Session 4: Trauma 1

Torsdag den 24. oktober
09:00 – 10:30
lokale: Helsinki/Oslo
Chairmen: Lonnie Froberg / Frank Damborg

31. Does choice of treatment of midshaft clavicle fractures affect early return to work?
Ban Ilija , Gromov Kirill, Troelsen Anders
Orthopaedic Surgery, Copenhagen University Hospital Hvidovre

Background: Optimal treatment of displaced midshaft clavicle fractures is debatable. Most patients suffering a displaced midshaft fracture are young males with a high physical demand including a demand of early return to work. Whether choice of primary treatment affects the ability to return early to work is unknown. Primary surgical treatment has become popular and the potential of early return to work has been used as an argument to favour surgical treatment.
Purpose / Aim of Study: To investigate whether choice of primary treatment, operative or conservative, of acute, displaced, midshaft clavicle fractures affect early return to work.
Materials and Methods: This study presents secondary endpoints from a randomised controlled trial where surgical treatment with a superior locking plate is compared to non-surgical treatment with one-year follow-up. Early return to work is defined as return to pre-fracture work status at the six-week follow-up.
Findings / Results: A total of 63 patients (57 males) were enrolled in the study (median age 38 years, range: 19-63). 35 patients were allocated to non-surgical treatment and 28 patients were treated surgically. The two groups were comparable with respect to age, sex and ASA score (p- values: 0.31, 0.57 and 0.90). At time of enrolment a total of 58 of 63 patients were working. At 6-weeks follow-up 22 of 31 patients treated conservatively and 25 of 27 patients treated surgically had returned to their pre-fracture work status (p=0.03).
Conclusions: Choice of operative primary treatment of acute, displaced, midshaft clavicle fractures does seem to be associated with a higher frequency of early return to work. However, multiple other factors and longer term outcome should be considered in the choice of treatment.

32. Feasibility of implant-tracking in orthopaedic surgery: High completeness and minimal time consumption.
Heidi Poulsen, Kirill Gromov, Peter Gebuhr, Anders Troelsen
Orthopedics, Hvidovre Hospital; Orthopedic, Hvidovre Hospital

Background: Currently no methods for tracking of implants, allowing intelligent monitoring of quality, exist. At present surgeons and administrators rely on implant labels in patient charts. In this study we introduce an online implant tracking system to be used with existing quality monitoring databases
Purpose / Aim of Study: We evaluate the introduction of an implant tracking system using unique implant barcodes, and evaluate the potential for continuous implant tracking and time consumption associated with this process
Materials and Methods: An implant tracking system was developed by Procordo Aps® and implemented as an addition to the Danish Fracture Database (DFDB). Orthopaedic implants used during surgery are scanned in the operating room (OR) using unique implant barcodes and are linked to the specific procedure enter into DFDB by the operating surgeon. We evaluated completeness of implant scans during a one-month period at two ORs at our institution. We also measured time consumption for experienced and untrained OR staff while scanning trauma and arthroplasty implants
Findings / Results: A total of 21 separately packed implants were used during the study period at the two OR’s combined. 20 of these implants were successfully scanned (95%) and 18 were linked correctly to the surgical procedure (86%). When scanning implants for revision THR surgery and trochanteric nail surgery untrained OR staff used on average 208 and 117 seconds, respectively. This was significantly reduced (p<0.05) to 55 and 35 seconds respectively in the hands of an experienced OR nurse
Conclusions: It was possible to introduce specific implant tracking of orthopaedic implants at two operating rooms in one orthopaedic department, with 95% of possible implants being scanned shortly after introduction of the system. Time consumption performing these scans by the OR staff was minimal

33. Virtual-reality simulation for the assessment of skills in hip fracture surgery
Poul Pedersen, Henrik Palm, Lars Konge
Centre for Clinical Education, Rigshospitalet, University and State hospital of Denmark; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Denmark

Background: Unsupervised junior surgeons have been shown to be a risk factor for reoperations among hip fracture patients. The need for improved education is increasingly acknowledged, and virtual-reality simulation- based surgical training might improve initial skills. A reliable simulation test would make it possible to assess and certify junior surgeons before proceeding to supervised practice on patients.
Purpose / Aim of Study: The aim of the study was to develop a reliable simulation-based test for internal fixation of hip fractures.
Materials and Methods: Twenty physicians from one orthopaedic department were divided into two groups of ten untrained novices and ten experienced orthopaedic surgeons. Each physician was tested on three procedures regarding internal fixation of an undisplaced femoral neck fracture: Two screws, two hookpins and a sliding hip screw. Simulator metrics with discriminatory abilities were identified, including a combined score for implant position, use of image intensifier etc. By using the contrasting groups method a pass/fail-level was determined and its consequences explored.
Findings / Results: The percentage of maximum combined score (PM-score) was the only simulator metric that showed significant differences between the two groups. The PM-score showed an inter-case reliability of 0.83 between the three procedures. The mean PM-score was 31% (SD 32) for the novices and 76% (SD 10) for the experienced surgeons (p<0.001). The tests pass/fail- level was a PM-score at 58%, resulting in none of the novices passing the test and a single experienced surgeon failing the test.
Conclusions: It was possible to create a reliable test on the simulator. The test and the pass/fail-level could help assess and guarantee the quality of future junior surgeons in simulation-based training programs before proceeding to supervised practice on patients.

34. Breakage at the proximal screw in long Gamma 3 titanium intramedullary femoral nail
Nikolaj Sode, Lonnie Froberg, Michael Brix
Department of Orthopedics, Odense University Hospital, Denmark

Background: Internal fixation with a long anterograde intramedullary femoral nail is a well established surgical technique for unstable intertrochanteric and subtrochanteric fractures of the femur. The nail is designed to be walked upon for at least 6 months before breakage. However; it is known that titanium loose up to 50% strength if scratches occurs during insertion of the K- wire or the collum screw.
Purpose / Aim of Study: We report a series of 8 patients osteosynthesised using long Gamma 3 titanium nails which all failed with breakage in the proximal cervical screw opening. Furthermore, 4 of these patients had a similar failure of the secondary nail after reoperation, for a total of 12 broken nails.
Materials and Methods: The study is a retrospective case series of patients treated for unstable intertrochanteric or subtrochanteric fractures with the long Gamma 3 titanium nail in the Southern Region of Denmark, from december 2010 to june 2012. Information was gathered through medical records and x-rays.
Findings / Results: The study included 8 patients, 4 female and 4 males representing 6 AO 31A3 fractures and 2 31A2 fractures. The median age was 68 years (35-90 years) and median BMI 25 (21-38). Median time to failure was 4 months (2-18 months) and median time to follow up 22,5 months (13-27 months). All nails were 11 mm in diameter. 5 patients had additional cables around the femoral bone. Post operative tip-apex distance was <25 mm in all cases. One patient had jamming of the collum screw.
Conclusions: We experienced an unexpected high number of nail breakage. We recommend careful insertion of the collum screw to avoid damage and thereby reducing tre strength of the nail.

35. Anamnestic medicine errors among hip fracture patients can be reduced by a pharmacist / pharmaconomist
Morten B. Andersen, Sanne H. Johansen , Marianne K. Jensen, Lise J. Nørregaard , Susanne D. Olsson, Henrik Palm
Department of Orthopaedic Surgery and The Hospital Pharmacy, Copenhagen University Hospital Hvidovre, Denmark; The Hospital Pharmacy, Copenhagen University Hospital Hvidovre, Denmark; Department of Orthopaedic Surgery , Copenhagen University Hospital Hvidovre, Denmark

Background: Hip fracture patients often have severe co-morbidity and use multiple types of medicine. Studies have shown that medicine anamnesis is often inadequately recorded on admission with risk of discrepancies and complications.
Purpose / Aim of Study: The purpose was to compare the medicine anamnesis recorded among hip fracture patients as usual in the emergency room (ER) with a secondary recording in the orthopedic department by a pharmacist / pharmaconomist.
Materials and Methods: 200 consecutive hip fracture patients (78% female, mean age 79 (range 22- 97)) admitted through the ER from Sept 2012 to March 2013 were included. The electronic ER medicine anamnesis was corrected within 48 hours in the orthopedic department by a pharmacist / pharmaconomist using min. 3 of following sources: Patient, patient record, national medicine database (PEM/ FMK-online), pharmacy, general practitioner and lists from relatives, visiting nurses or home care services. Only corrections accepted by medical doctors were recorded as errors.
Findings / Results: On average, each patient used 6 different drugs with 2 errors recorded. The total 413 errors was distributed as 209 (51%) drug omissions, 67 (16%) false prescribing, 64 (15%) false doses, 61 (15%) clinically relevant improper dosing time and 12 (3%) other errors. Most often errors were seen among ATC groups: nervous system (N), alimentary tract and metabolism (A), cardiovascular system (C), blood and blood forming organs (B) and respiratory system (R).
Conclusions: This study confirms that medicine anamneses among hip fracture patients are inadequately recorded on admission, where the available time and sources for information are suboptimal in the nowadays Danish health system. Secondary medicine anamneses by a pharmacist / pharmaconomist can in our eyes reduce the incidence of medicine errors and improve patient safety.

36. Ilizarov salvage procedure following failed osteosynthesis of the patella.
Tine Nymark, Lars Schjøtz, Ole Skov
Orthopedic, Odense University Hospital

Background: Patella fracture comprises approx 1% of all skeletal fractures. Failure of osteosynthesis of the patella fracture is rare, but can result in disrupted extensor mechanism, deep infection of the knee and soft tissue defects. Patellectomy, partial or complete, knee arthrodesis or femoral amputation has been described as treatment
Purpose / Aim of Study: We wanted to improve the treatment of failed osteosynthesis of the patella without compromising the knee joint.
Materials and Methods: From 2001-now 6 patients, mean age 68 years (range 49-77 years) with deep infection of the knee and failed osteosynthesis of the patella transferred to out unit 47 days (15-111 days) after primary operation. They had recieved 2 to 5 surgical revisions. We performed debridement, total synovectomia of the knee, revised the fracture and then stabilised the fracture using the Ilizarov technique, with two K- wires perpendicular to the major fracture plane mounted in two half-rings. In one case a gastrocnemius flap was used to cover an extensive tissue defect. Patients were allowed immediate weight-bearing. The knee was immobilised for two weeks, then allowed 0-30 degrees in week 3 and 4, 0-60 degrees in week 5 and 6.
Findings / Results: The Ilizarov was removed after 60 days (38- 103). At the end of follow-up, 218 days (134- 347) patients could extend between 0-5 degrees and bend the knee between 90-110 degree.
Conclusions: Using the Ilizarov technique proved effective in the treatment of these patients. However since the condition is rare, the treatment should be centralised to departments with expertice in treating such conditions as well as the possible need for plastic surgery.

37. Healing and morbidity in femoral and tibial non-unions when using reamer-irrigator-aspirator system
Søren Kjær Petersen, Morten Schultz Larsen
Orthopedic Surgery, medical student, University of Southern Denmark; Orthopedic Surgery, Odense University Hospital

Background: Non-unions often needs autologous bone grafts as part of treatment. This is traditionally harvested from the iliac crest(ICBG). Limited graft volume and donor site morbidity are drawbacks to this method. With RIA it is possible to harvest larger amount of graft material and only few complications are described.
Purpose / Aim of Study: The purpose of this survey is to evaluate bone healing and donor site morbidity for RIA and ICBG.
Materials and Methods: 21 consecutive patients were treated with RIA in the period of 05.10.2010-21.10.2012. 25 patients treated with ICBG were chosen as controls and matched among other due to age, gender and location of non-union. X- rays and reports were retrospectively studied with respect to healing and complications. Crude assessment of the needed amount of graft material was based on preoperative x-rays. Donor site pain was evaluated through telephonic interview.
Findings / Results: 8 of 9 femoral non-unions treated with RIA achieved union while 6 of 6 treated with ICBG. On tibia 10 of 11 in the RIA group achieved union while 18 of 19 in the ICBG group. There were no significant difference in healing between RIA and ICBG. In 16 of 21 RIA patients graft material exceeding assessable volume compared to anterior ICBG. Based on telephone interview ICBG showed a tendency to have more donor site pan 3 days and one month postoperative, but the difference was not significant. One adverse event is reported. One patient got a diaphyseal, femoral fissure during gait that required intramedullary nailing.
Conclusions: This retrospective survey has shown no difference in union rates using RIA and ICBG in treating lower extremity non-unions. Patients treated with RIA experience less pain compared to IBCG. Besides larger amounts of graft material can be harvested from the femur using RIA, though severe complications can occur.

38. Preoperative CT scan of tibial diaphyseal fractures distal to the isthmus influences treatment.
Paulius Nekrasas, Juozas Petruskevicius, Søren Kold
Orthopaedic, Aalborg University Hospital

Background: In 2012 the Nordic radiation authorities raised concern about the increased use of computed tomography.
Purpose / Aim of Study: To investigate whether preoperative CT scanning of tibial diaphyseal fractures below the isthmus changes fracture treatment.
Materials and Methods: Retrospective analysis of 34 tibial diaphyseal fractures distal to the isthmus. Inclusion criteria: 1) a tibial diaphyseal fracture distal to the isthmus in a skeletally adult; 2) both preoperative AP and lateral x- rays as well as a preoperative CT scan including the ankle joint had been performed. Exclusion criteria: Fractures which from preoperative x-rays could be classified as a tibial Pilon fracture.
Findings / Results: The tibial fractures were classified from preoperative x-rays according to the AO classification: 9 type 42A, 2 type 42B, 1 type 42C, 4 type 43A, 13 type 43B, 5 type 43C. In 14 out of 34 cases the AO classification was changed after additional preoperative CT scan. The main diaphyseal fracture was fixed with a intramedullary nail in 11 cases, circular external fixator in 19 cases and other type of osteosynthesis in 4 cases. In 10 out of 34 cases a fracture component at the ankle joint was treated with additional screw fixation. In 9 out of 34 cases the preoperative CT scan revealed a fracture component at the ankle that was unseen on preoperative x-rays and 5 of those needed additional screw fixation. There were 32 of 34 patients who had an ipsilateral fibula fracture. The level of fibular fracture was 148 (106) mm above the tip of lateral malleolus for the 20 patients with an intra-articular fracture versus 204 (134) mm for the 12 patients without an intra-articular fracture (two-sample t test, p = 0.2).
Conclusions: Preoperative CT scan of tibial diaphyseal fractures distal to the isthmus is justified as the CT led to change in surgery in 5 out of 34 cases.

39. Health related quality of life after severe trauma – comparison of EQ-5D with norm scores 15 years after injury
Thomas Laursen, Morten Wad, Sidsel Fruergaard, Claus Falck Larsen, Benny Dahl
Orthopaedic Surgery, Rigshospitalet; Trauma Center, Rigshospitalet

Background: Previously, outcome studies of trauma patients have primarily focused on short-term survival but an increasing number of studies have focused on long-term outcome and health related quality of life (HRQL). Most of these studies have shown a reduced HRQL in severely traumatized patients up to 5 years after injury but long-term studies are few.
Purpose / Aim of Study: The purpose of the present study was to compare HRQL with norm scores 15 years after severe trauma.
Materials and Methods: Patients more than 18 years of age, admitted to the emergency department at Rigshospitalet from March 1996 through September 1997 were included in the study. In May 2012 survival status was obtained and the Danish version of the European Quality of Life-5 Dimensions (EQ-5D) questionnaire, was mailed to all patients alive. The EQ-5D results were compared with results from the general population.
Findings / Results: Of the original 171 patients, 92 patients received the EQ-5D questionnaire. 46 patients responded and 41 questionnaires were available for analysis. The average EQ-5D index score in the trauma population was significantly reduced compared to the index score in the Danish norm population; 0.671 vs. 0.873 respectively (P = 0.000). Comparing the EQ-5D index scores in patients with less severe and severe injury showed that that the median EQ-5D index score in patients with ISS <16 was 0.824 vs. a median score of 0.660 in patients with ISS ≥16 (P = 0.022).
Conclusions: Fifteen years after severe trauma patients report reduced HRQL and Injury severity predicted poor HRQL. Further studies are required to assess the possible impact of co-morbidities or additional injuries.

40. Complications after osteosynthesis of distal radius fractures using a volar locking-plate
Roland Knudsen
Orthopaedic, Odense University Hospital

Background: Open Reduction and Internal Fixation (ORIF) of distal radius fractures using a volar locking plate has become one of the most common acute operations performed. There is only a limited amount of literature, which is describing the possible complications.
Purpose / Aim of Study: Our aim was to register which complications patients suffered from following the above mentioned operation, and how often these complications occurred.
Materials and Methods: We included all patients (165) who in 2008 and 2009 had a distal radius fracture operated on in Kolding Hospital using a volar locking plate. We did a retrospective cohorte study using the patient’s notes and X-rays. We registered any complication, which needed intervention. Some patients were operated using a “Locking Compression Plate” (LCP) and others using a “Distal Volar Radius plate” (DVR).
Findings / Results: 30/165 (24%) patients experienced a complication, which needed intervention. Of these 8 patients experienced more than one complication. Patients, who were operated using a LCP plate experienced more complications than those operated using a DVR plate. The difference was however not significant (p=0.054).
Conclusions: We registered more complications, which needed interventions, than we expected. There was a trend towards more complications when using LCP, but the difference was not significant apart from one subgroup of fractures. When 24% of patients experiences at least one complication, which require intervention, care must be shown not to over-treat these fractures. One must remember that some of these fractures can treated conservatively with no or limited sequelae. Other studies have shown similarly results regarding the frequency of complications.

41. Urinary tract infections and complications among hip fracture patients treated within a multimodal rehabilitation concept
Pia Søe Jensen, Nicolai Bang Foss, Ulrich Stab Jensen, Dorthe Gaby Bove, Henrik Palm, Henrik Kehlet
Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Anaesthesiology, Copenhagen University Hospital Hvidovre; Department of Microbiology, Copenhagen University Hospital Hvidovre; Section of Surgical Pathophysiology,, Rigshospitalet, Copenhagen University

Background: Urinary tract infections (UTI) are common among hip fracture patients, but whether this is associated with complications or prolonged hospitalization is not clear. The treatment of hip fracture patients includes early surgery, regional anaesthesia, early mobilisation, enhanced oral nutrition and urinary bladder catheters, which could cause nosocomial UTI.
Purpose / Aim of Study: To identify the incidence of pre-admission and nosocomial UTI, and the association with serious complications among hip fracture patients treated according to a well-defined multimodal rehabilitation concept, including urinary bladder catheters in the perioperative period.
Materials and Methods: Prospective observational study of 424 hip fracture patients aged >65, with urine culture tests on admission and the seventh postoperative day. All patients were treated with an indwelling urinary bladder catheter until the fourth postoperative day. Self- reported clinical symptoms on admission related to UTI were individually assessed, as were hospitalization length and serious postoperative complications such as pneumonia, delirium, cardiovascular events, renal failure, infections and reoperation.
Findings / Results: The incidence of admission bacteriuria (104 per ml, except e-coli 103) was 32% (137/424) with no significant association to self-reported clinical symptoms. The incidence of nosocomial bacteriuria was 58% (124/214; 73 without later urine culture test). Regression analysis showed no association between nosocomial bacteriuria and complications or prolonged hospitalization.
Conclusions: The incidence of preadmission and nosocomial bacteriuria was confirmed to be high among hip fracture patients, but not associated with self-reported clinical symptoms or decreased outcome.