To Örebro University

BACKGROUND: Whole blood transfusion (WBT) is associated with improved hemostasis and possibly mortality in patients with hemorrhagic shock after injury but there are no studies in patients with isolated severe traumatic brain injury (TBI). The objective of this investigation was to compare outcomes of balanced component therapy (BCT) versus WBT in patients with an isolated severe TBI.

METHODS: Adult patients (≥18 years) registered in the Trauma Quality Improvement Program (2016-2019) who suffered a blunt isolated severe TBI (head Abbreviated Injury Score ≥3 in the head and ≤1 in the remaining body regions) and who received a BCT (1-2:1 packed red blood cell (PRBC):fresh frozen plasma and 1-2:1 PRBC:platelets) or WBT were eligible for inclusion. Patients were matched, based on the transfusion received, using propensity score matching. The primary outcome of interest was in-hospital mortality.

RESULTS: A total of 217 patients received either WBT (n=82) or BCT (n=135). After propensity score matching, 50 matched pairs were analyzed. The rate of in-hospital mortality was significantly lower in the WBT compared with BCT group (43.1% vs 66.7%, p=0.025) corresponding to a relative risk (RR) reduction of 35% in in-hospital mortality (RR (CI 95%): 0.65 (0.43 to 0.97)). However, in subgroup analyses comparing those who were managed surgically and conservatively, this association only remained significant among patients who underwent neurosurgical intervention.

CONCLUSIONS: WBT in patients with severe isolated TBI is associated with better survival compared with BCT in patients who require neurosurgical intervention. Further investigation into this finding using an appropriately powered, prospective study design is warranted.

LEVEL OF EVIDENCE: Level III, therapeutic.

BACKGROUND: Atlantoaxial rotatory subluxation (AARS) is an important differential diagnosis in pediatric patients presenting with torticollis, which is caused by the subluxation of the C1 vertebra relative to the C2 vertebra. Because of the uncommon nature of this condition, there is a paucity in sufficiently sized studies describing AARS. The aim of the current investigation was therefore to characterize current clinical characteristics and management of AARS.

METHODS: The American College of Surgeons Trauma Quality Improvement Program database from 2016 to 2021 was queried for pediatric (17 years old or younger) patients who were diagnosed with AARS following blunt trauma. Patients were grouped by age in order to describe and compare demographics, clinical characteristics, and in-hospital outcomes. A subgroup analysis was also performed on patients with isolated AARS, defined as AARS without the presence of a cervical fracture and an Abbreviated Injury Scale score of ≤1 in all regions besides the spine.

RESULTS: A total of 469 cases of AARS were identified, 211 (45.0%) were isolated AARS. Of these patients, 56.3% of AARS patients and 64.5% of isolated AARS patients were 8 years old or younger. Atlantoaxial rotatory subluxation in adolescents was due to a motor vehicle collision in 60.0% of cases, while 52.5% of infants/toddlers were injured in falls. Of all patients with AARS, 87.4% were managed conservatively, with or without a brace/other immobilizing device, while surgery was only indicated in 9.3% of patients. In cases of isolated AARS, conservative treatment was even more prevalent, with 92.4% of patients managed conservatively and only 4.7% requiring surgical intervention.

CONCLUSION: Atlantoaxial rotatory subluxation is most common in children 8 years old and younger, with the majority of cases resulting from falls or motor vehicle accidents. In the Trauma Quality Improvement Program database, most cases were able to be managed conservatively without the need for surgical intervention.

LEVEL OF EVIDENCE: Care Management; Level III.

PURPOSE: Frailty has gained recognition as a crucial determinant of patient outcomes following traumatic spinal injury (TSI), particularly due to its increasing incidence in elderly populations. The aim of the current investigation was therefore to compare the ability of several frailty scores to predict adverse outcomes in surgically managed isolated TSI patients without spinal cord injury.

METHODS: All adult patients (18 years or older) who suffered an isolated TSI due to blunt trauma, and required surgical management, were extracted from the 2013-2021 Trauma Quality Improvement Program database. The ability of the Orthopedic Frailty Score (OFS), the Hospital Frailty Risk Score (HFRS), the 11-factor (11-mFI) and 5-factor (5-mFI) modified frailty index, as well as the Johns Hopkins Frailty Indicator to predict adverse outcomes was compared based on the area under the receiver-operating characteristic curve (AUC). Subgroup analyses were also performed on patients who were ≥ 65 years old and those who were injured due to a ground-level fall (GLF).

RESULTS: A total of 39,449 patients were selected from the TQIP database. The 5-mFI and 11-mFI outperformed all other frailty scores when predicting in-hospital mortality (5-mFI AUC: 0.73) (11-mFI AUC: 0.73), any complication (5-mFI AUC: 0.65) (11-mFI AUC: 0.65), and FTR (5-mFI AUC: 0.75) (11-mFI AUC: 0.75). Among the 14,257 geriatric patients, however, the OFS demonstrated the highest predictive ability for in-hospital mortality (AUC: 0.65). The OFS (AUC: 0.64) also performed on the same level as both the 5-mFI (AUC: 0.63) and the 11-mFI (AUC: 0.63) when predicting FTR in this population. Among the 9616 patients who were injured due to a GLF, the OFS performed on par with the 5-mFI and 11-mFI when predicting in-hospital mortality and FTR.

CONCLUSION: Simpler scores like the 5-factor modified Frailty Index and Orthopedic Frailty Score outperform or perform on par with more complicated frailty scores when predicting mortality, complications, and failure-to-rescue in surgically managed isolated traumatic spinal injury patients without spinal cord injury, particularly among geriatric patients and those injured in a GLF.

OBJECTIVES: To compare postoperative mortality regarding 2 techniques in the treatment of trochanteric hip fractures (THFs). DESIGN: Retrospective cohort study. SETTING: National databases.

PATIENTS: All consecutive surgically treated THF cases between 2008 and 2017 were included. Pathological fractures or patients younger than 60 years were excluded.

INTERVENTION: Patients were grouped based on the surgical technique: sliding hip screw (SHS) or intramedullary (IM) nail. This data set was cross-referenced with a National Board of Health and Welfare's patient registry and a Cause of Death registry.

MAIN OUTCOME MEASUREMENTS: Mortality, comorbidities, and length of stay (LOS).

RESULTS: Forty-six thousand one hundred twenty-one cases were included. Twenty-five thousand eight hundred seventy-seven patients received a SHS, and 20,244 received an IM nail. Patients in the IM group were more often female (71.8% vs. 69.2%, P < 0.001), slightly less fit for surgery (American Society of Anesthesiologists score ≥3: 61.2% vs. 60.1%, P = 0.003), and more frail (Orthopedic Frailty Score ≥2: 54.2% vs. 52.8%, P = 0.005). Multifragment fractures were more prevalent in the IM nail group (66.6% vs. 32.0%, P < 0.001), which suffered from a higher comorbidity burden. After adjusting for potential confounders, no clinically significant differences in 7-day, 30-day, 90-day, or 1-year postoperative mortality were observed. Subgroup analyses focusing on 2-fragment and multifragment fractures could not detect any difference in mortality. LOS was 1 day shorter for the IM nail group as a whole.

CONCLUSIONS: Based on 10 years of data including 46,121 patients with THF managed with SHS or IM nail, no difference was observed in mortality up to 1 year postoperatively, when comparing surgical technique. LOS was shorter for the IM nail group.

INTRODUCTION: As the incidence of traumatic spine injuries has been steadily increasing, especially in the elderly, the ability to categorize patients based on their underlying risk for the adverse outcomes could be of great value in clinical decision making. This study aimed to investigate the association between the Revised Cardiac Risk Index (RCRI) and adverse outcomes in patients who have undergone surgery for traumatic spine injuries.

METHODS: All adult patients (18 years or older) in the 2013-2019 TQIP database with isolated spine injuries resulting from blunt force trauma, who underwent spinal surgery, were eligible for inclusion in the study. The association between the RCRI and in-hospital mortality, cardiopulmonary complications, and failure-to-rescue (FTR) was determined using Poisson regression models with robust standard errors to adjust for potential confounding.

RESULTS: A total of 39,391 patients were included for further analysis. In the regression model, an RCRI ≥ 3 was associated with a threefold risk of in-hospital mortality [adjusted IRR (95% CI): 3.19 (2.30-4.43), p < 0.001] and cardiopulmonary complications [adjusted IRR (95% CI): 3.27 (2.46-4.34), p < 0.001], as well as a fourfold risk of FTR [adjusted IRR (95% CI): 4.27 (2.59-7.02), p < 0.001], compared to RCRI 0. The risk of all adverse outcomes increased stepwise along with each RCRI score.

CONCLUSION: The RCRI may be a useful tool for identifying patients with traumatic spine injuries who are at an increased risk of in-hospital mortality, cardiopulmonary complications, and failure-to-rescue after surgery.

The aim of the current investigation was to compare the ability of several frailty scores to predict adverse outcomes in hip fracture patients. All adult patients (18 years or older) who suffered a hip fracture due to a fall and underwent surgical fixation were extracted from the 2019 National Inpatient Sample (NIS) Database. A combination of logistic regression and bootstrapping was used to compare the predictive ability of the Orthopedic Frailty Score (OFS), the Nottingham Hip Fracture Score (NHFS), the 11-factor modified Frailty Index (11-mFI) and 5-factor (5-mFI) modified Frailty Index, as well as the Johns Hopkins Frailty Indicator. A total of 227,850 patients were extracted from the NIS. In the prediction of in-hospital mortality and failure-to-rescue (FTR), the OFS surpassed all other frailty measures, approaching an acceptable predictive ability for mortality [AUC (95% CI): 0.69 (0.67-0.72)] and achieving an acceptable predictive ability for FTR [AUC (95% CI): 0.70 (0.67-0.72)]. The NHFS demonstrated the highest predictive ability for predicting any complication [AUC (95% CI): 0.62 (0.62-0.63)]. The 11-mFI exhibited the highest predictive ability for cardiovascular complications [AUC (95% CI): 0.66 (0.64-0.67)] and the NHFS achieved the highest predictive ability for delirium [AUC (95% CI): 0.69 (0.68-0.70)]. No score succeeded in effectively predicting venous thromboembolism or infections. In summary, the investigated frailty scores were most effective in predicting in-hospital mortality and failure-to-rescue; however, they struggled to predict complications.

BACKGROUND: Studies have shown an increased risk of morbidity in elderly patients suffering rib fractures from blunt trauma. The association between frailty and rib fractures on adverse outcomes is still ill-defined. In the current investigation, we sought to delineate the association between frailty, measured using the Orthopedic Frailty Score (OFS), and outcomes in geriatric patients with isolated rib fractures.

METHODS: All geriatric (aged 65 years or older) patients registered in the 2013-2019 Trauma Quality Improvement database with a conservatively managed isolated rib fracture were considered for inclusion. An isolated rib fracture was defined as the presence of ≥1 rib fracture, a thorax Abbreviated Injury Scale (AIS) between 1 and 5, an AIS ≤1 in all other regions, as well as the absence of pneumothorax, hemothorax, or pulmonary contusion. Based on patients' OFS, patients were classified as non-frail (OFS 0), pre-frail (OFS 1), or frail (OFS ≥2). The prevalence ratio (PR) of composite complications, in-hospital mortality, failure-to-rescue (FTR), and intensive care unit (ICU) admission between the OFS groups was determined using Poisson regression models to adjust for potential confounding.

RESULTS: A total of 65 375 patients met the study's inclusion criteria of whom 60% were non-frail, 29% were pre-frail, and 11% were frail. There was a stepwise increased risk of complications, in-hospital mortality, and FTR from non-frail to pre-frail and frail. Compared with non-frail patients, frail patients exhibited a 87% increased risk of in-hospital mortality [adjusted PR (95% CI): 1.87 (1.52-2.31), p<0.001], a 44% increased risk of complications [adjusted PR (95% CI): 1.44 (1.23-1.67), p<0.001], a doubling in the risk of FTR [adjusted PR (95% CI): 2.08 (1.45-2.98), p<0.001], and a 17% increased risk of ICU admission [adjusted PR (95% CI): 1.17 (1.11-1.23), p<0.001].

CONCLUSION: There is a strong association between frailty, measured using the OFS, and adverse outcomes in geriatric patients managed conservatively for rib fractures.

BACKGROUND: With an aging global population, the prevalence of frailty in patients with traumatic spinal injury (TSI) is steadily increasing. The aim of the current study is to evaluate the utility of the Orthopedic Frailty Score (OFS) in assessing the risk of adverse outcomes in patients with isolated TSI requiring surgery, with the hypothesis that frailer patients suffer from a disproportionately increased risk of these outcomes.

METHODS: The Trauma Quality Improvement Program database was queried for all adult patients (18 years or older) who suffered an isolated TSI due to blunt force trauma, between 2013 and 2019, and underwent spine surgery. Patients were categorized as non-frail (OFS 0), pre-frail (OFS 1), or frail (OFS ≥2). The association between the OFS and in-hospital mortality, complications, and failure to rescue (FTR) was determined using Poisson regression models, adjusted for potential confounding.

RESULTS: A total of 43 768 patients were included in the current investigation. After adjusting for confounding, frailty was associated with a more than doubling in the risk of in-hospital mortality (adjusted incidence rate ratio (IRR) (95% CI): 2.53 (2.04 to 3.12), p<0.001), a 25% higher overall risk of complications (adjusted IRR (95% CI): 1.25 (1.02 to 1.54), p=0.032), a doubling in the risk of FTR (adjusted IRR (95% CI): 2.00 (1.39 to 2.90), p<0.001), and a 10% increase in the risk of intensive care unit admission (adjusted IRR (95% CI): 1.10 (1.04 to 1.15), p=0.004), compared with non-frail patients.

CONCLUSION: The findings indicate that the OFS could be an effective method for identifying frail patients with TSIs who are at a disproportionate risk of adverse events.

LEVEL OF EVIDENCE: Level III.

BACKGROUND: Traumatic spinal injuries are associated with a high risk of morbidity and mortality. The aim of this study is to investigate which variables best predict adverse outcomes in patients who had surgery for isolated traumatic spinal injury without spinal cord injury.

METHODS: The American College of Surgeons Trauma Quality Improvement Program database was used to identify adult (18 years or older) surgically managed patients with an isolated traumatic spinal injury, without spinal cord injury admitted between 2013 and 2021. An isolated injury was defined as a spine Abbreviated Injury Scale score ≥2 and an Abbreviated Injury Scale score ≤1 in the remaining body regions, as well as corresponding International Classification of Diseases, Ninth and Tenth Revision, codes. The predictive value of demographic, clinical, and comorbidity data was evaluated using logistic regression models and ranked using the permutation importance method.

RESULTS: A total of 39,457 patients were included in the study, of whom 554 died during hospitalization. The most important variables for predicting in-hospital mortality were age, sex, Glasgow Coma Scale on admission, Orthopedic Frailty Score, and cervical spine injury. The most important variables for predicting complications were age, cervical spine injury, the need for cervical spine surgery, Revised Cardiac Risk Index, and alcohol use disorder. Finally, age, cervical spine injury, sex, Glasgow Coma Scale on admission, and Orthopedic Frailty Score had the highest relative importance when predicting failure to rescue. Models based on the five most important variables for each outcome demonstrated an excellent predictive ability for in-hospital mortality (area under the receiver operating characteristic curve [AUROC], 0.84; 95% confidence interval [CI], 0.82–0.86) and failure to rescue (AUROC [95% CI], 0.86 [0.84–0.87]) as well as an acceptable predictive ability for complications (AUROC [95% CI], 0.72 [0.71–0.73]).

CONCLUSION: The most important factors identified to predict mortality, complications, and failure to rescue in traumatic spinal injury patients without spinal cord injury who undergo surgery were patients' age, sex, frailty, cervical spine injury that necessitated surgical intervention, and cardiovascular risk.

INTRODUCTION: The number of patients with hip fractures continues to rise as the average age of the population increases. Optimizing outcomes in this cohort is predicated on timely operative repair. The aim of this study was to determine if patients with hip fractures who are frail or have a higher cardiac risk suffer from an increased risk of in-hospital mortality when surgery is postponed >24 h.

METHODS: All patients registered in the 2013-2021 TQIP dataset who were ≥65 years old and underwent surgical fixation of an isolated hip fracture caused by a ground-level fall were included. Adjustment for confounding was performed using inverse probability weighting (IPW) while stratifying for frailty with the Orthopedic Frailty Score (OFS) and cardiac risk using the Revised Cardiac Risk Index (RCRI). The outcome was presented as the absolute risk difference in in-hospital mortality.

RESULTS: A total of 254,400 patients were included. After IPW, all confounders were balanced. A delay in surgery was associated with an increased risk of in-hospital mortality across all strata, and, as the degree of frailty and cardiac risk increased, so too did the risk of mortality. In patients with OFS ≥4, delaying surgery >24 h was associated with a 2.33 percentage point increase in the absolute mortality rate (95% CI: 0.57-4.09, p = 0.010), resulting in a number needed to harm (NNH) of 43. Furthermore, the absolute risk of mortality increased by 4.65 percentage points in patients with RCRI ≥4 who had their surgery delayed >24 h (95% CI: 0.90-8.40, p = 0.015), resulting in a NNH of 22. For patients with OFS 0 and RCRI 0, the corresponding NNHs when delaying surgery >24 h were 345 and 333, respectively.

CONCLUSION: Delaying surgery beyond 24 h from admission increases the risk of mortality for all geriatric hip fracture patients. The magnitude of the negative impact increases with the patient's level of cardiac risk and frailty. Operative intervention should not be delayed based on frailty or cardiac risk.