Fracture blisters: predictors for time to definitive fixation in pilon fractures.

PURPOSE: Fracture blisters, a common soft-tissue complication of pilon fractures, are associated with post-operative wound infections, delays in definitive fixation, and alterations in surgical plan. The purpose of this study was to (1) identify the delay in surgery attributable to the presence fracture blisters and (2) investigate the relationship of fracture blisters to comorbidities and fracture severity. METHODS: Patients with pilon fractures at an urban level 1 Trauma center from 2010 to 2021 were identified. The presence or absence of fracture blisters was noted, along with location. Demographic information, time from injury to external fixator placement, and time to definitive open reduction internal fixation (ORIF) were collected. Pilon fractures were classified according to AO/OTA guidelines using CT imaging and plain radiographs. RESULTS: 314 patients with pilon fractures were available for analysis, eighty (25%) of whom were found to have fracture blisters. Patients with fracture blisters had longer time to surgery compared to those without fracture blisters (14.2 days vs 7.9 days, p < 0.001). A greater proportion of patients with fracture blisters had AO/OTA 43C fracture patterns, compared with those without fracture blisters (71.3% vs 53.8%, p = 0.03). Fractures blisters were less likely to be localized over the posterior ankle (12%, p = 0.007). CONCLUSION: The presence of fracture blisters in pilon fractures are associated with significant delays in time to definitive fixation and higher energy fracture patterns. Fracture blisters are less commonly located over the posterior ankle which may support the implementation of a staged posterolateral approach when managing these injures.

Factors Contributing to Diurnal Variation in Athletic Performance and Methods to Reduce Within-Day Performance Variation: A Systematic Review.

ABSTRACT: Kusumoto, H, Ta, C, Brown, SM, and Mulcahey, MK. Factors contributing to diurnal variation in athletic performance and methods to reduce within-day performance variation: A systematic review. J Strength Cond Res 35(12S): S119-S135, 2021-For many individuals, athletic performance (e.g., cycle ergometer output) differs based on the time of day (TOD). This study identified factors contributing to diurnal variation in athletic performance and methods to reduce TOD performance variation. Comprehensive searches of PubMed, Ovid, EMBASE, Web of Science, and Cochrane Libraries were conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Peer-reviewed publications reporting quantitative, significant diurnal variation (p ≤ 0.05) of athletic performance with explanations for the differences were included. Studies providing effective methods to reduce diurnal variation were also included. Literature reviews, studies involving nonhuman or nonadult subjects, studies that intentionally manipulated sleep duration or quality, and studies deemed to be of poor methodological quality using NIH Quality Assessment Tools were excluded. Forty-nine studies met the inclusion criteria. Body temperature differences (n = 13), electromyographic parameters (n = 10), serum biomarker fluctuations (n = 5), athlete chronotypes (n = 4), and differential oxygen kinetics (n = 3) were investigated as significant determinants of diurnal variation in sports performance. Successful techniques for reducing diurnal athletic performance variability included active or passive warm-up (n = 9), caffeine ingestion (n = 2), and training-testing TOD synchrony (n = 3). Body temperature was the most important contributor to diurnal variation in athletic performance. In addition, extended morning warm-up was the most effective way to reduce performance variation. Recognizing contributors to diurnal variation in athletic performance may facilitate the development of more effective training regimens that allow athletes to achieve consistent performances regardless of TOD.

Patient Characteristics and Outcomes of Geriatric Ankle Fractures: Open Fracture Is the Key Risk Factor for Complications and Functional Decline.

OBJECTIVES: To determine whether open (O) or closed (C) geriatric ankle fractures had different patient characteristics or outcomes. METHODS: . DESIGN: Retrospective cohort study. SETTING: Urban Level 1 trauma center. PATIENT SELECTION CRITERIA: Patients, age 60 years and older, who underwent operative fixation of a rotational ankle fracture (OTA/AO 44A-C) between January 2012 and September 2021. OUTCOME MEASURES AND COMPARISONS: Morbidity, defined as 90-day reoperation, 90-day readmission, or loss of mobility, as well as 1-year mortality compared between patients with closed and open fractures. RESULTS: The open cohort was older (75 years vs. 68 years; P = 0.003) but had similar Charlson comorbidity indices (4.6 O vs. 4.0 C; P = 0.323) and preinjury rates of independent ambulation (70.4% O vs. 80.9% C; P = 0.363). There were higher rates of 1-year mortality (11% vs. 0%; P < 0.001), deep infection (14.8% vs. 3.9%; P = 0.019), and loss of mobility (64.7% vs. 23.0%; P < 0.001) in the open cohort. Multivariate regression identified open fracture as an independent predictor of 90-day reoperation (OR: 20.6; P = 0.022) and loss of mobility (OR: 5.1; P = 0.011). CONCLUSIONS: Despite having comorbidities and preinjury function similar to the closed geriatric ankle fracture cohort, open ankle fracture was independently predictive of greater loss of mobility. Nearly two-thirds of geriatric patients with open ankle fractures experienced a decline in functional independence, compared with 1 in 4 of those with closed fractures. Open fracture was associated with higher rates of deep infection, reoperation, and 1-year mortality. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Review of perioperative outcomes and management of hip fracture patients on direct oral anticoagulants.

Anticoagulation use is common in elderly patients presenting with hip fractures and has been shown to delay time to surgery (TTS). Delays in operative treatment have been associated with worse outcomes in hip fracture patients. Direct oral anticoagulants (DOACs) comprise a steadily increasing proportion of all oral anticoagulation. Currently, no clear guidelines exist for perioperative management of hip fracture patients taking DOACs. DOAC use is associated with increased TTS, with delays frequently greater than 48 h from hospital presentation. Increased mortality has not been widely demonstrated in DOAC patients, despite increased TTS. Timing of surgery was not found to be associated with increased risk of transfusion or bleeding. Early surgery appears to be safe in patients taking DOACs presenting with a hip fracture, but is not currently widely accepted due to factors such as site-specific anesthesiologic protocols that periodically delay surgery. Direct oral anticoagulant use should not routinely delay surgical treatment in hip fracture patients. Surgical strategies to limit blood loss should be considered and include efficient surgical fixation, topical application of hemostatic agents, and the use of intra-operative cell salvage. Anesthesiologic strategies have utility in minimizing risk and a collaborative effort to minimize blood loss should be undertaken by the surgeon and anesthesiologist. Anesthesia team interventions include considerations regarding positioning, regional anesthesia, permissive hypotension, avoidance of hypothermia, judicious administration of blood products, and the use of systemic hemostatic agents.

The Influence of Industry Affiliation on Randomized Controlled Trials of Platelet-Rich Plasma for Knee Osteoarthritis.

BACKGROUND: Industry funding and corporate sponsorship have played a significant role in the advancement of orthopaedic research and technology. However, this relationship raises concerns for how industry association may bias research findings and influence clinical practice. PURPOSE: To determine whether industry affiliation plays a role in the outcomes of randomized controlled trials (RCTs) investigating platelet-rich plasma (PRP). STUDY DESIGN: Meta-analysis; Level of evidence, 2. METHODS: A search of the PubMed, Cochrane, and MEDLINE databases for RCTs published between 2011 and the present comparing PRP versus hyaluronic acid, corticosteroid, or placebo for the treatment of knee osteoarthritis was performed. To determine industry affiliation, the conflict of interest, funding, and disclosure sections of publications were assessed, and all authors were assessed through the American Academy of Orthopaedic Surgeons disclosure database and the Centers for Medicare & Medicaid Services open payments database. Studies were classified as industry affiliated (IA) or non-industry affiliated (NIA). The outcomes of each study were rated as favorable, analogous, or unfavorable according to predefined criteria. RESULTS: A total of 37 studies (6 IA and 31 NIA) were available for analysis. Overall, 19 studies (51.4%) reported PRP as favorable compared with other treatment options, while 18 studies (48.6%) showed no significant differences between PRP and other treatment methods. There was no significant difference in qualitative conclusions between the IA and NIA groups, with the IA group having 3 favorable studies and 3 analogous studies and the NIA group having 16 favorable studies and 15 analogous studies (P = .8881). When comparing IA versus NIA studies using 6- and 12-month Western Ontario and McMaster Universities Arthritis Index and International Knee Documentation Committee scores, there were no significant differences in outcomes. CONCLUSION: The results of this study demonstrated that qualitative conclusions and outcome scores were found to not be associated with industry affiliation. Although the results of this study suggest that there is no influence of industry involvement on RCTs examining PRP, it is still necessary to carefully evaluate pertinent commercial affiliations when reviewing recommendations from studies before adopting new treatment approaches, such as the use of PRP for knee osteoarthritis.

Ambulation Distance Within 72 Hours after Surgical Management Is a Predictor of 90-Day Ambulatory Capacity in Elderly Patients with Hip Fracture.

INTRODUCTION: The inability to mobilize after surgical intervention for hip fractures in the elderly is established as a risk factor for greater morbidity and mortality. Previous studies have evaluated the association between the timing and distance of ambulation in the postoperative acute care phase with postoperative complications. The purpose of this study was to evaluate the association between ambulatory distance in the acute postoperative setting and ambulatory capacity at 3 months. METHODS: Patients aged 65 and older who were ambulatory at baseline and underwent surgical intervention for hip fractures from 2014 to 2019 were retrospectively reviewed. Consistent with previous literature, patients were divided into two groups: those who were able to ambulate 5 feet within 72 hours after surgical fixation (early ambulatory) and those who were not (minimally ambulatory). RESULTS: One hundred seventy patients (84 early ambulatory and 86 minimally ambulatory) were available for analysis. Using a multivariable ordinal logistic regression model, variables found to be statistically significant predictors of ambulatory status at 3 months were the ability to ambulate five feet in 72 hours (P < 0.0001), ambulatory distance at discharge (P = 0.012), and time from presentation to surgery (P = 0.039). Patients who were able to ambulate 5 feet within 72 hours had 9 times the odds of being independent ambulators rather than a lower ambulatory class (cane, walker, and nonambulatory). Pertrochanteric fractures were less likely than femoral neck fractures to independently ambulate at 3 months (17.2% vs. 42.3%; P = 0.0006). DISCUSSION: Ambulating 5 feet within 72 hours after hip fracture surgery is associated with an increased likelihood of independent ambulation at 3 months postoperatively. This simple and clear goal may be used to help enhance postoperative mobility and independence while providing a metric to guide therapy and help counsel patients and families.

Complications after Nonoperative Management of Hamate Fractures.

Hamate fractures are an infrequent injury and are often missed or have a delayed diagnosis with potential for significant patient morbidity. There is a relative paucity in the literature involving large population studies of hamate fractures and subsequent complications. Gaining a better understanding of complications associated with nonoperative management will help guide the decision for operative intervention. Methods: The PearlDiver patient records database was used to query for patients who sustained a hamate fracture using ICD-9 and ICD-10 codes. Postinjury complications within 1 year of diagnosis were assessed using ICD-9 and ICD-10 codes for diagnoses of complications. Results: A total of 1120 patients who sustained a hamate hook or body fracture met inclusion and exclusion criteria and were included in the study. Patients who were managed nonoperatively showed a nonunion rate of 2%, ulnar neuropathy rate of 1.7%, and tendon rupture rate of 0.2%. In a subanalysis using only ICD-10 codes to distinguish between hook and body fractures, hook fractures demonstrated a nonunion rate of 2.2%, ulnar neuropathy rate of 2.7%, and tendon rupture rate of 0%, while body fractures had a nonunion rate of 1.2%, ulnar neuropathy rate of 1%, and tendon rupture rate of 0%. Conclusion: The current study shows very low rates of nonunion, ulnar neuropathy and tendon rupture after nonoperative management of hamate fractures.