Does Local Aqueous Tobramycin Injection Reduce Open Fracture-Related Infection Rates?

OBJECTIVES

To examine the effect of local aqueous tobramycin injection adjunct to perioperative intravenous (IV) antibiotic prophylaxis in reducing fracture-related infections (FRIs) following reduction and internal fixation of open fractures.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Single academic Level I trauma center.

PATIENTS SELECTION CRITERIA

Patients with open extremity fractures treated with reduction and internal fixation with (intervention group) or without (control group) 80 mg of local aqueous (2 mg/mL) tobramycin injected during closure at the time of definitive fixation were identified from December 2018 to August 2021 based on population-matched demographic and injury characteristics.

OUTCOME MEASURES AND COMPARISONS

The primary outcome was FRI within 6 months of definitive fixation. Secondary outcomes consisted of fracture nonunion and bacterial speciation. Differences in outcomes between the 2 groups were assessed and logistic regression models were created to assess the difference in infection rates between groups, with and without controlling for potential confounding variables, such as sex, fracture location, and Gustilo-Anderson classification.

RESULTS

An analysis of 157 patients was performed with 78 patients in the intervention group and 79 patients in the control group. In the intervention group, 30 (38.5%) patients were women with a mean age of 47.1 years. In the control group, 42 (53.2%) patients were women with a mean age of 46.4 years. The FRI rate was 11.5% in the intervention group compared with 25.3% in the control group ( P = 0.026). After controlling for sex, Gustilo-Anderson classification, and fracture location, the difference in FRI rates between groups remained significantly different ( P = 0.014).

CONCLUSIONS

Local aqueous tobramycin injection at the time of definitive internal fixation of open extremity fractures was associated with a significant reduction in FRI rates when administered as an adjunct to intravenous antibiotics, even after controlling for potential confounding variables.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Safety of Magnetic Resonance Imaging in Orthopaedic Trauma Patients With External Fixation: A Two-Center Case Series

OBJECTIVES

To report on adverse events during magnetic resonance imaging (MRI) in patients with external fixators.

METHODS

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DESIGN

Retrospective case series.

SETTING

Two Level 1 trauma centers.

PATIENT SELECTION CRITERIA

Patients with external fixators on the appendicular skeleton or pelvis undergoing MRI between January 2005 and September 2023.

OUTCOME MEASURES AND COMPARISONS

Adverse events, defined as any undesirable event associated with the external fixator being inside or outside the MRI bore during imaging, including (subjective) heating, displacement or pullout of the external fixator, or early MRI termination for any reason.

RESULTS

A total of 97 patients with 110 external fixators underwent at least one MRI scan with an external fixator inside or outside of the MRI bore. The median age was 51 years (interquartile range: 39-63) and 56 (58%) were male. The most common external fixator locations were the ankle (24%), knee (21%), femur (21%), and pelvis (19%). The median duration of the MRI was 40 minutes (interquartile range: 26-58), 86% was performed using 1.5-Tesla MRI, and 14% was performed using 3.0-Tesla MRI. Ninety-five percent of MRI was performed for the cervical spine/head. Two MRI scans (1.6%), one of the shoulder and one of the head and cervical spine, with the external fixator outside of the bore were terminated early because of patient discomfort. There were no documented events of displacement or pullout of the external fixator.

CONCLUSIONS

These findings suggest that MRI scans of the (cervical) spine and head can be safely obtained in patients with external fixators on the appendicular skeleton or pelvis. Given the low numbers of MRI scans performed with the external fixator inside the bore, additional studies are necessitated to determine the safety of this procedure. The results from this study can aid orthopaedic surgeons, radiologists, and other stakeholders in developing local institutional guidelines on MRI scanning with external fixators in situ.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Operative and Nonoperative Management of Elderly Fragility Pelvic Ring Fractures

OBJECTIVES

To compare outcomes of nonoperative and percutaneous fixation of geriatric fragility lateral compression 1 (LC1) pelvic ring fractures.

METHODS

DESIGN

Retrospective.

SETTING

Two level 1 trauma centers.

PATIENT SELECTION CRITERIA

Included were patients who were 60 years or older with an isolated LC1 pelvic ring fracture managed nonoperatively or those who failed mobilization and were managed operatively with percutaneous sacral fixation. Patients with high-energy mechanisms of injury or polytrauma were excluded.

OUTCOME MEASURES AND COMPARISONS

The primary outcome was pain as measured by using the visual analog scale (VAS) after treatment. Secondary outcomes included length of stay, discharge disposition, mortality, readmission rates, and complications.

RESULTS

In total, 231 patients were included with a mean age of 79.5 years (range 60-100). One hundred eighty-five (80.0%) patients were female. Sixty-two (26.8%) patients received percutaneous sacral fixation after failed mobilization, and 169 (73.2%) were managed nonoperatively. In the operative group, the median time to surgery was hospital day 4. Nonoperative patients were older (81.5 ± 10.0 years vs. 74.2 ± 9.4 years, P < 0.01) and had a shorter hospital length of stay (4.8 ± 6.2 days) than the operative group (10.6 ± 9.5 days, P < 0.01). Patients in the operative group had more pain (VAS 7.9 ± 3.0) than those in the nonoperative group (VAS 6.6 ± 3.0) ( P = 0.01) on admission but had similar pain control postoperatively (VAS 4.4 ± 3.0) compared with the nonoperative group (VAS 4.5 ± 3.6) on the equivalent hospital day ( P = 0.91). Thus, patients in the operative group experienced more improvement in pain (VAS 3.3 ± 2.7) compared with the nonoperative group (VAS 1.9 ± 3.9) after treatment ( P = 0.02). Ninety-day mortality ( P = 0.21) and readmission rates ( P = 0.27) were similar for both groups. Two patients in the operative cohort sustained nerve injuries, whereas 1 patient in the nonoperative group had a nonunion and underwent surgery.

CONCLUSIONS

Patients who undergo percutaneous surgical fixation for low-energy LC1 injuries have similar discharge disposition, mortality, complication rates, and readmission rates compared with patients treated nonoperatively. Percutaneous surgical fixation may provide significant pain relief for patients who failed conservative management.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Cadaveric Study: Does Ankle Positioning Affect the Quality of Anatomic Syndesmosis Reduction?

OBJECTIVE

The objective of this study was to compare the quality of syndesmotic reduction with the ankle in maximal dorsiflexion versus neutral plantarflexion (normal resting position).

METHODS

Baseline computed tomography (CT) imaging of 10 cadaveric ankle specimens from 5 donors was obtained with the ankles placed in normal resting position. Two fellowship-trained orthopaedic surgeons disrupted the syndesmosis of each ankle specimen. All ankles were then placed in neutral plantarflexion and were subsequently reduced with thumb pressure under direct visualization through an anterolateral approach and stabilized with one 0.062-inch K-wire placed from lateral to medial in a quadricortical fashion across the syndesmosis. Postreduction CT scans were then obtained with the ankle in normal resting position. This process was repeated with the ankles placed in maximal dorsiflexion during reduction and stabilization. Postreduction CT scans were then obtained with the ankles placed in normal resting position. All postreduction CT scans were compared with baseline CT imaging using mixed-effects linear regression with significance set at P < 0.05.

RESULTS

Syndesmotic reduction and stabilization in maximal dorsiflexion led to increased external rotation of the fibula compared with baseline scans [13.0 ± 5.4 degrees (mean ± SD) vs. 7.5 ± 2.4 degrees, P = 0.002]. There was a tendency toward lateral translation of the fibula with the ankle reduced in maximal dorsiflexion (3.3 ± 1.0 vs. 2.7 ± 0.7 mm, P = 0.096). No other statistically significant differences between measurements of reduction with the ankle placed in neutral plantarflexion or maximal dorsiflexion compared with baseline were present (P > 0.05).

CONCLUSIONS

Reducing the syndesmosis with the ankle in maximal dorsiflexion may lead to malreduction with external rotation of the fibula. There was no statistically significant difference in reduction quality with the ankle placed in neutral plantarflexion compared with baseline. Future studies should assess the clinical implications of ankle positioning during syndesmotic fixation.

Nonoperative Treatment of Humeral Shaft Fractures With Immediate Functional Bracing Versus Coaptation Splinting and Delayed Functional Bracing: A Retrospective Study

OBJECTIVES

To compare radiographic and clinical outcomes in nonoperative management of humeral shaft fractures treated initially with coaptation splinting (CS) followed by delayed functional bracing (FB) versus treatment with immediate FB.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Academic Level 1 Trauma Center.

PATIENT SELECTION CRITERIA

Patients with closed humeral shaft fractures managed nonoperatively with initial CS followed by delayed FB or with immediate FB from 2016 to 2022. Patients younger than 18 years and/or with less than 3 months of follow-up were excluded.

OUTCOME MEASURES AND COMPARISONS

The primary outcome was coronal and sagittal radiographic alignment assessed at the final follow-up. Secondary outcomes included rate of failure of nonoperative management (defined as surgical conversion and/or fracture nonunion), fracture union, and skin complications secondary to splint/brace wear.

RESULTS

Ninety-seven patients were managed nonoperatively with delayed FB (n = 58) or immediate FB (n = 39). Overall, the mean age was 49.9 years (range 18-94 years), and 64 (66%) patients were female. The immediate FB group had less smokers ( P = 0.003) and lower incidence of radial nerve palsy ( P = 0.025), with more proximal third humeral shaft fractures ( P = 0.001). There were no other significant differences in demographic or clinical characteristics ( P > 0.05). There were no significant differences in coronal ( P = 0.144) or sagittal ( P = 0.763) radiographic alignment between the groups. In total, 33 (34.0%) humeral shaft fractures failed nonoperative management, with 11 (28.2%) in the immediate FB group and 22 (37.9%) in the delayed FB group ( P = 0.322). There were no significant differences in fracture union ( P = 0.074) or skin complications ( P = 0.259) between the groups.

CONCLUSIONS

This study demonstrated that nonoperative treatment of humeral shaft fractures with immediate functional bracing did not result in significantly different radiographic or clinical outcomes compared to treatment with CS followed by delayed functional bracing. Future prospective studies assessing patient-reported outcomes will further guide clinical decision making.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does Scheduled Low-Dose Short-Term NSAID (Ketorolac) Modulate Cytokine Levels After Orthopaedic Polytrauma? A Secondary Analysis of a Randomized Clinical Trial

OBJECTIVES

To determine whether scheduled low-dose, short-term ketorolac modulates cytokine concentrations in orthopaedic polytrauma patients.

METHODS

DESIGN

Secondary analysis of a double-blinded, randomized controlled trial.

SETTING

Single Level I trauma center from August 2018 to October 2022.

PATIENT SELECTION CRITERIA

Orthopaedic polytrauma patients between 18 and 75 years with a New Injury Severity Score greater than 9 were enrolled. Participants were randomized to receive 15 mg of intravenous ketorolac every 6 hours for up to 5 inpatient days or 2 mL of intravenous saline similarly.

OUTCOME MEASURES AND COMPARISONS

Daily concentrations of prostaglandin E2 and interleukin (IL)-1a, IL-1b, IL-6, and IL-10. Clinical outcomes included hospital and intensive care unit length of stay, pulmonary complications, and acute kidney injury.

RESULTS

Seventy orthopaedic polytrauma patients were enrolled, with 35 participants randomized to the ketorolac group and 35 to the placebo group. The overall IL-10 trend over time was significantly different in the ketorolac group ( P = 0.043). IL-6 was 65.8% higher at enrollment compared to day 3 ( P < 0.001) when aggregated over both groups. There was no significant treatment effect for prostaglandin E2, IL-1a, or IL-1b ( P > 0.05). There were no significant differences in clinical outcomes between groups ( P > 0.05).

CONCLUSIONS

Scheduled low-dose, short-term, intravenous ketorolac was associated with significantly different mean trends in IL-10 concentration in orthopaedic polytrauma patients with no significant differences in prostaglandin E2, IL-1a, IL-1b, or IL-6 levels between groups. The treatment did not have an impact on clinical outcomes of hospital or intensive care unit length of stay, pulmonary complications, or acute kidney injury.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

The Hawkins Sign of the Talus: The Impact of Patient Factors on Prediction Accuracy

BACKGROUND

Osteonecrosis is a complication of talar neck fractures associated with chronic pain and poor functional outcomes. The Hawkins sign, the radiographic presence of subchondral lucency seen in the talar dome 6 to 8 weeks after trauma, is a strong predictor of preserved talar vascularity. This study sought to assess the accuracy of the Hawkins sign in a contemporary cohort and assess factors associated with inaccuracy.

METHODS

A retrospective review of talar neck fractures at a level-I trauma center from 2008 to 2016 was conducted. Both the Hawkins sign and osteonecrosis were evaluated on radiographs. The Hawkins sign was determined on the basis of radiographs taken approximately 6 to 8 weeks after injury, whereas osteonecrosis was determined based on radiographs taken throughout follow-up. The Hawkins sign accuracy was assessed using proportions with 95% confidence intervals (CIs), and associations were examined with Fisher exact testing.

RESULTS

In total, 105 talar neck fractures were identified. The Hawkins sign was observed in 21 tali, 3 (14% [95% CI, 3% to 36%]) of which later developed osteonecrosis. In the remaining 84 tali without a Hawkins sign, 32 (38% [95% CI, 28% to 49%]) developed osteonecrosis. Of the 3 tali that developed osteonecrosis following observation of the Hawkins sign, all were in patients who smoked.

CONCLUSIONS

A positive Hawkins sign may not be a reliable predictor of preserved talar vascularity in all patients. We identified 3 patients with a positive Hawkins sign who developed osteonecrosis, all of whom were smokers. Factors impairing the restoration of microvascular blood supply to the talus may lead to osteonecrosis despite the presence of preserved macrovascular blood flow and an observed Hawkins sign. Further research is needed to understand the factors limiting Hawkins sign accuracy.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Talar Neck Fractures With Associated Ipsilateral Foot and Ankle Fractures Have a Higher Risk of Avascular Necrosis

OBJECTIVES

To determine if talar neck fractures with concomitant ipsilateral foot and/or ankle fractures (TNIFAFs) are associated with higher rates of avascular necrosis (AVN) compared with isolated talar neck fractures (ITNs).

METHODS

DESIGN

Retrospective cohort.

SETTING

Single level I trauma center.

PATIENT SELECTION CRITERIA

Skeletally mature patients who sustained talar neck fractures from January 2008 to January 2017 with at least 6-month follow-up. Based on radiographs at the time of injury, fractures were classified as ITN or TNIFAF and by Hawkins classification.

OUTCOME MEASURES AND COMPARISONS

The primary outcome was the development of AVN based on follow-up radiographs, with secondary outcomes including nonunion and collapse.

RESULTS

There were 115 patients who sustained talar neck fractures, with 63 (55%) in the ITN group and 52 (45%) in the TNIFAF group. In total, 63 patients (54.7%) were female with the mean age of 39 years (range, 17-85), and 111 fractures (96.5%) occurred secondary to high-energy mechanisms of injury. There were no significant differences in demographic or clinical characteristics between groups ( P > 0.05). Twenty-four patients (46%) developed AVN in the TNIFAF group compared with 19 patients (30%) in the ITN group ( P = 0.078). After adjusting for Hawkins classification and other variables, the odds of developing AVN was higher in the TNIFAF group compared with the ITN group [odds ratio, 2.43 (95% confidence interval, 1.01-5.84); ( P = 0.047)].

CONCLUSIONS

This study found a significantly higher likelihood of AVN in patients with talar neck fractures with concomitant ipsilateral foot and/or ankle fractures compared to those with isolated talar neck fractures after adjusting for Hawkins classification and other potential prognostic confounders.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Reuse of Surgical Masks During the COVID-19 Shortage: Association with the Incidence of Surgical Site Infections

The association between the reuse of surgical masks (SMs) for multiple procedures and rates of surgical site infections (SSIs) is unclear. Hence, the purpose of this study was to determine whether a policy mandating the reuse of SMs was associated with increased SSI incidence. It was hypothesized the rate of SSIs would be significantly greater during the postimplementation period compared with the preimplementation period. Retrospective chart review of patients who underwent orthopaedic and general surgery during the 60 days before and after policy implementation was performed. Focus was on consecutive procedures performed by the same surgeon on the same day. An assessment of SSI risk factors suggested the postimplementation group was at higher risk. However, the daily use of a single SM across multiple procedures was not associated with a clinically significant increase in SSIs. Because future pandemics and public health crises may be accompanied by similar shortages, it may be possible to reuse masks in these situations without concern for increased SSI. (Journal of Surgical Orthopaedic Advances 33(2):097-102, 2024).

A multi-institutional study of short-term mortality in COVID-positive patients undergoing hip fracture surgery: is survival better than expected?

PURPOSE

Early reports of 30-day mortality in COVID-positive patients with hip fracture were often over 30% and were higher than historical rates of 10% in pre-COVID studies. We conducted a multi-institutional retrospective cohort study to determine whether the incidence of 30-day mortality and complications in COVID-positive patients undergoing hip fracture surgery is as high as initially reported.

METHODS

A retrospective chart review was performed at 11 level I trauma centers from January 1, 2020 to May 1, 2022. Patients 50 years or older undergoing hip fracture surgery with a positive COVID test at the time of surgery were included. The primary outcome measurements were the incidence of 30-day mortality and complications. Post-operative outcomes were reported using proportions with 95% confidence interval (C.I.).

RESULTS

Forty patients with a median age of 71.5 years (interquartile range, 50-87 years) met the criteria. Within 30-days, four patients (10%; 95% C.I. 3-24%) died, four developed pneumonia, three developed thromboembolism, and three remained intubated post-operatively. Increased age was a statistically significant predictor of 30-day mortality (p = 0.01), with all deaths occurring in patients over 80 years.

CONCLUSION

In this multi-institutional analysis of COVID-positive patients undergoing hip fracture surgery, 30-day mortality was 10%. The 95% C.I. did not include 30%, suggesting that survival may be better than initially reported. While COVID-positive patients with hip fractures have high short-term mortality, the clinical situation may not be as dire as initially described, which may reflect initial publication bias, selection bias introduced by testing, or other issues.

LEVELS OF EVIDENCE

Therapeutic Level III.

Retrograde intramedullary nailing of the femur: identifying the true anatomic axis for the ideal start point

PURPOSE

Retrograde femoral intramedullary nailing (IMN) is commonly used to treat distal femur fractures. There is variability in the literature regarding the ideal starting point for retrograde femoral IMN in the coronal plane. The objective of this study was to identify the ideal starting point, based on radiographs, relative to the intercondylar notch in the placement of a retrograde femoral IMN.

METHODS

A consecutive series of 48 patients with anteroposterior long-leg radiographs prior to elective knee arthroplasty from 2017 to 2021 were used to determine the femoral anatomic axis. The anatomic center of the isthmus was identified and marked. Another point 3 cm distal from the isthmus was marked in the center of the femoral canal. A line was drawn connecting the points and extended longitudinally through the distal femur. The distance from the center of the intercondylar notch to the point where the anatomic axis of the femur intersected the distal femur was measured.

RESULTS

On radiographic review, the distance from the intercondylar notch to where the femoral anatomic axis intersects the distal femur was normally distributed with an average distance of 4.1 mm (SD, 1.7 mm) medial to the intercondylar notch.

CONCLUSION

The ideal start point, based on radiographs, for retrograde femoral intramedullary nailing is approximately 4.1 mm medial to the intercondylar notch. Medialization of the starting point for retrograde intramedullary nailing in the coronal plane aligns with the anatomic axis. These results support the integration of templating into preoperative planning prior to retrograde IMN of the femur, with the knowledge that, on average, the ideal start point will be slightly medial. Further investigation via anatomic studies is required to determine whether a medial start point is safe and efficacious in patients with distal femur fractures treated with retrograde IMNs.

Comparison of post-op opioid use and pain between short and long cephalomedullary nails in elderly intertrochanteric fractures

PURPOSE

It remains unknown if cephalomedullary nail (CMN) length has an impact on pain and opioid use following fixation. Given the lack of level I evidence favoring a specific CMN length to prevent adverse surgical outcomes, we investigated if CMN length impacts acute postoperative pain and opioid use. The authors hypothesize that the use of longer CMNs results in increased pain scores and morphine milligram equivalents (MME) intake during the 0-24 h (h) and 24-36 h postoperative period.

METHODS

A retrospective chart review was performed from 2010 to 2020 of patients ≥ 65 years-old who underwent CMN for IT fractures and fractures with subtrochanteric extension (STE). We compared patients who received short and long CMNs using numeric rating scale (NRS) pain scores and MME intake at 0-24 h and 24-36 h postoperatively.

RESULTS

330 patients receiving short (n = 155) and long (n = 175) CMNs met criteria. CMN length was found to not be associated with higher pain scores in the early postoperative phase. However, patients with long CMNs received higher MME from 0-24 h (25.4% estimated mean increase, p value = 0.02) and 24-36 h (22.3% estimated mean increase, p value = 0.04) postoperatively, even after adjusting for covariates, gender, and age.

CONCLUSION

Patients with long CMNs received greater MME postoperatively. Additionally, differences in pain and MME were not significantly different between patients with and without STE, suggesting our findings were not influenced by this pattern. These results suggest longer CMNs are associated with higher acute postoperative opioid intake among patients with IT fractures.

LEVEL OF EVIDENCE

Therapeutic level III.

Low-Dose Short-Term Scheduled Ketorolac Reduces Opioid Use and Pain in Orthopaedic Polytrauma Patients: A Randomized Clinical Trial

OBJECTIVE

To determine whether scheduled low-dose, short-term ketorolac is associated with reduced length of stay, opioid use, and pain in orthopaedic polytrauma patients.

DESIGN

Double-blinded, randomized controlled trial.

SETTING

One Level 1 trauma center.

PATIENTS

From August 2018 to October 2022, 70 orthopaedic polytrauma patients between 18-75 years-old with a New Injury Severity Score (NISS) > 9 were randomized. 70 participants were enrolled, with 35 randomized to the ketorolac group and 35 to the placebo group.

INTERVENTION

15 mg of intravenous (IV) ketorolac every 6 hours for up to 5 inpatient days or 2 mL of IV saline in a similar fashion.

MAIN OUTCOME MEASUREMENTS

Length of Stay (LOS), Morphine Milligram Equivalents (MME), Visual Analogue Scale (VAS), and Complications.

RESULTS

Study groups were not significantly different with respect to age, BMI, and NISS (p>0.05). Median LOS was 8 days (interquartile range [IQR], 4.5 to 11.5) in the ketorolac group compared to 7 days (IQR, 3 to 10) in the placebo group (p = 0.275). Over the 5-day treatment period, the ketorolac group experienced a 32% reduction in average MME (p = 0.013) and a 12-point reduction in baseline-adjusted mean VAS (p = 0.037) compared to the placebo group. There were no apparent short-term adverse effects in either group.

CONCLUSION

Scheduled low-dose, short-term IV ketorolac was associated with significantly reduced inpatient opioid use and pain in orthopaedic polytrauma patients with no significant difference in LOS and no apparent short-term adverse effects. The results support the use of scheduled low-dose, short-term IV ketorolac for acute pain control among orthopaedic polytrauma patients. Further studies are needed to delineate lasting clinical effects and potential long-term effects, such as fracture healing.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Postoperative mortality in the COVID-positive hip fracture patient, a systematic review and meta-analysis

PURPOSE

The extent to which concomitant COVID-19 infection increases short-term mortality following hip fracture is not fully understood. A systemic review and meta-analysis of COVID-19 positive hip fracture patients (CPHFPs) undergoing surgery was conducted to explore the association of COVID-19 with short-term mortality.

METHODS

Review of the literature identified reports of short-term 30-day postoperative mortality in CPHFPs. For studies including a contemporary control group of COVID-19 negative patients, odds ratios of the association between COVID-19 infection and short-term mortality were calculated. Short-term mortality and the association between COVID-19 infection and short-term mortality were meta-analyzed and stratified by hospital screening type using random effects models.

RESULTS

Seventeen reports were identified. The short-term mortality in CPHFPs was 34% (95% C.I., 30-39%). Short-term mortality differed slightly across studies that screened all patients, 30% (95% C.I., 22-39%), compared to studies that conditionally screened patients, 36% (95% C.I., 31-42%), (P = 0.22). The association between COVID-19 infection and short-term mortality produced an odds ratio of 7.16 (95% C.I., 4.99-10.27), and this was lower for studies that screened all patients, 4.08 (95% C.I., 2.31-7.22), compared to studies that conditionally screened patients, 8.32 (95% C.I., 5.68-12.18), (P = 0.04).

CONCLUSION

CPHFPs have a short-term mortality rate of 34%. The odds ratio of short-term mortality was significantly higher in studies that screened patients conditionally than in studies that screened all hip fracture patients. This suggests mortality prognostication should consider how COVID-19 infection was identified as asymptomatic patients may fare slightly better.

Association of Talar Neck Fractures With Body Extension and Risk of Avascular Necrosis

BACKGROUND

The objective of this study was to determine whether talar neck fractures with proximal extension (TNPE) into the talar body are associated with higher rates of avascular necrosis (AVN) compared to isolated talar neck (TN) fractures.

METHODS

A retrospective review of patients sustaining talar neck fractures at a level I trauma center from 2008 to 2016 was performed. Demographic and clinical data were collected from the electronic medical record. Fractures were characterized as TN or TNPE based on initial radiographs. TNPE was defined as a fracture that originates on the talar neck and extends proximal to a line subtended from the junction of the neck and the articular cartilage dorsal to the anterior portion of the lateral process of the talus. Fractures were classified according to the modified Hawkins classification for analysis. The primary outcome was the development of AVN. Secondary outcomes included nonunion and collapse. These were measured on postoperative radiographs.

RESULTS

There were 137 fractures in 130 patients, with 80 (58%) fractures in the TN group and 57 (42%) in the TNPE group. Median follow-up was 10 months (interquartile range, 6-18 months). The TNPE group was more likely to develop AVN as compared to the TN group (49% vs 19%, P < .001). Similarly, the TNPE group had a higher rate of collapse (14% vs 4%, P = .03) and nonunion (26% vs 9%, P = .01). Even after adjusting for open fracture, Hawkins fracture type, smoking, and diabetes, AVN still remained significant for the TNPE group as compared to the TN group with an odds ratio of 3.47 (95% CI, 1.51-7.99).

CONCLUSION

We found a higher rate of AVN, subsequent collapse, and nonunion in patients with TNPE compared to isolated TN fractures.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Functional Outcomes of Primary Arthrodesis (PA) versus Open Reduction and Internal Fixation (ORIF) in the Treatment of Lisfranc Injuries

OBJECTIVES

To determine whether PA or ORIF results in better functional outcomes via patient-reported outcome measures (PROMs). Reoperation rates and surgical characteristics amongst the two groups are evaluated as well.

DESIGN

A retrospective cohort study.

SETTING

Level 1 trauma center.

PATIENTS

Eighty-one patients treated via PA or ORIF for Lisfranc injuries between January 2010 and January 2019.

MAIN OUTCOME MEASUREMENTS

PROMs were collected via the validated Foot and Ankle Ability Measure (FAAM) questionnaire. Follow-up ranged from one to ten years post-treatment.

RESULTS

Two hundred patients underwent ORIF and 72 patients underwent PA. Eighty-one out of 272 patients responded to the questionnaire. The FAAM revealed ADL subscores for PA and ORIF of 69.78 ± 18.61 and 73.53 ± 25.60, respectively (P = 0.48). The Sports subscore for PA (45.81 ± 24.65) and ORIF (56.54 ± 31.13) were not significantly different (P = 0.11). Perceived levels of ADL (P = 0.32) and Sports (P = 0.81) function, compared to pre-injury levels, were also not significantly different between the two groups. Rates of reoperation were nearly identical for PA (28.1%) and ORIF (30.6%) (P = 1.00).

CONCLUSION

Our results suggest that neither PA nor ORIF is superior with regards to functional outcomes or rates of re-operation in the surgical treatment of Lisfranc injuries when appropriately triaged by the treating surgeon.Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does prophylactic local tobramycin injection lower open fracture infection rates?

Objective: To determine whether local aqueous tobramycin injection in combination with systemic perioperative IV antibiotic prophylaxis will reduce the rate of fracture-related infection (FRI) after open fracture fixation. Other Outcomes of Interest: (1) To compare fracture nonunion rates and report differences between treatment and control groups and (2) compare bacterial speciation and antibiotic sensitivity among groups that develop FRI. Design: Phase 3 prospective, randomized clinical trial. Setting: Two level 1 trauma centers. Participants: Six hundred subjects (300 in study/tobramycin group and 300 in control/standard practice group) will be enrolled and assigned to the study group or control group using a randomization table. Patients with open extremity fractures that receive definitive internal surgical fixation will be considered. Intervention: Aqueous local tobramycin will be injected into the wound cavity (down to bone) after debridement, irrigation, and fixation, following closure. Main Outcome Measurements: Outcomes will look at the presence or absence of FRI, the rate of fracture nonunion, and determine speciation of gram-negative and Staph bacteria in each group with a FRI. Results: Not applicable. Conclusion: The proposed work will determine whether local tobramycin delivery plus perioperative standard antibiotic synergism will minimize the occurrence of open extremity FRI. Level of Evidence: Level 1.

Outcomes of Reamed Intramedullary Nailing for Lower Extremity Diaphyseal Fractures in COVID-Positive Patients: A Multi-institutional Observational Study

OBJECTIVE

To determine if reamed intramedullary nailing (IMN) of tibial and femoral shaft fractures exacerbated the hypercoagulable state of COVID infection, resulting in increased thromboembolic and pulmonary complications.

DESIGN

Retrospective chart review.

SETTING

Eleven Level I trauma centers.

PATIENTS

From January 1, 2020, to December 1, 2022, 163 patients with orthopaedic trauma and COVID positivity and 36 patients with tibial and femoral shaft fractures were included.

INTERVENTION

Reamed IMN.

MAIN OUTCOME MEASURES

Incidence of postoperative thromboembolic and respiratory complications.

RESULTS

Thirty-six patients with a median age of 52 years (range, 18-92 years; interquartile range, 29-72 years) met criteria. There were 21 and 15 patients with femoral and tibial shaft fractures. There were 15 patients sustaining polytrauma; of which, 10 had a new injury severity score of >17. All patients underwent reamed IMN in a median of 1 day (range, 0-12 days; interquartile range = 1-2 days) after injury. Two patients developed acute respiratory distress syndrome (ARDS) and 3 pneumonia. No patients had pulmonary embolism, deep vein thrombosis, or died within 30 days.

CONCLUSION

In this multi-institutional review of COVID-positive patients undergoing reamed IMN, there were no thromboembolic events. All patients developing pulmonary complications (ARDS or pneumonia) had baseline chronic obstructive pulmonary disease, were immune compromised, or sustained polytraumatic injuries with new injury severity score of >20. Given this, it seems reasonable to continue using reamed IMN for tibial and femoral shaft fractures after evaluation for COVID severity, comorbidities, and other injuries.

LEVELS OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

An Off-Label Use of a Tensioned Proximal Humerus Plate for Tibiotalar Fusion: A Case Report

CASE

A 70-year-old man presented with a left pilon fracture after a 10-foot fall from a ladder. The severe amount of comminution, joint destruction, and impaction from this injury eventually resulted in a tibiotalar fusion. Owing to multiple tibiotalar fusion plates not being long enough to span the extent of the fracture, a tensioned proximal humerus plate was used as an alternative.

CONCLUSION

We do not endorse the off-label use of a tensioned proximal humerus plate for all tibiotalar fusions; however, we do believe that this is a useful technique in certain situations with large zones of distal tibial comminution.

Avascular Necrosis of the Talus Following Subchondroplasty: A Case Report and Review of Literature

CASE

Avascular necrosis (AVN) of the talus in a 45-year-old female following subchondroplasty with calcium phosphate bone filler for treatment of anterolateral and posteromedial talar dome bone marrow lesions (BMLs). The patient subsequently presented as consultation, 18 months postoperatively, with AVN of the talus. After failing conservative management, the patient underwent a total ankle arthroplasty at 46 months after subchondroplasty with resolution of pain.

CONCLUSION

There are few studies that have reported on the safety of subchondroplasty of the talus. Given the tenuous blood supply to the talar body and poor patient outcomes associated with AVN, caution should be taken before extrapolating the generally positive results of subchondroplasty in the knee.

LEVEL OF EVIDENCE

Level IV.

Inflammatory cytokines associated with outcomes in orthopedic trauma patients independent of New Injury Severity score: A pilot prospective cohort study

Traumatic injury is the leading cause of mortality in patients under 50. It is associated with a complex inflammatory response involving hormonal, immunologic, and metabolic mediators. The marked elevation of cytokines and inflammatory mediators subsequently correlates with the development of posttraumatic complications. The aim was to determine whether elevated cytokine levels provide a predictive value for orthopedic trauma patients. A prospective cohort study of patients with New Injury Severity Score (NISS) > 5 was undertaken. IL-6, IL-8, IL-10, and migration inhibitory factor levels were measured within 24-h of presentation. Demographic covariates and clinical outcomes were obtained from the medical records. Fifty-eight patients (83% male, 40 years) were included. Addition of IL-6 to baseline models significantly improved prediction of pulmonary complication (LR = 6.21, p = 0.01), ICU (change in R²  = 0.31, p < 0.01), and hospital length of stay (change in R²  = 0.16, p < 0.01). The addition of IL-8 significantly improved the prediction of acute kidney injury (LR = 9.15, p < 0.01). The addition of postinjury IL-6 level to baseline New Injury Severity Score model is better able to predict the occurrence of pulmonary complications as well as prolonged ICU and hospital length of stay.

Rethinking the Coronal Anatomic Axis of the Distal Tibia for Intramedullary Nail Placement: A Cadaveric Study

Background: Recent studies have reported that targeting a center-center position at the distal tibia during intramedullary nailing (IMN) may result in malalignment. Although not fully understood, this observation suggests that the coronal anatomic center of the tibia may not correspond to the center of the distal tibia articular surface. Questions/Purposes: To identify the coronal anatomic axis of the distal tibia that corresponds to an ideal start site for IMN placement utilizing intact cadaveric tibiae. Methods: IMN placement was performed in 9 fresh frozen cadaveric tibiae. A guidewire was used to identify the ideal start site in the proximal tibia and an opening reamer allowed access to the canal. Each nail was then advanced without the use of a reaming rod until exiting the distal tibia plafond. Cadaveric and radiographic measurements were performed to determine the center of the nail exit site in the coronal plane. Results: Cadaveric and radiographic measurements identified the IMN exit site to correspond with the lateral 59.5% and 60.4% of the plafond, respectively. Conclusions: Tibial nails inserted using an ideal start site have an endpoint that corresponds roughly to the junction of the lateral and middle third of the plafond. Further studies are warranted to better understand the impact of IMN endpoint placement on the functional and radiographic outcomes of tibia shaft fractures.

Patient-Specific Precision Injury Signatures to Optimize Orthopaedic Interventions in Multiply Injured Patients (PRECISE STUDY)

SUMMARY

Optimal timing and procedure selection that define staged treatment strategies can affect outcomes dramatically and remain an area of major debate in the treatment of multiply injured orthopaedic trauma patients. Decisions regarding timing and choice of orthopaedic procedure(s) are currently based on the physiologic condition of the patient, resource availability, and the expected magnitude of the intervention. Surgical decision-making algorithms rarely rely on precision-type data that account for demographics, magnitude of injury, and the physiologic/immunologic response to injury on a patient-specific basis. This study is a multicenter prospective investigation that will work toward developing a precision medicine approach to managing multiply injured patients by incorporating patient-specific indices that quantify (1) mechanical tissue damage volume; (2) cumulative hypoperfusion; (3) immunologic response; and (4) demographics. These indices will formulate a precision injury signature, unique to each patient, which will be explored for correspondence to outcomes and response to surgical interventions. The impact of the timing and magnitude of initial and staged surgical interventions on patient-specific physiologic and immunologic responses will be evaluated and described. The primary goal of the study will be the development of data-driven models that will inform clinical decision-making tools that can be used to predict outcomes and guide intervention decisions.

Most orthopaedic trauma patients are using the internet, but do you know where they're going?

PURPOSE

The Internet is a resource that patients can use to learn about their injuries, treatment options, and surgeon. Previously, it was demonstrated that orthopaedic trauma patients are unlikely to use a reliable, provided source. It is unknown however, if patients are seeking information from elsewhere. The purpose of this study was to determine if orthopaedic trauma patients utilize the Internet and what websites are utilized. Our hypothesis was that the majority of patients use the Internet and when they do, are unlikely to use a reliable source.

METHODS

Orthopaedic trauma patients were surveyed in clinic at a Level I trauma center in the United States. The survey queried demographics, injury information, Internet access, and eHealth Literacy Scale (eHEALS). Data were analyzed using t-tests, Chi-squared tests, and a multivariate logistic regression, as appropriate.

RESULTS

138 patients with a mean age of 47.1 years (95% confidence interval: 44.0-50.3; 51.1% female) were included in the analysis. Despite 94.1% reporting access, only 55.8% of trauma patients used the Internet for information about their injury. Of those, 64.5% used at least one unreliable source. WebMD (54.8%) was the highest utilized website. Age, sex, employment, and greater eHEALS score were associated with increased Internet use (p<0.001).

CONCLUSION

The Internet has potential to be a useful, low cost, and readily available informational source for orthopaedic trauma patients. This study illustrates that a majority of patients seek information from the Internet after their injury, including unreliable websites like Wikipedia and Facebook. Our study emphasizes the need for active referral to trusted websites and initiation of organizational partnerships (e.g. OTA/AAOS) with common content providers (e.g. WebMD) to provide patients with accurate information about their injury and treatment.

LEVEL OF EVIDENCE

Prognostic, Level II.

Hypercoagulable Disorders in Orthopaedics: Etiology, Considerations, and Management

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Hypercoagulable disorders (HCDs) can be inherited or acquired. An HCD of either etiology increases the chance of venous thromboembolic events (VTEs).

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Patients with an HCD often have the condition discovered only after surgical complications.

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We recommend that patients with a concern for or a known HCD be referred to the appropriate hematological specialist for workup and treatment.

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Tourniquet use in the orthopaedic patient with an HCD is understudied and controversial. We recommend that tourniquets be avoided in the surgical management of patients with an HCD, if possible. When tourniquets are applied to patients with unknown HCD status, close follow-up and vigilant postoperative examinations should be undertaken.