Session 12: Traume II

Fredag den 23. oktober
09:00 – 10:00
Lokale: Helsinki/Oslo
Chairmen: Hans Gottlieb / Peter Toft Tengberg

125. Time-to-surgery in hip fracture patients: 36 hours is feasible, but why and where do patients wait?
Haidar Karim Abd-El-Redda, Henrik Palm
Hip Fracture Unit, Copenhagen University Hospital Hvidovre

Background: Hip fracture patients should be operated within 36 hours from hospital admission, which due to optimized outcome is now a demand in DK and UK. Our hospital has lived up to this for years due to a high surgical priority, but increased patient number, comorbidity and use of blood- thinners is challenging.
Purpose / Aim of Study: To describe the timing of hip fracture patients from injury to surgery.
Materials and Methods: 325 consecutive patients admitted with a hip fracture from May - Dec 2014 were included. The time of injury, hospital admission and action/location steps until incision were retrospectively assessed from individual patient records, as the hospital database proved insufficient. Also use of blood-thinners and reason for delay beyond 36 hours were assessed.
Findings / Results: Mean age was 78 years (range 37-100), 65% (212/325) were female and 22% (72/325) used blood-thinners. 81% (182/226 with data) were injured 8:00-22:00, and 75% (245/325) were admitted 8:00-22:00. The mean time was 6 hours (range 15 min - 9 days) from injury to admission. From admission it took mean 47 min (range 0m- 21h) to first nurse notes, 3 hours (0m-20h) to patient record, 4 hours (18m-24h) to radiographs, 6 hours (16m-25h) to surgical plan, 8 hours (17m-22h) to anesthetic plan, 7 hours (29m-20h) to hip fracture ward preoperative arrival, 21 hours (3h-4d) to theater arrival and 23 hours (4h-4d) to incision start. 94% (304/325) incisions started 8:00-18:00 and all before 22:00. 91% (297/325) of patients were operated within 36 hours, with another 8 delayed due to blood-thinners and 4 to comorbidity, also 12 were delayed due to lack of capacity and 4 due to late fracture diagnosis.
Conclusions: 91% of patients were operated within the 36 hours, with half of delays caused by blood- thinners or comorbidity. The preoperative steps however appeared time-consuming.

126. Diagnostic accuracy of ultrasound screening on suspicion of extremity fractures in adults.
Helle Østergaard, Inger Mechlenburg, Lars Bolvig Hansen, Kjeld Søballe, Kaj Døssing
Orthopaedic Department, Viborg Regional Hospital ; Orthopaedic Department , Aarhus University Hospital; Department of Radiology, Aarhus University Hospital

Background: The conventional diagnostic approach on suspicion of upper and lower extremity fracture consists of a clinical and a radiographic examination. Fifty percent of the patients go through an x-ray examination having no fracture. Studies indicate that ultrasound (US) can effectively identify fractures in adults.
Purpose / Aim of Study: To determine the diagnostic accuracy of US screening to exclude extremity fractures in adults. Furthermore, to determine the inter- rater agreement of US images in this group of patients.
Materials and Methods: We consecutively enrolled 92 adults referred to x-ray at Viborg Regional Hospital, on suspicion of extremity fracture. To ensure blinding, US was consistently performed prior to x-ray. Similarly, no clinical examination was performed. X-rays were reviewed for the presence of fracture and considered to be the gold standard. Inter- rater agreement between one of the investigators and a blinded radiologist was conducted by evaluating 42 randomly selected US images.
Findings / Results: Prevalence of fractures was 27%. McNemars test found no systematic difference between the results of US and x- ray (p=0.69). The sensitivity of US in detecting fracture was 92% (95% CI: 74;1.0) and the specificity was 94% (95% CI: 85;1.0). The positive predictive value of US was 85% (95% CI: 66; 96) and the negative predictive value was 97% (95% CI: 0.89;1.0). The inter-rater agreement was 100%, equal to a kappa value of 1 (95% CI: 1;1).
Conclusions: US screening on suspicion of extremity fracture has a high accuracy and reliability. No systematic differences were found between the results of the two modalities. Due to the small study population, more studies are required before US can be recommended as a screening modality.

127. A systemic review of treatment guidelines for hip fracture surgery
Henrik Palm, Jordi Teixidor
Hip Fracture Unit, Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic and Trauma Surgery, Hospital Universitari Vall d'Hebron, Universitat Autónoma de Barcleona, Spain

Background: In hip fracture surgery, the exact choice of implant often remains somewhat unclear for the individual surgeon, but the growing literature consensus has enabled publication of evidence-based surgical treatment guidelines.
Purpose / Aim of Study: The aim of this study was to review author guidelines and national guidelines for hip fracture surgery and discuss a method for future guideline implementation and evaluation.
Materials and Methods: In a systemic review (PubMed search in March 2015) six studies of surgical treatment guidelines covering all types of hip fractures with publication after 1995 were identified. Also we searched the homepages of the national heath authorities and national orthopedic societies in West Europe and found 11 national or regional (in case of no national) guidelines including any type of hip fracture surgery.
Findings / Results: Guideline consensus is outspread (Internal Fixation for un-displaced femoral neck fractures and Prosthesis for displaced among the elderly; and Sliding Hip Screw for stabile- and Intramedullary Nails for unstable- and sub-trochanteric fractures) but they are based on a variety of criteria and definitions - and often leave wide space for the individual surgeons’ subjective judgment. Appearing neither exhaustive nor exclusive, most of the guidelines seem difficult to evaluate scientifically, which might explain why only very few have been evaluated for compliance, reliability and complications after implementation in an actual clinical setting. We therefore introduce a model for step-wise guideline implementation including proper scientific evaluation.
Conclusions: Treatment guidelines for hip fracture surgery are available in literature and nationally with somewhat evidence based treatment consensus, but the scientific evaluation of the guidelines them selves needs to be optimized.

128. Displaced midshaft clavicle fractures: Survey of treatment across centres in Sweden, Denmark and Finland
Ilija Ban, Anders Troelsen
Orthopaedics and Clinical Orthopaedic Research Hvidovre (CORH), Copenhagen University Hospital Hvidovre

Background: The best treatment for displaced clavicle fractures has been subject for an on-going debate throughout decades. Traditionally a non-operative approach of treating all types of clavicle fractures has been gold standard. Though several randomized trials have been performed comparing non-operative and operative treatment the evidence in favor of operative treatment is not compelling and therefor routine operative treatment is not recommended though it seems a trend
Purpose / Aim of Study: To identify the primary treatment modality used to treat patients with displaced midshaft clavicle fractures at public hospital across several counties in Scandinavia
Materials and Methods: A purpose made multiple-choice questionnaires in English was addressed to all public hospital across Denmark, Sweden and Finland. The orthopaedic surgeon responsible for clavicle fracture treatment was addressed and the questionnaires were collected from 88 of 118 hospitals. 3 responding hospitals did not treat acute clavicle fractures and were excluded leaving 85 for analysis
Findings / Results: Across the 3 countries, 81% (69/85) of all hospitals would treat displaced clavicle fractures operatively. Clear criteria for treatment allocation were used at 68% (58/85) of the hospitals with the remaining 32% (27/85) using individual assessment in collaboration with the patient. Precontured locking plates, placed either superiorly 64/85 or anteriorly 10/85, are most used. At 82% (70/85) of all hospitals displaced midshaft clavicle fractures are treated surgically by an orthopaedic specialist
Conclusions: Displaced midshaft clavicle fractures are predominantly treated surgical in Sweden, Denmark and Finland. Though surgical intervention is a reliable method with few complications, overtreatment seems to take place in these counties as the strategy is not supported by compelling evidence

129. Clavicle fractures: characteristics of patients with failure of primary treatment.
Ilija Ban, Anders Troelsen
Orthopaedics and Clinical Orthopaedic Research Hvidovre (CORH), Copenhagen University Hospital Hvidovre

Background: Identification of patients at high risk of nonunion, extensive pain or symptomatic malunion following a clavicle fracture is desirable at time on initial treatment. However, little is known about predictive factors associated with these complications and the magnitude of the problem seems unknown as reports on these complication rates vary from below 1% to 40%.
Purpose / Aim of Study: To characterise clavicle fracture patients in whom primary treatment (surgical or non-surgical) fail and surgical treatment is needed
Materials and Methods: Retrospective assessment of all patients, that based on a complication (non-union, extensive pain or symptomatic malunion), were treated surgical at our institute from 2008 to 2015. Inquiry of electronic patient files and radiographs was done, collecting following: patient demographics, smoking status, fracture type and surgical indication
Findings / Results: 59 patients (42 males, mean age 49 years (range 20-73)) were included. 53 of the patients had a midshaft fracture (2 fractures were undisplaced and 17 complex) the remaining had lateral fractures. 50 patients were primarily treated non-operatively the remaining surgically. The indications were 42 nonunions, 11 delayed unions, 4 symptomatic malunions and a single pseudoartrosis. Pain was primary symptom in all except one case and 28 were smokers. From 2008 to 2015 a total of 722 patients (age > 18 years) were diagnosed with a clavicle fracture at our institute, estimating an overall complication rate of approximately 8 %.
Conclusions: The complication rate following primary treatment of clavicle fractures is not negligible. Compared to epidemiological studies patients with complications seem characterised by older age, female of sex, a displaced midshaft fracture and more are smokers

130. Risk factors predicting complications after ankle fracture surgery
Kolja Weber, Amandus Gustafsson, Anders Troelsen, Ilija Ban
Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre

Background: The reported complication rates after ankle fracture surgery are reported as high as 40%. Diabetes, obesity and peripheral vascular disease are factors strongly associated with complications. Whether primary radiographic pathology is related to postoperative complications remains debatable.
Purpose / Aim of Study: Identify patient-, fracture- and surgery-related risk factors associated with complications after surgery for bi- and trimalleolar ankle fracture.
Materials and Methods: 406 patients operated treated for bi- and trimalleolar ankle fracture were retrospectively assessed. Through inquiry of pre- and postoperative radiographs and electronic patient files following data was collected; Demographic data, smoking status, AO classification, medial clear space, width of syndesmosis, fibular length, tibiotalar dislocation. Following was regarded as a complication; infection, wound problems, nonunion, thrombosis and fracture collapse.
Findings / Results: The overall complication rate was 17,2%. Most complications were associated with transsyndesmotic fibula fractures with a medial lesion. Patients with complications seemed older (mean 64 y vs 56y) had higher BMI (BMI>25 19.2% vs 15.5%) more had diabetes (28.9% vs 16.4%) and more were active smokers (20.4% vs 16.4%) compared to the group without complications. However none of the differences were significant. None of the preoperative or postoperative radiographic findings were statistically significant predictors of complications.
Conclusions: The overall complication rate after ankle fracture surgery seems still high. Our results could not identify any pre- or postoperative factors useful in predicting complication. Transsyndesmotic fibula fractures with a medial lesion should have more attention.

131. Exposed implant in below knee osteosynthesis – can hardware be preserved until fracture healing?
Malene Ringholm Bæk Larsen, Jesper Fabrin, Anna Kathrine Pramming
Orthopeadic, Køge Sygehus, Region Sjaelland

Background: The treatment goals in case of wound complications with exposed hardware prior to fracture healing are: fracture consolidation, healed soft tissue envelope and prevention of osteomyelitis. Formation of biofilm impedes the chance of eradicating the pathogen without implant removal. Newly developed vacuum therapy systems (NPWTi-d) allow automated intermittent instillation of topical wound solutions with dwell time, supposedly loosening contaminants and subsequently removing them during the negative pressure phase.
Purpose / Aim of Study: To illustrate a possible treatment path with NPWTd-i for patients with wound breakdown, exposed implant and an unhealed fracture.
Materials and Methods: 7 consecutive patients were included based on following criteria: Stable osteosynthesis below the knee , skin defect of min 1 cm with exposed hardware no later than 8 weeks after the primary surgery, presence of palpable foot pulses or ankle pressure>70 mm hg. Patients with peripheral ischemia were excluded. Surgical debridement with the implant left in situ was followed by vacuum wound therapy with instillation (VAC-veraFlo, KCI), successively conventional NPWT until granulation coverage of implant. Antibiotic treatment was given according to microbiological findings. Radiographic follow up was done 3 months postoperatively. All patients were followed until complete wound healing.
Findings / Results: Preservation of the implant until fracture healing was achieved in all patients. The mean length of vacuum wound therapy with instillation was 15 ± 3,4 days, followed by 10 ± 2,9 days of conventional NPWT. The mean inpatient time was 19± 7,8 days.
Conclusions: Debridement combined with NPWTi-d seems to provide fracture consolidation as well as soft tissue coverage in this series of early wound complications.

132. The case for continuing Clopidogrel® therapy during hip-fracture surgery. Results of a retrospective study and systematic review with meta-analysis.
Peter Toft Tengberg, Lisa Lethan, Ann Ganestam, Henrik Palm, Nicolai Bang Foss, Thomas Kallemose, Anders Troelsen
Ortopædkirurgisk Afdeling, Copenhagen University Hospital Hvidovre

Background: Hip-fracture patients should optimally receive prompt surgery preferably within 36 hours, but the increasing use of Clopidogrel poses a dilemma for orthopaedic surgeons and anaesthesiologists. Should the treatment be continued in order to reduce the risk of Thromboembolic Events (TE’s) or, be discontinued to avoid excessive and/or uncontrollable blood loss and then resumed after surgery.
Purpose / Aim of Study: We investigate if hip-fracture surgery conducted on patients under the effect of Clopidogrel therapy is safe?
Materials and Methods: We have conducted a retrospective observational study of 36 hip-fracture patients with extra-capsular fractures operated with a short intramedullary nail. We combined our results with a systematic review of the English language literature, with meta-analysis of Surgical Bleeding Events (SBE) and 30-day mortality. The retrospective study conducted at our institution combined with five other studies located in a systematic search of PUBMED and EMBASE included a total of 200 patients operated for hip- fractures while under the effect of Clopidogrel. We found; no incidences of uncontrollable blood loss during surgery; a significantly increased OR of 3.64 (95%CI = 1.04 — 12.78, p = 0.044) for SBE in the Clopidogrel group; and no difference in 30-day mortality OR of 0.99 (95%CI = 0.39 — 2.53, p = 0.986).
Findings / Results: Continued Clopidogrel therapy carry an increased risk of hematoma or wound discharge (SBE) after hip- fracture surgery, but does not carry a high risk of uncontrollable blood loss during surgery, nor does it impact 30 day mortality.
Conclusions: We recommend that hip-fracture surgery should be carried out without delay and without discontinuation of Clopidogrel therapy before surgery.