Efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment of acute pain after orthopedic trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma and the Orthopedic Trauma Association.

Objectives: Fracture is a common injury after a traumatic event. The efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) to treat acute pain related to fractures is not well established. Methods: Clinically relevant questions were determined regarding NSAID use in the setting of trauma-induced fractures with clearly defined patient populations, interventions, comparisons and appropriately selected outcomes (PICO). These questions centered around efficacy (pain control, reduction in opioid use) and safety (non-union, kidney injury). A systematic review including literature search and meta-analysis was performed, and the quality of evidence was graded per the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The working group reached consensus on the final evidence-based recommendations. Results: A total of 19 studies were identified for analysis. Not all outcomes identified as critically important were reported in all studies, and the outcome of pain control was too heterogenous to perform a meta-analysis. Nine studies reported on non-union (three randomized control trials), six of which reported no association with NSAIDs. The overall incidence of non-union in patients receiving NSAIDs compared with patients not receiving NSAIDs was 2.99% and 2.19% (p=0.04), respectively. Of studies reporting on pain control and reduction of opioids, the use of NSAIDs reduced pain and the need for opioids after traumatic fracture. One study reported on the outcome of acute kidney injury and found no association with NSAID use. Conclusions: In patients with traumatic fractures, NSAIDs appear to reduce post-trauma pain, reduce the need for opioids and have a small effect on non-union. We conditionally recommend the use of NSAIDs in patients suffering from traumatic fractures as the benefit appears to outweigh the small potential risks.

A predictive model for increased hospital length of stay following geriatric hip fracture.

BACKGROUND: The purpose of this study was to identify the risk factors that are significantly associated with hospital length of stay (LOS) following geriatric hip fracture and to use these significant variables to develop a LOS calculator. MATERIALS AND METHODS: This was a retrospective study examining 614 patients treated for geriatric hip fracture between January 2000 and December 2009 at an urban, Level 1 trauma center. A negative binomial regression analysis was used to identify perioperative variables associated with hospital LOS. RESULTS: 614 patients met the inclusion criteria, presenting with a mean age of 78 (±10) years. The most common pre-operative comorbidity was hypertension, followed by diabetes and COPD. After controlling for all collected comorbidities as well as demographics and operative variables, hypertension (IRR: 1.10, p = 0.029) and disseminated cancer (IRR: 1.24, p = 0.007) were found to be significantly associated with LOS. In addition, two demographic/presenting variables, admission to the medicine service (IRR: 1.48, p < 0.001) and male sex (IRR: 1.09, p = 0.034), were shown to be independent risk factors for prolonged LOS. These variables were synthesized into a LOS formula, which estimated LOS to within 3 days of the true length of stay for 0.758 of the series (95% confidence interval: 0.661 to 0.855). CONCLUSIONS: This study identified several comorbidity and perioperative variables that were significantly associated with LOS following geriatric hip fracture surgery. The resulting LOS model may have utility in the risk stratification of orthopaedic trauma patients presenting with hip fracture.

Hemiarthroplasty for Femoral Neck Fracture.

Hemiarthroplasty is a common treatment for femoral neck fractures in the elderly population. The main complications are periprosthetic dislocation and infection, which potentially impact morbidity and quality of life and may contribute to mortality. This procedure can be technically demanding, and adequate closure of the capsule and soft tissue cannot be emphasized enough. One advantage of a bipolar prosthesis is that it can be easily converted to a total hip arthroplasty without replacing the femoral component and with approximately the same complication rates as a revision total hip arthroplasty. Cement should be used when the patient is osteoporotic or has a Dorr type-C canal because there is a significant reduction in risk of fracture. The addition of a collared stem is helpful if there is a crack in the calcar extending from the fracture. The procedure is as follows. (1) The patient is placed in the lateral decubitus position. (2) The surgical site is prepared and draped to above the iliac crest and mid-sacrum. (3) A posterior approach is utilized. (4) The hip is dislocated. (5) A cut is made at the femoral neck. (6) The implant is templated with the femoral head. (7) The femur is broached. (8) The trial implant is placed. (9) The femur is cemented. (10) Trial implants are removed and cement is placed. (11) The final stem implant is placed in 5° to 10° of anteversion. (12) The final head and neck implants are trialed and then placed. (13) Implant position and range of motion are tested. (14) The surgical wound is irrigated. (15) Short external rotators are repaired. The posterior approach, which is often used, is known for increased rates of dislocation. The rate of dislocation can be minimized with repair of the posterior capsule and posterior soft tissue. Proper placement of the implants is of the utmost importance to minimize complications. Other contributing factors that lead to dislocation are implant malpositioning and patient factors.

Patient Outcomes in Orthopaedic Trauma: How to Evaluate if Your Treatment Is Really Working?

Outcomes are critical to gauge the success of our treatments and, in particular, surgical interventions in orthopaedic trauma. Patient-reported outcomes have evolved to become the primary measurement of success in surgery. This article reviews the concepts relevant to understanding these outcomes including general health outcomes, extremity- and disease-specific outcomes, minimum clinically important difference, economic analysis of treatment cost/benefit, and the impact of psychosocial factors on outcomes. An understanding of these concepts is important to allow for effective interpretation and critical analysis of the literature as well as to facilitate the practice of evidence-based medicine.

Opiate Prescribing Practices After Common Isolated Lower Extremity Injuries.

OBJECTIVE: This retrospective study aimed at identifying opiate prescribing practices, the number of morphine milligram equivalents (MMEs) prescribed by orthopaedic and nonorthopaedic providers in patients with operatively treated isolated lower extremity fractures, and provide opiate prescribing recommendations. METHODS: Patients older than 18 years with isolated lower extremity (unicondylar, bicondylar, tibial shaft, pilon, and ankle) fractures between 2005 and 2016 were identified. Prescribing information was obtained from the State Controlled Substance Monitoring Database. Descriptive statistics were calculated for each injury and plotted for MME use. Mann-Whitney and Wilcoxon tests were used for data analysis. To aid in clinical relevance, MMEs were converted to number of pills of oxycodone 10 mg (OC 10 mg). RESULTS: Three hundred forty-one patients met our inclusion criteria. Mean age was 45 years; 56% (192/341) were men. Forty-seven percent (159/341) were prescribed opiates before their injury. Orthopaedic providers prescribed more opiates to patients with pilon fractures compared with unicondylar (P = 0.010), tibial shaft (P < 0.001), and ankle (P < 0.001) fractures. Bicondylar plateau fracture patients also received more opiates when compared with unicondylar (P = 0.001), tibial shaft (P < 0.001), and ankle (P < 0.001) fractures. Nonorthopaedic providers prescribed more opiates to patients with pilon fractures when compared with unicondylar (P = 0.006), bicondylar (P < 0.001), tibial shaft (P < 0.001), and ankle fractures (P = 0.006). Differences between orthopaedic and nonorthopaedic MMEs prescribed are significantly different for each injury type (<0.05). CONCLUSIONS: Patients with pilon or bicondylar tibial plateau fractures are currently being prescribed more opiates when compared with other isolated fractures. We have developed an opiate prescription guideline based on what is being prescribed by orthopaedic providers.

Intramedullary Nail Fixation of Tibial Shaft Fractures: Suprapatellar Approach.

Intramedullary nailing is the most popular and widely used method for treating tibial shaft fractures. Intramedullary nailing involves minimal surgical dissection, allowing preservation of blood supply by not disrupting the soft tissue around the fracture. The procedure is performed with the following steps: (1) the patient is positioned supine on the radiolucent operating table with a bump under the ipsilateral hip; (2) a 4 to 6-cm longitudinal incision is made 2 to 4 cm directly proximal to the superior pole of the patella; (3) the quadriceps tendon is sharply incised at its midline and split longitudinally; (4) a cannula device with a blunt trocar and protective sleeve is inserted into the knee joint between the articular surface of the patella and the trochlea of the distal part of the femur, after which a second pin can be inserted through the cannula device and into the distal part of the femur to stabilize the cannula and keep it from backing out; (5) a 3.2-mm guide pin is inserted and placed resting at the junction of the articular surface and the anterior cortex of the tibia at the appropriate starting point in line with the intramedullary canal; (6) the guide pin is advanced 8 to 10 cm into the proximal part of the tibia, the inner centering sleeve is removed, and the cannulated entry drill is passed over the pin through the outer protective sleeve and used to ream down to the metadiaphyseal level of the proximal part of the tibia; (7) the fracture is reduced; (8) a ball-tipped guidewire is centrally passed across the fracture down to the level of the distal tibial physeal scar; (9) incremental reaming is performed, and the appropriate-size tibial nail is inserted down the tibial canal; (10) the appropriate nail position is confirmed radiographically, and distal interlocking screws are placed with a freehand technique, after which the proximal aiming arm is attached to the insertion handle and interlocking screws are drilled, measured, and placed into the proximal part of the tibia as well; and (11) all incisions as well as the quadriceps tendon are closed. Intramedullary nail fixation is a safe and effective method for treating tibial shaft fractures, and with appropriate surgical technique good outcomes and reproducible results can be expected. This soft-tissue-sparing method of fracture fixation achieves biomechanical stabilization of the fracture using a load-sharing device that allows for earlier postoperative ambulation.

Management of Femoral Defects Greater Than 5 cm Following Open Femur Fractures: A 12-Year Retrospective Review.

This study sought to evaluate the outcomes of patients with osseous defects exceeding 5 cm following open femur fractures. Size of the osseous defect, method of internal fixation (plate vs. intramedullary nail), patient demographics, medical comorbidities, and surgical complications were collected. Twenty-seven of the 832 open femur fracture patients had osseous defects exceeding 5 cm. Mean osseous defect size was 8 cm, and each patient had an average of four operations including initial debridement. Average time from injury to bone grafting was 123.7 days. The overall complication rate was 48.1% (n = 13). The most common complications were infection (26.0%, n = 7) and nonunion (41.0%, n = 11). Smoking, diabetes, ASA score, and defect size did not independently increase the risk of a complication. Management of open femur fractures with osseous defects greater than 5 cm is associated with high complication rate, driven primarily by infection and nonunion. (Journal of Surgical Orthopaedic Advances 27(3):203-208, 2018).

Opioid Prescribing Practices After Isolated Pilon Fractures.

The purpose of our study was to identify the opioid-prescribing practices after operative treatment of isolated pilon fractures at a level 1 trauma center. Patients ≥ 18 years of age with an operatively treated isolated pilon fracture between 2005 and 2015 were identified. Total morphine milligram equivalents (MMEs) were then calculated. Mean and standard deviations were calculated for patients without a history of opiate use and for patients with a history of opiate use within 1 year prior to injury. Data were obtained from the State Controlled Substance Monitoring Database. Seventy-two patients met our inclusion criteria; of these, 54% (39/72) were opiate exposed at the time of injury. Median MMEs prescribed were 2738 (range 375 to 12,360). Orthopedic providers prescribed 61% of all the MMEs (median 2010; range 113 to 6825), while nonorthopedic providers prescribed a median of 338 MMEs (range 0 to 10,080) (p < .05). Combined, patients with exposure 1 year before the injury received more MMEs (median 3600; range 840 to 12,360) than opiate-naive patients (median 2520; range 375 to 10,610) (p < .05). Twenty-eight (38.9%) patients continued using opiates for more than 6 months after their injury; 25% (7/28) were not previously exposed. There is great variability regarding the quantity of opiates being prescribed after isolated pilon fractures, and 39% of opiate prescriptions are coming from nonorthopedic prescribers. Opiate-exposed patients are more likely to be prescribed more opiates by orthopedists and outside physicians and for a longer duration. We believe that adequate pain control can be obtained by prescribing 40 pills of oxycodone 10 mg with a maximum of 1 additional refill. In cases in which a staged procedure is planned, an additional refill is expected (total of 3 refills).

Acute Compartment Syndrome: An Expert Survey of Orthopaedic Trauma Association Members.

OBJECTIVES: The goal of this study was to describe current opinions of orthopaedic trauma experts regarding acute compartment syndrome (ACS). DESIGN: Web-based survey. PARTICIPANTS: Active Orthopaedic Trauma Association (OTA) members. METHODS: A 25-item web-based questionnaire was advertised to active members of the OTA. Using a cross-sectional survey study design, we evaluated the perceived importance of ACS, as well as preferences in diagnosis and treatment. RESULTS: One hundred thirty-nine of 596 active OTA members (23%) completed the survey. ACS was believed to be clinically important and with severe sequelae, if missed. Responses indicated that diagnosis should be based on physical examination in an awake patient, and that intracompartmental pressure testing was valuable in the obtunded or unconscious patient. The diagnosis of ACS with monitoring should be made using the difference between diastolic blood pressure and intracompartmental pressure (ΔP) of ≤30 mm Hg. Once ACS is diagnosed, respondents indicated that fasciotomies should be performed as quickly as is reasonable (within 2 hours). The consensus for wound management was closure or skin grafting within 1-5 days later, and skin grafting was universally recommended if closure was delayed to >7 days. CONCLUSIONS: ACS is a challenging problem with poor outcomes if missed or inadequately treated. OTA members demonstrated agreement to many diagnostic and treatment choices for ACS. LEVEL OF EVIDENCE: Therapeutic Level V. See Instructions for Authors for a complete description of the levels of evidence.

Opioid Prescribing Practices by Orthopaedic Trauma Surgeons After Isolated Femur Fractures.

OBJECTIVE: The purpose of this retrospective study was to identify opioid prescribing practices, determine the number of morphine milliequivalents (MMEs) prescribed by orthopaedic/nonorthopaedic members to narcotic naive and previously exposed patients, and provide narcotic prescribing recommendations. METHODS: Patients older than 18 years with an isolated femur fracture sustained between 2013 and 2015 were identified using the CPT code 27506. Prescribing information was obtained from the State Controlled Substance Monitoring Database. Descriptive analysis of MMEs was then performed. Outliers and patients without prescriptions from orthopaedic providers were excluded to eliminate skewing of data. Mean and standard deviations were then calculated for patients without a history of opiates prescribed within 1 year of injury and for patients with a history of opiates prescribed within 1 year before the injury. RESULTS: Forty-five percent (40/88) of patients were opiate exposed at the time of injury. Previously exposed patients received 1491 MMEs (SD, 1044; median, 1350; range, 210-5140) and nonexposed patients received 1363 MMEs (SD, 977.2; median, 1260; range, 105-4935) from orthopaedic providers (P = 0.1473). Nonorthopedists prescribed 530 MMEs (SD, 780.7; median, 140; range, 0-3515) to previously exposed patients and 175 MMEs (SD, 393; median, 140; range, 0-1890) to patients without exposure (P < 0.0001). CONCLUSION: Patients with prior exposure are more likely to be prescribed more opiates after femoral shaft fracture treatment. We recommend a protocol of prescribing half the mean of MMEs currently prescribed by orthopedists equating to 47 (711 MMEs) pills of oxycodone 10 mg in up to 3 prescriptions.

Open Reduction and Internal Fixation with a Locking Plate Via Deltopectoral Approach for the Treatment of Three and Four-Part and Proximal Humeral Fractures.

Open reduction and internal fixation (ORIF) via the deltopectoral approach is the gold standard for operatively treated proximal humeral fractures when joint preservation is desired. Indications include an unacceptable deformity, need for stability and early mobilization, and osteoporotic bone. (1) A 12 to 14-cm incision is made in the deltopectoral groove. The fracture is reduced. (2) Pins and tension sutures are placed for provisional fixation. (3) The locking plate is placed with unicortical screws in the metaphysis of the proximal part of the humerus and bicortical screws in the shaft. (4) The rotator cuff tendon is sutured into the open suture holes of the plate. (5) The surgical wound is then closed in a layered fashion. Hertel et al. reported that calcar length <8 mm, disruption of the medial hinge, and complex fracture patterns are more predictive of future osteonecrosis. In a series of 34 patients managed with ORIF, Neviaser et al. showed that the length of the posteromedial hinge was not predictive of osteonecrosis. Additionally, with use of tetracycline labeling, Crosby et al. demonstrated that perfusion to the humeral head is maintained in more complex 3 and 4-part fractures following anatomic reduction. Although they are useful for surgical planning, the criteria proposed by Hertel et al. cannot accurately predict osteonecrosis. The most important predictor of ischemia is the length of the dorsomedial metaphyseal extension and the integrity of the medial hinge. Including medial support in the fixation greatly decreases the incidence of screw cutout and migration into the articular surface and increases functional outcomes. Proper and complete reduction is of the utmost importance because varus malreduction contributes to the loss of fixation and to technical complications, such as improper plate positioning, improper screw length, and screw cutout, that influence outcomes.

Outcomes of Distal Femur Nonunions Treated With a Combined Nail/Plate Construct and Autogenous Bone Grafting.

In this study, we sought to retrospectively evaluate union and infection rates after treatment of distal femur nonunions using a combined nail/plate construct with autogenous bone grafting obtained from the ipsilateral femur using a reamer irrigator aspirator system. Ten (10) patients treated at a Level I trauma center for nonunion of a femoral fracture using a combined nail/plate construct from 2004 to 2014 were included in the study. Union rate and postoperative infection rates were recorded. Mean interval from index surgery to nonunion repair was 12 months (range 4-36 months). Follow-up at 24 months indicated that the entire cohort of 10 patients achieved clinical union and radiographic union based on radiograph union score in tibias (RUST) criteria. Treatment of distal femur nonunions with a combined nail/plate construct and autogenous bone grafting results in a high rate of union with a low complication rate.

The impact of resident involvement on outcomes in orthopedic trauma: An analysis of 20,090 cases.

BACKGROUND: Involvement in patient care is critical in training orthopedic surgery residents for independent practice. As the focus on outcomes and quality measures intensifies, the impact of resident intraoperative involvement on patient outcomes will be increasingly scrutinized. We sought to determine the impact of residents' intraoperative participation on 30-day post-operative outcomes in the orthopedic trauma population. METHODS: A total of 20,090 patients from the American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2013 were identified. Patient demographics and comorbidities, surgical variables, and 30-day post-operative (wound, minor, and major) complications were collected. Chi-squared and analysis of variance statistical methods were used to compare the 30-day outcomes of patients with and without a resident's intraoperative involvement. RESULTS: Resident involvement had no effect in the incidence of wound and minor complications among all three anatomic sites of orthopedic trauma procedures (hip, lower extremity [LE], and upper extremity [UE]). There was no statistically significant difference in the incidence of major complications in the hip and LE groups. The UE group, however, demonstrated an increase in the rate of major complications (2.60% vs. 1.89%, p = 0.046). There was no difference in mortality or readmission rates. CONCLUSIONS: Resident involvement in orthopedic trauma cases did not significantly impact the 30-day outcomes in nearly all domains. Our findings support continued resident involvement in the care of the orthopedic trauma patient.

Posttraumatic Elbow Stiffness: A Critical Analysis Review.

Open and arthroscopic release are both effective surgical treatments for posttraumatic elbow stiffness. Both static and dynamic bracing are effective for increasing elbow range of motion when heterotopic ossification is not present. Some loss of immediate postoperative range of motion is expected. Recurrence of heterotopic ossification around the elbow is rare. The occurrence of ulnar nerve palsy is rare and often requires transposition.

Predictors of Adverse Events for Ankle Fractures: An Analysis of 6800 Patients.

Ankle fractures are one of the most common injuries seen by orthopedic surgeons. It is therefore essential to understand the risks associated with their treatment. Using the American College of Surgeons National Surgical Quality Improvement Program(®) database from 2006 to 2013, the patient demographics, comorbidities, and 30-day complications were collected for 5 types of ankle fractures. A bivariate analysis was used to compare the patient demographics, comorbidities, and complications across all Common Procedural Terminology codes. A multivariable logistic regression model was then used to assess the odds of minor and major postoperative complications within 30 days after open treatment. A total of 6865 patients were included in the analysis. Of these patients, 2507 (36.5%) had bimalleolar ankle fractures. The overall rate of adverse events for ankle fractures was low. Bimalleolar fractures had the greatest rate of major (2.6%, n = 64), minor (3.8%, n = 94), and total (5.7%, n = 143) complications. When controlling for individual patient characteristics, bimalleolar fractures were associated with 4.92 times the odds (95% confidence interval 1.80 to 13.5; p = .002) of developing a complication compared with those with a medial malleolar fracture. The risk factors driving postoperative complications for all ankle fractures were age >65 years, obesity, diabetes, American Society of Anesthesiologists score >2, and functional status (p < .05). Although the overall rate of adverse events for ankle fractures was low, bimalleolar fractures were associated with 5 times the odds of developing a complication compared with medial malleolar fractures. Orthopedic surgeons must be aware of the risk factors that increase the rate of ankle fracture complications to improve patients' quality of care.

Outcomes of Distal Femur Nonunions Treated with a Combined Nail/Plate Construct and Autogenous Bone Grafting.

SummaryIn this study, we sought to retrospectively evaluate union and infection rates after treatment of distal femur nonunions using a combined nail/plate construct with autogenous bone grafting. 10 patients treated at a Level I Trauma Center for nonunion of a femoral fracture using a combined nail/plate construct from 2004 to 2014 were included in the study. Union rate and postoperative infection rate were recorded.10 patients underwent treatment for nonunion of the distal femur. Mean interval from index surgery to nonunion repair was 12 months (range 4-36 months). All 10 patients achieved union at an average of 3.9 months (range 2.3-8 months) after initial nonunion repair. Treatment of distal femur nonunions with a combined nail/plate construct and autogenous bone grafting results in a high rate of union with a low complication rate. This technique combines two straightforward procedures familiar to orthopaedic trauma surgeons and offers distinct advantages including: availability of adequate bone graft volume, absence of donor site morbidity, and increased construct stability that may permit earlier weight-bearing.

Anterior versus posterior pin placement of pelvic C-clamp in relationship to anatomical structures: a cadaver study.

OBJECTIVES: The objective of this study was to compare anterior and posterior pin placement of the pelvic C-clamp with specific reference to the proximity of the sciatic nerve, sciatic notch, hip joint capsule, and superior gluteal neurovascular bundle. METHODS: The pelvic C-clamp (Synthes, Paoli, PA) was applied to eight extracted pelvic specimens and five full cadavers (26 hips in total). Anterior and posterior pin placements were measured in relationship to the described anatomical structures. RESULTS: In 100% of the hips the distance from the posterior pin to the hip joint capsule was in 21 (80.8%), 23 (88.5%), and 20 (76.9%) of the hips, the anterior pin distances were greater than the posterior pin distances to the sciatic nerve, sciatic notch, and superior gluteal neurovascular bundle, respectively. CONCLUSIONS: Anterior pin placement is further from all anatomical structures studies with the exception of the hip joint capsule. The posterior pin was closer to the sciatic nerve, sciatic notch, and superior gluteal neurovascular bundle in all cases. Clinical decision-making for C-clamp placement should be individualised on a case-by-case basis.