Early Treatment of Acetabular Fractures via an Anterior Approach Increases Blood Loss but not Packed Red Blood Cell Transfusion

OBJECTIVE: The objective of this study was to determine whether time from hospital admission to surgery for acetabular fractures using an anterior intrapelvic (AIP) approach affected blood loss. METHODS: Design: Retrospective review. Setting: Three level 1 trauma centers at 2 academic institutions. Patient Selection Criteria: Adult (18 years or older) patients with no pre-existing coagulopathy treated for an acetabular fracture via an AIP approach. Excluded were those with other significant same day procedures (irrigation and debridement and external fixation were the only other allowed procedures). Outcome Measures and Comparisons: Multiple methods for evaluating blood loss were investigated, including estimated blood loss (EBL), calculated blood loss (CBL) by Gross and Hgb balance methods, and packed red blood cell (PRBC) transfusion requirement. Outcomes were evaluated based on time to surgery. RESULTS: 195 patients were studied. On continuous linear analysis, increasing time from admission to surgery was significantly associated with decreasing CBL at 24 hours (−1.45 mL per hour by Gross method, P = 0.003; −0.440 g of Hgb per hour by Hgb balance method, P = 0.003) and 3 days (−1.69 mL per hour by Gross method, P = 0.013; −0.497 g of Hgb per hour by Hgb balance method, P = 0.010) postoperative, but not EBL or PRBC transfusion. Using 48 hours from admission to surgery to define early versus delayed surgery, CBL was significantly greater in the early group compared to the delayed group (453 [IQR 277–733] mL early versus 364 [IQR 160–661] delayed by Gross method, P = 0.017; 165 [IQR 99–249] g of Hgb early versus 143 [IQR 55–238] g Hgb delayed by Hgb balance method, P = 0.035), but not EBL or PRBC transfusion. In addition, in multivariate linear regression, neither giving tranexamic acid nor administering prophylactic anticoagulation for venous thromboembolism on the morning of surgery affected blood loss at 24 hours or 3 days postoperative (P > 0.05). CONCLUSION: There was higher blood loss with early surgery using an AIP approach, but early surgery did not affect PRBC transfusion and may not be clinically relevant. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence

Locked Plating vs. Nailing for Proximal Tibia Fractures: A Multicenter RCT

OBJECTIVES: The main two forms of treatment for extraarticular proximal tibial fractures are intramedullary nailing and locked lateral plating. The goal of this multicenter, randomized controlled trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN: Multicenter, randomized controlled trial. SETTING: Sixteen academic trauma centersPatients/Participants: 108 patients were enrolled. 99 patients were followed for 12 months. 52 patients were randomized to intramedullary nailing (IMN) and 47 patients were randomized to locked lateral plating (LLP). INTERVENTION: Intramedullary nailing or lateral locked plating. MAIN OUTCOME MEASUREMENTS: Functional scoring including SMFA, Bother Index, EQ-5DIndex and EQ-5DVAS. Secondary measures included alignment, operative time, range of motion, union rate, pain, walking ability, ability to manage stairs, need for ambulatory aid and number and complications. RESULTS: Functional testing demonstrated no difference between the groups, but both groups were still significantly affected 12 months post injury. Similarly, there was no difference in terms of time of surgery, alignment, nonunion, pain, walking ability, ability to manage stairs, need for ambulatory support or complications. CONCLUSIONS: Both intramedullary nailing and locked lateral plating provide for similar outcomes following these fractures. Patients continue to improve over the course of the year following injury but remain impaired even one year later

Locked Lateral Plating vs. Retrograde Nailing for Distal Femur Fractures: A Prospective Multicenter Randomized Trial

OBJECTIVES: The main two forms of treatment for distal femur fractures are locked lateral plating and retrograde nailing. The goal of this trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN: Prospective, multicenter randomized controlled trial. SETTING: 20 academic trauma centersPatients/Participants: 160 patients with distal femur fractures were enrolled. 126 patients were followed 12 months. Patients were randomized to plating in 62 cases and to intramedullary nailing in 64 cases. INTERVENTION: Lateral locked plating or retrograde intramedullary nailing. MAIN OUTCOME MEASUREMENTS: Functional scoring including SMFA, Bother Index, EQ Health and EQ Index. Secondary measures included alignment, operative time, range of motion, union rate, walking ability, ability to manage stairs and number and type of adverse events. RESULTS. Functional testing showed no difference between the groups. Both groups were still significantly affected by their fracture 12 months post injury. There was more coronal plane valgus in the plating group, which approached statistical significance. Range of motion, walking ability & ability to manage stairs were similar between the groups. Rate and type of adverse events were not statistically different between the groups. CONCLUSIONS: Both lateral locked plating and retrograde intramedullary nailing are reasonable surgical options for these fractures. Patients continue to improve over the course of the year following injury, but remain impaired one year post operatively. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence

Building a Clinical Research Network in Trauma Orthopaedics: The Major Extremity Trauma Research Consortium (METRC)

OBJECTIVESLessons learned from battle have been fundamental to advancing the care of injuries that occur in civilian life. Equally important is the need to further refine these advances in civilian practice, so they are available during future conflicts. The Major Extremity Trauma Research Consortium (METRC) was established to address these needs.METHODSMETRC is a network of 22 core level I civilian trauma centers and 4 core military treatment centers-with the ability to expand patient recruitment to more than 30 additional satellite trauma centers for the purpose of conducting multicenter research studies relevant to the treatment and outcomes of orthopaedic trauma sustained in the military. Early measures of success of the Consortium pertain to building of an infrastructure to support the network, managing the regulatory process, and enrolling and following patients in multiple studies.RESULTSMETRC has been successful in maintaining the engagement of several leading, high volume, level I trauma centers that form the core of METRC; together they operatively manage 15,432 major fractures annually. METRC is currently funded to conduct 18 prospective studies that address 6 priority areas. The design and implementation of these studies are managed through a single coordinating center. As of December 1, 2015, a total of 4560 participants have been enrolled.CONCLUSIONSSuccess of METRC to date confirms the potential for civilian and military trauma centers to collaborate on critical research issues and leverage the strength that comes from engaging patients and providers from across multiple centers