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.