services.
Body Weight 3 (1.8%) Notably, in the Introduction to ACS COT’s Best Practice Guidelines,
Multiple body parts 30 (18.3%) the trauma surgery professional organization acknowledged that
Objects as weapons 39 (23.8%)
Knife 14 (8.5%)
research on the identification and management of child abuse is much
Telephone 4 (2.4%) more mature and robust than in elder abuse. We hope that our work
Cabinet door 3 (1.8%) begins to fill this gap. Our work improves the ability to recognize
Cane 3 (1.8%) physical elder abuse injuries among purportedly unintentional injuries.
Keys 3 (1.8%)
Currently, when caring for older adults, most medical providers presume
Flashlight 2 (1.2%)
Other object c that injuries in older adults are unintentional unless the patient or
Multiple objects 2 (1.2%) someone else reports violence.
Both body parts and objects as weapons 13 (7.9%) Our finding that the most common mechanisms were an abuser
Environment as weapon 25 (15.2%) assaulting the victim with hands/fists as well as pushing/shoving them
Ground 18 (11.0%)
Wall 6 (3.7%)
or causing a fall during altercation suggests that abuse may have been
Stairs 1 (0.6%) precipitated by the escalation of an argument. Notably, the mechanism
Number of injury(ies) (median, IQR) 2.0, 1.0–5.2 of physical abuse of push/shove or fall during altercation was common
Body region(s) injured among the subjects within our study. This may be particularly difficult
Skull/brain 34 (20.7%)
to distinguish from unintentional fall and may make detection chal
Maxillofacial/dental/neck 104 (63.4%)
Chest/abdomen/back 47 (28.7%) lenging, particularly given that intentional fall is a very common false
Upper extremities 82 (50.0%) explanation that abusers and even older adults themselves give for abuse
Pelvis/buttocks 9 (5.5%) related injuries. When objects were used as weapons, abusers chose
Lower extremities 25 (15.2%) household objects rather than knives or guns. This also suggests that this
Multiple body regions injured 85 (51.8%)
Type(s) of injury
abuse occurred spontaneously with the abuser using whatever was
Bruise 110 (67.1%) available close at hand rather than a planned, premeditated attack.
Abrasion 55 (33.5%) Comparing body regions injured and types of injuries sustained be
Laceration 49 (29.9%) tween different mechanisms and weapons offers insights. While the
Fracture 20 (12.2%)
maxillofacial/dental/neck region is the most commonly injured in most
Skin tear 9 (5.5%)
Other d 81 (49.4%) mechanisms, push/shove/fall during altercation led to injuries also on
Multiple injury types 97 (59.1%) the upper extremities. Additionally, push/shove/fall during altercation
Fig. 1. Heat maps displaying the frequencies of injuries to specific body regions and specific types of injuries among physical elder abuse injuries (n = 680). Panel A
shows the relative frequencies of mechanisms while Panel B shows the relative frequencies of weapons.
was the only mechanism that commonly caused fractures. Notably,

Table 2
fractures were uncommon overall in older adults experiencing physical
Association of victim and abuser characteristics with mechanisms of injury in
elder abuse. Previous research demonstrating that fractures are much
physical elder abuse victims (n = 164).
more common in unintentional falls [19] suggests that the presence of a
Odds Ratio (95% Confidence p- fracture may be helpful in differentiating between unintentional injury
Interval) value
and physical elder abuse.
Blunt assault with hand/fist Objects as weapons more commonly led to injuries on the chest/
Age of victim (increased years, 0.95 (0.91 - 0.99) 0.026
abdomen/back than body parts as weapons. Also, body parts as weapons
continuous)
Victim female sex 2.27 (1.08 - 4.95) 0.031 were more likely to cause bruises and abrasions while objects as
Abuser female sex 0.73 (0.34 - 1.57) 0.43 weapons were more likely to cause lacerations.
Abuser relationship to victim 0.053 Though many of the injuries we examined were not serious or life-
Spouse/companion – threatening, detecting these injuries and initiating intervention may
Adult child 1.37 (0.57 - 3.37)
Other 0.54 (0.22 - 1.31)
prevent escalation to more serious injury. Previous studies have
Abuser alcohol/drug use at time of 0.75 (0.37 - 1.49) 0.41 demonstrated that physical elder abuse can lead to significant morbidity
incident and even mortality [32–34].
Push/shove, fall during altercation Our findings are similar in many ways to those from intimate partner
violence (IPV) among younger adults [22]. The most commonly re
continuous)
Victim female sex 1.56 (0.68 - 3.79) 0.29 ported mechanism of injury in IPV was being struck with a hand [22],
Abuser female sex 0.68 (0.27 - 1.59) 0.38 similar to elder abuse. Among IPV victims, nearly 2/3 suffered multiple
Abuser relationship to victim 0.95 mechanisms of injury [22]. Notably, in IPV, strangulation was more
Spouse/companion – common than in physical elder abuse in our study, occurring in more
Adult child 1.14 (0.42 - 3.20)
Other 1.18 (0.43 - 3.37)
than 50% of cases [22]. Similar to our findings for physical elder abuse,
Abuser alcohol/drug use at time of 2.39 (1.14 - 5.09) 0.021 use of guns or knives in IPV was much less common than household
incident objects, but use of these weapons carried a higher risk of mortality [22].
Blunt assault with object Female victims were significantly more likely than male victims to be
assaulted with hand or fist and less likely to be assaulted with an object.
continuous)
Victim female sex 0.32 (0.12 - 0.81) 0.017 This suggests that abusers may have felt less threatened by female older
Abuser female sex 2.03 (0.77 - 5.22) 0.15 adults, thinking that using weapons other than hand/fist was not
Abuser relationship to victim 0.35 necessary. Also, it is possible that assaults on female victims more often
Spouse/companion – occurred in circumstances where objects were not as easily accessible.
Adult child 1.51 (0.38 - 6.91)
Other 2.45 (0.69 - 10.4)
The importance of alcohol and illicit drugs in physical elder abuse,
Abuser alcohol/drug use at time of 0.25 (0.07 - 0.74) 0.010 which has been highlighted before [18,33,35–38], was evident among
incident these physical elder abuse cases, with use among abusers common. In
cases where the abuser was using alcohol or drugs at the time of the Acknowledgments
injury, the mechanism of injury was more likely push/shove/fall during
altercation and less likely blunt assault with object. Further research is The authors would like to thank members of the Elder Abuse Units of
needed to confirm end explain reasons for this finding. the Kings County District Attorney’s Office, King County Prosecuting
Attorney’s Office, and Westchester County District Attorney’s Office for
Limitations their invaluable partnership and support in this research as well as for
the important work they do on behalf of older adults.
This study has several limitations. Our research examines physical
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Injury 54 (2023) 110848
Injury
Epidemiology and socioeconomic consequences of work-related pelvic and

acetabular fractures recorded in the German Social Accident Insurance
Nico Hinz a, *, Julius Dehoust a, Klaus Seide a, b, Birgitt Kowald b, Stefan Mangelsdorf c,
Karl-Heinz Frosch a, d, Maximilian J. Hartel a, d
a
Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorfer Strasse 10, 21033 Hamburg, Germany
b
Laboratory for Biomechanics, BG Hospital Hamburg, Bergedorfer Strasse 10, 21033 Hamburg, Germany
c
Hochschule der DGUV (HGU) – University of Applied Sciences, Seilerweg 54, 10117 Bad Hersfeld, Germany
d
Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
Keywords: Introduction: Pelvic and acetabular fractures can result from work-related accidents and frequently require
Pelvic fractures lengthy medical treatments. Consequently, high medical costs as well as delayed or absent return to work can be
Acetabular fractures the consequence. Therefore, we aimed to study the socioeconomic consequences of work-related pelvic and
Work-related accidents
acetabular fractures.
Socioeconomics
Cost analysis
Materials and methods: This retrospective study investigated work-related pelvic and acetabular fractures
recorded in the German Social Accident Insurance in 2011 and 2017, in terms of age, sex, type of accident,
duration of incapacity to work, reductions in earning capacity, costs for outpatient and inpatient treatment and
costs for pension and severance pay.
Results: Among a total of 606 injuries in 2011 and 619 injuries in 2017, male patients and patients between 40
and 65 years were predominantly affected. Acetabular fractures caused higher rates of long absence from work of
6–12 months (2011: 24.7% vs. 9.5–16.9%; 2017: 26.1% vs. 6.1–11.0%) and >12 months (2011: 15.8% vs.
9.8–10.2%; 2017: 13.3% vs. 1.9–8.2%) as well as more cases with a reduction in earning capacity of at least 20%
(2011: 61 vs. ≤27 cases; 2017: 39 vs. ≤12 cases) compared to pelvic ring fractures. The total costs for pelvic ring
and acetabular fractures in the German social accident insurances amounted € 18,726,630 and € 9637,189 in the
periods 2011–2020 and 2017–2020, respectively. The average costs per case for treatment and rehabilitation
until 2020 was € 19,079 for injuries from 2011 and € 13,629 for injuries from 2017. Acetabular fractures were
found to be the most cost-intensive injuries compared to anterior, posterior or complex pelvic ring fractures.
Conclusions: Work-related pelvic and especially acetabular fractures have a considerable socioeconomic impact in
the German Social Accident Insurance. Measures to prevent work-related accidents and to improve treatment of
pelvic injuries can help to reduce their socioeconomic burden.
Introduction a reduced quality of life in the long-term clinical outcome. A good to

excellent clinical outcome is achieved in only 67% - 83% after treatment
About 10% - 40% of all pelvic ring fractures and about 10% - 12% of of pelvic and acetabular fractures [11,13,14,16,17]. Frequently reported
all acetabular fractures occur due to work-related accidents, especially long-term impairments are chronic pelvic pain, limp or irregular gain
in road traffic accidents (car, motorcycle, pedestrian) or falls from a pattern [16,18-22].
height [1–9]. Several short-term complications of conservatively or Orthopedic trauma in general, can have a considerable socioeco
surgically treated pelvic and acetabular fractures, such as nerve palsy, nomic impact by causing delayed return to work, unemployment and
urogenital injuries, failure of osteosynthesis, heterotopic ossifications loss of income [23]. Although pelvic and acetabular fractures are
and posttraumatic osteoarthritis, compromise their clinical outcome [1, comparably rare injuries, they also cause relevant socioeconomic con
7,9-16]. Moreover, several studies revealed functional impairments and sequences due to the challenging treatment, a high rate of complications
* Corresponding author at: BG Hospital Hamburg, Bergedorfer Strasse 10, 21033 Hamburg, Germany.
E-mail address: n.hinz@bgk-hamburg.de (N. Hinz).
N. Hinz et al. Injury 54 (2023) 110848
and long-term functional impairments. This leads to long hospital stays, Table 2
a lengthy period of rehabilitation and a prolonged or persistent in Defined injury groups for further analysis.
capacity to work [11-13,15,24,25]. DGUV-codes Description of the defined groups
Complications and persistent functional impairments after pelvic
330 Complex pelvic ring injury with multiple locations
and acetabular fractures account for a delayed return to work of up to 331, 333 Anterior pelvic ring (including pubic symphysis)
285 days, low rates of return to work (47 − 81%) and financial loss [1,4, 332, 335, 337 Posterior pelvic ring (including sacroiliac joints and os ilium)
5,14,19-22,24,26-30]. The financial loss and a limited competitiveness 711 Acetabulum
on the labor market threatens the patients’ financial viability, quality of
life and reintegration into society [14,23]. Additionally, treatment per
Codes, which were not mentioned in Table 2 (e.g. 334, 336 and 338),
se, long hospital stays, a delayed return to work, unemployment and
were not included in further analysis, as they do not describe pelvic and
early pensions cause high direct and indirect medical costs [3,24,31].
acetabular fractures. Patients with other concomitant injuries, which are
This in turn has an economic impact on the medical insurance system
not related to the pelvis or acetabulum and thus were not covered by the
[3].
codes in Table 2, were excluded.
However, studies about costs and further socioeconomic conse
Registry data of the two injury years 2011 and 2017 were analyzed in
quences of pelvic and acetabular fractures, especially after work-related
this retrospective analysis. These two cohorts allow the analysis of long-
accidents, are scarce but important to identify the need of improved
term as well as short-term socioeconomic consequences. Therefore, all
prevention measures and treatment strategies [25,32]. Therefore, the
patients, which suffered an isolated pelvic and/or acetabular fracture
objective of this study was to investigate the epidemiology of
(DGUV-codes 330, 331, 333, 332, 335, 337 and 711) in the years 2011
work-related pelvic and acetabular fractures recorded in the German
and 2017 and were recorded in the registry of the DGUV, were included
Social Accident Insurance. In a second step, this registry study aimed to
and grouped according to Table 2. Combined pelvic ring and acetabular
examine the costs for inpatient and outpatient treatment as well as for
fractures were each assigned to one of the groups based on the injury
pension and severance pay and the impact of recorded pelvic injuries on
with the highest severity and therefore with the greatest impact on
the job situation of the patients.
treatment and prognosis. The data retrieval was performed in September
2021.
Materials and methods
Outcome assessment
Study design and registry specifications
The four injury groups were analyzed and compared in terms of the
In this registry study, a retrospective analysis of patients with pelvic
following parameters for the injury years 2011 and 2017:
and acetabular fractures after work-related accidents, which were
recorded at the statistics section of the German Social Accident Insur
• Age at the time of injury
ance (DGUV), was conducted. In Germany, the statutory accident in
• Sex
surances cover the medical costs for treatment after a work-related
• Type of accident (workplace accident, work-related travel accident
accident as well as for costs for rehabilitation, wage replacements and
or commuting accident; road and non-road accidents are included in
injury pensions. Data on epidemiology, treatment modality, medical
each case)
costs and pension costs are continuously collected after a work-related
• Duration of incapacity to work
accident by the statutory accident insurances. These data are subse
• Reduction in earning capacity after 9 years (injury year 2011) or 3
quently transmitted to the statistics section of the German Social Acci
years (injury year 2017)
dent Insurance. After anonymization, these data can be retrieved for
• Costs for treatment and rehabilitation from 2011 - 2020 or from 2017
further analysis.
- 2020
• Costs for pension and severance pay from 2011 - 2020 or from 2017 -
Patient inclusion and grouping 2020
The data are grouped for different injury regions according to an Statistics
internal diagnosis system. Injuries of the pelvis and the acetabulum are
categorized as stated in Table 1. Statistical analyses and visualization of data were performed with
Based on the AO/OTA classification of pelvic ring injuries, these GraphPad Prism 9 (GraphPad Software Inc., San Diego, CA, USA),
items were grouped as listed in Table 2. including means and standard deviations for the reduction in earning
capacity. This study used only descriptive statistics.
Table 1
Internal diagnosis system and coding of the DGUV.
Ethics
DGUV- Description
code This registry study was reported to and checked by the local ethics
330 Entire area or several of the following items (e.g. anterior and posterior committee of the Ärztekammer (General Medical Council) Hamburg,
pelvic ring) Germany. The local ethic committee had no concerns regarding the
331 Anterior pelvic ring, ischium (os ischii), pubis (os pubis)
conduction of the study (reference number: 2021-300043-WF).
332 Posterior pelvic ring
333 Pubic symphysis
334 Perineum Results
335 Ala-of the ileum (os ilium)
336 Iliac crest (crista iliaca), iliac spine (spina iliaca), epi‑/apophysis of the
In 2011 a total of 606 pelvic and acetabular fractures were reported
iliac spine
337 Sacroiliac joint (articulatio sacroiliaca) in the German Social Accident Insurance according to the above-
338 Soft tissues (including buttock), vessels, nervs (N. pudendus, N. gluteus, mentioned inclusion criteria. This includes 79 (13.0%) cases of a com
N. ilio-inguinalis, N. cuteanus femoris lateralis, N. cuteanus femoris plex pelvic ring injury with multiple locations, 269 (44.4%) cases of an
dorsalis) anterior pelvic ring injury, 70 (11.6%) cases of a posterior pelvic ring
711 Acetabulum, acetabular floor
injury and 188 (31,0%) cases of an acetabular fracture. In 2017, a total
of 619 pelvic and acetabular fractures were recorded, including 68 or no incapacity to work was attested, e.g. for self-employed, voluntary
(11.0%) cases of a complex pelvic ring injury with multiple locations, worker or rehabilitants.
287 (46.4%) cases of an anterior pelvic ring injury, 59 (9.5%) cases of a Among the recorded durations of incapacity to work, the most
posterior pelvic ring injury and 205 (33.1%) cases of an acetabular frequently recorded duration after a pelvic or acetabular fracture was
fracture. The incidence of a combined pelvic ring and acetabular frac between > 3 month and 6 months in 2011 (160 cases; 31.7%) and 2017
ture was 5.3% (33 cases) in 2011 and 7.1% in 2017 (44 cases). (165 cases; 32.9%). Fig. 3 displays a detailed presentation of the dura
tions of incapacity to work for the four injury types and the grouping of
Age time ranges.
Acetabular fractures showed a trend towards longer absenteeism
In 2011 and 2017, most of the pelvic and acetabular fractures from work in 2011 and 2017, since they caused higher rates of in
occurred in the age of 40 - 65 years (2011: 374 cases; 61.7% and 2017: capacities to work of > 6 months and 12 months (2011: 39 cases; 24.7%
368 cases; 59.5%). A detailed list of the age distribution for 2011 and and 2017: 45 cases; 26.1%) as well as >12 months (2011: 25 cases;
2017 grouped for the four injury types is presented in Table 3 and 15.8% and 2017: 23 cases; 13.3%) compared to the other injury types.
Supplementary Fig. 1.
In the 2017 cohort, there was a trend towards more cases in the age
Reduction in earning capacity
group > 65 years in 2017 compared to 2011 in total (19.5% vs. 15%) as
well as for all injury types.
In German Social Accident Insurance, patients with a reduction in
earning capacity of at least 20% for over 26 weeks are eligible for
Sex
pension payments. The amount of payment depends on the level of
reduction in earning capacity.
Dividing the cohorts into four groups in terms of sex and age revealed
Overall, 115 and 57 reductions in earning capacity were recorded
that males ≤ 50 years was the most frequently affected group for pelvic
within 9 years in the 2011 cohort and within 3 years in the 2017 cohort,
and acetabular fractures within the 2011 cohort (207 cases; 34.2%),
respectively. The most frequently attested reduction in earning capacity
whereas males > 50 years was the most frequently affected group in
was 20% within 9 years follow up in the 2011 cohort (53 cases; 46.1%)
2017 (211 cases; 34.1%). A detailed presentation of the age-grouped sex
and within 3 years follow up in the 2017 cohort (34 cases; 59.6%). A
distribution for pelvic and acetabular fractures is displayed in Fig. 1 and
detailed analysis of the reductions in earning capacity for the four injury
Supplementary Table 1.
types are presented in Fig. 4.
In 2011 both cohorts, acetabular fractures and posterior pelvic ring
Acetabular fractures were the most frequently recorded injury type
injuries were predominantly found in males, independently of the age.
with a reduction in earning capacity by 20% in the 2011 cohort (33
Moreover, females > 50 years were most frequently affected by anterior
cases; 62.3%) and in the 2017 cohort (24 cases; 70,6%).
pelvic ring fractures in the 2011 (86 cases; 32.0%) and 2017 (123 cases;
42.9%) cohorts compared to the other age/sex groups.
Costs for treatment and rehabilitation
Type of accident
Total costs for treatment and rehabilitation of pelvic and acetabular
Three types of work-related accidents were distinguished using the fractures amounted € 11,561,935 over 9 years in the 2011 cohort,
DGUV registry. Workplace accidents are defined as accidents, which divided into € 3075,583 for outpatient treatment and € 8486,352 for
occur at the workplace per se. Commuting accidents occur during the inpatient treatment including acute treatment and rehabilitation. This
direct way from home to workplace or from workplace to home. Acci results in average costs per case of € 19,079, including € 5160 for
dents, which occur during travelling on direct order of the company e.g. outpatient treatment and € 14,657 for inpatient treatment and rehabil
from one workplace to another, are called work-related travel accidents. itation. In the 2017 cohort, the costs over 3 years amounted € 2138,264
The most common cause for pelvic and acetabular fractures was a for outpatient treatment, € 4813,513 for inpatient acute treatment and €
workplace accident in 2011 (368 cases; 60.7%) as well as 2017 (395 1430,133 for inpatient rehabilitation resulting in € 8381,910 total costs
cases; 63.8%), followed by commuting accidents (2011: 210 cases; for treatment and rehabilitation of pelvic and acetabular fractures.
34.7% and 2017: 205 cases; 33.1%) and work-related travel accidents Average costs per case of € 13,629 (outpatient treatment: € 3534;
(2011: 28 cases; 4.6% and 2017: 19 cases; 3.1%). A similar frequency inpatient acute treatment: € 8550; inpatient rehabilitation: € 9109) were
distribution of the types of accident could be observed for the four injury recorded. A detailed list of average costs per case and total costs for
types as presented in Fig. 2. treatment and rehabilitation grouped for the four injury types are pro
vided in Tables 4 and 5.
Duration of incapacity to work Acetabular fractures from 2011 and 2017 had the highest total costs
for treatment and rehabilitation (2011: € 4798,999 and 2017: €
In the subsequent analysis, only patients with a recorded duration of 3994,358). Additionally, acetabular fractures caused one of the highest
incapacity to work were included. For 102 patients in 2011 and 118 average costs per case in the periods from 2011 and from 2017 with €
patients in 2017 either the duration of incapacity to work was unknown 25,527 and € 19,580, respectively.
Table 3
Age distribution of pelvic and acetabular fractures recorded in 2011 and 2017 in the German Social Accident Insurance. Number of patients and frequency relative to
total cases of the corresponding injury type in% are displayed in the table cells.
Complex pelvic ring injury with Anterior pelvic ring Posterior pelvic ring Acetabulum Total
multiple locations
2011 2017 2011 2017 2011 2017 2011 2017 2011 2017
< 17 years 9 (11.4%) 7 (10.3%) 10 (3.7%) 9 (3.1%) 8 (11.4%) 3 (5.1%) 5 (2.7%) 6 (2.9%) 32 (5.3%) 25 (4.0%)
17 - 39 years 19 (24.1%) 11 (16.2%) 44 (16.4%) 46 (16.0%) 11 (15.7%) 14 (23.7%) 35 (18.6%) 34 (16.6%) 109 (18.0%) 105 (17.0%)
40 - 65 years 43 (54.4%) 36 (52.9%) 160 (59.5%) 167 (58.2%) 43 (61.4%) 35 (59.3%) 128 (68.1%) 130 (63.4%) 374 (61.7%) 368 (59.5%)
> 65 years 8 (10.1%) 14 (20.6%) 55 (20.4%) 65 (22.6%) 8 (11.4%) 7 (11.9%) 20 (10.6%) 35 (17.1%) 91 (15.0%) 121 (19.5%)
Total 79 68 269 287 70 59 188 205 606 619
2011 2017
130 130
male 50 years
120 120
male > 50 years
110 110
female 50 years
100 100 female > 50 years
90 90
Number of patients
Number of patients
80 80
70 70
60 60
50 50
40 40
30 30
20 20
10 10
0 0
ns y
m
ns y
tio ur
tio ur
rin
rin
rin
rin
lu
lu
ca nj
ca nj
bu
bu
c
c
lo g i
lo g i
vi
vi
vi
vi
ta
ta
el
el
el
el
le rin
le rin
ce
ce
rp
rp
rp
rp
A
A
tip c
tip c
io
io
io
io
ul vi
ul vi
m pel
er
er
m pel
er
er
nt
st
nt
st
ith x
ith x
Po
Po
A
A
w ple
w ple
om
om
C
C
Fig. 1. Age-grouped sex distribution of pelvic and acetabular fractures recorded in 2011 and 2017 in the German Social Accident Insurance. Bars represent total
numbers of patients grouped for the four injury types.
2011 2017
300 300
Workplace accident
280 280
Commuting accident
260 260
Work-related travel accident
240 240
220 220
200 200
Number of patients
Number of patients
180 180
160 160
140 140
120 120
100 100
80 80
60 60
40 40
20 20
0 0
r p on y
m
r p on y
ti r
rin
rin
ti r
rin
rin
lu
er ca inju
lu
er ca inju
el s
el s
bu
bu
c
c
vi
vi
vi
vi
A le l ng
ta
A le l ng
ta
el
el
ce
ce
ri
ri
rp
rp
o
o
A
A
tip c
tip c
io
io
ul vi
io
io
ul vi
m pel
er
m pel
er
nt
st
nt
st
ith x
Po
ith x
Po
w ple
w ple
om
om
C
C
Fig. 2. Types of accident responsible for pelvic and acetabular fractures recorded for 2011 and 2017 in the German Social Accident Insurance. Bars represent total
numbers of patients suffered the corresponding accident grouped for the four injury types.
Costs for pension and severance pay For the periods from 2011 and 2017, pension and severance pay
costs were recorded for acetabular fractures (2011: € 3547,503; 97cases
In 2011, there were 187 cases of pension and severance pay claim and 2017: € 812,401; 62 cases).
resulting in total pension and severance pay costs of € 7164,695 over the
9 years in the 2011 cohort. In the 2017 cohort, the total pension and Discussion
severance pay costs over 3 years amounted € 1255,279 for 99 cases of
pension and severance pay claim. Table 6 displays a detailed list of cases In this retrospective registry study, we analyzed a total of 606 pelvic
and costs for pension and severance pay claims after pelvic and and acetabular fractures from 2011 and a total of 619 fractures from
acetabular fractures. 2017, which were recorded in the German Social Accident Insurance
Fig. 3. Durations of incapacity to work after pelvic and acetabular fractures recorded in 2011 and 2017 in the German Social Accident Insurance. Bars represent total
numbers of patients with the corresponding duration of incapacity to work grouped for the four injury types.
Fig. 4. Reduction in earning capacity after pelvic and acetabular fractures recorded over 9 years for the 2011 cohort and over 3 years for the 2017 cohort in the
German Social Accident Insurance. Box plots represent the reduction of earning capacity in% grouped for the four injury types. Boxes represent 25%- and 75%-
percentile, “+” indicates mean, lines represent median, and whiskers represent range.
Table 4
Average costs per case for treatment and rehabilitation of pelvic and acetabular fractures recorded over 9 years for the 2011 cohort and over 3 years for the 2017 cohort
in the DGUV registry. Average costs per case in € of the corresponding injury type and time period are displayed in the table cells. Average costs per case were
calculated from all cases with available costs; cases without recorded costs were not included. This is why, the column totals could be lower than the sum of outpatient
treatment, inpatient treatment and inpatient rehabilitation. For the 2011 cohort only summed costs for inpatient acute treatment and inpatient rehabilitation are
available and the summed costs are displayed in the corresponding merged rows.
Complex pelvic ring injury Anterior pelvic ring Posterior pelvic ring Acetabulum Total
with multiple locations
2011 - 2020 2017 - 2020 2011 - 2020 2017 - 2020 2011 - 2020 2017 - 2020 2011 - 2020 2017 - 2020 2011 - 2020 2017 - 2020
Outpatient treatment € 8786 € 3367 € 3366 € 2650 € 4610 € 2346 € 6379 € 5173 € 5160 € 3534
Inpatient acute € 5653 € 6940 € 9062 € 11,596 € 8550
treatment
€ 18,574 € 9748 € 15,173 € 19,706 € 14,657
Inpatient € 7256 € 8754 € 8904 € 9587 € 9109
rehabilitation
Total € 26,308 € 9760 € 12,544 € 10,364 € 18,718 € 13,208 € 25,527 € 19,580 € 19,079 € 13,629
after work-related accidents. We aimed to examine their epidemiology frequently suffered from Tile B and C pelvic ring fractures as well as
and socioeconomic characteristics to raise awareness for their socio acetabular fractures due to high energy trauma than from Tile A pelvic
economic burden. ring fractures [6,8,21,33]. By contrast, females > 50 years was the most
Acetabular fractures and posterior pelvic ring injuries occurred more affected group suffering an anterior pelvic ring injury in this study.
frequently in male patients compared to female patients in our registry Consistently, Pereira et al. observed that pelvic ring injuries occurred
study. This could be explained by the fact that male patients more more frequently in female and older patients due to a fall from own
Table 5
Total costs for treatment and rehabilitation of pelvic and acetabular fractures recorded over 9 years for the 2011 cohort and over 3 years for the 2017 cohort in the
DGUV registry. Total costs in € of the corresponding injury type and time period are displayed in the table cells. For the 2011 cohort only summed costs for inpatient
acute treatment and inpatient rehabilitation are available and the summed costs are displayed in the corresponding merged rows.
Complex pelvic ring injury Anterior pelvic ring Posterior pelvic ring Acetabulum Total
with multiple locations
2011 - 2017 - 2011 - 2017 - 2011 - 2017 - 2011 - 2017 - 2011 - 2020 2017 -
2020 2020 2020 2020 2020 2020 2020 2020 2020
Outpatient treatment € 685,328 € 215,467 € 888,517 € 744,600 € 308,873 € 138,404 € 1192,865 € 1039,793 € 3075,583 € 2138,264
Inpatient acute € 356,161 € 1790,544 € 498,416 € 2168,392 € 4813,513
treatment
€ 1393,033 € 2485,787 € 1001,398 € 3606,134 € 8486,352
Inpatient € 72,559 € 428,943 € 142,458 € 786,173 € 1430,133
rehabilitation
Total € 2078,361 € 644,187 € 3374,304 € 2964,087 € 1310,271 € 779,278 € 4798,999 € 3994,358 € € 8381,910
11,561,935
Table 6
Total costs and number of claims for pension and severance pay after pelvic and acetabular fractures recorded over 9 years for the 2011 cohort and over 3 years for the
2017 cohort in the DGUV registry. Total pension and severance pay costs in € and cases of pension and severance pay claim of the corresponding injury type and time
period are displayed in the table cells.
Complex pelvic ring Anterior pelvic ring Posterior pelvic ring Acetabulum Total
injury with multiple
locations
2011 - 2017 - 2011 - 2017 - 2011 - 2017 - 2011 - 2017 - 2011 - 2017 -
2020 2020 2020 2020 2020 2020 2020 2020 2020 2020
Total pension and severance € 1097,344 € 38,795 € 1805,721 € 340,958 € 714,127 € 63,125 € 3547,503 € 812,401 € 7164,695 € 1255,279
pay costs
Cases of pension and 26 6 49 25 15 6 97 62 187 99
severance pay claim
height resulting in a higher proportion of Tile A injuries [6]. The aging the costs among the studies and in comparison to our registry study
society can explain the higher proportion of patients > 65 years could be due to differences in study populations, investigated coun
suffering a pelvic or acetabular fracture in 2017 compared to 2011 in tries/health systems, inclusion of costs (direct and indirect costs) and
our study. Moreover, in a large population-based study in France, Mel follow-up periods.
hem et al. could also observe an increase of patients suffering pelvic and We further revealed that acetabular fractures caused higher costs per
acetabular fractures in the age group > 60 from 2006 to 2016 [33]. case for inpatient and outpatient treatment as well as the highest total
Pelvic and acetabular fractures are associated with a high rate of costs for inpatient and outpatient treatment compared to the different
complications and long-term impairments as well as a lengthy treatment pelvic ring injuries. Longer hospital stays were shown to be one of the
and rehabilitation [11,13,16,18,20,25,26,30]. Consistently, we revealed mayor drivers of higher treatment costs [3,31]. The average length of
here that pelvic and acetabular fractures caused long durations of in hospital stay after a pelvic ring fracture was 6.5 days in 2007 [10],
capacity to work with a most frequently reported duration of > 3 months whereas acetabular fractures cause a substantially longer length of
- 6 months. In the study of Papasotiriou et al., the most frequently hospital stay of 16.6 - 16.7 days [1,7]. Furthermore, the mean length of
recorded time of return to work after a pelvic fracture was 3 month - 12 hospital stay after a pelvic or acetabular fracture increased with occur
months [4]. Other studies observed an average time to return to work rence of complications from about 8.1 - 8.7 days up to 17.2 - 22.5 days
after pelvic and acetabular fractures of 180 - 285 days [1,5,24,26,30]. [3,31]. In regard to this data, one explanation for higher treatment costs
Interestingly, work-related injuries of the pelvis were associated with a for acetabular fractures could be a longer length of hospital stay
lower rate of full return to work compared to non-work-related injuries. compared to pelvic ring injuries, probably due to a more complex
One explanation would be, that work-related pelvic injuries are associ treatment and longer rehabilitation as well as due to a higher rate of
ated with a higher injury severity and thus, with a poorer clinical complications.
outcome [4,34]. Furthermore, we identified a noticeable number of In addition to the economic burden of pelvic and acetabular fractures
cases with a reduction in earning capacity of 20% and more and a mean due to outpatient and inpatient treatment costs, they further caused
reduction in earning capacity of 20.0% - 34.0%. Schaffler et al. revealed significant costs for pension and severance pay and thus, caused a sig
a mean reduction in earning capacity of 28% after a pelvic ring injury nificant economic burden in the long-term follow-up. During the follow-
due to a work-related accident [5]. For comparison, the mean reduction up period 2011 – 2020 for injuries from 2011 costs of € 7164,695 and
in earning capacity after work-related tibial plateau fractures in the during the follow up period 2017 – 2020 for injuries from 2017 costs of €
German Social Accident Insurance was 23.7% - 24.8% [35]. 1255,279 for pension and severance pay due to pelvic and acetabular
We observed that work-related acetabular fractures were associated fractures were observed. For comparison, work-related tibial plateau
with longer durations of incapacity to work and more cases of a fractures recorded in the German Social Accident Insurance caused total
reduction in earning capacity of at least 20% compared to the different costs for pension and severance pay of € 7970,214 in the period 2010 -
pelvic ring injuries. The reason for this can be the complex acute 2019 for injuries from 2010 and € 2160,286 in the period 2016 - 2019
treatment, the lengthy rehabilitation and the high rate of complications for injuries from 2016 [35].
and long-term impairments after acetabular fractures. Although Nusser In line with the frequently recorded reduction in earning capacity of
et al. observed no difference between pelvic ring injuries and acetabular at least 20% after acetabular fractures in this study, more cases of
fractures in terms of return to work, they observed a trend towards pension and severance pay claims and subsequently higher costs for
higher rates of reduction of employment after acetabular fractures pension and severance pay arose from acetabular fractures compared to
compared to pelvic ring fractures (20.8% vs. 16.6%) [27]. the different pelvic ring injuries. As a possible explanation serves that
A laborious treatment, a long hospital stay, a lengthy rehabilitation the rate of complications after an acetabular fracture, especially the
and a long or persistent absence from work can be the driver for high development of a posttraumatic osteoarthritis, is higher than after a
direct and indirect medical costs after pelvic and acetabular fractures pelvic ring injury, long-term impairments loom large and the clinical
[24,25]. We demonstrated here that work-related pelvic and acetabular outcome after acetabular fractures is supposed to be poorer than for
fractures caused high costs for outpatient and inpatient treatment with a pelvic ring injuries [14].
total of € 11,561,935 and average costs per case of € 19,079 within 9 This study showed that work-related pelvic and acetabular fractures
years for injuries from 2011 as well as a total of € 8381,910 and average lead to a significant socioeconomic burden for the health and social care
costs per case of € 13,629 within 3 years for injuries from 2017. In a system and highlighted the need of further improvements of prevention
retrospective study, Aprato et al. observed mean direct and indirect total measures and treatment strategies. Prevention of work-related accidents
costs per case for pelvic and acetabular fractures of € 38,083 [24]. In the will be one of the most effective ways to reduce the incidence of pelvic
study of Childs et al., average costs of $ 44,917 for the index inpatient and acetabular fractures and thus, lessen their socioeconomic conse
care and in the study of Vallier et al. treatment costs of $ 71,253 for quences. For instance, improvements of the automobile safety, of work
pelvic and acetabular fractures were recorded [3,31]. Kay et al. revealed processes, especially for jobs in high altitude or at the building site, and
mean inpatient costs for surgically treated acetabular fractures of $ 71, of personal protective equipment will be helpful to prevent work-related
198 - $ 71,914, which were the second highest costs after femoral shaft injuries.
fractures among typical trauma surgery procedures [36]. Differences in Furthermore, early surgery after injury and an anatomical reduction
can reduce the rate of complications as well as long-term impairments fractures caused long durations of incapacity to work, high rates of
after pelvic and acetabular fractures and thus, can hamper their socio reduction in earning capacity as well as high costs for treatment and
economic consequences [25]. Consistently early definitive surgical rehabilitation as well as pension and severance pay. These data highlight
treatment of pelvic and acetabular fractures was shown to improve the the importance of prevention measures for work-related accidents and of
functional outcome of pelvic injuries and significantly reduce the length further improvements in the treatment of pelvic and acetabular fractures
of hospital stay, rate of pulmonary complications and costs of care by up to reduce their socioeconomic consequences.
to $ 100,000 [37–39]. Patients suffering complications after pelvic and
acetabular fractures displayed a significantly longer length of hospital Funding
stay and thus, cause $ 14,829 to $ 98,465 additional costs per compli
cation [3,31]. Another way to reduce the costs of treatment can be the No funds, grants, or other support was received for conducting this
use of minimally invasive surgical techniques in suitable patients. Ma study.
et al. detected a significant reduction in the direct in-hospital costs from
$ 8900 to $ 5786 when treating pelvic fractures with a minimally CRediT authorship contribution statement
invasive technique compared to open reduction and internal fixation
without any difference in functional outcome [40]. An interesting Nico Hinz : Conceptualization, Methodology, Formal analysis,
approach for minimally invasive plate osteosynthesis of acetabular Investigation, Writing original draft, Visualization. Julius Dehoust :
fractures with a full endoscopic technique was recently presented by Conceptualization, Formal analysis, Investigation, Writing review &
Hartel et al. [41]. Thus, development of programs addressing cost editing. Klaus Seide : Conceptualization, Methodology. Birgitt Kowald
increasing aspects in the treatment and rehabilitation of pelvic and : Methodology, Formal analysis, Investigation. Stefan Mangelsdorf :
acetabular fractures can improve cost containment. Conceptualization, Methodology, Data curation, Resources, Formal
A number of limitations of our registry analysis must be noticed. This analysis, Investigation, Writing review & editing. Karl-Heinz Frosch :
study only provides a descriptive analysis of the socioeconomic impact Writing review & editing, Supervision, Project administration. Max
of pelvic and acetabular fractures without any statistical testing. imilian J. Hartel : Conceptualization, Methodology, Writing review &
Furthermore, the notable difference in the sample sizes of the injury editing, Supervision, Project administration All authors read and
groups limits the comparability between the groups. However, we approved the final manuscript.
identified the need of further improvements of prevention and treatment
for work-related injuries, and we were able to formulate hypotheses, Ethical approval
which can be tested in further prospective studies. Additional parame
ters, which can have an influence on return to work as well as costs of This retrospective registry study approved by the local ethics com
treatment and pension, were not recorded in the German Social Accident mittee of the Ärztekammer Hamburg, Germany (2021-300043-WF).
Insurance and therefore, could not be examined in this study but can be This work was performed in accordance with the ethical standards of the
examined in further prospective studies. This includes for example institutional and national research committee as well as with the 1964
different treatment modalities, different surgical techniques and im Declaration of Helsinki.
plants and length of hospital stay. In addition, the type and volume of
hospital where the pelvic and acetabular fractures were managed may Informed consent
also have an impact on the outcome as has already been shown for hip
fractures and therefore can affect medical costs as well as other socio Not applicable.
economic aspects [42,43]. However, the type of hospital where the
surgery and the main treatment was performed was not recorded in the
Availability of data and materials
DGUV registry. Consequently, a subgroup analysis by differentiating the
types of hospitals with different expertise and volume in managing
The datasets used and analyzed during the current study are avail
pelvic and acetabular fractures was not possible in this study. Further
able from the corresponding author on reasonable request.
studies are required to investigate this hypothesis.
Although combined pelvic ring and acetabular fractures were
considered as a unique subtype of injury with a poorer outcome Declaration of Competing Interest
compared to isolated fractures in some studies, we assume that the
outcome of these combined fractures depends on the most severe one of The authors have no competing interests to declare that are relevant
the two injuries as also stated by other authors [38,44]. This is why, we to the content of this article.
assigned combined pelvic ring and acetabular fractures to one of the
defined injury groups based on the injury with the highest severity and Acknowledgments
thus with the biggest influence on the outcome. On the other hand,
pelvic and acetabular fractures with other concomitant injuries, such as None.
thorax traumata or urogenital injuries, were not included in our anal
ysis, although concomitant injuries can have a significant influence on Supplementary materials
clinical outcome [45,46]. However, this could also be a strength of this
study, since we were able to investigate the socioeconomic influence of Supplementary material associated with this article can be found, in
isolated pelvic and acetabular fractures without the influence of het the online version, at doi:10.1016/j.injury.2023.110848.
erogenic concomitant injuries.
References
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Injury 54 (2023) 110853
Injury
Short term clinical and patient reported outcomes following Virtual

Fracture Clinic management of fifth metatarsal fractures
Richard Galloway a, *, Nusrat Zahan b, Amogh Patil b, Batya Stimler b, Amit Patel b, Lee Parker b,
Francesc Malagelada Romans b, Luckshmana Jeyaseelan b
a
Department of Orthopaedics, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP United Kingdom
b
Barts Bone & Joint Health, The Royal London Hospital, Whitechapel Rd, London, E1 1FR United Kingdom
Keywords: Introduction: Fracture clinics are experiencing increased referrals and decreased capacity. Virtual fracture clinics
Virtual (VFC) are an efficient, safe, and cost-effective solution for specified injury presentations. There is currently a lack
Fracture of evidence to support the use of a VFC model in the management of 5th metatarsal base fractures. This study
Metatarsal
aims to assess clinical outcomes and patient satisfaction with the management of 5th metatarsal base fractures in
Clinic
VFC. We hypothesise that it is both safe and cost effectiveness.
Outcomes
Methods: Patients presenting to VFC at our major trauma centre with a 5th metatarsal base fracture, between
January 2019 and December 2019, were included. Patient demographics, clinic appointments, complication and
operative rates were analysed. Patients received standardised VFC treatment; walker boot/full weight bearing,
rehabilitation information and instructions to contact VFC if symptoms of pain persist after 4 months. Minimum
follow-up was one year; Manchester-Oxford Foot Questionnaires (MOXFQ) were distributed. A basic cost analysis
was performed.
Results: 126 patients met inclusion criteria. Mean age was 41.6 years (18–92). Average time from ED attendance
to VFC review was 2 days (1 – 5). Fractures were classified according to the Lawrence and Botte Classification
with 104 (82%) zone 1 fractures, 15 (12%) zone 2 fractures and 7 (6%) zone 3 fractures. At VFC, 125/126 were
discharged. 12 patients (9.5%) arranged further follow-up after initial discharge; pain the reason in all cases.
There was 1 non-union during the study period. Average MOXFQ score post 1 year was 0.4/64, with only 11
patients scoring more than 0. In total, 248 face-to-face clinic visits were saved.
Conclusion: Our experience demonstrates that the management of 5th metatarsal base fractures in the VFC
setting, with a well-defined protocol, can prove safe, efficient, cost effective and yield good short term clinical
outcomes.
Introduction the COVID − 19 pandemic [3]. Benefits of the VFC model include time
efficiency, cost-effectiveness and accessibility [4]. That said, critics of
Overwhelming demand for trauma services driven by increasing the model highlight increased potential for delayed or missed injuries,
emergency department attendances, has increased pressure on fracture inadequate treatment and poorer protection against medicolegal claims
clinics in many units. The British Orthopaedic Association (BOA) [5]. There is currently a lack of evidence to support the use of a VFC
guidelines on Fracture Clinic Services, states that all patients should be model in the management of fifth metatarsal fractures.
seen in a new fracture clinic within 72 h of injury presentation [1]. With Metatarsal fractures are the most common fractures in the foot, with
increasing numbers of referrals and decreased capacity, this is becoming fifth metatarsal fractures representing up to 45% of these injuries [6].
increasingly difficult to achieve [2]. The widespread use of Virtual Despite the high incidence of fifth metatarsal base fractures, there re
Fracture Clinics (VFCs) has provided a safe, effective solution to these mains little consensus regarding their optimum treatment. Treatment
challenges. The implementation of these pathways has been expedited options include protected weight bearing, immobilisation or surgery
by the requirements for physical distancing measures introduced during depending on location of the fracture, degree of displacement, and
* Corresponding author at: Flat 2, 105-109 Salusbury Road, London, Postal Code: NW6 6RG, United Kingdom
E-mail address: richard.galloway@nhs.net (R. Galloway).
R. Galloway et al. Injury 54 (2023) 110853
functional requirements of the patient. These injuries are predisposed to comfortable to do so. The patient is advised that after 3–4 weeks, they
poor healing due to the limited blood supply of specific areas at the fifth may begin to wean themselves out of the boot/shoe, if comfortable to do
metatarsal base [7]. Injury complications may include pain, delayed so. At 6 weeks they can discard the boot/shoe and walk unaided.
union, painful mal-union and non-union. When classified according to Following this process, patients with persistent pain beyond 3–4 months
the Lawrence and Botte classification, nondisplaced, conservatively are advised to contact the department to organise a face-to-face clinical
managed zone 1 fractures have low non-union rates reported between appointment, as per the VFC protocol.
0.5% and 1%, whereas zone 2 injuries have reported non unions rates as As part of the study, all radiographs were reviewed by two of the
high as 15 to 30% [8,9]. senior authors and fractures classified according to the Lawrence and
The safety and efficacy of VFC management of fifth metatarsal base Botte classification [11]. Cases were assessed considering fracture
fractures has been assessed before, with limited assessment of patient pattern, degree of displacement, individual patient functional re
reported outcomes (PROMS) or satisfaction with the VFC pathway [10]. quirements and medical background. Time from injury to VFC consul
The primary aim of this study aim is to assess short term clinical and tation was documented. Letters were sent to patients detailing diagnosis,
patient reported outcomes following managing fifth metatarsal fractures management plan and VFC contact details. All patients deemed appro
within a VFC model. Secondary aims include assessing associated pa priate for conservative management received the described standardised
tient satisfaction levels and an estimate of cost saving. We hypothesise treatment protocol.
that the VFC model can be both safe and acceptable to patients using the
service. Data collection
Materials and methods Patient electronic records on the Cerner Millennium Care Record
System (CRS) were retrospectively reviewed for baseline demographic
Study design data, including co-morbidities and smoking history. Requirement for
operative intervention and any complications, including mal and non-
We conducted a retrospective case series analysis of all patients union, were noted. Patients from the cohort who required further
presenting to the VFC at our Major Trauma Centre (MTC) with a fifth face-to-face appointments were noted and the reasons identified. The
metatarsal base fracture, between January 2019 and December 2019. number of clinic visits per patient was documented. A basic cost analysis
was performed to evaluate an estimate of cost saving to the unit.
Inclusion and exclusion criteria Patients were called after 1 year by an orthopaedic surgeon and
asked to complete the Manchester Oxford Foot Questionnaire (MOXFQ)
We included all patients with a fifth metatarsal base fracture that (Isis Innovation Ltd, Oxford, United Kingdom), a validated Patient Re
presented to our MTC, between January 2019 and December 2019. ported Outcome (PRO) measuring tool, over the phone whilst the re
Diaphyseal fractures were excluded. Patients with incomplete data sets, sponses were recorded [12,13]. The 16-item questionnaire provides a
irretrievable records, and those lost to follow up were included for the valid and reliable measure of issues of concern to patients including
purposes of this study design. function, mobility and pain. The questions within the MOXFQ can be
separated into three subscales, each representing impact on different
Ethical approval domains of quality of life. These are functionality, pain and social
interaction. In addition to analysing individual domain scores, we
Prior to data collection, our study was reviewed by the local research combined results to form an MOXFQ-Index, a numerical representation
and ethics committee and based on the HRA “Defining Research” leaflet of overall impact on patient quality of life [14]. A patient satisfaction
it was concluded that our project was classed as service evaluation and survey was performed retrospectively.
did not require approval from an Institutional Review Board (IRB). Pa
tient verbal consent was obtained prior to follow up questionnaire Results
completion. Local audit department approval was acquired for the
collection of patient data. Demographics
Initial patient assessment Table 1 shows patient demographics and fracture type. Mean age was
41.6 years (18–92), with 65 (61.6%) females and 61 (48.4%) males.
Patients attending the emergency department with trauma and foot
pain were assessed by emergency doctors, receiving anteroposterior, Table 1
oblique and lateral foot radiographs to aid diagnosis. Patients were Demographic data of participants meeting inclusion criteria.
either referred directly to VFC or discussed with the on-call orthopaedic
Demographics N = 126 Percentage (%)
team for confirmation of the diagnosis and then referred to VFC. No
Sex
patients in this study required referral via the latter route. Whilst
Male 61 48.4%
awaiting VFC appointment, patients were discharged from ED with a Female 65 51.6%
walking boot, information leaflets and advice to weight bear as toler Age (Mean) 41.3 NA
ated. Local protocol ensures that the patient is booked into the next days Smoking
VFC and that images are reviewed by a consultant orthopaedic surgeon. Currently smoking 7 5.6%
Ex-smoker 1 0.8%
Daily virtual fracture clinics were available. Non smoker 33 26.2%
Not documented 85 67.5%
VFC assessment and protocol Diabetic
Yes 6 4.8%
No 91 72.2%
During the one-year study period, 126 patients were referred to VFC
Not documented 29 23.0%
with a fifth metatarsal fracture. All these patients followed the VFC Fracture Classification (Lawrence and Botte
protocol for base of 5th metatarsal fractures. This protocolled manage Classification)
ment entails early mobilisation with full weight bearing as tolerated in a Zone 1 104 82.5%
boot or heel-bearing shoe. Additionally, it encourages patients to Zone 2 15 11.9%
Zone 3 7 5.6%
remove the boot/shoe at night and when not walking on it, if
Fractures were classified according to the Lawrence and Botte Classifi Manchester-Oxford foot questionnaire (MOXFQ) and patient reported
cation with 104 (82%) zone 1 fractures, 15 (12%) zone 2 fractures and 7 outcomes and satisfaction
(6%) zone 3 fractures. All patients referred to VFC had radiologically
identifiable fractures at the time of review. In total, 118 (93.7%) patients completed the questionnaire. All
participants answered all 16 questions. Regarding the remaining pa
VFC management and clinical outcomes tients, 5 were uncontactable and 3 declined to participate in the follow
up study. The raw and metric scores for the total results and individual
Median Average time from ED attendance to VFC review was 2 days domains can be appreciated in table 2. The average metric score for all 3
(1–5). At VFC, 125 (99.2%) patients were discharged (Fig. 1). The pa domains combined was 0.64. The average metric score for all 3 domains
tient not discharged had a slightly displaced zone 2 fracture qualifying combined for participants scoring greater than 0 was 6.8. Following VFC
for conservative management but required further radiological imaging. management, 115 (97.5%) responded “Yes” to point whether they were
This patient subsequently achieved union without surgery or compli happy with their injury management on the VFC pathway, and 1 (0.8%)
cations. All 126 patients received the standardised treatment protocol. responded “No”. This question was not asked or recorded in 2 (1.7%)
Twelve patients, less than 10% of the original cohort, arranged further cases. The previously mentioned single case of non-union was subse
follow-up after initial VFC discharge, of which 1 did not attend their quently discharged from clinic and, 1 year following, her MOXFQ score
appointment. Out of the 11 who attended clinic, 10 (90.9%) did so was 2/64.
within the recommended 3-month observation period. Of those
attending their appointments, the reasons for self-requested follow up
Cost analysis
was pain in 9 cases, and not documented in the others. The sum of this
groups total follow-up appointments was 36. The average number of
In total, 36 clinic slots were subsequently dedicated to follow up
follow ups per individual within this group was 3.3. At the conclusion of
cases in this cohort. As part of a traditional follow up pathway within our
follow up, these patients’ outcomes were: 9 discharged and 2 not
attending further appointments. It should be noted that one of these
Table 2
patients returned with ankle instability requiring surgical intervention.
Raw and metric scores for the total results and individual domains of the
Within the group of discharged patients who re-contacted VFC, there
MOXFQ.
was 1 non-union identified at follow up. The patient in question con
tacted VFC within a week of discharge as she was unhappy with the Table 2- Manchester- Single Index 3 scale/domain profile
Oxford Foot Score
outcome of the VFC, requesting further face to face appointments. Upon Questionnaire
questioning at further follow up, the patient had very mild symptoms of (MOXFQ)
pain on exertion, and the case was described as an asymptomatic non- Total respondents =118 All domains Walking/ Pain Social
union. The patient responded well to re-assurance and progressed to combined Standing Interaction
full sporting activity post conservative management. The potential for Average Raw score 0.41/64 0.11/28 0.25/ 0.02/16
surgery in the future was discussed however, the patient opted for 20
conservative management as they did not feel sufficiently impacted to Average Metric score 0.64 0.4 1.23 0.15
(Out of 100)
warrant surgical intervention. Number of respondents 11 4 11 3
Of the 12 patients in total requesting follow up appointments, 9 had scoring >0
zone 1 fractures, 2 had zone 2 fractures and 1 had a zone 3 fracture. Both % 9.3% 3.4% 9.3% 2.5%
the case of non-union and case requiring surgery for ligamentous Average Raw score of 4.4/64 3.5/28 2.8/ 1.0/16
respondents scoring 20
instability were classified as zone 1 fractures. All zone 2 and 3 fractures
>0
were discharged from latter follow up without further treatment. Average Metric score of 6.8 12.5 14.1 6.3
respondents scoring
>0 (Out of 100)
Fig. 1. Visual representation of outcomes following VFC referral.
trust, regardless of fifth metatarsal fracture pattern, patients would Considering the growing evidence base, standardised initial treatment
routinely receive at least 3 clinic follow up appointments post injury. plans have been implemented before with these injuries, yielding good
This includes an initial clinic assessment and then at least two follow up patient outcomes and high levels of patient satisfaction [10]. Our study
appointments for repeat imaging at 8 and 16 weeks post injury. Our shows that base of fifth metatarsal fractures can be managed safely in the
standard traditional clinic and VFC pathways can be visualised in Fig. 2. VFC setting, whilst yielding high rates of patient satisfaction with the
Despite this routine protocol, analysis of follow up post fifth metatarsal pathway.
base fractures in our unit, pre study period, demonstrated the average The management of fifth metatarsal base fractures in the VFC setting
number of face-to-face follow ups to be 4.7 per person. In the case of our has been previously reported in the UK [10]. This study demonstrated 8
126 patients, this would have equated to 592 face-to-face fracture clinic (7%) asymptomatic non-unions in zone 2 fractures, compared with none
appointments. Therefore, we can estimate that 556 outpatient clinic in our study. One of these patients required surgical intervention. None
slots were saved with our VFC model. Assuming an average cost of an of their conservatively managed zone 3 fractures experienced
outpatient clinic of £120, as per NHS England facts and figures, we have non-union, mal-union or subsequent surgery, as in our study. They
saved an estimated £66,720 in outpatient clinic costs [14]. The role of demonstrated that the pathway was safe and effective, with no adverse
running this VFC was divided amongst existing staff requiring no extra patient outcomes, and saved £60,000 of unit funds. The average number
payment. of clinic visits per person was 0.17 with the VFC system. Using the same
calculation method, ours was demonstrated as 0.08. Aligned with our
Discussion unit’s goal, this department aimed to begin definitive orthopaedic
management at point of first presentation, with subsequent VFC follow
Current literature suggests fifth metatarsal fractures have good uni up and expert review.
versal outcomes, with many cases responding positively to conservative A similar virtual fracture management system for fifth metatarsal
management [15]. Although an area of debate, some evidence suggests fractures was implemented in Glasgow [18]. They experienced no
immediate weightbearing in supportive orthotics is beneficial, pre adverse events during their transition from a traditional to virtual
dominantly for zone 1 and 2 fractures, and that initial treatment with model. Our VFC management similarly demonstrated no added clinical
casting can significantly delay return to full function [16,17]. value for routine outpatient follow-up of fifth metatarsal fractures. They
examined patient satisfaction levels with their new pathway via a
questionnaire, yielding a 63% response rate with a 79% satisfaction rate.
Our response rate was 93.7% with a satisfaction rate of 97.5%. This high
satisfaction level is positive and reflects the benefits VFC can provide for
both patients and healthcare services. Fifth metatarsal fractures can be
painful and debilitating, therefore emphasis must be placed on patient
education, management of patient expectations and dealing with any
queries or concerns at initial VFC review.
Pain was the most documented reason for attending further clinic
review. Bigsby et al. demonstrated that the prevalence of pain after these
injuries decreases with time [19]. At 1 year following injury, 28% of
their cohort still had some residual level of pain. Despite clear VFC
advice to allow 3–4 months of trial conservative management before
contacting the hospital, 90.9% of our patients returning to clinic did so
within 3 months. Considering that none of these patients underwent
surgery after extended follow up, it is reasonable to suggest that some of
these attendances may have been avoided with appropriate pain man
agement and patient education. Nevertheless, less than 10% of cohort
needed to return at all, none of which required surgery for their injury,
demonstrating the safety of the model.
Fracture clinic services are most appropriately used to facilitate re
view of complex fractures or injuries requiring face to face specialist
assessment [20]. Our institutional experience is that these clinics are
regularly used for reviewing fracture patterns which have well docu
mented positive outcomes from conservative management. The authors
suggest this is potentially an inefficient use of limited hospital resources
and unnecessarily time-consuming for patients. Our average time to VFC
review was 2 days, compared with 14 days in our regular pathway. This
has facilitated early appropriate care in our hospital, whilst simulta
neously reducing burden on the standard fracture clinic pathway.
There exist concerns that the VFC model may result in missed sig
nificant injuries requiring intervention, in particular Jones type frac
tures which have an increased risk of non-union [10]. No patients in our
study required surgery for their fifth metatarsal fractures. One patient
required surgery for lateral ligament instability, related to their initial
injury. Ideally, this would have been identified at initial ED presentation
and included in a VFC referral. However, the authors accept that this is a
potential pitfall of the VFC method and may suggest that the VFC
method is a worse pathway for identifying associated lesions. A suc
cessful VFC model relies on quality ED department clinician assessment.
Fig. 2. Traditional outpatient clinic pathway versus Virtual Fracture At VFC, radiographs are viewed in the context of ED department docu
Clinic pathway. mentation. Subtleties including patient functional requirements, if not
correctly assessed or documented, can alter decision making and choice boot, without requiring routine face to face or long term follow up to
of treatment. There is no current consensus defining a level of activity confirm diagnosis, management and prognosis. Any clinical guidelines
that warrants operative fixation, but we make the point that a thorough and recommendations regarding this treatment modality need to be
examination and functional history is mandatory on first presentation, based on a thorough analysis of constantly emerging data.
to facilitate VFC decision making. This theoretically shifts some burden
of care to the ED department, a sector of the NHS already under
considerable pressures. However, our experience shows that overall, Declaration of Competing Interest
with well-informed ED staff and clear standardised management path
ways, good quality control can be achieved and patient harm minimised. None
There was one case of non-union in our study, who was discharged at
initial VFC with a zone 1 fracture. They initially re-presented due to pain References
but progressed to be asymptomatic at later follow up, going on to have
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Injury 54 (2023) 110854
Injury
Occupational hand trauma – Mechanism of injury and transient risk factors

in Jerusalem
Shai Luria a, *, Hosam Khatib a, Madi El Haj a, Ido Volk a, Ronit Calderon-Margalit b
a
Faculty of Medicine, Hebrew University of Jerusalem; the Orthopedic Surgery Department, Hand and Microsurgery Unit, Hadassah Medical Center, Israel
b
School of Public Health, Hebrew University School of Medicine, Hadassah Medical Organization, Israel
Keywords: Introduction: Although prevalent, and variable geographically, there is little information on the incidence and risk
Occupational hand trauma factors for occupation hand trauma in our health care system. This pilot study was designed to determine the
Case-crossover study optimal data collection methods for transient risk factors locally
Transient risk factor
Methods: All adult patients with occupational hand trauma treated at an emergency department (ED) during a
Telephone interviews
three-month period were interviewed, either in person or by phone, using a case crossover designed question
naire, regarding occupation and exposure to potential transient risk factor.
Results: Of 206 patients treated with occupational trauma during the study period, 94 had trauma distal to the
elbow (46%). Patient compliance was high - 89% of the patients consented to phone interviews and 83%
completed in-person ED interviews. In the 75 patients which participated in the study, several risk factors were
found to be significant, including machine maintenance and being distracted, including by a cellular phone. We
found lack of job experience, limited training on the job site and reports of previous injuries in these workplaces
to be prevelent.
Discussion: The risk factors implicated in this study are similar to those reported in previous studies at other
locations and are modifiable although this is the first report linking cellular phone use and occupation trauma.
This finding should be further examined in a larger group and according to occupational categories. Compliance
with the study was high, in person or with phone interviews, making these options viable for further studies.
Several minor changes to the questionnaire were suggested although it did conform with the case-crossover study
design. According to this study, standard preventive measures may be lacking in Jerusalem and should be
implemented more uniformly, including specific workplace safety plans and education and taking into consid
eration the risk factors documented here.
Introduction stick prevention measures for health care workers [4]. Understanding
the specific mechanisms of injury in different locations is therefore
The hands are the most common site of injury in the body [1]. Hand crucial.
trauma commonly results in pain, disability and loss of productivity, Previous studies have indicated that the rate of occupational hand
frequently at a young age. Hand trauma imposes the highest financial injuries varies dramatically in different countries and locations and
burden of all injuries, due to the direct and indirect costs associated with ranges from 20 to 85% [1,5,6] of all hand trauma. The risk factors
their high incidence and the resulting disability [2]. Prevention of hand include permanent factors such as sleep disorders, regular alcohol use
trauma is therefore of considerable importance to public health. Iden and chronic disease, as well as transient risk factors, such as working
tifying populations at increased risk can facilitate the development of with malfunctioning equipment [7,8]. Specific professions have been
prevention programs. Interventions have been shown to be successful associated with different mechanisms of injury. According to an evalu
when they are tailored to specific mechanisms of injury, such as banning ation of work-related fractures from a West Virginia Workers Compen
pants with open side pockets in contact flag football games [3] or needle sation database, teachers suffer more frequently from forearm fractures
* Corresponding author at: Head of Hand and Microvascular Surgery Unit, Hadassah –Hebrew University Medical Center, Kiryat Hadassah, POB 12000, Jerusalem
91120, Israel.
E-mail address: shail@hadassah.org.il (S. Luria).
S. Luria et al. Injury 54 (2023) 110854
while mechanics have a high rate of finger fractures [9]. Table 1

Occupational trauma is widely recorded and analyzed but occupa Characteristics of occupational hand trauma patients in the Mount Scopus
tional hand trauma is difficult to isolate from these reports. In Israel, Hadassah Emergency Department (n = 75).
there is no country-wide pooling of specific data about these injuries Frequency Frequency
[10], although it is clear that they should be considered separately [11], (percent) (percent)
that prevention programs should be tailored specifically [12], and that Age -mean 30, SD-11 Occupational category
the magnitude of this problem necessitates consideration in its own median 26 Manual work 28 (37)
right. It is also clear that the available data from other countries [1,5,6, Gender Education & Health 23 (31)
Male 62 (83) Public Service 15 (20)
13] do not apply well to Israel.
Religion Other 9 (12)
Previous studies have employed a case-crossover study design which Muslim 42 (56) Job experience
can improve the evaluation of the relative risk of rare events, such as Jewish 31 (41) Under 3 years 55 (73)
heart attacks [14]. Using this study design, occupational hand trauma Christian 2 (3) 4–10 years 7 (10)
has been examined in other locations [7,8,13,15–17]. The Years of Over 10 years 13 (17)
education
case-crossover design was created in order to avoid inherent problems of 0–8 8 (11) Work training on task
case-control studies where job experience, risk-taking behavior and 9–12 48 (64) Yes 53 (71)
other personal factors may be confounding factors. In the case-crossover 13 or more 19 (25) No 22 (29)
design, each patient serves as his own control [17]. The goal of this study Type of injury Safety training on task
Cut 27 (36) No 17 (23)
was to examine the best methods to collect data on transient risk factors
Fracture 18 (24) Rarely 17 (23)
for occupational hand trauma in Israel on a national scale. The current Bruise 17 (23) Routinely 35 (47)
work was designed as a pilot study, and was conducted in a regional Stab 10 (13) Other 6 (8)
hospital in Jerusalem. Specifically, it evaluated in-person versus tele Other 3 (4) Hand injury previous
phone interviews, the adequacy of a new questionnaire written for this year
Location of Yes 18 (24)
purpose, and its conformity with the case-crossover study design.
injury
Finger 34 (45) No 57 (76)
Methods Thumb 9 (12) Work mate injured
previously
Palm 17 (23) Yes 18 (24)
This case-crossover study was conducted in collaboration with the
Wrist and 15 (20) No 57 (76)
Israel Institute for Occupational Safety and Hygiene, at the Hadassah forearm
Mount Scopus emergency department (ED). A questionnaire was devised
SD – standard deviation.
to assess transient risk factors related to acute hand injuries in the
workplace.
All trauma patients treated at the ED during a 3-month period be 5 Potential permanent or additional risk factors including smoking,
tween October 2018 and January 2019 and fulfilling the following in alcohol consumption, sleeping habits and chronic disease [21].
clusion criteria were asked to participate in the study. The inclusion
criteria included being age 18 or older, suffering from an injury that The questionnaire was administered in Hebrew and Arabic by in
occurred while engaged in work of any type, at any location, presenta terviewers proficient in these languages to avoid miscomprehension.
tion at ED within 3 days from the date of injury, and any type of acute Institutional ethical approval was obtained in advance. According to this
injury distal to the mid-forearm. The exclusion criteria included any approval, patient agreement to participate was considered informed
patient who did not consent or was not able to be interviewed or had consent.
worked for less than one month (necessary for the case-crossover study
design for transient risk factors). Sample size
The interviews were conducted in two forms. 1. On weekdays, pa
tients at the ED were interviewed during their visit by two research The sample size was estimated according to the most frequent risk
assistants; 2. Patients who were treated at other times were contacted by factor found in a previous ED study by the authors (occupational injury
phone for a similar interview within 72 h of the ED visit. For this pur related to “being in a hurry”) [22]. Assuming a proportion of 10%, a
pose, every day, the ED admissions office produced a list of potential sample size of 75 patients with a 95% confidence interval of 6.5% –
patients. This list was then screened according to the inclusion criteria 18.8% was needed.
and the patients were contacted by phone.
The questionnaire was designed to enable a case-crossover analysis Data analysis
and included the following sections:
The case-crossover design was composed of a stratified analysis
1 Demographic data including gender, age, years of education, number where individual subjects are the stratifying variable [16]. The
of children (Table 1). Mantele-Haenszel estimator was used to estimate relative risk and the
2 Information on occupation, including workplace safety education. 95% confidence interval for each transient risk factor examined. In this
The occupation was then classified according to the UN International method, the exposure to the hazard is considered at the time of injury,
Standard Classification of Occupations [18]. the previous day and the estimated exposure period during the pre
3 Information about the location of the injury in the extremity and its ceding month [8,13,20]. Relative risk (incidence rate ratio) and confi
characteristics. The injuries were then classified according to dence intervals exceeding 1 are considered significant. A detailed
mechanism as well as the type of injury as laceration, contusion, description of the analysis method may be found in the references [23].
puncture, avulsion, crush, burn, amputation or fracture [8,15].
4 Potential transient risk factors (see Table 2), such as using dysfunc Results
tional machinery, performing an unusual or new task, being
distracted by someone and other factors reported in the literature [8, During the study period, 206 patients over the age of 18 were treated
19,20]. We added an additional risk factor which has not been at the ED after being injured at work. Of these, 94 patients were injured
described, but is of considerable concern; namely, being distracted distal to the elbow (46%). Seventy-five of the 94 (80%) agreed to
by a cell phone. participate in the study, of whom 34 were interviewed during their ED
Table 2
Transient exposures and relative risks of occupational acute hand trauma.
Exposure No. of subjects Average no. of hours No. of subjects exposed in RR* 95% CI**
exposed at time of exposed in month prior to month prior to injury previous month exposure (Mantel-
injury injury Haenszel incidence rate ratio
(IRRMH))
I used a machine, tool, or work 8 0.6 10 39 18.8 –

material that was dysfunctional 81.5
Wearing gloves 20 50.2 46 1 0.6 – 1.2
I took care of a machine, tool, or 8 2.2 7 400 111.3 –
work material 1437.4
I performed an unusual or new task 4 3.9 6 20 7.5 – 53.9
I was distracted by someone 12 0.3 18 135 67.4 –
268.9
I rushed 10 6.3 22 13 8.9 – 17.9
Feeling ill 4 5.7 4 3 0.6 – 11.6
Working overtime 2 3.44 12 1 0.4 – 4.5
I was distracted by the cellular/ 5 0.1 19 109 44.8 –
smart phone 266.9
I was troubled by something else 10 26.6 13 56 18.7 – 166
*
RR, relative risk.
**
CI, confidence interval.The estimated average individual hours of exposure include subjects who report zero hours of exposure and considers individual differ
ences in hours worked including overtime.
visit (41 requests; 83% compliance) and 41 in a phone interview (of the adequacy of the questionnaire. We found several problems with the
53 patients we attempted to contact; 77% compliance). Of the 12 pa questionnaire which will be modified in the larger study. In particular,
tients where an attempt was made to contact them by phone, seven several questions examined distraction as a risk factor, either from
could not be reached (did not answer or wrong number) and five did not another person, a cell phone, or another source. We found that asking
agree to participate. Of the 46 patients who were successfully contacted these questions separately was confusing and time-consuming, in com
by phone, the compliance rate was 89%. parison to grouping them together. Practically speaking, these questions
The average age of patients was 30 (Table 1). Most of the patients had to be repeated for some of the participants, to ensure clarity and
with occupational hand trauma were male (83%) with a small majority differentiate between the distracting factors. The final answer for each of
of Muslims (56%) in comparison to Jewish patients (the Jerusalem these factors was then recorded.
population include 38% Muslims in 2019) [24]. Three percent of the The compliance rate for the phone interviews was found to be similar
Jewish patients were Ultra-Orthodox (although they make up 36% of the for the in-person interviews in the ED, as suggested by the literature
population of Jerusalem) [24]. The majority of the patients had no [26–28]. Little is known about differences in compliance between
chronic illness (79%) and no children (60%), typical of this young in-person versus telephone interviews. We were concerned that there
population. Smoking was found to be prevalent (57%) but not alcohol would be limited compliance after leaving the ED due to patient con
consumption (0%). There was a higher rate of manual workers with cerns about the legal implications of the injury. However, patients are
limited experience and a high rate of patients who reported they were reported to answer more freely on the phone when the information is
not trained to do their actual jobs (29%) and rarely if ever received sensitive [29]. Nevertheless, there were no significant differences in
safety training (46%). Twenty-four percent reported they had been compliance, which were high in both interview modes. The calls were
injured the previous year and 24% reported a work colleague injured in made within 3 days, which was perhaps early enough to gain patient
the past. A wide variety of injury types was reported (Table 1), more trust and participation before legal intervention. The sample was too
frequently in the dominant hand (59%) with a large majority in the palm small and study period too short to examine the implications or data
and fingers. regarding legal interventions or workers compensation questions. We
Several factors were found to be transient risk factors (Table 2) cannot rule out interference by these considerations when documenting
including maintenance of machinery (95% CI 19 – 82) or the use of the patients’ recollection of the event.
malfunctioning machinery (95% CI 111 – 1430), being distracted by Although designed as a pilot study, the information collected was
someone (95% CI 67 – 269), distracted by a cell phone (95% CI 45 – 267) sufficient to demonstrate several important risk factors, most of which
or by another source (95% CI 19 – 166), performing an unusual task have been described elsewhere (Table 3) [7,8,15]. Machine mainte
(95% CI 8 – 54) or rushing (95% CI 9 – 18). Most exposures were not nance and being distracted were found to be most significant in our
frequent (0.1 – 6.3 h a month) other than being distracted, which was study. Although the specific questions may differ, the factors may be
reported to occur 27 h a month. Being distracted by a cell phone was classified as equipment related factors, work practice-related factors and
reported as only 0.1 h a month. worker-related factors and these are true in any location [7].
To the best of our knowledge, this is the first report to include cell
Discussion phones as risk factor for occupational injury. The patients in this study
reported that the use of cell phones often caused distractions before the
Hand trauma constituted almost half of the occupational trauma accident. Elsewhere there are multiple reports of motor vehicle acci
treated during the 3-month period in the hospital’s ED (46%). This ex dents as well as bicycle and pedestrian accidents related to concomitant
ceeds the 20–28% reported rates of hand trauma out of all trauma in all cell phone use [30–32]. In a previous study of orthopedic injuries related
injury settings (occupation, home and leisure activities) [2,22] and the to cell phone use, only a small percentage of injuries were found for
36% of all trauma cases reported in out-of-hospital care centers for all industrial sites, farm or ranch locations, although 32% of the injury
injury settings in Israel [25]. locations were not accounted for [33]. Cell phone use as a risk factor in
The current study was designed as a pilot for a large multicenter the workplace may have dramatic consequences. In locations with heavy
examination of occupational hand trauma in Israel. The questionnaire machinery, high rates of injury, and a preponderance of manual work,
tested a number of common risk factors; however only working overtime banning the use of cellular phones on the job may be a sufficient pre
and using gloves showed no association, possibly supporting the ventive measure. Studies on distracted driving have shown that injury
Table 3 This study demonstrated the crucial role of a pilot study when col
Challenges and recommendations for occupational hand trauma prevention and lecting epidemiological data. The questionnaire could not only be
management. amended but also facilitated examination of an analysis method, which
Challenge Recommendation Level of is somewhat complex and not commonly used. A larger scale study
recommendation which will then be better planned, should include not only more patients
1. High rate of hand trauma Implementation of specific High but a variety of facilities (including out-of-hospital) and different ethnic
hand trauma protocols at and social groups to be examined in different geographical settings.
all levels of care, in and out Urban, agricultural and industrial centers should be represented.
of the hospitals
The use of phone interviews was found to be a suitable means of data
2. Low rate of safety Regional – Legislation, High
training and education enforcement and collections, when performed shortly after the injury. When collecting
regulation of safety data regarding specific patients arriving at all times of day, a phone
measures and education – interview may be a more practical option and not necessarily inferior to
for managers and workers an in-person interview at the ED. Interviewing a patient after the injury
Management – specifying
and implementing local
may be inadequate at times, with compliance limited by the patient’s
preventive measures, stress and medical condition.
regulations, protocols and This pilot study underscores the high rate of occupational hand
education. trauma as well as the successful implementation of a case-crossover
Professional organizations
study design to examine transient risk factors for injury and the high
and unions should
participate in the compliance with phone interviews. The findings point to the potential
regulation of methods and risk of hand trauma caused by distraction by cell phones use during
in administration of work. This finding should be examined in a larger population and ac
preventive means. cording to the occupational categories. This will allow more robust
3. Young manual workers Legislation and education High
conclusions regarding intervention options.
with less experience are should be directed
most in danger especially at this
workforce.
4. Ethnic and Education and regulation High
socioeconomic should address cultural and
differences will affect linguistic diversity. The authors declare that they have no known competing financial
rate and type of injury. In interests or personal relationships that could have appeared to influence
this study, the high rate
of Muslim patients.
5. Dysfunctional equipment Strict regulation of High
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Injury 54 (2023) 110855
Injury
Retrospective multicenter (TRON group) study of humeral shaft fragility

fractures: Analysis of mortality rates and risk factors
Ken Sato a, Yasuhiko Takegami a, *, Katsuhiro Tokutake b, Yuya Shimamoto a, Hiroki Ueno a,
Toshihiro Ando c, Shiro Imagama a
a
Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
b
Department of Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
c
Department of Orthopaedic Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
Keywords: Aims: This study aimed to show the mortality rate following humeral shaft fragility fractures (HSFF) in the
Humeral shaft fracture elderly. The secondary aim was to examine the predictors associated with mortality in elderly patients who have
Elderly sustained HSFF.
Mortality
Methods: From 2011 to 2020, all elderly patients aged 65 years and older with HSFF managed at our nine
Dominant hand
hospitals were retrospectively identified from our TRON database. Patient demographics and surgical charac
Treatment
teristics were extracted from medical records and radiographs, and multivariable Cox regression analysis was
used to identify factors affecting mortality.
Results: In total, 153 patients who sustained HSFF were included. The mortality rate for HSFF in the elderly was
15.7% at 1 year and 24.6% at 2 years. Multivariable Cox regression analysis showed significant differences in
survival for the following variables: older age (p < 0.001), underweight (p = 0.022), severely ill (p = 0.025),
mobility limited to indoors (p = 0.003), dominant-side injury (p = 0.027), and nonoperative treatment (p =
0.013).
Conclusion: The outcome following HSFF in the elderly population appears to be relatively grim. The prognosis of
elderly patients with HSFF is closely related to their medical history. In the elderly patients with HSFF, operative
treatment should be positively considered while taking into account their medical status.
Introduction randomized control trial comparing operative with nonoperative treat

ment using a functional brace among patients with closed displaced
Humeral shaft fractures are relatively common injuries, with an humeral shaft fractures. They showed that upper extremity function was
incidence of 13 per 100,000 per year. There is a bimodal incidence with not significantly different in the two treatment groups at 12 months and
a peak in the young and elderly, with most cases in the elderly being that initial operative treatment provides a faster and more predictable
fragility fractures. Fracture locations in the proximal and middle thirds course of recovery than nonoperative treatment. Among patients in the
of the humeral shaft are considered to be fragility fractures [1], and in nonoperative treatment group, 30% underwent later operative treat
the elderly, these fractures are associated with poor post-injury out ment due to unforeseen adverse events, mainly nounions [3]. The in
comes such as increased mortality rates and decreased quality of life [2]. crease in operative treatment can be attributed to the above advantages
It is important to consider prognosis in the elderly when selecting that have become apparent. However, it is unclear whether operative or
optimal management of fragility fractures. nonoperative treatment is better in terms of life expectancy.
Historically, humeral shaft fractures have been primarily managed A prior study indicated that the overall 1-year mortality rate
nonoperatively using a functional brace, which results in good func following humeral shaft fractures, comprising both pathological frac
tional outcome. Nevertheless, operative treatment for humeral shaft tures and high-energy traumas, was 9.2% [4]. For proximal humeral
fractures has been increasing. Rämö et al. conducted a multicentre fractures in the elderly, the 1-year mortality rate is 8.0%, according to
* Corresponding author at: Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550,
Japan
E-mail address: takegami@med.nagoya-u.ac.jp (Y. Takegami).
K. Sato et al. Injury 54 (2023) 110855
Korean national data [5]. However, to the best of our knowledge, in orthopedic trauma cases in the TRON database annually. The partici
formation regarding mortality following fragility fractures of the hu pating hospitals in the database are located in central Japan and are
meral shaft is limited, and factors associated with such mortality are associated with the Department of Orthopedic Surgery of our university.
unknown. In hip fractures, which are the most common fragility frac We collected cases of humeral shaft fracture from this database.
tures, men, cardiovascular disorders, and kidney disease have been re
ported as factors associated with mortality [6,7]. Subjects
In this multicentre study, we aimed to show the mortality rate of
humeral shaft fragility fractures (HSFF) in the elderly. Our secondary From the database, we extracted the 475 patients aged 18 years and
objective was to clarify the independent predictors of mortality among older who were diagnosed as having humeral shaft fractures and
patients suffering HSFF. received treatment at our nine hospitals between January 2011 and
December 2020. The radiographs of all eligible patients were examined,
Materials and methods with inclusion limited to those displaying a humeral shaft fracture,
excluding fracture lines extending to the proximal/distal end segment of
The ethics committee of each participating hospital approved this the humerus (just AO/OTA classification 12 and not including 11 and
multicentre retrospective study. All the patients provided informed 13). To focus on fragility fractures, we included the 245 patients over the
consent to participate in the study. Hospitals of the Trauma Research age of 65 years who received operative or nonoperative treatment. We
Group of our university, which is named TRON, have registered defined fragility fractures as any fractures that occur due to an injury
Fig. 1. Chart of patient flow in the study.
mechanism of a fall from a standing height or less [8]. We excluded Table 1

those patients who suffered high-energy trauma (not applicable to Patient characteristics.
low-energy trauma as described below), polytrauma, open fracture, Variables Value
pathological fracture due to malignant tumor, whose injury mechanism
Age, years (SD) 78.58 (7.47)
was unknown, whose data on patient and injury characteristics were Age, n(%)
missing, who were unknown to be alive or dead, and whose follow-up 65–74 years old 49 (32.0)
data were missing. Thus, 153 patients were included in the final anal ≧75 years old 104 (68.0)
ysis (Fig. 1). Sex, n (%)
Male 43 (28.1)
Female 110 (71.9)
Clinical evaluation BMI, kg/m2, n (%)
BMI <18.5 kg/m2 40 (26.1)
The data collected from the electronic medical records were patient BMI 18.5–24.9 kg/m2 90 (58.8)
BMI ≧25 kg/m2 23 (15.0)
age at the time of injury, sex, body mass index (BMI), comorbid condi
Smoke, n(%)
tion, pre-injury mobility level, date of injury, date of last follow-up, date Non-smoker 147 (96.1)
of death, fracture type, fracture location, and treatment (operative or Smoker 6(3.9)
nonoperative). CCI, n (%)
Patients were classified into three groups as underweight (BMI < 0 45 (29.4)
1 34 (22.2)
18.5 kg/m2), normal weight (BMI 18.5–24.9 kg/m2), and overweight 2 24 (15.7)
(BMI ≥ 25 kg/m2) [9]. Comorbid conditions were evaluated according ≧3 50 (32.7)
to the Charlson Comorbidity Index (CCI) [10], and we divided the pa Pre-injury mobility, n (%)
tients into four groups: normal (CCI = 0), mild (CCI = 1), moderate (CCI Freely mobile 99 (64.7)
mobilizing outdoors with walking aid 28 (18.3)
= 2), and severely ill (CCI ≥ 3). Data on pre-injury mobility level were
Limited to indoors 26 (17.0)
collected for the following three groups during analysis, as in a previous Injury side, n (༅)
study[11]: freely mobile (independent), mobilizing outdoors with Non-dominant 75 (49.0)
walking aid (cane ambulation and front walker or frame ambulation), Dominant 78 (51.0)
and mobility limited to indoors (wheelchair and bedridden). When the AO/OTA classification, n (%)
12-A1 52 (34.0)
vital status of patients was uncertain due to prior completion of 12-A2 40 (26.1)
follow-up, that is patients who had been deemed untraceable after the 12-A3 28 (18.3)
conclusion of data collection and had not visited the hospital within the 12-B1 14 (9.2)
preceding three months, we undertook proactive measures by placing 12-B2 8 (5.2)
12-B3 3 (2.0)
phone calls to their homes or nursing homes to inquire about their
12-C1 5 (3.3)
survival status. 12-C2 2 (1.3)
12-C3 1 (0.7)
Radiographic evaluation Fracture location, n (%)
Proximal 30 (19.6)
Middle 82 (53.6)
Anteroposterior and lateral radiographs were evaluated to assess Distal 13 (8.5)
fracture type and location. We divided fractures according to location Proximal & middle 21 (13.7)
(proximal, middle, distal, proximal & middle, and middle & distal). Middle & distal 7 (4.6)
Fracture type was classified according to the AO/OTA classification Treatment, n (%)
Operative 107 (66.9)
[12].
Nonoperative 46 (30.1)
Follow-up period, months (SD) 7.64 (8.05)
Treatment
SD – standard deviation, BMI – Body Mass Index, CCI – Charlson Comobidity
Index.
Among the 153 patients, 107 received operative treatment and 46
received nonoperative treatment. Treatment methods were chosen at
the discretion of each surgeon at our hospitals. The details of the oper reliability of radiography was 113 measured using Fleiss’ kappa value
ative cases were as follows:96 patients received antegrade intra and was found to be at a good level (Fleiss’ kappa = 0.90, 95% 114
medullary nailing, 7 patients received open reduction and plate fixation, confidence interval = 0.86– 0.94).
and the remaining 4 patients received other treatments. (1 Ender nail The Kaplan-Meier plot of overall survival is shown in Fig. 2. The
ing, 1 titanium elastic nail, 1 Kirchner wire fixation, 1 external fixation). mortality rates were 15.7% and 24.6% at 1 and 2 years, respectively.
Statistical analysis Risk factors associated with mortality
We estimated the survival rate using Kaplan-Meier curves, and the Kaplan-Meier plots showed that older patients, underweight patients
differences in survival were compared with the log-rank test. We per (BMI < 18.5 kg/m2), severely ill patients (CCI ≥ 3), patients with
formed multivariable Cox regression analysis to identify the risk factors mobility limited to indoors, and patients with nonoperative treatment
associated with mortality. In particular, we conducted a stratified were more likely to have shorter survival (Figs. 3 and 4).
analysis to assess the impact of surgery by considering specific charac The results of the multivariable Cox regression analysis are shown in
teristics and variables. Analysis was conducted using EZR software Table 2. This analysis showed significant differences in survival for the
version 1.61 (Saitama Medical Center, Jichi Medical University) [13]. following variables: older age, underweight (BMI < 18.5 kg/m2),
severely ill (CCI ≥ 3), mobility limited to indoors, dominant-side injury,
Results and nonoperative treatment. Sex, smoking status, fracture type accord
ing to the AO/OTA classification, and fracture location were not
The patients’ baseline characteristics are shown in Table 1. The mean significantly associated with mortality.
patient age at the time of the fracture was 78.58 ± 7.47 years, and the Stratified analysis indicated a significant difference in survival rates
mean follow-up period was 7.64 ± 8.05 years. The Interobserver between patients who underwent surgery and those who did not, except
Fig. 2. Kaplan-Meier curve for overall survival. The 1-year mortality rate was 15.7%, and the 2-year mortality rate was 24.6%.
for patients with a BMI of 18.5 or less and individuals with limited present study [14,15]. Lower BMI reflects poor nutritional status, which
mobility confined to indoors prior to the injury (Supplementary Figure). may have resulted in higher mortality. CCI is a tool used to calculate
comorbidity and predict mortality in patients with various health con
Discussion ditions, including proximal humerus fractures [19]. Following the pre
sent study, CCI is also a good predictor of mortality in HSFF. Prior study
To our knowledge, this multicentre study represents the first report has shown that mobility difficulties and poor self-reported mobility are
on the prognosis following HSFF in an elderly population, and the 1- and predictors of mortality in the elderly [20], which is consistent with the
2-year mortality rates were 15.7% and 24.6%, respectively. We also present study. Aging-associated decline in physical performance not
identified the following patient characteristics and treatment methods only increases the likelihood of falls and fractures [21], but it also
as independent predictors for poor prognosis after HSFF: older age, negatively impacts life expectancy following the occurrence of a frac
underweight (BMI < 18.5 kg/m2), severe illness (CCI ≥ 3), mobility ture. We have found this to be true not only for other fragility fractures,
limited to indoors, dominant-side injury, and nonoperative treatment. such as those of the hip and proximal humerus but also humeral shaft
Stratified analysis showed that surgical treatment had a better life ex fractures [22].
pectancy than nonoperative treatment in many circumstances. In patients with HSFF, injury to the dominant hand was an inde
The 1-year mortality rates was 15.7% in our study. A sole prior pendent factor affecting life expectancy. Contrary to the results of the
investigation documented mortality rates following humeral shaft present study, previous studies of proximal humeral fractures reported
fractures, reporting a 1-year mortality rate of 9.7% [4]. However, that no association with life expectancy with respect to dominant hand injury
study included individuals under 65 years of age, with high-energy [22,23]. However, impairment of the dominant hand leads to greater
trauma, pathological fractures, periprosthetic fractures, and open frac disability than that of the nondominant hand [24]. In the present study,
tures, making it difficult to compare mortality with our study which is fractures of the humerus shaft involve two joints, the shoulder and the
limited to fragility fractures in the elderly. When compared to other elbow, which leads to more pronounced harm to the dominant hand and
common fragility fractures of the upper extremity, the 1-year mortality may impede activities of daily living, potentially exacerbating the
rate of proximal humerus fractures has been reported to be 7.8–17.4% prognosis. Although Curtin et al. reported significantly higher mortality
[14–17]. Myeroff et al. conducted a study of patients similar to the in men with proximal humerus fractures [14], the present study found
present study and reported the 1-year mortality rate of 8% for proximal no difference in mortality by sex. Our analysis yielded an odds ratio of
humerus fractures [17]. In contrast, the mortality rate for HSFF shown in 0.59 (0.28–1.22) (P = 0.157) for the female. It suggested there is a po
the present study was notably higher. The following are possible reasons tential association, albeit statistically non-significant.
for this: there has been a report that has shown that upper limb The multivariate analysis of this study revealed that surgical treat
dysfunction in the elderly is associated with mortality, and humeral ment was an independent contributing factor in HSFF among the elderly
shaft fractures can affect both the shoulder and elbow joints, leading to a patients. Stratified analysis also showed that surgical treatment had a
greater likelihood of upper limb dysfunction and thus contributing to the better life expectancy than conservative treatment in many circum
higher mortality rate[18]. HSFF could also be more likely to occur in stances. These findings suggest that operative treatment for HSFF may
elderly patients with lower bone density and physical impairment enhance life expectancy by promptly restoring normal living abilities.
compared to proximal humerus fractures. Recently, the treatment of humeral shaft fractures has been reevaluated,
Aging-associated decline in physical performance, as characterized with a particular focus on operative treatment due to concerns regarding
by older age, underweight, severe illness, and mobility limited to in nonunion, premature return to work, and impaired range of motion [3,
doors, was shown to be clearly associated with mortality in the present 25]. Hence, a comprehensive and large-scale prospective study may be
study. Several previous studies have reported mortality risk following necessary to fully evaluate the benefits and drawbacks of operative
proximal humerus fractures, including older age, lower BMI, high CCI, treatment for HSFF in the future.
pre-injury assist device, which is consistent with the results of the Our study had several limitations. 1) This retrospective investigation
Fig. 3. Kaplan-Meier curves for the patients according to (A) BMI, (B) CCI, (C) pre-injury mobility, (D) injury side, (E) AO/OTA classification, and (F) fracture
location. BMI, body mass index, CCI: Charlson Comorbidity Index.
did not formulate a uniform algorithm for treatment selection, and the Funding
discretion for selecting a treatment modality was left to the surgeons at
each hospital. Consequently, there is also a lack of documentation There is no supporting funding.
regarding each surgeon’s decision to perform operative or nonoperative
treatment. 2) Some cases were excluded due to missing data on patient Availability of data and material
and injury characteristics, and follow-up.
The datasets during and/or analyzed during the current study
Conclusion available from the corresponding author on reasonable request.
The mortality rate of patients with fragility fractures of the humeral Authors’ contribution
shaft among the elderly was higher than expected. Older age, under
weight (BMI < 18.5 kg/m2), severe illness (CCI ≥ 3), mobility limited to KS: Data collection and assessment, Study design, Writing the paper.
indoors, dominant-side injury. Operative treatment may enhance life YT: Manuscript preparation, Study and Conception design. TK: Manu
expectancy. script preparation, Study design. YS and HU: Data collection, Manuscript
preparation. SI: Conception design, Guarantor
Fig. 4. Kaplan-Meier curves for the patients according to treatment type.
Ethic approval
Table 2
Risk factors associated with mortality by Cox regression model in patient
The approval number in our institute is 2020–0564 Consent to
characteristics.
participate and publication: All patients provided written informed for
Variables Hazard ratio (95% CI) P value
their data to be used.
Age 1.08 (1.03–1.13) <0.001
Sex Declaration of Competing Interest
Male Reference
Female 0.59 (0.28–1.22) 0.157
BMI, kg/m2 None.
BMI 18.5–24.9 kg/m2 Reference
BMI <18.5 kg/m2 2.13 (1.12–4.05) 0.022 Acknowledgment
BMI ≧25 kg/m2 1.12 (0.37–3.40) 0.849
Smoke
Non-smoker Reference We thank to Member of the Trauma research of Nagoya group
Smoker 0.84 (0.18–3.89) 0.825 (shown in alphabetical order of affiliation) are as follows: Dr. Takeshi
CCI, n (%) Oguchi (Anjo Kosei Hospital), Dr. Keigo Ito (Chubu Rosai Hospital); Dr.
0 Reference Tetsuro Takatsu (Gifu prefecture Tajimi Hospital), Dr. Masahiro Hana
1 1.41 (0.52–3.84) 0.506
bayashi (Ichinomiya Municipal Hospital), Dr. Hiroaki Yoshida (Kamiiida
2 1.73 (0.62–4.87) 0.297
≧3 2.89 (1.14–7.30) 0.025 Daiichi General Hospital), Dr. Tokumi Kanemura (Kounan Kosei Hos
Pre-injury mobility pital), Dr. Yuji Matsubara, (Kariya TOYOTA General Hospital), Dr.
Freely mobile Reference Hidenori Inoue (Japanese Red Cross Aichi Medical Center Nagoya
mobilizing outdoors with walking aid 0.91 (0.34–2.43) 0.858
Daiichi Hospital), Dr. Koji Maruyama (Nakatsugawa Municipal General
Limited to indoors 3.74 (1.57–8.92) 0.003
Injury side
Hospital), Dr.Hiroaki Kumagai (Nagoya Ekisaikai Hospital), Dr. Kenichi
Non-dominant Reference Yamauchi (Toyohashi Municipal Hospital); Dr. Yasuhide Kanayama
Dominant 2.04 (1.09–3.83) 0.027 (Toyota Kosei Hospital); Dr. Tadahiro Sakai (TOYOTA memorial Hos
AO/OTA classification pital), Dr. Nobuhiro Okui (Yokkaichi Municipal Hospital)
12-A Reference
12-B 1.39 (0.61–3.16 0.431
12-C 0.54 (0.07–4.37) 0.566 Supplementary materials
Fracture location
Proximal Reference Supplementary material associated with this article can be found, in
Middle 1.14 (0.50–2.62) 0.755
the online version, at doi:10.1016/j.injury.2023.110855.
Distal 0.42 (0.10–1.68) 0.219
Extension to adjacent segment 1.01 (0.35–2.89) 0.983
Treatment References
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Injury 54 (2023) 110856
Injury
Mikania micrantha extract enhances cutaneous wound healing activity

through the activation of FAK/Akt/mTOR cell signaling pathway
Gunjan Das a, *, Mohammad Farhan b, Sonam Sinha b, Himangsu K. Bora b,
Wangkheirakpam Ramdas Singh d, Syed Musthapa Meeran b, c
a
Department of Veterinary Medicine, College of Veterinary Sciences & Animal Husbandry, Central Agricultural University, Jalukie, Imphal, Nagaland 797110, India
b
Laboratory Animal Division, CSIR-Central Drug Research Institute, Lucknow, India
c
Laboratory of Cancer Epigenetics, Division of Endocrinology, CSIR-Central Drug Research Institute, Lucknow, India
d
Department of Veterinary Pharmacology and Toxicology, College of Veterinary Sciences & Animal Husbandry, Central Agricultural University, Jalukie, Imphal,
Nagaland 797110, India
Keywords: Mikania micrantha (MM) has been traditionally used for various health benefits, including mental health, anti-
Mikania micrantha inflammatory, wound dressing, and healing of sores. However, the molecular mechanisms and dose required
Wound healing for the wound healing activity of MM have yet to be reported. Therefore, a study was conducted to evaluate the
Angiogenesis
wound healing potential of a cold methanolic extract of MM through in vitro and in vivo studies. Human dermal
Skin remodeling
Fibroblast
fibroblast adult (HDFa) cells were treated with 0 (control), 75 ng/ml, 125 ng/ml, 250 ng/ml, and 500 ng/ml of
Wound contraction MMmethanolic extract (MME) for 24 h. MME at 75 ng/ml has significantly (p˂0.05) promoted HDFa cell pro
liferation and migration. Further, MME has also been shown to enhance the invasiveness of human umbilical
vascular endothelial cells (HUVECs), indicating the neovasculature for wound healing. The tube formation assay
demonstrated a significant (p<0.05) increase in the angiogenic effect of the MME starting at a concentration of
75 ng/ml as compared to the control. Treatment of excision wounds in Wistar rats with 5% and 10% MME
ointment significantly enhanced wound contraction compared to control animals. Incision wounds in rats treated
with 5% and 10% MME showed a significant (p<0.01) increase in tensile strength compared to control. HDFa
cells, and granulation tissue collected on day 14 post-wounding, revealed the modulation of the FAK/Akt/mTOR
cell signaling pathway during the enhancement of wound healing. The results of gel zymography showed
increased activity of MMP-2 and MMP-9 in the HDFa cells after treatment with the extract. It is concluded that
MMEcan potentially accelerate cutaneous wound healing.
Introduction medicinal properties [4]. Around 30% of the drugs sold worldwide
contain compounds derived from plant material [5].
A wound disrupts the structural and physiological continuity of One of the surveys conducted by the WHO reported that more than
living tissue. It may be produced by physical, chemical, thermal, mi 80% of the world’s population still depends upon traditional medicines
crobial, or immunological damage to the tissue. Healing wounds is one for various diseases.Plants and their derivatives account for 25% of
of the essentialareas of clinical medicine, as explained in many Ayur medical drugs in developed countries, and medicinal plants are well-
vedic texts [1]. The use of traditional medicinal remedies and plants in known among indigenous people in rural areas of many developing
treating burns and wounds is an important aspect of health treatment countries [6]. At present, there is an increasing loss of habitat for me
and, at the same time, reduces financial burden. Several medicinal dicinal plants and medicines derived from them worldwide, mainly
plants have been reported effective against skin disorders, burns, and because of a lack of public awareness and human activities [7]. Various
infected wounds [2]. Plants contain numerous secondary metabolites as reports indicate a gradual decline in the percentage of plant-derived
a part of their defensive mechanism to thrive in a particular environ medicines [8]. As a result, research into potential plant compounds
ment [3]. Many of these phytochemicals are known to possess several should be encouraged before they become extinct.Moreover, extensive
E-mail address: dasgunjan75@gmail.com (G. Das).
G. Das et al. Injury 54 (2023) 110856
use of antibiotics in treating wound infections is now proven to have Plant processing
adverse effects on the human body and, most importantly, accelerates
the development of antimicrobial resistance among pathogens. There Fresh leaves of the Mikania micrantha were carefully collected and
fore, attention has turned toward extracting biologically active com washed gently until the whole plant material looked clean. It was
pounds from plant species with wound-healing properties [9]. Many mopped with blotting paper and weighed. The plant material was air-
phytochemicals are being incorporated in antibiotic preparations as dried, protecting it from direct sunlight for one week. On complete
bioenhancers and for other effects to enhance the effectiveness of the drying, the whole plant material was finally powdered with the help of
medication during the treatment of an injury [10,11]. the Willey/Laboratory Mill and sifted through sieve number 22. About
Recent findings have explored many phytochemicals that could be 500 g of the powder was weighed and stored in a refrigerator in airtight
potentially used in treating delayed or chronic wounds. Phytochemicals plastic bags.
such as curcumin, icariin, kaempferol, and others modulate the
expression and activities of many cells and enzymes in the wounded Extraction of plant products
tissue, thereby enhancing wound healing. A combination of vancomycin
and icariin effectively controls infection and improves bone healing The dry powder of Mikania micrantha was subjected to cold extrac
[12]. Curcumin, combined with other antibiotics, is reported to be tion using methanol [26].A 500 g of powder soaked in 2.5 L of methanol
effective in treating different gram-positive and gram-negative bio (1:5 w/v) in a conical flask for 3 days with intermittent stirring. At the
film-forming bacterial infections [13]. Kaempferol enhanced the anti end of the third day, the content was filtered with muslin cloth followed
biotic activities of amikacin and gentamicin [14]. Such active by Whatman Filter Paper No. 1. For complete extraction of the active
compounds possess various pharmacological effects such as immuno principles, this process was repeated three times, using fresh solvent on
regulation, antioxidative effects, antimicrobial actions, cell proliferation each occasion or until the color of the methanol became clearly visible.
and migration, modulation of matrix metalloproteinase (MMPs) levels The filtrates obtained were pooled and further subjected to vacuum
and activities, anti-inflammatory effects, angiogenic effects, etc. [15, evaporation at 30–40 ◦ C. The extract was stored at -40ᵒC in a deep freeze
16]. MMP’s activities are crucial for the degradation of the extracellular in airtight containers until used [27].
matrix during the inflammatory phase, the breakdown of the capillary
basement membrane for angiogenesis and cell migration during the
proliferation phase, and the contraction and remodeling of tissue in the Formulation of drug
remodeling phase [17]. Not only is the level of MMPs important, but so
is the proper balance in the expression and activities of MMPs and tissue Mikania micrantha methanolic extract was prepared as 5% and 10%
inhibitor matrix metalloproteinase (TIMPs) in wound healing [18]. ointments using an ointment base consisting of soft paraffin (90%), hard
Excessive levels of MMPs in certain conditions, like diabetic wounds, paraffin (5%), and lanolin (5%) [16].
often produce excessive degradation of the ECM and a non-resolving
inflammatory phase, turning the wound into a non-healing chronic In vitro wound healing studies
wound [19].
Mikania micrantha is a medicinal plant native to Central and South Cell culture
America [20]. This plant is popularly used in many traditional medicines HUVECs and HDFa cells were purchased from Life Technologies,
for its multiple medicinal properties, such as antioxidant properties, Carlsbad, CA. HUVECs were cultured in M-200 phenol red-free medium
antimicrobial effects, anti-inflammatory and anti-dermatophyte activ supplemented with 2% low serum growth supplements (LSGS, Life
ities, and wound healing effects[21–23]. Different parts of this plant are Technologies), 10% fetal bovine serum (FBS), and 1% penicillin solution
reported to be effective as poultices for blood clotting and wound (Sigma-Aldrich, St. Louis, MO). HDFa cells were cultured in medium 106
healing [24]. A recent finding revealed a nanogel of leaf extract of (Life Technologies, Carlsbad, CA) with 2% LSGS, 10% FBS, and 1%
Mikania micrantha is effective in the treatment of diabetic wounds in rats penicillin solution. Cells were maintained in a humidified incubator at
[25]. To the best of our knowledge, no work has ever been done to 37 ◦ C with 5% CO2. The methanol-evaporated MME was dissolved in
characterize the cell signaling pathway involved in accelerating wound DMSO at a 50 mg/ml stock concentration and stored at 4 ◦ C. Further,
healing by Mikania micrantha. We investigated the cutaneous wound working concentrations of 75 ng/ml, 125 ng/ml, 250 ng/ml, and 500
healing potential of cold methanolic extract of Mikania micrantha (MME) ng/ml were prepared from the 50 mg/ml stock. The control (0 ng/ml)
using in vitro and in vivo studies. Our present work explores the modu used media with DMSO as the negative control, and the DMSO con
lation of the FAK/Akt/mTOR cell signaling pathway by the plant to centration was not more than 0.1% (v/v) in the medium, as mentioned
enhance cutaneous wound healing in rats. elsewhere [28,29]. Recombinant human VEGF proteins (Sigma-Aldrich)
were reconstituted according to the manufacturer’s instructions.
Material and methods
Cell proliferation assay
Collection of plant sample The MTT (3-(4,5-dimethylthiazol-2-yl)− 2,5-diphenyltetrazolium)
assay was used to determine the effect of the plant extract on cell pro
Leaves of Mikania micrantha were collected from the hilly regions of liferation [30]. A total of 1 × 104HDFa cells (human dermal fibroblast
Nagaland, India. Nagaland is a North East region in India, between 25◦ adult cells) per well in 200 µl complete medium were seeded in a 96-well
11′ 5″ and 27◦ 2′ 10″ north latitude and 93◦ 20′ and 93◦ 17′ 10″ east plate and treated with 0 (control), 75, 125, 250 and 500 ng/ml of MME,
latitude. The altitude varies approximately between 194 and 3048 m and VEGF (20 ng/ml) aspositive control. VEGF was chosen as a positive
above sea level. The maximum temperature may rise to 25 ◦ C in July and control because VEGF is known as the most potent proangiogenic
August, while the minimum may go down to even 0 ◦ C in the winter growth factor present in the skin, as well, the amount present in a wound
months of December and January. There is, however, regional variation can also significantly impact healing [31]. MTT solution (10 µl, 5 mg/ml
in temperature. The average annual rainfall varies from 150 to 280 cm, in PBS) was added to each well and incubated for 2 h. The MTT solution
and the rainfall is heavy during the monsoon. The valleys and foothills was aspirated from the wells and the MTT-formazan crystals were dis
are made up of alluvial and colluvial soils. Higher-altitude soils are solved in DMSO (150 µl). Absorbance was recorded at 540 nm. The re
primarily of the residual soil type. The plant was identified at the sults were represented as a percent cell proliferation over control. The
Regional Office, Botanical Survey of India (BSI), Shillong, India. MTT assay was performed after 24, 48, and 72 h of incubations to assess
cellular proliferation as previously described [30].
G. Das et al. Injury 54 (2023) 110856
Cell migration assay In vivo wound healing studies

HDFa cells were seeded to confluence onto fibronectin-coated six-
well tissue culture plates in cell culture medium 106 (Life Technologies, Laboratory animals
Carlsbad, CA). Cells were serum-starved for 12 h. Cell monolayers were Male Wistar rats weighing 180–200 g were supplied by Institutional
wounded with a sterile 100 µl pipette tip and washed with a starvation Animal House, COVSc& A.H., Mizoram, India.The rats were housed
medium to remove detached cells from the plates. At this time (t = 0 h), individually in polypropylene cages in a laboratory animal house,
wound margins were photographed. Cells were treated with 0 (control), maintaining controlled temperature (22±3 ◦ C), humidity (65%), and a
75, 125, 250 and 500 ng/ml of MME and VEGF (20 ng/ml) in full me 12 h light-dark cycle. The experimentation was initiated after main
dium and kept in a CO2 incubator. The same fields of the wound margin tainingthe animals in the house for 7 days for proper acclimatization to
were photographed at 0, 8 and 24 h post-creation of the wound. Pictures the new environment.
were superimposed using Photoshop (Adobe) and areas were measured
using ImageJ 1.45 s software. Creation of experimental wound
Xylazine and ketamine anesthesia (40 and 120 mg/kg b.w., respec
Matrigel invasion assay tively) were used to perform the surgical interventions under sterile and
The migration capacity of HUVEC cells was determined using Boy aseptic conditions. The dorsal fur of the animals is shaved with a clipper,
den Chambers, in which the two chambers were separated with and the anticipated area of the wound to be created is outlined on the
matrigel-coated Millipore membranes (6.5 mm diameter filters, 8 µM back of the animals with methylene blue using a circular stainless steel
pore size). HUVEC cells (1.5 × 104 cells/200 µl serum-reduced medium) stencil. Using toothed forceps, a surgical blade, and pointed scissors, an
were placed in the upper chamber of the Boyden chambers. The MME at aseptic circular wound (500 mm2) with a depth of 0.2 cm was created
the concentrations of 0 (control), 75 ng/ml, and 125 ng/ml were added along the markings. The entire wound was left open.
to the upper chamber (200 µl), and the lower chamber contained the
medium alone (150 µl). The chambers were assembled and placed in an Grouping of animals and application of ointment
incubator for 24 h. Cells from the upper surface of Millipore membranes The animals were randomly divided into 3 groups- control (group I),
were removed with gentle swabbing, and the migrant cells on the lower group II, and group III of six animals each. 0% (only ointment base), 5%,
surface of the membranes were then fixed and stained with crystal vi and 10% ointments of MME were topically applied twice daily on the
olet. Membranes were washed and mounted onto glass slides. The wounded area for 16 days in the control (group I), group II, and group
membranes were examined microscopically, and cellular invasionwas III, respectively.
counted.
Photographic evaluation and wound contraction measurement
In vitro angiogenesis assay The wound closure rate was assessed by tracing the wound on days 4,
The spontaneous formation of capillary-like structures by HUVEC on 8, 12, and 16 post-wounding using transparency papers and a permanent
a basement membrane matrix preparation (Matrigel, Becton Dickinson, marker. The wound areas (mm2) were measured planimetrically by
Bedford, MA) was used to assess angiogenic potential [32]. According to using graph paper. The number of days required for the scar to fall off
the manufacturer’s instructions, twelve-well plates were coated with without any residual raw wound reflected the epithelization period. The
matrix gel (10 mg/ml). HUVEC cells were seeded on coated plates at 1.5 pharmacological efficacy of the plant extract in the wound healing
× 105 cells/well in triplicatesand incubated at 37 ◦ C for 60 min. The process was evaluated in terms of the rate of wound contraction and
cultures were treated with 0 (control), 75 ng/ml, 125 ng/ml, 250 ng/ml, closure, period of epithelization, and histological repairing.
and 500 ng/ml of MME and VEGF (20 ng/ml) as a positive control and
incubated at 37 ◦ C for 24 h. Tube formation was observed and photo Collection of tissues
graphed over a 24-h period using an inverted phase contrast microscope. The animals were euthanized with ether on day 16 post-wounding
Images were captured, and the degree of tube formation was assessed by for the collection of healing tissue. One portion of the tissue was pre
counting the number of tubes contained in two random fields from each served in 10% neutral buffer formalin for the immunohistochemistry
well.Tubulogenesis was analyzed using ImageJ software version 1.47 h study. The other part of the tissue was homogenised in RIPA-lysis buffer
(http://imagej.nih.gov/ij). (Millipore, Billerica, MA) following the manufacturer’s instructions and
centrifuged for 10 min. at 12,000 rpm at 4 ◦ C. The aliquots of the su
Immunofluorescence staining for CD31 in HUVECs pernatant were prepared and stored at -80 ◦ C for western blot assays and
CD31 (PECAM-1) immunofluorescence staining was performed in gel zymography studies.
HUVEC cells. This is conducted to assess the angiogenic effect of MME.
Coverslips were, coated with 1% gelatin, and placed in 12-well culture Western blot assay
plates. 1 × 105 cells were seeded onto the top of the coverslip and Western blot analysis assessed the expression of various proteins in
incubated for 24 h in a CO2 incubator. After incubation, cells were HDFa cells and healing tissues in vitro and in vivo studies, respectively. In
treated with 75 ng/ml and 125 ng/ml MME for 24 h. Cells were fixed the studies, β-actin was used as a loading control. Stacking gel (5% in
with freshly prepared 2% paraformaldehyde for 15 min. at RT. After Tris–HCl buffer of pH 6.8) and resolving gel (12% Tris–HCl buffer of pH
washing with PBS, cells were quenched with 50 mM NH4Cl for 15 min. 8.8) were prepared between glass plates using a casting assembly with a
Cells were then permeabilized with 0.1% Triton X-100 and blocked for spacer of 1 mm thickness. The gel, after polymerization, was transferred
45 min.in 2% BSA. After blocking, cells were washed with PBS and into an electrophoretic apparatus, and buffer chambers were filled with
incubated with the anti-CD31 primary antibody (Cat. No. 3528S, dilu gel running buffer (0.025 M Tris, 0.192 M Glycine, 0.1% SDS, pH 8.3).
tion factor-1:250; Cell Signaling Technology) overnight. Cells were then Each sample (40 μg) was loaded into different wells of the gel. A pre
incubated for 1 h in FITC-conjugated secondary antibody (Sigma- stained protein ladder (5 μl) (cat. no. 26,616, Thermo Scientific) was
Aldrich). Counterstaining was done by DAPI (0.5 µg/ml) (Sigma- used as a marker and subjected to electrophoresis at 90 V till the tracking
Aldrich). Coverslips containing cells were then mounted on the glass dye reached the separating gel. The voltage was then increased to 120 V
slides. Images of cells were taken at 200X magnification. till the dye reached the bottom of the separating gel. The resolved
proteins were transferred onto the PVDF membrane (Millipore). Non-
specific sites were blocked using a blocking buffer (5% skimmed milk
in TBST) and incubated for 1 h. Membranes were then incubated over
night at 4 ◦ C with primary antibodies specific for p-FAK (Cat# sc-
G. Das et al. Injury 54 (2023) 110856
81,493; dilution factor-1:1000), FAK (Cat# sc-1688; dilution factor-

1:1000), and CD31 (PECAM-1) (Cat# sc-376,764; dilution factor-
1:500) (Santa Cruz Biotechnology, Santa Cruz, CA), p-mTOR (Cat#
2971; dilution factor-1:1000), mTOR (Cat# 4517; dilution factor-
1:1000), p-Akt (Cat# 5012; dilution factor-1:1000), Akt (Cat# 4691;
dilution factor-1:1000), and β-actin (Cat# 3700; dilution factor-1:2000)
(Cell Signaling Technology). After primary antibody incubation, the
membranes were washed thrice in TBST and were incubated with
appropriate secondary antibodies conjugated with horseradish peroxi
dase (HRP) for 1 h atRT. Protein expressions were visualized using the
enhanced chemiluminescence detection substrate (Millipore) on an
ImageQuant LAS4010 chemidocumentation system (GE Healthcare,
Amersham, UK). The protein bands were quantified and normalized
using ImageJ software version 1.47 h and β-actin as a loading control.
Gelatin zymography
The activities of matrix metalloproteinases, MMP-2 and MMP-9,
were measured by performing gelatin zymography as described previ Fig. 1. Effect of Mikania micrantha (MM) on cell proliferation in HDFa cells.
ously [33]. Cells were seeded in 6-well plates and then treated with 0 Mikania micrantha extract (MME) significantly (p<0.05) promoted the HDFa
ng/ml (control), 75 ng/ml, 125 ng/ml MME, and 20 ng/ml VEGF cells proliferation at 75 ng/ml and 125 ng/ml as compared to the control. The
(standard) for 24 h. The conditioned medium was centrifuged, and then effect of MME on cell proliferation was comparable to that of VEGF treatment (a
the supernatant was collected. After quantification, 30 μg of protein was positive control). Resultswere obtained from three independent experiments
resolved on 8% SDS-PAGE copolymerized with 2 mg/ml type-A gelatin mean ± SEM. *p < 0.05versus control.
substrate (Sigma-Aldrich). After electrophoresis, gels were washed in a
washing buffer (2.5% Triton X-100 in water) twice for 20 min. each. Incision wound model in wistarrats
After that, gels were incubated at 37 ◦ C for 18–20 h with gentleshaking The animals were divided into four groups, with six animals each.
in freshly prepared incubation buffer (50 mMTris buffer, 0.15 M NaCl, The dorsal fur of the animals was shaved with a clipper. A longitudinal
10 mM CaCl2, and 1 μM ZnCl2 pH 7.8) and then stained with 0.5% paravertebral incision, six centimeters long, was made through the skin
Coomassie brilliant blue G-250 (Sigma-Aldrich), followed by a and cutaneous muscle on the back. After the incision, surgical sutures
de-staining solution containing 40% methanol and 10% acetic acid in were applied to the parted skin at one-centimeter intervals using nylon
water for 2 h each. The gelatinolytic activity was visualized as negative surgical threads and a curved needle (No. 11). The wounds were left
staining bands using the ImageQuant LAS4010 instrument (GE undressed and exposed to the environment. The wound in groups 1, 2, 3,
Healthcare). and 4 were treated once daily withthe ointment of 0% MME (control),
betadine 10% (a standard), 5% MME, and 10% MME, respectively. The
Immunohistochemistry (IHC) for VEGF and pan-cytokeratin in excision sutures were removed on the 8th post-wound day, and the treatment was
wound continued. The breaking strength was measured on the 10th day.
Formalin-fixed and paraffin-embedded healing tissues were
dissected into 5 μm thick sections with the help of a microtome (Yorco, Statistical analysis
New Delhi, India). The sections were baked at 60 ◦ C for 1 h and then
deparaffinized using xylene and rehydrated using declining grades of The statistical significance of differences between the values of
alcohol. Antigen retrieval was performed by boiling the slides in 10 mM treated samples and controls was determined by one-way ANOVA with
citrate buffer (pH 6.0) for 20 min., Then the sections were allowed to Dunnett’s post-hoc test using GraphPad Prism version 3.00 for Windows
cool down at RT for another 20 min. Slides were washed in 10 mM software. All data were representative of ± SE of triplicates. In each
phosphate buffer saline (pH 7.4) and incubated in 0.3% H2O2 for 30 min. case, p<0.05 was considered statistically significant.
to quench the endogenous peroxidase activity. After washing withPBS,
sections were blocked in blocking serum (Vector Laboratory) and then Results
incubated with specific antibodies for VEGF(Cat# sc-7269; dilution
factor-1:250) (Santa Cruz Biotechnology) and pan-cytokeratin (Cat. No. In vitro assays
4545S, dilution factor-1:500 Cell Signaling Technology)overnight at
4 ◦ C. After that, sections were incubated with a universal biotin- MME promoted cellular proliferation in human dermal fibroblast adult
conjugated secondary antibody (Vector Laboratory) for 30 min at RT, (HDFa) cells
followed by washing and incubation with VECTASTAIN® ABC Reagent MMEsignificantly (p<0.05) promoted the HDFa cells proliferation at
(Vector Laboratory) for 30 min. at RT. The chromogenic reaction was 75 ng/ml and 125 ng/ml as compared to the control. The effect of
performed by incubating sections in ImmPACT™ DAB peroxidase sub MMEon cell proliferation was comparable to that of VEGF treatment (a
strate (Vector Laboratory) for 2–10 min. at RT. Nuclear staining was positive control) (Fig. 1).
done by Harris-hematoxylin stain (Sigma-Aldrich). Images were
captured using Nikon’s Eclipse TS100 microscope under 400x MME enhanced the migration and invasion abilities of HDFa cells
magnification. MMEpromoted the percent cell migration of HDFa cells significantly
(p< 0.05) at 75 ng/ml after 24 h of treatment as compared to the control
Hematoxylin and eosin staining for histopathological analysis (Fig. 2). The result was comparable to the effect shownby the VEGF
The cross-sectional, full-thickness skin specimens from healed positive control.
wounds were collected on day 16 post-wounding for the histopatho
logical evaluation. Samples fixed in 10% neutral buffered formalin were MME increased angiogenesis
processed, blocked with paraffin, and sectioned into 5 mm sections. The A tube formation assay was performed by treating HUVEC cells with
sections were stained with hematoxylin and eosin [34]. varying concentrations of MME to determine the effect on the tubulo
genesis of endothelial cells. The plant extract significantly (p<0.05)
G. Das et al. Injury 54 (2023) 110856
Fig. 3. Effect of Mikania micrantha (MM) on the formation of capillaries in

HUVECs cells.Mikania micrantha extract (MME) significantly (p<0.05) pro
moted the formation of capillary-like structures or tubes at concentrations
starting from 75 ng/ml as compared to control, suggesting a proangiogenic
effect of MM.Results were represented as an average number of nodes and
branches present in each treatment group. Resultswere obtained from three
independent experiments mean ± SEM. *p < 0.05versus control.
ng/ml and 125 ng/ml as compared to the control (Fig. S1B).

Fig. 2. Effect of Mikania micrantha (MM) on cell migration in HDFa cells.
Mikania micrantha increased the activity of MMP-2 and MMP-9 in HDFa
Mikania micrantha extract (MME) promoted the percent cell migration of HDFa
cells significantly (p< 0.05) at 75 ng/ml after 24 h of treatment as compared to cells
the control. VEGF at 20 ng/ml was used as a positive control.Each treatment MMP-2 and MMP-9activities were significantly (p<0.05) increased
was given in triplicates, and results were represented as percent migrated cells / in HDFa cells after treatment with MME at the concentrationsof 75 ng/
average number of invaded cells compared with untreated control. Resultswere ml, and 125 ng/ml for 24 h as compared to the control (Fig. 4). The
obtained from three independent experiments mean ± SEM. *p < 0.05; **p < effect is comparable to the effect from the treatment of the cells for 24 h
0.01; **p < 0.001 versus control. with 20 ng/ml of VEGF.
promoted the formation of capillary-like structures or tubes at concen MMEactivated FAK/Akt/mtTORsignalingin vitro
trations starting from 75 ng/ml as compared to the control, suggesting a The relative expressions of FAK, p-FAK, Akt, p-Akt, mTOR and p-
proangiogenic effect of MME (Fig. 3). The proangiogenic effect of the mTOR (Fig. 5) in the HDFa cells were determined by Western blot
plant was also demonstrated using immunofluorescence staining. The analysis. The results demonstrateda significantly higher level (p<0.05)
treatment of HUVECs with MME revealed upregulation of the expression of phosphorylated FAK, Akt, and mTOR at 24 h in all the cells treated
of CD31 significantly (p<0.05) at the concentrations of 75 ng/ml and with 75 ng/ml, 125 ng/ml MME,and VEGF (20 ng/ml), while the ex
125 ng/ml as compared to the control (Fig. S1A). These observations pressions of total FAK, Akt, and mTOR were insignificantly higher as
were further validated by Western blot analysis for the expression of compared to control.
CD31 in the HDFa cells. The treatment of HDFa with MME significantly
increased (p<0.05) the expression of CD31 at the concentrations of 75
G. Das et al. Injury 54 (2023) 110856
Fig. 4. Effect of Mikania micrantha

(MM) on MMP-2 and MMP-9 in HDFa
cell. MMP-2 and MMP-9 activities
significantly (p<0.05) increased in
HDFa cells after treatment with Mikania
micrantha extract (MME) at the con
centrations of 75 ng/ml, 125 ng/ml for
24 h as compared to control. Zymogr
pahy gel showing the pro (up)-and
active (down) MMP-2, and pro-and
active MMP-9 expressions. The average
relative band intensity was blotted and
analyzed compared to the control. Mean
± SEM. *p < 0.05 versus control.
Fig. 5. Effect of Mikania micrantha (MM) on FAK/Akt/mTOR cell signaling in HDFa cells. Western blot revealed a higher level (p<0.05) of phosphorylated FAK, Akt
and mTOR at 24 h in HDFa cells treated with 75 ng/ml, 125 ng/ml Mikania micrantha extract (MME) and VEGF (20 ng/ml), while the expressions of total FAK, Akt
and mTOR were insignificantly higher as compared to control. Here, FAK, Akt and mTOR used as a control of phosphorylated FAK, Akt and mTOR respectively.
While, β-actin was used as a loading control.The results are representative of three independent experiments. The average normalized relative band intensity was
blotted and analyzed. Mean ± SEM. *p < 0.05versus control.
In vivo analysis significantly more on all days post-woundingin groups that received 5%
and 10% MME compared to the control (Table 1). However, the increase
Topical application of MME increased wound contraction in rats in wound contraction was not significant on day 4 post-wounding in the
The wound contraction measured on days 4, 8, 12 and 16 post- group receiving 5% MME compared to the control.
wounding (Fig. 6) suggested a wound-healing effect of MMEsin an
excision wound model in Wistar rats. The wound contractions were
G. Das et al. Injury 54 (2023) 110856
Fig. 6. Effect of topical application of Mikania micrantha extract (MME) on cutaneous wound contraction in rats. Digital photographic evaluation of wound
contraction revealed enhancement of wound contractions measured on 4, 8, 12 and 16days of post-wounding in rats.
Table 1
Effect of topical application of Mikania micrantha extracts (MME) on wound contraction and epithelization. Values are mean ± SEM, n = 6 in each groups, ** = P ≤
0.01; * = P ≤ 0.05. versus control.
Group (Treatments) Contracted Wound Area (mm2) Epithelisation Time (Days)
4th day 8th day 12th day 16th day
I (Control) 41.42± 7.27 132.72± 7.302 217.67± 6.481 256.54± 7.620 25.833± 1.51
II (MME 5%) 43.17± 2.14 178.08**± 7.534 246.73**± 8.050 272.31*± 10.383 23.000**± 1.93
III (MME 10%) 59.63*± 3.572 144.39*± 4.804 273.59**± 8.542 293.47**± 7.582 21.833**± 0.94
stained sections revealed that MME-treated wound sections had better

Table 2
remodeling of healing tissue than control (Fig. S2C). There is more
Effect of topical application of Mikania micrantha extracts (MME) on ten
uniformity of collagen deposition and its rearrangement in the wound as
sile strength of incision wound on day 10 post-wounding in Wistar rats.
Values are mean ± SEM, n = 6 in each group, ** = P ≤ 0.01, versus
well as proper epithelization of the healing tissue in MME-treated
control. wound sections as compared to control.
Group (Treatments) Breaking Strength (g)

MME increased the breaking strength of the incision wound
I (Control) 257.20± 17.35 The incision wounds treated with 5% MME, 10% MME and a stan
II (Betadine® as standard) 303.83**± 10.56
dard drug (Betadine 10% ointment) showed a significant (p<0.01) in
III (MME 5%) 429.67**± 7.35
IV (MME 10%) 316.33**± 9.02 crease in tensile strength on day 10 post-wounding in Wistar rats as
compared to their respective controls (Table 2).
MMEenhancesangiogenesis Discussion
Vascular endothelial growth factor (VEGF) is a marker of angio
genesis, which acts as a primary stimulus for initiating the formation of Cutaneous wound healing is our body’s complex physiological
new blood vessels. Using an immunohistochemistry study, we analyzed defensive response to an injury in an attempt to completely or near
the expression of VEGF in formalin-fixed, paraffin-embedded excision completely restore the lost tissues. This vital response initiates with the
wound samples of untreated and treated rats. The expression of VEGF hemostasis phase, followed by the inflammatory, proliferative, and
was considerably increased in 5% MMEand 10% MME treated wound remodeling phases. Distortion in any one or more phases during the
sections as compared to control (Fig.S2A). process of wound healing often leads to a delay in healing [35].
Oxidative stress, infected wounds, abnormal immune responses, dia
MME improved remodeling of the healing skin betes mellitus, and others are some of the common causes of delayed
The immunohistochemistry for expressing epithelial markers (cyto wound healing. Antibiotics are often used clinically in treating wounds
keratin) in the healing tissues collected on Day 16 post-wounding was as preventives or for treating infected wounds [36]. With the increasing
also conducted using a pan-cytokeratin antibody capable of detecting all antibiotic resistance crisis, there is a growing need for a reduction in the
the isoforms. The study revealed increased cytokeratin expression in the widespread use of antibiotics. Many plant-derived compounds and me
MME-treated wound sections compared to control (Fig. S2B). H&E- dicinal plant extracts are being incorporated in antibiotic preparations
G. Das et al. Injury 54 (2023) 110856
Fig. A. Flowchart showing the possible mechanistic pathway of Mikania micrantha in the improvement of cutaneous wound healing in rats.
as bioenhancers and for other medicinal effects to enhance the effec while TIMPs inhibit the excess activity of MMPs to limit the degradation
tiveness of the medications during the treatment of an injury [10,11]. of ECM in healing tissues. MMPs are secreted by cells such as activated
Mikania micrantha is a well-known medicinal plant alsoused in many macrophages, lymphocytes, fibroblasts, etc. Improvements in MMP
traditional medicines for its multiple clinical properties, such as anti expression and activity during the proliferative phase of wound healing
oxidant properties and antimicrobial effects [21,22].The plant is also are linked to increased cell proliferation and migration and stimulation
known to enhance wound healing [24]. The methanolic extract of MM of angiogenesis and re-epithelialization [44]. However, prolonged and
have shown highest yield of various secondary metabolites such as excessive upregulation of MMPs results in chronic wounds, which often
tannin, saponins, cardiac glycosides, terpenoids, flavonoids and alka fail to heal in time [19]. MMPs can also be upregulated in inflammatory
loids. Amoung, the yield of flavonoids was the highest (7.16%) followed cells that infiltrate the wound and aid in pathogen clearance [45].The
by saponins (6.16%) and alkaloids in the methanoloic extract of MM proliferation of fibroblasts and their migration into healing tissue result
[37]. Flavonoids are known to enhance antioxidant activity and insufficient collagen deposition.During the remodeling of the healing
anti-inflmmatory activity. Saponins have been shown to enhance the tissue, the deposited collagen bundles grow in size and strength and
wound healing potential and accelerate the endothelial cell prolifera realign into an organized matrix to increase the tissue’s tensile strength
tion. Alkaloids can accelarte the initial phase of wound healing by [46].
stimulating fibroblast phase. Steroids help in regenerating the new skin The proliferation and migration of endothelial cells in granulation
cells [38]. tissue improves the formation of microvessel networks, ensuring a suf
Scientific validation of the medicinal properties of any plant extract ficient supply of oxygen and other nutrients necessary for repairing
is crucial for the optimization of their efficacy and for thedevelopment of tissues. Low oxygen tension in newly formed granulation tissues and
novel compounds from the plant. other angiogenic growth factors such as VEGF, PDGF, FGF, and others
In granulation tissue, fibroblasts are one of the dominant cells [39]. promote angiogenesis [47–49].Numerous phytochemicals are reported
The proliferation and migration of the fibroblast to the injury site are to improve angiogenesis and vasculogenesis in treating cutaneous
crucial steps during wound healing. Fibroblasts produce proteinases, wounds in normal and diabetic rats [50]. Treatment of HUVECs and
such as matrix metalloproteinases (MMP-1, MMP-2, and MMP-9), to cutaneous wounds in rats with MME also enhanced tubulogenesis and
degrade the provisional matrix while depositing collagen and other angiogenesis in favor of wound healing.
extracellular matrix (ECM) components to form granulation tissue [40]. The results of a western blot study revealed the activation of the
The cells release multiple cytokines and growth factors into the healing FAK/Akt/mTOR cell signaling pathway in the healing tissue after the
tissue, attracting various cells needed for healing the wound [41]. An topical treatment of the cutaneous wound with the extract of Mikania
injury triggers phenotypic differentiation of the fibroblast from the micrantha. This signaling pathway is known to play a crucial role in the
neighboring site of the wound to the myofibroblast[42]. Myofibroblasts development, proliferation, and migration of different types of cells as
secrete various ECM proteins and enhance wound contraction [43]. well as the modulation of MMPs. The treatment showed upregulation of
The use of MME increases HDFa cell migration and proliferation at a MMP-2 and MMP-9 expressions as well as an increased in their activities
concentration of 75 ng/mL.An idealbalance in the expression and ac in both in vitro and in vivo studies. The present study demonstrated that
tivities of MMPs and TIMPs is one of several factors influencing the using the cold methanolic extract of Mikania micrantha accelerated
proliferation, migration, and invasion of various cells, such as fibro wound healing both in vitro and in vivo. The cell signaling pathway,
blasts, keratinocytes, and endothelial cells [18]. MMPs degrade ECM, modulated by Mikania micrantha, which is possibly involved in
G. Das et al. Injury 54 (2023) 110856
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Activity of essential oils from Brazilian medicinal plants on Escherichia coli.
J Ethnopharmacol 2007;111(2):197–201. https://doi.org/10.1016/j.
The authors declare that they have no known competing financial jep.2006.11.034.
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the work reported in this paper. Analgesic and antioxidant activity of the hydromethanolic extract of Mikania
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Acknowledgment [23] Jyothilakshmi M, Jyothis M, Latha MS. Antidermatophytic activity of Mikania
micranthaKunth: an invasive weed. Pharmacogn Res 2015;7(Suppl 1):S20. https://
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The authors are grateful to the Department of Biotechnology (DBT), [24] Sheam M, Haque Z, Nain Z. Towards the antimicrobial, therapeutic and invasive
Government of India for providing the necessary funds and facilities. properties of Mikania micrantha Knuth: a brief overview. J Adv Biotechnol
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Evaluation of wound-healing potency of VernoniaarboreaHk. Indian J Pharmacol
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10
Injury 54 (2023) 110861
Injury
Allografts are not necessary for displaced proximal humeral fractures in

patients less than 65 years old, a retrospective cohort study
Ning Sheng a, #, Qiuke Wang b, #, Fei Xing a, Jie Wang a, Yunfeng Chen b, *, Zhou Xiang a
a
Department of Orthopedics, West China Hospital, Sichuan University, Guoxue Lane 37, Chengdu, 610041, Sichuan Province, China
b
Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, 600 Yishan Road, Shanghai, 200235, China
Keywords: Introduction: Displaced proximal humeral fractures (PHF) are frequently treated with locking plates to achieve
Proximal humeral fractures osteosynthesis. Bone grafts are used as augmentation techniques to improve stability in osteoporotic patients.
Allografts However, there has been little research into whether bone grafts are necessary for patients younger than 65 years
Locking plate
old. This study compared radiographic and clinical outcomes between PHFs augmented with bone grafts or not in
Augmentation
a younger population.
Methods: Between January 2016 and June 2020, 91 patients treated with a locking plate alone (LP), and 101
patients treated with locking plates augmented with bone grafts (BG) were analyzed. Potential confounding
factors for outcomes were adjusted by propensity score-matching analyses. For the retrospective cohort study, 62
patients from each group were evaluated for radiographic outcomes and clinical outcomes and compared.
Results: Sixth-two patients in each group, both with a mean age of 52 years old, were with a mean follow-up time
of 25 months in the LP group and 26 months in the BG group. There was no difference in demographic or surgical
characteristics between the two groups after propensity score-matching. With regard to radiographic outcomes,
the changes in neck-shaft angle (− 5.1 ± 4.9 vs. − 3.1 ± 5.3, p = 0.015) and humeral head height (− 1.5 ± 2.5 vs.
− 0.4 ± 2.7, p = 0.002) were more obvious in the BG group. However, regarding functional outcomes, there were
no significant differences between the two groups in DASH score, Constant–Murley score, or VAS score. More
over, the complication rate was not significantly different between two groups.
Discussion: Allografts only provide minor improvements of stability in radiography for patients less than 65 years
old after locking plate fixation of PHFs, but don’t improve shoulder function, relieve pain or reduce complica
tions. We concluded that allografts are unnecessary for younger patients with displaced PHFs.
Introduction could result in re-displacement, thereby causing loss of reduction and

even nonunion. Finally, an important question is whether a bone graft is
When proximal humeral fractures (PHFs) are treated with locking necessary for displaced PHFs among patients less than 65 years old.
plates, bone grafts are recommended in elderly and osteoporotic pa The aim of this study was to compare the differences in radiographic
tients at risk for fixation failure to improve stability and reduce and clinical outcomes between PHFs treated with locking plates alone
complication [1]. Although Patients aged less than 65 years account for and those treated with bone grafts augmentation combined with locking
about 30% of all PHFs [2,3], it is unknown whether a bone graft is plates, and to identify whether patients less than 65 years old benefit
needed in patients less than 65 years, especially those patients with bone from bone grafts.
defects, a broken medial cortex, or with complex fractures. Nonuse of
bone grafts may reduce the operation time and medical costs. More Methods
importantly, it can avoid complications associated with bone grafting,
such as difficulty in absorption (with allografts) and donor site In this retrospective study, a total of 612 PHF patients treated with
morbidity (with autogenous grafts) [4,5]. However, lack of stability locking plates at a general tertiary care hospital between January 2016
E-mail address: drchenyunfeng@sina.com (Y. Chen).
#
The first two authors contributed equally to this work.
Accepted 1 June 2023
N. Sheng et al. Injury 54 (2023) 110861
Fig. 1. Flow chart of patient selection.
and June 2020 were identified through the hospital information system. Postoperative rehabilitation
Two hundred and thirty-nine patients aged between 18 and 65 years
with acute unilateral fractures and a follow-up of at least 1 year fulfilled We encouraged all patient’s active exercises of wrists and elbows as
the inclusion criteria. Those patients with open fractures, multiple tolerated from the first after surgery. Passive activities were allowed
fractures, and pathological fractures were excluded. We also excluded from the second week. Functional practices were allowed from week
patients with previous ipsilateral upper extremity injuries and those four, including forward elevation, abduction, and internal and external
without complete data. Patients were divided into two groups according rotation. Patients would use a sling for four weeks. Gradually started
to treated with locking plates alone (LP group) or patients treated with weight-bearing exercise after 6 weeks.
bone graft augmentation as well as locking plates (BG group).
Clinical follow-up
Surgical technique
All patients were suggested to follow up by out-patient at 1, 3, 6, and
LP group: All procedures were performed with the patients under
12 or more months if necessary. A plain anteroposterior X-ray was taken
general anesthesia. Patients were placed in the beach-chair position. The
to evaluate radiological outcomes. The DASH score, the Con
deltopectoral approach was used in all patients to expose the site clearly.
stant–Murley score, and the VAS score were assessed with the patient’s
Nonabsorbable sutures were passed through the junction of the tuber
agreement. Moreover, complications were recorded, such as nonunion,
osities and the rotator cuff to help reduce fragmentation of the greater
malunion, screw penetration, humeral head necrosis, heterotopic ossi
tuberosity and the lesser tuberosity. These nonabsorbable sutures would
fication, infection, and arthritis.
ultimately be attached to the looking plate. Fracture fragments were
reduced with the help of K-wires. We tried to restore the neck–shaft
angle to 130◦ − 150◦ according previous study [6]. After fracture Data collection
reduction, K-wires were also used for temporary fixation, and a C-arm
X-ray machine was used to ensure anatomical reduction of the humeral Patients’ medical and radiological data were extracted from the in
head and the tuberosities. A locking plate was placed on the lateral to the formation system after obtaining Institutional Review Board approval
bicipital groove when the reduction was satisfactory. Calcar screws were (Approval No:2022–256). Informed consent was obtained from all pa
carefully inserted into the inferomedial quadrant of the humeral head. A tients included. The medical data included demographic features, the
final fluoroscopy check was performed to assess the reduction and the Disabilities of the Arm, Shoulder and Hand [DASH] score, the Con
location of plates and screws. After careful irrigation, the wound was stant–Murley score, visual analogue scale (VAS) score, and any reported
closed in layers. complications. The radiological data included pre- and postoperative
BG group: Fracture reduction was performed as described above but plain anteroposterior X-ray and computed tomography (CT) data. The
before fixation of the locking plates, cancellous bone from the ipsilateral neck–shaft angle (◦ ) and humeral head height (mm) were measured as
iliac crest or allograft bone was pressed into the bone defect area. A previously described [7,6]. The changes of neck–shaft angle and hu
fibular allograft (if needed) was inserted into the intramedullary canal meral head height were defined as the difference between the value on
and medialized maximally toward the medial calcar. The length of the the first day after the operation and the value at final follow-up. Prox
fibular allograft was decided by the surgeon during the operation. All imal humerus low BMD was identified when the average proximal hu
other surgical procedures were the same as described for the LP group. merus cortical thickness measurement was less than 6 mm [8]. Initial
fracture angulation was divided into neutral, varus, and valgus as re
ported by Little et al. [9]. Initial neck–shaft angles between 130 and
140◦ were considered neutral. Fractures with neck–shaft angles 〈 130◦
Table 1 smoking, diabetes, hypertension, high energy injury, proximal humerus

Patient characteristics according to operation type by unmatched and matched low BMD, NEER classification, initial fracture angulation, humeral head
data. extension, breakage of the medial hinge [11], fracture with dislocation,
Variables Before propensity score After propensity score days from fracture to surgery and quality of reduction as potential
matching matching confounders for comparison. Thus, propensity score-matching (PSM)
LP BG p Value LP BG p analysis was adapted to correct for confounding bias.
group group group group Values
(n = (n = (n = (n =
91) 101) 62) 62) Statistical analysis
Age, years, mean 48 52 0.029 51 52 0.565
(SD) (11.9) (9.4) (10.4) (9.8) Continuous variables are reported as the mean (standard deviation)
Sex, female (%) 50 62 0.366 35 41 0.269 and categorical variables are reported as the absolute amounts (per
(54.9) (61.4) (56.5) (66.1) centage). The equality of variances in continuous variables was tested by
BMI, kg/m2, mean 24 24 0.890 25 24 0.275 Levene’s test. Differences in continuous variables between the two
(SD) (2.8) (3.4) (2.7) (3.6)
Dominant arm, n 41 45 0.944 27 26 0.856
groups were compared by independent t-tests. Continuous data with
(%) (45.1) (44.6) (43.5) (41.9) asymmetrical distribution were compared using the Mann–Whitney U
Smoking, n (%) 16 14 0.478 10 12 0.638 test. Categorical variables were compared using the chi-squared or
(17.6) (15.8) (16.1) (19.4) Fisher’s exact test. PSM analysis was performed to adjust potential
Diabetes, n (%) 20 12 0.061 11 9 0.625
confounding factors. A 1:1 matched analysis using nearest-neighbor
(22.0) (11.9) (17.7) (14.5)
Hypertension, n 16 6 0.011 6 5 0.752 matching with a caliper distance of 0.1 without replacement was per
(%) (17.6) (5.9) (9.7) (8.1) formed based on the estimated propensity score of each patient. A p
High energy 18 31 0.083 17 15 0.694 value < 0.05 indicates the level of significance for all analyses. Statis
injury, n (%) (19.8) (30.7) (27.4) (24.2) tical analysis was performed using IBM SPSS Statistics 27 and GraphPad
Proximal humerus 33 51 0.735 33 36 0.588
low BMD, n (%) (53.2) (50.5) (53.2) (58.1)
Prism 8.0.
Neer <0.001 0.681
classification, n Results
(%)
Two-part 45 23 21 12
We included 91 patients in LP group and 101 patients in BG group.
(49.5) (22.8) (33.9) (29.0)
Three-part 30 47 25 32 After 1:1 propensity score-matching, 62 patients from each group were
(33.0) (46.5) (25.8) (51.6) selected for final analysis. The flow chart was shown in Fig. 1. A com
Four-part 16 31 16 12 parison of demographic features and surgical characteristics before and
(17.6) (30.7) (25.8) (19.4) after PSM was presented in Table 1. In the entire cohort (n = 192), there
Initial fracture 0.057 0.685
angulation, n
were significant differences in age (p = 0.029) and hypertension (p =
(%) 0.011) between the two groups. Compared with patients in the LP group,
Varus 21 28 14 18 patients in the BG group more often had a fracture with severe classi
(23.1) (27.7) (22.6) (29.0) fication (p < 0.001) and broken medial hinge (p < 0.001). However,
Neutral 52 41 33 29
there was no significant difference in any of the patient characteristics or
(57.1) (40.6) (53.2) (46.8)
Valgus 18 32 15 15 fracture characteristics after PSM matching of possible confounders (n
(19.8) (31.7) (24.2) (24.2) = 128). The mean age of the two groups was 51(range, 24 to 64)and 52
Humeral head 54 60 0.993 37 38 0.854 (range, 26 to 64)years old, respectively. The mean follow-up times were
extension ≥ 8 (59.3) (59.4) (59.7) (61.3) 25(range, 12 to 53)months in the LP group and 26(range, 12 to 48)
mm, n (%)
months in the BG group. The typical case for each group was shown in
Medial hinge 43 73 <0.001 31 40 0.102
broken, n (%) (47.3) (72.3) (50.0) (64.5) Fig. 2.
Fractured with 8 15 0.197 7 8 0.783
dislocation, n (8.8) (14.9) (11,3) (12.9) Comparison of the radiographic outcomes
(%)
Days from fracture 4 4 0.325 4 4 0.379
to surgery, days, (1.9) (1.9) (2.1) (1.9) For radiographic outcomes, the humeral head height and neck–shaft
mean (SD) angle data of all the patients at the final follow-up were pooled and the
Quality of 62 61 0.265 38 38 1.000 distribution of the neck-shaft angle in the patients without bone grafts
reduction, n of (68.1) (60.4) (61.3) (61.3) showed a trend towards varus (Fig. 3). Most of the neck–shaft angles
well reduced
(%)
were distributed between 120◦ and 150◦ The humeral head heights were
mainly between 7 mm and 22 mm. The changes in neck–shaft angle and
LP, looking plate; BG, bone graft; SD, standard deviation; BMI, body mass index; humeral head height in both groups are also shown (Fig. 4). The patients
BMD, bone mineral density.
in the LP group exhibited a significantly greater change in the neck–shaft
angle (4.9 ± 4.6 vs. 2.2 ± 5.3, p = 0.003) and a greater change in the
were considered varus, whereas neck–shaft angles 〉 140◦ were consid humeral head height (1.5 ± 2.4 vs. 0.4 ± 2.5, p = 0.005) compared to
ered valgus. The quality of reduction was categorized into well-reduced the BG group (Table 2).
or mal-reduced. Well-reduced was confirmed only if all the following
three criteria were met: a neck–shaft angle between 110◦ and 150◦ , Comparison of the clinical outcomes
head–shaft displacement less than 5 mm, and greater tuberosity
displacement less than 5 mm. Mal-reduced was defined as failing to meet When comparing functional outcomes at the final follow-up, the
at least one of these criteria [10]. All the above assessments were per DASH score (28.0 ± 20.1 vs. 22.3 ± 18.3, p = 0.156) and the Con
formed by two orthopedic surgeons independently. The average mea stant–Murley score (78.5 ± 11.3 vs. 76.9 ± 11.4, p = 0.198) showed no
surement by these two surgeons was used for continuous variables, and a significant difference between the two groups. There was also no sig
third orthopedic surgeon made the final decision if disagreements nificant difference in VAS score (0.6 ± 0.9 vs 0.9 ± 1.0, p = 0.177).
regarding discrete variables occurred. Within the follow-up period, complications occurred in nine (14.5%)
We considered age, sex, body mass index (BMI), dominant arm, patients in each group (Table 3). In the LP group, nonunion occurred in
Fig. 2. A typical case in each group. (a-c) The X-rays of pre-operative, immediate postoperative, and last follow-up time in a 57-year-old female treated with a plate
alone; (e-f) The X-rays of pre-operative, immediate postoperative, and last follow-up time in a 63-year-old female treated with a plate and allograft.
three (4.8%) patients. Two (3.2%) patients developed humeral head

necrosis and secondary screw penetration, and implant removal was
offered. Moreover, severe varus deformity (neck–shaft angle < 120◦ ),
radiographic osteoarthritis, and obvious heterotopic ossification were
also found. In the BG group, two (3.2%) patients developed nonunion.
Two (3.2%) patients developed humeral head necrosis, only one of
whom had screw penetration and was treated with implant removal.
Severe varus deformity and resorption of the tuberosities each occurred
in two (3.2%) patients. One (1.6%) patient with allograft cancellous
developed a superficial incision infection 3 months after surgery and
was treated with debridement.
Comparison between different allografts
In the BG group, no patient was treated with autograft, 49 patients

Fig. 3. Diagram showing the distribution of the neck-shaft angles and humeral
were augmented with cancellous bone allograft and 13 patients with
head heights. The neck-shaft angles and humeral head heights in the LP group
subjects are shown in blue. The neck-shaft angles and humeral head heights in
fibular strut allograft. We found only the changes in the neck–shaft angle
the BG group subjects are shown in red. LP, locking plate; BG, bone graft. (For showed a significant difference between different types of the allograft
interpretation of the references to colour in this figure legend, the reader is (2.8◦ vs. -0.28◦ , p = 0.042). There were no significant differences be
referred to the web version of this article.) tween the two groups in the changes of the humeral head height, the
DASH score, the Constant-Murley score, the VAS score, and the com
plications (Table 4).
Fig. 4. Violin plots of the change in the neck-shaft angle and humeral head height distribution. (A) The change of neck-shaft angle in LP (blue) and BG (red) group
subjects; (B) The change of humeral head height in LP (blue) and BG (red) group subjects. LP, locking plate; BG, bone graft. (For interpretation of the references to
colour in this figure legend, the reader is referred to the web version of this article.)
Table 2 Table 4
Operative outcomes according to operation type after propensity score Comparison between patients augmented with cancellous bone allograft and
matching. fibular strut allograft.
Variables LP group BG group p Variables Cancellous bone Fibular strut p
(n = 62), Mean (n = 62), Mean Values allograft (n = 49), allograft (n = 13), Values
(SD) (SD) Mean (SD) Mean (SD)
Changes in neck-shaft angle 4.9 (4.6) 2.2 (5.3) 0.003 Changes in neck-shaft 2.8 (5.1) − 0.28 (5.8) 0.042
(◦ ) angle (◦ )
Changes in humeral head 1.5 (2.4) 0.4 (2.5) 0.005 Changes in humeral 0.2 (2.4) 0.9 (2.9) 0.384
height (mm) head height (mm)
DASH score 28.0 (20.1) 22.3 (18.3) 0.156 DASH score 22.7 (19.1) 20.7 (15.4) 0.836
Constant-Murley score 78.5 (11.3) 76.9 (11.4) 0.198 Constant-Murley 76.2 (12.1) 74.5 (9.0) 0.472
VAS 0.6 (0.9) 0.9 (1.0) 0.177 score
Follow-up time, months 25 (9.1) 26 (8.4) 0.659 VAS 0.8 (1.2) 0.5 (0.9) 0.298
Complication, n% 8 (16.3) 1 (7.7) 0.670
LP, looking plate; BG, bone graft; DASH, Disabilities of the Arm, Shoulder and
Hand; VAS, visual analogue scale, 0 = no pain. DASH, Disabilities of the Arm, Shoulder and Hand; VAS, visual analogue scale, 0
= no pain.
Table 3 defects in the humeral head and metaphysis, even in younger patients
Cumulative rate of complications at the last follow-up. [18]. Surgeons may consider bone grafts to improve biomechanical
Complications LP group BG group p
stability, including autologous iliac bone grafts or allogeneic bone
(n = 62), n (n = 62), n Values grafts, even to aid for treating aseptic nonunion of the proximal humerus
(%) (%) [19]. However, there are no relevant studies to guide the use of bone
Total 9 (14.5) 9 (14.5) 1.00 grafts in this population. Thus, we performed this study to determine
Nonunion 3 (4.8) 2 (3.2) whether a bone graft was beneficial for the treatment of displaced PHFs
Humeral head necrosis with screw 2 (3.2) 2 (3.2) in patients younger than 65 years. Considering the confounding factors,
penetration we used PSM to correct confounding bias.
Varus deformity 2 (3.2) 2 (3.2)
Radiographic osteoarthritis 1 (1.6) 0
Changes in neck–shaft angle and humeral head height are commonly
Heterotopic ossification 1 (1.6) 0 used to evaluate reduction stability [7,20,21]. In a study by Cha et al., a
Bone resorption 0 2 (3.2) mean change in the neck–shaft angle of 10.2◦ and a change in the hu
Superficial incision infection 0 1 (1.6) meral head height of 3 mm was observed in comminuted PHFs in pa
LP, looking plate; BG, bone graft. tients treated by fixation with a locking plate alone, higher than in
patients who received an endosteal strut allograft [22]. In the present
Discussion study, after approximately 2 years of follow-up after the operation, the
patients with bone grafts also showed fewer changes in neck–shaft angle
The present study showed that allografts slightly reduced the and humeral head height than patients without bone grafts. The distri
changes in neck–shaft angle and humeral head height, but did not bution of the neck–shaft angle also showed that patients without bone
improve the functional outcomes, relieve pain or reduce complications. grafts tended to the varus side, which confirmed that bone grafts slightly
With trends in the management of PHF constantly evolving, there has reduced the re-displacement after surgery, at least in terms of radio
been an increase in the use of reverse total shoulder arthroplasty graphic findings. However, we observed only small differences in the
[12–14]. However, most studies have examined a population with a changes of both neck–shaft angle (2.7◦ ) and humeral head height (1.1
mean age of ≥ 65 years, and the findings cannot be generalized to mm).
younger and high-demand patients. Studies comparing surgical treat We also evaluated patients’ shoulder function using the DASH and
ment options show younger patients are likelier to receive locking plate Constant–Murley scores and found similar functional scores compared
fixation [12,15,16]. When treated with locking plates, it is crucial to to previous studies [7,23]. Subsequent analysis showed that there were
maintain fixation stability, particularly in osteoporotic patients and no differences in the DASH or Constant–Murley scores between the two
those with breakage of the medial calcar [1,17]. Moreover, we previ groups. The mean VAS scores also showed no significant difference.
ously found that displaced PHFs were frequently accompanied by bone Furthermore, patients in both groups showed comparable complication
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Declaration of Competing Interest functional outcomes following open reduction and internal fixation for proximal
humeral fractures: a retrospective comparative cohort study with minimum 2 years
follow-up. Injury 2021;52:506–10.
Each author certifies that there are no funding or commercial asso
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licensing arrangements, etc.) that might pose a conflict of interest in Int Orthop 2016;40:569–77.
connection with the submitted article related to the author or any im [26] Tenor Junior AC, Granja Cavalcanti AM, Albuquerque BM, et al. Treatment of
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[1] Mease SJ, Kraeutler MJ, Gonzales-Luna DC, et al. Current controversies in the
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Injury 54 (2023) 110862
Injury
Poorly controlled diabetes: Glycosylated hemoglobin (HA1c) levels >8%

are the tipping point for significantly worse outcomes following hip
fracture in the geriatric population
Lauren A. Merrell a, Garrett W. Esper a, Kester Gibbons a, Abhishek Ganta a, b, Kenneth A. Egol a, b,
Sanjit R. Konda a, b, *
a
Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, USA
b
Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Richmond Hill, USA
A R T I C L E I N F O
Introduction: The presence of diabetes has been associated with increased mortality risk after hip fracture,
Keywords: however, little has been published about the lab values of these diabetic patients and the role high labs play in
Hip Fracture morbidity and mortality. The purpose of this study is to quantify the severity of diabetes that is associated with
Diabetes worse outcomes in hip fracture patients.
Hemoglobin A1c Methods: A consecutive series of 2430 patients >55 years old who sustained a hip fracture between October
Glucose 2014-November 2021 were reviewed for demographics, hospital quality measures, and outcomes. Each patient
Geriatric with a diagnosis of diabetes mellitus (DM) was reviewed for hemoglobin-A1c (HA1c) and glucose values at
Outcomes
admission. Univariable comparisons and multivariable regression analyses were conducted to assess the impact
of diabetes and elevated lab values (HA1c) on outcomes such as hospital quality measures, inpatient compli
cations, readmission rates, and mortality rates.
Results: 565 patients (23%) carried a diagnosis of diabetes mellitus at the time of their injury. Considerable
demographic and comorbidity differences between diabetic and non-diabetic cohorts indicated that the diabetic
cohort was less healthy. The diabetic cohort had longer hospitalizations, higher rates of minor complications,
readmissions within 90-days, and mortality within 30-days/1-year. Stratification by HA1c levels found patients
with a HA1c>8% had a significantly higher rate of major complications, and mortality at all time points
(inpatient/30-day/1-year). Multivariable regression found HA1c>8% to be independently associated with a
higher rate of inpatient/30-day/1-year mortality in comparison to a diagnosis of diabetes alone which was not
independently significant.
Conclusion: While all patients with DM experienced worse outcomes than those without, those with poorly
controlled diabetes (HA1c>8%) at the time of hip fracture injury experienced poorer outcomes compared to
those with well-controlled diabetes. Treating physicians must recognize these patients with poorly controlled DM
at the time of arrival to adjust care planning and patient expectations accordingly.
Level of Evidence sustain a hip fracture have been found to have considerably higher rates
of mortality and worse functional outcomes over time following the
III injury [2,3]. While hip fractures carry a significant rate of morbidity and
mortality at baseline, the extensive comorbidity profile often seen in
Introduction older patients further stress the patient and lead to worse outcomes [4].
Diabetes is noted to be one of the most common comorbidities in pa
The prevention and effective management of hip fractures in the tients who sustain a hip fracture [1].
middle-aged and geriatric populations present a significant public Diabetes mellitus (DM) is a complex condition that has its highest
health concern [1]. Compared to healthy individuals, patients who incidence in the geriatric population; literature suggests that over one-
* Corresponding author at: NYU Grossman School of Medicine, Chairman of Orthopaedic Surgery, Medisys Health Network, Director of Orthopaedic Trauma,
Jamaica Hospital Medical Center, Director of Geriatric Orthopaedic Trauma, NYU Langone Health, 301 E. 17th Street, 14th Floor, New York NY 10003
E-mail address: sanjit.konda@nyulangone.org (S.R. Konda).
L.A. Merrell et al. Injury 54 (2023) 110862
third of diabetic patients are now over the age of 65 [5]. This diabetic alpha of 0.05.
population is similar to the population that faces the highest rate of hip
fractures [1]. The two coupled together have been shown to increase the Results
risk of mortality following operative treatment for hip fractures [6].
While the presence of diabetes has been associated with increased There were 2430 patients who presented with a hip fracture during
mortality risk after hip fracture, little has been published quantifying the the study period; all patients had a minimum of one-year clinical follow-
severity of diabetes that is associated with this risk. This study aims to up (excluding those who died before the one-year time point). Of these
quantify the association between quality of glucose control and worse 2430, 565 patients (23%) had a diagnosis of DM at the time of their
outcomes in middle-aged and geriatric hip fracture patients. injury. There were demographic differences between the DM and no DM
cohorts, including the DM cohort being younger, having a higher mean
Methods BMI, CCI, and STTGMA score. Additionally, patients in the DM cohort
were more likely to be male, non-White, and a household ambulator
This was a comparative retrospective study that queried a prospec (Table 1). The diabetic cohort had a longer index hospitalization, a
tively collected, Institutional Review Board approved middle-aged and higher rate of minor impatient complications, increased readmissions
geriatric hip fracture database for all patients aged 55 or older who
sustained a hip fracture (femoral neck, intertrochanteric, and sub Table 1
trochanteric fracture [AO/OTA fracture classifications: 31A, 31B, 32(A- Demographics.
C)]) via a low-energy mechanism (fall from standing or height <2 stairs) Demographics Diabetes No Diabetes Total P-
between October 2014-November 2021. Our entire study cohort was Value
treated at one urban academic medical center. This center included two n (%) n (%) n (%)
Level 1 trauma centers, one university-based tertiary care referral hos N 565 1865 2430
pital, and one orthopedic specialty hospital. Patients were excluded if Variables
they were younger than 55 or sustained their injury via a high-energy Age (years; mean± std) 79.66 ± 81.02 ± 80.71 ± <0.01
9.53 10.37 10.20
mechanism (fall from height >2 stairs, motor vehicle accident, etc.)
Body Mass Index 25.37 ± 23.81 ± 24.17 ± <0.01
All patients were reviewed for demographics including age, sex, 7.02 6.25 4.93
comorbidities (notably a prior diagnosis of diabetes), body mass index Charlson Comorbidity 2.44 ± 1.64 1.23 ± 1.64 1.51 ± 1.72 <0.01
(BMI), and baseline ambulatory status; hospital quality measures Index
including length of stay, need for intensive care unit (ICU) admission, STTGMA Score 2.53 ± 6.76 1.45 ± 5.08 1.70 ± 5.53 <0.01
Gender
and inpatient complications; and outcomes including readmission and
<0.01
Male 209 534 743
mortality rates. Comorbidities were represented utilizing the Charlson (36.99%) (28.63%) (30.58%)
Comorbidity Index (CCI). Inpatient complications were defined as major Female 356 1331 1687
or minor complications. Major complications included sepsis/septic (63.01%) (71.37%) (69.42%)
shock, pneumonia, deep vein thrombosis/pulmonary embolism, stroke, Race <0.01
White 320 1408 1728 <0.01
acute respiratory failure, and cardiac arrest. Minor complications (56.64%) (75.50%) (71.11%)
included acute kidney injury, acute blood loss anemia, urinary tract Black 59 121 (6.49%) 180 (7.41%) <0.01
infection, surgical site infection, and decubitus ulcer. A validated geri (10.44%)
atric risk assessment score, the Score for Trauma Triage in Geriatric and Hispanic 50 (8.85%) 74 (3.97%) 124 (5.10%) <0.01
Asian 79 121 (6.49%) 200 (8.23%)
Middle-Aged Patients (STTGMA) was calculated for each patient [7–14].
<0.01
(13.98%)
Those with a diagnosis of diabetes were grouped into the diabetes Other 9 (1.59%) 35 (1.88%) 44 (1.81%) 0.764
cohort. DM was diagnosed per CDC guidelines of Random Blood Sugar Unknown 33 (5.84%) 80 (4.29%) 113 (4.65%) 0.110
Test level >200 mg/dL [15]. The hemoglobin A1c (HA1c) and glucose Ambulatory Status <0.01
levels at time of admission for the diabetic cohort were recorded. Community Ambulator 346 1303 1649 <0.01
(61.24%) (69.87%) (67.86%)
Comparative analyses were conducted between the diabetic and Household Ambulator 193 492 685 <0.01
non-diabetic cohorts. HA1c levels were stratified in increments (<6.5, (34.16%) (26.38%) (28.19%)
6.6–6.9, 7.0–7.9, 8.0–8.9, 9–9.9, >10.0) to determine at which point Non-Ambulatory/ 26 (4.60%) 69 (3.70%) 95 (3.91%) 0.317
outcomes significantly worsened utilizing post-hoc analyses. The HA1c Wheelchair
Glasgow Coma Scale 14.89 ± 14.87 ± 14.87 ± 0.222
cutoff for each respective treatment control target were as follows: good
0.41 0.76 0.63
control group was HA1c < 7%, intermediate control group was 7% ≤ AIS Head/Neck 0.03 ± 0.28 0.03 ± 0.27 0.03 ± 0.27 0.441
HA1c < 8%, and the poor control group was HA1c ≥8% as defined by AIS Chest 0.01 ± 0.12 0.02 ± 0.21 0.02 ± 0.19 0.070
the American Diabetes Association in 2020 [16]. Comparative analyses Fracture Classification 0.530
were conducted between patients in the diabetes cohort with HA1c 31A 308 974 1282
(54.51%) (52.23%) (52.76%)
values above and below our study’s threshold cutoff (8%). It is impor 31B 233 818 1051
tant to note a portion of our diabetes cohort (n = 100) did not have (41.24%) (43.86%) (43.25%)
hemoglobin A1c labs drawn at their time of arrival, therefore these 32A 18 (3.19%) 45 (2.41%) 63 (2.59%)
patients were not included in the HA1c sub-analysis. Three separate 32B 1 (0.18%) 2 (0.11%) 3 (0.12%)
32C 5 (0.88%) 26 (1.39%) 31 (1.28%)
multivariable binary logistic regression analyses were conducted to
Treatment 0.203
independently assess the impact of diabetes and HA1c>8% in the overall Short Cephalomedullary 238 736 974
cohort on the rate of inpatient, 30-day, and 1-year mortality. For these Nail (42.12%) (39.46%) (40.08%)
analyses, all patients without a diagnosis of diabetes were considered to Long Cephalomedullary 74 262 336
have an HA1c value <8%. Nail (13.10%) (14.05%) (13.83%)
Hemiarthroplasty 134 426 560
For all comparative analyses, Independent Sample T-Tests, Chi (23.72%) (22.84%) (23.05%)
Square, Analyses of Variance (ANOVA) and Mann Whitney U tests were Total Hip Arthroplasty 27 (4.78%) 126 (6.76%) 153 (6.30%)
used as appropriate. Post-hoc analyses to determine the HA1c cutoff for Sliding Hip Screw 29 (5.13%) 72 (3.86%) 101 (4.16%)
worse outcomes included the Tukey test for ANOVA and adjusted cell CRPP 37 (6.55%) 173 (9.28%) 210 (8.64%)
Non-Operative 26 (4.60%) 70 (3.75%) 96 (3.95%)
residuals for Chi Square tests. All statistics were calculated with IBM
SPSS data software, Version 25 (Armonk, NY). Significance was set at an AIS=Abbreviated Injury Score; CRPP=Closed Reduction Percutaneous Pinning.
within 90-days, and higher mortality within 30-days and 1-year racial groups [20–22]. Finally, we found patients in the DM cohort
(Table 2). were more likely to be a household ambulator as compared to a com
Stratification by HA1c levels found patients within the 8–8.9% HA1c munity ambulator. The reasoning for this finding could be multifacto
cohort began to experience significantly worse hospitalizations and rial. Less active patients may have a higher BMI and more extensive
outcomes (Table 3). Therefore, a HA1c threshold cutoff of 8% was comorbidity profile, increasing the risk of diabetes. Likewise, DM pa
chosen for further analysis. Grouping around this cutoff found patients tients may have a worse overall health status and subsequently poorer
with an HA1c>8% had a significantly higher rate of major inpatient functional status. While these demographic differences exist between
complications and inpatient/30-day/1-year mortality (Table 4). our cohorts, they reflect the baseline differences often seen in patients
While significant on univariable comparative analysis, regression with diabetes throughout the literature.
analysis demonstrated a diagnosis of DM in the overall cohort was not When comparing the overall DM and no DM cohorts, our study found
found to be independently significant for inpatient, 30-day, and 1-year a higher rate of minor complications, readmissions within 90-days, and
mortality. However, multivariable regression found a HA1c>8% to be mortality within 30-days and 1-year. Additionally, these patients often
independently associated with a higher rate of inpatient, 30-day, and 1- experienced a longer length of stay for their admission. Poorer outcomes
year mortality in the overall cohort (Table 5). in patients with diabetes who sustain a hip fracture are well documented
in the literature. A retrospective study by Spaetgens et al. examined if
Discussion DM was associated with hip fracture type and increased postoperative
mortality [6]. The authors found that coupled with any hip fracture,
This study sought to quantify the severity of DM that is associated diabetes presents a 1.5x increased risk of mortality and higher rate of
with negative outcomes in the middle-aged and geriatric hip fracture inpatient medical complications. Similarly, a study by Rutenberg et al.
population. Our study found that patients with DM had higher rates of demonstrated a 1.4x higher 1-year mortality rate in diabetic patients
minor inpatient complications, 90-day readmission, 30-day and 1-year sustaining a fragility hip fracture when compared to a non-diabetic
mortality in the period following discharge, and a longer hospitaliza cohort [23]. While literature shows the DM population’s risk for
tion. Additionally, our study found that a hemoglobin A1c value of 8% worse outcomes following hip fracture, we believe it is also important to
or greater independently correlated with worse outcomes as patients identify how the severity of DM (measured by HA1c in this study) affects
with poorly controlled diabetes in this range had a higher risk of major outcomes.
inpatient complications and inpatient, 30-day, and 1-year mortality. In our analysis of the DM cohort, we found worse outcomes in pa
Our study found significant differences in baseline demographics tients with an HA1c>8%. This univariate finding was confirmed with a
between the DM and no DM cohorts. The DM cohort having a higher regression analysis that demonstrated an HA1c>8% was independently
mean CCI and STTGMA risk score are expected as the composite CCI associated with a 4.7x higher rate of inpatient mortality, 3.3x higher rate
score includes DM as one of the comorbidities, while the STTGMA score of 30-day mortality, and 5.2x higher rate of 1-year mortality when
utilizes the CCI score as a representation of each patient’s comorbidity controlling for other demographic variables. Our findings align with
profile. This study also highlighted a younger mean age and higher work by Rutenberg et al. who demonstrated similar results for patients
proportion of males in the DM cohort. This aligns with an epidemio with diabetes, showing heightened 1-year mortality and need for an
logical study by Kautzky-Willer et al. that found a higher rate of DM in intensive care unit following hip fracture [23]. In addition to analyzing
younger male patients [17]. Our DM cohort had a higher mean BMI the overall DM versus no DM cohorts, Rutenberg et al. provided evi
which again aligns with work by multiple authors that found a higher dence for the severity of DM being important in DM patient outcomes,
BMI in patients with diabetes [18,19]. Patients in our DM cohort were using the Diabetes Complications Severity Index Score (DCIS) as their
more likely to be non-White, a finding supported by the 2020 National severity metric. The DCIS score takes into account seven complication
Diabetes Statistics Report and work by multiple authors that demon categories, such as neuropathy, metabolic, and cardiovascular compli
strated a disproportionately higher rate of DM in multiple non-White cations. While Rutenberg et al. demonstrated worse outcomes for DM
and hip fracture patients using this DCIS score, one benefit to using
HA1c instead is that HA1c is comparatively easier to obtain (as it is one
Table 2
Hospital quality measures and outcomes of the overall cohort.
lab test versus a conglomerate of variables) and is thus more likely to be
adopted in middle-aged and geriatric hip fracture settings. Additionally,
Outcomes Diabetes No Diabetes Total P-
our study utilized the Charlson Comorbidity Index (CCI) which includes
Value
n (%) n (%) n (%) the severity of DM (none/diet controlled, uncomplicated, or end-organ
damage) as a value in the composite score, therefore accounting for
N 565 1865 2430
Complications
DM and the associated complications. Patients identified in these at-risk
Major Complications 70 (12.39%) 201 271 0.286 cohorts would likely benefit from early involvement of inpatient endo
(10.78%) (11.15%) crine/medicine teams with consistent outpatient follow-up with spe
Minor Complications 243 698 941 0.045 cialists for aggressive glucose management.
(43.01%) (37.43%) (38.72%)
The strength of these results is bolstered by our study’s relatively
Hospital Quality
Measures large N (565) for the DM cohort. However, this study has limitations.
LOS (d, *mean ± std) 7.02 ± 4.89 6.34 ± 4.29 6.50 ± 4.44 <0.01 First, this is a retrospective study that introduces the biases associated
Need for ICU 115 340 455 0.259 with this type of study design. We have sought to mitigate these biases
(20.35%) (18.23%) (18.72%) utilizing multivariable regression analyses and a comparison of de
Discharged Home 127 450 577 0.362
(22.48%) (24.13%) (23.74%)
mographics between cohorts. Second, the patients in this study were
Readmissions from a single urban academic medical center and related to a single
Within 30 days 53 (9.38%) 139 (7.45%) 192 (7.90%) 0.115 middle-aged and geriatric injury type, which may limit the generaliz
Within 90 days 98 (17.35%) 249 347 0.012 ability of our study findings. However, a study of major non-cardiac
(13.35%) (14.28%)
surgical outcomes by Underwood et al. found significant differences in
Mortality
Inpatient 16 (2.83%) 35 (1.88%) 51 (2.10%) 0.166 outcomes at 8% HA1c levels, corroborating that the 8% cutoff is a useful
Within 30 days 37 (6.55%) 81 (4.34%) 118 (4.86%) 0.033 clinical cutoff for risk stratification [24]. A portion of our DM cohort (n
1 Year 83 (14.69%) 204 287 0.049 = 110) did not have hemoglobin A1c labs drawn at their time of arrival,
(10.94%) (11.81%) therefore these patients were not included in the HA1c sub-analysis.
LOS=Length of Stay;. Aside from race, we found no differences in demographic variables
Table 3
Hospital quality measures and outcomes of the diabetic cohort stratified by hemoglobin a1c values on admission. post-hoc analyses utilizing the tukey test for anova
and adjusted cell residuals for the chi-square tests determine the significance of each specific HA1c cohort.
Outcomes NonDiabetes <6.5 6.5–6.9 7–7.9 8–8.9 9–9.9 10+ P-Value*
n (%) n (%) n (%) n (%) n (%) n (%) n (%)
N 1865 231 74 69 32 21 27
Complications
Major Complications 201 (10.78%) 20 (8.66%) 14 (18.92%) 7 (10.14%) 9 (28.13%) 6 (28.57%) 5 (18.52%) <0.001
Minor Complications 698 (37.43%) 90 (38.96%) 33 (44.59%) 30 (43.48%) 15 (46.88%) 9 (42.86%) 13 (48.15%) 0.788
Hospital Quality Measures
LOS (d, *mean ± std) 6.34 ± 4.29 6.98 ± 5.10 6.89 ± 4.33 6.59 ± 3.31 6.29 ± 2.21 9.70 ± 9.16 9.58 ± 11.13 0.066
Need for ICU 340 (18.23%) 52 (22.51%) 14 (18.92%) 10 (14.49%) 10 (31.25%) 5 (23.81%) 3 (11.11%) 0.227
Discharged Home 450 (24.13%) 64 (27.71%) 11 (14.86%) 19 (27.54%) 4 (12.50%) 3 (14.29%) 5 (18.52%) 0.098
Readmissions
Within 30 days 139 (7.45%) 19 (8.23%) 10 (13.51%) 10 (14.49%) 4 (12.50%) 1 (4.76%) 3 (11.11%) 0.778
Within 90 days 249 (13.35%) 39 (16.88%) 19 (25.68%) 12 (17.39%) 6 (18.75%) 3 (14.29%) 4 (14.81%) 0.988
Mortality
Inpatient 35 (1.88%) 4 (1.73%) 1 (1.35%) 0 (0.00%) 3 (9.38%) 3 (14.29%) 1 (3.70%) <0.001
Within 30 days 81 (4.34%) 17 (7.36%) 3 (4.05%) 0 (0.00%) 6 (18.75%) 4 (19.05%) 3 (11.11%) <0.001
1 Year 204 (10.94%) 37 (16.02%) 8 (10.81%) 4 (5.80%) 10 (31.25%) 8 (38.10%) 5 (18.52%) <0.001
LOS=Length of Stay; ICU=Intensive Care Unit;.

*
Post-hoc analysis highlighting 8–8.9 cohort in comparison to other HA1c cohorts <8%.
Table 4 Table 5
Hospital quality measures and outcomes of the diabetic cohort stratified by Multivariable binary logistic regression analyses assessing variables indepen
hemoglobin A1c >8% or <8% on admission. dently associated with each mortality time point.
Outcomes A1c >8% A1c <8% Total P- Multivariable Analyses for the Overall Cohort
Value Inpatient Mortality* Odds Standard 95% Confidence P Value
n (%) n (%) n (%) Ratio Error Interval
N 77 378 455 Age 1.047 0.018 1.011–1.085 0.010

Complications Female Gender 0.391 0.308 0.214–0.716 0.002
Major Complications 18 43 (11.38%) 61 (13.41%) <0.01 CCI 1.221 0.071 1.062–1.404 0.005
(23.38%) Ambulatory Status 1.851 0.232 1.174–2.918 0.008
Minor Complications 33 157 190 0.788 AO/OTA 0.105 0.690 0.027–0.406 0.030
(42.86%) (41.53%) (41.76%) Classification
Hospital Quality Hemoglobin A1c 4.668 0.475 1.841–11.841 <0.001
Measures >8%
LOS (d, *mean ± std) 7.81 ± 6.86 ± 4.34 7.02 ± 5.04 0.066
30 Day Mortality** Odds Standard 95% Confidence P Value
6.82
Ratio Error Interval
Need for ICU 16 78 (20.63%) 94 (20.66%) 0.926
(20.78%) Age 1.041 0.011 1.018–1.065 <0.001
Discharged Home 12 94 (24.87%) 106 0.098 Female Gender 0.551 0.202 0.371–0.819 0.003
(15.58%) (23.30%) CCI 1.228 0.047 1.119–1.348 <0.001
Readmissions Ambulatory Status 1.875 0.155 1.384–2.539 <0.001
Within 30 days 8 (10.39%) 39 (10.32%) 47 (10.33%) 0.778 Hemoglobin A1c 3.258 0.365 1.595–6.658 0.001
Within 90 days 13 70 (18.52%) 83 (18.24%) 0.988 >8%
(16.88%)
1 Year Mortality** Odds Standard 95% Confidence P Value
Mortality
Ratio Error Interval
Inpatient 7 (9.09%) 5 (1.32%) 12 (2.64%) <0.01
Within 30 days 12 21 (5.56%) 33 (7.25%) <0.01 Age 1.054 0.009 1.036–1.072 <0.001
(15.58%) Female Gender 0.472 0.150 0.352–0.632 <0.001
1 Year 23 49 (12.96%) 72 (15.82%) <0.01 CCI 1.301 0.037 1.210–1.399 <0.001
(29.87%) Ambulatory Status 1.690 0.120 1.335–2.138 <0.001
Hemoglobin A1c 5.166 0.364 2.531–10.547 <0.001
LOS=Length of Stay;.
>8%
CCI=Charlson Comorbidity Index.

between the excluded cohort and the remainder of the DM cohort *
Non-Significant Variables=Body Mass Index; Diabetes Diagnosis.
(Supplemental Table 1). Finally, our multivariable analysis considered **
Non-Significant Variables=Body Mass Index; AO/OTA Classification; Dia
patients without a diagnosis of diabetes to have a HA1c<8%. None of betes Diagnosis.
these patients had a Random Blood Sugar Test level >200 mg/dL which
met criteria for undiagnosed diabetes, therefore, we believe that the
Funding
HA1c estimation of <8% for non-diabetes patients to be appropriate
[15].
This study did not receive any specific grant from funding agencies in
the public, commercial, or not-for-profit sectors.
Conclusion
Ethical approval
While many patients with DM experienced worse outcomes than
those without, those with poorly controlled diabetes (HA1c>8%) at the This retrospective chart review study involving human participants
time of hip fracture injury experienced poorer outcomes compared to was in accordance with the ethical standards of the institutional and
those with well-controlled diabetes. Treating physicians must recognize national research committee and with the 1964 Helsinki Declaration
these patients with poorly controlled DM at the time of arrival to adjust and its later amendments or comparable ethical standards. The NYU
care planning and patient expectations accordingly.
Langone Health Office of Science and Research Institutional Review [10] Konda SR, Parola R, Perskin C, Egol KA. ASA physical status classification improves
predictive ability of a validated trauma risk score. Geriatr Orthop Surg Rehabil
Board (IRB) Langone approved this study. IRB approval was completed
2021;12:2151459321989534. https://doi.org/10.1177/2151459321989534.
before this particular study/manuscript started. [11] Konda SR, Ranson RA, Solasz SJ, Dedhia N, Lott A, Bird ML, et al. Modification of a
validated risk stratification tool to characterize geriatric hip fracture outcomes and
Declaration of Competing Interest optimize care in a post-COVID-19 world. J Orthop Trauma 2020;34:e317–24.
https://doi.org/10.1097/BOT.0000000000001895.
[12] Esper GW, Meltzer-Bruhn AT, Ganta A, Egol KA, Konda SR. Adaptive risk modeling:
All authors report no conflict of interest or financial disclosures. improving risk assessment of geriatric hip fracture patients throughout their
hospitalization. Injury 2022:S0020138322008622. https://doi.org/10.1016/j.
injury.2022.11.032.
Supplementary materials [13] Esper GW, Meltzer-Bruhn AT, Ganta A, Egol KA, Konda SR. Seasonality affects
elderly hip fracture mortality risk during the COVID-19 pandemic. Cureus 2022;14:
Supplementary material associated with this article can be found, in e26530. https://doi.org/10.7759/cureus.26530.
[14] Meltzer-Bruhn AT, Esper GW, Herbosa CG, Ganta A, Egol KA, Konda SR. The role of
the online version, at doi:10.1016/j.injury.2023.110862. smoking and body mass index in mortality risk assessment for geriatric hip fracture
patients. Cureus 2022;14:e26666. https://doi.org/10.7759/cureus.26666.
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Injury 54 (2023) 110872
Injury
Impact of Anesthesia selection on Post-Op Pain Management in Operatively

treated Hip Fractures
Jana M Davis a, Mario Cuadra a, Tamar Roomian a, Meghan K Wally a, Rachel B Seymour a, *,
Robert A Hymes b, Lolita Ramsey b, Joseph R Hsu a, EMIT Collaborative#
a
Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
b
Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Annandale, VA, USA
Keywords: Objectives: To determine if the use of Peripheral Nerve Block (PNB) versus Local Infiltration Analgesia (LIA) for
Pain hip fracture patients, affected opioid consumption in the early post-operative period.
Hip fracture Design: Retrospective cohort study
Anesthesia
Setting: Two level 1 trauma centers
Patients/Intervention: 588 patients with surgically treated AO/OTA 31A and 31B fractures between February
2016-October 2017 were included. 415 (70.6%) received general anesthesia (GA) alone, 152 received GA plus
perioperative PNB (25.9%), and 21 had GA plus LIA intra-operatively (3.6%). Median age was 82 years; pre
dominantly female (67%) and AO/OTA 31A fractures (55.37%).
Main Outcome Measures: Morphine Milligram Equivalents (MME) at 24 and 48 hours postoperatively, length of
stay (LOS) and the occurrence of any complication after surgery
Results: The PNB cohort was less likely to use any opioid than the GA group at 24 and 48 hours postoperatively
(OR: 0.36, 95% CI: 0.22-0.61 and OR: 0.56, 95% CI: 0.35-0.89 respectively). LOS ≥ 10 days had 3.24 times the
odds of 24- and 48-hour opioid administration compared to LOS ≤ 10 days (OR: 3.24, 95% CI 1.11-9.42; OR:
2.98, 95% CI 1.38-6.41, respectively). The most common complication was post-operative delirium, with PNB
more likely to present with any complication compared to GA (OR= 1.88, 95% CI 1.09-3.26). There was no
difference when comparing LIA to general anesthesia.
Conclusions: Our findings suggest PNB for hip fracture can help limit the use of post-operative opioids with
adequate pain relief. Regional analgesia does not seem to avoid complications such as delirium.
Introduction uncommon, with only 2% of patients under the age of 50 years. They
present different challenges in managing pain, as they report worse
Research on multimodal pain control strategies is increasing as a post-operative pain [5] and are more likely to misuse or abuse opioid
potential method to minimize opioid prescribing in response to the prescriptions [6]. As evidenced in the literature, opioid regimens pre
opioid epidemic[1,2]. These strategies may be especially important for scribed after an orthopaedic surgery frequently exceed inpatient opioid
older adults, particularly following hip fracture fixation. Minimizing use, up to double daily oral morphine equivalent dose 1. Because of these
opioid prescribing in the geriatric population is of particular interest as findings, along with a combined incidence of 90% of proximal femur
these patients are also at risk for polypharmacy and post-operative fractures between femoral neck and pertrochanteric fractures [7], there
delirium, in addition to risk of opioid use disorder and long-term has been a concerted effort to implement a more comprehensive
opioid use [3]. Furthermore, cognitively intact geriatric patients with multimodal pain management strategy to improve post-operative pain,
undertreated pain and inadequate analgesia were nine times more likely and potentially decrease the reliance on opioid therapy after major
to develop delirium than patients whose pain was adequately treated musculoskeletal surgery [3].
[4]. Younger patients with proximal femur fractures are rather The use of local infiltration analgesia (LIA), in which the surgeon
* Corresponding Author: Rachel B Seymour, PhD, 1320 Scott Ave, Charlotte, NC 28204, Phone: 704-355-6969
E-mail address: Rachel.seymour@atriumhealth.org (R.B. Seymour).
#
EMIT
J.M. Davis et al. Injury 54 (2023) 110872
injects a local anesthetic agent into the surgical field at the time of (3.6%). The PNB and LIA groups included some patients that had gen
surgery, has been previously studied in the total knee arthroplasty and eral anesthesia in addition to the regional anesthesia, as well as patients
total hip arthroplasty literature. Although it remains controversial, there who did not have general anesthesia. Patient demographic data can be
is evidence for reduced pain and opioid consumption and improved found in Table 1. The median age of all patients enrolled was 82 years
functional recovery, with lower rates of nausea and vomiting in the LIA (range 18-102). Most patients were female (67.18%), presented with
group[8]. Also, total arthroplasty patients have been shown to mobilize AO/OTA 31A fractures (55.37%), and experienced a fall (89.29%).
with physical therapy sooner and be discharged home quicker with the These patient characteristics differed significantly by group. Median age
addition of peripheral nerve block (PNB) [9]. This possible efficacy in was highest in the PNB group and lowest in the LIA group (85 and 77,
the arthroplasty setting suggests that this approach may have utility in respectively, p=0.0001). The LIA group was majority male, while the
the hip fracture setting. Although, the data for hip fracture surgery are PNB and general anesthesia alone group were majority female
far more limited, especially when fracture fixation is the choice of (p=0.0013). While the PNB and general anesthesia group were over
treatment[10], there is current research, including randomized whelmingly fractures due to falls (93.7% and 88.9%, respectively), the
controlled clinical trials, supporting the use of regional analgesia for local infiltration group had more variety in mechanism of injury (57.1%
patients with hip fractures to obtain pain control and decrease falls; p<0.0001). The PNB group had more 31B fractures than the other
post-operative opioid administration.[11–13] The current literature, two groups (p=0.0001).
however, has not shown benefits in reducing complications when The unadjusted and adjusted associations between anesthetic type,
compared to general anesthesia. demographic, clinical characteristics and opioid administration are
The purpose of this study was to investigate the use of PNB and LIA presented in Tables 2-3. Patient sex, MOI and AO/OTA fracture classi
for hip fracture patients and determine whether use of regional anes fication were not associated with opioid administration at either 24 or
thesia affected opioid consumption in the early post-operative period 48 hours in the univariate analysis. Characteristics that were significantly
while producing similar levels of pain relief. We hypothesized that both associated with opioid administration in the adjusted model were anes
types of regional anesthesia would be associated with lower opioid thesia type, length of stay > or equal to 10 days, and age > 65.
usage and fewer complications as compared to patients who received no At 24 hours post-surgery, patients in the PNB group were less likely
regional anesthesia. Finally, we sought to identify whether injury or than patients without regional anesthesia to use any opioid (OR=0.36,
patient-related factors (fracture type, mechanism of injury, length of 95%CI: 0.22-0.61). In the multivariable analysis, this finding remained
stay, patient age) were independently associated with pain scores and statistically significant (OR=0.42, 95%CI:0.25-0.73). At 48 hours after
use of opioids postoperatively. surgery the PNB cohort was less likely to use any opioid (OR=0.56, 95%
CI: 0.35-0.89) than the group without regional anesthesia; however,
Materials and methods PNB was not independently associated with opioid use in the multi
variable model (OR=0.65, 95%CI: 0.40-1.06). There was no statistically
After institutional review board approval, a retrospective cohort significant difference in opioid administration between LIA and no
review study was conducted of patients surgically treated for AO/OTA regional anesthesia or between LIA and PNB.
31A, 31B and 31C fractures at two level 1 trauma centers. Patients with Patients with lengths of stay of at least 10 days had three times the
operatively treated hip fractures at one of the two sites from February odds of both 24- and 48-hour opioid administration as compared to
2016 to October 2017 were included. Specifically, we included patients
with any type of fixation for AO/OTA 31A or 31B fractures. Patients
were excluded for incomplete records or missing data or if there were Table 1
bilateral or multiple same limb fractures. Patient Characteristics.
Patients were grouped into three cohorts: those having received No Regional PNB LIA All P-value
general anesthetic plus LIA on the surgical field, those who underwent Anesthesia
general anesthesia plus a perioperative peripheral nerve blockade N value 415 152 21 588
(PNB), and those who received general anesthesia alone. All patients Age, median 81 (70-87) 85 (76- 77 (60- 82 (72- 0.0001
(IQR) 90) 84) 88)
also received post-operative pain medication regimens per their treating
Range 18-102 60-102 25-94 18-102
surgeon’s protocol. Patient demographic data (age, sex, mechanism of <65 years 69 (16.63) 9 (5.92) 6 84 0.0009
injury), fracture pattern, length of stay, pain [Numeric Pain Rating Scale (28.57) (14.29)
(NPRS)], and use of general anesthetic were used to find correlations 65-84 years 192 (46.27) 64 10 266
between any opioid consumption at 24 hours and 48 hours and any post- (42.38) (47.62) (45.32)
85+ years 154 (37.11) 79 5 238
operative complication (including compartment syndrome, delirium,
(52.32) (23.81) (40.55)
postop fall, call to clinic for pain, postop pain readmission, infection, Sex
nonunion, and hardware failure). NPRS scores were reported numeri Female, n (%) 269 (64.82) 117 9 395 0.0013
cally and categorized as mild/none (0-4), moderate (5-6) severe (7-10). (76.97) (42.86) (67.18)
Male, n (%) 146 (35.18) 35 12 193
[14] Data were securely collected and stored in REDCap.[15]
(23.03) (57.14) (32.82)
Univariate and multivariable logistic or multinomial logistic Mechanism of
regression were conducted to describe associations between the type of Injury, n (%)
anesthesia administered, patient factors, and outcomes. Odds ratios and Fall 369 (88.92) 144 12 525 <0.0001
adjusted odds ratios were reported. P-values were adjusted for multiple (94.74) (57.14) (89.29)
Motor 25 (6.02) 2 (1.32) 6 33
comparisons using the Tukey-Kramer method. All statistical tests were
Vehicle/ (28.57) (5.61)
two-tailed and P-values <0.05 were considered statistically significant. Motorcycle
SAS software version 9.4 was used for all analyses (SAS Institute Inc., Other 21 (5.06) 6 (3.95) 3 30
Cary, NC, USA). (14.29) (5.10)
AO/OTA
Classification*
Results 31A 250 (60.24) 62 14 326 0.0001
(40.79) (66.67) (55.37)
A total of 588 patients met inclusion criteria. 415 patients (70.6%) 31B 165 (39.76) 90 7 262
received neither PNB or LIA (no regional anesthesia), 152 patients had (59.21) (33.33) (44.63)
Open Injury 8 (1.93%) 0 (0.00) 0 (0.00) 8 (1.36) 0.2046
PNB perioperatively (25.9%), and 21 patients had LIA intra-operatively
Table 2 Table 3
Odds of Opioids Administered during the 24 Hour Postoperative Period (n=587 Odds of Opioids Administered during the 48 Hour Postoperative Period (n=585
patients). patients).
Unadjusted Odds Ratios Adjusted Odds Ratios Unadjusted Odds Ratios Adjusted Odds Ratios
Odds 95 CL P-value Odds 95 CL P- Odds 95 CL P- Odds 95 CL P-
ratio ratio value ratio value ratio value
Regional Regional
Anesthesia Anesthesia
Nerve Block vs 0.36 (0.22- <.0001 0.42 (0.25- 0.0006 Nerve Block vs 0.56 (0.35- 0.0103 0.65 (0.40- 0.1014
No Regional 0.61) 0.73) No Regional 0.89) 1.06)
Local 1.64 (0.28- 0.7914 1.27 (0.20- 0.9503 Local 0.72 (0.24- 0.7756 0.63 (0.19- 0.6287
Infiltration vs 9.63) 8.05) Infiltration vs 2.21) 2.06)
No Regional No Regional
Nerve Block vs 0.22 (0.04- 0.1182 0.33 (0.05- 0.3551 Nerve Block vs 0.77 (0.24- 0.8576 1.04 (0.30- 0.9973
Local 1.32) 2.18) Local 2.44) 3.59)
Infiltration Infiltration
General 1.9 (1.17- 0.0096 1.44 (0.87- 0.1534 General 1.25 (0.80- 0.3367 1.02 (0.64- 0.9171
anesthesia 3.08) 2.39) anesthesia 1.95) 1.63)
(none=ref) (none=ref)
LOS LOS
0-9 days (ref) - - - 0-9 days (ref) - - -
10+ days 4.19 (1.49- 0.0065 3.24 (1.11- 0.0308 10þ days 3.13 (1.51- 0.0021 2.98 (1.38- 0.0053
11.77) 9.42) 6.46) 6.41)
Sex Sex
Female (ref) - - - Female (ref) - - -
Male 1.59 (1.00- 0.0514 1.12 (0.68- 0.6663 Male 1.24 (0.85- 0.2689 0.97 (0.65- 0.8858
2.54) 1.83) 1.82) 1.46)
Mechanism of Mechanism of
injury injury
Fall (ref) - - - Fall (ref) - - -
Motor vehicle 3.97 (0.70- 0.1479 0.62 (0.08- 0.8511 Motor vehicle 2.01 (0.68- 0.2859 0.54 (0.14- 0.5514
22.35) 5.00) 5.91) 2.14)
Other 2.3 (0.54- 0.3674 1.56 (0.35- 0.7678 Other 1.04 (0.40- 0.9948 0.74 (0.27- 0.7651
9.81) 6.99) 2.72) 2.05)
OTA OTA classification
classification 31A (ref) - - -
31A (ref) - - - 31B 0.80 (0.56- 0.2192 0.91 (0.63- 0.6126
31B 0.91 (0.60- 0.658 1.15 (0.74- 0.5296 1.14) 1.32)
1.38) 1.78) Age >= 65 0.28 (0.14- 0.0003 0.26 (0.12- 0.0011
Age >= 65 0.13 (0.04- 0.0008 0.17 (0.04- 0.0076 0.55) 0.59)
0.43) 0.62)
patients with a length of stay less than 10 days (OR = 3.24, 95% CI 1.11- Table 4
9.42; OR = 2.98, 95% CI 1.38-6.41, respectively). Conversely, age of 65 Complication Rates.
or older was associated with decreased odds of opioid administration at Complication No Regional PNB LIA
both 24- and 48-hours (OR = 0.17, 95% CI 0.04-0.62; OR = 0.26, 95% CI Anesthesia
0.12, 0.59). Post-op compartment 0 2 (1.3%) 0

Complications could not be modeled individually due to small syndrome
Delirium 32 (7.7%) 18 2 (9.5%)
numbers of each and were therefore pooled for analysis. A breakdown of
(11.8%)
the frequency of each complication type is provided in Table 4. The most Postoperative Fall 15 (3.6%) 11 (7.2%) 1 (4.7%)
common complication was post-operative delirium followed by post- Call to clinic for pain 3 (0.7%) 3 (2%) 0
operative falls. After controlling for length of stay, gender, mechanism Readmission for pain 5 (1.2%) 6 (3.9%) 0
of injury, age, and OTA classification, patients in the PNB were more Infection 12 (2.8%) 8 (5.2%) 0
Nonunion 5 (1.2%) 1 (0.6%) 1 (4.7%)
likely to present with any complication compared to patients who did Hardware Failure 11 (2.6%) 8 (5.2%) 0
not receive regional anesthesia (OR= 1.88, 95% CI 1.09-3.26).However,
the difference in complication rates when compared to local infiltration
was not statistically significant (OR= 2.09, 95% CI 0.42-10.29) Discussion
(Table 5).
There were no statistically significant differences by anesthesia type This study found that PNB was associated with decreased opioid
for reporting moderate or severe pain (as compared to mild/none) on utilization as compared to patients treated without regional anesthesia,
the first postoperative day (Table 6). On postoperative day 2, patients but patients treated with LIA had similar opioid utilization to those
treated with PNB were less likely to report moderate or severe pain than treated without regional anesthesia. Patients treated with PNB were
patients treated without regional anesthesia (OR=0.43, 95% CI 0.22- more likely to have complications than those treated without regional
0.84; OR=0.40, 95% CI 0.21-0.75, respectively). Additionally, patients anesthesia, while patients treated with LIA had similar complication
treated with PNB were less likely to report moderate or severe pain than rates to patients treated without regional anesthesia. Pain control was
patients treated with LIA (OR=0.06, 95% CI 0.004-0.953; OR=0.05, better in the PNB group compared to both no regional anesthesia and
95% CI 0.003-0.659, respectively). There was no difference when LIA. Patients with a long length of stay had higher odds of opioid use,
comparing LIA to no regional anesthesia. and patients age 65 or older had lower odds of opioid use. Otherwise,
patient-related factors were not independently associated with out
comes of opioid use, pain, or complications.
Table 5 general anesthesia alone and LIA. A systematic review of randomized

Odds of Any Complication (compartment, delirium, fall, call clinic for pain, controlled trials with 254 patients shows decreased pain associated with
readmit for pain, infection, nonunion, fail) (N=588). nerve blocks for hip fractures. Their primary outcome of pain showed
Unadjusted Odds Ratios Adjusted Odds Ratios significant mean difference of -2.13 point (in cm) (CI:-3.53,-0.72) on
Odds 95 CL P- Odds 95 CL P- visual analogue scale in the intervention group; however, the quality of
ratio value ratio value the evidence is low.[16] Another systematic review that included 31
Regional trials (1760 participants) found that peripheral nerve blocks reduced
Anesthesia pain on movement within 30 minutes of block placement (standardized
Nerve Block vs 1.95 (1.15- 0.0084 1.88 (1.09- 0.0191
mean difference (SMD) -1.41, 95% confidence interval (CI) -2.14 to
No Regional 3.30) 3.26)
Anesthesia -0.67).[17] They did not find any difference in risk of acute confusional
Local 0.85 (0.19- 0.9651 0.9 (0.19- 0.9867 state (risk ratio (RR) 0.69, 95% CI 0.38 to 1.27). One observational study
Infiltration vs 3.79) 4.23) also found significant pain score reduction and less opioid use in hip
No Regional fractures with preoperative FNB in subcapital femoral neck fracture,
Anesthesia
transcervical femoral neck facture, and intertrochanteric fracture.[18]
Nerve Block vs 2.29 (0.50- 0.4085 2.09 (0.42- 0.5267
Local 10.50) 10.29) They found more significant pain score reduction in intracapsular frac
Infiltration tures than in extracapsular fractures (P = 0.006). On average, the hip
General 0.84 (0.50- 0.5089 0.95 (0.56- 0.8407 fracture patients required 0.9 and 0.1 mg morphine equivalent/hour
anesthesia 1.41) 1.61)
before and after FNB block placement, respectively. Given that pain
(none=ref)
LOS relief is similar, regional analgesia might be a reasonable strategy to
0-9 days (ref) - - - attempt to reduce opioid consumption and/or avoid complications.
10+ days 1.22 (0.66- 0.5277 1.52 (0.79- 0.2082 Current research, including randomized controlled clinical trials,
2.25) 2.92) support the use of regional analgesia for patients with hip fractures to
Sex
decrease post-operative opioid administration.[11-13,19-21] One ran
Female (ref) - - -
Male 1 (0.64- 0.984 1.1 (0.69- 0.7 domized controlled trial by Beaudoin et al, conducted with 36 patients
1.54) 1.74) divided in 2 groups, 18 in each group, one with ultrasound guided
Mechanism of femoral nerve block (FNB) and the second managed with standard of
injury
care morphine parenteral, found that FNB patients had significantly
Fall (ref) - - -
Motor vehicle 0.42 (0.10- 0.3357 0.45 (0.09- 0.4693
reduced pain intensity over 4 hours, decreased amount of rescue anal
1.78) 2.24) gesia, and no appreciable difference in adverse events when compared
Other 1.8 (0.68- 0.3304 1.86 (0.67- 0.3222 to standard of care.[11] Foss et al. conducted a double blind randomized
4.74) 5.15) placebo-controlled trial with 48 patients in two groups of 24, one with
OTA classification
fascia iliaca compartment block (FICB) with mepivacaine plus intra
31A (ref) - - -
31B 1.4 (0.93- 0.1081 1.26 (0.83- 0.2796 muscular saline placebo, and the second with intramuscular morphine
2.11) 1.93) plus placebo block. They found that pain relief was superior in the FICB
Age >= 65 0.74 (0.39- 0.3489 1.07 (0.52- 0.8503 group both at rest (P < 0.01) and on movement (P = 0.02) and that
1.39) 2.20)
median total morphine consumption was 0mg compared to 6 mg in the
morphine group (P < 0.01).[12] These results are very similar to our
We found regional analgesia to have similar levels of pain relief when findings, particularly in elderly patients, which are the majority of pa
compared to no regional anesthesia (general anesthesia alone), with tients included in these trials. Furthermore, Abou-Setta et al., performed
PNB potentially providing improved pain relief when compared to a systematic review, finding 83 studies including 64 RCTs, and cate
gorically found that nerve blockade seems to be effective in reducing
Table 6
Adjusted Odds of Highest Pain Scores, Post op Days 1 and 2.
Highest Pain Score Highest Pain Score
Postop Day 1 Postop Day 2
N=512 N=472
Moderate Severe Moderate Severe
Ref = Mild/None
OR 95 CL OR 95 CL OR 95 CL OR 95 CL
Regional Anesthesia
Nerve Block vs No Regional Anesthesia 0.67 0.36-1.22 0.63 0.35-1.14 0.43 0.22-0.84 0.40 0.21-0.75
Local Infiltration vs No Regional Anesthesia 0.51 0.03-8.55 3.35 0.61-18.44 7.26 0.48-110.43 8.27 0.63-108.01
Nerve Block vs Local Infiltration 1.3 0.08-22.69 0.19 0.03-1.10 0.06 0.004-0.953 0.05 0.003-0.659
General anesthesia (none=ref) 1.33 0.77-2.31 1.96 1.10-3.50 1.0 0.55-1.81 1.17 0.65-2.08
LOS
0-9 days (ref) – – – – – – – –
10+ days 0.91 0.42-1.97 0.98 0.49-1.99 1.81 0.84-3.91 1.42 0.68-2.08
Sex
Female (ref) – – – – – – – –
Male 0.81 0.48-1.36 0.91 0.56-1.47 0.82 0.48-1.41 0.76 0.46-1.25
Mechanism of injury
Fall (ref) – – – – – – – –
Motor vehicle 0.22 0.02-2.14 0.42 0.09-2.00 0.33 0.04-2.81 0.74 0.15-3.79
Other 1.82 0.54-6.14 0.89 0.24-3.34 1.74 0.41-7.34 1.82 0.46-7.24
OTA classification
31A (ref) – – – – – – – –
31B 0.93 0.59-1.49 0.88 0.56-1.37 1.06 0.65-1.73 0.66 0.42-1.05
Age >= 65 0.35 0.11-1.15 0.08 0.03-0.24 0.46 0.15-1.35 0.16 0.06-0.40
acute pain after hip fracture, albeit not being able to draw firm con that the surgeons and anesthesiologists were free to choose the type of
clusions about the effect on complication reduction.[13] Most of the anesthesia based on the patient’s injury and medical co-morbidities.
studies presented similar rates of opioid use reduction, except for Foss Thus, patients with more medical co-morbidities or older patients may
et al., which showed greater reduction in opioid use than our findings. preferentially have been given one type of anesthesia over another. The
Much of the available literature investigating the effects of anesthetic multivariable analysis attempted to account for factors associated with
type on post-operative opioid use compares pain outcomes and com both the anesthesia type and outcomes, however, residual confounding
plications among patients receiving different types of anesthesia (i.e., may still have occurred. The two types of regional anesthesia (LIA and
LIA, general, regional, or neuraxial anesthesia), either separately or in PNB) were predominantly offered in one center (i.e., all LIA done at one
combination for hip fracture surgery.[22–24] While the findings are center and all PNB done at the other center). Therefore, the differences
predominantly favorable for pain control and achieving less opioid use attributed to the treatments might be due to unknown confounders by
with regional, the data is still conflicting regarding the avoidance of site. We also had a predominantly elderly population; results may not be
complications, particularly the cognitive ones.[25,26] In this regard, Liu generalizable to a young population, especially in regard to complica
et al. did a retrospective cohort study and found that, compared to tions such as delirium. In addition, our study is likely underpowered to
general anesthesia with intubation plus combined spinal-epidural detect differences due to the small number of patients in the LIA group in
anesthesia, general anesthesia with laryngeal mask plus nerve block particular. Furthermore, all patients in the LIA group were from one
had better postoperative analgesic effect and less disturbances on institution, while all of the PNB patients were from another institution.
intraoperative hemodynamics and postoperative cognition for elderly There may be institutional differences that are unaccounted for in this
patients undergoing intertrochanteric fracture surgeries.[24] This study study.
found that the Mini Mental State Exam was significantly lower in the
general anesthesia with intubation group than in the laryngeal mask Conclusion
plus nerve block (P<0.001). Compared to our study, they found lower
rates of cognitive complications with nerve block. Neuman et al. found This study found that PNB helps reduce opioid use in the 24 hours
in their large retrospective review of more than 18,000 patients having after surgery but does not help decrease complications, especially
surgery for hip fracture in New York in 2007 and 2008, that the use of delirium among older patients. We believe these findings contribute
regional anesthesia was associated with a 25 – 29 % reduction in major evidence to support the use of PNB for effective pain management in hip
pulmonary complications (odds ratio: 0.752, 95% CI 0.637, 0.887, P < fracture while limiting the use of post-operative opioids. However,
0.0001) and death (odds ratio: 0.710, 95% CI 0.541, 0.932, P = 0.014), further research is needed to determine the effect of PNB on specific
which adds to the body of evidence of safety and comorbidity reduction post-operative complications such as delirium, which could be related to
with regional anesthesia, with even greater reduction in complications anesthesia selection.
than our findings (odds ratio: 1.95, 95% CI 1.15-3.30, P = 0.0084),
albeit with a larger series.[25] Declaration of Competing Interest
We accounted for whether patient age played a role in pain presen
tation and the subsequent need for post-operative opioid administration The authors declare the following financial interests/personal re
following hip fracture stabilization. We found that increasing age was lationships which may be considered as potential competing interests:
associated with lower opioid utilization and was not associated with Dr. Hsu reports consultancy and speaker fees for Stryker, consultancy
reports of moderate or severe pain consistent with previously published and speaker fees from Smith & Nephew speakers’ bureau, soeaker fees
literature.[25–27] from Integra Lifesciences, and speaker fees from Depuy/Synthes.
Due to small numbers of total complications, we were unable to
analyze each complication individually. This finding was similar to a Acknowledgements
study by Debbi et al[23] who analyzed fascia iliaca peripheral nerve
blocks for differing types of hip fractures. In their study, complications None.
were analyzed as a secondary outcome measure with the fascia iliaca
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Injury 54 (2023) 110873
Injury
Shear’s role in non-union. Measuring mean angle of long bone

multi-fragmentary non-unions
Edward Allen a, *, James Houston b, Raymond M Smith c, Alex J Trompeter b
a
Royal Sussex County Hospital, Brighton & Sussex University Hospitals NHS Trust, Eastern Road, Brighton, United Kingdom
b
Department of Trauma and Orthopaedics, St Georges University Hospitals NHS Foundation Trust, Blackshaw Road, London, United Kingdom
c
Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
Keywords: Introduction: Both mechanical and biological theories have been proposed in the development of non-union. The
Non-union mechanical theory suggests that a high strain environment in a fracture will predispose it to non-union. While in
Multifragmentary simple fractures and wedge fractures there are only one and two primary fracture planes respectively, in multi-
Fracture
fragmentary fractures there are many and a non-union may form along any of the original fracture lines, however
Strain
Shear
the plane which experiences the highest strain is at 45O – the shear plane. We hypothesise that in multi-
Mechanical fragmentary fractures the initial fracture line that most often fails to unite will tend towards the plane with
the highest strain.
Objectives: 1) Define the mean non-union angle in a cohort of multi-fragmentary tibial and femoral fractures.
2) In wedge-like fractures within the cohort, define and compare the mean angle of initial fracture planes which
go on to form a non-union to those that unite
3) In comminuted fractures within the cohort, define the mean non-union angle
Design: Retrospective cohort study
Setting: Level-1 trauma centre
Methodology: Fractures were categorised into wedge-like and comminuted. A published technique was utilised to
measure fracture and non-union angles. In wedge-like fractures, united and non-united initial planes were
compared. In comminuted fractures only the mean non-union angle was defined. Demographic patient data was
also collected.
Results: 183 non-unions were screened, 68 patients were included. The mean non-union angle was 56◦ (SD 18)
across all fractures. In wedge-like fractures the mean non-union angle was 59◦ (SD 18). In comminuted fractures
the mean non-union angle was 50◦ (SD 19). Non-united initial fracture planes in wedge-like fractures showed a
peaked distribution about a mean of 58◦ while united fracture planes were distributed at the extremities of the
range.
Conclusions: In patients with multi-fragmentary fractures resulting in non-union, the mean tibial non-union angle
was 52◦ while the mean femoral non-union angle was 65◦ . In wedge-like fractures, non-unions occurred more
commonly than appropriate union in fractures between 41◦ -80◦ . The non-union angle is closer to 45◦ in
comminuted fractures than in wedge-like fractures. These results support the mechanical theory that strain from
the shear plane is an important factor in the formation of non-unions.
Level of Evidence: Prognostic level 3.
Introduction to the healthcare systems [2]. It has been suggested that

multi-fragmentary fractures are at a higher risk of forming non-union [4,
A non-union can be defined as the failure or cessation of the process 5].
of fracture healing [1]. Occurring in 5–10% of fractures [2], they have a Physiological bone healing depends on biological and mechanical
significant effect on patient quality of life [3] and incur significant cost factors [5,6]. Biological non-union risk factors include poor vascularity,
* Corresponding author at: Royal Sussex County Hospital, Brighton & Sussex University Hospitals NHS Trust, Eastern Road, Brighton, BN2 5BE, United Kingdom
E-mail address: edward.allen9@nhs.net (E. Allen).
E. Allen et al. Injury 54 (2023) 110873
infection, smoking, NSAID use [1,7] and high energy injuries [4]. The Methodology
mechanical factors that affect bone healing can be defined by stress, the
force experienced per unit area of a material, and by strain, the relative The population was formed from a retrospective study of a pro
movement due to applied stress [8]. Mechanical regulation of bone spectively collected database at St. George’s University Hospital, a level
healing, as described in Perren’s strain theory [6] and the work done by 1 major trauma centre in London, UK, and tertiary referral unit for the
Pauwels [9], requires the correct level of strain to elicit bone formation. management of non-union. All patients who presented with diaphyseal
Formation of bony callus as opposed to fibrous tissue will occur in low or metaphyseal non-unions were included.
but not absent strain environments [10]. Of the 183 patients screened, 3 were excluded due to being under
The shear strain within a fracture is caused by shear stress between [15] at the time of non-union treatment, 30 patients were excluded with
bone surfaces. In theory, & with all other variables controlled, the upper limb or lower limb non-unions that were not tibial or femoral, 28
fracture planes that experience the highest shear will be those at 45◦ to patients were excluded due to inadequate imaging and 54 patients were
the loading axis [11] (Fig. 1) as the translation of loading to shear stress excluded due to their initial fracture not being multifragmentary.
is greatest at this point. Houston et al. [12] investigated whether Adequate reduction was achieved in all patients that were included.
diaphyseal non-unions were associated with a particular geometric Fig. 2 demonstrates the methodology of exclusion used. A total of 68
orientation with respect to the anatomical axis. Their findings indicated patients were included in the study, their demographic data, including
that non-union angles tended towards a mean consistent with the shear age, sex, and affected bone, were recorded.
plane of 45◦ .
This new study builds on this research by considering only multi Defining fracture characteristics
fragmentary fractures that progress to non-union. Multi-fragmentary
fractures by their nature have multiple fracture planes allowing us to The cohort of fractures was categorised by fracture characteristics
observe which geometric fracture planes are more likely to fail to unite. into wedge-like fractures and comminuted fractures. Fractures with a
By broadening the search criteria to include metaphyseal fractures as butterfly-shaped segment defined by 2 fracture planes were classified as
well as diaphyseal in the cohort, we can also make the study more wedge-like fractures. Fractures with a wide area of skeletal injury and
representative of all fractures. non-distinct fracture planes were defined as comminuted fractures. In
If healing is incomplete in a multi-fragmentary fracture, an oblique wedge-like fractures with distinct fracture planes, the non-union may
uniplanar non-union typically forms along one of the original fracture only form along one of these initial fracture planes. In comminuted
lines [5,6,13]. Theoretically, a non-union can form along any of the fractures with multiple non-distinct fracture planes and a wide zone of
original fracture lines. By considering mechanical theories on the for skeletal injury, the non-union cannot be traced to an initial fracture
mation of non-union, high strain environments, defined as those with plane may form at any angle within the zone of injury.
greater than 10% strain, will play a key part in its eventual development
[6,9,14]. Mechanical modelling suggests that strain is greatest at 45◦ to Defining the initial fracture planes and non-union angles
the loading vector, and reduces as it moves further away from this angle.
Therefore, if strain predominates in the formation of non-union in a A fracture plane was defined as any characteristic fracture line on
multi fragmentary fractures, the most likely fracture to develop a plain radiographs that intersects both cortices or one cortex and another
non-union should be that which is closest to the 45◦ plane. fracture line. Using the plain radiographs taken soonest after initial
There are no published studies that have focused on the geometric fixation, the angle of any initial fracture plane was measured against the
properties of developing non-unions in multi-fragmentary fractures. anatomical axis of the bone. This methodology remained consistent with
Understanding the mechanisms behind the formation of these non- a previously published, standardised technique [12] . This technique
unions should allow for them to be better managed. This applies in used the anatomical axis of the bone (a line along the intermedullary
both the initial surgical treatment to prevent non-union, and in the canal that bisects the bone width in half [16]) and then drawing a second
management of non-unions once it has developed. Alternative fixation line between two points; either where the fracture plane passes through
techniques may be utilised to reduce strain in these high-risk planes to the cortex of the bone or between where the fracture plane passes
mitigate the effects of this serious complication. through the cortex and where it then meets another fracture plane. In
cases with a wide interruption of the cortex the point of the cortical
Fig. 1. Diagram showing the planar translation of compressive forces (P) to shear stress (τ) & normal force (σ)[11].
Fig. 2. Schematic flow chart of population formation.
break furthest from the centre of the non-union was used. The angle of Determining the initial fracture plane that went on to form a non-union
one line relative to the other can then be measured. Two orthogonal
plain films were used for each case. Using the anatomical axis, rather In wedge-like fractures a visual estimate of which initial fracture
than mechanical axis, allowed the use of radiographs that did not plane shared the most similar morphological characteristics to the
include the joints above and below the fracture. The angle of non-union subsequent non-union was performed (as demonstrated in the image
was measured using the same technique used to measure the angle of below). This primary initial fracture plane was then highlighted in the
initial fracture planes. For those categorised as wedge-like fractures all results and denoted as the non-united initial fracture plane with all others
initial fracture planes and non-union angles were measured; in commi denoted as united initial fracture planes. This method was used to avoid
nuted fractures, only the non-union angle was measured. While the the assumption that the initial fracture plane that was closest in angle to
mechanical axis is typically accepted to be the same as the anatomical the non-union must be the fracture plane that formed the non-union.
axis in the tibia, in the femur there is a difference of approximately 6 ◦ . Primary initial fracture planes were only determined in wedge-like
Therefore, a corrected value with a difference of plus or minus 6◦ fractures since only two fracture planes existed. In comminuted frac
depending on the orientation of the fracture plane was also presented tures, those with three or more planes that often intersected each other,
separately in the results. it was not possible determine a measurable single initial fracture plane
The method for measuring both the initial fracture plane angles and that correlated with a resultant non-union.
the non-union angle is shown in Figs. 3 and 4. The method used resulted
in angles that approach 0◦ as the fracture plane approaches the
Estimating a single fracture or non-union plane
anatomical axis.
The true angle of the measured plane may lie anywhere between the
AP and lateral measurements. As the image of the fracture plane rotates
Fig. 3. Schematic diagram of fracture plane measurement.
Fig. 4. Example of fracture plane measurement on AP film of tibia after intramedullary nail fixation.
the apparent angle will decrease until a point where the cortices in
Table 1
tersections are no longer visible. As the true angle of the non-union plane
Descriptive statistics for the demographic and clinical features of the cohort.
must be estimated from plain radiographs, rather than directly
Frequencies and percentages are shown.
measured, this was achieved by taking the larger of the two orthogonal
measurements to best represent the “approximate true plane”. This is Clinical Characteristic Frequency (Percentage)
consistent with the true angle estimation technique used in Houston Sex
et al.[12]. Male 52 (76%)
Female 16 (24%)
Age
Mean 46
Statistical analysis Range 20–84
Bone
The united and non-united initial fracture planes as well as non- Femur 23 (33%)
union angles measured, along with demographic data, were tabulated. Tibia 47 (67%)
Fracture Characteristic
SPSS v. 26 was used to carry out statistical analysis. In wedge-like Wedge-like 49 (70%)
fractures the means of the united and non-united fracture planes and Comminuted 21 (30%)
the mean angle of non-union were calculated in both AP and Lateral Number of Fracture Planes
planes. In comminuted fractures only the mean of non-union angles was 2 49 (70%)
3 8 (11%)
calculated in AP and Lateral planes. Histograms were plotted to illus
4 5 (7%)
trate the frequencies of united and non-united initial fracture planes and 5 7 (10%)
non-union angles. For comparison of means independent T-tests were 6 1 (2%)
used. Initial Fixation Technique All Tibia Femur
External Fixation 18 18 0
Intramedullary Nail 29 14 15
Results Plate 21 13 8
Intramedullary Nail + Plate 2 1 1
Population statistics Fracture Location Proximal Mid-shaft Distal
Tibia 5 21 20
Tibial External Fixation 3 6 9
In total 68 patients were included; the demographics of the popu Tibial Nail 0 12 2
lation are shown in Table 1. Two patients developed non-unions in 2 Tibial Plate 2 3 8
separate bones. In total 70 fractures and non-unions were measured. 49 Tibial Nail + Plate 0 0 1
(70%) were wedge-like fractures while 21 (30%) were comminuted. 23 Fracture Location Proximal Mid-shaft Distal
Femur 6 13 5
(33%) of the fractures were femoral and 47 (67%) tibial. The majority, Femoral Nail 5 7 2
42 (60%), of fractures were wedge fractures composed of 3 fragments. Femoral Plate 0 5 3
and therefore 2 fracture planes. 40% of the fractures had 4 or more Femoral Nail + Plate 1 0 0
fragments, and therefore 3 or more fracture planes. The initial fixation
techniques used were external fixation, 18 (26%), intramedullary nail,
Distributions
29 (41%), plate, 21 (30%), and intramedullary nail + plate, 2 (3%).
The distribution of approximate true non-union planes is shown in

Non-unions Fig. 5 and the distribution of non-union angles on both AP and lateral
views are shown in Fig. 6.
The descriptive statistics, including mean non-union angles, for the The distribution of approximate true planes for united and non-
entire cohort are shown in Table 2 while Tables 3 and 4 show the same united initial fracture planes and the relevant trendlines are shown in
descriptive statistics for comminuted and wedge-like fractures respec Fig. 7.
tively. Additionally, Table 4 shows the mean angle of united and non-
united initial fracture planes in wedge-like fractures. Further descrip
tive statistics are shown in Table 5.
Table 2 Table 4
Descriptive statistics for the outcome measure of non-union angle for tibial, Descriptive statistics for outcome measures of non-union angle, united and non-
femoral & all fractures measured on AP and lateral view or approximate true united initial fracture planes in wedge-like fractures measured on AP and lateral
plane estimate. view or approximate true plane estimate.
Characteristic (View) Angle (degrees) Wedge-like Fractures
Non-Union (approximate true All Tibial Femoral Corrected Characteristic (View) Angle (degrees)
plane) Femoral
Non-Union Angle (approximate true plane) All Tibial Femoral
Mean 56.34 51.72 65.21 63.67 Mean 58.96 54.97 67.19
Standard Deviation 18.32 18.08 15.25 15.23 Standard Deviation 17.58 17.29 14.64
Range 21–88 21–88 35–86 35–87 Range 28–88 28–88 35–86
Non-Union Angle (AP) Non-Union Angle (AP)
Mean 49.74 46.46 56.04 52.04 Mean 53.76 50.67 58.25
Standard Deviation 18.87 17.25 20.18 21.54 Standard Deviation 18.42 17.10 19.77
Range 19–88 19–88 20–86 14–87 Range 27 - 88 28–88 30–86
Non-Union Angle (Lateral) Non-Union Angle (Lateral)
Mean 49.54 45.39 57.5 – Mean 50.18 47.06 58.56
Standard Deviation 18.59 18.41 16.17 – Standard Deviation 18.54 18.41 17.74
Range 13–88 13–88 31–83 – Range 13 - 86 23–86 32–83
Mean Angle of United Fracture Planes (approximate true plane)
Mean 46.69 44.08 56.07
Standard Deviation 21.61 21.33 23.23
Table 3 Range 12–88 12–89 19–86
Descriptive statistics for the outcome measure of non-union angle in commi Mean Angle of United Fracture Planes (AP)
nuted fractures measured on AP and lateral view or approximate true plane Mean 37.05 34.95 42.50
estimate. Standard Deviation 24.09 22.20 26.84
Range 4–88 4–88 11–86
Comminuted Fractures Mean Angle of United Fracture Planes (Lateral)
Characteristic (View) Angle (degrees) Mean 37.24 37.32 37.05
Non-Union Angle (approximate true plane) Standard Deviation 21.94 20.01 25.59
Mean 50.24 Range 7–84 9–79 7–84
Standard Deviation 18.54 Mean Angle of Initial Fracture Plane That Failed to Unite (approximate true
Range 21 - 88 plane)
Non-Union Angle (AP) Mean 57.98 54.00 66.2
Mean 40.38 Standard Deviation 16.90 16.27 14.91
Standard Deviation 16.43 Range 27 - 89 28–89 31–86
Range 19 - 81 Mean Angle of Initial Fracture Plane That Failed to Unite (AP)
Non-Union Angle (Lateral) Mean 52.71 50.33 57.25
Mean 48.05 Standard Deviation 17.81 16.76 19.21
Standard Deviation 18.62 Range 27 - 89 27–89 29–86
Range 20 - 88 Mean Angle of Initial Fracture Plane That Failed to Unite (Lateral)
Mean 48.86 45.06 58.06
Standard Deviation 17.62 16.30 17.78
Range 19 - 79 19–79 27–78
Subgroup analysis
Fractures were grouped by age, sex, fracture location, number of 90◦ , where a perfectly transverse fracture would be measured to have an
fracture planes and fixation technique. The means of the initial fracture angle of 90◦ . Our results reflect the experience that although longitu
planes and non-union angles when categorised by these parameters were dinal fracture lines do occur, they are seen less often than oblique or
compared for significant difference. transverse fractures. As a fracture plane becomes more transverse the
There was no significant difference in the means of initial fracture surface area decreases. From the shear equation presented, shear will
planes or non-unions when results were grouped by sex, age, fracture increase as surface area decreases. While 45◦ produces the largest shear
location, number of fracture planes or initial fixation technique. stress value for a constant area a smaller area will also contribute to a
The means of non-united and united initial fracture planes within greater level of shear across the whole fracture plane. These observa
wedge-like fractures were compared. This showed a statistically signif tions may, somewhat, explain the skewing of our means above the angle
icant difference between these means on both AP and lateral views. The expected.
p-values for this statistical testing are shown in Table 6. Further sub Tibial non-union angles approach 45◦ , for AP & lateral views the
group analyses are shown in Table 7 - 10. non-union angles are within 1.5◦ of the shear plane while the approxi
mate true non-union angle is just under 7◦ more transverse (Table 2). In
Discussion contrast to the tibia, the anatomical and mechanical axes of the femur
vary by between 5–7◦ on an AP view [17]. If corrected to a theoretical
This study presents an analysis of the geometric form of non-union mechanical axis, femoral non-union values become closer to the shear
resulting from lower limb, multi-fragmentary fractures. This study is plane. However, they remain more transverse compared to the
the first to provide data to support the role that shear plays in the for non-union angles of the tibia.
mation of non-unions in multi-fragmentary fractures. Tibial & femoral Non-united fracture planes form a peaked distribution around 58◦
non-union angles are likely to be closer to the shear plane than the while united fracture planes were distributed at both extremities of the
fracture lines that go on to unite (Fig. 7). The mean tibial non-union total range (Fig. 7). The increased frequency of united planes as their
angle was 52◦ and the mean femoral non-union angle 65◦ . The data angles approach 0◦ and 90◦ suggests that more transverse or longitudi
presented supports the mechanical theory of bone healing and in nal planes are more likely to unite. While an increased frequency of
particular the importance of the shear plane in contributing to the united planes as angles approach 0◦ (longitudinal) may support surface
development of non-union. area rather than shear stress predominating in the process of bone
The mean non-union angle is higher than the 45◦ our hypothesis healing, however, the increase in union over non-union as angles
suggests. This could be due to the practical distribution of fracture lines. approach 90◦ does not. The increased frequency of non-united planes
The distribution of these fracture lines is unlikely to be equal from 0◦ to
Table 5 around the centre of the range suggests around this point there is a
Descriptive statistics comparing the fixation technique effect on outcome mea greater likelihood of non-union. Observing a peaked distribution, in
sures of non-union angle for tibial & femoral fractures measured on AP and place of a single angle at which non-unions occur, suggests that several
lateral view or approximate true plane estimate. agents contribute, including biological, as well as mechanical factors.
Tibial In multi-fragmentary fractures, the mean non-union angle trends
Frame Nail Plate closer to 45◦ than in wedge-like fractures (Table 4). This further sup
Non-Union (approximate true plane) ports the role of shear in non-union. This is due to the non-union forming
Mean 52.05 58.71 42.08 somewhere within a ‘zone of skeletal injury’ instead of over a primary
Standard Deviation 19.26 15.75 12.12 fracture plane. Our data suggests that shear force will determine the
Range 22–88 30–88 21–66
angle within the zone of skeletal injury where a non-union will form.
Non-Union Angle (AP)
Mean 44.65 50.93 38.54 The most common initial fixation techniques were intramedullary
Standard Deviation 19.13 16.78 10.45 nails in femoral non-unions and external fixation in tibial non-unions.
Range 19–79 30–88 21–66 Plating was less common in both tibial and femoral non-unions and
Non-Union Angle (Lateral)
plate + nail fixation being the least common of all. This simply reflects
Mean 45.8 50.29 38.69
Standard Deviation 21.24 16.11 11.40 local practice patterns. Table 5 outlines the mean non-union angles
Range 13–88 25–71 20–59 between fixation modalities. Tibial non-unions that were initially plated
Femoral had a mean closest to the theoretical shear plane while the mean of those
Plate Nail that were initially managed with intramedullary nailing was further
Non-Union (approximate true plane)
from the theoretical shear plane. The difference in means between tibial
Mean 69.88 62.60
Standard Deviation 15.95 14.76 fractures fixed with intramedullary nails and plates was statistically
Range 35–83 44–86 significant (Table 7), while all other differences in means were not
Non-Union Angle (AP) statistically significant (Tables 6,8,9,10). Without a comparative control
Mean 68.00 51.60
group of fractures that went on to unite, conclusions cannot be made on
Standard Deviation 16.19 19.00
Range 20–81 43–86
whether one surgical treatment modality is more or less likely to result
Non-Union Angle (Lateral) union. These data do suggest that there is a significant difference in the
Mean 57.88 56.67 mechanical environment experienced by fractures fixed by intra
Standard Deviation 12.00 18.30 medullary nailing and plating, with intramedullary nailing having a
Range 27–78 44–87
greater effect on this environment than plating. However, further
investigation with greater statistical power should be undertaken to
Fig. 5. Histogram of approximate true non-union angles for entire population.
Fig. 6. Histogram of non-union angles for entire population for both AP and Lateral views.
Fig.. 7. Histogram of approximate true united and non-united initial fracture plane angles with respective trendlines.
Table 6 Table 10
Statistical mean analysis of united and non-united initial fracture planes in Statistical mean analysis of non-union angles in tibial fractures fixed with plate
wedge-like fractures measured on AP and lateral views. vs frame.
AP Lateral AP Lateral Approximate True
N Mean P Value N Mean P Value Plane
A N Mean P Value Mean P Value Mean P Value
Non-united 49 52.71 <0.001 49 48.86 0.030
United 58 37.05 60 37.24 Frame 18 47.00 0.132 44.89 0.329 51.83 0.113
Plate 13 38.54 38.69 42.08
Table 7 predisposes it to do so. Perren suggests that the level of strain determines
Statistical mean analysis of non-union angles in femoral fractures fixed with cellular differentiation and in turn tissue formation [6]. In Pauwels’
plate vs intramedullary nail.
theory of tissue differentiation, Pauwels suggested that mesenchymal
AP Lateral Approximate True stem cells under compression will differentiate into chondrocytes, while
Plane
shear stimulates mesenchymal stem differentiation into fibroblasts. It is
only when the environment around the soft tissues has stabilised that
Nail 15 51.60 0.061 56.67 0.854 56.67 0.331 osteoblast differentiation is favoured [9,18]. Claes et al. (1998) [14]
Plate 8 68.00 57.88 57.88
found that as strain increases from zero to 5% osteoblast proliferation
increases but above this point it will decrease [14]. Perren suggested
that an environment where strain remains below 2% is required for
Table 8 lamellar bone while woven bone may form in the presence of strain up to
Statistical mean analysis of non-union angles in tibial fractures fixed with plate 10%. Once an environment exceeds these optimal strain levels, fibro
vs intramedullary nail.
blast differentiation predominates, leading to fibrous tissue formation
AP Lateral Approximate True and net bone resorption.
Plane
Strain is defined as the amount of deformation of a material when a
force is applied. This is dependant on the Young’s modulus of the ma
Nail 14 50.93 0.036 50.29 0.048 58.71 0.007 terial and the stress the material is put under. In the case of fractures, the
Plate 13 38.54 38.69 42.08
stress that causes deformation is the shear stress between the adjacent
surfaces of the fracture. Shear stress is dependant on the force applied
and the angle at which the force is acting in relation to the plane in
Table 9 question. The equation for shear stress under axial loading is τ = (P/A)*
Statistical mean analysis of non-union angles in tibial fractures fixed with frame (sin θ)*(cos θ) [19] where P = force and A= surface area of the plane. As
vs intramedullary nail.
such, if force and area remain constant the angle which will produce the
AP Lateral Approximate True greatest shear stress is 45◦ . Normal stress acts perpendicular to the
Plane
fracture surface, the formula for which is σ = (P/A)*(cos θ) [2]. The
planes at which normal stress is at its maximum, and minimum, are at
Nail 14 50.93 0.550 50.29 0.442 58.71 0.299 0◦ and 90◦ . At these planes shear stress is at a minimum 11. As strain is
Frame 18 47.00 44.89 51.83
dependant on stress, it follows that the fracture planes that experiences
the highest strain will be those at 45◦ . In simple terms a fracture plane at
confirm this. The authors also note that compression fixation of a frac 45◦ will experience maximal translation of compression stress to shear
ture in conjunction with any of the treatment modalities could be used to stress, in turn leading to maximal strain [11]. From a mechanical
reduce the strain environment and potentially reduce the risk of non- standpoint therefore, the fractures most likely to form non-unions are
union. those that occur at 45◦ , as this is where the highest levels of strain will be
Non-unions that occur after multi-fragmentary fractures may form found. The femoral and tibial multi-fragmentary fractures investigated
along any of the initial fracture planes. It follows that the fracture plane allow us to define the mean angle of fracture planes that went on to form
that goes on to form a non-union must bear some characteristic that non-unions and the mean angle of their resultant non-unions.
We recognise certain limitations in this study. Although adequate, and in turn the mechanical strain experienced by a fracture are impor
the sample size remains small, leading to a large standard deviation. We tant factors in the formation of non-unions.
will recommend other institutions confirm or refute the findings of these
of relatively rare events by attempting to reproducing the study. A larger Other information
sample size in future studies may allow for comparison between non-
unions by fixation technique, fracture location and other possible sub- There was no funding received for this study and there are no con
categorisations of the population. This may be particularly relevant flicts of interest
with fixation technique as the inclusion of fractures that were fixed with
axially stabilised locked medullary nails as well as other fixation tech Source of funding
niques may have affected the reliability of non-union analysis. Further
investigation may also wish to include multi-fragmentary fractures that No funding was received for this study.
went on to heal appropriately, which would allow comparison of the
characteristics of multi-fragmentary fractures that unites compared to
those that don’t. Declaration of Competing Interest
The measurement technique allows for subjectivity in interpreting
the exact exit point of a fracture line on a cortex, especially in the The authors declare the following financial interests/personal re
presence of callus formation in non-union. Further studies should lationships which may be considered as potential competing interests:
involve multiple observers to increase the reliability of their measure AT provides consultancy for R&D to Stryker. AT is on the speaker’s
ments. The radiographs themselves varied in resolution quality, which bureau for Stryker, Smith and Nephew and Orthofix. For the remaining
made the interpretation of some fracture planes less accurate. Addi authors none were declared.
tionally, assumptions were made that the two images (AP and lateral)
were taken in an orthogonal manner although this was not standardised. Acknowledgments
Future studies could consider 3 dimensional reconstructions of the
fractures as a means of taking measurements. No further acknowledgments
This study did not include a formal control group; comparing a multi-
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Injury 54 (2023) 110875
Injury
Emergency Severity Index (ESI) algorithm in trauma patients: The impact of

age during the pandemic
Melissa K. James a, Amarachukwu Okoye b, Venus Wahab c, Shadenie Bolton d, Shi-Wen Lee d, *
a
Department of Surgery, Jamaica Hospital Medical Center, New York, United States of America
b
Department of Surgery, SUNY Upstate Medical University, New York, United States of America
c
William Carey University College of Osteopathic Medicine, Mississippi, United States of America
d
Department of Emergency Medicine, Jamaica Hospital Medical Center, New York, United States of America
Keywords: Objective: The ESI algorithm is widely used to triage patients in the emergency room. However, few studies have
ESI assessed the reliability of ESI to accurately triage trauma patients. The aim of this study was to compare vital
Triage signs, resource utilization, and patient outcomes among trauma patients during the pandemic in 2020 vs. the
Emergency severity index
previous year prior to the pandemic.
Trauma
COVID-19
Methods: This retrospective study was conducted over a 24-month period at an urban adult level one trauma
Geriatric center. Demographic and clinical characteristics, resource utilization, and patient outcomes were extracted from
the electronic medical records and trauma registry. Trauma patients assigned ESI level 2 were stratified by age
(<65 years and ≥ 65 years) and year (2019 vs. 2020) for data analysis.
Results: A total of 3,788 trauma patients were included in the study. Males represented 68.4% (2,591) of patients
and the median age was 50 years (IQR: 31, 69). The majority of patients were assigned ESI level 2 (2,162, 57.1%)
and had a blunt mechanism of injury (3,122, 82.4%). In 2020, patients <65 years of age utilized less resources
compared to 2019 (p < 0.001). Likewise, patients >65 years of age required less lab tests [OR: 0.1, 95% CI: (0.05
– 0.4)], IV fluids [OR: 0.2, 95% CI: (0.2 -0.3)], IV medications [OR: 0.6, 95% CI: (0.4 - 0.7)], and specialty
consultations [OR: 0.4, 95% CI: (0.3 -0.5)] compared to 2019 (p < 0.0001). Within 2020, vital signs and re
sources utilized between younger and elderly patients varied significantly (p < 0.01). Correspondingly, the
clinical outcomes between younger and elderly patients within 2020, differed significantly (p < 0.01).
Conclusions: The COVID-19 pandemic affected the triage of trauma patients. During 2020, patients utilized less
resources compared to the previous year. Additionally, younger and elderly patients had different vital signs,
resource utilization, and clinical outcomes although both being assigned ESI level 2. Younger trauma patients
may have been over-triaged in 2020 due to the COVID-19 pandemic.
Introduction States [5]. The ESI is a five-level ED triage algorithm that provides
clinically relevant stratification of patients into five groups from 1 (most
Emergency departments (ED) encounter high patient volumes, urgent) to 5 (least urgent) on the basis of acuity and resource needs [6,
overcrowding, and various complex diseases. Thus, effective triage is 7].
required when demand outweighs capacity as is seen in most emergency ESI has been shown to be valid and reliable in a wide range of patient
departments. Due to limited resources, the objective of triage is to populations [8–12]. However, only a few studies have assessed the
identify patients with critical conditions and prioritize their care over validity of its use in trauma patients. One study showed the ESI tool to be
more stable patients. Triage systems are similar at their core and share valid in calculating resources used by traumatic brain injury patients; it
the goal of identifying and prioritizing patients with time sensitive needs suggested that the ESI may be used to predict mortality [13]. The
[1,2]. They also prevent triage errors, which can result in increased principle of caring for patients with trauma is providing timely care.
morbidity and mortality [3,4]. There are various triage systems but the Trauma care can create an environment for medical errors due to un
Emergency Severity Index (ESI) is the most widely used in the United stable patients, incomplete histories, time sensitive decisions,
* Corresponding author at: Department of Emergency Medicine, Jamaica Hospital Medical Center, 8900 Van Wyck Expressway, Jamaica, NY 11418.
E-mail address: slee@jhmc.org (S.-W. Lee).
M.K. James et al. Injury 54 (2023) 110875
involvement of many disciplines and highly stressed providers. The ESI Table 1
handbook suggests that trauma patients with a high risk mechanism of Demographics, mechanism of injury, and acuity (2020 vs. 2019).
injury should be categorized as ESI level 2 [6,7]. If the patient presents Variable All 2019 2020 Difference
with unstable vital signs and requires immediate intervention then the patients
patient should be triaged as ESI level 1 [6,7]. However, in hospitals that N=3788 N=1660 N=2128 (95% CI)
are designated trauma centers there are often specific criteria for the Age (years) 50 (31, 69) 54 (33, 73) 47 (30, 67) -7 (-6 - -3)
triage of trauma patients [14,15]. Trauma triage algorithms are usually Sex
based on physiological parameters, specific injuries, underlying mech Male 2591 1055 1536 8.7 (5.6 – 11.7)
(68.4) (63.5) (72.2)
anism of injury, and Glasgow Coma Scale (GCS) among other factors Female 1197 605 (36.4) 592 (27.8) -8.6 (5.6 – 11.7)
[14–16]. These factors are used to determine the personnel and re (31.6)
sources needed [8,15]. Race
In comparison to younger patients, geriatric patients often have White 1412 627 (37.8) 785 (36.9) -0.9 (-2.2 – 4)
(37.3)
underlying co-morbidities that can confound their treatment and result
AA/Black 1303 537 (32.3) 766 (36) 3.6 (0.6 – 6.7)
in higher mortality and complication rates following a traumatic injury (34.4)
[17,18]. Therefore, it’s plausible that geriatric trauma patients are more Asian 142 (3.7) 39 (2.3) 103 (4.8) 2.5 (1.3 – 3.7)
likely to be under-triaged when using the ESI tool. Several studies have Other 931 (24.6) 457 (27.5) 474 (22.3) -5.2 (2.4 – 8.1)
assessed the validity of the ESI triage algorithm in triaging geriatric Ethnicity
Hispanic 943 (24.9) 416 (25.1) 527 (24.8) -0.3 (-2.5 – 3.1)
patients. Some studies have suggested that utilizing the ESI tool is an Non-Hispanic 2845 1244 1601 0.3 (-2.5 – 3.1)
effective way to triage geriatric patients, while other studies suggested (75.1) (74.9) (75.2)
that geriatric patients were under-triaged when the ESI tool was used Arrival Mode
[19–24]. In the early phase of the pandemic, geriatric patients were EMS 3188 1369 1819 3 (0.6 – 5.4)
(84.2) (82.5) (85.5)
considered high risk and more vulnerable to infection. Whether or not
Non-EMS 600 (15.8) 291 (17.5) 309 (14.5) -3 (0.6 – 5.4)
this had an effect on ED triage and assignment of an ESI level is un Injury Type
known. The aim of this study is to compare vital signs, resource utili Blunt 3122 1447 1675 -8.4 (6 – 10.8)
zation, and patient outcomes among younger and elderly trauma (82.4) (87.2) (78.7)
patients during the pandemic. We hypothesized that all trauma patients Penetrating 634 (16.7) 201 (12.1) 433 (20.3) 8.2 (5.9 - 10.6)
Burn 18 (0.5) 9 (0.5) 9 (0.4) -0.1 (-0.4 – 0.7)
were over-triaged during 2020 compared to the previous year and that
Other 14 (0.4) 3 (0.2) 11 (0.5) 0.3 (-0.1 – 0.8)
elderly patients were over-triaged when compared to younger patients ESI Level
during the same time period. 1 323 (8.5) 123 (7.4) 200 (9.4) 2 (0.2 – 3.8)
2 2162 826 (49.8) 1336 13 (9.8 – 16.2)
(57.1) (62.8)
Methods
3 1231 666 (40.1) 565 (26.5) -13.6 (10.5 -
(32.5) 16.6)
This retrospective study included trauma patients, over a 24-month 4 71 (1.9) 44 (2.6) 27 (1.3) -1.4 (0.5 - 2.4)
period, who presented to the Emergency Department (ED) at an 5 1 (0.03) 1 (0.06) 0 (0) -0.06 (-0.2 –
urban, adult, level 1 trauma center. ESI triage level, vital signs, resource 0.4)
Pre-existing 2177 913 (55) 1264 4.4 (1.2 – 7.6)
needs, and clinical outcomes were obtained from the trauma registry
Condition (57.5) (59.4)
and electronic medical records. This study was approved by the Insti
tutional Review Board; patient consent was not required. AA, African American; EMS, emergency medical services; ESI, emergency
severity index; CI, confidence interval.
Study setting
initial triage due to the following reasons: they were direct admissions
This study was performed at a level 1 trauma center where there are for an elective procedure (N = 141), they were determined dead on
two tiers of trauma activations, with the urgency and severity increasing arrival (N = 19), or if they were transferred-in from another hospital (N
from tier 2 to tier 1. Trauma activations are managed by a team con = 140). At our institution the triage policy is uniform regardless of
sisting of an emergency medicine physician, attending trauma surgeon, arrival mode. The proportion of patients who arrived via emergency
surgical resident team, anesthesia attending, trauma program manager, medical services (EMS) vs. non-EMS was similar among patients who
respiratory therapist, radiology technician, social services, two ED had no ESI level assigned and patients who were assigned an ESI level
registered nurses, and security services. The trauma surgeon and the and included in the study. When a patient was not assigned an ESI level
anesthesia attending are only required to be present at tier 1 activations. it was mainly due to the exclusions listed above.
For tier 2 activations, the chief surgical resident is required to be pre
sent, while the presence of the trauma surgeon is optional unless deemed Data collection
necessary. ED physicians are present at all trauma activations. Upon
trauma activation, all trauma team members have a maximum of 15 min Variables including demographics, arrival mode, mechanism of
to arrive in the trauma bay. Additionally, trauma patients who do not injury, trauma activation level, ESI level, ED vitals, ED treatments/
meet criteria for Tier 1 or 2 activations are either seen as a trauma procedures, diagnostic tests performed, injury severity score, ED
consult or a surgical consult. Trauma/Surgical consults are ordered after disposition, hospital disposition, intensive care unit (ICU) length of stay
the patient has been examined in-house and based on the discretion of (LOS), hospital LOS, ED LOS, and comorbidities were collected from the
an emergency medicine physician, patients are seen within 30 min of the trauma registry and electronic medical records as needed.
order. These consults were referred to as non-activations in the tables.
Data analysis
Inclusion and exclusion criteria
GraphPad Prism 9 (GraphPad Software Inc., La Jolla, CA) was used
All adult patients who presented to the ED and who were defined as for statistical analysis, p < 0.01 was considered significant. Patients
trauma patients based on the American College of Surgeons’ national assigned ESI 2 were grouped by age: <65 years and ≥ 65 years. Vital
trauma data standard patient inclusion criteria were included in the signs, resources used, and clinical outcomes of patients who presented in
study. Patients were excluded if an ESI level was not assigned during 2020 were compared to patients from 2019. Younger patients (< 65
Table 2
Demographics and other factors stratified by age (2020 vs. 2019).
Variable 2019 2020 OR 2019 2020 OR 2020 2020 OR
<65 <65 (95% CI) ≥65 ≥65 (95% CI) <65 ≥65 (95% CI)
(N=547) (N=970) (N=279) (N=366) (N=970) (N=366)
Gender
Male 412 (75.3) 795 (82) 1.5 (1.1 – 1.9) 133 (47.7) 196 (53.5) 1.3 (0.9 – 1.7) 795 (82) 196 (53.5) 0.2 (0.2 – 0.3)
Female 135 (24.7) 175 (18) 0.7 (0.5 – 0.9) 146 (52.3) 170 (46.4) 0.8 (0.6 – 1.1) 175 (18) 170 (46.4) 3.9 (3.0 – 5.1)
Race
White 175 (32) 287 (29.6) 0.9 (0.7 – 1.1) 140 (50.2) 198 (54.1) 1.2 (0.8 – 1.6) 287 (29.6) 198 (54.1) 2.8 (2.2 – 3.6)
AA/Black 217 (39.7) 442 (45.6) 1.3 (1.0 – 1.6) 61 (21.9) 60 (16.4) 0.7 (0.5 – 1.0) 442 (45.6) 60 (16.4) 0.2 (0.2 – 0.3)
Asian 10 (1.8) 28 (2.9) 1.6 (0.8 – 3.3) 8 (2.9) 29 (7.9) 2.9 (1.3 – 6.2) 28 (2.9) 29 (7.9) 2.9 (1.7 – 4.9)
Other 145 (26.5) 213 (22) 0.8 (0.6 – 1.0) 70 (25.1) 79 (21.6) 0.8 (0.6 – 1.2) 213 (22) 79 (21.6) 1.0 (0.7 - 1.3)
Injury Type
Blunt 428 (78.2) 668 (68.9) 0.6 (0.5 – 0.8) 276 (98.9) 354 (96.7) 0.3 (0.1 – 1.0) 668 (68.9) 354 (96.7) 12.8 (7.2 – 22.9)
Penetrating 117 (21.4) 291 (30) 1.6 (1.2 – 2.0) 2 (0.7) 6 (1.6) 2.3 (0.5 – 11.3) 291 (30) 6 (1.6) 0.04 (0.02 – 0.08)
Burn 2 (0.4) 6 (0.6) 1.7 (0.4 – 8.3) 1 (0.4) 2 (0.5) 1.5 (0.2 – 22.2) 6 (0.6) 2 (0.5) 0.9 (0.2 – 3.7)
Other 0 (0) 5 (0.5) 3.4 (0.6 – 39.1) 0 (0) 4 (1.1) 3.8 (0.5 – 45.5) 5 (0.5) 4 (1.1) 2.1 (0.6 – 7.1)
Arrival Mode
EMS 484 (88.5) 863 (89) 1.0 (0.8 – 1.5) 264 (94.6) 348 (95.1) 1.1 (0.5 – 2.2) 863 (89) 338 (95.1) 2.3 (1.4 – 3.8)
Non-EMS 63 (11.5) 107 (11) 0.9 (0.7 – 1.3) 15 (5.4) 18 (4.9) 0.9 (0.4 – 1.8) 107 (11) 18 (4.9) 0.4 (0.3 – 0.7)
Pre-existing Conditions 508 (92.9) 970 (100) 151 (9.2 – 2458) 249 (89.2) 364 (99.4) 17.8 (4.9 – 65.4) 970 (100) 364 (99.4) 0.1 (0.003 – 1.6)
AA, African American; EMS, emergency medical services, OR, odds ratio; CI, confidence interval.
Table 3
Vital signs and resource utilization stratified by age (2020 vs. 2019).
Vital signs & resources utilized 2019 2020 OR 2019 2020 OR 2020 2020 OR
<65 <65 (95% CI) ≥65 ≥65 (95% CI) <65 ≥65 (95% CI)
(N = 547) (N = 970) (N = 279) (N = 366) (N = 970) (N = 366)
Heart Rate >100 181 310 (32) 0.9 (0.8 – 1.2) 46 (16.5) 76 (20.8) 1.3 (0.9 – 2.0) 310 (32) 76 (20.8) 0.6 (0.4 – 0.7)
(33.1)
Respiratory Rate >20 92 (9.7) 185 1.2 (0.9 – 1.5) 23 (8.2) 34 (9.3) 1.1 (0.7 – 2.0) 185 34 (9.3) 0.4 (0.3 – 0.6)
(19.1) (19.1)
Saturated O2 <92% 5 (0.9) 14 (1.4) 1.6 (0.6 – 4.0) 11 (3.9) 14 (3.8) 1.0 (0.4 – 2.1) 14 (1.4) 14 (3.8) 2.7 (1.2 – 5.9)
Labs Done 544 930 0.1 (0.05 – 0.4) 279 (100) 349 0.04 (0.002 – 0.6) 930 349 0.9 (0.5 – 1.5)
(99.4) (95.9) (95.3) (95.9) (95.3)
ECG 397 835 2.3 (1.8 – 3.0) 229 345 3.6 (2.1 – 6.2) 835 345 2.6 (1.6 – 4.2)
(72.6) (86.1) (82.1) (94.3) (86.1) (94.3)
Radiology 523 933 1.2 (0.7 – 1.9) 275 363 1.8 (0.5 – 7.0) 933 363 4.2 (1.4 – 12.6)
(95.6) (96.2) (98.6) (99.2) (96.2) (99.2)
IV Fluids 220 138 0.2 (0.2 – 0.3) 77 (27.6) 31 (8.5) 0.2 (0.1 – 0.4) 138 31 (8.5) 0.6 (0.4 – 0.8)
(40.2) (14.2) (14.2)
IV/IM or Nebulized 426 642 0.6 (0.4 – 0.7) 205 210 0.5 (0.3 – 0.7) 642 210 0.7 (0.5 – 0.9)
Medications (77.9) (66.2) (73.5) (57.4) (66.2) (57.4)
Specialty Consultation 476 (87) 687 0.4 (0.3 – 0.5) 262 294 0.3 (0.1 – 0.5) 687 294 1.7 (1.3 – 2.3)
(70.8) (93.9) (80.3) (70.8) (80.3)
Simple Procedure 235 (43) 331 0.7 (0.5 – 0.8) 97 (34.8) 101 0.7 (0.5 – 1.0) 331 101 0.7 (0.6 - 1.0)
(34.1) (27.6) (34.1) (27.6)
Complex Procedure 67 (12.2) 72 (7.4) 0.6 (0.4 – 0.8) 28 (10) 40 (10.9) 1.1 (0.7 – 1.8) 72 (7.4) 40 (10.9) 1.5 (1.0 – 2.3)
Required Surgery 222 326 0.7 (0.6 – 0.9) 79 (28.3) 91 (24.9) 0.8 (0.6 – 1.2) 326 91 (24.9) 0.6 (0.5 – 0.9)
(40.6) (33.6) (33.6)
ECG, electrocardiogram; IV, intravenous; IM, intramuscular; OR, odds ratio; CI, confidence interval.
years) and elderly patients (≥ 65 years) who presented during 2020 blunt mechanism of injury (3122, 82.4%). Most of the patients (2162,
were also compared. Variables were summarized using appropriate 57.1%) were assigned ESI level 2, 1231 (32.5%) were assigned ESI level
measures of central tendency based on variable type and normality of 3, 323 (8.5%) were assigned ESI level 1, 71 (1.9%) were assigned ESI
data distribution. Data was presented as median and interquartile range level 4, and only one patient was assigned ESI level 5. Differences be
(IQR) for continuous variables and count and percentage for categorical tween the patient populations in 2020 compared to 2019 were presented
variables. Comparisons between variables were presented as difference in Table 1. For Tables 2–4, patients assigned ESI level 2 were stratified
in proportions or medians with a 95% confidence interval (CI) and odds by year and age for data comparison, 1517 (70.2%) were less than 65
ratios with 95% CI. To compute 95% CIs for the difference between years of age and 645 (29.8%) were 65 years or older.
proportions the Newcombe/Wilson method with a continuity correction In 2020 compared to 2019, younger patients had greater odds of
was used. To compute the CI of an odds ratio the Baptista-Pike method, being male [OR (95% CI): 1.5 (1.1 - 1.9)], being Black [OR (95% CI): 1.3
was used. (1.0 – 1.6)] or Asian [OR (95% CI): 1.6 (0.8 – 3.3)], of having a pene
trating [OR (95% CI): 1.6 (1.2 – 2.0)] or burn injury [OR (95% CI): 1.6
Results (1.2 – 2.0), and having a preexisting condition [OR (95% CI): 151 (9.2 –
2458)] (Table 2). Similar results were observed when elderly patients
A total of 3788 trauma patients were included in the study. The from 2020 were compared to 2019 (Table 2). In 2020, when younger (<
median age was 50 years (IQR: 31, 69) and 2591 (68.4%) were male. 65 years) and elderly (≥ 65 years) patients were compared, elderly
The majority of patients (3188, 84.2%) arrived via ambulance and had a patients had greater odds of being female [OR (95% CI): 3.9 (3.0 – 5.1)],
Table 4
Clinical outcomes stratified by age (2020 vs. 2019).
Clinical Outcomes 2019 2020 OR 2019 2020 OR 2020 2020 OR
<65 <65 (95% CI) ≥65 ≥65 (95% CI) <65 ≥65 (95% CI)
(N=547) (N=970) (N=279) (N=366) (N=970) (N=366)
Trauma Activation Level

Tier 1 167 (30.5) 260 (26.8) 0.8 (0.7 – 51 (18.3) 54 (14.7) 0.8 (0.5 – 260 (26.8) 54 (14.7) 0.5 (0.3 –
1.0) 1.2) 0.6)
Tier 2 239 (43.7) 499 (51.4) 1.4 (1.1 – 142 (50.9) 205 (56) 1.2 (0.9 – 499 (51.4) 205 (56) 1.2 (0.9 –
1.7) 1.7) 1.5)
Non-Activations/ 141 (25.8) 211 (21.7) 0.8 (0.6 – 86 (30.8) 107 (29.2) 0.9 (0.7 – 211 (21.7) 107 (29.2) 1.5 (1.1 –
Consults 1.0) 1.3) 1.9)
Intubated (in ED) 46 (8.4) 27 (2.8) 0.3 (0.2 – 9 (3.2) 5 (1.4) 0.4 (0.1 – 27 (2.8) 5 (1.4) 0.5 (0.2 –
0.5) 1.2) 1.2)
COVID-19 Positive - - - - - - 24 (2.5) 10 (2.7) 1.1 (0.5 –
2.3)
Injury Severity Score 5 (2, 9) 4 (1, 9) -1 (-1 – 0) 6 (4, 10) 5 (2, 9) -1 (-1 – 0) 4 (1, 9) 5 (2, 9) 1 (0 – 1)
(Median)*
<15 (%) 487 (89) 880 (90.7) 1.2 (0.9 – 244 (87.4) 330 (90.2) 1.3 (0.8 – 880 (90.7) 330 (90.2) 0.9 (0.6 –
1.7) 2.1) 1.4)
>15 (%) 60 (11) 90 (9.3) 0.8 (0.6 – 35 (12.5) 36 (9.8) 0.8 (0.5 – 90 (9.3) 36 (9.8) 1.1 (0.7 –
1.2) 1.2) 1.6)
ED Length of Stay 331 (202, 382.5 (245.5, 51.5 (6 – 405 (247, 427.5 (272, 22.5 (-16 – 382.5 (245.5, 427.5 (272.5, 45 (-71 -
(minutes)* 575) 560) 58) 581) 625) 63) 560) 625.3) -10)
ED Disposition
Admitted 483 (88.3) 619 (63.8) 0.2 (0.2 – 263 (94.3) 268 (73.2) 0.2 (0.1 – 619 (63.8) 268 (73.2) 1.5 (1.2 –
0.3) 0.3) 2.0)
Discharged 63 (11.5) 339 (34.9) 4.1 (3.1 – 16 (5.7) 95 (26) 5.8 (3.3 – 339 (34.9) 95 (26) 0.6 (0.5 –
5.5) 9.9) 0.9)
Transferred/Other 1 (0.2) 12 (1.2) 6.8 (1.1 – 0 (0) 1 (0.3) 2.3 (0.1 – 12 (1.2) 1 (0.3) 0.2 (0.02 –
Hospital 73.5) 56.5) 1.4)
Deceased 0 (0) 0 (0) 0.6 (0.01 – 0 (0) 2 (0.6) 3.8 (0.2 – 0 (0) 2 (0.6) 13.3 (0.6 –
28.5) 80.2) 278)
ICU Length of Stay 3 (2, 6) 2.5 (2, 5) -0.5 (-1 – 0) 3 (2, 6) 4 (2, 8) 1 (-1 – 1) 2.5 (2, 5) 4 (2, 8) 1.5 (-1 – 0)
(days)*
Hospital Length of Stay 3 (2, 6) 2 (1, 5) -1 (-1 – 0) 5 (3, 8) 4 (2, 7.2) -1 (-1 – 1) 2 (1, 5) 4 (2, 7.2) 2 (-1 – 0)
(days)*
Hospital Disposition
Home 434 (79.3) 791 (81.5) 1.1 (0.9 – 141 (50.5) 204 (55.7) 1.2 (0.9 – 791 (81.5) 204 (55.7) 0.3 (0.2 –
1.5) 1.7) 0.4)
Rehabilitation/SNF 46 (8.4) 75 (7.7) 0.9 (0.6 – 121 (43.4) 114 (31.1) 0.6 (0.4 – 75 (7.7) 114 (31.1) 5.4 (3.9 –
1.3) 0.8) 7.4)
Hospice/Deceased 11 (2) 9 (0.9) 0.5 (0.2 – 10 (3.6) 27 (7.4) 2.1 (1.1 – 9 (0.9) 27 (7.4) 8.5 (4.1 –
1.0) 4.4) 18.2)
Other 56 (10.2) 95 (9.8) 0.9 (0.7 – 7 (2.5) 21 (5.7) 2.3 (1.9 – 95 (9.8) 21 (5.7) 0.6 (0.3 –
1.3) 1.0) 0.9)
ED, emergency department; ICU, intensive care unit; SNF, skilled nursing facility; OR, odds ratio; CI, confidence interval; * Difference in Median (95% CI) was used for
this variable when comparing 2020 to 2019.
being White [OR (95% CI): 2.8 (2.2 – 3.6)] or Asian [OR (95% CI): 2.9 (Table 4). Notable, in 2020 compared to 2019, elderly patients were
(1.7 – 4.9)], and having a blunt trauma injury [OR (95% CI): 12.8 (7.2 – more likely to be an ED [OR (95% CI): 3.8 (0.2 – 80.2)] or hospital [OR
22.9)] (Table 2). Additional details are presented in Table 2. (95% CI): 2.1 (1.1 – 4.4)] mortality (Table 4). During 2020, elderly
In Table 3, vital signs and resource needs assessed to assign ESI level patients were more likely to be admitted for treatment [OR (95% CI):1.5
2 were compared. Overall, vital signs did not differ significantly among (1.2 – 2.0)], to die in the ED [OR (95% CI):13.3 (0.6 – 278)], and to have
patients regardless of age and less resources were used when comparing a hospital disposition of mortality [OR (95% CI): 8.5 (4.1 – 18.2)] or
2020 to 2019 (Table 3). In 2020 compared to 2019, younger patients rehabilitation/SNF [OR (95% CI): 5.4 (3.9 – 7.4)] when compared to
were more likely to have a saturated O2 <92% [OR (95% CI): 1.6 (0.6 – younger patients (Table 4). In addition, elderly patients had a longer ED
4.0)] and have an ECG performed [OR (95% CI): 2.3 (1.8 – 3.0)]. While LOS (+45 min), ICU LOS (+1.5 days), and hospital LOS (+2 days)
elderly patients had greater odds of having a heart rate >100 [OR (95% compared to younger patients. Additional details are presented in
CI): 1.3 (0.9 – 2.0)], an ECG [OR (95% CI): 3.6 (2.1 – 6.2)] or radiology Table 4.
[OR (95% CI): 1.8 (0.5 – 7.0)] performed (Table 3). When comparing To determine if elderly patients were over-triaged in 2020, elderly
younger and elderly trauma patients within 2020, with the exception of patients assigned ESI level 2 were compared to both < 65 and ≥ 65 years
lab tests performed, there was significant variability among these groups old trauma patients who were assigned ESI level 1 (Tables 5 & 6).
of patients (Table 3). In 2020, when compared to younger patients, more Although, elderly patients assigned ESI level 2 had higher odds of having
elderly patients had a saturated O2 <92% [OR (95% CI): 2.7 (1.2 – 5.9)], a heart rate >100 [OR (95% CI): 2.2 (0.8 – 5.8)], a respiratory rate >20
ECG performed [OR (95% CI): 2.6 (1.6 – 4.2)], radiology scans done [OR [OR (95% CI): 1.8 (0.5 – 7.8)], and having an ECG [OR (95% CI): 2.6
(95% CI): 4.2 (1.4 – 12.6)], and specialty consultations [OR (95% CI): (1.0 – 7.2)] or lab [OR (95% CI): 1.8 (0.5 – 6.2)] performed the differ
1.7 (1.3 – 2.3)] (Table 3). ences between ESI level 1 and level 2 elderly patients were not signifi
In Table 4, clinical outcomes were assessed. In 2020 compared to cant (Table 5). Similar results were observed for clinical outcomes,
2019, both younger and elderly trauma patients both had higher odds of elderly patients assigned ESI level 2 had a greater odds of having an ISS
being tier 2 trauma activations, of having a longer ED LOS, or an ISS <15 [OR (95% CI): 4.4 (2.0 – 9.1)], and an ED [OR (95% CI): 2.9 (1.0 –
<15, and of being ED discharged or transferred to another hospital 7.8)] or hospital [OR (95% CI): 2.3 (1.2 – 4.7)] disposition of home
Table 5 needed then patients should be assigned ESI level 1 [6,7]. The majority
Vital signs and resource utilization stratified by age and ESI level (2020). of patients in our population were assigned ESI level 2, and most of these
Vital signs & ESI ESI OR ESI ESI OR patients were tier 1 and tier 2 trauma activations. However, there were
resources level 1 level 2 (95% level 1 level 2 (95% patients that were considered trauma patients based on mechanism of
utilized ≥65 ≥65 CI) <65 ≥65 CI) injury but were still assigned ESI level 3–5. Although most of these pa
(N = (N = (N = (N =
tients were non-activations, approximately 7% of patients were tier 1
37) 366) 163) 366)
and tier 2 trauma activations. Therefore, ESI level did not positively
Heart Rate 4 76 2.2 (0.8 51 76 0.6 (0.4 correlate with the trauma activation level and the severity of sustained
(10.8) (20.8) – 5.8) (31.3) (20.8) – 0.9)
injuries were not accurately identified in some instances. This suggests
>100
Respiratory 2 (5.4) 34 1.8 (0.5 30 34 0.4 (0.3
Rate >20 (9.3) – 7.8) (17.2) (9.3) – 0.8) ESI level might be assigned pro forma for patients who meet trauma
Saturated O2 3 (8.1) 14 0.4 (0.1 24 14 0.2 (0.1 activation criteria but for trauma patients who do not meet that criteria,
<92% (3.8) – 1.5) (9.2) (3.8) – 0.5) ESI level is assigned prior to determination of trauma triage level.
Labs Done 34 349 1.8 (0.5 124 349 6.5 (3.5
During 2020, significant variability was discovered between younger
(91.9) (95.3) – 6.2) (76.1) (95.3) – 11.6)
ECG 32 345 2.6 (1.0 107 345 8.6 (5.0 and older trauma patients assigned ESI level 2. This suggests that age
(86.5) (94.3) – 7.2) (65.6) (94.3) – 11.6) should be considered when assigning an ESI triage level to trauma pa
Radiology 37 363 0.7 134 363 26.2 tients, as highlighted in similar recent studies [23,25]. Most of the
(100) (99.2) (0.04 – (82.2) (99.2) (8.5 – elderly patients in our population had a blunt mechanism of injury, with
14.2) 82.6)
IV Fluids 8 31 0.3 (0.1 28 31 0.4 (0.3
falls being the primary cause of injury. Of note, older patients assigned
(21.6) (8.5) – 0.8) (17.2) (8.5) – 0.8) ESI level 2 had a higher mortality rate implying that they were initially
IV/IM or 21 210 1.0 (0.5 96 210 0.9 (0.6 under-triaged. Data showed that this was not due to injury severity,
Nebulized (56.8) (57.4) – 2.0) (58.9) (57.4) - 1.4) preexisting conditions, or COVID-19 infection. However, elderly pa
Medications
tients were more likely to have a saturated O2 <92% compared to
Specialty 30 294 0.9 (0.4 105 294 2.3 (1.5
Consultation (81.1) (80.3) – 2.3) (64.4) (80.3) – 3.4) younger patients. In 2020, elderly patients also had longer stays in the
Simple 17 101 0.4 (0.2 59 101 0.7 (0.4 ICU and hospital, and were more likely to require rehabilitation
Procedure (45.9) (27.6) – 0.9) (36.2) (27.6) – 1.0) post-discharge compared to younger patients. This further supports the
Complex 12 40 0.3 (0.1 59 40 0.2 (0.1 idea that the initial triage did not accurately assess the needs of these
Procedure (32.4) (10.9) – 0.5) (36.2) (10.9) – 0.3)
patients. Geriatric specific characteristics should be considered and
Required 11 91 0.8 (0.4 66 91 0.5 (0.3
Surgery (27.7) (24.9) – 1.7) (40.5) (24.9) – 0.7) incorporated into the ED triage algorithm to help improve elderly pa
tient outcomes.
ECG, electrocardiogram; IV, intravenous; IM, intramuscular; OR, odds ratio; CI,
The resource utilization of younger and elderly trauma patients
confidence interval.
differed significantly during 2020. Elderly patients had more electro
cardiograms, radiology scans, specialty consultations, and complex
when compared to elderly patients assigned ESI level 1 (Table 6).
procedures performed compared to younger patients. This was also the
However, when compared to younger (<65 years) ESI level 1 patients, case for vital signs, younger patients had higher rates of heart rate >100,
ESI level 2 elderly patients differed significantly and only had few
respiratory rate >20, while older patients had a higher rate of saturated
similarities (Tables 5 & 6). O2 <92%. Even though the both age groups were assigned ESI level 2,
they were only similar in regards to lab tests performed. This implies
Discussion that one of the age groups were either under-triaged or over-triaged.
There was less variability between elderly patients from 2019 vs.
Trauma patients can be challenging to triage given the possibility of 2020, suggesting that younger trauma patients were more likely over-
internal injuries without visible external signs of injury. The ESI hand triaged in 2020, while older patients were triaged more accurately.
book states that trauma patients with a high risk mechanism of injury During 2020, younger patients had significantly more penetrating in
should be assigned ESI level 2, but if an immediate intervention is juries when compared to elderly trauma patients, this may account for
Table 6
Clinical outcomes stratified by age and ESI level (2020).
Clinical Outcomes ESI Level 1 ESI Level 2 OR ESI Level 1 ESI Level 2 OR
≥65 ≥65 (95% CI) <65 ≥65 (95% CI)
(N=37) (N=366) (N=163) (N=366)
Trauma Activation Level

Tier 1 32 (86.5) 54 (14.7) 0.03 (0.01 – 0.07) 153 (93.9) 54 (14.7) 0.01 (0.006 – 0.02)
Tier 2 2 (5.4) 205 (56) 22.3 (5.8 – 95) 6 (3.7) 205 (56) 33.3 (15 – 71.3)
Non-Activations 3 (8.1) 107 (29.2) 4.7 (1.5 – 14.8) 4 (2.4) 107 (29.2) 16.4 (6.3 – 42.5)
Intubated (in ED) 9 (24.3) 5 (1.4) 0.04 (0.02 – 0.1) 57 (35) 5 (1.4) 0.03 (0.01 – 0.06)
COVID-19 Positive 1 (2.7) 10 (2.7) 1.0 (0.1 - 6.1) 10 (6.1) 10 (2.7) 0.4 (0.2 – 1.1)
Injury Severity Score (Median)* 9 (4, 20) 5 (2, 9) -4 (1 – 7) 9 (1, 20) 5 (2, 9) -4 (1 - 5)
<15 (%) 25 (67.6) 330 (90.2) 4.4 (2.0 – 9.1) 107 (65.6) 330 (90.2) 4.8 (3.0 – 7.7)
>15 (%) 12 (32.4) 36 (9.8) 0.2 (0.1 – 0.5) 56 (34.3) 36 (9.8) 0.2 (0.1 – 0.3)
ED Length of Stay (minutes)* 253 (99.5, 589.5) 427.5 (272.5, 625.3) 174.5 (46 - 228) 91 (22, 247) 427.5 (272.5, 625.3) 336.5 (239 – 319)
ED Disposition
Admitted 30 (81.1) 268 (73.2) 0.6 (0.3 – 1.5) 99 (60.7) 268 (73.2) 1.8 (1.2 – 2.6)
Discharged 4 (10.8) 95 (26) 2.9 (1.0 – 7.8) 26 (15.9) 95 (26) 1.8 (1.1 – 2.9)
Transferred/Other Hospital 1 (2.7) 1 (0.3) 0.1 (0.005 – 1.9) 0 (0) 1 (0.3) 1.3 (0.05 – 33.1)
Deceased 2 (5.4) 2 (0.6) 0.1 (0.01 – 0.6) 38 (23.3) 2 (0.6) 0.02 (0.004 – 0.07)
ICU Length of Stay (days)* 4 (2, 6) 4 (2, 8) 0 (-1.0 – 2.0) 4 (2, 8) 4 (2, 8) 0.0 (-1.0 – 1.0)
Hospital Length of Stay (days)* 4 (2, 8.5) 4 (2, 7.2) 0 (-1.0 – 1.0) 2 (1, 6) 4 (2, 7.2) 2.0 (0 – 1.0)
ED, emergency department; ICU, intensive care unit; SNF, skilled nursing facility; * Difference in Median (95% CI) was used for this variable when making
comparisons.
the assignment of ESI level 2 although requiring less resources and same ESI level 2 in the previous year. This suggested that there was a
having better clinical outcomes than elderly patients. COVID-19 induced over-triage of trauma patients in 2020. COVID-19
When younger and elderly trauma patients from 2019 to 2020 were may have complicated the triage process compared to previous years.
compared, there was variability among both age groups. Although they Within-year data analysis further revealed that younger and elderly
were both assigned ESI level 2, both younger and elderly patients trauma patients assigned ESI level 2 varied significantly in vital signs,
required and utilized more resources in 2019 compared to 2020. This resource utilization, and clinical outcomes. This implies that age and
suggests that during the early stages of the pandemic in 2020, trauma geriatric specific characteristics should be incorporated into the ESI
patients were over-triaged compared to the previous year. Of note, the algorithm.
variances were less among elderly patients compared to younger pa
tients. This suggests that there was a COVID-19 induced over-triage of
younger trauma patients. This is not surprising given the uncertainty Declaration of Competing Interest
and lack of a vaccine or cure during the early phase of the pandemic. The
variability in the resources utilized also translated to variance in the The authors declare that they have no known competing financial
clinical outcomes. In 2019, younger trauma patients were more likely to interests or personal relationships that could have appeared to influence
be intubated, admitted for treatment, or have a longer LOS in the ICU the work reported in this paper.
and hospital compared to younger patients in 2020. Several COVID-19
related factors most likely played a role and complicated the usual References
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Injury 54 (2023) 110879
Injury
Prehospital cervical spine immobilization in earthquakes: A modified protocol
Dear Editorial Team, prehospital approach to suspected C-Spine injuries. Especially since the
On Monday, February 6th, 2023, 7.8 and 7.6 Richter-scale earth enormous victim numbers likely supersede collar availability. It is
quakes struck the Kahramanmaras region affecting Turkey and Syria, important to consider the potential harms of immobilization and bal
killing at least 33,180 and injuring over 100,000 victims [1]. We wish to ance them with the potential benefits while also considering medical
express our concerns about the prehospital cervical spine (C-Spine) supply availability. As the Pre-Hospital Trauma Life Support (PHTLS)
immobilization practices we observed in videos emerging from this protocol suggests, C-Spine immobilization should follow physical ex
disaster. amination and clinical judgment [2]. Physical signs of C-Spine injuries
Cervical collars limit the cervical range of motion by up to 50–90% include bony tenderness over the posterior midline of the neck (the
[2]. In theory, collars should protect patients from secondary spinal cord nuchal ridge and spinous processes) and any focal neurological signs.
injuries by restricting the movement of unstable cervical injuries. Generally, if the physical examination is concerning, the patient should
However, as reviewed by Sundstrøm et al., no significant evidence be immobilized until further clearance. If the patient has an altered level
supports this theory [3]. Unfortunately, spinal immobilization has po of consciousness or has a distracting injury, we suggest assessing the
tential harm, such as pressure ulcers, airway obstruction, and patient setting for risk of C-Spine injury due to their low incidence. High-risk
discomfort [2,3]. In a review of previous earthquakes by Gosney et al., scenarios should include signs of axial injuries such as a fall from
C-Spine injuries were recorded in 2–12% of victims [4]. Furthermore, in height or ruins hitting the spine. In earthquake scenarios where patients
a study by Dong et al., C-Spine injuries were less common in earthquake are alert and self-ambulating, a normal C-Spine examination should be
scenarios compared to non-earthquake scenarios (Relative Risk = 0.47, enough to avoid collars.
p < 0.001) [5]. In the 19 patients, trapped for 48 to 168 h, and rescued We urge medical professionals and first responders to exercise clin
during the Israel Defense Force aid delegation to Turkey, no cervical ical judgment in deciding when to apply collars and avoid unnecessary
injuries were detected [personal communication]. application without a physical examination of the patient and assess
Thus, in mass casualty earthquakes, we recommend a modified ment of the scene (see Fig. 1).
Letter to the Editor Injury 54 (2023) 110879
Fig. 1. Suggested approach to cervical spine immobilization in earthquakes.
Sincerely, [5] Dong Z, Yang Z, Chen T, et al. Earthquake-related versus non-earthquake-related

injuries in spinal injury patients: differentiation with multidetector computed to
The authors
mography. Crit Care 2010;14(6):R236.

Ilan Y. Mitchnika,1,*, Yoram Aneksteinb,2, Avraham I. Rivkindc,3
a
Department of Military Medicine, Hebrew University, Jerusalem, Israel
None. b
Department of Orthopaedic Surgery, Shamir Medical Center and Tel Aviv
University, Israel
References c
Department of General Surgery and Shock Trauma Center, Hadassah –
[1] Spike J, Fraser S, El-Deeb S. As survival window closes, more rescued in quake in
Hebrew University Medical Center, Jerusalem, Israel
turkey | AP news [Internet]. Associated Press News; 2023 [cited 2023 Feb 13];
Available from, https://apnews.com/article/disaster-planning-and-response-2023 *
Corresponding author.
-turkey-syria-earthquake-earthquakes-a7ae0cf86757d238dc0dd5f6a5dd96ce.
[2] National Association of Emergency Medical Technicians (NAEMT). PHTLS: pre E-mail address: ilan.mitchnik@mail.huji.ac.il (I.Y. Mitchnik).
hospital trauma life support. 9th ed. Jones & Bartlett Learning; 2020.
[3] Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K. Prehospital use of
cervical collars in trauma patients: a critical review. J Neurotrauma 2014;31(6):
531–40.
[4] Gosney JE, Reinhardt JD, von Groote PM, Rathore FA, Melvin JL. Medical reha
1
bilitation of spinal cord injury following earthquakes in rehabilitation resource- Department of Orthopaedic Surgery, Shamir Medical Center (Assaf Har
scarce settings: implications for disaster research. Spinal Cord 2013;51(8):603–9. ofeh), Zerifin, Israel, Tel: +972–52–885–6151
2
Department of Orthopaedic Surgery, Shamir Medical Center (Assaf
Harofeh), Zerifin, Israel, Tel: +972–8–977–9437
3
Department of General Surgery, Hadassah University Medical Center,
Ein Kerem, Jerusalem, Israel, Tel: +972–2–677–9500
Injury 54 (2023) 110883
Injury
Transverse posterior wall acetabular fracture pattern is associated with

increased risk of periprosthetic joint infection after conversion total
hip arthroplasty✰
Kyle H. Cichos a, b, c, Brandon Boyd a, Gerald McGwin Jr d, Elie S. Ghanem a, e, *
a
Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, 35205, USA
b
The Hughston Foundation, Columbus, GA, 31909, USA
c
The Hughston Clinic, Columbus, GA, 31909, USA
d
Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL 35233, USA
e
Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, 65201, USA
Keywords: Introduction: Acetabular fracture subtypes are associated with varying rates of subsequent conversion total hip
Acetabular fracture arthroplasty (THA) after open reduction internal fixation (ORIF) with transverse posterior wall (TPW) patterns
Conversion having a higher risk for early conversion. Conversion THA is fraught with complications including increased
Hip arthroplasty
rates of revision and periprosthetic joint infections (PJI). We aimed to determine if TPW pattern is associated
Infection
with higher rates of readmissions and complications including PJI after conversion compared to other subtypes.
Fracture pattern
Transverse posterior wall Methods: We retrospectively reviewed 1,938 acetabular fractures treated with ORIF at our institution from 2005
to 2019, of which 170 underwent conversion that met inclusion criteria, including 80 TPW fracture pattern.
Conversion THA outcomes were compared by initial fracture pattern. There was no difference between the TPW
and other fracture patterns in age, BMI, comorbidities, surgical variables, length of stay, ICU stay, discharge
disposition, or hospital acquired complications related to their initial ORIF procedure. Multivariable analysis was
performed to identify independent risk factors for PJI at both 90-days and 1-year after conversion.
Results: TPW fracture had higher risk of PJI after conversion THA at 1-year (16.3% vs 5.6%, p = 0.027).
Multivariable analysis revealed TPW independently carried increased risk of 90-day (OR 4.89; 95% CI
1.16–20.52; p = 0.03) and 1-year PJI (OR 6.51; 95% CI 1.56–27.16; p = 0.01) compared to the other acetabular
fracture patterns. There was no difference between the fracture cohorts in 90-day or 1-year mechanical com
plications including dislocation, periprosthetic fracture and revision THA for aseptic etiologies, or 90-day all-
cause readmission after the conversion procedure.
Conclusion: Although conversion THA after acetabular ORIF carry high rates of PJI overall, TPW fractures are
associated with increased risk for PJI after conversion compared to other fracture patterns at 1-year follow-up.
Novel management/treatment of these patients either at the time of ORIF and/or conversion THA procedure are
needed to reduce PJI rates.
Level of evidence: Therapeutic Level III (retrospective study of consecutive patients undergoing an intervention
with analyses of outcomes).
Introduction However, it is well-documented that ORIF may require conversion to

total hip arthroplasty (THA) for consequent complications including
Open reduction internal fixation (ORIF) is considered the standard of avascular necrosis and posttraumatic arthritis [1,3–5]. Different
care for treating displaced acetabular fractures (>2 mm) to provide joint acetabular fracture subtypes based on Letournel Classification are
stability, congruity, and maintain the integrity of the native joint [1,2]. associated with varying rates of subsequent conversion THA [6,7]. Some
✰
All work performed at the University of Alabama at Birmingham, Birmingham, AL, 35205
* Corresponding author at: Department of Orthopaedic Surgery, University of Missouri, Columbia, MO 65201, USA.
E-mail address: elieghanem@gmail.com (E.S. Ghanem).
K.H. Cichos et al. Injury 54 (2023) 110883
studies emphasized posterior wall involvement as a driver for conver to the acetabular fracture ORIF procedure that were deemed relevant in
sion THA while others concluded that the higher energy fracture pat developing PJI after conversion THA were identified through a thorough
terns such as transverse posterior wall (TPW) were prone to greater risk review of medical records. SSI that developed after acetabular ORIF was
for conversion following initial ORIF [7,8]. TPW patterns are often due defined as previously described, by 2 positive deep tissue cultures
to high-energy trauma, which leads to increased articular surface growing the same virulent organism or the presence of deep purulence/
damage, progression to post-traumatic arthritis, chondrocyte apoptosis, pus [8]. Hence, only infections in the deep tissues or around the implants
and inevitably THA [9]. were included. The TPW acetabular group had less males than the other
Outcomes after conversion THA in general and specifically for acetabular classifications (51.3% vs 68.9%, p = 0.027), and a lower
acetabular fractures are significantly different compared to primary incidence of chronic kidney disease (CKD) (1.3% vs 10%, p = 0.02). The
elective THA for osteoarthritis with extended hospital length of stay and two fracture groups were similar in all other measured comorbidities
longer operative time requiring more resource utilization [10]. The and surgical variables related to their prior acetabular fracture ORIF that
conversion procedure is fraught with complications including hetero we deemed as potential confounders for PJI after conversion THA
topic ossification, hip dislocation, as well as increased rates of revision, (Table 1).
and periprosthetic joint infections (PJI) [1,3,6,11,12]. Studies have Acetabular fracture patients that developed symptomatic hip pain
shown the rate of PJI following conversion THA can range from 1.3 to affecting and limiting their activities after ORIF were referred by the
18%, with consequent high morbidity and mortality rates for these PJI treating trauma surgeon to arthroplasty specialists in our institution for
cases while placing a heavy financial burden on the healthcare system further workup and management including possible conversion THA.
[10,13,14]. Early identification of patients who are at high risk for PJI The preoperative diagnosis prior to conversion was either post-
after conversion THA is critical in developing novel management stra traumatic arthritis (85%) or osteonecrosis (15%). Preoperative workup
tegies and pathways tailored to this high-risk group [11]. including serology and hip aspirate, as well as intraoperative cultures
It is noted that TPW fracture patterns are prone to high early con taken during revision THA procedure were used to diagnose PJI, which
version THA rates within two years of ORIF due to the associated high was defined according to the MSIS criteria [15]. Cultures were moni
energy imparted to the surrounding soft tissues during the trauma [8]. tored for a minimum of 5 days for aerobic cultures and 10 days for
Recently, a correlation between time to THA conversion after acetabular anaerobic cultures at our institution. Perioperative characteristics and
fracture and subsequent PJI was observed with the highest rates of PJI in-hospital variables including complications, length of stay, and
occurring in patients converted within 2 years of ORIF [11]. Hence, the discharge disposition after conversion THA were obtained by medical
impetus of our study was to determine if TPW fracture patterns are an
independent risk factor for PJI and prone to higher rates of PJI after
conversion THA. Our secondary goal was to determine if conversion Table 1
THAs after TPW ORIF have higher rates of readmissions and mechanical Patient characteristics and surgical variables relevant to prior acetabular frac
ture ORIF procedure eventually undergoing conversion THA, separated by
complications compared to other fracture patterns.
fracture pattern.
Patients and methods Characteristic Total (n TPW (n Other acetabular p-

= 170) = 80) fracture (n = 90) value
Institutional review board approval was obtained prior to initiating Age, y, mean (SD) 50 (12) 50 (14) 51 (13) 0.52
BMI, kg/m2, mean (SD) 30.6 30.9 30.4 (5.4) 0.62
our study. All patients that were treated operatively for acetabular
(5.8) (6.5)
fractures at our Level 1 trauma center from 2005 to 2019 were identified Male Sex, n (%) 103 (61) 41 (51) 62 (69) 0.03
using Current Procedural terminology (CPT) codes, (27226, 27227, and Comorbid Conditions
27228). One-thousand nine hundred thirty-eight acetabular fractures in Obesity 87 (51) 43 (54) 44 (49) 0.54
DM 38 (22) 21 (26) 17 (19) 0.27
skeletally mature adults were identified, of which 225 underwent con
HF 4 (2) 0 (0) 4 (4) 0.12
version THA. Our inclusion criteria consisted of the following: the pa CKD 10 (6) 1 (1) 9 (10) 0.02
tients had index acetabular ORIF and conversion surgery both Tobacco Use 66 (39) 28 (35) 38 (42) 0.35
performed at our institute, underwent conversion THA for post- IV drug Use 4 (2) 0 (0) 4 (4) 0.12
traumatic osteoarthritis (PTOA) or avascular necrosis (AVN) without Charlson Comorbidity Index
0 68 (40) 33 (41) 35 (39) 0.68
use of augments/cages, absence of native joint infection diagnosed prior
1 35 (20) 15 (19) 20 (22)
to conversion THA for which they received treatment including irriga 2 25 (15) 15 (19) 10 (11)
tion and debridement and/or two-stage exchange procedure, and had a ≥3 42 (25) 17 (21) 25 (28)
minimum 1-year follow-up after conversion procedure. Of these 225 Time from index ORIF to 620 582 654 (687) 0.70
converted patients, 18 were excluded due to the following reasons: 10 conversion THA, d, mean (584) (518)
(SD)
patients underwent 2-stage conversion THA after resection arthroplasty Reason for conversion THA
and insertion of antibiotic cement spacer treatment for native joint PTOA 144 (85) 69 (86) 75 (83) 0.672
infection, and 8 patients underwent initial percutaneous fixation of AVN 26 (15) 11 (14) 15 (17)
acetabular fracture with planned/staged conversion THA within 6–8 Index Acetabular ORIF Variables
Blood Loss, mL, mean (SD) 752 778 738 (565) 0.22
weeks of pinning as part of a prospective clinical trial being conducted at
(552) (550)
our institution. Of the remaining 207 patients, 30 (14%) were lost to Operative Duration, 220 (55) 227 218 (54) 0.35
follow-up or had immediate post-op care transferred to orthopedic minutes, mean (SD) (57)
surgeons close to home in another state and did not reach the minimum SSI after acetabular ORIF, 16 (9) 9 (11) 7 (8) 0.60
1-year follow-up, and 7 (3%) received conversion THA at an outside n (%)
Dislocation after 16 (9) 7 (9) 9 (10) 0.80
hospital closer to home. The final conversion THA cohort consisted of acetabular ORIF, n (%)
170 conversions that were eligible for analysis, 80 of which were clas Revision/Reoperation after 12 (7) 5 (6) 7 (8) 0.77
sified as TPW fracture pattern prior to ORIF. The remaining 90 fracture acetabular ORIF, n (%)
patterns consisted of 1% (n = 1) anterior column, 2% (2) transverse, 2% Abbreviations defined: ORIF, open reduction and internal fixation; THA, total
(2) anterior column posterior hemitransverse, 10% (9) both column, hip arthroplasty; TPW, transverse posterior wall; BMI, body mass index; DM,
14% (13) T-type, 25% (22) posterior column posterior wall, and 46% diabetes mellitus; CKD, chronic kidney disease; HF, heart failure; IV, intrave
(41) posterior wall fractures. nous; PTOA, post-traumatic osteoarthritis; AVN, avascular necrosis; SSI, surgical
Patient characteristics, comorbidities, and surgical variables related site infection.
chart review. The posterior hip approach was utilized for the conversion Table 2
procedure in the majority of cases (97%), while incorporation of the Perioperative characteristics and in-hospital variables of conversion THA pro
prior incision was used during the ORIF procedure in 89% of the cases. cedure by fracture pattern.
Institutional perioperative THA care protocols were adhered to, with Variable Total (n TPW (n Other acetabular p-
minor variations based on surgeon preference. All patients received = 170) = 80) fracture (n = 90) value
perioperative antibiotics within one hour prior to incision including dual Preoperative ESR, mm/h, 30.1 28.0 31.9 (30) 0.87
antibiotic regimen of Cefazolin and Vancomycin unless there is a severe mean (SD) (25) (23)
allergy reaction to either one for which Clindamycin was substituted. Preoperative CRP, mg/L, 22.9 14.8 30.1 (60) 0.50
mean (SD) (32) (24)
Intraoperative culture samples were routinely taken during conversion
Preoperative Aspiration (all 22 (13) 12 (15) 10 (11) 0.74
THA and sent for aerobic/anaerobic and fungal testing. negative), n (%)
The conversion procedures were performed by 6 arthroplasty ASA Status, n (%)
fellowship trained surgeons during the study period. These patients were 1 3 (2) 2 (2) 1 (1) 0.35
followed postoperatively by our arthroplasty surgeons and were seen 2 52 (30) 26 (33) 26 (29)
3 114 (67) 52 (65) 62 (69)
routinely in clinic. The average duration of follow-up after THA was 3.8 4 1 (1) 0 (0) 1 (1)
years (1–13 years). Patient characteristics, comorbidities, surgical var Surgical Approach, n (%)
iables related to the conversion procedure, and postoperative outcomes Anterior 5 (3) 2 (2) 3 (3) 1.00
and complications including PJI and mechanical etiologies for THA Posterior 165 (97) 78 (98) 87 (97)
Prior Incision Utilized, n 151 (89) 77 (96) 74 (82) 0.006
failure at 90 days, 1-year, and 2-year follow-up were identified through
(%)
medical chart review of hospital records, clinic notes, and phone Hardware Removal, n (%) 95 (56) 44 (55) 51 (57) 0.88
evaluations. Some Hardware Retained 50 (53) 22 (50) 28 (56) 0.86
(partial hardware
Statistical analysis removal), n (%)
Use of metal cutting burr, n 53 (56) 24 (55) 29 (57) 0.84
(%)
Fisher’s exact and chi-squared tests were used to compare categorical HO excision at time of 26 (15) 18 (23) 8 (9) 0.02
variables between patients who underwent conversion THA after index conversion THA, n (%)
ORIF for a TPW fracture and those who had other acetabular fracture Cemented THA, n (%) 6 (4) 1 (1) 5 (6) 0.22
THA Operative Duration, 119 (45) 120 118 (48) 0.50
patterns. T-tests were used for continuous variables. Multivariable lo
min, mean (SD) (44)
gistic regression was used to identify factors associated with PJI by Blood Loss, mL, mean (SD) 580 560 598 (466) 0.40
estimating odds ratios (ORs) and 95% confidence intervals (CIs). All the (405) (353)
variables related to the index acetabular ORIF procedure and the con Intraoperative Blood 21 (12) 11 (14) 10 (11) 0.65
version THA described above were examined as potential risk factors for Transfusion, n (%)
Intraoperative Blood 2.0 (0.7) 1.9 2.0 (0.8) 0.79
PJI. Variables from the univariate analysis with p values less than 0.10 Transfusion, units pRBCs, (0.7)
were included in the model. P-values of less than 0.05 (two-sided) were mean (SD)
considered statistically significant. Total Hospital Blood 41 (24) 20 (25) 21 (23) 0.86
Transfusion, n (%)
Total Hospital Blood 2.6 (1.2) 2.9 2.3 (1.0) 0.22
Results
Transfusion, units pRBCs, (1.5)
mean (SD)
There were no significant differences in perioperative characteris LOS, d, mean (SD) 3.9 (2.5) 3.9 (3) 3.9 (2) 0.82
tics, comorbidities, and in-hospital variables including HACs, trans ICU Stay, n (%) 5 (3) 3 (4) 2 (2) 0.67
fusion rate, and ICU stay of the conversion THA procedure when ICU LOS, d, mean (SD) 2.2 (0.7) 2.7 1.5 (0.7) 0.13
(0.6)
separated by fracture pattern except for heterotopic ossification (HO) Hospital acquired conditions (HACs), n (%)
excision that was more prevalent in the TPW fracture group (p = 0.018) Anemia 36 (21) 18 (22) 18 (20) 0.62
(Table 2). Other 8 (5) 3 (4) 5 (6)
The LOS (p = 0.815) and discharge disposition (0.845) were similar None 126 (74) 59 (74) 67 (74)
Discharge Disposition, n (%)
between the two groups where the majority of patients were discharged
Home 138 (81) 64 (80) 74 (82) 0.85
home (≥80%). TPW fracture pattern was not associated with higher SNF/IPR 32 (19) 16 (20) 16 (18)
postoperative mechanical complications including dislocation, peri
Abbreviations defined: THA, total hip arthroplasty; TPW, transverse posterior
prosthetic fracture, and overall revision for aseptic etiologies at 90-days
wall; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein; ASA,
and 1-year follow-up (Table 3).
American Society of Anesthesiologists; HO, heterotopic ossification; pRBCs,
The 90-day all-cause readmission after conversion was similar for packed red blood cells; ICU, intensive care unit; LOS, length of stay; IPR, inpa
both fracture groups as well (18.8% vs. 14.4%, p = 0.536). tient rehabilitation; SNF, skilled nursing facility.
Although TPW fracture patients had similar culture positive rates
(two or more positive cultures growing the same virulent organism)
year-follow-up (Table 4).
during the conversion procedure (10.5% vs. 7.7%, p = 0.896), they
The time to conversion THA (498 [PJI] vs 598 days [No PJI], p =
sustained significantly higher rates of PJI compared to the other
0.53) and the conversion rate within two years from index ORIF (69%
acetabular fracture patterns at 1-year follow-up (16.3% vs. 5.6%, p =
[PJI] vs 91% [No PJI], p = 0.05) were similar between the TPW patients
0.027). For the TPW patients, there were 2/19 patients with positive
that developed PJI and those who did not at 1-year follow-up.
intraoperative cultures at conversion, of which 1/2 developed eventual
PJI compared to 2/26 patients with positive intraoperative cultures from
Discussion
the other fracture pattern group, of which 1/2 developed eventual PJI.
All 4 of the patients with positive cultures at the time of conversion were
The preferred management of acetabular fractures is ORIF, but
treated similarly with appropriate IV antibiotics. The PJI risk was three-
studies have shown that up to 30% of these patients undergo conversion
fold higher in the TPW group at 90-days, but it did not reach statistical
THA early on after their index ORIF [2,7,16,17]. Cichos et al. showed
significance (13.8% vs. 4.4%, p = 0.055). Multivariable analysis of
that patients with TPW fractures have an increased risk of early con
significant variables in the univariate analysis revealed that TPW
version to THA within 2 years of their index ORIF compared to other
pattern was associated with increased risk of PJI at both 90-days and 1-
Table 3 first two years after index ORIF for acetabular fracture have higher PJI
Outcomes of conversion THA from previous acetabular fracture ORIF by fracture rates compared to patients who require THA at later intervals [11]. We
pattern. were not able to appreciate this significant difference in time to con
Variable Total (n TPW (n Other acetabular p- version from index ORIF or conversion rate within two years between
= 170) = 80) fracture (n = 90) value TPW patients who developed PJI and those who were infection free at
90-day 1-year follow-up. In fact, in our cohort contrary to prior studies, only
PJI 15 (9) 11 (14) 4 (4) 0.06 69% of patients who developed PJI after conversion underwent con
Dislocation 13 (8) 8 (10) 5 (6) 0.39 version within two years of index ORIF compared to 91% of those who
Periprosthetic fracture 2 (1) 2 (3) 0 (0) 0.19
did not develop PJI (p = 0.05).
Revision THA (aseptic/ 4 (2) 2 (3) 2 (2) 1.00
mechanical) Cichos et al. recommended that a CRP >12 mg/L prior to conversion
90-day readmission 28 (16) 15 (19) 13 (14) 0.54 THA was significantly associated with developing postoperative PJI and
(all cause) required additional preoperative workup [20]. This raises the suspicion
1-year that an infectious process is occurring in the native joint after the ORIF
PJI 18 (11) 13 (16) 5 (6) 0.03
Dislocation 17 (10) 10 (13) 7 (8) 0.32
procedure for these high-risk acetabular fractures driving the high in
Periprosthetic fracture 2 (1) 2 (3) 0 (0) 0.19 flammatory markers. Based on this growing evidence, we believe that
Revision THA (aseptic/ 7 (4) 3 (4) 4 (4) 1.00 these high-risk early conversion THAs may not be due to merely
mechanical) post-traumatic arthritis but possibly underlying chronic septic arthritis
Abbreviations defined: ORIF, open reduction and internal fixation; THA, total where the infection is transmitted to the consequent THA after ORIF and
hip arthroplasty; TPW, transverse posterior wall; PJI, periprosthetic joint is particularly problematic in the TPW fracture pattern as we have
infection. shown. These details pose a conundrum for how to manage these TPW
fracture patterns and what to do with them at the time of ORIF and when
they present for conversion THA for symptomatic PTOA or AVN. To
Table 4 address these matters, novel management strategies should be investi
Multivariable analysis of risk factors for PJI after conversion THA, adjusting for gated that occur either during the ORIF procedure or the conversion
covariates.
THA surgery to minimize PJI. We have started at our institution a pro
OR 95% CI p-value spective clinical trial in patients with TPW fractures treating them with
90-day PJI percutaneous pinning and staged THA 6–8 weeks later to minimize the
Female Sex 1.20 0.387–3.686 0.76 effects of our postulated second hit phenomena and consequent PJI after
CKD 0.15 0.021–1.061 0.06 conversion THA. Similarly, for patients that present for conversion THA
Prior Incision Used 1.20 0.129–11.153 0.87
HO Excision 1.03 0.243–4.350 0.97
across all fracture patterns, we are routinely drawing serology and rely
TPW fracture pattern 4.89 1.16–20.52 0.03 on CRP >12 mg/L to guide our management for which we have started
1-year PJI performing two stage exchange procedures for patients with elevated
Female Sex 1.19 0.412–3.415 0.75 serological values.
CKD 0.08 0.012–0.491 0.007
Although our study found that TPW fractures were associated with
Prior Incision Used 2.80 0.469–16.731 0.26
HO Excision 0.86 0.23–3.20 0.83 PJI after conversion THA, it is not without limitations. First, selection
TPW fracture pattern 6.51 1.561–27.164 0.010 bias is a possibility given the retrospective design of the study. Some
patients in the initial ORIF population were managed with acute ORIF
Abbreviations defined: THA, total hip arthroplasty; TPW, transverse posterior
wall; PJI, periprosthetic joint infection; CKD, chronic kidney disease; HO, het
and THA, while other patients were treated non-operatively due to
erotopic ossification. associated comorbidities, albeit the number of patients excluded from
the initial ORIF cohort was quite small and should not have affected our
results. The rate of patients who were lost to follow-up or had immediate
fracture patterns, which they postulated due to the soft tissue damage
post-op care transferred to orthopedic surgeons close to home in another
from the high-energy trauma associated with that fracture pattern [8].
state and did not reach the minimum 1-year follow-up was approxi
However, the conversion THA procedure itself is plagued by high
mately 18% which may have affected our analysis and conclusions. The
postoperative PJI rates and can reach up to18% [10,11,13,14]. There is
patients in each fracture cohort were similar in comorbidities except for
a paucity of literature on the association between acetabular fracture
a higher incidence of males and CKD in the non-TPW fracture group that
patterns and rates of PJI following conversion THA which was the
are known factors for PJI, which further strengthens our case that TPW is
impetus of our investigation.
a factor driving the infection rate. Our study is not designed to address
Our study was able to determine that the TPW acetabular fracture
the underlying etiology of PJI occurring after conversion, whether it is
pattern as an independent risk factor for developing PJI following con
consequent to indolent septic arthritis after the ORIF procedure or new
version THA. The risk of PJI was significantly higher at 1-year post
onset infection after THA, although we postulate based on strong data
operatively following the conversion procedure even though there was
from our study and prior work in the literature that support the septic
no significant difference in comorbidities between the two groups except
arthritis mechanism.
for male sex and CKD which were more prevalent in the other fracture
patterns and have been shown to be risk factors for PJI [18,19]. The
Conclusion
TPW fracture pattern was not associated with mechanical complications
at 90-days, 1-year, or 2-years postoperatively after conversion. We
In conclusion, acetabular fractures that fail ORIF and require con
postulate that the increased rate of PJI in the TPW group as compared to
version THA, in particular TPW fracture patterns, need to be closely
other acetabular fracture patterns may stem from the soft tissue and
analyzed prior to conversion THA given their increased risk of PJI.
muscle damage, and joint bleeding incurred by the high energy trauma
Preoperative workup with serology may be helpful in identifying these
mechanism. The patient then undergoes an ORIF procedure requiring
patients before undergoing THA, but significant research is still required
extensive dissection which exposes the hip joint to further trauma
to determine the optimal management of these high-risk cases to
analogous to a second hit phenomena encountered in other joints after
decrease the risk of PJI.
major trauma and subsequent ORIF weakening the local immune system
in the joint and predisposing to bacterial seeding. A recent study
discovered that patients who undergo early conversion THA within the
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[12] Morison Z, Moojen DJF, Nauth A, Hall J, McKee MD, Waddell JP, et al. Total hip
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more complications. Clin Orthop Related Res 2016;474:392–8.
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hip arthroplasty. J Arthroplasty 2016;31:16–21.
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Injury 54 (2023) 110887
Injury
Review
Surgical stabilisation in equivocal pelvic ring injuries – Into the grey zone
Eran Keltz a, *, Yaniv Keren b, Arvind Jain a, Terry Stephens a, Alexey Rovitsky b, Nabil Ghrayeb b,
Doron Norman b, Eli Peled b
a
Department of Orthopedic Surgery, Alfred Health, Melbourne, Victoria, Australia
b
Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa, Israel
Keywords: Pelvic ring injuries comprise a spectrum of bony, ligamentous and muscular injuries, described by several
Pelvic ring common classification systems. However, the majority of injuries lie in areas of intermediate severity, where
Stability complexity and variable nature make it extremely hard to define in detail. This fact and associated injuries make
Trauma
it extremely difficult to conduct randomised control trials, with purpose to direct treatment guidelines. Thus,
Lateral compression
AP compression
special interest and expertise are required by pelvic trauma surgeons, while surgical indications and fixation
Open book methods rely on their experience, at least in part. Namely, a significant grey zone of indication exists.
Examination under anaesthesia As fixation methods evolve, specifically percutaneous fixation using osseous fixation pathways, some injuries
Tile in which morbidity bound with surgical fixation was considered too high relative to its benefits, may be
Young and burgess considered eligible for surgical treatment nowadays. Moreover, due to significant progress in the treatment of the
acute polytrauma casualties, the survival rate increased over the years, emphasizing the effect of long-term
morbidity and functional outcome of pelvic ring injuries.
The purpose of this manuscript is to describe the equivocal areas of controversies, hence "the grey zone", and
to provide the readership with up-to-date published data. We aimed to collect and detail clinical and radiological
clues in the diagnosis of intermediate unstable anterior-posterior compression and lateral compression injuries,
and for the selection of treatment methods and sequence. Recent publications have provided some insights into
specific injury features that are correlated with increased chance of instability, pain and delay in ambulation.
Specific focus is given to the utility of examination under anaesthesia in selected cases. Other publications
surveyed the shared experience of pelvic trauma surgeons as for the classification, indication and treatment
sequence of pelvic ring injuries. Although the data hasn’t matured yet to a comprehensive treatment algorithm, it
may serve clinicians well when making treatment decisions in the grey zone of pelvic ring injuries, and serve as a
basis for future prospective studies.
Introduction How would an injured pelvis be considered stable? Olson and Pollak
defined a stable injured pelvic ring as one which would sustain the
The pelvic ring is a complex anatomical structure that is formed by the physiological forces involved in partially protected weight bearing and/or
Sacrum and the two Innominate bones, each comprises the union of the bed and chair mobilisation, without any secondary deformity of the pelvis,
Iliac, Ischium, and Pubis bones. Its stability is based on the osseous ring until osseous and ligamentous healing occurs naturally (3). A stable pelvis
integrity and an array of extremely strong ligaments (namely the Pubic must be one with preserved osseous and ligamentous structure [3]. Their
Symphysis, the anterior and posterior Sacro-Iliac ligaments, the Sacro- study defined the clinical surgical indications of leg length discrepancy
Spinous ligament and the Sacro-Tuberous ligament). This bony- (LLD) of 1.5 cm, complete loss of internal rotation of the hip, less than 30◦
ligamentous structure may be analogised to a chords bridge. Cadaveric of external rotation of the hip, or pubic deformity affecting the vagina or
studies consider the Sacro-Iliac ligaments and the Pubic Symphysis as perineum (causing dyspareunia). However, they also stated that the
crucial for pelvic stability [1]. In addition, it is suggested that the abdominal consideration between conservative and surgical treatment is expertise
muscles play a role in stabilizing an injured pelvic ring [2]. When assessing a that need nurturing through clinical experience, literature updates, and
pelvic ring injury, one must address these various elements considered. maintaining an active interest in the subject. Ever since then, orthopaedic
E-mail address: e.keltz@alfred.org.au (E. Keltz).
0020-1383/Crown Copyright © 2023 Published by Elsevier Ltd. All rights reserved.
E. Keltz et al. Injury 54 (2023) 110887
and general surgeons practicing in the field of pelvic trauma are trying to symphyseal disruption higher than 4 cm was considered such an injury,
optimise patient selection for the appropriate treatment plan. but later findings cast doubts on this threshold (Figs. 1 and 2).
Several clinicians have attempted to classify pelvic ring injuries. However, our ability to evaluate this injury is affected by several
Letournel had classified it in correspondence to the anatomical location limitations. Firstly, plain radiographs or computerised tomography (CT
of injury [4]. Pennal et al. presented in 1980 the first injury scan) are performed in a static scenario, and not when deforming forces
mechanism-based classification – Anterior-Posterior compression (APC) are present. Secondly, during resuscitation, the pelvis is often bounded
and lateral compression (LC), which may be stable or non-stable in using a binder or a sheet in the trauma bay, which obscures its real extent
juries, and vertical shear (VS), which is considered almost exclusively as of deformation during imaging. Thirdly, Gardner et al. demonstrated
an unstable injury [5]. Bucholz published a sub-division of APC injuries significant recoil of the pelvis in 48% of APC and 80% of LC injuries in
with a dual impact skeletal injury [6]. These classifications were cadaveric models [16] (see Fig. 3). Thus, there is a significant difficulty to
developed further and correlated with clinical manifestations by Young estimate which of the lower degrees of APC and LC injuries (presumably
and Burgess and their team from Baltimore Shock and Trauma center, designated for conservative treatment and early mobilisation) are in fact
adding a fourth type named combined mechanism (CM) [7,8]. Conse injuries of higher degrees, indicating surgical stabilisation. This issue
quently, they demonstrated the utility of this classification, proving a brings up the goals of treatment – early mobility, prevention of deformity,
correlation between the injury mechanism and the kinematics, blood a decrease of acute and chronic pain, and reduction of concomitant
product consumption, associated injuries, and survival [9]. These in complications such as deep vein thrombosis, pulmonary embolisation,
sights were used to develop treatment protocols [10]. At the same time, pressure sores, aspirations, etc. The goal of this paper is to discuss the
Marvin Tile published his classification system [11,12], based on the controversies and highlight some tools and clues published recently, with
degree of stability: Completely stable, partially stable (rotationally un purpose to optimise our decision-making and refine surgical indications.
stable), completely unstable (rotationally and vertically unstable),
which is the foundation for the comprehensive AO classification AP compression injury
(developed by Helfet) [13]. Additionally, due to the ageing of the pop
ulation alongside increasing activity of the third age, Rommens et al. Deformation and stability
developed a new classification system of fragility fractures of the pelvis
[14]. Doro et al. tried to determine the threshold of symphyseal disruption
As in almost any classification system, the Young and Burgess and the with a stable pelvis (meaning prior to the disruption of the other liga
Tile classifications represent a spectrum of injuries. APC1 (Pubic Sym ments) on 20 pelvises, resulting in an average of 2.2 cm [17]. However,
physis disruption of less than 2.5 cm) and LC1 of a minor degree the variance was high, with 80% of the pelvises losing stability with less
(compression fractures of the Sacral Ala-and the Pubic rami) according than 2 cm or more than 3 cm of symphyseal disruption. They found that
to Young and Burgess, or Tile type A, are considered stable pelvic in the anterior Sacro-Iliac ligaments are always preserved with a disruption
juries which allow early mobility with conservative treatment. In less than 1.8 cm, and always torn with one exceeding 4.5 cm, but the
contrast, APC2/3 ("open book" injury), LC3 ("windswept pelvis" injury), Sacro-Spinous and Sacro-Tuberous ligaments are not torn in synchro
and VS (vertical instability of the hemipelvis), are considered overtly nisation with them, despite Tile’s assertion. They also demonstrated a
unstable pelvic injuries and indicate surgical stabilisation. These injuries difference between males and females concerning the Pubic opening
would be classified as B3 or C types according to Tile classification [7,8, required for complete disruption of the Symphysis (2.5 cm and 1.8 cm,
11,12,15]. In between remains a wide spectrum of injuries which are respectively). A magnetic resonance imaging (MRI) based study in 25
debated between pelvic surgeons whether Young and Burgess APC1/2 pelvic injuries demonstrated that the injury patterns are compatible
and LC1/2 injuries, or Tile B1/2 injuries (or OTA/AO 61B1/2), comprise with Young and Burgess’ classification, aside from the fact that in 50% of
a relative indication for surgical stabilisation, or should they indicate APC2 injuries (symphyseal disruption higher than 2.5 cm) no strain of
early mobility without surgery. In fact, a large part of pelvic injuries the Sacro-Spinous ligament was demonstrated [18].
belongs to this group, causing this to be a common clinical question for Another possible indicator of instability is an APC injury which is not
orthopaedic trauma surgeons. The purpose of this manuscript is to purely uniplanar, but is bilplanar, and carries a horizontal rotational and
provide tools for decision-making in these scenarios. flexion/extension component. Although to the best of our knowledge it is
The fundamental definitions of shearing injuries (vertical shear or not detailed in isolation by existing classification systems, it is the authors
translation), internal rotation (lateral compression) and external rota opinion that Pubic symphyseal disruption with biplanar anterior ring
tion (equivalent to AP compression) are based upon Tile’s studies in translation (horizontal and vertical) suggests some disruption of the pelvic
cadavers combining live video documentation. He defined an external floor or Sacro-Iliac ligaments, and as such is a risk factor for occult pos
rotation ("open book") injury as one derived by external rotation force terior ring flexion/extension instability, even if the horizontal Pubic
delivered by the Femur, or a direct Anterior-Posterior force upon the Symphysis diastasis is lower than 2.5 cm, as demonstrated in Fig. 4. For
pelvis. This injury causes the Pubic Symphysis to disrupt (or the Pubic example, Wakefield et al. reported a case of chronic instability in a similar
rami to fracture, in some cases) the pelvic floor to rupture with the scenario, which required a later Symphysis fusion [19]. This observation
anterior Sacro-Iliac ligaments. The pelvis is left hanging on the strong corresponds to Sagi’s interpretation of flexion/extension sagittal plane
posterior Sacro-Iliac ligaments, acting as a hinge, and is considered instability in APC2 injuries [20]; however, our view is that this may be
stable against vertical shearing forces or Anterior-Posterior translation implemented also in some APC1 injuries with occult instability.
forces, but not against rotation forces. Tile’s study determined a
disruption of the Pubic Symphysis of less than 2.5 cm as one which
doesn’t tear the anterior Sacro-Iliac and pelvic floor ligaments, resulting Stress tests
in a stable pelvis (A2 type). Disruption of more than 2.5 cm was deter
mined to be partially stable (B1 type) due to some damage to these Based on these insights, Sagi et al. designed in 2011 a prospective
structures. Disruption of the posterior Sacro-Iliac ligaments, Iliac or trial of stress examination under anaesthesia (EUA) with the purpose to
Sacral fracture, or Sacro-Iliac joint dislocation (or fracture-dislocation), detect occult instability [20]. 68 patients with presumably stable pelvic
would result in a completely unstable pelvis (C1 type). Historically, injuries were included, attempting to diagnose an occult unstable injury.
Each patient was examined under fluoroscopy on AP, inlet and outlet
Fig. 1. Young & Burgess Classification.

APC – Anterior Posterior Compression; LC – Lateral Compression; VS – Vertical Shear.
Fig. 2. Tile Classification.

A –Stable pelvic ring; B – Partially stable pelvic ring; C – Completely unstable pelvic ring.
views, at a neutral position, internal rotation, external rotation, and symphyseal disruption less than 2.5 cm under EUA, thus the surgeon
shear (push-pull of the lower extremities and vice-versa) – with a total of decided not to fixate him, although radiographs on admission demon
15 views per patient. The treatment selected was according to the sur strated a disruption exceeding the 2.5 cm threshold.
geon’s consideration per case, as the patient had given informed consent A similar study, with fluoroscopy calibration, had evaluated using
before anaesthesia for a surgical fixation, should it be found justified. EUA 22 patients with APC1 injury, with a symphyseal disruption be
Major limitations of this study were that the forces applied weren’t tween 1 cm and 2.5 cm. Six patients (27%) had demonstrated opening
defined accurately, and the fluoroscopy views weren’t calibrated. Seven interval exceeding 2.5 cm, and thus were surgically stabilised [21].
of 15 patients (50%) with APC1 injury demonstrated symphyseal in
terval higher than 2.5 cm under EUA with external rotation force,
consequently defined as APC2, and operated for anterior external fixa Fixation method
tion. amongst these seven patients three weren’t stable with internal
rotation force, thus they were stabilised posteriorly using Ilio-Sacral A known controversy is what is the minimal fixation required for APC2
screws. 13 of 23 patients (57%) with APC2 injury were confirmed as injuries. Phieffer et al. examined 13 patients with APC2 injury (average
type 2a, and were stabilised anteriorly (11 internal fixation, two external Pubic interval of 4.6 cm) following anterior fixation alone [22]. All pa
fixation), as nine patients (39%) were diagnosed with type 2b due to tients had demonstrated posterior pelvic stability under EUA, and were
significant posterior disruption, stabilised anteriorly and posteriorly. allowed partial weight bearing (PWB) on the injured side until 6 weeks. At
Interestingly, none of them demonstrated vertical translation (defined as one year follow-up, a single patient demonstrated pelvic ring deformity
type APC3), but one patient (4%) of this group demonstrated a with clinical manifestations and was surgically revised for Sacro-Iliac
fusion. Simonian and Routt demonstrated in cadavers that anterior
Fig. 3. Pelvic Recoil – a polytrauma patient following a fall from height.

A, B: CT 3-D reconstruction on admission demonstrating Sacral and Pubic fractures with a translation of the hemipelvis. C, D: Follow-up radiographs demonstrating
spontaneous recoil of the pelvis. E, F: Stress examination under anaesthesia demonstrating pelvic stability. Internal fixation was avoided accordingly.
Fig. 4. A polytrauma patient with a Pubic Symphysis disruption.

A: Pelvis AP radiograph demonstrating a symphyseal diastasis of 1.0 cm with binder removal, and biplanar Pubic translation, suggesting sagittal rotational instability
B: The patient was surgically stabilised both anteriorly and posteriorly.
fixation doesn’t prevent motion in the Sacro-Iliac zone, and posterior amongst 176 surgeons querying the fixation method indicated in APC
fixation doesn’t prevent one in the Pubic Symphysis. However, they found injuries showed a bisection of preference with 56% preferring anterior
no mechanical difference between Ilio-Sacral screws and plates when plating only and 44% preferring anterior plating and posterior stabilisa
Sacro-Iliac fusion is concerned [23,24]. An AO international survey tion with Ilio-sacral fixation [25]. Interestingly, the first group comprised
averagely older and more experienced surgeons. In a multi-centre study by healed without the need for later surgery, as only eight had resulted with
Avilucea et al., 134 patients were operated on for APC2 injury stabilisa a translation of more than 1 cm of the Ilium, Sacrum, or Ischium height
tion, while the fixation method was selected at their surgeons’ choice, with at final follow-up. However, no functional results or pain level were
PWB protocol for 12 weeks following surgery [26]. 17 of 42 (40%) pa reported, but the main limitation is the additional 199 patients who
tients treated with anterior plate fixation alone had demonstrated fixation hadn’t completed their follow-up (hence a drop-out rate of 63%). In
failure, as 15 patients (36%) resulted in malunion. Only 5 of 92 (5.4%) order to try and predict which of these LC1 injured patients would
patients treated with anterior plate and Ilio-Sacral screws had demon develop secondary displacement and unsatisfactory function due to
strated fixation failure with a single patient (1.1%) demonstrating mal pelvic instability, Bruce et al. followed 117 patients (average age of 39
union. Therefore, the literature suggests anterior and posterior fixation years) with LC1 injury, with Sacral compression\translation of less than
when treating APC2 injury. However, other considerations, such as future 5 mm, allowing immediate weight bearing as tolerated (if no other ex
pregnancy and delivery might affect the surgeon’s consideration, since tremity injury had precluded it) [37]. AP, inlet, and outlet views were
pelvic fixation increases the risk for Caesarean Section [27]. The order of obtained at a follow-up averaging 19 weeks, with nine different pa
fixation is to be done at the surgeon’s preference. Usually it is considered rameters measured. Of 54 patients with incomplete Sacral fracture and
easier to start from the anterior fixation, but in case of biplanar deformity either unilateral or no Pubic fracture, no patient had displacement, as
it may withhold reduction of the Sacro-Iliac joint, hence in some cases the amongst the two patients with complete Sacral fracture with no Pubic
opposite sequence may be required. fracture. However, two of 22 (9%) patients with an incomplete Sacral
fracture and bilateral Pubic fractures, six of 17 (33%) with a complete
Lateral compression injury Sacral fracture and unilateral Pubic fracture, and 15 of 22 (68%) pa
tients with a complete Sacral fracture and bilateral Pubic fracture, had
Lateral compression injuries are allegedly restricted to the axial demonstrated secondary displacement, usually a rotational one.
plane but might affect the Acetabulum position in a way that affects Consequently, Pubic fractures and complete Sacral fractures demon
lower extremity length and rotation, pelvic tilt, and sitting posture. strated secondary displacement in 39% and 50% of the cases, respec
Traditionally, LC type 1 injury is considered quite stable, usually treated tively, illustrating these factors as predicting ones on admission. In a
conservatively with PWB protocol on the injured side, as 1.5 cm LLD is retrospective cohort, Ellis et al. focused on the morphology of the Pubic
considered acceptable (probably due to efficient orthotic treatment). In rami fractures in non-operative management of LC1 injuries [38]. At a
his canonical paper Tile stated that a Pubic rami fracture of the minimum follow-up of 4 weeks, patients who had unilateral either su
contralateral side relative to the injured side is less stable than an ipsi perior and inferior Pubic rami comminuted or oblique fractures, and to a
lateral one, due to higher degree of ligamentous strain [11]. lesser extent, either superior or inferior rami fracture pattern as such
were likely to displace. Bilateral Pubic rami fractures also demonstrated
Pain a similar trend, as Tile foresaw. In contrast, transverse Pubic rami
fractures didn’t result in displacement in any of the patients.
As a result of the wide range of LC injuries, especially type 1, in Another possible radiologic feature for pelvic instability in LC injuries is
which the traditional classification systems do not differ, there is only a the presence of an avulsion fracture of the transverse processes (TP) of L4 or
moderate agreement between surgeons for surgical indications [28–30]. L5 vertebrae. Starks et al. retrospectively reviewed 80 pelvic ring injuries
Numerous studies have demonstrated insufficient reduction of pain level and found L5 TP fracture correlated with a relative risk of 2.5 for pelvic
and opioid consumption [31], or that a statistically significant reduction instability, as defined by Young & Burgess classification [39]. Chmelova
was found but whether it surpasses the minimum clinical importance et al. found a significant correlation with AO type B and much more with
difference (MCID) was in doubt [32,33]. In contrast, Barei et al. study type C unstable pelvic ring injuries amongst 106 injured patients [40]. A
resulted in an average of 48% pain reduction and 34% of opioid con more recent study by Winkelmann et al. retrospectively analysed 728 pelvic
sumption following surgical treatment [34], and Tosounidis et al. pro ring injuries, and found that an L4 or L5 TP fracture holds a relative risk of
spective trial demonstrated an average decrease of 5◦ of the VAS score, 5.5 for unstable pelvic ring injury according to the AO, and Young &
75% in opioid dosage, 5 days to painless ambulation and 4 days of Burgess classifications [41]. However, a different study including a modest
hospital stay [35]. The common limitation in these trials is the intention group of 56 patients didn’t find such correlation [42]. It is important to
to treat; they are all based on the surgeon’s decision-based on injury emphasise that the correlation between translation per se and functional
kinematics and severity and the extent of the deformity, thus highly outcome is more obscure. For example, Gaski et al. didn’t find any corre
influenced by selection bias. One exception is a two-centre randomised lation between anterior pelvic injury and the functional outcome, with 35 of
control trial (RCT) published recently by Slobogean et al., in which 99 37 patients conservatively treated for LC1 injuries, as long as they didn’t
patients with LC type 1 with less than 1 cm displacement were rando suffer concomitant lower extremity injuries (these patients had resulted
mised (61 patients) or selected (38 patients) between conservative or with fair or poor outcomes in half of the cases) [43]. This study also had a
operative treatment [33]. The results were an average 1.2 points high drop-out rate, with only half of the patients completing the follow-up.
decrease in the VAS score and 8% improvement of the Majeed function
score on 3 months and 1 year follow-up. The probability of surgical Stress tests
fixation to achieve the MCID, set at 1 point decrease of the VAS score and
10% improvement of the Majeed score, was 67% and 25%, respectively. In Sagi et al. EUA study, described earlier, 31 patients with LC injury
were included [19]. Seven of 19 (37%) LC1 injuries demonstrated
Deformation and malunion considerable displacement and were surgically stabilised (six patients
anteriorly and posteriorly, and one with anterior fixation alone). Five of
Sebmler Soles et al. study demonstrated the rationale for conserva eight (63%) with LC2 and all four with LC3 injury demonstrated
tive treatment and early mobility in LC1 injuries, with less than 1 cm displacement and were stabilised anteriorly and posteriorly. The three
translation, according to a single senior surgeon’s judgement (Paul patients with LC2 injury which hadn’t displaced were indicated for con
Tornetta from Boston University Hospital) [36]. 117 of 118 patients had servative treatment. Again, the main limitation is that the forces applied
upon the pelvis weren’t clearly defined. This obscurity is reflected in a Table 1
survey conducted with 15 pelvic surgeons, resulting in 80% agreement on Beckmann Score [46].
which pelvis would be considered stable, but only 60% on which pelvis Parameter Score
should be surgically stabilised [44]. Indeed, how to perform the EUA and
< 2mm 1
what is the clinical threshold for surgery are questions not fully answered. Sacral displacement
≥ 2mm 2
In contrast, in a different study involving ten surgeons, the agreement rate
Zone 1 1
concerning stability doubled from 40% to 80% following EUA, as the Denis classification Zone 2 2
surgical indication agreement had improved more moderately [45]. Zone 3 3
Additional supporting evidence to the possible contribution of EUA was
1 column 1
published by Tosounidis et al., using an arbitrary threshold of 2 cm Fractured Sacral columns 2 columns 2
displacement under stress as a surgical indication, in LC1 injuries with 3 columns 3
complete sacral fractures [35]. However, the 35 patients surgically sta Minimal 1
bilised were compared to 28 patients with displacement of less than 2 cm, Inferior Pubic Ramus fracture displacement > 50% 2
treated non-operatively. As described earlier, the study yielded superior > 100% or segmental fracture 3
short-term functional and pain results for the operated group, possibly Ramus base 1
suggesting that the displacement threshold should be less than 2 cm. Superior Pubic Ramus fracture position Mid Ramus 2
Interestingly, none of the patients with rotational instability had demon Symphysial area 3
strated vertical instability under stress. Beckmann Score [51].
The high negative predictive value (NPV) of EUA was proved in
Whiting et al. multi-centre study [46]. The threshold of instability was again bilateral Pubic rami fracture as an instability predicting factor. In
defined as Pubic rami overlap exceeding 1 cm in LC1 injury, any a retrospective analysis, Ellis et al. found a similar trend, in which 11 of
displacement in LC2 injury, and symphyseal disruption exceeding 2.5 21 patients (52%) with LC1 injury, who were stabilised with a posterior
cm in APC injury. amongst 22 patients with LC1 injury, four with LC2 fixation only method, had translated during follow-up of a minimum of
injury, and eight with APC1 injury, none had demonstrated displace four weeks [38]. In contrast, only one patient out of 113 (<1%) who
ment under EUA. They were allowed full weight bearing as tolerated, were stabilised anteriorly and posteriorly had translated during
and none had demonstrated secondary displacement in 6 month follow-up. All patients from the posterior fixation only group who hadn’t
follow-up. Hence, EUA resulted in 100% of NPV. translated had no Pubic ramus fracture or a transverse one, suggesting
Recent studies have presented that AP radiographs in lateral decu the importance of a stable anterior ring over the extent ("completeness")
bitus position [47] or internal and external rotational stress tests under of posterior sacral comminution.
fluoroscopy in the emergency department (ED) [48] can be performed In an attempt to create a more precise correspondence regarding LC1
without anaesthesia, with reliable results, similar to the ones obtained injuries, Beckmann et al. have created a novel scoring method [51],
by EUA [47,48]. The later study had proven a high NPV. The former based upon a survey amongst 111 experienced surgeons, which ranked
study by Parry et el. addresses in an elegant way the issue of stand different parameters (see Table 1) in 27 LC1 pelvic injuries, using plain
ardisation of the stress applied, which is always a bias in EUA. It may radiographs and CT scans. A score of 6 or less resulted in an indication
very well be that a routine ED examination and imaging would dismiss for conservative treatment, 7–9 score indicated EUA, and 10 and more
the expected surgical bias and concern for overtreatment, as the odds for indicated surgical fixation. Substantial inter-observer agreement was
surgical fixation might increase when the operating theatre is already found (Cohen Kappa=0.77). The most significant parameters predicting
occupied for EUA. The authors challenged their own hypothesis in a surgical indication were Denis classification of the Sacral fracture with
subsequent study in which the lateral stress test (LSR) was compared to an odds ratio (OR) of 10, and a fracture of two or three Sacral columns
an early mobilisation protocol, as the index for surgical fixation [49]. (OR=5.7).
They state they chose to adhere to the LSR radiographs due to their
predictive value for poorer outcomes and their utility to make an early Discussion
decision during the admission, while the mobilisation protocol resulted
in a much longer time for surgery for those who needed it. As the indication for conservative treatment of completely stable
pelvic injuries (Tile type A) and the indication for surgical fixation in
Fixation indication high-degree injuries (Tile type C, LC2/3, APC3, VS) are quite clear, the
treatment of a wide range of intermediate-degree of injury remains
Like in APC injury, the issue of anterior, posterior, or combined equivocal (Tile type A2/B, APC1/2, LC1/2). In APC injuries the dis
anterior-posterior fixation is an old controversy. Although biomechan cussion primarily concerns the suggested ligamentous damage, with the
ically fixing only the posterior part, close to the hinge of internal rota extent of the Pubic Symphysis disruption interval as its representative
tion deformity, has limited lever arm against the anterior pelvis’ [11,16,17]. A low threshold of suspicion for occult instability in APC1
fulcrum, some surgeons advocate it. Six pelvic surgeons from different injuries and occult posterior instability (probably involving the inter
centres in the USA had attempted to create a protocol for gradual osseous Sacro-Iliac ligaments, defined as APC2b by Sagi et al.) should be
evaluation under anaesthesia during LC injury fixation surgery - initially applied. It seems that EUA with stress tests [20,21,35] or MRI [18] may
in purpose to decide if to stabilise or not at all, and following posterior have some value to relieve the surgeon’s doubts in borderline cases. It
fixation using Ilio-Sacral screws, to determine if anterior fixation is may also prove valuable in cases of ongoing symptoms despite minimal
required [50]. The threshold defined was identical to Whiting et al.’s displacement on imaging, as demonstrated by Wakefield et al. [19].
study. 36 of 72 (50%) patients were stabilised anteriorly and posteriorly, In contrast, LC injuries represent a higher variance between cases,
as the rest were stabilised posteriorly alone. Patients were advised to possibly due to the combination of ligamentous injury and complex
PWB for 12 weeks. The mean follow-up was 11 months. No secondary fracture patterns. For example, Lefaivre et al. described a multi-
displacement occurred in the first group, while nine patients (25%) from parametric description of 100 LC1 injuries, supporting the claim that
the second group, all with bilateral Pubic rami fractures, had displaced LC1 injury is a spectrum of different levels of severity [28]. It is also
7.5 mm on average (range 5–12 mm) by the time to union, although they reflected in Beckmann et al. survey amongst 111 surgeons, which found
were demonstrated stable following posterior fixation under EUA. In substantial interobserver agreement as for the surgical indication in only
contrast, the remaining 27 patients (75%) with unilateral Pubic rami nine of 27 cases [30]. Similarly, a recently published survey amongst 19
fractures hadn’t displaced following posterior fixation alone, marking pelvic surgeons demonstrated no to minimal agreement between
participants concerning LC1 injury [52]. Structural support to this hy mobility, and the prevention of deformity or long-term instability. While
pothesis was demonstrated by Khoury et al., showing a variety of secondary displacement is not very common, it may certainly happen
different motions in each axis with 3-D analysis of 60 pelvises with LC (see Fig. 5), even after surgical fixation [54], and the consequences may
injury (Tile B2) [53]. The collected literature data supports bilateral be catastrophic [55,56]. Early mobility and pain reduction are classic
Pubic rami fractures, unilateral inferior and superior comminuted or treatment goals, indicating surgery in complex patients, e.g. geriatric
oblique fractures, complete sacral fractures (stretching to the posterior proximal Femoral fractures, but the indications are less unequivocal
cortex, or a two/three column fracture according to Beckmann et al.), when pelvic ring injury is concerned. LLD may be considered a debili
sacral comminution, Denis type 2/3, and EUA resulting with instability, tating deformity, but it may very well be that a hemipelvis height
all suggestive of a potential indication for surgical fixation of LC1 in variance will disturb the patient more in sitting posture (when the pelvic
juries. Although these findings are yet to be united into an established tilt resembles the outlet view), and rotational deformity will disturb the
grading system, they may serve as clues to guide the clinician regarding patient when ambulating more than LLD which can often be compen
the surgical indication of borderline LC injuries and the fixation extent sated using orthotics.
and sequence. See Table 2 which demonstrates equivocal clinical sce Prognosis prediction and the development of precise treatment
narios and suggests possible tools to assist in decision making. When protocols are limited due to the pelvis’ anatomical and surgical
defining treatment indications, the treatment goals must be defined. In complexity, the prevalence of high-energy injuries, and associated in
general, the discussion can be divided into pain treatment, early juries. In the last four decades, a significant advancement has been
Table 2
Pelvic ring injury scenarios with equivocal indication for surgical fixation ("grey zone"), clues which suggests instability, possible investigation and fixation strategy.
grey zone situation clues of instability further investigation fixation strategy (if needed)
Clinical Imaging Imaging Theatre
APC 1
Sequential fixation: Anterior/

APC 1 – Pubic Symphysis<2.5 cm + • Symphysis disruption > 1.8 cm [17] Posterior > imaging\EUA >
SIJ widening • Variable Pubic Symphysis interval in Posterior/Anterior [26]
different imaging
• Sagittal rotational component – Pubic • Standing XR
Symphysis biplanar disruption • CT scan
EUA [20,
• SIJ injury without a
21,46]
• Retroperitoneal haematoma binder
• MRI [18]
• Ongoing\
APC with sagittal rotational
chronic pain
component (biplanar deformity)
[34,35]
• Tenderness
over the SIJ
Consider posterior reduction and
• Patient can’t
fixation prior to anterior fixation
weight bear
[49]
• High energy
mechanism
LC 1
Marginal indication – may fixate the
posterior pelvis only
Bilateral Pubic rami Fx – fixate
posterior and anterior pelvis [50]
• Segmental/comminuted Pubic ramus Fx Comminuted/oblique unilateral Pubic
[38] • Lateral rami Fx – fixate posterior pelvis >
• Bilateral Pubic rami Fx [11,37] decubitus XR EUA > consider anterior fixation [38]
• Oblique Pubic ramus Fx [38] [47] EUA [20,
• Complete Sacral Fx [37,51] • CT scan 35,46,
LC 1 with Perched Pubis rami • Beckman score [51] without a 48]
• Overlap deformity which is not reduced binder
when binder is off • MRI
• L4/L5 transverse process Fx [39–41]
Anterior and posterior fixation
APC: Anterior posterior compression; LC: Lateral compression; SIJ: Sacro-Iliac joint; XR: X-ray (plain radiograph); CT: Computerized tomography; MRI: Magnetic reso
nance imaging; Fx: Fracture; EUA: Examination under anaesthesia.
APC: Anterior posterior compression; LC: Lateral compression; SIJ: Sacro-Iliac joint; XR: X-ray (plain radiograph); CT: Computerized tomography; MRI: Magnetic
resonance imaging; Fx: Fracture; EUA: Examination under anaesthesia.
Fig. 5. A polytrauma patient with a pelvic ring injury and a left Acetabular fracture.
A, B: CT on admission demonstrating APC type 1 injury (symphyseal disruption < 2.5 cm). C, D: Follow-up CT (due to intra-peritoneal injury) demonstrates sig
nificant disruption of the anterior Sacro-Iliac joint and the Pubic Symphysis, hence it’s an APC type 2 injury. Patient was stabilised accordingly.
achieved in understanding pelvic stability and the development of [5] Pennal GF, Tile M, Waddell JP, Garside H. Pelvic disruption: assessment and
classification. Clin Orthop Relat Res 1980;151:12–21. Sep.
reduction and fixation methods. However, since these surgeries carry
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[12] Tile M. Acute pelvic fractures: II. principles of management. J Am Acad Orthop
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[14] Rommens PM, Hofmann A. Comprehensive classification of fragility fractures of
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10
Injury 54 (2023) 110887
Injury
Review
Surgical stabilisation in equivocal pelvic ring injuries – Into the grey zone
Eran Keltz a, *, Yaniv Keren b, Arvind Jain a, Terry Stephens a, Alexey Rovitsky b, Nabil Ghrayeb b,
Doron Norman b, Eli Peled b
a
Department of Orthopedic Surgery, Alfred Health, Melbourne, Victoria, Australia
b
Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa, Israel
Keywords: Pelvic ring injuries comprise a spectrum of bony, ligamentous and muscular injuries, described by several
Pelvic ring common classification systems. However, the majority of injuries lie in areas of intermediate severity, where
Stability complexity and variable nature make it extremely hard to define in detail. This fact and associated injuries make
Trauma
it extremely difficult to conduct randomised control trials, with purpose to direct treatment guidelines. Thus,
Lateral compression
AP compression
special interest and expertise are required by pelvic trauma surgeons, while surgical indications and fixation
Open book methods rely on their experience, at least in part. Namely, a significant grey zone of indication exists.
Examination under anaesthesia As fixation methods evolve, specifically percutaneous fixation using osseous fixation pathways, some injuries
Tile in which morbidity bound with surgical fixation was considered too high relative to its benefits, may be
Young and burgess considered eligible for surgical treatment nowadays. Moreover, due to significant progress in the treatment of the
acute polytrauma casualties, the survival rate increased over the years, emphasizing the effect of long-term
morbidity and functional outcome of pelvic ring injuries.
The purpose of this manuscript is to describe the equivocal areas of controversies, hence "the grey zone", and
to provide the readership with up-to-date published data. We aimed to collect and detail clinical and radiological
clues in the diagnosis of intermediate unstable anterior-posterior compression and lateral compression injuries,
and for the selection of treatment methods and sequence. Recent publications have provided some insights into
specific injury features that are correlated with increased chance of instability, pain and delay in ambulation.
Specific focus is given to the utility of examination under anaesthesia in selected cases. Other publications
surveyed the shared experience of pelvic trauma surgeons as for the classification, indication and treatment
sequence of pelvic ring injuries. Although the data hasn’t matured yet to a comprehensive treatment algorithm, it
may serve clinicians well when making treatment decisions in the grey zone of pelvic ring injuries, and serve as a
basis for future prospective studies.
Introduction How would an injured pelvis be considered stable? Olson and Pollak
defined a stable injured pelvic ring as one which would sustain the
The pelvic ring is a complex anatomical structure that is formed by the physiological forces involved in partially protected weight bearing and/or
Sacrum and the two Innominate bones, each comprises the union of the bed and chair mobilisation, without any secondary deformity of the pelvis,
Iliac, Ischium, and Pubis bones. Its stability is based on the osseous ring until osseous and ligamentous healing occurs naturally (3). A stable pelvis
integrity and an array of extremely strong ligaments (namely the Pubic must be one with preserved osseous and ligamentous structure [3]. Their
Symphysis, the anterior and posterior Sacro-Iliac ligaments, the Sacro- study defined the clinical surgical indications of leg length discrepancy
Spinous ligament and the Sacro-Tuberous ligament). This bony- (LLD) of 1.5 cm, complete loss of internal rotation of the hip, less than 30◦
ligamentous structure may be analogised to a chords bridge. Cadaveric of external rotation of the hip, or pubic deformity affecting the vagina or
studies consider the Sacro-Iliac ligaments and the Pubic Symphysis as perineum (causing dyspareunia). However, they also stated that the
crucial for pelvic stability [1]. In addition, it is suggested that the abdominal consideration between conservative and surgical treatment is expertise
muscles play a role in stabilizing an injured pelvic ring [2]. When assessing a that need nurturing through clinical experience, literature updates, and
pelvic ring injury, one must address these various elements considered. maintaining an active interest in the subject. Ever since then, orthopaedic
E-mail address: e.keltz@alfred.org.au (E. Keltz).
and general surgeons practicing in the field of pelvic trauma are trying to symphyseal disruption higher than 4 cm was considered such an injury,
optimise patient selection for the appropriate treatment plan. but later findings cast doubts on this threshold (Figs. 1 and 2).
Several clinicians have attempted to classify pelvic ring injuries. However, our ability to evaluate this injury is affected by several
Letournel had classified it in correspondence to the anatomical location limitations. Firstly, plain radiographs or computerised tomography (CT
of injury [4]. Pennal et al. presented in 1980 the first injury scan) are performed in a static scenario, and not when deforming forces
mechanism-based classification – Anterior-Posterior compression (APC) are present. Secondly, during resuscitation, the pelvis is often bounded
and lateral compression (LC), which may be stable or non-stable in using a binder or a sheet in the trauma bay, which obscures its real extent
juries, and vertical shear (VS), which is considered almost exclusively as of deformation during imaging. Thirdly, Gardner et al. demonstrated
an unstable injury [5]. Bucholz published a sub-division of APC injuries significant recoil of the pelvis in 48% of APC and 80% of LC injuries in
with a dual impact skeletal injury [6]. These classifications were cadaveric models [16] (see Fig. 3). Thus, there is a significant difficulty to
developed further and correlated with clinical manifestations by Young estimate which of the lower degrees of APC and LC injuries (presumably
and Burgess and their team from Baltimore Shock and Trauma center, designated for conservative treatment and early mobilisation) are in fact
adding a fourth type named combined mechanism (CM) [7,8]. Conse injuries of higher degrees, indicating surgical stabilisation. This issue
quently, they demonstrated the utility of this classification, proving a brings up the goals of treatment – early mobility, prevention of deformity,
correlation between the injury mechanism and the kinematics, blood a decrease of acute and chronic pain, and reduction of concomitant
product consumption, associated injuries, and survival [9]. These in complications such as deep vein thrombosis, pulmonary embolisation,
sights were used to develop treatment protocols [10]. At the same time, pressure sores, aspirations, etc. The goal of this paper is to discuss the
Marvin Tile published his classification system [11,12], based on the controversies and highlight some tools and clues published recently, with
degree of stability: Completely stable, partially stable (rotationally un purpose to optimise our decision-making and refine surgical indications.
stable), completely unstable (rotationally and vertically unstable),
which is the foundation for the comprehensive AO classification AP compression injury
(developed by Helfet) [13]. Additionally, due to the ageing of the pop
ulation alongside increasing activity of the third age, Rommens et al. Deformation and stability
developed a new classification system of fragility fractures of the pelvis
[14]. Doro et al. tried to determine the threshold of symphyseal disruption
As in almost any classification system, the Young and Burgess and the with a stable pelvis (meaning prior to the disruption of the other liga
Tile classifications represent a spectrum of injuries. APC1 (Pubic Sym ments) on 20 pelvises, resulting in an average of 2.2 cm [17]. However,
physis disruption of less than 2.5 cm) and LC1 of a minor degree the variance was high, with 80% of the pelvises losing stability with less
(compression fractures of the Sacral Ala-and the Pubic rami) according than 2 cm or more than 3 cm of symphyseal disruption. They found that
to Young and Burgess, or Tile type A, are considered stable pelvic in the anterior Sacro-Iliac ligaments are always preserved with a disruption
juries which allow early mobility with conservative treatment. In less than 1.8 cm, and always torn with one exceeding 4.5 cm, but the
contrast, APC2/3 ("open book" injury), LC3 ("windswept pelvis" injury), Sacro-Spinous and Sacro-Tuberous ligaments are not torn in synchro
and VS (vertical instability of the hemipelvis), are considered overtly nisation with them, despite Tile’s assertion. They also demonstrated a
unstable pelvic injuries and indicate surgical stabilisation. These injuries difference between males and females concerning the Pubic opening
would be classified as B3 or C types according to Tile classification [7,8, required for complete disruption of the Symphysis (2.5 cm and 1.8 cm,
11,12,15]. In between remains a wide spectrum of injuries which are respectively). A magnetic resonance imaging (MRI) based study in 25
debated between pelvic surgeons whether Young and Burgess APC1/2 pelvic injuries demonstrated that the injury patterns are compatible
and LC1/2 injuries, or Tile B1/2 injuries (or OTA/AO 61B1/2), comprise with Young and Burgess’ classification, aside from the fact that in 50% of
a relative indication for surgical stabilisation, or should they indicate APC2 injuries (symphyseal disruption higher than 2.5 cm) no strain of
early mobility without surgery. In fact, a large part of pelvic injuries the Sacro-Spinous ligament was demonstrated [18].
belongs to this group, causing this to be a common clinical question for Another possible indicator of instability is an APC injury which is not
orthopaedic trauma surgeons. The purpose of this manuscript is to purely uniplanar, but is bilplanar, and carries a horizontal rotational and
provide tools for decision-making in these scenarios. flexion/extension component. Although to the best of our knowledge it is
The fundamental definitions of shearing injuries (vertical shear or not detailed in isolation by existing classification systems, it is the authors
translation), internal rotation (lateral compression) and external rota opinion that Pubic symphyseal disruption with biplanar anterior ring
tion (equivalent to AP compression) are based upon Tile’s studies in translation (horizontal and vertical) suggests some disruption of the pelvic
cadavers combining live video documentation. He defined an external floor or Sacro-Iliac ligaments, and as such is a risk factor for occult pos
rotation ("open book") injury as one derived by external rotation force terior ring flexion/extension instability, even if the horizontal Pubic
delivered by the Femur, or a direct Anterior-Posterior force upon the Symphysis diastasis is lower than 2.5 cm, as demonstrated in Fig. 4. For
pelvis. This injury causes the Pubic Symphysis to disrupt (or the Pubic example, Wakefield et al. reported a case of chronic instability in a similar
rami to fracture, in some cases) the pelvic floor to rupture with the scenario, which required a later Symphysis fusion [19]. This observation
anterior Sacro-Iliac ligaments. The pelvis is left hanging on the strong corresponds to Sagi’s interpretation of flexion/extension sagittal plane
posterior Sacro-Iliac ligaments, acting as a hinge, and is considered instability in APC2 injuries [20]; however, our view is that this may be
stable against vertical shearing forces or Anterior-Posterior translation implemented also in some APC1 injuries with occult instability.
forces, but not against rotation forces. Tile’s study determined a
disruption of the Pubic Symphysis of less than 2.5 cm as one which
doesn’t tear the anterior Sacro-Iliac and pelvic floor ligaments, resulting Stress tests
in a stable pelvis (A2 type). Disruption of more than 2.5 cm was deter
mined to be partially stable (B1 type) due to some damage to these Based on these insights, Sagi et al. designed in 2011 a prospective
structures. Disruption of the posterior Sacro-Iliac ligaments, Iliac or trial of stress examination under anaesthesia (EUA) with the purpose to
Sacral fracture, or Sacro-Iliac joint dislocation (or fracture-dislocation), detect occult instability [20]. 68 patients with presumably stable pelvic
would result in a completely unstable pelvis (C1 type). Historically, injuries were included, attempting to diagnose an occult unstable injury.
Each patient was examined under fluoroscopy on AP, inlet and outlet
Fig. 1. Young & Burgess Classification.

APC – Anterior Posterior Compression; LC – Lateral Compression; VS – Vertical Shear.
Fig. 2. Tile Classification.

A –Stable pelvic ring; B – Partially stable pelvic ring; C – Completely unstable pelvic ring.
views, at a neutral position, internal rotation, external rotation, and symphyseal disruption less than 2.5 cm under EUA, thus the surgeon
shear (push-pull of the lower extremities and vice-versa) – with a total of decided not to fixate him, although radiographs on admission demon
15 views per patient. The treatment selected was according to the sur strated a disruption exceeding the 2.5 cm threshold.
geon’s consideration per case, as the patient had given informed consent A similar study, with fluoroscopy calibration, had evaluated using
before anaesthesia for a surgical fixation, should it be found justified. EUA 22 patients with APC1 injury, with a symphyseal disruption be
Major limitations of this study were that the forces applied weren’t tween 1 cm and 2.5 cm. Six patients (27%) had demonstrated opening
defined accurately, and the fluoroscopy views weren’t calibrated. Seven interval exceeding 2.5 cm, and thus were surgically stabilised [21].
of 15 patients (50%) with APC1 injury demonstrated symphyseal in
terval higher than 2.5 cm under EUA with external rotation force,
consequently defined as APC2, and operated for anterior external fixa Fixation method
tion. amongst these seven patients three weren’t stable with internal
rotation force, thus they were stabilised posteriorly using Ilio-Sacral A known controversy is what is the minimal fixation required for APC2
screws. 13 of 23 patients (57%) with APC2 injury were confirmed as injuries. Phieffer et al. examined 13 patients with APC2 injury (average
type 2a, and were stabilised anteriorly (11 internal fixation, two external Pubic interval of 4.6 cm) following anterior fixation alone [22]. All pa
fixation), as nine patients (39%) were diagnosed with type 2b due to tients had demonstrated posterior pelvic stability under EUA, and were
significant posterior disruption, stabilised anteriorly and posteriorly. allowed partial weight bearing (PWB) on the injured side until 6 weeks. At
Interestingly, none of them demonstrated vertical translation (defined as one year follow-up, a single patient demonstrated pelvic ring deformity
type APC3), but one patient (4%) of this group demonstrated a with clinical manifestations and was surgically revised for Sacro-Iliac
fusion. Simonian and Routt demonstrated in cadavers that anterior
Fig. 3. Pelvic Recoil – a polytrauma patient following a fall from height.

A, B: CT 3-D reconstruction on admission demonstrating Sacral and Pubic fractures with a translation of the hemipelvis. C, D: Follow-up radiographs demonstrating
spontaneous recoil of the pelvis. E, F: Stress examination under anaesthesia demonstrating pelvic stability. Internal fixation was avoided accordingly.
Fig. 4. A polytrauma patient with a Pubic Symphysis disruption.

A: Pelvis AP radiograph demonstrating a symphyseal diastasis of 1.0 cm with binder removal, and biplanar Pubic translation, suggesting sagittal rotational instability
B: The patient was surgically stabilised both anteriorly and posteriorly.
fixation doesn’t prevent motion in the Sacro-Iliac zone, and posterior amongst 176 surgeons querying the fixation method indicated in APC
fixation doesn’t prevent one in the Pubic Symphysis. However, they found injuries showed a bisection of preference with 56% preferring anterior
no mechanical difference between Ilio-Sacral screws and plates when plating only and 44% preferring anterior plating and posterior stabilisa
Sacro-Iliac fusion is concerned [23,24]. An AO international survey tion with Ilio-sacral fixation [25]. Interestingly, the first group comprised
averagely older and more experienced surgeons. In a multi-centre study by healed without the need for later surgery, as only eight had resulted with
Avilucea et al., 134 patients were operated on for APC2 injury stabilisa a translation of more than 1 cm of the Ilium, Sacrum, or Ischium height
tion, while the fixation method was selected at their surgeons’ choice, with at final follow-up. However, no functional results or pain level were
PWB protocol for 12 weeks following surgery [26]. 17 of 42 (40%) pa reported, but the main limitation is the additional 199 patients who
tients treated with anterior plate fixation alone had demonstrated fixation hadn’t completed their follow-up (hence a drop-out rate of 63%). In
failure, as 15 patients (36%) resulted in malunion. Only 5 of 92 (5.4%) order to try and predict which of these LC1 injured patients would
patients treated with anterior plate and Ilio-Sacral screws had demon develop secondary displacement and unsatisfactory function due to
strated fixation failure with a single patient (1.1%) demonstrating mal pelvic instability, Bruce et al. followed 117 patients (average age of 39
union. Therefore, the literature suggests anterior and posterior fixation years) with LC1 injury, with Sacral compression\translation of less than
when treating APC2 injury. However, other considerations, such as future 5 mm, allowing immediate weight bearing as tolerated (if no other ex
pregnancy and delivery might affect the surgeon’s consideration, since tremity injury had precluded it) [37]. AP, inlet, and outlet views were
pelvic fixation increases the risk for Caesarean Section [27]. The order of obtained at a follow-up averaging 19 weeks, with nine different pa
fixation is to be done at the surgeon’s preference. Usually it is considered rameters measured. Of 54 patients with incomplete Sacral fracture and
easier to start from the anterior fixation, but in case of biplanar deformity either unilateral or no Pubic fracture, no patient had displacement, as
it may withhold reduction of the Sacro-Iliac joint, hence in some cases the amongst the two patients with complete Sacral fracture with no Pubic
opposite sequence may be required. fracture. However, two of 22 (9%) patients with an incomplete Sacral
fracture and bilateral Pubic fractures, six of 17 (33%) with a complete
Lateral compression injury Sacral fracture and unilateral Pubic fracture, and 15 of 22 (68%) pa
tients with a complete Sacral fracture and bilateral Pubic fracture, had
Lateral compression injuries are allegedly restricted to the axial demonstrated secondary displacement, usually a rotational one.
plane but might affect the Acetabulum position in a way that affects Consequently, Pubic fractures and complete Sacral fractures demon
lower extremity length and rotation, pelvic tilt, and sitting posture. strated secondary displacement in 39% and 50% of the cases, respec
Traditionally, LC type 1 injury is considered quite stable, usually treated tively, illustrating these factors as predicting ones on admission. In a
conservatively with PWB protocol on the injured side, as 1.5 cm LLD is retrospective cohort, Ellis et al. focused on the morphology of the Pubic
considered acceptable (probably due to efficient orthotic treatment). In rami fractures in non-operative management of LC1 injuries [38]. At a
his canonical paper Tile stated that a Pubic rami fracture of the minimum follow-up of 4 weeks, patients who had unilateral either su
contralateral side relative to the injured side is less stable than an ipsi perior and inferior Pubic rami comminuted or oblique fractures, and to a
lateral one, due to higher degree of ligamentous strain [11]. lesser extent, either superior or inferior rami fracture pattern as such
were likely to displace. Bilateral Pubic rami fractures also demonstrated
Pain a similar trend, as Tile foresaw. In contrast, transverse Pubic rami
fractures didn’t result in displacement in any of the patients.
As a result of the wide range of LC injuries, especially type 1, in Another possible radiologic feature for pelvic instability in LC injuries is
which the traditional classification systems do not differ, there is only a the presence of an avulsion fracture of the transverse processes (TP) of L4 or
moderate agreement between surgeons for surgical indications [28–30]. L5 vertebrae. Starks et al. retrospectively reviewed 80 pelvic ring injuries
Numerous studies have demonstrated insufficient reduction of pain level and found L5 TP fracture correlated with a relative risk of 2.5 for pelvic
and opioid consumption [31], or that a statistically significant reduction instability, as defined by Young & Burgess classification [39]. Chmelova
was found but whether it surpasses the minimum clinical importance et al. found a significant correlation with AO type B and much more with
difference (MCID) was in doubt [32,33]. In contrast, Barei et al. study type C unstable pelvic ring injuries amongst 106 injured patients [40]. A
resulted in an average of 48% pain reduction and 34% of opioid con more recent study by Winkelmann et al. retrospectively analysed 728 pelvic
sumption following surgical treatment [34], and Tosounidis et al. pro ring injuries, and found that an L4 or L5 TP fracture holds a relative risk of
spective trial demonstrated an average decrease of 5◦ of the VAS score, 5.5 for unstable pelvic ring injury according to the AO, and Young &
75% in opioid dosage, 5 days to painless ambulation and 4 days of Burgess classifications [41]. However, a different study including a modest
hospital stay [35]. The common limitation in these trials is the intention group of 56 patients didn’t find such correlation [42]. It is important to
to treat; they are all based on the surgeon’s decision-based on injury emphasise that the correlation between translation per se and functional
kinematics and severity and the extent of the deformity, thus highly outcome is more obscure. For example, Gaski et al. didn’t find any corre
influenced by selection bias. One exception is a two-centre randomised lation between anterior pelvic injury and the functional outcome, with 35 of
control trial (RCT) published recently by Slobogean et al., in which 99 37 patients conservatively treated for LC1 injuries, as long as they didn’t
patients with LC type 1 with less than 1 cm displacement were rando suffer concomitant lower extremity injuries (these patients had resulted
mised (61 patients) or selected (38 patients) between conservative or with fair or poor outcomes in half of the cases) [43]. This study also had a
operative treatment [33]. The results were an average 1.2 points high drop-out rate, with only half of the patients completing the follow-up.
decrease in the VAS score and 8% improvement of the Majeed function
score on 3 months and 1 year follow-up. The probability of surgical Stress tests
fixation to achieve the MCID, set at 1 point decrease of the VAS score and
10% improvement of the Majeed score, was 67% and 25%, respectively. In Sagi et al. EUA study, described earlier, 31 patients with LC injury
were included [19]. Seven of 19 (37%) LC1 injuries demonstrated
Deformation and malunion considerable displacement and were surgically stabilised (six patients
anteriorly and posteriorly, and one with anterior fixation alone). Five of
Sebmler Soles et al. study demonstrated the rationale for conserva eight (63%) with LC2 and all four with LC3 injury demonstrated
tive treatment and early mobility in LC1 injuries, with less than 1 cm displacement and were stabilised anteriorly and posteriorly. The three
translation, according to a single senior surgeon’s judgement (Paul patients with LC2 injury which hadn’t displaced were indicated for con
Tornetta from Boston University Hospital) [36]. 117 of 118 patients had servative treatment. Again, the main limitation is that the forces applied
upon the pelvis weren’t clearly defined. This obscurity is reflected in a Table 1
survey conducted with 15 pelvic surgeons, resulting in 80% agreement on Beckmann Score [46].
which pelvis would be considered stable, but only 60% on which pelvis Parameter Score
should be surgically stabilised [44]. Indeed, how to perform the EUA and
< 2mm 1
what is the clinical threshold for surgery are questions not fully answered. Sacral displacement
≥ 2mm 2
In contrast, in a different study involving ten surgeons, the agreement rate
Zone 1 1
concerning stability doubled from 40% to 80% following EUA, as the Denis classification Zone 2 2
surgical indication agreement had improved more moderately [45]. Zone 3 3
Additional supporting evidence to the possible contribution of EUA was
1 column 1
published by Tosounidis et al., using an arbitrary threshold of 2 cm Fractured Sacral columns 2 columns 2
displacement under stress as a surgical indication, in LC1 injuries with 3 columns 3
complete sacral fractures [35]. However, the 35 patients surgically sta Minimal 1
bilised were compared to 28 patients with displacement of less than 2 cm, Inferior Pubic Ramus fracture displacement > 50% 2
treated non-operatively. As described earlier, the study yielded superior > 100% or segmental fracture 3
short-term functional and pain results for the operated group, possibly Ramus base 1
suggesting that the displacement threshold should be less than 2 cm. Superior Pubic Ramus fracture position Mid Ramus 2
Interestingly, none of the patients with rotational instability had demon Symphysial area 3
strated vertical instability under stress. Beckmann Score [51].
The high negative predictive value (NPV) of EUA was proved in
Whiting et al. multi-centre study [46]. The threshold of instability was again bilateral Pubic rami fracture as an instability predicting factor. In
defined as Pubic rami overlap exceeding 1 cm in LC1 injury, any a retrospective analysis, Ellis et al. found a similar trend, in which 11 of
displacement in LC2 injury, and symphyseal disruption exceeding 2.5 21 patients (52%) with LC1 injury, who were stabilised with a posterior
cm in APC injury. amongst 22 patients with LC1 injury, four with LC2 fixation only method, had translated during follow-up of a minimum of
injury, and eight with APC1 injury, none had demonstrated displace four weeks [38]. In contrast, only one patient out of 113 (<1%) who
ment under EUA. They were allowed full weight bearing as tolerated, were stabilised anteriorly and posteriorly had translated during
and none had demonstrated secondary displacement in 6 month follow-up. All patients from the posterior fixation only group who hadn’t
follow-up. Hence, EUA resulted in 100% of NPV. translated had no Pubic ramus fracture or a transverse one, suggesting
Recent studies have presented that AP radiographs in lateral decu the importance of a stable anterior ring over the extent ("completeness")
bitus position [47] or internal and external rotational stress tests under of posterior sacral comminution.
fluoroscopy in the emergency department (ED) [48] can be performed In an attempt to create a more precise correspondence regarding LC1
without anaesthesia, with reliable results, similar to the ones obtained injuries, Beckmann et al. have created a novel scoring method [51],
by EUA [47,48]. The later study had proven a high NPV. The former based upon a survey amongst 111 experienced surgeons, which ranked
study by Parry et el. addresses in an elegant way the issue of stand different parameters (see Table 1) in 27 LC1 pelvic injuries, using plain
ardisation of the stress applied, which is always a bias in EUA. It may radiographs and CT scans. A score of 6 or less resulted in an indication
very well be that a routine ED examination and imaging would dismiss for conservative treatment, 7–9 score indicated EUA, and 10 and more
the expected surgical bias and concern for overtreatment, as the odds for indicated surgical fixation. Substantial inter-observer agreement was
surgical fixation might increase when the operating theatre is already found (Cohen Kappa=0.77). The most significant parameters predicting
occupied for EUA. The authors challenged their own hypothesis in a surgical indication were Denis classification of the Sacral fracture with
subsequent study in which the lateral stress test (LSR) was compared to an odds ratio (OR) of 10, and a fracture of two or three Sacral columns
an early mobilisation protocol, as the index for surgical fixation [49]. (OR=5.7).
They state they chose to adhere to the LSR radiographs due to their
predictive value for poorer outcomes and their utility to make an early Discussion
decision during the admission, while the mobilisation protocol resulted
in a much longer time for surgery for those who needed it. As the indication for conservative treatment of completely stable
pelvic injuries (Tile type A) and the indication for surgical fixation in
Fixation indication high-degree injuries (Tile type C, LC2/3, APC3, VS) are quite clear, the
treatment of a wide range of intermediate-degree of injury remains
Like in APC injury, the issue of anterior, posterior, or combined equivocal (Tile type A2/B, APC1/2, LC1/2). In APC injuries the dis
anterior-posterior fixation is an old controversy. Although biomechan cussion primarily concerns the suggested ligamentous damage, with the
ically fixing only the posterior part, close to the hinge of internal rota extent of the Pubic Symphysis disruption interval as its representative
tion deformity, has limited lever arm against the anterior pelvis’ [11,16,17]. A low threshold of suspicion for occult instability in APC1
fulcrum, some surgeons advocate it. Six pelvic surgeons from different injuries and occult posterior instability (probably involving the inter
centres in the USA had attempted to create a protocol for gradual osseous Sacro-Iliac ligaments, defined as APC2b by Sagi et al.) should be
evaluation under anaesthesia during LC injury fixation surgery - initially applied. It seems that EUA with stress tests [20,21,35] or MRI [18] may
in purpose to decide if to stabilise or not at all, and following posterior have some value to relieve the surgeon’s doubts in borderline cases. It
fixation using Ilio-Sacral screws, to determine if anterior fixation is may also prove valuable in cases of ongoing symptoms despite minimal
required [50]. The threshold defined was identical to Whiting et al.’s displacement on imaging, as demonstrated by Wakefield et al. [19].
study. 36 of 72 (50%) patients were stabilised anteriorly and posteriorly, In contrast, LC injuries represent a higher variance between cases,
as the rest were stabilised posteriorly alone. Patients were advised to possibly due to the combination of ligamentous injury and complex
PWB for 12 weeks. The mean follow-up was 11 months. No secondary fracture patterns. For example, Lefaivre et al. described a multi-
displacement occurred in the first group, while nine patients (25%) from parametric description of 100 LC1 injuries, supporting the claim that
the second group, all with bilateral Pubic rami fractures, had displaced LC1 injury is a spectrum of different levels of severity [28]. It is also
7.5 mm on average (range 5–12 mm) by the time to union, although they reflected in Beckmann et al. survey amongst 111 surgeons, which found
were demonstrated stable following posterior fixation under EUA. In substantial interobserver agreement as for the surgical indication in only
contrast, the remaining 27 patients (75%) with unilateral Pubic rami nine of 27 cases [30]. Similarly, a recently published survey amongst 19
fractures hadn’t displaced following posterior fixation alone, marking pelvic surgeons demonstrated no to minimal agreement between
participants concerning LC1 injury [52]. Structural support to this hy mobility, and the prevention of deformity or long-term instability. While
pothesis was demonstrated by Khoury et al., showing a variety of secondary displacement is not very common, it may certainly happen
different motions in each axis with 3-D analysis of 60 pelvises with LC (see Fig. 5), even after surgical fixation [54], and the consequences may
injury (Tile B2) [53]. The collected literature data supports bilateral be catastrophic [55,56]. Early mobility and pain reduction are classic
Pubic rami fractures, unilateral inferior and superior comminuted or treatment goals, indicating surgery in complex patients, e.g. geriatric
oblique fractures, complete sacral fractures (stretching to the posterior proximal Femoral fractures, but the indications are less unequivocal
cortex, or a two/three column fracture according to Beckmann et al.), when pelvic ring injury is concerned. LLD may be considered a debili
sacral comminution, Denis type 2/3, and EUA resulting with instability, tating deformity, but it may very well be that a hemipelvis height
all suggestive of a potential indication for surgical fixation of LC1 in variance will disturb the patient more in sitting posture (when the pelvic
juries. Although these findings are yet to be united into an established tilt resembles the outlet view), and rotational deformity will disturb the
grading system, they may serve as clues to guide the clinician regarding patient when ambulating more than LLD which can often be compen
the surgical indication of borderline LC injuries and the fixation extent sated using orthotics.
and sequence. See Table 2 which demonstrates equivocal clinical sce Prognosis prediction and the development of precise treatment
narios and suggests possible tools to assist in decision making. When protocols are limited due to the pelvis’ anatomical and surgical
defining treatment indications, the treatment goals must be defined. In complexity, the prevalence of high-energy injuries, and associated in
general, the discussion can be divided into pain treatment, early juries. In the last four decades, a significant advancement has been
Table 2
grey zone situation clues of instability further investigation fixation strategy (if needed)
Clinical Imaging Imaging Theatre
APC 1
Sequential fixation: Anterior/

APC 1 – Pubic Symphysis<2.5 cm + • Symphysis disruption > 1.8 cm [17] Posterior > imaging\EUA >
SIJ widening • Variable Pubic Symphysis interval in Posterior/Anterior [26]
different imaging
• Sagittal rotational component – Pubic • Standing XR
Symphysis biplanar disruption • CT scan
EUA [20,
• SIJ injury without a
21,46]
• Retroperitoneal haematoma binder
• MRI [18]
• Ongoing\
APC with sagittal rotational
chronic pain
component (biplanar deformity)
[34,35]
• Tenderness
over the SIJ
Consider posterior reduction and
• Patient can’t
fixation prior to anterior fixation
weight bear
[49]
• High energy
mechanism
LC 1
Marginal indication – may fixate the
posterior pelvis only
Bilateral Pubic rami Fx – fixate
posterior and anterior pelvis [50]
• Segmental/comminuted Pubic ramus Fx Comminuted/oblique unilateral Pubic
[38] • Lateral rami Fx – fixate posterior pelvis >
• Bilateral Pubic rami Fx [11,37] decubitus XR EUA > consider anterior fixation [38]
• Oblique Pubic ramus Fx [38] [47] EUA [20,
• Complete Sacral Fx [37,51] • CT scan 35,46,
LC 1 with Perched Pubis rami • Beckman score [51] without a 48]
• Overlap deformity which is not reduced binder
when binder is off • MRI
• L4/L5 transverse process Fx [39–41]
Anterior and posterior fixation
APC: Anterior posterior compression; LC: Lateral compression; SIJ: Sacro-Iliac joint; XR: X-ray (plain radiograph); CT: Computerized tomography; MRI: Magnetic reso
nance imaging; Fx: Fracture; EUA: Examination under anaesthesia.
APC: Anterior posterior compression; LC: Lateral compression; SIJ: Sacro-Iliac joint; XR: X-ray (plain radiograph); CT: Computerized tomography; MRI: Magnetic
resonance imaging; Fx: Fracture; EUA: Examination under anaesthesia.
Fig. 5. A polytrauma patient with a pelvic ring injury and a left Acetabular fracture.
A, B: CT on admission demonstrating APC type 1 injury (symphyseal disruption < 2.5 cm). C, D: Follow-up CT (due to intra-peritoneal injury) demonstrates sig
nificant disruption of the anterior Sacro-Iliac joint and the Pubic Symphysis, hence it’s an APC type 2 injury. Patient was stabilised accordingly.
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10
Injury 54 (2023) 110888
Injury
Review
The effect of drugs on implant osseointegration- A narrative review

Christiana Zidrou a, *, Artemis Kapetanou b, Stavroula Rizou c
a
2nd Orthopaedic Department, G. Papageorgiou General Hospital, Thessaloniki, Greece
b
Orthopaedic Surgeon, Thessaloniki, Greece
c
National and Kapodistrian University of Athens, Athens, Greece
Keywords: Objective: This narrative review aims to investigate the effects of drugs on implant osseointegration, analyzing
Drug effects their potential positive or negative impact on the direct structural and functional connection between bone and
Osseointegration load-carrying implants.
Implant
Background: The review seeks to provide a comprehensive understanding of osseointegration, which refers to the
Bisphosphonates
successful integration of an implant with living bone, resulting in no progressive relative movement between
Drug delivery systems
them. Exploring the effects of drugs on implant osseointegration is crucial for optimizing outcomes and
enhancing patient care in orthopedic implant procedures.
Methods: Relevant studies on the effects of drugs on implant osseointegration were identified through a literature
search. Electronic databases, including PubMed, Embase, and Google Scholar, were utilized, employing appro
priate keywords and MeSH terms related to osseointegration, implants, and drug interventions. The search was
limited to English studies.
Discussion: This overview presents a detailed analysis of the effects of drugs on implant osseointegration. It ex
plores drugs such as bisphosphonates, teriparatide, statins, angiotensin-converting enzyme inhibitors, beta-
blockers, nitrites, and thiazide diuretics as promoters of osseointegration. Conversely, loop diuretics, non-
steroidal anti-inflammatory drugs, corticosteroids, cyclosporine A, cisplatin, methotrexate, antibiotics, proton
pump inhibitors (PPIs), antiepileptics, selective serotonin reuptake inhibitors (SSRIs), and anticoagulants are
discussed as inhibitors of the process. The role of vitamin D3 remains uncertain. The complex relationship be
tween drugs and the biology of implant osseointegration is emphasized, underscoring the need for further in vitro
and in vivo studies to validate their effects
Conclusion: This narrative review contributes to the literature by providing an overview of the effects of drugs on
implant osseointegration. It highlights the complexity of the subject and emphasizes the necessity for more
extensive and sophisticated studies in the future. Based on the synthesis of the reviewed literature, certain drugs,
such as bisphosphonates and teriparatide, show potential for promoting implant osseointegration, while others,
including loop diuretics and certain antibiotics, may impede the process. However, additional research is
required to solidify these conclusions and effectively inform clinical practice.
Introduction worsening relative motion between the implant and the bone with
which it is in direct contact. The term osseointegration describes a
Osseointegration refers to a direct structural and functional clinical condition that provides long-term stability of the prosthesis but
connection between living bone and the loading surface of the implant is not a biological property of any implant or metal system. In other
[1]. The initial observations of osseointegration were made in the 1950s words, the direct contact with the bone observed histologically can be an
by implanting titanium screws into rabbit bones and completely incor indicative factor of a lack of local or systemic biological reaction on the
porating them to the extent that their removal could only be accom surface with which the implant comes into contact. For this reason, it is
plished by fracture [2]. proposed that osseointegration is not the result of an advantageous
Today an implant is considered integrated when there is no biological response of the tissue but the lack of a negative histological
E-mail address: czidrou@gmail.com (C. Zidrou).
C. Zidrou et al. Injury 54 (2023) 110888
reaction [3]. experimental rats’ models [6,7].

The concept of osseointegration is an extremely complex phenome In mice showing rapid bone loss due to ovectomy, the systemic
non that depends on many known and unknown factors and has been administration of zoledronic acid, alendronate and strontium ranelate
defined at multiple levels i.e. clinical, anatomical, histological and causes better osseointegration of the implants. Alendronate and stron
microscopic [4]. The main factors affecting osseointegration as tium ranelate have similar positive effects regarding osseointegration,
mentioned are those related to the implant (proper design, chemical while single dose zoledronic acid had more positive effects as far as bone
composition, surface topography, overlay of the prosthesis), those density and osseointegration [8].
related to the bone matrix (minimization of surgical trauma, angiog The administration of alendronate prior to implant placement in
raphy, bone deficits, osteoporosis, rheumatoid arthritis, smoking), the experimental rabbit models increases healing ability around implants
mechanical stability of the prosthesis as well as the use of adjuvant [9]. In a systematic review of preclinical studies was supported that the
treatments and drugs (bone grafts, systemic administration of local administration of zoledronic acid appears to increase osseointe
bisphosphonates and teriparatide, indomethacin, warfarin, heparin, gration or new bone formation around implants in experimental models
methotrexate) [3,4]. [10]. Moreover, in a preclinical meta-analysis the systematic adminis
The biological process of osseointegration closely resembles the tration of zoledronic acid appears to improve the osseointegration of
marvelous phenomenon of fracture healing. It is, therefore, realized how orthopedic implant in animal models while for the local administration
important the study of the osseointegration process is. there is a similar trend but the results need to be further analyzed [11].
The purpose of this narrative review is to investigate the factors and Furthermore, from a clinical point of view, more randomized studies
especially the drugs that positively or negatively affect the process of with long-term follow-up should be conducted in this direction. In
implant osseointegration. particular, a systematic review from Brazil supported that the local
administration of bisphosphonates seems to have positive effects in
Methods osseointegration of titanium implants in humans [12].
In another systematic review and meta-analysis, it was argued that
Relevant studies on the effects of drugs on implant osseointegration coating implants with alendronate increases new bone formation, the
were identified through a literature search of electronic databases bone-implant interface, as well as the biomechanical properties [13].
(PubMed, Embase, and Google Scholar). The search was limited to Given that bisphosphonates inhibit bone resorption, an important
English-language studies. Inclusion criteria encompassed both in vitro stage of fracture healing, these drugs have been widely studied in pre
and in vivo studies, including preclinical and clinical trials, focusing on clinical models regarding their influence on fracture healing. Anyway,
various drugs such as bisphosphonates, teriparatide, statins, angiotensin bisphosphonates appear safe to use in the management of recent upper
converting enzyme inhibitors, beta-blockers, nitrites, and diuretics- and lower extremity fractures in humans [14].
thiazides. The role of vitamin D3 and other drugs in implant osseoin A systematic review from UK suggested that patients with distal
tegration was also examined. Duplicate articles were removed, and title radius fractures treated with bisphosphonates, had a significantly longer
and abstract screening was conducted to identify potentially relevant fracture healing time compared to control groups, but the observation
studies. Full-text articles were then assessed with additional studies did not concern patients who had sustained femur fractures [15].
identified through reference lists. The selected studies were critically Finally, in a systematic review from China, it was concluded that early
reviewed and analyzed to extract information on drug interventions, administration of bisphosphonates after surgery did not appear to clin
outcome measures, and results. The findings were synthesized and ically or radiologically delay fracture healing [16]. Nonetheless, there is
presented in a narrative format, highlighting the positive or negative an urgent need for better designed studies of the clinical effect of
effects of drugs on implant osseointegration. bisphosphonates on fracture healing in large numbers of patients.
Results Teriparatide
Teriparatide is a synthetic form of parathyroid hormone (PTH),
Positive factors-promotion which is a naturally occurring hormone involved in regulating bone
metabolism. When administered, teriparatide activates osteoblasts. It
Bisphosphonates stimulates the production of new bone tissue, enhances bone remodel
Bisphosphonates are a class of drugs commonly used to treat bone- ing, and increases bone mineral density. At the bone/implant interface,
related disorders such as osteoporosis. In the context of the bone/ teriparatide promotes the formation of new bone around the implant.
implant interface, bisphosphonates exert their effects through a dual This leads to better integration between the implant and the surrounding
mechanism of action. Firstly, bisphosphonates inhibit osteoclast activ bone tissue, enhancing the stability and longevity of the implant.
ity. By suppressing osteoclast function, bisphosphonates reduce the Teriparatide improved the stability of implants using stainless steel
breakdown of bone tissue at the implant interface. This helps to main screws 2–4 weeks after its administration increasing the contact be
tain the structural integrity of the bone and prevents the loosening of the tween the bone and the implant [17]. The effect of teriparatide occurred
implant. Secondly, bisphosphonates have an affinity for the mineralized regardless of the implant used, but earlier in porous-coated implants and
bone matrix. When bisphosphonates are incorporated into the bone, resulted in thickening of the trabecular bone and increased bone mass in
they act as local anti-resorptive agents. This localized effect helps to the area around the implant [18]. Thus, teriparatide could be considered
enhance the stability and integration of the implant within the bone. The a potentially useful drug in improving the integration of orthopedic
time point at which bisphosphonates exert their effects in the bone/ implants.
implant interface can vary. It depends on factors such as the specific In particular, Zati et al. reported a case of loosening in a cementless
bisphosphonate used, the dosage, and the individual patient’s response. total hip arthroplasty where stabilization was achieved after 8 months of
Generally, bisphosphonates are administered before or after implant treatment with teriparatide [19]. Moreover, Daugaard et al. reported
placement to optimize the osseointegration process. The effects can be that intermittent administration of teriparatide improved histological
seen within weeks to months, as the bisphosphonates gradually accu osseointegration of press-fit prostheses in cancellous bone, without
mulate in the bone and exert their anti-resorptive actions, promoting additional improvement in initial mechanical stabilization [20].
implant stability and integration. Additionally, the effect of teriparatide and zoledronic acid alone or in
Bisphosphonates increase early implant stability in patients with low combination on fracture healing was investigated using implants to
bone mass [5]. Administration of ibandronate improves osseointegra stabilize tibial fractures in ovariectomized mice. The combined treat
tion and stabilization in hydroxyapatite-coated titanium implants in ment promoted fracture healing more than either treatment alone 12
months after implant placement [21]. crucial for proper bone mineralization and the integrity of the bone/
Furthermore, a meta-analysis conducted in China found insufficient implant interface. By regulating calcium homeostasis, vitamin D3 en
evidence regarding the effectiveness of teriparatide administration on sures a favorable environment for optimal osseointegration. The time
fracture healing, highlighting the need for high-quality randomized point at which the effects of vitamin D3 become apparent at the bone/
controlled studies to assess its efficacy [22]. implant interface can vary. Vitamin D3 deficiency has been associated
Finally, in another study from China, it was argued that the post with impaired bone healing and reduced implant stability. Supplemen
operative administration of teriparatide for 6 months seems to be an tation with vitamin D3 is typically initiated prior to implant placement
effective adjunctive treatment for patients with osteoporotic inter to ensure adequate levels in the body.
trochanteric fractures. However, given the limited power of the study, a In the study by Javed et al., on the efficacy of vitamin D3 in
prospective, randomized, large-scale study is necessary to be conducted osseointegration, six experimental studies were included, involving four
to determine the effectiveness of teriparatide [23]. rodent studies and two rabbit studies [30]. The results from these studies
demonstrated that vitamin D3 supplementation around the implants
Statins increased new bone formation and osseointegration (bone-implant
Statins, commonly used as cholesterol-lowering medications, have contact) of the implants. However, the role of vitamin D3 in the
shown potential benefits in promoting bone health and osseointegration osseointegration of implants is questionable and requires further
at the bone/implant interface. The mechanism of action of statins in this investigation.
context involves their effect on bone metabolism and inflammation. Additionally, in a study by Gorter et al., the effect of vitamin D levels
Statins inhibit an enzyme called HMG-CoA reductase, which is involved on fracture healing was investigated [31]. Vitamin D levels at the time of
in cholesterol synthesis. However, beyond their cholesterol-lowering fracture were found to influence the healing process but further research
properties, statins have been found to have pleiotropic effects, is necessary to confirm these results. In conclusion, vitamin D has a role
including modulation of bone metabolism. Statins promote osteoblast in fracture healing, but the available data are insufficient to clarify how
activity leading to increased bone mineral density and bone formation. and in what way [31].
At the bone/implant interface, statins enhance the osseointegration
process by stimulating new bone formation around the implant. This Angiotensin converting enzyme inhibitors
improved bone formation facilitates the integration and stability of the Angiotensin converting enzyme inhibitors (ACE inhibitors) are pri
implant within the bone. The time point at which statins exert their marily used to treat hypertension and heart failure. While their direct
effects in the bone/implant interface can vary. Studies have shown that mechanism of action at the bone/implant interface is not fully under
the beneficial effects of statins on bone health and osseointegration may stood, they may indirectly influence bone metabolism through their
take several weeks to months to become apparent. This timeframe al effects on the renin-angiotensin system. The renin-angiotensin system
lows for the statins to stimulate bone remodeling and enhance the plays a role in regulating blood pressure and fluid balance, but it is also
maturation of bone tissue around the implant. involved in bone remodeling. ACE inhibitors block the conversion of
Simvastatin has osteoanabolic effects. Histomorphometric studies angiotensin I to angiotensin II, a potent vasoconstrictor, and modulator
have shown increased bone ingrowth, increased power in the contact of the renin-angiotensin system. By reducing angiotensin II levels, ACE
interface, superiority of stability, bone adaptation at the bone-implant inhibitors may indirectly affect bone metabolism. Angiotensin II has
interface in the group of patients treated with simvastatin [24]. been shown to stimulate bone resorption and inhibit bone formation. By
Fang et al. reported that statin-loaded implants by an electro inhibiting its production, ACE inhibitors may potentially reduce bone
chemical process improved osseointegration of implants in osteoporotic resorption and promote bone formation. This could have positive effects
experimental mouse models [25]. In a recent study, Tao et al. reported on the bone/implant interface, facilitating implant stability and inte
that the combined administration of teriparatide and simvastatin in gration. The time point at which the effects of ACE inhibitors on the
creases the stabilization of hydroxyapatite-coated titanium implants in bone/implant interface become evident is not well established. It is
osteoporotic experimental mouse models [26]. likely that the timing depends on various factors, including the specific
In a systematic review by Kellesarian et al. was investigated the ef ACE inhibitor used, dosage, treatment duration, and the individual pa
ficacy of local and systemic administration of statins in osseointegration tient’s response. Further research is needed to elucidate the precise
of implants. In experimental models, local and systemic administration mechanisms and determine the optimal timing for observing the effects
of statins appears to increase osseointegration; But from a clinical point of ACE inhibitors on the bone/implant interface. It is important to note
of view, further studies are necessary to determine the role of statins in that while ACE inhibitors have shown potential benefits for bone health,
promoting osseointegration around implants [27]. their primary indications are cardiovascular conditions. The use of ACE
In another systematic review by An and colleagues, statin therapy inhibitors in the context of implant osseointegration should be evaluated
was associated with a reduced risk of osteoporotic and hip fractures, on a case-by-case basis, considering the patient’s overall health, car
increased bone density in the hip and spine and an increase in osteo diovascular status, and the specific circumstances of the implant
calcin [28]. procedure.
Currently limited drugs including statins could play a future key role In a study of 3887 patients aged >65 years with hypertension, the
in the fracture healing process but data are lacking. Further in-depth use of angiotensin II converting enzyme inhibitors was associated with
understanding of the healing process is essential in order to identify higher femoral neck BMD in women, whereas in men BMD was higher at
new effective weapons in the pharmaceutical quiver [29]. the femoral neck, total hip, and lumbar spine [32].
Furthermore, in a study by Garcia et al., was investigated the role of
Vitamin D3 angiotensin-converting enzyme inhibitors during fracture healing [33].
Vitamin D3 plays a crucial role in bone health and the bone/implant Specifically, perindopril treatment improved periosteal pore formation,
interface. Its mechanism of action involves promoting calcium absorp bone bridging of the fracture gap, and resistance to torsional forces.
tion in the intestines, enhancing calcium deposition in bone tissue, and Therefore, ACE inhibitors are able to accelerate fracture healing and
regulating bone remodeling. At the bone/implant interface, vitamin D3 bone remodeling. Despite of these, multiple observational studies and
contributes to the osseointegration process through several mechanisms. high-quality data from randomized controlled trials are needed to
Firstly, it stimulates the differentiation and activity of osteoblasts. This confirm these findings.
leads to increased bone mineralization and the formation of new bone
around the implant. Secondly, vitamin D3 helps maintain adequate Beta-blockers
calcium levels in the bloodstream. Sufficient calcium availability is Beta-blockers are commonly used to treat cardiovascular conditions
such as hypertension, angina, and arrhythmias. Their primary mecha Moreover, another study by Pouwels and colleagues found that the
nism of action is to block the beta-adrenergic receptors in the body, risk of hip fracture was significantly lower in those who used organic
particularly the beta-1 receptors found in the heart and blood vessels. In nitrites because they needed them compared to those who received them
the context of the bone/implant interface, the mechanism of action of in a maintenance dose [39].
beta-blockers is not well understood. Limited research suggests that In conclusion, it can be said that the use of nitroglycerin in the
beta-blockers may have indirect effects on bone metabolism. They may treatment of osteoporosis is not recommended. However, post
influence bone remodeling through their impact on the sympathetic menopausal women taking long-term nitrites for chronic stable angina
nervous system and the release of various hormones and neurotrans may have a lower risk of osteoporosis and faster fracture healing.
mitters. Beta-blockers are thought to inhibit the activity of osteoclasts,
the cells responsible for bone resorption. By reducing osteoclast activity, Diuretics-Thiazides
beta-blockers may potentially decrease bone loss and contribute to the Diuretics, specifically thiazide diuretics, are commonly used to treat
preservation of bone density. The specific time point at which the effects conditions such as hypertension and edema by promoting increased
of beta-blockers on the bone/implant interface become evident is not urine production and reducing fluid retention. Their primary mecha
clearly established. It may vary depending on factors such as the specific nism of action involves inhibiting the reabsorption of sodium and
beta-blocker used, dosage, treatment duration, and individual patient chloride ions in the kidney tubules, leading to increased urine output.
characteristics. It is important to note that the effects of beta-blockers on In terms of the bone/implant interface, thiazide diuretics have been
bone metabolism and the bone/implant interface are still being inves associated with potential effects on bone metabolism. Thiazides are
tigated, and further research is needed to fully understand their role. believed to enhance calcium reabsorption in the kidney, leading to
Beta-blockers are drugs with numerous cardiological indications. increased serum calcium levels. This elevation in serum calcium can
Their action on bone metabolism is not sufficiently documented. An stimulate bone mineralization and reduce urinary calcium excretion. As
experimental study in rat tibiae investigated the effect of propranolol, a a result, thiazides may contribute to increased bone density. The exact
β-blocker on fracture healing and implant osseointegration. In partic time point at which thiazides exert their effects on the bone/implant
ular, propranolol was found to accelerate fracture healing, increase the interface is not well-established and may vary depending on factors such
contact surface between bone and implant, and osseointegration [34]. In as dosage, treatment duration, and individual patient characteristics.
addition, another experimental study in mice investigated the effect of The risk of hip fracture increases approximately 2–3 times in the first
nebivolol, which is a selective β-blocker, and was found to have a pos days after starting diuretic therapy. An eight-year study of 28.703
itive effect on fracture healing [35]. people found that the risk of fracture was greatest in the first 7 days after
In a study by Graham et al., it was argued that β-blockers in addition receiving a loop diuretic and in the first 8–14 days after receiving a
to their documented effect on the cardiovascular system have a positive thiazide diuretic [40].
effect on bone formation, bone metabolism and fracture healing [36]. A meta-analysis of 13 observational studies including nearly 30,000
Although there are some conflicting studies, most research data support patients showed that thiazide diuretic use reduced the risk of hip frac
β-blockers as promising drugs for the treatment of osteoporosis and ture by 18%. Their protective effect ceased to exist approximately 4
fracture healing [36]. months after stopping treatment [41]. Furthermore, Kruse et al. support
that continuous and long-term treatment is more important than dosage
Nitrites regarding the protective effect exerted by thiazides on bone metabolism
Nitrites, such as sodium nitrite, are not commonly associated with and fracture risk [42].
specific effects on the bone/implant interface. Nitrites are primarily In conclusion, literature data support the beneficial effect of thiazide
used as vasodilators in certain medical conditions. diuretics on bone metabolism, reducing fracture risk and fracture
In the context of the bone/implant interface, there is limited research healing, but there are no study data to support their use in relation to the
on the direct effects of nitrites. Nitric oxide (NO), which can be gener survival and integration of orthopedic implants [43].
ated from nitrites, has been implicated in bone metabolism and may play
a role in bone remodeling and regeneration. NO is involved in various Negative factors-inhibition
cellular processes, including vasodilation, neurotransmission, and im
mune response. However, the specific mechanism of action of nitrites in Loop diuretics
the bone/implant interface is not well understood, and their direct ef Loop diuretics, such as furosemide and bumetanide, are commonly
fects on implant osseointegration have not been extensively studied. used to treat conditions such as edema and hypertension. Their primary
Further research is needed to elucidate the potential role of nitrites in mechanism of action involves inhibiting the reabsorption of sodium,
bone metabolism and their influence on the bone/implant interface. chloride, and other ions in the ascending limb of the loop of Henle in the
Regarding the time point of action, it would depend on the specific kidney, leading to increased urine output and reduced fluid retention.
circumstances and administration of nitrites. If nitrites are being used as In the context of the bone/implant interface, loop diuretics have
a vasodilator to improve blood flow, their effects on bone metabolism been associated with potential effects on bone metabolism. However,
and the bone/implant interface may occur relatively quickly, within their precise mechanism of action in relation to the bone/implant
minutes to hours after administration. However, if nitrites are being interface is not well understood and requires further research. Loop
considered in the context of bone healing or implant osseointegration, diuretics can lead to increased urinary calcium excretion, which may
further research is necessary to determine the optimal timing and result in a negative calcium balance. This calcium imbalance may
duration of their administration. indirectly affect bone metabolism, potentially contributing to decreased
There are data that support the view of the favorable effect of nitrites bone mineral density and increased fracture risk. Additionally, loop
on bone metabolism and fracture healing. High levels of nitric oxide diuretics may impact the electrolyte balance in the body, which can
inhibit osteoclast activity and simultaneously reduce bone resorption. indirectly influence bone health. The time point at which loop diuretics
Two randomized trials looked at the long-term effects of transdermal may exert their effects on the bone/implant interface is not well-defined
nitroglycerin and were conflicting. In the first study, after three years of and may vary based on factors such as dosage, treatment duration, and
follow-up the bone density reduction rates in the hip and lumbar spine individual patient characteristics
were similar whether or not nitroglycerin was administered [37]. In the A meta-analysis by Xiao F and colleagues suggests that the use of
second study, it was observed significant increase in bone density at loop diuretics shows a positive association with overall fracture risk and
both the hip and lumbar spine in women given nitroglycerin which in particular hip fracture risk [44]. Moreover, a study by Corrao et al.
appears to increase bone density and decrease bone resorption [38]. associated the use of antihypertensive drugs and specifically loop
diuretics in a total of 81.617 Italian patients during the period inflammatory response.
2005–2009 with an increased risk of hospitalization for hip fracture In the context of the bone/implant interface, corticosteroids can have
[45]. both direct and indirect effects. Directly, they can inhibit the activity of
In conclusion, the action of loop diuretics is opposite to thiazide osteoblasts, the cells responsible for bone formation, and impair the
diuretics as they appear to reduce bone density, increase fracture risk, synthesis of new bone. Additionally, corticosteroids can interfere with
but there are insufficient literature data on their action on osseointe the normal remodeling process by inhibiting the activity of osteoclasts,
gration of orthopedic implants [43]. the cells involved in bone resorption. Indirectly, corticosteroids can
modulate the immune response and reduce inflammation, which may
Non-steroidal anti-inflammatory drugs have an impact on the healing process and osseointegration of the
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used implant. The time point at which corticosteroids exert their effects on
to alleviate pain, reduce inflammation, and manage various conditions. the bone/implant interface can vary depending on factors such as the
The primary mechanism of action of NSAIDs involves inhibiting the specific corticosteroid used, dosage, duration of treatment, and indi
enzymes called cyclooxygenases (COX), specifically COX-1 and COX-2. vidual patient factors. It is important to note that corticosteroids can
By inhibiting these enzymes, NSAIDs interfere with the production of have both short-term and long-term effects on bone metabolism
prostaglandins, which are chemical messengers involved in inflamma Taking corticosteroids for systemic disease does not seem to have
tion and pain signaling. significant implications on osseointegration. Therefore, they are not
In the context of the bone/implant interface, NSAIDs can impact considered a contraindication for dental implant placement [52].
bone healing and osseointegration. They may interfere with the in In another study by Liu and colleagues was suggested that long-term
flammatory response necessary for the normal bone healing process. administration of glucocorticosteroids >3 months significantly delays
Prostaglandins, which are inhibited by NSAIDs, play a role in bone fracture healing and adversely affects bone biomechanical properties
remodeling and repair. By reducing prostaglandin levels, NSAIDs can [53].
potentially inhibit bone formation and delay the integration of the
implant with the surrounding bone. The time point at which NSAIDs Cyclosporine A- Cisplatin-methotrexate
exert their effects on the bone/implant interface is not precisely defined Cyclosporine A is an immunosuppressive drug commonly used in
and may vary depending on factors such as the specific NSAID used, organ transplantation to prevent rejection. Its mechanism of action in
dosage, duration of treatment, and individual patient characteristics. volves inhibiting the activation of T lymphocytes, which are key players
When fracture healing or spinal fusion is desired, non-steroidal anti- in the immune response. By suppressing the immune system, cyclo
inflammatory drugs should be avoided. Selective cyclooxygenase-2 sporine A may indirectly affect the bone/implant interface by reducing
(COX-2) inhibitors when given for 6 consecutive weeks in an experi inflammation and immune-mediated processes. However, the direct
mental model were statistically found to cause less internal bone effects of cyclosporine A on bone and implant integration are not well
growth, however, when administered for 2 weeks, they do not appear to understood.
interfere with bone internal growth [46]. Cisplatin is a chemotherapeutic drug primarily used in the treatment
Celecoxib does not appear to inhibit bone ingrowth or bone forma of various cancers. Its mechanism of action involves binding to DNA and
tion when administered for perioperative pain relief in patients with forming cross-links, thereby interfering with DNA replication and cell
bilateral total knee arthroplasty [47]. division. Cisplatin is not specifically targeted towards the bone/implant
Meloxicam negatively affects bone healing in cortical and cancellous interface, and its use is primarily focused on cancer treatment. However,
bone around titanium implants in experimental mouse models after it’s important to consider the potential systemic effects of cisplatin, such
continuous administration [48]. A study by Gomes and colleagues as bone marrow suppression, which may indirectly impact bone healing
showed that in animal studies that any drug that inhibits and implant integration.
cyclooxygenase-2 (COX-2) can negatively affect the process of osseoin Methotrexate is another chemotherapy drug used in the treatment of
tegration and they must be administered with particular care during the cancer, as well as autoimmune conditions such as rheumatoid arthritis.
postoperative period [49]. It works by inhibiting an enzyme involved in the synthesis of DNA, RNA,
NSAIDs and older non-selective COX-2 inhibitors adversely affect and proteins. Methotrexate is not directly targeted towards the bone/
fracture healing to varying degrees. Regarding modern COX-2 selective implant interface. However, similar to cisplatin, its systemic effects on
inhibitors, the literature is unclear, with their effect on fracture healing bone metabolism and immune function may have an indirect influence
being dose-dependent and depending on the duration of their adminis on bone healing and implant integration.
tration. Anyway, they are preferable and the duration of their admin An histomorphometric study in rabbits suggests that treatment with
istration should not exceed 10 days. Selective COX-2 inhibitors should cyclosporine A negatively affects osseointegration around titanium im
be avoided in patients who smoke, take corticosteroids, suffer from plants due to particularly low values of bone-implant contact interface,
diabetes mellitus, and a fracture showing signs of delayed or non-union fraction of filling in the bone area within the glomeruli of the implant,
[50]. Despite of these, there are no sufficient clinical data to prohibit the and bone mineral density [54].
use of NSAIDs in patients with fractures [51]. Cisplatin chemotherapy has negative effects on the osseointegration
In conclusion, anti-inflammatory drugs as well as cyclooxygenase-2 of dental implants mainly when used in experimental rabbit models
(COX-2) selective inhibitors have negative effects on osseointegration. [55]. Moreover, an experimental rabbit study by Matheaus et al. con
In general, all NSAIDs, selective or not, should be administered in the cludes that cisplatin chemotherapy adversely affects bone regeneration
lowest effective dose for the shortest possible duration of treatment and in the area around implants, compromising the integration of titanium
no two NSAIDs should be taken orally at the same time. However, the implants [56].
bibliographic data regarding their action in fracture healing are still Disease-modifying antirheumatic drugs probably have adverse ef
unclear. fects regarding bone healing and osseointegration of mainly dental im
plants [57]. Additionally, a biomechanical study in dogs suggests that
Corticosteroids methotrexate interferes with the osseointegration process by delaying
Corticosteroids, such as prednisone and dexamethasone, are potent bone healing and osseointegration of implants [58]. Finally, a study
anti-inflammatory medications commonly used to suppress the immune from Japan suggested that low-dose methotrexate does not affect the
response and reduce inflammation in various medical conditions. Their early process of endochondral bone formation during fracture healing,
mechanism of action involves binding to glucocorticoid receptors, while high doses could delay the progress of new periosteal bone for
which are present in many cell types, including those involved in the mation [59].
Antibiotics association between PPI intake and impaired bone regeneration but
Antibiotics are medications used to treat bacterial infections. Their more studies are needed to determine whether the association is due to
mechanism of action in the bone/implant interface is primarily directed PPI intake or co-existing factors [62].
at preventing or treating infection-related complications associated with Another experimental study from Canada claimed that systemic
implant placement or bone healing. administration of omeprazole interferes with and weakens the process of
When antibiotics are administered systemically, they circulate osseointegration of implants and fracture healing [63]. A study from
throughout the body and can reach the site of the bone/implant inter Germany comes to similar conclusions, arguing that pantoprazole, a
face. They work by inhibiting bacterial growth and killing bacteria, proton pump inhibitor, delays fracture healing in mice by affecting both
either by directly targeting the bacteria themselves or by interfering bone formation and bone remodeling [64].
with essential bacterial cellular processes. This helps prevent the In conclusion, proton pump inhibitors appear to interfere with and
development of an infection or eliminates an existing infection, reducing adversely affect the osseointegration process and fracture healing.
the risk of complications at the bone/implant interface. The time point
at which antibiotics exert their effects in the bone/implant interface Antiepileptics-Selective serotonin reuptake inhibitors (SSRI)
depends on several factors, including the specific antibiotic used, the The mechanism of action of antiepileptics and selective serotonin
severity of the infection, and the patient’s response to treatment. In reuptake inhibitors (SSRIs) in the bone/implant interface is not directly
some cases, antibiotics may be administered prophylactically before or related to their primary therapeutic effects but rather to their potential
during the implant procedure to prevent infection. In other cases, they influence on bone metabolism. Antiepileptic drugs, which are used to
may be used therapeutically if an infection develops at the bone/implant manage seizures and certain neurological disorders, can affect bone
interface. The duration of antibiotic treatment also varies depending on health through various mechanisms. Some antiepileptic drugs, such as
the specific infection and its severity. Short-term antibiotic courses are phenytoin and carbamazepine, have been associated with decreased
commonly prescribed for prophylactic purposes, while longer courses bone mineral density and increased risk of fractures. The exact mecha
may be required for the treatment of established infections. nisms by which they affect bone are not fully understood, but they may
Among the widely used antibiotics in orthopedics is ciprofloxacin, interfere with vitamin D metabolism, alter hormone levels, or affect
for the use of which there are few negative points. One of its major bone turnover. Selective serotonin reuptake inhibitors (SSRIs) are a class
disadvantages is the literature-reported harmful effect on the chon of antidepressant medications that primarily work by increasing the
drocyte, which can have an effect on both the articular cartilage and the concentration of serotonin in the brain. While their main therapeutic
mechanism of the fracture healing [60]. effect is in the central nervous system, there is evidence suggesting that
Another experimental study in rabbits investigated the effect of SSRIs may also have an impact on bone metabolism. Serotonin has been
cefazolin and cefuroxime (two commonly used antibiotics in orthope found to play a role in bone regulation, and the inhibition of its reuptake
dics) at therapeutic doses on fracture healing. Τhe study concluded that by SSRIs may affect bone density and turnover. The exact time point at
cefuroxime appears to disrupt the healing process more than cefazolin in which the effects of antiepileptics and SSRIs may influence the bone/
the experimental model. If the results are similar in humans, the use of implant interface is not clearly defined. The impact on bone metabolism
cefuroxime during fracture healing should be avoided in daily clinical may occur gradually over time as the drugs are administered and reach
practice [61]. steady-state concentrations in the body. The duration of drug use, in
dividual patient characteristics, and the presence of other factors that
Proton pump inhibitors (PPI) affect bone health may also influence the timing and magnitude of any
Proton pump inhibitors (PPIs) are a class of medications commonly effects on the bone/implant interface.
used to reduce gastric acid production in the stomach. Their mechanism In an experimental study from Turkey, it was argued that the
of action in the bone/implant interface is indirect and primarily related administration of antiepileptics, specifically gabapentin, affects the
to their effects on the gastrointestinal system. PPIs work by irreversibly process of fracture healing especially in terms of histological deterio
binding to the proton pump, an enzyme present in the gastric parietal ration and biomechanical strength of the fracture in an experimental
cells that is responsible for secreting acid into the stomach. By inhibiting rabbit model [65].
the activity of the proton pump, PPIs significantly reduce the production Selective serotonin reuptake inhibitors (SSRIs), the most commonly
of gastric acid, leading to a decrease in the acidity of the stomach. used drugs to treat depression, have been reported to decrease bone
In the context of the bone/implant interface, the use of PPIs can be formation and increase fracture risk. As osseointegration is influenced
relevant due to their potential influence on bone health and healing. by bone metabolism, a study from Canada suggested that treatment with
Gastric acid plays a crucial role in the absorption of certain minerals, SSRIs is associated with an increased risk of failure of dental implant
such as calcium, which are essential for bone formation and remodeling. integration and that preoperative planning is necessary in patients using
By reducing gastric acid secretion, PPIs may interfere with the absorp SSRIs [66].
tion of calcium and other minerals, potentially affecting bone meta
bolism. The time point at which the effects of PPIs may impact the bone/ Anticoagulants
implant interface is not well-defined and can vary among individuals. Anticoagulants are medications used to prevent or treat blood clots
PPIs are typically taken orally and are absorbed in the gastrointestinal by interfering with the normal blood clotting process. In the context of
tract. Once in the bloodstream, they can circulate throughout the body, the bone/implant interface, anticoagulants may indirectly impact
including the skeletal system. However, the specific impact on the bone/ osseointegration by affecting blood flow and clotting mechanisms. The
implant interface may take time to manifest and may be influenced by mechanism of action of anticoagulants involves inhibiting certain pro
factors such as the duration and dosage of PPI use, the individual’s teins or enzymes involved in the clotting cascade. For example, common
overall bone health, and the presence of other risk factors. It’s important anticoagulants like heparin and warfarin interfere with the clotting
to note that while there is some evidence suggesting a potential asso factors involved in the formation of blood clots. This inhibition prevents
ciation between long-term PPI use and increased fracture risk or the formation of clots or reduces their size, making it less likely for blood
impaired bone healing, the clinical significance of these findings and the vessels to become blocked.
exact mechanisms involved are still being investigated. At the bone/implant interface, adequate blood supply is crucial for
Many analyses have supported that proton pump inhibitor therapy the delivery of oxygen, nutrients, and cells necessary for bone healing
affects bone regeneration, the process of osseointegration, causing and osseointegration. By reducing the ability of blood to clot, antico
increased bone fracture risk, worsening bone metabolism, and impaired agulants may help maintain blood flow around the implant, potentially
fracture healing. A review study from Romania suggested that there is an enhancing the healing process. The time point at which anticoagulants
exert their effects on the bone/implant interface may vary. The impact different effects on the early stages of bone healing. However, enox
can be observed during the initial stages of implant placement and the aparin from the first week of its administration increases the possibility
subsequent healing process, where the prevention of excessive clotting of mesenchymal cells migrating to the wound area and multiplying,
or blood vessel blockage can facilitate proper blood circulation and while additionally inhibiting the differentiation of mesenchymal cells
subsequent bone remodeling. It is important to note that while antico into osteoblasts, meaning it has undesirable effects on bone healing. On
agulants can be beneficial in preventing thrombotic events, their use can the other hand, rivaroxaban has no significant effect on the metabolism
also carry the risk of increased bleeding. Careful management is of mesenchymal cells or their capacity for osteogenetic differentiation in
necessary to balance the benefits and potential risks associated with experimental studies [74].
anticoagulant therapy in the context of implant osseointegration. The In contrast to the previous study, Prodinger et al., in a recent
specific timing and duration of anticoagulant use will depend on indi comparative study of Rivaroxaban and Enoxaparin in a closed femoral
vidual patient factors, the type of implant procedure, and the overall fracture model in mice did not find significant differences between the
treatment plan. two drugs regarding their effects on bone quality, quantity and finally
Warfarin, low molecular weight heparins (enoxaparin and delta fracture healing [75].
parin) and unfractionated forms of heparin negatively affect implant Finally, in an experimental study in rats by Kapetanou et al. found
osseointegration through the reduction of type II collagen and miner that Rivaroxaban, one of the newer oral anticoagulants for thrombo
alization. However, this is not the case with Fondaparinux, a synthetic prophylaxis at least does not adversely affect the osseointegration pro
anticoagulant. cess of a stainless-steel screw in the tibia of rats compared to the control
In particular, administration of warfarin was found to significantly group [4].
affect both attachment strength and bone ingrowth in nonporous im This finding is encouraging for the use of oral anticoagulants post
plants made of cobalt, chromium, and molybdenum; however, a similar operatively in patients with implanted materials. The results of the
inhibitory effect was not observed in hydroxyapatite-coated implants present study are only indicative and future studies of a larger extent and
[67]. more specialized techniques for assessing osseointegration, both in vitro
Enoxaparin, deltaparin and unfractionated heparin led to a signifi and mainly in vivo, are required.
cant decrease in type II collagen synthesis and mineralization while Moreover, it should be emphasized that the change of medication
having deleterious effects on fracture healing-porosity and the process of from warfarin to rivaroxaban in patients with atrial fibrillation was
osseointegration of orthopedic materials [68,69]. associated with an increase in bone production markers and a decrease
The administration of low molecular weight heparins for 3–6 months in bone resorption markers [76].
may not increase the risk of fractures, but long-term administration of
more than 24 months especially in cancer patients and the elderly leads Discussion
to an increased risk of bone loss or fracture [70].
Melagatran shows less inhibitory effects in experimental studies on The present review provides an overview of the effects of various
human osteoblasts compared to deltaparin or unfractionated heparin. drugs on implant osseointegration. Bisphosphonates, statins, and
This study by Winkler et al. is the first to suggest that direct thrombin particularly teriparatide appear to have a positive impact on implant
inhibitors may help prevent the negative effects of heparin on bone osseointegration. These drugs have shown beneficial effects in promot
metabolism [71]. ing bone remodeling and improving bone metabolism. Vitamin D3,
Papathanasopoulos et al. reported that osteogenetic and chon however, has an uncertain role in the osseointegration process of im
drogenetic differentiation were not affected by either tinzaparin or plants, and further studies are required to clarify its effect.
Fondaparinux in experimental studies, mesenchymal cell proliferation Angiotensin-converting enzyme inhibitors and β-blockers show
was negatively affected by tinzaparin but no side effects were reported promising potential in accelerating fracture healing and bone remod
from Fondaparinux which suggests its use in orthopedic surgery [69]. eling. Angiotensin-converting enzyme inhibitors have demonstrated the
Fondaparinux is a synthetic anticoagulant similar to heparin, which ability to promote bone regeneration, while β-blockers exhibit an
showed no inhibitory effects in laboratory conditions on human osteo anabolic effect on bone metabolism, making them potential candidates
blasts at least in the concentration range investigated (0.01–100 µg/ml). for the treatment of osteoporosis and bone metabolism disorders. Nitrite
For this reason, Fondaparinux can be used to avoid the negative effects therapy also shows promise in reducing fracture risk and accelerating
of heparin on osteoblast-dependent fracture healing as well as implant fracture healing, but further research is needed to establish a causal
integration [72]. relationship.
Although the exact mechanism of action of low molecular weight Thiazide diuretics have been associated with positive effects on bone
heparins in bone biology is not fully elucidated, it appears that HLMWs metabolism, fracture risk reduction, and fracture healing. However,
reduce cancellous bone volume by acting directly on osteoblasts and there is a lack of study data specifically addressing their impact on or
basal cells at very early stages of the healing process [68,73]. thopedic implant survival and integration. Conversely, loop diuretics
However, it is difficult to determine the true effect of low molecular appear to have detrimental effects on bone density and fracture risk, but
weight heparins (LMWHs) on fracture healing. Based on the literature their influence on implant osseointegration remains inadequately
review, there are no studies on the role of low molecular weight heparins studied.
in the fracture healing process in humans as well as in the osseointe Anti-inflammatory drugs and cyclooxygenase-2 (COX-2) selective
gration of orthopedic materials. The difficulties in assessing the effects inhibitors negatively affect implant osseointegration. However, the
of LMWHs on the human musculoskeletal system arise from two main literature regarding their impact on fracture healing is still inconclusive.
reasons. First, the number of patients receiving LMWHs for a long period Corticosteroids, while not affecting implant osseointegration, signifi
of time is limited. Second, because there are risks and complications cantly delay fracture healing when administered systemically. Cyclo
involved in experiments concerning healing fractures in humans. For sporine A, methotrexate, and cisplatin have been shown to have
these reasons the most important evidence for the role of LMWHs in negative effects on implant osseointegration.
fracture healing and implant osseointegration comes from experimental Proton pump inhibitors, anticonvulsants, and selective serotonin
studies. reuptake inhibitors (SSRIs) have been associated with impaired
There is some evidence that the newer oral anticoagulants, in osseointegration and delayed fracture healing. Warfarin, low molecular
particular Rivaroxaban (Xarelto), do not substantially interfere with weight heparins (enoxaparin and deltaparin), and unfractionated forms
bone metabolism and do not affect the bone formation process [74,75]. of heparin negatively affect osseointegration through the reduction of
A comparative study of enoxaparin and rivaroxaban found to have type II collagen and mineralization. However, Fondaparinux, a synthetic
anticoagulant, does not exhibit the same negative effect on osseointe disciplinary research, and rigorous clinical trials are expected to shape
gration. Initial studies on Rivaroxaban (Xarelto), a newer oral antico the field. Advancements in biomaterials science will lead to the devel
agulant, indicate no negative impact on the osseointegration process in opment of implant alloys with improved properties, influencing drug-
experimental rat models. implant interactions. Tailored drug delivery systems will provide
While the effect of alloy type on osseointegration can vary depending controlled and localized drug release, maximizing therapeutic effects
on several factors, including the specific alloy composition and the host while minimizing side effects. Personalized medicine approaches will
bone characteristics, some general insights are as follows: a) The optimize drug selection and dosing based on individual patient char
biocompatibility of the alloy is a crucial factor in osseointegration. Some acteristics and genetic variations. Sophisticated in vitro and in vivo
alloys, such as titanium and its alloys, are known for their excellent models will better replicate cellular and physiological environments,
biocompatibility, as they can form a thin oxide layer on the surface that improving the accuracy of drug response predictions. Collaboration
promotes osseointegration. Other alloys may have different surface among researchers from various disciplines will lead to comprehensive
properties that can influence the biological response and affect the investigations and a holistic understanding of drug-implant-bone in
integration process. b) The mechanical properties of the alloy, such as its teractions. Clinical trials and long-term follow-up studies will assess the
strength, stiffness, and fatigue resistance, can play a role in implant efficacy, safety, and durability of drug-modulated osseointegration
osseointegration. Implants with suitable mechanical properties can outcomes. Overall, the future holds tailored and effective approaches to
provide the necessary stability for load transfer and support during the enhance the success and longevity of implant osseointegration,
healing process, facilitating osseointegration. Mismatched mechanical improving patient outcomes in orthopedic and dental implant proced
properties between the implant and bone may hinder successful inte ures. Through continued research, collaboration, and technological in
gration. c) The corrosion behavior of the alloy can also impact novations, the field will advance and provide valuable insights for
osseointegration. Corrosion products or ions released from the implant optimizing the effects of drugs on implant osseointegration.
can potentially have adverse effects on the surrounding tissue, leading to
inflammation and impaired osseointegration. Alloys with high corrosion
resistance, such as titanium alloys, are often preferred for implants to Declaration of Competing Interest
minimize such issues. d) Surface modifications, such as coatings or
treatments, can enhance the osseointegration process. Different alloys The authors declare that they have no known competing financial
may respond differently to surface treatments, affecting their ability to interests or personal relationships that could have appeared to influence
promote bone integration. Surface modifications can alter the topog the work reported in this paper.
raphy, chemistry, and bioactivity of the implant surface, facilitating cell
attachment, proliferation, and bone formation. References
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10
Injury 54 (2023) 110889
Injury
Review
Current concepts in the management of “Terrible Triad” injuries of

the elbow
Rebecca Waterworth a, *, Graham Finlayson a, Marieta Franklin b, Monu Jabbal c,
Alastair Faulkner d, Brendan Gallagher e
a
Department of Trauma and Orthopaedics, Musgrave Park Hospital, Stockmans Lane, Belfast, BT9 7JB, United Kingdom
b
Department of Trauma and Orthopaedic Surgery, Whiston Hospital, Warrington Rd, Rainhill, Prescot, L35 5DR, United Kingdom
c
Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom
d
Department of Trauma and Orthopaedics Surgery, Ninewells Hospital, Dundee, DD1 9SY, United Kingdom
e
Department of Trauma & Orthopaedics, Musgrave Park Hospital, Stockmans Lane, Belfast, BT9 7JB, United Kingdom
Keywords: Terrible triad injuries of the elbow are complex injuries which can result in long term complications and sig
Terrible triad injury nificant disability. They must be identified correctly, and managed appropriately in order to maximise functional
Elbow fracture-dislocation outcomes. A clear understanding of the bony and ligamentous anatomy is essential to plan appropriate surgical
Elbow instability
reconstruction to provide elbow stability. Urgent reduction of the elbow, followed by 3-dimensional imaging and
Elbow trauma
surgical repair or replacement of the injured structures is the mainstay of treatment in the majority of cases. This
review presents a summary of the relevant anatomy and the evidence for the management of these complex
injuries.
Introduction can achieve positive outcomes for patients, although these remain
technically demanding injuries for the orthopaedic surgeon to treat.
The so called “Terrible Triad” injury of the elbow, is a valgus external
rotation injury with combined radial head fracture, anterolateral coro
noid fracture and posterior dislocation of the ulnohumeral joint [1]. The Anatomy of the elbow
elbow is regarded as a notoriously unforgiving joint with the twin
challenges of instability and stiffness requiring great vigilance from the The anatomy of the elbow has a reputation for being conceptually
treating surgeon [1–3]. challenging. A recent systematic review has found many activities of
A clear understanding of the anatomy and biomechanics of the joint, daily living (ADLs) at times need flexion of between 130 and 150◦ [8]. It
and in particular of the multiple osseous and ligamentous structures is more commonly recognized that a normal range of motion at the
contributing to the stability of the elbow joint [4–7] is essential in the elbow is 0–140◦ with a range of 30–130◦ being the requirement for ADLs
surgical management of this injury. Restoring stability to allow early [9].
range of movement and avoid stiffness should be the primary goal in the The function of the elbow is to facilitate positioning of the hand in
treatment of these injuries. space through flexion and extension. To allow this, the elbow is a
As well as the well-known complications of infection, neurovascular trochleoginglymoid joint consisting of the humeroradial, humeroulnar
injury, mal or non-union, early or late instability can be a result of the and proximal radioulnar joints [9,10] (Fig. 1). The humeroulnar joint is
terrible triad injury. Stiffness, as with any elbow injury, can be a hinged or ‘ginglymoid’, and the radiocapitellar joint is trochoid (from
particular challenge and the combination of instability and intra the Greek word trochos, meaning wheel) [11]. The distal humerus ends
articular damage may lead to long term osteoarthritis [3]. with the spindle shaped trochlea on the ulnar side and the hemispherical
Despite the challenges of terrible triad injuries, sound application of capitellum on the radial side. The distal humerus has a 30-degree
anatomical and biomechanical knowledge with basic surgical principles anterior tilt and the trochlear notch of the ulna has a comparable pos
terior tilt [12]. Key to the osseous anatomy is the coronoid process of the
E-mail address: rebeccawaterworth@doctors.org.uk (R. Waterworth).
R. Waterworth et al. Injury 54 (2023) 110889
proximal ulna which is composed of three important elements; the Table 1

sublime tubercle, anteromedial and anterolateral facets [13]. The Primary and secondary stabilisers of the elbow joint. Adapted from
coronoid process acts as a buttress and site of ligamentous attachment. Aquilina & Grazette [12].
The proximal ulna also has the greater and lesser sigmoid notches which Primary Stabilisers Secondary Stabilisers
articulate with the trochlea and radial head respectively. The ulnotro Olecranon Radial Head
chlear joint is highly congruent and allows flexion and extension. The Trochlear Joint Capsule
radial head is concave and cartilage covered including approximately Coronoid Flexor origin
270◦ of its articular margin to facilitate pronosupination [9]. The radial MCL Extensor origin
LCL Muscles crossing the joint
head resists valgus and anterior force, and has been shown to contribute
up to 30% of the valgus restraint in the elbow [12].
Elbow joint stability is provided by both static and dynamic stabil disruption of this can lead to varying degrees of instability [22,23].
isers (Table 1) which O’Driscoll describes as being analogous to the Edwards et al. [24] describe a thickening of the posterolateral capsule
defenses of a fortress [7]. The main static stabiliser of the elbow is the that attaches to the posterior capitellum as the ‘Osborne-Cotterill Liga
anterior band of the medial collateral ligament (MCL) complex which ment’, and suggest that it is considered part of the lateral ligamentous
attaches to the sublime tubercle of the coronoid [14] and resists valgus complex. In their biomechanical study, they showed that sectioning of
and internal rotational stress [15]. The MCL has three ligamentous the Osborne-Cotterill ligament contributed to increased radial head
bands. The anterior oblique ligament (AOL), which has both anterior displacement at both 30 and 60◦ of flexion.
and posterior bands and is the strongest part of the MCL with the Furthermore, whilst the RCL remains relatively isometric throughout
greatest contribution to elbow stability. The posterior oblique ligament the arc of flexion, the LUCL is looser in elbow extension, tightening with
(POL), and the transverse ligament (TL), also known as Cooper’s liga flexion, with an isometric point approximately 1–2 mm proximal to the
ment, which is thought to be far less important [16,17]. The AOL takes centre of the capitellum [25,26]. These concepts are critical to the
its origin from the anterior inferior medial epicondyle and inserts on the successful surgical management of these injuries.
coronoid at the sublime tubercle [12]. The POL originates from the The AL as the name suggests is ring-like and takes its origin and
medial epicondyle and runs in a fan-shape posteriorly to insert on the insertion from the sigmoid notch on the ulna and serves to stabilise the
medial olecranon, the TL passes between the AOL and POL attachments proximal radioulnar joint [9].
(Fig. 2). Aquilina et al. [12] describe the anterior joint capsule attachments as
The MCL exerts a cam effect on the elbow joint as its’ origin is pos being proximal to the radial and coronoid fossae of the humerus and on
terior to the mid-axial line. From 0–60◦ of flexion the anterior band of the anterior aspect of the medial and lateral epicondyles. Distally it at
the AOL is taut, and from 60 to 120◦ the posterior band is taut [12]. taches to the coronoid process of the ulna and the annular ligament. The
The lateral collateral ligament complex is a primary static stabiliser posterior attachment is from the superior margin of the olecranon fossa
of the elbow, limiting external rotation of the radius and ulna relative to to the olecranon process and annular ligament. The anterior capsule has
the humerus [18,19]. It is traditionally thought to consist of the radial a role in providing valgus stability [5] and joint proprioception. It is
collateral ligament (RCL), annular ligament (AL) and the lateral ulnar commonly torn in dislocations and this can be a cause of persistent
collateral ligament (LUCL) [12] although an accessory collateral liga ulnohumeral instability [12].
ment has also been described [9] (Fig. 3). The elbow has both anterior and posterior fat pads that overlie the
The LUCL is often considered the main constraint to posterolateral radial, coronoid and olecranon fossae. The anterior pad is displaced by
rotatory instability [20] but some biomechanical studies have chal brachialis, and the posterior pad by triceps brachii as they insert into the
lenged this, instead suggesting the whole of the lateral ligamentous coronoid process and olecranon respectively [12].
complex has a part to play in resisting the rotational forces involved In a paper published in 2021, Watts et al. [27] described the
[21]. Rather than considering the lateral ligamentous complex as indi “three-column concept” considering the elbow joint as a three-column
vidual components, it has been suggested that it functions as a contin structure consisting of a lateral column (radial head and capitellum), a
uous collagenous capsuloligamentous complex, originating from the middle column (anterolateral facet of the coronoid and lateral trochlea)
lateral epicondyle and inserting on the lateral aspect of the proximal and medial column (anteromedial facet of the coronoid and medial
ulna, along the supinator crest and sigmoid notch, it is thought that any trochlea). Key to this concept is the fulcrum to varus/valgus instability
Fig. 1. Bony anatomy of the elbow joint.
Fig. 2. Medial ligament complex of the elbow joint.
Fig. 3. Lateral ligament complex of the elbow joint.
which lies between the medial and middle columns [27]. This concept is dislocations of the elbow. It has been named the ‘Horii Circle’ [7]. The
particularly useful when looking at injury patterns and planning fixation disruption that occurs during this process begins laterally and progresses
(Fig. 4). medially in 3 distinct stages. Stage 1 - disruption of the lateral collateral
ligament. Stage 2 - disruption of the anterior and posterior capsular
Mechanism of injury attachments. Stage 3 - disruption of the medial collateral ligament and it
is an osseous extension of this stage that is most frequently associated
Terrible triad injuries of the elbow may be seen in both high and low with impaction fracture of the radial head and shear fracture of the
energy trauma. Approximately 60% of these injuries result from a fall coronoid process, the terrible triad injury [7,30,32].
from standing height with the arm in an outstretched position [28–30].
As previously described, the TTI is a combination of posterior elbow Classification
dislocation, radial head and anterolateral coronoid process fractures
which is often described as a posterolateral fracture-dislocation, and With regards to the bony injuries that occur to the radial head and
accounts for approximately 80% of complex elbow dislocations [31]. It coronoid, these can be graded independently using their own classifi
occurs through the combination of axial loading, external rotation (su cation systems.
pination) of the forearm and a valgus force as the hand contacts the Two classification systems are used for coronoid fractures. Classi
ground lateral to the body [4]. cally the Regan-Morey system classified the fracture based on the height
This pattern of injury was first described by O’Driscoll et al. [4] of the coronoid involved when viewed on a lateral radiograph. Type 1 –
following a study of 13 cadaveric elbows and is seen during simple avulsion of the tip of the process; Type 2 – involving <50% coronoid
Fig. 4. The three-column model demonstrating the fulcrum which lies between the medial and middle columns.
height; Type 3 – involving >50% coronoid height [33]. This however [36] who described a Type 4 radial head fracture when occurring in
failed to consider the three dimensional fan-shape of the coronoid and combination with a humeroulnar dislocation (Fig. 6). Broberg and
was updated by O’Driscoll et al. [34] with a classification which pro Morrey [37] amended Mason’s system by adding in specific measure
vides a guide for surgical management through understanding the ments of displacement and most recently Hotchkiss [38], who developed
pattern of injury. This system classifies coronoid fractures based on Mason’s system further by adding in clinical and intra-operative findings
anatomical location with subtypes according to severity of coronoid to help guide management decisions. Type 1 – fracture <2 mm
involvement. Type 1 – fracture of the coronoid tip, Type 2 – fracture of displacement, no mechanical block and suitable for non-operative
the anteromedial facet, Type 3 – basal coronoid fractures (Fig. 5). management; Type 2 – fracture >2 mm displacement, mechanical
The most well-known classification system used to grade radial head block present and felt likely to be suitable for repair; Type 3 – a
fractures is the Mason classification. This system classifies the fracture comminuted fracture that is not suitable for repair and will therefore
according to radiological findings. Type 1 – fracture of the radial head require excision or replacement [38]. It is important to note that a sig
without displacement; Type 2 – fracture of the radial head with nificant proportion of radial head fractures have an associated bony,
displacement; Type 3 – comminuted fracture involving the entire radial chondral or ligamentous injury. The likelihood of this increases with
head [35]. This has since been modified by others including Johnston severity of the fracture and it is essential that other injuries including
Fig. 5. O’Driscoll classification of coronoid fractures. a) Normal coronoid anatomy b) Type 1 – fracture of the coronoid tip, c) Type 2 – fracture of the anteromedial
facet, d) Type 3 – basal coronoid fracture.
Fig. 6. Mason-Johnston classification system of radial head fractures. a) Type 1 – fracture of the radial head without displacement, b) Type 2 – fracture of the radial
head with displacement, c) Type 3 – comminuted fracture involving the whole radial head, d) Type 4 – radial head fracture in combination with a humeroulnar
dislocation.
injury to the LCL, MCL and distal radioulnar joint (DRUJ) are identified Clinical and radiological assessment
to ensure appropriate management [39,40].
In 2019 Watts et al. [27] highlighted the lack of classification system Initial presentation
for complex elbow-fracture dislocations and proposed the ‘Wrightington
Classification’. This is based on the previously discussed three-column Patients presenting with a suspected elbow injury should undergo a
concept of elbow joint stability. Through an understanding of each focused examination of the elbow joint specifically assessing for
injury pattern this classification helps guide appropriate management of swelling, lateral bruising and open wounds. The presence of varus or
both the osseous and capsuloligamentous injuries [31]. This system valgus instability will help predict underlying structural damage, how
describes four types of injury pattern; Type A to D+ with Type C ever this is difficult to assess in the acutely injured limb. Careful
(combined anterolateral coronoid facet and radial head or comminuted neurological examination should be undertaken and any neurovascular
radial head fractures) being equivalent to the TTI currently being dis compromise should be clearly documented prior to and after manipu
cussed [27] (Fig. 7). lation or application of splintage. A full secondary survey should be
completed to exclude any concomitant injuries
Radiological assessment
Anteroposterior and lateral radiographs of the elbow should be taken

pre and post reduction, specifically looking for direction of dislocation,
posterolateral or posteromedial with posterolateral dislocations being
more common [31], and fractures of the radial head and/or coronoid
(Fig. 8). Once radiographs have been performed and a TTI diagnosed, a
computed tomography (CT) scan should be performed as this increases
the accuracy of classification for pre-operative planning (Fig. 9) [27].
Magnetic Resonance Imaging (MRI) may also be used to provide more
detailed information of the soft tissues, specifically looking at the pri
mary (anterior and posterior bundles of MCL, LLC) and secondary sta
bilisers (common flexor and extensor origins) to ensure these are
considered during planning of surgical management [41]. In the situa
tion where diagnosis is unclear, dynamic ultrasound offers the ability to
display joint line instability and disruption of both the medial and lateral
ligamentous complexes using a relatively affordable modality without
exposure to ionising radiation [42].
Management options
Conservative management
As with all orthopaedic trauma, the TTI can be managed either

conservatively or surgically following an assessment of the injury and
needs of the patient. Chan [43] and Guitton [44] have suggested four
Fig. 7. Wrightington Classification Type C; combined anterolateral coronoid conditions which if satisfied could allow for conservative management
facet and radial head or comminuted radial head fractures. and recommend a protocol similar to the treatment of a ‘simple
dislocation’; (1) Congruency of plain radiographs and computed to

mography scan after closed reduction with humeroulnar distance
<4 mm on lateral radiograph. (2) A small coronoid fracture (Regan-
Morrey Type 1 or 2 or <5 mm). (3) No block to rotation due to radial
head fracture, and (4) a stable arc of motion with minimum 30◦ exten
sion. If these radiographical criteria are fulfilled the patient can be seen
in outpatient clinic within a week by an upper limb specialist. These
criteria may be difficult to achieve due to pain and swelling in the acute
setting, and it is noted that only a minority of true TTI are able to be
treated conservatively. It is debatable whether dynamic instability can
be predicted on static imaging, as position of elbow may affect joint
congruency [45]. Patients must be followed up closely for a minimum of
12 months [46]. If the joint remains congruent at follow-up, early ROM
exercises can commence. Overhead flexion/extension should be unre
stricted and can be performed with the patient supine and shoulder
flexed to 90◦ . This reduces gravitational force on the ulnohumeral joint,
with active concentric and eccentric contractions also providing a
muscular compressive force aiding joint stability [47].
An elbow orthosis can be used to aid comfort and reduce force
transmission across the healing structures. The orthosis may be hinged
to allow flexion/extension but resist any varus/valgus stress. Caution
should be taken to ensure any orthosis is well fitting with no compres
sion of the ulnar nerve. If satisfactory progress has been made the
Fig. 8. Lateral radiograph of an elbow showing joint incongruency, radial head orthosis can be discarded at around 6 weeks [48].
fracture and suspected coronoid fracture in keeping with a terrible triad injury. Indications for operative management over conservative include:
mal-reduced ulnohumeral or radiocapitellar joint; a comminuted, dis
placed or angulated radial head fracture; a displaced coronoid fracture
>5 mm or extension of the anterolateral facet fracture (Wrightington
Type C) to involve the anteromedial facet (Wrightington Type B+) [13].
Fluoroscopic examination under anaesthesia can be performed to assess
range of movement and stability. If the elbow has been reduced, lateral
radiograph must not show a “drop sign” defined as an increase in
ulnohumeral distance >4 mm. Varus and Valgus instability can be
shown by >1 mm increase in joint space on stressing with no firm end
point. Posterolateral rotatory instability (PLRI) can be demonstrated by
recurrent posterior radial head subluxation when load is applied with
the elbow in flexion and supination. Mechanical block to range of mo
tion and recurrent instability are indications for surgery [9].
Surgical management
Despite the option for conservative management, the vast majority of

TTI require surgical intervention in order to achieve a satisfactory level
of stability to allow early mobilisation [30]. The surgical protocol can be
remembered by approach “from outside inward” (LCL, radial head and
coronoid) and repair “from inside outward” [49]. The more recently
established Wrightington classification of elbow fracture-dislocations,
while not specific to terrible triad injuries, provides a useful treatment
algorithm based on the three-column concept of elbow stability which
may be particularly helpful for the general trauma surgeon in planning
surgical approach, order of fixation, and restoration of stability [50].
Surgical approaches
While there are multiple available approaches to the elbow, the

single posterior midline incision offers access to both sides of the joint.
In the TTI the anterolateral coronoid fracture does not always require
fixation as it does not contribute to stability once the radial head has
been addressed. If the fracture extends to involve the anteromedial facet
then the coronoid must be fixed and, in such cases, a dedicated lateral
incision using either the Kocher or Kaplan approach may be preferred,
particularly if the radial head is to be replaced. If this is not possible then
a separate medial approach may be required to access the coronoid. The
Fig. 9. Computed Tomography (CT) image of a terrible triad injury. Coronal Kocher approach (posterolateral) is through the intermuscular plane of
cut showing both a radial head fracture and anterolateral facet fracture of anconeus (radial nerve) and extensor carpi ulnaris (posterior inteross
the coronoid. eous nerve). The LCL can be visualised and even released to further
expose the radial head and coronoid, the posterior interosseous nerve radial head fracture with a fracture of both coronoid facets which may
(PIN) is protected by keeping the arm pronated [51]. The Kaplan be a basal fracture, equivalent to an O’Driscoll type 3. Some will view
(lateral) approach is more anterior, using the interval between extensor this as a TTI but it is a different injury pattern and importantly the
digitorum communis and extensor carpi radialis brevis. It allows access coronoid must be fixed in these injuries to restore stability.
to the radial head and coronoid through the annular ligament avoiding
the LCL, however is in close proximity of the PIN with risk of injury. Radial head fracture
Ultimately surgical approach is determined by the pattern and severity
of injury, the planned repair as well as surgeon preference and experi In the TTI the crucial role of the radial head as a valgus stabiliser
ence [52]. means that restoration of a stable, congruent surface either through
internal fixation or radial head arthroplasty is essential [57]. Fragments
Coronoid fixation which constitute less than 25% of the articular surface may still be
suitable for simple excision, although persistent instability after excision
The anterior capsule of the elbow joint attaches approximately 5–6 is an indication for radial head arthroplasty [53]. Fragments of the
mm distal to the most prominent ridge of the coronoid. In larger coro radial head greater than 25% of the articular surface may be suitable for
noid fractures, the fracture fragment remains attached to the anterior reconstruction using cannulated, headless screw fixation [58].
capsule and is associated with significant capsular disruption [53].
Cadaveric studies have shown that larger coronoid fragments therefore Soft tissue repair
have a significant effect on elbow stability and congruency, however
smaller fragments (<10%) with no capsular attachment have little ef The LCL is typically avulsed from its humeral origin although can less
fect, however this may depend on the extent of the soft tissue injury commonly have a mid-substance tear or avulsion at the ulnar insertion.
[54]. There are various fixation options available depending on size of The isometric point is at the origin, and has been thought to be identical
the coronoid fragment and preference of the surgeon. These options to the axis of rotation, located at the centre of the capitellum. Fixation
include internal fixation with lag screws for larger fragments, sutures or here will allow stability through its range of motion [25]. Repair may be
suture anchors for smaller fragments, and plate fixation for a basal using suture anchors or transosseous suture [59] (Fig. 10). Additionally,
fracture [28,55]. According to the Wrightington classification, Type C stability can be achieved with augmentation using fibre tape or an in
(terrible triad) injuries most commonly have a small anterolateral facet ternal brace [60].
coronoid fracture. Applying the three column theory as described pre The MCL can be treated conservatively more often than the LCL
viously, this theory states that as long as the lateral column is restored complex. After repair of the coronoid, radial head and LCL any ongoing
via radial head fixation or replacement and the LCL is repaired, fixation instability in extension requires surgical exploration and repair of the
of the anterolateral facet fracture is not required [13,31]. Treatment MCL. Repair is again with suture anchors and specific care taken to
according to the Wrightington protocol has shown favourable results protect the ulnar nerve [61]. MCL tears should be identified early as its
with median Mayo Elbow Performance Score (MEPS) of 100 and median presence can lead to over tightening of the lateral side, leading to medial
ROM of 123◦ at the final follow-up [56]. A Wrightington B+ injury is a gapping [62]. If instability continues to persist, a dynamic external
Fig. 10. Post-operative radiographs of the elbow showing both a long-stem radial head replacement and transosseous suture anchor following LCL repair. Coronoid
fixation was not required due to restoring stability as per the three column theory. A) Anteroposterior radiograph B) Lateral radiograph.
fixator can be placed to allow safe active movement [63]. • Follow up lateral radiographs obtained in the outpatient clinic
should be requested as “shoot through” lateral radiographs. In this
Rehabilitation case, the cassette is placed at the patient’s side, between the body
and the elbow. This should mitigate against the undue gravitational
Immediate active mobilisation on day 0 is advocated. Recruitment of varus stresses placed on the LCL that can occur when standard lateral
muscle groups can aid as dynamic stabilisers. Terminal extension should radiographs, whereby the elbow is placed on a cassette on a table in
be avoided initially if there is any uncertainty of stability [53]. Wolff and front of the patient, are obtained.
Hotchkiss described a graduated overhead rehabilitation protocol [47].
Phase one involves putting the elbow in a position of stability: the pa Complications
tient is supine with the shoulder flexed to 90◦ , adducted, and in a neutral
to external rotation position to minimize the effect of gravity and allow A recent systematic review by Chen et al. [66] reported as many as
the triceps to function as an elbow stabiliser. Two exercises are per 54.5% of patients undergoing surgery for ‘Terrible Triad Injuries’
formed: active-assisted forearm pronation-supination and required re-operation. The commonest causes for re-operation were
active-assisted elbow flexion-extension. The limits of motion are mainly cited as metalwork issues, stiffness, instability, and ulnar nerve prob
determined by patient tolerance as no restrictions are imposed while in lems. In addition to these, one must not forget the incidence of hetero
this protected position. Phase two begins at week 3 or 4, and allows topic ossification and post-traumatic arthritis is over 10% [66] in this
these exercises in an upright or seated position. Phase three begins 6 patient group and can be hugely debilitating. Indeed, Tangtiphai
weeks after injury and includes range of movement exercises without boontana et al. [67] concluded that heterotopic ossification had been
limits, strength and endurance exercises, and resumption of normal underreported in their 2020 paper. They found that persistent elbow
activities of daily life. Schreiber et al. investigated this protocol in 27 dislocation that required a closed reduction, a longer period of dislo
patients with simple elbow dislocation. They found final mean arc of cation and a delay to surgical intervention were associated with het
extension to flexion was from 6◦ to 137◦ , and of pronation to supination erotopic ossification.
was from 87◦ to 86◦ , with no patients suffering recurrent instability, and
all returning to previous levels of functioning at a mean of 29 months Conclusion
[64].
Terrible triad injuries are complex injuries which are challenging to
Outcomes manage. They all share key features and a similar patho-mechanical
process. Accurate diagnosis, often assisted with 3-dimensional imag
Early clinical case series reported poor results with high levels of ing, is essential. Early restoration of elbow stability using either fixation
stiffness, instability, persistent pain, post traumatic arthritis, heterotopic or replacement as necessary in order to allow early active motion is
ossification and ulnar neuropathy [65]. Advances in operative tech crucial in avoiding long term stiffness and optimising patient outcomes.
nique, implant technology, understanding of elbow biomechanics and
the availability of CT scanning has led to improvements in results over Declaration of Competing Interest
time [49]. Chen et al. have reviewed the literature and report on 312
patients from 16 studies. Mean Mayo elbow performance scores ranged We wish to confirm that there are no known conflicts of interest
from 78 to 95/100. Mean Broberg-Morrey scores ranged from 76 to associated with this publication.
90/100. Mean DASH scores ranged from 9 to 31/100. The proportion of Additionally there has been no financial support for this work that
patients who required reoperation due to complications ranged from has influenced its outcome.
0 to 54.5% (overall = 70/312 [22.4%]) [66]. By fully understanding the
injury and structures involved, surgical restoration of native anatomy Acknowledgments
and therefore stability and early active mobilisation, we can ensure that
we move away from the "terrible” results of the past. We would like to say a special thank you to Professor Adam Watts for
his knowledge and expertise which he kindly shared with us when
Pitfalls writing this paper.
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Injury 54 (2023) 110890
Injury
Implementing an orthoplastic treatment protocol for open tibia fractures

reduces complication rates in tertiary trauma unit
Antti A.J. Ylitalo a, †, *, Hanna Hurskainen b, †, Jussi P. Repo a, Juha Kiiski b, Piia Suomalainen a,
Ilkka Kaartinen b
a
Unit of Musculoskeletal Disease, Department of Orthopaedics and Traumatology, Tampere University Hospital and University of Tampere, Tampere, Finland
b
Unit of Musculoskeletal Disease, Department of Plastic and Reconstructive Surgery, Tampere University Hospital and University of Tampere, Tampere, Finland
Keywords: Introduction: Open tibia fracture (OTF) causes a considerable increase in morbidity and risk for complications
Open fracture compared to closed fractures. The most significant OTF complication leading to morbidity is commonly
Trauma considered to be fracture-related infection (FRI). In September 2016, Tampere University Hospital (TAUH)
Tibia
introduced a treatment protocol for OTFs based on the BOAST 4 guideline. The aim of this study is to investigate
Infection
the outcomes before and after implementation of the OTF treatment protocol.
Nonunion
Orthoplastic Materials and methods: A retrospective cohort study was conducted using handpicked data from the patient record
Complications databases of TAUH from May 1, 2007, to May 10, 2021. For patients with OTF, we collected descriptive in
Soft tissue coverage formation, known risk factors for FRI and nonunion, bony fixation method, possible soft tissue reconstruction
BOAST 4 method, information about the timing of internal fixation and soft tissue coverage, and timing of primary
Gustilo-Andersson classification operation. As outcome measures, we collected information on FRI, reoperation due to non-union, flap failure,
and secondary amputation. We then compared the incidence of complications before and after the imple
mentation of the OTF treatment protocol at TAUH.
Results: After predefined exclusions, a total of 203 patients with OTF were included. Of these, 141 were treated
before and 62 after the implementation of the OTF treatment protocol. The FRI rate in the pre-protocol group was
significantly higher compared to the protocol group (20.6% vs 1.6%, p = 0.0015). The incidence of reoperation
due to nonunion was also significantly higher in the pre-protocol group (27.7% vs 9.7%, p = 0.0054). According
to multivariable analysis, definitive fixation and soft tissue coverage performed in separate operations was an
independent risk factor for both FRI and reoperation due to nonunion.
Conclusions: After implementation, the BOAST 4 based OTF treatment protocol reduced the rate of FRI and
reoperation due to nonunion in patients with OTF treated at TAUH during the study period. We, therefore,
recommend the implementation of such a treatment protocol in all major trauma centers treating patients with
OTF. Furthermore, we also recommend the immediate referral of patients with complex OTF from hospitals
lacking the preconditions to provide BOAST 4 based treatment to specialized centers.
Introduction fractures [6], making them the most common long bone open fracture
with an incidence of 3.4 per 100 000 person-years [7]. The leading
Tibia fractures are a common type of long bone fracture. The inci mechanism for open tibia fractures (OTF) is a high energy trauma due to
dence of proximal, diaphyseal, and distal tibia fractures is reported to be road traffic accidents or falls from heights [4,8–10].
7.2 to 12 per 100 000 person-years, 8.1 to 21.5 per 100 000 person- Compared to closed fractures, OTF cause a considerable increase in
years, and 6.9 to 15 per 100 000 person-years, respectively [1–5]. morbidity and risk for complications [11]. The most significant OTF
Moreover, it is estimated that at least 12 % of tibia fractures are open complication leading to morbidity is commonly considered to be deep
* Corresponding author at: Department of Orthopedic Surgery, Tampere University Hospital, University of Tampere, PL 2000, Elämänaukio 2, 33521 Tampere,
Finland.
E-mail address: antti.ylitalo@fimnet.fi (A.A.J. Ylitalo).
†
Antti Ylitalo and Hanna Hurskainen contributed equally to this work.
0020-1383/© 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
A.A.J. Ylitalo et al. Injury 54 (2023) 110890
infection. Indeed, previous studies have revealed the incidence rates of operation theatre every 2–3 days. No dressing changes are performed on
deep infection in patients with OTF to be as high as 36% [12]. the ward. A comprehensive treatment plan is then made by a multidis
The management of OTF has been debated for many years, and ciplinary team of senior plastic and orthopaedic surgeons specialized in
clinical practices have varied in regards to the timing of the operation, lower limb trauma. The definitive bony fixation and soft tissue coverage
antibiotic treatment, method of bony fixation, and wound management are performed within 7 days of initial trauma by an experienced
strategies [13–15]. In the United Kingdom, collaboration between or orthoplastic team. Simultaneous soft tissue coverage and bony fixation is
thopaedic and plastic surgeons generated the BOA/BAPRAS (British performed if internal fixation is used. Those patients with peri‑ and
Orthopaedic Association/British Association of Plastic, Reconstructive, intra-articular open distal tibia fracture are preferably treated with a
Aesthetic Surgeons) treatment protocol, Standards for the Management modern ring fixator rather than plate fixation to avoid implant-related
of Open Fractures of the Lower Limb, Standards for Trauma Number 4 deep infections.
(BOAST 4) guideline [16]. Based on the findings of previous studies Our OTF treatment protocol study was conducted as a retrospective
conducted in the United Kingdom, the implementation of the BOAST 4 cohort study using handpicked data from the electronic patient record
guideline has led to a markedly decreased rate of deep infections and an databases of TAUH. We retrieved all operatively treated tibia fractures
increased rate of union [17,18]. retrospectively from the TAUH operative database between April 1,
Tampere University Hospital (TAUH), Finland is a tertiary trauma 2007, and May 10, 2021, using the tibia fracture procedural codes
unit with a catchment population of 900 000 inhabitants. At the NGJ60, NGJ62, NGJ70, NGJ84, NGJ99, NGJ64. In order to report OTF
beginning of September 2016, TAUH introduced a structured treatment patients with primary or secondary amputation, we also retrieved the
protocol for OTFs based on the BOAST 4 guideline. The aim of the lower limb amputation procedural codes NGQ10, NGQ20, and NGQ48
present study is to investigate patient outcomes before and after associated with the tibia fracture related ICD-10 codes S82.1, S82.2,
implementation of the OTF treatment protocol. We hypothesized that S82.3, S82.9, S88.1 or S88.9. We excluded patients with closed tibia
the protocol would reduce both the incidence of deep fracture-related fractures, lower limb fracture other than tibia fracture, patients under 15
infection (FRI) and the incidence of infection-induced nonunion. Ac years of age, patients treated with titanium elastic nail (TEN nailing,
cording to Finnish research legislation, review by a formal ethics com open physes), patients referred to another hospital for definite treat
mittee is not required because the study was registry-based, and the ment, patients referred to another university hospital district for follow-
integrity of the patients was maintained. up, patients referred to TAUH after primary procedure, patients who
deceased before definitive treatment, and patients who underwent pri
Materials and methods mary amputation (Fig. 2). Patients with bilateral OTF or consecutive
OTFs were considered as separate cases. The follow-up data were
The OTF treatment protocol implemented at TAUH is a modification collected one year after the end of the study period.
of the BOAST 4 guideline (Fig. 1). On arrival at the emergency room, For all the identified patients with OTF, we handpicked further in
intravenous antibiotics are administered as soon as possible. The soft formation from the TAUH electronic patient database. We also collected
tissue injury is then documented with photographs. Neurovascular sta descriptive information (patient sex and age) and known risk factors for
tus is assessed, and signs of compartment syndrome or other limb- FRI and nonunion (smoking, diabetes, substance abuse, Gustilo-
threatening conditions are monitored. Wounds are covered with Anderson grading). Additionally, we collected information about the
saline-soaked gauze. After primary assessment, the limb is re-aligned bony fixation method, possible soft tissue reconstruction method, in
and splinted. Primary debridement is performed within 12 h by senior formation about simultaneous internal fixation and soft tissue coverage,
plastic and orthopaedic surgery consultants. If secondary assessment is time from trauma to definitive fixation, and information on whether the
needed before definitive reconstruction, assessment is conducted in the first operation was conducted during the first 24 h after the trauma. For
Fig. 1. Flowchart of patient selection.
Fig. 2. BOAST 4 based OTF treatment protocol at TAUH.
outcome measures, we collected information on FRI, reoperations due to medical reports of all the retrieved patients from the TAUH electronic
non-union, flap loss complications, and secondary amputations. The patient record database were reviewed. We identified 203 OTF cases
definition of secondary amputation was amputation after primary that met the inclusion criteria. Detailed information on the excluded
salvage attempt and fixation. The criteria for FRI was determined ac patients is presented in Fig. 2.
cording to confirmatory criteria defined by the FRI consensus group Of the 203 included OTF patients, 141 were treated before the
[19]. Findings of purulent drainage, fistula, presence of pus or presence implementation of the TAUH OTF treatment protocol and 62 thereafter.
of microorganisms in deep tissue specimens was an indication for FRI. There was no statistically significant difference between the character
We compared the incidence of complications before and after istics of the study groups (Table 1). However, there was a statistically
implementation of the TAUH OTF treatment protocol in September significant difference in the distribution of Gustilo-Anderson grades
2016. The primary outcome measure of this study was the incidence of between the study groups (p-value 0.0012) (Table 2). Indeed, Gustilo-
FRI. Secondary outcome measures were incidences of reoperation due to Anderson III OTFs were graded more often as IIIA in the pre-protocol
nonunion, partial or total flap loss, and secondary amputation.
Statistical analyses between groups were made using R, version 3.6.2
(R Core Team (2019). R: A language and environment for statistical Table 1
computing. R Foundation for Statistical Computing, Vienna, Austria. Patient characteristics.
URL https://www.R-project.org/). Fisher’s exact test and Mann- Study population April 1, 2007 - May 10, 2021
Whitney U test were used for assessing statistical differences between 203
protocol groups. In addition, multivariable analyses were performed Pre-protocol group Protocol group Sep 1,
using binary logistic regression models separately for FRI and reopera April 1, 2007-Aug 31, 2016-May 10, 2021
2016
tion due to nonunion, with definitive fixation and soft tissue recon 141 62 p-value
struction in separate operations, GA grade, time from trauma to
Diabetes 9 6.4% 4 6.5% 1.0000*
definitive fixation, and primary operation within 24 h as independent
Smoking 30 21.3% 11 17.7% 0.7047*
variables. Substance abuse 25 17.7% 11 17.7% 1.0000*
Male 93 66.0% 43 69.4% 0.7462*
Results Female 48 34.0% 19 30.6% 0.7462*
Age (mean/median) 44.3 44.0 42.9 43.5 0.8254**
A total of 331 OTFs were treated during the study period. The *Fisher´s test,.
**Mann-Whitney test.
Table 2 Table 4
Fracture and treatment characteristics. Primary outcome measures.
Study population April 1, 2007 - May 10, Study population April 1,
2021 2007 - May 10, 2021
203 203
Pre-protocol Protocol group p-value Pre-protocol Protocol p-value (Fisher’s
group April 1, Sep 1, 2016-May group April group Sep test)
2007-Aug 31, 10, 2021 1, 2007-Aug 1, 2016-
2016 62 31, 2016 May 10,
141 2021
141 62
Definitive fixation and soft 117 83.0% 62 100% 0.0001*
tissue coverage in the Fracture-related infection 29 20.6% 1 1.6% 0.0015
same operation (FRI)
Gustilo-Anderson grade 0.0012* Reoperation due to non- 39 27.7% 6 9.7% 0.0054
G-A I 54 38.3% 26 41.9% union
G-A II 28 19.9% 13 21.0% Secondary amputation 4 2.8% 1 1.6% 1.0000
G-A IIIA 38 27.0% 4 6.5%
>G-A IIIB 19 13.5% 14 22.6%
G-A IIIC 2 1.4% 5 8.1% difference (p = 1.000). Flap loss complications were reported in patients
Primary operation <24 h 124 87.9% 54 87.1% 0.8214* who had undergone soft tissue reconstruction with pedicled or free flap
Time from trauma to Average 2.86 Average 3.21 0.0226**
definitive fixation Median 1 Median 2
(Table 5). There was, however, no significant difference in flap loss
(days) complications between study groups.
Definitive fixation method 0.0355* All patients in the OTF protocol group underwent direct wound
Plate fixation 46 32.6% 12 19.4% closure or flap reconstruction in the same operation as definitive
Intramedullary nailing 88 62.4% 42 67.7%
osteosynthesis. However, in the pre-protocol group, only 83% (117/
External fixation 6 4.3% 8 12.9%
Screw fixation 1 0.7% 0 0.0% 141) of patients underwent definitive internal fixation and soft tissue
coverage in the same operation (p-value 0.0001).
*Fisher´s test,.
Multivariable analysis was conducted using the whole study popu
**Mann-Whitney test.
lation as one group. Definitive fixation and soft tissue coverage per
formed in separate operations was an independent risk factor for both
group (27.0% vs 6.5%) and as IIIB in the protocol group (13.5% vs FRI (OR 7.2517 [95% confidence interval (CI) 2.3875 to 22.0258], p-
22.6%). The distributions of definitive fixation methods are presented in value 0.0005) and reoperation due to nonunion (OR 6.9648 [95% CI
Table 2. A statistically significant difference was found between the 2.4407 to 19.8751], p value 0.0003). Additionally, a delay between
study groups (p-value 0.0355). Intramedullary nailing was the most trauma and definitive fixation showed a progressive increased risk for
common bony fixation method in both groups (pre-protocol group FRI (OR 1.1038 [95% CI 1.0024 to 1.2156], p-value 0.0446).
62.4% vs protocol group 67.7%). Plating was used in 32.6% of patients
in the pre-protocol group and in 19.4% of patients in the protocol group.
Discussion
External fixation was used as definitive fixation more often in the pro
tocol group (4.3% vs 12.9%). Before implementation of the OTF treat
The present study found a significant reduction in incidence of FRI
ment protocol, 26 (18.4%) patients had soft tissue reconstruction with
from 20.6% to 1.6% after the implementation of the OTF treatment
pedicled flap and 23 (16.3%) with free flap. After implementation of the
protocol. Similar results have been published earlier showing a signifi
OTF treatment protocol, 9 (14.5%) patients were treated with pedicled
cant reduction in FRI rates after the implementation of OTF treatment
flap and 14 (22.6%) with free flap. However, no statistically significant
protocols based on BOAST 4. Mathews et al. [13] compared the FRI rates
difference was found (Table 3). There was no significant difference in
of patients with Gustilo-Anderson grade III OTF treated with single-stage
the incidence of primary amputation between the study groups (11/220
definitive fixation and soft tissue coverage (n = 48) to those patients
5.0% vs 7/111 6.3% [p-value 0.6155]).
who had separate operations (n = 26), resulting in FRI rates of 4.2%
By the end of the follow-up period, FRI was diagnosed in only 1 OTF
versus 34.6%, respectively. Wordsworth et al. [18] also reported a
patient after the implementation of the OTF treatment protocol at
reduction in FRI incidence after the implementation of their BOAST 4
TAUH, making the FRI rate significantly lower in the protocol group
based OTF treatment protocol compared to historical data from the same
compared to the pre-protocol group (20.6% vs 1.6%, p-value 0.0015,
unit. Their cohort of 65 consecutive Gustilo-Anderson IIIB tibia fractures
Table 4, Fig. 3).
had an FRI incidence of only 1.6% (1/65 patients), whereas a publica
The incidence of reoperation due to nonunion was also significantly
tion from the same institute in 2006 [20] reported an FRI incidence of
higher in the pre-protocol group (27.7% vs 9.7%, p-value 0.0054,
8.5% (6/71 patients). Ali et al. [17] reported a reduction in the inci
Table 4, Fig. 3). Secondary amputation was performed on 4/141 (2.8%)
dence of FRI from 27% to 8% after implementation of a BOAST 4 based
patients before and on 1/62 (1.6%) patients after the implementation of
treatment protocol. However, the difference was not found to be sig
the TAUH OTF treatment protocol, with no statistically significant
nificant (p = 0.247). In their treatment protocol, the objective was to
complete soft tissue coverage within 72 h rather than a combined
simultaneous approach to reconstruct soft tissue coverage and bony
Table 3
Flap reconstruction. fixation; median time from bony fixation to soft tissue coverage was 2
days. Moreover, only limited conclusions can be drawn due to their
Study population April 1, 2007 - May 10,
small sample size (50 patients divided into three study periods).
2021
203 At TAUH, the rate of reoperation due to nonunion was reduced from
Pre-protocol group Protocol group Sep p-value (Fisher´s test) 27.7% to 9.7% in those patients treated after the implementation of the
April 1, 2007-Aug 1, 2016-May 10, OTF treatment protocol. In previous studies, there has been a wide
31, 2016 2021
variation in incidences of nonunion reported in OTF patients. The most
141 62 commonly reported incidences vary between 0% and 32.6% [12,21,22].
Pedicled flap 26 18.4% 9 14.5% 0.5510 Based on the presented results, it would be reasonable to assume that
Free flap 23 16.3% 14 22.6% 0.3251
the implementation of the BOAST 4 based OTF treatment protocol at
Fig. 3. Rate of FRI, reoperation due to non-union and secondary amputation in pre-protocol group and protocol group.
injury [16]. The results of the present study suggest that when a sys
Table 5
tematic treatment protocol is combined with meticulous orthoplastic
Incidence of total and partial flap loss amongst patients who underwent soft
execution, OTF can be treated with an acceptable risk for FRI or
tissue reconstruction with pedicled or free flap.
nonunion even if the 72-hour target time is sometimes surpassed.
Pre-protocol Protocol group p-value (Fisher’s test)
Due to the retrospective nature of this study, only limited conclu
group April 1, Sep 1, 2016-May
2007-Aug 31, 10, 2021
sions can be drawn. We were unable to present the patient-reported
2016 outcomes of our study population, which could have provided a better
insight of the long-term outcomes of the two treatment groups. In
Free flap 23 14 0.77
Total flap loss 1 4.3% 0 0.0% addition, the follow-up period between the study groups varied between
Partial flap loss 4 17.4% 1 7.1% 5 and 14 years in the pre-protocol group and between 1 and 5 years in
Pedicled flap 26 9 1.00 the protocol group. We considered the minimum follow-up period of one
Total flap loss 0 0.0% 0 0.0%
year to be satisfactory, since our primary outcomes (FRI and reoperation
Partial flap loss 4 15.4% 1 11.1%
due to nonunion) generally occur within normal clinical follow-up
periods.
TAUH has led to a reduction in FRI and reoperation due to nonunion
rates. The lower complication rates cannot be explained by increased Conclusions
primary amputation rates, as no significant difference was found be
tween the study groups. In the pre-protocol group, 11/220 (5.0%) pa The BOAST 4 based OTF treatment protocol reduced the rate of
tients and 7/111 (6.3%) patients in the protocol group underwent fracture related infection and reoperation due to nonunion in OTF pa
primary amputation (p = 0.616). Secondary amputation was performed tients treated at TAUH during the study period. We, therefore, recom
on 2.8% of patients in the pre-protocol group and on 1.6% of patients in mend the implementation of such a treatment protocol in all major
the protocol group with no statistically significant difference (p = trauma centers treating patients with OTF. Furthermore, we also
1.000). In previous studies, the amputation rate for Gustilo-Anderson recommend the immediate referral of patients with complex OTF from
IIIB OTFs has been reported to be 0% to 17.6% [11,12,23]. The lower hospitals lacking the preconditions to provide BOAST 4 based treatment
amputation rates reported in the present study can be explained by the to specialized centers.
inclusion of all Gustilo-Anderson OTF types.
In the present study, Gustilo-Anderson grade III OTFs were graded Declaration of Competing Interest
more often IIIB in the protocol group (13.5% vs 22.6%) and IIIA in the
pre-protocol group (27.0% vs 6.5%). This could be explained by the The author(s) declared no potential conflicts of interest with respect
execution of the OTF treatment protocol. According to the protocol, to the research, authorship, and/or publication of this article.
plastic surgeons are involved in the treatment of OTF patients from the
beginning, leading to a more accurate evaluation of the soft tissue injury Acknowledgements
and Gustilo-Anderson grade. During the study period, the use of plate
fixation diminished in favour of intramedullary nailing and external We thank MD Tiia Kivelä for her assistance with data collection. We
fixation (Table 2). are also grateful for MSc Mika Helminen for his assistance with statis
The execution of all the independent parts of the TAUH OTF treat tical analyses that considerably improved the manuscript. A grant for
ment protocol could not be reported in this study. Hence, comprehensive the study was given by Tampere University Hospital Foundation.
conclusions about which parts of the treatment protocol are the most
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Injury 54 (2023) 110893
Injury
Firearm injury survival is only the beginning: The impact of socioeconomic

factors on unplanned readmission after injury
Derek C Lumbard *, Chad J Richardson, Frederick W Endorf, Rachel M Nygaard
Department of Surgery, Hennepin Healthcare, Minneapolis, MN 55415, United States
Keywords: Background: Firearm trauma remain a national crisis disproportionally impacting minority populations in the
Firearm Injury United States. Risk factors leading to unplanned readmission after firearm injury remain unclear. We hypothe
Unplanned Readmission sized that socioeconomic factors have a major impact on unplanned readmission following assault-related
Trauma
firearm injury.
Assault
Methods: The 2016–2019 Nationwide Readmission Database of the Healthcare Cost and Utilization Project was
used to identify hospital admissions in those aged >14 years with assault-related firearm injury. Multivariable
analysis assessed factors associated with unplanned 90-day readmission.
Results: Over 4 years, 20,666 assault-related firearm injury admissions were identified that resulted in 2,033
injuries with subsequent 90-day unplanned readmission. Those with readmissions tended to be older (31.9 vs
30.3 years), had a drug or alcohol diagnosis at primary hospitalization (27.1% vs 24.1%), and had longer hospital
stays at primary hospitalization (15.5 vs 8.1 days) [all P<0.05]. The mortality rate in the primary hospitalization
was 4.5%. Primary readmission diagnoses included: complications (29.6%), infection (14.5%), mental health
(4.4%), trauma (15.6%), and chronic disease (30.6%). Over half of the patients readmitted with a trauma
diagnosis were coded as new trauma encounters. 10.3% of readmission diagnoses included an additional ‘initial’
firearm injury diagnosis. Independent predictors of 90-day unplanned readmission were public insurance (aOR
1.21, P = 0.008), lowest income quartile (aOR 1.23, P = 0.048), living in a larger urban region (aOR 1.49, P =
0.01), discharge requiring additional care (aOR 1.61, P < 0.001), and discharge against medical advice (aOR
2.39, P < 0.001).
Conclusions: Here we present socioeconomic risk factors for unplanned readmission after assault-related firearm
injury. Better understanding of this population can lead to improved outcomes, decreased readmissions, and
decreased financial burden on hospitals and patients. Hospital-based violence intervention programs may use
this to target mitigating intervention programs in this population.
Introduction improve patient outcomes after injury [15,16]. However, firearm injury
remains difficult to study, particularly on the national scale, due to a
Firearm violence and injury impact the lives of our patients, the lack of national tracking of non-fatal firearm injuries.
health care system, and society; yet is the least-researched cause of Risk factors associated with firearm injury vary by the intent of the
mortality in the United States (U.S.) [1–3]. Outcomes following firearm injury [17]. Assault-related firearm injury patients are not only less
trauma vary by intent of the injury (self-inflicted, assault, unintentional) likely to have insurance compared to those with self-inflicted and un
[4]. For example, Assault-related firearm injury has the second highest intentional injuries, but also self-pay insurance status is a risk factor for
mortality rate following self-inflicted firearm injury [1,5]. Interventions worse outcomes after firearm injury [18,19]. Insurance, but not intent of
that improve social and economic wellbeing can mitigate the risk of injury, was shown as risk factors for all readmissions to the same or
reinjury and mortality associated with firearm injury [6–14]. Efforts are different hospitals following firearm injury [16].
underway to better understand the physical, psychological, and finan It remains unclear if there are specific factors associated with
cial burden associated with firearm injury hospitalization as well as improved outcomes in the assault-related firearm injury population. One
* Corresponding author at: 701 Park Ave S, P5, Minneapolis, MN 55415, United States
E-mail address: Derek.Lumbard@hcmed.org (D.C. Lumbard).
D.C. Lumbard et al. Injury 54 (2023) 110893
measure of favorable outcomes is the absence of unplanned readmission defined as the first assault-related firearm admission occurring between
following discharge from the hospital. The purpose of this study was to January and September of each calendar year to allow for 3-month
characterize and identify risk factors for unplanned readmission after follow-up for possible readmission. To prevent over reporting of read
assault-related firearm injury. We hypothesized that socioeconomic risk missions, the NRD combines patient hospitalizations when the recorded
factors have an impact on readmission in this patient population. discharge date equaled the admission date for another hospitalization.
Firearm-injured patients transferred to another acute care center over
Methods night were also excluded (Fig 1).
NRD variables descriptions are available on their website [21]. These
This was a retrospective analysis using the Nationwide Readmission included: age, sex, urban-rural classification scheme, zip-code income
Database (NRD) of the Healthcare Cost and Utilization Project (HCUP) quartile, insurance type, length of stay, total hospital charge for initial
from 2016–2019. The HCUP is a partnership sponsored by the Agency stay and readmission, and discharge disposition. Zip code income
for Healthcare Research and Quality (AHRQ) that includes the largest quartile is defined as the estimated median household income based on
collection of healthcare data in the U.S. with approximately 18 million the patient’s zip code [21]. Severity of injury was categorized using all
discharges each year [20]. The NRD is generated from the state inpatient patient refined diagnosis related group (APR-DRG) Severity developed
databases and post-stratified to reflect inpatient discharges from com by 3 M Health Information Systems included in the NRD [22]. The
munity hospitals while excluding discharges from rehabilitation and urban-rural classification scheme categorizes populations into six levels
long-term acute care facilities. based off census data within counties. Charlson Comorbidity Index were
Patients were identified using associated International Classification of calculated based on published methods [23]. Researcher generate var
Diseases, Tenth Revision, codes for “initial” assault-related firearm injury iables included: age groups (0–12 and 13–17), insurance/payor groups
(X93, X94, X95, Y38) and readmission diagnosis. The primary outcome (private, medicaid/care, self-pay, or other/unknown), and discharge
variable was defined as unplanned readmission after assault-related disposition groups (home, skilled nursing/home with care/other hos
firearm injury. Secondary outcomes variables were reasons for un pital, or AMA). Readmission diagnosis was based on the Clinical Clas
planned readmission following assault-related firearm injury. Patient’s sifications Software Refined (CCSR) for ICD-10 diagnosis code category
aged 14 years and older in the NRD were included in the analysis. Pa labels developed by the AHRQ HCUP databases [24]. These readmission
tients with missing length of stay, missing discharge disposition, and diagnoses were grouped into: complications, infection, mental health or
elective admissions were excluded. Index firearm hospitalizations were drug/alcohol, trauma, chronic disease/cancer, or other. Abbreviated
Fig. 1. Cohort of patients included in analysis.
Injury Score (AIS) and Revised Injury Severity Score (ISS) were calcu Table 1
lated using ICD-10 diagnosis codes [25]. 2016–19 Nationwide readmission database 90-day unplanned readmission
Descriptive statistics comparing characteristics, treatment, and out following assault-related firearm injury.
comes of repeat admissions following firearm injury included Student’s Cohort Survived with Survived with P
T-test for continuous variables and Chi2 test for categorical variables. No 90-day 90-day valuea
Logistic regression analysis was used to assess factors associated with Unplanned Unplanned
Readmission Readmission
90-day unplanned readmission in those that survived their initial
firearm injury. Multivariable logistic regression models included age, 20,666 17,712 2033
Age years, mean 30.4 30.3 (11.5) 31.9 (12.0)
sex, NCHS urban-rural classification, patient income quartile based on <0.001
(SD) (11.6)
zip code, insurance group, APR-DRG Severity, Charlson Comorbidity Female, N (%) 2315 1963 (11.1) 244 (12.0) 0.213
Index group, Drug or alcohol abuse diagnosis, grouped disposition, and (11.2)
clustered by hospital to account for interfacility differences in practice. NCHS Urban- 0.003
Statistical analyses were performed using Stata 15.1 (StataCorp, College Rural, N (%)
Central 9150 7803 (44.8) 922 (46.3)
Station, TX). (45.0)
Our Internal Review Board for Human Subjects Research deemed Fringe 3833 3269 (18.8) 425 (21.4)
that this study does not fall within the jurisdiction of human subjects (18.9)
research review per Office for Human Research Protections Guidance on metro 250–999k 4452 3827 (22.0) 403 (22.3)
(21.9)
publicly available, deidentified data sets.
metro 25–249k 1295 (6.4) 1132 (6.5) 102 (5.1)
micropolitan 964 (4.7) 838 (4.8) 83 (4.2)
Results not metro or 636 (3.1) 563 (3.2) 55 (2.8)
micro
We identified 20,666 patients with assault-related firearm injury Patient zip-code 0.842
income
admissions from 2016–2019 (Table 1). A total of 2033 (9.9%) patients quartile, N (%)
required unplanned readmission within 90 days of hospital discharge. Lowest 11,423 9810 (56.1) 1140 (56.8)
The majority of patients in both cohorts were male, from central/fringe (56.0)
populations greater than one million, and resided in the lowest esti 2 4570 3915 (22.4) 450 (22.4)
(22.4)
mated income quartile based on zip-code. 11,469 admissions included
3 3061 2609 (14.9) 296 (14.7)
procedures on the first hospital day. (15.0)
Most readmissions occurred to the same hospital with 26.8% Highest 1334 (6.5) 1147 (6.6) 122 (6.1)
occurring at a different hospital. A higher proportion of patients with Insurance, N (%) <0.001
readmission had a drug or alcohol diagnosis (27.1% vs 25.0%; P = Private 3492 3045 (17.2) 307 (15.1)
(16.9)
0.038). Patients with readmission also had significantly longer hospital Medicaid/ 11,280 9582 (54.1) 1232 (60.6)
stays at primary hospitalization (15.5 vs 8.3 days; P < 0.001). The Medicare (54.6)
overall cost of primary hospitalization was significantly higher than Self-pay/No 4323 3708 (20.9) 362 (17.8)
those without readmissions ($255,209 vs $136,894; P<0.001). A ma Charge (20.9)
Other/Unknown 1571 (7.6) 1377 (7.8) 132 (6.5)
jority of patients were discharged to home in both the groups however a
Severity Risk, N <0.001
lower proportion were discharged home from the group with read (%)
missions (64.6% vs 80.6%). A higher proportion of patients with read Minor loss of 3571 3398 (19.2) 166 (8.2)
mission had discharges to home with care, short-term hospitals, SNF/ function (17.3)
Intermediate care, and AMA. The mortality rate in the primary hospi Moderate loss of 6789 6282 (35.5) 486 (23.9)
function (32.9)
talization was 4.5% (n = 921). Major loss of 5295 4580 (25.9) 565 (27.8)
We then conducted multivariable regression analysis to assess factors function (25.6)
associated with 90-day unplanned readmission to the hospital (Fig. 2). Extreme loss of 5011 3452 (19.5) 816 (40.1)
Patients with Medicaid/Medicare insurance (adjusted odds ratio [aOR] function (24.3)
ISS, N (%)
1.21, P = 0.008), lowest income quartile (aOR 1.23, P = 0.048), living in <0.001
≤8 6341 5832 (38.1) 480 (25.7)
a larger urban region (aOR 1.49, P = 0.01), discharging with additional (35.0)
care (aOR 1.61, P < 0.001), and discharge AMA (aOR 2.39, P < 0.001) 9 - 14 4197 3681 (24.0) 422 (22.6)
were more likely to be readmitted with 90 days of discharge. Those with (23.2)
increased Charlson Comorbidity Index (aOR 1.60, P < 0.001) and injury 16 - 24 2712 2211 (14.4) 360 (19.3)
(15.0)
severity defined as moderate (aOR 1.57, P < 0.001), severe (aOR 2.44, P
≥25 4853 3593 (23.5) 604 (32.4)
< 0.001), or extreme (aOR 4.25, P < 0.001) were also at increased risk of (26.8)
readmission to the hospital. Primary reasons for readmission included: AIS head ≥3, N 2330 1655 (9.3) 188 (9.3) 0.887
complications (29.6%), infection (14.5%), mental health (4.4%), trauma (%) (11.3)
Charlson
(15.6%), and chronic disease (30.6%) [Table 2]. When specifically <0.001
Comorbidity
looking at the patients coded under trauma, we found that 72% (230/ Index group, N
318) were new trauma encounters. The majority of these were fractures (%)
(N = 95, 41.3%) and crush or internal injury (N = 79, 34.4%). Moreover, 0 19,272 16,666 (94.1) 1330 (87.3)
approximately 10% of the patients readmitted had an additional ‘initial’ (93.3)
1 750 (3.6) 584 (3.3) 89 (5.8)
firearm injury diagnosis. These injuries were associated with these
2 644 (3.1) 462 (2.6) 105 (6.9)
anatomical regions: face (N = 11, 5%), head/neck (N = 14, 6.7%), ex Drug or alcohol 5037 4426 (25.0) 551 (27.1) 0.038
tremity (N = 73, 34.9%), chest (N = 58, 27.8%), and abdomen (N = 56, abuse (24.4)
26.8%). diagnosis, N
(%)
LOS, mean (SD) 8.8 (13.9) 8.3 (12.9) 15.5 (21.2) <0.001
Discussion
(continued on next page)
This study assesses socioeconomic factors associated with unplanned
Table 1 (continued ) readmission following assault-related firearm injury on a national scale.

Cohort Survived with Survived with P Nearly 10% of patients present with unplanned readmission within 90
No 90-day 90-day valuea days of discharge. Insurance coverage type, income, and residing in an
Unplanned Unplanned urban environment, were independent predictors of unplanned read
Readmission Readmission mission. Discharge requiring additional care and discharging AMA were
Total Charges, 15,361 136,894 255,209 <0.001 also associated with unplanned readmission. The most common reasons
mean (SD) (236,900) (209,757) (375,372) for readmission were complications associated with initial admission,
Disposition, N <0.001
however 15% were due to trauma. This risk of repeat injury may be
(%)
Home 15,582 14,269 (80.6) 1313 (64.6) mitigated through implementation and investment in a hospital-based
(75.4) violence intervention programs (HVIP). HVIPs have shown substantial
Home with care 2131 1828 (10.3) 303 (14.9) reductions in repeat firearm injuries through providing mitigating in
(10.3) terventions and resources after hospitalization [26,27]. Providing this
Short-term 239 (1.2) 183 (1.0) 56 (2.8)
hospital
additional support to this vulnerable population could potentially
SNF/ 1283 (6.2) 1012 (5.7) 271 (13.3) impact modifiable risk factors associated with readmission leading to
Intermediate improved outcomes, decreased readmissions, and decreased financial
Care burden on patients and the U.S. healthcare system.
AMA 510 (2.5) 420 (2.3) 90 (4.4)
Repeat firearm injuries, compared to other types of violent trauma,
Expired 921 (4.5) 0 (0) 0 (0)
are more severe with each successive admission [8]. This study found
a
Student’s T-test for continuous variables and Chi2 for categorical variables. that 10% of patients readmitted with new traumatic injuries had repeat
Abbreviations: AIS, abbreviated injury score; ISS, injury severity score; LOS, firearm injuries. Previous work showed that almost half of recidivists
length of stay.
were previously treated and released from the ED after firearm injury
[9]. The NRD does not include prior discharges from the ED, so our
findings are likely an under-reporting of readmissions. While our sample
Fig. 2. Multivariable logistic regressions of factors associated with 90-day unplanned readmission following firearm injury. Model is additionally adjusted for
comorbidities, severity of injury, and clustered by hospital to account for center specific differences.
Table 2
Unplanned readmissions.
Primary Diagnosis N Age Mean LOS days Mean Total Charges $ Mean Time to readmission days Mean Mortality N
(%) (SD) (SD) (SD) (SD) (%)
Complications 602 (29.6) 32.1 (11.9) 7.2 (8.8) 71,825 (104,138) 18.5 (20.9) 3 (0.5)
Infections 294 (14.5) 33.4 (13.4) 7.8 (11.1) 92,530 (176,264) 28.0 (25.5) 4 (1.4)
Psych/drug 90 (4.4) 32.2 (10.0) 6.6 (10.5) 28,054 (40,511) 33.3 (25.9) 0 (0)
Traumatic injury 318 (15.6) 30.7 (11.5) 8.0 (14.4) 103,662 (191,667) 18.2 (22.2) 3 (0.9)
New initial traumatic 230 (72.3) 31.0 (11.9) 7.8 (12.8) 110,076.9 (193,259) 19.3 (23.3) 3 (1.3)
injury
Chronic disease/Cancer 622 (30.6) 31.7 (12.1) 5.9 (11.8) 57,890 (112,453) 22.7 (23.6) 4 (0.6)
Other 107 (5.3) 30.7 (11.3) 5.0 (6.5) 48,030 (63,238) 31.8 (28.3) 0 (0)
Abbreviations: LOS, length of stay; SD, standard deviation.
period only includes 90 days after discharge, single center studies this limitation, we cannot speculate on the life-saving nature of any
examining violent trauma recidivism report rates ranging from 3.1 - specific procedures. Additionally, the NRD does not allow reporting of
11.7% and an average time from index injury to repeat trauma from 2 to low Ns, so to protect the anonymity of patients, and does not allow for
4.1 years [8–11,28,29]. We found that 27% present to a different hos identifying specific hospitals included in the database. This limits our
pital for readmission, this is higher than readmissions following any ability to drill down to assess some details associated with repeat
intent firearm injury reported at 16% [16]. Rattan et al. used this same injuries.
database, but in prior years that included only ICD-9 codes; this may
have impacted the selection of the study cohort. Conclusion
Numerous studies have demonstrated a connection between
increased risk of gun violence and measures of poverty (home values, Our study provides a description of characteristics and risk factors in
unemployment, and single-parent households) [6,14,30–32]. In the assault-related firearm injury population. Better understanding of
contrast, reduced racial segregation, new community development, this population can lead to improved outcomes, decreased readmissions,
increased social capital, better upward mobility, and more generous and decreased financial burden on hospitals and patients. Trauma sys
Medicaid benefits were all associated with lower rates of firearm tems are designed and experienced at implementing best practice
violence [6,7,13,14,33]. Prior studies in urban environments have also guidelines across the country, this could be an initiative to reduce
shown that firearm injuries were concentrated in lower income areas, additional traumatic injury and unplanned readmissions in a vulnerable
however, race still impacted injury risk despite neighborhood income population. Additionally, this study lends support for HVIPs mission to
level [34]. We found that survivors in the lowest median household improve outcomes following firearm trauma.
income quartile had higher rates of readmission, this was also recently
observed in the general trauma population [35]. While this study does Source of Funding
not specifically look at race/ethnicity, due to limitations in the NRD, the
literature clearly shows there are racial disparities associated with out The Hitchcock Surgical Society Resident Research Fund provided
comes following assault-related firearm injury. Ultimately, additional funds to purchase the Nationwide Readmission Database.
studies including data that includes race/ethnicity are needed for a more
complete and accurate assessment of risk factors and outcomes. CRediT authorship contribution statement
Our previous work revealed that self-pay insurance status was an
independent risk factor for mortality after firearm injury regardless of D.C.L., F.W.E., C.J.R., and R.M.N. contributed to the conceptualiza
race/ethnicity [19]. Here we found that Medicaid/Medicare insurance tion and methodology of the study. D.C.L. and R.M.N. curated the data
was a risk factor for readmission to the hospital. Interestingly, the in and contributed to visualization. D.C.L., F.W.E., C.J.R., and R.M.N.
surance status at time of discharge may reflect future expected coverage performed formal analysis and investigation. D.C.L. and R.M.N. wrote
and not the current payor status [36]. This is in part due to expansion of the original draft. F.W.E. and C.J.R. reviewed and edited the article.
Medicaid and Medicare with the Hospital Readmissions Reduction
Program (HRRP) as well as the addition of Hospital Presumptive Eligi
bility (HPE) in 2014 to include trauma patients who are likely to qualify
for Medicaid [37]. Efforts are underway to better understand how in
No authors of this manuscript report any conflicts of interest
surance in this vulnerable population can be obtained and maintained
regarding this potential publication.
[36].
This study used 90 days post discharge as a timeframe for read
Acknowledgements
mission. Previous studies in trauma and emergency general surgery
looked at nonelective readmissions within 30 days of discharge [16,35,
We thank the Hitchcock Surgical Society Resident Research Fund for
38]. While short term complications associated directly with read
providing funds to purchase the NRD. The authors thank Rebecca Freese
mission are more likely to occur within 30 days of discharge, little is
for assistance with analysis.
known about the impact that firearm injury admission has on chronic
medical problems that may be exacerbated during recovery. We found a
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Injury 54 (2023) 110894
Injury
Negative laparotomy rates and outcomes following blunt traumatic injury

in the United States
Kathryn Atkins, Andrew Schneider, Anthony Charles *
Department of Surgery, University of North Carolina at Chapel Hill, USA
Keywords: Introduction: Exploratory laparotomy remains the mainstay of treatment following blunt abdominal trauma.
Blunt traumatic injury However, the decision to operate can be difficult in hemodynamically stable patients with unreliable physical
Abdominal injury exams or equivocal imaging findings. The risk of a negative laparotomy and the subsequent complications must
Exploratory laparotomy
be weighed against the potential morbidity and mortality of a missed abdominal injury. Our study aims to
Negative laparotomy
evaluate trends and the effect of negative laparotomies on morbidity and mortality in adults with blunt traumatic
injuries in the United States.
Methods: We reviewed the National Trauma Data Bank (2007–2019) for adults with blunt traumatic injuries who
underwent an exploratory laparotomy. Positive or negative laparotomy of abdominal injury was compared. We
performed bivariate analysis and a modified Poisson regression to estimate the effect of negative laparotomy on
mortality. A sub-analysis of patients who underwent computed tomography (CT) of the abdomen and pelvis was
performed.
Results: 92,800 patients met the inclusion criteria of the primary analysis. Negative laparotomy rates were 12.0%
in this population, down-trending throughout the study. Negative laparotomy patients had a significantly higher
crude mortality (31.1% vs. 20.5%, p < 0.001), despite lower injury severity scores (20 (10–29) vs. 25 (16–35), p
< 0.001) than positive laparotomy patients. Patients that underwent negative laparotomy had a 33% higher risk
for mortality (RR1.33, 95% CI 1.28–1.37, P < 0.001) than positive laparotomy patients after adjusting for
pertinent covariates. Patients that underwent CT abdomen/pelvis imaging (n = 45,654) had a lower rate of
negative laparotomy (11.1%) and decreased difference in crude mortality (22.6% vs. 14.1%, p < 0.001)
compared to positive laparotomy patients. However, the relative risk for mortality remained high at 37% (RR
1.37, 95% CI 1.29 – 1.46, p < 0.001) for this sub-cohort.
Conclusion: Negative laparotomy rates in adults with blunt traumatic injuries are trending down in the United
States but remains substantial and may show improvement with increased use of diagnostic imaging. Negative
laparotomy has a relative risk for mortality of 33% despite lower injury severity. Thus, surgical exploration in
this population should be thoughtfully undertaken with appropriate evaluation via physical exam and diagnostic
imaging to prevent unnecessary morbidity and mortality.
Introduction people [3]. Abdominal trauma occurs in 6.0 – 14.9% of all traumatic
injuries [4–6].
Trauma is the leading cause of death in persons under 45 years in the Blunt abdominal trauma is challenging to manage, as injuries are not
United States, with blunt traumatic injury accounting for 80 – 90% of all apparent, and indications for exploratory laparotomy are not as
traumatic injuries [1]. Motor vehicle collisions and pedestrian injuries straightforward as in penetrating abdominal trauma. Deciding on
account for the majority of injuries in this population [2]. In 2020, there treatment may be difficult, and the fear of missing injuries is always
were 278,345 deaths due to traumatic injury in the United States, present. Many solid visceral injuries are suitable for conservative man
approximately 84.5 deaths per 100,000 people. Of those deaths, 42,632 agement [7]. Hemodynamic instability, peritonitis, or concern for hol
were attributed to motor vehicle collisions, at 12.9 deaths per 100,000 low viscus injury or free intraperitoneal fluid on computed tomography
* Corresponding author at: Department of Surgery, UNC School of Medicine, 4008 Burnett Womack Building, CB 7228.
E-mail address: anthchar@med.unc.edu (A. Charles).
K. Atkins et al. Injury 54 (2023) 110894
(CT) are unequivocal indications for exploratory laparotomy [2,7–10]. categorical variables and Kruskal-Wallis and Student’s t-test for
Exploratory laparotomies for trauma have been performed since the continuous variables for bivariate analysis. We performed a modified
late 1800s for diagnostic and therapeutic indications. It demonstrated Poisson regression model to assess the relative risk for mortality in pa
high rates of negative laparotomies from 1880 to the 1960s [7,11]. A tients that underwent a negative laparotomy. Significant potential
laparotomy is defined as negative if no abdominal injuries are identified confounding covariates (age, sex, arrival SBP, pulse rate, modified CCI,
upon exploration. A laparotomy is defined as non-therapeutic if an total initial GCS, and ISS) were controlled for in the model. Missingness
injury is identified but does not require any intervention [7,11]. As was evaluated for all variables, and missingness in confounding cova
diagnostic modalities such as ultrasonography and CT imaging have riates did not exceed 5% (Table 1).
improved, negative laparotomies have subsequently decreased from 30 We performed a sub-analysis of all patients within the cohort that
to 40% to an estimated 7 – 10% [8,11–13]. There is considerable vari received imaging via CT Abdomen/Pelvis (with or without contrast)
ability in the current negative laparotomy rate in the United States, during their admission (n = 45,654) to evaluate the effect of diagnostic
ranging from as low as 3.9% to as high as 36% in some studies, but most imaging on mortality outcomes and rates of negative laparotomy. We
are single-institution studies [7–9,14]. Furthermore, the complication performed a modified Poisson regression model to assess the relative risk
rate following negative laparotomy has been reported to range between for mortality in patients that underwent a negative laparotomy and CT
22 and 61% [7–9,13,15]. imaging of the abdomen/pelvis, controlling for the same covariates as
Our study aims to evaluate adults sustaining blunt abdominal trauma our primary model.
in the United States to determine trends in negative laparotomy rates, We utilized StataCorp v17.0, College Station, Texas, for all statistical
the clinical characteristics of these patients, and the effect of negative analyses [18]. The institutional review board at the University of North
laparotomies on morbidity and mortality within this population. Carolina at Chapel Hill exempted the study (IRB: 20–3018).
Further, we aim to assess the impact of diagnostic imaging on these
outcomes. Results
Methods Over the study period, 92,800 patients in the NTDB met our inclusion
criteria (Fig. 1). Of the patients analyzed, 68.0% were male, with a mean
We retrospectively analyzed the National Trauma Data Bank from age of 42.5 (18.5 SD) years. No abdominal injuries were found in 11,145
2007 to 2019. The NTDB encompasses over 900 participating trauma patients who underwent an exploratory laparotomy, conferring a 12.0%
centers in the United States, making it the most extensive national average negative laparotomy rate in this study (Table 1). Negative
database available, and it includes demographics, diagnoses, proced laparotomy rates trended down throughout the study from a high of
ures, and outcomes. Participating trauma centers are permitted access to 13.3% in 2007 to a low of 10.9% in 2019 (Table 2).
the repository by the American College of Surgeons (ACS) for quality Patients that underwent negative laparotomies were older on
and research purposes [16]. average (49.7 vs. 41.6 years old, p < 0.001), more often male (69.5% vs.
Our study focused on adult trauma patients (≥16 years old) who 67.8%, p < 0.001), with more comorbidities (modified CCI 0.4 vs. 0.2, p
sustained blunt traumatic injuries and underwent an exploratory lapa < 0.001) and more likely to be Black (14.0% vs. 11.9%, p < 0.001) when
rotomy. Utilizing the International Classification of Diseases (ICD), 9th compared to patients with positive laparotomies. The mechanism of
and 10th revisions, we selected patients who underwent an exploratory blunt injury was primarily motor vehicle collision (MVC) in both cohorts
laparotomy (ICD-9: 54.11; ICD-10: 0DJ00ZZ, 0DJ60ZZ, 0DJD0ZZ, of patients, more often in those with positive laparotomies (55.4% vs.
0DJU0ZZ, 0DJW0ZZ, 0WJG0ZZ, 0WJJ0ZZ, 0WJP0ZZ, 0WJR0ZZ). Pa 41.5%, p < 0.001). However, a significant number of patients with
tients were stratified by the presence or absence of an abdominal injury negative laparotomies were injured via a fall compared to those positive
using the Abbreviated Injury Scale (AIS). A negative laparotomy was for abdominal injuries (25.0% vs. 10.1%, p < 0.001).
defined as a patient undergoing an exploratory laparotomy without an On arrival to the ED, patients that underwent negative laparotomy
abdominal injury. had better vital signs overall with a higher average SBP (120.2 vs. 113.8
Patient variables collected included the year of traumatic injury, age, mmHg, p < 0.001), lower pulse rate (96.8 vs. 101.1 bpm, p < 0.001), and
sex, race, ethnicity, mechanism of blunt injury, and level of the trauma a more favorable shock index (0.9 vs. 1.0, p < 0.001) compared to those
center. Clinical variables collected included vital signs (systolic blood with positive laparotomies. Total initial GCS was significantly lower in
pressure (SBP), pulse rate, and respiratory rate (RR)) recorded upon patients with no abdominal injury (10.3 vs. 11.5, p < 0.001). Negative
patient arrival to the Emergency Department (ED), initial total GCS, laparotomy patients had significantly lower median ISS (20 (10 – 29) vs.
Injury severity score (ISS), presence of AIS system injury and max score 25 (16 – 34), p < 0.001) and fewer total AIS systems injured (3.0 vs. 4.0,
for each system (Head, Face, Neck, Thorax, Abdomen, Spine, Upper p < 0.001) compared to those with positive laparotomies. Patients that
Extremity and Lower Extremity), and the total number of AIS systems underwent a negative laparotomy were more likely to have head (51.8%
injured. Procedures performed during admission, including diagnostic vs. 42.1%, p < 0.001) and neck (5.2% vs. 4.5%, p < 0.001) injuries,
adjuncts such as abdominal ultrasound and computed tomography (CT) respectively than those found to have abdominal injuries (Table 1,
of the abdomen and pelvis (with and without contrast), were obtained Fig. 2).
using AIS coding. Each patient’s shock index was calculated by dividing Imaging rates increased steadily throughout the study. Rates of CT
the pulse rate by SBP. A modified Charlson comorbidity index (CCI) was abdomen/pelvis (with or without contrast) imaging in patients with
calculated for each patient using previously described methods [17]. blunt trauma increased from a low of 28.7% in 2007 to a high of 69.9%
The primary outcome measure for this study was in-hospital mor in 2019. Similarly, rates of abdominal ultrasound increased from 15.4%
tality, defined as all deaths before hospital discharge. Secondary out in 2007 to 37.7% in 2019. These trends persisted when stratified by
comes such as hospital length of stay, hospital complications (Deep vein negative versus positive laparotomies (Table 3). Patients with negative
thrombosis (DVT), pulmonary embolism (PE), stroke, sepsis, ventilator- laparotomies underwent abdominal ultrasound (23.1% vs. 28.8%, p <
associated pneumonia (VAP), unplanned intensive care unit (ICU) 0.001) and CT abdomen/pelvis (45.7% vs. 49.7%, p < 0.001) less often
admission, intubation, cardiac arrest, deep surgical site infection (SSI), than those found to have abdominal injuries upon exploratory laparot
superficial incisional SSI, pressure ulcer, catheter-associated urinary omy (Table 1).
tract infection (CAUTI), central line-associated bloodstream infection Negative laparotomy patients had significantly higher rates of nearly
(CLABSI), and acute kidney injury (AKI)), and hospital discharge all hospital complications evaluated than positive laparotomy patients.
disposition were evaluated. We defined statistical significance for all Rates of sepsis (10.1% vs. 5.6%, p < 0.001), VAP (19.7% vs. 14.4%, p <
hypotheses tested at p < 0.05. We used Chi2 and analysis of variance for 0.001), intubation (9.2% vs. 4.6%, p < 0.001), cardiac arrest (12.7% vs.
Table 1
Demographic and clinical characteristics of all adults (≥16 years old) who underwent laparotomy for blunt traumatic injury.
Negative laparotomy Positive laparotomy Total p-value Total missing values
N = 11,145 (12.0%) N = 81,655 (88.0%) N = 92,800
Age (years) 49.7 (20.0) 41.6 (18.0) 42.5 (18.5) <0.001 838 (0.9%)
Sex (Male) 7728 (69.5%) 55,251 (67.8%) 62,979 (68.0%) <0.001 183 (0.2%)
Race/Ethnicity <0.001 0 (0%)
White Non-Hispanic 7055 (63.3%) 52,470 (64.3%) 59,525 (64.1%)
White Hispanic 1322 (11.9%) 11,929 (14.6%) 13,251 (14.3%)
Black 1558 (14.0%) 9737 (11.9%) 11,295 (12.2%)
Asian 205 (1.8%) 1954 (2.4%) 2159 (2.3%)
Other 974 (8.7%) 5390 (6.6%) 6364 (6.9%)
Mechanism of Blunt Injury <0.001 3 (0.003%)
Fall 2788 (25.0%) 8229 (10.1%) 11,017 (11.9%)
MCC 1186 (10.6%) 9156 (11.2%) 10,342 (11.1%)
MVC 4627 (41.5%) 45,212 (55.4%) 49,839 (53.7%)
Pedestrian vs. MVC/Other 1207 (10.8%) 8297 (10.2%) 9504 (10.2%)
Bicyclist vs. MV/Other 288 (2.6%) 1690 (2.1%) 1978 (2.1%)
Other 1048 (9.3%) 9069 (11.1%) 10,117 (11.0%)
Modified CCI 0.4 (1.0) 0.2 (0.6) 0.2 (0.7) <0.001 0 (0%)
Arrival Vital Signs
SBP (mmHg) 120.2 (39.2) 113.8 (33.6) 114.6 (34.4) <0.001 2229 (2.4%)
Pulse Rate (bpm) 96.8 (30.0) 101.1 (28.7) 100.6 (28.9) <0.001 1765 (1.9%)
RR (bpm*) 18.3 (8.6) 19.4 (8.5) 19.3 (8.5) <0.001 4887 (5.3%)
Shock Index 0.9 (0.9) 1.0 (0.9) 1.0 (0.9) <0.001 4808 (5.2%)
Total Initial GCS 10.3 (5.4) 11.5 (5.0) 11.3 (5.1) <0.001 2487 (2.7%)
Abdominal Ultrasound 2577 (23.1%) 23,485 (28.8%) 26,062 (28.1%) <0.001 0 (0%)
CT Abdomen/Pelvis (þ/- contrast) 5089 (45.7%) 40,565 (49.7%) 45,654 (49.2%) <0.001 0 (0%)
ISS 20 (10 - 29) 25 (16 - 35) 25 (16 - 34) 1996 (2.2%)
Total AIS Systems Injured 2.9 (1.7) 4.0 (1.8) 3.9 (1.8) <0.001 0 (0%)
AIS Abdomen Max 0.0 (0.0) 3.3 (1.1) 2.9 (1.5) <0.001 0 (0%)
AIS by Systems 0 (0%)
AIS Head Injury 5771 (51.8%) 34,355 (42.1%) 40,126 (43.2%) <0.001 0 (0%)
AIS Head Max 1.8 (2.0) 1.3 (1.7) 1.3 (1.8) <0.001 0 (0%)
AIS Face Injury 3941 (35.4%) 28,440 (34.8%) 32,381 (34.9%) 0.27 0 (0%)
AIS Face Max 0.5 (0.8) 0.5 (0.7) 0.5 (0.7) <0.001 0 (0%)
AIS Neck Injury 584 (5.2%) 3667 (4.5%) 4251 (4.6%) <0.001 0 (0%)
AIS Neck Max 0.1 (0.6) 0.1 (0.5) 0.1 (0.5) <0.001 0 (0%)
AIS Thorax Injury 6685 (60.0%) 55,452 (67.9%) 62,137 (67.0%) <0.001 0 (0%)
AIS Thorax Max 2.0 (1.8) 2.1 (1.7) 2.1 (1.7) <0.001 0 (0%)
AIS Spine Injury 4191 (37.6%) 30,604 (37.5%) 34,795 (37.5%) 0.80 0 (0%)
AIS Spine Max 1.0 (1.4) 0.8 (1.2) 0.8 (1.2) <0.001 0 (0%)
AIS Upper Extremity Injury 4452 (39.9%) 35,011 (42.9%) 39,463 (42.5%) <0.001 0 (0%)
AIS Upper Extremity Max 0.8 (1.0) 0.8 (1.0) 0.8 (1.0) 0.003 0 (0%)
AIS Lower Extremity Injury 5859 (52.6%) 47,513 (58.2%) 53,372 (57.5%) <0.001 0 (0%)
AIS Lower Extremity Max 1.4 (1.5) 1.5 (1.5) 1.5 (1.5) <0.001 0 (0%)
Trauma Center Level 0.01 30,233 (32.6%)
Level I Trauma Center 5487 (73.9%) 39,927 (72.4%) 45,414 (72.6%)
Level II Trauma Center 1815 (24.4%) 14,377 (26.1%) 16,192 (25.9%)
Level III Trauma Center 123 (1.7%) 838 (1.5%) 961 (1.5%)
ED Disposition <0.001 1591 (1.7%)
Non-ICU Admission 1564 (14.4%) 5295 (6.6%) 6859 (7.5%)
ICU Admission 3655 (33.7%) 15,804 (19.7%) 19,459 (21.3%)
Operating Room 5617 (51.8%) 59,274 (73.7%) 64,891 (71.1%)
Hospital Discharge Disposition <0.001 2224 (2.4%)
Home 2809 (25.8%) 38,007 (47.7%) 40,816 (45.1%)
Inpatient Rehab 1606 (14.8%) 9073 (11.4%) 10,679 (11.8%)
Nursing Facility 1287 (11.8%) 5675 (7.1%) 6962 (7.7%)
Short/Long-Term Care Facility 1266 (11.6%) 8385 (10.5%) 9651 (10.7%)
Hospice 140 (1.3%) 292 (0.4%) 432 (0.5%)
Deceased 3468 (31.9%) 16,708 (21.0%) 20,176 (22.3%)
Mental Health Facility/Jail 294 (2.7%) 1566 (2.0%) 1860 (2.1%)
Hospital Complications
DVT 706 (8.3%) 4107 (7.0%) 4813 (7.2%) <0.001 25,628 (27.6%)
Pulmonary Embolism 280 (3.3%) 1699 (2.9%) 1979 (2.9%) 0.04 25,628 (27.6%)
Stroke 179 (2.1%) 872 (1.5%) 1051 (1.6%) <0.001 25,628 (27.6%)
Sepsis 853 (10.1%) 3306 (5.6%) 4159 (6.2%) <0.001 25,628 (27.6%)
Ventilator associated Pneumonia 1673 (19.7%) 8441 (14.4%) 10,114 (15.1%) <0.001 25,628 (27.6%)
Unplanned ICU Admission 633 (10.1%) 2347 (5.3%) 2980 (5.9%) <0.001 42,308 (45.6%)
Intubation 784 (9.2%) 2716 (4.6%) 3500 (5.2%) <0.001 25,628 (27.6%)
Cardiac Arrest 1079 (12.7%) 5690 (9.7%) 6769 (10.1%) <0.001 25,628 (27.6%)
Deep SSI 176 (2.1%) 1044 (1.8%) 1220 (1.8%) 0.04 25,628 (27.6%)
Superficial Incisional SSI 179 (2.1%) 1229 (2.1%) 1408 (2.1%) 0.91 25,628 (27.6%)
Pressure Ulcer 610 (7.2%) 2547 (4.3%) 3157 (4.7%) <0.001 25,628 (27.6%)
CAUTI 397 (6.4%) 2058 (4.7%) 2455 (4.9%) <0.001 42,308 (45.6%)
CLABSI 71 (1.1%) 368 (0.8%) 439 (0.9%) 0.02 42,308 (45.6%)
AKI 902 (10.6%) 4402 (7.5%) 5304 (7.9%) <0.001 25,628 (27.6%)
(continued on next page)
Table 1 (continued )
N = 11,145 (12.0%) N = 81,655 (88.0%) N = 92,800
ICU LOS (days) 14.3 (15.3) 10.7 (12.4) 11.2 (12.8) <0.001 20,795 (22.4%)
Hospital LOS (days) 20.6 (22.9) 16.0 (18.3) 16.6 (19.0) <0.001 580 (0.6%)
Deceased LOS (days) 9.0 (15.5) 5.8 (12.0) 6.3 (12.7) <0.001 415 (0.4%)
Mortality 3468 (31.1%) 16,708 (20.5%) 20,176 (21.7%) <0.001 0 (0%)
Data presented as mean (SD), median (IQR) or n (%).

Abbreviations: MCC: Motorcycle collision; MVC: Motor vehicle collision; MV: Motor vehicle; CCI: Charlson comorbidity index; SBP: Systolic blood pressure; bpm: beats
per minute; RR: Respiratory rate; bpm*:breaths per minute; GCS: Glasgow coma scale; CT: Computed tomography; ISS: Injury severity score; AIS: Abbreviated Injury
Scale; ED: Emergency department; ICU: Intensive care unit, DVT: Deep vein thrombosis; SSI: Surgical site infection; CAUTI: Catheter-associated urinary tract infection;
CLABSI: Central line-associated bloodstream infection; AKI: Acute kidney injury; LOS: Length of stay.
9.7%, p < 0.001), and AKI (10.6% vs. 7.5%, p < 0.001), were signifi negative laparotomy compared to patients deceased following positive
cantly higher in the negative laparotomy cohort. The rate of superficial laparotomy (9.0 vs. 5.8 days, p < 0.001). Crude mortality was signifi
incisional SSI was the same between the two cohorts (2.1% vs. 2.1%, p = cantly higher in negative laparotomy patients than those with abdom
0.91). However, the rate of deep SSI was significantly higher in patients inal injuries during laparotomy (31.1% vs. 20.5%, p < 0.001; Table 1).
that underwent a negative laparotomy (2.1% vs. 1.8%, p = 0.04; Upon modified Poisson regression analysis, patients who underwent
Table 1). negative laparotomy had a 33% higher risk of mortality (RR 1.33, 95%
Patients that underwent a negative laparotomy were less likely to CI 1.28–1.37, P < 0.001), compared to positive laparotomy patients,
discharge home (25.8% vs. 47.7%, p < 0.001) and had longer lengths of after adjusting for age, sex, SBP, pulse rate, total initial GCS, modified
hospital stay (20.6 vs. 16.0 days, p < 0.001) than positive laparotomy Charlson comorbidity index, and ISS (Table 4). Subset analysis was
patients. Hospital length of stay was longer in patients that underwent performed on patients that underwent CT abdomen/pelvis imaging and
Fig. 1. Flow diagram of patient selection and exclusion criteria for primary and subset analysis.
Abbreviations: NTDB: National Trauma Data Bank; CT: Computed tomography.
Table 2 95% CI 1.29 – 1.46, p < 0.001) compared to those positive for abdominal
Rates of laparotomies, positive or negative for abdominal injury, in adults with injury, controlling for the same covariates (Table 4).
blunt traumatic injury by year of admission.
Abdominal injury Discussion
Year of admit Negative laparotomy Positive laparotomy Total
2007 706 (13.3%) 4622 (86.7%) 5328 Our study of adult patients sustaining blunt trauma found the mean
2008 777 (12.9%) 5269 (87.1%) 6046 yearly negative laparotomy rate to be 12.0% from 2007 to 2019. Pa
2009 735 (12.4%) 5188 (87.6%) 5923 tients who underwent negative laparotomy were more likely to have
2010 775 (12.6%) 5396 (87.4%) 6171
2011 840 (12.6%) 5853 (87.4%) 6693
significantly lower injury severity and better initial vital signs on eval
2012 825 (11.5%) 6333 (88.5%) 7158 uation than those with positive laparotomies, yet were found to have
2013 879 (12.4%) 6222 (87.6%) 7101 higher rates of nearly all hospital complications, longer lengths of hos
2014 878 (12.3%) 6249 (87.7%) 7127 pital stay, and a 33% higher mortality risk than those with positive
2015 979 (12.3%) 7012 (87.7%) 7991
laparotomies. However, patients that underwent CT abdomen/pelvis
2016 816 (11.7%) 6150 (88.3%) 6966
2017 981 (11.3%) 7666 (88.7%) 8647 imaging had a marginally lower rate of negative laparotomy (11.1%) but
2018 971 (11.3%) 7620 (88.7%) 8591 maintained a 37% higher mortality risk despite diagnostic imaging than
2019 983 (10.9%) 8075 (89.1%) 9058 those with positive laparotomies.
Total 11,145 (12.0%) 81,655 (88.0%) 92,800 Our study demonstrates a higher negative laparotomy rate than the
recently published studies, with a significantly higher mortality risk.
laparotomy (n = 45,654; Fig. 1). Negative laparotomy rates were lower However, our analysis utilizes an extensive national database focusing
in this subset of patients at 11.1% (n = 5089) comparatively. Patients solely on blunt traumatic injuries. Most comparative studies combine
that underwent negative laparotomy were older on average (50.3 vs. penetrating and blunt traumatic injuries using single institution data.
41.6 years old, p < 0.001), more often male (69.2% vs. 67.6%, p = Haan et al. conducted a retrospective review of 820 patients that un
0.023), with more comorbidities (modified CCI 0.5 vs. 0.2, p < 0.001). derwent laparotomy for trauma from 1998 to 2001, reporting a com
Similarly, vital signs were better in the patients that underwent negative bined 6% negative and non-therapeutic laparotomy rate [19]. The study
laparotomy (SBP 124.7 vs. 116.5 mmHg; Pulse rate 97.6 vs. 101.5 bpm, comprised 24% blunt traumatic injury and a mean ISS of 9. The most
p < 0.001), and median ISS was lower in this cohort (19.5 (10 – 29) vs. common indication for laparotomy was CT scan findings questionable
25 (17 – 35), p < 0.001) when compared to patients that were found to for hollow viscus or diaphragmatic injury (36%), followed by peritonitis
have abdominal injuries upon laparotomy. The significant increase in (18%). The overall mortality in the study was 4% and unrelated to the
crude mortality persisted for those who underwent negative laparotomy non-therapeutic laparotomy, reporting a 12% complication rate within
and CT abdomen/pelvis imaging compared to patients with positive the cohort [19].
laparotomies (22.6% vs. 14.1%, p < 0.001; Table 5). In 2010, a single institution study by Crookes et al. of 599 patients
When both laparotomy outcomes analyzed patients in conjunction with blunt abdominal trauma, a 4.7% negative laparotomy rate was
with CT abdomen/pelvis imaging, patients that underwent negative reported from 1996 to 2007 [7]. Overall, the mortality rate in the study
laparotomy demonstrated a 37% increased risk of mortality (RR 1.37, was 7.1%, with 0.8% attributed to patients that had undergone negative
laparotomy [7]. In 2012, Schnüriger et al. reviewed 1871 laparotomies
Fig. 2. Concurrent AIS systems injured in adults with blunt traumatic injury, stratified by presence or absence of abdominal injury.
Abbreviations: AIS: Abbreviated injury scale.
Table 3
Rates of diagnostic imaging in adults with blunt traumatic injuries who underwent laparotomy by year of admission, stratified by presence or absence of abdominal
injury.
Negative laparotomy Positive laparotomy All laparotomies
Year of CT abdomen/ Abdominal Total CT abdomen/ Abdominal Total CT abdomen/ Abdominal Total
admit Pelvis ultrasound Pelvis ultrasound Pelvis ultrasound
2007 197 (27.9%) 85 (12.0%) 706 1334 (25.0%) 736 (17.9%) 4622 1531 (28.7%) 821 (15.4%) 5328
2008 210 (27.0%) 93 (12.0%) 777 1521 (25.2%) 826 (15.5%) 5269 1731 (28.6%) 919 (15.2%) 6046
2009 222 (30.2%) 132 (18.0%) 735 1479 (25.0%) 817 (21.0%) 5188 1701 (28.7%) 949 (16.0%) 5923
2010 252 (32.5%) 139 (17.9%) 775 1879 (30.4%) 1088 (22.2%) 5396 2131 (34.5%) 1227 (19.9%) 6171
2011 321 (38.2%) 154 (18.3%) 840 2210 (33.0%) 1198 (26.4%) 5853 2531 (37.8%) 1352 (20.2%) 6693
2012 318 (38.5%) 162 (19.6%) 825 2517 (35.2%) 1543 (27.8%) 6333 2835 (39.6%) 1705 (23.8%) 7158
2013 352 (40.0%) 188 (21.4%) 879 2832 (39.9%) 1758 (33.8%) 6222 3184 (44.8%) 1946 (27.4%) 7101
2014 403 (45.9%) 202 (23.0%) 878 3290 (46.2%) 2102 (40.0%) 6249 3693 (51.8%) 2304 (32.3%) 7127
2015 542 (55.4%) 284 (29.0%) 979 4161 (52.1%) 2502 (29.8%) 7012 4703 (58.9%) 2786 (34.9%) 7991
2016 411 (50.4%) 219 (26.8%) 816 3388 (48.6%) 2092 (46.1%) 6150 3799 (54.5%) 2311 (33.2%) 6966
2017 581 (59.2%) 302 (30.8%) 981 5026 (58.1%) 2836 (37.8%) 7666 5607 (64.8%) 3138 (36.3%) 8647
2018 615 (63.3%) 296 (30.5%) 971 5264 (61.3%) 2895 (40.6%) 7620 5879 (68.4%) 3191 (37.1%) 8591
2019 665 (67.7%) 321 (32.7%) 983 5664 (62.5%) 3092 (38.3%) 8075 6329 (69.9%) 3413 (37.7%) 9058
Total 5089 (45.7%) 2577 (23.1%) 11,145 40,565 (43.7%) 23,485 (28.8%) 81,655 45,654 (49.2%) 26,062 (28.1%) 92,800
Data presented as n (%).

Abbreviations: CT: Computed tomography.
morbidity and mortality [7,13]. Several studies show that even when
Table 4
controlling for injury severity, increased comorbidities are associated
Relative risk of in-hospital mortality of all adults with blunt traumatic injury,
with significantly higher morbidity and mortality. Furthermore, as
who underwent laparotomy, in relation to the presence of abdominal injury (n =
92,800) and subset analysis of the patients that underwent additional CT shown in our study, patients with negative laparotomies had more
abdomen/pelvis imaging (n = 45,654). preexisting comorbidities and were older. This association strongly il
lustrates that increasing comorbidities may serve as a marker of lower
Risk 95% CI p-value
ratio
physiologic reserve and be an independent variable for increased mor
tality [20–22]. Additionally, patients that underwent negative laparot
Abdominal Injury- All Patients (ref: Positive
omy had higher rates of nearly all hospital complications evaluated,
Laparotomy)*
Negative Laparotomy 1.33 1.28 – <0.001 particularly sepsis, VAP, intubation, cardiac arrest, AKI, and deep SSI,
1.37 potentially indicating the detrimental impact of a negative laparotomy
Abdominal Injury- Patients with CT on morbidity in this population.
Abdomen/Pelvis Imaging (ref: Positive
Negative laparotomies are bound to occur in unstable patients, and
Laparotomy)*
Negative Laparotomy 1.37 1.29 - <0.001 the best clinical judgment must be used when deciding to operate on this
1.46 population. However, our study shows negative laparotomy patients
had more stable vital signs than those with abdominal injuries upon
Abbreviations: CT: Computed tomography; CI: Confidence Interval; ref: refer
exploration. Approximately 54% of patients that underwent negative
ence group.
*
Adjusted for age, sex, modified Charlson comorbidity index, Systolic blood laparotomy in this study did not undergo CT diagnostic imaging, indi
pressure, pulse rate, total initial Glasgow coma scale, and Injury severity score. cating an area of potential improvement in this subset of patients. Of
further concern, 46% of negative laparotomy patients did undergo CT
performed at Los Angeles County, a Level 1 trauma center, over six years imaging. Computed tomography is less sensitive in diagnosing hollow
[14]. Their study comprised 41.1% blunt traumatic injury and an viscous injuries [4,10]. Thus, in patients with questionable or equivocal
average ISS of 12 (SD 11.6). They reported a 3.9% negative laparotomy. imaging findings, there is a role for observation, serial abdominal exams,
Indication for surgery in these patients was most frequently peritonitis and diagnostic laparoscopy in the setting of hemodynamic stability.
(54.8%), transient hypotension (28.8%), and suspicious CT scan find These may have the potential to prevent negative laparotomies. Lin et al.
ings (27.4%). The complication rate after negative laparotomy was evaluated the use of laparoscopy for potential blunt hollow viscus and
14.5%, with 10.1% directly related to the operation. The crude mortality mesenteric injuries in 2015, reporting an 11.9% non-therapeutic lapa
rate in this cohort was 5.4%. However, none of the deaths were related roscopy rate, an 8.5% conversion to laparotomy rate, with no missed
to laparotomy [14]. injuries and no deaths within the cohort that underwent laparoscopy,
Our study is the first to our knowledge to utilize a sizeable national indicating laparoscopy has a potential role in this population to decrease
trauma database to evaluate negative laparotomy rates, associated pa negative laparotomies [10].
tient characteristics, and subsequent effects on morbidity and mortality Utilizing a large national administrative dataset has inherent limi
in primarily blunt traumatic injuries in the United States. Given the tations. The quality of data relies upon the collection and reporting
major differences in injury patterns and outcomes between penetrating processes of each reporting trauma center and the quantity of missing
and blunt traumatic injuries, it is essential to evaluate blunt injuries data. Despite strict data coding standards, some data variation will be
separately. Improved understanding of current rates of negative lapa present. Although the NTDB has over 900 participating trauma centers
rotomies, characteristics of these patients, and evaluation methods are nationwide, some smaller, rural hospitals may not participate. Thus, this
important as trauma surgeons strive to improve mortality rates and dataset is less representative of outcomes and patient characteristics in
decrease morbidity in this population. those settings. Data regarding the timing of operations and procedures,
The reasons for the increased morbidity and mortality noted in pa such as CT imaging and ultrasound regarding admission, are
tients with negative laparotomy are multifactorial. Firstly, blunt trauma unavailable.
is diffuse and may inflict other distracting extra-abdominal injuries, Further, data regarding the cause of death and timing of mortality in
such as traumatic brain and thoracic injuries. Delays in recognizing and relation to procedures are unavailable. This lack of data limits the ability
treating these extra-abdominal injuries may translate into increased to evaluate these characteristics as potential points for intervention.
Table 5
Demographic and clinical characteristics of all adults (≥16 years old) who underwent laparotomy and CT Abdomen/Pelvis for blunt traumatic injury.
N = 5089 (11.1%) N = 40,565 (88.9%) N = 45,654
Age (years) 50.3 (20.0) 41.6 (18.0) 42.6 (18.4) <0.001 314 (0.7%)
Sex (Male) 3517 (69.2%) 27,395 (67.6%) 30,912 (67.8%) 0.02 68 (0.1%)
Race/Ethnicity <0.001 0 (0%)
White Non-Hispanic 3312 (65.1%) 26,649 (65.7%) 29,961 (65.6%)
White Hispanic 488 (9.6%) 5391 (13.3%) 5879 (12.9%)
Black 692 (13.6%) 4964 (12.2%) 5656 (12.4%)
Asian 87 (1.7%) 927 (2.3%) 1014 (2.2%)
Other 498 (9.8%) 2542 (6.3%) 3040 (6.7%)
Mechanism of Blunt Injury <0.001 0 (0%)
Fall 1331 (26.2%) 3777 (9.3%) 5108 (11.2%)
MCC 499 (9.8%) 4530 (11.2%) 5029 (11.0%)
MVC 2235 (43.9%) 23,712 (58.5%) 25,947 (56.8%)
Pedestrian vs. MV/Other 500 (9.8%) 3875 (9.6%) 4375 (9.6%)
Bicyclist vs. MV/Other 115 (2.3%) 774 (1.9%) 889 (1.9%)
Other 409 (8.0%) 3897 (9.6%) 3996 (9.5%)
Modified CCI 0.5 (1.0) 0.2 (0.7) 0.2 (0.7) <0.001 0 (0%)
Arrival Vital Signs
SBP (mmHg) 124.7 (34.6) 116.5 (30.4) 117.4 (31.0) <0.001 773 (1.7%)
Pulse Rate (bpm) 97.6 (27.1) 101.5 (26.4) 101.0 (26.5) <0.001 703 (1.5%)
RR (bpm*) 19.1 (7.8) 20.1 (7.8) 20.0 (7.8) <0.001 2039 (4.5%)
Shock Index 0.9 (1.2) 0.9 (1.0) 0.9 (1.0) <0.001 1418 (3.1%)
Total Initial GCS 10.9 (5.2) 12.0 (4.7) 11.9 (4.8) <0.001 1065 (2.3%)
Abdominal Ultrasound 1711 (33.6%) 16,218 (40.0%) 17,929 (39.3%) <0.001 0 (0%)
ISS 19.5 (10 – 29) 25 (17 – 35 25 (16.0 – 34) <0.001 277 (0.6%)
Total AIS Systems Injured 3.1 (1.7) 4.2 (1.8) 4.1 (1.8) <0.001 0 (0%)
AIS Abdomen Max 0.0 (0.0) 3.2 (1.1) 2.9 (1.4) <0.001 0 (0%)
AIS by Systems
AIS Head Injury 2751 (54.1%) 18,128 (44.7%) 20,879 (45.7%) <0.001 0 (0%)
AIS Head Max 1.8 (1.9) 1.3 (1.7) 1.3 (1.7) <0.001 0 (0%)
AIS Face Injury 1918 (37.7%) 15,066 (37.1%) 16,984 (37.2%) 0.45 0 (0%)
AIS Face Max 0.6 (0.8) 0.5 (0.8) 0.5 (0.8) <0.001 0 (0%)
AIS Neck Injury 302 (5.9%) 2187 (5.4%) 2489 (5.5%) 0.11 0 (0%)
AIS Neck Max 0.1 (0.6) 0.1 (0.5) 0.1 (0.5) 0.002 0 (0%)
AIS Thorax Injury 3068 (60.3%) 28,619 (70.6%) 31,687 (69.4%) <0.001 0 (0%)
AIS Thorax Max 1.9 (1.8) 2.2 (1.7) 2.2 (1.7) <0.001 0 (0%)
AIS Spine Injury 2093 (41.1%) 17,108 (42.2%) 19,201 (42.1%) 0.15 0 (0%)
AIS Spine Max 1.0 (1.4) 0.9 (1.2) 0.9 (1.2) <0.001 0 (0%)
AIS Upper Extremity Injury 2181 (42.9%) 18,859 (46.5%) 21,040 (46.1%) <0.001 0 (0%)
AIS Upper Extremity Max 0.8 (1.0) 0.8 (1.0) 0.8 (1.0) 0.002 0 (0%)
AIS Lower Extremity Injury 2716 (53.4%) 24,941 (61.5%) 27,657 (60.6%) <0.001 0 (0%)
AIS Lower Extremity Max 1.4 (1.4) 1.6 (1.5) 1.5 (1.5) <0.001 0 (0%)
ED Disposition <0.001 552 (1.2%)
Non-ICU Admission 745 (15.0%) 2804 (7.0%) 3549 (7.9%)
ICU Admission 2036 (41.1%) 9075 (22.6%) 11,111 (24.6%)
Operating Room 2177 (43.9%) 28,265 (70.4%) 30,442 (67.5%)
Hospital Complications
DVT 380 (9.4%) 2426 (7.9%) 2806 (8.0%) 0.001 10,758 (23.6%)
Pulmonary Embolism 157 (3.9%) 1004 (3.3%) 1161 (3.3%) 0.04 10,758 (23.6%)
Stroke 100 (2.5%) 523 (1.7%) 623 (1.8%) <0.001 10,758 (23.6%)
Sepsis 449 (11.0%) 1752 (5.7%) 2201 (6.3%) <0.001 10,758 (23.6%)
Ventilator associated Pneumonia 844 (20.8%) 4356 (14.1%) 5200 (14.9%) <0.001 10,758 (23.6%)
Unplanned ICU Admission 404 (12.0%) 1681 (6.4%) 2085 (7.0%) <0.001 10,758 (23.6%)
Intubation 473 (11.6%) 1803 (5.8%) 2276 (6.5%) <0.001 10,758 (23.6%)
Cardiac Arrest 372 (9.2%) 2134 (6.9%) 2506 (7.2%) <0.001 10,758 (23.6%)
Deep SSI 113 (2.8%) 611 (2.0%) 724 (2.1%) <0.001 10,758 (23.6%)
Superficial Incisional SSI 92 (2.3%) 749 (2.4%) 841 (2.4%) 0.52 10,758 (23.6%)
Pressure Ulcer 338 (8.3%) 1549 (5.0%) 1887 (5.4%) <0.001 10,758 (23.6%)
CAUTI 221 (6.5%) 1176 (4.5%) 1397 (4.7%) <0.001 16,064 (35.2%)
CLABSI 35 (1.0%) 218 (0.8%) 253 (0.9%) 0.22 16,064 (35.2%)
AKI 443 (10.9%) 2446 (7.9%) 2889 (8.3%) <0.001 10,758 (23.6%)
Hospital LOS Overall (days) 23.0 (22.8) 17.5 (18.0) 18.1 (18.7) <0.001 255 (0.6%)
Deceased LOS (days) 12.6 (17.6) 8.3 (14.2) 9.0 (14.9) <0.001 157 (0.3%)
Mortality 1152 (22.6%) 5720 (14.1%) 6872 (15.1%) <0.001 0 (0%)
Data presented as mean (SD), median (IQR) or n (%).

Abbreviations: CT: Computed tomography; MCC: Motorcycle collision; MVC: Motor vehicle collision; MV: Motor vehicle; CCI: Charlson comorbidity index; SBP:
Systolic blood pressure; bpm: beats per minute; RR: Respiratory rate; bpm*:breaths per minute; GCS: Glasgow coma scale; ED: Emergency department; ISS: Injury
severity score; AIS: Abbreviated Injury Scale; ICU: Intensive care unit, DVT: Deep vein thrombosis; SSI: Surgical site infection; CAUTI: Catheter-associated urinary tract
infection; CLABSI: Central line-associated bloodstream infection; AKI: Acute kidney injury; LOS: Length of stay.
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The authors whose names are listed immediately below certify that 41(3):509–13. https://doi.org/10.1097/00005373-199609000-00021.
[16] About NTDB. https://www.facs.org/quality-programs/trauma/tqp/center-
they have NO affiliations with or involvement in any organization or programs/ntdb/about.
entity with any financial interest (such as honoraria; educational grants; [17] Knowlin L, Stanford L, Moore D, Cairns B, Charles A. The measured effect
participation in speakers’ bureaus; membership, employment, consul magnitude of co-morbidities on burn injury mortality. Burns 2016;42(7):1433.
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tancies, stock ownership, or other equity interest; and expert testimony [18] StataCorp.. Stata statistical software: release 17. College Station, TX: StataCorp
or patent-licensing arrangements), or non-financial interest (such as LLC; 2021.
personal or professional relationships, affiliations, knowledge or beliefs) [19] Haan J, Kole K, Brunetti A, Kramer M, Scalea TM. Nontherapeutic laparotomies
revisited. Am Surg 2003;69(7):562–5.
in the subject matter or materials discussed in this manuscript. [20] Elkbuli A, Yaras R, Elghoroury A, Boneva D, Hai S. Comorbidities in trauma injury
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This work was supported by the National Institute of Health under J Emerg Trauma Shock 2017;10(3):146–50. https://doi.org/10.4103/JETS.JETS_
award number: 5T32GM008450–23 (Atkins) 62_16.
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Injury 54 (2023) 110895
Injury
Hybrid emergency operating room for life-saving combined cranial surgery and extra-cranial
surgery or procedure in severe trauma patients: A promising technical alternative
Dear Editor, resuscitative endovascular balloon occlusion of the aorta (REBOA); their
I read with interest the work by Jang and colleagues [1] which aimed mean ISS was 63. The mean Marshall class on the brain CT scan was 5.7
to assess the efficacy of the workflow for the transfer of trauma patients out of 6, and 16 patients (80%) presented an extra-axial hematoma
in a specific hybrid emergency operating room (HR) compared to a requiring surgical evacuation. Eleven patients (55%) underwent
classic operating room (OR). decompressive craniectomy (DC) whereas nine patients (45%) under
Although there are clear guidelines for the emergency management went craniotomy (Co), whether it was for hematoma evacuation (n=4),
of patients suffering from isolated severe traumatic brain injury (STBI), exploratory burr holes (n=4), or external ventricular drainage (n=1).
[2] and for severe trauma patients (STP) with concomitant STBI, [3] no Twelve patients (60%) underwent simultaneous extra-cranial surgery,
such guidelines exist in case of associated cranial and extracranial in while 13 patients (65%) underwent concomitant arterial or venous
juries requiring emergency surgery. It is currently recommended to stop embolization. Ten patients (50%) suffered from profound intraoperative
the extra-cranial bleeding first, and that the neurosurgical emergency hemorrhagic shock. Eleven patients survived (55%) and nine patients
should dealt with right afterwards. [3,4] This strategy reduces the deceased (45%). The mean Glasgow Outcome Scale (GOS) was 2.65
exsanguination-related mortality during the first 24 h following trauma. (±1.8) out of 5. Notably, the GOS was 3.36 (±1.7) in the DC group
[5] compared to 2.11 (±1.5) in the Co group.
To date though, there are no guidelines for the acute care of STP
suffering from combined life-threatening cranial and extra-cranial Damage-control cranial surgery
traumatic lesions. [6] Scarce evidence points the benefits of managing
such patients in a dedicated HR, addressing the issue of the preventable This patient series illustrates two recent paradigm shifts in the
neurological morbidity by allowing to reduce the time spent with management of STP.
intracranial hypertension and to hasten the admission to the intensive First, DC has become the gold-standard procedure for surgical
care unit. [7] Nevertheless, given the exceptional occurrence of these management of STBI in the young: [14–16] it allows to evacuate any
patients accounting for 0.008% of trauma [1] and 2.6% of patients intracranial hemorrhage and it provides long-term control of intracra
requiring emergency cranial surgery, [8] there is a need for a specific nial hypertension. [17] These assertions corroborate the findings of this
trauma pathway and available on-duty surgical and interventional series, where patients who benefited from DC harbored a better neuro
teams. logical functional outcome compared to the Co group [1,8,11–13].
Emergence of combined surgical procedures: proof-of-concept Damage-control extra-cranial procedures
Combined surgery for STP finds its roots in strained resources mobile Second, the management of extra-cranial bleeding has shifted from
field surgical units deployed overseas, where military surgeons had to damage-control surgery [18] to endovascular embolization in the early
manage multiple-shrapnel injured patients. [9] This strategy has been 2000s. [10] This is clearly illustrated here, where STP managed in a
adapted later on for STP in the civilian setting [10]. Nevertheless, there classic OR (2007–2021) underwent mostly damage-control laparotomy,
is only scarce practical evidence concerning the combined management [8] whereas STP managed in HR (2011–2018) benefited from endo
of cranial and extracranial life-threatening traumatic injuries. [1,8, vascular embolization. [12] By allowing a more selective treatment of an
11–13] active bleeding, endovascular embolization reduces preventable surgi
cal morbidity such as the complications of asplenia. Table 1
Combined cranial surgery and extra-cranial surgery or
procedure: scoping review Increased risk of exsanguination during combined surgery
A scoping review conducted on Medline database yielded five recent The trauma leader must keep in mind that STP undergoing combined
articles for a total of 20 STP. [1,8,11–13] The mean age was 42.1 (±18) procedures are particularly exposed to massive bleeding. In our insti
years-old and the male to-female ratio was 1:1. The mean Injury Severity tution, six out of eight patients (75%) presented with coagulopathy, and
Score (ISS) was 48.2 (±13.7), and the mean GCS score was 6.3 (±3.2) seven patients (88%) benefited from massive transfusion protocol. [8]
upon admission. Three patients (15%) underwent the placement of a What is more, three patients from the whole cohort (15%) required
Jang JY et al. The need for a rapid transfer to a hybrid operating theater: Do we lose benefit with poor efficiency? Injury 2020;51:1987–93.
GOS REBOA. [1,8,11–13] Even though STP managed in HR may benefit from
≥2 faster hemostasis compared to those managed in OR [19], they usually
1
1
2
3
1
1
4
4
5
1
5
5
5
5
1
present more serious ISS (29 versus 21) [1] and they are therefore at
higher risk of intraoperative exsanguination. This risk can be amplified
Shock in OR
by intraoperative blood loss during the large surgical approach of DC,

[8] leading to profound intraoperative hemorrhagic shock in up to 50%
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
of the cases. [1,8,11–13]
–
–
–
–
–
–
Emb intercostal, splenic, internal iliac A
Paradigm shift from reduction of mortality to improvement of
neurological functional outcome
Emb intercostal, internal iliac A
Emb hepatic, internal iliac A
One drawback to the use of the HR is the longer delay taken to bring
Extra-cranial intervention
the patient in compared to classic OR (87 min, IQR 67–97 versus 60 min,
Emb renal A, portal V
Emb internal iliac A

IQR 50–88). [1] From an organizational point of view, there is a need for
carotid artery
Emb intercostal A
both a dedicated trauma team and an interventional radiology team who
hepatic A
splenic A should be specifically trained on a daily setting in this HR. [1] From a
pelvis
Patients undergoing combined cranial and extra-cranial surgery for concomitant cranial and extra-cranial life-threatening trauma lesions: Medline literature review.
practical point of view, the patient must bypass the classic path to the
Emb
Emb
Emb
Emb
– emergency room directly to the HR in order to optimize delay to surgery.
–
–
–
–
–
–
[7,8,12]
This being said, operative duration [10] and delay from HR admis
EF femur, tibia, wrist. Leg debridement sion to hemostasis (p=0.005) appear shorter in HR compared to classic
Abdominal packing, splenectomy

OR. [19] These considerations may overcome the inconvenience of a
longer patient transfer. Faster admission to the intensive care unit allows
earlier treatment of the lethal triad, thus reducing secondary brain
injury. [20]
Extra-cranial surgery
Perihepatic packing
Abdominal packing
Abdominal packing
These elements indicate the need for implementation of a specific

tPNO drainage
workflow for STP requiring combined procedure in HR after full-body

Splenectomy
Splenectomy
Slenectomy
CT scan. [1,21] Last, the management in HR may reduce the time

spent with intracranial hypertension, improving the neurological
PPP
PPP
PPP
PPP
PPP
outcome. [6,7,22]
–
–
–
Cranial surgery
Conclusion
ICP, EVD
DC, EVD
ICP, BH
ICP, BH
ICP, BH
ICP, BH
ICP, DC
ICP, DC
ICP, DC
ICP, Co
ICP, Co
ICP, Co
Sometimes, STP with concomitant life-threatening cranial and extra-

DC
DC
DC
DC
DC
DC
DC
cranial injuries can be admitted to level-1 trauma centers. Combined

Co
cranial surgery and extra-cranial procedure is an emerging concept

REBOA
which reduces both the time spent with intracranial hypertension and
Yes
Yes
Yes
the admission delay to the intensive care unit. Given the difficulty in
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
coordinating two different surgical and/or interventional teams, Jang

ISS
highlights the need for the implementation of a specific trauma work

57
59
66
66
45
50
57
66
45
29
51
50
22
48
34
27
41
41
66
–
flow for patient transfer to the HR, and for a daily use of this HR by
6 (EDH, ASH, diffuse injury)
dedicated trauma teams in order to improve the outcome of the rare

patients requiring combined surgery.
6 (EDH, contusion)
6 (ASH, contusion)
6 (ASH, contusion)
6 (ASH, contusion)
5 (DSF, contusion)
Marshall CT class
6 (non-evacuated
6 (non-evacuated
6 (non-evacuated
6 (non-evacuated
6 (non-evacuated
6 (non-evacuated
4 (diffuse injury)
3 (diffuse injury)

hematoma)
hematoma)
hematoma)
hematoma)
hematoma)
hematoma)
None.
6 (EDH)
6 (ASH)
6 (ASH)
6 (ASH)
6 (ASH)
–
References
GCS
13
11
10
6
3
3
8
9
7
3
7
3
–
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12 m fall
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Ecole du Val-de-Grâce, French Military Health Service Academy, 1 place
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Injury 54 (2023) 110896
Injury
Predictors of postoperative complications of tension band wiring

techniques for patella fracture: A retrospective multicenter (TRON
group) study
Hiroki Oyama a, Yasuhiko Takegami a, *, Katsuhiro Tokutake b, Fuminori Murase a,
Oki Arakawa a, Takeshi Oguchi c, Shiro Imagama a
a
Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
b
Department of Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
c
Department of Orthopaedic Surgery, Anjo Kosei Hospital, Anjo, Japan
Keywords: Objective: The relationship between postoperative complications and operative techniques of tension band wiring
Patella fracture (TBW) is not well studied. We aimed to evaluate the incidence of implant breakage, implant migration, and loss
Complications of reduction in patellar fractures treated with TBW and identify radiographic factors associated with these
Migration
postoperative complications.
Implant breakage
Methods: This multicenter (named, TRON group) retrospective study included 224 patients who underwent open
reduction and internal fixation of patella fractures using TBW from January 2016 to December 2020. Radio
graphic findings were evaluated by experienced orthopedic surgeons, and radiographic outcomes were assessed
for K-wire migration, implant breakage, and loss of reduction. Logistic regression analysis was performed to
identify radiographic factors associated with postoperative complications.
Results: Implant migration occurred in 44 cases (19.6%), with bending of a single K-wire end identified as a
significant risk factor (OR: 12.90; 95% CI: 4.99–33.30; P < 0.001). Implant breakage occurred in 43 cases
(19.2%), with a large patella-tension band ratio (OR: 291.0; 95% CI: 19.60–4330; P < 0.001) and a wide distance
between K-wires (OR: 1.15; 95% CI: 1.060–1.250; P = 0.001) identified as significant risk factors. Loss of
reduction occurred in 5 cases (2.0%), but no significant risk factors were identified.
Conclusion: This study highlights the importance of bending both ends of the K-wires and proper placement of the
tension band and K-wires in reducing postoperative complications in patellar fractures treated with TBW. Further
research is needed to better understand the risk factors associated with loss of reduction.
Introduction throughout its course, both superiorly and inferiorly [2]. Although TBW
is considered a relatively easy technique, it is associated with common
Patellar fractures account for approximately 1% of all skeletal frac complications [3], among which are postoperative radiographic com
tures and can disrupt extensor function and damage the articular surface plications such as implant breakage [4], implant migration, and even
of the patellofemoral joint [1]. Tension band wiring (TBW) is one of the loss of reduction [5].
most common surgical fixation methods for patellar fractures as it en However, few studies have thoroughly examined the relationship
ables early motion, improves outcomes, and decreases posttraumatic between postoperative complications and operative techniques,
arthritis. TBW consists of two parallel Kirschner wires (K-wires) inserted including bending of the K-wire ends and the position of the soft wire
perpendicular to the fracture line and one figure-of-8 wire passing and K-wires. Postoperative radiographic complications of TBW can be
anterior to the patella and posterior to the K-wires [2]. According to this particularly challenging because there is limited information on their
principle, the TBW should be placed as close as possible to the bone prevalence and incidence in the literature. Therefore, this multicenter
* Corresponding author at: Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550,
Japan.
E-mail address: takegami@med.nagoya-u.ac.jp (Y. Takegami).
H. Oyama et al. Injury 54 (2023) 110896
retrospective study aimed to evaluate the incidence of implant breakage, Radiographical evaluation
implant migration, and loss of reduction, and to identify radiographic
factors associated with postoperative complications such as implant Radiographic findings were evaluated by an experienced orthopedic
migration, implant breakage, and loss of reduction. surgeon. The AO fracture classification was determined from the pre-
operative fracture X-rays [8]. On the immediately postoperative
Materials and methods X-rays, the length of the patella (a) was measured as shown in Fig. 2A. As
shown in Fig. 2B, the length of the tension band wire was determined by
Patients and methods measuring the medial and lateral K-wire lengths (b), with the larger
length being used, and the distance between the two K lines was
This multicenter retrospective study was approved by the ethics measured proximally and distally (c), also with the larger value being
commission of each participating hospital. All patients provided their used. The thickness of the patella (d) and the maximum distance be
informed consent to participate in the study. Hospitals of the Trauma tween the K-wire and articular surface of the patella (e) were also
Research Group, named TRON, have registered cases of orthopedic measured (Fig. 2C).
trauma surgery in the TRON database annually. The hospitals partici We introduced two novel metrics to evaluate the patellar fixation
pating in the database were all hospitals associated with the Department procedure: the patella-tension band ratio, which is the quotient obtained
of Orthopedic Surgery of our university. At these hospitals in Central by dividing the value of parameter (a) by that of parameter (b), and the
Japan, orthopedic surgeons performed all surgeries. We collected the patella–K-wire ratio, which is the quotient obtained by dividing the
cases of patella fracture from this database that were treated surgically. thickness of the patella (d) by the distance between the K-wire and the
articular surface (e).
Subjects The radiographic outcomes were assessed for K-wire migration,
implant breakage, and loss of reduction. K-wire migration ((g)-(f), in Fig
Fig. 1 shows the patient flowchart. From January 2016 to December 3) was defined as the maximum value of the end of the K-wire migrating
2020, 429 patients underwent open reduction and internal fixation of more than 5 mm within 6 months after the operation, as illustrated in
patella fractures in our 9 hospitals. We excluded the following patients: Fig. 3A and B [9]. Implant breakage was defined as a fracture or
70 patients who underwent other surgical fixations, 8 with open frac breakage of the K-wire or soft wire used during the procedure. Loss of
tures, 19 with high-energy trauma, and 108 who were lost to follow-up reduction was defined as a fracture gap >3 mm, which necessitated
six months after surgery. Ultimately, 224 patients were included in the revision surgery. Two observers (HO and YT) retrospectively and inde
final analysis. pendently evaluated the radiographs. Interobserver reliability was
measured using Fleiss’ kappa value and the internal coefficient corre
lation (ICC), and both were found to be at a good level (Fleiss’ kappa =
Data collection
0.90, 95% confidence interval [CI] = 0.86–0.94, ICC = 0.86, 95% CI =
0.84–0.88).
The data collected from the medical records included patient age,
sex, body mass index (BMI), type of injury (low-energy or high-energy),
smoking status (current/former smoker or not), medical comorbidities, Operative technique and postoperative procedure
open fracture, multiple fractures (vertebral compression fracture, ankle
fracture, femoral fracture), and the American Society of Anesthesiolo All patients were placed in the supine position. We used spinal
gists Performance Status (ASA-PS) classification [6] to evaluate the anesthesia or general anesthesia, and sedation was administered as
patients’ general condition. We obtained the operative time and blood needed. Orthopedic surgeons performed all operative procedures. First,
loss as surgical information. 1.8 mm or 2.0 mm K-wires were inserted into the fracture fragments to
An injury was considered a high-energy trauma if it involved a motor align from the superior to the inferior pole of the patella. A soft wire was
vehicle accident or fall from a height of 1 m or more and as a low-energy then threaded through the ends of the two K-wires to create a longitu
trauma if the fracture resulted from slipping or stumbling at ground level dinal figure-of-eight tension band at the anterior aspect of the patella.
or falling from a height less than 1 m [7]. The upper and/or lower ends of the K-wire were bent into hooks and
Fig. 1. Patient flowchart.
Fig. 2. On the immediate postoperative radiographs, (A) the lateral view of the patella. (a) The length of the patella, (b) the length of the tension band wire, (B) the
anterior-posterior view of the patella. (B) The anterior-posterior view of the patella. (C) (d) the thickness of the patella (e) the maximum distance from the K-wire to
the articular surface of the patella.
Fig. 3. The distance between the end of the K-wire and the tension band wire in the same case. (A) (f) on the immediate postoperative radiograph (B) (g) 6 months
after surgery.
buried in the peripatellar tissue. Reduction of the patellar surface was Jichi Medical University, Tochigi Prefecture) [10].
evaluated intraoperatively with fluoroscopy to ensure satisfactory
reduction. All patients underwent almost the same postoperative man Results
agement protocol in which the patients received a splint, cast, or knee
brace to maintain knee stability. Surgeons allowed full weight bearing This study enrolled 224 patients, including 78 men (34.8%) and 146
postoperatively, and patients started range of motion training (flexion women (65.2%). Their mean age was 66.5 ± 12.4 years old, mean BMI
and extension of the knee joint) after splint removal within the range of was 22.39 ± 3.69 kg/m2, and the median follow-up duration was 13.56
pain that they could tolerate. (range 6–88) months. Among them, 149 fractures (66.5%) were classi
fied as AO/OTA 34-C1, 49 (21.9%) as AO/OTA 34-C2, and 26 (11.6%) as
AO/OTA 34-C3 (Table 1).
Statistical analysis
There were 63 out of 224 patients who underwent additional cerc
lage treatment. The percentage of additional treatment did not show
Univariate and multivariate logistic regression analyses were per
significant differences among the different fracture types (Supplemental
formed to identify radiographic findings as risk factors for the presence
Table 1).
or absence of implant migration, implant breakage, and loss of reduc
tion. We conducted additional analysis, which revealed no statistical
1 Implant migration
differences among the fracture types regarding implant migration,
implant breakage, and loss of reduction.
Implant migration occurred in 44 (19.6%) patients. Table 2 shows
A P value of <0.05 was considered to indicate statistical significance.
the associations between the risk factors and migration as determined by
All statistical analyses were conducted using EZR software (version 1.40,
Table 1 Table 3
Patient demographics (n = 224). Odds ratios of radiographic factors for implant breakage by univariate and
Factor Overall
multivariate analysis.
Variables Univariate analysis Multivariate analysis
Age, years (SD) 66.54 (12.39)
Odds ratio (95% P value Odds ratio (95% P value
Sex, n (%)
CI) CI)
Male 78 (35.0)
Female 145 (65.0) Age 1.030 0.067 1.040 0.327
BMI, kg/m2 (SD) 22.39 (3.69) (0.998–1.06) (1.000–1.070)
Follow-up period, m (SD) 13.56 (7.26) Bent K-wire end, n
Beginning of ROM, weeks (SD) 1.58 (1.40) (%)
ASA-PS, n (%) Both (proximal Reference Reference
1 108 (48.2) and distal)
2 100 (44.6) Single (proximal 0.715 0.337 0.804 0.572
3 16 (7.1) or distal) (0.361–1.420) (0.377–1.720)
Diabetes mellitus, n (%) Patella-tension 78.9 <0.001 291.0 <0.001
Yes 42 (18.8) band ratio (6.730–924.0) (19.60–4330)
No 182 (81.2) Patella–K-wire 4.340 0.343 1.080 0.963
AO classification, n (%) ratio (0.209–90.10) (0.041–28.90)
C1 149 (66.5) Distance between 1.120 0.003 1.150 0.001
C2 49 (21.9) two K-wires (1.040–1.200) (1.060–1.250)
C3 26 (11.6)
Bent K-wire end, n (%) CI, confidence interval.
Single (proximal or distal) 98 (43.8)
Both (proximal and distal) 126 (56.2)
Patella-tension band ratio, (SD) 1.14 (0.13) Table 4
Patella–K-wire ratio, (SD) 0.42 (0.11) Odds ratios of radiographic factors for loss of reduction by univariate and
Distance between two K-wires, mm (SD) 11.11 (4.43)
multivariate analysis.
SD, standard deviation; BMI, body mass index; ROM, range of motion; ASA-PS, Variables Univariate analysis Multivariate analysis
The American Society of Anesthesiologists Physical Status. Odds ratio (95% P Odds ratio (95% P
CI) value CI) value
Age 1.100 0.086 1.080 0.142

Table 2 (0.987–1.220) (0.975–1.20)
Odds ratios of radiographic factors for implant migration by univariate and Bent K-wire end, n
multivariate analysis. (%)
Both (proximal Reference Reference
Variables Univariate analysis Multivariate analysis
and distal)
Odds ratio (95% P value Odds ratio (95% P value
Single (proximal 1.960 0.467 2.63 0.331
CI) CI)
or distal) (0.321–12.00) (0.373–18.60)
Age 1.010 0.401 1.030 0.113 Patell- tension band 0.0013 0.262 0.0035 0.335
(0.984–1.040) (0.994–1.06) ratio (0.001–147) (0.001–343)
Bent K-wire end, n Patella–K-wire ratio 0.057 0.500 0.0013 0.362
(%) (0.001–234.0) (0.001–144)
Both (proximal Reference Reference Distance between 1.110 0.266 1.160 0.178
and distal) two K-wires (0.923–1.330) (0.936–1.430)
Single (proximal 13.20 <0.001 12.90 <0.001
or distal) (5.280–33.10) (4.99–33.30) CI, confidence interval.
Patella-tension 0.488 0.597 0.173 0.277
band ratio (0.034–7.01) (0.003–4.08) associations between the risk factors and loss of reduction as determined
Patella–K-wire ratio 0.021 0.018 0.130 0.281
by the univariate and multivariate logistic regression analyses. Although
(0.001–0.508) (0.003–5.30)
Distance between 0.937 0.116 0.998 0.961 there was no significant difference compared to the patients without loss
two K-wires (0.864–1.02) (0.905–1.10) of reduction, higher age showed a tendency to increase the risk of loss of
reduction.
CI, confidence interval.
The results indicated that the fracture type was not associated with
implant migration, implant breakage, or loss of reduction. (Supple
the univariate and multivariate logistic regression analyses. Bending of a
mental Table 2) Stratified analysis by fracture type yielded similar re
single end of the K-wire was associated with a significant risk of
sults for C1 and C2; however, no significant factors were identified for
migration (odds ratio [OR]: 12.90; 95% CI: 4.99–33.30; P < 0.001).
C3. (Supplemental Table 3, 4 and 5)
1 Implant breakage
Discussion
Implant breakage occurred in 43 (19.2%) patients. Table 3 shows the
This multicenter retrospective study was conducted to evaluate
associations between the risk factors and implant breakage as deter
postoperative radiographic complications of TBW for patellar fractures.
mined by the univariate and multivariate logistic regression analyses. A
Among the 224 enrolled patients, the following findings were observed:
large patella-tension band ratio indicated that placement of the tension
1) Implant migration occurred in 19.6% of cases. Notably, bending a
band distant from the patella is associated with a significant risk of
single end of the K-wire was significantly associated with a higher risk of
implant breakage (OR: 291.0; 95% CI: 19.60–4330; P < 0.001) and a
implant migration. 2) Implant breakage was reported in 19.2% of cases.
wide distance between the K-wires (OR: 1.15; 95% CI: 1.060–1.250; P =
Factors such as a large patella-tension band ratio and a wide distance
0.001).
between the K-wires were significantly associated with an increased risk
of implant breakage. 3) Loss of reduction was observed in 2.0% of cases,
1 Loss of reduction
but no significant risk factors were identified.
Our study revealed that bending of K-wires on both ends could
Loss of reduction occurred in 5 cases (2.0%). Table 4 shows the
prevent implant migration. Huang et al. reported that the fixation
method whereby both ends of the K-wire are bent can reduce the pos inconsistencies in how different sources recorded information. Second,
sibility of K-wire migration and improve fixation stability [11]. In although many cases were collected in this multicenter study, the
addition, Eggink and Jaarsma reviewed 60 patients and reported that number of TypeC3 cases was small (26 cases); the number of cases may
failure due to migration occurred only in whom only the proximal end of not have been sufficient to detect the factors associated with the
the K-wire was bent [12]. A prior study comparing the use of cannulated complications.
screws with K-wires demonstrated no significant difference in the inci
dence of implant migration when compared to K-wire-only TBW. [13] Conclusion
Implant migration occurs because of a lack of connection between the
K-wires and the tension band wire, which causes irritation [9]. We This multicenter retrospective study investigated the postoperative
believe that it is easy to bend the K-wire at both ends is easy to do, and radiographical complications of TBW for patellar fractures in 224 pa
we recommend that surgeons do so to prevent anticipated tients. The results showed that implant migration occurred in 19.6% of
complications. patients, implant breakage in 19.2%, and loss of reduction in 2.0%. The
Implant breakage occurred in 43 patients (19.2%). Choi et al. re study identified bending of a single end of the K-wires as a significant
ported the migration of broken wire to the popliteal fossa [14], and risk factor for implant migration, whereas a large patella-tension band
Biddau et al. reported remote migration to the heart 13 years after the ratio and a wide distance between the K-wires were significant risk
initial operation [15]. These rare but critical case reports highlight the factors for implant breakage. No significant risk factors were identified
necessity of preventing implant breakage. Loss of reduction is a potential for loss of reduction. On the basis of these findings, we recommend that
factor contributing to implant failure, although implant failure occurred surgeons bend both ends of the K-wires and ensure proper placement of
less frequently compared to the incidence of loss of reduction in our tension band and K-wires to minimize postoperative complications.
study. Possible causes of cerclage wire fracture without reduction Further research is needed to better understand the risk factors associ
include: 1) tension exerted by the contraction of the quadriceps muscle ated with loss of reduction in patellar fractures treated with TBW.
as the wire passes within the quadriceps muscle; 2) deterioration due to
friction between the K-wire and the soft wire caused by knee flexion and Funding
extension movements. The suture tension band fixation technique, as
described in a previous report, presents an alternative treatment option There is no supporting funding.
for patellar fractures that could reduce the incidence of friction between
metal implants [16]. Non-metallic fixation methods could be considered Availability of data and material
as potential solutions to address this issue. We also found that a large
patella-tension band ratio, which indicates distant placement of the The datasets during and/or analyzed during the current study
tension band from the patella, is associated with a significant risk of available from the corresponding author on reasonable request.
implant breakage. Hsu et al. reported that the rate of implant breakage
increased in patellar fractures fixed with an elongated band wire Ethic approval
(exceeding 1.25 times the patellar length) [9]. Placing the tension band
close to the patella is not easy because passing the wires through the The approval number in our institute is 2020-0564
surrounding dense tendon is difficult; however, surgeons should be All eligible patients were registered using an opt-out consent process.
careful to place the tension band as close as possible to the patella to Patients were provided with a letter and a brochure informing them that
reduce postoperative complications. The wide distance between the two they had been registered, the purpose of the registration, and the pro
K-wires is associated with increased implant breakage. A previous cedure to remove themselves from the registry. The registry received
finite-element study showed that the position of the K-wires is related to ethical approval from all participating institutions, and this study
mechanical stress in patellar fractures. Proper placement of the K-wire received institutional ethical approval.
may play a key role in preventing displacement of the fracture fragment
and in withstanding tension [17]. The authors of that study showed that CRediT authorship contribution statement
the position of the K-wires has an influence on the outcome of modified
TBW in fixing patellar fractures. A narrower K-wire distance may result Hiroki Oyama: Investigation, Validation, Writing – original draft.
in less implant breakage. Therefore, further research is required in this Yasuhiko Takegami: Conceptualization, Formal analysis, Methodol
regard. ogy, Project administration, Validation, Writing – review & editing.
Loss of reduction occurred in only five of the 224 study patients. Katsuhiro Tokutake: Methodology, Writing – review & editing.
Several previous studies have shown that the incidence of attenuation Fuminori Murase: Investigation. Oki Arakawa: Investigation. Takeshi
after tension banding and wiring ranged from 0 to 6.9%. Our results are Oguchi: Investigation, Resources. Shiro Imagama: Conceptualization,
similar to these reports. [11,13,18] The mean age of these patients was Supervision.
slightly higher than that of the other patients. Miller et al. reported that
older age was a risk for fixation failure [19], and Böstman et al. reported Declaration of Competing Interest
that patients under 30 years old had better results compared to older
patients [20]. However, we did not evaluate bone quality, including The authors declare that they have no known competing financial
osteoporosis, and it is reasonable to assume that older patients might interests or personal relationships that could have appeared to influence
have poorer quality bones, which could cause complications. the work reported in this paper.
Limitations Acknowledgements
There are several limitations to this study. First, it might lead to the We thank to Member of the Trauma research of Nagoya group
several bias. One of the main biases is selection bias. This can happen if (shown in alphabetical order of affiliation) are as follows: Dr. Keigo Ito
the study sample is not randomly selected or if there are missing data on (Chubu Rosai Hospital); Dr. Masahiro Hanabayashi (Ichinomiya
important variables. Another bias that can affect retrospective studies is Municipal Hospital), Dr. Hiroaki Yoshida (Kamiiida Daiichi General
information bias, which occurs when there are errors or inaccuracies in Hospital), Dr. Tokumi Kanemura (Kounan Kosei Hospital), Dr. Hidenori
the data collected from medical records or other sources. This can Inoue (Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hos
happen if the data were not collected systematically or if there were pital), Dr. Toshihiro Ando (Japanese Red Cross Aichi Medical Center
Nagoya Daini Hospital), Dr. Koji Maruyama (Nakatsugawa Municipal [9] Hsu KL, Chang WL, Yang CY, Yeh ML, Chang CW. Factors affecting the outcomes of
modified tension band wiring techniques in transverse patellar fractures. Injury
General Hospital), Dr. Kenichi Yamauchi (Toyohashi Municipal Hospi
2017;48(12):2800–6.
tal); Dr. Yasuhide Kanayama (Toyota Kosei Hospital); Dr. Tadahiro [10] Kanda Y. Investigation of the freely available easy-to-use software ’EZR’ for
Sakai (TOYOTA memorial Hospital), Dr. Nobuhiro Okui (Yokkaichi medical statistics. Bone Marrow Transplant 2013;48(3):452–8.
Municipal Hospital) [11] Huang PH, Hsu CH, Hsu SL, Liu HC. Treatment of displaced fractures of the patella:
tension band wiring technique with the one-end or both-ends K-wire bending
fixation method. J Orthop Surg (Hong Kong) 2021;29(1):2309499020988179.
Supplementary materials [12] Eggink KM, Jaarsma RL. Mid-term (2-8 years) follow-up of open reduction and
internal fixation of patella fractures: does the surgical technique influence the
outcome? Arch Orthop Trauma Surg 2011;131(3):399–404.
Supplementary material associated with this article can be found, in [13] Liu C, Ren H, Wan C, Ma J. Comparison of the therapeutic effects of tension band
the online version, at doi:10.1016/j.injury.2023.110896. with cannulated screw and tension band with Kirschner wire on patella fracture.
Comput Math Methods Med 2020;2020:4065978. https://doi.org/10.1155/2020/
4065978. Published 2020 Aug 25doi:10.1155/2020/4065978.
References [14] Choi HR, Min KD, Choi SW, Lee BI. Migration to the popliteal fossa of broken wires
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Injury 54 (2023) 110899
Injury
Ski and snowboard injury patterns in the United States from 2010 to 2020
in pediatric patients
Andrew Warren a, Michael Dea a, Ileana G. Barron b, Isain Zapata a, *
a
Department of Biomedical Sciences, Rocky Vista University College of Osteopathic Medicine, Parker, CO 80134, United States of America
b
Department of Epidemiology, University of Alabama Birmingham School of Public Health, Birmingham, AL 35233, United States of America
Keywords: Background: Children and adolescents are at higher risk of injuries from winter sports like skiing and snow
Snowboarding boarding which can cause severe lifelong debilitation and death.
Skiing Purpose: The objective of this study is to perform a nationwide analysis of pediatric skiing and snowboarding
Accidents
injuries to identify patterns regarding patient demographics, type of injuries, outcomes, and admission rates.
Injuries
Snow sports
Study Design: Descriptive Epidemiological Study.
Methods: This was a retrospective cohort study of publicly available data. Cases were sourced from the National
Electronic Injury Surveillance System (NEISS) from 2010 to 2020 and included 6421 incidents.
Results: Even when the highest percentage of injuries was the head at 19.30%; the diagnosis of concussion was
placed third while fractures were the most common diagnosis at 38.20%. The proportion of pediatric incidents by
hospital type is changing with children’s hospitals currently managing the majority of cases.
Conclusions: These findings can assist clinicians in the ED across different hospital types in understanding the
patterns of injury to be better prepared for new cases.
Introduction emphasize certain body parts in need of particular consideration. Many

prior studies have reported the most common anatomical locations of ski
Skiing and snowboarding remain to be popular winter sports for and snowboarding injuries. Upper and lower limbs were the most
children and adolescents, but it does not come without its collection of frequently injured areas, followed by the head, lower back, and chest/
injuries and risk for long term medical damage [1,2]. Prior studies have abdomen [6]. Although head and neck injuries tend to be less common
suggested that youth may be at a higher risk of injuries resulting from than orthopedic injuries, they are considered the primary cause of fa
participation in winter sports compared to the adult population due to talities in ski injuries [8]. It is important to monitor the patterns in skiing
behavioral, physiological, and anatomical differences [3–6]. Children and snowboarding injuries in pediatrics due to the possibility of severe
tend to demonstrate less control while skiing and snowboarding which and long-term impairment that these injuries may impose [12]. Previous
makes them more prone to injury [7]. In addition, the anatomy of pe reports have focused on certain types of injuries only [4,10,13] or not
diatric participants places them at a higher risk of falling as they have a focused solely on pediatrics and adolescents [13–15]. Emergency room
higher center of gravity and an increased head-to-body ratio [6]. They incident disposition has been presented in prior studies on specific types
are also vulnerable due to growth-related factors such as musculoskel of injuries such as lower extremity injuries [4] and head and neck in
etal immaturity, underdeveloped coordination, and adolescent growth juries [13]. While there have been studies in international settings [1,5,
spurts [3,8]. Age of the participants has also been associated with dif 6,9,11] there are no recent reports at a national level that display a
ferences in the distribution of injuries within the pediatric population general picture of a large pediatric patient demographic and their
[9]. Summers et al. observed a higher rate of injury in adolescents for emergency room disposition.
both sports, which is in accordance with prior studies [8,10]. In contrast, Therefore, the objective of this study is to perform a nationwide
other authors have found that younger participants had an increased risk analysis of pediatric skiing and snowboarding related injuries to identify
of snowboarding [5] and skiing injury [11]. patterns with respect to patient demographics, type of injuries,
Location of injury is an important factor to examine as it may anatomical location, general patient outcomes and admission rates.
* Corresponding author at: 8401 S. Chambers Rd. Parker, CO 80112 United States of America.
E-mail address: izapata@rvu.edu (I. Zapata).
A. Warren et al. Injury 54 (2023) 110899
With this, a more accurate representation of pediatric skiing and Results

snowboarding related injuries may be accomplished as well as the spe
cific types of injuries most reported. The results provide insight for cli The results gathered from the 11-year data sets were compiled and
nicians into understanding the types of injuries they are likely to expect analyzed and included a total of 6421 incidents. Fig. 1 shows the trends
in their practice as well as a direction for increased safety measures. over the ten-year history, injury occurrence per age group per activity,
and cases per activity and by sex. The general trend in the sample of the
Methods number of injury cases shows a substantial decrease from 2010 to 2020
from 1022 to 372 cases (Fig. 1A). Unsurprisingly, the majority of oc
Snow sports injury data currences of these injuries occurs during the winter months of December
to March with the highest percentage occurring during January and
This was a retrospective cohort study of publicly available data. February. Males remain to be more frequently injured relative to fe
Cases were sourced from the United States Consumer Product Safety males, however their number of cases has also decreased from 2010 to
Commission’s database, the National Electronic Injury Surveillance 2020 from 723 cases to 255 cases per year (Fig. 1B). In the sample
System (NEISS). NEISS data are collected by trained chart reviewers at studied, in 2010, snowboarding had higher injury incidences at 642
roughly one hundred emergency departments throughout the country. cases compared with skiing at four hundred cases, however during the
These emergency departments are selected to accurately represent the 11-year period, the number of snowboarding cases has decreased to
5000+ emergency departments in the United States. The information is approximately the same number of cases that skiing had in 2015
streamlined by a comprehensive coding manual, reviewed by NEISS (Fig. 1C). The proportion of skiing vs snowboarding incidents was
programming, and identifiers are removed prior to public release [16]. reversed when comparing children (0 to 12 years of age) to teenagers
The study was vetted by the IRB and deemed as exempt. (13 – 17 years of age) being children more often injured while skiing as
NEISS data is released each year for the data collected the previous opposed to teenagers that are more often injured while snowboarding
year. For this study, NEISS was searched for all injuries, in all regions of (Fig.1D).
the body, which occurred in patients 0 – 17 years of age from 2010 to The highest percentage of injuries is the head followed by the wrist
2020 that were associated with skiing and snowboarding (NEISS and shoulder. Even though the injuries to the head are the highest
“product” codes 3283 and 5031 respectively). The search included all percentage of all injuries, the diagnosis of concussion is third with
incidents involving skiing and snowboarding as primary or secondary fractures being the most common diagnosis. Among the fractures, the
products (since some incidents often have multiple product codes). occurrence of open fractures is very low, with only 6 incidents in the 11
NEISS datasets for each year were queried using the previously defined year period (0.0009% of all cases). Within these, the most frequent body
parameters to extract all skiing and snowboarding incidents for persons part location for open fractures is the Tibia/Fibula (4 out of the 6). In
under 18 years of age. These datasets were compiled into a single cidents involving probable polytraumatic injuries are also relatively rare
dataset. Data were then stratified by age, sex, nature of injury (fracture, with a total of 39 incidents across the 11 year period (0.0061%). Poly
dislocation, concussion etc.), anatomical location, activity (skiing vs traumatic most often lead to admission (76.92%) with the rest being
snowboarding), and disposition (treated and released or examined and transferred to a more specialized unit. No fatalities were reported for the
released without treatment, treated and transferred to another hospital, 11 year time period in this dataset. The frequency of body parts injured
treated and admitted for same-facility hospitalization, held/admitted for and diagnoses given are presented in Fig. 2.
observation, left without being seen/left against medical advice, or fa Children’s hospitals, small, medium, and very large remained
tality including dead on arrival, died in the ED, and died after admis approximately the same in terms of proportion of cases while large
sion). Certain anatomic locations are grouped together for the purposes hospitals had the smallest proportion (Fig. 3). Over the 11-year period
of coding in the NEISS database. For example, lumbar, sacrum, coccyx evaluated, children’s hospitals gained a major proportion of the cases
and pelvis are coded as “lower trunk”, thoracic and midback are coded moving from fourth place in 2010 to first place in 2020 (Fig. 3B).
as “upper trunk”, ulna and radius are coded as “lower arm”, and tibia The top body part injured from 2010 to 2020 remained to be the
and fibula are coded as “lower leg”. Head injuries (NEISS “body part” head and the most common diagnosis was fractures. By hospital type,
code 75) and concussion diagnosis (NEISS “diagnosis” code 52) were still the most common injury was the head, however in children’s hos
further filtered to evaluate associations specific to these types of injury. pitals, the second most common was the lower arm. Among all hospital
The narrative was reviewed by two persons to identify and remove cases types, the most frequent disposition for snowboarding and skiing in
that were ineligible based on: injuries not related directly to skiing or cidents was release from ER (90%) followed by admission to hospital
snowboarding, injuries involving other non-related sport equipment. (5%), no fatalities were reported in the dataset (0%). The top five body
Open fractures and probable polytraumatic injuries (as defined by the parts injured and the top five diagnoses across all years are summarized
revised “Berlin definition" [17–19] were reviewed by two authors using in Fig. 4.
the narrative included in the dataset. Because of the limitations of the Concussions were linked to head injuries in all 57.4% of incidents.
narratives, our assessment can only suggest probable polytrauma diag Patients with diagnosed concussion were released in 92.98% of cases
nosis. The severity which is required to determine accurately the ISS with only 5% being admitted. When evaluating the proportions at which
score is uniformly reported in the narratives across incidents and addi pediatric head injuries with a concussion diagnosis are handled ac
tional clinical findings (hypotension, level of consciousness, acidosis, cording to hospital type, we estimated the expected numbers assuming
coagulopathy and partial thromboplastin time are not available in the an equal distribution across different hospital types. In this analysis, it
data. was found that Children’s hospitals diagnose concussions at more than
the expected proportion of head injury incidents (P = 1.7E-06) while
medium sized hospitals diagnose a lower-than-expected proportion of
Statistical analysis head injuries (P = 0.0069). Other locations displayed a concussion
diagnosis proportion not different from the expectation. This observa
All descriptive statistics and tests for associations were performed in tion suggests that there is likely a self-selection effect on where head
SAS/STAT v.9.4 (SAS Institute Inc. Cary, NC). Descriptive statistics and injuries are preferably handled or there is a notorious difference in the
frequencies were carried out using PROC FREQ and PROC MEANS. standard of care. Using the NEISS dataset on snowboarding and skiing
Testing for associations was performed with contingency tables using incidents, there was no evidence of increased risk of concussion due to
chi-square tests using PROC FREQ. Associations are declared significant Skiing (P = 0.2148) or Snowboarding (P = 0.2523).
at P ≤ 0.05 although exact p-values are provided. In summary, our data evaluation described the following trends: the
Fig. 1. Incident occurrence. A) All incidents across years. B) Comparison of the number of cases by sex C) Comparison of the number of incidents by activity
(Snowboarding vs. Skiing). D) Comparison of the number of incidents by activity by age group.
frequency of snowboarding and skiing incidents decreased from 2010 to all ages, all types of injures were more likely to occur in snowboarders
2017 and kept steady up until 2020. Males are more frequently injured than skiers [24,25]. However, recent studies have found that skiers tend
in comparison to females. Snowboarding and skiing incidents are very to sustain injuries that are more likely to require transfer [14] and
evenly represented in these incidents, but children are more frequently hospital admission [26] compared to snowboarders. In our most recent
injured while skiing while teenagers are more frequently injured while data, we show that the frequencies of incidents of these two sports is
snowboarding. Head, wrist, lower arm, shoulders, and knees are the very similar in the last 5 years and overall the likelihood of severe in
most frequently injured body parts with fractures, strains, concussions, cidents is relatively low as observed in the low rate of admission of ~5%,
contusions, and internal organ injuries being the most frequent types of the low occurrence of open fractures, polytraumatic incidents an no
diagnosis. There are differences in the proportions and types of injuries fatalities reported. Because NEISS data does not allow for follow-up of
that are handled by hospital type. severe case outcomes (as it is limited to emergency room visits) there is a
possibility that severe cases may had led to fatalities after admission or
Discussion transfer. Our findings are in concordance with the trends reported for
pediatric trauma centers [27]. The decrease in snowboarding injury
The primary purpose of this study was to perform a nationwide from our data can potentially be attributed to an improvement in
evaluation of pediatric skiing and snowboarding related injuries. The equipment over the last decade, but it could also be related to a decrease
number of cases of all pediatric injuries related to skiing and snow in participation in snowboarding in particular [27].
boarding has decreased significantly from the years 2010 to 2020. This The overall trend for injuries across the years is in decline for both
pattern may be due to a factors such as the advancement of safety sexes; nevertheless, males still represent the highest proportion of in
equipment [7], the increased push for education on the equipment [6, juries. The distribution of injuries by sex has not been clearly defined in
20,21] and a decrease in participation in these sports [4]. The economic the literature: some authors have found a higher overall occurrence of
impact of snowboarding and skiing injuries is an important factor to injury in males regardless of sport type [9,26,28], while others have not
consider. In previous studies, it was estimated that hospital costs were found conclusive evidence of a gender predisposition [5,6,11,27]. It has
between $22,000 and $28,000 per patient admitted, and outpatient been proposed in past literature that boys may be at a higher risk of
services were estimated at $15,243 per patient [22,23]. The reduction of injury due to behaviors such as readiness to assume risk [9,29]. It has
incidents observed in the data may have a significant reduction of the been previously reported that certain age groups may participate in one
economic burden although it is unreliable to extrapolate from the NEISS activity over the other: children (6–12 years) are more likely to ski while
sample since exposure rates for skiing and snowboarding are undefined. adolescents are more likely to snowboard [6]. However, there have been
In previous reports exploring the injury occurrence in participants of few studies that explore the differences in injuries by activity by age
Fig. 2. Body part injured and diagnosis. A) Body part injured percentage across all years. B) Diagnosis percentage across all years.
Fig. 3. Cases by hospital type and proportion of cases by type of hospital across all years. A) Overall proportion of cases by hospital type for the 2010–2020 period. B)
Proportion of cases by year.
group. We found that a higher percentage of skiers compared to snow the head. Head injuries are more likely to get reported because of the
boarders (43.47% vs 57.82% respectively) presented to the ED in the risk of long-term complications and death [30]. In a previous study from
younger age group (6–12 years). In the older age group [13–17] snow 1996 to 2010, traumatic brain injury (TBI) made up the majority of
boarding injuries were more common (61.49% snowboarding vs 39.57% ED-reported head injuries from skiing and snowboarding in children and
skiing). A similar pattern of distribution was reported previously by in adolescents [10]. Though the head is the most injured body part in our
Polites et al. [27]. These differences could be explained by the decrease data, the most common diagnosis was fracture followed by sprains and
in snowboarding in recent years as reported in the literature [4]. strains; concussions were reported to be the third most common diag
The most common body part injured throughout 2010 – 2020 was nosis. This finding may be related to the increase in helmet usage over
Fig. 4. Top 5 body parts injured and top 5 diagnosis. A) Top 5 body part injured percentage across all years. B) Top 5 body part injured percentage across hospital
type. C) Top 5 diagnosis percentage across all years. D) Top 5 diagnosis percentage across hospital type.
the last decade [6,31]. Many winter resorts do not typically require the centers. Most level-1 pediatric-only trauma centers are located in free
use of helmets but highly recommend their use. The importance of standing children’s hospitals [35]. Additionally, there is evidence that
helmet usage to reduce concussion risk and poor outcomes when injured pediatric-verified level-1 trauma centers are associated with a signifi
has been supported strongly by the literature [3,20,32,33]. We did not cant mortality decrease compared to level-1 general trauma centers
find evidence of risk differences in concussion vs snowboarding in our [35]. This positive trend in outcomes is also observed when comparing
sample. While other studies have found that pediatric and young adult freestanding vs. non freestanding children’s hospitals [36] and is also
snowboarders had a higher risk of concussion compared to skiers [13], recognized by parents [37] and staff [38]. This positive perception of
Summers et al. reported similar findings to our study in the pediatric children’s hospitals may account for the observed increase in the pro
population [6]. In previous studies examining ski injuries in pediatric portion of cases handled.
patients, it was found that young skiers across all ages are most sus The study presented is limited by the distribution of the emergency
ceptible to lower-extremity injuries most likely related to improperly departments from which NEISS data are collected. The NEISS estimates
adjusted equipment and bindings that malfunction [6,8,27]. The recent are adjusted and evaluated heavily for their representativeness [16], but
injury trends in our study do not support this idea as upper limb, head, it must be noted that there are geographic considerations for specific
and torso injuries are more frequent in recent years across both activities like skiing and snowboarding. Proliferation of more urgent
activities. care centers and regional hospitals in the vicinity of ski resorts in recent
We observed changes in the volume of incidents handled by hospital years may also be reducing the declining case numbers that reach hos
type as well as in the proportion of diagnosis of concussions. Children’s pitals that report to the NEISS. This may be a future direction to explore.
hospitals are diagnosing concussions at more than their expected pro It must also be acknowledged that more minor or insidious injuries
portion compared with other hospital types. In a 2006 study examining would not be accounted for in the NEISS database if these cases did not –
the characteristics of pediatric patients injured at winter resorts, at least initially – present to a treatment facility. Narratives in the NEISS
perceived severity of injury, weather conditions, transport time, and are also a limitation to be considered when following up our findings.
accessibility to patient’s location were factors informally used by ski These are limited and may not be detailed enough or consistent across
patrol to determine the type of transport needed [34]. Injuries involving the years, which may affect the incidence we observed in polytraumatic
the face and head were more likely to be referred to air vs ground and open fracture incidents. Another limitation may include the lack of
transportation, and patients transported by air were preferentially knowledge of predisposing factors prior to injury, which the data does
transported to trauma centers [34]. Based on these findings, we specu not include and thus were not evaluated in this study.
late that head and face injuries are more likely to be sent to trauma Lastly, it is important to mention that the decrease in pediatrics
skiing/snowboarding injuries can be due to lower participation of [14] Pierpoint LA, Kerr ZY, Crume TL, Grunwald GK, Comstock RD, Selenke DK, et al.
A comparison of recreational skiing-and snowboarding-related injuries at a
younger skiers and snowboarders. This is an important confounder that
Colorado ski resort, 2012/13-2016/17. Res Sport Med 2020;28(3):413–25.
is difficult to account for with public aggregated datasets. Future studies [15] Dickson TJ, Terwiel FA. Injury trends in alpine skiing and a snowboarding over the
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and sledding as they are a common recreational winter activity for [16] US Consumer Product Safety Commission. NEISS frequently asked questions
[Internet]. 2022 [cited 2022 May 16]. Available from: https://www.cpsc.gov/
young children, which also poses risks of injury and head trauma. Research–Statistics/NEISS-Injury-Data/Neiss-Frequently-Asked-Questions.
[17] Pape HC, Lefering R, Butcher N, Peitzman A, Leenen L, Marzi I, et al. The definition
Conclusion of polytrauma revisited: an international consensus process and proposal of the
new ‘Berlin definition. J Trauma Acute Care Surg. 2014;77(5):780–6.
[18] Frenzel S, Krenn P, Heinz T, Negrin LL. Does the applied polytrauma definition
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significantly in the last 11 years. This can be attributed to an increase in Scand J Trauma Resusc. Emerg. Med. 2017;25(1):87.
[19] Hardy BM, King KL, Enninghorst N, Balogh ZJ. Trends in polytrauma incidence
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proper training and education. Among all body parts, the head remains org/10.1007/s00068-022-02200-w.
to be the most injured at 19.30%, followed by the wrist at 15.87%. The [20] Milan M, Jhajj S, Stewart C, Pyle L, Moulton S. Helmet use and injury severity
among pediatric skiers and snowboarders in Colorado. J Pediatr Surg 2017;52(2):
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compared with females. Because studies have cited male gender and Epidemiology of severe paediatric trauma following winter sport accidents. Acta
Paediatr 2020;109(10):2125–30.
youth as pre-disposing risk factors for skiing/snowboarding related in
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handled by hospital types is changing with children’s hospitals now assessment of morbidity and management strategies. J Pediatr Surg 1999;34(1):
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gency departments across different types of hospitals in understanding Quebec. Epidemiology 2004:279–86.
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Declaration of Competing Interest visits from falls from skiing, snowboarding, skateboarding, roller-skating, and
using nonmotorized scooters. Clin Pediatr (Phila) 2016;55(8):738–44.
[27] Polites SF, Mao SA, Glasgow AE, Moir CR, Habermann EB. Safety on the slopes: ski
None of the authors in this study have any conflicts of interests to versus snowboard injuries in children treated at United States trauma centers.
declare. J Pediatr Surg 2018;53(5):1024–7.
[28] Stracciolini A, Casciano R, H Levey Friedman, Stein CJ, Meehan III WP, Micheli LJ.
Pediatric sports injuries: a comparison of males versus females. Am J Sports Med
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Injury 54 (2023) 110900
Injury
Percutaneous osteosynthesis of acetabular fractures with quadrilateral plate

involvement using an infra-pectineal plate through a new paramedial
approach: Description of the technique using cadaveric specimens
Edgardo Ramos a, *, Armando Torres b, Héctor Torres c, Ingmar Buffo d, Fernando García c,
Eduardo Callejas a, Moises Micha a, Valeria Alvarez a
a
Orthopedic Department, American British Cowdray Medical Center, Cuajimalpa, ZC, 05300, Ciudad de Mexico, Mexico
b
American British Cowdray Medical Center, Alvaro Obregon, ZC, 01120, Ciudad de Mexico, Mexico
c
Orthopedic Department of Hospital General Regional #2 IMSS, Coyoacán, ZC, 04980, Ciudad de Mexico, Mexico
d
Dalinde Medical Center. Cuauhtémoc, ZC, 06760, Ciudad de Mexico, Mexico
Keywords: Percutaneous osteosynthesis of acetabular fractures with quadrilateral plate involvement using an infra-pectineal
Acetabular fractures plate through a new paramedial approach using cadaveric specimens.
Quadrilateral plate Background: Intrapelvic approaches and infrapectineal plates have been used since the mid-nineties to solve
Paramedial approach
Quadrilateral Plate osteosynthesis, with some problems in applying screws in the correct direction and difficulty
Percutaneous osteosynthesis
Infrapectineal plate
in fracture reduction. We describe a minimally invasive paramedial approach and new ways to fix infrapectineal
Reverse fixation plates using one-step osteosynthesis (reduction and fixation).
Methods: Four transverse and four posterior hemitransverse acetabular fractures were reproduced using four
fresh frozen cadavers. Acetabular osteosynthesis was performed using the paramedial approach. Sequential
lasting time and reduction/stability quality were measured using analysis of variance (ANOVA) with Bonferroni
Correction as the statistical method, registering iatrogenic injuries.
Results: Osteosynthesis was performed on seven acetabulae using infrapectineal horizontal plates for transverse
fractures and vertical plates for posterior hemitransverse fractures. The duration of incision was 3:08 min and
osteosynthesis was 55:12 min, with a total of 58:29 min. Median fracture displacement of 13.25 mm turned to a
median of 0.01 mm once fracture osteosynthesis was performed with a p = 0.017. The peritoneum was injured
twice and good osteosynthesis stability was observed.
Conclusion: The paramedial approach is safe with direct access to key anatomical structures for acetabular
osteosynthesis. Infrapectineal with reverse fixation plate osteosynthesis provides an excellent reduction rate and
good stability once the implants act against displacement forces, making it possible to direct them freely. Further
clinical and biomechanical trials are required to confirm our findings. We believe that there was an improvement
of up to 60% in the result quality for some cases; however, this technique must be compared with other tech
niques. Evidence Level IV (Experimental Trial)
Introduction manage acetabular fractures with QLP involvement, either using the
ilioinguinal approach or anterior intrapelvic (AIP) approaches [3–5].
Involvement of the quadrilateral plate (QLP) of the acetabulum However, despite the effectiveness of these surgical approaches for
makes this type of fracture even more challenging [1]. reduction and fixation of the QLP component of the acetabulum,
The separation of the QLP can be complete or incomplete, and the important intrapelvic anatomical structures, pelvic three-dimension,
fracture can be simple or multifragmentary, leading ElNahal et al. [2] to secondary fracture traces, and QLP morphology limit reduction ma
propose a specific classification for this region and divide these fractures neuvers and implant positioning in many cases [1,4-8].
into four basic types. Currently, most orthopedic trauma surgeons In this scenario, the use of endoscopic techniques with minimally
* Corresponding author at: Dr. Alfonso Caso Andrade 83-A, Las Aguilas, Alvaro Obregon, Zip Code 01710, Ciudad de Mexico, Mexico.
E-mail address: centrodeortopediaytraumatologia@abchospital.com (E. Ramos).
E. Ramos et al. Injury 54 (2023) 110900
Fig. 1. Landmarks: Secure zone for incision between medial/intermediate third of the line from Pubic Tubercle to Anterior Superior Iliac Spine.
Fig. 2. The sharp dissection of layers end once the Transversalis Fascia is cut out.
invasive reduction maneuvers and internal fixation through small win approach to reduce and fix the quadrilateral plate component, including
dows has recently been proposed to avoid all the difficulties and po impacted fractures of the medial portion of the acetabular roof (Gull
tential drawbacks of the classic ilioinguinal approach or alternative AIP sign) [8]. In most cases, it is not necessary to use classical reduction
approaches [9]. However, the use of endoscopic pelvic rim exposures instruments to position the suprapectineal and infrapectineal plates,
and standard laparoscopic instruments is unfamiliar to almost all or thereby providing the surgeon with a true anatomical safety corridor,
thopedic surgeons. This makes the technique promising but difficult to reducing the need to perform complex and risky maneuvers, and mini
apply in most trauma centers where patients with acetabular fractures mizing the risk of injury to important anatomical structures. In the
are treated; however, these infrapectineal plate fixation systems could present study, we describe percutaneous fixation of acetabular fractures
be a new opportunity to obtain better results. with quadrilateral plate involvement using an infra-pectineal plate
Since 2012, Ramos et al. [6,7] described the use of a paramedial through a new paramedial approach. Cadaveric specimens were used to
Fig. 3. The surgeon inserts a finger into the Retzius space, sweeps backward along iliopectineal brim performing peritoneum blunt dissection.
Fig. 4. Surgeon´s hand touching Quadrilateral Plate.
illustrate the procedure as the most important feature of the surgical (approval numbers FMED/CI/SPRL/063/2015 and project ID 027/
approach and the percutaneous placement of the infrapectineal plate. 2015). Four fresh-frozen pelvises of human cadaveric specimens (seven
The objective of this study was to demonstrate a novel minimally hips in total) without pre-existing surgery or deformity were obtained
invasive paramedial approach and the new infrapectineal plates’ ad from the Department of Anatomy of the School of Medicine of UNAM
vantages, safety, feasibility, specific indications and osteosynthesis re (Universidad Nacional Autonoma de Mexico) and used in this study. One
sults in cadaver specimens. hip was excluded because of a previous nonsurgical management of an
acetabular fracture presenting with a bone defect in the posterior col
Materials and methods umn. The specimens consisted of three males and one female, with an
average age of 62.25 years (range, 48–72 years), an average height of
Cadaver specimens 167 cm (range, 154–178 cm), and a weight of 72.5 kgs (range, 68–80
kg).
The study was approved by the Ethics Committee of the Institution
Fig. 5. Different position of infrapectineal plate for different indications.
Table 1
Essential and optional anatomical structures that must/can be identified.
Essential anatomical structures Optional anatomical structures
Iliopectineal brim Iliopectineal External iliac Internal iliac

eminence artery artery
Iliopubic rami Pubic body Iliac vein Inguinal ligament
Major sciatic notch Sciatic spine Inguinal conduct Superior gluteal
artery
Minor sciatic Quadrilateral Sciatic nerve Intraperitoneal
notch Wall viscera
Sacrospinosus Obturator bundle Smpermatic cord Deferens conduct
ligament
Internal obturator Bladder Sacrotuberous Iliopectineal
muscle ligament ligament
Corona mortis Peritoneum Sacroiliac joint
Surgical technique
In the supine position, a straight line was drawn from the anterior
superior iliac spine (ASIS) to the pubic tubercle (PT). Dividing this line
into three thirds, a 7 - 10 cm vertical incision was made just at the
junction of the medial and intermediate thirds (Fig. 1), ending 1 cm
proximal to the inguinal line, which can also be made at the pubic tu
bercle level (just along the anterior rectus edge). Sharp dissection of fat
tissue and abdominal muscles was performed in the same direction as Fig. 6. Vernier´s caliper measurement of fracture displacement.
the skin incision (Fig. 2).
The fascia transversalis was identified and dissected to prevent
inadvertent peritoneum invasion. The surgeon’s finger was introduced a T-handle. If the acetabular fracture was transverse, an infrapectineal
into the Retzius space and advanced dorsally along the iliopectineal plate was inserted transversely. If the fracture extends to the posterior
brim for blunt dissection of the peritoneum (Fig. 3). Anatomical struc column (posterior hemitransverse fracture) in the QLP, a vertical plate is
tures from the pubis body to the sacroiliac joint were identified, as well required. Therefore, the internal obturator muscle must be bluntly
as the internal obturator muscle covering the QLP, lesser and greater dissected using Kelly forceps to allow for direct plate-to-bone contact. If
sciatic notches, and the ischiatic spine (Fig. 4). a transverse plate was indicated, dissection of this muscle was not
When the femoral head is deeply medialized, a Schanz screw can be necessary once the plate was placed 1 cm beneath the iliopectineal brim
inserted through the femoral neck to lateralize it by pulling traction with (Fig. 5). Although posterior hemitransverse fractures are always
Fig. 7. Plates must be contoured according the plate version to use: vertical (left) or horizontal (right).
combined with anterior column fractures, we decided to reproduce touch sensations, an image intensifier (Siemens Arcadis Varic C-Arm;
posterior hemitransverse osteotomy alone to demonstrate the efficacy of Siemens Healthineers AG, Erlangen, Germany), and a Vernier caliper
vertical infrapectineal plate osteosynthesis of the QLP. However, it is (Fig. 6). All measurements were recorded and compared to verify intra-
also possible to perform anterior column and anterior wall osteosyn and inter-observer agreement and obtain the median and standard de
thesis through this approach using a suprapectineal 3.5 mm recon viation (SD).
struction plate, which was not the objective of this trial because of the In the third phase of the study, osteosynthesis was performed for
great difficulty in reproducing this acetabular fracture combination. transverse acetabular fractures using a 7-hole straight 10.2 mm wide,
3.2 mm thick special plate in a transverse fashion. The plate was pre
Surgical dissection and outcome measurements viously contoured with benders to the iliopectineal curvature, using a
pelvic plastic bone model as a template (Fig. 7).
Six orthopedic surgeons with different levels of expertise in acetab The plate was introduced to the true pelvis approximately 1 cm
ular osteosynthesis were invited to participate in this study. The youn beneath the iliopectineal brim and fixed ventrally with a short 8-mm
gest was a 4th year Orthopaedic Resident without any experience in length and 4.5 mm diameter cannulated screw and an 8-mm length
these acetabular fracture types, and the most experienced surgeon with and 5.8 mm diameter sex bolt using an aiming device to locate the first
30 years of experience and 40 acetabular osteosynthesis procedures per ventral plate hole drilling the bone with a 2.5-mm drill guide (Fig. 8a,b).
year. All participants were informed of the study aims and signed an Inside the first hole, a 6-mm cannulated drill bit was used to enlarge the
Informed Consent Form for participation. Subsequently, they were taken bone hole and remove the 2.5-mm drill guide. A flexible threaded cable
to the Department of Anatomy so that the principal investigator (PI) (1.6 mm diameter) was introduced into the cannulated drill bit from the
could perform a step-by-step approach and clear all doubts related to the outside to the intrapelvic region of the pelvis to prevent bone hole or
operative technique. All dissections were performed by the same sur screw loss. A cannulated screw and the corresponding female bolt were
geon, with PI acting as an assistant. introduced through the cable (instead of the threaded cable, currently
In the first phase of the study, surgeons were asked to perform this we use a 1.2 mm nitinol guide wire). Then, the plate was fixed through
approach. During dissection, the surgeon was asked to identify all the most dorsal hole using a 26-mm long and 4.5 diameter cannulated
anatomical structures that could be identified. The working team screw and 20-mm and 5.8 mm diameter female bolt following the same
decided to consider the essential structures that must be identified for steps and using a specially designed aiming device (Fig. 8c).
successful surgery; however, the optional structures were not considered Once this procedure was completed, the reduction and the fixation of
relevant (Table 1). the fracture were assessed. It is important to use a washer to prevent
In the second phase, four hips were used to create a transtectal screw head from sinking into the lateral pelvic cortex.
transverse acetabular fracture and three hips were used to create pos In the fourth phase of the study, osteosynthesis was performed for
terior hemitransverse acetabular fractures. All the fractures were posterior hemitransverse acetabular fractures using a 5-hole straight
created through the same incision by adding other small incisions. 10.2 mm wide, 3.2 mm thick plate in a vertical position. The plate was
Chisels were used to create and displace the fractures. Surgeons were previously contoured with benders to perfectly adapt to the QLP, using a
then asked to measure the degree of displacement using their finger pelvic plastic bone model as a template (Fig. 7). The internal obturator
and the time spent on both osteosynthesis procedures were recorded and
added together to obtain the total procedure time.
ANOVA with Bonferroni Correction was used for the reduction

assessment based on direct measurement using a Vernier caliper, finger
touch sensation, and C-arm imaging according to the Matta criteria [8].
Incision duration was measured in seconds to obtain the mean and
Standard Deviation (SD), as well as the duration of osteosynthesis.
The identified anatomical structures were recorded, remarking
essential structures and surgically injured anatomical structures.
Results
Phases 1 and 2
All surgeons performed this approach by adequately exposing the

pubic body to the sacroiliac joint. All essential and some optional
anatomical structures were correctly identified by almost all surgeons
(Fig. 12a,b).
The mean time from skin incision to identification of the iliopectineal
brim and QLP was 3:08 (SD, 1:07) min, ranging from 1:45 to 4:59 min
(Fig. 13).
The degrees of fracture displacement and reduction are shown in
(Fig. 13). No significant differences were found in the assessment of
inter- and intra-participant displacement and reduction, as well as
measuring methods using finger touch sensation, image intensifiers, or
caliper. Although the caliper measurement was the most precise, the
image intensifier method was preferred overall because it was the only
method that could be demonstrated and measured again, and there were
no significant differences among the measurement methods. The final
reduction ranged from 0 to 1 mm (SD 0.38 mm), with a mean difference
between displacement and reduction of 11.9 mm (p = 0.017), ranging
from 5 to 28 mm (Table 2).
Phases 3 and 4
Fig. 8. Transverse infrapectineal plate
a. Aiming device for anterior plate hole fixation to bone.
The mean time spent for both osteosynthesis versions was 55:12 min
b. Aiming device for posterior plate hole fixation to bone.
c. Simultaneous reduction and fixation (osteosynthesis) of fracture fragments. ranging from 47 to 79 min and the total procedure time was 58:29 min
(Fig. 14).
The peritoneum was invaded twice during the osteosynthesis. No
other important anatomical structures were damaged during osteosyn
muscle was bluntly dissected and the plate was placed along the pos
thesis, as documented at the end of the procedure, through extended
terior column. A long version of the aiming device was used to locate the
incisions in the anterior and posterior parts of the pelvis and hips
second distal plate hole (Fig. 9a). The aiming device indicated the
(Fig. 15).
location of the lateral stab incision. Blunt dissection was performed to
protect the sciatic nerve during introduction of the aiming device, which
Discussion
was advanced through a stab incision until the surgeon felt the ischium.
The distal part of the plate was fixed first at its second hole, using a
We observed that the new paramedial approach is an adequate op
plunger (Fig. 9a,b), in order to get the sex bolt into the bone hole and the
tion for percutaneous fixation of acetabular fractures with QLP
screw into the sex bolt and tightened, followed by the most proximal
involvement by using an infra-pectineal plate. The plate was used in a
hole using the same technique described previously but now using the
transverse fashion for transverse acetabular fractures and vertically for
short version of the aiming device and plunger (Fig. 9c,d).
posterior hemitransverse acetabular fractures (along the posterior col
A 26-mm long and 4.5 diameter cannulated screw and 20-mm and
umn). Six surgeons with different levels of expertise performed this
5.8 mm diameter sex bolts were used for the distal and proximal plate
approach, and all the intrapelvic anatomical structures were correctly
fixation, respectively. It is important to note that these plates reduce and
identified during dissection. The mean time from skin incision to iden
fix the fractures in one step (Fig. 10a,b).
tification of the iliopectineal brim and QLP was approximately 3 min,
At the end of both procedures, abdominal incisions were extended to
and the time spent for both osteosynthesis procedures was less than 55
assess iatrogenic injuries. The distal posterolateral stab incisions were
min. Additionally, the total procedure time (dissection and osteosyn
extended to determine whether the sciatic nerve was damaged (Fig. 11).
thesis) was less than 60 min. Unfortunately, we did not find a lasting
The time from skin incision to identification of the iliopectineal brim
time difference between the approach and total procedure in any
Fig. 9. Vertical infrapectineal plate

a. Aiming device for distal posterior column
plate fixation.
b. A plunger introducing the sex bolt into bone
hole through the distal 2nd plate hole.
c. Aiming device for proximal posterior column
plate fixation.
d. Introducing the sex bolt with the plunger
pulling the cable wire.
Fig. 10. Fracture fragments reduction

a. Black arrows pointing at displacement of posterior hemitransverse acetabular fracture fragments.
b. One black arrow to show reduction and compression of fracture fragments.
Fig. 11. Enlargement of posterior and distal stab incision to asses sciatic nerve integrity.
published articles. need to use reduction forceps diminishing the risk of iatrogenic injury. In
There is no doubt that acetabular fractures are difficult to manage our technique, the plate is used as a reduction tool, pulling out and
properly, starting with the complexity of their adequate diagnosis and buttressing the QLP fragment, which is not always possible using other
the preferred approach [8–12]. The paramedial approach offers a very techniques. Regarding the basic principles of AO articular fracture
expedite and safe exposure to perform acetabular osteosynthesis, with osteosynthesis, the best way to fix them is to apply the compression
an excellent window to reach all intrapelvic anatomical key structures principle with the consequent absolute stability, which can be achieved
[6,7]. Even in cases where there is an extension to the iliac wing as part using this novel technique.
of high anterior column fractures, it is necessary to use the lateral The limitations of this study include the small sample size (four
window of the ilioinguinal approach because the paramedial approach specimens, seven hips) and lack of biomechanical assessment. Because
allows adequate management of almost all anterior low column frac we used frozen cadaveric specimens with intact hips, it was difficult to
tures, anterior wall, and anterior plus the posterior hemitransverse obtain a larger sample, either because of the high cost in our country or
fractures involving the QLP plate, as well as the anterior component of because of the low supply at the Department of Anatomy at our insti
elementary transverse fractures and T-type fractures. Other anterior tution. Regarding the level of experience, we adopted this methodology
intrapelvic approaches have almost the same indications [11,12], but to verify whether the described surgical approach would be feasible for
greater dissection and mobilization of the intrapelvic structures are surgeons with different levels of training. This allowed us to infer that
required. In addition, the angle of attack for screw placement through this approach is reproducible, even when dealing with intrapelvic sur
these approaches must be medial to lateral, making reduction and fix gical dissection for the fixation of a highly complex acetabular fracture,
ation more difficult. In contrast, in our newly described approach, the and it is possible to perform acetabular osteosynthesis of the transverse,
screws come from the outer pelvis to the inner pelvis, thus requiring no T-type, posterior column, anterior wall, and anterior column and their
further retraction of the bladder, vessels, or other anatomical compo combination through this approach by adding suprapectineal plates and
nents (Fig. 9c, 10b). Moreover, due to the same difficulties with intra the first window of the ilioinguinal approach when necessary. Osteo
pelvic structures and space, the procedure can be much more difficult [5, synthesis of the posterior wall fractures cannot be performed using this
8,11]. approach.
One of the greatest advantages of the new paramedial approach is the A key strength of the present study is the controlled technique used
safe use of an anatomical corridor. In our study, during osteosynthesis, to create both transverse and posterior hemitransverse acetabular frac
the peritoneum was invaded twice, with no other important anatomical tures. The degree of displacement was assessed using the finger touch
structures suffering any damage, as documented at the end of the pro sensation, image intensifier, and caliper, with no significant differences
cedure, through extended incisions to the anterior and posterior parts of among them.
the pelvis and hips. Owing to excellent exposure to QLP, surgeons rarely
Fig. 12. Anatomical structures identified

a. Essential structures for osteosynthesis making.
b. Optional structures (not strictly necessaire for surgery performance).
*Foot Note: one of the six surgeons participated in two procedures.
Fig. 13. Fracture displacement and reduction.
Funding
Table 2
Fracture displacement and reduction. Statistical analysis
FN: X ray were chosen because it can be demonstrated.
Funding was received for this work.
All of the sources of funding for the work described in this publica
Stage X-Ray Tactile Visual p*
tion are acknowledged below:
Pre-reduction 12.29 (4.57) 12.43 (6.40) 12.00 (8.00) 0.992 [List funding sources and their role in study design, data analysis, and
Post-reduction 0.14 (0.38) 0.14 (0.38) 0.14 (0.38) 1.000 result interpretation]
*ANOVA. No statistical differences among groups with Bonferroni Correction. X No funding was received for this work.
*Paired t-test.
Intellectual property
Conclusion X We confirm that we have given due consideration to the protection

of intellectual property associated with this work and that there are no
The newly described paramedial approach to the acetabulum is impediments to publication, including the timing of publication, with
adequate for managing different fracture patterns of the QLP. No vital respect to intellectual property. In so doing we confirm that we have
intrapelvic structures were injured during dissection, even when the followed the regulations of our institutions concerning intellectual
approach was performed by less experienced surgeons and the injured property.
peritoneum was sutured. There is no need for special reduction clamps,
as the plate is used for both reduction and fixation of the QLP fragment Research ethics
(s) as a single step. Finally, fixation is performed from the outer to the
inner part of the pelvis, thus reducing the risk of damage to the bladder X We further confirm that any aspect of the work covered in this
and other intrapelvic structures and allowing the correct screw direction manuscript that has involved human patients has been conducted with
for adequate articular reduction and fixation. This experimental trial the ethical approval of all relevant bodies and that such approvals are
was performed by six surgeons with very different degrees of expertise acknowledged within the manuscript.
who obtained very similar results, reinforcing the feasibility of the X IRB approval was obtained (required for studies and series of 3 or
procedure. more cases)
10
Fig. 14. Procedure lasting time (step by step and total).
Fig. 15. Injured anatomic structures.
Written consent to publish potentially identifying information, such financial support for this work that could have influenced its outcome.
as details or the case and photographs, was obtained from the patient(s)
or their legal guardian(s). Supplementary materials

We wish to confirm that there are no known conflicts of interest
associated with this publication and there has been no significant
11
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12
Injury 54 (2023) 110902
Injury
Increasing incidence of ED-visits and admissions due to traumatic brain

injury among elderly patients in the Netherlands, 2011–2020
Juliette A.L. Santing a, *, Crispijn L.Van Den Brand b, Martien J.M. Panneman c,
J.Susanne Asscheman c, Joukje van der Naalt d, Korné Jellema a
a
Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands
b
Department of Emergency Medicine, Erasmus Medical Center & Haaglanden Medical Center, PO Box 2040, 3000 CA, PO Box 432, 2501 CK The Hague, Rotterdam,
the Netherlands
c
Research Department, Consumer Safety Institute, PO Box 75169, 1070 CE, Amsterdam, the Netherlands
d
Department of Neurology, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, the Netherlands
Keywords: Background and importance: Traumatic brain injury (TBI) is a leading cause of disability and mortality worldwide.
Traumatic brain injury Nowadays the highest combined incidence of TBI-related emergency department (ED) visits, hospitalizations and
Elderly adults deaths occurs in older adults. Knowledge of the changing patterns of epidemiology is essential to identify targets
Trend analysis
to enhance prevention and management of TBI.
ED visit
Admission
Objective: To examine time trends of ED visits, admissions, and mortality for TBI comparing non-elderly and
Mortality elderly people (aged ≥ 65 years) in the Netherlands from 2011 to 2020.
Design: We conducted a retrospective observational, longitudinal study of TBI using data from the Dutch Injury
Surveillance System (DISS) and Statistics Netherlands from 2011 to 2020.
Outcome measure and analysis: The main outcome measures were TBI-related ED visits, hospitalizations, and
mortality. Temporal trends in population-based incidence rates were evaluated using Poisson regression. We
compared patients under 65 years and patients aged 65 years or older.
Main results: From 2011 to 2020, absolute numbers of TBI related ED visits increased by 244%, and hospital
admissions and mortality showed an almost twofold increase in patients aged 65 years and older. The incidence
of TBI-related ED visits and hospital admission increased also in elderly adults, with 156% and 51% respectively,
whereas the mortality remained stable. In contrast, overall rates of ED visits, admissions, and mortality, and
causes for TBI did not change in patients younger than 65 years during the study period.
Conclusion: This trend analysis shows a significant increase of ED-visits and hospital admission for TBI in elderly
adults from 2011 to 2020, whereas the mortality remained stable. This increase cannot be explained by the aging
of the Dutch population alone, but might be related to comorbidities, causes of injury, and referral policy. These
findings strengthen the development of strategies to prevent TBI and improve the organization of acute care
necessary to reduce the impact and burden of TBI in elderly adults and on healthcare and society.
Introduction causes health loss and disability for individuals, but also represent an
economic burden to health-care systems through lost productivity and
Traumatic brain injury (TBI) is defined as an alteration of brain high health-care costs [2].
function or other evidence of brain pathology, caused by an external The epidemiology and underlying causes of TBI are changing.
force to the head [1]. It is a common neurological condition and a Nowadays, patients with TBI in high-income countries are characterized
leading cause of morbidity, disability, and mortality worldwide [2,3]. by an older age, with falls as the primary mechanism of injury [2,3,5].
Each year approximately 2.8 million patients in the United States (US) The highest combined incidence of TBI-related emergency department
and 2.5 million in the European Union (EU) sustain a TBI [4]. It not only (ED) visits, hospitalizations, and deaths in fact occur in older adults [6,
Abbreviations: ED, Emergency department.

* Corresponding author at: Haaglanden Medical Center, PO Box 432, 2501 CK the Hague, the Netherlands.
E-mail address: j.santing@haaglandenmc.nl (J.A.L. Santing).
J.A.L. Santing et al. Injury 54 (2023) 110902
7]. By 2050, the number of elderly adults will have risen worldwide to T02.0, T04.0).
2.1 billion [8].
Official statistics report large variations in ED visits, hospital ad Statistical analysis
missions and mortality rates for TBI across the EU, likely due to differ
ences in data collection, case ascertainment, and case definition [5,9]. We expressed absolute numbers and the estimated annual incidence
Between 1998 and 2012, there were approximately 500 000 TBI-related of ED visits, hospital admissions and mortality rates for TBI per 100 000
ED visits, 222 000 TBI-related admissions and 17 000 TBI-related deaths population for the equivalent Office for National Statistics, Statistics
in the Netherlands [10]. In the same period, the figures for persons aged Netherlands, population estimate for that year. ED visits were specified
65 years and older comprised 81 000 TBI-related ED visits, 53 000 for age and sex for each year. Hospital admissions, deaths, and trauma
TBI-related admissions and 8000 TBI-related deaths. The exact epide mechanisms only for age. Because of a certain measure of uncertainty,
miology and patterns of geriatric TBI for the Netherlands and many numbers are rounded to thousands in this manuscript. We defined the
other European countries in the last decade is unknown. Timely epide following age groups: 0–64 years and ≥65 years. Poisson regression was
miologic studies are needed to estimate the trends in ED visits, admis used to estimate the rate ratio (multiplicative increase of the rate per
sion numbers and mortality of patients over time at global, regional, and year over the study period) and 95% confidence intervals. Rate ratios for
national levels to guide evidence-based health-care policy for improved the overall study period (2011–2020) were estimated with a rate ratio of
prevention and management of TBI and to provide a projection for the 1.0 implying no annual change in rate, and a 95% confidence interval
future. Therefore, this study aims to evaluate time trends of ED visits, that includes 1.0 indicating that the observed rate ratio is not statisti
admissions, and mortality for traumatic brain injury comparing cally significant. All statistical analyses were performed using IBM Sta
non-elderly and elderly people (aged ≥ 65 years) in the Netherlands tistical Package for Social Sciences (SPSS) version 27.
from 2011 to 2020.
Results
Methods
During the study period from 2011 through 2020 approximately 6
Data sources 984 000 ED visits, 1 427 000 hospital admissions and 81 000 deaths due
to trauma were registered. Of these, 518 000 ED visits (7.4% of total),
In this observational longitudinal study, we included all patients 238 000 hospital admissions (16.7% of total), and 14 000 deaths (17.3%
with ED visits, hospital admissions or mortality because of TBI in the of total) were a consequence of TBI (Table 1). Elderly adults accounted
period 2011–2020 using two Dutch registration systems, namely the for 34%, 35%, and 64% of these TBI numbers. The population increased
Dutch Injury Surveillance System (DISS) (Letsel Informatie Systeem; in this period from 16.7 million in 2011 to 17.4 million (4% increase) in
LIS) and the Office for National Statistics, Statistics Netherlands (Cen 2020 in the Netherlands. In the same period, the population aged ≥65
traal Bureau voor de Statistiek; CBS), respectively. years increased from 2.6 million in 2011 to 3.4 million (31% increase) in
We extracted data on ED visits and hospital admissions from the DISS 2020.
database which is an ongoing monitoring system of the Dutch Consumer
Safety Institute (VeiligheidNL). Information is registered from all pa Incidence rates
tients who attend the ED for an injury. DISS is based on a selection of
fourteen geographically distributed Dutch hospitals that provide a 24- We present an overview of the absolute numbers of TBI-related ED-
hour medical emergency service, forming a representative sample of visits, hospital admissions and mortality by age group in Table 1. Figs. 1
hospitals in the Netherlands. The DISS data set represents 16% of all EDs and 2 show the changes in incidence rates of TBI- related ED-visits (2a),
in the Netherlands and includes general and academic hospitals. hospital admissions (2b) and mortality (2c) in non-elderly and elderly
Therefore, data collected in the DISS hospitals can be extrapolated to people between 2011 and 2020.
national estimates. For extrapolation of the sample, the number of
trauma-related ED treatments in DISS hospitals is multiplied by a factor ED visits
derived from the quotient of all trauma-related hospital admissions in
the Netherlands divided by trauma-related hospital admissions in DISS From 2011 until 2020, the absolute number of ED visits among pa
hospitals [11]. tients aged 65 years and older increased by 244%; from 9 200 in 2011 to
The cause of death statistic by the Office for National Statistics, 31 000 in 2020. Besides this absolute increase, the incidence rates
Statistics Netherlands (CBS) [12] is a registration based on causes of increased from 357 in 2011 to 910 ED visits per 100 000 population per
death (ICD-10) from all deceased individuals registered in the year in 2020 (156% increase; IRR 2.556; 95% CI 2.261–2.889). The
Netherlands. The information is based on the compulsory notification of absolute number of ED visits due to TBI in adults under 65 years of age
cause of death by the physician treating the deceased at the time of increased far less, from 33 000 in 2011 to 37 000 in 2020 (increase
death or by a pathologist. For every deceased, a cause of death certificate 12%). In addition, there was a nonsignificant overall change in the
is completed, which is used exclusively for statistical purposes, and is incidence rates of TBI related ED visits, from 236 in 2011 to 264 ED
sent to CBS. The reliability of registration of causes of death is generally visits per 100 000 population per year in 2020 (12% increase; IRR 1.119;
good [13]. 95% CI 1.039–1.333). The changes in incidence rates of TBI-related ED
visits in men and women per age group are shown in Table 2.
Study population
Hospital admissions
We included all patients who attended the ED for TBI, were admitted
to the hospital (which was linked with the DISS database) for TBI or died The absolute number of TBI-related hospital admissions almost
because of TBI between 1 January 2011 and 31 December 2020. Elderly doubled among patients aged 65 years and older, from 6 000 in 2011 to
adults were defined as having an age of 65 years or older. In the DISS 11 000 in 2020. In line with the increase in absolute numbers, the
database, injuries in the ED are coded according to a classification of the incidence rates increased from 222 to 334 hospital admissions per 100
type of injury and the location of the body, based on the International 000 population per year (51% increase; IRR 1.505, 95% CI
Classification of Diseases (ICD-10-CM) [14]. TBI is defined in the DISS 1.270–1.783). In contrast to patients aged 65 years or older, absolute
registration as having a concussion (ICD10-CM code S06.0) or other numbers of TBI-related hospital admissions decreased by 6.7%, from 15
skull-brain injury (S02.0-1, S02.7, S02.9, S06.1-9, S04.0-9, S07.1-9, 000 in 2011 to 14 000 in 2020. The incidence rates showed a
Table 1
Key figures on traumatic brain injury between 2011 and 2020 in the Netherlands: emergency department visits, hospital admissions, and mortality.
2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
ED visits TBI< 65 (total) 33 000 34 000 30 000 30 000 33 000 35 000 33 000 37 000 39 000 37 000
ED visits TBI 65+ (total) 9 000 10 000 10 000 11 000 16 000 18 000 19 000 24 000 29 000 31 000
Admissions TBI <65 (total) 15 000 17 000 16 000 14 000 16 000 15 000 14 000 20 000 15 000 14 000
Admissions TBI 65+ (total) 6 000 6 000 6 000 6 000 9 000 9 000 9 000 9 000 11 000 11 000
Mortality TBI <65 (total) 500 500 500 400 500 500 500 400 400 500
Mortality TBI 65+ (total) 700 800 800 900 1 000 1 000 1 000 1 000 1 000 1 000
Population (total) 16 656 16 730 16 780 16 829 16 901 16 979 17 082 17 181 17 282 17 408
000 000 000 000 000 000 000 000 000 000
Population <65 14 061 14 014 13 955 13 910 13 893 13 893 13 922 13 942 13 968 14 015
000 000 200 000 000 000 000 000 000 000
Population 65+ 2 595 000 2 716 000 2 824 000 2 919 000 3 008 000 3 085 000 3 160 000 3 239 000 3 314 000 3 393 000
ED visits TBI 65+/ ED TBI (total) (%) 22 23 25 27 32 35 36 39 43 46
Admissions TBI 65+/Admissions TBI 27 26 29 30 35 39 38 32 42 45
(total) (%)
Mortality TBI 65+/ Mortality TBI (total) 59 63 63 68 67 71 72 76 75 75
(%)
ED=emergency department, TBI=traumatic brain injury.
Fig. 1. Time trends in ED-visits, hospital admissions and mortality per 100 000 population from 2011 to 2020 in patients younger and over 65 years of age.
ED=emergency department, TBI=traumatic brain injury.
comparable decrease from 108 in 2011 to 101 admissions per 100 000 aged 65 years and older (127 000 ED visits; 64%).
population per year in 2020 (7% decrease; IRR 0.935; 95% CI Over time, the overall incidence rates of TBI related to falls, RTA, and
0.713–1.227). other causes (e.g. entrapment, self-mutilation, bumping head against
object) increased significantly as cause for TBI, from 233 to 676 per 100
Mortality 000 population per year (190% increase; IRR 2.901 95% CI
2.500–3.367) for falls, from 81 to 157 per 100 000 population per year
The mortality rate for TBI increased with 43% in patients aged 65 (96% increase; IRR 1.938; 95% CI 1.482–2.534) for RTA, and from 34 to
years and older, from 700 in 2011 to 1000 in 2020. The incidence rates 59 per 100 000 population per year (79% increase; IRR 1.788; 95% CI
showed a nonsignificant increase in mortality due to TBI, from 27 to 41 1.168–2.738) for other causes. In contrast, we observed no trends for
deaths per 100 000 population per year (52% increase; IRR 1.519; 95% trauma mechanisms for TBI in patients younger than 65 years since 2011
CI 0.934–2.468). In patients younger than 65 years of age, the mortality (Table 3).
rate remained stable with 500 deaths in both 2011 and 2020. Incidence
rates for mortality did not change significantly, from 4 to 3 per 100 000 Discussion
population deaths per year (25% decrease; IRR 0.750; 95% CI
0.168–3.351). We found that among patients aged 65 years or older in the
Netherlands, absolute numbers of TBI related ED visits increased by
244%, with an almost twofold increase of hospital admissions and
Trauma mechanisms
mortality between 2011 and 2020. In addition, incidence rates of TBI-
related ED visits and hospital admissions have consistently increased
Table 3 shows the trauma mechanisms causing TBI in patients equal
since 2011 in this category, indicating that the rise in the number of
or older than 65 years and younger than 65 years in 2011 compared to
elderly adults treated and admitted in hospitals cannot be explained by
2020. Throughout the study period, falls and road traffic accidents
aging and changing population structure alone, but might be related to
(RTA) were the main cause for TBI in patients younger than 65 years of
comorbidities, causes of injury, and referral policy.
age (128 000 and 113 000 ED visits; 35% and 33%) and falls in patients
Fig. 2. Incidence proportions on a logarithmic scale of TBI ED visits (A), admissions (B), and mortality (C) in the Netherlands per 100 000 population, 2011 and 2020
compared. ED=emergency department, TBI=traumatic brain injury.
In the current study we observed that between 2011–2020 the ED- in Europe is available.
visits and hospital admissions due to TBI in patients aged 65 years or The question is whether these absolute numbers reflect only the in
older kept increasing, although this was less steep than in the period crease of elderly in the overall population. During the study period, the
1998–2012 [10] with an increase in ED visits of 237%, compared to overall population aged 65 years and older increased by 31%. The ED
199% between 2011 – 2020. For hospital admissions the increase was visits and hospital admission-based incidence rates in this age group
from 156% to 51% from 2011–2020. In contrast, the incidence of increased with 156% and 51% respectively. As such, this increase cannot
TBI-related ED-visits and hospital admissions in patients younger than be explained by the aging of the Dutch population alone. The increment
65 years of age remained stable during the study period. in ED visits of older adults with TBI might have several causes. First,
A recent systematic review on the epidemiology of TBI in Europe elderly adults are more mobile compared to the past due to improved
showed that mean incidence rates remained broadly the same across health care services and the development of mobility aids [20]. As a
studies of all ages [9]. However, longitudinal studies in several Euro result of a more active and mobile lifestyle, elderly adults are supposed
pean countries and the United States during the same period observed to be at higher risk for falling or a RTA with a TBI as a consequence.
that the overall incidence of ED-visits and hospital admissions in elderly Second, as people age, the number of patients living with various
adults increased [6,15–19]. Nevertheless, no recent comprehensive medical conditions will increase [21]. The presence of pre-existing
description of the trends in the elderly population for a decade or longer health conditions is a known risk factor for sustaining a TBI [22].
Fig. 2. (continued).
Table 2 Table 3
Characteristics of ED-visits for TBI in men and woman between 2011 and 2020. Causes of injury in non-elderly and elderly adult presenting with TBI in the ED
Age-group Incidence Rate per 100 IRR (95% CI) p-value
covering the period from 2011–2020.
000 people Trauma Incidence Rate per IRR (95% CI) p-
2011 2020 2011 2020 mechanism 100 000 value
people
Men <65 y 20 21 283 302 1.067 0.432
2011 2020 2011 2020
000 000 (0.907–1.255)
Woman <65 13 16 188 225 1.197 0.069 Patients < 65
y 000 000 (1.023–1.502) y
Men ≥ 65 y 4 000 14 357 880 2.629 <0.001 Fall 12 16 88 112 1.271 0.104
000 (2.327–2.970) 000 000 (0.963–1.683)
Woman ≥ 5 000 17 356 936 2.465 <0.001 RTA 10 11 74 78 1.054 0.152
65 y 000 (2.180–2.788) 000 000 (0.767–1.449)
Work 1 000 2 000 9 11 1.222 0.655
CI=confidence interval, IRR=incidence rate ratio, TBI=traumatic brain injury,
(0.506–2.949)
y=years. Sports 3 000 3 000 18 21 1.167 0.631
(0.622–2.190)
Furthermore, elderly adults are more likely to use antithrombotic Violence 3 000 2 000 21 15 0.714 0.320
(0.368–1.386)
medication which can increase the risk and severity of intracranial
Other 4 000 4 000 26 27 1.038 0.891
hemorrhage after sustaining a TBI. Accordingly, elderly adults with (0.606–1.779)
comorbidities and use of antithrombotics are more often referred to the Patients ≥ 65
ED for a head CT or treatment of co-occurring injuries [22,23]. In y
Fall 6 000 23 233 676 2.901
addition, the introduction and increased use of direct oral anticoagu <0.001
000 (2.500–3.367)
lants (DOACs) since 2009 [24], especially in elderly people, may have RTA 2 000 5 000 81 157 1.938 <0.001
contributed to increased ED referrals en hospital admission. Despite (1.482–2.534
their potential benefits, including a rapid onset, fixed dosing an no need Work 20 200 1 5 5.00 0.142
for monitoring, the prescription of DOACs was initially challenged, due (0.584–42.797)
Sports 100 300 4 9 2.250 0.177
to lack of reversal agents, unknown bleeding risk, uncertainty about the
(0.693–7.306)
risk of hematoma progression and lack of guidance on how to manage Violence 134 142 5 4 0.800 0.739
TBI patients using a DOAC. These insecurities might have lowered the (0.215–2.979)
threshold for ED referral and hospital admission of DOAC–treated pa Other 1 000 2 000 34 59 1.788 0.008
tients after TBI. Third, changes in the head injury guideline of the Dutch (1.168–2.738)
College of General Practitioners in 2015 might have resulted in an ED=emergency department, CI=confidence interval, IRR=incidence rate ratio,
increased awareness among primary care professionals of the risk of TBI=traumatic brain injury, RTA=road traffic accident, y=years.
traumatic intracranial lesions in the elderly after TBI and, consequently,
in increased referral practices. More defensive medicine and lower explanation might be an increase of injury severity in elderly adults. The
thresholds for diagnostic imaging might be other possible causes. The majority of TBIs sustained by elderly adults are nowadays attributed to
observation that the number of ED visits increased much more than the falls [26]. Although it may seem counterintuitive, this apparently
hospital admissions could support this theory. low-energetic injury mechanism may lead to a higher proportion of se
Regarding the increase in hospital admissions, it is possible that the vere injuries (extra-axial hemorrhages or contusions) than traffic acci
increased use of head CTs and improvement of the quality of CT scanners dents, possibly because of more focal damage aggravated by
in the last decade might have led to better detection of traumatic lesions antithrombotics [17,27]. Moreover, due to anatomic and physiologic
and, as a result, in an increase in hospital admissions [25]. Another
changes that accompany aging, older patients experience more severe treatments. This hampers the interpretation of causal mechanisms
consequences than younger people, even from seemingly mild injuries behind the observed trends. Another limitation concerns the classifica
[28–31]. In addition, a recent nationwide cohort study in the tion of TBI. TBI patients treated at the ED and admitted to the hospital
Netherlands found that moderate and severe TBI was far more common were registered in the DISS as having a ‘‘Concussion’’ or ‘‘Other skull –
in the elderly than in the overall study population, with falls as main brain injury’’ (including fractures and intracranial injury). Due to this
cause of TBI in their elderly population as well [32]. Half of the elderly undercoding, we could not provide detailed stratification of the TBI
adults in this study had an injury severity score (ISS) over 16, indicating severity. Last, the results only relate to the Netherlands and therefore
major trauma [33] and almost half of polytrauma patients were elderly may not be translated to other countries. However, the trends we
adults. Therefore, one could imagine that these patients are more often observed seem comparable to figures from European studies [15–19].
admitted for further treatment.
Consistent with previous findings, in our study falls were the main Conclusions
cause of TBI in the elderly and fall related TBI incidence rates increased
over time in this age group[23]. We also observed an increase in RTA as This trend analysis shows that ED-visits and hospital admission for
a cause for TBI in elderly adults. A clear explanation for this finding is TBI have significantly increased in elderly adults in the last decade from
not yet known although this rise might be due to an increase in bicycle- 2011 to 2020. This increase cannot be explained by the aging of the
related TBI in elderly adults. It is possible that elderly adults do cycle Dutch population alone, but might be related to comorbidities, causes of
more nowadays than they used to do in the past, because of the intro injury, and referral policy. Strengthening of strategies to prevent TBI as
duction of e-bikes [34–36]. Currently, elderly adults account for almost well as improving the organization of acute care is necessary to reduce
45% of all bicycle-related ED visits in the Netherlands [37], and older the impact and burden of TBI in elderly adults and on healthcare and
cyclists have been identified as an important risk group for TBI as they society.
represent highest ED attendance, injury severity, admission to hospital
and intensive care unit, and economic costs [38–40]. Future research is Funding
necessary to gain a better insight in the observed trends in trauma
mechanisms, to improve the approach for prevention of TBI in elderly Juliette Santing was funded by a grant from the HMC
adults in the Netherlands. Wetenschapscommissie.
The trend of increasing TBI related ED visits and hospital admissions
in elderly will have consequences for the workload on healthcare pro
fessionals, available hospital beds and health care expenses. The popu Declaration of Competing Interest
lation of elderly people is expected to double by 2050 [8] and the
increasing trends in ED-visits and hospital admissions are likely to No competing financial interests exist.
continue as well. Related to this, healthcare consumption and healthcare
costs are expected to show a rise in the coming decades on top. There Acknowledgements
fore, policy makers need to consider the changing demands of TBI on
health-care services and proactively improve the organization of acute We are grateful to the Landsteiner Institute for their support.
care aiming to not overburden the already struggling post-COVID-19
healthcare systems. References
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Injury 54 (2023) 110904
Injury
The impact of both-bone forearm fractures on acute compartment

syndrome: An analysis of predisposing factors
Shuo Yang a, b, 1, Tao Wang a, b, 1, Yubin Long a, b, c, 1, Lin Jin a, b, Kuo Zhao a, b, Jiaqi Zhang d,
Junfei Guo a, b, *, Zhiyong Hou a, b, e, **
a
Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
b
Orthopaedic Research Institute of Hebei Province, Shijiazhuang, Hebei, China
c
The Third Department of Orthopedics, Baoding First Central Hospital, Baoding, Hebei, China
d
Department of Anesthesiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
e
NHC Key Laboratory of Intelligent Orthopaedic Equipment (The Third Hospital of Hebei Medical University), Shijiazhuang, Hebei, China
Keywords: Objectives: Acute compartment syndrome (ACS) is a severe medical condition that, if left untreated, can cause
Both-bone forearm fractures permanent nerve and muscle damage, and may even require amputation. The objective of this study was to
Acute compartment syndrome identify the risk factors associated with the development of ACS in patients with both-bone fractures of the
Crush injury
forearm.
Neutrophil
Creatine kinase
Methods: Between November 2013 and January 2021, a retrospective data collection was conducted on 611
individuals who experienced both-bone forearm fractures at a level 1 trauma center. Among these patients, 78
patients were diagnosed with ACS, while the remaining 533 patients did not have ACS. Based on this division, the
patients were categorized into two groups: the ACS group and the non-ACS group. Demographics (including
factors such as age, gender, body mass index, crush injury, etc.), comorbidities (including conditions such as
diabetes, hypertension, heart disease, anemia, etc.), and admission lab results (including complete blood count,
comprehensive metabolic panel, and coagulation profiles, etc.) were analyzed using univariate analysis, logistic
regression, and ROC curve analysis.
Results: Predictors of ACS were identified through the final multivariable logistic regression analysis, which
revealed that crush injury (p < 0.001, OR = 10.930), the levels of neutrophils (NEU) (p < 0.001, OR = 1.338) and
the levels of creatine kinase (CK) (p < 0.001, OR = 1.001) were significant risk factors. Additionally, age (p =
0.045, OR = 0.978) and albumin (ALB) level (p < 0.001, OR = 0.798) were found to provide protective effects
against ACS. Furthermore, the receiver operating characteristic (ROC) curve analysis determined cut-off values
for NEU and CK to predict ACS: 7.01/L and 669.1 U/L respectively.
Conclusions: Our study identified crush injury, NEU, and CK as significant risk factors for ACS in patients with
both-bone forearm fractures. We also determined the cut-off values of NEU and CK, allowing for the individu
alized evaluation of ACS risk and the implementation of early targeted treatments.
Abbreviations: ACS, acute compartment syndrome; ROC, receiver operating characteristic curve; AUC, area under the curve; BMI, body mass index; BAS, basophil;
EOS, eosinophil; HCT, hematocrit; HGB, hemoglobin; LYM, lymphocyte; MCH, mean corpuscular hemoglobin; MCHC, mean corpuscular hemoglobin concentration;
MCV, Mean Corpuscular Volume; MON, monocyte; MPV, mean platelet volume; NEU, neutrophil; PLT, platelet; RBC, red blood cell; ALB, albumin; AST, aspartate
aminotransferase; ALT, alanine transaminase; CK, creatine kinase; GLOB, globulin; APTT, activated partial thromboplastin time; FIB, fibrinogen.
* Corresponding author at: Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Orthopaedic Research Institute of Hebei Province,
Shijiazhuang, 050051, Hebei, China.
** Corresponding author at: Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Orthopaedic Research Institute of Hebei Province,
NHC Key Laboratory of Intelligent Orthopaedic Equipment (The Third Hospital of Hebei Medical University), Shijiazhuang, 050051, Hebei, China.
E-mail addresses: drjfguo@163.com (J. Guo), drzyhou@gmail.com (Z. Hou).
1
Equal contribution
S. Yang et al. Injury 54 (2023) 110904
Introduction study aims to provide a more comprehensive understanding of the un

derlying risk factors contributing to the onset of ACS after both-bone
Both-bone forearm fractures are a common occurrence, typically forearm fractures, which in turn can lead to improved patient out
caused by a sudden and forceful impact directly on the forearm bone. comes, enhanced treatment strategies, and a reduction in the burden of
For instance, a fall onto an outstretched hand with the wrist extended is ACS-related complications.
a common mechanism [1,2]. However, these fractures can have serious
consequences, as they may lead to the development of acute compart Materials and methods
ment syndrome (ACS). ACS arises from an excessive increase in pressure
within a closed compartment in the forearm, such as the superficial Ethics statement
volar, deep volar, extensor, or mobile wad compartments [3]. Although
ACS is less frequently observed in the upper limb compared to the lower We conducted a retrospective review of the electronic medical re
limbs, it remains more prevalent in the forearm than in any other part of cords of all 611 patients who suffered double fractures of the forearm
the upper limb [4,5]. Importantly, forearm fractures are the leading with or without ACS and were diagnosed and treated at our hospital
cause of ACS in the forearm, surpassing both soft tissue injuries and between November 2013 and January 2021. The institutional review
vascular injuries [6]. ACS is a critical medical emergency that can occur board at our hospital gave permission for the study, and it was done in
in the limbs following trauma or other factors that lead to bleeding, line with the ethical guidelines in the Helsinki Declaration of 1964
edema, or compromised limb perfusion [7,8]. Extensive research has (NCT04529330, S2020-022-1).
shed light on the underlying pathogenic mechanisms of ACS, which
involve the movement of fluids between the bloodstream, extracellular
spaces, and intracellular compartments. This fluid shift results in Patients
elevated pressure within the affected muscle tissue, leading to decreased
blood flow, impaired tissue oxygenation, and potentially severe conse Conducted at our hospital, the study involved the collection of a total
quences such as prolonged hospitalization, increased healthcare costs, of 979 patients with both-bone forearm fractures. According to the in
and even mortality [9]. clusion and exclusion criteria for this research, patients younger than 18
While prior studies have examined risk factors associated with ACS years old, those who had ACS prior to admission, those with incomplete
in lower extremity fractures, such as age, gender, and smoking history medical records, patients with open fractures, and those with an injury-
[10–13], there is a significant research gap when it comes to under to-hospital admission time exceeding one week were excluded (Fig. 1).
standing the risk factors specific to ACS after both-bone forearm frac Therefore, a total of 611 patients (366 men and 245 women) were
tures. Furthermore, existing literature has predominantly focused on included in the study.
specific factors, overlooking the crucial role of laboratory investigations Of the 611 patients, 78 had developed ACS after suffering from
in their research objectives. In contrast, our study not only pioneers the diaphyseal both-bone forearm fractures, while the remaining 533 pa
analysis of ACS risk factors in both-bone forearm fractures but also tients had the same kind of fractures but did not develop ACS. In our
underscores the pivotal importance of comprehensive laboratory as study, all patients underwent surgical treatment for diaphyseal both-
sessments in unraveling the intricate complexities surrounding ACS. bone forearm fractures. We put the patients into two groups based on
Through meticulous collection of various blood cell counts and whether or not they had ACS after having double fractures in their
comprehensive evaluations of liver and kidney function, blood coagu forearms: the ACS group and the non-ACS group.
lation, and inflammation during patients’ admission, our research takes When diaphyseal both-bone forearm fractures were suspected based
a groundbreaking approach to analyze the risk factors associated with on physical examination results, radiography was conducted using front
ACS. By integrating these laboratory findings with clinical data, our and side plain x-rays. Furthermore, CT and MRI examinations are typi
cally reserved for detecting joint or soft tissue injuries, which are
Fig. 1. Flow diagram of included patients.
relatively infrequent in both-bone forearm fractures, thus doctors often Table 1

do not recommend these tests. Maintaining adequate range of motion of Demographics data and comorbidities data of patients with and without ACS.
the distal upper extremity is crucial for completing activities of daily Characteristics ACS group (n = Non-ACS group (n P
living. Therefore, once diagnosed with a double forearm fracture, sur 78) = 533)
gical treatment should be performed. Closed reduction in forearm Age, years 27.0 (6.0~40.3) 35.0 (11.0~56.0) <0.001
fractures achieves satisfactory alignment in most cases [14]. To avoid *
circular definition, we have established strict diagnostic criteria for the Gender, n (%) 0.121
diagnosis of compartment syndrome. These criteria encompass the male 53 (67.9%) 313(58.7%)
female 25 (32.1%) 220(41.3%)
classic clinical signs and symptoms of compartment syndrome, which Body mass index, kg/m2 22.7 23.0(19.2~26.1) 0.634
include pain out of proportion (Intense pain may occur when stretching (17.8~26.5)
the fascial compartment) and paresthesia, as well as objective measures <24 48 (61.5%) 312 (58.5%) 0.540
of compartment pressure [15,16]. For a subset of patients with less 24–28 18 (23.1%) 153 (28.7%)
12 (15.4%) 68 (12.8%)
obvious clinical manifestations of ACS, we utilize direct measurement of >28
Crush injury, n (%) <0.001
muscle tissue pressure in order to make a diagnosis of compartment *
syndrome based on established criteria. These patients were subject to Yes 27 (34.6%) 15 (2.8%)
regular clinical evaluations and hourly Intracranial Pressure (ICP) No 51 (65.4%) 518 (97.2%)
monitoring before and after their surgeries, spanning 24 – 48 h. This Referral, n (%) 0.323
Yes 62 (79.5%) 396 (74.3%)
involved the insertion of a continuous ICP slit catheter, with hourly No 16 (20.5%) 137 (25.7%)
measurements taken by our nursing staff. The surgical team was Multiple fractures, n (%) 0.106
promptly alerted to any unusual clinical findings or abnormal pressure Yes 20 (25.6%) 186 (34.9%)
readings, with a sustained ΔP—the difference between the diastolic No 58 (74.4%) 347 (65.1%)
History of forearm 0.346
blood pressure and the compartment pressure—less than 30 mm Hg for
fracture, n (%)
2 h considered diagnostic of ACS. This method of tissue pressure mea Yes 0 (0.0%) 6 (1.1%)
surement is not only objective but also reproducible, thereby mini No 78 (100.0%) 527 (98.9%)
mizing the impact of subjective judgment and diagnostic errors. In our Smoking history, n (%) 0.305
study, we observed a total of 78 patients with ACS, of which 62 were Yes 2 (2.6%) 28 (5.3%)
No 76 (97.4%) 505 (94.7%)
diagnosed with ACS after admission but prior to the fixation surgery
Alcohol history, n (%) 0.900
(internal or external), while the remaining 16 were diagnosed with ACS Yes 2 (2.6%) 15 (2.8%)
after undergoing the bilateral forearm fracture surgery. In cases where No 76 (97.2%) 518 (97.2%)
ACS is diagnosed, it is of utmost importance to promptly perform a Dehydrating agent or not, 0.348
n (%)
fasciotomy to alleviate pressure and restore blood flow to the affected
Yes 54 (69.2%) 340 (63.8%)
compartment, as this can help prevent poor outcomes [16,17]. The di No 24 (30.8%) 193 (36.2%)
agnoses and surgical interventions were carried out by experienced or Arrhythmia, n (%) 0.443
thopedic surgeons who had at least ten years of experience in their field. Yes 0 (0.0%) 4 (0.8%)
This study gathered data on patients’ demographics, comorbidities, No 78 (100.0%) 529 (99.3%)
Hypertension, n (%) 0.442
and admission laboratory exams. Demographics included age, gender,
Yes 6 (7.7%) 56 (10.5%)
BMI, open and multiple fractures, referral, and dehydrating agent use. No 72 (92.3%) 477 (89.5%)
Comorbidities such as arrhythmia, hypertension, diabetes, cerebral Diabetes, n (%) 0.239
infarction, anemia, and hypoproteinemia were also examined. The study Yes 1 (1.3%) 21 (3.9%)
No 77 (98.7%) 512 (96.1%)
also investigated a range of admission laboratory indicators, including
Cerebral Infarction, n (%) 0.863
various blood cell counts and tests for liver and kidney function, blood Yes 2 (2.6%) 12 (2.3%)
coagulation, and inflammation (as shown in Table 2). No 76 (97.4%) 521 (97.7%)
Anemia, n (%) 0.003*
Statistical analysis Yes 24 (30.8%) 90 (16.9%)
No 54 (69.2%) 443 (83.1%)
Hypoproteinemia, n (%) <0.001
We analyzed the data using SPSS software (version 25.0, SPSS Inc., *
New York, USA) and considered a p-value < 0.05 to be statistically Yes 8 (10.4%) 0 (0.0%)
significant. Continuous variables were assessed for normality using the No 69 (89.6%) 533 (100.0%)
Shapiro-Wilk test, and normally distributed variables were reported as Values are presented as the number(%) or the median(interquartile range).
mean ± SD using the t-test. Non-normally distributed variables were *
p < 0.05, statistical significance.
analyzed using the Mann-Whitney U test. Chi-square test was used for
categorical variables. Finally, we used logistic regression analysis to gender, BMI, referrals, multiple fractures, history of forearm fractures,
identify the independent risk factors for ACS. Furthermore, we used the smoking history, alcohol history, and use of dehydrating agents (all p >
receiver operating characteristic (ROC) analysis to determine optimal 0.05).
cut-off values for NEU and CK and assessed diagnostic accuracy by Table 1 also displayed the comorbidity data comparison between the
calculating area under the ROC curve (AUC). ACS and non-ACS groups. Anemia (p = 0.003) and hypoproteinemia (p
< 0.001) were more prevalent in the ACS group, whereas no significant
Results differences were found in the occurrence of other investigated comor
bidities (all p > 0.05). Table 2 presented the laboratory test findings of
This study enrolled 611 participants, among whom 78 individuals both the ACS and non-ACS groups at the time of admission. The results
developed ACS while the remaining 533 did not. Table 1 provided a revealed that the ACS group had significantly higher levels of BAS (p <
comparison of baseline characteristics between the ACS and non-ACS 0.001), EOS (p < 0.001), MCHC (p = 0.041), MON (p < 0.001), NEU (p
groups. Significant differences were found between the two groups in < 0.001), CK (p < 0.001), AST (p < 0.001), ALT (p < 0.001), and GLOB
terms of age (p < 0.001) and the mechanism of injury (p < 0.001), with a (p < 0.001) than the non-ACS group. However, after adjusting for
higher proportion of crush injuries in the ACS group. Conversely, there multiple testing, only NEU and CK remained significant predictors of
were no significant differences between the two groups in terms of
Table 2 0.978, 95% CI (0.958 – 0.999)) and higher ALB levels (p < 0.001, OR =
Laboratory results of patients with and without ACS. 0.798, 95% CI (0.726 – 0.877)) were identified as protective factors
Laboratory ACS group (n = 78) Non-ACS group (n = P against ACS in these patients (Table 3). Additionally, our analysis pre
results 533) sents combined ROC curves in Fig. 2 for NEU and CK and detailed
BAS 0.05 (0.02~0.10) 0.03 (0.02~0.04) <0.001 predictor information in Fig. 3. The predictors, CK (p < 0.001, AUC =
* 0.830, 95%CI (0.798 – 0.859)) and NEU (p < 0.001, AUC = 0.752, 95%
EOS 0.12 (0.08~0.18) 0.07 (0.02~0.12) <0.001 CI (0.716 – 0.786)), with cut-off values of 669.1 U/L and 7.01 /L,
* respectively, are displayed. The combined factors significantly increased
HCT 39.02 (35.86~42.49) 39.24 (36.97~41.48) 0.543
HGB 130.58 131.10 0.343
the AUC area, indicating a better diagnostic value. The highest diag
(117.85~142.45) (123.10~139.65) nostic value of 0.899 was achieved with the combination of NEU and CK,
LYM 1.71 (1.32~2.20) 1.76 (1.43~2.24) 0.679 as indicated by the area under the receiver operating characteristic
MCH 30.02 (28.29~31.33) 30.25 (28.54~31.48) 0.338 curve. (Fig. 4)
MCHC 333.30 335.30 0.041*
(327.80~339.33) (330.50~340.90)
MCV 89.89 (84.88~93.61) 90.05 (85.29~93.61) 0.702 Discussion
MON 0.79 (0.56~1.05) 0.59 (0.46~0.75) <0.001
* Forearm fractures are common upper extremity injuries, with distal
MPV 8.82 (7.71~9.65) 8.52 (7.89~9.28) 0.794
fractures more frequent than proximal [1]. These fractures result from
NEU 8.70 (5.62~12.79) 5.43 (4.13~7.17) <0.001
* direct force to the bone, causing symptoms such as reduced range of
PLT 243.50 239.90 0.720 motion, discomfort, swelling, and deformity [2]. Severe cases can lead to
(187.75~298.58) (192.95~283.45) ACS, a medical emergency [16]. Despite the prevalence of forearm
RBC 4.41 (4.10~4.71) 4.41 (4.10~4.70) 0.928 fractures, risk factors for developing ACS in patients with both-bone
ALB 36.46 (36.24~41.59) 43.89 (41.31~46.61)
forearm fractures are unclear. This study investigates the relationship
<0.001
*
CK 2216.00 149.40 <0.001 between ACS and demographic, comorbidity, and laboratory factors.
(427.80~6174.41) (89.10~274.00) * Identifying high-risk patients could improve outcomes and healthcare
ALT 38.00 (21.50~48.86) 17.00 (12.00~24.00) <0.001 resource allocation. Our study explored risk factors for ACS in patients
*
with both-bone forearm fractures. Logistic regression found NEU, crush
AST 59.00 (28.00~122.83) 20.00 (16.00~25.00) <0.001
* injury history and elevated CK to be independent risk factors for ACS.
CREA 60.87 (50.76~63.21) 54.87 (43.39~65.80) 0.052 Older age and higher ALB levels were found to be protective. Further
GLOB 21.73 (19.65~24.18) 24.00 (21.66~26.86) <0.001 analysis, including ROC curve assessment, indicated that the cut-off
* values for CK and NEU to predict ACS were 669.1 U/L and 7.01 /L,
APTT 30.60 (28.93~32.90) 30.70 (28.40~33.05) 0.752
respectively. Notably, the most accurate diagnosis was achieved when
FIB 3.09 (2.61~3.60) 3.06 (2.69~3.48) 0.713
NEU and CK are all considered together.
BAS = basophil; EOS = eosinophil; HCT = hematocrit; HGB = hemoglobin; LYM Our research has demonstrated that age is a protective factor for the
= lymphocyte; MCH = mean corpusular hemoglobin; MCHC = mean corpusular occurrence of ACS in patients with both-bone forearm fractures. In
hemoglobin concentration; MCV = Mean Corpuscular Volume; MON = mono
Shadgan et al.’s retrospective study, the mean age of those who devel
cyte; MPV = mean platelet volume; NEU = neutrophil; PLT = platelet; RBC = red
oped ACS (33.08 ± 12.8) was significantly lower than that of those who
blood cell; ALB = albumin; AST = aspartate aminotransferase; ALT = alanine
transaminase; CREA = Creatinine; GLOB = globulin; APTT = activated partial did not (42.01 ± 17.3, P < 0.001), indicating that age is a significant risk
thromboplastin time; FIB = fibrinogen. Values are presented as the number (%) factor for ACS following acute tibial diaphyseal fractures [11]. Besides,
or the median (interquartile range). Gamulin et al. discovered that individuals under the age of 45 were at an
*
p < 0.05, statistical significance. elevated risk of ACS when undergoing treatment for tibial plateau
fractures [18]. These findings align with those of other studies [19–22],
ACS in the multivariable logistic regression analysis presented in including our own, that have identified younger age as a significant
Table 3. On the other hand, the non-ACS group showed a relatively factor in the development of ACS. One explanation for this phenomenon
higher level of ALB (p < 0.001) than the ACS group. Other laboratory is the increased intra-compartmental pressure that arises when a
results did not show significant differences between the two groups (all
p > 0.05).
While Tables 1 and 2 present the results of univariate analyses,
Table 3 provides the findings of a logistic regression analysis to identify
variables that independently predict the occurrence of ACS. The logistic
regression analysis revealed significant associations between both-bone
forearm fractures and ACS with elevated NEU (p < 0.001, OR = 1.338,
95% CI (1.187 – 1.509)), a history of crush injury (p < 0.001, OR =
10.930, 95% CI (3.893 – 30.692)) and elevated CK (p < 0.001, OR =
1.001, 95% CI (1.000 – 1.001)). However, older age (p = 0.045, OR =
Table 3
Binary logistic regression analysis of variables associated with ACS.
Characteristics OR 95%CI P
Age 0.978 0.958 – 0.999 0.045*

Crush injury 10.930 3.893 – 30.692 <0.001*
ALB 0.798 0.726 – 0.877 <0.001*
NEU 1.338 1.187 – 1.509 <0.001*
CK 1.001 1.000 – 1.001 <0.001*
ALB = albumin; NEU = neutrophil; CK = creatine kinase.

*
p < 0.05, statistical significance. Fig. 2. ROC curves for CK and NEU.
Fig. 3. Detailed information on the ROC curves of NEU and CK.
initial high-energy dissipated on soft tissue during trauma can cause ACS
[12]. Furthermore, the increased size of the damaged tissues after an
acute crush injury or from reperfusion of ischemic areas can cause
intracompartmental swelling, leading to ACS. It is noteworthy that some
studies have arrived at conclusions that are contrary to our findings,
stating that there was no association between high-energy trauma and
the occurrence of ACS [4,21,28] and even suggesting that low-energy
trauma was related to the development of ACS [29]. One possible
explanation for this discrepancy is that attempting to determine the
amount of energy released during the initial trauma may prove unreli
able due to the limitations of medical records review, which may not
offer a comprehensive understanding of the injury mechanism,
including details such as the cause of a crush injury or the precise
location of a squeeze.
An increase in intracavitary pressure, which in turn causes the
establishment of a hypoxic and ischemic milieu, always precedes the
development of ACS [30,31]. It is no longer surprising that immune cells
Fig. 4. The ROC curve combining NEU and CK. have changed in this case. In our study, we collected some information
on the levels of immune cells in patients, including BAS, EOS, LYM, and
younger person’s larger muscle mass is constrained by a tight fascia. NEU. Univariate analysis showed significant differences in BAS, EOS,
Additionally, Park et al. posited that young men might have a greater and NEU levels between the two groups, but logistic regression analysis
amount of collagen in their muscles, as well as in their fascia and only showed NEU to be an independent risk factor for ACS occurrence.
intermuscular septa [21]. Moreover, high-energy trauma is more com In addition, we determined that the cut-off value for NEU is 7.01 /L by
mon among younger people, who may be more inclined to engage in ROC curve analysis. ACS’s pathogenesis is primarily characterized by an
risky behavior. According to a study by Turnipseed et al. [23], the increase in tissue pressure surrounding enclosed muscles caused by
increased pressure within a compartment was believed to be linked to heightened vascular permeability and the formation of interstitial
the rigidity of the fascia. This suggested that there may be differences in edema [32]. Activated NEU produces oxygen radicals via the NADPH
the thickness and stiffness of the fascia between younger and older pa oxidase system and secrete enzymes such as elastase, proteinases, and
tients. In particular, older individuals may have thicker and less pliable myeloperoxidase. The latter catalyzes potent cytotoxic oxidants such as
fascia, which could lead to higher intra-compartmental pressures and an hypochlorous acid and N-chloramines, which damage endothelial cells
increased risk of compartment syndrome. Understanding these and increase their vascular permeability [33–35]. NEU’s aforemen
age-related differences in fascial properties could be important for tioned actions may be the cause of ACS. Besides, Tollens et al. have
diagnosing and treating compartment syndrome in patients of different discovered that NEU has the potential to exacerbate tissue injury and
ages. Although, as mentioned above, numerous studies have shown that edema in the reperfused muscle after migrating to the affected area [35].
there is a negative correlation between age and the incidence of ACS, Therefore, clinical practitioners should not underestimate the signifi
given the severity of ACS, older patients should not take it lightly. cance of elevated NEU levels in patients with both-bone forearm
Crush injuries were typically considered to be high-energy injuries fractures.
because they could result in extensive tissue damage and destruction CK is predominantly found in muscle cells and is commonly utilized
[24–27]. Our study has revealed that patients who suffered from in clinical practice to detect acute myocardial injury due to its excep
both-bone forearm fractures caused by crushing injuries were 10.930 tional sensitivity and specificity [36]. Furthermore, CK has been applied
times more likely to develop ACS than those who experienced ACS due to monitor other types of injuries, including skeletal muscle injury, thus
to other forms of injury. Mortensen et al. conducted a meta-analysis of demonstrating its broad clinical utility [37]. As far as we know, there
48,887 patients and reported a direct correlation between high-energy have been limited studies investigating the association between CK and
trauma and the occurrence of ACS [27]. Besides, Wang et al. and the onset and progression of compartment syndrome. Our study has
Menetrey et al. also found that high-energy trauma was associated with identified CK as an independent risk factor for ACS in patients with
the development of ACS [10,12]. Our study’s findings are consistent forearm diaphyseal fractures. We have also determined a cut-off value of
with those of these researchers. This could be because the amount of 669.1 U/L. Moreover, Valdez et al. [38] have reported an association
between CK levels and ACS in lower extremity, which is consistent with analysis, publication decisions, or manuscript preparation.
the findings of our study. Interestingly, Valdez et al. found a CK cut-off
value of greater than 4000 U/L for the association with ACS, whereas in CRediT authorship contribution statement
our study, we observed a significantly lower cut-off value of 669.1 U/L.
These differences could potentially be attributed to the severity of SY and YBL made significant contributions to the study’s conceptu
muscle damage and necrosis in patients with lower limb fractures, alization, research objectives, and initial drafting of the article. The
leading to a higher release of CK and a correspondingly higher cut-off collaborative effort extended to LJ, KZ, JQZ, ZYH, and TW, who pro
value. Furthermore, differences in sample size between the two vided valuable expertise during the review and editing process, ensuring
studies could also contribute to variations in the CK cut-off values a meticulous manuscript. Additionally, ZYH and TW played an impor
observed. The correlation between elevated CK levels and ACS is a tant role in both the review and writing of the article, contributing to its
plausible finding. CK is primarily stored in muscle cells, and when comprehensive and coherent final version. All authors read and
compartment pressure exceeds capillary pressure, cellular ischemia can approved the final manuscript.
occur. While early stages of ischemia may not present with overt signs or
symptoms, cellular debris, including the release of CK from cells, would
be expected to occur. Therefore, the elevation of maximum CK levels is a Declaration of Competing Interest
potential indicator of the onset of CS, supporting the validity of this
correlation. The authors have no relevant financial or non-financial interests to
Although our study is the first to investigate risk factors for ACS in disclose.
patients with both-bone forearm fractures, there are limitations that
should be noted. Firstly, as a retrospective study, we were unable to Acknowledgements
collect all potential variables related to ACS, such as the exact fracture
type. Secondly, relying on self-reported patient-specific variables may We appreciate the great help from our hospital and university.
introduce inaccuracies or inconsistencies in the data. Thirdly, the rela
tively small sample size may limit the power of statistical analyses, and a References
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Injury 54 (2023) 110906
Injury
Surface electromyography evaluation of selected manual and physical

therapy interventions in women with temporomandibular joint pain and
limited mobility. Randomized controlled trial (RCT)
Magdalena Gębska a, Bartosz Dalewski b, Łukasz Pałka c, *, Łukasz Kołodziej a
a
Department of Rehabilitation Musculoskeletal System, Pomeranian Medical University, Szczecin, Poland
b
Department of Dental Prosthetics, Pomeranian Medical University, Szczecin, Poland
c
Private Dental Practice, Zary, Poland
A B S T R A C T
Non-invasive approach is gaining an increasing recognition in the TMD patients management. It is therefore reasonable to conduct RCTs evaluating the effectiveness
of both physical and manual physiotherapy interventions. The aim of this study was to evaluate the short-term efficacy of selected physiotherapeutic interventions
and their effect on the bioelectrical function of the masseter muscle in patients with pain and limited TMJ mobility. The study was conducted on a group of 186
women (T) with the Ib disorder diagnosed in DC/TMD. The control group consisted of 104 women without diagnosed TMDs. Diagnostic procedures were performed
in both groups. The G1 group was randomly divided into 7 therapeutic groups in which the therapy was carried out for 10 days: magnetostimulation (T1), mag
netoledotherapy (T2), magnetolaserotherapy (T3), manual therapy- positional release and therapeutic exercises (T4), manual therapy – massage and therapeutic
exercises (T5), manual therapy – PIR and therapeutic exercises (T6), self therapy - therapeutic exercises (T7). In the T4 and T5 groups, the treatments led to complete
resolution of pain after the 10th day of therapy and to the largest minimal clinically significant difference in the MMO and LM parameter. GEE model for PC1 values
using treatment method and time point showed that T4, T5 and T6 treatments had the strongest effect on the parameters studied. Therefore, it may be concluded that
SEMG testing is a helpful indicator to assess the therapeutic effectiveness of physiotherapeutic interventions.
Background: Non-invasive approach is gaining an increasing recognition in the TMD patients management. It is therefore reasonable to conduct RCTs evaluating the
effectiveness of both physical and manual physiotherapy interventions in a qualitative and quantitative manner. However, there were numerous controversies re
ported regarding the use of surface electromyography (SEMG) in Orofacial Pain patients. Therefore, we wanted to assess the effectiveness of physiotherapy in
terventions in TMD patients using SEMG.
Purpose: Evaluation of the short-term efficacy of selected physiotherapeutic interventions and their effect on the bioelectrical function of the masseter muscle in
patients with pain and limited TMJ mobility.
Material and Methods: The study was conducted on a group of 186 women (T) with the Ib disorder diagnosed in DC/TMD (Ib - myofascial pain with restricted
mobility). The control group consisted of 104 women without diagnosed TMDs (normal reference values for TMJ ROM and masseter muscle SEMG bioelectric
activity). Diagnostic procedures were performed in both groups (SEMG of the masseter muscles at baseline and during exercise, measurement of TMJ mobility,
assessment of pain intensity - NRS scale). The G1 group was randomly divided into 7 therapeutic groups in which the therapy was carried out for 10 days: mag
netostimulation (T1), magnetoledotherapy (T2), magnetolaserotherapy (T3), manual therapy- positional release and therapeutic exercises (T4), manual therapy –
massage and therapeutic exercises (T5), manual therapy – PIR and therapeutic exercises (T6), self-therapy - therapeutic exercises (T7). Each time after therapy, the
intensity of pain and TMJ mobility were assessed. Sealed, opaque envelopes were used for randomization. After 5 and 10 days of therapy, bilateral SEMG signals of
the masseter muscles were acquired. PC1 factor analysis was performed. A score of 99% in the PC1 parameter, demonstrates the clinical relevance of electromy
ography (MVC).
Results: Synergism of physical factors will lead to a higher MID on the NRS scale. Evaluating the MID of the therapeutic interventions used showed a better ther
apeutic effect of manual interventions over physical and self-therapy. In the T4 and T5 groups, the treatments led to complete resolution of pain after the 10th day of
therapy and to the largest minimal clinically significant difference in the MMO and LM parameter. GEE model for PC1 values using treatment method and time point
showed that T4, T5 and T6 treatments had the strongest effect on the parameters studied.
Conclusions: 1. Exercise SEMG testing is a helpful indicator to assess the therapeutic effectiveness of physiotherapy interventions. 2. Manual therapy treatments are
superior to physical treatments in their relaxation and analgesic efficacy and should therefore be prescribed as a first line non-invasive intervention for TMD pain
patients.
E-mail address: dr.lpalka@gmail.com (Ł. Pałka).
M. Gębska et al. Injury 54 (2023) 110906
Introduction has been applied in the treatment of neuralgia and nerve damage or
paralysis (lingual, inferior alveolar, facial) [29].
The term ’temporomandibular disorders’ (TMD) includes issues of A systematic review by McNeely et al. looked at physical and self-
the temporomandibular joints (TMJ), masticatory muscles and adjacent therapy interventions, i.e. exercise, acupuncture, electrophysiological
tissues [1]. Mainstays of TMD are orofacial pain and limitations in methods and mechanical therapy devices, but concluded that there was
mandible opening [2]. The condition is estimated to affect between 5 no evidence to support electrophysiological methods (ultrasound and
and 12% of the population, according to various demographic data [3]. transcutaneous electrical nerve stimulation) in the treatment of TMD.
Some studies have even shown a higher incidence of up to 25% [4] and The same review suggested that there is an improvement in mouth
33% [5] to 40% [6] in the general population. According to the World opening with muscle awareness relaxation therapy (MART), biofeed
Health Organisation’s (WHO) report, TMD is the third dental issue back training and low-level laser therapy [30].
recognised as a population disease after dental caries and periodontitis Ucar et al. found the use of ultrasound with at home exercise pro
[7]. gram to be effective compared to home exercise alone, contradicting the
TMD symptoms are unequivocally reported to be more common in data collected in the previously mentioned systematic review, which
women than in men [8]. The prevalence of orofacial pain in TMDs was concluded eventually that ultrasound was not an effective treatment
described to be 21% in men and 30% in women [9]. Young women method [31].
under the age of 30 are also at an increased risk of TMD [10]. Plesh et al. As of now, conclusions regarding the effectiveness of the use of
found the presence of racial disparities, as facial and jaw pain was shown physiotherapy interventions in patients with TMD are not consistent. In
to be more common in Caucasians, compared to African-Americans accordance with above scientific reports, there are discrepancies in the
[11]. effectiveness of physical treatments compared to manual treatments,
Etiology of temporomandibular joint disorders may include, but is which are more likely to show a beneficial therapeutic effect, but these
not limited to biological, environmental (smoking), emotional (depres observations require further research [27–31].
sion and anxiety), social and cognitive factors. There is a consistent Effectiveness of TMDs treatment largely depends on the proper
association with other pain conditions (e.g. chronic headaches), fibro diagnosis establishment, performed second to a subjective and physical
myalgia, autoimmune disorders (e.g. Sjogren’s syndrome, rheumatoid examination (e.g. DC/TMD) and diagnostic imaging (e.g. CBCT, MRI).
arthritis and lupus erythematosus), psychiatric diseases and obstructive Palpation of masticatory, face and neck muscles in standard diagnostic
sleep apnea [10,12]. methods only allows a subjective assessment of increased muscle tone.
The multifactorial and often unclear etiology of TMD has led to the One among many measurement tools available for muscle quantitative
development of numerous therapeutic interventions for the treatment of examination is SEMG. It might be an important complement to the ex
this often-painful disorder. Current clinical recommendations suggest a amination of masticatory muscle function, as well as for monitoring
multidisciplinary approach with conservative interventions recom entire treatment process [32]. This method has been very well described
mended for TMD [2]. Physiotherapy (PT) is a non-invasive and one of as well as its guidelines established by SENIAM project (www.seniam.
the most commonly used treatments [13] and aims to reduce pain, in org). Hence, some study results still turned out these results to be con
crease joint mobility and correct abnormal motor behavior [14]. It has a tradictory [33]. Advocates of this neurophysiological diagnostic method
wide range of therapeutic techniques [15] i.e.: manual treatments - MT believe that it should be used for, among others: determining increased
(e.g. positional release, joint mobilisations, massage, post-isometric and decreased muscle tone, and assessing the effects of treatment, e.g.
muscle relaxation -PIR), kinesiotherapy (e.g. active exercises, iso after chiropractic, orthodontic and physiotherapeutic treatment [34].
metric exercises) physical therapy (e.g. magnetic field, laser, ultrasound, Sousa et al. showed that low-energy laser therapy treatments in women
electrotherapy) [16,17]. suffering from myogenic TMD have a short-term therapeutic effect in the
According to Rashid et al., up to 72% of respondents found physio form of changes in SEMG parameters [35]. In a study by Urbanski et al.
therapy to be an effective form of treatment for TMD, with the most comparing the therapeutic effect of PIR and myofascial release treat
effective treatments being therapeutic TMJ exercises (79%), ultrasound ments, a significant decrease in SEMG activity of the masticatory mus
(52%), manual therapy (48%), acupuncture (41%) and laser therapy cles tested and a significant decrease in spontaneous pain intensity were
(15%) [18]. Randomized controlled trials (RCT) have demonstrated the observed in both treatment groups. There were no significant differences
effectiveness of manual therapy in patients with TMD, showing im between groups [36].
provements in pain, maximal mouth opening (MMO) and pressure pain Previously described scientific data indicate significant therapeutic
threshold (PPT) [19–21]. benefits from the use of physiotherapeutic methods in TMD patients, and
Systematic reviews showed positive results for TMJ movement and the SEMG examination of the masticatory muscles can be a valuable tool
pain when MT interventions were used. These interventions included to assess therapeutic effects. However, more randomized studies on
myofascial release and muscle soft tissue massage, cervical spine comparing the effectiveness of different TMD treatments should be
mobilization and manipulation with TMJ mobilization techniques designed and its’ results published.
[22–24]. Hence, we hypothesised that the use of manual treatments (MT),
Biasotto-Gonzales et al. demonstrated the efficacy of masticatory physical therapy and therapeutic exercises (TE) promotes a reduction in
muscle massage in the treatment of soft tissue disorders, achieving both masticatory muscle potential, pain relief and improved TMJ range of
muscle relaxation, improved tissue blood supply and joint range of motion.
motion and reduced pain [25]. Post-isometric relaxation (PIR) is one of Therefore, we investigate the effect of the short-term efficacy of
the best-known mobilization techniques using the phenomena of muscle selected physiotherapeutic interventions (manual, physical therapy and
excitation and inhibition. It is now commonly used in daily clinical self-therapy -ST) and their impact on the bioelectric function of the
practice for both musculoskeletal therapy and TMD disorders [26]. masseter muscle in patients with TMJ pain and limited mobility.
Authors were unable to find any studies on the evaluation of therapy
with extremely low-frequency magnetic fields on the bioelectrical Material and methods
function of the masticatory muscles, pain symptoms and range of
mobility of the TMJ. However, studies to date indicate a positive effect The study was conducted on female patients from the University
of magnetostimulation in acute pulpitis and complications of endodontic Dental Clinic of the Pomeranian Medical University in Szczecin, Poland.
treatment, after tooth replantation, in bone regeneration, surgical pro The study was approved by the Ethics Committee of the Pomeranian
cedures, complications after anesthesia, orthodontic and prosthetic Medical University in Szczecin, Poland, according to Good Clinical
treatment and TMJ arthropathies [12,27,28]. In addition, the method Practice (resolution number KB-0012/102/13) and registered under
ClinicalTrials.gov Identifier: NCT05619380, subsequently. Patients be with zero meaning “no pain” and 10 meaning “the worst pain imagin
tween 20 and 45 years of age diagnosed with myofascial pain with able). Mandibular mobility (MMO, and lateral movement to the right
limited mouth opening (Ib) based on DC/TMD criteria were included in and left was measured using an electronic calliper). Mean values of
the study. Exclusion criteria included: inflammation in the oral cavity lateral mandibular movements between (mLM) were then calculated
that emerged as myospasm or preventive muscle contraction, earlier (Fig 1).
splint therapy, pharmacotherapy (e.g., oral contraception, hormone Control group (n = 104) consisted of the same number of healthy
replacement therapy, and antidepressants), systemic diseases (e.g., women, aged 20 to 45, without claimed TMD and pain disorders, in
rheumatic and metabolic diseases), mental illness, lack of mandible whom SEMG tests and TMJ mobility measurements were performed.
orthopedic stability, masticatory organ or whiplash injury, pregnancy, Patients with T group were randomly assigned (simple randomiza
patients undergoing orthodontic treatment, other types of inflammation tion) to the experimental groups (T1-T7) using the closed envelope
in the oral cavity (e.g., pulp inflammation or impacted molars), and fi method. In order to conceal the allocation, consecutively numbered,
bromyalgia, contraindications to the use of physical treatments in the opaque, sealed envelopes were used. Care was taken to ensure that they
manual therapy. remained undamaged and not see-through when held against a light
All women underwent an intra-oral and extra-oral dental examina source throughout entire process.
tion performed by Orofacial Pain trained dentist. Aim was to exclude Outcome assessors were blind to group allocation, and were not
odontogenic, periodontal and articular causes of TMD pain. Women involved in providing the interventions. The statisticians conducting the
meeting the above criteria constituted the study group (T, n = 186). The statistical analyses were blind to group allocation until after the analyses
patients qualified for the study underwent instrumental diagnostics were completed.
(SEMG of the masseter muscles at rest and exercise, linear measurement The physiotherapeutic intervention such as the following was
of the range of mandibular mobility) and the level of pain intensity was implemented in the masseter muscle over a period of 10 days (excluding
assessed on the NRS numerical scale (pain severity scale from 0 to 10, Saturdays and Sundays):
Fig. 1. CONSORT flowchart of the participants’ progress through the trial phases [37].
• T1 physical treatment: magnetostimulation: hands. After 10 s of isometric tension, the patient relaxed the muscles,
and the therapist escorted the mandible to the new functional barrier.
A pulsating, heterogeneous magnetic field generated by the appa The described cycle was repeated thrice during a single treatment,
ratus using an elliptical applicator with a beam width of approx. 5 cm. In starting from the previously obtained functional barrier [39].
this subgroup, a therapeutic program was prescribed of increasing in
tensity from "3″ to "7″, increasing by one level, every other day. The • T7- self-therapy:
elliptical applicator remained stationary in the same place during the
treatment. Each patient was given a therapeutic exercise program, with in
structions to perform them daily throughout the study [40].
• T2- physical treatment: magnetoledotherapy:
a) Gerry’s exercise starting position: tongue positioned on the palate
Synergic action of a slow-changing magnetic field and LEDs with a movement: slow movements of opening and closing the mouth
wavelength of 860 nm. An elliptical magnetic - light (IR) applicator with number of repetitions: 6 times a day for 10 repetitions
a diameter of 5 cm containing 47 infrared diodes was used. The method b) Active exercises for lateral movements of the mandible starting po
of applying the applicator, the type of program, its application and the sition: maxillary and mandibular teeth separated by about 5 mm
duration of the procedure were the same as in the MS subgroup. movement: the slow movement of the mandible to the left and back
to the median line, then the direction of the mandible to the right and
• T3- physical treatment: magnetolaserotherapy: back to the median line number of repetitions: 6 times a day for 10
repetitions
Synergic operation of a slowly changing magnetic field and a low- c) Side-to-side exercise Starting position: Place a pen or pencil in the
energy IR laser, with a wavelength of 808 nm, maximum power of mouth and hold it between your teeth. Movement: Slowly move the
300 mW and a frequency of 181.8 Hz. During the procedure, it was jaw from one side to the other side. Repeat this exercise ten to fifteen
important to observe the principle of perpendicular incidence of the times and three to five daily sets. Number of repetitions: 6 times a
radiation beam on the tissue and the use of protective glasses by the day for 10 repetitions
patient and the therapist. The patients were dosed with laser radiation d) Protrusion and mouth opening starting position: teeth slightly
with an increasing intensity from 3.0 J/cm2 to 5.0 J/cm2 (with an in separated movement: a) lowering the jaw forward b) opening the
terval of 2 days, the intensity was increased by 0.5 J/cm2). The total mouth c) closing the mouth d) retracting the lower jaw number of
dose of laser radiation administered to each patient was 40 J/cm2. repetitions: 6 times a day for 10 movements
• T4- manual treatment: mobilization of painful points (positional Physical procedures were performed using the Viofor JPS Clinic
release): device (Med&Life, Komorow, Poland) (in the case of MA and MLE)
connected via a link with the Viofor Laser JPS apparatus (in the case of
Therapist searches for a pain point within the masseter muscle MLA). In each treatment group, the duration of the procedure within one
(working direction from the zygomatic bone downwards towards the masseter muscle was 12 min.
mandibular branch, band by band). Once the point has been located, the All manual therapy treatments were carried out by the same phys
therapist keeps the index finger on it and positions the mandible in a iotherapist with 12 years’ experience, with treatments lasting 12 min.
position where the pressure soreness at the point disappears or the in In women with T, pain was assessed on the NRS scale each time after
tensity of the pain decreases to 2 e on a scale of 0–10. This position is therapy and the range of mandibular mobility was assessed. After
maintained for 90 s. Each patient was released between 5 and 10 points treatment days 5 and 10, a follow-up SEMG was performed.
during the session [38].
SEMG test of masseter muscle
• T5- manual treatment: massage and self-therapy:
SEMG recordings from the masseter muscles were performed with a
(a) intraoral massage The massage was carried out on the right and two-channel NeuroTrac MyoPlus 2 device with NeuroTrac software
then the left masseter muscle. The therapist positioned the thumb on the (Verity Medical Ltd., Tagoat, Ireland). Clinical Mode EMG was used
zenith of the patient’s mouth and the index finger inside - ’pincer grip’. during the study. To obtain precise SEMG measurements, a band-stop
The massage was carried out by performing 10 vertical movements in a filter was used, which guarantees that the frequencies of 50 Hz and
direction from the upper attachment to the lower attachment of the 60 Hz (mains) will not interfere with the recording of muscle activity
masseter muscle - band by band. Then, using the exact grip, 10 hori (measured in microvolts). Specialized filtering allows SEMG to be
zontal movements were carried out from the medial to the lateral side of measured with a precision of 0.1 µV.
the muscle in the same direction as above. The pressure applied by the In order to avoid magnetic interference, when collecting SEMG
therapist during therapy was approximately 0.5 kg during each ma measurements, the device was not placed in the vicinity of cell phones
neuver. (b) functional massage With a pinch grip (as in ‘a’), the phys (<4 m) or other sources that might affect the results. Unipolar electrodes
iotherapist performed a vertical massage of the masseter muscle, during were used for the test, which were attached at a distance of 20 mm from
which the patient was asked to make 10 slow movements of opening and each other. The main principle used in all subjects was to place the
closing the mouth (to the limit of pain and/or discomfort) [38]. electrodes over the center of muscle belly, parallel to the path of its fi
bers. The basis for the precise placement of the electrodes was a careful
• T6- manual treatment: post-isometric relaxation of the masseter palpation of the muscle. The masseter muscles were assessed in an up
muscle (PIR) and self-therapy: right sitting position, with the head in a natural, postural position, hands
resting on the knees and feet resting on the ground. Before the electrodes
While performing this technique, the therapist placed his thumbs on were applied, the skin was cleaned with rubbing alcohol disinfectant,
the patient’s premolar and molar chewing surfaces and then passively following electrode manufacturers’ manual. The neutral electrode was
retracted the mandible until the so-called functional barrier was located on the cervical section - C7 styloid process, which is usually
reached. In this position, the patient performed an isometric contraction devoid of vastly active muscle fibers.
of the mandibular adductors, using about 20% of their maximum
strength - the initiated contraction was balanced by the therapist’s
a) Examination of the electrical activity of the masseter muscle at rest principal component analysis (PCA). Analysis showed that one factor
(Rest Test): the test was performed on relaxed and relaxed patients. explaining 99% of the variance, which was used to model the variables
The dental arches remained slightly open during the examination. In under study. In order to more accurately assess the effects of therapy on
order to eliminate the registration of signals related to the electrical the patient, a generalised estimating equations (GEE) regression model
activity of the eye circular muscle, these persons had their eyelids was used to assess the impact of type of therapy and the effect of time on
closed during the measurements. The patients were instructed not to patient outcomes. Results of the model are presented as coefficient
swallow saliva during the examination and to place their tongue in a values, standard error and p-value for each component statistic. The
resting position. interaction effect between the time point and the therapy used was
b) Study of the bioelectrical activity of the masseter muscle during included in the model. Model diagnostics were carried out by assessing
maximal muscle contraction (MVC): SEMG signal was recorded in a the mean value of the residuals and analysing their distribution. Values
sitting position, while clenching the teeth, using the greatest possible of p < 0.05 were considered significant, and the analysis was performed
force, within 5 s. The computer program with which the device in R language in the RStudio environment (PBC, Boston, MA, US,
cooperated registers the minimum and maximum values and calcu http://www.rstudio.com) [43].
lates the average values of electric potentials.
Results
The SEMG values obtained were normalized as the ratio of RLX to
MVC. In Table 1 the results of the analysis of the minimal important dif
Activity normalized to MVC [%] = RLX [µV]/ MVC [µV] x 100% ference are presented.
[41]. As can be seen from Fig.4 between the control and T1-T7 study
Mean SEMG values were then calculated between the right and left groups, statistical differences (p < 0.001) were obtained in all parame
masseter muscles. ters assessed. There was no statistical difference between the T-treat
Mean SEMG values between the right and left masseter muscles ment groups in the variables studied before the start of therapy (p >
(mSEMG RLX, mSEMG MVC, mSEMG MVC%) were then calculated. 0.001).
As depicted in Fig.2 there are significant correlations between all the Fig.5. Statistical analysis of the SEMG distribution, mandibular
variables studied (p < 0.05). The strongest correlation was observed in mobility range and pain intensity in the treatment groups and the con
the exercise mSEMG parameter, as it is correlated with every variable trol group after a 10-day therapy.
studied, positively with resting mSEMG and NRS and negatively with As can be seen from Fig.5a more favourable therapeutic effect was
mandibular movements (MMO, mLM). shown by manual therapies (T4 - T6) compared to physical therapies
(T1-T3). The T4 and T5 treatments led to the resolution of pain (NRS 0),
the greatest decrease in all mSEMG tests, and the most improvement in
Statistical analysis TMJ range of motion (MMO, mLM).
Fig.6. Parameters analysis in the therapeutic groups (T1-T7) before,
In order to assess the normalcy of the variables, the Shapiro Wilk test during and after the end of the therapies.
and Q-Q plot were used. Variables were analyzed using the nparLD test As Fig.6 shows TM treatments (T4-T6) presented the greatest effec
with a post hoc test for multiple comparisons. MID value was calculated tiveness after both 5 and 10 treatments. The greatest variations in pa
as 1/2 of the standard deviation of the initial value of each parameter rameters in all treatment groups occurred only after the 10th treatment.
[42]. Correlations between parameters were assessed using the The PC1 index in the T4-T6 methods shows a significant increase. A
Spearman coefficient. Due to the significant correlations between all the statistical difference was obtained between therapies (p<0.001)
parameters studied, it was decided to reduce the dimensions using
Fig. 2. Correlations between measurements. Numbers in each square represent Spearman Correlation coefficient.
Legend: m- mean, RLX – Rest test; MVC- Maximal Voluntary Contraction;%MVC - percentage of maximum voluntary contraction, MMO -maximal mouth open, LM –
lateral movement, NRS- numeric rating scale of pain.
Fig. 3. Results of PCA. A: Screen plot for obtained principal components, B:% of contribution for PC1 (DIM-1).
Principal component analysis revealed a single factor explaining 99% of the variance in the system under study. The SEMG value of MVC was the main contributor to
explaining the variance, with a factor construction contribution of 99% (Fig.3).
and signs and symptoms of TMD, suggesting the potential effectiveness

Table. 1
of SEMG in distinguishing myogenic TMD [47]. Castroflorio et al. [48]
Minimal important difference (MID).
and Lauriti et al. [49] found that masticatory muscle SEMG indices were
Variable Mean SD MID reproducible in identifying patients with and without TMD in the resting
MMO [mm] 38.2 2.92 1.46 position and during MVC [9]. Other researchers have also reached
mLL [mm] 6.17 1.2 0.436 similar conclusions [50,51].
NRS scale 4.05 2.35 1.18
By analyzing the results obtained, the authors of the study came to
mSEMG (RLX) [µV] 16.2 28.3 7.05
mSEMG (MVC) [µV] 133 114 57.1 important conclusions that may contribute to the knowledge regarding
mSEMG (%MVC) 12.9 6.24 3.12 the validity of performing SEMG in patients with TMD. As shown in our
study, mSEMG MVC correlates strongly with all variables in patients
Legend: m- mean, RLX – Rest test; MVC- Maximal Voluntary Contractions;%
with painful TMD, i.e. mSEMG RLX (0.63), MMO (− 0.6), mLM (− 0.47),
MVC - percentage of maximum voluntary contraction, MMO -maximal mouth
open, LM – lateral movement, NRS- numeric rating scale of pain. NRS (0.6). Furthermore, in the PC1 analysis, the mSEMG MVC showed
99% variability, i.e. this parameter can be considered to best describe a
patient with TMD pain and limited mandibular mobility during phys
(Table 2).
iotherapy treatments. Thus, it can be cautiously concluded that exercise
As can be seen from the above analysis, MT (p < 0.001) and MT with
SEMG is a method that is worthwhile to include in the diagnostic process
self-therapy (p < 0.001) treatments had the most tangible influence on
of a TMD patient and as a tool to assess the effects of the therapies used,
the patients’ recovery during entire course of therapy (Table 3).
however, this research needs further follow-up.
Comprehensively, occlusal splints and pharmacological treatment
Discussion
[1,52] are mainstays as a primary therapeutic modalities in painful
TMDs. However, in order to maintain this therapeutic effect over a
Complexity of TMDs etiological factors, numerous co-morbid
longer period of time, other supportive treatments should be used,
symptoms and overall increase in the number of attending patients
which include physiotherapy treatments [53].
has prompted clinicians and researchers to undertake an effort to
The aim of the physiotherapeutic approach in TMD is, among other
develop and refine diagnostic and therapeutic protocols. While non-
things, is to restore baseline metabolism, improve oxygenation and
invasive therapeutic methods, i.e. physiotherapy, do not raise doubts
nutrients supply via increased blood flow to fatigued muscles, relax
about their validity, the use of electromyography in the process of
them, improve TMJ range of motion and proprioception, and control
diagnosis and assessment of therapeutic effects remains debatable, due
pain avoiding local sensitization [1].
to the significant variability of results reported [44,45]. In their sys
While conducting the above study, the authors aimed to evaluate the
tematic review Al.-Saleh et al. showed no confirmation of the efficacy of
effectiveness of selected physiotherapeutic interventions and their effect
SEMG as a diagnostic tool for TMD [32]. In contrast, a study by Berni
on the bioelectric function of the masseter muscle in patients with pain
et al. found moderate accuracy of SEMG values for the masticatory
and limited TMJ mobility. Patients were divided into seven groups (T1-
muscles when assessing TMD in adults [44]. In their study, Manfredini
T7) and the therapies used were physical treatments (T1-magneto
et al. evaluating the diagnostic accuracy of SEMG in the diagnosis of
stimulation, T2-magnetoledotherapy, T3-magnetolaserotherapy),
people with painful TMD, concluded that the use of EMG indices in the
manual treatments with or without self-therapy (T4-relaxation of
diagnosis of myogenic TMD should be used carefully, rarely or not at all,
maximally painful points; T5-massage in combination with self-therapy;
due to the potential risk of false positives [46]. Since their results
T6- PIR and self-therapy) and self therapy (T7).According to our
showed unacceptable performance of SEMG at rest in discriminating
knowledge no similar studies comparing the effectiveness of the above
between symptomatic and asymptomatic subjects (AUC = 0.28–0.48)
therapeutic treatments were found in the available literature so far.
and a fairly good to excellent degree of accuracy of EMG during MVC
Despite the available publications [52,54] assessing the difference in
(AUC > 0.7) [46]. In contrast, a different conclusion was reached by De
muscle tone in TMD patients, only a single study has evaluated the effect
Felício et al. who observed a positive correlation between SEMG indices
of combination treatment involving magnetostimulation, on
Fig. 4. The results of the analysis of variables (mSEMG,MMO, mLM, NRS,) in the control and study groups (T1-T7) before the physiotherapy treatments.
lateral movement, NRS- numeric rating scale of pain, T1 – magnetostimulation, T2 – magnetoledotherapy T3 – magnetolaserotherapy, T4 - positional release, T5 –
massage and self-therapy, T6 – PIR and self-therapy, T7 – self therapy.
masticatory muscle tone and mandibular pain and mobility in TMD. Rój interventions can have an effect on reducing mandibular muscle spas
et al. compared the effects of chiropractic therapy combined with ticity, e.g. through percutaneous electrical nerve stimulation [58,59].
magnetostimulation on SEMG parameters and pain intensity. According However, later studies have not confirmed analogous effects beyond
to their study, the therapy used contributed to a gradual reduction in pain reduction [60].
pain in both the study and control groups. However, the reduction in Moreover, we found no papers that evaluated the effectiveness of
patients’ pain was more effective in the group that received adjunctive magnetolaserotherapy in patients with TMD and its effect on SEMG .
therapy with magnetic stimulation. There was no statistical difference However, the current state of knowledge on low-level laser therapy
between the groups in the SEMG parameter [55]. These results stand (LLLT) as a therapeutic modality for TMD is primarily based on previ
mostly in line with László et al. who obtained positive results in the ously conducted prospective clinical trials with uncertain results
treatment of masticatory pain with extremely low frequency magnetic [61–63] Few studies have shown superior efficacy of LLLT compared to
fields [56]. placebo [61–63], while others showed similar action of LLLT and pla
A study by Kubala et al. compared the analgesic effect of magneto cebo in the treatment of TMD [64,65].
stimulation and magnetoledotherapy in patients with TMD. In their Some systematic reviews have shown controversial results regarding
study, a subgroup of patients treated with magnetoledotherapy showed the efficacy of LLLT in TMD [66,67]. Meta-analyses by Gama et al. [68]
a better analgesic effect compared to magnetostimulation [57]. This were unable to establish the efficacy of LLLT therapy in TMJ pain.
may be due to the deeper local effect and the simultaneous application of However, a meta-analysis by Chang et al. suggested that LLLT has a
both stimuli in one treatment. Light of a fixed wavelength applied reasonable analgesic effect on TMJ pain [69]. Shousa et al. confirm the
together with an electromagnetic field penetrates deeper than that short-term therapeutic effect of LLLT on improving VAS, MMO and
applied alone. This synergy of the two treatment modalities is therefore SEMG in women suffering from myogenic TMD [35].
more beneficial from a therapeutic point of view [57]. According to the authors’ study, the application of physical treat
Some researchers have indicated that the use of physiotherapeutic ments in the form of magnetostimulation (T1) and synergism of physical
Fig. 5. The results of the analysis of variables (mSEMG, MMO, mLM, NRS) in the control and study groups (T1-T7) after the physiotherapy treatments (day 10 of
therapy).
Legend: m- mean, RLX – Rest test; MVC- Maximal Voluntary Contractions;%MVC - percentage of maximum voluntary contraction, MMO -maximal mouth open, LM –
agents (magnetoledotherapy-T2 and magnetolaserotherapy-T3) did not subjects undergoing a single PIR treatment, whereas no significant
lead to significant therapeutic effects. MID analysis shows that at T1, T2 change in the parameter studied was found in the group of subjects
and T3, minimal clinical relevance was not achieved in the mSEMG undergoing the positional release method [70]. Other conclusions were
parameters RLX, MVC and%MVC and in PC1. There was also a lack of reached by Ibanez-Garcia et al. who compared the therapeutic effect of
MID in mandibular movement parameters (MMO and mLM). However, PIR and the positional release method. According to their study, both
MIDs on the NRS scale were demonstrated after 10 days of therapy, with methods were highly effective in reducing pressure pain threshold (PPT)
magnetoledotherapy (MID - NRS 3.27) and magnetolaserotherapy (MID and increasing the maximum pain-free active range of motion of the
- NRS 3.50) showing a better analgesic effect than magnetostimulation mandible, with a moderate effect on reducing the intensity of local pain
alone (MID - NRS 1.35), consistent with the findings of other authors induced by palpation [71]. In their study, the authors showed MID after
[57]. Thus, it can be concluded that the synergism of physical agents has the 10th day of therapy in both groups (T4 and T6) in both the mSEMG
a more favourable effect on the decrease of pain intensity in female TMD parameter RLX, MVC,%MVC and mandibular movements. According to
patients. the authors’ study, after the 10th day of therapy, positional release
Clinical effectiveness of treatment protocols consisting of multiple treatments were more effective in terms of analgesia (T4, NRS 0)
forms of physiotherapy is increasingly reported in the literature. How compared to the effectiveness of PIR and self-therapy (T6, NRS 2).
ever, there are few scientific reports evaluating and comparing selected According to the authors’ study, TM treatments proved to be a more
TM methods for their effectiveness in painful TMD. effective form of therapy compared to physical therapy (p < 0.001). MID
Blanco et al. compared the effectiveness of PIR and positional release analysis shows that already after day 5 of therapy, the T4 (positional
(strain/counterstrain) in the treatment of TMD pain. A significant in release) and T5 (massage and TE) groups showed a clinically significant
crease in pain-free active mandibular range of motion was observed in difference in the mSEMG parameter RLX, MVC,%MVC. On the other
Fig. 6. The effect of the applied physiotherapeutic treatments in all seven therapeutic subgroups on mSEMG, MMO, mLM, NRS during the initial study (1), after 5
days of therapy (2), and after the 10th treatment day.
day 5 of therapy. TM also proved more effective than physical therapy in

Table. 2
its analgesic effect. Analysing the pain parameter, we find that already
Results of the therapeutic effects in the study groups (nparLD test).
after day 5 of therapy, T4 (MID - NRS 5.91), T5 (MID-NRS 5) and T6
Variable p (MID - NRS 2.48) showed significant improvement. In the T4 and T5
group time group x time
groups, there was complete resolution of pain (NRS 0) after the 10th day
PC1 <0.001 <0.001 <0.001 of therapy.
mSEMG RLX 0.00
<0.001 <0.001
As can be seen from the data obtained above, PIR in combination
mSEMG MVC <0.001 <0.001 <0.001
mSEMG%MVC <0.001 <0.001 <0.001
with TE proved to be the least effective manual therapy from an anal
MMO <0.001 <0.001 <0.001 gesic point of view and was the only one that did not significantly
mLM <0.001 <0.001 <0.001 improve lateral mandibular movements after day 5 of therapy. Thus, it
NRS <0.001 0.00 <0.001 can be concluded that, from a clinical point of view, manual treatments
Legend: PC1 - first principal component, m- mean, RLX – Rest test; MVC- based on positional release and massage combined with self-therapy are
Maximal Voluntary Contraction;%MVC - percentage of maximum voluntary more effective forms of TM than post-isometric muscle relaxation
contraction, MMO -maximal mouth open, LM – lateral movement, NRS- numeric combined with TE.
rating scale of pain. Authors’ study shows that self-therapy only after the 10th day of
therapy led to MID in the parameter MMO, mLM, NRS (MID - NRS 2.36),
hand, after day 10, the MID showed all manual treatments. Manual mSEMG MVC, while no difference was obtained in%MVC. As per MID
treatments (T4-T6) also showed MID after day 5 of therapy in the MMO mSEMG RLX was after day 5 of therapy. From the results, it can be
parameter. T4 and T5 groups showed MID in lateral movements after concluded that self-therapy alone has a slight effect on the resolution of
Table. 3 Conclusions
GEE model for PC1 values using treatment and time point.
Coefficients: 1 Exercise SEMG is a method worth considering when assessing the
Estimate Std.err Wald Pr(>|W|) Estimate SE Wald p therapeutic effect of physiotherapy in TMD patients.
(Intercept) -87.084 18.315 22.608 <0.001 2 Manual treatments show greater clinical relevance than physical
Time 1.756 2.963 0.351 0.553 treatments in patients with pain, restricted TMJ mobility and
T2 32.948 24.757 1.771 0.183 increased masticatory muscle tension.
T3 18.613 22.637 0.676 0.410
T4 61.015 22.879 7.112 0.007
T5 54.139 22.275 5.907 0.015 Ethics information
T6 74.615 21.397 12.16 0.000
T7 5.131 22.186 0.054 0.817 The study was approved by the Ethics Committee of the Pomeranian
Time: T2 0.552 3.923 0.02 0.888 Medical University in Szczecin, Poland, according to Good Clinical
Time: T3 -0.817 3.644 0.05 0.822
Time: T4 19.724 3.404 33.571 <0.001
Practice (resolution number KB-0012/102/13) and registered under
Time: T5 20.650 3.344 38.131 <0.001 ClinicalTrials.gov Identifier: NCT05619380, subsequently
Time: T6 14.291 3.247 19.367 <0.001
Time: T7 5.499 3.486 2.488 0.114
Funding
Legend: SE- standard Error, Wald- wald statistic value; T2 – magnetoledotherapy
T3 – magnetolaserotherapy, T4 - positional release, T5 – massage and self- This research received no external funding.
therapy, T6 – PIR and self-therapy, T7 – self therapy.
Informed consent statement
symptoms in TMD patients compared to TM, however, it is more effec
tive than physical therapy. Similar conclusions were reached by Kalamir Informed consent was obtained from all subjects involved in the
et al. who used two groups of therapies with patients: G1: manual study.
therapy and G2: education and self-care. Authors concluded that pa
tients with myogenic TMD who received manual therapy had signifi Data availability statement
cantly lower pain scores than those in the education and self-care [72].
In contrast, Nagata et al. showed that short-term TM combined with TE, The data presented in this study are available upon request from the
resulted in a significant increase in MMO compared to TE alone [73]. corresponding author. The data are not publicly available due to sensi
Tucer et al. found that manual therapy combined with a home exercise tive information.
program was more effective than a home exercise program alone in
reducing pain and maximal mouth opening [74]. Authors of the study
Consent for publication
also came to similar conclusions.
Cleland et al. showed improvements in MMO and pain with con
Not applicable
servative physiotherapy including manual therapy, therapeutic exercise
and patient education [15].
To sum up, we would like to highlight the most important results and Declaration of Competing Interest
insights possible to obtain by conducting this research. First of all, it is
noteworthy that SEMG demonstrated a significant role for patients with The authors declare that they have no known competing financial
TMD. A score of 99% in the PC1 parameter, demonstrates the clinical interests or personal relationships that could have appeared to influence
relevance of electromyography, which should be emphasised in the the work reported in this paper.
diagnostic management and evaluation of treatment effects. However,
further research should be conducted to assess the validity and repro Supplementary materials
ducibility in conducting SEMG in patients with TMDs, probably on
larger cohorts. When assessing the minimal important difference (MID) Supplementary material associated with this article can be found, in
and the GEE model for PC1 values using the method of therapy and the the online version, at doi:10.1016/j.injury.2023.110906.
time point of the therapeutic interventions used, the superiority of
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12
Injury 54 (2023) 110909
Injury
Should nails be locked dynamically or statically in atypical femoral

fractures? – A radiological analysis of time to union and reoperations in 236
displaced fractures with 4 years average follow-up
Christian Fang a, Wan Yiu Shen b, Janus Siu Him Wong a, *, Dennis King-Hang Yee a,
Colin Shing-Yat Yung a, Evan Fang a, Yuen Shan Lai c, Siu Bon Woo c, Jake Cheung a,
Jackie Yee-Man Chau c, Ka Chun Ip b, Wilson Li b, Frankie Leung a
a
Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
b
Department of Orthopaedics and Traumatology, Queen Elizabeth Hospital, Kowloon, Hong Kong
c
Department of Orthopaedics and Traumatology, Kwong Wah Hospital, Yau Ma Tei, Hong Kong
Keywords: Introduction: Atypical femoral fractures (AFFs) are associated with delayed union and higher reoperation rates.
Bisphosphonate Axial dynamization of intramedullary nails is hypothesized to reduce time-to-union (TTU) and fixation failure as
Atypical femoral fracture compared to static locking.
Intramedullary nail
Methods: Consecutive acutely displaced AFFs fixed with long intramedullary nails across five centres between
Dynamic locking
Dynamisation
2006 and 2021 with a minimum postoperative follow-up of three months were retrospectively reviewed. The
primary outcome was TTU, compared between AFFs treated with dynamically or statically locked intramedullary
nails. Fracture union was defined as a modified Radiographic Union Score for Tibial fractures score of 13 or
greater. Secondary outcomes involved revision surgery and treatment failure, defined as non-union beyond 18
months or revision internal fixation for mechanical reasons.
Results: A total of 236 AFFs (127 dynamically locked and 109 statically locked) were analysed with good
interobserver reliability of fracture union assessment (intraclass correlation coefficient = 0.89; 95% CI =
0.82–0.98). AFFs treated with dynamized nails had significantly shorter median TTU (10.1 months; 95% CI =
9.24–10.96 vs 13.0 months; 95% CI = 10.60–15.40) (log-rank test, p = 0.019). Multivariate Cox regression
revealed that dynamic locking was independently associated with greater likelihood of fracture union within 24
months (p = 0.009). Reoperations were less frequent in the dynamic locking group (18.9% vs 28.4%), although
the difference was not statistically significant (p = 0.084). Static locking was an independent risk factor for
reoperation (p = 0.049), as were varus reduction and lack of teriparatide use within three months of surgery.
Static locking also demonstrated a higher frequency of treatment failure (39.4% vs 22.8%, p = 0.006) and was an
independent predictor of treatment failure in logistic regression (p = 0.018). Other factors associated with
treatment failure included varus reduction and open reduction.
Conclusions: Dynamic locking of intramedullary nails in AFFs is associated with faster time to union, lower rate of
non-union, and fewer treatment failures.
Introduction microfractures, AFFs often present acutely displaced following only

minor trauma [7–9]. Preceding an AFF, patients may experience pro
Atypical femoral fractures (AFFs) are known to exhibit slow union dromal pain and radiological evidence of a stress fracture. AFFs will
and high reoperation rates. They are associated with long-term continue to be a challenge as bisphosphonate therapy remains a stan
bisphosphonate use, excessive femoral bowing, and Asian ancestry dard treatment for osteoporosis [7,10].
[1–6]. Due to impaired homoeostasis and accumulation of Long cephalomedullary intramedullary nailing (IMN) is the standard
* Corresponding author at: The University of Hong Kong, Pokfulam, Hong Kong.
E-mail address: januswong@connect.hku.hk (J.S.H. Wong).
nc-nd/4.0/).
C. Fang et al. Injury 54 (2023) 110909
Fig. 1. mRUST criteria for defining radiological union.
treatment for both displaced AFFs and stress fractures with impending The need for informed consent was waived due to the retrospective
displacement [11]. Sufficient stability allows for patients to weight bear nature of the study.
immediately following surgery [12–14], however, AFFs treated with
IMN have been observed to exhibit higher rates of non-unions and
Grouping and baseline variables
reoperations than typical femoral fractures [11].
Axial dynamization is typically used for transverse or short oblique
Patients were grouped based on the locking mode of the interlocking
shaft fractures. This facilitates fracture gap closure and introduces
screw, being either dynamic or static. Dynamically locked IMNs were
micromotion which may be advantageous for callus formation [15–17].
defined as having 2 mm or more space available for collapse in the
The effects of nail dynamization have not been previously studied in
elongated screw slot in the immediate post-operative X-ray. Those
AFFs. The purpose of this study was to compare the effect of static versus
having less than 1 mm of available collapse were considered to be
dynamic locking of IMNs on time to union and treatment failure rates
statically locked. The option for dynamic or static locking was deter
following fixation of AFFs.
mined intraoperatively based on the preference of the operating team
considering fracture configuration, stability, and surgeon’s personal
Methods
preference.
Baseline variables were collected, including open versus closed
Study design
reduction, reduction quality, fracture location (proximal, middle, or
lower third of femur), presence of wedge fragments, teriparatide pre
A cohort of patients with AFFs from five hospitals was recruited
scriptions initiated within three months post-fracture, presence of
through a centralized regional electronic operative record registry. All
radiographical evidence of AFF in the contralateral femur, or fixation of
consecutive femoral fractures coded under the International Classifica
AFF (prophylactic or fractured) in the contralateral femur. The presence
tion of Diseases 9th revision (ICD-9-CM) procedure codes 820.21,
of any mini-incisions at the fracture site was considered to be an open
820.22, 820.32, 821.0, 821.1, 821.20 and 821.3 were retrospectively
fracture. Reduction quality was assessed based on the criteria set out by
identified. All cases having three or more months of radiographic follow-
Baumgartner and Cho[18] where fracture reduction was considered
up data were analysed for study inclusion. Cases were included if they
“good” if there remained less than 4 mm of translation and less than 5 ◦
met the following inclusion criteria: (i) meeting four of the five major
of varus or flexion angulation. Reduction quality was assigned as
American Society for Bone and Mineral Research (ASBMR) 2014 criteria
“good”, “acceptable”, or “poor” based on fulfilment of both, one, or
for AFFs [4], (ii) being acutely displaced, (iii) and having been treated
neither of the above criteria, respectively.
by a long intramedullary nail that extended to the distal femoral met
aphysis. Pathological fractures, prophylactic fixations for undisplaced
fractures, and fixations other than long nailing were excluded. Outcome measures
Follow-up were scheduled at post discharge 2 weeks, then 3 weeks later,
6 weeks later, 3 months later, and 6 monthly subsequently. Patients with The primary outcome was time to union (TTU), defined as the time
radiological follow-up of less than three months were also excluded. from the operative date to the date of the first radiograph demonstrating
Ethical approval for this study was granted [blinded for peer-review]. definite radiological union. Fracture union was quantitively assessed
using the Modified Radiographic Union Score for Tibia (mRUST) [19].
Fig. 2. STROBE flow chart of the study.
This scale has demonstrated superior reliability over the original RUST Reliability assessment
score [20] and is also applicable to assessing femoral fracture healing
[19]. The score estimates fracture healing and is calculated as the sum of To assess interobserver reliability of fracture healing assessment, 40
the individual scores of the four fractured cortices seen on ante randomly selected radiographs with an mRUST score between 8 and 16
roposterior and lateral radiographs (Fig. 1) with a maximum score of 16. were re-assessed 2 weeks apart by independent observers. The interob
A review of all radiographs was performed by three investigators who server intraclass correlation coefficient was 0.89 (95% CI, 0.82 – 0.98),
are orthopaedic surgeons each having more than 10 years of operative indicating good interobserver reliability.
experience [blinded for peer-review] after a consensus meeting. Definite
radiological union was defined as mRUST ≥ 13 with at least one cortical
surface demonstrating evidence of remodelling. Consecutive radio
graphs were compared and the date of the earliest radiograph with an
Data were analysed using SPSS software (Version 27, IBM, Armonk,
mRUST score >=13 was considered the date of fracture union.
USA) and R Statistical Software version 4.0.3. Missing data was not
Secondary outcomes included (i) any revision surgery for the
imputed. Variable selection was made upon a consensus building session
affected femur, (ii) treatment failure, and (iii) fracture callus size.
with domain experts comprising 3 senior orthopaedic trauma surgeons
Treatment failure was a composite outcome defined as non-union
each having more than 10 years of operative experience in the treatment
beyond 18 months or revision of the internal fixation for mechanical
of atypical femoral fractures. Descriptive statistics were reported for
reasons. Revision surgeries not defined as treatment failure included
baseline and outcome data. Categorical variables were tested for sta
infection debridement, secondary dynamization by only removal of
tistical significance using Pearson’s chi-squared test and continuous
static locking screws, and refixation for new traumatic fractures. Facture
variables with unpaired t-test. The median TTU was presented with its
callus size was measured as the percentage of the cortical thickness on
95% confidence interval (95% CI). Variables with significant differences
the latest radiograph with an mRUST <13 before definite union.
in TTU were included in a Kaplan-Meier time-to-event analysis using
log-rank (Cox-Mantel) tests. To control for confounding and identify
independent risk factors, all factors were subjected to multivariate
Table 1
Baseline demographics and treatment variables of the patients.
Dynamic group (n Static group (n p
= 127) = 109) value
Patient demographics
Age (mean, years) 72.9 ± 9.3 73.2 ± 10.1 0.783
*
Female 124 (97.6%) 101 (92.7%) 0.071
Follow up (mean, months) 50.2 ± 35.4 46.2 ± 31.8 0.372
*
Drugs taken prior to fracture 0.107
Alendronate 77 64
Ibandronate 11 10
Risedronate 6 1
Zoledronate 4 1
Unspecified bisphosphonate 13 8
Denosumab 4 3
Strontium ranelate 1 0
Corticosteroid 1 0
None of above 10 22
Contralateral leg status 0.814
Uninvolved 44 (35.8%) 36 (34.6%)
Operated for other reasons 3 (2.4%) 5 (4.8%)
Radiographically involved 33 (26.8%) 28 26.9%)
only
Operated for AFF 43 (35.0%) 35 (33.7%)
Femur fracture location 0.642
Proximal 1/3 62 (48.8%) 52 (47.7%)
Middle 1/3 62 (48.8%) 52 (47.7%)
Distal 1/3 3 (2.4%) 5 (4.6%)
Charlson Comorbidity Index 0.455
(CCI)
0 76 (59.8%) 61 (56.0%)
1 29 (22.8%) 22 (20.2%)
2+ 22 (17.3%) 26 (23.9%)
Wedge fragment 0.001
Present 22 (17.3%) 39 (35.8%)
Absent 105 (82.7%) 70 (64.2%)
Treatment variables
Reduction Type 0.233
Open / Mini-open 52 (40.9%) 35 (33.3%)
Closed 75 (59.1%) 70 (66.7%)
Proximal locking 0.026
With cephalic fixation 117 (92.1%) 90 (82.6%)
Without cephalic fixation 10 (7.9%) 19 (17.4%)
Teriparatide within 3 months 0.928
of surgery
Yes 18 (14.2%) 15(13.8%)
No 109 (85.8%) 94 (86.2%)
Reduction quality 0.027
(translation) Fig. 3. Kaplan-Meier time-to-event curve showing difference in union times
81 (63.8%) 84 (77.1%)
comparing between (a) static vs dynamic locking (b) varus reduction and (c)
<4mm
>4mm 46 (36.2%) 25 (22.9%)
teriparatide use within 3 months from surgery, with shaded colours repre
Reduction quality (angulation) 0.887
Valgus or Neutral 85 (66.9%) 72 (66.1%) senting 95% confidence intervals and number of subjects at risk below
Varus ≥ 5◦ 42 (33.1%) 37 (33.9%) the chart.
Reduction quality (overall) 0.009
Good 61 (48.0%) 69 (63.3%)
throughout.
Acceptable 43 (33.9%) 18 (16.5%)
Poor 23 (18.1%) 22 (20.2%)
Follow-up length 0.337 Results
*
3 months+ 127 (100%) 109 (100%) Study patients
6 months+ 121 (95.3%) 107 (98.2%)
12 months+ 110 (86.6%) 96 (88.1%)
24 months+ 91 (71.7%) 74 (67.9%) Medical records and radiological data of 375 femurs in 301 patients
36 months+ 71 (55.9%) 60 (55.0%) with suspected displaced AFFs were screened (Fig. 2). The final sample
48 months+ 55 (43.3%) 44 (40.4%) consisted of 236 femurs in 221 patients who fulfilled all inclusion
*
Unpaired t-test. All other factors were tested for significance using chi-square criteria, of which 225 (95.3%) patients were female. Mean age was 73.0
test. Statistically significant values are denoted in bold. ± 9.7 years. Operative dates ranged from December 2006 to April 2021.
Surgeries were performed by orthopaedic specialists and residents under
analysis. Cox proportional hazards multivariate regression analysis was supervision. The mean radiological follow-up was 48 ± 33.8 months
performed for TTU outcome. Binary logistic regression was used for (range, 3–142 months). Thirty femurs (12.7%) did not reach the fracture
factors related to revision and failure. Adjusted hazard ratios (HR) union endpoint due to patient death (range, 20–159 months). A history
determined from multivariable analysis were reported with 95CI values. of predisposing medication use was identified in 202 patients (86%).
A p-value of less than 0.05 was considered statistically significant
Table 2
List of all reoperations, failures, and other outcomes within both groups.
Outcomes
Dynamic group (n = 127) Static group (n = 109) Total p value
Total reoperations 24 (18.9%) 31 (28.4%) 55 0.084

Non-mechanical
Infection debridement 0 1 1
Secondary dynamization 15 21 36
Reoperations Neck fracture – new injury 2 0 2
Prominent screw removal 0 2 2
Mechanical
Plate revision 1 2 3
Nail revision “Failures” 6 5 11
Non-union beyond 18 months 28 (22.0%) 41 (37.6%) 49 0.009
Total “Failures” 29 (22.8%) 43 (39.4%) 63 0.006
Other Outcomes
Callus size 0.155
Minimal callus 13 (10.2%) 19 (17.4%)
<50% cortical width ratio 56 (44.1%) 51 (46.8%)
>50% cortical width ratio 58 (45.7%) 39 (35.8%)
Subsidence till union (mean, mm) Ψ 2.2 ± 1.9 2.2 ± 1.9 0.7 ± 2.4 <0.001*
1–2mm 52 (40.9%) 13 (11.9%)
2–5mm 34 (26.8%) 5 (4.6%)
5–9mm 7 (5.5%) 1 (0.9%)
10–20mm 0 2 (1.8%)
Time-to-union (mRUST≥13) (Median) 10.1 months 13.0 months 11.2 months 0.019**
Healed at 6 months 12 (9.4%) 10 (9.2%)
Healed at 12 months 76 (59.8%) 50 (45.9%)
Healed at 18 months 99 (78.0%) 68 (62.4%)
Healed at 24 months 109 (85.8%) 81 (74.3%)
Healed at 36 months 117 (92.1%) 97 (89.0%)
Healed at 48 months 118 (92.9%) 98 (89.9%)
*
Unpaired t-test.
**
Log-rank test. All other factors were tested for significance using chi-square test. Statistically significant values are denoted in bold.
ΨTotal shortening including from revision surgery.
Treatment failure defined as non-union beyond 18 months or revision of the internal fixation for mechanical reasons.
Patient demographics and treatment variables reduced rates of fracture union at 24 months. Multivariate Cox regres
sion showed that dynamic locking (HR = 1.53; 95% CI = 1.11–2.11),
Patient demographics and treatment variables are presented in good angular reduction (HR = 1.67; 95% CI = 1.05–2.66) and a lower
Table 1. Dynamic locking was used in 127 femurs (54%) and static Charlson Comorbidity Index (CCI) (HR = 0.87; 95% CI = 0.77–0.98)
locking in 109. Dynamic locking was more highly associated with were independent cofactors associated with faster healing at 24 months.
proximal cephalic fixation (92.1% vs 82.6%, p = 0.026), absence of a In the Cox regression model, teriparatide use was independently asso
wedge fragment (82.7% vs 64.2%, p = 0.001), translational reduction ciated with higher probability of fracture union until 6 months but not
with >4 mm remaining shift (36.2% vs 22.9%, p = 0.027), and lower afterwards (HR = 5.35; 95% CI = 2.00–14.32). Factors such as fracture
likelihood of a “good” overall reduction quality (48% vs 63.3%, p = location, reduction technique and comminution were not independently
0.009). No significant differences were found between the two groups in associated with time-to-union at any time point. Dynamically locked
terms of age, sex, osteoporotic drug use, contralateral leg AFF status, femurs had greater a mean total subsidence (2.2 ± 1.9 mm) compared to
fracture location, CCI, use of open reduction, teriparatide prescriptions statically locked femurs (0.7 ± 2.4 mm) at final follow up (p < 0.001).
status, or incidence of varus reduction. Across time during the study No patients with dynamic locking had nail subsidence of more than 10
period, there was no statistically significant difference between the rates mm at the time of fracture union. On the contrary, two cases (1.8%) in
of open reduction in the first and second halves of the study (chi-square the statically locked cohort had shortening of more than 10 mm when
test p-value of 0.102). Similarly, there was no statistically significant accounting for reoperations. A complete list of factors included the
difference in the rates of cephalic fixation (chi-square test p-value of univariate TTU analysis and the Cox regression model is presented in
0.728). Analyses of secondary associations outside of the main study Appendix Tables A4 and A5 (Fig. 3).
objective are presented in Appendix Tables A1–A3.
Reoperations & treatment failures
Time to union
There was a total of 55 reoperations (Table 2). The incidence of
AFFs treated with dynamically locked femoral nails had significantly reoperation was 24 (18.9%) in the dynamic locking group and 31
faster median time-to-union (10.1 months; 95% CI = 9.24–10.96]) (28.4%) in the static locking group, however this difference was not
compared to their statically locked counterparts (13.0 months; 95% CI statistically significant (p = 0.084). Secondary dynamization by locking
= 10.60–15.40) (log-rank test, p = 0.005 at 18 months). Kaplan-Meier bolt removal was performed for 15 (11.8%) patients in the dynamic
analysis revealed that dynamic stabilization (HR = 1.51; 95% CI = group and 21 (19.3%) in the static group. Reoperations were signifi
1.13–2.02; p = 0.005) and good angular reduction (HR = 1.87; 95% CI, cantly associated with the quality of initial reduction, being 48.9% for
1.36–2.55; p < 0.001) were associated with faster union within 24 “poor”, 23% for “acceptable”, and 14.6% for “good” reduction cases (p
months. The use of teriparatide was associated with higher probability < 0.001) (Table 3). A significantly lower rate of reoperation was also
of fracture union at 6 months (HR = 3.96; 95% CI = 1.66 – 9.46). found for patients who were prescribed teriparatide within 3 months of
Proximal fractures (HR = 0.58; 95% CI = 0.43–0.77) and use of open surgery (9.1% vs 25.6%, p = 0.037). Multivariate binary logistic
reduction (HR = 0.72; 95% CI = 0.53–0.97) were associated with regression revealed that static locking (HR = 2.07; 95% CI = 1.00–4.27;
Table 3
Univariate analysis and multivariate logistic regression for all risk factors for reoperations.
Risk factors for reoperations
n with missing data Univariate analysis Multivariate analysis
Reoperations
No (%) Yes (%) p value HR (95%C.I.) p value
Age (Mean ± SD) 0 73.3 + 9.4 71.9 + 10.7 0.349* 1.00 (0.96–1.04) 0.913
Sex 0 0.681 2.04 (0.34–12.35) 0.437
Female 172 (76.4%) 53 (23.6%)
Male 9 (81.8%) 2 (18.2%)
Charlson Comorbidity Index 0 0.471 1.26 (0.81–1.94) 0.305
0 109 (79.6%) 28 (20.4%)
1 37 (72.5%) 14 (27.5%)
2+ 35 (72.9%) 13 (27.1%)
Contralateral AFF involvement 9 0.962 1.04 (0.79–1.37) 0.794
Normal 60 (75.0%) 20 (25.0%)
Radiological change 48 (78.7%) 13 (21.3%)
Operated for AFF 59 (75.6%) 19 (24.4%)
Femur fracture location 4 0.012 1.69 (0.70–4.07) 0.241
Proximal 1/3 78 (68.4%) 36 (31.6%)
Middle 1/3 97 (85.1%) 17 (14.9%)
Distal 1/3 6 (75.0%) 2 (25.0%)
Open reduction 0 0.021 1.91 (0.92–3.97) 0.085
Closed 119 (82.1%) 26 (17.9%)
Open 60 (69.0%) 27 (31.0%)
Wedge fragment 0 0.783 1.14 (0.51–2.54) 0.750
Present 46 (75.4%) 15 (24.6%)
Absent 135 (77.1%) 40 (22.9%)
Reduction quality (translation) 0 0.005 1.57 (0.70–3.51) 0.273
<4 mm 135 (81.8%) 30 (18.2%)
>4 mm 46 (64.8%) 25 (35.2%)
Reduction quality (angulation) 0 <0.001 5.62 (1.99–15.87) 0.001
Valgus or Neutral 135 (86.0%) 22 (14.0%)
Varus ≥ 5◦ 46 (58.2%) 33 (41.8%)
Overall Reduction Quality 0 <0.001
Good 111 (85.4%) 19 (14.6%)
Acceptable 47 (77.0%) 14 (23.0%)
Poor 23 (51.1%) 22 (48.9%)
Teriparatide use in 3 months 0 0.037 5.17 (1.39–19.24) 0.014
Yes 30 (90.9%) 3 (9.1%)
No 151 (74.4%) 52 (25.6%)
Dynamic locking 0 0.084 2.07 (1.00–4.27) 0.049
Yes 103 (81.1%) 24 (18.9%)
No (Static locking) 78 (71.6%) 31 (28.4%)
Proximal locking 0 0.078 3.85 (0.77–1.30) 0.101
*
Unpaired t-test. All other factors were tested for significance using chi-square test in the univariate model. Statistically significant values are denoted in bold.
p = 0.049), varus reduction (HR = 5.62; 95% CI = 1.99–15.87; p = Discussion

0.001) and lack of teriparatide use within 3 months post-surgery (HR =
5.17; 95% CI = 1.39–19.24; p = 0.014) were factors associated with In our study, dynamic locking resulted in faster union and lower
reoperation. When comparing dynamically locked AFFs without varus failure rates. The use of dynamic locking and good angular reduction
alignment versus those statically locked and in varus, the relative risk for were synergistic factors for lower reoperation and failure risk.
non-unions, reoperations and treatment failure was respectively 1.88, There are no previous studies of nail dynamization in AFFs and only
2.40 and 2.03 (p < 0.001), with treatment failure defined as non-union limited prospective evidence in traumatic fractures. Dynamic locking is
beyond 18 months or revision of the internal fixation for mechanical generally avoided in wedge fragments, long oblique, and spiral patterns
reasons. Age, sex, CCI, contralateral femur status, fracture location, open where a lack of fracture end opposition may result in excessive limb
reduction, comminution, fracture translation and use of cephalic fixa shortening [21–24] and delayed union [22,24–27]. In one randomized
tion did not demonstrate significant associations in the multivariate study by Basumalick et al. (n = 50), dynamization resulted in shorter
model. average TTU by 4 weeks with similar union rates [28]. Conversely, in a
Statically locked nails had a significantly higher incidence of treat non-randomized series, Tigani et al. [29]. showed that static locking was
ment failure as a composite outcome (39.4% vs 22.8%, p = 0.006) associated with shorter TTU (14.9 vs 18 weeks, p = 0.005) in 179
(Table 4). Other factors significantly associated with treatment failure femoral shaft fractures. Differences in fracture pattern, host biology,
included varus alignment (p < 0.001), proximal fracture location (p = rehabilitation, reduction technique, nail stiffness, and fracture union
0.002), and open reduction (p = 0.011). Logistic regression showed that assessment criteria may account for the differences.
static locking (HR = 2.20; 95% CI = 1.15–4.22; p = 0.018), varus Of the 15 patients in the dynamically locked group who required
reduction (HR = 2.78; 95% CI, 1.14–6.76; p = 0.025) and open reduc secondary dynamization, two-thirds of these were attributable to im
tion (HR = 2.05; 95% CI = 1.06–3.98; p = 0.033) were independently plants with shorter oblong holes or due to technical failure in placing the
associated with treatment failures (Table 5). screw at the most distal limit, thereby limiting the distance available for
subsidence. While secondary dynamization has been shown to offer a
slight benefit in traumatic fractures [21,22,26,28,30], there is
Table 4
Univariate analysis and multivariate logistic regression for all risk factors for treatment failures.
Risk factors for "Treatment failure" (Revision for mechanical reasons or non-union of fracture beyond 18 months)
n with missing data Univariate analysis Multivariate analysis
"Treatment failures"
No (%) Yes (%) p value HR (95%C.I.) p value
Age (Mean ± SD) 0 73.1 ± 9.3 72.7 ± 10.5 0.806* 1.01 (0.98–1.05) 0.470
Sex 0 0.666 1.43 ( 0.32–6.40) 0.642
Female 157 (69.8%) 68 (30.2%)
Male 7 (63.6%) 4 (36.4%)
Charlson Comorbidity Index 0 0.445 1.29 (0.88–1.89) 0.196
0 99 (72.3%) 38 (27.7%)
1 35 (68.6%) 16 (31.4%)
2+ 30 (62.5%) 18 (37.5%)
Contralateral AFF involvement 9 0.609 1.02 (0.79–1.30) 0.895
Normal 53 (66.3%) 27 (33.8%)
Radiological change 42 (68.9%) 19 (31.1%)
Operated for AFF 56 (71.8%) 22 (28.2%)
Femur fracture location 4 0.002 1.10 (0.51–2.38) 0.810
Proximal 1/3 67 (58.8%) 47 (41.2%)
Middle 1/3 91 (79.8%) 23 (20.2%)
Distal 1/3 6 (75.0%) 2 (25.0%)
Open reduction 0 0.011 2.05 (1.06–3.98) 0.033
Closed 111 (76.6%) 34 (23.4%)
Open 53 (60.9%) 34 (39.1%)
Wedge fragment 0 0.399 1.28 (0.61–2.69) 0.512
Present 45 (73.8%) 16 (26.2%)
Absent 119 (68.0%) 56 (32.0%)
Reduction quality (translation) 0 0.680 1.43 (0.65–3.12) 0.377
<4mm 116 (70.3%) 49 (29.7%)
>4mm 48 (67.6%) 23 (32.4%)
Reduction quality (angulation) 0 <0.001 2.78 (1.14–6.76) 0.025
Valgus or Neutral 121 (77.1%) 36 (22.9%)
Varus ≥ 5◦ 43 (54.4%) 36 (45.6%)
Overall Reduction Quality 0 0.011
Good 97 (74.6%) 33 (25.4%)
Acceptable 44 (72.1%) 17 (27.9%)
Poor 23 (51.1%) 22 (48.9%)
Teriparatide use in 3 months 0 0.704 1.02 (0.42–2.46) 0.967
Yes 22 (66.7%) 11 (33.3%)
No 142 (70.0%) 61 (30.0%)
Dynamic locking 0 0.006 2.20 (1.15–4.22) 0.018
Yes 98 (77.2%) 29 (22.8%)
No (Static locking) 66 (60.6%) 43 (39.4%)
Proximal locking 0 0.426 1.24 (0.40–3.88) 0.714
*
Unpaired t-test. All other factors were tested for significance using chi-square test in the univariate model. Statistically significant values are denoted in bold.
Table 5
Main adverse outcomes in relation to alignment and locking mode with relative risks.
No varus | Dynamic No varus | Static Varus | Dynamic Varus | Static Relative risk (95%CI)* p value**
(n = 85) (n = 72) (n = 42) (n = 37)
Non-union at 18 months 16 (18.8%) 20 (27.8%) 12 (28.6%) 21 (56.8%) 1.88 (1.28 – 2.75) <0.001
Reoperated for any reason 9 (10.6%) 13 (18.1%) 15 (35.7%) 18 (48.6%) 2.40 (1.39 – 4.13) <0.001
Mechanical failures 16 (18.8%) 20 (27.8%) 13 (31.0%) 23 (62.2%) 2.03 (1.37 – 2.99) <0.001
*
Relative risk between the first group (No Varus & Dynamic) versus the last group (Varus & Static),.
**
Chi-Square test.
insufficient data to analyse its effect in our study, as the indication for requiring an extended observation period and more data gathered per
secondary dynamization was not standardized and no matched control patient. This method appears to be sufficiently specific as none of our
group could be drawn. patients who reached the mRUST ≥13 endpoint experienced further
The major strength of our study is the large, multi-centre, consecu problems. However, adoption of this criteria resulted in apparently
tive cohort with sufficient follow-up comprising only of displaced frac longer union times in our patient series when compared to other studies
tures. We excluded all prophylactic nailing for undisplaced fractures as [32–35].
they have much lower complication rates and difficulty in radiographic From our data, the use of dynamic locking and good angular
assessment of fracture healing. Plates and short cephalomedullary nails reduction without varus angulation were synergistically associated with
are known to have higher failure rates and were also excluded [31,32]. faster union times and lower failure rates. Our findings echo multiple
The mRUST score had good interobserver reliability in defining fracture prior studies where varus and increased bowing were linked to failures
union but was more stringent than other commonly used criteria. The [18,32–34]. Moreover, open reduction was an independent risk for
mRUST scoring method requires visible cortical remodelling, thus treatment failure, albeit with a lower HR and borderline statistical
Fig. 4. A patient with statically locked cephalomedullary nail with good reduction. Serial radiographs shown on both AP and lateral views. Numbers in the box
denoting mRUST sub-score for each cortex. Definite union is reached at 6 months with cortical bone remodelling according to the mRUST≥13 criteria with no
nail subsidence.
Fig. 5. A patient with dynamically locked cephalomedullary with both varus alignment and translation. Serial radiographs shown on both AP and lateral views.
Numbers in the box denoting mRUST sub-score for each cortex. Definite union is reached at 13 months according to the mRUST≥13 criteria with 3 mm of
nail subsidence.
significance. The authors hypothesise that this could potentially be and is also a speaker for Depuy Synthes, he has received research sup
contributed by periosteal stripping and compromise to bone biology port from AO Trauma. All other authors declare no conflicts of interest.
during open reduction, with the association between open reduction and
non-union having been previously reported [41]. Nonetheless, our Acknowledgements
findings support that obtaining a good reduction should be of utmost
priority and that when a closed reduction fails, an open approach should The authors would like to thank Grace Pui Yi Ho and Kathine Ching
be attempted. for project and administrative support.
Our subgroup of 33 patients who received teriparatide within three
months exhibited faster TTU at 6 months with a large multivariate HR of
5.3 (p < 0.001). However, this effect was not demonstrated beyond 12
months. Additionally, our data also showed that teriparatide use is
linked to larger callus formation, although callus formation was not
enhanced by dynamic locking. In our study, the median TTU was 9.6
months in patients with abundant callus (>50% of cortical width),
versus 18 months in those with minimal observable callus. Of note, one References
third of patients in our cohort were observed to have union with
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May;.
10
Injury 54 (2023) 110910
Injury
Treatment and outcome of fracture-related infection of the clavicle

Jonathan Sliepen a, b, Harm Hoekstra b, c, Jolien Onsea b, c, Laura Bessems b, c, Melissa Depypere d,
Nathalie Noppe e, Michiel Herteleer b, c, An Sermon b, c, Stefaan Nijs f, Jan J Vranckx g,
Willem-Jan Metsemakers b, c, *
a
University Medical Center Groningen, Department of Trauma Surgery, University of Groningen, 9713 GZ Groningen, The Netherlands
b
University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium
c
KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium
d
University Hospitals Leuven, Department of Laboratory Medicine, 3000 Leuven, Belgium
e
University Hospitals Leuven, Department of Radiology, 3000 Leuven, Belgium
f
University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
g
University Hospitals Leuven, Department of Plastic and Reconstructive Surgery, 3000 Leuven, Belgium
Keywords: Introduction: The number of operatively treated clavicle fractures has increased over the past decades. Conse
Fracture-related infection quently, this has led to an increase in secondary procedures required to treat complications such as fracture-
Infection related infection (FRI). The primary objective of this study was to assess the clinical and functional outcome
Clavicle
of patients treated for FRI of the clavicle. The secondary objectives were to evaluate the healthcare costs and
Fracture
propose a standardized protocol for the surgical management of this complication.
Reconstruction
Treatment Methods: All patients with a clavicle fracture who underwent open reduction and internal fixation (ORIF) be
Bone defect tween 1 January 2015 and 1 March 2022 were retrospectively evaluated.
Dead space management This study included patients with an FRI who were diagnosed and treated according to the recommendations of a
multidisciplinary team at the University Hospitals Leuven, Belgium.
Results: We evaluated 626 patients with 630 clavicle fractures who underwent ORIF. In total, 28 patients were
diagnosed with an FRI. Of these, eight (29%) underwent definitive implant removal, five (18%) underwent
debridement, antimicrobial treatment and implant retention, and fourteen patients (50%) had their implant
exchanged in either a single-stage procedure, a two-stage procedure or after multiple revisions. One patient
(3.6%) underwent resection of the clavicle. Twelve patients (43%) underwent autologous bone grafting (tri
cortical iliac crest bone graft (n = 6), free vascularized fibular graft (n = 5), cancellous bone graft (n = 1)) to
reconstruct the bone defect. The median follow-up was 32.3 (P25-P75: 23.9–51.1) months. Two patients (7.1%)
experienced a recurrence of infection. The functional outcome was satisfactory, with 26 out of 28 patients (93%)
having full range of motion. The median healthcare cost was € 11.506 (P25-P75: € 7.953–23.798) per patient.
Conclusion: FRI is a serious complication that can occur after the surgical treatment of clavicle fractures. In our
opinion, when treated adequately using a multidisciplinary patient-specific approach, the outcome of patients
with an FRI of the clavicle is good. The median healthcare costs of these patients are up to 3.5 times higher
compared to non-infected operatively treated clavicle fractures. Although not studied individually, we consider
factors such as the size of the bone defect, condition of the soft tissue, and patient demand important when it
comes to guiding our surgical decision making in cases of osseous defects.
Introduction displaced clavicle fractures has increased over the course of the past
decades [4]. This can be attributed to recent studies demonstrating
Fractures of the clavicle are common, with recent large national lower non-union rates, faster return to function and less pain for oper
studies demonstrating an incidence ranging between 59.3 and 101 per atively treated displaced fractures of the clavicle compared to non
100,000 persons per year [1–3]. The number of operatively treated operatively treated fractures [5–10]. However, high quality evidence on
* Corresponding author at: Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
E-mail address: willem-jan.metsemakers@uzleuven.be (W.-J. Metsemakers).
J. Sliepen et al. Injury 54 (2023) 110910
the superiority of surgical treatment of displaced midshaft clavicle follow-up and both the clinical and functional outcome were recorded.
fractures with respect to long term functional outcome is still lacking
[8–10]. Definitions and outcome measures
With the number of surgeries increasing, the number of secondary
procedures will increase as well. One of the most important indications The classification of fractures was based on the AO/OTA classifica
for such a secondary procedure is a fracture-related infection (FRI) [8, tion. This was evaluated using a standard radiograph (X-ray) and/or
11]. FRI is a serious complication that is often related to orthopedic computed tomography (CT) scan. The overall management of the FRI
trauma. Studies showed that it has a major impact on the patient’s patient was based on the recommendations of a multidisciplinary team.
quality of life [12] and can increase hospital-related healthcare costs by The MDT was composed of at least orthopedic/trauma surgeons, plastic
up to eight times compared to non-infected fractures [13]. Although surgeons, microbiologists, infectious disease specialists, radiologists,
studies focusing on infection after operatively treated displaced mid pharmacists, physiotherapists and specialist nurses. All decisions and
shaft clavicular fractures are scarce, infection rates ranging between agreements made by the MDT were documented in the patient’s elec
0.4% and 7.8% have been reported [14–17]. As scientific data related to tronic medical record. Recurrence of infection was defined as the
the management of FRI after the operative treatment of clavicular recurrence of a confirmatory sign according to the FRI consensus defi
fractures is limited, standardized treatment protocols are almost nition, within the follow-up period after cessation of surgical and anti
nonexistent. The importance of standardized treatment protocols – microbial treatment [19,20].
based on a multidisciplinary team (MDT) approach – has recently been
addressed by the FRI Consensus Group [18]. Clinical outcome
The primary objective of this study is to retrospectively evaluate the
clinical and functional outcome of patients treated for FRI of the clav Outcome was based on clinical, functional and radiological evalua
icle. The secondary objectives are to evaluate the healthcare costs of tion during the last follow-up visit. During physical examination patients
patients treated for FRI of the clavicle and propose a standardized pro were monitored for signs of infection and shoulder function was assessed
tocol for the surgical management of this complication. using the AO neutral 0-method: active anteflexion (40 – 180◦ ) and
scapular abduction (0 – 180◦ ) [21]. Full range of motion (FROM) was
Methods defined as reaching 180◦ in both planes. Evaluation of bone healing was
performed by a musculoskeletal radiologist and an experienced trauma
Study and patient characteristics surgeon and was based on plain X-rays, and/or CT-scans in case osseous
reconstruction was required.
This retrospective study was conducted at the University Hospitals
Leuven, which is a designated level-1 trauma referral center in Belgium. Healthcare costs and utilization
The protocol has been approved by the hospital’s Ethics Committee
(S66740). Between 1 January 2015 and 1 March 2022, 626 patients with The patient’s total healthcare costs are the sum of four main hospital-
630 fractures underwent open reduction and internal fixation with plate related cost categories: honoraria, materials, hospitalization (cost of
and screw osteosynthesis for a clavicular fracture. These patients were daily patient care), and pharmaceuticals [22]. In summary, honoraria
identified from the operating theater logbooks. Of the identified pa mainly consist of fees related to medical activities, mainly based on a
tients, the data were retrieved from the hospital electronic patient file fee-for-service principle (i.e., surgery, consults, and imaging).
system and included in the study’s database if they met the inclusion Material-related costs refer to the actual implants and other required
criteria. Inclusion criteria were: patients of sixteen years of age and older materials. The hospitalization-related costs are the sum of the patient’s
who were diagnosed with an FRI of the clavicle according to the criteria actual length-of-stay multiplied by the day-based care fee. The
of the FRI consensus definition [19,20]. Exclusion criteria were: index day-based care fees were €647, €620, €670, €664, €650, €686 and €765
surgery outside the study period (i.e., before 1 January 2015 or after 1 for 2015, 2016, 2017, 2018, 2019, 2020 and 2021, respectively. Phar
March 2022), noninfected fractures, non-operatively treated fractures maceutical costs are all costs for received drugs and blood products. All
and pathological fractures. Patients who were initially treated elsewhere costs were allocated with prices of 2015.
for primary fracture fixation but who were later referred to our center
for treatment of FRI were also included in this study. Statistical analysis
Study variables Study data was collected and managed using REDCap electronic data
capture tool hosted at University Hospitals Leuven, Belgium [23]. Data
Patient files were screened for the following data: sex, age at time of was analyzed using Rstudio for Windows version 4.1.2. (RStudio Team
initial infection surgery, body mass index (BMI), Arbeitsgemeinschaft (2020). RStudio: Integrated Development for R. RStudio, PBC, Boston,
für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) MA URL http://www.rstudio.com/). Counts and percentages were used
fracture classification, fracture type (open/closed), American Society of to report descriptive statistics of categorical variables. The Shapiro-Wilk
Anesthesiologists (ASA) classification, initial fracture fixation device test was performed to test normality of continuous variables. Normally
type, time to onset of FRI, treatment method, type of bone graft used and distributed variables were reported using mean and standard deviation
the total number of surgeries related to the treatment of infection. Pa (SD) and the median and inter-quartile range (P25-P75) were used for
tients were classified based on the definitive treatment method, i.e., non-normally distributed variables.
definitive implant removal; Debridement, Antimicrobial therapy, and
Implant Retention (DAIR); exchange of the implant in either a single- Results
stage, a two-stage or a multiple-stage revision approach; resection of
the clavicle. Patients who underwent exchange of the implant were Patient characteristics
subclassified in the following groups: 1) exchange of the implant
without structural bone grafts; 2) exchange of the implant with autol Out of the 626 patients with 630 clavicle fractures, 28 FRI patients,
ogous cancellous bone grafts (ACBG); 3) exchange of the implant with with a median age of 42.0 (22.5 - 49.5) years were included in this study.
bone reconstruction using a tricortical autologous iliac crest bone graft The infection rate in the group of patients initially treated in our center
(ICBG) or 4) exchange of the implant and reconstruction with a free for their fracture was 2.9% (n = 18). Ten patients (1.6%) were initially
vascularized fibular bone graft (FVFG). Furthermore, the duration of treated for a clavicle fracture in another center and were later referred to
Table 1 fractures (n = 4, 14%), as described in Table 1.

Baseline patient characteristics. In 27 cases (96%) the initial fracture fixation was done using a plate
N = 28 and screw osteosynthesis while one patient (3.6%) was treated with
screw osteosynthesis alone. In all cases, at least one pathogen was
Sex
Female 6 (21.4) identified through culture. Twenty-three cases were monomicrobial and
Male 22 (78.6) five cases were polymicrobial. The most frequently cultured pathogens
Age (years) 42.0 (22.5–49.5) were Cutibacterium acnes followed by Staphylococcus. aureus and
BMI (kg/m2) 24.1 (22.3–27.4) S. epidermidis (Fig. 1).
ASA classification
1 15 (53.6)
2 12 (42.9) Antimicrobial treatment
3 1 (3.6)
Referral As standard of care, patients undergoing initial fracture surgery were
Yes 10 (35.7)
No 18 (64.3)
given 2 g cefazolin (single dose) intravenously before the operative
AO/OTA fracture classification intervention. In case of confirmed or suspected infection, antimicrobial
15.2A 14 (50.0) therapy was not initiated until intraoperative cultures were obtained.
15.2B 4 (14.3) Empirical therapy consisted of vancomycin and piperacillin/tazobactam
15.2C 7 (25.0)
intravenously. As soon as the culture results were available this was
15.3A 2 (7.1)
15.3C 1 (3.6) switched to (oral) targeted therapy. The treatment duration for patients
Open fracture followed the hospital’s guidelines at that time, with a total of six weeks
No 28 (100) after implant removal and 12 weeks after implant retention or
Yes 0 (0) replacement. Local antibiotic therapy (gentamicin and vancomycin)
Initial primary fixation device
using polymethylmetacrylate (PMMA) cement as a carrier was given to
Plate and screw osteosynthesis 27 (96.4)
Screw osteosynthesis 1 (3.6) ten patients as part of staged revision surgery before definitive recon
Time to onset of FRI (days) 55 (37–132) structive surgery with a bone graft. One patient declined to follow the
Data are shown as median (P25-P75) or as n (%). Inter-quartile range 25th
recommended six-week oral antibiotic regimen and instead received
and 75th percentile; BMI: body mass index; ASA classification: American oral antibiotics for two weeks after implant removal. At the final follow-
Society of Anesthesiology classification; AO/OTA: Arbeitsgemeinschaft für up (at 55 months), this patient had an asymptomatic non-union and
Osteosynthesefragen/Orthopaedic Trauma Association; FRI: fracture- refused further treatment.
related infection.
Surgical treatment
our center for treatment of the FRI. The cohort consisted of 22 males
(79%) and six females (21%). Nearly all patients were classified as either Eight patients (29%) underwent definitive implant removal, five
ASA 1 (n = 15, 54%) or ASA 2 (n = 12, 43%) and one patient was patients (18%) underwent a DAIR approach, and one patient (3.6%)
classified as ASA 3 (3.6%). Out of all 630 clavicle fractures, only three underwent resection of the clavicle after multiple revisions. Fourteen
patients suffered an open fracture, none of them developed an FRI. Most patients (50%) were treated with an exchange of the implant (Table 2).
fractures (n = 25, 89%) were midshaft and a minority (n = 3; 11%) was This was done in a single-stage approach in three patients, a two-
classified as lateral clavicle fractures. Simple diaphyseal clavicle frac stage approach in seven patients and four patients required multiple
tures (15.2A) were most common (n = 14, 50%), followed by commi revisions before definitive osteosynthesis could be performed. Twelve
nuted diaphyseal fractures (15.2C) (n = 7, 25%) and diaphyseal wedge patients (43%) received an autologous bone graft: ICBG (n = 6) (Fig. 2),
FVFG (n = 5), ACBG (n = 1)) to reconstruct the bone defect. An overview
Fig. 1. An overview of the causative pathogens identified by microbiological culturing (left), and the number of monomicrobial and polymicrobial infections (right).
Table 2 follow-up was 32.3 months (P25-P75: 23.9–51.1). In 26 out of 27 patients

Treatment strategies and outcome parameters. (96%) fracture consolidation was achieved. One patient (3.7%) had an
N = 28 asymptomatic non-union. One patient who underwent resection of the
clavicle was excluded from the evaluation of consolidation. FROM was
Definitive FRI treatment
DAIR 5 (17.9) achieved in 26 out of 28 patients (89%). Both of the patients who did not
Implant removal 8 (28.6) regain FROM, did have FROM prior to the fracture. One patient had
Exchange of implant 14 (50.0) FROM before the FRI occurred, while the other patient developed a
Single-stage revision 3 (10.7) frozen shoulder during the period between initial fracture treatment and
Two-stage revision 7 (25.0)
Multiple revisions 4 (14.3)
the onset of FRI. One patient had slightly limited anteflexion (160◦ ) and
Resection of the clavicle 1 (3.6) limited scapular abduction (130◦ ) and the second patient had a slightly
Bone graft limited scapular abduction (160◦ ).
None 16 (57.1) Two patients (7.1%) suffered a recurrence of infection. One of these
Autologous cancellous bone graft 1 (3.6)
patients had a failed DAIR, five months after cessation of antimicrobial
Tricortical autologous iliac crest graft 6 (21.4)
Free vascularized fibula graft 5 (17.9) therapy. Here the fracture had healed, thus the implants were removed,
Number of reoperations median (min-max) 1 (0–19) and antimicrobial therapy was started. The patient remained infection-
Duration of follow-up (months) 32.3 (23.9–51.1) free during follow-up. The other patient underwent several complex
Outcome surgical procedures with a massive allograft but presented with a fistula
No recurrence infection 26 (92.9)
Recurrence of infection 2 (7.1)
ten months later. Infection control was achieved after multiple surgical
debridements, removal of the allograft and resection of the clavicle. This
Data are shown as median (P25-P75) or as n (%). FRI: fracture-related infection; patient regained FROM and remained infection-free during follow-up.
DAIR: debridement, antimicrobial therapy and implant retention.
Healthcare costs
of the patients treated with a bone graft is presented in Table 3.
Figs. 3, 4 and 5 present a patient treated for an FRI of the clavicle,
The healthcare costs are related to the patients treated for clavicle
with a two-stage surgical approach for a 7 cm bone defect using a FVFG.
fractures, which were complicated with an FRI. Of note, a total of ten
patients that were initially managed for their fracture (and infection) at
Clinical outcome other hospitals before being referred to our hospital for infection
treatment, were included in the cost analyses as well. Overall, the total
All FRI patients had at least twelve months of follow-up after healthcare cost for the treatment of FRI of the clavicle was calculated at
cessation of surgical and antibiotic therapy. The median duration of €587.210. This corresponds to a median cost of €11.506 (P25-P75:
Fig. 2. A 20-year-old male suffering

from a fracture-related infection of the
right clavicle, treated with a two-stage
surgical approach for a 3 cm bone
defect. (A) The patient presented at the
outpatient clinic with wound break
down, six weeks after primary fracture
treatment. (B) Standard X-ray shows
loosening of the medial screws six
weeks after the initial fracture stabili
zation using plate and screw osteosyn
thesis (external hospital). (C) The first
phase consisted of removal of all
necrotic bone and hardware followed by
placement of a polymethylmethacrylate
(PMMA) cement spacer over a Titanium
Elastic Nail (TEN). Cultures revealed the
presence of Staphylococcus epidermidis.
(D) In a second stage the cement spacer
was removed and a tricortical autolo
gous iliac crest bone graft (ICBG; 3 cm)
was wedged into the remaining clavicle
ends and stabilized with plate and screw
osteosynthesis. (E-F) Standard X-ray
revealed full consolidation of the frac
ture 24 months after the primary sur
gery, with no clinical signs of infection
and a good functional outcome.
Table 3
The application of bone grafts in the treatment of patients with a fracture-related infection of the clavicle.
Sex Age BMI (kg/ ASA- Referral Fracture Type of bone Duration of follow-up Outcome ROM
(years) m2) classification classification graft (months)
Female 17 19.46 1 Yes 15.2A FVFG 65.9 No recurrence Full

Male 56 30.79 2 No 15.2B ACB 50.4 No recurrence Full
Male 17 20.37 1 Yes 15.2A ICBG 61.0 No recurrence Full
Male 45 27.74 2 No 15.2A ICBG 36.2 No recurrence Full
Male 49 25.94 1 Yes 15.2C ICBG 16.8 No recurrence Full
Female 26 25.18 2 Yes 15.2A FVFG 27.8 No recurrence Full
Male 50 22.30 1 Yes 15.2A FVFG 18.0 No recurrence Full
Male 45 26.19 2 Yes 15.2B FVFG 12.0 No recurrence Full
Male 49 27.41 2 Yes 15.2A ICBG 13.9 No recurrence Full
Female 37 28.72 1 No 15.2A FVFG 24.8 No Anteflexion: full;
recurrence* abduction: 160◦
BMI: body mass index (kg/m2); ASA classification: American society of anesthesiologists; ROM: range of motion; FVFG: free vascularized fibular bone graft; ACB:
autologous cancellous bone graft; ICBG: tricortical autologous iliac crest bone graft. *Recovery was complicated by ankle instability which required fixation with a
syndesmosis screw.
Fig. 3. A 50-year-old male suffering a fracture-related infection of the left clavicle, treated with a two-stage surgical approach for a 7 cm bone defect. The patient
underwent two surgical revisions for infection after the primary fracture fixation at different external hospitals. (A) Standard X-ray and (B) coronal computed to
mography (CT) scan demonstrate loosening of the medial screws, 29 months after the initial fracture stabilization using plate and screw osteosynthesis. (C) Standard
X-ray demonstrates the polymethylmethacrylate (PMMA) cement spacer which was moulded over a Titanium Elastic Nail (TEN) and placed after removal of all
necrotic bone and hardware during the first stage. Cultures revealed the presence of Staphylococcus epidermidis. In a second stage the cement spacer was removed, and
a free vascularized fibular bone graft (FVFG) was wedged into the remaining clavicle ends and stabilized with plate and screw osteosynthesis. (D) Standard X-ray and
(E) coronal CT scan show the FVFG during the first postoperative week. (F) Standard X-ray, (G) axial and (H) coronal CT scan images demonstrate full incorporation
of the FVFG approximately two years after implantation.
€7.953–23.798) per patient. The distribution of costs over the four cost Discussion
categories is displayed in Table 4.
With an increase in the number of operatively treated clavicle frac
tures, related complications like FRI are encountered more frequently.
FRI of the clavicle is a challenging complication that requires
Fig. 4. A 50-year-old male suffering a fracture-related infection of the left clavicle, treated with a two-stage surgical approach for a 7 cm bone defect using a free
vascularized fibular bone graft (Fig. 2). (A-D) Approximately two years postoperatively, the skin island has integrated completely, and the patient remained infection-
free with a good functional outcome.
Fig. 5. A 50-year-old male suffering a fracture-related infec

tion of the left clavicle, treated with a two-stage surgical
approach for a 7 cm bone defect using a free vascularized
fibular bone graft (Fig. 2,3). (A-B) An anteroposterior view of a
3D-reconstructed computed tomography (CT) image of both
clavicles. These 3-dimensional images illustrate the left clavicle
(red-blue) that was operatively treated with a vascularized
fibular bone graft (FVFG) (purple) (A), as well as the mirrored
contralateral clavicle (green) (B). The plate (yellow) position is
added for demonstrational purposes. Note the importance of
correcting the length of the clavicle. The images were
segmented and aligned in Mimics innovation suite 20.0
(materialise, Leuven, Belgium).
Table 4 treated with a DAIR approach, all underwent their FRI surgery within
Healthcare costs for patients with a fracture-related infection of the clavicle (N seven weeks after initial fracture fixation. One of these patients, treated
= 28). with a DAIR approach at three weeks, was diagnosed with a recurrence
Category Per patient Total Relative of infection. Three patients received a one-stage approach for FRI, with
share one of them receiving ACBG. None of these patients experienced a
Honoraria €1.985 (370 – 3.839) €153.011 26% recurrence of infection. Seven patients underwent a two-stage revision
Materials (implants & €1.264 (999 – 1.769) €41.263 7% surgery, with six receiving ICBG and one receiving FVFG, all without
screws) recurrence of infection. Of the five patients who needed multiple re
Hospitalization €4.213 (1.284 – €347.992 59%
visions, four were successfully treated with FVFG, and one patient had a
16.126)
Pharmaceuticals €717 (492 – 1.147) €44.944 8% recurrence after the use of a massive allograft. Overall, two patients
Total €11.506 (7.953 – €587.210 100% (7.1%) suffered a recurrence of infection. Both were treated for the
23.798) recurrent infection and remained infection-free ever since (follow-up >
The per patient costs show the median followed by P25-P75. 3 years).
The functional outcome in our cohort was satisfactory. Only two
patients had minor limitations in their range of motion. Fracture
debridement of all non-viable tissues, which may result in an osseous
consolidation was achieved in 96% of the patients. The relatively low
defect that requires a complex surgical reconstruction. The main ob
recurrence rate, good functional outcome and high consolidation rate in
jectives of this study were to evaluate the clinical outcome and health
our patient cohort underline the importance of a multidisciplinary team
care costs for patients treated for FRI of the clavicle and propose a
approach. In case of complex reconstructions (e.g., FVFG), treating
standardized treatment algorithm.
physicians should strongly consider referring these patients to special
In our cohort of 630 clavicular fractures, we observed a total of 28
ized centers.
FRIs. Eighteen (2.9%) of these patients were from our hospital, and ten
(1.5%) were referred from other hospitals with an infection. The prev
alence of infection is in line with a study by Wolf et al. who observed an Healthcare costs
infection rate of 3.1% (21/672) [16], but higher than the 0.4% (1/251)
observed by Shen et al. [17]. However, neither of these studies used a The median healthcare costs per patient, following treatment of an
validated definition to define infection. In the study by Shen et al. an FRI of the clavicle (€11.506; P25-P75:(€7.953 – €23.798)) were 3.5 times
additional four patients were diagnosed with a ‘superficial infection’. higher compared to non-infected operatively (€3.296; P25-P75:(€2.857 –
Furthermore, the incidence in our study might be higher than may be €4.025)) treated clavicle fractures [24]. It is likely that the actual
expected as our hospital is a level-1 trauma center that receives many number is even greater, as the healthcare costs incurred by patients
complex referral cases. before they were referred to our hospital were not considered in this
study. The main cost driver in our study was length-of- stay. In com
parison, healthcare costs for the treatment of FRI of the patella and tibia
Clinical and functional outcome in our center were approximately 3 and 4 times more, respectively [22,
25]. Nevertheless, the relative share of the different cost categories was
Out of the eight patients who had their implant removed, none rather similar, with hospitalization as the main cost driver [22,25]. The
experienced a recurrence of infection. Among the five patients who were current study differs from both the patella and tibia FRI study in that the
Fig. 6. Standardized treatment protocol for the treatment of fracture-related infection of the clavicle with a bone defect. The subdivision in centimetres is arbitrary,
but it should help the surgeon plan the procedure. One of the most important aspects is the stability of the construct using an implant with a sufficient length. *
Patients with an FRI without a bone defect should be treated according to the general FRI treatment principles [21]. ✝ Patient demand should be based on age, level
of preoperative physical activity, job demands, and demands in daily living. ** In most healthy adult patients, harvesting tricortical autologous iliac crest bone grafts
of up to 3 cm can be performed safely. When larger grafts are required, there is a risk of avulsion of the anterior superior iliac spine. ‡ Alternatives to a vascularized
fibular bone graft, such as the Masquelet technique, should be discussed with the patient if they are unfit to undergo the procedure due to comorbidities or if they are
unwilling to undergo the procedure. It should be stated that in larger bone defects these alternatives probably have a lower success rate.
patient cohort was larger (28 vs. respectively 10 and 12 patients) and the grafts in clavicular fractures. In case of infection with poor surrounding
total costs per patient were distributed less equally. Moreover, the me soft tissues, a vascularized graft is considered to be superior to
dian hospitalization cost (i.e., length-of-stay) was more than five times non-vascularized grafts as it induces angiogenesis which aids in fighting
lower after FRI of the clavicle. There are some possible explanations for of the infection and contributes to fracture healing due to its osteogenic
the lower hospitalization costs or shorter length-of-stay for patients with properties [46]. Moreover, a skin island can significantly improve soft
an FRI of the clavicle. One being that multiple revision surgeries (and tissue healing. Therefore, in our opinion, there should be a low threshold
hospitalizations) in cases of bone transport of the tibia for example, are for choosing a vascularized bone graft including a skin island in case of
not necessary for the clavicle. poor soft tissue coverage (Figs. 3 and 4). Patients should be involved in
the decision making and they should be clearly informed about possible
Treatment strategies complications. For example, using large ICBG can cause wound healing
problems and pain at the donor site. Additionally, there is a risk of
For the treatment of FRI of the clavicle without a bone defect we avulsion of the anterior superior iliac spine postoperatively [36,47].
recommend following the general FRI treatment principles [26]. For Similarly, using an FVFG can also result in donor site morbidity,
patients with an infection and an osseous defect we advocate for a including problems with wound healing or changes in gait [48]. In our
standardized treatment protocol based on the defect size, quality of cohort one patient who was treated with an FVFG, suffered post
surrounding soft tissues, and patient’s needs. The treatment algorithm operative ankle instability that required fixation with a syndesmosis
applied in this study is based on expert opinion and is shown in Fig. 6. As screw.
mentioned in previous publications, time from fracture fixation is not
the only factor that should be considered in treatment planning of FRI Limitations
[27]. Other factors such as fracture stability, dead space management
and adequate soft tissue coverage are also essential for successful This study is subject to some limitations. First, due to the retro
treatment of FRI [18]. Fracture (construct) stability is of great impor spective nature of this study, no exact measures of the defect sizes could
tance to prevent and/or eradicate infection [28] and this is in our be calculated. Measuring the size of the defect is challenging due to the
opinion especially true in case of clavicle fractures. As structural bone inaccuracy of postoperative x-rays. Even with CT scans, it is difficult to
grafts provide more stability than cancellous bone grafts, we recom measure the defect size accurately since pre-fracture CT images are not
mend using structural bone grafts in segmental defects. Partial osseous always available, and comparing the length based on the contralateral
defects may be treated with ACBG as the remaining part of the clavicle side can be challenging and is sometimes not accurate. Second, clinical
may function as a container for the ACBG and provide stability. While outcome was based only on physician assessment. Patient reported
some studies have reported positive results using ACBG in revision outcome measures such as the Constant-Murley score (CMS) would have
surgery for aseptic non-union, to the best of our knowledge, there are been a good tool to assess shoulder function. However, interpretation of
currently no studies specifically examining the use of ACBG for treating the CMS would have been difficult in this cohort as this was a retro
FRI of the clavicle [29–31]. The Masquelet technique to treat larger spective study, and prospective administration of the questionnaires
segmental defects of the clavicle resulting from FRI, is not our preferred would mean that all patients would have to fill out the questionnaire at
treatment option since it does not provide adequate stability. The only different timepoints in their follow-up. Lastly, for the ten patients who
publication that reported the use of the Masquelet technique for treating were referred to our hospital after being treated elsewhere, it was not
segmental clavicular defects in adults was a case report, which showed possible to calculate the costs incurred in the hospital where the patient
that the technique was successful in treating an aseptic non-union with a was initially treated. This led to an underestimation of healthcare costs
four-centimeter segmental defect [32]. of referral patients.
Several studies have focused on the reconstruction of segmental
osseous defects using ICBG or FVFG after non-union of the clavicle [11, Conclusion
33-40]. Most of these were case reports or case series [33–40] and only
one of the studies had FRI as their main focus area [11]. The use of ICBG FRI is a serious complication that can occur after the surgical treat
showed a good outcome with union rates ranging from 75% to 100%, ment of clavicle fractures. In our opinion, when treated adequately using
with a significant improvement in shoulder function and pain reduction a multidisciplinary patient-specific approach, the outcome of patients
after surgery [35–39]. Four case reports describing the use of FVFG in with an FRI of the clavicle is good. The median healthcare costs of these
nine patients demonstrated good results, with fracture union in eight out patients are up to 3.5 times higher compared to non-infected operatively
of the nine patients, with osseous defect sizes ranging from four centi treated clavicle fractures. Although not studied individually, we
meters up to twelve centimeters [11,33,34,40]. consider factors such as the size of the bone defect, condition of the soft
The use of other free vascularized grafts for defect management has tissue, and patient demand important when it comes to guiding our
also been described. Vascularized medial femoral condyle cortico surgical decision making in cases of osseous defects.
periosteal bone grafts were successfully used to treat defects up to five
centimeters [41,42]. We have no experience with this technique and
prefer bone grafts with an anatomical shape that closely resembles that
of the clavicle, as changes in clavicular curvature and/or length can
All authors declare no conflict of interest with respect to the prepa
result in scapular dyskinesis [39,43].
ration and writing of this article.
Shortening of 10% or more already significantly affects the scapular
kinematics [44]. Therefore, to optimize the chance to return to FROM,
shortening (or lengthening) of the clavicle should be prevented, espe Acknowledgements
cially in highly demanding patients. In our center 3D planning is
therefore a critical step in the management of these cases (Fig. 5) [11]. This research received no specific grant from any funding agency in
Patient demands and other patient specific factors should be considered the public, commercial, or not-for-profit sectors.
when evaluating the options for bone grafting. One of these factors is the
soft tissue envelope overlying the infection site. A good soft tissue en References
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10
Injury 54 (2023) 110914
Injury
Use of single agent Cefotetan for Gustilo-Anderson type III open

fracture prophylaxis
Garrhett G. Via a, *, David A. Brueggeman a, Victoria A. Murray a, Andrew W. Froehle a,
Steven D. Burdette b, Michael J. Prayson a
a
Wright State University Department of Orthopaedic Surgery, 30 E. Apple St., Ste 2200, Dayton, Ohio 45409 United States of America
b
Wright State University Department of Infectious Disease, 30 E. Apple St., Ste 6258, Dayton, Ohio 45409 United States of America
Keywords: Introduction: : The prophylactic intravenous antibiotic regimen for Gustilo-Anderson Type III open fractures
Open fracture traditionally consists of cefazolin with an aminoglycoside plus penicillin for gross contamination. Cefotetan, a
Cefotetan second-generation cephalosporin, offers a wide spectrum of activity against both aerobes and anaerobes as well
Prophylaxis
as against Gram-positive and Gram-negative bacteria. Cefotetan has not been previously established within or
Gustilo-Anderson
thopedic surgery as a prophylactic intravenous agent.
Surgical site infection
Patients and Methods: : Cefotetan monotherapeutic prophylaxis versus any other antibiotic regimen (standard/
literature-supported and otherwise) was studied for patient encounters between September 2010 and December
2019 within a single Level 1 regional trauma center. Patient comorbidities, preoperative fracture characteristics,
and in-hospital/operative metrics (including length of stay [LOS], number of antibiotic doses, and antibiotic
costs [US$]) were included for analysis. Postoperative outcomes up to 1 year included rates of surgical site
infection (SSI), deep infection necessitating return to the operating room (OR), non-union, prescribed outpatient
antibiotics, hospital readmissions, and related returns to the emergency department (ED). Sensitivity analyses
were also conducted to include standard/literature-supported antibiotic regimens as a nested random factor
within the non-cefotetan cohort.
Results: : The nested variable accounting for standard/literature-supported antibiotic regimens had no significant
effect in any model for any outcome (for each, P ≥ 0.302).
Thus, 1-year data for 138 Type III open fractures were included, accounting for only the binary effect of cefotetan
(n = 42) versus non-cefotetan cohorts. The cohorts did not differ significantly at baseline. The cefotetan cohort
received fewer in-house dose/day antibiotics (P < 0.001), was less likely to receive outpatient antibiotics in the
following year (P = 0.023), had decreased return to the OR (35.7% versus 54.2%, P = 0.045), and demonstrated
non-union rates of 16.7% versus 28.1% (P = 0.151). When adjusted for length of stay (LOS), the dose/day total
costs for antibiotics were $8.71/day more expensive for the cefotetan cohort (P = 0.002). Type III open fractures
incurred overall rates of SSI reaching 16.7% in the cefotetan cohort and 14.7% for non-cefotetan (P = 0.773).
Deep infections necessitating return to the OR were 9.5% and 11.6%, respectively (P = 0.719).
Conclusion: : Cefotetan alone may provide superior antibiotic stewardship with similar infectious sequalae
compared to more traditional antibiotic prophylaxis regimens for Gustilo-Anderson Type III open long bone
fractures.
Level of Evidence: : Level III Retrospective Cohort Study
Introduction a substantially higher risk for infectious sequelae compared to closed

fractures. As a result of this heightened risk, prophylactic intravenous
Due to their inherent environmental interaction, open fractures have antibiosis is a recommended standard practice for open fractures [1–8].
Abbreviations: GA, Gustilo-Anderson; ABX, Antibiotic; SSI, Surgical site infection; CSN, Contact serial number; ED, Emergency department; LOS, Length of stay;
OR, Odds ratio.
E-mail address: ggvia.md@gmail.com (G.G. Via).
G.G. Via et al. Injury 54 (2023) 110914
Gustilo and Anderson (GA) developed a classification system for cate administration, administration of any other ABX, time of injury, arrival
gorization and general management strategies of these injury patterns time to trauma bay/hospital, time of first cefotetan dose, cost to the
[9]. Type III open fractures were later subcategorized due to the vastly pharmacy of all administered ABX, operative interventions during CSN,
differing severity of soft tissue injury among the A, B, and C subtypes of time to final wound closure, non-union rates (all causes), length of stay,
patient presentation [10]. Regarding infectious sequelae, Type IIIA open discharge disposition, patient demographics (e.g. age, body mass index
fractures have up to 10% probability of infection, whereas Types IIIB [BMI], sex, smoking etc.), and medical comorbidities (e.g. diabetes).
and IIIC may exceed 50% [5]. Hospital data within the host institution’s electronic medical record
Research on prophylactic intravenous antibiotic (ABX) administra system were reviewed post-discharge for up to 1 year to determine the
tion in open fracture care has produced widely variable results and number of emergency department (ED) visits, hospital readmissions,
continues to evolve. Despite this evolution, cefazolin has classically been prescription of outpatient ABX, and subsequent operative interventions
among the ABX agents of choice for open fracture prophylaxis. It is a related to infection of the injured limb. Distinction was made between
first-generation cephalosporin and currently serves as the standard those patients with SSI (any infection requiring ABX, nonoperative/local
monotherapy for Type I and Type II open fractures [2]. Several studies therapies, or operative intervention) and patients with deep infection
have described other evidence-based regimens for Type III open frac (necessitating operative intervention). Infections were diagnosed uti
tures. These consist of cefazolin plus an aminoglycoside, lizing criteria established in the January 2023 update from the National
piperacillin-tazobactam monotherapy, or ceftriaxone plus/minus van Safety Healthcare Network surgical site infection guidelines developed
comycin. For grossly contaminated wounds, the classic regimen adds by the Centers for Disease Control and Prevention.
penicillin [2,3,6,7,11].
As an alternative to cefazolin or other combination regimens, cefo Statistical analysis
tetan was proposed by our institution’s infectious disease specialists as a
standardized monotherapeutic prophylaxis regimen for Type III open Statistical analysis was performed in SAS 9.4 (SAS Institute, Cary,
fracture care based upon local antibiograms and a wide antibiotic NC) with significance set to α=0.05.
spectrum of activity. Cefotetan is a second-generation cephalosporin of Patients were divided into cefotetan and non-cefotetan cohorts.
the cephamycin subclass [12]. It has a wide spectrum of activity against However, among patients receiving non-cefotetan ABX regimens,
both aerobes and anaerobes, as well as against Gram-positive and considerable variation was noted in the selection of antibiotic agents.
community-acquired Gram-negative bacteria [13]. In contrast to cefa Patient baseline covariates and fracture characteristics analyzed
zolin, cefotetan is dosed twice-daily. Although typically utilized for included age (y), sex (M/F), BMI (kg•m− 2), tobacco use (Y/N), diabetes
abdominal/colorectal and obstetric-gynecologic procedures, cefotetan is status (Y/N), GA Type III subtype (IIIA vs. IIIB/C—subtypes B and C
indicated for respiratory and urinary tract infections, as well as for in were collapsed into a single category for the purposes of this analysis in
fections of bone, skin, and joints [12–15]. Despite what is currently accordance with the methodology of Lack et al.) [4,5]. Long bone seg
known about cefotetan, both clinically and biochemically, there is a ments were collapsed into upper extremity (upper arm, forearm) and
paucity of literature to establish efficacy within the realm of orthopedic lower extremity (thigh, leg) for the purposes of this analysis.
surgery. Operative characteristics included time to first ABX administration
The aim of the present study is to evaluate the use of single agent (minutes), number of surgeries, time to wound closure (days), length of
cefotetan for the antibiotic prophylaxis of Type III open long bone hospital stay (LOS, in days), total ABX administered in-hospital (gross
fractures at a single, Level 1 trauma center. It is hypothesized that total doses, and doses/day), total pharmacy cost [US$] of ABX admin
cefotetan prophylaxis in Type III open fractures will demonstrate equal istered in-hospital (gross total [US$], and [US$]/day), and discharge
to superior outcomes versus the currently accepted standard antimi disposition (home vs. non-home discharge). We included 1 year of post-
crobial regimens for the primary outcome metric of surgical site infec operative follow-up with outcomes recorded as any/none, including
tion (SSI), both superficial and deep. The null hypothesis is that no mortality, return to OR, hospital readmission, ED visits, non-union rate,
difference exists between the regimens. any SSI, deep infections, and additional ABX prescriptions.
Univariate analysis compared cefotetan and non-cefotetan cohorts
Patient and methods for baseline covariates, fracture characteristics, operative characteris
tics, and 1-year follow-up outcomes using independent samples t-tests
Patient selection and data (continuous variables), Wilcoxon rank sum tests (interval variables) or
chi square tests (categorical variables). All tests were two-tailed. Bino
Patients presenting with GA Type III open long bone fractures from mial logistic regression was used to test for the effects of cohort (cefo
September 2010 to December 2019 were included in this exploratory, tetan vs. non-cefotetan), GA Type III subtype, segment, and any
retrospective cohort study, for which local Institutional Review Board covariates that differed significantly between cohorts, on the likelihood
approval was obtained. Eligible patients were treated by fellowship- of 1-year follow-up outcomes. Full model statistics, effect statistics, and
trained orthopedic traumatologists at a Level 1, regional trauma cen odds ratios (OR) with 95% confidence intervals for significant effects
ter. Patients were systematically included if any portion of the record were derived for each outcome model. Because of the aforementioned
contained procedure codes/diagnoses corresponding to operative irri variation in non-cefotetan ABX regimens, we also conducted a series of
gation and debridement and/or external fixation and an open GA Type sensitivity analyses that included in each model a subtype for standard/
IIIA, B, or C fracture involving a major long bone (humerus, radius, ulna, literature-supported ABX regimens as a nested random factor within the
femur, tibia) as determined by an attending orthopedic surgeon. Patients non-cefotetan cohort. These included: 1) cefazolin + aminoglycoside, 2)
were excluded if they were less than 18 years of age, experienced cefazolin + aminoglycoside + penicillin, and 3) cefazolin + any other
mortality within 30 days (including during the index admission), ABX. To account for patients with allergies that may have affected their
received amputation of the affected extremity during the index hospital antibiotic dosing, regimens of: 1) vancomycin/clindamycin + amino
encounter for definitive management, or sustained a gunshot wound as glycoside, and 2) vancomycin/clindamycin + any other ABX were also
the index injury. All patient records were manually verified for included.
inclusion.
Inpatient records of patients admitted with GA Type III open frac
tures were reviewed based upon patient contact serial number (CSN).
Metrics under review included initial irrigation and debridement and/or
external fixation with an orthopedic surgeon, cefotetan or cefazolin
Results Table 2
Group characteristics.
Sample characteristics Variablea Cefotetan (N = No cefotetan (N = Pb
42) 96)
The nested variable from the sensitivity analyses had no significant Age (y) 43.3 ± 18.3 41.2 ± 15.8 0.520
effect in any model for any outcome (for each, P ≥ 0.302). Thus, the Sex (%F) 33.3% 30.2% 0.716
results presented below include only the binary effect of comparing the BMI (kg•m− 2) 31.4 ± 8.0 29.4 ± 8.0 0.190
cefotetan/non-cefotetan cohorts, without the subtype nested effect for Tobacco use (% yes) 9.5% 10.4% 0.872
Diabetes (% yes) 2.4% 5.2% 0.429
the standard/literature-supported ABX regimens included. GA IIIA / GA IIIB/C (%) 71.4% / 28.6% 57.3% / 42.7% 0.116
A total of 146 GA Type III open fractures during the study period Upper extremity / Lower 16.7% / 83.3% 13.5% / 86.5% 0.631
were reviewed. See [Table 1] for a breakdown of this sample by GA Type extremity (%)
III subtype and fractured segment. We excluded 7 for amputation of the a
Presented values are means ± SD for continuous variables, and frequencies
fractured limb segment and 1 for in-hospital mortality, leaving a study for categorical variables.
sample of 138 patients. Within this sample, 42 patients received cefo b
P-values are for independent samples t-tests (continuous variables) or chi
tetan alone and 96 did not. Other antibiotic regimens included combi square tests (categorical variables). All tests were two-tailed.
nations of ampicillin-sulbactam, aztreonam, cefazolin, cefepime,
ceftriaxone, cefuroxime, ciprofloxacin, clindamycin, gentamycin, levo
floxacin, metronidazole, moxifloxacin, penicillin, piperacillin- Table 3
tazobactam, tobramycin, trimethoprim-sulfamethoxazole, and vanco Group characteristics.
mycin. Baseline covariates and fracture characteristics within each Variablea Cefotetan (N = No cefotetan (N = Pb
cohort are presented in [Table 2]. 42) 96)
The cohorts were similar and did not differ significantly for age, sex, Time to first ABX 17.0 ± 11.2 14.0 ± 15.1 0.520
BMI, tobacco use, and diabetes status (for each, P ≥ 0.190). Lower ex administration (min)
tremity fractures were far more common in both cohorts (cefotetan: Number of surgeries 3 (2–4) 2 (2–4) 0.653
Time to wound closure (day) 4.00 2.75 (1.00–7.50) 0.135
83.3%; non-cefotetan: 86.5%; P = 0.631). The cefotetan cohort had a
(1.25–12.25)
moderately lower rate of GA IIIB/C fractures than the non-cefotetan Non-union (%) 16.7% 28.1% 0.151
cohort (28.6% vs. 42.7%, respectively), but this difference did not Length of stay (day) 11.50 10.00 0.311
reach statistical significance (P = 0.116). Time to initial ABX adminis (6.75–18.25) (5.00–18.00)
Discharge disposition (% to 40.5% 37.5% 0.741
tration was similar between the cohorts.
home)
a
Operative outcomes Presented values are means ± SD for continuous variables, median (IQR) for
ordinal variables, and frequencies of categorical variables.
b
The cefotetan and non-cefotetan cohorts had broadly similar oper P-values are for independent samples t-tests (continuous variables), Wil
coxon rank sum tests (ordinal variables), or chi square tests (categorical vari
ative outcomes, including, number of surgeries, time to wound closure,
ables). All tests were two-tailed.
LOS, and discharge disposition. Compared to the non-cefotetan cohort,
patients receiving cefotetan had a lower rate of non-union (28.1% vs.
16.7%, respectively), but the difference was not statistically significant Postoperative follow-up
(P = 0.151) (see [Table 3]).
During the initial hospital stay, cefotetan patients were administered After 1-year of follow-up, the cefotetan and non-cefotetan cohorts
significantly fewer ABX doses than were non-cefotetan patients, whether exhibited similar rates of mortality (0.0% vs. 2.1%; P = 0.226), read
cefotetan was included in the calculation (cefotetan cohort: 1.67 ± 1.02 missions (67.7% vs. 59.5%; P = 0.356), ED visits (26.2% vs. 32.3%; P =
doses/day; non-cefotetan cohort: 2.41±1.11 doses/day; P < 0.001) or 0.470), SSI (16.7% vs. 14.7%; P = 0.773), and deep infections (9.5% vs.
not (cefotetan cohort: 0.99 ± 1.13 vs. non-cefotetan cohort: 2.41 ± 1.11 11.6%; P = 0.719), none of which differed significantly. Significant
doses/day; P < 0.001). See [Fig. 1]. differences were observed (see [Fig. 3]) between cefotetan and non-
Absolute total pharmacy costs for ABX doses were ~30% higher for cefotetan patients returning for any reason to the OR (35.7% vs.
cefotetan patients ($239.05 ± 201.27 [US$]) compared to non- 54.2%, respectively; P = 0.045) and for additional ABX prescriptions
cefotetan patients ($187.46 ± 540.69 [US$]), but this difference was (21.4% vs. 41.1%, respectively; P = 0.023). See [Table 4] for logistic
not statistically significant (P = 0.550). Adjusting for LOS, however, the regression statistics. Logistic regression analysis found no significant
doses-per-day ([US$]/day) cost was significantly higher for cefotetan effects of cefotetan, GA subtype, or fractured segment on 1-year mor
versus non-cefotetan patients ($19.61 ± 15.92 vs. $10.90 ± 13.91, tality, superficial infections, or deep infections (for each, P ≥ 0.099). The
respectively; P = 0.002; [US$]). See [Fig. 2]. overall model for 1-year ED visits was not significant (P = 0.131),
although within this model the effect of GA Type III subtype was sig
nificant (P = 0.044; OR = 2.17, 95% CI: 2.02–4.62). All remaining
models were statistically significant. In the case of discharge disposition
(overall model P = 0.049), only segment had a significant effect (P =
0.015; OR=3.38, 95% CI: 1.24–9.23). With regard to 1-year return to OR
Table 1
Open fractures by Gustilo-Anderson classification and segment. (overall model P = 0.028), only GA Type III subtype had a significant
effect (P = 0.035; OR=2.17, 95% CI: 1.05–4.48). Similarly, for 1-year
Category N Upper Arm Forearm Thigh Leg
readmissions (overall model P = 0.016), the sole significant effect was
a
Total 146 11 (8%) 10 (7%) 40 (27%) 85 (58%) GA Type III subtype (P = 0.002; OR=3.38, 95% CI: 1.48–7.69). Finally,
GA IIIA 87 (60%) 3 7 29 48
additional ABX prescriptions (overall model P = 0.001) were affected by
GA IIIB 50 (34%) 7 3 11 29
GA IIIC 9 (6%) 1 — — 8 GA Type III subtype (P = 0.016; OR = 2.55, 95% CI: 1.19–5.49) as well
a
as segment (P = 0.015; OR = 4.38, 95% CI: 1.16–16.57) [Fig. 4].
A total of 146 open fractures classified as GA III were reviewed. Of these, 7
patients were excluded because the injured region was amputated, and 1 patient
was excluded for in-hospital mortality, leaving a final sample for analysis of N =
138.
Fig. 1. Distributions of antibiotic doses per day in each cohort (cefotetan: gray boxes; non-cefotetan: white boxes). Boxes represent the interquartile range (25th to
75th percentiles), horizontal lines with the boxes are medians, and whiskers represent the 10th and 90th percentiles. P-values are for between-groups comparisons
(Wilcoxon rank sum tests). A. Total antibiotic doses per day, including cefotetan. B. Antibiotic doses per day other than cefotetan.
Fig. 2. Distributions of antibiotic costs in each cohort (cefotetan: gray boxes; non-cefotetan: white boxes). Boxes represent the interquartile range (25th to 75th
percentiles), horizontal lines within the boxes are medians, and whiskers represent the 10th and 90th percentiles. P-values are for between-groups comparisons
(Wilcoxon rank sum tests). A. Total antibiotic costs for the entire length of stay. B. Antibiotic costs per day.
Fig. 3. Frequencies of (A) return to OR and (B) additional antibiotics prescriptions during 1-year follow-up. Gray bars represent the cefotetan cohort and white bars
represent the non-cefotetan cohort. Error bars represent the upper limits of the frequencies’ 95% confidence intervals. P-values are for between groups comparisons
(chi square tests).
Discussion Gustilo-Anderson Type III open long bone fractures. Inpatient cefotetan
was associated with a minimal additional dose/day cost of $8.71 [US$],
With some early evidence of favorable outcomes including fewer and a mean overall additional cost of $51.59 [US$]. These small dif
inpatient and outpatient antibiotics as well as decreased return to the ferences may be negligible and worthwhile if complications can be
OR, the present study demonstrates that cefotetan may represent an reduced by improving prophylactic intravenous antibiotic regimens.
appealing monotherapeutic alternative for infection prophylaxis in While not yet well-established in the literature, cefotetan may be a
Table 4
Logistic regression results.
Outcome Variablea Overall Model Cefotetan GA III Subtype Segment
X2 P X2 P OR (95% CI) X2 P OR (95% CI) X2 P OR (95% CI)
Discharge disposition 7.88 0.049 0.14 0.710 — 1.03 0.311 — 5.90 0.015 3.38 (1.24–9.23)
1-year mortality 2.12 0.548 1.31 0.252 — 0.07 0.794 — 0.61 0.434 —
1-year readmissions 10.39 0.016 0.28 0.595 — 9.26 0.002 3.38 (1.48–7.69) 0.01 0.939 —
1-year return to OR 9.07 0.028 2.85 0.091 — 4.47 0.035 2.17 (1.05–4.48) 1.15 0.283 —
1-year ED visits 5.63 0.131 0.24 0.625 — 4.07 0.044 2.17 (2.02–4.62) 0.52 0.470 —
Surgical site infections 2.24 0.525 0.26 0.607 — 2.15 0.143 — 0.08 0.780 —
Deep infections 1.15 0.764 0.08 0.772 — 0.04 0.848 — 1.02 0.313 —
Additional ABX Rx 15.48 0.001 3.47 0.063 — 5.86 0.016 2.55 (1.19–5.49) 5.93 0.015 4.38 (1.16–16.57)
a
. Effects and odds ratios (ORs) describe the likelihood of a "negative" outcome relative to a "positive" outcome. For discharge disposition, the negative outcome is
non-home discharge, and for all other outcomes the negative outcome is yes/any. For all models, the reference levels for each effect are: cefotetan group=non-
cefotetan; GA III subtype=Type IIIA; segment=lower extremity.
Fig. 4. Odds ratios for outcomes by (A) GA Type III subtype (GA IIIB/C vs. GA IIIA reference) or (B) segment (lower extremity vs. upper extremity reference). Circles
represent the odds ratio estimate and error bars represent the 95% confidence interval. Vertical lines in each plot represent an odds ratio of 1.00, or no effect of the
predictor on the outcome.
promising alternative for antibiotic prophylaxis. As a second-generation 8 h [12]. Cefotetan is generally safe and well-tolerated with a mild side
cephalosporin, cefotetan provides coverage for a broad range of effect profile. The most common side effects include nausea, vomiting,
community-acquired pathogens, including Gram-negative and Gram- lack of appetite, and abdominal pain [13]. Rare adverse reactions
positive aerobes and anaerobes [13]. It is bactericidal and acts by include hypersensitivity reactions and drug-induced immune hemolytic
interfering with the penicillin-binding proteins required for peptido anemia [13]. Hypersensitivity reactions to cephalosporins are a concern
glycan cross-linking, thereby inhibiting cell wall synthesis [13]. Ceph associated with penicillin allergies. However, cross-reactivity between
alosporins, including cefotetan, also exhibit a role in the activation of penicillins and most cephalosporins remains exceptionally low (<1%),
bacterial autolysins which contribute to cell lysis [15]. Due to its mo and the authors advocate infusion for patients in almost all in-hospital
lecular structure, cefotetan is highly stable even in the presence of circumstances [16–19].
beta-lactamases. It is administered on a 12-hour dosing schedule, mak Given the expenses of medical care, cost is an important consider
ing it an attractive alternative to cefazolin, which is administered every ation in the evaluation of any treatment option. Analysis of inpatient
pharmacy data cefotetan use demonstrated statistically significant identified retrospectively using algorithms, it is a possibility that some
increased costs with a doses-per-day cost of $19.61±15.92 [US$], eligible patients failed to be included in the study. Cefotetan was not
whereas non-cefotetan regimens cost $10.90±13.91 [US$]. Although introduced at our institution until midway through the data collection
statistically significant, it is important to consider the clinical signifi period (late 2016), and the monotherapy was not adopted in full until
cance of this finding. Total costs to the pharmacy in the cefotetan cohort mid-2017. Related to antibiotic prophylaxis, the non-cefotetan cohort
were ($239.05±201.27 [US$]) compared to non-cefotetan patients had non-standardized antibiotic regimens prescribed at the discretion of
($187.46±540.69 [US$]). While these costs may be acutely higher with various physicians across the emergency department, general trauma
the use of cefotetan during the index admission, it is reasonable to surgery, and orthopedic trauma surgery teams, which may affect the
believe that savings will compound over the following year, given that generalizability of outcomes. Data collection on post-discharge out
the cefotetan cohort had reduced return to surgery and fewer additional comes was performed using only the host institution’s electronic medi
antibiotic prescriptions. Thus, the elevated initial cost of selecting cal records system, potentially omitting the possibility of including any
cefotetan for infection prophylaxis may be a trivial investment relative post-surgical infections/complications treated at other institutions.
to improved short-term outcomes. Furthermore, these outcome data were modeled as binary variables
Gustilo-Anderson subtype had a statistically significant impact on (present/absent) which prevents the identification of causality and may
several outcomes, including return to OR, readmissions, and outpatient also limit generalizability. During data analysis, a lower rate of Type
antibiotic use. Within each of these variables Type IIIB/C fractures IIIB/C fractures was noted within the cefotetan cohort. This was
resulted in poorer outcomes. Type IIIB/C fractures in the hands of the addressed statistically by including Gustilo-Anderson classification
study’s institution often require repeat washouts and temporary fixa within the logistic regression models, in which it was demonstrated that
tion, necessitating return to OR and potential readmission. Past studies antibiotic dosing outcomes were independent of Gustilo-Anderson
have reported infection rates as high as 50% in Type III open fractures, classification. Other considerations include the adoption of a contem
particularly for those categorized as IIIC [4–6,20]. While not statistically porary, validated open fracture scoring system to the dataset such as the
significant, the cefotetan cohort did have fewer Type IIIB/C fractures Orthopaedic Trauma Association Open Fracture Classification (OTA-
than the non-cefotetan cohort, which may explain fewer related returns OFC) or the Orthopaedic Trauma Society open fracture classification
to the OR, SSI, and non-union in the cefotetan cohort. However, GA (OTS) rather than the GA classification.
subtype was included in the logistic regression analysis, accounting for
the effects of cefotetan and GA subtype on study outcomes independent Conclusion
of one another.
Interestingly, several differences were observed between upper and In conclusion, cefotetan monotherapy for Gustilo-Anderson Type III
lower extremity fractures. Patients presenting with upper extremity open fracture prophylaxis was associated with lower rates of inpatient
fractures were more likely to be discharged home and less likely to and outpatient antibiotic use, and reduced return to the OR. Deep in
receive outpatient antibiotics. These findings suggest that, compared to fections necessitating return to the OR were 9.5% and 11.6% in the
upper extremity fractures, lower extremity fractures may be more cefotetan and non-cefotetan cohorts, respectively. These findings,
associated with disability and morbidity. Activities of daily living coupled with a mild side effect profile, broad spectrum coverage, and
requiring use of the lower extremity for ambulation may require greater twice-daily dosing make cefotetan an appealing monotherapeutic
assistance and rehabilitation prior to returning home. One study showed alternative to other prophylactic intravenous antibiotic regimens for
that lower extremity fractures were typically more severe and more Type III open fractures. Cefotetan alone may provide superior antibiotic
likely to be caused by high-energy trauma (i.e. motor vehicle accidents), stewardship with similar infectious sequalae to other more traditional
which may also influence discharge disposition [21]. As described by antibiotic prophylaxis regimens for Type III open long bone fractures.
Rodriguez et al., the difference in outpatient antibiotic use between The authors, however, caution the adoption of these findings into clin
upper extremity and lower extremity fractures may be attributed to ical practice in the absence of additional data provided in a large, pro
increased rates of infection in lower extremity injuries, likely due to spective, multicenter trial.
poorer vascularization and soft tissue coverage [3,7,22].
The cefotetan cohort did demonstrate a non-statistically-significant Funding
increased rate of SSI compared to the non-cefotetan cohort. However,
there were fewer deep infections necessitating return to the OR as well No funding was received for the completion of this work.
as a lower rate of non-union in the cefotetan cohort, but these differ
ences were also not statistically significant. The findings suggest that CRediT authorship contribution statement
while cefotetan may be associated with slightly decreased rates of deep
infection, orthopedic surgeons need to remain cognizant of superficial Garrhett G. Via: Conceptualization, Data curation, Methodology,
infections necessitating oral antibiotics and/or nonoperative/local Writing – original draft, Writing – review & editing. David A. Brueg
therapies during follow-up. Past studies have produced similar findings geman: Conceptualization, Writing – original draft, Writing – review &
regarding severe infection, suggesting that cephalosporin monotherapy editing. Victoria A. Murray: Data curation, Writing – original draft.
was either non-inferior or even preferable to other antibiotic regimens Andrew W. Froehle: Conceptualization, Formal analysis, Methodology,
[20]. Additionally, combination therapies were associated with Writing – original draft, Writing – review & editing. Steven D. Bur
increased rates of acute kidney injury, which led to the conclusion that dette: Data curation, Supervision, Writing – review & editing. Michael
monotherapy may be preferable [20]. Depcinski et al. described similar J. Prayson: Conceptualization, Methodology, Supervision, Writing –
findings, showing that combination therapy may actually worsen review & editing.
infection rates by means of poor antibiotic stewardship [1].
This study has several limitations. This study relied on a small
retrospective convenience sample and statistical power is limited.
Despite a 10-year study period, Type III open fractures comprise a small
The authors declare that they have no competing interests.
percentage of all orthopedic injuries, making it difficult to amass larger,
prospective samples. At the level of α=0.05, the present study would
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https://doi.org/10.1089/sur.2006.7.379. [14] Kays M, Capitano B. Cephalosporins. Antimicrobial therapy and vaccines, volume
[4] Lack WD, Karunakar MA, Angerame MR, et al. Type III open tibia fractures: ii antimicrobial agents. 2nd ed. Pittsburgh: ESun Technologies LLC; 2014.
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(1):1–6. https://doi.org/10.1097/BOT.0000000000000262. therapy and vaccines, volume ii antimicrobial agents. 2nd ed. Pittsburgh: ESun
[5] Okike K, Bhattacharyya T. Trends in the management of open fractures: a critical Technologies LLC; 2005.
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[6] Redfern J, Wasilko SM, Groth ME, Mcmillian WD, Bartlett CS. Surgical site cell-mediated hypersensitivity to penicillins. J Allergy Clin Immunol 2016;138(1):
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with cefazolin plus gentamicin versus piperacillin/tazobactam. J Orthop Trauma [17] Romano A., Valluzzi R.L., Caruso C., Maggioletti M., Quaratino D., Gaeta F. Cross-
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Injury 54 (2023) 110915
Injury
Reliability of reverse sural artery fasciocutaneous flap in older adult

patients: Comparison study between older and younger patients
Kyeong-Hyeon Park a, Chang-Wug Oh b, *, Joon-Woo Kim b, Hyun-Joo Lee b, Hee-June Kim b
a
Department of Orthopedic Surgery, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul 03722, Korea
b
Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu
41944, Korea
Keywords: Background: The reverse sural artery fasciocutaneous (RSAF) flap is a popular option for patients with soft tissue
Lower extremity defects of the distal lower extremities. However, most studies have focused on young patients without comor
Soft-tissue defect bidities. This study aimed to report the clinical application of the RSAF flap and to evaluate its reliability in older
Sural flap
adult patients.
Methods: A retrospective study of fifty-one patients who underwent RSAF flap was included in this study between
September 2016 and October 2021. Reconstruction outcomes and wound complications were compared between
groups A (21 patients over 60 years of age) and B (30 patients under 60 years of age).
Results: Overall, 74.5% of the flaps healed primarily. The demographics of the two groups were similar, except for
comorbidities (P = 0.01). The risk factors that affected the survival of RSAF flaps were not significantly different
between the two groups (P > 0.05). The rate of wound complications in group A (42.85%) was significantly
higher than that in group B (13.3%) (P = 0.04). However, all wound complications were treated using a simple
procedure (skin grafting or simple suturing).
Conclusions: The RSAF flap can be a reliable salvage option to repair soft tissue defects of the lower extremities in
older adult patients. It is safe and easy to harvest and transfer the flap; however, surgeons should be aware of the
possibility of wound complications in older patients with comorbidities.
Introduction used in reconstructive surgery. The flap survival rate has increased
gradually, indications have become more extensive, and a variety of flap
Soft tissue defects of the distal lower extremities are common in older techniques have evolved [6–10].
adult patients, and the reconstruction of these defects is challenging. However, partial necrosis is still a concern and has been reported in
Free flaps are considered by many surgeons as the gold standard for the literature to range from 8.3 to 30.6% [11,12]. Although the RSAF
reconstruction of soft tissue defects [1]. However, due to the complexity flap is reliable in young, healthy patients, it has significant complication
of the operation and need for longer operation and anesthesia times, rates in patients with comorbidities. Comorbidities, such as diabetes
older adult patients are subjected to more postoperative complications mellitus, peripheral vascular disease, and hypertension, increase with
[1,2]. The pedicled flap, with a shorter operation duration and simpler advancing age, which may adversely affect flap survival. However, most
procedure, is preferred for the treatment of distal lower extremity de studies on distally based sural flaps have targeted young and healthy
fects in older adult patients. patients [13–15]. There are few reports in the literature on the appli
The distally based reverse sural artery fasciocutaneous (RSAF) flap cation of this flap to older adults. Many studies have shown that
can be used to cover wounds around the distal tibia, ankle, and foot and advanced age (higher than 60 years) is an independent risk factor that
is a popular and mainstay flap for reconstructing soft-tissue defects in affects partial necrosis of the RSAF flap, and flap survival is also
the distal lower extremity [3–5]. Owing to its rich blood supply, rela threatened by smoking and medical comorbidities (i.e., hypertension,
tively simple procedure, and reliable survival, this flap has been widely diabetes, and atherosclerosis) in older adult patients [16–18]. This study
* Corresponding author at: Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130
Dongdeok-ro, Jung-gu, Daegu 41944, South Korea
E-mail address: cwoh@knu.ac.kr (C.-W. Oh).
K.-H. Park et al. Injury 54 (2023) 110915
aimed to report the clinical application and verify the reliability of the intraoperatively using a handheld Doppler ultrasound device. The pivot
RSAF flap in older adult patients. point was marked at least 5 to 6 cm above the tip of the lateral malleolus
to preserve as many perforators as possible. Flap and skin extensions
Patients and methods were designed along the course of the neurovascular axis. The lesser
saphenous vein and sural neurovascular bundle were found in the
This retrospective study was performed at a tertiary care teaching mid-axis of the flap and were ligated proximally. The flap is raised un
hospital by a single orthopedic surgeon. An approval was obtained from derneath the deep fascial layer using the anterograde retrograde method
Kyungpook National University Hospital IRB (2022–03–017). Patients to maintain a sizable peroneal artery perforator at the base of the fascial
who consecutively underwent RSAF flap for soft tissue defects of the pedicle [19]. The width of the skin extension (1.5 to 2 cm) over the
lower limb between September 2016 and October 2021 were included in pedicle was narrower than that of the neurovascular pedicle bundle (3 to
the study. All patients were followed-up for at least six months. The 4 cm). The flap was transferred to the defect through the incised passage
following patient demographics were reviewed retrospectively: age, to avoid compression of the subcutaneous tunnel and the pedicle. The
gender, cause of defect, location of defect, comorbidities (including skin was mobilized on each side, creating a very thin skin flap to pre
smoking, diabetes mellitus, peripheral vascular disease, and hyperten serve the superficial vein and cutaneous nerve on the bed. This provides
sion), flap parameters (including the pivot point site, length and width of sufficient space for the pedicle with skin extension. After the flap was
the fascial pedicle, length and width of the skin island, total length of the transposed to the recipient site and sutured, the open bridge for the
flap, and the length-width ratio [LWR]). Among all patients who un pedicle was repaired to the adjacent skin extension without tension. The
derwent RSAF flap, those over 60 years of age were classified into group donor site of the flap was closed directly or covered with a skin graft if
A, and those under 60 years of age were classified into group B. needed (Fig. 1).
We assessed major flap complications (total flap loss or partial flap Postoperatively, the patients were managed with their limbs
loss [more than 10% loss], resulting in an additional coverage proced elevated using pillows in bed. Patients were on strict bed rest for seven
ure) and minor flap complications (marginal [tip or edge] flap necrosis days, after which minimal movements were allowed with the aid of
and flap dehiscence) [18,19]. Flap healing was considered primary if it crutches while offloading the foot for at least three weeks. Any com
healed with the index surgery. plications, including flap failure or donor-site morbidity, were noted and
recorded during the observation period.
Surgical procedure
The surgical procedure was followed as described in previous studies
[4,15,16,19]. With the patient under general or spinal anesthesia and The data was analyzed using IBM SPSS Statistics for Windows,
placed in the prone position, the recipient site was debrided, and the version 20 (IBM Corp., Armonk, N.Y., USA). Continuous variables were
defect size was measured. The peroneal perforators were identified expressed as mean ± standard deviation using a t-test to analyze the
Fig. 1. Soft-tissue defect on the lateral aspect of ankle in a 68-year-old woman with diabetes covered by a sural flap. (A) Ankle lateral wound after debridement of
osteomyelitis. (B and C) The flap was designed and harvested. (D) The skin bridge between the defect and pivot point is incised and the skin extension left over the
pedicle covered this opening. The flap was harvested with a skin extension. (E) The flap survived, and excellent outcomes were achieved at 10 months follow-up.
data. Categorical variables were expressed as rates, and the Chi-square Table 2
test or Fisher’s exact test was used to analyze the data. Results with a Comparison of flap risk factors between the two groups.
P value < 0.05 indicate that the difference is statistically significant. Parameters Group A (n = 21) Group B (n = 30) P-value
Fascial pedicle (cm)

Results Length 8 ± 2.75 7.9 ± 2.72 0.72
Width Skin island (cm) 3.26 ± 0.78 3.35 ± 0.85 0.86
This study included 51 patients (32 men and 19 women). The Length 7.8 ± 2.52 8.47 ± 2.43 0.21
average age of the patients was 57 (range, 16 to 94) years at the time of Width 5.19 ± 0.94 5.18 1.91 0.58
Dimension (cm2) 32 ± 13.5 36.8 ± 22.5 0.75
surgery. The mean follow-up period was 18 (range, 6–55) months. Soft Total length (cm) 15.81 ± 3.31 16.38 ± 3.34 0.58
tissue was caused by trauma in 32 patients (62.7%) and by non-trauma LWR 3.14 ± 0.89 3.41 ± 0.99 0.32
in 19 patients (37.3%). The anatomic location of the defect was a pre Pivot point (cm) 11.52 ± 2.75 12 ± 2.53 0.53
tibial lesion in 13 (25.5%) patients, medial or lateral malleolus in 17 LWR, length-width ratio.
(33.3%), Achilles tendon and heel in 12 (23.5%), and foot in 9 (17.6%). P < 0.05 was considered statistically significant.
The defect of the weight-bearing location (plantar surface of foot and
heel) was 5 (10%) patients. There were 32 comorbidities (62.7%),
including smoking in 13 (25.5%), diabetes mellitus and hypertension in Table 3
9 (17.6%), diabetes mellitus in 7 (13.7%), and peripheral vascular dis Comparison of flap complications between the two groups.
ease in 1 (2%) patient. The mean size of the raised flap (skin island) was Parameters Group A (n = Group B (n = P-
50 cm2 (range, 7–123 cm2). 21) 30) value
There were 21 (14 males, 7 females) patients in group A and 30 (26 Total (%) 9 (42.8) 4 (13.3) 0.02*
males, 4 females) patients in group B. Demographic factors, such as age, Major 4 (19) 3 (10) 0.43
sex, and cause and location of the defect, were similar between the two Total flap loss 0 0
groups. Comorbidities were significantly higher in group A than in Partial flap loss 4 3
Pretibial defect 2 0
group B (P = 0.01). Patient demographic data are shown in Table 1. The
Malleolus defect 1 1
length and width of the fascial pedicle; the length, width, and dimension Achilles tendon and heel 0 1
of the skin island; total length; LWR; and pivot point were similar be defect
tween the two groups (Table 2). Foot defect 1 1
Overall, 74.5% of the flaps (38 of 51) healed primarily. Thirteen flaps Minor 5 (23.8) 1 (3.3) 0.07
Marginal (tip/edge) necrosis 5 1
(25.5%) had postoperative complications, including 7 major complica Pretibial defect 3 0
tions (13.7%) and 6 minor complications (11.8%). When both groups Malleolus defect 0 1
were compared with regard to wound complications, group A showed Achilles tendon and heel 1 0
significantly higher total (major and minor) complications (P = 0.02). defect
Foot defect 1** 0
The incidence of major complications was similar between the two
Dehiscence 0 0
groups. All major complications included partial flap loss (< 30% ne
*
crosis), which was managed with a skin graft. The minor complication P < 0.05 was considered statistically significant.
**
rate was higher in group A; however, the difference was not significant. weight-bearing location of the defect.
And there was no difference in complications according to the location
of the defect (Table 3). All minor complications (marginal necrosis) were Discussion
treated with dressings and secondary sutures. In group A, there was no
significant difference in the wound complication rate of flaps between The RSAF flap has become increasingly popular for distal lower ex
patients aged 60 to 70 years (6/11, 54.5%) and those older than 70 years tremity reconstruction, with most studies reporting on young and
(3/10, 30%) (P = 0.27). All patients’ wounds healed successfully during healthy patients with traumatic wounds [12,20]. This study differs from
the follow-up period. previous studies on RSAF flaps as it included several non-traumatic
defects, older patients, and patients with comorbidities compared with
healthy patients. Through this study, we were able to determine realistic
complication rates in older adult patients with comorbidities rather than
Table 1
in young, healthy orthopedic trauma patients. Although the overall
The demographics of patients in the two groups.
survival rate of the RSAF flap was excellent with satisfactory wound
Group A (n = 21) Group B (n = 30) P- coverage, there were abundant wound complications. This resulted in
value
the need for additional operations and longstanding admissions for
Age, mean ± SD (years) 71 ± 10 47 ± 12 wound care, especially in patients with comorbidities. This is important
Gender 0.16
because the RSAF flap is often chosen in older patients with multiple
Male 14 (67%) 26 (87%)
Female 7 (33%) 4 (13%)
comorbidities as a “safer” alternative to the longer and more complex
Cause of defect 0.56 free flaps. However, most complications were minor, and when the
Traumatic 12 (57%) 20 (67%) RSAF flap was used in the study on older patients with comorbidities,
Non-traumatic 9 (43%) 10 (33%) the results were satisfactory overall.
Comorbidities 0.01
As the older adult population is increasing, soft-tissue defects in the
Yes 17 (81%) 13 (43%)
No 4 (19%) 17 (57%) distal lower extremity are also gradually increasing. Reconstruction of
Anatomic location of defect 0.79 these defects is mandatory; however, it is still challenging. Some studies
Pretibial 5 (24%) 8 (27%) have shown that advanced age is a risk factor for partial necrosis of the
Lateral/medial malleolus 7 (33%) 10 (33%)
flap due to medical comorbidities and long-term adverse lifestyles [16,
Achilles tendon and heel 5 (24%) 7 (23%)
Foot 4 (19%) 5 (17%)
18,21]. In a retrospective study of 58 RSAF flaps, 9 major complications
Weight-bearing location of 2 (10%) 3 (10%) 1. (3 total losses and 6 partial losses) and 17 minor complications were
defect reported [18]. Advanced age and comorbidities (smoking, obesity, and
SD, standard deviation. peripheral artery disease) were identified as risk factors for flap com
P < 0.05 was considered statistically significant. plications. We found that RSAF flaps performed in older patients for
coverage of lower extremity wounds were likely to result in more wound achieves its outcomes via the following elements: wound transudate
complications. This is similar to previous studies that have demonstrated removal, infection prevention, blood flow optimization, and edema
higher flap complications in this age group [16,18,21]. minimization [25]. NPWT has also been shown to decrease wound
The RSAF flap has a wide arc of rotation, which allows wide coverage edema, increase the rate of vascular ingrowth and fibroblast migration,
from the lower half of the leg up to the forefoot [3,6]. However, and possibly reduce local bacterial proliferation [26]. The incisional
excessive pedicle rotation is required when the defect is located at the NPWT (iNPWT) after flap technique is efficient and safe for comorbid
very distal foot, such as the dorsum of the foot. The flap healing can vary ities patients [27,28]. The iNPWT after RSAF flap may be considered a
depending on the defect’s location due to the pedicle’s excessive rota practical alternative technique in promoting wound healing and
tion. Perumal et al. reported that RSA flap for defects proximal to the reducing the risk of complications in patients with comorbidities.
ankle joint level (65%) has a higher rate of primary healing compared The present study has several limitations. First, this was a retro
with flaps distal to the ankle joint line (42%) [12]. Although the RSAF spective study, and double-blind randomization could not be achieved.
flaps were performed at various locations of defects in this study, the Subsequent prospective enrolment with a larger sample size is required
defect locations between the two groups were similar. In addition, there to confirm the success rate in the older adult population. Finally,
was no difference in flap survival according to location. When excessive although this is a comparative study, there is a limitation to comparing
pedicle rotation was required, such as in the foot dorsum, we performed the two groups directly because their comorbidities were different.
sufficient soft tissue dissection around the pivot point of pedicle and
checked blood flow using a Doppler ultrasound device. Surgeons should Conclusion
be aware of the chances of flap necrosis when excessive pedicle rotation
is required. Although the RSAF flap for soft tissue defects of the lower extremity
Most operating units face an acute shortage of resources, including in older adult patients has a higher wound complication rate than in
workforce, anesthetic drugs, and operating facilities, in the current younger patients, all flaps survived. In conclusion, the RSAF flap can be
coronavirus disease 2019 (COVID-19) pandemic [22]. Despite the a reliable salvage option for repairing soft tissue defects of the lower
cancelation of elective procedures, orthopedic surgeons continue to extremities in older adult patients. It is safe and easy to harvest and
treat limb-threatening conditions due to trauma and severe infections transfer the flap; however, surgeons should be aware of partial flap
[23]. The patients are often older and can have many comorbidities; necrosis when comorbidities are present.
some may even have an active COVID-19 infection. Soft tissue recon
struction is necessary in some of them. In patients with COVID-19
infection, soft tissue reconstructions that can be performed quickly are Declaration of Competing Interest
preferred, rather than free flaps that may have better functional and
cosmetic outcomes, but require greater surgical resources. The RSAF All authors have certified that they have no commercial associations
flap is an ideal solution for reconstructing defects in patients with active (e.g., consultancies, stock ownership, equity interest, or patent/
COVID-19 infection for several reasons. It can be performed under a licensing arrangements, etc.) that might pose a conflict of interest in
regional block, which minimizes the risk of aerosolization from intu connection with this article. There are no conflicts of interest to disclose.
bation during general anesthesia [23]. Second, it can be performed
quickly, thereby minimizing surgical time. Third, it does not require Acknowledgements
microsurgical expertise and a single surgeon can perform the procedure.
Finally, postoperative care was straightforward. Unlike free flaps, these This research was supported by a grant of the Korea Health Tech
local flaps do not require high-volume fluid regimens that may be nology R&D Project through the Korea Health Industry Development
detrimental to interstitial lung injury. Therefore, the authors believe Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic
that the RSAF flap could be effectively used to repair soft tissue defects of Korea (grant number : HR22C1832).
of the lower extremity in older adult patients with COVID-19.
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Injury 54 (2023) 110916
Injury
Mid-term functional and radiological outcomes after total hip replacement

performed for complications of acetabular fractures
Martin Salášek a, b, *, Tomáš Pavelka a, Jan Rezek c, Kryštof Šídlo c, Miroslav Šimánek c, d,
Adam Whitley e, f, Valér Džupa c, f
a
Department of Orthopaedics and Traumatology, Faculty of Medicine of Charles University, and University Hospital, Pilsen, Czech Republic
b
New Technologies for the Information Society, Facult of Applied Sciences, University of West Bohemia, Pilsen, Czech Republic
c
Department of Orthopaedics and Traumatology, Third Faculty of Medicine, Charles University and University Hospital Královské Vinohrady, Prague, Czech Republic
d
Department of Orthopaedics, Hospital Sokolov, Czech Republic
e
Department of Surgery, Third Faculty of Medicine, Charles University and University Hospital Královské Vinohrady, Prague, Czech Republic
f
Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic
Keywords: Objective: Acetabular fractures can lead to serious complications such as avascular necrosis of the femoral head
Acetabular fracture (AVN), osteoarthritis, non-union. Total hip replacement (THR) is a treatment option for these complications. The
Total hip replacement purpose of this study was to assess the functional and radiological outcomes of THR at least 5 years after the
Complication
primary implantation.
Modified Harris hip score
Femoral head AVN
Methods: This retrospective study analysed clinical data from 77 patients (59 males, 18 females) who were
treated from 2001 to 2022. Data was collected on the incidence of AVN of the femoral head, complications,
interval from fracture to THR, reimplantation. The modified Harris Hip Score (MHHS) was used to evaluate
outcome.
Results: The mean age at the time of fracture was 48 years. Avascular necrosis developed in 56 patients (73%),
with 3 cases of non-union. Osteoarthritis without AVN developed in 20 patients (26%), non-union without AVN
in one patient (1%). The mean time from fracture to THR was 24 months for AVN with non-union, 23 months for
AVN alone, 22 months for AVN with arthritis, 49 months for hip osteoarthritis without AVN. The time interval
was significantly shorter for cases of AVN than for cases of osteoarthritis without AVN (p = 0.0074). Type C1
acetabular fracture was found to be a risk factor for femoral head AVN (p = 0.0053). Common complications of
acetabular fractures included post-traumatic sciatic nerve paresis (17%), deep venous thrombosis (4%), in
fections (4%). Hip dislocation was the most common complication of THR (17%). There were no cases of
thrombosis following THR. According to Kaplan-Meier analysis, the proportion of patients without revision
surgery within 10-year period was 87.4% (95% CI 86.7–88.1). The results of the MHHS after THR: 59.3% of
patients had excellent results, 7.4% good, 9.3% satisfactory results, and 24.0% had poor results. The mean MHHS
was 84 points (95% CI 78.5–89.5). Paraarticular ossifications were observed in 69.4% of patients in the radio
logical evaluation.
Conclusion: Total hip replacement is an effective treatment for serious complications of acetabular fracture
treatment. Its results are comparable to THR peformed for other indications, although it is associated with a
higher number of paraarticular ossifications. Type C1 acetabular fracture was found to be a significant risk factor
for early femoral head AVN.
Introduction motor vehicle crash and falls from heights. However, they may also
occur with low energy trauma, such as in patients with osteoporosis
Fractures of the acetabulum are serious injuries, regardless of the age [1–14]. Acetabular fractures can be treated surgically or conservatively.
of patients. They usually occur as a result of high-energy trauma, such as Surgical approaches to acetabular factures include open reduction and
* Corresponding author at: Alej Svobody 80, 304 60, Plzeň, Czech Republic.
E-mail address: salasekm@fnplzen.cz (M. Salášek).
M. Salášek et al. Injury 54 (2023) 110916
Table 1 used a simple exponential equation. The changes in incidence were

AO/OTA types of acetabular fractures. analyzed using the Mann-Kendall test, and the slope of the trend was
N % 95% CI estimated using Sen’s slope. For categorical data, we conducted Fisher’s
exact test or the Chi2 test (when there were 7 or more degrees of
A1 25 32.47 22.23 44.10
A2 12 15.58 8.32 25.64 freedom). We compared parametric quantitative data using the exact
A3 2 2.60 0.32 9.07 form of the Mann-Whitney-Wilcoxon test. For multiple groups of data,
B1 19 24.68 15.56 35.82 we applied the Kruskal-Wallis test and used the Mann-Whitney-
B2 4 5.19 1.43 12.77 Wilcoxon test for pairwise post-hoc comparisons. To evaluate the risk
B3 5 6.49 2.14 14.51
C1 4 5.19 1.43 12.77
factors for avascular necrosis development, we utilized Kaplan-Meier
C2 4 5.19 1.43 12.77 charts followed by multiple log-rank tests.
C3 2 2.60 0.32 9.07 We also assessed the Modified Harris Hip Score using linear regres
chi2 (Yates) 9 × 2 p ¼ 0,0006 sion analysis. To identify the significant parameters during linear
regression, we calculated the Pearson’s correlation coefficient and used
T-test approximation with 95% confidence intervals.
internal fixation (ORIF) and mini-invasive techniques. Both conserva
Relative rating was expressed as count and percentage with the
tive and surgical treatments can be complicated by the development of
corresponding 95% confidence interval (Clopper-Pearson exact).
avascular necrosis of the femoral head (AVN), severe posttraumatic
Results were considered significant if the p-value was less than 0.05.
coxarthrosis or acetabular non-union [15–30]. These complications can
be treated by total hip replacement (THR). The aim of this study was to
evaluate the medium-term functional and radiological results and Results
complications occurring after THR to treat complications following the
treatment of acetabular fractures. There were significantly more men than women in the patient cohort
(p ¼ 0.0014). According to the AO/OTA classification the most frequent
Material and methods fracture types were A1 (n = 25), B1 (n = 19) and A2 (n = 12). Other
fractures types were much less common, each occurring in less than 10
In this retrospective, longitudinal observational study, we analyzed patients. In pairwise comparisons, type A1 fractures occurred signifi
data from all patients who underwent a THR procedure to address the cantly more frequently than types A2, A3, B2, B3, C1, C2 and C3. The
complications arising from acetabular fracture treatment at two level 1 proportion of B1 fractures was similar to that of A1 fractures (p =
trauma centers between the years 2001 and 2021. The study included all 0.3723) and A2 fractures (p = 0.2276). Table 1 shows the number of
cases of acetabular fractures and their respective treatments. However, each type of fractures.
we excluded patients under the age of 18, those with pathological The overall incidence of acetabular fractures increased over the 20-
fractures, and individuals who underwent THR as the initial treatment of year follow-up period. The average annual increase was 1.2 (95% CI: 0.5
their acetabular fracture. A total of 77 patients with 79 acetabular - 2.1; p = 0.0163). This ascending trend might be caused by acetabular
fractures were included in the study, comprising of 59 male and 18 fe insufiency fractures.
male patients. The average age of the patients at the time of the The number of conservatively treated acetabular fractures also
acetabular fracture was 47.7 years, and at the time of the THR proced increased by 1.2 per year (95% CI: 0.4 - 2.3; p = 0.0037). However, there
ure, it was 51.1 years. was no significant change in the number of patients undergoing surgical
The data collected regarding the primary fracture comprised of the treatment of acetabular fractures during the study period (95% CI: -0.4 -
following information: the type of fracture as classified by the AO/OTA 0.3; p = 0.7546).
system, any associated injuries, the cause of the injury, the presence of Our guidelines for osteosynthesis were concordant with AO/OTA
sciatic nerve paresis, accompanying femoral head dislocation, and recommendation – displaced acetabular fractures, articular step up to 2
"central dislocation". Additionally, we documented the types of com mm in the loading zone, unstable hip after closed hip reduction, Pipkin
plications that arose after the surgical treatment of the acetabular type 4 fractures, “central” hip dislocation more than 2 mm.
fractures, the incidence of thromboembolic events, and the interval Trends in the incidence and treatment of acetabular fractures are
between the fracture and the THR procedure. shown in Graphs 1A, 1B and 1C.
The indications for the THR procedure were avascular necrosis in 56 The total count of THRs performed annually significantly increased
patients (73%), severe post-traumatic coxarthrosis in 20 patients (26%), over the study period, by on average 30.4 per year (95% CI: 24.1 - 36.4;
and non-union without avascular necrosis in one patient (1%). We also p < 0.0001). However, the number of THRs performed for complications
recorded and evaluated intraoperative and postoperative complications of acetabular fracture treatment decreased by -0.03 per year (95% CI:
of the THRs and the length of time from the acetabular fracture to the -0.21 - 0.16; p = 0.8967).
THR surgery (revision free interval). Yearly changes in the total number of THRs and THRs performed
At medium follow-up, defined as 5 to 15 years we evaluated secondarily to complications of acetabular fracture treatment are shown
functional and radiological outcomes [32]. Functional outcomes were in Graphs 1D and 1E.
evaluated using the Modified Harris Hip Score (MHHS). Radiological Treatment type and AO/OTA fracture type were identified as risk
outcomes were evaluated on anteroposterior radiographs of the hip factors for the early development of avascular necrosis of the femoral
joint. In addition to the position of both the acetabular and the femoral head. The incidence of avascular necrosis was found to be higher after
component we also classified the extent of radiolucency around the surgically treated acetabular fractures, particularly those treated using
endoprosthesis, which may signify loosening or migration. Around the combined surgical approaches for fracture types A3 and C1 (risk ratio
acetabulum we evaluated the radiolucent zone in three sectors accord 1.40 (95% CI: 1.02 -1.90); p = 0.0345; Fisher exact test p = 0.0084). The
ing to DeLee and Charnley [11]. multiple log rank test comparing the different surgical approaches to
In the region of the femoral component, we evaluated radiolucency conservative treatment was significant (p = 0.0008). Post-hoc compar
in seven sectors according to Gruen [15]. In both regions migration was isons showed that avascular necrosis was more frequent after the com
defined as complete loosening. Para-articular calcification (ossification) bined approach (Bonferroni p = 0.0023, Fisher exact test p = 0.0055),
was classified into five grades according to Brooker [4]. with a risk ratio of 2.60 (95% CI: 1.31 - 5.17; p = 0.0065), as seen in
To determine the annual incidence of patients requiring THR Graph 2a.
following acetabular fracture treatment at these two trauma centers, we A sub-analysis of the combined approach and type of injury was
performed, with and without avascular necrosis. The 9 × 2 table chi2
Table 2a Table 4a
Complications of primary acetabular fracture. Paraaarticular calcification (Brooker).
Count % 95% CI Brooker % 95% CI
Dehiscence with secondary suture 1 1.30 0.03 7.02 None 19 30.65 19.56 43.65
Early onset infection 1 1.30 0.03 7.02 Grade 1 17 27.42 16.85 40.23
Late onset infection 3 3.90 0.81 10.97 Grade 2 10 16.13 8.02 27.67
Deep venous thrombosis 3 3.90 0.81 10.97 Grade 3 15 24.19 14.22 36.74
Sciatic nerve paresis 13 16.88 9.31 27.14 Grade 4 2 3.23 0.39 11.17
Men vs. women risk ratio 2.22 (1.08 -4.54), p ¼ 0.0297
Table 2b
Complications of total hip replacement. Table 4b
Significant paraarticular calcification risk factors.
Count % 95% CI
odds ratio 95% CI p
TEN (deep venous 2 2.60 0.32 9.07
thrombosis 7.4667 1.6207 34.3995 0.0099 K-L approach vs. conservative
10 times THR dislocation 4 5.19 1.43 12.77 6.8400 1.8710 25.0055 0.0036 more calcification in men
dislocation in 7.7778 1.7381 34.8054 0.0073 more calcification in surgery
one patient
Sciatic nerve paresis 2 2.60 0.32 9.07
Periprosthetic Acetabular 0 0.00 0.00 4.68
fracture intraoperative Table 4c
Femoral 1 1.30 0.03 7.02 Relative risk of calcification according approach.
intraoperative
Revision surgery Soft tissue revision 2 2.60 0.32 9.07 Approach calcification without % 95% CI
head exchange, head 2 2.60 0.32 9.07 Conservative therapy 3 7 30.00 6.67 65.25
and insert exchange Kocher-Langenbeck 32 10 76.19 60.55 87.95
Acetabular cup 2 2.60 0.32 9.07 Ilioinguinal 3 0 100.00 29.24 100.00
revision Combined 5 2 71.43 29.04 96.33
Stem revision 2 2.60 0.32 9.07 Fisher 4 £ 2 p ¼ 0.0288
Secondary Femoral fracture in 1 1.30 0.03 7.02
osteosynthesis the stem region
Deep infection Infection of the stem 1 1.30 0.03 7.02 fractures (Wilcoxon p = 0.0030). AVN also developed earlier in patients
Dehiscence 0 0.00 0.00 4.68
with A3 fractures than those with C1 fractures. These findings are
depicted in Kaplan-Meier graphs (Graphs 2B, 2C). In the 2 × 2 tables
comparing A3 to A1 fractures, the risk ratio was 1.44 (95% CI: 1.12 -
Table 3a 1.87; p = 0.0049). The same risk ratio was observed in the comparison of
Radiological results of acetabular component (cup). C1 to A1 fractures.
Total N = 62 Count % 95% CI Complications after osteosynthesis for the primary acetabular
X-ray acetabular Without losening 50 80.65 68.63 89.58 fractures were: sciatic nerve paresis (n = 13, 16.9%), deep vein
component (cup) Radiolucent zone 12 19.35 10.42 31.37 thrombosis (n = 3, 3.9%), late infections (n = 3, 3.9%), early infections
I 3 4.84 1.01 13.50 (n = 1, 1.3%) and wound dehiscence requiring resuture (n = 1, 1.3%)
II 9 14.52 6.86 25.78
(Table 2a).
III 5 8.06 2.67 17.83
Losening with 1 1.61 0.04 8.66 The length of time from the acetabular fracture to THR differed
migration significantly depending on the type of complication of the acetabular
fracture treatment (p = 0.0459). There was a significantly shorter length
of time for patients who developed avascular necrosis (mean 23.6
Table 3b months (95% C: 13.9 - 33.1). For cases of posttraumatic coxarthrosis
Radiological results of femoral component (stem). without non-union the mean length of time to THR was 49.3 months
(95% CI: 26.7 - 71.9).
Total N = 62 Count % 95% CI
On pairwise post hoc comparisons, there was a significant difference
X-ray femoral Without losening 44 70.97 58.05 81.80 in the comparison of avascular necrosis and coxarthrosis without avas
component (stem) Radiolucent zone 18 29.03 18.20 41.95
I 11 17.74 9.20 29.53
cular necrosis of the femoral head (p ¼ 0.0074). This association can
II 5 8.06 2.67 17.83 also be seen on the pairwise comparison in the Kaplan-Meir graph
III 2 3.23 0.39 11.17 (graph 2d), which shows the survival curves for coxarthrosis without
IV 4 6.45 1.79 15.70 non-union and avascular necrosis without non-union. When approxi
V 1 1.61 0.04 8.66
mated using the Wilcoxon test, the differences were significant p =
VI 6 9.68 3.63 19.88
VII 11 17.74 9.20 29.53 0.0129. The presence of avascular necrosis thus significantly shortens
Losening with 1 1.61 0.04 8.66 the time from the primary acetabular fracture to THR.
migration Complications of THR were: dislocation (n = 4, 5.2%), deep vein
thrombosis (n = 2, 2.6%), sciatic nerve paresis (n = 2, 2.6%), and
intraoperative periprosthetic fracture in the femoral region (n = 1, 1,
test showed a p value of < 0.0001, with avascular necrosis occurring
3%). Periprosthetic fractures in the acetabular area and wound dehis
significantly more frequently in C1 fractures (p = 0.0001). This indicates
cence did not occur. Deep infection in the shaft occurred once (1.6%).
that the higher incidence of avascular necrosis in the combined
Secondary osteosynthesis of the femur for a late periprosthetic fracture
approach is likely due to the severity of the primary injury rather than
was performed once (1.6%) (Table 2b).
the operative approach itself.
A total of 8 patients (10.4%) required revision surgery after THR. For
An analysis of fractures by type showed that AVN developed earlier
superficial infectious complications, simple soft tissue while preserving
in patients with A3 fractures than those with A1 fractures (Wilcoxon p =
the implant were performed in two patients (2.6%). Replacement of the
0.0191) and earlier in those with C1 fractures than those with A1
Fig. 1. Radiographic documentation of a 71-

year-old patient with a hip fracture (AO/OTA
61-B3.2), acetabular fracutre (AO/OTA 31-
C2.1) and femoral head dislocation (AO/OTA
62-A3.1) after being hit by a tractor: a - pelvic
X-ray after the injury, b - after stabilization of
the hip fracture (two ventral plates and one
iliosacral screw on each dorsal side) and
acetabular fracture (one supra-acetabular
compression screw), c - after cemented THR
with a 12-day interval after hip and acetabular
stabilization, d - finding of paraarticular ossifi
cations (Brooker 3) three years after injury with
a favorable clinical state.
Fig. 2. X-ray documentation of a 32-year-old

patient who was originally treated for a pelvic
and acetabular fracture after a motor vehicle
crash with insufficiently stable fixation: a –
acetabular joint collapse 8 months after the
primary treatment, when the patient was
transferred to our care, b – after removal of the
original fixation material, two plates were fixed
with screws in such a way as to not interfere
with future acetabular processing for THR, c –
control X-ray 8 months after reosteosynthesis
with a healed joint and no femoral head ne
crosis, d – after implantation of a cementless
THR without interference with the osteosyn
thetic material.
head or head and polyethylene liner were performed in two patients was 57.3 years (95% CI: 49.6 - 65) for patients with revisions, and 50.1
(2.6%). Revision surgery with replacement of the acetabular component years (95% CI: 46.5 - 53.7), p = 0.1622, MWW exact) for patients
was performed twice (2.6%) and revision surgery with replacement of without. The gender ratio of patients with revisions was 8:3 M:F, and
the femoral component was performed in two patients (2.6%). without revision was 51:15 (Fisher 2 × 2 p = 0.7123).
The average time from the initial THR to the first revision surgery During the follow-up period 11 patients (14.3%) died. Fifty-four
was 6.2 ± 4.5 years (95% CI: 3.0 - 9.3). Due to the relatively low number patients agreed to complete the follow-up questionnaire (70.1%).
of revision surgeries, we could not accurately evaluate using Cox Radiological data at least five years after the THR was available for 62
regression the risk factors for early revision surgery. However, there was patients (80.5%).
no significant effect of age on the need for revisions. The average age All respondents to the questionnaire (n = 54) completed the
Graph 1. a: Annual incidence of acetabular fractures. An average annual increase of 1.2 fractures was observed (95% CI: 0.5 - 2.1, p = 0.0163). Green line is
predicted trend, blue dotted lines are 95% confidence interval lines. b: Annual incidence of conservatively treated acetabular fractures. The incidence of conser
vatively treated acetabular fractures increased by an average of 1.2 cases per year p = 0.0037. (95% CI: 0.4 - 2.3) c: Incidence of total hip replacements after
acetabular fractures There was a non-significant decrease in the number of total hip replacements after acetabular fractures of 0.03 per year (p = 0,8967, 95% CI:
(-0.21) - 0.16)) d: Overall incidence of total hip replacements regardless of indication. The incidence increased over the study period. The average annual increase
was 30.4 (95% CI: 24.1 - 36.4, p < 0.0001) e: Incidence of surgically treated acetabular fractures There was no apparent trend. The average annual change was 0.0 (p
= 0.7546, 95% CI: ((-0,4) - 0,3)).
modified Harris Hip Score (MHHS). The average score was 84.0 points 86.4 (95% CI: 75.2 - 97.6).
(95% CI: 78.5 - 89.5). Multivariate analysis was performed to identify factors affecting the
A categorial breakdown of these results is: excellent (n = 32, 59.3%), MHHS. Multiple linear stepwise regression showed that age and type of
good (n = 4, 7.4%), satisfactory (n = 5, 9.3%), and poor (n = 13, 24.1%). associated injuries were significant factors. A model with these two
The average modified Harris Hip Score did not significantly differ be parameters had a P value of 0.0063 and multiple R of 0.4246. Other
tween male and female patients (p = 0.7950). In male patients the tested factors (gender, fracture types according to AO/OTA, mechanism
MHHS score was 83.2 (95% CI: 76.9 - 89.6), and in female patients it was of injury, occurrence of sciatic nerve paresis, occurrence of posterior
Graph 1. (continued).
dislocation, and "central" dislocation) were not significant. We then used there were 44 patients (71.0%, n = 62) without loosening and 18 pa
univariate analysis for age and associated injuries. tients (29.0%) with a radiolucent border. The most frequent looseness
Linear regression analysis of MHHS against age found a significant was observed in zones I and VII, affecting 11 patients (17.7%) in these
negative correlation with increasing age. The Pearson correlation coef zones. Complete loosening and migration of the component were re
ficient R was -0.3346 (95% CI: -0.5968 to -0.0724; p = 0.0134), which is ported once (1.6%). The number of looseness cases in other zones is
shown on Graph 3a. The 95% CI area is delimited by dashed lines. The shown in Table 3b.
evaluation of the impact of associated injuries (classified as monotrauma Classification of paraarticular calcifications (ossifications) using
(isolated acetabular fracture), combined injuries (ISS<16), and poly the Brooker classification on X-rays showed that 19 patients (30.7%, n =
trauma (ISS ≥ 16)) on the Modified Harris Hip Score (MMHS) revealed 62) had no calcifications, 17 patients (27.4%) had grade 1 calcifications,
that polytrauma was significantly associated with a lower MMHS (76.2 10 patients (16.1%) had grade 2, 15 patients (24.2%) had grade 3, and 2
(95% CI: 64.3 - 88.0)) compared to monotrauma (90.1 (95% CI: 83.0 - patients (3.2%) had grade 4 (Table 4a).
97.2)), with a p-value of 0.0273 (as seen in Graph 3b). In one patient with bilateral acetabular fractures, grade 1 calcifica
A comparison of the various types of injury caused by low-energy tions were present on the side without total hip replacement, while
simple falls showed that the risk of AVN was higher in incidents such grade 4 calcifications were present on the side with TEP implant.
as being hit by a car (p = 0.0286, relative risk 100.0%), a motorcycle The results showed that men had a significantly higher risk of
accident (p = 0.0286, relative risk 100.0%), a fall from a height (p = developing calcifications (risk ratio 2.22 (95% CI: 1.08 - 4.54; p =
0.0182, relative risk 88.9%), and due to overloading (p = 0.0476, 0.0297)). However, the average MMHS did not differ based on the de
83.3%). However, the cohort size was not sufficient to demonstrate the gree of calcifications (Kruskal-Wallis test for degrees of calcifications
mechanism of injury as an independent risk factor for AVN (Chi2 8 × 2 p 0 to 5, p = 0.9973), which is consistent with the regression model.
= 0.0707, Yates p = 0.0378). The occurrence of calcifications also differed significantly based on
By fitting the Kaplan-Meier graph to an exponential dependence the surgical approach. The overall comparison in the 4 × 2 table showed
using exponential regression, the estimated percentage of patients a significance of p = 0.0288. This significance was determined by
without revision surgery (95% CI) was calculated as 92.6% (92.0 - comparing the posterior (Kocher-Langenbeck) approach to conservative
93.1) at 5 years, 87.7% (86.7 - 88.1) at 10 years, and 82.5% (81.6 - treatment (Fisher’s exact test, p = 0.0090, odds ratio 7.5 (95% CI: 1.6 -
83.3) at 15 years after the first THR. These results are presented in the 34.4; p = 0.0099)). Detailed information can be found in Tables 4b and
Kaplan-Meier graph (Graph 4). 4c.
When evaluating radiological results in the area of the acetabular
component, no loosening was reported in 50 patients (80.7%, n = 62), Discussion
while a radiolucent rim as observed 12 patients (19.4%). The most
common regions of radiolucency were in zone II (in 9 patients, 14.5%). Depending on the type, extent, and stability of acetabular fractures,
Socket migration occurred once (1.6%). Additional data are shown in they can be treated either conservatively or surgically [6,10,11,12]. The
Table 3a. surgical options include open reduction and internal fixation [19,20],
In the evaluation of radiographic results for the femoral component, closed reduction with minimally invasive osteosynthesis [10],
Graph 2. a: Time from acetabular fracture to avascular necrosis without non-union (green) and osteoarthritis without non-union (blue). There was a significant
different in the time interval from acetabular fracture to development of avascular necrosis without non-union (green) and osteoarthritis without non-union
(Wilcoxon p = 0,0129) b: Time from A1 and A3 acetabular fractures to total hip replacement There was a significant different revision free intervals for A1 and
A3 acetabular fracutres (Wilcoxon p = 0.0191). c: Time interval from A1 and C1 types of acetabular fractures and total hip replacements There was a significant
difference in time interval for A1 and C1 types of fracutres. (Wilcoxon p = 0.0030) d: Time between first signs of avascular necrosis by types of approach for surgically
treated acetabular fractures Comparison of surgical approach and time to development of avascular necrosis. There was a significant difference between the types of
approach (multiple log rank test p = 0.0008).
arthroscopically assisted minimally invasive reduction, and primary its own risks, including significant blood loss, extended surgical time,
implantation of a total hip endoprothesis with or without concomitant higher risk of endoprosthesis dislocation, and paraarticular calcification,
osteosynthesis [1,2,3,8,9,26,29,30]. The indications for primary hip particularly following the posterior approach. Furthermore, primary
replacement include: (1) devitalization of the femoral head resulting total hip replacement is not suitable for all types of fractures [6,7,
from dislocated fractures of the femoral neck or multifragmentary 24-27]. In older patients, a combination of minimally invasive osteo
fractures of the femoral head (Pipkin IV), (2) cases where reconstruction synthesis of the acetabulum and implantation of a total hip prosthesis
of the joint surfaces is not technically feasible, (3) presence of severe may be considered a more appropriate treatment (Fig. 1) [9,10,12,24,
coxarthrosis at the time of fracture, which occurs primarily in elderly 32]. Smakaj et al. [32] found better HHS score in elder patients treated
patients [16]. by Acute fix and replace procedure than ORIF, but described cohort of
Performing a primary hip replacement in the setting of acetabular patients was relatively small.
fractures is technically more challenging than in cases of primary cox Due to the risks associated with primary total hip replacement, in
arthrosis. Although endoprotheses can be used for the primary opera both our institutions THR is reserved from the treatment of complica
tion, revision acetabular implants are often required, such as Harrison’s tions of acetabular fractures, such as severe coxarthrosis, avascular ne
acetabuloplasty using a graft from the femoral head for reconstruction of crosis, and non-union with coxarthrosis. However, it is important to note
the posterior wall, or a combination of plate osteosynthesis and total hip that delayed THR is not without its own risks. To minimize these risks,
replacement [23–27]. However, primary total hip replacement carries we perform preoperative computed tomography with joint surface
Graph 2. (continued).
reconstruction and coxometry for all patients undergoing THR, using a in the fracture spectrum towards osteoporotic fractures, which are more
two-photon technique with iterative Metal Artifact Reduction common in patients over 60 years of age for women and over 65 years of
(iMAR). age for men [23]. Although we don’t routinely perform dual-energy
Based on the results of this examination, we choose the appropriate X-ray absorptiometry (DEXa) for elderly patients, we have started to
operative approach, either anterolateral or posterior. In some cases, change this practice in recent years by conducting osteological exami
revision acetabular components may still be necessary, especially for nations (including vitamin D levels and dual-energy X-ray absorptiom
patients with large joint surface defects or post-traumatic acetabular etry) for female patients over 65 years of age and male patients over 70
protrusion of more than 1 cm. To facilitate pre-operative planning, we years of age hospitalised for primary fractures.
may also use 3D printing of the acetabulum based on CT scans or Our analysis of risk factors for early AVN was limited by the cohort
planning software for individual acetabular component selection. size and the fact that we included only patients with complications after
Additionally, when performing primary osteosynthesis of an acetabular acetabular fractures. The risk of AVN for C1 fractures is related to the
fracture, we aim to place screws and plates in a manner that will not force of the trauma and medialization of the head in "central luxation" in
interfere with future milling of the acetabulum during total hip A3 fractures can contribute to avascular necrosis [22].
replacement, if necessary (Fig. 2). In a previous study, we showed that the risk was significant
Our patient cohort has a moderate size, which is smaller compared to when displacement exceeded 2 mm [22]. Larger studies have iden
large epidemiological studies but larger than many single-center studies tified other risks such as posterior wall fractures, transverse fractures,
[22,23]. The overall incidence of acetabular fractures has increased in combined posterior and transverse fractures, and type C fractures with
several other studies, similar to our study, but this trend hasn’t been concurrent posterior wall fractures [20,26,29]. The risk of AVN is also
reflected in the total number of THRs [22,23]. This can be attributed to higher in patients over 60 years of age and in cases with valgus cen
the improvement in the treatment of the primary fractures and the shift trum–collum–diaphysis angles [22]. Khoshbin et al. identified age as a
Graph 3. a: Modified Harris hip score by age, b: Comparison of modified Harris hip score according associated injuries (P = polytrauma (ISS ≥ 16), A = associated
trauma (ISS < 16), M = monotrauma, isolated acetabular fracture.
risk factor for early post-traumatic coxarthrosis when using ORIF in the rounded value of the correction factor 1.1 [28]. Our study was limited
treatment of acetabular fractures [17]. Cichose et al. identified trans by being retrospective, so we did not evaluate the difference in MHHS
verse posterior wall fractures, post-traumatic protrusion, traumatic hip before implantation and after TEP implantation. Nevertheless, the sig
dislocation, obesity, older age, infection, and instability after ORIF as nificance of the increase in HHS/MHHS has already been demonstrated
risk factors for the need for early hip replacement [7]. in other studies, and our aim was to demonstrate that the average MHHS
In terms of mechanism of injury, there is a higher risk of AVN after is not inferior to other indications for TEP of the hip.
being hit by a car, motorcycle accidents, and being crushed under heavy The average MHHS in our study was 84.1 ± 20.6 (95% CI:
objects. However, due to the small size of the individual subgroups, it 78.5–89.5), which is comparable to the average Harris hip score of 87.6
was not possible to demonstrate the mechanism of injury as an inde points reported by Stibolt et al. in a recent meta-analysis that analyzed
pendent risk factor. data from 238 THRs [29]. The meta-analysis by Stibolt et al. also showed
We used the modified Harris Hip Score to evaluate the functional a significant increase in HHS after THR, with an average increase of 46.2
clinical results, which differs from the classical Harris Hip Score by not points. The average follow-up time in their analysis was 82 months,
measuring the range of motion in the hip joint. The advantage of the which is similar to the follow-up time in our study. We believe that
MHHS is that patients can complete it remotely, which was beneficial comparing the results of our study to this meta-analysis is more clini
during the COVID-19 pandemic [28]. cally relevant than comparing to individual cohort studies, each with
The MHHS has good reliability and reproducibility, as verified by their own limitations.
Stasi et al. 2021 [28]. To obtain the same values as in the HHS, the re We observed fewer revision surgeries compared to the meta-analysis
sults from the MHHS are multiplied by a correction factor of 100/91 (10.4% vs. 18.5%), which may be due to the medium-term follow-up of
(corresponding to maximum HHS points / maximum MHHS points). To our patients.
use the same categorical rating as in the HHS, some authors use a Complete agreement was found between our study and the meta-
Graph 4. Time to revision surgery after total hip replacement. The 95% CI area is marked by blue dashed lines (the lost of dispenspensary is marked by little green
vertical lines and the black triangles show the mortality at corresponding time step).
analysis for iatrogenic sciatic nerve paresis after THR (2.6% in our study However, our study did not find a significant worsening of the MHHS
vs. 2.77% in the meta-analysis). Endoprosthesis dislocations were also with grade 3 and 4 calcifications, unlike the findings of the study by
comparable (5.2% vs. 6.2%). On the other hand, we recorded fewer Chémaly et al. [6].
infectious complications (deep infections 1.3%, superficial soft tissue The number of implants without loosening or revision in the 10-year
infections 2.6%, total 3.9% vs. 10.2%) [29]. interval was 87.7% (95% CI: 86.7–88.1), which aligns with the 83.74%
Multivariate linear regression analysis revealed that age and type of reported in a meta-analytic study [29]. According to Lucchini et al. [19],
associated trauma were significant factors for worse MHHS scores. better results can be obtained with the use of a ceramic insert and
Polytrauma as the primary injury was significantly associated with a ceramic head. However, these may not be available or feasible in the
lower MHHS score compared to monotrauma. Ipsilateral femoral frac case of a cemented socket.
tures, particularly fractures around the knee and concomitant pelvic It is important to note that our study has several limitations, such as
fractures, likely play a significant role in this association. Additionally, being a retrospective study, the lack of routine dual-energy X-ray ab
concomitant pelvic injuries, such as floating hip type A (fracture of the sorptiometry performed in patients older than 65, and the use of a
femur on the same side as the acetabular fracture) and floating hip type modified Harris Hip Score rather than the Harris score due to COVID-19
B (fracture of the pelvic ring and femur on the opposite side to the restrictions, and missing the sagittal balance aligment analysis of the
acetabular fracture), were also associated with a lower MHHS score. lumbar spine [31].
However, due to the small number of patients in the individual sub Nevertheless, the strengths of our study include a relatively long
groups, we were unable to validate these assumptions statistically. patient follow-up period, analysis of epidemiological, clinical, and
Our study also showed a decrease in MHHS scores with increasing radiological data over time, from primary fracture to the development of
age, which was also found by Busch et al. in 2019 [5]. However, their complications and mid-term results after total hip endoprosthesis
study did not show a significant reduction in MHHS scores in poly implantation.
traumatized patients. Other studies did not show a significant effect of
age on either the complications of acetabular fractures [6] or on Harris Conclusion
Hip Scores [12]. Kumar et al. used the 12-Item Short Form Health Sur
vey (SF-12) in addition to the Harris Hip Score in a study on total hip The total hip replacement (THR) is a causal treatment for serious
replacement after open reduction and internal fixation of the acetabu complications of acetabular fractures. During the observed 20-year
lum, and both scores were well-correlated in their study [18]. period, we recorded a significant increase in the overall number of
The incidence of radiolucent zones in both acetabular and femoral acetabular fractures, but without an increase in THR implantations after
components in our study was found to be comparable to other studies, these fractures. Functional results of THR according to the modified
with an incidence of 20.32% as reported in a meta-analysis [29]. Harris Hip Score were fully comparable to THRs in other indications.
However, the incidence of para-articular calcifications in our study was Higher patient age and cases polytrauma were associated with worse
higher, nearly double, compared to other indications for total hip modified Harris hip scores.
replacement, as reported in the same meta-analysis. The reason for this Para-articular calcifications occurred more frequently in male pa
increase cannot be explained but it is presumed that the higher inci tients and after the posterior (Kocher-Langenbeck) approach. The
dence of para-articular calcifications did not significantly impact the treatment of acetabular fracture complications with THR requires indi
modified Harris hip score. vidualization of the procedure for each patient.
Our study found that men and patients who underwent a posterior
approach (Kocher-Langenbeck) had a higher risk of calcification. Ethics approval
According to a study by Chémaly et al. [6], factors such as high-energy
trauma, craniocerebral trauma, associated extremity trauma, and early Our study has been performed in accordance with the ethical stan
THR for displaced acetabular fractures increase the risk of calcification. dards laid down in the 1964 Declaration of Helsinki and its later
10
amendments. Our research had been approved by the institutional re 5- to 23-year follow-up with clinical and radiological analysis. Hip Int 2020 May;
30(3):339–46. https://doi.org/10.1177/1120700019836413.
view board of the authors’ affiliated institutions. Data acquisition and
[15] Gruen TA, McNeice GM, Amstutz HC. „Modes of failure“ of cemented stem-type
analysis had been concordant with the STROBE protocol. Written femoral components: a radiographic analysis of loosening. Clin Orthop 1979;141:
informed consent had been gain prior enrolment to this clinical trial. 17–27.
Written informed consent had been gain prior publication of clinical [16] Iqbal F, Ullah A, Younus S, Aliuddin A, Zia OB, Khan N. Functional outcome of
acute primary total hip replacement after complex acetabular fractures. Eur J
data. Orthop Surg Traumatol 2018 Dec;28(8):1609–16. https://doi.org/10.1007/
s00590-018-2230-y.
Declaration of Competing Interest [17] Khoshbin A, Hoit G, Henry PDG, Paterson JM, Huang A, Atrey A, Kreder HJ,
Jenkinson R, Wasserstein D. Risk of Total Hip Arthroplasty After Acetabular
Fracture Fixation: the Importance of Age. J Arthroplasty 2021 Sep;36(9):3194–9.
All authors declared no conflict of interest. https://doi.org/10.1016/j.arth.2021.04.025. e1.
[18] Kumar P, Sen RK, Kumar V, Dadra A. Quality of life following total hip arthroplasty
in patients with acetabular fractures, previously managed by open reduction and
Acknowledgements internal fixation. Chin J Traumatol 2016 Aug 1;19(4):206–8. https://doi.org/
10.1016/j.cjtee.2015.07.012.
This work is supported by the European Regional Development [19] Lucchini S, Castagnini F, Giardina F, Tentoni F, Masetti C, Tassinari E, Bordini B,
Traina F. Cementless ceramic-on-ceramic total hip arthroplasty in post-traumatic
Fund-Project “Application of Modern Technologies in Medicine and osteoarthritis after acetabular fracture: long-term results. Arch Orthop Trauma
Industry” (No. CZ.02.1.01/0.0/0.0/17 048/0007280). This work is Surg 2021 Apr;141(4):683–91. https://doi.org/10.1007/s00402-020-03711-0.
supported by Charles University (Cooperatio 43). [20] Meena UK, Tripathy SK, Sen RK, Aggarwal S, Behera P. Predictors of postoperative
outcome for acetabular fractures. Orthop Traumatol Surg Res 2013 Dec;99(8):
929–35. https://doi.org/10.1016/j.otsr.2013.09.004.
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11
Injury 54 (2023) 110917
Injury
Biomechanical analysis of different internal fixation methods for special

Maisonneuve fracture of the ankle joint based on finite element analysis
Chaomeng Wu a, Xingyu Wang b, Hao Zhang b, Shuihua Xie b, Jianhua He b, *
a
Jiangxi university of Traditional Chinese Medicine, Nanchang 33004, China
b
Jiangxi Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Nanchang 33003, China
Keywords: Objective: The objective of this study was to evaluate the biomechanical properties of different internal fixation
Finite element analysis methods for Maisonneuve fractures under physiological loading conditions.
Maisonneuve fracture Methods: Finite element analysis was used to numerically analyze various fixation methods. The study focused on
High fibular fracture
high fibular fractures and included six groups of internal fixation: high fibular fracture without fixation + distal
Distal tibiofibular joint injury
Biomechanical analysis
tibiofibular elastic fixation (group A), high fibular fracture without fixation + distal tibiofibular strong fixation
(group B), high fibular fracture with 7-hole plate internal fixation + distal tibiofibular elastic fixation (group C),
high fibular fracture with 7-hole plate internal fixation + distal tibiofibular strong fixation (group D), high fibular
fracture with 5-hole plate internal fixation + distal tibiofibular elastic fixation (group E), and high fibular
fracture with 5-hole plate internal fixation + distal tibiofibular strong fixation (group F). The finite element
method was employed to simulate and analyze the different internal fixation models for the six groups, gener
ating overall structural displacement and Von Mises stress distribution maps during slow walking and external
rotation motions.
Results: Group A demonstrated the best ankle stability under slow walking and external rotation, with reduced
tibial and fibular stress after fibular fracture fixation. Group D had the least displacement and most stability,
while group A had the largest displacement and least stability. Overall, high fibular fracture fixation improved
ankle stability. In slow walking, groups D and A had the least and greatest interosseous membrane stress.
Comparing 5-hole plate (E/F) and 7-hole plate (C/D) fixation, no significant differences were found in ankle
strength or displacement under slow walking or external rotation.
Conclusion: Combining internal fixation for high fibular fractures with elastic fixation of the lower tibia and fibula
is optimal for orthopedic treatment. It yields superior outcomes compared to no fibular fracture fixation or strong
fixation of the lower tibia and fibula, especially during slow walking and external rotation. To minimize nerve
damage, a smaller plate is recommended. This study strongly advocates for the clinical use of 5-hole plate in
ternal fixation for high fibular fractures with elastic fixation of the lower tibia and fibula (group E).
Introduction posterior malleolus fracture. However, the literature reported some

patients with undamaged medial structure in MFF cases, that is, no
Maisonneuve fracture of the fibula (MFF) is a special type of ankle deltoid ligament rupture or medial malleolus fracture [2,3]. Perry et al.
fracture, accounting for approximately 7% of ankle fractures [1]. The explained the mechanism of fibular fracture based on cadaver experi
characteristics of the injury include proximal fibular fracture, medial ments. One of the mechanisms includes tearing of the interosseous lig
structure injury of the ankle joint (medial malleolus fracture or deltoid ament and pulling backward of the fibula by the complete lateral
ligament injury), distal tibiofibular syndesmosis injury (anterior liga collateral ligament of the ankle, which causes fibular fracture in supi
ment of the distal tibiofibular syndesmosis, posterior ligament of the nation–external rotation [4,5]. Bartoníček et al. analyzed the imaging
distal tibiofibular syndesmosis, transverse ligament of the distal tibio examination of MFF patients and found that approximately 25% of
fibular syndesmosis, and intertibiofibular ligament injury), and fibular fractures were not visible in the anteroposterior position but
E-mail address: 13707096886@139.com (J. He).
0020-1383/© 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
C. Wu et al. Injury 54 (2023) 110917
visible in the lateral position, which can easily ignore proximal fibular trauma, or ankle surgery were excluded from the study. The ethics
fractures in MFF [6]. committee of Jiangxi Provincial Hospital of Integrated Traditional Chi
Currently, no reliable evidence has shown whether proximal fibular nese and Western Medicine approved the study. We used Mimics21.0
fractures should be fixed. Porter et al. proposed that the most important software (materialise Company, Belgium) to extract data and recon
concepts for MFF treatment were the reconstruction of the correct struct a normal complete ankle joint model (Fig. 1, a). This study was set
tibiofibular septum, fibular length, and the correct tibial and fibular to high fibular fracture (Fig. 2), corresponding to the six groups of in
alignment. However, they do not support proximal fibular fracture fix ternal fixation: group A: high fibular fracture + elastic fixation of the
ation [7], but they were unable to explain the reason for the lower tibia and fibula; group B: high fibular fracture + strong fixation of
non-fixation. Analysis of the injury mechanism showed that the closer the lower tibia and fibula; group C: high fibular fracture with 7-hole
the fibular fracture was to the proximal end, the greater the risk of lig
ament rupture and related instability. The treatment of lower tibio
fibular syndesmosis is controversial. Currently, treatment consists of
penetrating three or four layers of the cortex to fix the lower tibiofibular
syndesmosis. When four layers of the cortex are used for fixation, there is
a risk of broken nails [8], and the ankle joint activity is smaller than that
of the three cortexes. Based on postoperative imaging examination and
recovery of normal ankle function, Manjoo et al. reported no difference
in the effect of tricortical and tetracortical fixation [9]. The use of suture
buttons also has a good effect on lower tibiofibular joint fixation.
Compared with screw fixation, it provides many potential advantages,
including increasing the range of motion of the joint, facilitating the
ankle joint movement, restoring weight-bearing and movement faster,
and removing the screws without secondary surgery [10–13]. These
studies will provide a theoretical basis for our model.
We used finite element analysis (FEA) to analyze the biomechanics of
MFF. However, most of these studies focused on the separation and
fixation of the lower tibia and fibula, ignoring the finite element model
study of the high fibular fracture in MFF [14–22]. Because different
loads at the ankle joint will significantly affect the stress level and dis
tribution of the bone or internal fixator, we innovatively proposed the
high fibula simulated fracture and fixed with plate and screw in the
finite element modeling and used physiological real loads (such as loads
during walking and ankle rotation) to accurately evaluate the perfor
mance of different internal fixations, which will be crucial.
Method Fig. 2. Finite element model grouping: Complete ankle model, including the
upper end of the tibia and fibula; A Group A: high fibular fracture without
Three-dimensional model of bone and simulated surgical reconstruction fixation + distal tibiofibular elastic fixation; B Group B: high fibular fracture
without fixation + distal tibiofibular strong fixation; C Group C: high fibular
fracture with 7-hole plate internal fixation + distal tibiofibular elastic fixation;
First and foremost, a healthy volunteer, aged 26, male, with a height
D Group D: high fibular fracture with 7-hole plate internal fixation + distal
of 172 cm and weight of 60 kg, was carefully chosen to participate in this tibiofibular strong fixation; E Group E: high fibular fracture with 5-hole plate
study. The volunteer willingly provided informed consent and under internal fixation + distal tibiofibular elastic fixation; F Group F: high fibular
went anteroposterior, lateral, double oblique, and dynamic X-ray im fracture with 5-hole plate internal fixation + distal tibiofibular strong fixation;
aging of the ankle. Prior to selection, individuals with a history of bone G: elastic fixing; H: rigid fixation; I: 7-hole plate with 6 screws; J: 5-hole plate
deformities, fractures, tumors, infections, personal diseases, previous with 4 screws.
Fig. 1. Construction of finite element model workflow: a: Three-dimensional reconstruction of ankle joint model; b: the geometric diagram of the normal group
model; c: anatomical location of the final model and important ligament tissue of the ankle joint; d: relevant ligaments to be used; e: use of the boundary and loading
conditions of the model (slow walking and external rotation states).
C. Wu et al. Injury 54 (2023) 110917
plate internal fixation + distal tibiofibular elastic fixation; group D: high Table 1
fibular fracture with 7-hole plate internal fixation + distal tibiofibular Number of finite element mesh elements and nodes.
strong fixation; group E: high fibular fracture with 5-hole plate internal Sequence Groups Number of nodes (units) Number of units (units)
fixation + distal tibiofibular elastic fixation; group F: high fibular frac
1 Normal 22,920 103,951
ture with 5-hole plate internal fixation + distal tibiofibular strong fix 2 Group A 77,878 386,329
ation. In the elastic fixation group, a 2-mm diameter guide needle was 3 Group B 70,632 349,690
used to drill from the lateral fibula to the tibial side by 30◦ , and a 4.5-mm 4 Group C 85,495 409,371
diameter channel was drilled along the guide needle. The 2.5-mm 5 Group D 75,985 372,732
6 Group E 95,561 459,755
diameter tendon rope (placed before and after the loop plate, not 7 Group F 86,513 422,739
through the articular cartilage) was used to penetrate the four layers of
the cortex, and the guide needle was used to introduce the suture plate
system from the lateral fibula to the medial tibia. The medial tibial
Table 2
button plate was confirmed in place, the fibular side suture was tight
Ligament material parameters in the finite element model.
ened, and the button plate was knotted. The suture button system con
sists of a lock, fiber, guide needle, and lead. In the rigid fixation group, Ligament name Spring stiffness (N/
mm)
we used a 3.5-mm diameter screw, which was close to the upper part of
the lower tibiofibular syndesmosis, parallel to the tibiotalar joint surface Tibiofibular ligament (anterior and posterior) 90
Tibiofibular interosseous ligament 234
at 2 cm, tilted backward and forward by 25◦ –30◦ , fixed three layers of
Anterior talofibular lateral collateral ligament 141.8
the cortex (bilateral fibula and lateral tibial cortex), and the screw top Lateral collateral ligament posterior talofibular 82
was located in the tibial medullary cavity. This study aimed to make the Anterior tibiotalar triangle ligament 122.6
ankle joint adapt to the normal micromovement of the lower tibiofibular Triangular ligament posterior tibiotalar 60
syndesmosis and prevent screw fracture. The fixation techniques Other ligaments (including anterior and posterior ligaments 80
of the fibula)
employed for high fibular fractures encompass the utilization of either a
5-hole or 7-hole 3.5 mm reconstruction plate in conjunction with a 3.5
mm locking screw. In the case of the 5-hole plate, a total of 4 screws will
be positioned, with 2 screws installed above and below the fracture line. Table 3
Material parameters of each structure in the finite element model.
Similarly, for the 7-hole plate, a total of 6 screws will be used, following
the same installation pattern of 3 screws. Regardless of the chosen Name Elastic modulus Poisson
(MPa) ratio
method, each screw permeates two layers of cortical bone.
Cortical bone 17,000 0.30
Finite element setting Cancellous bone 700 0.20
Articular cartilage 12 0.42
Plate and screw, loop plate, strong screw (Ti- 106,000 0.33
The geometric model of each group of reversely processed structures 6Al-4 V)
was improved. Subsequently, the cortical bone/cancellous bone of the Elastic fixation (tendon rope) 215.3 0.40
tibiofibular talus bone was segmented, the articular cartilage was sup
plemented, and some important ligament tissues (including the ante
Based on previous studies’ contact settings, the fracture surface is
rior/posterior tibiofibular ligament, intertibiofibular ligament, lateral
assumed to be completely broken, with contact and non-common node
collateral ligament, anterior/posterior tibiofibular ligament, anterior/
connections. The contact friction coefficient between the fracture blocks
posterior tibiofibular ligament of the deltoid ligament, anterior/poste
is set to 0.46 [29,30]. The screw is simplified as a cylinder using the
rior fibular head ligament, etc.) were supplemented based on the anat
conventional approach and is constrained by contact friction settings. To
omy and position of the ligament in 3dbody software (ShangHai
simulate the locking effect of the steel plate and screw in fibular fracture
QiaoMedia Information Technology Co., Ltd, ShangHai, China), and
internal fixation, the steel plate and screw are bound as common nodes,
then the structural model wiring, coplanar, contact, and other issues
ensuring a reliable connection without loosening. The contact rela
were redistributed (Fig. 1, c d). The STP files of each group of structural
tionship between the bone and the screw is set with a friction coefficient
geometric models were imported into the Hypermesh14.0 software
of 0.3 [31,32]. Complete common node contact is established between
(Altair Company, Michigan State, USA) for meshing, and the BDF file
the articular cartilage and bone, with a friction coefficient of 0.001 [33].
was exported and imported into the MSC.Patran2019 software (NASA
The friction coefficient between the steel plate and the bone surface is
Company, Washington, D.C, USA) for finite element mesh attribute
set at 0.3 [29,30]. The tendon rope used for elastic fixation is approxi
setting, material parameter definition, load application, and boundary
mately simulated by the graft of the knee joint reconstruction ligament.
condition constraint. Subsequently, the finite element post-processing
The tendon rope is considered a nonlinear material subjected only to
was uploaded to the MSC.Nastran2019 software (NASA Company,
tension [34], and the friction coefficient between the tendon rope and
Washington, D.C, USA) for calculation analysis and viewing of the re
the bone tunnel is set to 0.3 [35].
sults. Fig. 2 shows the finite element mesh models of each group.
In this study, the finite element simulation analysis of six groups of
Grid division: The cortical bone, cancellous bone, fracture block,
different internal fixation ankle joint models was performed based on
articular cartilage, internal fixation plate and screw, loop plate, and
the published ankle biomechanical literature on the loading method,
tendon rope corresponding to bone adopt TetMesh Tet4 Element tetra
load, and constraint boundary conditions. We compared and analyzed
hedral solid grid unit, and some important ankle ligaments adopt 1d
the biomechanical characteristics of the six groups of ankle joints under
spring unit (Tables 2 and 3). Table 1 shows the number of finite element
different internal fixations, which focused on the structural strength and
mesh elements and nodes.
stability of the ankle fracture after internal fixation. Considering the
actual stress characteristics of the lower tibia and fibula and the sig
Material properties and boundary conditions
nificant effect of external rotation violence on high fibular fracture,
boundary constraint assumptions were made for several groups of in
Please refer to the published material parameters [1,23–28] listed in
ternal fixation models. All nodes on the lower talar surface were fixed,
Table 3. It is assumed that cortical bone, cancellous bone, articular
and the degrees of freedom in six directions were limited. An 1800-N
cartilage, plate and screw, loop plate and tendon rope, and strong screw
pressure load (Fig. 1, e) was applied on the upper tibial and fibular
are isotropic, uniform, and exhibit continuous linear elastic behavior.
C. Wu et al. Injury 54 (2023) 110917
surface to simulate the biomechanical characteristics of 60-kg in (MPa) of the tibia and fibula, plate and screw, and interosseous mem
dividuals in a slow walking state (the pressure load during slow walking brane under slow walking and external rotation, and the displacement
is approximately thrice the weight of normal individuals [36], of which data (mm) of the overall structure under two different movements.
the tibia and fibula bear approximately 80% and 20% of the total load,
respectively). To simulate the changes in biomechanical properties of Von mises equivalent stress
the external rotation load, an external rotation torque of 10 N.m was
applied to the upper tibial and fibular end [22]. In both states (slow walking and external rotation), the stress of the
tibia and fibula decreased after plate and screw fixation of the fibular
Model validation fracture (Figs. 4 and 5). In groups A and C and groups B and D, the stress
of the tibia and fibula decreased by approximately 25.61% and 36.30%,
To test whether the finite element modeling method, material respectively, and the corresponding elastic fixation stress decreased by
parameter setting, boundary constraint, load loading, and model approximately 22.68% and 40.46%, respectively. In groups C and D, the
simplification in the process of three-dimensional simulation are stress of the tibia and fibula and that of the plate and screw corre
reasonable and correct. Previous studies reported the application of sponding to the strong fixation of the lower tibia and fibula increased by
applied a 600-N pressure load to verify the correctness of the model [37, approximately 19.85% and decreased by approximately 17.56%,
38], and the biomechanical finite element analysis was performed from respectively. During external rotation, the changes in the tibia and fibula
the perspective of quali- and quantitative analyses and compared with stress and plate and screw stress in the four groups of different fixations
the study by Anderson [39] that used sample experiment and finite were unclear, and the stress difference was approximately 5%. In groups
element method calculation results to verify the correctness of the ankle A and C and groups B and D, the stress of the elastic fixation and strong
model in this study. Fig. 3 shows the stress distribution of the tibiotalar fixation of the lower tibia and fibula after the fibular fracture was fixed
joint surface by the Anderson specimen experiment, finite element with a steel plate and screw significantly reduced by 53.22% and
analysis, and contact stress distribution of the tibiotalar joint surface. 60.26%, respectively. When comparing the same type of internal fixa
From the tibiotalar joint surface contact stress distribution and stress tion (group C and group E, group D and group F) for treating fibular
peak, Anderson et al. studied the peak contact pressure of the tibiotalar fractures with a 5-hole steel plate using 4 screws versus a 7-hole steel
joint surface corresponding to the two groups of in vitro experiments of plate using 6 screws, the differences in ankle joint structural strength are
2.92 and 3.69 MPa, which was 3.74 and 2.74 MPa in the finite element not significant, whether during slow walking or external rotation. The
study. Accordingly, finite element simulation in this study showed that variance in peak stress among the structures ranges from approximately
the peak contact stress of the tibiotalar joint surface is approximately 0.53% to 19.13%, with external rotation showing the most noticeable
2.80 MPa, which was close to the results of Anderson’s in vitro experi difference. Although there is a slightly more pronounced stress on the
ment and finite element analysis. Thus, the normal group tibia model in plate and screws, the disparity in peak stress is approximately 12.50%,
this study is correct and effective. which still falls within the yield strength of the titanium alloy at 816.6
MPa.
Fig. 4 shows interosseous membrane stress. In the slow walking state,
Results
the interosseous membrane stress corresponding to groups D and A is the
smallest and largest, respectively. Compared with groups A and B, the
We performed finite element analysis on six different fixation
stress of interosseous membrane in groups C and D after plate and screw
methods. Table 4 shows the peak value of Von Mises equivalent stress
fixation at the fibular fracture decreased by approximately 23.05% and
22.07%, respectively. By comparing groups A and B, elastic fixation or
strong fixation was performed in the lower tibia and fibula. Compared
with group A, the stress of the interosseous membrane after strong fix
ation was also reduced by approximately 15.39%. Compared with
groups C and D, the stress of the interosseous membrane after strong
fixation of the lower tibia and fibula decreased by approximately
14.31%, which was smaller than that of elastic fixation. In the state of
external rotation, the stress of the interosseous membrane in groups D
and C was the smallest and largest, respectively. Because the stiffness of
the lower tibiofibular structure area in groups A and C was smaller than
that in groups B and C, the stress in the elastic fixation group was
reduced by approximately 7.02%. If the fibular fracture was fixed with a
plate and screw, the stress of the interosseous membrane in group D
decreased by approximately 13.49%, which was significantly lower than
that in group C. Compared with groups A and C and groups B and D, the
stress of the interosseous membrane corresponding to the elastic and
strong fixation groups increased by 28.57% and 19.62%, respectively,
after fixing the fibular fracture with a steel plate and screw.
Displacement of the overall structure
Under the two motion states (slow walking and external rotation),
Figs. 4 and 5 shows that the overall displacement of group D is the
smallest, and the structure is the most stable; however, that of group A is
the largest, and the structure is the most unstable. The internal fixation
Fig. 3. Verification of the finite element model: (a) biomechanical finite of the plate and screw after a high fibular fracture increases the overall
element analysis of this study; (b) Anderson specimen experiment and finite stability of the ankle joint. Comparing groups A (walking, 3.21 mm;
element analysis; (c) comparison of the stress distribution of the tibiotalar joint external rotation, 4.11 mm) with C (walking, 1.74 mm; external rota
surface with Anderson sample experiment and finite element analysis. tion, 2.57 mm) or groups B (walking, 2.26 mm; external rotation, 2.40
C. Wu et al. Injury 54 (2023) 110917
Table 4
Peak Von Mises equivalent stress (MPa) of the ankle joint structure and displacement data (mm) of the whole structure under slow walking and external rotation.
Maximum displacement of the whole Peak Von Mises equivalent stress (MPa) of each group Slow walking/ Interosseous membrane stress comparison,
structure (mm) under slow walking and external rotation slow walking, external rotation, interosseous
external rotation membrane under slow walking and external
rotation (MPa)
Slow walking Outward spin motion Tibiofibular Plate/screw Elastic fixation Rigid fixation Slow walking Outward spin motion
Normal 0.51 2.25 25.61/36.25 – – – 12.52 10.00

Group A 3.21 4.11 241.15/44.84 – 107.21/49.89 – 13.71 7.84
Group B 2.26 2.40 337.50/42.01 – – 611.94/60.47 11.60 7.29
Group C 1.74 2.57 179.38/46.30 131.85/97.48 82.90/23.34 – 10.55 10.08
Group D 1.50 1.84 214.98/46.61 108.70/94.91 – 364.34/24.03 9.04 8.72
Group E 1.77 2.77 176.56/44.12 130.11/85.29 82.05/25.10 – 10.75 10.27
Group F 1.50 1.82 213.85/38.97 87.91/83.06 – 371.40/25.72 9.34 9.53
mm) with group D (walking, 1.50 mm; external rotation, 1.84 mm), the which tends to be shown in a normal individual.
overall structural displacement of the ankle joint was significantly To date, various treatment strategies have been used to treat Mai
reduced after the plate screw was placed at the fibula. The displacement sonneuve fractures. However, whether internal fixation should be per
reductions in the slow walking and external rotation states were 45.79% formed in high fibular fractures has not been discussed [7]. The distal
and 33.63%, and 37.47% and 23.33%, respectively. Comparison be tibiofibular syndesmosis is a micro-motion joint that should be fixed
tween groups A and B showed a fibular fracture, and lower tibiofibular elastically after injury rather than rigidly. Rigid fixation will limit the
elastic fixation (3.21 mm, 4.11 mm) and strong fixation (2.26 mm, 2.40 displacement and rotation of the fibula relative to the tibia, affecting the
mm) were performed, respectively. The overall displacement of group B compliance regulation of ankle points on talar movement. Many
was significantly reduced, and the displacement reductions under the methods exist for tibiofibular fixation. Most scholars recommend using
two motion states were approximately 29.60% and 41.61%, respec metal screws recommended by AO (Arbeitsgemeinschaftfür Osteosyn
tively. The stability of strong fixation was better than that of elastic thesefragen), but there is no consensus on the number of screw fixations,
fixation. The fibula was fixed with a steel plate and screw in groups C number of cortical crossings, screw diameter, and screw removal time.
and D. Moreover, the overall displacement of the ankle joint after strong The button steel plate suture device uses a high-strength suture to
internal fixation (1.74 mm, 2.57 mm) of the lower tibia and fibula was tighten the lower tibiofibular joint on both ankle joints through the
also smaller than that of elastic fixation (1.50 mm, 1.84 mm). The button steel plate and tie it. Its advantages include limiting the separa
displacement reductions under the two motion states were approxi tion of the lower tibiofibular syndesmosis while allowing a certain de
mately 13.79% and 28.40%, respectively. Similarly, the stability of gree of micromotion [40]. With regard to relevant finite element model
strong fixation was also better than that of elastic fixation. When literature, we mostly focused on studies that evaluated different screws
comparing the same type of internal fixation (group C and group E, and titanium plates used in lower tibiofibular syndesmosis injury. Four
group D and group F) for treating fibular fractures with a 5-hole steel studies evaluated simple screws, including screw thickness, placement
plate using 4 screws versus a 7-hole steel plate using 6 screws, the location, and the number of cortical layers to be penetrated. One study
maximum displacement of the ankle joint structure shows a minimal reported on a simple titanium plate; four studies reported on screws
difference. Whether during slow walking or external rotation motion, combined with a titanium plate, including the distance between the ti
the range of displacement difference is approximately 1.90 to 13.61%. tanium plate and screw and a comparison of the effect of the titanium
Group E and group F exhibit slightly larger overall structural displace plate and screw alone [14–22]. The Taguchi method was used to design
ment compared to group C and group D. However, it is important to note and compare four different types of titanium screws in the study by Er
that the stability of both approaches meets the clinical requirements for et al. A 3.5-mm single cortical screw is sufficient if the three-layer cortex
internal fixation. is penetrated, and the choice of a 3.5-mm cortical screw is more
reasonable [5]. The selected position is the most critical during lower
Discussion tibiofibular joint fixation. Güvercin et al. reported that placing a tita
nium plate 2 cm parallel to the tibiofibular joint surface can prevent
We used the finite element method to quantitatively and qualita tibiofibular joint relaxation and enhance ankle joint stability [22]. A
tively study the biomechanics of plate and screw fixation, lower tibio prospective study [41] compared the difference between button plate
fibular elastic fixation, and rigid fixation of high fibular fracture of the and metal screw fixation, and the average AOFAS (Ankle Hindfoot Scale)
ankle joint. Subsequently, we obtained biomechanical conclusions with score of patients with button plate fixation was significantly higher than
certain reference significance. This model proposes fixing the high fibula that of patients with screw fixation, and they could carry weight and
based on the simulation of lower tibiofibular syndesmosis injury, which return to work earlier postoperatively.
is theoretically effective. However, when a single screw is used to fix the The proximal fibula should not be fixed in high fibular fractures. The
lower tibiofibular syndesmosis, the displacement of the single screw proximal fibula [5] is closely related to many important ligaments and
during the external rotation of the ankle joint is reduced compared with neurovascular structures. Open reduction and fixation of the fibula are
the six groups. Currently, the displacement of slow motion and external usually prohibited because the peroneal nerve could possibly be injured
rotation of a single screw is the smallest, followed by single-buckle plate intraoperatively. Because of limited analysis data comparing proximal
fixation, whereas that of high-position fixation without the fibula is the fibular fracture, most scholars consider performing fibular incision and
largest, indicating that high fibular fixation significantly influences the fixation when obvious displacement, shortening, rotation, loss of fibular
selection of internal fixation instruments and stability of the fracture length, or high fibular dislocation in the high fibular fracture is observed
ends. Therefore, using a single screw or a buckle plate to fix the lower [8,42]. Considering the analysis and avoiding these factors, proximal
tibiofibular joint is recommended when such ankle injuries occur, and fibular fixation can enhance ankle joint stability. By comparing the four
plate and screw internal fixation is used for the high fibula to increase groups, the displacement value and Von Mises equivalent stress data can
ankle joint stability. The lower tibiofibular single screw and buckle plate be beneficial to prove this study’s purpose. Thickening of the distal end
fixation can reduce the overall displacement, but the buckle plate can of the interosseous membrane forms the inferior tibiofibular inteross
provide sufficient displacement space to the lower tibiofibular joint, eous ligament. Its function is similar to that of a spring, which allows the
C. Wu et al. Injury 54 (2023) 110917
Fig. 4. Statistical results of the six

groups of finite element models. ①:
Comparison of Von Mises equivalent
stress among the structures in groups A,
B, C, and D during slow walking motion;
②: Comparison of Von Mises equivalent
stress among the structures in groups A,
B, C, and D during external rotation
motion; ③: Comparison of Von Mises
equivalent stress of the interosseous
membrane in groups A, B, C, and D
during slow walking and external rota
tion; ④: Comparison of displacement of
the overall structure of the ankle joint
among groups A, B, C, and D; ⑤: Com
parison of Von Mises equivalent stress
among the structures in groups C, D, E,
and F during slow walking motion; ⑥:
Comparison of Von Mises equivalent
stress among the structures in groups C,
D, E, and F during external rotation
motion; ⑦: Comparison of Von Mises
equivalent stress of the interosseous
membrane in groups C, D, E, and F
during slow walking and external rota
tion; ⑧: Comparison of displacement of
the overall structure of the ankle joint
among groups C, D, E, and F.
distal tibia and fibula to be slightly separated during ankle dorsiflexion, patients with MFF had interosseous membrane damage; thus, we also
thereby allowing the talus to be embedded in the ankle joint and sta analyzed the interosseous membrane stress of the model, and the results
bilizing the ankle joint during weight loading. In terms of internal and were similar to our expectations. Plate and screw internal fixation was
external displacement, an experimental [43] study on the movement of performed at the high fibula. The stress of the interosseous membrane
the distal tibiofibular syndesmosis showed that separating the inter was reduced and increased in the slow walking, and external rotation
osseous ligament causes the largest relative outward displacement of the states, respectively. The interosseous membrane can share the stress of
distal fibula during the gradual separation of the distal tibiofibular the lower tibia and fibula, making the lower tibia and fibula and the
syndesmosis, suggesting that the interosseous ligament may be the most interosseous membrane tend to be whole, which prevents fibular end
important in preventing the separation of the distal tibiofibular syn displacement, which is important for the postoperative rehabilitation of
desmosis. Manyi et al. [44] reported that in the MRI examination, all patients. Moreover, when the plate is exposed near the common
C. Wu et al. Injury 54 (2023) 110917
Fig. 5. The Von Mises stress value and displacement value of the normal and the six groups after internal fixation under two motion states.
C. Wu et al. Injury 54 (2023) 110917
peroneal nerve, a larger plate increases the risk of nerve damage, while a structure. Simple fixation was performed in the lower tibia and fibula.
smaller plate can minimize or avoid potential harm to the nerve. The Von Mises stress value of the tibia and fibula was 241.15 and
Consequently, we simulated two types of plate and screw fixation 337.50 MPa in the elastic and strong fixation groups, respectively. Under
methods for fibular fractures. Through a comparison of group C, group the same configuration, Numan et al. [19] study obtained 160.7 MPa
D, group E, and group F, it was observed that the plate and screws under elastic fixation, and Diego et al. [21] obtained 336.1 MPa under
remained intact without any damage. Both the use of a 5-hole plate with strong fixation, which was consistent with the lower tibiofibular joint
4 screws and a 7-hole plate with 6 screws for fixing high fibular fractures injury we studied. In each group, the peak value of Von Mises equivalent
meet the structural strength requirements based on biomechanical stress is increased, and the maximum displacement of the whole struc
forces. However, when considering clinical application, the use of a ture is decreased under slow walking or external rotation by comparing
5-hole plate with 4 screws results in less soft tissue trauma and reduced groups A and B or groups C and D, indicating that the overall ankle joint
costs. Therefore, the preferred choice for clinical practice is the utili stiffness under strong fixation is greater than that under elastic fixation.
zation of a 5-hole plate with 4 screws. The stress analysis of the interosseous membrane showed that strong
Currently, the commonly used fixation methods for lower tibio fixation is superior to elastic fixation in protecting the structural
fibular joint injury are strong fixation and elastic fixation. Rigid fixation strength of the interosseous membrane. However, the results were the
is generally screw fixation. This study showed that a tricortical screw opposite in external rotation. After elastic fixation, the ankle joint still
(3.5 mm) was used to fix the tibiofibular syndesmosis injury. Screw had certain activity, resulting in interosseous membrane stress corre
fixation has been considered the main surgical treatment of distal sponding to the lower tibiofibular rigid fixation group being less than
tibiofibular syndesmosis [3], but this method has unavoidable defects, that of the elastic fixation group. The screw limited the tibiofibular joint
including ankle stiffness and dysfunction caused by long-term non- and stiffened the tibiofibular joint. When the steel plate was used for
weight-bearing, and early weight-bearing exercise may lead to screw fixation, it was closer to the complete ankle joint configuration.
breakage, screw loosening, and secondary trauma caused by internal Our study has limitations, such as simulating the clinical situation
fixation removal surgery. Elastic fixation is generally fixed with a loop approximately, and it does not simulate the related muscles, ligaments,
plate. Compared with the traditional lower tibiofibular joint screw fix and joint capsules. Concurrently, important anatomical results are
ation, the buckle plate device, such as the suture button fixation tech simplified based on the relevant literature, such as the representation of
nique, has two prominent advantages, including the retention of the the ligament by a linear spring to simulate its linear tension. Similarly,
small titanium alloy button in the subcutaneous tissue and removal of secondary factors, such as muscle contraction, have been ignored, which
the connecting line retained in the bone. Its strength is close to the screw only slightly affected this study. For the model analysis, only finite
[45], and microelasticity is not available for screw fixation, allowing element analysis of the model in the state of slow walking and external
patients to perform unrestricted weight-bearing and functional exercise rotation was performed, ignoring the internal rotation and back exten
earlier. Currently, many studies confirmed that screw fixation could sion of the ankle joint. To improve the dynamic simulation of more ankle
easily lead to the abnormal reduction of distal tibiofibular syndesmosis joints, appropriate material parameters, and boundary conditions
[46]. Franke et al. [47] believed that the deformity was mostly man should be established as much as possible, which increases the clinical
ifested as anterior fibular displacement and distal fibular internal rota significance of the results. We also lack the medical records of specific
tion. Marmor et al. [48] found that distal fibular internal rotation within patients who underwent such surgeries and the corresponding cadaver
10◦ and distal fibular external rotation within 30◦ could not be detected specimens. Moreover, the model can be verified and evaluated by the
in conventional radiography. Therefore, the anatomical reduction of the biomechanics of cadavers in such studies [18], and its mechanical
distal tibiofibular syndesmosis is not easily ensured in intraoperative behavior changes are studied from the perspective of theory combined
conventional X-ray fluoroscopy. The reduction of lower tibiofibular with practice. Promoting the development of clinical surgery for the
syndesmosis deformity destroys the biomechanical stability of the ankle internal fixation of ankle fractures is helpful.
joint and likely causes ankle osteoarthritis, which is often related to the
abnormal distribution of ankle joint pressure caused by the reduction of Conclusion
the distal fibular deformity. Based on biomechanical studies, Ramsey
et al. [49] reported that 1-mm lateral talar displacement can reduce the In conclusion, the combination of internal fixation for high fibular
contact area of the tibiotalar joint by 42%, thereby increasing local fracture with elastic fixation of the lower tibia and fibula proves to be
stress and arthritis risk. Curtis et al. [50] found that 30◦ external rotation the optimal choice for orthopedic surgeons in treating patients. It
of the fibula reduced the tibiotalar joint contact area by 9%, and a 2-mm demonstrates superior outcomes compared to the absence of high fibular
fibular shortening reduced the average contact area by 8%. Thord et al. fracture fixation or strong fixation of the lower tibia and fibula, partic
[51] studied the reduction of compound deformity of the distal fibula. ularly when subjected to slow walking and external rotation load.
By measuring the pressure changes of the tibiotalar joint when the fibula Moreover, to minimize or prevent potential nerve damage at the fibula,
was shortened by 2, 4, and 6 mm, moved outward by 2, 4, and 6 mm, and the utilization of a small plate is unequivocally recommended. Conse
rotated outward by 5◦ , 10◦ , and 15◦ under 700-N axial load, the quently, this study strongly advocates for the implementation of 5-hole
maximum contact pressure point was the middle and outer quadrants of plate internal fixation for high fibular fracture combined with elastic
the top of the talus, and the maximum contact pressure occurred when fixation of the lower tibia and fibula (group E).
the fibula was shortened to the greatest extent. Each shift method
significantly increases the pressure in the posterolateral quadrant. The Funding
increase of each displacement or rotation increases the contact pressure
in the lateral and posterolateral areas of the tibiotalar joint. Harris et al. None.
[52] showed that the tibiotalar joint contact area was reduced by 55%
and 77% when the distal fibula was moved 2 and 4 mm, respectively. CRediT authorship contribution statement
The posterior superior displacement of 2 and 4 mm reduced the area by
39% and 70%, respectively. Chaomeng Wu: Conceptualization, Methodology, Software, Writing
Relevant literature was also compared. Although the constructed – review & editing. Xingyu Wang: Data curation, Writing – original
ankle joint model, screw, and implantation methods, data quantification draft. Hao Zhang: Visualization, Investigation. Shuihua Xie: Supervi
results, and other factors are different, the six groups in this study did sion. Jianhua He: Software, Validation.
not exceed the ultimate yield strength of titanium alloy (Ti-6Al-4 V) at
896 MPa [1], which met the strength requirements of internal fixation
C. Wu et al. Injury 54 (2023) 110917
CRediT authorship contribution statement [19] Mercan N, Yıldırım A, Dere Y. Biomechanical analysis of tibiofibular syndesmosis
injury fixation methods: a finite element analysis. J Foot Ankle Surg 2023;62(1).
https://doi.org/10.1053/j.jfas.2022.05.007. 107-14.
Chaomeng Wu: Conceptualization, Methodology, Software, Writing [20] Liu ZX, Wang W, Zhang X, Yang J. Preliminary finite element analysis of anterior
– review & editing. Xingyu Wang: Data curation, Writing – original inferior tibiofibular syndesmosis injuries treated with screw and tight-rope
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Declaration of Competing Interest cmpb.2021.106272.
[22] Güvercin Y, Abdioğlu AA, Dizdar A, Yaylacı EU, Yaylacı M. Suture button fixation
method used in the treatment of syndesmosis injury: a biomechanical analysis of
The authors declare that they have no known competing financial the effect of the placement of the button on the distal tibiofibular joint in the mid-
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10
Injury 54 (2023) 110918
Injury
Resource implications of managing paediatric femoral fractures in a major

trauma centre: Analysis of 98 cases
Maheshi P Wijesekera, Ellen Martin, Chun Tang, James Chowdhury, Mohamed Y Sabouni,
Patrick Foster *
Trauma and Orthopaedics Department, Leeds Children’s Hospital, Leeds LS1 3EX, United Kingdom
Keywords: Introduction: The management of paediatric femoral shaft fractures is expensive and is guided by age and fracture
Paediatric characteristics. The primary aim of this study was to perform a cost evaluation for managing paediatric femoral
Child shaft fractures. The secondary aim of this study was to perform and compare costs of the different techniques of
Femur
managing paediatric femoral shaft fractures.
Shaft
Fracture
Methods: Ninety-eight femoral shaft fractures in children aged ≤16 were identified between 01/06/2014–30/06/
Hip spica 2019. Retrospective data of clinical complications were obtained on infection, malunion and non-union. Data on
Flexible elastic nail additional intervention, reoperations for complications and routine removal of metal work were obtained.
Submuscular plate Costing analysis was performed by a bottom-up calculation, and gathering Patient Level Information and Costing
Rigid nail System (PLICS) data.
Cost Results: There were 41 hip spica casting (HSC), 21 flexible intramedullary nailing (FIN), 14 submuscular plating
Economic evaluation (SMP), 19 rigid intramedullary nailing (RIN) and 3 external fixation (EF). Complications observed were HSC 3
(7%); FIN 8(38%); SMP 2(14%); RIN 1(5%); EF 2(67%). The total costs for managing femoral shaft fractures
were £8,955pp the costs for the different managements were; HSC £3,442pp; FIN £7,739pp; SMP £6,953pp; RIN
£8,925pp; EF £19,116pp. The additional costs incurred for managing complications and routine removal of metal
work for the internal fixation methods were: HSC 0.7%, FIN 23.7%, SMP 16.3%, RIN 10.9%, EF 28.1%.
Conclusion: The operative management of paediatric femoral shaft fractures is associated with a high cost burden
and this study demonstrates how financial data can be used to influence clinical management strategy. RIN carry
a high initial implant cost however when considering the additional costs, such as treating complications it
remains comparable to other modes of fixation. Our cost analysis did not demonstrate a significant difference
between FIN, SMP and RIN. Due to the clinical complications observed and associated additional costs, we have
discontinued the routine use of FIN for femoral shaft fractures at our centre. We recognise other centres may have
a different complication and cost profile for each technique, but recommend they evaluate their practice given
the potential economic benefit it has on the service provider.
Introduction United Kingdom [3,4]. In current orthopaedic practice, there are trends
to using more expensive implants [5–6]. The financial burden associated
Health economics ensures cost effective treatments are delivered to with novel technology together with the ageing population has chal
patients. It allows healthcare stakeholders in decision making, by lenged the sustainability of health care services. Costing aids external
eliminating costs whilst maintaining quality of care [1]. In 2020 health decision making, and has influenced national benchmarking initiatives
service expenditure trends in the United States saw an accelerated rise in such as Get It Right First Time (GIRFT) [7], demonstrating the drive for
costs by 9.7% per year due to the Covid-19 pandemic [2]. Despite the efficient utilisation of medical resources.
expected normalisation back to the pre-pandemic levels, the predicted Traditionally, paediatric fractures have a propensity to be managed
projections continue to demonstrate that the health care expenditures non-operatively, as opposed to fractures in adults [8]. It has financial
outpace the cost of inflation. Similar trends have been described for the benefits by cost saving through less surgical time and implant use
E-mail address: patrick.foster@nhs.net (P. Foster).
M.P. Wijesekera et al. Injury 54 (2023) 110918
Table 1 Table 2
Costs of intervention. Patient demographics and clinical outcomes.
Total Cost HSC FIN SMP RIN

n = 41 n = 21 n = 14 n = 19
Routine resources and activities
Children’s specialist orthopaedic bed (bed per day)* £428.00 Median age (IQR) 2.67 6.8 8.68 (6.93 13.7
Children’s specialist orthopaedic theatre (per minute theatre £10.60 years (1.90–3.22) (4.8–8.2) − 10.25) (13.0–14.9)
time) Gender (M:F) 36:5 15:5 11:3 9:10
X-ray £18.96 Median time to 3(1–5) 1 (1–2) 2 (1–4) 1(1–2)
Outpatient follow-up clinic (per visit) £154.00 surgery (IQR)
Implants days
Hip spica casting - plaster material NegligibleΔ Median surgical 35 (30–40) 129 129 (102- 164
Flexible intramedullary nail £217.54 time (IQR) mins (73–148) 157) (114–255)
Submuscular plating £247.39 Median LOS (IQR) 4.0 (2–6) 6.0 (4–8) 6.5(5–9) 6.0(5–9)
Rigid intramedullary nail £1,087.00 days
External fixator £1,704.00 - Median follow-up 5.59 11.95 13.04 20.3
£2,580.00 (IQR) months (2.92- 42) (9.5- (9.74–24.74) (8.7–25.4)
18.35)
*Day case procedures were treated as needing one bed per day stay. Median number 3 (3–4) 5 (4–8) 5 (4–6) 5( 3–6)
Δ
not included in bottom-up calculation, however included in PLICS value as a post op X-rays
miscellaneous cost. (IQR)
Median number of 4(2–5) 6 (4–8) 5 (3–6) 5(4–7)
clinic visits
however, it is associated with indirect costs secondary to the prolonged (IQR)
stay and complications. This is in addition to the negative impact pro Removal of metal n/a 15 2 (14.3%) 6 (31.6%)
longed immobilisation has on the developing child’s wellbeing. In the work (71.4%)
Complications (%) 3 (7.3%) 8 (38.1%) 2 (14.3%) 1 (5.3%)
UK femoral shaft fractures have an average annual incidence of 5.82 per
100,000 amongst the paediatric population [9]. With the introduction of HSC: hip spica casting, SMP: submuscular plating FIN: flexible intramedullary
GIRFT to paediatric trauma and orthopaedics (PTO) [10], it has high nailing RIN: rigid intramedullary nailing.
lighted the importance of early mobilisation, reducing length of stay and n: number of fractures, IQR: interquartile range, M:F male: female, LOS: length
early discharge when managing lower limb fractures. of stay, n/a: not applicable.
Patient Level Information and Costing System (PLICS) is a micro
costing technique that allows for an accurate mode of economical techniques of managing paediatric femoral shaft fractures. Due to the
evaluation of surgical intervention [11]. It allocates costs to individual wide age range (0–16 years) we acknowledge from the outset that in
patients utilising resources and provides a reflection of the cost of dividual clinical case options will be limited amongst the different
healthcare delivery. The PLICS data aids the efficiency and techniques.
cost-effectiveness of patientcare at a local level, and can aid in setting
the National Health Service (NHS) tariffs. Methods
The current evidence base for evaluating the cost benefit of different
fixation modalities for paediatric femoral shaft fractures is limited and This study was performed at a level 1 major trauma centre. Approval
focusses on the index surgery [12–14]. from the institution of quality and governance department was ob
The primary aim of this study was to perform a cost evaluation in tained. Children presenting with a femoral shaft fracture (AO classifi
managing paediatric femoral shaft fractures and compare this to the cation 32-D) to our unit were identified between June 2014 and June
hospital remuneration received. The secondary aim of this study was to 2019. We included all children aged 16 years and younger. Those who
perform a cost identification analysis by comparing the different sustained proximal or distal femoral fracture such as those involving the
Fig. 1. Cost calculation.
Table 3
Bottom-up cost analysis.
Cost breakdown Total % of
Additional costs*
HSC Initial resource costs LOS: £428.00 x 220 0.7%

(n ¼ 41) Surgical time: £10.68 x 1436
X-ray: £18.96 x 140
Clinic: £154.00 x 182
£140,178.88
£3,419.00pp
Complications £962.00 £141,140.00
£3,442.46pp
FIN Initial resource costs Implants: £217.54 x 21 23.7%
(n ¼ 21) LOS: £428.00 x 170
Surgical time £10.68 x 2378 £124,018.42
X-ray: £18.96 x 124 £5,905.64pp
Clinic: £154.00 x 123
Removal of metal work £13,970.76 £137,989.18

£6,570.91pp
Complications £24,542.95 £162,532.13
£7,739.63pp
SMP Initial resource costs Implants: £247.39 x 14 £81,441.02 16.3%
(n ¼ 14) LOS: £428.00 x109 £5,817.22pp
Surgical time £10.68 x1947
X-ray: £18.96 x 60
Clinic: £154.00 x 61

£6,088.96pp
Complications £12,102.75 £97,348.25
£6953.45pp
RIN Initial resource costs Implants: £1,087.00 x 19 £151,127.52 10.9%
(n ¼ 19) LOS: £428.00 x 176 £7,954.08pp
Surgical time £10.68 x 3580
X-ray: £18.96 x 96
Clinic: £154 x 98

£8,154.32pp
Complications £14,645.75 £169,577.75
£8,925.14pp
EF Initial resource costs Implants: £7,324.00 28.1%
(n ¼ 3) Other surgery: £1748
LOS: £428.00 x 29
Surgical time £10.68 x 864 £41,245.36
X-ray: £18.96 x 54 £13,748.45pp
Clinic: £154 x 45

£14,393.35pp
Complications £14,169.21 £57,349.25
£19,116.42pp
HSC: hip spica casting, SMP: submuscular plating FIN: flexible intramedullary nailing RIN: rigid intramedullary nailing EF: external fixation LOS: length of stay, pp:
per person.
*Additional costs - includes routine removal of metal work and complication costs.
physis or femoral neck were excluded from this analysis. Children who have occurred or as implant failure prior to fracture union. Unplanned
had a pathological fracture as a result of osteogenesis imperfecta or reoperation was included in cases where there was a loss of reduction
infection were excluded due to the longevity of follow up and/or need secondary to minor low energy trauma, as fixation should be able to
for specialist surgical equipment. Those patients that were transferred to withstand this as a basic principle.
our unit for revision surgery were excluded. Retrospective data was The cost identification analysis was performed at two levels, initially
obtained from clinical coding, patient and theatre records regarding a bottom-up micro costing analysis for the care delivered at a patient
demographics, length of stay (LOS), surgical time, implants used and level was calculated. This included the costs of the initial resource de
follow-up. Open injuries were described using the Gustilo-Anderson livery and additional costs acquired by routine removal of metalwork
(GA) Classification. Complications included were infection, malunion, and treatment of complications. Cost drivers for direct costs were
non-union and unplanned reoperation. Infection was based on clinical identified as LOS, theatre time, implants, X-rays and the number of
findings and deep infection was diagnosed on positive intraoperative outpatient follow-up clinics. The average costs across the financial years
samples. Fracture union was defined as the presence of bridging callus for resources and implant costs are demonstrated in Table 1. The costs of
on 3 of 4 cortices on orthogonal views and pain free weightbearing. the typical implant used with manufacturers’ details are supplied in the
Malunion was defined as shortening 1 cm or angular rotational defor supplementary table.
mity ≥10◦ . Non-union was defined as failure to show progression on Hip spica casting (HSC) was applied by a qualified plaster technician
radiographs for at least 12 weeks where normal fracture union would under X-ray guidance. The cost of materials for this was considered
Table 4
PLICS analysis and reimbursement.
Crude cost Total cost Reimbursed
HSC Initial resource costs £140,178.88

(n ¼ 41) £3,419.00pp £174,351.47
Complications £962.00 £4,252.47pp
£23.46pp £196,606.00
Miscellaneous £1,653.12 £4,798.27pp
£40.32pp
Overheads £31,557.47£
769.69pp
FIN Initial resource costs £124,018.42
(n ¼ 21) £5,905.64pp
£665.27pp £12,102.67pp
Complications £24,542.95 £247,862.59
£1,168.71pp £11,802.98pp
Miscellaneous £40,535.53
£1,930.26pp
Overheads £44,794.93
£2,133.09pp
SMP Initial resource costs £81,441.02 £120,377.00
(n ¼ 14) £5,817.22pp £8,598.36pp
Removal of metal work £3,804.48
£271.75pp
Complications £12,102.75
£864.48pp £123,984.00
Miscellaneous £4194.75 £8,856.00pp
£299.63pp
£1,602.93pp
RIN Initial resource costs £151,127.56
(n ¼ 19) £7,954.08pp £253,637.35
Removal of metal work £3,804.48 £13,349.33pp
£200.23pp
Complications £14,645.75 £202,867.00
£770.83pp £10,677.21pp
£1,742.85pp
£2,681.33pp
EF Initial resource costs £41,245.36 £77,766.36 £45,598.00
(n ¼ 3) £13,748.45pp £25,922.12pp £15,199.33pp
Removal of metal work £1,934.68
£644.89pp
Complications £14,169.21
£4,723.07pp
£653.58pp
£6,152.12pp
HSC: hip spica casting, SMP: submuscular plating FIN: flexible intramedullary nailing RIN: rigid intramedullary nailing EF: external fixation pp: per person.
negligible. Flexible intramedullary nails (FIN) were used in children the care delivered. The cost calculation is demonstrated in Fig. 1. The
weighing <50 kg, and two retrograde flexible titanium nails were used PLICS data aimed to highlight the total costs involved in the delivery of
to maintain fracture reduction. For the submuscular plating (SMP) care which included miscellaneous costs and departmental overhead
group, children were most commonly managed with a locking dynamic costs. The miscellaneous costs included other direct costs attained
compression plate (71%), accepting that some patients had anatomical through physiotherapy, medication, pathology and other consumable
plates inserted. Rigid intramedullary nails (RIN) were inserted as costs. The departmental overheads were estimated at 22.1% of the total
anterograde using a lateral trochanteric entry point or as retrograde costs as per the trust financial calculations.
insertion in those with a closed physis. External fixators (EF) were used The reimbursement received to our trust for the treatment provided
to achieve a stable fracture configuration in select complex cases such as was collected through our trust accounts team, which included costs of
contaminated open fractures. The items utilised for this are reused after overheads. This was based on the tariffs from annual submission of the
sterilisation thus costs being negligible, however for the purpose of this national estimates of costs and was compared to the PLICS value at a per
study the EF implants are treated as new items. If there were any further patient cost.
intervention, to manage complications such as radiological in The secondary aim was analysed by performing a cost identification
vestigations or therapeutic interventions this was added to the bottom- analysis comparing the management modes of HSC, FIN, SMP, RIN and
up calculation. EF of femoral shaft fractures.
The second level of cost analysis involved obtaining PLICS data for
Fig. 2. 8M with a femoral shaft fracture and contralateral tibial fracture. Developed varus malunion requiring hemiepiphyseodesis at 8 months. This patient also
sustained a contralateral tibial fracture undergoing circular frame fixation (not shown).
Fig. 3. 5F with a femoral shaft fracture managed initially with flexible intramedullary nailing which resulted in varus malunion and shortening. Subsequently
underwent corrective osteotomy and lengthening using a monolateral external fixator.
Results simultaneous bilateral FIN, the other underwent FIN and SMP of their
femoral shaft fractures. Where the management of the bilateral fractures
We identified 98 consecutive fractures in 96 children with femoral were different, each fracture was considered as a separate entity for the
shaft fractures managed at our centre between 01/06/2014–30/06/ cost analysis and reimbursed values equally divided. Of note there were
2019. There were 41 fractures that were treated with HSC, 21 fractures no cases of deep infection in our study. Table 2 demonstrates the patient
treated with FIN, 14 fractures were treated with SMP, 19 fractures demographics and clinical outcomes observed. The total cost of man
treated with RIN and 3 fractures managed definitively with an EF. Two aging 98 femoral shaft fractures were £877,601.77 (£8,955.12pp)
patients had bilateral femoral shaft fractures. One child had regardless of the type of fixation modality. The total renumeration
Fig. 4. 10 M presenting with an oblique femoral shaft fracture undergoing submuscular plating using an anatomical plate.
received to our department was £699,227.00 (£7,134.97pp). Table 3 with a contralateral tibial fracture. There were 6(32%) cases of routine
demonstrates bottom-up cost analysis where as Table 4 describes the removal of metal work done at a median of 15.8(IQR 12.9- 25.8)
PLICS analysis and reimbursement received. months. There were 3 children who only underwent removal of the
symptomatic distal locking screws. There was one complication
• Hip spica casting observed, where early shortening was noted 7 days after the surgery for
a communited diaphyseal fracture which required lengthening. This
There were 41 femoral shaft fractures that were managed with a child went on to develop non-union and required treatment with low-
HSC. All these injuries were isolated. The median age was 2.67(IQR intensity ultrasound therapy followed by exchange nailing. The initial
1.90–3.22) years with 71% of patients being ≤3 years. There were two treatment cost for this RIN group was £7,954.08pp and the management
non-ambulatory children aged ≥6 years with neuromuscular conditions, of any secondary intervention was £971.06pp.
which were managed with HSC. Children were on skin traction for a
median duration of 3(IQR 1–5) days prior to the application of the HSC. • External fixation
Four children were transferred from peripheral hospitals for tertiary
care. Thirty seven children (90%) had this applied within the first week There were three children that were definitively managed with an
of admission. The median LOS was 4(IQR 2–6) days. Thirty two (78%) EF. One child aged 14 years had an isolated GA 3B with heavy
children were discharged on the day of or the day after the application of contamination. They were initially managed with debridement and
HSC. Eleven (27%) were formally assessed for non-accidental injury. external fixation followed by delayed primary closure, with a 10 day
Children were followed up for a median of 5.59(IQR 2.92- 42.00) LOS. They presented with delayed union at 4 months and underwent
months from surgery. Three complications of malunion were observed, debridement with acute shortening using a monolateral EF, followed by
one child returned for surgery at 8 weeks and underwent trimming of lengthening. This was further complicated by non-union that became
bone. The other two were conservatively managed and followed-up until apparent upon removal of the EF by refracturing. They underwent
resolution. The PLICS calculation revealed a cost of £3,419.00pp for further surgery with autologous bone graft and reapplication of a
initial treatment for HSC, and £23.46pp for the management of any monolateral EF and were subsequently followed up until skeletal
additional intervention. maturity.
The second child, aged 11 years had a GA-3C of their femur and a
• Flexible intramedullary nailing pelvic fracture. They underwent bypass surgery, debridement and
external fixation to their pelvis and femur at initial presentation with a 5
There were 21 fractures managed with FIN. Five (25%) children had day LOS. This patient went on to union and the EF was removed at 12
more than one injury. Twenty (95.2%) femurs underwent removal of months. Due to the prolonged immobilisation they suffered arthrofib
their FIN, with 15(71.4%) being uncomplicated routine removal of their rosis of the knee and underwent manipulation under anaesthesia. They
metal work. This was performed at a median of 8.8(IQR 8.2–10.9) were followed up for 4 years until symptom resolution.
months after initial surgery. The other causes for removal were for The third child, aged 12.8 years had an isolated GA-1 injury which
complications; 3(14.3%) undergoing revision surgery, and 2(9.5%) un was managed with an EF. This was removed at 3 months with no com
dergoing staged removal. plications observed and discharged at 5 months.
There were eight (38.1%) complications observed in this group. Two The cost of managing children with EF was £13,748.45pp, whereas
(9.5%) children underwent staged removal secondary to superficial the cost to manage any additional intervention was £5,367.96pp.
infection or migration of FIN. There were two (9.5%) non-unions, with
one child undergoing revision to a RIN at 7 months and the other SMP at Discussion
10 months after their index surgery. Two (9.5%) children had varus
malunion, with one undergoing hemiepiphyseodesis (Fig. 2). The other, This study demonstrates a comprehensive cost evaluation of man
underwent a corrective osteotomy with a monolateral EF (Fig. 3). Both aging paediatric femoral shaft fractures in addition to the different
required further surgery for removal of their revision metal work. There techniques used in this population. These injuries carry a significant cost
were two (9.5%) cases of reoperation where there was fracture burden and the renumeration received from the service provider just
displacement following a minor low-energy fall requiring application of about meets the costs incurred by the trust for the low energy or younger
a HSC under anaesthetic, within the first 2 weeks. The PLICS analysis child. Whereas in the polytrauma adolescent the reimbursement is often
demonstrated the FIN cost £5,905.64pp initially and £1,833.98pp to insufficient to cover the costs sustained.
manage any secondary intervention. HSC is an established method of managing fractures in children aged
6 months-5 years [15] and can be performed early or delayed. Early
• Submuscular plating application has been shown to be successful with a minimal complica
tion profile [16,17] with the principle challenge is to identify patients at
There were 14 femoral shaft fractures that underwent SMP. There risk of shortening. In our study there were two children who had clinical
was one child who had bilateral femoral fractures, all others had isolated shortening of 1 cm, however they did not require any operative inter
injuries. Fig. 4 demonstrates radiographs of an uncomplicated case. Two vention. Many institutions within the UK still manage these injuries with
(14.3%) underwent routine removal of metalwork. There were two long periods of traction prior to delayed HSC application or with traction
(14.3%) complications that required further surgical intervention. One alone [10]. This is associated with higher costs given the longer inpa
child developed non-union that was revised to a RIN and the other, had a tient stay. At our institution, children are managed with less time in
varus malunion and underwent revision plating. The initial cost of SMP traction thus gaining from the financial benefits associated with a
was £5,817.22pp whereas costs of managing secondary intervention was shorter LOS, and have observed a low complication profile.
an additional £1,136.23pp. FIN (also referred to as elastic stable intramedullary nailing) is a
commonly utilised fixation method for those aged 4–12 years [15,18]
• Rigid intramedullary nailing whereas for those aged >11 years either FIN, RIN or SMP is recom
mended [18]. FIN is limited to children who weigh <50kgs and is
There were 19 children with femoral fractures managed with RIN. associated with complications such as malunion, non-union, migration,
One (5%) child in this group was initially managed with an EF. Sixteen skin erosion in addition to its preference for removal [19,20]. In our
(84%) patients had other injuries associated with polytrauma and had cohort FIN was utilised in those age <11 years with an observed
surgery within the first day of admission. Fig. 5 demonstrates such a case complication rates of 38.1%. Within the literature the complication rate
Fig. 5. 15 M sustained a femoral shaft fracture and underwent rigid intramedullary nailing. They also sustained a contralateral tibial fracture which was managed
with a circular frame. At two months after the surgery this patient was involved in a road traffic collision, which resulted severe distortion of the circular frame,
however the rigid intramedullary nail construct remained stable.
for FIN is reported to be 27% [21] however there is a lack of clear to that which has been described in the literature [23], with no reported
consensus on the definition of malunion and its treatment threshold for cases of avascular necrosis. The additional costs for this group were
femoral fractures. Our observed difference is likely secondary to our 10.9% of the total costs, the lowest of the fixation modalities despite
lower threshold of intervening for malunion. being responsible for higher material costs.
SMP is preferred for length unstable fractures and minimises the The use of external fixation for paediatric femoral shaft fractures are
effect of periosteal stripping. Edwards et al. [18] concluded that plating indicated in complex injuries [25] thus having a limited evidence base.
femoral shaft fractures has a lower relative risk of complications in This study demonstrates that 28.1% of the total costs were incurred
comparison to FIN and EF. This lower complication profile is echoed in through additional costs. The loss in reimbursement to the trust, is ex
our study, acquiring to 16.3% additional costs in this cohort. pected as it is unlikely to be solely attributable to the choice of fixation
The complications associated with increase in age and FINs has led given the complex and severe nature of these fractures in addition to the
the American Association of Orthopaedic Surgeons (AAOS) to recom cost of managing additional injuries in this group. Another reason for the
mend the use of RIN with lateral entry for those aged >12years [15,20]. discrepancy could be due to the inaccuracies in coding that are enhanced
Historical surgical techniques for RIN were associated with complica with the complexity of the procedure, a challenge recognised in PTO
tions such as avascular necrosis and proximal valgus deformity [22]. [10].
With better understanding of the vascularity to the proximal femur it has The current evidence base for evaluating the cost benefit of different
been identified that the lateral greater trochanteric entry point mini fixation modalities is limited to HSC, FIN, SMP and former techniques of
mises this risk [22,23]. This provides a stable fixation and can be kept in RIN [12–14]. They draw conclusions based on the index procedure, not
without its routine removal. In some centres there is now an increase in taking into consideration the impact complications have on cost [12].
uptake in RIN in the those <11 years [24] as modern implants allow Amongst the more recent studies, for those aged between 3 and 6 years
smaller diameter options down to 7 mm. RIN is preferred in children HSC has been attributed to cost approximately USD556.00pp
with multiple injuries as it allows for earlier weightbearing. Our RIN (£428.12pp) and FIN USD1,840.50pp (£1,417.19pp) [13]. A further
group had 84% with polytrauma which would have influenced LOS and comparative study demonstrated average costs for FIN were USD2,
the higher initial costs. Our complication profile observed is comparable 186.71pp (£1,380.38pp), whereas plate fixation cost USD 2,686.97pp
(£2,015.23pp) in children aged 5–11 years of age [12]. PLICS to calculate tariffs. In addition to this, tariffs derived from refer
Although the aim of the study was not to directly compare methods, ence costing and PLICS make adjustments to the outlier values. Utilising
our bottom-up cost analysis shows that there is no difference in direct a mixed methodology for micro-costing using bottom-up, in addition to
costs between the three fixation methods SMP, FIN and RIN. The addi the locally derived PLICS values, we are able to obtain an accurate
tional costs for FIN are 23.7% which challenges its use from both an representation of the direct costs and highlight the complications and
economical and as a clinically effective mode of fixation. Since the routine removal of metal work have as a cost driver. We provided a cost
introduction of FIN, there have been more advanced techniques and evaluation from a clinical and service provider point of view however,
implants introduced notably with SMP and RIN. Based on our experi one should also consider the societal costs that highlight the burden on
ence, as a department we utilise FIN rarely given its complication profile patient families and the intangible costs such interventions have on the
in addition to its poor cost effectiveness. Even in the most experienced developing child. It is challenging to perform an accurate cost effec
hands, FIN alone does not offer any inherent axial stability and renders tiveness analysis, across heterogenous groups based on complexity of
children non-weightbearing for longer. This would impact on school and injury and age as seen in the HSC and EF groups.
work absences on both the patient and parents. This effect is amplified
when children have complications requiring further intervention. The Conclusion
use of endcaps however may be attempted to limit axial collapse and
backing out of flexible nails and reduce the complication profile. The The treatment of paediatric femoral shaft fractures is expensive and
implant choice is influenced by patient factors and fracture character the reimbursement hospitals receive for the polytrauma, complex or
istics and therefore should be assessed on a case-by case basis. Where open injuries is insufficient. Irrespective of the short term financial
clinically indicated, FIN could be utilised for the fixation of femoral shaft implications, we have discontinued treating femoral shaft fractures
fractures by adhering to techniques described [26] to minimise the using FIN due to the complication profile observed and its associated
complications. long term costs. We recommend other centres to evaluate their practice
Figs. 2 and 3 demonstrate examples where optimal stability was not of treating femoral fractures in children and the associated cost profile.
achieved with FIN which resulted in complications. If gold standard FIN In other centres a different clinical and financial cost profile may be
technique was employed, our complication rate may have been lower demonstrated, for instance more in favour of FIN. Even if the cost profile
which would have reduced the need for removal of metal work and is different this study supports to identify the potential economic benefit
revision fixation. FIN is a paediatric technique that has limited exposure to the service provider and patient via alternative methods of fixation.
amongst trainees, whereas surgical techniques for SMP and RIN in This study provides insight in to the resource implications of managing
children are similar to trauma surgery performed in adults. It is therefore femoral shaft fractures while considering clinical outcomes such as
probable that an individual surgeon is more familiar with RIN and SMP union. Prospective multicentre studies should be performed to compare
compared to FIN and thus more likely to avoid pitfalls. However, we the economic impact of FIN, SMP and RIN across homogenous samples.
appreciate that this discrepancy in training and experience may not
apply in other centres. It is also the senior author’s experience that the Declaration of Competing Interest
typical modes of failure demonstrated (loss of length, varus collapse) are
frequent indications for tertiary referral for subsequent deformity None.
correction in cases with established malunion. As these are elective cases
referred from external units these cases are not included in this study. Acknowledgments
Fig. 4 demonstrates a case of SMP where a patient had an anatomical
plate utilised for fixation. This was the case only in a minority of the Leeds Teaching Hospitals Trust Costing and PLICS department
group (28.5%), whereas majority had locking dynamic compression
plates. In general, healthy paediatric bone is unlikely to benefit from Supplementary materials
locking plate technology over the traditional dynamic compression plate
with cortical screws thus giving the service provider an opportunity to Supplementary material associated with this article can be found, in
save on expenses. the online version, at doi:10.1016/j.injury.2023.110918.
The age range in SMP and RIN are heterogenous to the FIN group,
however consideration should be given to such alternative fixation References
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10
Injury 54 (2023) 110919
Injury
Biomechanical comparison of tension band suture fixation and tension

band wiring in olecranon fractures
Liv Vesterby a, Asger Martin Haugaard d, Jonas Adjal a, Huda Ibrahim Muhudin b, Kevser Sert b,
Morten Grove Thomsen a, Ilija Ban a, Søren Ohrt-Nissen c, *
a
Department of orthopedic surgery, Copenhagen University Hospital, Hvidovre, Copenhagen, Denmark
b
Department of health technology, Technical University of Denmark (DTU), Copenhagen, Denmark
c
Department of orthopedic surgery, Copenhagen University Hospital, Rigshospitalet, Denmark
d
Department of orthopedic surgery, Zealand University Hospital, Køge, Denmark
Keywords: Purpose: Traditional tension band wire fixation (TBWF) of olecranon fractures is associated with high revision
Forearm fracture rates due to implant-related complications. The purpose of the study was to compare the strength of fixation in
Olecranon fracture olecranon fractures between TBWF and an all-suture based technique.
Biomechanical
Methods: A transverse fracture was created in 20 paired fresh-frozen human cadaveric elbows. Fractures were
Tension band wiring
Tension band suture fixation
randomly (alternating right-left) assigned for fixation with either tension band suture fixation (TBSF) or TBWF.
The elbow was fixed in 90◦ of flexion and underwent cycling loading by pulling the triceps tendon to 300 N for
200 cycles. Fracture displacement was optically recorded using digital image correlation (DIC). Finally, load-to-
failure was assessed by a monotonic pull to 1000 N and failure mechanism was recorded.
Results: Two specimens in the TBSF group were excluded from the cycling loading analysis due to technical
difficulties with the DIC. After cyclic loading, median (min-max) fracture displacement was 0.28 mm (0.10–0.44)
in the TBSF group and 0.18 mm (0.00–1.48) in the TBWF group (p = 0.315). No difference was found between
the two groups in the repeated measures analysis of variance (p = 0.329). In the load-to-failure test, 6/10
specimens failed in the TBSF group (median load-to-failure 791 N) vs. 8/10 in the TBWF group (median load-to-
failure 747 N). The TBSF constructs failed due to fracture of the dorsal cortex, suture breakage or triceps failure.
The TBWF constructs failed due to breakage of the wire.
Conclusion: There was no difference in fixation strength between the TBWF and TBSF constructs. Our findings
suggest TBSF to be a feasible alternative to TBWF and we hypothesize that a non-metallic implant may have
fewer implant-related complications.
Level of evidence: Basic science study
Introduction not been able to verify that this mechanism of fracture compression
actually occurs [3–5] and the TBWF technique is associated with a high
Olecranon fractures account for approximately 10% of upper ex proportion of secondary operations. Revision rates range from 30 to
tremity fractures [1]. Surgical management may be indicated for dis 80%, the most frequent indication being implant loosening/prominence
placed fractures or rupture of the extensor mechanism [2]. Tension band followed by infection and loss of reduction [6–9].
wire fixation (TBWF) using k-wires and figure-of-eight metal wire is A tension band suture fixation (TBSF) technique was described in
commonly used for treating simple, displaced olecranon fractures (Mayo 2016 as an alternative to TBWF in treating olecranon fractures and has
type 2A). The biomechanical principle of the TBWF construct is to shown promising clinical results in terms of functional outcome and a
achieve absolute fracture stability through functional elbow movement low rate of revision [10–12]. TBSF aims to reduce hardware problems
and converting tensile forces into compression through the activation of without compromising mechanical stability but has only been evaluated
the triceps and brachialis. However, several biomechanical studies have in small retrospective case series [12].
* Corresponding author at: Department of Orthopedic Surgery, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
E-mail address: ohrtnissen@gmail.com (S. Ohrt-Nissen).
L. Vesterby et al. Injury 54 (2023) 110919
Our study aimed to compare the strength of fixation between TBWF

and TBSF in a biomechanical setup. Our hypothesis was that TBSF would
perform equally to TBWF in terms of maintaining fracture reduction.
Material and methods
The study was conducted with the approval of the regional ethics
committee (H-19,051,911).
Twenty paired fresh-frozen cadaveric elbows from a total of ten
human donors were used.
The elbows were stored at − 20◦ (no formalin fixation). The elbows
were prepared before fixation by removing all soft tissues except the
elbow joint capsule, medial and lateral collateral ligament, annular
ligament, and the triceps tendon. The humeral bone was cut 10 cm above
the joint line and the forearm (ulna and radius) was cut 15 cm below the
joint line. A simple transverse fracture was created using an oscillating
saw through the cartilage bare area of the greater sigmoid notch.
Surgical technique
Fixation of the olecranon fractures was performed by one trauma

surgery consultant to secure continuity. The surgeon was experienced in
both fixation techniques. Fractures were reduced and held in place with
a reduction forceps and two 1.6 mm k-wires. Reduction was verified by
fluoroscopy. Elbows from each matched pair were randomly (alter
nating left and right) assigned to one of the two fixation techniques.
Tension band wire fixation
TBWF was performed as described by the Arbeitsgemeinshaft für

Osteosyntesefragen (AO) [13]. Two parallel 1.6 mm K-wires were
inserted bicortical in the proximal end of the ulna aiming for the anterior
cortex passing as close as possible to the articular surface. A transverse Fig. 1. The final osteosynthesis for TBSF illustrating the placement of the
drill hole was created 40 mm distally to the fracture line with a 2.7 mm two sutures.
drill bit. A 1.25 mm wire was passed through the transverse drill hole
and beneath the triceps tendon in a figure-of-eight configuration. The clamps were made of stainless steel and covered with 3D printed layer of
wire was twisted laterally and medially simultaneously to achieve the ribbed textured polylactic acid. The clamp was attached perpendicular to
desired tension. The proximal ends of the K-wires were bend in 180◦ and the triceps tendon 30 mm above the tip of the olecranon. Testing was done
driven into the tip of the olecranon. by connecting the clamp to the sealed end of the cable and pulling to a
prespecified load with the MTS® crosshead, equipped with a force
Tension band suture fixation transducer. To analyze the displacement of the fracture with the DIC®
system (Aramis 12 M, GOM), adhesive reference point markers were
The TBSF technique was performed as described by Phadnis et al. used. Each marker was placed above and below the fracture line such
[11]. In short, a bicortical 2.7 mm transverse drill hole was made that they were aligned and matched vertically. When capturing with the
through the dorsolateral aspect of the ulna 20 mm distal from the DIC®, two digital cameras were positioned one meter from the test
fracture line and 10 mm from the dorsal cortex. A #2 FiberWire® with specimen.
needle was passed through the transverse drill hole from lateral to
medial, then grasped with a stitch horizontally in the medial aspect of Biomechanical testing
the triceps tendon and brought back through the transverse drill hole
from medial to lateral. A similar stitch was made in the lateral aspect of The biomechanical testing consisted of cyclic loading followed by
the triceps tendon and then tightened with a surgeon’s knot. A second failure testing. A total of 200 cycles of loading from 0 to 300 N were
suture was passed through the transverse drill hole from lateral to repeated or until failure occurred. The choice of loading force was
medial and a horizontal stitch was made in the lateral aspect of the guided by normative age-matched reference values during isometric
triceps tendon. The suture was brought back through the transverse drill elbow extension [14]. The loading responses on the MTS® apparatus
hole from medial to lateral and a final stitch was made in the medial were recorded while the DIC® (synchronized to the MTS) continuously
aspect in the triceps tendon before the suture was tightened. Both su monitored fracture displacement.
tures were tightened with the elbow in full extension and the knots were After cyclic loading, we performed a load-to-failure test by applying
placed in the lateral aspect of the proximal ulna (Fig. 1). a monotonic pull to 1000 N or until failure. Failure was defined as a
A specialized test rig was developed and tested (Fig. 2 and 3). The decrease in force that the MTS’ force transducer could detect below the
elbow was fixed in 90 flexion in a mounting base of the mechanical crosshead. This failure load was chosen since most failures in reference
testing machine (MTS Sintech®) (Fig 1 and 2). The rig was developed to studies occurred at 500–700 N [15–18].
eliminate vertical (along flexion/extension axis) and rotational move
ment. The humerus and forearm were fixed in stainless-steel cylinders Statistical analysis
and enclosed in 3D-printed casts of thermoplastic polyurethane to pre
vent slippage during loading. The movable crosshead of the MTS® R version 3.4.0 (R Core Team) was used for statistical analyses [14].
applied load to the triceps tendon using a clamp and a pulley system. The
Fig. 2. Schematic illustration of the test setup.
Fig. 3. Left: Specimen mounted in the test rig. Right: Example of TBSF specimen with markers for DIC tracking.
Data is presented as medians with min-max values. The main result was group did not fail at max load (1000 N) compared to two in the TBWF
fracture displacement 200 cycles after the initial cycle. Using the Wil group. Median load at failure in the remaining specimens were 791 N for
coxon rank sum test, we analyzed differences in fracture displacement. TBSF and 747 N for TBWF (p = 0.755). The six failed TBSF constructs
Additionally, we used repeated measures analysis of variance (rmA failed due to fracture of the dorsal cortex of the transverse suture tunnel
NOVA), which takes into account numerous repeated samples, to eval (N = 3), suture breakage (N = 1) or triceps failure (N = 2). In all eight
uate the impact of surgical technique. The load-to-failure threshold was failed TBWF constructs, the mechanism was breakage of the wire.
the secondary outcome. Failure threshold was defined as the maximum
load that the construct could withstand before a decline in force indi Discussion
cated that resistance had been lost in the construct.
The main finding of this study is that there was no clinically or statistically
Results significant difference in fracture displacement between the TBSF and
TBWF technique. Less than 0.5 mm of fracture displacement was seen
Eight out of ten were female, with a median age of 76 years (range after 200 cycles, indicating overall good performance of both surgical
60–90). Two specimens in the TBSF group had to be excluded due to procedures under cyclic stress. The pattern of fracture displacement was
technical errors during cyclic loading. These two specimens were similar between the two constructs (Fig. 4) reflecting that the underlying
included in the load-to-failure analysis. technique is similar with a basket figure-of-eight configuration. The
After 200 cycles of loading, median displacement was 0.28 mm load-to-failure analysis was compromised by the fact that several of the
(0.10–0.44) in the TBSF group and 0.18 mm (0–1.48) in the TBWF group constructs did not fail at max load. It is worth noting that we saw four vs
(p = 0.315) (Fig. 4). The rmANOVA showed no difference in displace two non-failures in the TBSF and STWF groups, respectively, and that
ment between TBSF and TBWF (p = 0.329) at any point. the failure load was slightly higher in the TBSF group (791 N vs 747 B).
The load-to-failure test included all 20 specimens. Four in the TBSF These results indicate that the TBSF technique provides a fixation that is
Fig. 4. Fracture displacement between the two groups during cyclic loading. The red line illustrates the median fracture displacement in the TBSF group. The red
area is the minimal and maximal displacement in the group. Correspondingly, gray line and area for the TBWF group.
non-inferior to TBWF both in terms of cyclic loading within a physio biomechanical characteristics of the fracture fixation structures and, as a
logical load and at max loading well beyond a clinical postoperative result, to assess the relative efficacy of each construct. Size of the
regime. specimen, age, weight, gender, and bone mineral density are all vari
As the material strength of non-metal implants improve, studies are ables that affect the quality of the bones. By using matched specimens
emerging examining the application in olecranon fractures. Our results alternating left and right for each technique, we aimed to reduce the signifi
are in line with a recently published study by Ernsbrunner showing cance of these biases.
similar fixation strength between tension band tape fixation and k-wire
fixation [19].. Von Keudell et al. found similar results using a different Conclusion
suture technique, although only seven specimens were included [20]..
Some of these studies employ passive extension of the elbow to mimic a There was no difference in fracture displacement between the TBWF
physiological range of motion while other used traction forces on a fixed and TBSF constructs. Our findings suggest TBSF to be a feasible alter
elbow [18,21]. We chose the latter approach to minimize angular native to TBWF in relation to biomechanical features. We hypothesize
movement of the construct, which improves measurement accuracy of that a suture-based implant may have fewer hardware-related compli
the DIC®. cations and propose that our verification of biomechanical equivalence
Biomechanical studies of this nature are vulnerable to sample size may form the basis for clinical comparative studies.
issues. A substantial amount of time and money goes into the test of each
specimen and while this is one of the largest biomechanical studies on Ethical approval
human cadaveric olecranon fractures, including more specimens would
have strengthened the analysis of our results. The study was conducted with approval from The Regional Com
Considering the biomechanical equivalence of TBSF and the TBWF, mittee of the capital region of Denmark, the regional branch of The
future studies should consider the potential benefits of a suture-based National Ethical Committee, file no. H-19,051,911
technique. The revision rate due to metallic implant-related issues is high
[7,8] and suture-based implants has the potential to lower these revision Declaration of Competing Interest
rates. A few smaller clinical studies have been published on suture fix
ation of olecranon fracture. Bateman et al. [22] reported on eight elderly The authors or their immediate families have not received any
patients with Mayo 2A and B fractures operated with suture anchor financial payments or other benefits from any commercial entity related
fixation. The authors found good radiological and clinical outcomes and to the subject of this article.
no reoperations. Ravenscroft et al. [23] found similar results in 22 pa Cadaveric specimens were handled in accordance with the protocol
tients (combined fractures and osteotomies). Phadnis et al. examined the of the Faculty of Health and Medical Science - University of Copenhagen
clinical results in 168 patients operated with either TBWF, TBSF or plate and funded by Department of Orthopedic Surgery, Copenhagen Uni
osteosynthesis. Reoperation rates were 36%, 2% and 11% respectively. versity Hospital, Hvidovre.
Overall, there a growing body of low-level evidence suggesting that
TBSF can be a viable alternative to metallic implants in simple trans Acknowledgements
verse olecranon fractures, but prospective comparative studies are
needed. The authors thank Jørgen Tranum-Jensen from Panum Institute,
The following limitations should be considered: The observed results Copenhagen University for his contribution to the biomechanical setup.
cannot be extended to other fracture patterns, as only simple transverse The authors thank Merteash Manouchehr from the Danish technical
fractures were tested. Cadaveric specimens cannot imitate in vivo var University for his contribution.
iables, such as bone quality and bone healing. Our matched-pair study
design, however, made it possible to examine the relative variations in
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Injury 54 (2023) 110921
Injury
Hindfoot nailing for displaced ankle fractures in the elderly: A

case-control analysis
Cindy Ou a, *, Joseph F. Baker a, b
a
Department of Orthopaedic Surgery, Waikato Hospital, Hamilton, New Zealand
b
Department of Surgery, University of Auckland, Auckland, New Zealand
Keywords: Introduction: Management of fragility ankle fractures in the elderly poses a surgical dilemma. An alternative to
Ankle fracture open reduction and internal fixation (ORIF) with screw and plate construct in selected elderly patients who may
Hindfoot nail be significantly frail and comorbid is a tibio-talo-calcaneal (TTC) or hindfoot nail. Hindfoot nailing potentially
Elderly
reduces the risk of wound infection and increases likelihood of earlier return to function by allowing earlier
Frailty
weightbearing. The aim of this study was to examine the outcomes and complications of patients who received a
hindfoot nail compared to patients who underwent an ORIF.
Methods: A retrospective review identified patients who underwent hindfoot nailing from Jan 2010 to Dec 2021.
Patients aged >65-years who underwent ORIF in the same time period were concurrently identified. The patients
in the ORIF group were matched with patients in the hindfoot nail group by age, gender, comorbidity according
to their Charlson Comorbidity Index (CCI) and their pre-injury function by Karnofsky Performance Scale (KPS).
Clinical Frailty Scale (CFS) was also collected as part of patient demographics. Outcomes examined include
mortality, length of stay, operation time, return to previous mobility, wound complications, metalware failure
and infections.
Results: Twenty-six patients were identified in the hindfoot nail group and matched to 26 patients who under
went ORIF. Mean age was 84 and 83 years in the nail and ORIF group respectively. Overall, there were 12 and 11
complications from the hindfoot nail and ORIF group respectively with seven and two requiring return to theatre
in the nail group and ORIF group (P = 0.07). The hindfoot nail group waited an average of 22 days after the
operation for weightbearing compared to 59 days in the ORIF group (P < 0.001). There were no significant
differences in length of stay (P = 0.58) and operation time (P = 0.19).
Conclusion: Hindfoot nailing was associated with an increased risk of complications and higher risk of return to
the operating theatre. Despite the potential attraction of earlier weightbearing, surgeons and patients need to be
aware of these potential pitfalls.
Introduction surgical treatment for displaced ankle fractures. However, due to vari
able outcomes in surgical management of ankle fractures in the elderly
Fragility ankle fractures are increasingly prevalent in an aging pop population, there is no consensus on how best to treat these [7,8].
ulation, especially in post-menopausal females [1–4]. Such ankle fac Complicating factors include but are not limited to poor bone stock, poor
tures result from low energy trauma in patients with poor physiological tissue quality and coverage, higher post-operative infection rates, pa
reserve; subsequently this leads to significant loss of function and in tient dissatisfaction and pain, and difficulty with complying with
crease morbidity [1,2]. Unsurprisingly, the peri‑operative period is weightbearing status post-operatively [7,9].
often difficult for this frail group of patients as they are vulnerable to The use of a tibio-talo-calcaneal (TTC) or hindfoot nail for the
internal and external stressors and are at an increased risk of adverse management of unstable ankle fractures in the elderly patient has
peri‑operative events, worsening disability and decline [5,6]. increased in recent years [10–21]. A hindfoot nail minimizes the soft
Open reduction and internal fixation (ORIF) is the conventional tissue injury associated with an open procedure and allows early
* Corresponding author at: Waikato Hospital, Pembroke Street, Hamilton, 3240, New Zealand.
E-mail address: Xou131@aucklanduni.ac.nz (C. Ou).
C. Ou and J.F. Baker Injury 54 (2023) 110921
weightbearing, thereby reducing the harms associated with prolonged Surgical technique and post-operative care
immobilization [10–21]. Most reports on the use of hindfoot nails for
fragility ankle fractures are retrospective case studies; there is one Majority (24 of 26) of nail fixation was performed using Valor
randomized control trial comparing hindfoot nails and ORIF in elderly Hindfoot Fusion Nail (Wright Medical, Tennessee, United States) and
population [11]. Generally, these studies have reported a low compli Expert Hindfoot Arthrodesis Nail (DePuy Synthes, Oberdorf,
cation rate with favourable patient outcomes [10–21]. Switzerland); two were performed with Trigen Hindfoot Fusion Nail
This study aims to report on the outcomes (complication rate, (Smith & Nephew, London, United Kingdom). Diametre of the nails
reoperation rate, readmission rate and mortality) of elderly patients ranged from 10 mm to 13 mm; length of the nails ranged from 150 mm
with ankle fractures treated with a hindfoot nail compared with a to 300 mm. Patients were place supine. Joint surfaces were preserved in
matched cohort undergoing ORIF with a plate and screw construct. all cases. Closed reduction was undertaken with image intensifier
Institutional approval for this retrospective outcome analysis was guidance. A guidewire was inserted via the plantar surface of the heel,
obtained from the Clinical Audit Support Unit. Given the retrospective guided through the calcaneus, talus and distal tibia before a two to three
nature of the analysis, using already collected data, patient consent was centimetre incision was made around the entry point. The canal was
not required. gradually reamed, and a hindfoot nail was inserted over the guidewire
and locked with proximal and distal locking screws. In the hindfoot nail
Methodology group, there was one case of posterior malleolus fixation with percuta
neous anterior-to-posterior 3.5 mm cortical screws.
A retrospective case-control study was conducted using data from a ORIF was performed in accordance with AO principles. Small frag
Level I trauma center. Patients who underwent surgical treatment for an ment sets were used in all cases: via an open lateral approach, fibular
unstable ankle fracture from 1st January 2010 to 31st December 2021 fractures were reduced, fixed with a lag screw if appropriate before the
were identified from intra-operative images from a filtered search in fracture fixation neutralized or the fracture bridged using one-third
Picture Archiving and Communication System (PACS). tubular plates. Medial malleolus fractures were fixed with cancellous
Between the above dates, 504 patients in total were surgically screws in all except in one case where a buttress plate was used for a
treated for an ankle fracture. Patients were included in the study if they more vertical fracture pattern. There were two cases in the ORIF group
1) were aged 65 years and above 2) had an unstable ankle fracture that where posterior malleolus fractures were fixed: one with a T-plate via
required surgical fixation (including uni-, bi-, and trimalleolar patterns) posterolateral approach and one with anterior-to-posterior cortical
and 3) sustained the fracture from a low energy mechanism. Patients screws.
were excluded if they had 1) pathological fractures and 2) fractures in Posterior malleolus fractures were fixed if a large fragment involving
the setting of polytrauma. >25% of the articular surface was present. The method of surgical fix
From the above cohort, 27 consecutive patients aged 65 years and ation was decided by the surgeon performing the operation. In the only
above were surgically treated for an unstable ankle fracture with a case of posterior malleolus fixation from the hindfoot nail group, the
hindfoot nail. One patient was excluded as the fracture was sustained in posterior malleolus was a large fragment that involved approximately
context of polytrauma. There were no cases of pathological fractures. 50% of the articular surface; this was fixed prior to the hindfoot nail
This left 26 patients in the hindfoot nail group. insertion. Of the ORIF group, both posterior malleolus fractures fixed
From the same cohort, 477 consecutive patients aged 65 and above involved >25% of the articular surface.
were treated for an unstable ankle fracture with ORIF. Eight patients All patients were given prophylactic antibiotics at anaesthetic in
were excluded due to fractures in the setting of polytrauma. There were duction and for 24 h post-surgery in line with hospital protocols. Pa
no pathological fractures. Therefore, 469 patients were available in the tients in both groups were immobilized in a plaster cast after the
final ORIF pool for matching. operation and made non-weightbearing unless they were unable to
A comprehensive review of electronic and written records was per comply with these restrictions due to physical or cognitive reasons.
formed. Baseline demographics were collected for all patients. Patient Patients were assessed by a multi-disciplinary team prior to
comorbidities were quantified using the Charlson Comorbidity Index discharge; a decision was made as to whether the patient was 1) fit for
(CCI) which is a weighted index that predicts the 10-year survival of discharge home with or without home-based rehabilitation 2) require
patients admitted into hospital with specific conditions; a higher CCI temporary convalescent care 3) require admission to an inpatient
predicts lower 10-year survival [22]. The pre-injury function of patients rehabilitation facility 4) require nursing home or hospital level of care.
was represented with Karnofsky Performance Scale (KPS) which is an Routine follow-up consists of clinical and radiographic review at two
assessment tool for daily functional ability; a higher score means that weeks, six weeks and three months post-operatively for both groups.
patients can carry out more daily activities [23]. Clinical frailty scale Patients in the hindfoot nail group were permitted to weight-bear in a
(CFS) is a screening tool for measure of fitness or frailty of the elderly moonboot at the two-week post-operative mark if wound healing was
population; the higher the CFS the frailer the patient [24]. The hindfoot adequate (Fig. 1). Patients in the ORIF group were permitted to weight-
nail and ORIF cohort were matched as close as possible by their age, sex, bear at six weeks if follow-up radiographs appeared adequate (Fig. 2). If
CCI and pre-injury KPS. there were concerns with complications, patients in both groups were
The decision to proceed with hindfoot nailing was made on a case- followed up at more frequent intervals and/or for periods extending
by-case basis by the orthopaedic surgeon on-call at the time of admis beyond the three months until fracture union.
sion. Factors considered include patient pre-injury ambulatory status
and weightbearing demands, medical co-morbidities and soft tissue Statistics
quality. All operations were performed either by a consultant ortho
paedic surgeon or by a registrar under supervision. For continuous variables, the mean, standard deviation (s.d.) and
The primary outcome of interest was the rate of post-operative range were calculated. Paired Student’s t-test and chi-square test were
complication (wound breakdown/delayed wound healing, superficial applied to the evaluate the statistical differences between variables be
wound infections, metalware infection/osteomyelitis, metalware fail tween the two groups [Microsoft Excel 2020 Version 16.42]. Statistical
ure). Secondary outcomes include mortality, length of hospital stay, significance was defined at 5% (p value < 0.05).
length of operation, days to weightbearing, time on ward until opera
tion, post-surgery function, post-injury mobility, post-injury residence/
care setting, radiographic evidence of healing at three months post-
surgery and ankle pain at three-months post-surgery.
Fig. 1. Anteroposterior (AP) and lateral x-rays showing left ankle bimalleolar fracture-dislocation in an 87-year-old female. A and B show AP and lateral x-rays of
initial injury. C and D are AP and lateral x-rays taken at six months post hindfoot nailing with synthes expert hindfoot arthrodesis nail.
Results Outcomes
Demographics Summary of outcomes are provided in Table 3.

The one-year mortality rate was 15% and 12% for the hindfoot nail
Twenty-six patients in the hindfoot nail group were identified. group and the ORIF group respectively. One patient in the hindfoot nail
Twenty-three were female and three were male. The mean age was 84 group died day one post-operatively due to cardio-respiratory failure.
years (range 65 – 96, s.d. 8). There were 12 bimalleolar and 14 tri Three more patients from the hindfoot nail group died within one year of
malleolar fractures; of these, four were open fractures. The mean CCI, operation for reasons not directly related to the surgery or anaesthesia.
pre-injury KPS and CFS for this group was 7.3 (range 4–11, s.d. 2), 62 There were no perioperative deaths in the ORIF group: all three mor
(range 30 – 80, s.d. 12) and 5.3 (range 3 – 8, s.d. 1.5) respectively. talities from the ORIF group were thought not to be caused directly by
Patients from the ORIF group were matched based on age, gender, the surgery or anaesthesia.
CCI and pre-injury KPS. From the match, there were 23 females and The mean time to weightbearing for hindfoot nail patients were 23
three males. The mean age was 83 years (range 65 – 97, s.d. 8). There days (range 3 – 56, s.d. 13). Eleven cases required further one to two
were three unstable unimalleolar fractures, 12 bimalleolar fractures and weeks in cast to allow wound to heal. There were three patients who
11 trimalleolar fractures; of these, five were open fractures. The mean progressed to weightbearing before the two-week mark: two had sig
CCI, pre-injury KPS and CFS for this group was 7.2 (range 4 – 10, s.d. 2), nificant cognitive impairment and were unable to comply with the non-
64 (range 40 – 80, s.d. 11) and 4.8 (range 2 – 8, s.d. 1.5) respectively. weightbearing status, one began weightbearing day three after the
Demographic and patient overview is provided in Table 1 and CCI operation due to instructions from the consultant orthopaedic surgeon.
breakdown is provided in Table 2. The mean CFS in our hindfoot nail All three were put into weightbearing casts.
cohort was higher but not significantly so (p = 0.30). Of note, the The mean time to weight-bear for the ORIF group were 59 days
hindfoot nail group has a lower mean body mass index (BMI) of 26 (range 37 – 125, s.d. 24). One patient died after discharge from hospital
compared to 28 in the ORIF group (p < 0.05). There were a significant prior to commencing weightbearing. There were seven patients who
number of patients in the hindfoot nail group with a diagnosis of pe were made non-weightbearing beyond the 50-day mark for issues with
ripheral vascular disease and connective tissue disease (p < 0.05). Eight wound healing. Of these cases, one patient did not start weightbearing
patients in the hindfoot nail group were actively on immunosuppressant until 125 days after the initial operation due to osteomyelitis that
medication at the time of surgery compared to none in the ORIF group. required extended antibiotic treatment and metalware removal.
Twenty-three and twenty-two patients demonstrated radiographic
evidence of healing at three months post-surgery from the hindfoot nail
and ORIF group respectively (p = 0.68). At this point, patients were
routinely discharged if satisfactory functional gains and clinical progress causing pain and/or skin compromise; three patients returned to theatre
was made. From the hindfoot nail group, there was one case of delayed for removal. This is possibly a reflection that these three patients had
union due to infection which began to exhibit radiographic signs of higher physical demands that initially deemed appropriate for the nail.
healing at seven months. From the ORIF group, there was one case of There were also two cases of distal screw backing out from the ORIF
non-union diagnosed on CT scan at seven months; they did not undergo group, however, those patients were mobilizing pain-free with no skin or
further surgery. There were two cases of delayed union – one patient wound compromise over the screw and opted not to have it removed.
died from complications from another co-morbidity and therefore lost to
further follow-up; the other patient started to exhibit radiographic evi Discussion
dence of healing at six months.
The number of patients who remained at their pre-hospital residence Achieving acceptable outcomes for this specific population group
and who returned to their baseline mobility at one year were similar poses a continual dilemma to orthopaedic surgeons. There is no
from both groups (Table 4). consensus on the optimal management for unstable ankle fractures for
this demographic, though hindfoot nailing has provided an alternative
Complications in the last 10 – 20 years. The conventional surgical method of ORIF has
reported to produce poor outcomes due to poor condition of skin and
Details of complications are provided in Table 5. bone [7]. Individual patient factors that accompany this population also
In the hindfoot nail group, there were 12 complications in total. Four affect wound and fracture healing and post-operative recovery. These
patients had pressure areas/non-infected wound breakdown. Four pa include but are not limited to diabetes, peripheral vascular disease,
tients were diagnosed with deep infections and four with metalware immunosuppression, long-term steroid use and frailty. TCC nailing was
failure. Seven of the 12 cases required reoperation. No further metal therefore introduced with the aim to allow early mobilization and to
ware was inserted in any of the re-operated cases. reduce the risk of complications in those that are elderly and frail.
In the ORIF group, there were 11 complications in total. Four pa In our study, we reported a complication rate of 46% and a re-
tients had pressure areas/non-infected wound breakdown. Four had operation rate of 27% in the nail group which is the highest rate re
superficial wound infections that were successfully treated with antibi ported of any series to date, and well above the reoperation rate of
otics. One patient was diagnosed with a deep infection and two were 10.1% (95% CI 6.1–16.2%) published by Tan et al. in a 2021 systematic
diagnosed with metalware failure. Two patients from the ORIF group review and meta-analysis [25]. There were no cases of amputation or
required reoperation; indications were metalware infection and wound peri‑implant fracture in our series of patients.
breakdown with metalware exposure. The patients who experience The only published randomized control trial on this topic was by
metalware failure were not reoperated on. Georgiannos et al. in 2017 [11]. The sex and age distribution were
Metalware failure and deep infection were the main reasons for similar to our hindfoot nail and ORIF cohorts, but the complication rates
reoperation in the hindfoot nail cohort. All four cases of metalware were significantly different: the re-operation rates were 2.7% and 13.8%
failure from this group were due to the calcaneal screw backing out and compared to 27% and 8% in our study for the nail and ORIF group
Fig. 2. Anteroposterior (AP) and lateral x-rays showing right ankle fracture-dislocation in an 87-year-old female with a small posterior malleolus fragment. A and B
show AP and lateral x-rays of initial injury. C and D are AP and lateral x-rays taken at three months post bimalleolar ankle fixation showing satisfactory union.
respectively. The trial excluded open fractures, patients with cognitive subsequent surgery poses to them. This demonstrates that hindfoot
impairment, severe peripheral disease and diabetic angiopathy, which nailing can be considered in the appropriate cohort keeping in mind the
comprised a large proportion of our patient group – indeed some may likelihood for complications and re-operation.
see these major comorbidities as the main indication to consider a Weight loss and low BMI are recognized hallmarks of frailty [5,6].
structurally sound intramedullary device that permits early weight Frailty is associated with higher complication, mortality, reoperation
bearing over the conventional ORIF with the traditional period of and infection rates, increased length of stay and poorer functional out
immobilization. comes in context of fractures [6]. KPS was used for matching as it was a
Only four studies that specified three or more medical co-morbidities measure that was easily collected retrospectively and more closely
in their patients reported on reoperation rates [10,13,16,21]. When assembled the functional scores reported by the previous studies pub
compared with these studies, re-operation rate is higher in our patient lished in this topic. Based on the CFS, our hindfoot nail cohort was on
group (27% vs 0–20%). One case series used CCI as their marker of average frailer (although not statistically significantly so) - this could
co-morbidities as we have; the mean CCI in that patient group was 5.05 explain the differences in complication and reoperation rates compared
which was lower than the 7.3 and 7.2 for our hindfoot nail and ORIF to our matched ORIF cohort as well as to the studies reported in the
group respectively [10]. The mean age was higher in our series at 84 and literature [10–21].
83 compared to their 77.82 [10]. The limitations of this study include its retrospective nature, small
Mortality rate for our hindfoot nail cohort is 15% which is less than numbers, and heterogeneity within each group. Because the data was
the pooled mean of 26.6% published by Tan et al. [25]. Of the patients collected retrospectively and spanned across 11 years, we were unable
who survived past one year in our study, we reported comparative rates to obtain functional outcome or foot and ankle specific scores as most
of patients remaining at their pre-injury residence between the hindfoot patients have died beyond the follow-up period. However, from thor
nail and ORIF groups (22 vs 21, i.e. 86% and 87% respectively). Three ough clinical documentation, we were able to obtain pre- and post-
papers reported on this variable for the hindfoot nail group; our results injury mobility status, independence and living situation as markers of
fall within the range described in the literature (60% – 94%) [12,13,16]. outcome and function. As noted with previous studies on the subject,
Of those who survived past one year, 59% of our hindfoot nail cohort there are no universal guideline as to the indications for selecting pa
returned to their pre-injury level of mobility; this is comparable to 52% tients for hindfoot nailing, therefore we assume variability in the pa
of our ORIF group. The reported post-injury mobility status for the tients who are selected for hindfoot nailing.
hindfoot nail group falls within the range described in the literature (50
– 94%) [[10–13,16,19,20]. Despite higher rates of reoperation overall, Conclusion
the likelihood of return to previous residence and mobility status is of
important note in the hindfoot nail group, especially when considering Hindfoot nailing was associated with a higher re-operation rate
the population and the threat to independence such injury and the compared to a cohort of ORIF patients matched by age, sex, CCI and pre-
Table 1 Table 2
Patient demographics. CCI breakdown.
Hindfoot nail ORIF p- Hindfoot nail ORIF p-value
value
Age 60–69 2 2 0.94
Age 84 ± 8 (65 - 83 ± 8 (65 - 0.81 70–79 5 6
96) 97) ≥80 19 18
Sex Female 23 23 1 Myocardial infarction 8 11 0.39
Male 3 3 Congestive heart failure 9 8 0.77
Ethnicity NZ European 20 20 0.50 Peripheral vascular disease 8 1 <0.05
Māori 0 0 Cerebral vascular accident/transient ischaemic 9 9 1
Other European 6 4 attack
Asian 0 2 Hemiplegia 3 6 0.27
Fracture Weber C/unstable 0 3 0.25 Dementia 8 7 0.76
pattern Weber B Chronic obstructive pulmonary disease 10 5 0.13
Bimalleolar 12 12 Connective tissue disease* 13 2 <0.05
Trimalleolar 14 11 Peptic ulcer disease 2 1 0.55
Open 4 5 0.71 Liver disease 0 1 1
% Open 15% 19% NA Diabetes Total 8 7 0.76
Smoker Non/Ex- 23 26 0.24 Uncomplicated 4 5 0.71
Current 3 0 End-organ damage 4 2 0.39
BMI 26.01(14.38 – 28.35 (20.00 <0.05 Chronic kidney disease 0 0 1
33.33) – 37.83) Solid tumour Total 4 9 0.11
ASA 2.84 2.73 0.48 Localized 4 8 0.14
CFS 5.3 (3 – 8) 4.8 (2 – 8) 0.30 Metastatic 0 1 1
Anaesthesia General 21 24 0.42 Leukaemia 1 1 1
type Spinal 5 2 Lymphoma 0 0 1
CCI 7.3 (4 – 11) 7.2 (4 – 10) 0.71 AIDS 0 0 1
Pre-injury KPS 62 ± 12 64 ± 11 0.48
(30–80) (40–80) *Eight on long-term immune suppressant in nail group at time of surgery, none
in ORIF group.
Abbreviations: ORIF, open reduction internal fixation; BMI, body mass index; Abbreviations: CCI, Charlson Comorbidity Index; ORIF, open reduction internal
ASA, American Society of Anaesthesiologists; CFS, Clinical Frailty Score; CCI, fixation; AIDS, acquired immunodeficiency syndrome;.
Charlson Comorbidity Index; KPS, Karnofsky Performance Scale; NA, not
applicable.
Table 3 Table 5
Outcomes. Post-operative complications breakdown.
Hindfoot nail ORIF p-values Hindfoot nail ORIF p-
values
Mortality 30 days 1 1 1
3 months 0 1 1 Total complications 12 11 0.78
1 year 3 1 0.61 Pressure area/non-infected wound breakdown 4 4 1
Total 4 3 0.68 Requiring reoperation 0 1 1
One-year mortality 15% 12% NA Superficial wound infection 0 4 0.11
rate Requiring reoperation 0 0 1
Length of stay 13 ± 6 (5 - 28) 15 ± 10 (2 - 45) 0.58 Deep infection 4 1 0.35
Length of operation 119 ± 35 (70 – 195) 108 ± 23 (70 – 180) 0.20 Requiring reoperation 4 1 0.35
(minutes) Metalware failure (non-infective) 4 2 0.39
Days from admission to 6 ± 4 (0 - 16) 6 ± 6 (0 - 30) 0.92 Requiring reoperation 3 0 0.24
definitive fixation Total cases requiring return to theatre 7 2 0.07
Days to weight bear 23 ± 13 (3 - 56) 59 ± 11 (37 - 125) <0.05 Reoperation rate 27% 8% NA
Radiographic evidence 23 22 0.68 Definitions:.

of healing at three Non-infected wound breakdown: defined by documented delayed wound heal
months ing and dehiscence/breakdown that did not require or receive antibiotic treat
Ankle pain at three 6* 3 0.27 ment. Patients are excluded from this category if treated with antibiotics.
months and beyond Superficial wound infection: wounds that received antibiotic treatment
Pre-injury KPS 62 ± 12 (30–80) 64 ± 11 (40–80) 0.48 excluding open fractures and routine prophylaxis. Patients are excluded from
Post-injury KPS 43 ± 24 (0 - 80) 53 ± 23 (0 - 80) 0.27 this category if initially thought to be superficial wound infection but later
Number of patients 22 21 0.71
diagnosed as a deep infection.
remaining in pre-
Deep infection: radiological or clinical diagnosis of deep infection with sup
injury residence at
one year porting microbiology from intra-operative deep tissue samples.
Number of patients 13 12 0.78 Metalware failure: any documentation of loosening or breakage of screws/nail/
returning to pre- plate whether symptomatic or not.
injury mobility at Abbreviations: ORIF, open reduction internal fixation; NA, not applicable.
one year
Complications 12 11 0.78
Complication rate 46% 42% NA morbid KPS. Despite the potential attraction of allowing earlier weight-
*
bearing through an intramedullary device and avoiding soft tissue
One patient developed complex regional pain syndrome
complications, patients and surgeons need to be aware of the potential
Abbreviations: ORIF, open reduction internal fixation; KPS, Karnofsky Per
complications. A large-scale randomized control trial or metanalysis is
formance Scale; NA, not applicable.
desirable.
Table 4
Pre- and post-injury breakdown. Declaration of Competing Interest
Hindfoot nail ORIF
All authors declare that they have no conflict of interest.
Pre-injury and post-injury residence at one year
Residence Pre- Post- Pre- Post-
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Injury 54 (2023) 110924
Injury
Editorial
Back to the future – Augmented Reality in orthopedic trauma surgery
The options to use Augmented Reality (AR) - technology have and cross-sections to aid instrument guidance, thereby ensuring high
influenced our daily life, not just in terms of gaming. In a recent precision targeting of implants. [7,8]. By now, these new AR systems
advertisement video from meta promoting AR - technology for use in the have been implemented in thousands of spinal surgeries. They use
metaverse, a crew of firefighters uses a heads-up navigation system to dedicated hardware, consisting of specific devices, extra hardware and
successfully navigate through the dense smoke in a burning house [1]. external tracking [9,10]. Among the reasons for focusing on spinal
This advertisement underlines the fact that the mainstream con surgeries may be a commercial focus. Furthermore, the mechanics of
sumer market has now been reached. When looking back, the technol performing spinal surgery are usually simpler compared to open trauma
ogy has undergone the “Gartner hype cycle”, i.e. an initial hype at the [11] or orthopedic trauma surgery, as the field for visualization is usu
beginning of the millennium, followed by a long period of disillusion. [2, ally smaller. While in spinal procedures, intraoperative movement is
3] (Fig. 1). minimal, in orthopedic trauma surgery, the surgical site usually has to
In line with our initial example, the indoor AR navigation system for be manipulated throughout the surgery. Successful AR-visualization can
firefighters had been proposed more than 20 years earlier, directly thus only be achieved with intraoperative 3D-imaging [12,13], usually
following the 9/11 terrorist attacks in New York City [4]. After 20 years requiring a mobile 3D C-arm or a hybrid OR [14], respectively.
of additional development, this AR navigation concept has finally A promising new technology addressing this problem proposes using
proven itself viable. 2D- and 3D-imaging at defined times or milestones during an inter
Medical AR-imaging has followed a similar path. Early medical head- vention. AR-visualization via head-mounted-displays can bridge the
mounted-displays had several disadvantages and among them, they were time in-between. This technology utilizes existing c-arms and machine-
expensive, quite bulky, and heavy. This precluded their widespread use learning to estimate patient anatomy [15].
during lengthy surgical procedures. Furthermore, the quality of these Further products, such as Holoma (HoloMedicalAssistant; ICB-M
early visualizations was insufficient and therefore of limited help. The Sofia, Bulgaria; https://holoma.info), may also be useful in the opera
desired quality of visualization necessitates the overlay of a 3D medical tive setting. It is based on an open-source software engine that does not
data on the patient’s real anatomy – it is named “in-situ-visualization”. require specialized hardware. Its modular structure enables its use in a
This paradigm is based on three pillars: “right time, right place, and wide array of interventional tasks. Imaging data from various sources
right way” [5]. can be used and existing surgical instruments can be integrated. Finally,
“Right time” deals with minimizing latency, while “right place” deals different registration methods and visualization modes can be tested.
with correct spatial visualization and registration issues. Finally, the This promising software tool appears to be a step in the right direction
most difficult of the pillars, known as the “right way,” refers to chal towards the use of standardized open interfaces. These interfaces and
lenges in ensuring proper human-machine interfacing, redundancy of definitions are needed for instruments, registration methods and soft
information, and access to software-tools to support the surgeon. To ware tools as well.
address these challenges, developers began to enter operating rooms to AR promises an array of new tools that can be utilized in orthopedic
observe how surgeons orient themselves with respect to anatomy, trauma surgery. Modern head-mounted-displays such as Hololens
localize surgical landmarks, introduce implants, and especially, perform (Microsoft, Redmond, Washington, USA) are light, easy to wear, not
image-guided minimally invasive procedures. associated with VR nausea or 3D headache [16] and can be very helpful
Nowadays, AR is successfully and increasingly implemented in pa intraoperatively [17]. The use of AR-technologies should be considered
tient and medical education [6] particularly in orthopedic surgery. A and more research to further develop these technologies should be
simple example of the didactic value of AR is the visualization of pursued.
percutaneous pelvic screws to enhance the imagination of the orthope
dic surgeon in preoperative planning and during surgery. Instead of Disclosure of funding
bringing a pelvic plastic model into the OR to get an idea for the right
screw direction a hologram of the patient’s pelvis may be used for None.
orientation and ideally for navigated drilling as well (Figs. 2 and 3).
Several medical AR systems have been successful and are commer
cially available today for intraoperative use. These systems are based on Declaration of Competing Interest
learnings from those early experiments. The current systems use a so-
called “hybrid visualization mode.” They display in-situ visualizations VR is a co-founder of ICB-M developing the Holoma Software.
GAW is a consultant for ICB-M; SMH and HCP: none.
Available online 19 July 2023

Editorial Injury 54 (2023) 110924
Fig. 1. The Gartner hype cycle and its stage indicators (adapted from [2,3]).
Fig. 2. Visualization of the corridors for sacroiliac screws

(green) and antegrade posterior column screw (orange) as well
as planned screw trajectories using virtual reality: lateral view
(a), outlet view (b), and slightly rotated inlet view for better
visualization of the corridor and trajectory of the antegrade
posterior column screw (c). Pelvic CT-images were uploaded
into Holoma (ICB-M) software and visualized by Hololens 2
(Microsoft) after planning of the respective screw trajectories
(Mimics Innovation Suite, Materialise, Leuven, Belgium).
Editorial Injury 54 (2023) 110924
Fig. 3. Visualization of the corridors and trajectories for sacroiliac screws (S1, S2, green) and antegrade posterior column screw (orange) from a lateral point of view
in augmented reality using the Hololens 2 (a). Holographic view for navigated drilling of the trajectory of the S2 screw (b) as well as for the antegrade posterior
column screw with starting point from the iliac fossa (c). The red line (b) shows the aiming process, correct alignement of the drill bit is indicated by green spots at
both the base and the tip of the drill bit (Colibri II, Synthes) (c).
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Injury 54 (2023) 110925
Injury
A long term follow-up for a randomised trial of total hip arthroplasty versus
hemiarthroplasty for displaced intracapsular fractures
Martyn J. Parker *, Shirley Cawley
Department of Orthopaedics, Peterborough City Hospital, North West Anglia NHS Foundation Trust, CBU PO Box 211, Bretton Gate, Peterborough PE3 9GZ, England,
United Kingdom
Keywords: 104 patients with a displaced intracapsular fracture were randomised to surgical treatment with either a
Intracapsular hip fracture cemented hemiarthroplasty or a cemented total hip arthroplasty. All surviving patients were followed up for five
Randomised trial years from injury by a blinded observer. No differences in outcome between groups was seen for the degree of
Arthroplasty
residual pain or regain of function or independence. There was a tendency to more complications and re-
operations for those treated with the total hip arthroplasty.
We continue to recommend that caution should be exercised regarding the increased promotion of THR for
intracapsular hip fractures until further studies with long term follow up are completed.
Introduction independently out of doors with no more than the use of a stick (mobility
scale 3 or less)(Table 1), [13] not cognitively impaired (mental test score
Whilst displaced intracapsular fractures in the elderly are generally 8 or more) [14] and medically fit for either procedure. Exclusion criteria
treated with an arthroplasty, debate continues as whether the arthro were those with restricted mobility prior to the injury (mobility scale 4
plasty should just involve replacing the femoral head (hemiarthroplasty) or more, Table1), age less than 60 years, age 60 and above in which
or also replacing the acetabular surface (total hip replacement). Previ internal fixation was felt the be the choice of treatment due to a pre
ous randomised trials on the more active and fitter group of patients dicted good long term survival, admission when the lead trialist was not
have suggested improved outcomes with a total hip arthroplasty (THR) available, those who were not considered to be medically fit for either
[1–6]. Controversy exists as whether these benefits still exist for a wider procedure, patients who declined to participate, significant degenera
group of patients with an intracapsular fracture who may be less active tive arthritis of the hip, acetabular dysplasia, senile dementia and those
and have a shorter life expectancy. There have recently been reported a without the capacity to give informed consent.
number of more contemporary trials on a larger group of patients with Randomisation was undertaken using numbered sealed opaque en
these broader inclusion criteria. All these studies to date, have failed to velopes. Surgical treatment was with either a cemented unipolar double
demonstrate the advantages of a THR [7–12]. We have previously re tapered stem hemiarthroplasty or a total hip arthroplasty with the same
ported on a randomised trial for 104 patients treated with either a stem in conjunction with a cemented acetabular cup. Follow-up After
cemented polished tapered stem hemiarthroplasty or a cemented total discharge from hospital the first follow-up was an initial review in a hip
hip arthroplasty with a cemented acetabular cup [12]. This report de fracture clinic at eight weeks from admission. Functional assessments
tails the five year follow-up for all surviving patients using a blinded and pain scores were assessed by a research nurse who was blinded to
assessment of functional outcome. the treatment allocation. At this visit limb shortening and loss of flexion
from the contralateral hip was measured for those patients with a
Patients and methods normal contralateral hip. Subsequent assessments were by the same
nurse by phone calls at three, six, nine and twelve months from injury
Full details of the trial methodology have been previously published and then annually thereafter for up to five years. Fracture healing
in this journal [12]. Inclusion criteria for the study was a patient pre complications reported at any follow-up visit were recorded. In addition;
senting with a displaced intracapsular fracture who was able to walk if any patient was referred back for implant related complications at any
E-mail address: Martyn.Parker@pbh-tr.nhs.uk (M.J. Parker).
Available online 5 July 2023
M.J. Parker and S. Cawley Injury 54 (2023) 110925
Fig. 1. Flow diagram for patients (patients may have been excluded for more than one reason).
time, these complications were recorded and included in the presenta

tion of the results. Pain was assessed on a scale of one (no pain) to eight
(constant and severe)(Table 1). The patients’ walking ability was
assessed using a mobility scale and social dependence with a de
pendency score (Table 1) [13].
Statistical analysis. All results were analysed on an intention-to-treat
basis. Binary outcomes for the two groups were analysed using Fisher
exact test and continuous outcomes with the unpaired t-test. (GraphPad
InStat version 3.00 for Windows 95, GraphPad Software, San Diego
California USA). A p-value of p < 0.05 was considered as statistically
significant.
Results
Fig. 1 details the flow diagram for patients admitted and followed up. Fig. 2. Mean pain scores.
All surviving patients were followed up for five years. Two patients were
lost to follow-up in the hemiarthroplasty group, one after two years and the THR group and one in the hemiarthroplasty group had a later per
one after four years. One in the THR group was lost to follow-up after i‑prosthetic fracture treated by internal fixation. One patient in the THR
one year. The mean age of the patients was 77 years and 81% were fe group had revision of the acetabular cup for loosening, one patient in the
male. There were no statistically significant differences between groups THR group had three closed reductions of a dislocated hip and one
in the patient characteristics (Table 2) [12]. developed sepsis around the implant at three years post surgery,
Mean operation times were longer for the THR group (51 versus 84 requiring a two stage revision. One patient in the hemiarthroplasty
min) and mean blood loss was increased for the THR group (335mls group had a dislocation requiring open reduction.
versus 247mls). These differences were statistically significant [12]. General medical complications were encountered for 6 patients in
Secondary operations were required for eight patients. Three patients in the hemiarthroplasty group and 12 in the THR group [12]. Summation
of all general and surgical complications gives a total of 8 complications
The UK guidance for hip fracture has advocated using a total hip
arthroplasty for a fairly broad group of patients [17]. The criteria are
those patients with a displaced intracapsular fracture who are able to
walk independently out of doors with no more that the use of a stick and
not cognitively impaired and medically fit for the procedure. With the
subsequent publication of less favourable randomised trials, additional
advice has been added suggesting that the THR should be restricted to
those that are able to carry out activities of daily living independently
beyond 2 years [17]. The finding of this study suggest that this guidance
may still be inaccurate and not reflecting current evidence with suggests
a more cautious approach for the use of THR. For the majority of elderly
patients with a displaced intracapsular fracture, hemiarthroplasty is a
less invasive procedure with a lower risk of complications and equiva
lent functional outcomes.
Fig. 3. Mean change in mobility scale.
Responsibilities
MJ Parker was responsible for the design and initiation of the study,
recruitment of participants, data collection and analysis and writing the
manuscript. S Cawley was responsible for the blinded assessment of the
patients.
re - A long term follow-up for a randomised trial of total hip

arthroplasty versus hemiarthroplasty for displaced intracapsular
fractures.
Neither of the authors has received any benefits for personal or
professional use from a commercial party related directly or indirectly to
the subject of this article.
Fig. 4. Mean change in social dependency scale.
in the hemiarthroplasty group versus 19 in the THR group (p = 0.01,
Relative risk 0.41, 95% confidence interval 0.20 – 0.86). Supplementary material associated with this article can be found, in
Over the five year period there was no statically significant differ the online version, at doi:10.1016/j.injury.2023.110925.
ence between groups for the degree of residual pain, change in mobility
or social independence (Figs. 2–4) (supplementary tables 1.2.3) References
[1] Baker RP, Squires B, Gargan MF, Bannister GC. Total hip arthroplasty and
Discussion hemiarthroplasty in mobile, independent patients with a displaced fracture of the
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One potential disadvantage of hemiarthroplasty compared to a THR [2] Blomfeldt R, Tornkvist H, Eriksson K, Soderqvist A, Ponzer S, Tidermark J.
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a more extensive surgical procedure. Furthermore the addition of an
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recent randomised trials involving a less selected group of patient had Jt Surg - American Volume 2006;88(2):249–60.
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over a five year period to increased pain or reduced walking ability for [7] Bhandari M, Devereaux PJ, Einhorn TA, Thabane L, Schemitsch EH, Koval KJ,
those treated with a hemiarthroplasty. A 12 year follow of a similar Frihagen F, Poolman RW, Tetsworth K, Guerra-Farfán E, Madden K, Sprague S. The
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Access 2019;4(2):e0059.
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was favoured. Regrettably due to the limited number of included pa femoral head replacement in the treatment of femoral neck fractures in elderly
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cost analysis was undertaken, but a THR will always incur extra implant Bonke H, Goslings JC, van Dijk CN, Raaymakers EL. A comparison of
and theatre time costs in comparison to hemiarthroplasty. hemiarthroplasty with total hip replacement for displaced intracapsular fracture of
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Injury 54 (2023) 110713

Contents lists available at ScienceDirect

Anxiety and depression are associated with poor outcomes in open

Introduction (OEA) is shown to be a reliable and effective intervention for PTES in

Table I interventions in orthopedic surgery can improve patient satisfaction in

Contents lists available at ScienceDirect

Effect of surgical delay on 30-day mortality in patients receiving direct oral

The primary outcome was all-cause mortality within 30 days after

DOA: Direct Oral Anticoagulants.

not treated with oral anticoagulants (median 61 h, IQR 42–77 versus 44

reported that DOA therapy was independently associated with increased

− 6.0[− 8.0;− 4.1]

− 0.8 [− 1.6; 0.2]

− 0.2[− 0.8; 0.2]

Our study has several limitations. First, being retrospective, several

5.2 [1.3; 9.1]

confirmation with other study designs addressing this limitation. Sec­

represent potential cofounding factors. Finally, as a single center study

level of hours and minutes. In contrast, in many administrative datasets

Third, our study offers time specific epidemiologic description of the

increased prevalence of DOA in patients admitted for hip fracture sur­

years 2015 to 2019 from 2 to 12%. These epidemiological data

0.01 [− 0.6; 0.6]

0.4 [− 1.6; 3.3]

emphasize the need to improve our knowledge on the best therapeutical

on DOA treatment, surgical treatment performed within 48 h was

associated with decreased mortality. There was a small tendency to an

suggest more research is needed on the optimal surgical timing in

DOA Direct Oral Anticoagulants; Pr(diff>0): probability of superiority to 0.

Declaration of Competing Interest

EN and JP are local investigators for a research study promoted by

TAKEDA Pharmaceutical (TAK-330–3001).

Supplementary material associated with this article can be found, in

the online version, at doi:10.1016/j.injury.2023.05.044.

care for the older patient. JAMA 2012;307:2185–94.

Contents lists available at ScienceDirect

Letter to the Editor

Pathological fracture in prior diagnosed malignancies: A dilemma

Contents lists available at ScienceDirect

The effect of ultrasound on bone healing across a bone gap, an experimental

Introduction The aim of this study is to determine whether ultrasound accelerates

1 (a) Bone Gap Closed 3 3 3 3 - - -

3. Bone Gap Maintained 18 18 15 12 9 6 3

4. Bone Gap Maintained 18 18 15 12 9 6 3

Medullary or Dead Amorphous Tissue 0

Hard Callus adjacent to intracortical hard callus union -16

Histological sections and corresponding angiography of each tibial

with delayed union showed sclerosis on each side of the gap.

3 Tibial Bone Gap Maintained, treated with Ultrasound

The overall pattern of bone repair at gaps treated with ultrasound

4 Tibial Bone Gap Maintained, treated with Mock Ultrasound

The group of eighteen specimens treated with Mock Ultrasound

Fig. 6. Angiography of an Untreated Bone Gap a Two Weeks of the specimen

Fig. 5. Mature Band of fibrous tissue in posterior cortical gap of an Untreated

Contents lists available at ScienceDirect

Increases in adolescent firearm injuries were associated with school

Background occurred in the US [2], included increased availability of firearms [3–5],

John N. Bliton: Conceptualization, Formal analysis, Methodology,

Linear Model: Adolescent Firearm Injuries, Jan 2016-Jun 2021

AFIs per Month

Fig. 4. Model fit. This model is based on Atlanta-wide, monthly data.

Contents lists available at ScienceDirect

Evaluation of a 30-day-mortality risk calculator for patients undergoing

Low risk 9 337 57.9 0.39 3.14 2.60 0.821

confirmation with other study designs addressing this limitation. Sec

increased prevalence of DOA in patients admitted for hip fracture sur

treatment, preventative measures should be taken to reduce the occur

Three interconnected subsections are described as follows. The nu

Introduction randomized control trial comparing operative with nonoperative treat