Session 8: Trauma

17. November
09:30 - 11:00
Lokale: Vingsal 1
Chair: Per Gundtoft and Peter Toft Tengberg

51. How treatment of distal radius fractures in adults have changed over the years – a nationwide register study from Denmark of 276,145 fractures from 1997-2018
Søren Tofte¹, Per Hviid Gundtoft²³, Anders Bo Rønnegaard², Signe Steenstrup Jensen², Dennis Karimi², Bjarke¹² Viberg
Department of Orthopaedic Surgery and Traumatology, Odense University Hospital¹; Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital – University Hospital of Southern Denmark²; Department of Orthopaedic Surgery and Traumatology, Aarhus University Hospital³

Background: The recommended treatment of distal radius fracture (DRF) is an issue of debate and two guidelines have been published in the last two decades. The impact of the guidelines on the treatment of DRF have not been studied on a national level.
Aim: To assess the incidence, treatment and choice of surgery concerning DRF in the adult population. Secondarily, to assess the differences in age groups 18-64 and 65+ years.
Materials and Methods: This is a populations-based register study comprising all patients with DRF above 18 years registered in the Danish National Patient Registry from 1997-2018. Data was extracted using ICD-10 code for DRF (DS525*) and incidence was calculated using data from Statistics Denmark. Primary surgery was defined as surgical treatment within 3 weeks from fracture diagnosis. Procedure codes were used to define plate (KNCJ65), external fixation (ExFix – KNCJ25), k-wire (KNCJ45), and others (KNCJ35,55,75,85,95).
Results: A total of 276,145 fractures were included, depicting an overall incidence of 229/100,000/year. The mean incidence was 189 for 18-64 years compared to 679 for 65+ years. During the study period, the incidence of DRF increased from 209 to 249 with an increase of 31% in the total amount of DRF. This was primarily due to a 41% increase in the 65+ population. Surgical treatment increased from 8% in 1997 to 22% in 2010, after which the increase plateaued to 24% in 2018. There were no differences regarding this increase in the two age groups. In 1997, the treatment distribution of DRF were 59% ExFix, 20% plate, and 18% k-wire. In 2007, plate was the primary choice with 41%, which increased to 96% in 2018. The trends were similar in the two age groups, but with a slightly higher use of ExFix in the 65+ years from 1997- 2008 with a mean 59% compared to 48% in the 18-64 years.
Interpretation / Conclusion: This study found an increase in DRF, probably due to an increase in the elderly population. The surgical rate markedly increased from 1997- 2010 with no seeming difference between the two age groups. A change in trend of surgical method was found with volar plates being the predominant choice in 2018. There seems to be little impact of national guidelines and a surgical rate of 24% must be questioned.

52. Degree of articular injury as measured by CT is associated with poor physical function following the treatment of bicondylar tibial plateau fractures
Kyla Huebner a, Jacob Mandell b, Michael Weaver a,b, Arvind von Keudell a,b,c
aHarvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, Massachusetts, USA bDepartment of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA cDepartment of Orthopaedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark

Background: Bicondylar tibial plateau are complex injuries that commonly require surgical repair. Bicondylar plateau fractures have been typically associated with worse reductions and outcomes. Optimal long- term clinical outcome is challenging due to leg alignment abnormalities, instability and difficulties restoring condylar width. While intuitive, the degree of direct articular injury has not been linked to outcomes in patients with bicondylar tibial plateau fractures.
Aim: The primary aim of the study was to quantify the articular surface disruption to assess for any correlation between the degree of articular injury and patient reported physical function.
Materials and Methods: We examined patients that had surgical repair for a bicondylar tibial plateau fracture at two level 1 trauma centers from 2013- 2016. Sixty patients with bicondylar plateau fractures were consecutively selected. Three patients did not have appropriate CT scans and were excluded. A total of 57 patients were analyzed CTs were evaluated by a blinded MSK radiologist. The intraclass correlation coefficient was calculated and Bland-Altman analysis was performed to determine inter- reader agreement PROMIS® scores were collected from patients in clinic at a minimum of 2 years post-operative. Pearson correlation was performed to assess associations between percentage of disrupted articular surface and PROMIS® scores.
Results: 57 patients included with an average age of 58 ± 14.3. Intraclass correlation coefficient for the CT measurement was 0.913 (95% CI 0.79 – 0.96). There was near-perfect inter- reader agreement, with no bias. There was a correlation between percentage of articular surface disruption and total PROMIS® scores (0.4, CI: 0.2- 0.5, p=0.007). There was also a correlation between surface damage and the physical function of the PROMIS® scores (0.4, CI: 0.2- 0.6, p<0.001)
Interpretation / Conclusion: The novel method of quantifying articular surface damage as a percentage of cross sectional area on CT in this study is easy and demonstrates high inter-reader reliability, and correlation with PROMIS® scores at minimum 2-year follow-up. It has potential to help determine classification, fixation strategies, and outcomes.

53. Evidence-based orthopaedic practice can be implemented in a structured way: the CEBO model
Jens-Christian Vedel, Dennis Winge Hallager, Stig Brorson
Centre for Evidence-Based Orthopaedics, Department of Orthopaedic Surgery, Zealand University Hospital, Denmark.

Background: Background: Orthopaedic practice and clinical guidelines are not always updated with evidence from randomized clinical trials. The result can be an evidence- practice gap. Management of distal radius fractures (DRFs) in adults with open reduction and internal fixation (ORIF) using volar locking plate is common practice in Denmark. This is partly based on a national clinical guideline from 2014 which has not been updated despite substantial new high- quality evidence.
Aim: Purpose: To study the feasibility of changing surgeons’ practice according to best evidence when treating DRF in a Danish university hospital.
Materials and Methods: Materials and methods: A new implementation model from Centre for Evidence-Based Orthopaedics (CEBO) was applied. It consists of 4 phases: 1) baseline practice is held up against best available evidence and barriers to change are assessed. 2) A consensus-based symposium actively involving all stakeholders discussing best evidence is held and agreement on a new local guideline is obtained. 3) The new guideline based on the consensus decisions at the symposium is prepared and implemented into daily clinical practice. 4) Changes in clinical practice are recorded. We applied the model on the clinical question of whether to use ORIF or closed reduction and percutaneous pinning (CRPP) in adults with dorsally displaced DRF.
Results: Findings: Prior to application of the model only ORIF was used in the department. Based on best evidence the symposium found that a change in practice was justified. A consensus-based local guideline stating CRPP as first surgical choice was implemented. If acceptable reduction could not be obtained the procedure was converted to ORIF. A year after implementation the rate of ORIF had decreased from 100% to 44 %.
Interpretation / Conclusion: Conclusions: It is feasible to change surgeons’ practice according to best evidence using a structured implementation model.

54. The effect of plate working length on interfragmentary motion in a distal femoral fracture – A biomechanical study
Jacob Lagoni, Isabelle Bilde Pfander, Asger Haugaard, Maria Sand Traberg, Ilija Ban, Søren Ohrt-Nissen
Department of Orthopaedics, Holbæk Hospital; Department of Health Technology, Denmarks Technical University; Department of Orthopaedics, Herlev hospital; Department of Health Technology, Denmarks Technical University; Department of Orthopaedics, Hvidovre Hospital; Department of Orthopaedics, Hvidovre Hospital.

Background: Distal femoral fractures are typically treated by bridging with locking plates. The mechanical environment is influenced, among other things, by working length (WL). Theoretically, increasing the WL will increase the micromotion of the construct (and thereby movement across the fracture), but how the WL of modern locking plates affects micromotion at an approximated physiological load is not well established.
Aim: To quantify the effect of WL on micromotion in distal femoral fractures.
Materials and Methods: Fifteen fourth-generation composite femurs were sectioned to create a 10 mm transverse fracture gap. The fracture was fixed (leaving the 10mm gap) using a 13-hole locking plate with a short (95mm), medium (135mm) and long (175mm) WL. The constructs were mounted in an Instron machine and then axially loaded from 50-750 N 50,000 times. The primary outcome was the range of axial deformation (micromotion) of the implant-femur construct under cyclic loading. A simplified Bernoulli-Euler beam model analysis was performed to evaluate the contribution of plate deformation on the observed micromotion and serve as a control of the results.
Results: One sample from the long WL group was excluded due to technical errors during testing leaving 14 constructs for analysis. In the cyclic loading analysis, the median (min-max) deformation was 2.47 (2.24-2.53) mm for the short WL, 2.54 (2.18-2.73) mm for the medium and 2.53 (1.92-3.14) mm for the long WL (p=0.817). The range of deformation remained constant throughout the 50,000 cycles irrespective of the WL. In the beam model, which neglected large displacement effects, we found that the applied loads were several orders of magnitude below the critical buckling load of the plate. Thus, the contribution of axial plate compression to the observed deformation was negligible.
Interpretation / Conclusion: We found very small differences in fracture micromotion between the three WL when applying approximated physiological loading. We could not confirm the well-established theory that WL is an important contributor to micromotion (and thereby fracture healing) in locking plate bridging of distal femur fractures.

55. A multicenter cohort study of complication risk factors in intramedullary bone lengthening nails.
Markus Winther Frost ¹ ², Ole Rahbek ¹ ², Christopher Iobst ³ , Anirejuoritse Bafor ³ , Molly Duncan ³ , Søren Kold ¹ ²
1.Department of Orthopedic Surgery Aalborg University Hospital Hobrovej 18-22 9000 Aalborg Denmark: 2. Department of Clinical Medicine Faculty of Medicine Aalborg University Sdr. Skovvej 15 9000 Aalborg, Denmark: 3.Department of Orthopaedic Surgery Center for Limb Lengthening and Reconstruction Nationwide Children's Hospital 700 Children's Drive Suite T2E-A2700

Background: Lower limb lengthening with externally controlled bone lengthening nails has become increasingly popular. Today the FITBONE and the PRECICE lengthening nails are the most used and successful bone lengthening nails. There is, however, a lack of knowledge of the complication risk factors of these bone lengthening nails.
Aim: The study investigated complication risk factors in lower limb bone lengthening with the FITBONE and the PRECICE nail.
Materials and Methods: A retrospective chart review was performed from two limb lengthening hospitals of patients operated with externally controlled bone lengthening nails in the lower extremity. Only completed nail removal of the FITBONE and PRECICE nails were included. Recorded patient data were: complications, nail information, and patient demographics. Complications were assessed as (yes/no) per segment. Complication risk factors were evaluated with modified Poisson regression (relative risk (RR)).
Results: We found 257 patients with 314 segments. The femur was the most frequently lengthened segment (80%), and the predominantly used nail was the FITBONE (75%). Complications were identified in 144 patients (56 % of 257 patients) and 175 segments (56% of 314 total segments). The risk analysis showed an increased risk for complications for the tibia compared to the femur(RR: 1.6 CI(1.3-2)), decades age groups above 19 years compared to 10-19 years(RR range from 1.4 to 2.5 dependent on age group), acute deformity correction and lengthening compared with no deformity correction (RR: 1.3 CI(1.01-1.6)) and bone length gained per mm (RR: 1.01 (1.00-1.02)). The retrograde/antegrade femur approach did not show increasing risk (RR: 1 CI(0.6-1.5)). PRECICE nail showed a reduced risk of complication compared to the FITBONE(RR 0.7 CI(0.5-0.99)).
Interpretation / Conclusion: Patients and segments treated with bone lengthening nails should expect complications in 56 %, which is more common than earlier described. We have identified five risk factors that may be used for clinical risk assessment and further research into reducing complication rates.

56. Comparison of Injury Characteristics and Surgical outcomes after ORIF of Bicondylar Schatzker VI (AO Type C) Tibial Plateau Fractures in Young versus Elderly Patients
Mihir Dekhne a, Derek Stenquist bc, Michael Petersen d,e, Anders Odgaard d, Michael Weaver b, c, Arvind von Keudel b,d
aHarvard Medical School, Boston, Massachusetts, USA bHarvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, Massachusetts, USA cDepartment of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA dDepartment of Orthopaedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark eDepartment of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark

Background: The surgical management of bicondylar tibial plateau (BTP) fractures in elderly patients aims to restore knee stability while minimizing soft tissue complications.
Aim: The purpose of this study was to compare injury characteristics and surgical outcomes after ORIF of BTP fractures (AO/OTA 41-C (Schatzker VI)) in young (< 50 years) versus elderly (> 65 years) patients.
Materials and Methods: A retrospective cohort study was conducted using data from two American College of Surgeons (ACS) level I trauma centers. Inclusion criteria were: (1) age 18 years or older, (2) bicondylar tibial plateau fracture (AO/OTA 41-C or Schatzker VI), (3) treatment with ORIF, and (4) minimum of 6 months follow-up. Patients between 50 and 65 years of age were excluded. Data collection was performed by reviewing electronic medical records, operative reports, and radiology reports.
Results: We identified 323 patients (61% male) with 327 BTP fractures and a median follow-up of 685 days. There were 230 young patients (71%) < 50 years and 93 elderly patients (29%) >6 5 years at time of presentation. Elderly patients were significantly more likely to have a low energy mechanism of injury (44.6 vs. 16.2%, p < 0.001), and present with diabetes (19.4 vs. 4.4%, p < 0.001) or coronary artery disease (12.9 vs. 1.3%, p < 0.001). Elderly patients were also significantly less likely to undergo staged management with initial knee-spanning external fixation followed by delayed ORIF (19.2 vs. 33.9%, p = 0.008). Elderly patients had a lower arc of motion at final follow-up (105 vs. 113?, p < 0.001) and reduced PROMIS-10 function scores (43.8 vs. 49.8, p=0.013). No differences were observed in rates of superficial infection, deep infection, reoperation, or EQ-5D scores between age groups.
Interpretation / Conclusion: This is the largest study to compare injury characteristics and outcomes after ORIF of BTP fractures according to age. The results of this study suggest that ORIF of BTP fractures in elderly patients is associated with similar complication rates and outcomes as in younger patients despite higher comorbidities and poorer bone quality in the elderly population.

57. Adverse events following bicondylar tibial plateau fractures – A systematic review
Emilie Ullahammer¹, Peter Larsen², Lærke Korup³, Rasmus Elsøe4
Department of Orthopaedics, Aalborg University Hospital¹; Department of Orthopaedics, Aalborg University Hospital²; Department of Orthopaedics, Aalborg University Hospital³; Department of Orthopaedics, Aalborg University Hospital4

Background: Tibial plateau fractures have a reported incidence of 10.3/100.000 per year. The complex tibial plateau fractures are bicondylar, and correspond to a Schatzker type V and VI and AO/OTA type 41-C. The accepted treatment of choice has been open or closed reduction followed by internal fixation. There are a wide range of known associated adverse events, but only limited information is offered in the literature on the rate at which these adverse events can be expected to occur.
Aim: To identify the risk of suffering an adverse event following surgical treatment with internal fixation of a bicondylar tibial plateau fracture of Schatzker type V and VI and/or AO/OTA type 41-C.
Materials and Methods: A systematic literature search was performed in PubMed, Embase and Cochrane Library. Literature screening and data extraction will be performed following the guideline of PRISMA. Duplicates were removed. Title and abstracts were reviewed by two unblinded co-authors. Bias were assessed using the Modified Newcastle-Ottawa Quality assessment Scale. To report on the approximated risk of suffering an adverse event, the average percentages of the adverse events will be calculated based on the percentages reported in the articles.
Results: The literature search yielded 7284 articles, 2401 duplicates were removed. 4883 articles were screened and 56 articles were considered for inclusion after review of title and abstract. After review of full text, 25 articles were included. 1 RCT, 2 case series, 10 retrospective-, 8 prospective- and 4 register based studies. The average risks identified were; 6.5% superficial wound infection, 6.2% deep wound infection, 13.7% DVT, 9.0% compartment syndrome, 2.1% amputation, 4.9% peroneal nerve palsy, 15.0% re-surgery for hardware related problems, 6.4% stiffness and manipulation under GA and 8.7% debridement to clear infection.
Interpretation / Conclusion: A bicondylar tibial plateau fracture is a complex and severe injury giving cause to development of a wide range of adverse events; wound infection, ligamentous and meniscal injury, deep vein thrombosis, hardware related problems requiring re- surgery and compartment syndrome being the ones with the highest reported risk of occurring in the existing literature.

58. Detection of hip fracture using deep learning artificial intelligence (AI). The algorithm increases accuracy of clinical readers
Nicholas Bonde, Kristian Kjærgaard, Henriette Aunaas, Stine Hangaard, Cecilie Laubjerg Daugaard, Liv Engell, Michael j. Lundemann, Søren Overgaard
1Copenhagen University Hospital, Bispebjerg, Department of Orthopaedic Surgery and Traumatology; University of Copenhagen, Department of Clinical Medicine, Faculty of Health and Medical Sciences; Odense Universitetshospital, Department of othopedic surgery; Svendborg Hospital, Department of Internal Medicine; Copenhagen University Hospital, Nordsjælland, Department of Radiology; Næstved Hospital, Department of Radiology; Radiobotics ApS

Background: X-ray imaging is the recommended first-line imaging modality in patients with suspected hip fracture. The initial fracture detection is most often done by the frontline personnel in the Acute and Emergency (A&E) clinic. Recently, AI algorithms implementing deep-learning models have shown great promise in detecting fractures with radiologist-level performance, thus with the clinical potential to bring down the rate of missed fractures.
Aim: To investigate the change in diagnostic accuracy among young A&E doctors when using a decision support tool (RBfracture) for diagnosing non-obvious hip fractures.
Materials and Methods: In this diagnostic accuracy study a dataset of 1913 X-ray studies of patients with suspected hip fractures were available and 248 studies were included in the study. These studies were read by eight resident doctors of varying experience both with and without the fracture decision support of RBfracture. The change in diagnostic accuracy was evaluated by comparing the reader’s sensitivity and specificity for fracture detection both with and without decision support. The fracture reference standard was established by two radiologists with more than ten years of experience. The success of the study required demonstration of both the superiority of the average patient-wise sensitivity and the noninferiority (margin 3%) of the average patient-wise specificity for studies read with support compared to no support.
Results: The average absolute change in sensitivity was 0.0514 (95%CI: 0.03,0.08), p=0.00450 (superiority) and the average change in specificity was 0.0121 (95%CI: -0.02,0.05), p=0.00038 (noninferiority, -3% margin). The false-negative diagnoses were reduced from 7 to 4 and the missed fractures were predominantly of type AO31A1 and Garden type I-II. The gain in sensitivity was consistent across reader experience. Readers with less than two years of experience consistently improved in specificity, whereas readers with more experience became less specific.
Interpretation / Conclusion: The diagnostic accuracy among young A&E doctors has shown to improve when using a decision support tool (RBfracture) for the detecting of non-obvious hip fractures on X-ray images resulting in a decrease of false negative diagnosis

59. Surgical Demographics of Acute Thigh Compartment Syndrome
Jocelyn Rodriguez¹, Nishant Suneja¹ ², Arvind von Keudell¹ ² ³, Dafang Zhang¹ ²
Harvard Medical School, Boston, MA, USA¹; Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, MA, USA²; Afedlingslæge, Trauma sektion, Ortopædkirugisk afd. U, Afsnit 6011, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark³

Background: Acute compartment syndrome is a surgical emergency, but there is a paucity of literature regarding acute thigh compartment syndrome, as it is less common than in other anatomic locations. Demographic, injury-related, treatment-related, and outcome-related characteristics for this entity remain poorly described.
Aim: The objective of this study was to identify demographic, injury-related, and treatment-related characteristics of patients who underwent decompressive fasciotomies for acute thigh compartment syndrome.
Materials and Methods: A cohort of 38 adult patients with acute thigh compartment syndrome treated with fasciotomy at two tertiary care referral centers over a 10- year time period from January 1, 2006 to June 30, 2015 was retrospectively identified. We searched the electronic medical record for patient-related variables (e.g., age, sex, race, smoking status, diabetes mellitus), injury-related variables (e.g., mechanism of injury, associated fractures, other traumatic injuries), treatment- related variables (e.g., delay of treatment, compartments released, number of debridements, use of split-thickness grafts), and outcomes (e.g., amputation, death, sensory/motor impairments at final follow up).
Results: The mean age of our cohort was 47 years, and 35 patients (92%) were male. There were varying mechanisms of injury, but the most common mechanisms were spontaneous hematoma (21%), followed by motor vehicle accidents (16%). Associated leg fractures were present in 15 (39%) patients. Delay between time of injury and fasciotomy was greater than 24 hours in 27 patients (71%), 12 to 24 hours in 6 patients (16%), and less than 6 hours in 3 patients (8%). The most frequently released compartment was the anterior compartment only (68%). Six patients (16%) had motor impairment, and 2 patients (5%) had sensory impairment at final follow-up.
Interpretation / Conclusion: Delays to fasciotomy are frequent in the treatment of acute thigh compartment syndrome. The demographics of acute thigh compartment syndrome demonstrate a strong male predominance. Treating providers should recognize spontaneous hematoma and motor vehicle accident as the most common causes of acute thigh compartment syndrome.

60. A possible explanation of early failure following tension band osteosynthesis of patella fractures
Rasmus Jørgensen¹ , Jonas Lindberg², Jacob Gasberg², Johan Larsen², Rasmus Elsøe¹, Peter Larsen³
Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg, Denmark¹; Science and Technology, Aarhus University, Aarhus, Denmark²; Department of Occupational Therapy and Physiotherapy, Aalborg University Hospital, Aalborg, Denmark³

Background: The risk of early failure following surgical treatment of patella fractures are in recent research reported to be between 4.7 and 14.4%. Although this potentially represents a serious impairment to the outcome of treatment, the etiology lacks evidence. At our clinic, we have observed several cases of similar early failure following tension-band osteosynthesis of simple two part patella fractures, where the distal fragment seems to refracture in the coronal plane during the first six weeks of surgery. This could easily be attributed to overlooked fractures preoperatively but could also represent a biomechanical issue regarding the surgical method.
Aim: The aim was to establish a biomechanical model exploring how tension forces are transferred through the intact patella and following osteosynthesis of a two-part patella fracture using Finite Element Analysis.
Materials and Methods: A 3D computer assisted design (CAD) model of a knee joint was established based on a CT-scan of an adult male without prior knee problems. Distal femur and proximal tibia geometries are included for determining proper boundary conditions. Surface count of the model is reduced to 25% for mesh- simplification. The 3D model was assembled in SolidWorks, and the finite element analysis was completed in ANSYS Mechanical. Load was gradually applied via the quadriceps tendon to show non-linear effects, increasing to 500 N, in 0°, 30°, 60° and 90° of flexion.
Results: When load is applied tensions within the patella bone following tension-band surgery increases up to 10 times compared with the intact patella bone. Especially in the z-axis, representing shearing forces, tensions increased from 8,48 MPa in the intact patella, to 87,2 MPa after tension band surgery.
Interpretation / Conclusion: The biomechanical properties of tension band osteosynthesis of a two part patella fracture creates tensions within the porous trabecular bone, loading the patella from the inside, opposed to how the intact patella handles loading. This could potentially override the strength of the patella bone. This study may serve as one explanation for the high risk of early failures following surgical treatment of patella fractures.