Early accurate assessment of the clinical status of severely injured patients is crucial for guiding the surgical treatment strategy. Several scales are available to differentiate between risk categories. They vary between expert recommendations and scores developed on the basis of patient data (level II). We compared four established scoring systems in regard to their predictive abilities for early (e.g., hemorrhage-induced mortality) versus late (Multiple Organ Failure (MOF), sepsis, late death) in-hospital complications. A database from a level I trauma center was used. The inclusion criteria implied an injury severity score (ISS) of ≥16 points, primary admission, and a complete data set from admission to hospital-day 21. The following four scales were tested: the clinical grading scale (CGS; covers acidosis, shock, coagulation, and soft tissue injuries), the modified clinical grading scale (mCGS; covers CGS with modifications), the polytrauma grading score (PTGS; covers shock, coagulation, and ISS), and the early appropriate care protocol (EAC; covers acid–base changes). Admission values were selected from each scale and the following endpoints were compared: mortality, pneumonia, sepsis, death from hemorrhagic shock, and multiple organ failure. Shapiro-Wilk test for normal distribution, Pearson Chi square, odds ratios (OR) for all endpoints, 95% confidence intervals. Fitted, generalized linear models were used for prediction analysis. Krippendorff was used for comparison of CGS and mCGS. Alpha set at 0.05. In total, 3668 severely injured patients were included (mean age, 45.8±20 years; mean ISS, 28.2±15.1 points; incidence of pneumonia, 19.0%; incidence of sepsis, 14.9%; death from hem. shock, 4.1%; death from multiple organ failure (MOF), 1.9%; mortality rate, 26.8%). Our data show distinct differences in the prediction of complications, including mortality, for these scores (OR ranging from 0.5 to 9.1). The PTGS demonstrated the highest predictive value for any late complication (OR = 2.0), sepsis (OR = 2.6, p = 0.05), or pneumonia (OR = 2.0, p = 0.2). The EAC demonstrated good prediction for hemorrhage-induced early mortality (OR = 7.1, p<0.0001), but did not predict late complications (sepsis, OR = 0.8 and p = 0.52; pneumonia, OR = 1.1 and p = 0.7) CGS and mCGS are not comparable and should not be used interchangeably (Krippendorff α = 0.045). Our data show that prediction of complications is more precise after using values that covers different physiological systems (coagulation, hemorrhage, acid–base changes, and soft tissue damage) when compared with using values of only one physiological system (e.g., acidosis). When acid–base changes alone were tested in terms of complications, they were predictive of complications within 72 hours but failed to predict late complications. These findings should be considered when performing early assessment of trauma patients or for the development of new scores.

Trauma is the leading cause of death in the working population. The World Health Organisation (WHO) reports 4.4 million deaths annually due to unintentional or violence-related injuries; one in three of these deaths results from road traffic injuries (RTIs). For individuals aged 5–29 years, three of the top five causes of death are injury-related. Major trauma is the eighth leading cause of death across all age groups and the leading cause of death among children and young adults. The highest rates of trauma-related deaths are observed in low-income countries. Globally, men face twice the risk of dying from injuries as women, with approximately 75% of injury-related deaths resulting from trauma and RTIs.

Background: Fat embolism (FE) continues to be mentioned as a substantial complication following acute femur fractures. The aim of this systematic review was to test the hypotheses that the incidence of fat embolism syndrome (FES) has decreased since its description and that specific injury patterns predispose to its development. Materials and Methods: Data Sources: MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases were searched for articles from 1 January 1960 to 31 December 2019. Study Selection: Original articles that provide information on the rate of FES, associated femoral injury patterns, and therapeutic and diagnostic recommendations were included. Data Extraction: Two authors independently extracted data using a predesigned form. Statistics: Three different periods were separated based on the diagnostic and treatment changes: Group 1: 1 January 1960–12 December 1979, Group 2: 1 January 1980–1 December 1999, and Group 3: 1 January 2000–31 December 2019, chi-square test, χ² test for group comparisons of categorical variables, p-value < 0.05. Results: Fifteen articles were included (n = 3095 patients). The incidence of FES decreased over time (Group 1: 7.9%, Group 2: 4.8%, and Group 3: 1.7% (p < 0.001)). FES rate according to injury pattern: unilateral high-energy fractures (2.9%) had a significantly lower FES rate than pathological fractures (3.3%) and bilateral high-energy fractures (4.6%) (p < 0.001). Conclusions: There has been a significant decrease in the incidence of FES over time. The injury pattern impacts the frequency of FES. The diagnostic and therapeutic approach to FES remains highly heterogenic to this day.

Background: Osteoporotic vertebral fractures (OVFs) have become increasingly common, and previous nonrandomized and randomized controlled trials (RCTs) have compared the effects of cement augmentation versus nonoperative management on the clinical outcome. This meta-analysis focuses on RCTs and the calculated differences between cement augmentation techniques and nonsurgical management in outcome (e.g., pain reduction, adjacent-level fractures, and quality of life [QOL]). Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, and the following scientific search engines were used: MEDLINE, Embase, Cochrane, Web of Science, and Scopus. The inclusion criteria included RCTs that addressed different treatment strategies for OVF. The primary outcome was pain, which was determined by a visual analog scale (VAS) score; the secondary outcomes were the risk of adjacent-level fractures and QOL (as determined by the EuroQol-5 Dimension [EQ-5D] questionnaire, the Oswestry Disability Index [ODI], the Quality of Life Questionnaire of the European Foundation for Osteoporosis [QUALEFFO], and the Roland-Morris Disability Questionnaire [RDQ]). Patients were assigned to 3 groups according to their treatment: vertebroplasty (VP), kyphoplasty (KP), and nonoperative management (NOM). The short-term (weeks), midterm (months), and long-term (>1 year) effects were compared. A random effects model was used to summarize the treatment effect, including I ² for assessing heterogeneity and the revised Cochrane risk-of-bias 2 (RoB 2) tool for assessment of ROB. Funnel plots were used to assess risk of publication bias. The log of the odds ratio (OR) between treatments is reported. Results: After screening of 1,861 references, 53 underwent full-text analysis and 16 trials (30.2%) were included. Eleven trials (68.8%) compared VP and NOM, 1 (6.3%) compared KP and NOM, and 4 (25.0%) compared KP and VP. Improvement of pain was better by 1.31 points (95% confidence interval [CI], 0.41 to 2.21; p < 0.001) after VP when compared with NOM in short-term follow-up. Pain effects were similar after VP and KP (midterm difference of 0.0 points; 95% CI, −0.25 to 0.25). The risk of adjacent-level fractures was not increased after any treatment (log OR, −0.16; 95% CI, −0.83 to 0.5; NOM vs. VP or KP). QOL did not differ significantly between the VP or KP and NOM groups except in the short term when measured by the RDQ. Conclusions: This meta-analysis provides evidence in favor of the surgical treatment of OVFs. Surgery was associated with greater improvement of pain and was unrelated to the development of adjacent-level fractures or QOL. Although improvements in sagittal balance after surgery were poorly documented, surgical treatment may be warranted if pain is a relevant problem. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Orthopedic trauma surgery has multiple, both patient-based and surgeon-based risk factors. Evaluating and modifying certain patient safety factors could mitigate some of these risks. This study investigates the influence that the time of day of surgery has on mortality and complication rates. This study evaluates whether the time of day of orthopedic trauma surgery influences complication or mortality rates. A prospective Swiss surgical database developed as a nationwide quality assurance project was reviewed retrospectively. All patients with trauma-coded diagnoses that were surgically treated in Swiss hospitals between 2004 and 2014 were evaluated. Surgery times were stratified into morning, afternoon, evening and night. The primary outcomes were in-hospital mortality and complication rates. Co-factors were sought in bivariate and multivariable analysis. Of 31,692 patients, 13,969 (44.3%) were operated in the morning, 12,696 (40.3%) in the afternoon, 4,331 (13.7%) in the evening, and 550 (1.7%) at night. Mortality rates were significantly higher in nighttime (2.4%, OR 1.26, p=0.04) and afternoon surgery (1.7%, OR 1.94, p=0.03) vs. surgery in the morning (1.1%). Surgery performed in the afternoon and at night showed significantly increased general complication rates vs. surgery performed in the morning. (OR 1.22, p=0.006 and OR 1.51, p=0.021, respectively). This study observed higher complication and mortality rates for surgery performed after-hours, which correlates with other recent studies. Surgeon fatigue is a potential contributing factor for these increased risks. Other potential factors include surgeon experience, surgery type, and the potential for more severe or emergent injuries occurring after-hours.