Session 16: Trauma
17. November
12:45 - 13:45
Lokale: 01+02
Chair: Per H Gundtoft and Annie Primdahl
131. Trends in Treatment of Clavicle Fractures in Adults: An Epidemiological Study in Denmark, 1996-2018.
Ida Tryggedsson1, Bjarke Viberg2,3, Gundtoft Per Hviid4, Ilija Ban1, Søren Overgaard1,5, Arvind von Keudell1,6
1. Department of Orthopaedic Surgery and Traumatology, Copenhagen
University Hospital, Bispebjerg, Denmark;
2. Department of Orthopaedic Surgery and Traumatology, Odense
University Hospital;
3. Department of Orthopaedic Surgery and Traumatology, Hospital
Lillebaelt Kolding;
4. Department of Orthopaedic Surgery, Aarhus University Hospital;
5. Department of Clinical Medicine, Faculty of Health and Medical
Sciences;
6. Harvard Orthopaedic Trauma Initiative, Brigham and Women’s Hospital,
Boston, USA
Background: In recent years, several randomized
studies have been conducted to
determine the best treatment for clavicle
fractures (CF), but no clear difference in
functional outcome after surgical or non-
surgical (NS) treatment has been shown.
Historically, CF are treated NS, but this
has been challenged due to a few
studies that reported higher rates of
nonunion and decreased functionality
following NS treatment. As a result,
surgical treatment has gained popularity,
adding to the ongoing controversy over
optimal treatment for CF. In 2012,
National Clinical Guidelines
recommended NS treatment as the
primary approach for CF in Denmark.
Aim: To assess treatment patterns for CF in
adults; investigating general trends as well
as gender and age differences in Denmark
from 1996-2018.
Materials and Methods: Data on diagnosis and interventions were
obtained from Danish National Patient
Register in the period 1996-2018. We
included all patients aged 18 years and
above with a CF diagnose (DS420).
Patients treated surgically were categorized
based on codes for the use of plates or
other techniques. NS treatment was defined
as no surgical code within 3 weeks of
fracture.
Results: We found a total of 81,597 CF (67%
men) with a mean yearly incidence of
65/100,000/year. Absolute numbers
increased from 3,156 in 1996 to 3,885 in
2018. This increase was only seen in the
50+ cohort and mainly among men.
75,501 (92.5%) were treated NS, leaving
6,096 CF for surgical treatment with
plates accounting for 95% of the
modalities. Surgery was primarily
performed on patients under the age of
65. In 1996, only 1% were treated
surgically, but the surgery rate inclined
gradually until a sudden increase in
2008, peaking at almost 14% in 2011-12,
then declining to 8% in 2016 and
subsequent years. In 2018, the mean
surgical percentage was 7.2 but varied
from 0.0 to 14.7% among hospitals.
Interpretation / Conclusion: Despite an increase of CF, NS treatment
remained the main treatment of choice.
There was a notable increase in the use of
surgical treatment from 2008-12, followed
by a decline in 2016 and subsequent years.
The fluctuations in treatments may have
been influenced by studies supporting
surgical treatment and national guidelines
recommending NS treatment.
132. Translation, cultural adaptation and psychometric testing of the 'The Brachial Assessment Tool' (BrAT) for brachial plexus injury.
Helene Kissow1, Sofie Høj Wiingreen1, Bridget Hill Hill2, Alice Ørts Hansen1,3
1 Department of Orthopaedic surgery, Odense University Hospital, Odense, Denmark.
2 Epworth Monash Rehabilitation Medicine Unit Epworth HealthCare, Melbourne,
Australia
3 Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
Background: There is a growing need for valid and reliable
patient-rated outcome measures for use in
clinical practice and research. 'The Brachial
Assessment Tool' (BrAT) is a unidimensional, 3
sub scale, 31-item, 4-response patient-reported
outcome measure designed to assess the ability
of adults with traumatic Brachial Plexus injury
(BPI) to perform activities of daily living. The
BrAT has been shown to be a valid, reliable, and
responsive tool.
Aim: To translate and cross-culturally adapt the BrAT into
Danish and assess face validity and reliability in
adults with traumatic BPI.
Materials and Methods: The translation followed international guidelines. The
pre-final version was cognitive tested by 19 adults
who had a traumatic BPI. Face validity and reliability
were evaluated according to the COSMIN guideline.
Patients were recruited at an outpatient hand clinic.
Results for the subscales and summed score were
compared at time 1 and time 2 to determine test-
retest using intraclass correlation coefficient model
2.1, internal consistency using Cronbach alpha and
the smallest detectable change.
Results: The Danish translation revealed minor cultural
differences, which were clarified. Cognitive
testing showed no major issues with completion
and understanding. All participants found the
items relevant and important.
64 patients with traumatic BPI were recruited in
the reliability arm. 56 completed the retest, 50
reported a stable hand condition between tests
and were included in the analysis. Mean (sd) age
was 47.06 (17.34), and 72% of participants were
men. The Intra-class-correlation coefficients for
the three sub-scales and the total score ranged
from 0.91 to 0.95 (95% CIs 0.85 to 0.97). Internal
consistency ranged from 0.87 to 0.98. Smallest
detectable change scores ranged from 3.95 to
9.17 for the subscales and 15.71 for the total
score.
Interpretation / Conclusion: BrAT (DK) appears to have face validity and is a
reliable measure of activity for adults with traumatic
BPI. It can be used in clinical practice for goal
setting and to inform future interventions and
treatment evaluations.
133. Assessment of technical competence in distal radius fracture fixation by a volar locking plate: A global Delphi consensus study.
Mads Emil Jacobsen1, 2, 3, Leizl Joy Nayahangan2, Monica Ghidinelli4, Chitra Subramaniam5, Kristoffer Borbjerg Hare6, 7, Lars Konge2, 3, Amandus Gustafsson1, 2, 3
1: Center for Orthopaedic Research and Innovation (CORI), Department of
Orthopaedics, Næstved, Slagelse, and Ringsted Hospitals
2: Copenhagen Academy for Medical Education and Simulation (CAMES),
Rigshospitalet
3: Faculty of Health and Medical Sciences, University of Copenhagen
4: AO Education Institute, AO Foundation, Davos, Switzerland
5: AO North America, AO Foundation, Wayne, PA, USA
6: Department of Orthopaedics, Odense University Hospital
7: Department of Regional Health Research, University of Southern Denmark
Background: Volar locking plate fixation of distal radius fractures is among the most
common orthopaedic trauma procedures and should be mastered by
graduating orthopaedic residents. Surgical education in orthopaedic trauma
is transitioning from a traditional time-based approach to competency-based
medical education (CBME). Constituting a cornerstone of CBME, valid and
objective assessment is a prerequisite for a successful transition.
Aim: The aim of this study was to develop a
procedure specific assessment tool to evaluate
technical competence in volar locking plate
osteosynthesis of a distal radius fracture.
Materials and Methods: We invited international orthopaedic/trauma experts involved in resident education to
participate as panelists in an iterative, four-round Delphi process to reach consensus
on the content of the assessment tool. Round 1 was an item generating round where
the panelists identified all potential assessment parameters. In round 2 the panelists
rated the importance of each of the suggested assessment parameters and reached
consensus on which to include in the assessment tool. Round 3 yielded specific
assessment score intervals for specific bone and fracture models included in a
virtual reality simulator currently under development. In round 4 the panelists
weighted the scores for each assessment parameter that would impact the overall
results.
Results: Eighty-seven surgeons representing forty-two countries participated in the study. Round
1 resulted in forty-five potential assessment parameters grouped into five procedural
steps. After round 2, the number of parameters was reduced to thirty-nine. After the final
round an additional parameter was removed, and weights were assigned to each of the
remaining parameters.
Interpretation / Conclusion: Using a systematic methodology, an assessment tool to evaluate technical competence in distal radius
fracture fixation was developed. Consensus of international experts ensures the content validity of the
assessment tool. The development of this assessment tool represents a first step in the evidence-based
assessment that is essential to CBME. Before implementation, further studies exploring validity and
reliability of the assessment tool will be conducted.
134. Intra- and interrater reliability of the Radiographic Union Score for HUmeral fractures (RUSHU)
Peter Bremholm1, Kasper Eriksen1, Line Houkjær2, Martin Hochheim3, Kristoffer Hare4, Joakim Jensen4, Bjarke Viberg4, 5, Dennis Karimi1
1. Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital:
University Hospital of Southern
2. Centre for Evidence-Based Orthopaedics, Zealand University Hospital and
Department of Clinical Medicine, University of Copenhagen
3. Department of Orthopaedic Surgery and Traumatology, Hvidovre Hospital:
Copenhagen University Hospital
4. Department of Orthopaedic Surgery and Traumatology, Odense University
Hospital
5. Department of Clinical Research, University of Southern Denmark
Background: The Radiograhic Union Score for HUmeral
fractures (RUSHU) is a tool used to assess
healing in humeral shaft fractures. Patients who
score below 8 points after six weeks from time of
injury have a 12 times higher risk of nonunion.
However, the score must demonstrate high
external validity through reliable measurements
before it can be utilized as a valid tool in clinical
practice.
Aim: This study aimed to evaluate the intra- and
interrater reliability of the RUSHU.
Materials and Methods: A random sample of 175 patients with a
humeral shaft fracture were selected from a
database of 327 cases, provided they met the
inclusion criteria of being over 17 years of age,
having radiographs approximately six weeks
after the diagnosis, and having non-
pathological fractures. The radiographs were
independently assessed twice by six raters
(two medical students, two residents, and two
trauma specialists) with a minimum interval of
two weeks. The raters were provided with a
guide to measure the RUSHU. Intraclass
Correlation Coefficient (ICC) was used to
calculate intra- and interrater reliability, with
ICC values interpreted as poor (<0.50),
moderate (0.50–0.75), good (0.75–0.90), and
excellent (>0.90). ICC was calculated for the
individual cortices, the total RUSHU, and the
Binary Score of <8 or ?8.
Results: Intrarater ICCs ranged from 0.82 to 0.99 (95%
CI: 0.75-0.99) for individual cortices, 0.94 to 1.00
(95% CI: 0.92-1.00) for the total RUSHU, and
0.83 to 0.99 (95% CI: 0.77-0.99) for the Binary
Score. Interrater ICCs ranged from 0.87 to 0.91
(95% CI: 0.82-0.94) for individual cortices and
were 0.93 (95% CI: 0.87-0.96) for the total
RUSHU and 0.92 (95% CI: 0.88-0.94) for the
Binary Score.
Interpretation / Conclusion: The study findings show excellent intra- and
interrater reliability for the total RUSHU and
good to excellent intra- and interrater reliability
for the individual cortices and Binary Score. The
RUSHU can be used reliably by medical
students to specialists. However, further studies
are necessary to confirm the predictive value of
the RUSHU as a prognostic tool for nonunion
risk before it can be widely implemented in
clinical practice.
135. Steady-State Piperacillin Concentrations in the Proximity of an Orthopedic Implant: A Microdialysis Porcine Study
Johanne Gade Lilleøre1,2, Andrea René Jørgensen1,2, Martin Bruun Knudsen1,2, Pelle Hanberg1,2, Kristina Öbrink-Hansen1,3, Sara Kousgaard Tøstesen1,2, Kjeld Søballe1,4, Maiken Stilling1,2,4, Mats Bue1,2,4
1. Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark
2. Aarhus Denmark Microdialysis Research Group (ADMIRE), Aarhus University Hospital,
8200 Aarhus, Denmark
3. Department of Infectious Diseases, Internal Medicine, Gødstrup Hospital, 7400
4. Herning, Denmark Department of Orthopedic Surgery, Aarhus University Hospital,
8200 Aarhus, Denmark
Background: Implant-associated osteomyelitis is one of the most
feared complications following orthopedic surgery.
Although the risk is low it is crucial to achieve
adequate antibiotic concentrations proximate to the
implant for a sufficient amount of time to protect the
implant surface and ensure tissue integration.
Aim: The aim of this study was to assess steady-state
piperacillin concentrations in the proximity of an
orthopedic implant inserted in cancellous bone.
Materials and Methods: Six female pigs received an intravenous bolus
infusion of 4 g/0.5 g piperacillin/tazobactam over 30
min every 6 h. Steady state was assumed achieved
in the third dosing interval (12–18 h). Microdialysis
catheters were placed in a cannulated screw in the
proximal tibial cancellous bone, in cancellous bone
next to the screw, and in cancellous bone on the
contralateral tibia. Dialysates were collected from
time 12 to 18 h and plasma samples were collected
as reference.
Results: Time above the minimal inhibitory concentration
(fT>MIC) was evaluated for MIC of 8 (low target)
and 16 µg/mL (high target). For the low piperacillin
target (8 µg/mL), comparable mean fT>MIC across
all the investigated compartments (mean range: 54–
74%) was found. For the high target (16 µg/mL),
fT>MIC was shorter inside the cannulated screw
(mean: 16%) than in the cancellous bone next to the
screw and plasma (mean range: 49–54%), and
similar between the two cancellous bone
compartments.
Interpretation / Conclusion: To reach more aggressive piperacillin fT>MIC
targets in relation to the implant, alternative dosing
regimens such as continuous infusion may be
considered.
136. Use of the bioabsorbable Activa IM-Nail™ in pediatric diaphyseal forearm fractures: a prospective cohort study with six months follow-up
David Gøttsche1, Morten Jon Andersen1,2
1. Dept of Orthopedic Surgery, Copenhagen University Hospital - Herlev and
Gentofte
2. Dept of Clinical Medicine, University of Copenhagen
Background: Pediatric diaphyseal forearm fractures (PDFF)
are very common injuries. Fractures needing
surgery are most often treated with metal Elastic
Stable Intramedullary Nails (ESIN). Nail removal
is widely advocated; however, it is a substantial
burden on the child, the family and healthcare
economy. Bioabsorbable Intramedullary Nails
(BIN) made from poly L-lactide-co-glycolide
(PLGA) have been developed for some of the
same indications as metal ESIN.
Aim: To evaluate the feasibility and safety of the
Activa IM-Nail™ for PDFF.
Materials and Methods: From May 1st 2021 all patients with open
physes and unstable PDFF of the radius, ulna or
both were sought to be prospectively and
consecutively recruited. If consented patients
were operated with the Activa IM-Nail™.
Primary outcome was radiographic healing
assessed by the Radiographic Union Score
(RUS) at 3 months. Secondary outcomes were
pain, wound appearance, neurovascular status,
bilateral elbow and forearm range of motion
(ROM), fracture angulation and displacement.
Results: 26 children were eligible for inclusion, 9 children
were excluded due to criteria, 17 children were
operated with BIN, 7 girls and 10 boys, mean
age 10 years (4-14). There were no serious
adverse device effects (SADE). Two children
had postoperative fracture angulation that did
not require manipulation. After 3 months, all
patients had pain free and normal ROM. RUS
was at least 8 at three months and 10 at six
months follow up.
Interpretation / Conclusion: We did not see any SADEs. All children had
solid healing and normal ROM at 3 months. The
use of BIN for PDFF is feasible, seems very
safe, and eliminates the need for implant
removal.
137. KKR 2023: Operative versus non-operative management of olecranon fractures in low-demand elderly patients (Updated KKR 2018).
Liv Vesterby1, Anne-Kathrine Belling Sørensen1, Michael Brix2
1. DSSAK, 2 DOT
Background: Fractures of the olecranon account for approximately 20% of all forearm fractures. Tension band wire (TBW) and plate fixation (PF) are well-known methods for treating stable displaced fractures of the olecranon (Mayo type II A+B). However, operative treatment has a high rate of complications, including wound breakdown, infection, loss of reduction and further surgery to remove prominent metalwork. Several recent studies have advocated for non-operative treatment for stable displaced olecranon fractures in the elderly.
Aim: To evaluate the effect of operative treatment versus non-operative treatment for stable displaced fractures of the olecranon in elderly low-demand patients.
Materials and Methods: A review of the literature from January 2018 to March 2023 was performed using MeSH term in PubMed. 35 studies were imported for screening. Initial screening by title was performed by three authors. Two authors then screened the remaining abstracts and ultimately the full-length articles leaving 8 studies for inclusion (3 reviews and 5 observational studies). Inclusion criteria were studies available in English reporting outcomes on operative and non-operative treatment in elderly low-demand patients with stable, dislocated fractures of the olecranon (Mayo type II A+B). Critical outcomes were defined as risk of further surgery following primary surgery or conservative treatment. Secondary outcomes were defined as patient reported outcome scores. Observational studies were included, given the limited amount of literature on the topic.
Results: The 3 reviews report an overall high risk of reoperation in patients treated with TBW or PF compared with patients treated non-operatively. The observational studies published later on support the findings of the reviews.
Interpretation / Conclusion: Non-operative treatment is recommended in elderly low-demand patients with stable displaced olecranon fractures (Mayo type II A+B), as the benefit of operative treatment may be limited and uncertain, and due to high risk of complications, such as infection, loss of reduction and need of further surgery. The evidence of the guideline is considered low due to lack of high evidence studies.