22nd European Congress of Trauma & Emergency Surgery

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Prof. Dr.

PD Dr.

Septic two stage hip revision – Evaluation of a new spacer technique using original prosthesis implants

Skeletal trauma and sports medicine

Abstract text (incl. references and figure legends) Background: In septic two-stage revision hip arthroplasty widespread concepts comprise the installation of a Girdlestone-situation or the use of prefabricated PMMA-spacers. These techniques show complications such as abrasio of bone-cement particles, dislocation, soft tissue contractures or periprosthestic fractures. To counter these complications a new spacer technique has been proposed where new original prostheses are implanted using an inferior cementation technique. To date, the use of regular implant components as a spacer was accompanied by concerns of a higher risk of infection or complications during explantation. We evaluated this novel technique with respect to complication rate and its infection-related non-inferiority. Methods: Retrospective evaluation of periprosthetic joint infections was performed according to the 2014 MSIS criteria. Radical surgical debridement was performad after prosthesis explantation. A new femoral shaft was coated with PMMA cement that had been individually loaded with antibiotics. Before implantation, the shaft was covered with the patient's blood and cement was only used at 6 minutes. This ensured impaired iterdigitation for easier later removal. On the acetabular side a polyethylene cup was cemented into a cage fixed with screws. Results: A total of 130 patients was evaluated with a median follow-up of five years. The rate of reinfection-free patients during follow-up was around 92%. Complication rate of this spacer technique was about 10% (9% dislocation, 1% peri-implant fracture). Conclusion: The 5-year reinfection-free rate of 92% is at a comparable level as in other reported techniques. The 10% complication rate is low. The described results thus appear very promising. Advantages of such a novel technique should be a better soft tissue management with a higher range of motion postoperatively.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

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Conservative and postoperative care of proximal humeral fractures regarding permissive weight bearing: A survey among surgeons in the Netherlands

Education

Abstract text (incl. references and figure legends) Background Proximal humeral fractures (PHF) are common and mostly caused by low-energy injuries in the elderly population. Adequate rehabilitation is essential when it comes to regaining function, regardless of whether it is treated conservatively or operatively. Permissive weight bearing (PWB) is a relatively new rehabilitation concept, characterized by earlier mobilization of the affected limb/joint after trauma. Despite the fact that there are multiple studies investigating the effect of PWB for the lower extremities, this trend, however promising, has not been translated to comparable trauma in the upper extremity i.e PHF. Our aim was to investigate the current state and variability of rehabilitation of PHF and the role of implementing PWB in the aftercare. Methods An online survey, comprising of 23 questions, was distributed amongst Dutch orthopaedic- and trauma surgeons via the Dutch Orthopaedic and Dutch Trauma Society newsletter. Results Our response rate was 29% (n=88) of which 69 were orthopaedic surgeons and 17 were trauma surgeons. Early mobilization after trauma is advised by most of the respondents and seems to start after less than two weeks of immobilization for both conservatively treated patients (35.2%) and operatively treated patients (33.3%). 53.4% (n=49) advised starting PWB after 6-weeks for conservatively treated patients and 59.8% (n=52) for operative treatment (only osteosynthesis). A wide variation in usage of different types of exercises used after immobilization was found in both groups. The usage of a sling after operative treatment was advised by 86% (N=74) of all respondents. Discussion/Conclusion The present study found limited consensus about the aftercare and the role of PWB after trauma regarding PHF. More prospective convincing clinical outcome are needed to form an evidence based protocol focusing on the aftercare of PHF and to optimize patients" comfort.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Prof.

The use of a modular fixing device for an arthrodesis after a periprosthetic femoral fracture (clinical case)

Disaster and military medicine

Abstract text (incl. references and figure legends) Relevance. Knee arthrodesis, namely the elimination of a joint, has a restricted field of application, especially with the collateral joint immobilized. However, in some cases: in patients with periprosthetic fractures and prosthetic components' instability, excessive body weight and severe comorbid conditions, knee arthrodesis may become the remedy to preserve the limb's weight-bearing capacity and create conditions for early rehabilitation. It might appear final intervention to ensure a result acceptable for patients. Clinical case. A female patient, 68 years old. Diagnosis at hospitalization: periprosthetic fracture of a lower third of the left femur. Aseptic instability of the femoral component of her knee endoprosthesis, defects of left femoral condyles. Conditions after the right knee joint arthrodesis. 3rd stage of obesity (body weight - 160 kg, height - 160 cm). Severe comorbid pathology (Charlson index 4), including a neurogenic dysfunction of a bladder. During the pre-operation planning, we considered different variants to fix the fracture. Plates and IM nailing looked unattractive due to the instability of the endoprosthesis and femoral condylar defects. Severe comorbid pathology and obesity limited options for revision arthroplasty. As an option, we considered an amputation on the level of the middle third of the femur. However, the patient abandoned it categorically. Finally, we have chosen a special modular IM nail for arthrodesis FN (by a Polish manufacturer) for surgical treatment. This implant ensured osteosynthesis of the femoral bone and recovery of the length of the extremity thanks to the metal cages we applied, having removed impaired condyles during the surgery. Conclusions. The modular IM nail for knee arthrodesis ensured early verticalization of the patient, the recovery of the length of the extremity and consolidation of the femoral fracture. The patient was satisfied with the result despite the restrictions in daily routines.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Surgical treatment for combined acetabulum and pelvic ring injuries: What are the factors that make acetabulum reduction difficult?

Polytrauma

Abstract text (incl. references and figure legends) Introduction: Combined acetabulum and pelvic ring injuries are not rare. However, despite the complexity of the fracture morphology, there is no protocol for surgical treatment, and reduction of the acetabulum is often difficult. So, this study is to clarify the factors that make it difficult to reduce the acetabulum articular surface in combined acetabulum and pelvic ring injuries. Material &amp; Methods: Records of 14 patients admitted with a diagnosis of combined acetabulum and pelvic ring injuries were reviewed retrospectively. Postoperative reduction of the acetabulum articular surface was evaluated based on Matta's criteria. We divided the patients into two groups (the good group and the poor group) and compared the factors that led to the poor reduction. The classification of pelvic ring/acetabular fractures (AO and Judet-Letournel classification) and injury type of posterior pelvic lesion were compared between groups. Results: There were 11 patients in the good group and 3 patients in the poor group. According to the AO classification of pelvic injury, there were 9 B type and 2 C type injuries in the good group, and 1 B type and 2 C type in the poor group. According to the Judet-Letournel classification of acetabulum injury, there were 5 elementary fractures and 6 associated fractures in the good group, and all fractures in the poor group were associated fractures. In the poor group, all cases were combined with sacral fractures and were injured on bilateral posterior lesion of the pelvic ring. Conclusion: In addition to the complex fracture morphology of both the pelvic ring and acetabulum, sacral fractures and damage to bilateral posterior pelvic ring are considered to be the factors for poor reduction. Those sacral fractures tend to be poorly reduced by indirect reduction and they might lead to malreduction of the acetabulum. References: 1, Tiziani S. Injury. 2021;52:2712-2718. 2, T Suzuki. J Orthop Trauma. 2010;24:303–308.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Implants removal after a successful osteosynthesis

Abstract text (incl. references and figure legends) Introduction. Today, there is no uniform approach to the removal of implants after bone fusion. Doubtless, implants must be removed due to infection, nonunion, motion discomfort, conflicts between metal devices and soft tissues, protruding of implants under the skin, or peri-implant fractures. However, its expediency is discussible in other cases. Although removing implants looks like an easy procedure, even experienced surgeons may have difficulties extracting an implant. This operation could be even more traumatic than the osteosynthesis itself. Materials and methods. Implant removal in 250 patients after successful fusions without infection, treated with IM nailing (IMN) and LCP plating (LCP). The mean age of the patients was 44 years old (a standard deviation of 15 years); 56% (n=140) of patients were women. The fractures most frequently occurred to a tibia/condyles – 48% (LCP – 98.8%, IMN – 1.2%), less frequent to clavicles – 23.8% (LCP – 100%), shoulder 12.4% (LCP- 100%), femur – 9.2% (LCP – 17,3%, IMN – 82,7%), and forearm – 6.6% (LCP – 100%). On average, the implants got removed in 18.2 months (8.1 to 76.7 months) after the surgical osteosynthesis. The main indications were irritation of the skin and soft tissues, pain and discomfort, and a patient's wish. Results. For 72 patients (28.8%), technical difficulties have been reported. The most frequent problems were: a crew head jamming in an LCP plate, stripped screw heads unmanageable for a screwdriver, and their combinations. In 56 patients (22.4%), we failed to remove the metal structure completely, and broken screws remained in the intramedullary channel. Conclusions: A decision to remove an implant should be made exceptionally after a thorough study of the medical, social, and economic consequences of this surgical procedure. Young inexperienced surgeons shall not carry out removals of orthopaedic implants. Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

A natural experiment study: Low profile double plating versus conventional single plating technique in midshaft clavicle fractures

Emergency surgery

Abstract text (incl. references and figure legends) Introduction Clavicle fractures account for 2% to 5% of all fractures in adults. Single plate osteosynthesis is most commonly used for surgical stabilization. Structural low profile double plating technique might form a possible solution for the high removal rates associated with single plating. Although randomized controlled trials (RCTs) are considered the gold standard for testing the efficacy of such new interventions, its design sets highly artificial condition on surgical practice. A natural experiment (NE) design offers a possible solution. NEs are observational studies in which patients are exposed to either the experimental or the control condition and treatment allocation is determined by factors outside the control of the investigators. The present study encompasses a natural experiment comparing low profile double plating to single plating in midshaft clavicle fractures. Material &amp; Methods Adult patients (≥18 years) with a primary midshaft clavicula fractures (Robinson Type II or AO 15.2) that are eligible for operative treatment will be included (Figure 1). Treatment allocation will be determined by geographical location. Five hospitals will participate in this study. In three centers, single plating is the treatment of choice and in two low profile double plating currently is the standard treatment. For the double plating group, one superiorly positioned VariAx 2.0mm plate and one anterior VariAx 2.4mm or 2.7mm plate will be used. For the single plating group, the standard local available implant will be used. The primary and secondary objectives are shown in Table 1. Discussion This study will help us understand if double plating has significant clinical and cost-effective benefits over a single plating technique in midshaft clavicle fractures as suggested in a previous meta-analysis by our study group. It will also provide insight on how the NE design functions in a research field where it has rarely been used.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) This investigator-driven study has been provided with a grant from Stryker Osteonics SA to cover the logistical costs (salary study coordinator, data management, costs related to congresses and publications fees). No conflicts of interest have been reported by research management. The manuscript shall be published in a peer reviewed journal. Contact details: Stryker Osteonics SA, Niederlassung Biberist, Burgunderstraße 13, CH-4562 Biberist / SO.

Epidemiology of proximal humeral fractures in patients 65-years and older: No increase in the incidence, fracture type and treatment options in the 5 years period

Abstract text (incl. references and figure legends) Background. Proximal humeral fractures (PHF) represent one of most common fractures in elderly people. Some epidemiological data suggests increasing incidence of this injuries by time. The aim of our study was to analyze epidemiological data of patients with PHF treated in the trauma level 1 center from the year 2015 to 2020. Incidence, fracture type and treatment options were analyzed. Material &amp; Methods. In the retrospective study we included all elderly patients aged above 65 years PHF which were treated in the level 1 trauma center from 2015-2020. Patients" records were reviewed. The primary objective was the number and the type of fractures. Secondary objective of the study was the type of treatment for the 3-part and 4-part PHF. For this matter detailed analyses for the years 2015 and 2020 was conducted.Results. Number of treated patients with PHF was 399 in year 2015 and 428 in 2020. Average age of patients was 78.9 years and 79.1 years respectively. Additionally, there is stable number of treated patients for every single year reported from 2015 to 2020. Detailed analyses for the years 2015 and 2020 revealed no significant difference in fracture type. Nonoperative treatment remained the most frequent modality. No significant difference was noted in number of interventions or implants used, although there is increased trend toward treatment with reverse shoulder arthroplasty. Conclusions. Despite quickly increasing numbers of elderly people in population, the number of patients with PHF in a 5-year window remain stable. Furthermore, no significant difference in fracture type and modality of treatment was noted between years 2015 and 2020. Based on the epidemiological results we do not expect higher incidence of PHF or number of surgical interventions in elderly in the next decade. Reference. Below. Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No Reference. Miha Ambrožič, Rok Bergman, Luka Hodnik, Roman Luštrik, Franc Štefanič, Matej Cimerman et al. Decision-making and treatment results of complex proximal humerus fracutres in geriatric patients: retrospective study from a level 1 trauma center. Signa Vitae. 2022. doi: 10.22514&quot;sv.2022.040.

Acute Lisfranc injuries: Simultaneous 2nd and 3rd tarso-metatarsal joint fusion using Medartis® aptus wing plate: A retrospective cohort study

Abstract text (incl. references and figure legends) Introduction: Lisfranc injuries can have devastating consequences and are often associated with poor functional outcomes and high rates of disability, due to arch collapse and post-traumatic arthritis. Anatomical reduction of the midfoot arch and fusion of the Lisfranc joint is essential in preventing these outcomes. While dorsal plating has been proved to provide satisfactory biomechanical and clinical outcomes, the simultaneous 2nd and 3rd tarsometatarsal joint fusion using a single locking plate may combine the already proved superior fatigue resistance with improved sort and long-term clinical outcomes.Materials/Methods: 26 patients (18 men, 8 women) with acute Lisfranc injuries were retrospectively analyzed; all underwent open reduction and internal fixation, using a simultaneously 2nd and 3rd tarsometatarsal joint fusion using a single locking plate between 2017-2021. They were followed up for at least 18 months and AOFAS score, X-rays and CT&quot;s were used to assess their postoperative clinical progress.Results: 24 Patients with a median age of 34[27-48] completed the follow up protocol with a mean follow up time of 24 months[18- 42] and analyzed per protocol. The median Injury to Surgery Time was 8 days[4-21]. Their mean AOFAS score at 6 month was calculated to 74%[± 9%] and in the 18th month 81%[± 12%]. OA lesions developed in 1 patient in 26 months. 2 postop infection cases were addressed with antibiotics and hardware removal. Chronic pain was reported in 2 cases. 1 of them underwent revision arthrodesis, due to non-union. Conclusion: Simultaneously 2nd and 3rd tarsometatarsal joint fusion, using a single locking plate, may lead to better functional outcome and a lower incidence of post-traumatic arthritis and fatigue related complications, when compared to standard two plate technique. A larger prospective comparative study is required to produce higher-quality evidence.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Results of surgical treatment for displaced acetabular fractures

Abstract text (incl. references and figure legends) INTRODUCTION: Acetabular fractures are often associated with politrauma and the treatment of these fractures remains a challange. The aim of this study is to perform a retrospective analysis of complications following the surgical treatment of displaced acetabular fractures. MATERIALS &amp; METHODS: Between January 2011 and October 2020 a number of 147 patient with displaced acetabular fractures were treated surgically. According to the Letournel classification (1), the most common fractures types were: posterior wall fractures (28.7%), transverse fractures (21%) and transverse and posterior wall fractures (20.3%). Clinical outcome was evaluated using Merle d"Aubigne score modified by Matta (2). RESULTS: Intraoperative complicatons were vascular injuries (8 cases) and damage to the static nerve (4 cases). Quality of reduction based on Matta's criteria showed anatomical reduction in 94 cases (63.9%), imperfect reduction in 34 cases (23.1%) and poor reduction in 19 cases (12.9%). Two-year follow-up results (available for 106 patients) were excellent in 46 cases (43.3%), good in 38 cases (35.8%), fair in 12 cases (11.3%) and poor in 10 cases (9.4%). There was a statistically significant correlation between quality of reduction and clinical results. Other complications were heterotopic ossifications. osteonecrosis of the femoral head and arthrosis. Hip arthroplasty was the final solution for 16 patients (15%). CONCLUSIONS: Despite the relatively large number of complications, surgical treatment for displaced acetabular fractures is the optimal choice. REFERENCES: Judet R, Judet J, Letournel E. Fractures of the acetabulum: Classification and surgical approaches for open reduction: Preliminary report. J Bone Joint Surg Am. 1964;46: 1615-46. Matta J M, Mehne D K, Roffi R. Fractures of the acetabulum. Early results of a prospective study. Clin Orthop 1986; (205): 241-50. Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Comparing blade sliding mechanism between PFNA and TFNA (DePuy-Synthes) in unstable proximal femoral fractures: A single center experience

Abstract text (incl. references and figure legends) Background and purpose — Intramedullary nailing has become standard for unstable trochanteric fractures. Research has led to modification of existing implants, such as the DePuy Synthes TFN-ADVANCED™ (TFNA) which is replacing the existing PFNA nail. At our institution, complications with the TFNA blade mechanism have been observed.TFNA introduced new static vs. dynamic blade locking options. We hypothesized that the blade locking mechanism modification increases friction and impairs blade movement. The purpose of this article was to confirm our hypothesis.Patients and methods — We compared trochanteric fracture fixation between both nails to determine the amount of blade sliding. All trochanteric fractures treated at our institution with the TFNA since its introduction in early 2022 were retrospectively reviewed for fixation failure, tip-to-apex distance (TAD), and lateral blade migration (LBM). Sliding failure was defined as central protrusion (cut through). A PFNA control group based on a similar cohort has been established for comparison.Results — After exclusion, 96 patients were identified in TFNA and 90 in the PFNA group.The mean LBM was 6.1mm in the TFNA and 4.8mm in PFNA group. The difference was 1,3 mm (21,3%).Mean TAD was 17,7mm in the TFNA and 20,1mm in PFNA group. The difference was 2,4 mm (22%).The PFNA group has a higher incidence (14%) of high TAD compared to TFNA group (11%).Cut-through was observed in five patients ( 5 %) in the TFNA and one patient (1 %) in the PFNA group respectively. The total complication rate, requiring revision surgery was 7% in the TFNA group and 1% in the PFNA group.Interpretation — Our hypothesis regarding the TFNA sliding mechanism was incorrect. Although we did observe a higher incidence of cut-through in the TFNA group it seems the sliding mechanism is not the reason for failure and further research on the topic is required.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

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