The Intermalleolar Method for Intraoperative Rotational Assessment of the Tibia-A Prospective Clinical Validation Study.

OBJECTIVES: To determine the accuracy of the intermalleolar method, an intraoperative fluoroscopic method for assessing tibial rotation in patients undergoing intramedullary nail fixation for tibial shaft fractures, by comparing it with the gold standard computed tomography (CT). DESIGN: Prospective cohort study. SETTING: Academic Level 1 trauma center. PATIENT SELECTION CRITERIA: Consecutive patients, aged 18 years and older, with unilateral tibial shaft fractures who underwent intramedullary fixation from September 2021 to January 2023. OUTCOME MEASURES AND COMPARISONS: Intraoperatively, tibial rotation measurements were obtained using the intermalleolar method on both the uninjured and injured limbs. Postoperatively, patients underwent bilateral low-dose lower extremity rotational CT scans. CT measurements were made by 4 blinded observers. Mean absolute rotational differences and standard errors were calculated to compare the injured and uninjured limbs. Subgroup analysis was performed assessing accuracy relating to injured versus uninjured limbs, body mass index, OTA/AO fracture pattern, tibial and fibular fracture location, and distal articular fracture extension requiring fixation. RESULTS: Of the 20 tibia fractures, the mean patient age was 43.4 years. The intermalleolar method had a mean absolute rotational difference of 5.1 degrees (standard error 0.6, range 0-13.7) compared with CT. Sixty percent (24/40) of the measurements were within 5 degrees, 90% (36/40) of the measurements were within 10 degrees, and 100% (40/40) were within 15 degrees of the CT. No patients were revised for malrotation postoperatively. CONCLUSIONS: The intermalleolar method is accurate and consistently provides intraoperative tibial rotation measurements within 10 degrees of the mean CT measurement for adult patients undergoing intramedullary nail fixation for unilateral tibial shaft fractures. This method may be employed in the operating room to accurately quantify tibial rotation and assist with intraoperative rotational corrections. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The Opioid Risk Tool Correlates With Increased Postsurgical Opioid Use Among Patients With Orthopedic Trauma.

The aim of this study was to determine whether the Opioid Risk Tool (ORT), which has been validated in patients with chronic pain, relates to postoperative opioid consumption. The purpose was to investigate a tool that could help identify patients with orthopedic trauma at high risk for opioid abuse. Patients 18 to 80 years old presenting between May 2018 and August 2018 to UNC Hospitals with isolated orthopedic injuries that required surgical intervention were considered for inclusion. At 2 weeks postoperatively, the ORT was administered. At 6 weeks postoperatively, total morphine milligram equivalents (MME) was determined for each patient. Each patient was also categorized as either low risk (LR) or moderate to high risk (M-HR) based on the cumulative ORT score. Finally, opioid prescriptions provided after 6 weeks postoperatively was recorded. One hundred four patients met the inclusion criteria, and 42 completed the questionnaire. Thirty patients were categorized as LR and 12 patients as M-HR. Patients who were at M-HR consumed a significantly higher MME than LR patients (LR=406 [95% CI, 287-526]; M-HR=824 [95% CI, 591-1057]; P=.001). Linear regression analysis showed that for each additional risk factor, opioid consumption increased by 61 MME, and approximately 58% of the variation in opioid consumption could be explained by the ORT (beta=61, R2=0.58, P=.02). In this study, the ORT predicted which patients would have increased opioid consumption after orthopedic trauma surgery. Each additional risk factor correlated with increased opioid use. The ORT did not predict which patients would continue to receive opioid prescriptions after 6 weeks postoperatively. [Orthopedics. 2023;46(4):e219-e222.].

Administration of Venous Thromboembolism Chemoprophylaxis Within 12 Hours of Pelvic and Acetabular Surgery Has No Effect on Estimated Blood Loss, Perioperative Change in Hemoglobin, or Need for Transfusion.

OBJECTIVE: To determine if preoperative administration of venous thromboembolism (VTE) chemoprophylaxis (PPx) before pelvic and acetabular fracture surgery affects estimated blood loss (EBL), perioperative change in hemoglobin (ΔHgb), or transfusion rates. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center, southeastern United States. PATIENTS/PARTICIPANTS: All pelvic and acetabular surgeries performed between April 2014 and February 2020. MAIN OUTCOME MEASUREMENTS: EBL, immediate and 24-hour postoperative ΔHgb, and intraoperative/postoperative transfusion. RESULTS: In all, 267 surgeries were included: 97 prechange and 170 postchange. Median injury severity score was 17 before versus 14 after the change. One surgeon retired and two started during the study, producing differences in acetabular approaches. Median surgical duration was longer postchange. Cohorts were otherwise similar. No differences were observed in EBL, ΔHgb, or transfusion rates. Rates of VTE and surgical site complications were unchanged. No VTE-related deaths occurred. In the as-treated analysis (63 patients given low-molecular-weight heparin <12 hours preoperatively vs. 190 patients not given PPx), no differences were observed. CONCLUSIONS: Administration of VTE PPx within 12 hours of pelvic and acetabular surgery had no effect on perioperative blood loss. This study is limited by changes in faculty, but it suggests that traumatologists need not advocate for holding VTE PPx before pelvic and acetabular trauma surgery. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Impact of academic collaboration and quality of clinical orthopaedic research conducted in low- and middle-income countries.

BACKGROUND: Little is known about the quality of orthopaedic investigations conducted in low- and middle-income countries (LMICs). Academic collaboration is one model to build research capacity and improve research quality. Our study aimed to determine (1) the quality of clinical orthopaedic research conducted in LMICs, (2) the World Bank Regions and LMICs that publish the highest quality studies, (3) the pattern of collaboration among investigators and (4) whether academic collaboration between LMIC and non-LMIC investigators is associated with studies that have higher levels of evidence. METHODS: Orthopaedic studies from 2004 to 2014 conducted in LMICs were extracted from multiple electronic databases. The World Bank Region, level of evidence and author country-affiliation were recorded. Collaboration was defined as a study that included an LMIC with non-LMIC investigator. RESULTS: There were 958 studies that met inclusion criteria of 22,714 searched. Ninety-seven (10.1%) of included studies achieved Level 1 or 2 evidence, but case series (52.3%) were the most common. Collaboration occurred in 14.4% of studies and the vast majority of these (88.4%) were among academic institutions. Collaborative studies were more likely to be Level 1 or 2 (20.3% vs. 8.4%, p < 0.01), prospective (34.8% vs. 22.9% p = 0.04) and controlled (29.7% vs. 14.4%, p < 0.01) compared to non-collaborative studies. CONCLUSIONS: Although orthopaedic studies in LMICs rarely reach Level 1 or 2 evidence, studies published through academic collaboration between LMIC and non-LMIC investigators are associated with higher levels of evidence and more prospective, controlled designs.