Complications and Outcomes After Fixation of Lisfranc Injuries at an Urban Level 1 Trauma Center.

OBJECTIVES: To evaluate patients with tarsometatarsal fractures and dislocations and describe complications and secondary operations. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENT SELECTION CRITERIA: Consecutive adults treated acutely for Lisfranc injuries with reduction and fixation using standard techniques of rigid medial fixation and flexible lateral fixation. OUTCOME MEASURES AND COMPARISONS: Complications include infections, wound healing problems, nonunion, malunion, and posttraumatic arthrosis (PTA), and secondary unplanned procedures after a minimum of 2-year radiographic follow-up. RESULTS: Mean age of the included 118 patients was 40 years (range, 18-73 years) and 96 (74%) were male. Comorbidities included obesity (n = 32; 40%), diabetes mellitus (n = 12; 9%), and tobacco use (n = 67; 52%). Thirty (23%) were open injuries, and concomitant forefoot injuries were present in 47% and hindfoot injuries in 12%. Unplanned secondary procedures, including implant removals, were performed on 39 patients (33%), most often for removal of painful implants (26%) or infectious debridement (9%). Sixty-seven complications occurred, with PTA most frequent (37%). Deep infections occurred in 8%. On multivariate analysis, open injury ( P = 0.028, CI = 1.22-30.63, OR = 6.12) and concomitant forefoot injury ( P = 0.03, CI = 1.12-9.76, OR = 3.31) were independent risk factors for complication. CONCLUSIONS: Open Lisfranc injuries were associated with complications, with deep infections occurring in 9%. Secondary procedures were most often performed for pain relief; the most common late complication was PTA, warranting counseling of patients about potential long-term sequelae of injury. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Social Media and Digital Footprints in Orthopaedic Trauma: An Analysis of 1465 Orthopaedic Trauma Association Members.

OBJECTIVES: The purpose of this study was to quantify social media usage among Orthopaedic Trauma Association (OTA) members. METHODS: All active OTA members were searched for involvement among common social media platforms. Surgeons were then classified as "active" on any given social media site if they posted within the past 6 months. Surgeons were also identified by the region they practiced in, sex, and their practice setting (academic vs. private). Finally, a surgeon's score and number of reviews from common physician review websites were examined. RESULTS: A total of 1465 OTA members were included in the analysis. Most surgeons were male (89.1% [n = 1305]) and practiced in a private setting (54.5% [n = 799]). A total of 590 surgeons (40.3%) had at least one form of social media account. Social media sites most used were LinkedIn with 48.7% (n = 713) and ResearchGate with 29.2% (n = 428). Academic surgeons were more likely to have a ResearchGate, LinkedIn, and Twitter account while private surgeons were more likely to have a personal website ( P < 0.05). Finally, there was no correlation between surgeons more active on social media and average scores on Vitals.com or Healthgrade.com ( P > 0.05). CONCLUSIONS: Most orthopaedic trauma surgeons do not have professional social media accounts. Although social media may help spread scholarship, having a professional social media account does not correlate with better online physician reviews or increased online reviews among orthopaedic trauma surgeons.

Prophylactic Intrawound Antibiotics Significantly Reduce the Risk of Deep Infections in Fracture Fixation: Subgroup Meta-analyses of the Type of Fracture, Antibiotics, and Organism.

OBJECTIVES: To analyze the efficacy of subgroups of various intrawound local antibiotics in reducing the rate of fracture-related infections. DATA SOURCES AND STUDY SELECTION: PubMed, MEDLINE via Ovid, Web of Science, Cochrane database, and Science Direct were searched for articles in English on July 5, 2022, and December 15, 2022. STUDY SELECTION: All clinical studies comparing the incidence of fracture-related infection between the administration of prophylactic systemic and topical antibiotics in fracture repair were analyzed. DATA EXTRACTION: Cochrane collaboration's assessment tool and the methodological bias and the methodological index for nonrandomized studies were used to detect bias and evaluate the quality of included studies, respectively. DATA SYNTHESIS: RevMan 5.3 software (Nordic Cochrane Centre, Denmark) was used to conduct the meta-analyses and generate forest plots. CONCLUSIONS: From 1990 to 2021, 13 studies included 5309 patients. Nonstratified meta-analysis showed that intrawound administration of antibiotics significantly decreased the overall incidence of infection in both open and closed fractures, regardless of the severity of open fracture and antibiotics class [OR = 0.58, ( P = 0.007)] [OR = 0.33, ( P < 0.00001)], respectively. The stratified analysis revealed that prophylactic intrawound antibiotics significantly lowered infection rate in open fracture patients with Gustilo-Anderson type I (OR = 0.13, P = 0.004), type II (OR = 0.29, P = 0.0002), type III (OR = 0.21, P < 0.00001), when either tobramycin PMMA beads (OR = 0.29, P < 0.00001) or vancomycin powder (OR = 0.51, P = 0.03) was applied. This study demonstrates prophylactic administration of intrawound antibiotics significantly decreases the overall incidence of infection in all subgroups of surgically fixated fractures but does not affect the patient's length of hospital stay. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Diagnosis of traumatic shoulder arthrotomies using saline load test with intra-articular pressure monitoring.

PURPOSE: The purpose of this study was to investigate the amount of saline required to identify a positive traumatic shoulder arthrotomy in a cadaveric model. In addition, intra-articular pressure monitoring was conducted to confirm needle placement and evaluate peak pressure curves prior to capsular failure. METHODS: We conducted a cadaveric study using thirty fresh-frozen upper extremities with maintained glenohumeral joint. A shoulder arthrotomy was made in the deltopectoral interval using a 4.4-mm trocar. The joint was loaded using an 18-gauge spinal needle inserted posteriorly and attached to a pressure monitoring system. Fluid was introduced at a uniform rate of 1 cc/sec until active extravasation was visualized from the anterior arthrotomy site. Statistical analysis included assessment of distribution, ANOVA and linear regression. RESULTS: A positive joint challenge was obtained in all specimens (n = 30) within a maximum of 59 ml of fluid (mean 28 ml, STD 15.4). Average intra-articular pressure at visualization (PAV) was 166.8 mmHg (min., 107; max., 268). In twelve specimens, peak pressures (PP) exceeded PAV, showing a corresponding fall in pressure prior to visualization (ΔPP-PAV = 16.5). To reach a sensitivity of 90% and 95% of arthrotomies, 50 and 58 ml of fluid had to be injected. CONCLUSION: Results demonstrated 58 ml of fluid was required to identify a majority of shoulder arthrotomies. Intra-articular pressure monitoring identified successful needle placement. Pressure curve analysis could identify capsular failure before fluid extravasation visualization which could enhance clinical identification and treatment of traumatic shoulder arthrotomies. LEVEL OF EVIDENCE: Level IV Diagnostic.

Weight-bearing status may influence rates of radiographic healing following reamed, intramedullary fixation of diaphyseal femur fractures.

OBJECTIVE: To investigate the effect of weight-bearing status on radiographic healing of diaphyseal femur fractures. DESIGN: Retrospective 1:1 matched cohort study. SETTING: Single-level 1 trauma center. PARTICIPANTS: One-hundred forty-four (N = 154) patients matched 1:1 in non-weight bearing (NWB) and weight-bearing as tolerated (WBAT) groups. INTERVENTION: Non-weight bearing following reamed, statically locked intramedullary fixation of diaphyseal femur fracture, generally due to concurrent lower extremity fracture. MAIN OUTCOME MEASUREMENT: Postoperative radiographic healing using modified Radiographic Union Scale for Tibia fractures (mRUST) scores. RESULTS: Groups were well matched on age, sex, race, prevalence of tobacco and alcohol use, diabetes mellitus status, Injury Severity Score, fracture pattern and shaft location, vascular injury, open fracture prevalence, and operative characteristics. Radiographic follow-up was similar between groups (231 vs 228 days, P = .914). At 6 to 8 weeks status post intramedullary fixation, the median mRUST score in the NWB group (9) was lower than that of the WBAT group (10) (mean: 8.4 vs 9.7, P = .004). At 12 to 16 weeks, the median mRUST in the NWB group (10) was again lower than the WBAT group (12) (mean: 9.9 vs 11.7, P = .003). The median number of days to 3 cortices of bridging callous was 85 in the WBAT group, compared with 122 in the NWB group (P = .029). Median time to mRUST scores of 12 (111 vs 162 days, P = .008), 13 (218 vs 278 days, P = .023), and 14 (255 vs 320 days, P = .028) were all longer in the NWB group compared with the WBAT group. CONCLUSIONS: Non-weight bearing after intramedullary fixation of diaphyseal femur fractures delays radiographic healing, with median time to 3 cortices of bridging callous increased from 85 days in WBAT groups to 122 days in NWB groups. These results provide clinicians with an understanding of the expected postoperative course, as well as further support the need to expeditiously advance weight-bearing status.Level of Evidence: IV.

Compartment syndrome following use of tissue plasminogen activator for frostbite in the setting of concomitant diaphyseal tibia fracture.

BACKGROUND: Tissue plasminogen activator (tPA) is a thrombolytic agent increasingly being employed for the treatment of acute frostbite. Although tPA has been shown with success to increase digit salvage rates, data on potential complications, including risk of hemorrhage, is limited. As a result, acute trauma is considered a contraindication to use in many institution-based protocols. Currently, there is a paucity in the literature regarding use of tPA for frostbite in patients with concomitant extremity fractures. CASE PRESENTATION: We report the case of a 36-year-old male treated with tPA for frostbite to digits of his bilateral hands in the setting of a concomitant diaphyseal tibia fracture. He subsequently developed acute compartment syndrome in his lower extremity. This was followed by emergent fasciotomy and staged fracture fixation with serial wound debridement and subsequent closure. Despite this complication, the patient went on to early radiographic and clinical union of his tibia fracture. His frostbite wounds healed without functional deficits. CONCLUSIONS: In patients with severe frostbite injury with digital perfusion defects, tPA for thrombolysis may be indicated. Use of thrombolytics for frostbite in trauma patients or those with concomitant extremity fractures requires a multidisciplinary discussion regarding potential risks. Contingency planning is essential to ensure that potential bleeding complications, including development of compartment syndrome, are diagnosed and treated early. Given the paucity in the current literature regarding use of thrombolytics in trauma patients, further study is warranted to inform the surgical community on instances in which the benefits of tPA administration may outweigh the risks. LEVEL OF EVIDENCE: Case report; Level V.

Fixation of Transverse Acetabular Fractures With Precontoured Plates Alone Causes Fracture Malreduction: A Biomechanical Assessment.

BACKGROUND: Precontoured quadrilateral surface buttress (PQSB) plates have grown in popularity for acetabular fracture fixation. However, our experience has pushed us to hypothesize that their use as sole means of fixation may cause fracture malreduction. A biomechanical model was created to investigate this theory. METHODS: A transverse acetabular fracture was created and reduced anatomically in 18 synthetic hemipelvises. The reduced hemipelvises were fixated using 3 different techniques. Group A fixation included anterior and posterior column screws plus a suprapectineal pelvic reconstruction plate; group B models were fixed using a PQSB plate only; and group C models were fixed with an anterior column screw and a PQSB plate. Acetabular tracking points were placed before final fixation and used to quantify any postfixation displacement. One-way analysis of variance and Tukey HSD testing were used to determine the significant difference (P < 0.05). RESULTS: Models in group B had significant fracture displacement after final fixation when compared with group A and group C models. The average amount of displacement at the anterior column and within the acetabulum was 1.37 mm (95% CI, 1.08-1.65) in group B constructs compared with 0.32 mm (95% CI, 0.22-0.42) and 0.26 mm (95% CI, 0.15-0.38) in groups A and C constructs, respectively. There were no significant differences in displacement after final fixation between group A and group C models. CONCLUSIONS: PQSB plates for acetabular fractures cause malreduction when applied in isolation in this biomechanical model. If a PQSB plate is chosen for fixation, we suggest the use of a columnar lag screw at minimum to hold reduction before plate application.

Precontoured Quadrilateral Surface Acetabular Plate Fixation Demonstrates Increased Stability When Compared With Pelvic Reconstruction Plates: A Biomechanical Study.

OBJECTIVE: To compare the stability of 3 fixation strategies for a transverse acetabular fracture: a reconstruction plate with anterior and posterior column screws (group A); an infrapectineal precontoured quadrilateral surface buttress (iPQSB) plate alone (group B); and an anterior column lag-screw and iPQSB plate (group C). METHODS: A transverse acetabular fracture was created in 18 synthetic hemipelvises. Six were fixed by each of the 3 methods described. Specimens underwent cyclic axial compressive loading to 1700N for 42,000 cycles while anterior and posterior column displacements were measured, followed 4800N for 50 cycles. Displacement and stiffness data were analyzed with analysis of variance and Tukey HSD. A Cox proportional hazards regression model was used to determine survival rate. P values < 0.05 were considered significant. RESULTS: Group C had significantly less posterior column displacement (0.16 ± 0.06 mm) compared with group B (0.38 ± 0.37 mm, P < 0.0001) and group A (0.38 ± 0.37 mm, P < 0.0001). In addition, group A had significantly more anterior column displacement (0.28 ± 0.11 mm) than group B (0.22 ± 0.14 mm, P = 0.0310) and group C (0.18 ± 0.09 mm, P = 0.0001). Group C was 10.5% stiffer than group A (P = 0.0037). Group B had a 7.27x greater rate of failure than group C (95% confidence interval, 1.6-33.2). DISCUSSION AND CONCLUSION: Under anatomical loading, iPQSB plates with anterior column lag-screw fixation demonstrate increased stability in a synthetic bone transverse acetabular fracture model. Based on our data, we support additional evaluation of early weight-bearing after transverse acetabular fracture fixation in patients with healthy bone when an anterior column screw-iPQSB plate construct is used.

A New Fastener With Improved Bone-To-Implant Interface Shows Superior Torque Stripping Resistance Compared With the Standard Buttress Screw.

OBJECTIVE: The conventional AO buttress screw used for fracture fixation relies on a historic buttress thread design, which is prone to stripping at the bone-implant interface. We hypothesized that a new Bone-Screw-Fastener with an innovative interlocking thread design demonstrates increased resistance to torque stripping forces compared with the buttress screw, without compromising pullout strength. METHODS: A biomechanical model was established in 6 matched pairs of adult human cadaveric tibiae to test torque resistance between the 3.5 mm Bone-Screw-Fastener and the 3.5 mm cortical AO buttress screw until failure. Uniaxial pullout testing of both screw types was performed as an internal control experiment. RESULTS: The 3.5 mm Bone-Screw-Fastener had a significantly increased resistance to torque failure compared with the standard 3.5 mm AO buttress screw (P = 0.0145). In contrast to the buttress screws, none of the Bone-Screw-Fasteners stripped from the bone but rather failed at the screwdriver-implant interface in terms of a metal-on-metal failure. The internal control experiments revealed no significant difference in axial pullout strength between the 2 implants (P = 0.47). CONCLUSIONS: These data demonstrate the superiority of the new Bone-Screw-Fastener over the conventional AO buttress screw regarding protection from torque stripping forces. In addition, the new thread design that interlocks to the bone does not sacrifice axial pullout resistance conveyed by the buttress screw. Future controlled trials will have to validate the in vivo relevance of these findings in a clinical setting.

Introducing the "Bone-Screw-Fastener" for improved screw fixation in orthopedic surgery: a revolutionary paradigm shift?

BACKGROUND: Conventional screws used for fracture fixation in orthopedic surgery continue to rely on the historic buttress thread design. While buttress screws generally provide solid resistance against unidirectional axial loading forces, their design suffers from several limitations, as the buttress thread does not adequately resist multiaxial forces. Furthermore, the buttress screw is prone to stripping at the bone-screw interface and can cause microfracturing of the surrounding bone due to its thread design. Standard buttress screws are therefore at risk of adverse postoperative outcomes secondary to failure of bone fixation. A new patented Bone-Screw-Fastener was recently designed that is based on an interlocking thread technology. This new fastener provides distributive forces from the threads onto the bone and therefore resists loads in multiple directions. The underlying concept is represented by a "female thread" bone cutting technology designed to maximize bone volume, preserve bone architecture, and create a circumferential interlocking interface between the implant and bone that protects the thread from stripping and from failing to multiaxial forces. PRESENTATION OF THE HYPOTHESIS: We hypothesize that the new Bone-Screw-Fastener overcomes the classic shortcomings of conventional orthopedic screws with buttress threads by ease of insertion, improved bone preservation, increased resistance to off-axis multidirectional loading forces and to stripping of the threads. These advanced biomechanical and biological properties can potentially mitigate the classic limitations of conventional buttress screws by providing better resistance to implant failure under physiological loads, preserving bone biology, and thus potentially improving patient outcomes in the future. TESTING THE HYPOTHESIS: The presumed superiority of the new fastener will require testing and validation in well-designed prospective multicenter randomized controlled trials (RCTs), using the conventional buttress screw as control. IMPLICATIONS OF THE HYPOTHESIS: Once validated in multicenter RCTs, the new Bone-Screw-Fastener may drive a change in paradigm with regard to its innovative biomechanical principles and biologic bone preservation for surgical applications requiring screw fixation.

Arsenic, cadmium, lead, and mercury in surface soils, Pueblo, Colorado: implications for population health risk.

Decades of intensive industrial and agricultural practices as well as rapid urbanization have left communities like Pueblo, Colorado facing potential health threats from pollution of its soils, air, water and food supply. To address such concerns about environmental contamination, we conducted an urban geochemical study of the city of Pueblo to offer insights into the potential chemical hazards in soil and inform priorities for future health studies and population interventions aimed at reducing exposures to inorganic substances. The current study characterizes the environmental landscape of Pueblo in terms of heavy metals, and relates this to population distributions. Soil was sampled within the city along transects and analyzed for arsenic (As), cadmium (Cd), mercury (Hg) and lead (Pb). We also profiled Pueblo's communities in terms of their socioeconomic status and demographics. ArcGIS 9.0 was used to perform exploratory spatial data analysis and generate community profiles and prediction maps. The topsoil in Pueblo contains more As, Cd, Hg and Pb than national soil averages, although average Hg content in Pueblo was within reported baseline ranges. The highest levels of As concentrations ranged between 56.6 and 66.5 ppm. Lead concentrations exceeded 300 ppm in several of Pueblo's residential communities. Elevated levels of lead are concentrated in low-income Hispanic and African-American communities. Areas of excessively high Cd concentration exist around Pueblo, including low income and minority communities, raising additional health and environmental justice concerns. Although the distribution patterns vary by element and may reflect both industrial and non-industrial sources, the study confirms that there is environmental contamination around Pueblo and underscores the need for a comprehensive public health approach to address environmental threats in urban communities.