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23rd European Congress of Trauma & Emergency Surgery

Prof. Dr.

Reliability and accuracy of the Outerbridge classification in staging of cartilage defects

Skeletal trauma and sports medicine

Education

Introduction Numerous grading systems are available to describe cartilage defects. In clinical use are mostly the ICRS classification or its predecessor, the Outerbridge classification. The threshold to perform cartilage repair is thereby at the border from II° to III° lesions. When using the ICRS classification, the surgeon must, however, allocate the lesion correctly in a scale containing ten different grades. In the Outerbridge classification, still 5 different grades are possible. Objectives Aim of the present study was to evaluate intra- and interobserver reliability of the Outerbridge classification and to reevaluate its accuracy on the basis of histological analyses. Material &amp; methods Nine cartilage defects from cadaveric knees were imaged using stardard arthroscopy. After four weeks, the acquired images were randomised and presented to 3 different observers. Under identical conditions, these observers tried to allocate the correct Outerbridge grade. Thereafter, a joint training session was performed to harmonise grading between observers. Finally, a second round of grading was performed, the results of which were compared with histological analyses of the investigated defects. Results Interrater-reliability in the second round ranged statistically from poor to good (Cohen's kappa 0.24 - 0.70). Intrarater-reliability was fair to good (kappa 0.55-0.66). Histologically 1 Outerbride grade I, 1 grade II, 5 grade III, and 2 grade IV defects were found. More than half of the arthroscopic allocations did not match the histological results. In the majority of cases, defect severity was underrated, especially at the transition from II° to III°. Conclusion Altough clinically in routine use, the Outerbridge classification is far from being a reliable tool to correctly evaluate cartilage defect severity. This is especially of relevance at the decision, whether cartilage repair strategies should be attempted or not.No

Poster

Supra-intercondylar periprothetic fracture of the knee initial treatment with revision

Trauma and Emergency surgery | Miscellaneous

Case History: Female, 56y, with right total knee arthroplasty within 1 year postop. Presented in the ER with a fall from standing height with direct knee trauma. Clinical findinds: Pain, sweeling and deformity, unable to move. Results/ Diagnosis: X-Ray showed supra-intercondylar periprosthetic of the right femur, Lewis type III and Rorabeck. Therapy and Progressions: The patient before the fall already had a history of mechanical pain and joint stiffness. The authors decided to do an arthroplasty revisiom with semi-restrictive prosthesis with femoral and tibial stems. The external condyle/external lateral ligament was fixed with an anchor and the internal condyle with 2 Kirschner wires. Complication-free post-operative. The patient followed a rehabilitation plan, according to the service"s protocol. At 2 months, gait whith 2 crutches, painless and arch of mobility 0º-90º. At 6 months, Walking without crutches, mobility arc of 0º-100º, KSS 90/100. Kirschner wires were removed due to complaints of pain on palpation of the medial condyle of the femur. Comments: Revision arthroplasty is a valid option for the treatment of peri-prosthetic fractures in selected cases, especially when the aim is to restore function. The options considered were osteosynthesis with an LCP-type plate and revision prosthesis. We opted for the revision prosthesis due to the previous history of joint pain and stiffness, due to poor placement of the primary implant. The authors consider that, despite the technical difficulty and risks inherent to knee revision arthroplasty, in this particular case, it was the best option, both due to complaints before the trauma, as well as the characteristics of the fracture, saving the patient from other surgical interventions and inherent risks. References: Ebraheim et al,2015; Cacciola et al, 2021; Kuzyk et al, 2017; Kamal et al, 2020 No

Bullseye – Knee penetrating injury

Case history: 25-year-old man brought to the ER victim of accidental penetrating trauma with spearfishing harpoon, which was transfixive in his knee causing pain and joint blockage in flexion. Clinical findings: On physical examination, the harpoon was seen entering the anterolateral aspect of the knee, moving in the inferior-medial-posterior direction, and exiting the posterolateral face, without clinical evidence of neurovascular injury. Investigation & Diagnosis: A CT scan with intravenous contrast showed an interarticular path of the harpoon in the space of the cruciate ligaments, without major bone, nerve or vascular damage. Therapy: The harpoon was easily removed in an anterograde manner in the operating room. Progressions: The patient was discharged on the 2nd postoperative day with no functional deficits. The absence of significant soft tissue injury was confirmed on a knee MRI performed 2 months later. Comments: Penetrating injuries caused by accidental firing from spearfishing weapons are rare but likely to cause serious tissue injuries. Most of these weapons are designed to catch and hold resisting fish, so are usually sharp and narrow in the front and wider in the rear, with or without spurs. Further information on its exact shape, trajectory and estimated damage is of utmost importance when planning the method of extraction, and for that a CT scan is crucial. Because of their very irregular shape, simple extraction by pulling is not recommended, because further damage may occur. The principles of management after fishing harpoon penetrating injuries include primary basic life support, followed by trajectory surgical removal of the projectile, careful exploration of the object tract and wound care. References: 1. Dudkiewicz, I et al. Fishing penetration injuries. Br J Sports Med. 2000; 34:459-462. 2. Pothiawala, S et al. A rare case of penetrating intra-abdominal trauma by a fishing speargun. The New Zealand Med J. 2022; 135(1565).No

Bilateral septic arthritis of the knee with a history of avascular necrosis by corticotherapy due to myasthenia gravis

Emergency surgery

A 26-year-old male with AP of severe myasthenia gravis immunosuppressed by prolonged steroid treatment and rituximab who had already presented episodes of monoarthritis in the knees, including an episode of septic arthritis due to S. aureus treated with arthrocentesis and antibiotic. In the ED he showed pain and swelling in both knees. Suspecting recurrent septic arthritis, a new arthrocentesis was performed with cultures and cefazolin was started. During admission, arthroscopy of both knees was performed, and purulent fluid was obtained, also showing diffuse synovitis and delamination of the articular cartilage in loading areas. In the control MRI bone infarcts were observed in both femurs and tibias that conditioned fractures due to insufficiency, without being able to rule out osteomyelitis, so daptomycin was added to the treatment. Three-phase scintigraphy was performed showing findings compatible with bilateral osteomyelitis.In surgical cultures, S. Aureus was isolated in the surgical cultures. Bilateral septic arthritis of the knee complicated with osteomyelitis due to immunosuppression treatment. Added to cefazolin infusion, antibiotic suppression with dalbavancin was performed in a day hospital for 8 weeks to achieve bone therapeutic levels and subsequently complemented with chronic suppressive treatment. Two months after discharge, the patient comes walking without aids. He refers right gonalgia controlled with NSAIDs. Examination revealed the absence of phlogosis signs and an improvement in the range of motion of both knees. Myasthenia gravis is an autoimmune disorder that includes corticosteroid therapy as a treatment. Prolonged high doses can cause osteonecrosis. Due to the immunosuppressed state, our patient has developed recurrent septic arthritis. The treatment of septic arthritis consists of arthroscopic debridement associated with long-term antibiotherapy. In the presence of osteomyelitis, it would be necessary to add other antibiotics. No

Simultaneous bilateral quadriceps tendon rupture

Case history: A 71-year-old male with known hypertension, hyperlipidemia presented to the emergency department (ED) with bilateral thigh pain after sudden fell while standing. He re-presented to ED with recurrence fall. He was able to extend his right knee actively, but with an extensor lag of 15-20 degrees, while the extensor mechanism of his left knee was disrupted. Investigations: Magnetic resonance imaging (MRI) confirmed the diagnosis of bilateral distal QTRs, with resultant hematomas in bilateral suprapatellar regions, larger on the left. Progression: Patient underwent left quadriceps tendon reconstruction with Pulvertaft Weave with Allograft and right quadriceps tendon repair with VY-plasty Advancement. He was last reviewed 1 year post-op. He is able to ambulate independently. The range of motion of left knee is 0-100 degrees, whereas the range of motion for right knee is 0-110 degree. There was no extension lag over bilateral lower limbs. Discussion: QTR is reported to have an incidence of 1.37/100,000 compared to 0.68/100,000 for patellar tendon ruptures. Extensor mechanism ruptures are most commonly unilateral. It usually affecting mainly middle aged males (M:F 4.1:1, mean age: 51.1 years) [1,2] and those with underlying medical illnesses. Conclusion: It is a rare injury that require a high index of suspicion for prompt diagnosis, early surgical repair, and subsequently physiotherapy to achieve a good functional outcome. Clinicians, especially emergency physicians, should be familiar with diagnosing quadriceps tendon rupture from the initial presentation to prevent delay in diagnosis. References 1. Jacob D. Pope; Youssef El Bitar; Ahmed Mabrouk; Mark P. Plexousakis, "Quadriceps Tendon Rupture", StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): 2023 Jan-, 2. Clayton RA, Court-Brown CM. The epidemiology of musculoskeletal tendinous and ligamentous injuries. Injury. 2008;39(12):1338–1344. doi: 10.1016/j.injury.2008.06.021.No

Prof.

Surgical treatment of gunshot diaphyseal shin fractures

Disaster & military surgery

Introduction: Gunshot fractures of extremities are problematic due to their high-energetic character, frequent infectious complications, pseudoarthroses and bone tissue lesions, high rate of slow consolidations. The share of diaphyseal fractures reaches 50%; shin bones possess from 27 to 36% of their totality. Material and methods: The research covers 128 patients with dominating combat shin traumas. The first of two groups gathered 68 patients treated by an external fixation device (EFD), and the second 60 with extra focal osteosynthesis replaced by an internal one. Functional results have been assessed according to the LEFS (Lower Extremity Functional Scale) to see the progress, namely 3, 6, 12, and 18 months after the injury. Results: The concept of replacement (conversion) of an EFD with intramedullary nailing is not new. The use of EFD for shin gunshot fractures with later replacement by IM nailing benefits from both these methods but some conditions must be met. During the first two to three weeks, both groups showed no statistically significant difference. Their average score according to the LEFS was 15.75 points with a standard deviation of 4.51. The difference was most remarkable from 6 to 12 months after the injury, 39.4±2.4 (EFD) and 57.3±2.1 (IMN). After 18 months, 20.7% of patients from the study group and 15.8% of the control group reported excellent results (LEFS 61 – 80). Results were good in 43.2% and 33.1%. 28.1% and 39.3%, respectively, had satisfactory results (LEFS 41-60), and 8.0% of the study group and 11.8% of the control group (p&lt;0.05) had poor ones. Conclusions: Thus, outcomes after the gunshot diaphyseal shin fractures show that the use of conversion according to the respective indications and criteria reduces the share of infectious complications by 13.5%, fastens consolidation by 4±2.3 weeks, reduces the frequency of consolidation disorders by 10.6%, improves the patients&quot; functional results by 14.4%, evidencing its efficiency.No

Treatment of fractures of the inferior pole of patellar in elderly patients using strong suture

【Introduction】Tension band wiring is the gold standard for osteosynthesis of patellar fractures, but irritation between the skin and the wire during flexion is a serious problem. In the case of lower pole fractures, if the bone fragment is large enough, it can be fixed with an implant such as a screw, but there is a problem of fixation force in osteoporotic bones, and if the lower pole is shattered, it is difficult to fix with implant like screws. We have obtained good results using a surgical technique with a strong suture (No. 5 Fiberwire® suture) and report the results here.【Objectives】To verify the usefulness of fixation with strong suture for lower pole fractures of patellar in elderly patients.【Material＆Methods】5 cases aged 60 years or older treated with strong suture for lower pole fractures of patellar between December 2021 to June 2023 were enrolled for this study. There were 2 males and 3 females with a mean age of 74.4 (64-90) years. 1 was classified as 34A1, 3 as 34C1.3, and 1 as 34C2 according to the AO classification. In all cases, Krackow suture was applied to the patellar tendon using a No. 5 Fiberwire® suture and pulled out through the bony foramen to the superior pole for fixation. Patients underwent full-load walking with a knee brace and range-of-motion training from the early postoperative period.【Results】Bone union was achieved in all patients. The mean time to bone union was 2.7 months. There were no cases of postoperative reduction loss. The mean knee range of motion at the last observation was 134° in flexion and 0° in extension. There were no obvious complications such as skin trouble, or pain around the knee joint.【Conclusions】fixation of lower pole fractures of patellar with strong suture is useful even in elderly patients.【References】Ponrachai Wongthongsalee, Thanapon Chobpenthai, Techniques in Ｏrthopaedics 37(4):p224-231, December 2022.No

Rare comorbidity with distal femoral shaft fracture, when all of your plans go wrong

A middle-aged man with previous childhood left femur fracture and congenital vascular malformation in his medical history, fell in his backyard, and suffered a distal femur fracture on the same limb. Primary treatment occured in a regional hospital, which was unsuccesfull, because of massive bleeding that led to hematodinamycal instability of the patient. He was transferred to our centre for further treatment. Initially, MRI and CT angio scan was performed, and several femoral malformations were found. X-ray revealed a hypoplastic femur shaft. The preoperative plan was to fix the fracture with a plate from anterior approach. Surgical intervention was performed by two well experienced trauma and vascular surgeon. During the operation, a sudden emerge of circulation compromise, forced the team to change the fixation method, so two titan elastic nail was inserted into the femur. Patient was stabilized, and intraoperative pictures were made. The fracture was fixed with moderate axial deviation. Postoperatively the left limb placed in plaster. The patient received 12 units of RBC concentrate, 8 units of platelet concentrate, and 3 units of FFP. Serous discharging from the wound reported in the first month, infection markers remained low. Mobilisation went successfully. His treatment was carried on with an orthesis, and from the sixth week, partial weight bearing was commenced. Half year ensuing the operation, the x-ray showed sufficient bony consolidation of the fracture. No signs of infection were detected, the patient was eligible to start full body weight loading. Of importance, in case of non-union of the fracture, retrograde nailing as an alternative treatment was dismissed, in order not to expose the patient for further life threatening conditions, because intramedullary bleeding could not be excluded safely. Thus, additional correction was abandoned. Our case clearly shows that diligent preoperative planning is essential to provide secure treatment.no

Is void filling necessary in lateral tibia plateau fractures treated with the rafting technique?

Introduction Lateral tibial plateau fractures often involve significant joint depression and the risk of post-operative subchondral subsidence. It is common to combine osteosynthesis with grafting of the bonedefect created after elevation of the depression. The Rafting technique, characterized by the placement of additional subchondral pins or screws may however eliminate the need for grafting. Objective This retrospective study presents outcomes of posterolateral tibia plateau fractures treated with the Rafting technique without the use of bone grafts. Materials &amp; Methods 18 consecutive patients with Ao Type B3 lateral tibial plateau fractures were treated by the same surgeon with the Rafting Technique. Rasmussen radiological scores (RRS) were measured pre and post-operatively, depression volume was analyzed. All patients were asked to fill in the KOOS and EQ-5L-5D questionnaire. Statistical analysis was done with SPSS, significance was set at P&lt;0.01. Results The average age of the patient population was 55.8 years (STD 14.7). 10 Male, 8 Female. Preoperative RRS averaged 12.0 (STD 3.3), postoperative RRS increased to a mean score of 17.7 (STD 0.77) (P&lt;0,01, Sample t-test). Screw-to-joint line-depth averaged 1.7 mm (STD 1,6). One case had post-operative subsidence. This case had the highest screw-to-joint line-depth (8mm). The average depression volume was 4.04 ml (STD 3.31 ml). Ten patients completed post-operative assessment, average follow-up period of 2.8 years (STD 1.8). Post-operative KOOS scores indicated favorable outcomes: Symptoms: mean 88.9 (STD 7,8), Pain: 86.9 (STD 11,2), ADL: 93.4 (STD 8,2), Sport: 70.5 (29,9), and QoL: 72.50 (STD 16,9). Flexion averaged 132.8° (STD 11,75), full extension was achieved in all cases. Conclusion Lateral tibial plateau fractures with joint depression can safely be treated with The Rafting technique, without the need for bonegrafts. Furthermore it highlights the importance of true subchondral screw placement. No

PD Dr.

Non-invasive assessment of perfusion using new ultrasound-based power Doppler-techniques for early diagnosis in compartment syndrome of the lower extremities

Research

Introduction Reliable diagnosis of acute compartment syndrome in extremities is still a challenge despite modern diagnostics. However, an early diagnosis and surgical intervention are critical to the outcome. Gold standard in diagnostics is clinical impression, which is situation- and experience-dependent. Apparative diagnostics can be separated into invasive and non-invasive diagnostics. They are often prone to failure, mostly not safely validated and often not available. In this study, a non-invasive diagnostic method, Doppler ultrasound, was investigated by examining the change in perfusion in a simulated early phase of compartment syndrome in the lower extremity. Material &amp; Methods Using a standardized and validated simulation protocol, simulation of a developing compartment syndrome in the lower leg was performed. The assessment was performed using three Doppler ultrasounds: monochrome Superb Microvascular Imaging (mSMI), Color Superb Microvascular Imaging (cSMI) and Power Doppler (PD). The main measure was defined as the perfusion ratio per area in a fixed region of interest (ROI) of the tibialis ant. muscle. After data collection, descriptive and statistical analysis was performed. Results The study showed an increase in perfusion per area in all three tools. In all three Doppler techniques a p.m. of perfusion change was detected at the highest simulation level. In relation to the base value, an increase in perfusion was demonstrated to be 1.39-higher in mSMI, 1.99-higher in cSMI, and 3.16-higher in PD. An indirect dependence of perfusion to pressure was proven. Conclusions The new examination tools are capable of detecting changes in perfusion already in the early phase of the compartment syndrome. Accordingly, the investigated examination tool represents an interesting, innovative and promising possibility to support the early and valid diagnosis of a compartment syndrome. Given the limitations of a study on a very homogeneous group, further studies are now necessary. no

Management of a tibial pilon fracture with the Masquelet technique

Polytrauma

In this clinical case, a 59-year-old woman presented at the emergency department following a fall from height. After the initial stabilization, the patient underwent an osteosynthesis of a tibial pilon fracture with a medial and anterolateral distal tibia plates, and a distal fibula plate. At one-month post-operative there was a significant soft tissue loss resulting in the exposure of the osteosynthesis material. Consequently, the tibial plates were removed, necrotic areas were debrided, and due to a large tibial bone defect, it was decided to do the Masquelet technique. An external fixator for distraction was applied and the bone defect was filled with a cement spacer with antibiotics. To address the soft tissue defect, a sural flap was done. Intraoperative samples revealed a serratia liquefaciens. In the following months, the patient received multiple courses of antibiotics, and her soft tissue healing progressed favorably. Approximately two months later, the masquelet technique was finished. The non-viable fibular bone was excised, the cement spacer was removed, and a calcaneal-tibial arthrodesis was performed using a nail. At this point, all intraoperative samples were sterile. Nine months after the last surgery the patient reported being pain free and showed a complete soft tissue healing. The term tibial pilon fracture has been used to depict the situation where the lower part of the tibia takes on a pestle-like shape due to substantial axial forces on the talus, leading to tibia bursting. The treatment of these fractures continues to be challenging; however, careful management of soft tissue injury holds the key to reduce complications and improve outcomes. The two-phase method described by Masquelet has become increasingly popular as there have been promising reports of its success in various conditions. Our case represents the valuable of its use in the setting of a complex distal tibia fracture with severe bone and soft tissue loss.No.

The post-operative opioid requirements for tibial fractures

Introduction: This study investigates opioid prescribing patterns for orthopedic fractures, focusing on isolated tibial fractures in the first post-operative year. With limited opioid use guidelines in orthopedic cases, analgesia needs vary widely. We explore associations between opioid usage and factors such as definitive fixation type, fracture location, type, and comorbidities. Methods: A retrospective analysis of isolated tibial fracture surgeries at a major trauma center (2015-2022) was conducted. Primary outcomes included monthly total opioid dosage in morphine milligrams equivalents (MME) and days opioids were used in the first post-operative year, representing opioid strength and coverage. Predictive factors included fixation type, fracture details, age, BMI, ASA grade, gender, Charlston Comorbidity Index (CCI), and comorbidities. Results: The study comprised 1,814 patients with 1,970 fractures. Tibial plateau fractures had the highest opioid strength and coverage requirements (p&lt;0.05), followed by pilon fractures. Tibial shaft fractures showed similar needs to non-tibial shaft fractures, while ankle fractures required fewer opioids. Open tibia fractures needed more opioids in the first two months than closed fractures. External frame fixation had higher opioid strength requirements than IM nailing and plate ORIF, especially in closed fractures. Limited differences existed between plate ORIF and IM nailing. Comorbidities such as chronic kidney disease(x1.37), hypertension(x1.43), COPD(x1.90), depression(x1.41), diabetes(x1.46), and obesity (x1.78) were associated with increased opioid strength requirements. Conclusions: Our study offers insights into long-term opioid requirements after tibial fractures, considering fracture characteristics, surgical approaches, and comorbidities. This information aids clinicians in anticipating patients' rehabilitation journeys and making informed opioid prescription decisionsno

Poster session 5
Session 5: Lower extremity: Knee

Appointment

Chairs

Topic

Programme

Poster session 5Session 5: Lower extremity: Knee

Appointment

Chairs

Topic

Programme

Poster session 5
Session 5: Lower extremity: Knee