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.

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.

In this study, we evaluated risk factors for gram-negative fracture-related infection in a mixed cohort of gram-positive and gram-negative fracture-related infections to guide perioperative antibiotic prophylaxis for surgical fixation of fractures. We performed a retrospective review of all patients with fracture who were treated at an urban academic level I trauma center between February 1, 2012, and June 30, 2017. Inclusion criteria were as follows: (1) open or closed fracture with internal fixation; (2) deep, acute to subacute (<6 weeks), culture-positive fracture-related infection; and (3) age 18 years or older. Infections were classified as gram positive, gram negative, or polymicrobial. Demographic, surgical, and postoperative characteristics were compared among groups. Of 3360 patients, 43 (1.3%) had a fracture-related infection (15 gram negative, 14 gram positive, and 14 polymicrobial). Risk factors for gram-negative infection included initial external fixation (P=.038), the need for soft tissue coverage of an open fracture site (P=.039), lower albumin level at the time of infection (P=.005), and hospitalization for longer than 10 days (P=.018). Perioperative gram-negative antibiotic prophylaxis for fracture fixation surgery should be considered for those who have been staged with external fixation, require soft tissue coverage, are at risk for malnutrition in the postoperative period, and have prolonged inpatient hospitalization. [Orthopedics. 20XX;XX(X):xx-xx.].

OBJECTIVES/OBJECTIVE:To determine if matching by trauma risk score is non-inferior to matching by chronic comorbidities and/or a combination of demographic and patient characteristics in observational studies of acute trauma in a hip fracture model. DESIGN/METHODS:Retrospective cohort study SETTING: Level-1 Trauma Center PATIENTS: 1,590 hip fracture [AO/OTA 31A and 31B] patients age 55 and over treated between October 2014 and February 2020 at 4 hospitals within a single academic medical center. INTERVENTION/METHODS:Repeatedly matching randomized subsets of patients by (1) Score for Trauma Triage in Geriatric and Middle-Aged (STTGMA), (2) Charlson Comorbidity Index (CCI), or (3) a combination of sex, age, CCI and body mass index (BMI). MAIN OUTCOME MEASUREMENTS/METHODS:"Matching failures" where rate of significant differences in variables of matched cohorts exceeds the 5% expected by chance. RESULTS:STTGMA and combination matching resulted in no "matching failures". Matching by CCI alone resulted in "matching failures" of BMI, ASA class, STTGMA, major complications, sepsis, pneumonia, acute respiratory failure, and 90-day readmission. CONCLUSIONS:STTGMA matching in observational cohort studies is less likely to yield significant differences of demographics and outcomes than CCI matching. STTGMA matching is noninferior to matching a combination of demographic variables optimized for each treatment cohort. STTGMA matching is apt to reflect equipoise of health at admission and outcome likelihood in observational cohort studies of orthopedic trauma, while maintaining consistent weighting of demographic and injury characteristic variables that may expand the generalizability of these studies. LEVEL OF EVIDENCE/METHODS:Level III.

Although surgical procedures have been occurring as early at 6500 BC, the modern sense of the operating room (OR) did not exist until more recently. As aseptic techniques and surgical procedures began to evolve, so too did the OR table. The OR table began to transition from a static, wooden table to a dynamic table with the ability to position patients for a variety of procedures. With the advent of intraoperative imaging for orthopaedic procedures, OR tables have adapted and allow for imaging of bony anatomy by using radiolucent materials. These changes have led to the development of numerous OR tables, each with their own sets of advantages and disadvantages. There is currently no summary of the development, indications, benefits, and disadvantages of the various OR tables available to orthopaedic surgeons in the literature. The purpose of this review is to provide a comprehensive review of orthopaedic operating tables for both the junior orthopaedic resident and experienced attending surgeon.

PURPOSE/OBJECTIVE:The purpose of this study is to determine the effects of blood transfusion timing in hip fracture patients. METHODS:A consecutive series of hip fracture patients 55 years and older who required a blood transfusion during hospitalization were reviewed for demographic, injury, clinical outcome, and cost information. A validated risk predictive score (STTGMA) was calculated for each patient. Patients were stratified to preoperative, intraoperative, or postoperative first transfusion cohorts. The intraoperative and postoperative cohorts were matched by STTGMA, sex, and procedure to the preoperative cohort. Baseline patient characteristics and outcomes were compared before and after matching. RESULTS:Prior to matching, the preoperative cohort was more often male (p < 0.001) with increased Charlson comorbidity index (p = 0.012), ASA class (p < 0.002), STTGMA (p < 0.001), total transfused volume (p = 0.002), incidence of inpatient mortality (p = 0.045), myocardial infarction (p = 0.005) and cardiac arrest (p = 0.014). After matching, the preoperative cohort had increased total transfused volume (p = 0.015) and decreased pneumonia incidence (p = 0.040). CONCLUSION/CONCLUSIONS:Matching STTGMA score, sex, and procedure results in non-inferior outcomes among hip fracture patients receiving preoperative first blood transfusions compared to intraoperative and postoperative transfusions.

Nail plate constructs (NPC) have shown promising results in complex lower extremity peri-articular fractures as well as in peri-prosthetic fractures. The combination of both implants allows for improved mechanical stability and immediate weight bearing. The use of NPC has not been described in the upper extremity in the literature. We herein describe potential indications and surgical technique for NPC usage for complex upper extremity trauma and reconstruction.

BACKGROUND:Tibial nonunion remains a considerable burden for patients and the surgeons who treat them. In recent years, alternatives to autogenous grafts for the treatment of tibial nonunions have been sought. The purpose of this study was to evaluate the efficacy of autogenous iliac crest bone graft (ICBG) in the treatment of tibial shaft nonunions. MATERIAL AND METHODS/METHODS:Sixty-nine patients were identified who underwent ICBG for repair of atrophic or oligotrophic tibial nonunion and had complete data with at least one year of follow-up (mean 27.9 months). Surgical treatments consisted of revision/supplemental fixation ± ICBG. Surgical approaches for graft placement were either posterolateral (PL), anterolateral (AL), or direct medial (DM). Healing status, time to union, postoperative pain, and functional outcomes were assessed. RESULTS:Bony union was achieved by 97.1% (67/69) of patients at a mean time of 7.8 ± 3.2 months postoperatively. There was no significant difference in mean time to union between the three surgical approach groups: (PL (44.9%) = 7.3 months, AL (20.3%) = 9.2 months, DM (34.8%) = 7.6 months; p = 0.22). Intraoperative cultures obtained at the time of nonunion surgery were positive in 27.5% of patients (19/69). Positive cultures were associated with need for secondary surgery as 8/19 patients (42.1%) with positive cultures required re-operation. Two out of four patients that developed iliac donor site hematomas/infections requiring washout had positive intraoperative cultures as well. There was no difference in final SMFA among the three surgical approach groups. CONCLUSIONS:Autogenous ICBG remains the gold standard in the management of persistent tibial nonunions regardless of surgical approach. There is a small risk for complication at the iliac crest donor site. Given the high union rate, autogenous iliac crest bone grafting for tibial nonunion remains the gold standard for this difficult condition. LEVEL OF EVIDENCE/METHODS:Level III.

Hip fractures are increasingly common and often occur in patients with complex medical comorbidities. There remains a need for a safer anesthetic option for these patients for the operative repair of their injury other than general or neuraxial anesthesia. At our institution, for medically complex and physiologically tenuous patients, we perform Monitored Anesthesia Care and Soft-Tissue Infiltration of Local Anesthetic (MAC-STILA) when performing percutaneous fixation techniques for hip fractures. We describe our technique here.