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24th European Congress of Trauma & Emergency Surgery 

Prof.

Goals of care in geriatric lower extremity fracture patients and their proxies: A longitudinal prospective survey study

Trauma and Emergency surgery | Miscellaneous

Skeletal trauma and sports medicine

IntroductionThe primary objective of this study was to explore which Goals of Care are most important to geriatric lower extremity fracture patients.MethodsA multicenter cross-sectional study was performed between October 2024 and February 2025 at two level 1 trauma centers where all patients aged 65 years or above who will undergo or have undergone surgery for a lower extremity fracture (pilon, tibial shaft, tibia plateau, or femur) and their proxies were included. Both patients and proxies were asked independently to rank seven Goals of Care at two different points in time: perioperatively and during outpatient follow-up. In addition to ranking these Goals of Care, patients and proxies were instructed to allocate a total of 35 points across the domains to indicate the relative importance of each goal, providing both a ranking and a weighting. For each Goal of Care, a baseline assessment was conducted using specific questions within the survey. To evaluate cognitive status, a Mini-Cog test was administered prior to the interview. Patients with mild cognitive impairment were included in the survey, while for those with severe cognitive impairment, only proxies participated.ResultsCategorical data were presented as frequencies with percentages and continuous data were represented as means with standard deviation or medians with interquartile ranges, depending on data distribution based on visual inspection of histograms. Goals of Care were ranked on medians, and ranking of these Goals of Care was tested using chi-square tests. Differences between patient"s and proxies ranking was tested using Whitney U tests, and the change of ranking over time will be tested using Wilcoxon signed rank tests.ConclusionThis study aids physicians in identifying the most important Goals of Care for geriatric lower extremity fracture patients and their proxies. It also highlights the importance of recognizing differences between patients' and proxies' rankings of these goals.No

Oral presentation

Is lower socioeconomic status related to increased frailty in geriatric hip fracture patients?

IntroductionThe primary objective of this study was to explore whether lower socioeconomic status is related to increased frailty in geriatric hip fracture patients. Secondary objectives included exploring whether lower socioeconomic status is related to increased one-year mortality in geriatric hip fracture patients and whether the effect of frailty on one-year mortality changes based on socioeconomic status.MethodsA multicenter retrospective cohort study was performed at two level 1 trauma centers, where patients aged 70 years or above who sustained a hip fracture between January 2014 and December 2021 were included. Baseline variables, level of frailty, socioeconomic status, and clinical outcomes were collected from the electronic patient file. Frailty was defined using a Frailty Index based on the Comprehensive Geriatric Assessment. Socioeconomic status was measured by the Area Deprivation Index. Data on mortality was extracted from the National Death Index.ResultsCategorical data were presented as frequencies with percentages and continuous data were represented as means with standard deviation or medians with interquartile ranges, depending on data distribution based on visual inspection of histograms. The association between lower socioeconomic status and increased frailty was assessed using Spearman rank correlation. Logistic regression analysis was used to assess whether lower socioeconomic status is related to increased one-year mortality in geriatric hip fracture patients. Multiple logistic regression analysis was used to assess whether there is an interaction between frailty and socioeconomic status on one-year mortality rates in hip fracture patients.ConclusionThis study allows healthcare providers and policy makers to better understand the etiology of frailty. Furthermore, it might provide opportunities for interventions, e.g. social support structures.No

Quick shot presentation

PD Dr. med.

Univ. Prof. Dr. med.

Prof. Dr.

Prof. Dr. med.

Surgical treatment variation of displaced femoral neck fractures in certified “centres for geriatric trauma” and arthroplasty centers in Germany

Research

There is a special certification structure in Germany in which clinics can be certified either as TraumaZentrum DGU®, AltersTraumaZentrum DGU® or arthroplasty center, among others. Geriatric patients with displaced femoral neck fractures represent a highly relevant entity for trauma centers, whose structural and process quality can be validated within the framework of certification as both an AltrsTraumaZentrum DGU® (ATZ) and endoprosthetic center (EPZ).Objective: Is there a treatment variation between certified geriatric trauma centers and dual certified geriatric and arthroplasty centers?Material&Methods: Data from the ATR-DGU were analyzed from 46 clinics with ATZ and 52 clinics with ATZ+EPZ. The follow-up period included both the in-hospital stay and a 120-day interval. The primary outcome was mortality, secondary endpoints included mobility, reoperations and health status. Univariate and multivariate analyzes were performed to calculate odds ratios (ORs) after adjustment for age, gender, ASA score and concomitant injuries.The median age of the collective was 84 years, 29.6% and 29.8% were male, the median time until surgery was 20.9 hours (ATZ) vs. 20.5 hours (ATZ+EPZ). The rate of internal fixation was significantly increased in ATZs compared to clinics with dual certification (ATZ: 8.6% vs. ATZ+EPZ: 2.6%; OR=3.63). The re-operation rate was comparable in the primary stay (3.7% vs. 3.9%). Revisions due to periprosthetic fractures occurred more frequently in ATZs (8.2% vs. 3.5%). The multivariate analysis showed an increased mortality in the acute phase (OR 1.26; 1.02-1.56; p=0.031), an increased rate of re-operations in the 120-day course (OR 1.45; 1.06-2.02; p=0.024) and inpatient readmissions (OR 1.42, 1.02-2.00; p=0.043).Conclusion: In Germany, an institutional treatment variation for geriatric displaced femoral neck fractures exists. In certified geriatric trauma centers without certified arthroplasty center, there is a significantly increased rate of internal fixation with effects in terms of morbidity and mortality in the acute phase.None

Long-term outcome after middle third fractures of the femur shaft: A comparison between antegrade and retrograde nailing

Polytrauma

Introduction: The aim of this study was to compare patient reported functional outcome, range of motion and radiological amount of malalignment, between antegrade and retrograde nailing in patients with true midshaft fractures of the femur (middle third of AO/OTA type 32 fractures). Materials and Methods: A retrospective study of adult patients with an acute true midshaft femoral fracture treated from January 1, 2001 to May 1, 2016 was conducted. Patients were asked to visit the outpatient clinic once to complete four questionnaires. In addition, patients underwent physical examination to measure length and rotation of both legs and range of motion of both hips and knees. The final position of union was assessed on the last postoperative radiograph available. Results: A total of 162 consecutive patients with 173 midshaft femoral fractures were included. The median follow up time was 8.2 years. Altogether 52 patients completed full follow up and another eleven patients only completed the questionnaires. Rotational malalignment measured with a 90° flexed hip was observed in four of the 52 (8%) patients; with an extended hip rotational malalignment >15° was measured in three of the 52 (6%) patients. The flexion-extension range of the knee in the antegrade nail group was somewhat larger than in the retrograde group (130º vs 125º); p=0.019. Patients treated with an antegrade nail showed a statistically significant better LKS (83 points (P25-P75 68-95) versus 61 points (P25-P75 48-84); p=0.041) and function index of the SMFA (13 points (P25-P75 5-23) versus 29 points (P25-P75 9-43); p=0.026) than patients with a retrograde nail. Conclusion: Antegrade nailing in patients with middle third fractures of the femoral shaft results in a better range of knee motion, less discomfort on the LKS, and higher function index of the SMFA than achieved after retrograde intramedullary nailing. No

PD Dr. med. univ.

PD Dr.

Refixation of solid avulsion fractures of the posterior cruciate ligament with headless compression screws – A biomechanical investigation

Introduction: Avulsion fractures of the posterior cruciate ligament (PCL) are commonly treated with various refixation methods, including open refixation and arthroscopic techniques. Headless compression screws (HCS) reduce material irritation and include absorbable options like magnesium. This study aimed to compare the biomechanical properties of conventional screw fixation with both titanium and magnesium HCS. We hypothesized that (1) HCS demonstrate biomechanical properties comparable to conventional fixation and (2) absorbable magnesium HCS offer similar primary stability to titanium HCS.Material and Methods: Forty fresh frozen porcine knee joints, with intact menisci and ligaments were used. A PCL avulsion fracture (15x10x20mm) was created. Four groups (n=10) were assigned: Group 1 (native), Group 2 (Ti-CS; 2 3.5x30mm small fragment screws + washer), Group 3 (Ti-HCS; Synthes HCS 2 3.5x30mm titanium), and Group 4 (Mg-HCS; Medical Magnesium 2 3.5x30mm magnesium). Potting femur and tibia in polymethymethacrylate, a simulated posterior drawer test was performed with a uniaxial testing machine. 500 cycles with 10-100N at 200mm/min followed by Load to Failure (LTF) were performed. Stiffness, yield load, LTF, and displacement were measured. Statistical analysis used one-way ANOVA with post hoc correction (p<.05).Results: LTF for the intact PCL (1982.0±285.4N) was significantly higher than for refixations: Ti-CS (1034.8±236.1N), Ti-HCS (693.9±220.5N), and Mg-HCS (686.7±174.6 N). No significant differences in cyclic displacement or yield load were observed among groups. The stiffness values were also similar across fixation methods, all below that of an intact PCL. No failure of the implants itself was shown.Conclusions: Current refixation techniques for PCL avulsion fractures do not fully restore biomechanical properties of the intact PCL. HCS provides a viable alternative to conventional refixation, with magnesium HCS showing comparable properties to titanium HCS.The Magnesiusm HCS were provided by Medical Magnesium

Plate augmented posteroanterior screw fixation is mandatory in comminuted Letenneur type II Hoffa fractures – A biomechanical study

Introduction: Recommendations regarding fixation of comminuted coronal plane fractures of the posterior femoral condyles (Hoffa fractures) are lacking. The aim of this study was to compare the biomechanical properties of different plate-augmented constructs and stand-alone posteroanterior screw fixation in comminuted lateral Hoffa fractures.Material and methods: Comminuted Letenneur type II lateral Hoffa fractures were simulated in 24 human cadaveric distal femora. The fractures were fixed either with isolated crossed posteroanterior screws (PA screws) or additionally with either a posterior buttress plate (PA screws + buttress plate), lateral locking plate (PA screws + lateral plate) or combined posterior buttress and lateral locking plate (PA screws + double plate). All specimens were biomechanically tested under progressively increasing cyclic loading until failure, while capturing the interfragmentary movements with motion tracking.Results: Plate-augmented posteroanterior screw fixation of Letenneur type IIb fragments exhibited higher cycles to failure and failure loads (p<0.05) and less axial displacements after 5000 cycles (p<0.05) compared to isolated PA screw fixation. For the intercalary fragment, additional lateral locking and double plate fixation provided higher cycles to failure and failure loads (p<0.05) and less axial displacement from 4000 cycles onwards (p<0.05) compared to isolated PA screw fixation, whereas additional posterior buttress plate did not significantly improve cycles to failure, failure loads and axial displacement (n.s.).Conclusions: Plate-augmented posteroanterior screw fixation of comminuted Letenneur type II Hoffa fractures provided greater biomechanical stability than isolated posteroanterior screw fixation. While additional lateral or double plate fixation improves the stability of both the intercalary and Hoffa fragment, buttress plating stabilized only the Hoffa fragment.No

Three-dimensional surgical planning including patient-specific drilling guides for tibial plateau fractures: A prospective feasibility study

Background: Proper preoperative planning benefits fracture reduction, fixation and stability in tibial plateau fracture surgery. We developed and clinically implemented a novel workflow for 3D surgical planning including patient-specific drilling guides in tibial plateau fracture surgery.Methods: A prospective feasibility study was performed in which consecutive tibial plateau fracture patients were treated with 3D surgical planning including patient-specific drilling guides applied to standard off the shelf plates. A postoperative CT-scan was obtained to assess whether the screw directions, screw lengths, and plate position were performed according the preoperative planning. Quality of the fracture reduction was assessed by measuring residual intra-articular incongruence (maximum gap and step-off) and was compared to a historical matched control group.Results: A total of 15 patients were treated with 3D surgical planning in which 83 screws were placed by using drilling guides. The median deviation of the achieved screw trajectory from the planned trajectory was 3.4° (interquartile range[IQR]:2.5-5.4) and the difference in entry points (i.e. plate position) was 3.0 mm (IQR:2.0-5.5) as compared to the 3D preoperative planning. The length of 72(86.7%) screws were according to the planning. As compared to the historical cohort, 3D guided surgery showed an improved surgical reduction in terms of median gap(3.1 vs. 4.7 mm; p=0.13) and step-off(2.9 vs. 4.0 mm; p=0.03).Conclusion: The use of 3D surgical planning including drilling guides was feasible and facilitates accurate screw directions, screw lengths and plate positioning. Moreover, the personalized approach improved fracture reduction as compared to a historical cohort.No disclosures

Dr. med.

Dr. Ing.

Treatment of delayed unions and nonunions following tibial shaft fractures: Which factors really matter?

Introduction The aim of this study was to investigate risk factors of delayed union or nonunion of tibial shaft after fractures and its impact on the success rate their treatment. Material & Methods This retrospective cohort study included adult patients treated for a delayed union or nonunion following fracture of the tibial shaft at one academic Level 1 trauma center from 2012-2022. The primary outcome of the study was recalcitrant nonunion after 6 months following primary nonunion treatment; the secondary outcome was time to radiological union following primary treatment of impaired bone healing. Non-parametrical tests were implemented for comparisons between groups. Binomial logistic regression analysis was implemented to determine the risk factors that independently influenced treatment success. Results Overall, 59 patients (49 male; 25 delayed unions, 34 nonunion), with a median age of 38 years and a median ASA score I, were included. According to the AO/OTA classification, fracture types C3 (21 patients) and A3 (10 patients) were most common, of which 34 were open fractures. The union rate following primary nonunion treatment was 79.7% with a median time to union of 272 days. 12 recalcitrant nonunions were detected. The number of operative revisions (p=0.02) and the time interval (days) from primary fracture treatment till nonunion treatment (p=0.04) were independent risk factors for recalcitrant nonunion. The union rate was independent of age, gender, ASA score and total volume of bone defect. Conclusions Amount of surgeries and time delay till surgical revision treatment of delayed union/nonunion following tibial shaft fracture seem to negatively impact union rates. This underlines the importance of timely diagnosis and treatment of impaired bone healing following tibial shaft fractures.No.

Innovations in primary transtibial amputation

IntroductionSoft tissue coverage is often a limiting factor in prosthetic rehabilitation following transtibial amputation. Surgical techniques such as myodesis, myoplasty, and myopexies aim to refix muscles in the residual limb (RL), providing cushioning for the distal bone and muscular guidance. Rupture or dislocation of muscle transpositions can lead to inadequate soft tissue coverage, ulcerations, pain and biomechanical limitations.Material & MethodsThe Agonist-Antagonist Myoneural Interface (AMI) represents a novel surgical approach that connects agonist and antagonist muscles through a tenorrhaphy. Perioperative data, modifications of the surgical technique, complication rates, longitudinal RL volume changes, walking ability, balance, amputation-related pain, and embodiment were analyzed.ResultsOver a 24-month follow-up, 20 patients underwent a primary transtibial amputation utilizing AMIs. Of these, 14 were unilateral and 6 bilateral. 70% of the AMI-candidates lost their lower leg due to acute trauma (n=6), sepsis (n=5) or late failure of limb salvage (n=4). Complications included two early and one late infection requiring resection of AMIs. RL volume analysis showed a consistent increase at six of seven measurement points. Only 15% reported life-altering amputation-related pain.ConclusionsAMIs were successfully used across various indications during primary amputations, with no documented dislocations as experienced after standard myoplasty or myodesis. Muscle functionality was reliably preserved in all patients, resulting in palpable contractions at the RL. RL volume reductions remained <10%, compared to 17-35% observed after standard amputations at 100 days follow-up. Incidence of amputation related pain was lower than after standard amputation. Object of future investigations remains the agonist-antagonist relationship and whether preserving proprioceptive structures enhances motor control and ambulation capabilities of the RL and prosthesis.No

Split pectoralis major transfer for winging scapula

Introduction: Serratus anterior dysfunction can cause abnormal scapular movement and winging, often associated with trapezius palsy. This condition is typically due to thoracic nerve injury from violent upper-limb stretching, leading to scapular winging, pain, and shoulder dysfunction.Objectives: The primary objective of this study was to evaluate the outcomes of split pectoralis major transfer in 26 shoulders after one year of conservative treatment. Additionally, the study aimed to explore the modification of scapular insertion in cases with trapezius palsy.Material and Methods: Twenty-two patients (26 shoulders) underwent split pectoralis major transfer, some with a gracilis graft. In 8 cases with trapezius palsy, the transfer was modified to fix the pectoralis 5 cm cranially on the medial scapular blade. Patients were followed for a minimum of 24 months.Results: The dynamic muscle transfer, including split pectoralis major transfer, demonstrated significantly improved outcomes compared to static procedures. Patients experienced notable improvements in mean shoulder function (52.5-63.5), forward elevation (157.1-165.4), and pain (visual scale 4.8-3.0). Two complications of scapular detachment occurred, one traumatic and one spontaneous.Conclusions: The split pectoralis major transfer has emerged as a highly effective treatment for prolonged scapular winging. The modified cranial fixation technique, which has shown remarkable success as an alternative to the Eden-Lange procedure, particularly in cases with both serratus anterior and trapezius palsy, instills confidence in the efficacy of these procedures.ReferencesBurkhart, S. S., Morgan, C. D., & Kibler, W. B. (2003). The disabled throwing shoulder: spectrum of pathology part I: pathoanatomy and biomechanics. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 19(4), 404-420.No

Oral session 2
Skeletal trauma I

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Oral session 2Skeletal trauma I

Appointment

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Topic

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Oral session 2
Skeletal trauma I