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23rd European Congress of Trauma & Emergency Surgery

The role of additional fibula fixation on alignment in distal lower leg fractures

Skeletal trauma and sports medicine

Research

Introduction: The use of fibula fixation (FF) concomitant to intramedullary nailing (IMN) or plate osteosynthesis (POS) to treat distal lower leg fractures is a topic of debate as available literature regarding this topic is inconclusive. The aim of this study was to assess the role of FF in the treatment of combined distal tibia and fibula fractures. Materials &amp; Methods: A retrospective cohort study was performed including 130 patients who had sustained an operative treatment following distal third, combined tibia and fibula fractures. Tibia alignment and fracture characteristics were determined by radiograph analyses. Mean alignment and loss of reduction after FF and conservative treatment of the fibula were compared using Student&quot;s t-test. Bivariate analysis was used to determine relative risks on malalignment, nonunion, secondary surgery and infection. Results: Type of tibia osteosynthesis correlated significantly with tibia fracture height with respect to the tibia plafond (POS: 74.6 mm ± 26.3 mm vs. IMN: 31.6 mm ± 22.6 mm, p= 0.000). FF was not significantly associated with alignment or union. In case of tibial POS, additional FF resulted in less coronal malalignment (RR 0.51, 95%CI: 0.30 – 0.88) and a reduced risk of secondary surgery (RR 0.31 95%CI 0.10 -0.98). No association between fibula treatment and LOR was found. Conclusions: FF does not affect alignment after tibial IMN. Also, FF is not associated with tibia union or LOR. However, in case of tibial POS, FF reduces the risk of coronal malalignment and secondary surgery.no

Poster

Type B ankle fractures with additional medium-sized posterior fragment: Radiological and functional outcome after 6 years follow up

Trauma and Emergency surgery | Miscellaneous

Introduction Guidelines for treatment of medium-sized posterior fragments in trimalleolar fractures are scarce and show varying advices. Recent results (unpublished) of our RCT (POSTFIX-trial) on fixation of posterior fragments show no difference in functional and radiological outcome after 1 year follow up. We performed a prospective cohort study to evaluate functional outcome and development of osteoarthritis after 6 years follow up. Methods Retrospective cohort study on type B ankle fractures with additional medium-sized (5-25% of joint surface) posterior malleolar fragments. All patients operated between 2014 and 2018 were approached for inclusion. ORIF of posterior fragment via the posterolateral approach was compared to no fixation. Choice of treatment was based on surgeons preference. Concomitant fractured medial and lateral malleoli were treated according to AO-principles. Functional outcome was measured by VAS pain (0-10), OMAS and AOFAS questionnaires. Development of osteoarthritis was assessed on plain radiographs. A subanalysis of the patients (n=30) included in the POSTFIX trial was performed. Results 27 patients were included in the ORIF group (group 1) and 58 patients in the no fixation group (group 2). Baseline characteristics were equal (sex, age, ASA, BMI, fracture classification, fragment size). Postoperative step-off on CT-scan favored group 1, but not significantly. After 6 years, no significant difference was observed on functional outcome (OMAS 85 vs 88, AOFAS 90 vs 95, VAS pain 1 vs 1). No differences in development of posttraumatic osteoarthritis were seen in both groups after 6 years. The subanalysis showed similar outcomes. Complication rates were similar between the two groups. Conclusion ORIF of posterior fragments in AO 44-B3 fractures does not lead to better functional outcome or less development of osteoarthritis after 6 years follow up. These findings confirm the results from the POSTFIX trial. no

Prof. Dr.

Ass. Prof.

Open reduction and fixation does not improve short-term outcome of medium-sized posterior fragments in AO type-B ankle fractures: 1-year results of the POSTFIX-trial

Introduction Guidelines for treatment of medium-sized posterior fragments in trimalleolar fractures are scarce and show varying advices. To test the hypothesis that open reduction and fixation (ORIF) of medium-sized posterior fragments is meaningful, we performed a multicenter randomized clinical trial.(1) Methods Multicenter RCT on ORIF of medium-sized (5-25% of joint surface) posterior malleolar (PM) fragments in AO 44-B3 fractures. Computer-randomization for ORIF or non-fixation of the PM fragment; concomitant fractured medial and lateral malleoli are treated according to AO-principles. Pre- and postoperative CT-scans were performed. Outcome was measured by VAS pain (0-10), VAS general health (0-100), OMAS and AAOS questionnaires with 1Y follow-up. Plain radiographs were performed at 1 year postoperative to assess signs of osteoarthritis. Results 41 patients were allocated to ORIF of the PM fragment and 40 to non-fixation. Baseline characteristics were equal (table1). Postoperative step-off favoured ORIF when assessed on radiograph, but was similar on CT-scan. After 1Y, no significant difference was seen on functional outcome (AAOS 90 vs 93, OMAS 73 vs 75, VAS pain 2 vs 1, general health 80 vs 83) (table 2). No difference in development of posttraumatic osteoarthritis was seen in both groups after 1Y. Complication rates were similar. Conclusion The POSTFIX-trial is the largest RCT worldwide to analyse the effects of ORIF the PM in AO 44-B3 trimalleolar fractures. ORIF of the PM does not lead to better functional outcome or less development of osteoarthritis after 1Y follow up. References Verhage S, van der Zwaal P, Bronkhorst M, van der Meulen H, Kleinveld S, Meylaerts S, Rhemrev S, Krijnen P, Schipper I, Hoogendoorn J. Medium-sized posterior fragments in AO Weber-B fractures, does open reduction and fixation improve outcome? the POSTFIX-trial protocol, a multicenter randomized clinical trial. BMC Musculoskelet Disord. 2017 Feb 23;18(1):94no

Fracture classification 2.0: Automated determination of 3D morphology of calcaneal fractures

Quantitatively assessing calcaneal fractures is complex yet critical for determining the appropriate therapeutic approach, the postoperative recovery strategy and potential functional outcome. Traditional 2D imaging does not fully capture the 3D complexity of calcaneal fractures. In addition, current methods of fracture assessment rely on manual interpretation, leading to potential inconsistencies and subjective variances. Thus, a need for an automated, reliable, and quantitative method to evaluate the 3D morphology of calcaneal fractures exists. This study aims to develop and assess algorithms capable of automatically quantifying 3D morphology of calcaneal fractures from CT scans. CT scans were collected from two populations: patients with healthy calcanei and those with fractures. Using a deep learning algorithm, 3D models of the calcaneus and talus were constructed. Additional algorithms were developed to automatically measure critical diagnostic angles (Böhler's and Gissane's angles), varus-valgus angulation, and evaluate the incongruity of the subtalar joint by measuring the average distance in the joint space. Healthy and fractured calcanei were compared using automated measurements, followed by a manual inspection to ensure consistency with clinical expectations. The study included 3D models of 40 healthy and 37 fractured calcanei. The automated measurements indicated a significantly larger Böhler's angle in healthy calcanei (27°±5°) than in fractured ones (11°±12°; p&lt;0.001). Fractured calcanei exhibited significant varus or valgus angulation, with an average difference of more than 9° in comparison with the unfractured population (p=0.007). A subtalar joint incongruency was more pronounced in fractured (4.5 mm ±1.8 mm) than in healthy calcanei (2.7 mm ± 0.4 mm; p&lt;0.001). The developed algorithm effectively automates the measurement of 3D morphology and has demonstrated significant differences between healthy and fractured calcanei.No

Prof.

Minimally invasive locking plate fixation of intraarticular calcaneal fractures comparison of radiographic and clinical results according to the plate configuration

Background: Minimally invasive approaches for intra-articular calcaneal fracture have become widely used, and complications can be reduced. Recently, locking plate has been commercially available for minimally invasive use. The purpose of this study is to determine whether minimally invasive plates can be used safely and provide good fixation, and to determine whether there are differences in fixation between different types of plates. Materials and Methods: 88 feet with intra-articular calcaneal fractures treated from 2016 to 2018 who could be followed for at least 12 months. All fractures were treated by A.L.P.S MIS LC Plate System (Zimmer Biomet) through Sinus Tarsi Approach (STA). Radiological evaluation was done with Böhler angle, Preiss angle, calcaneal height, width, and step-off of the articular surface, and for clinical evaluation, AOFAS Ankle-Hindfoot scale was recorded at the final follow-up. The mean age at the time of injury was 60.5 years, with 59 feet in 55 male patients, the mean waiting time for surgery was 6.53 days, and the mean operative time was 111.9 minutes. The implants used were standard (SP) in 12 cases and extended (EP) in 76 cases. Two patients had wound dehiscence improved without additional surgery. No deep infection was observed. Bone union was achieved in all patients, with a mean functional score of 88.7 at the final follow-up. SP had significantly greater loss of correction of Böhler and Preiss angles from postoperative period to time of bone union compared to EP. There was a correlation between Böhler angle and walking distance score, and between Preiss angle and pain score. Conclusion: Minimally invasive plate could be safely used even with a short waiting period. EP had an advantage over SP in maintaining the reduction, thereby improving the clinical outcome.No conflict of interst

A case report of cerebral fat embolism resulting in death due to increased cerebral pressure

Purpose: Fat embolism syndrome is a serious complication associated with bone fractures and can result in respiratory symptoms, disturbance of consciousness, and petechiae, but atypical symptoms may also be experienced. Here, we report a case of cerebral fat embolism syndrome that resulted in death due to increased cerebral pressure. Case history: A 21-year-old man was injured when the truck he was driving collided with another. He was hospitalized with direct traction for a left femoral shaft fracture and a left tibial shaft fracture. Approximately 11 hours after the injury, he developed symptoms of restlessness. Afterwards, his level of consciousness gradually decreased, and a cranial CT scan revealed swelling. MRI showed diffuse patchy areas of high signal intensity on FIAIR and DWI. He underwent external fixation for the fracture. Although we performed artificial respiration, intracranial pressure control by inserting an ICP sensor, and steroid pulse therapy, he became clinically brain dead on the 6th day of illness and died on the 11th day of illness. No respiratory symptoms were observed during the course. Discussion: Fat embolism syndrome is often relatively mild and will often cause respiratory symptoms. However, there could be cases like ours where lesions occur only in the brain, which can be fatal. When treating long bone fracture cases, it is important to keep this possibility in mind when performing treatment. Particular attention should be paid to young patients and those with multiple fractures, and early fixation was likely necessary.No

Prof. Dr. med.

TraumaEvidence – Dissemination and translation of research results in orthopaedics and traumatology

Education

Introduction Implementing evidence-based medicine (ebm) requires an overview of current evidence. In 2019, the project TraumaEvidence was established by the German Society of Traumatology (DGU) and the University Hospital Düsseldorf (UKD). One objective of TraumaEvidence is to promote the dissemination and implementation of research results and thus, ebm in orthopedics and traumatology. Materials &amp; Methods Since March 2020, the TraumaEvidence publishes a newsletter to help surgeons access the latest evidence. The newest systematic reviews in orthopedics and traumatology are briefly summarized and critically commented on. To provide access to this evidence beyond the reach of the newsletter, the Thesaurus database was developed at the end of 2022. This database enables the search for current evidence from TraumaEvidence newsletter on a specific topic. In addition to the core message of the newsletter article, three aspects of the commented systematic review are assessed and clearly presented: (1) relevance for practice, (2) methodological implementation, and (3) the level of evidence of the included studies. Results As of October 2023, 38 issues of the TraumaEvidence newsletter have been published and are send out to more than 250 surgeons in the Germany and beyond, commenting on more than 140 systematic reviews. Clinical commentaries are regularly included that discuss the relevance of the results for clinical practice. All newsletter articles can be accessed through the Thesaurus database. The critical assessment enables clinicians to interpret the research results in a short but comprehensive fashion. Conclusion The TraumaEvidence newsletter together with the Thesaurus database facilitate access to current evidence in orthopedics and traumatology which fosters ebm in orthopedics and traumatology research and practice.No

PD Dr.

Stress fractures in the military context

Disaster & military surgery

Introduction – Soldiers, especially as recruits, are exposed to significantly elevated stress patterns of the foot due to occupation-related marching and excessive running. This can lead to military-specific stress fractures of the metatarsals, i.e., marching fractures. The treatment and prevention of stress fractures are of particular importance in the military context due to the impact on oper- ational capability and treatment costs. A uniform classification of these fractures does not yet exist. Objectives – We conducted a review of stress fractures in the military setting with presentation of the incidence, risk factors, classification, treatment and prevention possibilities. Materials &amp; Methods – A PubMed®-based review of the current literature on stress fractures in the military context was conducted and the results were discussed with a focus on specific military medical treatment options. Results – There are several possibilities to classify stress fractures, the most well-known being a 4-level magnetic resonance imaging (MRI)-based classification. Prevention and treatment possibilities are multifaceted but so far insufficiently validated. Conclusion – Military-specific stress fractures should be grouped according to a 4-level and MRI-based classification. The treatment options include both conservative and surgical measures and should be implemented taking the patient&quot;s individual requirements into account. Preventive measures play a key role in the military context. They include the adaptation of screening tools, training and equipment and require continuous evaluation and development.No

Is it possible to control infection by CLAP for high infection risk group of open fractures?

Emergency surgery

Introduction In Gustilo grade 3 open fractures, infection rate was reported 7-50%. We have introduced Continuous Local Antibiotic Perfusion (CLAP) as a new drug delivery system, which perfuses high doze gentamicin efficiently through bone marrow needles and drainage tubes at the site of infection. According to this system, infection was successfully eradicated with retaining the implant in fracture related infection. For open fractures, we apply CLAP for high infection risk case and try to fix fractures at the earliest convenience. Objectives The purpose of this study was to review retrospectively open fractures to assess the influence the CLAP for infection rate and fracture fixation process. Patients &amp; methods Between May 2022 and June 2023 , all patients diagnosed with open fractures (excluding the fingers and foot except for calcaneus) and who underwent treatment at our institution with an observation period of more than 3 months were reviewed. In case of high risk cases, CLAP was applied by attending doctors decision during fracture treatment as a CLAP group. The remaining cases were non-CLAP group. Patient backgrounds, fracture factors (fracture site, Gustilo classification), treatment details (type of fixation methods during the initial intervention), and the presence of infection within 3 months after injury were compared between two group. Results 39 patients (16 CLAP group and 23 non-CLAP group) were included this study. The ratio of Gustilo type III cases were 75% in CLAP group and 30% in non-CALP group. The ratio of the cases who underwent immediate internal fixation was 94% in CLAP group, while 52% in non-CLAP group. The duration until ORIF was 0.8 days in the CLAP group and 4.0 days in the non-CLAP group.The infection rate at the 3month after injury was 8% (3/39 cases), with a rate of 13% in the CLAP group and 4% in the non-CLAP group. Conclusion This study suggests that CLAP contributes to infection control in early internal fixation protocol.No

Is the cortical thickness index useful as the screening tool for severe osteoporosis?

Introduction: The correlation between Cortical Thickness Index (CTI) and Bone Mineral Density (BMD) is well-known. The effectiveness as a screening tool for severe osteoporosis has not been proven. Objectives: The purpose of this study is to investigate the relationship between CTI and BMD obtained by dual-energy X-ray absorptiometry (DXA) in patients with proximal femoral fractures and to determine the diagnostic ability of CTI for severe osteoporosis. Patients &amp; methods: One hundred nine proximal femoral fractures (79 females and 30 males) were included for this study, and measured BMD by DXA within 14 days after their initial visit. CTI was measured following the method reported by Baumgartner. The relationship between CTI and BMD of lumbar spine and proximal femur were investigated. Statistical analysis was performed using Pearson's correlation coefficient test. Additionally, the diagnostic ability and cut-off value of CTI for YAM &lt;60% (roughly equivalent to " T score of BMD of the lumbar spine＜-3.3SD") were determined using the ROC curve. Results: Significant positive correlations were observed between CTI and BMD of lumbar spine (r=0.48, p&lt;0.01), and also between CTI and YAM of lumbar spine (r=0.48, p&lt;0.01). There is a strong positive correlation between CTI and BMD of proximal femur (r=0.70, p&lt;0.01), and also between CTI and YAM of femur (r=0.75, p&lt;0.01). Using the ROC curve, the diagnostic ability of CTI for YAM&lt;60% was as follows: For the lumbar spine, the cut-off value was 0.50 with a sensitivity of 100%, specificity of 55%, and AUC of 0.80. For the proximal femur, the cut-off value was 0.47 with a sensitivity of 91%, specificity of 68%, and AUC of 0.86. Conclusion: Significant correlations were observed between CTI and BMD of both lumbar spine and proximal femur. Given its extremely high sensitivity in diagnosing YAM&lt;60%, CTI may be valuable as a screening tool for severe osteoporosis, particularly in patients with proximal femoral fractures.No

Novel therateutic strategies: Anti-fibrotic short-term effects of nintedanib on post-traumatic joint stiffness in a rat model

Introduction: As with all fibrotic diseases (FD), post-traumatic joint stiffness (PTJS) is characterized by an uncontrolled deposition of connective tissue as response to an inflammatory stimulus. This causes a multidimensional disturbance in the organs architecture. In PTJS this disturbance may impair mobility and lead to chronic pain. Objective: A pharmacological approach represents a promising alternative to current therapeutic standards as their traumatic nature may further fuel the underlying pathomechanism. Common cellular pathways in FD allow the translation of nintedanib, as it has demonstrated a substantial antifibrotic effect in other FDs. Methods: In this blinded set-up, twenty-six Sprague Dawley rats were randomized into equally sized nintedanib or control groups. Following a standardised knee trauma, the joint was immobilised for 2 weeks - the apex of most pronounced fibrotic progression. Pharmacotherapy with nintedanib or placebo (2*5 mg/kg/day) was initiated on the day of trauma and continued for the entire course. Joint contracture was measured using a novel automated precision instrument, in addition to a molecular biological assessment. Results: Nintedanib has significant biomechanical effect on PTJS. Systemic therapy resulted in a higher joint mobility of 14.5° compared to its control group (p = 0.0101). This is also reflected at the molecular level. Differences in gene expression were most pronounced for α-SMA, an important component of the main effector cell in fibrosis (p = 0.0024). Other pro-fibrotic factors (TGF-β, CTGF, Il-6, Nfk-B) revealed no marked changes. Conclusion: Nintedanib confirms its reputation as an all-purpose weapon in the treatment of various FDs. It appears to be one of the few drugs to have a significant anti-fibrotic effect on different levels of PTJS. It remains to be seen whether these changes are also reflected at the histological level and whether intra-articular application is on a par with systemic therapy.No.

Predicting complications in conservatively managed rib fracture patients

Introduction: Studies have shown an increased risk of morbidity in patients admitted to the hospital after suffering a rib fracture. Objective: The aim of this study is to investigate which variables best predict complications in rib fracture patients. Patients and Methods: The ACS Trauma Quality Improvement Program database was used to identify all adult patients (age 18 or older) with a conservatively managed rib fracture as a result of suffering an isolated thoracic injury. An isolated thoracic injury was defined as a thorax AIS ≥1 and an AIS ≤1 in all other regions. The predictive value of demographic, clinical, and comorbidity data was evaluated using logistic regression models and ranked using the permutation importance method. Results: 172,964 patients were included in the study, of whom 1,832 suffered a complication during hospitalization. The most important variables for predicting complications were the Revised Cardiac Risk Index, diabetes mellitus, age, Glasgow Coma Scale on admission, and congestive heart failure. A logistic regression model based on the five most important variables for each outcome demonstrated an acceptable discriminative ability for complications [AUC (95% CI): 0.70 (0.69-0.71)]. Conclusion: The most important factors for predicting complications in conservatively managed rib fracture patients were patients&quot; cardiac risk, age, and level of consciousness at admission.No

Poster session 7
Session 7: Skeletal trauma: Miscellaneous

Appointment

Chairs

Topic

Programme

Poster session 7Session 7: Skeletal trauma: Miscellaneous

Appointment

Chairs

Topic

Programme

Poster session 7
Session 7: Skeletal trauma: Miscellaneous