The Effect of an Abnormal BMI on Orthopaedic Trauma Patients: A Systematic Review and Meta-Analysis

The effect of omentoplasty in various surgical operations: systematic review and meta-analysis

BACKGROUND

Omentoplasty is commonly used in various surgeries. However, its effectiveness is unsure due to lack of convincing data and research. To clarify the impact of omentoplasty on postoperative complications of various procedures, this systematic review and meta-analysis was performed.

METHODS

A systematic review of published literatures from four databases: PubMed, Web of Science, Cochrane Library, and Embase before 14 July 2022. The authors primarily included publications on five major surgical operations performed in conjunction with omentoplasty: thoracic surgery, esophageal surgery, gastrointestinal surgery, pelvi-perineal surgery, and liver surgery. The protocol was registered in PROSPERO.

RESULTS

This review included 25 273 patients from 91 studies ( n =9670 underwent omentoplasty). Omentoplasty was associated with a lower risk of overall complications particularly in gastrointestinal [relative risk (RR) 0.53; 95% CI: 0.39-0.72] and liver surgery (RR 0.54; 95% CI: 0.39-0.74). Omentoplasty reduced the risk of postoperative infection in thoracic (RR 0.38; 95% CI: 0.18-0.78) and liver surgery (RR 0.39; 95% CI: 0.29-0.52). In patients undergoing esophageal (RR 0.89; 95% CI: 0.80-0.99) and gastrointestinal (RR 0.28; 95% CI: 0.23-0.34) surgery with a BMI greater than 25, omentoplasty is significantly associated with a reduced risk of overall complications compared to patients with normal BMI. No significant differences were found in pelvi-perineal surgery, except infection in patients whose BMI ranged from 25 kg/m 2 to 29.9 kg/m 2 (RR 1.25; 95% CI: 1.04-1.50) and anastomotic leakage in patients aged over 60 (RR 0.59; 95% CI: 0.39-0.91).

CONCLUSION

Omentoplasty can effectively prevent postoperative infection. It is associated with a lower incidence of multiple postoperative complications in gastrointestinal and liver surgery.

Development of early complications after treatment of trochanteric fractures with an intramedullary sliding hip screw in a geriatric population

PURPOSE

Although trochanteric fractures (TF) are a frequent event in the geriatric population, studies reporting on complication rates associated with surgical treatment are sparse. Thus, this study investigated the relevance of fracture-, implant-, and surgery-associated complications in TF. Furthermore, the role of possible risk factors for the before mentioned complications was investigated.

METHODS

A consecutive series of patients with TF treated by intramedullary nailing with a sliding screw device was evaluated. Data were sampled retrospectively from the hospital patient information system and anonymized at the source. Demographic data and information regarding fracture pattern, the treatment performed, hospital stay, and evaluation of operative and follow-up radiographs were analyzed. Intraoperative problems (i.e., technical problems with the implant, intraoperative fracture) and postoperative complications were investigated.

RESULTS

Postoperative surgical complications were noted in 11.7%. The most frequent surgical problem was a difficult fracture reduction (13%) and intraoperative fracture dislocation (3.6%). The most frequent postoperative complication was intra-hospital mortality (3.6%), delayed/non-union (2.7%), and a cut-out of the lag screw in the femoral head (2.3%). Implant failure (1,4%) was significantly associated with morbid obesity while cut-out (2,3%) correlated with a higher tip-apex distance (TAD). A complex fracture type and a suboptimal screw position significantly increased the cut-out rate to 5% (p = 0.018).

CONCLUSION

Complications after TF treatment occur frequently. While patient-associated variables such as morbid obesity cannot be influenced by the surgeon, correct fracture reduction and implant positioning remain to be of highest importance.

Underweight patients experience higher inpatient complication and mortality rates following acetabular fracture

PURPOSE

Underweight patients experience poor outcomes after elective orthopaedic procedures. The effect of underweight body mass index (BMI) on complications after acetabular fracture is not well-described. We evaluate if underweight status is associated with inpatient complications after acetabular fractures.

METHODS

Adult patients (≥ 18 years) presenting with acetabular fracture between 2015 and 2019 were identified from Trauma Quality Program data. Adjusted odds (aOR) of any inpatient complication or mortality were compared between patients with underweight BMI (< 18.5 kg/m2) and normal BMI (18.5-25 kg/m2) using multivariable logistic regression and stratifying by age ≥ 65 years.

RESULTS

The 1299 underweight patients aged ≥ 65 years compared to 11,629 normal weight patients experienced a 1.2-times and 2.7-times greater aOR of any complication (38.6% vs. 36.6%, p = 0.010) and inpatient mortality (7.9% vs. 4.2%, p < 0.001), respectively. The 1688 underweight patients aged 18-64 years compared to 24,762 normal weight patients experienced a 1.2-times and 1.5-times greater aOR of any inpatient complication (38.9% vs. 34.8%, aOR p = 0.006) and inpatient mortality (4.1% vs. 2.5%, p < 0.001), respectively.

CONCLUSION

Underweight adult patients with acetabular fracture are at increased risk for inpatient complications and mortality, particularly those ≥ 65 years old.

LEVEL OF EVIDENCE

Prognostic Level III.

Establishment of a scoring model for the differential diagnosis of white coat hypertension and sustained hypertension

OBJECTIVES

This study aimed to establish a scoring model for the differential diagnosis of white coat hypertension (WCH) and sustained hypertension (SHT).

METHODS

This study comprised 553 adults with elevated office blood pressure, normal renal function, and no antihypertensive medications. Through questionnaire investigation and biochemical detection, 17 parameters, such as gender and age, were acquired. WCH and SHT were distinguished by 24 h ambulatory blood pressure monitoring. The participants were randomly divided into a training set (445 cases) and a validation set (108 cases). The above parameters were screened using least absolute shrinkage and selection operator regression and univariate logistic regression analysis in the training set. Afterward, a scoring model was constructed through multivariate logistic regression analysis.

RESULTS

Finally, six parameters were selected, including isolated systolic hypertension, office systolic blood pressure, office diastolic blood pressure, triglyceride, serum creatinine, and cardiovascular and cerebrovascular diseases. Multivariate logistic regression was used to establish a scoring model. The R2 and area under the ROC curve (AUC) of the scoring model in the training set were 0.163 and 0.705, respectively. In the validation set, the R2 of the scoring model was 0.206, and AUC was 0.718. The calibration test results revealed that the scoring model had good stability in both the training and validation sets (mean square error = 0.001, mean absolute error = 0.014; mean square error = 0.001, mean absolute error = 0.025).

CONCLUSION

A stable scoring model for distinguishing WCH was established, which can assist clinicians in identifying WCH at the first diagnosis.

Obesity classification predicts early complications and mortality after acetabular fracture

INTRODUCTION

Obesity remains a global epidemic. The effect of obesity on the risk of complications after acetabular fracture is unknown. Here, we evaluate the effect of BMI on early complications and mortality after acetabular fracture. We hypothesize that the risk of inpatient complications and mortality will be greater in patients with high BMI when compared to those with normal BMI.

METHODS

Adult patients with acetabular fracture were identified via the Trauma Quality Improvement Program data from 2015 to 2019. The primary outcome was overall complication rate with reference to normal-weight patients (BMI = 25-30 kg/m²). The secondary outcome was rates of death. The association of obesity class on the primary and secondary outcomes was assessed using Bonferroni-corrected multiple logistic regression models considering patient, injury, and treatment covariates.

RESULTS

A total of 99,721 patients with acetabular fracture were identified. Class I obesity (BMI = 30-35 kg/m²) was associated with 1.2 greater adjusted relative risk (aRR; 95% confidence interval (CI) 1.1-1.3) of any adverse event, without significant increases in adjusted risk of death. Class II obesity (BMI = 35-40 kg/m²) was associated with aRR = 1.2 (95% CI 1.1-1.3) of any adverse event and aRR = 1.5 (95% CI 1.2-2.0) of death. Class III obesity (BMI ≥ 40 kg/m²) was associated with aRR = 1.3 (95% CI 1.2-1.4) of any adverse event and aRR = 2.3 (95% CI 1.8-2.9) of death.

CONCLUSION

Obesity is associated greater risk of adverse events and death following acetabular fracture. Obesity severity classification scales with these risks.

Which external fixation method is better for the treatment of tibial shaft fractures due to gunshot injury?

INTRODUCTION

The present study aimed to evaluate the functional and radiological outcomes of AO type monolateral external fixator (AO-EF) and Ilizarov type external fixator (I-EF) in definitive fixation of tibial shaft fractures due to gunshot injury.

HYPOTHESIS

Patients undergoing I-EF would have faster fracture healing with the help of early weight-bearing and the functional scores would be better compared to AO-EF.

MATERIAL AND METHODS

The study consisted of 76 (67M, 9F) patients who underwent surgery between 2010 and 2016 for tibial shaft fracture due to low-velocity gunshot injury (LVGI). The patients were divided into two groups according to the fixation method (AO-EF and I-EF) which was discussed by the surgeon team due to their experience. The average age at the time of injury was 37.8±9.8 (20 to 59 years). Groups are compared according to LEFS score, coronal-sagittal-rotational angle, Johner-Rush score, and complications such as nonunion, malunion, osteomyelitis, and pin-tract infection. The mean follow-up time 31.61±3.83 months (between 24 and 44 months).

RESULTS

No statistical difference was found between groups in terms of demographic characteristics. There was no statistical difference between groups regarding body mass index (BMI). LEFS score and operation duration were higher in the I-EF group (p=0.000 and p=0.006 respectively, p˂0.05). In the I-EF group, hospitalization period, full weight-bearing time, and healing time was shorter than the AO-EF group (p=0.001, p=0.000, and p=0.025 respectively, p˂0.05).

DISCUSSION

Although AO-EF has advantages such as ease of application and short surgery time in the definitive fixation of LVGI tibia shaft fractures, I-EF is a superior technique in terms of functional scores. However, I-EF is a surgical approach that requires relatively more experience. Therefore, the choice of fixator should be determined according to the surgeon's experience in the permanent treatment of LVGI tibial shaft fractures.

LEVEL OF EVIDENCE

IV; retrospective, case-control study.

The impact of body mass index on mortality rates of hip fracture patients: a systematic review and meta-analysis

Obesity has been recognized as a global epidemic as approximately one-third of the world's population. Findings on early and late mortality rates between obese, overweight, and underweight vs normal body mass index (BMI) patients confirm that the obese and overweight patients were found to have lower risk and underweight patients were found to have increased risk of mortality as compared to normal weighted patients. It is unclear if the "obesity paradox" exists with survival outcomes of hip fracture patients. We hereby reviewed early (in-hospital and 30-day mortality) and late mortality (≥ 1-year) rates between obese, overweight, and underweight vs normal body mass index (BMI) patients with hip fractures. PubMed, Embase, ScienceDirect, CENTRAL, and Google Scholar were searched for studies reporting mortality rates of hip fracture patients based on BMI. We pooled crude and adjusted mortality rates in a random-effects model. Eleven studies were included. Meta-analysis indicated significantly reduced risk of early (RR: 0.64 95% CI: 0.59, 0.69 I² = 0% p < 0.00001) and late mortality rates (RR: 0.78 95% CI: 0.67, 0.91 I² = 93% p = 0.002) in obese vs normal BMI patients. Meta-analysis failed to demonstrate any statistically significant difference in early mortality (RR: 0.90 95% CI: 0.54, 1.53 I² = 44% p = 0.71) but significantly reduced risk of late mortality in overweight vs normal BMI patients (RR: 0.85 95% CI: 0.73, 0.93 I² = 84% p = 0.003). Scarce data suggested increased risk of early (RR: 1.44 95% CI: 1.08, 1.93 I² = 26% p = 0.01) and late mortality (RR: 1.23 95% CI: 1.08, 1.41 I² = 7% p = 0.002) in underweight vs normal BMI patients. Adjusted data corroborated the reduced risk of mortality in overweight (HR: 0.78 95% CI: 0.74, 0.83 I² = 0% p < 0.0001) and obese patients (HR: 0.66 95% CI: 0.60, 0.73 I² = 0% p < 0.0001). Our results indicate that the "obesity paradox" exists with survival outcomes of hip fracture patients. Obese and overweight patients were found to have lower risk and underweight patients were found to have increased risk of mortality as compared to normal weighted patients.

'The Armor Phenomenon' in Obese Patients with Penetrating Thoracoabdominal Injuries: A Systematic Review and Meta-Analysis

BACKGROUND

Obesity represents a growing global health threat, which generally portends increased morbidity and mortality in the context of traumatic injuries. We hypothesized that there may exist a protective effect related to increased weight and truncal girth provided for obese patients in penetrating torso injuries, although this may not exert a significant positive impact overall upon clinical outcomes.

METHODS

A comprehensive review of the literature was conducted across five databases up to March 2021 (Medline, Pubmed, Embase, Web of Science and the Cochrane library) to examine the effect of obesity on penetrating thoracoabdominal injuries. The primary outcome was to determine the rate of non-significant injury and injury patterns. Secondary outcomes examined were lengths of stay, complications, and mortality. Comparisons were drawn by meta-analysis. The study protocol was registered with PROSPERO under CRD42020216277.

RESULTS

2,952 publications were assessed with twelve meeting the inclusion criteria for review. Nine studies were included for quantitative analysis including 5,013 patients sustaining penetrating thoracoabdominal injuries, of which 29.6% were obese. Obese patients that sustained stab injuries underwent more non-therapeutic operations. Obese patients that sustained gunshot injuries had longer intensive care and total hospital length of stay. Obese patients suffered more respiratory complications and were at an increased risk of death during their admission.

CONCLUSION

The 'armor phenomenon' does not truly protect obese patients, a population that experiences increased morbidity and mortality following penetrating thoracoabdominal injuries.

LEVEL OF EVIDENCE

Systematic Review and Meta-Analysis, prognostic Level III.

Treatment of tibial shaft nonunion with a retained nail in morbidly obese patients

PURPOSE

Morbid obesity is a rising worldwide health problem. Tibial shaft nonunion with retained intramedullary nail (IMN) in the morbidly obese is a challenging orthopaedic problem. Prolonged immobilization carries a significant risk of complications. This study aimed to investigate whether decortication and cancellous bone grafting with the application of a circular external fixator (CEF) over the preexisting IMN can achieve fracture union and avoid serious complications.

METHODS

We retrospectively reviewed 27 consecutive morbidly obese patients treated for tibial diaphysis aseptic nonunion after failed IMN. All cases were treated with osteoperiosteal decortication, cancellous bone grafting, and fixation with CEF over the IMN. Peri-operative multidisciplinary patient evaluation included internal medicine, cardiology, chest, vascular surgery, and anesthesia consultations. The union rate, bone results, functional results, and complications were recorded.

RESULTS

The mean age of the patients was 37.9 years. The mean BMI was 45.8. Sixteen cases (59.3%) were treated for hypertrophic nonunion, while 11 cases (40.7%) were treated for atrophic nonunion. Seven cases (25.9%) had open initial injury, 14 cases (51.9%) had associated comorbidities, and seven cases (25.9%) were smokers. Twenty-six cases united. The mean time to union was 5.2 months. Bone results and functional results were good to excellent in 96.3% of the cases. We recorded 25 complications in 21 patients. However, most of the complications were minor.

CONCLUSION

Decortication and cancellous bone grafting with the application of CEF over the preexisting nail is a safe and reliable treatment method for aseptic tibial shaft nonunion with retained IMN in morbidly obese patients.

Are the rib fracture score and different computed tomography measures of obesity predictors for mortality in patients with rib fractures? A retrospective cohort study

Background

There is missing knowledge about the association of obesity and mortality in patients with rib fractures. Since the global measure of obesity (body mass index [BMI]) is often unknown in trauma patients, it would be convenient to use local computed tomography (CT)-based measures (e.g., umbilical outer abdominal fat) as a surrogate. The purpose of this study was to assess (1) whether local measures of obesity and rib fractures are associated with mortality and abdominal injuries and to evaluate (2) the correlation between local and global measures of obesity.

Materials and methods

A retrospective cohort study included all inpatients with rib fractures in 2013. The main exposure variable was the rib fracture score (RFS) (number of rib fractures, uni- or bilateral, age). Other exposure variables were CT-based measures of obesity and BMI. The primary outcome (endpoint) was in-hospital mortality. The secondary outcome consisted of abdominal injuries. Sex and comorbidities were adjusted for with logistic regression.

Results

Two hundred and fifty-nine patients (median age 55.0 [IQR 44.0–72.0] years) were analyzed. Mortality was 8.5%. RFS > 4 was associated with 490% increased mortality (OR_adjusted = 5.9, 95% CI 1.9–16.6, p = 0.002). CT-based measures and BMI were not associated with mortality, rib fractures or injury of the liver. CT-based measures of obesity showed moderate correlations with BMI (e.g., umbilical outer abdominal fat: r = 0.59, p < 0.001).

Conclusions

RFS > 4 was an independent risk factors for increased mortality. Local and global measures of obesity were not associated with mortality, rib fractures or liver injuries. If the BMI is not available in trauma patients, CT-based measures of obesity may be considered as a surrogate.

Multicenter evaluation of therapeutic strategies of inpatients with osteoporotic vertebral fractures in Germany

PURPOSE

The aim of this study was to assess therapeutic strategies of inpatients with osteoporotic thoracolumbar fractures (OTF) in Germany.

METHODS

Prospective multi-center study including 16 German-speaking trauma centers over a period of 7 months. All inpatients with OTF were included. Radiological and clinical data on admission and treatment modalities were assessed.

RESULTS

Seven hundred and seven (99.3%) out of 712 included patients (73.3% female) could be evaluated. Mean age was 75 years (30-103). 51.3% could not remember any traumatic incident. Fracture distribution was from T2 to L5 with L1 (19%) most commonly affected. According to the Magerl classification type A1 (52.1%) and A3 (42.7%) were most common. B and C type injuries (2.6%) and neurological deficits (3.1%) were rare. Previous progression of vertebral deformation was evident in 34.4% of patients and related to t score below - 3 (Odds ratio 1.9661). Patients presented with anticoagulation medication (15.4%), dementia (13%), and ASA score > 3 (12.4%) frequently. 82.3% of patients complained of pain > 4 on VAS, 37% could not be mobilized despite pain medication according to grade II WHO pain ladder. 81.6% received operative treatment. Kyphoplasty (63.8%) and hybrid stabilization including kyphoplasty with (14.4%) or without screw augmentation (7.6%) were the techniques most frequently used. Invasiveness of treatment increased with degree of instability.

CONCLUSIONS

OTF are mostly type A compression fractures. Patients suffer from severe pain and immobilization frequently. Progression of deformity is correlated to t score below - 3. Treatment of inpatients is mainly surgical, with kyphoplasty followed by hybrid stabilization as commonly used techniques.

The Prognostic Value of Body Mass Index in Patients With Urothelial Carcinoma After Surgery: A Systematic Review and Meta-Analysis

Background:

The clinical evidence of body mass index (BMI) for survival has increased in urothelial carcinoma (UC). This study aimed to investigate the prognostic value of BMI on the oncologic outcomes of patients with UC after surgery.

Methods:

The systematic review and meta-analysis was performed using Pubmed, Embase and Cochrane Library. We collected hazard ratio (HR) and 95% confidence interval (CI) on cancer specific survival (CSS), overall survival (OS) and recurrence-free survival (RFS) from the studies including upper tract urothelial carcinoma (UTUC) and urothelial carcinoma of bladder (UCB).

Results:

A total of 13 studies comprising over 12,200 patients were enrolled in the quantitative synthesis. Compared with normal weight, overweight was associated with better CSS (HR = 0.87, 95% CI: 0.79-0.95) and RFS (HR = 0.86, 95% CI: 0.78-0.96). Meanwhile, we found that obese patients had worse CSS (HR = 1.14, 95%CI: 1.03-1.26), OS (HR = 1.31, 95% CI: 1.19-1.44) and RFS (HR = 1.24, 95% CI: 1.12-1.37). We observed that underweight was associated with inferior CSS (HR = 1.87, 95% CI: 1.54-2.26) in UTUC patients.

Conclusions:

Overweight was a protective factor for patients with UC after surgery, while obesity and underweight predicted unfavorable survival. Individual BMI may be considered for prognostication after surgeries and patient stratification for clinical trials.