Session 9: Trauma

16. November
13:30 - 15:00
Lokale: 01+02
Chair: Arvind Von Keudell and Katrine Borum

74. Team-based Digital Communication Reduces Patient-initiated Phone Calls to the Hospital After Discharge: Preliminary Results from a Randomized Clinical Trial
Lili Worre Høpfner Jensen1, Søren Kold1, Hans-Christen Husum1, Ole Rahbek1
Interdisciplinary Orthopaedics, Aalborg University Hospital, 9000 Aalborg, Denmark

Background: Digital communication solutions open up new opportunities for asynchronous post-discharge communication between patients and healthcare professionals. Concerns have been raised about an increased consumption of resources when patients are provided with easy digital access, e.g., that digital contact leads to more phone calls or double contacts.
Aim: We aimed to investigate the effects of a GDPR- safe team-based digital communication solution between orthopaedic surgery patients and healthcare professionals after hospital discharge (eDialogue) on phone calls to the hospital after discharge.
Materials and Methods: In a randomized clinical trial (n=70), we compared the number of phone calls to the hospital two months after discharge in patients randomized to standard communication pathways (n=35) or eDialogue (n=35). A secondary outcome was patients’ perceptions of continuity of care, measured by The Patient Continuity of Care Questionnaire (PCCQ). The intervention group was given access to eDialogue and the control group used standard communication pathways after discharge, typically by phone. All patients answered weekly questionnaires regarding phone calls to the hospital. PCCQ was collected at baseline on the day of discharge (27 items) and four weeks after (14 items).
Results: Preliminary results four weeks after discharge shows that the intervention group had significantly less phone calls to the hospital than the control group (8 vs 50, p<0.05). The proportion of patients who called the hospital after discharge was 14% in the intervention group versus 46% in the control group (p<0.05). Patients in both groups reported similar perceptions of continuity of care at baseline and four weeks after discharge.
Interpretation / Conclusion: The study demonstrates that providing patients access to eDialogue can significantly reduce the number of phone calls to hospitals after discharge, while patients’ perception of continuity of care remains the same.

Rasmus Stokholm1, Peter Larsen 1,2, Juozas Petruskevicius3, Jan D. Rölfing3, Morten K. Rasmussen4, Steffen S. Jensen4, Rasmus Elsøe1
1. Department of Orthopaedic Surgery, Aalborg University Hospital; 2. Department of Occupational Therapy and Physiotherapy, Aalborg University Hospital; 3. Department of Orthopaedic Surgery, Aarhus University Hospital; 4. Department og Orthopaedic Surgery, Viborg Hospital

Background: In recent years patient-reported outcome measures (PROMs) have become prominent when evaluating the effect of treatment and patient satisfaction following orthopaedic disorders. Several generic and body region-specific PROMs have been used to assess patients with tibial shaft fractures. However, evidence is lacking in psychometric properties such as validity, reliability, responsiveness, and minimal clinically important difference when assessing patients with a tibial shaft fracture
Aim: To establish validity, reliability and responsiveness and to estimate the minimal clinically important difference (MICD) for each of the five KOOS subscales in patients with closed tibial shaft fractures.
Materials and Methods: This study is a multicentered prospective clinical trial including consecutive patients with closed tibial shaft fractures (AO 42-). Primary outcome measurement was the KOOS subscales pain, symptoms, ADL, sport and recreational activities (sport/rec) and QOL. Follow-up was repeated at 14 days, 6 weeks, and 3, 6 and 12 months postoperatively. Content validity was evaluated by patients ranking relevance of all the items in the KOOS questionnaíre, test-retest reliability by interclass correlation coefficient, responsiveness by effect size end estimation of minimal clinical important difference (MCID) by the anchor-base method.
Results: A total of 35 patients were included in the study. Mean age of patients was 46.2 with a range from 20 to 72. Female sex represents 11 of the 35 patients. Results indicated an acceptable content validity of all the KOOS subscales. The test-retest reliability was high for all the five subscales, with ICCs ranging 0.8-0.9. At follow-up 6- and 12- months responsiveness shows moderate to large effect sizes for the subscales pain, ADL, symptoms, and sport/rec, ranging 0.5- 1.2. The MCID of the KOOS subscales were: pain 5.2, symptoms 7.1, ADL 2.7, sport/rec 8.8 and QOL 8.8.
Interpretation / Conclusion: The KOOS appears to be a valid and useful questionnaire to capture patient perceived outcome within one year follow a closed tibial shaft fracture in adults. The questionnaire showed high content validity, high reliability, and acceptable responsiveness.

Jan Duedal Rölfing1,2, Lisa Beicker Salling1, Steven Long3, Bjoern Vogt4, Donald D. Anderson3,5,6, Geb W. Thomas3,6, Rune Dall Jensen1
1. Corporate HR, MidtSim,Aarhus, Denmark; 2. Department of Orthopaedics, Aarhus University Hospital; 3. Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics; 4. Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery, Muenster University Hospital; 5. Department of Biomedical Engineering, University of Iowa; 6. Department of Industrial and Systems Engineering, University of Iowa.

Background: Antegrade femoral intramedullary nailing (IMN) is a common orthopedic procedure that residents are exposed to early in their training. A key component to this procedure is placing the initial guide wire with fluoroscopic guidance. A simulator was developed to train residents on this key skill, building off an existing simulation platform originally developed for wire navigation during a compression hip screw placement.
Aim: The objective of this study was to assess the construct validity of the IMN simulator.
Materials and Methods: Thirty orthopedic surgeons participated in the study: 12 had participated in fewer than 10 hip fracture or IMN related procedures and were categorized as novices; 18 were faculty, categorized as experts. Both cohorts were instructed on the goal of the task, placing a guide wire for an IM nail, and the ideal wire position reference that their wire placement would be graded against. Participants completed 2 assessments with the simulator. Performance was graded on the distance from the ideal starting point, distance from the ideal end point, wire trajectory, duration, fluoroscopy image count, and other elements of surgical decision making. A two-way ANOVA analysis was used to analyze the data looking at experience level and trial number.
Results: The expert cohort performed significantly better than the novice cohort on all metrics but one (overuse of fluoroscopy). The expert cohort had a more accurate starting point and completed the task while using fewer images and less overall time.
Interpretation / Conclusion: This initial study shows that the IMN application of a wire navigation simulator demonstrates good construct validity. With such a large cohort of expert participants, we can be confident that this study captures the performance of active surgeons today. Implementing a training curriculum on this simulator has the potential to increase the performance of the novice level residents prior to their operating on a vulnerable patient.

77. Using smartphones for remote monitoring of orthopaedic patients' physical activities during the perioperative period
Arash Ghaffari1, Rikke Emilie Kildahl Lauritsen1, Michael Christensen2, Trine Rolighed Thomsen3, 4, Harshit Mahapatra2, Robert Heck4, Søren Kold1, Ole Rahbek1
1. Interdisciplinary Orthopaedics, Aalborg University Hospital; 2. Alexandra Institute, Aarhus N, Denmark; 3. Department of Chemistry and Bioscience, Aalborg University; 4. The Danish Technological Institute, Aarhus C, Denmark.

Background: Smartphones are often equipped with inertial sensors capable of measuring individuals' physical activities. Their role in monitoring the patients' physical activities in telemedicine, however, needs to be explored.
Aim: The main objective of this study was to explore the correlation between a participant's daily step counts and the daily step counts reported by their smartphone.
Materials and Methods: This prospective observational study was conducted on patients undergoing lower limb orthopedic surgery and a group of non- patients. The data collection period was from 2 weeks before until four weeks after the surgery for the patients and two weeks for the non-patients. The participants’ daily steps were recorded by physical activity trackers employed 24/7, and an application recorded the number of daily steps registered by the participants' smartphones. We compared the cross-correlation between the daily steps time-series taken from the smartphones and physical activity trackers in different groups of participants. We also employed mixed modeling to estimate the total number of steps.
Results: Overall, 1067 days of data were collected from 21 patients (11 females) and 10 non-patients (6 females). The cross-correlation coefficient between the smartphone and physical activity tracker was 0.70 [0.53–0.83]. The correlation in the non-patients was slightly higher than in the patients (0.74 [0.60–0.90] and 0.69 [0.52–0.81], respectively).
Interpretation / Conclusion: Considering the ubiquity, convenience, and practicality of smartphones, the high correlation between the smartphones and the total daily step time-series highlights the potential usefulness of smartphones in detecting the change in the step counts in remote monitoring of the patient's physical activity.

78. Trends in Non-Operative Management of Low-Impact Pelvic Fracture Using the Nationwide Inpatient Sample from 2011 to 2018
Alexander Farid1, Stephen Stearns1, Joseph Atarere1, Nishant Suneja1, Michael Weaver1, Arvind Von Keudell1, 2
1Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA. 2Department of Orthopaedic Trauma, Bispebjerghospitalet, University of Copenhagen, 2400 Copenhagen, Denmark.

Background: Nonoperative treatment remains the more common treatment modality for low-impact pelvic fractures.
Aim: In this study, we aim to better characterize the epidemiology of the population treated nonoperatively following low-energy pelvic fracture, while identifying recent trends in management of these patients.
Materials and Methods: We evaluated data from the Nationwide Inpatient Sample database, the largest inpatient care database in the United States, from 2011 to 2018. We selected for all adult patients with ICD-9 or -10 codes for pelvic fracture, excluding acetabular fracture, femoral fracture, and polytrauma to better isolate low-impact mechanisms. We then excluded operative patients. We collected data on baseline demographics and outcomes (length of stay, in-hospital mortality, hospital disposition) and assessed for change over time.
Results: 123,936 patients underwent nonoperative management of pelvic fracture. Mean age was 68.7. 70% were female, decreasing from 75% to 66% during our time frame. 59% of fractures featured pubic bone involvement. Average CCI was 3.83 with a stable trend. 62.4% of patients received care at an urban teaching hospital. Mean length of stay was 6.3 days. 62.8% of patients were discharged to a skilled nursing facility (SNF) (62.1-65.0%), while 2.0% (18.4-21.1%) were discharged home. Mean in-hospital mortality was 3.28%, stable over time, with increased mortality among men (5.1%, versus 2.5% among women) and those of Asian descent (3.8%).
Interpretation / Conclusion: Demographic trends have remained relatively stable, indicating the majority of patients being treated nonoperatively following low-impact pelvic fracture are female, in their mid-60s, with relatively low comorbidity. There was a relatively high rate of in-hospital mortality at 3.28%, particularly with male patients and patients of Asian descent, suggesting the need for higher surveillance for additional injury in patients with these characteristics. Patients were more often discharged to a SNF rather than home, indicating necessity for prolonged rehabilitation in this patient population. This persistent trend is notable in the setting of increasing consideration of cost of inpatient admissions and improvement in outpatient management of orthopedic injuries.

79. Etiologies of non-traumatic extremity compartment syndrome: A multi-center retrospective review
Richard Smith1,2, Dafang Zhang1, Michael Weaver1, Arvind Von Keudell1,3
1. Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA 2. Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA 3. Bispebjerg Hospital, Department of Orthopaedic surgery, University of Copenhagen, Copenhagen, Denmark

Background: Compartment syndrome is a disorder of increased intracompartmental pressure leading to decreased perfusion and tissue necrosis. Compartment syndrome often develops because of trauma. While less common, non-traumatic causes also exist. Etiologies of non-traumatic extremity compartment syndrome (NTECS) are often insidious and can occur when patients have altered levels of consciousness. Therefore, a high index of suspicion should be maintained.
Aim: The aim of this study is to determine the different etiologies of NTECS, understand the demographics of NTECS patients, and establish their rate of in- hospital mortality.
Materials and Methods: This is a retrospective cohort study of all patients diagnosed with NTECS at two level 1 trauma centers between January 2006-December 2019. Data related to the etiology of NTECS, patient demographics, and in-hospital mortality were collected from electronic medical records.
Results: Six hundred and four patients were included in this study with an average age of 54.6±9.0 years. The causes of NTECS for each patient was broadly categorized into one of seven etiologies. These included 243 hypercoagulable states, 132 found- down secondary to substance use, 64 perioperative positioning, 60 shock, 60 hypocoagulable states, 29 infection, and 16 IV infiltration. The IV infiltration etiology of NTECS had the highest percentage of female patients (50%) whereas the etiology of found down secondary to substance use had the highest percentage of male patients (71%). In-hospital mortality was highest in patients who developed NTECS due to hypercoagulable states (36%), shock (33%), and hypocoaguable states (25%). The average in hospital-mortality for all NTECS etiologies was 22%.
Interpretation / Conclusion: Many etiologies of NTECS exist. The etiologies are often insidious and associated with high rates of mortality. On average, more than 1 in 5 patients who develop NTECS will die during their hospitalization. Raising awareness, in addition to future research efforts, are necessary to improve clinical outcomes for these patients.

80. Risk of re-operation after treatment of distal femoral fractures with locking plates. A retrospective single-center cohort study
Adalet Corap1, Fatma Kandela1, Yasemin Corap1, Bjarke Viberg1, Michael Brix1, Martin Lindberg-Larsen1
Orthopaedic Research Unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Department of Clinical Research, University of Southern Denmark

Background: The incidence of distal femoral fractures and periprosthetic distal femoral fractures seems to be increasing, especially after the age of 60 years. There is currently no treatment algorithm regarding native and periprosthetic distal femoral fractures, however many cases are treated with internal fixation such as a locked compression plating (LCP). The risk of reoperation in hip fractures treated with internal fixation has been reported to be 21% within 1 year postoperatively
Aim: The aim of this study is to report the reoperation rate after treatment of distal femoral fractures with locked compression plating
Materials and Methods: We retrospectively identified 263 patients by procedure codes (KNFJ64, KNFJ65, KNFJ84, KNFJ85) and diagnosis codes (DS723, DS724, DS728, DS729) in a single institution from 2011 to 2022. Indications for surgery were native distal femoral fracture(n=117) and periprosthetic femoral fractures(n=45). A reoperation was defined as an amputation, new or re-osteosynthesis, primary or revision knee arthroplasty, or soft tissue revision within 1 year after native treatment. A major reoperation was defined as an amputation or a knee arthroplasty
Results: Out of the 162 eligible patients, 125 (77%) were female. The study population had a mean age of 74.8 years (SD 16.4). Overall, 37(23%) patients underwent reoperation within the follow-up period, 30 (18%) patients underwent reoperation within 1 year after surgery, 35 (21%) within 2 years, and all 37 patients underwent a reoperation within 5 years (23%). Causes of reoperation were infection(n=13), non-or malunion (n=5), pain (n=7), periprosthetic fracture(n=3), mechanical failure (n=3) or other (n=6). Only 6 patients underwent a major reoperation. 3 patients underwent more than 1 reoperation
Interpretation / Conclusion: The overall reoperation rate was 22.8% and the 1year reoperation rate were 18.5% % after treatment of distal femoral fractures with LCP. The overall reoperation rate was similar to the overall reoperation rate of 21% reported after operative management of hip fractures 1 year postoperatively hence, further analysis of causes of reoperations and risk factors are needed, and the treatment of distal femoral fractures with LCP should be monitored closely

81. Risk of complications and the influence on patient-reported outcome following patella fractures
Marie Arildsen1,2, Peter Larsen1,2, Kasper Kristensen1,2, Kristian Damgaard Lyng1,3, Rasmus Elsøe1,2
1. Department of Orthopaedics, Aalborg University Hospital 2. Interdisciplinary Orthopaedics, Aalborg University Hospital

Background: Although a high rate of both early and late complications following surgical treatment of patella fractures is common, current literature lacks large- scale clinical studies investigating the incidence of complications. The impact of early and late complications on patient-reported outcomes also lacks evidence.
Aim: The present study aimed to investigate the incidence of early and late complications following surgical treatment of patella fractures. Secondary aims were to investigate the association between early and late complications and the patient-reported outcome.
Materials and Methods: Cross-sectional study including all patients recorded with a patella fracture residing in the Northern Region of Denmark between 2010 and 2020. Early (before three months) and late complications were investigated by retrospective review of charts and x- rays. All patients were invited to participate in the study by reporting current knee-specific symptoms using the Knee Injury and Osteoarthritis outcome score (KOOS).
Results: 798 patients were included in the study. A total of 532 (67%) patients were treated conservatively, and 266 (33%) patients underwent surgery. The mean age at the time of fracture was 66.8, ranging from 6–103 years of age. The mean follow-up time was 6.4 years, ranging from 1.1– 12.3 years follow-up. Overall, the rate of complications was 26%. Overall, the rate of complication for the surgical group was 57%. The most common early complication was the loss of reduction followed by the removal of symptomatic hardware. The most common late complication was the removal of symptomatic hardware and knee arthroscopy. In all the five KOOS subscales (Pain, Symptoms, ADL, sport, and QOL), patients presenting with early and late complications reported statistically significantly worse scores than those without complications.
Interpretation / Conclusion: The overall incidence of complications in patients presenting with a patella fracture was 26%, with a mean follow-up time of 6.4 years. In the surgical group, 57% of patients experience at least one complication during the follow-up period. Early and late complications were significantly associated with worse patient-reported KOOS outcome scores.

82. Individual comorbid diseases as predictors of infection after surgery for hip fracture: a population-based cohort study among 87,593 patients
Nadia R. Gadgaard1, Claus Varnum2,3, Rob Nelissen4, Christina Vandenbroucke-Grauls1,5, Henrik T. Sørensen1, Alma B. Pedersen1
1. Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Denmark; 2. Department of Orthopedic Surgery, Lillebaelt Hospital – Vejle, Denmark; 3. Department of Regional Health Research, University of Southern Denmark, Denmark; 4. Department of Orthopedics, Leiden University Medical Center, The Netherlands; 5. Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, Amsterdam, The Netherlands;

Background: Comorbidity level is strongly associated with risk of infection up to one year after hip fracture surgery. However, the impact of individual comorbidities as predictors of infection in patients with hip fracture is poorly understood.
Aim: We aimed to investigate individual comorbidities as predictors of infection among hip fracture patients.
Materials and Methods: Utilizing Danish population-based medical registries we obtained data on patients undergoing hip fracture surgery (2004-2017). Information on 27 comorbidities with prevalence of =1% was obtained 5 years prior to surgery. The main outcome was any hospital-treated infection within the first postoperative year and secondary outcomes were hospital-treated pneumonia and urinary tract infection (UTI). Cumulative incidence of infection was calculated considering death a competing risk. We used logistic regression to compute crude odds ratios (OR) with 95% confidence interval for infection.
Results: Of 87,593 hip fracture patients, 71% were female and the median age was 83 years. Most prevalent comorbidities were hypertension (23%), heart arrhythmia (15%), and cerebrovascular disease (14%). Among patients without any comorbidity, one- year incidence of any infection was 21%. Incidences of any infection were highest among patients with renal disease (43%), chronic pulmonary disease (43%), and hypotension (41%), and lowest for patients with dementia (28%), solid tumor (30%), and cerebrovascular disease (34%). ORs of any infection varied between 1.1 (1.0-1.1) for dementia and 2.1 (2.0- 2.2) for chronic pulmonary disease. Highest ORs for pneumonia was 2.9 (95% CI: 2.7-3.0) for chronic pulmonary disease, 1.9 (95% CI: 1.7-2.2) for pulmonary circulation disorders, and 1.9 (95% CI: 1.6-2.1) for hypotension. Highest ORs for UTI was 1.8 (95% CI: 1.6-2.1) for hypotension, 1.6 (95% CI: 1.5-1.8) for depressions/anxiety, and 1.5 (95% CI: 1.4-1.7) for complicated diabetes.
Interpretation / Conclusion: Most comorbidities were predictors of infection among hip fracture patients. Doctors should be aware of the risk of infection, particularly in patients with renal disease, chronic pulmonary disease, or hypotension given the high incidence of infection in these patients.

83. KKR 2023: Treatment of displaced unstable ankle fractures in patients above 70 years of age–fibular nail or ORIF?
Rasmus Elsøe1, Morten Schultz Larsen2, Rasmus Jørgensen3, Lasse Bayer4, Simone Dalskov5
1. Ortopædkirurgisk afdeling, Aalborg Universitets Hospital; 2. Ortopædkirurgisk afdeling, Odense Universitets Hospital; 3. Ortopædkirurgisk afdeling, Aarhus Universitets Hospital; 4. Ortopædkirurgisk afdeling, Nordsjællands Hospital, Hillerød; 5. Ortopædkirurgisk afdeling, Aalborg Universitets Hospital

Background:Ankle fractures can be treated by ORIF or minimal invasive fibular nail.
Aim:This KKR was conducted to evaluate if unstable ankle fractures in patients above 70 years of age should be treated with fibular nail or ORIF.
Materials and Methods:
Results:The evidence level was low and showed comparable results regarding functional outcome between the two treatment modalities and conflicting evidence regarding complications
Interpretation / Conclusion:Hence, no recommendations regarding treatment of unstableankle fractures in patients above 70 years with regards to treatment with fibula nails or ORIF canbe made