Faculty Bibliography

OBJECTIVES/OBJECTIVE:To investigate if any injury to the three primary branches of the popliteal artery in open tibia fractures lead to increased soft-tissue complications, particularly in the area of the affected angiosome. DESIGN/METHODS:Retrospective cohort comparative study. SETTING/METHODS:Two academic level one trauma centersPatients/Participants: Sixty-eight adult patients with open tibia fractures with a minimum one-year follow up. INTERVENTION/METHODS:N/A. MAIN OUTCOME MEASUREMENTS/METHODS:Soft-tissue outcomes as measured by wound healing (delayed healing, dehiscence, or skin breakdown) and fracture related infection (FRI) at time of final follow-up. RESULTS:Eleven (15.1%) tibia fractures had confirmed arterial injuries via CTA (7), direct intraoperative visualization (3), intraoperative angiogram (3). Ten (91.0%) were treated with ligation and 1 (9.1%) was directly repaired by vascular surgery. Ultimately, 6 (54.5%) achieved radiographic union and 4 (36.4%) required amputation performed at a mean of 2.62 ± 2.04 months, with one patient going on to nonunion diagnosed at 10 months. Patients with arterial injury had significantly higher rates of wound healing complications, FRI, nonunion, amputation rates, return to the OR, and increased time to coverage or closure. After multivariate regression, arterial injury was associated with higher odds of wound complications, FRI, and nonunion. Ten (90.9%) patients with arterial injury had open wounds in the region of the compromised angiosome, with 7 (70%) experiencing wound complications, 6 (60%) FRIs, and 3 (30%) undergoing amputation. CONCLUSIONS:Arterial injuries in open tibia fractures with or without repair, have significantly higher rates of wound healing complications, FRI, delayed time to final closure, and need for amputation. Arterial injuries appear to effect wound healing in the affected angiosome. LEVEL OF EVIDENCE/METHODS:Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

INTRODUCTION/BACKGROUND:The purpose of this study was to demonstrate a novel technology used to measure improvements in quality and value of care for treatment of hip fracture patients. METHODS:A novel value-based triaging methodology uses a risk prediction (risk M) and inpatient cost prediction (risk C) algorithm and has been demonstrated to accurately predict high-risk:high-cost episodes of care. Two hundred twenty-nine hip fracture patients from 2014 to 2016 were used to establish baseline length of stay (LOS) and total inpatient cost for each (16) risk:cost quadrants. Two hundred sixty-five patients between 2017 and 2019 with hip fractures were input into the algorithm, and historical LOS and cost for each patient were calculated. Historical values were compared with actual values to determine whether the value of the inpatient episode of care differed from the 2014 to 16 cohort. RESULTS:When evaluated without risk or cost stratification, the mean actual LOS and cost of the baseline cohort compared with the 2017 to 2019 cohort were 8.0 vs 7.5 days (P = 0.43) and $25,446 vs $29,849 (P = 0.15), respectively. This analysis demonstrates that there was only a small change in value of care provided to patients based on LOS/cost over the studied period; however, risk:cost analysis using the novel methodology demonstrated that for select risk:cost quadrants, value of care measured by LOS/cost improved, whereas for others it decreased and for others there was no change. CONCLUSION/CONCLUSIONS:Risk-cost-adjusted analysis of inpatient episodes of care rendered by a value-based triaging methodology provides a robust method of assessing improvements and/or decreases in value-based care when compared with a historical cohort. This methodology provides the tools to both track hospital interventions designed to improve quality and decrease cost as well as determine whether these interventions are effective in improving value.

PURPOSE/OBJECTIVE:The purpose of this study was to examine hospital quality measures and the long-term functional outcomes associated with lateral compression type 1 [LC1] pelvic ring injuries. METHODS:A query was performed from December 2011 to September 2020 at two institutions within one hospital system for patients with a pelvic fracture diagnosis. Chart review was performed on admitted patients to determine demographic information, medical co-morbidities (to calculate Charlson Co-morbidity Index), in-hospital complications, length of stay [LOS], discharge disposition, and 30-day readmission rates. All patients included were treated nonoperatively. An attempt was made to contact all patients for long-term follow-up to assess current functional status with a Short Musculoskeletal Function Assessment [SMFA]. RESULTS:Two-hundred and eighty-six patients were included, with 172 (65.9%) patients admitted and analyzed with respect to hospital quality measures. Patients admitted were older (83 vs 80 years, p = 0.015) with more medical co-morbidities (p = 0.001) than those discharged from the emergency department. The average LOS was 5.7 ± 3.7 days and 31 (18%) experienced in-hospital complications. The inpatient mortality rate was 1.2%, and the 30-day readmission rate was 8.1%. When comparing admitted patients without concomitant injuries, admitted patients with concomitant injuries, and non-admitted patients, admitted patients with concomitant injuries were found to have more medical co-morbidities (p = 0.001). Forty-three patients were available for long-term follow-up (average 36.6 ± 7.3 months), with an average SMFA score of 29.0 ± 25.7. CONCLUSIONS:Patients admitted for LC1 pelvic fractures are likely to be older with more medical co-morbidities, and up to 1/5th will experience inpatient complications. Although inpatient mortality remains low, this injury pattern can lead to significant functional disability that persists for several years after injury.

INTRODUCTION/UNASSIGNED:The purpose is to investigate the incidence of wound complications for total knee arthroplasty (TKA) following tibial plateau open reduction and internal fixation (ORIF). MATERIALS AND METHODS/UNASSIGNED:A prospective arthroplasty registry was queried for patients with CPT codes for primary TKA, tibial plateau ORIF, removal of hardware (ROH), and diagnosis of post-traumatic arthritis. Patients were included if they had undergone tibial plateau ORIF and subsequent TKA. Chart review was performed to obtain demographic, clinical and post-operative information. RESULTS/UNASSIGNED:Twenty-one patients were identified, with average age of 56.23 ± 13.2 years at time of tibial plateau ORIF and 62.91 ± 10.8 years at time of TKA. Seven (33.3%) patients had a tibial plateau fracture-related infection (FRI). Eight (38.1%) patients underwent ROH prior to TKA. Seven (33.3%) patients' TKA incision incorporated the prior plateau incisions. Eight (36.4%) patients developed wound complications following TKA and 5 (23.8%) developed an acute periprosthetic joint infection (PJI) following TKA and had the plateau incision incorporated into the TKA incision. FRI history did not increase the rate of wound complications but did increase the rate of ROH prior to TKA. CONCLUSIONS/UNASSIGNED:Previous FRI involving tibial plateau repair surgery doesn't correlate with PJI after conversion TKA for post traumatic OA. Surgeon-controlled factors such as staged ROH and incision placement can help reduce the rate of wound complications following TKA performed after tibial plateau ORIF. LEVEL OF EVIDENCE/UNASSIGNED:Prognostic Level IV. SUPPLEMENTARY INFORMATION/UNASSIGNED:The online version contains supplementary material available at 10.1007/s43465-022-00709-1.

OBJECTIVE:To assess the effectiveness of a multimodal analgesic regimen containing "safer" opioid and non-narcotic pain medications in decreasing opioid prescriptions following surgical fixation in orthopedic trauma. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:One urban, academic medical center. SUBJECTS/METHODS:Traumatic fracture patients from 2018 (848) and 2019 (931). METHODS:In 2019 our orthopedic trauma division began a standardized protocol of post-operative pain medications that included: 50 mg of tramadol four times daily, 15 mg of meloxicam once daily, 200 mg gabapentin twice daily, and 1 g of acetaminophen every 6 hours as needed. This multimodal regimen was dubbed the "Lopioid" protocol. We compared this protocol to all patients from the prior year who followed a standard protocol that included Schedule II narcotics. RESULTS:Greater mean MME were prescribed at discharge from fracture surgery under the standard protocol compared to the Lopioid protocol (252.3 vs 150.0; p < 0.001) and there was a difference in the type of opioid medication prescribed (p < 0.001). There was a difference in the number of refills filled for patients discharged with opioids after surgical treatment between standard and Lopioid cohorts (0.31 vs 0.21; p = 0.002). There was no difference in the types of medication-related complications (p = 0.710) or the need for formal pain management consults (p = 0.199), but patients in the Lopioid cohort had lower pain scores at discharge (2.2 vs 2.7; p = 0.001). CONCLUSIONS:The Lopioid protocol was effective in decreasing the amount of Schedule II narcotics prescribed at discharge and the number of opioid refills following orthopedic surgery for fractures.

Pain management in the setting of acute and subacute orthopedic trauma can be challenging. Due to the recent focus on the rising opioid epidemic, as well as the adverse side of effects of opioid pain medication, multimodal pain control has become the standard of care for management of orthopedic trauma, particularly during operative fixation. The purpose of this paper is to report on the use of regional anesthesia for surgical intervention of extremity fractures in patients who present following traumatic injury as part of a multimodal pain management protocol. Types of, indications for, and outcomes of both upper and lower extremity peripheral nerve blocks will be reviewed.
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Introduction/UNASSIGNED:The purpose of this study was to investigate the effect of delayed closures, whether delayed primary closure (DPC) or split-thickness skin grafting (STSG), of operatively treated forearm fractures on short-term soft tissue outcomes. Methods/UNASSIGNED:In this retrospective cohort comparative study of two academic-level one trauma centers from 2010 to 2020, adult patients with diaphyseal forearm fractures who underwent open reduction and internal fixation (ORIF) were either closed primarily at index surgery, or underwent delayed closure, either with DPC or with a STSG. Primary outcome measures were soft-tissue outcomes as measured by wound healing (delayed healing, dehiscence, or skin breakdown) and fracture-related infection (FRI) at time of final follow-up. Results/UNASSIGNED:Eighty-one patients with 81 diaphyseal forearm fractures underwent ORIF with a mean follow-up of 14.3 months. Forty-one fractures (50.6%) were open injuries. Thirteen patients (16.0%) were unable to be closed primarily and underwent an average of 2.46 ± 0.7 surgeries including final coverage, with an average of 4.31 ± 2.8 days to final coverage. Four patients (30.8%) underwent DPC and 9 (69.2%) underwent STSG. Five (6.6%) patients in the delayed closure group had pre-operative compartment syndrome and underwent formal two-incision fasciotomies. There were no significant differences between delayed versus primary closure in wound healing complication rates, FRI, or radiographic union. Conclusions/UNASSIGNED:Diaphyseal forearm fractures that undergo ORIF have equivalent short-term soft tissue outcomes when closed primarily at index surgery or when closed in a delayed fashion.

PURPOSE/OBJECTIVE:Chronic use of selective serotonin reuptake inhibitors (SSRIs) for the treatment of depression has been linked to an imbalance in bone metabolism leading to osteoporosis. More recently, the use of SSRIs in murine models has been shown to delay bone healing both in vivo and in vitro by decreasing the osteoblastic differentiation and mineralization. The purpose of this study was to evaluate whether or not chronic use of SSRI's in nonunion patients increases their time to union after surgical intervention. METHODS:We retrospectively analyzed 343 patients in a nonunion database to determine which patients were on SSRI medication. Of these patients, 139 could be contacted and of those 102 were not taking SSRIs and 37 were taking SSRIs. Patient's time to union from nonunion surgical intervention between each cohort at our institution was recorded as the primary outcome. Patient's medical comorbidities that could affect union rates such as diabetes and smoking status were also noted. Baseline Short Musculoskeletal Function Assessment (SMFA) index for bother and function were recorded from the time of nonunion surgery as well as last follow-up. RESULTS:Compared to recent census data, we found significantly more patients in the nonunion cohort using SSRIs (26.6%) than patients in the general population using any type of antidepressant (11%). There was no significant difference in the patients' baseline characteristics other than patients on SSRI treatment had a higher body mass index (BMI) and age (p = 0.048 and p = 0.043, respectively). There was no significant difference noted in the fracture types (p = 0.2063). Patients on SSRIs had a higher SMFA bother index and function index on follow-up (p = 0.0103, p = 0.0147). Patients in the SSRI group had a mean time to union from nonunion surgery of 6.1 months compared to 6.0 in patients without SSRI usage (p = 0.74). These did not reach statistical significance when subcohort analysis for long bone fractures was performed for the femur, tibia, and humerus. CONCLUSION/CONCLUSIONS:To our knowledge, this is the first clinical study to investigate the effects of SSRIs on fracture healing. While in vivo and in vitro murine models have shown that SSRIs can have a deleterious effect on osteoblastic activity, our retrospective analysis did not show a significant difference in time to union between patients with chronic SSRI use and patients who have not been on SSRIs. However, this investigation did show a higher incidence of SSRI use in the nonunion cohort when compared to the general population. In the context of the recent animal model study, this may point to a negative effect of SSRI use on the acute fracture healing process.