23rd European Congress of Trauma & Emergency Surgery

Prof.

Prof. Dr.

Push-Pull Locking Plate (PP-LP) versus Traditional Locking Plate (T-LP) in proximal humeral fractures: A finite element analysis study

Purpose Varus angulated fractures of the proximal humerus treated with locking plates have a high risk of failure. The push-pull principle (an apical pulling subchondral suture anchor combined with a locking plate with downward-directed locking screws) has clinically shown lower varus recurrence and secondary screw penetration rates. However, this technique was applied by intra-operatively adapting T-LPs. To standardize this method, a "push-pull "dedicated design is needed. The FEA study compares the biomechanical performance of a novel PP-LP with a T-LP. Methods A defect below the humeral head mimicked a 2-part fracture. All boundary conditions were identical for the two plates. The pull mechanism for the PP-LP was simulated as a force vector between the head apex anchorage point and the proximal plate-end (pre-tension). Axial compression, torsion bending, and compression bending were simulated. The stress distributions (SD) on bone, plate, and screws were calculated Results SD on the proximal humerus was more homogeneous for the push-pull model, showing less unloaded areas of the screws: the number of elements returning Von Mises stress lower than 0.05 MPa was 57.45% lower for PP-LP compared to T-LP for axial compression, 1.21% for torsion bending and 78.82% for compression bending. Similar patterns were found in the plate. SD on the distal humerus was similar for both plates. Conclusion This FEA study showed a more homogeneous SD on the screws with the push-pull principle in all set-ups compared to the T-LP. This mechanism may explain the clinically observed lower failure rateNo

Research

Skeletal trauma and sports medicine

Abstract talk

Return to work after proximal humeral fractures: A single center study comparing conservative and operative treatment

Background: Proximal humeral fractures (PHF) are a common injury and can result in loss of joint function. Adequate treatment is crucial to fully regain function of the shoulder and with this faster return to work (RTW). Identifying factors that influence RTW after PHF are important to deliver more effective patient care and minimize prolonged work disability. The present study aims to identify the effect of conservative and operative treatment on return to work and recovery. Materials and methods:In this retrospective case-control study, a total of 858 patients between the ages of 18-68 were treated for a PHF between 2018 and 2021 in Zuyderland Medical Center. Questionnaires (n=342) were sent out to eligible operatively treated patients and 191 matched controls, who were treated conservatively. Questionnaires assessed RTW, quality of life (EQ5D) and functional outcome measures (DASH,ASES). Non-normal distributed data were analyzed using Mann Whitney-U test, and categorical variables were analyzed using Chi-squared test. A Kaplan-Meier analysis was performed for RTW in weeks. Results: Response rate was 38%. A total of 73 patients (40 OG,34 CG) were included in the data analysis of which 67.1%(49) was female. Prior to trauma, 60% were employed. Almost 70%(n= 19 and 11) of employed patients returned to work, and all patients returned back to their previous jobs. In the OG group, 65.5%(n=14) resumed full-time employment and 41.7%(n= 5) in the CG (p=0.826). Of the patients returning to work, median time in weeks RTW tended to be later for the OG vs CG (OG 10.5, IQR 22 vs. CG 6.00, IQR 8, p=0.072). PROMs showed no statistical difference between groups (p=0.542,p=0.257,and p=0.530, respectively). Conclusion: While the proportion of patients treated for PHF returning to work was not different between operatively and conservatively treated patients, surgically treated patients tended to return to work 4 weeks later than conservatively treated patients. PROMs did not differ.No

Prof. Dr. med.

Reliability of preoperative conventional X-Ray diagnostics for multifragmentary clavicular fractures: A retrospective cohort study

This study aimed to assess the reliability of preoperative conventional X-ray diagnostics for identifying multifragmentary clavicular fractures using intraoperative findings as the reference standard and explores potential implications for surgical approach modification. Data from 326 patients with isolated central clavicular fractures who underwent surgical treatment between July 1, 2012, and June 30, 2023, were retrospectively analyzed. Among these, 73 were female, and 253 were male in a mean age of 37.5 ± 17 years. The fractures were classified pre- and intraoperatively using the AO classification system. 31 out of 248 comminuted fractures were only discovered intraoperatively, accounting for 10% of all fractures. According to the AO Classification 43 out of 326 fractures (13%) exhibited a disparity between preoperative and intraoperative assessments, resulting in a change in the surgical approach for 40 patients, 12% of the total cohort or 91% of the fractures that were classified differently preoperatively compared to intraoperatively. In these cases, fractures were treated with open reduction and angular stable plate fixation instead of the preoperatively planned elastic stable intramedullary nailing (ESIN). The results of this study suggest that conventional X-ray diagnostics may not always detect comminuted clavicle shaft fractures.No.

Trauma and Emergency surgery | Miscellaneous

Nonoperative treatment of multiple rib fractures, the results to beat: An international multicenter prospective cohort study among 845 patients

Background: Optimal treatment (i.e. nonoperative or operative) for patients with multiple rib fractures remains debated. Studies that compare treatments are rationalized by the alleged poor outcomes of nonoperative treatment. Methods: The aim of this prospective international multicenter cohort study (between January 2018 and March 2021) with one-year follow-up, was to report contemporary outcomes of nonoperatively treated patients with multiple rib fractures. Including 845 patients with three or more rib fractures. Primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay (HLOS), (pulmonary) complications, and quality of life. Results: Mean age was 57.7 ±17.0 years, median Injury Severity Score was 17 (13-22) and the median number of rib fractures was 6 (4-8). In-hospital mortality rate was 1.5% (n=13), 112 (13.3%) patients had pneumonia and four (0.5%) patients developed a symptomatic non-union. The median HLOS was 7 (4-13) days, and median intensive care unit length of stay was 2 (1-5) days. Mean EQ-5D-5L index value was 0.83 ±0.18 one year after trauma. Polytrauma patients had a median HLOS of 10 (6-18) days, a pneumonia rate of 17.6% (n=77) and mortality rate of 1.7% (n=7). Elderly patients (³65 years) had a median HLOS of 9 (5-15) days, a pneumonia rate of 19.7% (n=57) and mortality rate of 4.1% (n=12). Conclusions: Overall, nonoperative treatment of patients with multiple rib fractures shows low mortality and morbidity rate and good quality of life after one year. Future studies evaluating the benefit of operative stabilisation should use contemporary outcomes to establish the therapeutic margin of rib fixation.This work was financially supported by DePuy Synthes; grant number DPS-TCMF-2017-036 and registered in the Netherlands Trial Register (NTR6833).

Revolutionizing patient care: Development and external validation of the "Rotterdam hip fracture mortality prediction – 30 days" (RHMP-30) – A comprehensive multidimensional approach to prognosticating 30-day mortality in hip fracture patients

Aim: The aim of this study is to develop an accurate and clinically relevant prediction tool for 30-day mortality after hip fracture surgery. The prediction tool is based on a detailed and careful collected clinical dataset yielding nuanced insights into patient mortality rates. Patients and methods A prospective hip fracture database of two hospitals was used to obtain data between 2011 and 2021. The prediction model is developed by an adaptive Least Absolute Shrinkage and Selection Operator (LASSO) with the data of the first hospital. The cohort of the second hospital was used to validate the prediction model externally by performing a Receiver Operating Characteristics curve and a calibration plot. Results: In total, 3523 patients were analyzed of which 302 patients (8.6%) died within 30 days after surgery. The prediction model was developed based on the cohort of the first hospital. After the adaptive LASSO 7 over 26 variables were included in the prediction model: age, gender, ASA 4, dementia, albumin level, KATZ-ADL-score and living in a nursing home. The Area Under the Curve (AUC) of the prediction model in the first cohort was 0.789. The external validation of the prediction model was performed in the second hospital with an AUC of 0.775. Conclusion: The &quot;Rotterdam Hip Fracture Mortality Prediction – 30 days &quot; (RHMP-30) is developed and externally validated in two up to date, extensive hip fracture cohorts from two different hospitals. The RHMP-30 can support in clinical decision making and informed consent for the most fragile patients in the hip fracture population.No

Emergency surgery

Clinical results of the brand new compression hip screw: Oblique locking hip screw

Introduction: Proximal femoral fractures are a common clinical concern. This study delves into the efficacy of a novel implant, the Oblique Locking Hip Screw (OLHS), in the treatment of these fractures. Material &amp; Methods: Our research covers trochanteric femoral fractures managed at our institution from April 2020 to September 2022. Key variables studied include fracture fixation, patient demographics, fracture classification, reduction techniques, surgical duration, postoperative surveillance, and clinical outcomes. Results: Our dataset includes 119 trochanteric femoral fractures, with 67 treated using intramedullary nails and 52 with OLHS. A detailed comparative analysis of 51 OLHS cases, excluding one non-fragility fracture, was conducted. The patient cohort had an average age of 86.2 years, with 14 males and 37 females. Fractures were classified using the AO/OTA Classification, with 29 as 31A1 and 22 as 31A2. According to the Tang classification, 37 cases were type 1, while types 2, 3, 4, and 5 had 0, 7, 4, and 3 cases, respectively. Using the Baumgaertner criteria, 43 cases were 'good,' 6 'acceptable,' and 2 'poor.' By Chang criteria, 41 were 'excellent,' 9 'acceptable,' and 1 'poor.' Mean surgical time was 75.4 minutes, and mean follow-up was 12.3 months. Sadly, 3 deaths occurred within a month, and 2 more within 3 months post-surgery. Impressively, no implant failures or loosening were observed during follow-up. Conclusion: Our comprehensive analysis reveals the potential of the Oblique Locking Hip Screw (OLHS) in addressing unstable trochanteric femoral fractures, potentially enhancing patient care and outcomes. References:Sharon R Lewis, et al. Cochrane Database Syst Rev. 2022;1(1)no

Dr. med.

3D-navigation for SI screw fixation – How does it affect radiation exposure for patients and medical personnel?

Background: 3D-navigation for percutaneous sacroiliac (SI) screw fixation is becoming increasingly common and several studies report great advantages of this technology. However, there is still limited clinical evidence on the efficacy regarding radiation exposure for patient and personnel. Methods: This is a retrospective, single-center cohort study. All patients who underwent percutaneous sacroiliac screw fixation for an injury of the posterior pelvic ring from 2014 to 2021 were screened. Inclusion criteria were: conclusive radiation dosage reports, signed informed consent, a twelve month follow up and a complete data set. Patients were stratified in two groups (3D-navigation (Group 3D-N) vs. control (Group F)) based on the imaging modality used. Primary outcomes were radiation exposure for patient and personnel. Secondary outcomes were reoperations, complications, and intraoperative precision. Results: Of 392 patients screened, 174 patients (3D-N: n=50, F: n=124) could be included for final analysis. We noted a significant reduction of the dose corresponding to potential radiation exposure for medical personnel (-15.3 mGy, 95%CI: -2.1 to -28.5, p = 0.0232), but also a significant increase of the dose quantifying radiation exposure for patients (+77.0 mGy, 95%CI: +53.3 to +100.6, p &lt; 0.0001), when using navigation. In addition, the rate of radiographic malplacement was significantly reduced (F: 11.3% vs. 3D-N: 0%, p = 0.0113) despite a substantial increase in transsacral screw placement (F: 19.4% vs. 3D-N: 76%). Conclusion: Our data clearly suggests that the use of 3D-navigation for percutaneous SI screw fixation decreases radiation exposure for medical personnel, while increasing radiation exposure for patients. Furthermore, intraoperative precision is improved, even in more challenging operations.No

Changes in stiffness of the extracellular and pericellular matrix in the anulus fibrosus of lumbar intervertebral discs over the course of intervertebral disc disease

Introduction Analogous to articular cartilage, changes in spatial chondrocyte organisation have been proposed to be a strong indicator for local tissue degeneration and destruction in the intervertebral disc (IVD). While a progressive structural and functional degradation of the extracellular (ECM) and pericellular (PCM) matrix occurs in osteoarthritic cartilage, these processes have not yet been biomechanically elucidated in the IVD. Objectives We aimed to evaluate the local stiffness of the ECM and PCM in the anulus fibrosus of the IVD on the basis of local cellular spatial organisation. Materials &amp; Methods Using atomic force microscopy, we measured the Young's modulus of the local ECM and PCM in human and bovine disc samples using the spatial chondrocyte patterns as an image-based biomarker. Results By measuring tissue from 31 patients and six bovine samples, we found a significant difference in the elastic moduli (E) of the PCM in clusters when compared to the healthy patterns single cells (p=0.029), pairs (p=0.016), and string-formations (p=0.010). The ECM/PCM ratio ranged from 0.62-0.89. Interestingly, in the bovine IVD, the ECM/PCM ratio of the E significantly varied (p=0.002) depending on the tissue origin. Overall the reduced E in clusters demonstrates that cluster formation is not only a morphological phenomenon describing disc degeneration, but it marks a compromised biomechanical functioning. Conclusion This study is the first to describe and quantify the differences in the E of the ECM in relation to the PCM in the anulus fibrosus of the IVD by means of atomic force microscopy on the basis of spatial chondrocyte organisation. Advanced disc degeneration is accompanied by a biomechanically compromised tissue functioning.No

Education

Ass. Prof.

Type C ankle fractures with additional medium-sized posterior malleolus fragment: Radiological and functional results of osseous reconstruction of the syndesmosis

Introduction Standard treatment of type C ankle fractures with an additional posterior fragment (PF) consists of closed reduction and stabilisation using syndesmotic positioning screws. Biomechanical studies show that in case of a PF the posterior ligaments (PITFL) are always intact, and therefore stability can be obtained by fixation of only the PF. However, to date there are no published in-vivo studies supporting this hypothesis. Methods Multicenter prospective cohort study. Patients presenting between 2015 and 2020 with type C fractures with additional PF (5-25% of the joint surface) were approached for inclusion. Patients operated in center 1 are treated according to protocol 1 (placement of syndesmotic screws alone). Patients operated in center 2 are treated according to protocol 2 (open reduction and internal fixation of the PF using the posterolateral approach). Concomitant fractured medial and lateral malleoli are treated according to AO-principles. Pre- and post-operative radiographs and CT-scans were obtained for radiological outcome and validated questionnaires for functional outcome. Functional outcomes were assessed at 1Y using the VAS-pain (0-100), AAOS and Olerud and Molander (OMAS) questionnaires. Results 9 patients were included in group 1 and 17 in group 2. Medial fractures were more common in group 1 (table 1). PF size was 15% vs 20%. No additional positioning screws were placed in group 2. Compared to the uninjured side on bilateral CT-scan, the fibula was malpositioned in the incisura in 22% vs 12%. Radiological outcome: medial clearspace 3.7 vs 3.4 mm, superior clearspace 3.2 vs 3.5 mm, step-off 2.7 vs 0.8 mm. Functional outcomes after 1Y were: VAS 28 vs 18, AAOS 83 vs 89, OMAS 63 vs 80 (table 2). Development of osteoarthritis and complications were similar after 1Y. Conclusion Fixation of the PF in type C ankle fractures with additional PF is an effective way to obtain syndesmotic reduction without using positioning screws.no

The treatment of very large traumatic bone defects with a poly-ε-caprolactone β-tricalcium phosphate 3D printed cage. A review of six cases

Background In large traumatic bone defects, the need for an artificial scaffold is clear. Strategies such as vascularized grafts or bone transport have high complication rates. Other autografts, like Reamer Irrigator Aspirator (RIA) derived cancellous bone do not provide sufficient material or graft retention. Although multiple treatment options are available, amputation in segmental defects of ≥ 10 centimeters is still often performed. Especially when an infection is present. The use of custom biodegradable osteoconductive scaffolds can be a valuable option in these defects. We present six (infected) long bone nonunion with a segmental defect of ≥10cm treated with a 3D printed poly-ε-caprolactone β-tricalcium phosphate (PCL-TCP) cage in combination the Induced membrane technique (IMT). Cases Six patients, between the age of 23 and 64, were treated for a tibial or femoral defect nonunion after sustaining Gustilo grade 3 open fractures. All had a segmental bone defect of ≥ ten centimeters (11-15cm). First stage IMT consisted of extensive debridement, fixation and placement of anterior lateral thigh flaps (ALT). Bacterial cultures were positive in all patients but one and treated with specific systemic antibiotics for 12 weeks. The PCL-TCP cage (Osteopore, Singapore) was designed based on the CT scan obtained after the first stage IMT. In the second procedure, on average two months after the first, the cage was placed in the defect in combination with biological adjuncts (BMAC, RIA derived autograft, iFactor and BioActive Glass). SPECT and radiographs after 6 months showed bridging of the defect and active bone regeneration. All six patients regained function and reported less pain. Conclusion This case report shows that 3D printed PCL-TCP cages in combination with biological adjuncts is a novel addition to the treatment of very large bone defects in (infected) nonunion. This combination could overcome some of the current drawbacks in this challenging indication.No

The induced membrane technique improves the health-related quality of life in patients with a post-traumatic long bone non-union

Introduction: The optimal treatment strategy for post-traumatic long bone non-unions is subject of an ongoing discussion. At the Maastricht University Medical Center (MUMC+) the induced membrane technique is used to treat post-traumatic long bone non-unions. This technique uses a multimodal treatment algorithm involving bone marrow aspirate concentrate (BMAC), the reamer-irrigator-aspirator (RIA) and P-15 bioactive peptide (iFactor, Cerapedics). When infection is suspected, bioactive glass (S53P4 BAG, Bonalive) is added. This study aims to objectify the effect of this treatment algorithm on the health-related quality of life (HRQoL) of patients with post-traumatic long bone non-unions. We hypothesized that HRQoL would improve after treatment. Methods: From January 2020 to March 2023, MUMC+ evaluated patients with post-traumatic long bone non-unions using the Non-union severity score (NUSS). The EuroQol-5D-5L and Lower Extremity Functional Score (LEFS) were used to measure HRQoL before and after surgery, with follow-ups at 6, 18, and 35 weeks. Results: At baseline (T0), 76 patients had a mean NUSS of 40 (±13 SD). Thirty-eight had their first follow-up at 6 weeks (T1), 31 at 18 weeks (T2), and 20 at 35 weeks (T3). The EQ-5D index mean increased from 0.480 at T0 to 0.618 (T1), 0.636 (T2), and 0.702 (T3). HRQoL showed a significant difference between T0 and T1, as well as T2 and T3 (p&lt;0.001; p=0.011). The LEFS improved from 26 pre-intervention to 34, 39, and 43 after treatment (p&lt;0.001; p=0.033; p=0.016). Conclusion: This study demonstrated significant improvement in the health-related quality of life of patients with post-traumatic long bone non-unions after the multimodal treatment following the induced membrane technique. Brinker MR. et al., Debilitating Effects of Femoral Nonunion on Health-Related Quality of Life. Journal of Orthopaedic Trauma. 2017;31(2):e37-e42. Masquelet, A. Induced Membrane TechniquePearls and Pitfalls.Journal of Orthopaedic Trauma, 2017.The Maastricht Universiteit Medisch Centrum has a consortium agreement with Cerapedics and Osteopore.

Oral abstract session 2

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