Objective:
To analyze gender differences in a cohort of polytraumatized patients over a 25-year period.
Methods:
Retrospective data analysis of 953 consecutive polytraumatized patients treated at a level I trauma center between 1995 and 2019.
Results:
Out of all polytraumatized patients 29.9% were female. Female patients were significantly older than male patients (41.26 vs. 47.19; p=0.001). No gender differences in the injury severity score (mean 35.71 points; 18 to 75 points) were detected. Overall, 29.4% of all patients died due to the trauma, whereas 19.1% died within the acute phase of trauma and 10.3% died within the late phase. A motor vehicle related accident remained the most common mechanism of injury (58.9%). Severe traumatic brain injury (TBI) was seen in 44% of patients. Female patients showed a significantly higher over-all mortality rate (p=0.039) and tend to die more often within the acute phase (p=0.057). No gender differences regarding the trauma mechanisms could be seen, but female patients showed significantly higher rates of suicidal attempts (p=0.006). A significant influence of age (p<0.001), suicidal attempt (p=0.037) and concomitant severe TBI (p<0.001) on the overall survival of polytraumatized patients could be detected.
Conclusion:
Female polytraumatized patients are significantly older than male polytraumatized patients. Although no gender related differences regarding injury mechanism and injury severity could be detected, female patients show significantly higher overall mortality rates and tend to die more often in the acute phase. Age, suicidal attempt and concomitant severe TBI remain as prognostic factors on the survival of polytraumatized patients.

Objectives: With the increasing popularity of e-bikes, accident statistics have shown that e-bikes are also increasingly involved in traffic accidents. The aim of this study was to assess differences in severity and localization of injuries to the lower extremity after accidents with the electric bicycles, bicycles and motorbikes. Methods: A retrospective cohort-analysis of patients who sustained traumatic accidents with two-wheeled vehicles transferred to a level 1 trauma center in Switzerland was performed. We assessed patient demographics, injury pattern, and trauma severity (ISS), with subgroup analysis of outcomes stratified by vehicle. Results: In total, 624 patients (71% male) with injuries to the lower extremity after bicycle (n=279), electric bike (n=19) and motorcycle (n=326) accident were included. The mean age of all assessed patients was 42.4 years (SD 15.8) with a significantly higher age in the e-bike cohort (p=0.0001). High-velocity injuries were found significantly more often in the motorcycle and e-bike group. Open fractures, especially Type 3 open fractures, were most often found in the motorcycle group (p=0.001). The mean ISS across all patients was 16.0 (SD 10.6). The motorcycle group had a significantly higher mean ISS (17.6) than the other groups (p=0.0001). Motorcyclists showed significantly more dislocations of the ankle joint-foot-complex than the other vehicle groups (p=0.0001) and bicyclists showed more contusions than their counterparts (p=0.001). Conclusion: E-bike accidents produce a different injury profile to the lower extremity compared to motorcycle or bicycle accidents. Higher age, higher velocity and different protective equipment seem to have an impact on these fracture patterns.

Purpose: Subtrochanteric and reverse oblique intertrochanteric fractures are challenging and often difficult to reduce. While intramedullary nailing (IMN) is considered the standard treatment, achieving anatomic reduction prior to fixation is essential. This study aimed to assess the impact of cerclage wiring with IMN on the outcomes and complication rate in treating subtrochanteric and reverse oblique intertrochanteric fractures. Methods: PubMed, Cochrane, Web of Science and Google Scholar were searched till July 2021. Articles that compared intramedullary nailing (IMN) versus intramedullary nailing and cerclage wiring (IMN-C) in the treatment of subtrochanteric and reverse oblique intertrochanterc fractures were included. The primary outcome was the time-to-union. The secondary outcomes were operative time, blood loss, quality of reduction, reduction alignment, complications and re-operations. Results: This meta-analysis included 415 patients with subtrochanteric and reverse oblique intertrochanteric fracture from 6 comparative studies. Our findings showed that IMN-C was significantly associated with higher mean duration of surgery and blood loss. However, IMN-C had significantly lower mean time to union compared to IMN alone. In addition, IMN-C had lower pooled prevalence of varus reduction and overall complications. Conclusion: This study showed that the use of cerclage wiring is associated with lower time-to-union, lower prevalence of varus reduction and overall complications. Therefore, cerclage wiring augmentation is a safe technique with low complication rate and may be advised whenever open reduction is needed in the management of subtrochanteric and reverse oblique intertrochanteric fractures. Keywords: Subtrochanteric fractures ; Intertrochanteric ; reverse oblique fractures ; Femur ; Intramedullary nail ; Cerclage

The aim of this study was to analyze the effects of occult hypoperfusion(OH) of local circulation and inflammation.
Twenty-four male landrace pigs with standardized polytrauma: femoral fracture, blunt chest trauma, liver laceration and a pressure controlled hemorrhagic shock. One hour after trauma resuscitation: femoral nailing, liver packing and volume replacement. Animals stratified into GroupNorm (n= 19); normalized lactate levels 6 hours after trauma) and a Group OH (n=5; persistent lactate levels above 2 mmol/l 6 hours after trauma). Local circulation measured with optical sensors on the side of the fractured extremity and abdominal organs. Local inflammatory parameters included interleukin (IL) 6, 8, 10, heat shock protein (HSP), analyzed in the fatty tissue and the muscle tissue of the fractured extremity.
The shock severity and total amount of blood loss were comparable among Group Norm and Group OH. Following resuscitation Group OH significantly lower amounts of hemoglobin at the fractured extremity compared with GroupNorm (39.4, SD 5.3 vs. 63.9, SD 27.6 A.U., p = 0.031). Local oxygenation significantly lower in group OH compared to Group Norm (60.4, SD 4.6 vs. 75.8, SD 12.8, p = 0.049). Local IL-6 in fatty tissue significantly higher in GroupOH (318.3, SD 326.6 [pg/ml]) compared with GroupNorm (73.9,SD 96.3[pg/ml], p = 0.03). Local circulation at abdominal organs comparable in both groups.
OH is associated with increased local inflammation at the extremity. OH should be taken into consideration, since the decreased local inflammation and the increased local inflammation might affect the rate for complications during polytrauma management.

Background: The aim of this retrospective cohort study is to examine chronic pain and limping in relation to lower extremity and pelvic fracture location in addition to fracture combinations if multiple fractures are present on the same leg. Methods: A sample of 637 patients who suffered a polytrauma between 1973 and 1990 and were re-examined at least 10 years postinjury provided the base of our study population. 525 patients met the inclusion criteria: age 3-58 years at the time of injury, Injury Severity Score (ISS) of ≥ 16 and associated fractures to the lower limb and/or pelvis. Patients with incomplete follow-up examinations and amputees were excluded. Target variables were obtained using self-administered patient questionnaires as well as standardized physical examinations as performed by a trauma surgeon. Results: 57% of patients showed chronic lower limb pain 10 years postinjury. 10% of all patients with chronic pain displayed persistent pain. The highest proportion of fracture combinations was found in tibial shaft fractures in combination with either femoral shaft or proximal tibial fractures, at 13%. 151 patients reported load-dependent pain; 120 patients reported intermittent pain; a persistent limp was seen in 30 patients. Conclusion: In polytrauma patients with lower extremity injuries, the combination of fractures and their location are critical factors in long-term outcome. Femoral shaft fractures in combination with articular fractures are often associated with chronic persistent or load-dependent pain.
Patients with these injury patterns may benefit from structured and targeted long-term physiotherapy to prevent the development of chronic pain.

Background: The management of pertrochanteric hip fractures is still debatable. There is a lack of supporting evidence regarding the length of the nails used to treat such injuries. This systematic review and meta-analysis on randomized controlled trials aimed to investigate the outcomes of using short and long nails in the management of pertrochanteric femur fractures. Methods: This systematic review and meta-analysis followed the PRISMA guidelines. The search was conducted across Cochrane, PubMed, Google Scholar, and Web of Science databases from inception until 7 March 2022. All randomized controlled trials comparing the outcomes of using short and long nails in the management of pertrochanteric hip fractures were included. Results: Our meta-analysis included 620 patients with trochanteric fractures from 6 randomized controlled trials. A short nail was used in 50.3% of the patients (312/620). The use of short nail was significantly associated with lower operative time (Weighted Mean Difference (WMD) = -20.33; 95%CI: -29.90- -10.76) and less blood loss (WMD = -106.31; 95%CI: -155.43- -57.19). There was no significant difference between the two implants in the tip-apex index, Harris Hip Score, complication rate, reoperation rate, mortality, or length of hospital stay. Conclusion: Short nails offer shorter operative time, less blood loss, and a shorter length of hospital stay when compared to long nails in the management of pertrochanteric fractures. However, the length of the nail has no significant impact on the need of blood transfusion, Harris hip scores, complication rate, reoperation rate, and 1-year mortality rate.

The purpose of this study was to survey a broad group of prosthetists on their experience with amputees with knee disarticulations (KD) and transfemoral amputations (TFA) in order to determine their preference of amputation level, opinions on patient preference, and common problematic issues in order to guide decision making for patients and surgeons faced with the decision of a high-level lower extremity amputation. A blinded electronic mail survey was completed by 102 prosthetists. Each prosthetist was asked (1) what amputation level (KD or TFA) do they prefer and why?, and (2) which amputation level do they believe patients prefer and why? There was no consensus among prosthetists regarding amputation level preference. Fifty-four (53%) prosthetists preferred KD and 48 (47%) preferred TFA. 55 (54%) prosthetists believed patients preferred TFA and 47 (46%) believed patients preferred KD. Amputation level preference often depended on age, functional goals, and concerns with cosmesis. The most common benefits given for KD over TFA included distal end weight bearing (n=53), a lower subischial socket (n=43), and better function (n=30). The most common disadvantages given for KD over TFA, included component limitations due to space available below amputation (n=56), poor cosmesis (n=49), an asymmetrical knee axis (n=42), and difficulties with sitting/standing (n=13). No consensus exists between prosthetists regarding preference for KD versus TFA. The advantages and disadvantages of KD reported in this study, along with the associated decision tree, can be used for future counseling of patient’s faced with high-level lower extremity amputations.

Introduction
The goal was to investigate the four vicious cycles (shock, coagulopathy, hypothermia, soft tissue injury) on timing of definitive surgery in polytrauma.

Methods
Retrospective cohort study. polytrauma patients (injury severity score (ISS) >16 points and ICU). Stratification according timing of definitive surgery: No surgery, no definitive surgery (NDS), immediate surgery (IMS, definitive surgery <12h), safe definitive surgery (SDS,<48h), delayed definitive surgery (DDS, >48h). Factors: lactate, hemoglobin, temperature, INR, ROTEM, AIS head, thorax, abdomen/pelvis, lowerextremity.

Results
813 polytraumata, Group no surgery (n=256, 31.5%), NDS(n=93, 11.4%), IMS (n=48, 5.9%), SDS(n=362, 44.5%), DDS (n=5.4, 6.6%)
Highest ISS in DDS(27.5 ± 12.2 points) vs SDS(24.6 ± 10.8 points) vs IDS(19.8 ± 14.0 points) vs NDS(23.9 ± 10.6) vs No surgery (20.2 ± 11.4, p < 0.001). Admission lactate comparable amongst all groups (2.3 ± 2.1mmol/l, p = 0.957). Shock stable: No surgery (n = 124, 53.2%), NDS (n = 51, 65.0%), IDS (n = 25, 53.2%), SDS (n = 182, 51.7%), DDS (n = 27, 51.9%, p = 0.005). Coagulation unstable: No surgery (n = 53, 74.6%), NDS (n =34, 75.6%), IDS (n = 21, 87.5%), SDS (n = 158, 73.8%), DDS (n = 20, 74.1). Unstable soft tissue status significantly lower in SDS(n = 83, 68.0%) compared with DDS(n = 18, 85.7%), NDS(n = 32, 94.1%), or No surgery(n = 67, 85.9%, p = 0.03).

Conclusion
Among the four cycles, soft tissue (brain injury, lung contusion, abdominal injury, pelvic and crush injuries) outweighed the others in delay of early definitive fracture fixation.

Introduction: Problems associated with treatment of infected non-union of long bones are multiple surgeries/hospitalization, prolonged treatment, high morbidity, financial burden, unsure results, high rate of functional disability and sometimes amputation. Single stage definitive treatment can reduce these complications by simultaneously providing both, stability (for fracture) and local high concentration of antibiotic (to eradicate infection), which can be done by Antibiotic Cement impregnated intramedullary K- nail. Material and methods: We treated 60 (48 tibia and 12 femur) patients of infected non-union of long bones with antibiotic cement impregnated intramedullary K nail (ACIN) with bone defect less than 2 cm. Functional results were evaluated with regard to control of infection, bony union using RUST score, clinical assessment of fracture union, deformity and complications. Results: Mean age was 35.4 year (age 18 yrs – 60 yrs). Union without infection was achieved in all cases except 4, in mean duration of 6.3 months (range 4 to 8 months). Mean duration for infection control was 3.7 weeks (range 2.1 to 8 weeks). 5 patients needed split thickness skin graft for wound closure. Mean follow up period was 16 months (range 12 to 34 months). Conclusion : Single stage ACINs provide simultaneously high concentration of antibiotics locally and mechanical stability which leads to good infection control, promotes bone union that to without any deformity.

Background:
Combined ipsilateral femoral neck and shaft fractures are rare and present a challenging management dilemma. This study aimed to assess the outcome of concomitant fixation of the ipsilateral femoral neck and shaft fracture using single versus double surgical implants.
Methods:
A single-center retrospective analysis of patients who underwent fixation of ipsilateral femoral neck and shaft fractures was performed over a 13-years period. Different techniques were employed to fix the complex injury. Both the reduction and the union time were assessed radiographically.
Results A total of 36 patients with ipsilateral femoral neck and shaft fractures were retrospectively identified and included in this study. Twenty-four patients (66.6%) were managed with a single cephalomedullary nail, while the remaining cases were treated with two devices. All cases were operated upon within an average of 3.7 ± 7.1 days. Eight patients (22.2%) developed postoperative complications. The average follow-up period was 7.3 ± 6.8 months. There was no statistically significant difference between the two groups, however, the femoral neck fractures showed shorter union time in patients treated with one implant compared to patients treated with two implants (3.0 ± 2.3 months vs. 4.2 ± 2.6 months). Another observation is that higher percentages of implant removal/failure and malunion/nonunion were seen in patients who had one implant compared to the two implants group (12.5% vs. 8.3%).
Conclusion:
Early surgical fixation of both fractures is associated with good outcome results. No difference in outcome was observed between both groups.

Introduction: Proximal tibia fractures are complex articular injuries .These fractures are difficult to characterise, quantify and treat. Luo et al. published a new classification system-
three column specific fixation concept: which is dependent on the understanding of the fractures using CT scans.
Schatzker came up with a new classification system using 2D and 3D CT scan images. Aim of the study was to assess and compare the inter observer reliability and intra observer repeatability of New Schatzker and Three column classification of Proximal tibia fractures.
Methods: 100 Patients with proximal tibia fractures who underwent CT scan were evaluated by three independent orthopaedic surgeons with different years of experience. Fractures were all classified into New Schatzker and three column classification systems and were evaluated in a randomised and blinded fashion at a remote time. Kappa coefficients are used to test statistical reliability and the Kappa values are interpreted according to the categorical rating by Landis and Koch.
Results: With New Schatzker classification, The level of agreement between observer A and B was found to be highest with 96.9% agreement and Kappa values of 0.9156 suggesting almost perfect agreement better than Luo's classification. Intraobserver reliability with New Schatzker was better than Luo's classification.
Conclusion: Our study concludes that both Luo’s three column classification and New Schatzker classification are accurate and surgeons need to understand them and implement to reduce variability over time. New Schatzker classification was found to be more accurate in knowing the fracture pattern and knowing the spatial location.

Background: We have developed a novel surgical technique using locking compression miniplates in a combination of long locking screws or cannulated screws in treatment of multifragmentary, comminuted patellar fracture.
Methods: We retrospectively reviewed the medical and radiologic records of patients who were surgically treated with locking compression miniplates for patellar fracture from June 2018 to November 2011. Primary outcome was bone union, and secondary outcomes were postoperative complications associated with procedure. Functional outcomes included Lysholm scores and range of motion.
Results: A total of 20 patients with AO/OTA 23-C 2 and 3 patellar fracture were followed up for an average of 15 months (range: 11~18). Primary fracture union healing was seen in 19 out of 20 patients (95%), and an average time to bone union was 15.6 weeks (range 10~40). There were no fixation failure or postoperative infection. All of the patients achieved the postoperative average ROM of 120 degrees, and the mean Lysholm score at the final follow-up was 90.4
Conclusion: Multiple interfragmentary fixation with miniplates is a versatile, low-profile, and effective surgical technique for comminuted patella fracture.

Keywords: comminuted patella fracture, locking compression miniplates

Background: This study aimed to evaluate the clinical, radiological and functional outcome following the use of uniaxial and polyaxial locking plates to treat proximal tibia fractures. Methods: This study enrolled 40 patients with proximal tibia fractures (AO/ OTA 41 B-C) and an indication for locking plate osteosynthesis. Fractures were classified according to the Schatzker and Luo classification, and patients were grouped as Low grade (Schatzker 1, 2 and 3) and High grade (Schatzker 4, 5 and 6). Patients were then randomized for fixation into uniaxial vs polyaxial locking plate groups. After a time interval of 3, 6 and 12 months postoperatively, we conducted clinical (Range of motion and the Rasmussen score), radiological (Rasmussen Radiological score) and functional (Knee Society functional score and Knee Injury and Osteoarthritis Outcome Score) follow-ups. Results: A total of 32 high grade and eight low grade fractures predominantly in young males (M:F:: 37:3) randomized into the polyaxial and the uniaxial group (20 in each) were included in our study. Polyaxial plating groups needed a shorter OT time and were associated with less radiation exposure. Both groups showed no significant difference in follow up clinical, radiological and functional scores. Conclusion: Monoaxial and polyaxial screw insertion allow for mechanical stabilization in the plating of intra-articular proximal tibia fractures. Uniaxial and polyaxial implants are associated with comparable clinical, radiological and functional outcomes. Besides providing ease of screw application, no benefit was found in polyaxial over uniaxial plating in proximal tibia fractures.

Introduction: The mainstay of management of subtrochanteric femoral fractures is a cephalomedullary nail (CMN). The main designs of CMNs are single-lag or dual-lag screw constructs. CMNs can be complicated by screw cut-out and mechanical implant failure. Theoretically, dual-lag CMNs are able to withstand higher torsional forces and have increased surface contact area. The aims of our study are to identify the failure rates between the Stryker Gamma3 (single-lag) and T2 Recon (dual-lag) CMN systems in the management of subtrochanteric fractures.

Methods: A retrospective audit identified 199 patients who had undergone CMN fixation for subtrochanteric fractures between 2000-2021. Baseline demographics, mechanism of injury, comorbidities and type of fixation were recorded. Data on implant failure including location, cause, duration from index procedure and subsequent management were also recorded.

Results: Our patient cohort was mostly female, with a mean age of 78 years. 81 patients were treated with a Gamma3 CMN and 118 with a T2 Recon CMN. Most fractures were due to low energy trauma. Although not statistically significant, pathological fractures were more common in the T2 Recon nail group. 5 failures (0.02%) were identified in our cohort (3 Gamma vs 2 T2 Recon). All failures were due to non-union, occurred at the lag screw aperture, and required proximal femoral replacements for subsequent management. Mean time to failure was 279.6 days.

Conclusion: Failure rate at our institution appear similar to published data. Gamma3 CMN may potentially be at higher risk of failure. Potential risk factors for failure include diabetes and osteoporosis.

Background: limb length discrepancy can be caused in many ways one of the causes are warfare injuries especially in areas where there is war for example Afghanistan.
Objectives :Bone loss is not only a cosmetic concern but it’s also functional concern especially in lower limb, the main objective our study is how to replace the bone loss to have an equal limbs .
Methods : This descriptive study is done from 2021/01/01-2021/03/30 on 35 patients in 300 bed Police Central Hospital in Kabul .35(100%) patients had lower limb discrepancy 30(85.71%) patients were male ,age 12-35 years. 5(14.28%) patients were females, age 15-35 years. The procedure of lengthening in 4(11.42% ) patients with Intramedullary nailing along with Ilizarov , 5(14.28% )patients with Ilizarov external fixator and 26(74.28% ) patients with Nasir Awais external fixators. According to the cause of bone lose, 8(22.85%) patients Mine explosions and 22(62.85%) patients due to Gun shout injuries and 5(14.28%)patients due to RTA.
Results: 35 patients with limb length discrepancy ranging from 5-13 cms average was 7cm that were included in this study.
A: 22(62.85%) Excellent result.
B: 7(20%) good results.
C: 4(11.42%) poor results.
D: 2(5.71%) complications.
Majority of our patients were male and with G.S and Mine explosion and Tibia ware affected more than Femure.
Conclusion: we used Nasir Awais External fixators more than others because it’s more easy to apply in a short time with simple technique of distraction and is with little joints and muscles stiffness and little training.

Introduction
The aim of this study was to assess factors that allow definitive surgical stabilization in polytrauma patients with severe TBI.

Methods
Retrospective cohort study polytrauma patients defined by an ISS of >16 and require ICU. Polytrauma patients with severe TBI as AIS head of >3. Exclusion:early death (<72hours), geriatric(>70years). Stratified into early (within 48 hours) and delayed (after 48hours) group according timepoint of first definitive surgical treatment.

Results
225 polytrauma patients with severe TBI, 123(87.2%) survived 72 hours and 91(73.9%) had at least one definitive surgical fixation. 13(14.3%) were in Group delayed, and 78(85.7%) in Group early. Both groups comparable in ISS, lactate, and coagulation. Risk factors for early death: ISS, coagulopathy, shock, hypothermia.
Patients in Group early with significantly lower ICUstay (8.5 ± 5.4 days versus 15.4 ± 9.9 days, p = 0.015). Duration of assisted ventilation significantly lower (4.5 ± 6.7 days vs 11.2 ± 9.3 days, p = 0.002). Early definitive surgery associated with decreased ICU stay by 6.9 days ± 2.8. Corrected for coagulopathy, CRP and lung function, early fixation still associated with a decreased duration of ICU stay by 3.2 ± 2.1 days, p = 0.03. Mortality rate comparable (10.3% in Group early, and 15.4% in Group delayed, p = 0.945).

Conclusion
Despite severe TBI, the majority of patients qualified for early fracture fixation. Early fixation associated with shorter ICU stay without association with mortality.
Polytrauma patients without increased risk factors for early death (shock, coagulopathy, hypothermia) might benefit from SDS despite severe TBI.

Aim: To evaluate the clinical, radiographic, and functional outcomes of patients treated with ORIF with variable angle volar locking plates for displaced dorsally comminuted fractures of the distal radius. Materials and methods: Prospective, clinical research done at Tertiary care center (Level 1 trauma center) located in a large urban area. Fifty two patients with an average age of 30 years (range 20 to 50 years) were included in the study. All the patients underwent ORIF of fractures of the distal radius using variable angle locking plates. Observation: Clinical, radiographic, CT scan for intra-articular fractures and functional assessments were performed at an average follow-up of 26 months (range 12–40 months). Functional outcomes were assessed using the Gartland and Werley scoring system and DASH scoring system. Results: Satisfactory reduction was achieved in all 52 fractures at the time of operative fixation with no subsequent loss of fracture reduction during the post operative period. There were no cases of mal-union, nonunion or implant failure. We encountered 4 minor complications. No patients required reoperation. Final follow-up was at 5 years postop. Forty seven patients had an excellent (83%), 6 had a good (17%) result according to the Gartland and Werley scoring system. The mean DASH score was 4.6 (range 0–14) out of a maximum 100. Conclusion: Our findings suggest that open reduction and internal fixation with variable angle volar locking plate of the distal radius is a safe and effective treatment option for dorsally comminuted distal radius fractures.