22nd European Congress of Trauma & Emergency Surgery

Chairs

Cast versus removable orthosis for the management of stable type b ankle fractures: A systematic review and meta-analysis

Abstract text (incl. references and figure legends) Purpose: There is currently no consensus on nonoperative management in adult patients after a stable type B ankle fracture. The aim of this review is to compare a removable orthosis versus a cast regarding safety and functional outcome in the NOM of stable type B ankle fractures. Results: Five studies were included. Two were randomized clinical trials, and three were observational studies, including a total of 516 patients. A meta-analysis showed statistically significant higher odds of developing complications in the cast group (odds ratio (OR), 4.67 (95% Confidence Interval (CI) 1.52 to 14.35)) (figure 1). The mean difference of functional outcome in OMAS did not vary significantly at six weeks; OR -6.64 (95% CI -13.72 to 0.45)), and 12 weeks; OR -6.91 (95% CI -18.73 to 4.91) (figure 2). The mean difference of functional outcome in OMAS at 26 weeks or longer was significantly higher in the removable orthosis group in favour of the removable orthosis; OR -2.63 (95% CI -5.01 to -0.25). Conclusion: Results of this systematic review and meta-analysis show that a removable orthosis is a safe alternative type of NOM, as complication numbers are significantly lower in the orthosis group. In addition, no statistically significant differences were found in terms of functional outcome between a removable orthosis and a cast at six and twelve weeks. After 26 weeks a removable orthosis is non-inferior to a cast in terms of functional outcome in patients with stable type B ankle fractures. 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

Education

Skeletal trauma and sports medicine

Poster

Prof.

A novel concept in intramedullary nailing for distal tibia fractures

Abstract text (incl. references and figure legends) 【Introduction】The gold standard of surgical treatment for tibial shaft fractures is the intramedullary nailing. In recent years, due to implant improvements, the indication for intramedullary nailing has expanded to epiphyseal fractures. However, distal tibia fractures with a wide medullary cavity have a high risk of nonunion due to insufficient fixation. In this study, we inserted an intramedullary nail below the epiphyseal scar using a newly introduced intramedullary reamer, and good results were observed. We report this novel and effective surgical concept of anchoring in the tibial plafond.【Material＆Methods】10 cases treated by intramedullary nailing for distal tibia fractures between August 2020 and September 2022 were enrolled for this study. There were 5 males and 5 females with a mean age of 50.2 (28-74) years. All cases were distal 3rd tibial fractures including 1 open fractures. 8 were classified as 42A1, 1 as 42A3, and 1 as 42C3 according to AO classification. 8 cases had an associated simple intraarticular fracture. Smith &amp; Nephew META-NAIL was used in all cases. After the guide rod was driven into the tibial plafond, &quot;the finish reamer&quot; was applied to ream over the epiphyseal scar, and the intramedullary nail was inserted deeply and fixed.【Results】Bone union was achieved in all patients. There were no cases of postoperative reduction loss. There were no obvious complications such as heat necrosis, infection, or pain around the ankle joint.【Conclusions】An anchoring with the tip of intramedullary nail in the tibial plafond may be a useful surgical concept for more rigid fixation in very distal tibial fractures.【References】1) Mohammed A, Saravanan R, Zammit J, King R. Intramedullary tibial nailing in distal third tibial fractures: distal locking screws and fracture non-union. International Orthopaedics (SICOT). 2008;32:547–549. 2) Talerico M, Ahn J. Intramedullary Nail Fixation of Distal Tibia Fractures: Tips and Tricks. J Orthop Trauma. 2016;30:S7-11.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

Polytrauma

Usefulness of the rotator cuff interval approach in intramedullary nailing of the humerus

Abstract text (incl. references and figure legends) 【Introduction】The rotator cuff interval approach that minimizes the risk of rotator cuff damage has been reported. However, few clinical researches have followed. In this study, we report cases of humeral fractures treated by an intramedullary nail fixed via this approach with good postoperative courses.【Material＆Methods】 7 patients were enrolled for this study between July 2020 to September 2022. There were 4 males and 3 females with a mean age of 51.4 (24-71) years. In the beach chair position, an approximately 5cm skin incision is made from the anterior angle of the acromion to the coracoid process. The deltoid muscle is divided and the capsule is incised minimally to identify the long head tendon of the biceps. The humeral head can be widely seen by extending the incision of the capsule and retracting the long head tendon of the biceps anteriorly and the supraspinatus posteriorly. The insertion point of the nail appears by shoulder extension. The capsule is reattached with absorbable suture. In all cases, range of motion exercise of shoulder including elbow is permitted from the day after surgery. The mean range of motion and the visual analogue scale (VAS) during movement were evaluated at the last follow up.【Results】Bone union was achieved in all patients. The average shoulder range of motion was excellent. No patient complained of postoperative pain. There were no complications.【Conclusions】The rotator cuff interval approach is useful with eliminating the risk of rotator cuff injury and may reduce the risk of postoperative periarticular shoulder pain and limited range of motion after intramedullary nailing.【References】1). Park J-Y, Pandher DS, Chun J-Y, et al. Antegrade Humeral Nailing Through the Rotator Cuff interval: A New Entry Portal. J Orthop Trauma 2008; 22(6): 419-425.2). Patino J.M, Ramella J.C, Michelini A.E, et al. Plate vs. nails in humeral shaft fractures: Do plates lead to a better shoulder function? JSES International 2021; 5(4): 765-768.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. Dr.

Intracompartmental pressures in the deep posterior compartment of the leg and conservative treatment outcome for exercise related leg pain in military service members

Abstract text (incl. references and figure legends) Introduction Intracompartmental pressure (ICP) measurements are routinely performed in patients with exercise-related leg pain (ERLP) to diagnose CECS. However, the relationship between ICP of the deep posterior compartment and treatment outcomes is under debate. Therefore, the aim of this study was to evaluate the association between ICP values of the deep posterior compartment and the outcomes of a conservative outpatient treatment program in military service members with chronic ERLP. Material &amp; Methods This cohort study was performed in the Royal Netherlands Armed Forces. The main outcome measures were return to active duty and development of acute on chronic compartment syndrome. A generalized linear mixed model was used to identify predictor variables associated with return to active duty. Results During the 5-year study period (2015-2019), 266 military patients completed a conservative treatment program for chronic ERLP. Eighty-three service members with 145 affected legs met all inclusion criteria. Sixty service members (72%) successfully returned to active duty (Table 1). No association between ICP values of the deep posterior compartment and conservative treatment outcome was found (odds ratio 1.02; 95% CI, 0.97-1.07; p=0.50). A low SANE-score (more severe symptoms at baseline), was negatively associated with return to duty (odds ratio 0.95; 95% CI, 0.90-0.99; p=0.01) (Table 2). None of the patients developed acute on chronic compartment syndrome during the treatment program. Conclusions There was no association between a single post-exercise ICP value of the deep posterior compartment of both legs in military service members and return to active duty after a comprehensive conservative outpatient treatment program. None of the patients developed acute on chronic compartment syndrome. In this population, ICP measurement of the deep posterior compartment can be safely postponed until conservative treatment fails and surgical treatment is considered.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

Disaster and military medicine

Treatment of double tension band wiring with AI wiring system for transcondylar distal humeral fractures

Abstract text (incl. references and figure legends) Introduction: As AI wiring system is united the pin with the cable due to compressed sleeve, the pin is never deviated. We review the treatment of transcondylar distal humeral fractures with AI wiring system in geriatric patients. Patients &amp; Methods: 8 were identified as receiving this surgery. All patients were female and their mean age was 72 years. They were assessed union rate, range of motion for elbow joint, postoperative complication and functional outcome for Japanese Orthopedic score. Results: Union rate was 100%. The mean arch of motion was 100°at latest follow-up. The complications were detected 3 cases which were temporary ulnar palsy for 2 cases and hardware failure for 1 case. The average of functional outcome was 73 points (73/100). Conclusion: Tension band wiring of transcondylar distal humeral fractures with AI wiring system provides stable fixation for osteoporotic bone and tiny fragment.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

Multi-phase treatment of a septic subtrochanteric fracture

Abstract text (incl. references and figure legends) A young male patient suffered a right subtrochanteric fracture fixed by a long trochanteric nail and cerclage wires. Ten days after the first operation, dislocation of the fracture was revealed on x-ray, due to having overloaded of the operated limb. Second look surgery was realized to strenghten the fracture by additional cerclage wires. During follow ups, prolonged fracture healing was observed, with discharge at the distal screws. Culture samples showed the presence of Staphylococcus epidermidis, however, inflammatory blood markers were low. Dental focal infection was found, which could suggest a hematogenous spread, one year after the fracture. Decision of re-admission and revision surgery was made. All implants were taken out, the medullary canal was reamed, and antibiotic cement coated intramedullary pin was placed. The fracture was stabilized with external fixation. Multiple samples were taken for culture, followed by 5 weeks of antibiotic treatment. All inflammatory markers normalized. After 5 weeks, a long trochnteric nail was re-inserted, and the fracture site was augmented with a corticospongious span. Despite all efforts in the early postoperative period, discharge from the wound appeared. Decision of a third look surgery was made, antibiotic impregnated osteoconductive graft was placed to the fracture site, and the intravenous antibiotic treatment was changed. The recovery and mobilisation went succesfully. Dental focal infection treatment was done.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

Emergency surgery

Preoperative CT-based evaluation of the iliolumbar arteries for pararectus approach in the acetabular fractures

Abstract text (incl. references and figure legends) &lt;Introduction&gt; The purpose of this study was to investigate branches of ILAs which should be treated during pararectus approaches using preoperative enhanced computed tomography (CT). &lt;Materials and Methods&gt;From 2013 and 2021, forty-two cases who needed anterior approach for internal fixation and with enhanced CT taken preoperatively were included to this study. Thirty-three cases were male. Mean age was 60±19 years. Unaffected sides were also evaluated (total 84 sides). Thin slices of enhanced CT images were used to evaluate the ILAs. Origin of the ILAs and the number of ILAs crossing the sacroiliac joints were evaluated. The branch of ILA crossing around at the anterior edge of the sacroiliac joint and distributing to the iliopsoas was defined as "the iliopsoas branch" and the branch crossing the sacroiliac joint posteriorly and running along the iliac crest was defined as "the iliac branch" (Figure 1). The distance from the anterior edge of the sacroiliac joint to branches and transverse diameter of branches were also measured. &lt;Results&gt;ILAs originated from common iliac arteries (4 sides: 4.8%), internal iliac arteries (50 sides: 59.5%), posterior trunk (26 sides: 31.0%), the other arteries (2 sides: 2.4%), and unknown origins (2 sides: 2.4%). The number of ILA branches to iliopsoas were three in 8 sides (9.5%), two in 64 sides (76.2%), and one in 10 sides (11.9%), none confirmed in 3 sides (3.6%). Branches of ILAs were not confirmed in 5 cases (11.9%) due to hematoma. The iliopsoas branches cross the sacroiliac joint at the mean 3.4±6.6 mm posterior to the anterior edge and mean diameter was 1.9±0.4 mm, whereas the iliac branches cross at 23.3±7.5 mm and mean diameter was 1.8±0.4 mm. &lt;Conclusions&gt;ILAs originates mainly from the internal iliac artery. In the most cases, there were the iliopsoas branches which should be treated during pararectus approach. The ILAs were not confirmed only in 11.9% with preoperative enhanced CT images.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

Use of 3D planning and printing in preoperative planing of complex distal radius fracture

Abstract text (incl. references and figure legends) Case history, clinical findings, investigation and diagnosis: 57 year old woman, fell while riding a bike. Deformity of her left wrist was present. X ray diagnostics showed a C3.3 distal radius fracture with fairly proximal involvement. After preliminary reduction in anaesthesia, a CT scan for further preoperative planning was made. Operative treatment was indicated. Preoperative planning: With the use of 3D technology for preoperative planning surgery plan was done. The main reasons were severe comminution and to see if osteosinthetic material we have will be of proper dimension for this fracture. After doing a 3D reconstruction in the software we first analysed the fracture and the necessary steps for the reduction. After doing a virtual reduction we printed a reduced 3D fracture model in 1:1 ratio. When we combined the model with the intended plate - 85 cm long distal radius volar plate, we could see that the length of the plate is appropriate and made sure, that the distal part of the long plate is not too wide for the patient"s bone. Treatment: Patient was operated one week after the injury when swelling of soft tissues was acceptable. The operation went according to preoperative plan, with all the steps being done as planned virtually. No additional steps were necessary. After the operation the patient had protection splint for pain management. 3 weeks after the surgery physiotherapy started. Despite developing some signs of CRBS, the range of movement 5 months after the surgery was 25° of wrist flexion and 35°of extension with good pronation/supination. The fracture was radiographically healed in good position. Comments:3D planning with the additional help of 1:1 printed model is a great tool when dealing with complex fractures It can shorten the time of surgery and eliminate unnecessary steps that would appear if the plan would not be thoroughly developed. 3D planning and printing is another step to safer and better surgery procedure.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

Cardiac and pulmonary bonecement embolism during dorsal instrumentation - A case report

Abstract text (incl. references and figure legends) Introduction: Loosening and pull out of pedicle screws are common problems in spine surgery. Hence, more and more pedicle screws are augmented, especially in osteoporotic bone. A feared complication is cement leakage into the venous system with consecutive pulmonary cement embolism. Evidence based recommendations to handle these complications are rare. Material and Methods: Case report: In a 59-year-old female patient with a burst fracture of the first lumbar vertebrae, cement leakage into the inferior vena cava over a distance of 4 cm occurred during a spondylodesis with cement augmented pedicle screws. A review of the literature followed by an interdisciplinary discussion panel including a trauma surgeon, a vascular surgeon, an angiologist and an interventional radiologist was performed to determine the most appropiate intervention with the lowest possible patient risk. Results: Incidences of cement leakage are described very vague in the literature. Most cases occur asymptomatic and the most abundant complication is a pulmonary cement embolism. Treatment recommendations include observation, temporary oral anticoagulation, percutaneous interventional removal, and open procedures. In our case, we decided –due to the thromboembolic risk and the relatively young patient– to attempt percutaneous interventional cement removal by an interventional radiologist with a vascular surgeon and cardiac surgeon on standby. After catching the cement line with a snare, the cement became aberrant and moved into the right atrium. From the right atrium the major part could be secured piecewise with the snare. A small part however caused a peripheral pulmonary cement embolism. Within the first three months postoperatively the patient remained asymptomatic under oral anticoagulation with Phenprocoumon. Conclusion: Recommendations for the management of cement leakage of augmented pedicle screws do only exist on observations in small series and case reports. Prospective clinical trials are not expected to be available in the near future. An interdisciplinary approached is obligatory for a good treatment outcome.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"

Safety, efficacy and tracking of multiple mesenchymal stem cells transplantations in acute cervical spinal cord injury

Abstract text (incl. references and figure legends) Background: Current treatment of spinal cord injuries (SCI) options remain limited to early surgical treatment and minimizing secondary SCI. Mesenchymal stem cell (MSC) therapy is one of promising methods for cellular repair after SCI.Materials and methods: Eight patients with complete cervical SCI and urgent spinal cord decompresion and stabilisation were enrolled in the study. Bone marrow (BM) MSC were first harvested from patients iliac crests and cultivated, thereafter patients received an iv. transplantation. One month after intravenous (IV) transplantation, patients received three intrathecal (IT) transplantations of BM MSC each. BM MSC were radiolabeled and cell migration was evaluated with whole-body planar and hybrid (SPECT/CT) imaging. Neurologic function safety and feasibility was regulary assessed. Results:Serious side effects after transplantation were not observed. Neurologic improvement was observed in 75% of patients. All patients were classified as ASIA A prior MSC application. MSC tracking with hybrid SPECT/CT imaging revealed that after iv. administration BM MSC were distributed in the reticuloendothelial system and in the lung parenchyma. BM MSC retention at the site of spinal cord injury was unremarkable at any time frame. After IT administration BM MSC immediately migrated to the site of injury even months after SCI. In one patient, cell migration was unremarkable, probably due to persistent severe spinal cord edema obliterating the spinal canal as shown on control MRI.Conclusion:Our study suggests that application of mesenchymal stem cells is safe and feasible for treatment of SCI. We found that BM MSC migrate to the site of SCI after transplantation and that retention of cells after IT administration at the injury site is superior to the retention after IV administration. Although neurologic recovery was observed it could not be attributed solely to BM MSC transplantation. Due to small sample size we can not exclude endogenous recovery or placebo effectDisclosure: 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

Use of cerclage wires in femoral fractures and periosteal blood flow compromise. Where is the evidence?

Abstract text (incl. references and figure legends) OBJECTIVE Cerclage wiring is well known in the treatment of femoral fractures but there is some controversy amongst surgeons regarding compromise of periosteal blood flow. Additional reaming and compromise of endosteal blood supply aggravates these concerns. There is also debate about the viability of single and double loop application. We performed a literature overview in search of evidence of bone necrosis associated with cerclage wires, effects on bone biology and healing, and the best mode of application. STUDY SELECTION We included studies of adult femoral fractures (AO/OTA from 31A2 to 33A2) managed with intramedullary nails and cerclage and studies of periprosthetic and peri-implant fractures treated with cerclage with or without plates. Biomechanical studies and studies on bone biology after cerclage application were also reviewed. 24 studies were chosen for final inclusion. Studies about non-metallic cerclages and studies without the use of plates or nails were excluded. FINDINGS and DISCUSSION Although some animal studies showed a significant decrease in blood circulation through the affected area of the bone, none of the studies showed signs of bone necrosis due to cerclage wire use. No statistical advantage in using cerclage was shown, either with a locking plate when treating periprosthetic hip fractures or in using cerclage wire with an intramedullary nail when treating trochanteric fractures. The frequency of reoperation, nonunion, loss of fixation, implant failure and time to union was the same in both groups. An advantage favoring cerclage wiring was seen in accuracy of fracture reduction. The technique was more frequently used in high energy fracture patterns. Double loop configuration was shown superior in withstanding cyclical load resistance. Our review of literature showed that cerclage wires are a good adjunct in osteosynthesis of proximal femur and peri implant fractures with little to no risk of bone necrosis on the application site.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 management of a medial clavicle physeal fracture following blunt trauma

Abstract text (incl. references and figure legends) Case history Medial clavicle physeal fractures, also known pseudodislocation of the sternoclavicular joint, are rare injuries to the medial physis of the clavicle in children. Treatment is generally nonoperative management but rarely, surgical management might be indicated. We present a case of a 6-year-old male who suffered a head and shoulder trauma following a box falling onto himself. Clinical findings, Investigation/Results and Diagnosis He presented to the emergency department with a epicranial haematoma and a right shoulder and chest oedema and tenderness. Radiographs and CTscans revealed no head or cervical spine injuries but showed a medial clavicle physeal fracture with significant cranial and slight anterior dislocation. Therapy and Progressions He was subsequently admitted to the operating room where he was submitted to an open reduction and fixation with transosseous sutures using a direct medial clavicle approach, achieving anatomic reduction.In the immediate post-operative period, he was immobilized with a velpeau-like sling which he maintained for 3 weeks.He evolved with anatomic bone healing of the fracture and no range of motion limitation at the 6-month follow-up. Comments Non-operative treatment is usually indicated in most asymptomatic injuries, anterior and posterior displacement (if no injury to mediastinal structures). Stable reduction is often difficult to maintain and an open reduction may be required. Even though, in the present case, there was not a mandatory surgical indication per se, we found the huge cranial displacement and clinical skin tenting to be of too great significance for a non-operative management. The patient evolved with anatomic healing and great shoulder function with no pain. In the light of the aforementioned, we therefore believe this approach to have been a successful application of surgical treatment in this rare pattern of fracture. References DOI: 10.1155/2018/4986061 , 10.1016/j.ijscr.2021.105656Disclosure: 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

Poster Session 18
Skeletal trauma and sports medicine 3

Appointment

Chairs

Programme

Poster Session 18Skeletal trauma and sports medicine 3

Appointment

Chairs

Programme

Poster Session 18
Skeletal trauma and sports medicine 3