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Huang K, Rockov ZA, Foster LO, Najdawi J, Robles AS, Marecek GS. Optimizing the Entry Point for Medullary Hip Screws. J Am Acad Orthop Surg 2024; 32:279-285. [PMID: 38181514 DOI: 10.5435/jaaos-d-23-00360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 11/26/2023] [Indexed: 01/07/2024] Open
Abstract
INTRODUCTION Medullary hip screws (MHSs) are the most common treatment of intertrochanteric hip fractures because they can be used for varied fracture patterns and resist shortening. Identifying the appropriate MHS entry point can be intellectually and technically challenging. We aimed to quantify the variability in the ideal entry point (IEP) for MHSs. METHODS Standing alignment radiographs of 50 patients were evaluated using TraumaCad (Brainlab). The femoral neck shaft angle and the offset from the tip of the greater trochanter (GT) to the femur's longitudinal axis ('greater trochanter offset') were measured. Five MHS system templates were superimposed on the femur's longitudinal axis, and the distance from the GT tip to MHS's top center was measured. Five independent reviewers each templated 20 images such that all images were measured at least twice. A random sample of five images was selected for all five raters to measure and to calculate an intraclass coefficient Mean IEPs were compared with an independent sample Student t -test. RESULTS The mean GT offset was 13.5 ± 5.6 mm (range 12.9 to 26.7 mm). The mean neck shaft angle was 129.5 ± 4.0 (range 120 to 139). The mean IEP for nail systems ranged from 5.7 to 7.1 mm medial to the GT tip; there was no notable difference in pairwise comparison of nail systems or in aggregate. Intraclass coefficient for all ratings, measurements, and nail types ranged from moderate to good. Both intra-rater and inter-rater reliability were excellent. DISCUSSION AND CONCLUSION In a sample with broad variation in femoral anatomy, there is a specific, roughly 1.5 mm wide interval that is 6.4 mm medial to the GT tip that serves as the IEP for the most common MHS systems. No notable difference seems to exist in the IEP among these MHS systems.
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Affiliation(s)
- Kevin Huang
- From the Cedars-Sinai Medical Center, Department of Orthopaedic Surgery, Los Angeles, CA
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Erdman MK, Schottel P, Little M, Marecek GS. Axial Plane Deformity: How to Avoid It and How to Correct It. Instr Course Lect 2024; 73:815-830. [PMID: 38090942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Malreductions in the axial plane (ie, length and rotation) are common when managing long bone fractures. Careful attention to detail during the initial treatment can prevent these malreductions. Various fluoroscopy-based techniques exist for the prevention of malrotation and limb-length discrepancy during surgery for fracture. If malreductions do occur, a systematic clinical and radiographic evaluation can provide the necessary information to correct rotational malreduction and limb-length discrepancy.
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Tucker DW, Chen MJ, Reddy A, Carney JJ, Gardner MJ, Marecek GS. Limb position affects intraoperative assessment of condylar width. Eur J Orthop Surg Traumatol 2024; 34:451-457. [PMID: 37578569 PMCID: PMC10771358 DOI: 10.1007/s00590-023-03672-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/02/2023] [Indexed: 08/15/2023]
Abstract
PURPOSE We sought to define how changes in position and rotation of fluoroscopic imaging may affect the assessment of condylar widening intraoperatively. METHODS Thirty-three patients with tibial plateau fractures were prospectively identified and included in this study. Fluoroscopic images of the uninjured tibial plateau were obtained in (1) full extension and (2) slight flexion on foam ramp. Beginning with a plateau view, additional views of the tibial plateau were then obtained by rotating the fluoroscope around the knee in 5 degree increments up to 15 degrees in both internal and external rotation. Measurements of distal femoral condylar width (DFW), distal femoral articular width (FAW), proximal tibial articular width (TAW) and lateral plateau width (LPW) were performed. RESULTS LPW was decreased in flexion compared to extension at all degrees of rotation (p = 0.04-0.00001). There was a trend toward increasing LPW with increasing degrees of internal rotation which reached significance at 15˚ of internal rotation when the knee was flexed. On ANOVA, there was a significant difference of LPW with increasing degree of internal rotation when the knee was in flexion (p = 0.008), but not in extension. There were no differences in DFW, FAW, TAW and DFW/TAW at any point though LPW was decreased in flexion at all degrees of rotation. The FAW/TAW ratio was increased in flexion at all degrees of rotation. DISCUSSION The knee in flexion will underestimate the measurement of condylar width compared to the knee in full extension, by ~ 2 mm. Rotation of the knee, in comparison, did not have a significant effect on condylar width assessment. LEVEL OF EVIDENCE Diagnostic II.
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Affiliation(s)
- Douglass W Tucker
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael J Chen
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
| | - Akhil Reddy
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - John J Carney
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
| | - Geoffrey S Marecek
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 S San Vicente #603, Los Angeles, CA, 90048, USA.
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Robles AS, Blough CL, Kurapaty S, Lee A, Ewing BA, Marecek GS. Does Fibular Displacement Predict Tibial Malrotation in Simulated Tibia-Fibula Fractures. J Am Acad Orthop Surg 2023; 31:1221-1227. [PMID: 37850972 DOI: 10.5435/jaaos-d-23-00043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 08/10/2023] [Indexed: 10/19/2023] Open
Abstract
INTRODUCTION Tibial malrotation can occur with medullary nailing of diaphyseal tibial fractures. Fibular alignment has been proposed as a surrogate for axial plane reduction intraoperatively. The purpose of this study was to determine whether fibular alignment is a reliable marker of accurate tibial rotation. METHODS Deidentified CT scans of 50 patients with normal tibial anatomy were selected. Using ImageJ software, we simulated osteotomies at three sites (proximal third, mid-diaphysis, and distal third). We overlaid adjacent CT slices and rotated them around the central axis of the tibia in 5° increments of external rotation (ER) and internal rotation (IR). At each increment, measurements of fibular overlap (%) were obtained from anteroposterior (AP) and lateral views. To simulate fixation of the fibula, we repeated rotation around the axis of the fibula with and without a simulated medullary implant in the tibia. RESULTS A total of 50 patients were included. The mean age was 62 years, average BMI was 25.8, and 28 of 50 patients (56%) were male. Earliest loss of fibular contact occurred at 24° ER and 22° IR at the proximal site. Contact was lost at 26° ER and 28° IR on the AP view and 42° ER and 29° IR on the lateral view. The mean fibular contact at each 5° increment was similar for ER and IR. Fibular contact was reduced to 50% at 10 to 15° of rotation in ER and IR at all sites. Tibial canal contact was lost at 24° in both ER and IR around the fibula. With a virtual medullary implant, the mean maximal rotation was 6°. DISCUSSION Surgeons should be aware that 20° or more of malrotation is likely present when fibular contact is lost during medullary nailing of the tibia. Greater than 50% loss of contact should raise suspicion for malrotation. A fixed fibula and medullary tibial implant theoretically preclude significant tibial malrotation.
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Affiliation(s)
- Abrianna S Robles
- From the Department of Orthopaedic Surgery. Cedars-Sinai Medical Center, Los Angeles, CA (Robles, Blough, Lee, Ewing, and Marecek), and the Department of Orthopaedic Surgery, Northwestern University, Chicago, IL (Kurapaty)
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Robles AS, Piple AS, DeSanto DJ, Lamb A, Gibbs SJ, Heckmann ND, Marecek GS. Standard versus low-dose computed tomography for assessment of acetabular fracture reduction using novel step and gap measurement technique. Eur J Orthop Surg Traumatol 2023; 33:3703-3709. [PMID: 37311829 PMCID: PMC10651530 DOI: 10.1007/s00590-023-03616-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 06/04/2023] [Indexed: 06/15/2023]
Abstract
PURPOSE Quality of reduction is of paramount importance after acetabular fracture and is best assessed on computed tomography (CT). A recently proposed measurement technique for assessment of step and gap displacement is reproducible but has not been validated. The purpose of this study is to validate a well-established measurement technique against known displacements and to determine if it can be used with low dose CT. METHODS Posterior wall acetabular fractures were created in 8 cadaveric hips and fixed at known step and gap displacements. CT was performed at multiple radiation doses for each hip. Four surgeons measured step and gap displacement for each hip at all doses, and the measurements were compared to known values. RESULTS There were no significant differences in measurements across surgeons, and all measurements were found to have positive agreement. Measurement error < 1.5 mm was present in 58% of gap measurements and 46% of step measurements. Only for step measurements at a dose of 120 kVp did we observe a statistically significant measurement error. There was a significant difference in step measurements made by those with greater and those with fewer years in practice. CONCLUSION Our study suggests this technique is valid and accurate across all doses. This is important as it may reduce the amount of radiation exposure for patients with acetabular fractures.
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Affiliation(s)
- Abrianna S Robles
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Amit S Piple
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, CA, USA
| | - Donald J DeSanto
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ashley Lamb
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, CA, USA
| | | | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, CA, USA
| | - Geoffrey S Marecek
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Westrick ER, Bernstein M, Little MT, Marecek GS, Scolaro JA. Orthopaedic Advances: Use of Three-Dimensional Metallic Implants for Reconstruction of Critical Bone Defects After Trauma. J Am Acad Orthop Surg 2023; 31:e685-e693. [PMID: 37384878 DOI: 10.5435/jaaos-d-22-00676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 04/26/2023] [Indexed: 07/01/2023] Open
Abstract
Multiple successful strategies exist for the management of critical-sized bone defects. Depending on the location and etiology of an osseous defect, there are nuances that must be considered by the treating surgeon. The induced membrane technique and various modifications of the Ilizarov method (bone transport by distraction osteogenesis) have been the most common methods for biologic reconstruction. Despite the versatility and high union rates reported, they may not be practical for every patient. The rapid expansion of three-dimensional printing of medical devices has led to an increase in their use within orthopaedic surgery, specifically in the definitive treatment of critical bone defects. This article proposes indications and contraindications for implementation of this technology and reviews the available clinical evidence on the use of custom nonresorbable implants for the treatment of traumatic bone loss. Clinical cases are presented to illustrate the scenarios in which this approach is viable.
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Affiliation(s)
- Edward R Westrick
- From the Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA (Westrick), the Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada (Bernstein), the Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (Little), the Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (Marecek), and the Department of Orthopaedic Surgery, University of California Irvine, Orange, CA (Scolaro)
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Robles AS, Najdawi JJ, Wang J, Rockov ZA, Parikh HB, Little MTM, Marecek GS. Optimizing the Entry Point for Reconstruction Nailing of the Femur. J Am Acad Orthop Surg 2023; 31:e721-e726. [PMID: 37205875 DOI: 10.5435/jaaos-d-22-00778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 04/16/2023] [Indexed: 05/21/2023] Open
Abstract
INTRODUCTION Varus after antegrade medullary nailing of the proximal femur is associated with worse outcomes. Anecdotally, a more medialized "trochiformis" entry is beneficial to avoid varus with valgus-bend (greater trochanteric entry) femoral nails. However, the optimal entry point remains unknown. The purpose of this study was to define the optimal entry point for reconstruction nailing. METHODS Using standing alignment radiographs from 51 patients, we templated the ideal entry point for straight and valgus-bend nails from three major manufacturers using TraumaCad software. We measured the distance from the tip of the trochanter to the ideal entry site for each nail. We compared piriformis (PF) with trochanteric (GT) entry for each company and across manufacturers. RESULTS The mean greater trochanter offset from the femoral axis was 15.2 mm. The mean PF entry was 5.9 to 6.7 mm medial to the mean GT entry for each company's nail and was statistically distinct. No differences were observed in GT and PF entry points across manufacturers. Only 2 of 153 ideal GT entry points were lateral to the tip of the trochanter. An increased neck-shaft angle (NSA) and increased GT offset were correlated with a more medial ideal entry point. DISCUSSION The ideal entry point for GT nails is similar across manufacturers and is medial to the tip of the greater trochanter; however, PF and GT entry sites remain distinct. During preoperative planning and when executing femoral nailing intraoperatively, it may also be important to consider the NSA and GT offset of a patient before committing to a certain entry point.
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Affiliation(s)
- Abrianna S Robles
- From the Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
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Slobogean GP, Sprague S, Wells JL, Bhandari M, Harris AD, Mullins CD, Thabane L, Wood A, Della Rocca GJ, Hebden JN, Jeray KJ, Marchand LS, O'Hara LM, Zura RD, Lee C, Patterson JT, Gardner MJ, Blasman J, Davies J, Liang S, Taljaard M, Devereaux PJ, Guyatt G, Heels-Ansdell D, Marvel D, Palmer JE, Friedrich J, O'Hara NN, Grissom F, Gitajn IL, Morshed S, O'Toole RV, Petrisor B, Mossuto F, Joshi MG, D'Alleyrand JCG, Fowler J, Rivera JC, Talbot M, Pogorzelski D, Dodds S, Li S, Del Fabbro G, Szasz OP, Bzovsky S, McKay P, Minea A, Murphy K, Howe AL, Demyanovich HK, Hoskins W, Medeiros M, Polk G, Kettering E, Mahal N, Eglseder A, Johnson A, Langhammer C, Lebrun C, Nascone J, Pensy R, Pollak A, Sciadini M, Degani Y, Phipps H, Hempen E, Johal H, Ristevski B, Williams D, Denkers M, Rajaratnam K, Al-Asiri J, Gallant JL, Pusztai K, MacRae S, Renaud S, Adams JD, Beckish ML, Bray CC, Brown TR, Cross AW, Dew T, Faucher GK, Gurich Jr RW, Lazarus DE, Millon SJ, Moody MC, Palmer MJ, Porter SE, Schaller TM, Sridhar MS, Sanders JL, Rudisill Jr LE, Garitty MJ, Poole AS, Sims ML, Walker CM, Carlisle R, Hofer EA, Huggins B, Hunter M, Marshall W, Ray SB, Smith C, Altman KM, Pichiotino ER, Quirion JC, Loeffler MF, Cole AA, Maltz EJ, Parker W, Ramsey TB, Burnikel A, Colello M, Stewart R, Wise J, Anderson M, Eskew J, Judkins B, Miller JM, Tanner SL, Snider RG, Townsend CE, Pham KH, Martin A, Robertson E, Bray E, Sykes JW, Yoder K, Conner K, Abbott H, Natoli RM, McKinley TO, Virkus WW, Sorkin AT, Szatkowski JP, Mullis BH, Jang Y, Lopas LA, Hill LC, Fentz CL, Diaz MM, Brown K, Garst KM, Denari EW, Osborn P, Pierrie SN, Kessler B, Herrera M, Miclau T, Marmor MT, Matityahu A, McClellan RT, Shearer D, Toogood P, Ding A, Murali J, El Naga A, Tangtiphaiboontana J, Belaye T, Berhaneselase E, Pokhvashchev D, Obremskey WT, Jahangir AA, Sethi M, Boyce R, Stinner DJ, Mitchell PP, Trochez K, Rodriguez E, Pritchett C, Hogan N, Fidel Moreno A, Hagen JE, Patrick M, Vlasak R, Krupko T, Talerico M, Horodyski M, Pazik M, Lossada-Soto E, Gary JL, Warner SJ, Munz JW, Choo AM, Achor TS, Routt ML“C, Kutzler M, Boutte S, Warth RJ, Prayson MJ, Venkatarayappa I, Horne B, Jerele J, Clark L, Boulton C, Lowe J, Ruth JT, Askam B, Seach A, Cruz A, Featherston B, Carlson R, Romero I, Zarif I, Dehghan N, McKee M, Jones CB, Sietsema DL, Williams A, Dykes T, Guerra-Farfan E, Tomas-Hernandez J, Teixidor-Serra J, Molero-Garcia V, Selga-Marsa J, Porcel-Vazquez JA, Andres-Peiro JV, Esteban-Feliu I, Vidal-Tarrason N, Serracanta J, Nuñez-Camarena J, del Mar Villar-Casares M, Mestre-Torres J, Lalueza-Broto P, Moreira-Borim F, Garcia-Sanchez Y, Marcano-Fernández F, Martínez-Carreres L, Martí-Garín D, Serrano-Sanz J, Sánchez-Fernández J, Sanz-Molero M, Carballo A, Pelfort X, Acerboni-Flores F, Alavedra-Massana A, Anglada-Torres N, Berenguer A, Cámara-Cabrera J, Caparros-García A, Fillat-Gomà F, Fuentes-López R, Garcia-Rodriguez R, Gimeno-Calavia N, Martínez-Álvarez M, Martínez-Grau P, Pellejero-García R, Ràfols-Perramon O, Peñalver JM, Salomó Domènech M, Soler-Cano A, Velasco-Barrera A, Yela-Verdú C, Bueno-Ruiz M, Sánchez-Palomino E, Andriola V, Molina-Corbacho M, Maldonado-Sotoca Y, Gasset-Teixidor A, Blasco-Moreu J, Fernández-Poch N, Rodoreda-Puigdemasa J, Verdaguer-Figuerola A, Cueva-Sevieri HE, Garcia-Gimenez S, Viskontas DG, Apostle KL, Boyer DS, Moola FO, Perey BH, Stone TB, Lemke HM, Spicer E, Payne K, Hymes RA, Schwartzbach CC, Schulman JE, Malekzadeh AS, Holzman MA, Gaski GE, Wills J, Pilson H, Carroll EA, Halvorson JJ, Babcock S, Goodman JB, Holden MB, Williams W, Hill T, Brotherton A, Romeo NM, Vallier HA, Vergon A, Higgins TF, Haller JM, Rothberg DL, Olsen ZM, McGowan AV, Hill S, Dauk MK, Bergin PF, Russell GV, Graves ML, Morellato J, McGee SL, Bhanat EL, Yener U, Khanna R, Nehete P, Potter D, VanDemark III R, Seabold K, Staudenmier N, Coe M, Dwyer K, Mullin DS, Chockbengboun TA, DePalo Sr. PA, Phelps K, Bosse M, Karunakar M, Kempton L, Sims S, Hsu J, Seymour R, Churchill C, Mayfield A, Sweeney J, Jaeblon T, Beer R, Bauer B, Meredith S, Talwar S, Domes CM, Gage MJ, Reilly RM, Paniagua A, Dupree J, Weaver MJ, von Keudell AG, Sagona AE, Mehta S, Donegan D, Horan A, Dooley M, Heng M, Harris MB, Lhowe DW, Esposito JG, Alnasser A, Shannon SF, Scott AN, Clinch B, Weber B, Beltran MJ, Archdeacon MT, Sagi HC, Wyrick JD, Le TT, Laughlin RT, Thomson CG, Hasselfeld K, Lin CA, Vrahas MS, Moon CN, Little MT, Marecek GS, Dubuclet DM, Scolaro JA, Learned JR, Lim PK, Demas S, Amirhekmat A, Dela Cruz YM. Aqueous skin antisepsis before surgical fixation of open fractures (Aqueous-PREP): a multiple-period, cluster-randomised, crossover trial. Lancet 2022; 400:1334-1344. [PMID: 36244384 DOI: 10.1016/s0140-6736(22)01652-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Chlorhexidine skin antisepsis is frequently recommended for most surgical procedures; however, it is unclear if these recommendations should apply to surgery involving traumatic contaminated wounds where povidone-iodine has previously been preferred. We aimed to compare the effect of aqueous 10% povidone-iodine versus aqueous 4% chlorhexidine gluconate on the risk of surgical site infection in patients who required surgery for an open fracture. METHODS We conducted a multiple-period, cluster-randomised, crossover trial (Aqueous-PREP) at 14 hospitals in Canada, Spain, and the USA. Eligible patients were adults aged 18 years or older with an open extremity fracture treated with a surgical fixation implant. For inclusion, the open fracture required formal surgical debridement within 72 h of the injury. Participating sites were randomly assigned (1:1) to use either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate immediately before surgical incision; sites then alternated between the study interventions every 2 months. Participants, health-care providers, and study personnel were aware of the treatment assignment due to the colour of the solutions. The outcome adjudicators and data analysts were masked to treatment allocation. The primary outcome was surgical site infection, guided by the 2017 US Centers for Disease Control and Prevention National Healthcare Safety Network reporting criteria, which included superficial incisional infection within 30 days or deep incisional or organ space infection within 90 days of surgery. The primary analyses followed the intention-to-treat principle and included all participants in the groups to which they were randomly assigned. This study is registered with ClinicalTrials.gov, NCT03385304. FINDINGS Between April 8, 2018, and June 8, 2021, 3619 patients were assessed for eligibility and 1683 were enrolled and randomly assigned to povidone-iodine (n=847) or chlorhexidine gluconate (n=836). The trial's adjudication committee determined that 45 participants were ineligible, leaving 1638 participants in the primary analysis, with 828 in the povidone-iodine group and 810 in the chlorhexidine gluconate group (mean age 44·9 years [SD 18·0]; 629 [38%] were female and 1009 [62%] were male). Among 1571 participants in whom the primary outcome was known, a surgical site infection occurred in 59 (7%) of 787 participants in the povidone-iodine group and 58 (7%) of 784 in the chlorhexidine gluconate group (odds ratio 1·11, 95% CI 0·74 to 1·65; p=0·61; risk difference 0·6%, 95% CI -1·4 to 3·4). INTERPRETATION For patients who require surgical fixation of an open fracture, either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate can be selected for skin antisepsis on the basis of solution availability, patient contraindications, or product cost. These findings might also have implications for antisepsis of other traumatic wounds. FUNDING US Department of Defense, Canadian Institutes of Health Research, McMaster University Surgical Associates, PSI Foundation.
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Tucker DW, Carney JJ, Little MTM, Westrick ER, Marecek GS. Survey Analysis of Orthopedic Call Compensation. Orthopedics 2022; 45:293-296. [PMID: 35576488 DOI: 10.3928/01477447-20220511-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We sought to determine the type, frequency, and compensation details of orthopedic call for orthopedic traumatologists. We administered a 24-question survey to all members of the Orthopaedic Trauma Association regarding the number and type of orthopedic surgeons within the call pool, frequency of call, number of hospitals covered, and compensation for weekday, weekend, holiday, and pediatric calls. A total of 105 orthopedic surgeons replied. The most common number of physicians in the call pool was 6 to 10 (42.9%), whereas the most common number of traumatologists was 0 to 5 (90.5%), with 71.4% taking call at 1 hospital. Further, 56.7% were paid separately for weekday trauma call, with the most common number of call days per week being 2. The most common compensation was $1001 to $1500 (31.6%). For weekend call, 49.5% of physicians were paid separately, with the most common number of weekends on call per year being 11 to 15 (34.3% of replies). For pediatric call, 54.3% of physicians took call, with 28.6% paid separately and 33.3% receiving $0 to $500. For holiday call, 40.2% of physicians were paid separately, with 30.8% receiving $1001 to $1500. We describe the characteristics of traumatology call. Approximately 50% of physicians (range, 28.6%-56.3%) are compensated separately for taking different forms of call (ie, weekday, weekend, holiday). [Orthopedics. 2022;45(5):293-296.].
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Marmor MT, Agel J, Dumpe J, Kellam JF, Marecek GS, Meinberg E, Nguyen MP, Sims S, Soles GL, Karam MD. Comparison of the Neer classification to the 2018 update of the Orthopedic Trauma Association/AO fracture classification for classifying proximal humerus fractures. OTA Int 2022; 5:e200. [PMID: 36425090 PMCID: PMC9580046 DOI: 10.1097/oi9.0000000000000200] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/15/2022] [Indexed: 06/10/2023]
Abstract
Background The classification of fractures is necessary to ensure a reliable means of communication for clinical interaction, education and research. The Neer classification is the most commonly used classification for proximal humerus fractures. In 2018 the Orthopedic Trauma Association (OTA) and the AO Foundation provided an update to the OTA/AO Fracture Classification Scheme addressing many of the concerns about the previous versions of the classification. The objective of the present study was to evaluate the rater reliability of the 2 classifications and if the classifications subjectively better characterized the fracture patterns. Methods X-rays and CT scans of 24 proximal humerus fractures were given to 7 independent raters for classification according to the Neer and 2018 OTA/AO classification. Both full-forms and short-forms of the classifications were tested. The Fleiss Kappa statistic was used to assess inter-rater agreement and intra-rater consistency for the 2 classifications. For each case the raters subjectively commented on how well each classification was able to characterize the fracture pattern. Results All raters graded the 2018 OTA/AO classification as good as or better than the Neer classification for an adequate description of the fracture patterns. The short-form 2018 OTA/AO classification had the most 4 rater and 5 rater agreement cases and the second most 6 rater agreement cases. The short-form Neer classification had the second most 4 rater and 5 rater agreement cases and the most 6 rater agreement cases. The full 2018 OTA/AO had the least 4, 5, or 6 rater agreement cases of all the classification systems. Inter-rater agreement was fair for the full and short form of both the Neer and 2018 OTA/AO classification. The full and short Neer classifications together with the short 2018 OTA/AO classification had moderate intra-rater consistency, while the full 2018 OTA/AO classification only had slight intra-rater consistency. Conclusions The 2018 OTA/AO classification is equivalent in its short-form to the Neer classification in inter-rater reliability and intra-rater consistency; and is superior in its full form for characterizing specific fracture types. The low inter-rater reliability of the full 2018 OTA/AO classification is a concern that may need to be addressed in the future.
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Affiliation(s)
- Meir T Marmor
- University of California San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA
| | - Julie Agel
- University of Washington, Harborview Medical Center, Seattle, WA
| | - Jarrod Dumpe
- Orthopaedic Trauma Institute, Atrium Health - Navicent, Macon, GA
| | | | | | - Eric Meinberg
- University of California San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA
| | - Mai P Nguyen
- University of Minesota St. Paul, Regions Hospital, Saint Paul, MN
| | - Stephen Sims
- Atrium Health Orthopaedic Surgery, Carolinas Medical Center, Charlotte, NC
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Erdman MK, Gibbs SJ, Tucker DW, Lee AK, Fleming ME, Marecek GS. Radiographic detection of lateral plateau involvement in medial tibial plateau fractures (AO/OTA 41-B1.2, 1.3, 3.2 and 3.3). Eur J Orthop Surg Traumatol 2021; 32:1501-1508. [PMID: 34557963 DOI: 10.1007/s00590-021-03117-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/06/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To assess the accuracy of radiographs in detecting the lateral plateau involvement of medial tibial plateau fractures as well as describe the impact of CT on preoperative planning for this specific fracture morphology. METHODS Radiograph and CT imaging of patients with a Schatzker type IV tibial plateau fractures (AO/OTA 41-B1.2, B1.3 h, B2.2. B3.2, and B3.3) between January 2013 and July 2017 were reviewed by three trauma fellowship-trained orthopedic surgeons to identify fractures of the medial condyle with an intact anterolateral articular surface. RESULTS Lateral plateau involvement was identified in 16 (37%) radiographs and 26 (61%) CT images (p = 0.051). Radiographic detection of lateral plateau involvement demonstrated a sensitivity of 62% and specificity of 100%, and radiographs were able to predict the recommendation for surgical intervention for lateral plateau involvement with a positive predictive value (PPV) of 75% and a negative predictive value (NPV) of 60% compared to recommendations based on CT imaging. Radiographs predicted a need for a separate surgical approach with PPV of 63% and NPV of 70% when compared to recommendations based on CT images. CONCLUSIONS Radiographs are reliable in ruling in lateral plateau involvement of medial plateau fractures, but occult lateral articular extension may only be identified in CT imaging for some cases. Surgical planning may be impacted by CT imaging for this fracture morphology, but further study is warranted to evaluate the correlation between preoperative planning and clinical outcomes. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Mary Kate Erdman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, 1520 San Pablo Street, Los Angeles, CA, USA.
| | - Stephen J Gibbs
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, 1520 San Pablo Street, Los Angeles, CA, USA
| | - Douglass W Tucker
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Adam K Lee
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, 1520 San Pablo Street, Los Angeles, CA, USA
| | - Mark E Fleming
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, 1520 San Pablo Street, Los Angeles, CA, USA
| | - Geoffrey S Marecek
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
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Tucker DW, Homere AJ, Wier JR, Bougioukli S, Carney JJ, Wong M, Inaba K, Marecek GS. Ballistic trauma patients have decreased early narcotic demand relative to blunt trauma patients: Blunt ballistic injury opioid use. Injury 2021; 52:1234-1238. [PMID: 32948328 DOI: 10.1016/j.injury.2020.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 09/07/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Blunt and ballistic injuries are two common injury mechanisms encountered by orthopaedic traumatologists. However the intrinsic nature of these injures may necessitate differences in operative and post-operative care. Given the evolving opioid crisis in the medical community, considerable attention has been given to appropriate management of pain; particularly in orthopaedic patients. We sought to evaluate relative postoperative narcotic use in blunt injuries and ballistic injuries. DESIGN Retrospective Cohort Study. SETTING Academic Level-1 Trauma Center. PATIENTS 96 Patients with blunt or ballistic fractures. INTERVENTION Inpatient narcotic pain management after orthopaedic fracture management. MAIN OUTCOME MEASUREMENTS Morphine equivalent units (MEU). RESULTS Patients with blunt injuries had a higher MEU compared to ballistic injuries in the first 24 hours postoperatively (35.0 vs 29.5 MEU, p=0.02). There were no differences in opiate consumption 24-48 hours (34.8 vs 28.0 MEU), 48 hours - 7 days post op (28.4 vs 30.4 MEU) or the 24 hours before discharge (30.0 vs 28.6 MEU). On multivariate analysis, during the 24-48 hours and 24 hours before discharge timepoints total EBL was associated with increased opioid usage. During days 3-7 (p<0.001) and in the final 24 hours prior to discharge (p=0.012), the number of orthopaedic procedures was a predictor of opioid consumption. CONCLUSION Blunt injuries required an increased postoperative narcotic consumption during the first 24 hours of inpatient stay following orthopedic fracture fixation. However, there was no difference at other time points. Immediate post-operative pain regimens may be decreased for patients with ballistic injuries. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Douglass W Tucker
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Andrew J Homere
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Julien R Wier
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Sofia Bougioukli
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - John J Carney
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Monica Wong
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States
| | - Geoffrey S Marecek
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States.
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Abstract
» The optimal regimen for wound irrigation in the setting of an open fracture has been a subject of debate. Basic science evidence as well as results from a recent prospective clinical trial have shed new light on this controversial topic.
» While normal saline solution appears to be the optimal irrigation agent, the optimal timing and volume often are determined by the surgeon. Future clinical trials are needed to determine the optimal timing for debridement and irrigation, as well as the ideal volume of irrigant.
» Irrigation pressure and the use of pulsatile lavage do not appear to have an effect on outcomes.
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Affiliation(s)
- Nathanael Heckmann
- Department of Orthopedics, Keck Medical Center of USC, Los Angeles, California
| | - Trevor Simcox
- Department of Orthopedics, Keck Medical Center of USC, Los Angeles, California
| | - Daniel Kelley
- Department of Orthopedics, Keck Medical Center of USC, Los Angeles, California
| | - Geoffrey S Marecek
- Department of Orthopedics, Keck Medical Center of USC, Los Angeles, California
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Telis AL, Tucker DW, Compton E, DeSanto DJ, Carney JJ, Scolaro JA, Marecek GS, Lee AK. Treatment of tibial plateau fractures with a novel fenestrated screw system for delivery of bone graft substitute. Eur J Orthop Surg Traumatol 2021; 31:1321-1327. [PMID: 33486537 DOI: 10.1007/s00590-021-02871-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/08/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of this study was to describe the incidence of subsidence in patients with AO/OTA 41 (tibial plateau) fractures which were repaired with a novel fenestrated screw system to used to deliver CaPO4 bone substitute material to fill the subchondral void and support the articular reduction. METHODS Patients with unicondylar and bicondylar tibial plateau fractures were treated according to the usual technique of two surgeons. After fixation, the Zimmer Biomet N-Force Fixation System®, a fenestrated screw that allows for the injection of bone substitute was placed and used for injection of the proprietary calcium phosphate bone graft substitute into the subchondral void. For all included patients, demographic information, operative data, radiographs, and clinic notes were reviewed. Patients were considered to have articular subsidence if one or more of two observations were made when comparing post-operative to their most recent clinic radiographs: > 2 mm change in the distance between the screw and the lowest point of the tibial plateau, > 2 mm change in the distance between the screw and the most superior aspect of the plate. Data were analyzed to determine if there were any identifiable risk factors for complication, reoperation, or subsidence using logistic regression. Statistical significance was set at p < 0.05. RESULTS 34 patients were included with an average follow-up of 32.03 ± 22.52 weeks. There were no overall differences between height relative to the medial plateau or the plate. Two patients (5.9%) had articular subsidence. Six patients (15.2%) underwent reoperation, two (6%) for manipulations under anaesthesia due to arthrofibrosis, and four (12%) due to infections. There were 6 (19%) total infections as 2 were superficial and required solely antibiotics. One patient had early failure. CONCLUSION Use of a novel fenestrated screw system for the delivery of CaPO4 BSM results in articular subsidence and complication rates similar to previously published values and appears to be a viable option for addressing subchondral defects in tibial plateau fractures. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Alexander L Telis
- Department of Orthopaedic Surgery, Providence Sacred Heart Medical Center and Children's Hospital, Spokane, WA, USA
| | - Douglass W Tucker
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Edward Compton
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Donald J DeSanto
- Department of Orthopaedic Surgery, University of California Irvine, Orange, CA, USA
| | - John J Carney
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - John A Scolaro
- Department of Orthopaedic Surgery, University of California Irvine, Orange, CA, USA
| | - Geoffrey S Marecek
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Adam K Lee
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.
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Marecek GS. Sage Advice from the Wu Tang Clan? On the Importance of Protecting the (Femoral) Neck: Commentary on an article by Hans Peter Bögl, MD, et al.: "Reduced Risk of Reoperation Using Intramedullary Nailing with Femoral Neck Protection in Low-Energy Femoral Shaft Fractures". J Bone Joint Surg Am 2020; 102:e101. [PMID: 32890074 DOI: 10.2106/jbjs.20.01296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Erdman MK, Munger AM, Brown M, Schellenberg M, Tucker D, Inaba K, Fleming ME, Marecek GS. Injury and treatment patterns of ballistic pelvic fractures by anatomic location. Eur J Orthop Surg Traumatol 2020; 31:111-119. [PMID: 32720105 DOI: 10.1007/s00590-020-02744-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 07/14/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Pelvic ballistic injuries threaten critical gastrointestinal, vascular, and urinary structures. We report the treatment patterns and injury profiles of ballistic pelvic fractures and the association between location of ballistic fractures of the pelvis and visceral injuries. METHODS A prospectively collected database at an academic level I trauma center was reviewed for clinical and radiographic data on patients who sustained one or more ballistic fractures of the pelvis. Main outcomes compared included: procedures with orthopedic surgery, emergent surgery, concomitant intrapelvic injuries, and mortality. RESULTS Eighty-six patients were included. Eight patients (9.3%) underwent surgical debridement with orthopedic surgery, no ballistic pelvic fractures required surgical stabilization. The anatomical locations of ballistic pelvic fractures included: 10 (14.7%) anterior ring, 13 (19.1%) posterior ring, 27 (39.7%) anterior column, and 18 (20.9%) posterior column. There was a statistically significant association between anterior ring and rectal injury. The association between anterior ring injury and bladder injury approached significance. CONCLUSIONS This case series included 86 patients with a ballistic fracture of the pelvis, none requiring pelvic ring surgical stabilization. The unpatterned behavior of these injuries demands a high suspicion for visceral injury, with special attention to the rectum and bladder in the setting of anterior ring involvement. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Mary Kate Erdman
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Alana M Munger
- Yale Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Meghan Brown
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Morgan Schellenberg
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Douglass Tucker
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Kenji Inaba
- Yale Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Mark E Fleming
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Geoffrey S Marecek
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Carney J, Ton A, Alluri RK, Grisdela P, Marecek GS. Complications following operative treatment of supination-adduction type II (AO/OTA 44A2.3) ankle fractures. Injury 2020; 51:1387-1391. [PMID: 32197830 DOI: 10.1016/j.injury.2020.03.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION There are few published studies that investigate the surgical treatment of supination-adduction (SAD, AO/OTA 44A2.3) ankle fractures. The purpose of this study was to describe the complications and outcomes following operative fixation of SAD type 2 ankle fractures. MATERIALS AND METHODS We identified all SAD-2 ankle fractures that presented at our institution's two hospitals from 2006-2018. Demographics, operative data, and complications (deep infection, superficial infection, delayed union, failure of fixation, and unplanned reoperation) were recorded for all patients. Lastly, all included patients were contacted by telephone for the administration of an 8-question Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference questionnaire (PI). Univariate and multivariate analysis was performed to identify risk factors for complication or poor functional outcome score. RESULTS 65 patients met inclusion criteria. The average time to surgery was 14 days and average follow-up was 20.5 (range: 0.4-60.9) weeks. There were 9 (13.8%) complications (4 deep infections, 3 superficial infections, 1 delayed union, 1 failure of fixation) and 6 unplanned reoperations. Univariate and multivariate analysis failed to identify any statistically significant risk factors for complication or reoperation. Eleven patients participated in the administration of PROMIS score questionnaires at a mean of 3.4 years postoperatively. The average PROMIS Physical Function T-score was 42.3 ± 11.3 and the average PROMIS Pain Interference T-score was 55.8 ± 7.8. Younger age was associated with a higher physical function score. The use of a direct medial approach to the medial malleolus was associated with a lower pain interference score. CONCLUSION The overall complication rate for SAD (OTA/AO 44A2.3) type 2 ankle fractures is similar to that of the general ankle fracture population. We were unable to identify risk factors for complication or reoperation. Mean patient reported outcomes are within one standard deviation of the general population. LEVEL OF EVIDENCE III, retrospective cohort study.
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Affiliation(s)
- J Carney
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery, 1520 San Pablo Street, Suite 2000, Los Angeles, CA 90033, United States
| | - A Ton
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery, 1520 San Pablo Street, Suite 2000, Los Angeles, CA 90033, United States
| | - R K Alluri
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery, 1520 San Pablo Street, Suite 2000, Los Angeles, CA 90033, United States
| | - P Grisdela
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery, 1520 San Pablo Street, Suite 2000, Los Angeles, CA 90033, United States
| | - G S Marecek
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery, 1520 San Pablo Street, Suite 2000, Los Angeles, CA 90033, United States.
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Choi JT, Foster BD, Soraya Heidari K, Carney JJ, Hatch GF, Marecek GS. Effect of bariatric surgery on outcomes in the operative treatment of hip fractures. Injury 2020; 51:688-693. [PMID: 32033806 DOI: 10.1016/j.injury.2020.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 11/26/2019] [Accepted: 01/19/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Few studies have evaluated the effect of prior bariatric surgery on outcomes following the operative treatment of hip fractures. The purpose of this study is to evaluate these metrics in a population of bariatric surgery patients compared to a control group who were operatively treated for hip fractures. MATERIALS AND METHODS The California Office of Statewide Health Planning & Development (OSHPD) discharge database was accessed to identify patients who sustained a hip fracture between 2000-2014. CPT codes were utilized to identify patients who had a prior history of bariatric surgery within this time period. A control cohort of patients who had undergone previous appendectomy were queried similarly. The study evaluated complication rates and inpatient mortality at 30- and 90-days postoperatively as well as 30- and 90-day readmission rates. RESULTS There were 1,327 bariatric and 2,127 control patients identified. Survival rates were significantly lower in bariatric patients compared to controls (87.2% vs. 91.8%, p = 0.048) at 5 years. After controlling for confounders, bariatric patients had higher 30- (OR 1.46, p = 0.005) and 90-day (OR 1.38, p = 0.011) readmission rates. There were no differences in all-cause complication and inpatient mortality rates between groups at 30 or 90 days. DISCUSSION Bariatric surgery patients are at increased risk of readmission after hip fracture surgery. Further research is warranted to delineate potential risk factors and mitigate readmission in these patients. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jihoon T Choi
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, 1200N. State St. GNH 3900, Los Angeles, CA 90033, United States.
| | - Brock D Foster
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, 1200N. State St. GNH 3900, Los Angeles, CA 90033, United States
| | - K Soraya Heidari
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, 1200N. State St. GNH 3900, Los Angeles, CA 90033, United States
| | - John J Carney
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, 1200N. State St. GNH 3900, Los Angeles, CA 90033, United States
| | - George F Hatch
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, 1200N. State St. GNH 3900, Los Angeles, CA 90033, United States
| | - Geoffrey S Marecek
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, 1200N. State St. GNH 3900, Los Angeles, CA 90033, United States
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Carney JJ, Hwang A, Heckmann N, Bernstein M, Marecek GS. Characteristics of Marijuana Use Among Orthopedic Patients. Orthopedics 2020; 43:108-112. [PMID: 31841610 DOI: 10.3928/01477447-20191212-07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 01/14/2019] [Indexed: 02/03/2023]
Abstract
Marijuana use among orthopedic patients has not been extensively studied. The purpose of this study was to investigate the prevalence of marijuana use among orthopedic surgery patients. Additionally, the authors sought to better characterize how and why their patients use marijuana. Patients presenting at 3 institutions in 2 states for orthopedic surgery were asked to complete a voluntary survey. In addition to basic demographic information, the survey contained questions regarding the frequency of, methods of, and reasons for marijuana use. Patients who had used marijuana in the past year were categorized as marijuana users. A total of 275 patients completed surveys, of whom 94 (34%) endorsed marijuana use in the past year. A majority of marijuana users (55%) endorsed using marijuana either daily or weekly. Smoking was the most common means of marijuana use (90%), followed by edible products (35%) and vaporizing (24%). Pain management (54%) and recreation (52%) were the most commonly cited reasons for using marijuana. Eighty-six percent of marijuana users indicated that they would stop using marijuana if told by their physician that marijuana use would adversely affect their surgery. Marijuana use is common among orthopedic patients. Many patients believe marijuana is beneficial for managing pain and other medical conditions, although most would be willing to stop using marijuana if told it would negatively impact their surgery. Further study into the effects of marijuana use on musculoskeletal health is warranted because marijuana use may be a risk factor easily modified to improve surgical outcomes. [Orthopedics. 2020; 43(2): 108-112.].
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Marecek GS, Little MT, Gardner MJ, Stevanovic M, Lefebvre R, Bernstein M. Management of Critical Bone Defects. Instr Course Lect 2020; 69:417-432. [PMID: 32017743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Bone defects may occur after trauma, infection, or oncologic resection. A critical sized defect is any defect that is unable to spontaneously heal and will require secondary procedure(s) to obtain union. Autologous grafting is widely used, but may be insufficient to obtain union in these situations. Other options include the induced membrane technique, bone transport through distraction osteogenesis, or free vascularized bone transfer. This chapter will review options for obtaining graft, and the aforementioned special techniques for managing these challenging problems.
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Stone MA, Flato RR, Pannell W, Cohen JR, Wang JC, Marecek GS. Operatively Treated Talus Fractures: Complications and Survivorship in a Large Patient Sample. J Foot Ankle Surg 2018; 57:737-741. [PMID: 29703458 DOI: 10.1053/j.jfas.2017.12.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Indexed: 02/03/2023]
Abstract
Talus fractures are relatively uncommon; however, the sequelae of talus fractures can cause significant morbidity. Although avascular necrosis has been a consistently reported complication, the reported rates of subsequent arthrodesis have varied widely. The purpose of the present study was to report the complications in a large patient sample of operatively treated talus fractures and to describe the survivorship of open reduction internal fixation (ORIF) of the talus. Patients undergoing talus ORIF for closed or open fractures from 2007 to 2011 were identified in the United Healthcare System database by International Classification of Diseases, 9th revision, code 825.21 and Current Procedural Terminology codes 28445, 28436, and 28430. Patients with a nonoperative talus fracture or isolated osteochondral defect were excluded, leaving 1527 patients in the final analysis. We also identified patients who had required subsequent subtalar, pantalar, and tibiotalocalcaneal arthrodeses using Current Procedural Terminology codes 28725, 28705, and 28715, respectively. Complications and demographic data were recorded. Of the 1527 patients, 29 (1.9%) had undergone subsequent arthrodesis within 4 years; 64 patients (4.2%) developed wound complications that did not require surgical intervention, 11 patients (0.7%) were readmitted, 204 (13.3%) presented to the emergency department (ED), and 96 (6.3%) underwent operative irrigation and debridement (I&D). The overall complication rate was 19.5%. Patients aged >34 years had a significantly greater rate of ED visits (54.7%, p = .015) and overall complications (56.8%, p < .001). In conclusion, ORIF of talus fractures has good survivorship when considering the failure of initial surgery or the requirement for secondary arthrodesis. Medical complications and hospital readmission were relatively rare; however, ED visits and infection requiring I&D were relatively common after ORIF of talus fractures.
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Affiliation(s)
- Michael A Stone
- Resident in Orthopaedic Surgery, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.
| | - Russell R Flato
- Medical Student, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - William Pannell
- Resident in Orthopaedic Surgery, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Jeremiah R Cohen
- Medical Student, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Jeffrey C Wang
- Professor of Clinical Orthopaedic Surgery and Neurosurgery, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Geoffrey S Marecek
- Assistant Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Lim PK, Stephenson GS, Keown TW, Byrne C, Lin CC, Marecek GS, Scolaro JA. Use of 3D Printed Models in Resident Education for the Classification of Acetabulum Fractures. J Surg Educ 2018; 75:1679-1684. [PMID: 29929817 PMCID: PMC6346736 DOI: 10.1016/j.jsurg.2018.04.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 03/21/2018] [Accepted: 04/30/2018] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To determine if three-dimensional (3D) printed models can be used to improve acetabular fracture pattern recognition and be a valuable adjunct in orthopedic resident education. DESIGN Fifteen randomized testing stations with each containing plain radiographs (XRs), two-dimensional computed tomography (CT) scans, or 3D model of an acetabular fracture. SETTING Two orthopedic residency programs based at Level 1 trauma centers. PARTICIPANTS Forty-one orthopedic residents, PGY 1-5. RESULTS Senior residents were superior to junior residents at correctly identifying the provided acetabular fracture pattern. Overall, use of CT scans or the 3D model improved fracture classification as compared to standard XRs, but there was no significant difference between use of the CT scans and 3D models. Subjective survey results indicated agreement among residents that 3D models were accurate representations of acetabular fractures and that models would be a desired educational modality. CONCLUSIONS 3D models improved the accuracy of acetabular fracture identification compared to XR. In addition, trainees were able to use 3D models to obtain similar accuracy compared to CT scans despite not having previous exposure to the models. Interobserver agreement improved when comparing CT to 3D, but did not provide greater than a fair agreement indicating that fracture patterns were difficult to accurately classify even with the use of 3D models. Residents' subjective responses indicated a positive experience with the use of 3D models. We conclude that the incorporation of 3D models could be an important adjunct to orthopedic residency education for the evaluation complex fracture patterns, but is not significantly superior to identification with CT scans.
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Affiliation(s)
- Philip K Lim
- UC Irvine Department of Orthopaedic Surgery, Division of Orthopaedic Trauma, Irvine, California
| | | | | | - Connor Byrne
- UC Irvine School of Medicine, Irvine, California
| | | | - Geoffrey S Marecek
- USC Department of Orthopaedic Surgery, Division of Orthopaedic Trauma, Los Angeles, California
| | - John A Scolaro
- UC Irvine Department of Orthopaedic Surgery, Division of Orthopaedic Trauma, Irvine, California.
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Cooper J, Tilan J, Rounds AD, Rosario S, Inaba K, Marecek GS. Hip dislocations and concurrent injuries in motor vehicle collisions. Injury 2018; 49:1297-1301. [PMID: 29739656 DOI: 10.1016/j.injury.2018.04.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 04/21/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Motor Vehicle Collisions (MVC) can cause high energy hip dislocations associated with serious injury profiles impacting triage. Changes in safety and regulation of restraint devices have likely lowered serious injuries from what was previously reported in the 1990s. This study aims to describe modern-day injury profile of patients with traumatic hip dislocations, with special attention to aortic injury. METHODS Retrospective review of a prospectively maintained trauma database at an urban level 1 trauma center was conducted. Patients with hip dislocation following MVC between January 2005 and December 2015 were grouped based on seatbelt use and airbag deployment. Patients with unknown restraint use were excluded. Multiple logistic regression was used to identify risk of injury profile between groups. RESULTS Of 204 patients with hip dislocation after MVC, nearly 57% were unrestrained. Seatbelt alone was used in 36 (17.7%), airbag deployed in 14 (6.9%), and 38 (18.6%) with both. Gender and number of injuries were similar between groups. The most common concomitant injury was acetabular fracture (53.92%) and the abdominopelvic region was the most injured. Use of a seatbelt with airbag deployment was protective of concomitant pelvic ring injury (OR = 0.22). Airbag deployment was significantly protective of lumbar fracture (OR = 0.15) while increasing the likelihood of radial and ulnar fracture or dislocation (OR = 3.27), acetabular fracture (OR = 5.19), and abdominopelvic injury (OR = 5.07). The no restraint group had one patient (0.80%) with an intimal tear of the thoracic aorta identified on CT chest that was successfully medically managed. DISCUSSION AND CONCLUSION Hip dislocations are high energy injuries with severe associated injuries despite upgrades in restraint devices. These patients require careful examination and heightened awareness when evaluating for concomitant injuries.
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Affiliation(s)
- Joseph Cooper
- Department of Orthopedic Surgery, Keck School of Medicine of University of Southern California, 1520 San Pablo St, Suite 2000, Los Angeles, CA, 90033, United States
| | - Justin Tilan
- Department of Orthopedic Surgery, Washington University in St Louis, 660 S Euclid Ave., St. Louis, MO, 63110, United States
| | - Alexis D Rounds
- Keck School of Medicine of University of Southern California, 1520 San Pablo St, Suite 2000, Los Angeles, CA, 90033, United States
| | - Santano Rosario
- Keck School of Medicine of University of Southern California, 1520 San Pablo St, Suite 2000, Los Angeles, CA, 90033, United States
| | - Kenji Inaba
- Department of Surgery, Los Angeles County + USC Medical Center, 1983 Marengo St., Los Angeles, CA, 90033, United States
| | - Geoffrey S Marecek
- Department of Orthopedic Surgery, Keck School of Medicine of University of Southern California, 1520 San Pablo St, Suite 2000, Los Angeles, CA, 90033, United States.
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Leland HA, Rounds AD, Burtt KE, Gould DJ, Marecek GS, Alluri RK, Patel KM, Carey JN. Soft tissue reconstruction and salvage of infected fixation hardware in lower extremity trauma. Microsurgery 2017; 38:259-263. [DOI: 10.1002/micr.30176] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 03/06/2017] [Accepted: 03/10/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Hyuma A. Leland
- Division of Plastic and Reconstructive Surgery; Keck School of Medicine of USC; Los Angeles California
| | - Alexis D. Rounds
- Division of Plastic and Reconstructive Surgery; Keck School of Medicine of USC; Los Angeles California
| | - Karen E. Burtt
- Division of Plastic and Reconstructive Surgery; Keck School of Medicine of USC; Los Angeles California
| | - Daniel J. Gould
- Division of Plastic and Reconstructive Surgery; Keck School of Medicine of USC; Los Angeles California
| | - Geoffrey S. Marecek
- Department of Orthopaedic Surgery; Keck School of Medicine of USC; Los Angeles California
| | - Ram K. Alluri
- Department of Orthopaedic Surgery; Keck School of Medicine of USC; Los Angeles California
| | - Ketan M. Patel
- Division of Plastic and Reconstructive Surgery; Keck School of Medicine of USC; Los Angeles California
| | - Joseph N. Carey
- Division of Plastic and Reconstructive Surgery; Keck School of Medicine of USC; Los Angeles California
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Abstract
Jones fractures are reportedly prone to nonunion and generally treated with a period of non-weightbearing or operative treatment. Extended non-weightbearing can have adverse effects, and operative treatment poses various risks. We report the clinical results of patients treated without weightbearing restriction. All patients treated for metatarsal fractures by a single surgeon from January 1, 2000 to December 31, 2009 were identified through the clinical billing records by International Classification of Diseases, ninth revision, code. Through a radiographic and medical record review, 27 consecutive patients with acute Jones fractures treated without weightbearing restriction were identified. The demographic information and clinical and radiographic results were recorded. Of the 27 patients, 24 (89%) had achieved clinical union at a mean of 8.0 ± 2.6 weeks. Complete radiographic union was noted in 13 (48%) patients, and 13 (48%) others had made significant progress toward radiographic union but had not yet reached it. Two (8.3%) patients were lost to follow-up. One patient (4%) developed nonunion. Patients with acute Jones fractures can be treated without weightbearing restriction. This protocol results in rapid clinical union and a low rate of nonunion.
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Affiliation(s)
- Geoffrey S Marecek
- Assistant Professor, Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA.
| | - Jeffrey S Earhart
- Assistant Professor, Rush University Medical Center, Rockford Orthopedic Associates, Rockford, IL
| | - William P Croom
- Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Bradley R Merk
- Associate Professor, Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
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Marecek GS, Earhart JS, Gardner MJ, Davis J, Merk BR. Surgeon preferences regarding antibiotic prophylaxis for ballistic fractures. Arch Orthop Trauma Surg 2016; 136:751-4. [PMID: 27043840 DOI: 10.1007/s00402-016-2450-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Scant evidence exists to support antibiotic use for low velocity ballistic fractures (LVBF). We therefore sought to define current practice patterns. We hypothesized that most surgeons prescribe antibiotics for LVBF, prescribing is not driven by institutional protocols, and that decisions are based on protocols utilized for blunt trauma. MATERIALS AND METHODS A web-based questionnaire was emailed to the membership of the Orthopaedic Trauma Association (OTA). The questionnaire included demographic information and questions about LVBF treatment practices. Two hundred and twenty surgeons responded. One hundred and fifty-four (70 %) respondents worked at a Level-1 trauma center, 176 (80 %) had received fellowship education in orthopaedic trauma and 104 (47 %) treated at least 10 ballistic fractures annually. Responses were analyzed with SAS 9.3 for Windows (SAS Institute Inc, Cary, NC). RESULTS One hundred eighty-six respondents (86 %) routinely provide antibiotics for LVBF. Those who did not were more apt to do so for intra-articular fractures (8/16, 50 %) and pelvic fractures with visceral injury (10/16, 63 %). Most surgeons (167, 76 %) do not believe the Gustilo-Anderson classification applies to ballistic fractures, and (20/29, 70 %) do not base their antibiotic choice on the classification system. Few institutions (58, 26 %) have protocols guiding antibiotic use for LVBF. CONCLUSIONS Routine antibiotic use for LVBF is common; however, practice is not dictated by institutional protocol. Although antibiotic use generally follows current blunt trauma guidelines, surgeons do not base their treatment decisions the Gustilo-Anderson classification. Given the high rate of antibiotic use for LVBF, further study should focus on providing evidence-based treatment guidelines.
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Affiliation(s)
- Geoffrey S Marecek
- Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, 1200 N. State St, GNH 3900, Los Angeles, CA, 90033, USA.
| | - Jeffrey S Earhart
- Rockford Orthopedic Associates, Rush University Medical Center, Rockford, IL, USA
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jason Davis
- Department of Orthopaedic Surgery, University of Texas Health Sciences Center, Houston, TX, USA
| | - Bradley R Merk
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Pannell WC, Banks K, Hahn J, Inaba K, Marecek GS. Antibiotic related acute kidney injury in patients treated for open fractures. Injury 2016; 47:653-7. [PMID: 26854072 DOI: 10.1016/j.injury.2016.01.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 01/11/2016] [Accepted: 01/14/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Antibiotic administration during the treatment of open fractures has been shown to reduce infection rates and is considered a critical step in the management of these injuries. The purpose of this study was to determine if aminoglycoside administration during the treatment of open fractures leads to acute kidney injury. METHODS Patient records at a level I trauma centre were reviewed for adult patients who presented in 2014 with open fractures were screened for inclusion. Patients were excluded with fractures of the phalanges, metatarsals, and metacarpals, with isolated traumatic arthrotomies, or pre-existing renal dysfunction. Charts were reviewed for patient age, gender, race, past medical history, medication history, injury severity score, intravenous dye studies and fracture type. Patients were divided into those given cefazolin (Group A) and cefazolin with gentamicin (Group B). Laboratory values were used to determine which patients developed kidney dysfunction as measured using the RIFLE criteria. Wilcoxon-Mann-Whitney test and Chi-square were used to compare interval and categorical variables, respectively. Significance was set at P<0.05. RESULTS One-hundred and fifty-nine patients met inclusion criteria. Forty-one (25%) patients were given cefazolin alone and 113 (68%) patients were given cefazolin with gentamicin. Ten (18%) patients with Gustilo-Anderson type III fractures were given cefazolin alone and 67 (67%) patients with types I or II fractures were given a cefazolin with gentamicin. Baseline characteristics and risk factors for renal dysfunction did not vary between groups. Two (4.8%) patients in Group A and 5 (4%) patients in Group B developed acute kidney injury (P=0.599). CONCLUSIONS Gentamicin use during the treatment of open fractures does not lead to increased rates of renal dysfunction when used in patients with normal baseline renal function.
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Affiliation(s)
- William C Pannell
- Department of Orthopaedic Surgery, USC, Los Angeles, CA, United States.
| | - Kian Banks
- Keck School of Medicine at USC, Los Angeles, CA, United States
| | - Joseph Hahn
- Department of Orthopaedic Surgery, USC, Los Angeles, CA, United States
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, USC, Los Angeles, CA, United States
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Affiliation(s)
- Geoffrey S Marecek
- Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, 1520 San Pablo, Suite 2000, Los Angeles, CA 90033
| | - John A Scolaro
- Department of Orthopaedic Surgery, University of California, Irvine, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA 92868
| | - Milton L Chip Routt
- University of Texas-Health Sciences Center at Houston, 6431 Fannin Street, Houston, TX 77030
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Marecek GS, Weatherford BM, Fuller EB, Saltzman MD. The effect of axillary hair on surgical antisepsis around the shoulder. J Shoulder Elbow Surg 2015; 24:804-8. [PMID: 25487899 DOI: 10.1016/j.jse.2014.10.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 10/01/2014] [Accepted: 10/05/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND Infection after shoulder surgery can have devastating consequences. Recent literature has implicated Propionibacterium acnes as a causative agent for postoperative shoulder infections. Axillary hair removal has been suggested as a method for infection prevention, although data quantifying its effect on the bacterial load around the shoulder are lacking. METHODS We clipped one randomly selected axilla in 85 healthy male volunteers with commercially available surgical clippers. Aerobic and anaerobic culture specimens were taken from the clipped and unclipped axillae. Each shoulder was then prepared with 2% chlorhexidine gluconate and 70% isopropyl alcohol. Repeated culture specimens were then taken from both axillae. Cultures were held for 14 days and recorded with a semiquantitative system (0-4 points). Results were compared by the Wilcoxon signed rank test. RESULTS There was no difference in the burden of P. acnes between the clipped and unclipped axillae before or after surgical preparation (P = .109, P = .344, respectively). There was a significantly greater bacterial burden in the clipped shoulder compared with the unclipped shoulder before preparation (P < .001) but not after preparation (P = .285). There was a significant reduction in total bacterial load and P. acnes load for both axillae after surgical preparation (P < .001 for all). CONCLUSIONS Removal of axillary hair has no effect on the burden of P. acnes in the axilla. Clipped axillae had a higher total bacterial burden. A 2% chlorhexidine gluconate surgical preparation is effective at removal of all bacteria and specifically P. acnes from the axilla.
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Affiliation(s)
- Geoffrey S Marecek
- Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA, USA.
| | - Brian M Weatherford
- Department of Orthopaedic Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Eric B Fuller
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Matthew D Saltzman
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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White EA, Matcuk GR, Schein A, Skalski M, Marecek GS, Forrester DM, Patel DB. Erratum to: Coronal plane fracture of the femoral condyles: anatomy, injury patterns, and approach to management of the Hoffa fragment. Skeletal Radiol 2015; 44:45. [PMID: 25331357 DOI: 10.1007/s00256-014-2038-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Eric A White
- Keck Medical Center of USC, 1500 San Pablo, Los Angeles, CA, 90033, USA,
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31
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Marecek GS, Routt MLC. Percutaneous manipulation of intra-articular debris after fracture-dislocation of the femoral head or acetabulum. Orthopedics 2014; 37:603-6. [PMID: 25350613 DOI: 10.3928/01477447-20140825-04] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 10/02/2013] [Indexed: 02/03/2023]
Abstract
Traumatic fracture-dislocation of the hip usually warrants prompt management by closed manipulative reduction. In some patients, debris malpositioned between the femoral head and the acetabular dome obstructs a completely concentric reduction of the injured hip. To avoid damage to the articular surfaces, the debris between them should be removed in a timely fashion. Techniques for removal include open approaches with or without fracture fixation or hip arthroscopy. Fracture fixation and hip arthroscopy have associated risks and potential complications, may require special equipment, and may not be familiar to all surgeons. The authors present a simple fluoroscopically guided technique for the percutaneous removal of intra-articular debris between the femoral head and the acetabular dome after traumatic femoral head or acetabular fracture-dislocation.
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Saucedo JM, Marecek GS, Wanke TR, Lee J, Stulberg SD, Puri L. Understanding readmission after primary total hip and knee arthroplasty: who's at risk? J Arthroplasty 2014; 29:256-60. [PMID: 23958236 DOI: 10.1016/j.arth.2013.06.003] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Revised: 05/27/2013] [Accepted: 06/01/2013] [Indexed: 02/06/2023] Open
Abstract
Readmission has been cited as an important quality measure in the Patient Protection and Affordable Care Act. We queried an electronic database for all patients who underwent Total Hip Arthroplasty or Total Knee Arthroplasty at our institution from 2006 to 2010 and identified those readmitted within 90 days of surgery, reviewed their demographic and clinical data, and performed a multivariable logistic regression analysis to determine significant risk factors. The overall 90-day readmission rate was 7.8%. The most common readmission diagnoses were related to infection and procedure-related complications. An increased likelihood of readmission was found with coronary artery disease, diabetes, increased LOS, underweight status, obese status, age (over 80 or under 50), and Medicare. Procedure-related complications and wound complications accounted for more readmissions than any single medical complication.
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Affiliation(s)
- James M Saucedo
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Geoffrey S Marecek
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Tyler R Wanke
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jungwha Lee
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - S David Stulberg
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lalit Puri
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Saucedo J, Marecek GS, Lee J, Huminiak L, Stulberg SD, Puri L. How accurately are we coding readmission diagnoses after total joint arthroplasty? J Arthroplasty 2013; 28:1076-9. [PMID: 23768916 DOI: 10.1016/j.arth.2013.05.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 04/29/2013] [Accepted: 05/07/2013] [Indexed: 02/01/2023] Open
Abstract
Readmission rates have been cited as an important quality measure in the Affordable Care Act. Accordingly, understanding and accurately tracking the causes for readmission will be increasingly important. We queried an electronic database for all patients who underwent primary THA or TKA at our institution from 2006 through 2010. We identified those readmitted within 90 days of surgery and analyzed 87 random de-identified medical records. We then assigned a clinical diagnosis for each readmission, which was then compared with the coder-derived diagnosis by ICD-9 code. The overall 90-day readmission rate was 7.9%. We identified 22 of 87 patients for whom there was disagreement (25.3%, 95% CI=16.6-35.8%). The most common were procedure-related complications. Coded diagnoses frequently did not correlate with the physician-derived diagnoses. The unverified use of coded readmission diagnoses in calculating quality measures may not be clinically relevant.
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Affiliation(s)
- James Saucedo
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Abstract
Superior mesenteric artery syndrome is obstruction of the third portion of the duodenum by compression between the abdominal aorta and superior mesenteric artery. Pediatric orthopedists are familiar with this entity, as the association between superior mesenteric artery syndrome and spinal fusion or body casting has been well established. However, patients with spinal deformities usually experience superior mesenteric artery syndrome after orthopedic intervention, with rates after corrective spinal surgery reported between 0.5% and 2.4%. Symptoms of superior mesenteric artery syndrome typically include nausea, bilious emesis, abdominal pain, early satiety, and anorexia. Initial treatment focuses on gastric decompression and maintaining euvolemia and electrolyte balance. The patient should receive enteral nutrition via nasojejunal tube or parenteral nutrition to allow for weight gain and subsequent resolution of the obstruction. The superior mesenteric artery takes off from the duodenum at an angle of 45 degrees to 60 degrees in normal individuals. The third portion of the duodenum is suspended between these vessels by the ligament of Treitz. Any variation in this relationship that decreases the arteriomesenteric angle may induce obstruction. Specifically, lumbar hyperextension or hyperlordosis can traction the mesentery and vessels. Only 2 cases of superior mesenteric artery syndrome in patients with sagittal plane spinal deformity have been described in the literature. In patients with concomitant superior mesenteric artery syndrome and spinal deformity, correction of the deformity may help alleviate the obstruction and result in faster recovery. The contribution of spinal column deformity to the arteriomesenteric angle should not be overlooked.
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Affiliation(s)
- Geoffrey S Marecek
- Department of Orthopedic Surgery, Northwestern University, 676 N Saint Clair St, Ste 1350, Chicago, IL 60611, USA.
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Abstract
Shoulder arthroscopy is generally a safe and effective method for treating a wide variety of shoulder pathology. Fortunately, complications following shoulder arthroscopy are rare, with reported rates between 4.6% and 10.6%.¹⁻⁷ These rates may be underestimated, as underreporting of complications and varying definitions of the term complication are likely. During shoulder arthroscopy, complications may occur at numerous points. The surgeon must be aware of potential problems and take necessary measures to prevent them. This article describes common complications after arthroscopic shoulder surgery. Although failure of treatment and postoperative stiffness are undesirable outcomes, they are not described.
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Affiliation(s)
- Geoffrey S Marecek
- Department of Orthopedic Surgery, Northwestern University, Chicago, Illinois 60611, USA
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Abstract
BACKGROUND Deep infection following shoulder surgery is a rare but devastating problem. The use of an effective skin-preparation solution may be an important step in preventing infection. The purposes of the present study were to examine the native bacteria around the shoulder and to determine the efficacy of three different surgical skin-preparation solutions on the eradication of bacteria from the shoulder. METHODS A prospective study was undertaken to evaluate 150 consecutive patients undergoing shoulder surgery at one institution. Each shoulder was prepared with one of three randomly selected solutions: ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol), DuraPrep (0.7% iodophor and 74% isopropyl alcohol), or povidone-iodine scrub and paint (0.75% iodine scrub and 1.0% iodine paint). Aerobic and anaerobic cultures were obtained prior to skin preparation for the first twenty patients, to determine the native bacteria around the shoulder, and following skin preparation for all patients. RESULTS Coagulase-negative Staphylococcus and Propionibacterium acnes were the most commonly isolated organisms prior to skin preparation. The overall rate of positive cultures was 31% in the povidone-iodine group, 19% in the DuraPrep group, and 7% in the ChloraPrep group. The positive culture rate for the ChloraPrep group was lower than that for the povidone-iodine group (p < 0.0001) and the DuraPrep group (p = 0.01). ChloraPrep and DuraPrep were more effective than povidone-iodine in eliminating coagulase-negative Staphylococcus from the shoulder region (p < 0.001 for both). No significant difference was detected among the agents in their ability to eliminate Propionibacterium acnes from the shoulder region. No infections occurred in any of the patients treated in this study at a minimum of ten months of follow-up. CONCLUSIONS ChloraPrep is more effective than DuraPrep and povidone-iodine at eliminating overall bacteria from the shoulder region. Both ChloraPrep and DuraPrep are more effective than povidone-iodine at eliminating coagulase-negative Staphylococcus from the shoulder.
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Affiliation(s)
- Matthew D Saltzman
- Department of Orthopaedic Surgery, Northwestern University, 676 North Saint Clair, 13th Floor, Chicago, IL 60611, USA.
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