Faculty Bibliography

SUMMARY/CONCLUSIONS:We present the case of a 53-year-old male laborer who slipped and fell on ice and had acute right shoulder pain. Plain radiographs and a computed tomography scan of the scapula were obtained that demonstrated a comminuted and displaced extra-articular scapula body fracture with approximately 2 cm of medialization of the glenoid. The anatomy, examination, diagnosis, and surgical approach options are reviewed. In this case, open reduction and internal fixation of the scapula is performed through a modified Judet approach. At the 3-month postoperative visit, radiographs demonstrated a healed scapula fracture. The patient was allowed to return to work as a laborer. A modified Judet approach can be performed for surgical fixation of comminuted and displaced extra-articular scapula body fractures with excellent clinical results.

SUMMARY/CONCLUSIONS:This is the case of a 12-year-old boy presented with a displaced radial and ulnar shaft fracture. Historically, these fractures were managed conservatively with closed reduction and cast immobilization; however, there has been an increasing trend toward operative fixation. Malalignment is an indication for operative fixation of pediatric both bone forearm fractures. Flexible nailing was performed in this case because of the small incisions, minimal tissue disruption, shorter operative time, and ease of implant removal. Five years postoperatively, the patient's fracture was healed. Patient presented with an excellent clinical outcome including full range of motion and no pain. He had full strength of his arm and no deficits.

SUMMARY/CONCLUSIONS:A case of a 27-year-old man with a right-sided largely infra-foveal femoral head fracture dislocation with posterior wall acetabular fracture repaired via a Kocher-Langenbeck approach is presented. This is an atypical approach for fixation of the femoral head and acetabulum used because of the size and displacement of both the posterior wall fracture and the femoral head fracture. Indications for fixation of both the femoral head and the acetabulum include a displaced acetabular fracture with: (1) a fracture of the weight-bearing portion of the femoral head and/or (2) a fracture of the femoral head that engages the anterior or posterior wall. Overall, midterm outcomes are expected to be excellent to good if anatomic reduction and a concentrically stable hip joint is restored.

SUMMARY/CONCLUSIONS:We present the case of a 49-year-old male pedestrian struck by a car while cycling, sustaining a displaced anterolateral tibial plateau fracture and a large coronal plane fracture of the posterolateral plateau involving approximately one-third of the anterior posterior dimension of the articular surface. The posterolateral approach without a fibular osteotomy allows direct access to the posterolateral plateau and avoids complications associated with a fibular head osteotomy. The combined anterolateral and posterolateral approach to the proximal tibia without fibular osteotomy is a viable technique to achieve biomechanically sound fixation for lateral tibial plateau fractures that involve the anterolateral and posterolateral aspects of the tibial plateau.

SUMMARY/CONCLUSIONS:We present the surgical technique for arthrodesis of the subtalar and calcaneocuboid joints of a Sanders type IV calcaneal fracture nonunion via a distraction bone block arthrodesis technique with tricortical iliac crest allograft combined with reamer/irrigator/aspirator autograft from the patient's femur. A lateral extensile approach to the calcaneus was used for the exposure, which allowed the surgeon to follow the stepwise complex surgical plan outlined here. Calcaneal nonunions are difficult to treat, but good outcomes can be achieved if proper technique with bone grafting is used.

OBJECTIVES/OBJECTIVE:This study compares demographics, outcomes, and costs of patients with similar multifragmentary pertrochanteric (MP) fracture patterns treated with either a short or long cephalomedullary nail (CMN) to determine treatment efficacy and value during hospital admission. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:Level-1 trauma center. PATIENTS/METHODS:384 patients who presented with a MP fracture [AO/OTA 31A2.2 and 31A2.3] at 1 of 3 hospitals within a single academic medical center. INTERVENTION/METHODS:Surgical treatment with either short or long CMN Main outcome measurements: Operative time, in-hospital complications, discharge disposition, procedural and total costs of admission. RESULTS:Sixty-nine (18.0%) patients were treated with long CMNs compared to 315 patients treated with short CMNs. Patients treated with long CMNs had increased rates of transfusions of allogenic packed red blood cells (52.2% vs 34.0%, p = 0.005), discharge to rehabilitation facilities (91.3% vs 80.3%, p = 0.030), and had costlier hospital stays ($28,632.50 vs $23,024.86, p = 0.014) with longer (74.9 vs 52.3 min, p <0.001), costlier procedures and implants ($12,090.31 vs $9,647.41, p = 0.014) compared to patients treated with short CMNs. There were no differences in timing of radiographic healing, rates of readmission, nonunion, screw cut out, fixation failure, or peri‑implant fracture. CONCLUSIONS:Short and long CMNs are equally suitable implants for the most unstable intertrochanteric fracture patterns. Short CMNs correlate with reduced operative time and costs with non-inferior in-hospital complication rates, hospital quality measures, and less frequent rehabilitation facility discharges. Given the similar long-term outcomes demonstrated here and in the literature, this data suggests nail length selection should be driven more by cost and discharge considerations for MP fractures. LEVEL OF EVIDENCE/METHODS:level III.

Obese patients with hip fractures are at increased risk of perioperative complications due to both their size and associated medical conditions. The purpose of this report is to describe a technique for intraoperative positioning of obese patients who sustain a hip fracture. A 62-year-old female with a history of morbid obesity (BMI 48.06kg/m²), type II diabetes mellitus, and hypertension presented with a right intertrochanteric fracture and was admitted for operative fixation on a fracture table. A standardized approach for systematic patient positioning and abdominal panniculus taping is described, which facilitates operative repair of the hip fracture using a cephalomedullary nail. This report describes the intraoperative positioning technique of a morbidly obese patient with an intertrochanteric hip fracture in order to highlight specific techniques used to deal with the physical aspects of obesity that can improve the surgical efficiency of the procedure. By positioning obese patients in a standardized way, intraoperative time and complications will be decreased, potentially mitigating some of the risks associated with this patient population.

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.

The dataset presented was collected via retrospective review from an orthopedic trauma database approved by the institutional review board at the author's institution from patients treated at any of the four hospitals serviced by the academic orthopedic surgery department. Femoral neck and intertrochanteric hip fracture patients from low energy mechanisms admitted between October 2014 and February 2020, were selected if they were age 55 or older and had recorded sex, body mass index (BMI), Charlson Comorbidity Index (CCI), American Society of Anaesthesiologists (ASA) physical status classification, Glasgow Coma Score, Abbreviated Injury Severity score for the chest, head and neck, and extremities, and ambulation status prior to injury. The resultant 1,590 subject dataset may be analysed via the supplied R statistical code to determine the frequency of equipoise in baseline and outcome variables from propensity matching via three matching schemes. The code implements three matching schemes including matching by (1) The Score for Trauma Triage in Geriatric and Middle-Aged (STTGMA) (2) CCI alone, or (3) a combination of sex, age, CCI and BMI. The code selects a subset of ten percent of hip fracture patients by a pseudorandom number generator (PRNG). The code matches the remaining patients 1:1 to the selected patients by propensity score generated by logistic regression of STTGMA, CCI, or a combination of sex, age, CCI and BMI using greedy nearest neighbor matching without replacement by the MatchIt package for R software. The code then compares matched cohorts by Chi-square, Fisher, or Mann-Whitney U test with significance level of 0.05 representing a 5% chance of significant differences due to random sampling of subjects. The supplied code repeats the random selection, matching and testing process 100,000 times for each matching method. The resultant code output is the frequency of significantly different demographic or outcome parameters among matched cohorts by matching method. This data and statistical code have reuse potential to explore alternative matching schemes. The supplied baseline variables should be robust enough to derive alternative risk scores for each patient which may be included as a matching variable for comparison. The authors also look forward to unexpected ways that this data may be used by readers.

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.