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.

Background: Electric bicycles (E-bikes) are an increasingly popular means of transport, and have been designed for a higher speed comparable to that of small motorcycles. Accident statistics show that E-bikes are increasingly involved in traffic accidents. To test the hypothesis of whether accidents involving E-bikes bear more resemblance to motorcycle accidents than conventional bicyclists, this study evaluates the injury pattern and severity of E-bike injuries in direct comparison to injuries involving motorcycle and bicycle accidents. Methods: In this retrospective cohort study, the data of 1796 patients who were treated at a Level I Trauma Center between 2009 and 2018 due to traffic accident, involving bicycles, E-bikes or motorcycles, were evaluated and compared with regard to injury patterns and injury severity. Accident victims treated as inpatients at least 16 years of age or older were included in this study. Pillion passengers and outpatients were excluded. Results: The following distribution was found in the individual groups: 67 E-bike, 1141 bicycle and 588 motorcycle accidents. The injury pattern of E-bikers resembled that of bicyclists much more than that of motorcyclists. The patients with E-bike accidents were almost 14 years older and had a higher incidence of moderate traumatic brain injuries than patients with bicycle accidents, in spite of the fact that E-bike riders were nearly twice as likely to wear a helmet as compared to bicycle riders. The rate of pelvic injuries in E-bike accidents was twice as high compared with bicycle accidents, whereas the rate of upper extremity injuries was higher following bicycle accidents. Conclusion: The overall E-bike injury pattern is similar to that of cyclists. The differences in the injury pattern to motorcycle accidents could be due to the higher speeds at the time of the accident, the different protection and vehicle architecture. What is striking, however, is the higher age and the increased craniocerebral trauma of the E-bikers involved in accidents compared to the cyclists. We speculate that older and untrained people who have a slower reaction time and less control over the E-bike could benefit from head protection or practical courses similar to motorcyclists.

Injuries to the acromioclavicular (AC) joint are one of the most common among sporting injuries of the upper extremity. Several studies investigated different treatment options comparing surgical and non-surgical treatment, and type of operative interventions. This study aims to evaluate treatment decisions regarding injuries of the AC joint and to compare different treatment strategies depending on the specific training of the treating physician. We performed a nationwide survey by contacting different experienced physicians and sending them questionnaires. The questionnaire included 37 questions that assessed preferred treatment strategies in AC joint injuries. We addressed different surgical and nonsurgical options as well as level of experience and factors that might influence the decision on treatment strategy. The physicians were stratified according to their training into general surgeons (group trauma associated) and orthopedic surgeons (orthopedic associated). The AC joint lesions were categorized according to the widely used Rockwood classification. This study analyses 96 questionnaires. We included 46 (47.9%) colleagues in group trauma and 50 (52.1%) in group orthopedics. Most of the colleagues (98.9%) prefer non-operative treatment of type I and type II AC lesions. Similarly, 96.8% agree on surgical treatment of types IV, V, and VI lesions. The treatment of type III lesions is performed in 41.6% of cases non-operatively and in 58.4% of cases surgically. Trauma-associated colleagues are 3.4 times more likely to treat AC lesions with a hook plate compared to orthopedic-associated colleagues (p = 0.05). In decreasing order, the most commonly used non-surgical technique is sling immobilization (63.7%), and the most commonly performed surgical treatment is the hook plate (41.1%) in treating type III injuries. This study shows a distinct difference in treatment of AC joint injuries depending on the training of the physician. Further, the need for high-quality studies arises to define the optimal treatment of type III lesions.

In terms of upper extremity fractures by patients with multiple injuires, a lot of studies have assessed the functional outcome following trauma to have less favorable outcomes in regards to functional recovery. We tested the hypothesis that differences in clinical outcome occur between shaft and articular injuries of the upper extremity, when patients that sustained neurologic deficits (e.g. brachial plexus lesions) are excluded. We involved Patients with isolated or combined upper extremity fracture, ISS > 16 in a level one trauma center. The follow up was at least 10 years after the initial injury. Both clinical examination (range of motion, instability, contractures, peripheral nerve damage) and radiographic analysis were carried out. We evaluated also the development of heterotopic ossifications. To analyse patients were subdivided into 3 different subgroups (articular [IA], shaft [IS], and combined [C]). A statistically significant difference was found when ROM was compared between Group IS and C (p = 0.012), for contractures between Groups IA and C (p = 0.009) and full muscle elbow forces between Groups IS and C (p = 0.005) and Group IA and IS (p = 0.021). There was a significantly increased incidence in heterotopic ossifications when articular involvement was present. This applied for the isolated (p < 0.02) and the combined group (Group C vs Group IS, p = 0.003). When Brooker type I/II in group IA and Brooker types III/IV were combined, there was a significant difference (p < 0.001). In group IA (n = 1) and in group C (n = 6), HO developed or worsened after revision surgery, all of which were performed for malunion or nonunion. In this study, patients with isolated shaft fractures of the upper extremity tend to have a more favorable outcome in comparison with combined to isolated articular fractures in terms of range of motion, pain and the ability to use the arm for everyday activities. In the clinical practice of the treatment of polytraumatized patients with upper extremity injuries, we feel that the relevance of these injuries should not be underestimated. They are especially prone to development of heterotopic ossifications, thus requiring prophylactic measures, if necessary. As their incidence increases with the rate of reoperations, we feel that even during initial care, meticulous surgery is required to avoiding the necessity of revision surgeries. Similar to injuries below the knee, upper extremity injuries, should be treated to avoid any functional disability.

Introduction: It is currently unclear whether the additional effort to perform an intraoperative computed tomography (CT) scan is justified for articular distal radius fractures (DRFs). The purpose of this study was to assess radiological, functional, and clinical outcomes after surgical treatment of distal radius fractures when using conventional fluoroscopy vs. intraoperative CT scans. Methods: Inclusion criteria: Surgical treatment of DRF between 1 January 2011 and 31 December 2011, age 18 and above. Group distribution: intraoperative conventional fluoroscopy (Group Conv) or intraoperative CT scans (Group CT). Exclusion criteria: Use of different image intensifier devices or incomplete data. DRF classification according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification. Outcome variables included requirement of revision surgeries, duration of surgery, absorbed radiation dose, and requirement of additional CT scans during hospitalization. Results: A total of 187 patients were included (Group Conv n = 96 (51.3%), Group CT n = 91 (48.7%)). AO Classification: Type A fractures n = 40 (50%) in Group Conv vs. n = 16 (17.6%) in Group CT, p < 0.001; Type B: 10 (10.4%) vs. 11 (12.1%), not significant (n.s.); Type C: 38 (39.6%) vs. 64 (70.3%), p < 0.001. In Group Conv, four (4.2%) patients required revision surgeries within 6 months, but in Group CT no revision surgery was required. The CT scan led to an intraoperative screw exchange/reposition in 23 (25.3%) cases. The duration of the initial surgery (81.7 ± 46.4 min vs. 90.1 ± 43.6 min, n.s.) was comparable. The radiation dose was significantly higher in Group CT (6.9 ± 1.3 vs. 2.8 ± 7.8 mGy, p < 0.001). In Group Conv, 11 (11.5%) patients required additional CT scans during hospitalization. Conclusion: The usage of intraoperative CT was associated with improved reduction and more adequate positioning of screws postoperatively with comparable durations of surgery. Despite increased efforts by utilizing the intraoperative CT scan, the decrease in reoperations may justify its use.

Reconstruction of proximal humerus fracture continues to represent a challenge, especially in severe osteopenia. However, there still is a lack of consensus and clear indication on use of allograft augmentation. Therefore, this study aims to investigate outcome after osteosynthesis with and without allograft augmentation. It focuses on bone density results obtained by DEXA as potential examination that might help decision-making. This study included patients aged 65 years and older that were treated at one Level 1 trauma center between 2007 and 2018. Inclusion criteria: Proximal humerus fracture treated with or without allograft, conclusive data-sets. Exclusion criteria: prior surgical treatment of the proximal humerus, open fracture with bone loss, neurological damage. Patients were stratified according to the use of allograft augmentation in two groups: Group NA (no allograft augmented PHILOS) and Group A (PHILOS with allograft augmentation). Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Fractures were graded according to the classification by Neer. Radiographic union was analyzed at 6 weeks, 12 weeks, and at year follow up. Complications include surgical site infection, implant failure, humeral head necrosis, or delayed union. Allograft was used in cases of 1inch/3cm³ bone-loss or an egg-shell situation, where the patient refused arthroplasty. This study included 167 patients, with 143 (85%) in the Group NA, and 24 (15%) in the Group A. There were no significant differences in age, gender, injury distribution, and distribution of Neer classification or CCI. Patients in Group A had significantly lower T-scores preoperatively (-2.87 ± 1.08 versus -0.9 ± 2.12, p = 0.003). No difference occurred in any of the complications. At one-year follow-up, the range of motion was comparable in both groups. In patients with allograft augmentation and severe osteopenia, similar clinical and radiological results were obtained when compared with patients with better preoperative bone density scores (T-scores, DEXA). In view of a lack of guidelines indicating the indication for the use of allograft, this difference may be worth further study.