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

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.