Delayed debridement of open tibia fractures beyond 24 and 48 h does not appear to increase infection and reoperation risk.

PURPOSE: Surgical debridement is critical to the treatment of open tibia fractures, although the effects of delayed debridement have not been well-established. Other factors such as Gustilo-Anderson type, prompt initiation of antibiotics, and time to definitive closure may be more predictive of infection than time to surgery. We sought to determine the effect of a prolonged delay to surgical debridement with respect to infection and reoperation rates for open tibia fractures. METHODS: All open diaphyseal tibia fractures with > 12-week follow-up were evaluated. Patient demographics, Gustilo-Anderson type, and rates of deep infection and all-cause reoperation were recorded. Patients were divided into 3 groups based on time to surgery: early (< 24 h), delayed (24-48 h), and late (> 48 h). Univariate and multivariate analyses were performed to evaluate the relationship between time to surgery, fracture type, infection, and reoperation. RESULTS: In total, 96 open tibia fractures with average follow-up of 59.3 weeks and infection rate of 13.5% were included. Infection rates for the early, delayed, and late groups were 13.3%, 17.2%, and 9.1%, respectively (p = 0.70). Reoperation rates for the early, delayed, and late groups were 29.8%, 31.0%, and 22.7%, respectively (p = 0.80). The groups did not vary in proportion of Gustilo-Anderson fracture types; infection rates between Gustilo-Anderson types were similar (p = 0.57). Type IIIA-C fractures required more reoperations than other fracture types (p = 0.01). CONCLUSION: Delayed surgical debridement of open tibia fractures did not result in greater rates of infection or reoperation. Gustilo-Anderson classification was more predictive of reoperation, with Type IIIA-C injuries having a significantly higher reoperation rate.

Scaphoid Nonunion Is a Disabling Problem in a Military Population.

BACKGROUND: Scaphoid nonunion can occur in up to 55% of displaced scaphoid fractures. Long-term functional outcomes of this injury are lacking. In addition, no study has published rate of return to active military service after this injury. Our goal was to educate providers and patients on expected functional outcomes and return to duty after treatment of scaphoid nonunion. METHODS: We conducted a retrospective review of patients who underwent scaphoid nonunion repair at our institution from 2008 to 2017. The primary outcome measures were union rates, return to duty rates, and functional outcome scores obtained by telephone call. A total of 144 patients were included and 40 responded to our call for long-term follow-up. RESULTS: A total of 72% of patients achieved union after surgery, 18% required revision surgery, and 74% of patients were able to return to full duty after surgery. However, this number progressively decreased at 1, 2, and 5 years after surgery. At an average of 5.9 years after surgery, the mean Quick Disabilities of the Arm, Shoulder, and Hand (qDASH) score was 23.9. The mean qDASH for patients who achieved union (21.9) was significantly lower than those with persistent nonunion (29.2) (P = .0115). CONCLUSION: Scaphoid nonunion is a difficult problem in the military. We found a high rate of persistent nonunion often requiring revision to partial or full wrist arthrodesis. In addition, our long-term functional outcome scores demonstrate significant disability after this injury, even when union is achieved. This information can help us better counsel our patients and set expectations after treatment of this injury.

Bilateral Atypical Tension-sided Femoral Neck Stress Fractures in a Military Recruit.

A case report of a Marine Recruit with bilateral atypical tensile-sided femoral neck stress fracture. The patient was treated nonoperatively with protected weightbearing following an established protocol that included close observation with serial exams and advanced imaging. He recovered uneventfully and was able to return to running. He was eventually diagnosed with bilateral femoral acetabular impingement syndrome at the end of his treatment course demonstrating a growing association warranting further investigation.

Improved Functional Outcomes Following Operative Treatment of Midshaft Clavicle Fractures in an Active Duty Population.

Clavicle fractures are common orthopedic injuries that occur in a young active population and are even more common in the military. Military fitness test data presents the unique opportunity to analyze functional ability with regard to military-specific activities. The primary goal of this study was to compare functional outcomes using military fitness test data between operative and non-operative treatment of midshaft clavicle fractures.  We performed a retrospective review of active-duty U.S. Navy and Marine patients with midshaft clavicle fractures treated at our institution over a seven-year period. There were 94 and 153 patients in our operative and non-operative cohorts, respectively. Average follow-up time from the date of injury or surgery was 28 months. The rate of infection in the operative group (4%) was significantly greater than in the non-operative group (0%, p = 0.023). The rate of non-union in the operative group (3%) was significantly lower than in the non-operative group (14.5%, p = 0.004). The rate of symptomatic malunion in the operative group (0%) was significantly different from that in the non-operative group (4.6%, p = 0.036). There was no significant difference in the rate of revision surgery between the operative (9.2%) and non-operative (13.2%) groups (p = 0.105). A total of 51 marines met inclusion criteria for our functional outcome analysis using Marine Corps Physical Fitness Test (PFT) data. Of those who underwent operative fixation, 68% were able to meet or surpass their pre-injury average amount of pull-ups in their first PFT after surgery and 88% by the next PFT at least one year after surgery. While 69% of non-operative patients met their pre-injury average in their first PFT, only 57% maintained this level at least one year after surgery. This difference was statistically significant. In our functional outcome subgroup analysis, we found improved outcomes for pull-ups at least one year out when midshaft clavicle fractures are treated operatively compared to non-operatively. While similar findings in the literature are based on functional outcome questionnaires, physical fitness performance data has not been reported on to our knowledge.

Streamlining Definitive Care for Occult Scaphoid Fractures: A Retrospective Review of the Workup of Scaphoid Nonunions and Applying Lessons Learned.

INTRODUCTION: The process for working up scaphoid fractures from frontline providers to the specialty care clinic is variable. Initial imaging can often be negative and the management algorithm is not clearly defined. Delays in diagnosis are a contributing factor to scaphoid nonunion. Fractures may not be identified by frontline providers on initial presentation because of radiographically occult injuries. If not treated promptly, scaphoid fractures may be complicated by nonunion, avascular necrosis, and osteoarthritis. MATERIALS AND METHODS: Retrospective review of scaphoid nonunions from 2017 to 2018 in a single tertiary care institution after internal review board approval was obtained (NMCSD.QI.2019.0003). Cases were identified using an ICD 10 search for "scaphoid (navicular) fracture non-union" and subtypes. Charts were examined for time between injury and presentation, injury and diagnosis, initial radiologic workup, and limited duty (LIMDU). Nonparametric statistical analysis for linear and categorical data was conducted using SPSS. A subgroup of patients who had a delay in diagnosis of greater than 30 days upon entering the medical system was further analyzed and identified as the "delayed diagnosis" cohort. RESULTS: In total, 30 patients with scaphoid nonunion were identified. Overall, 35% of patients had negative initial X-rays and averaged 42.1 days until diagnosis. In total, 100% of patients required at least one LIMDU period, averaging 1.4 periods, for a total of 6,404 days and 16% went on to a physical evaluation board (PEB). In 9 (30%) of these patients, injury was initially not identified upon entering the medical system resulting in average of 139.7 days until diagnosis; this became known as the delayed diagnosis subgroup. Further analysis of the delayed diagnosis subgroup demonstrated significantly more initial negative X-rays (P < .005) at a rate of 77% (7/9). A delay in diagnosis was significantly associated with PEB (R = 0.4, P = .031) with 33% of these patients going on to a PEB. CONCLUSIONS: Delayed diagnosis of a scaphoid fracture is a contributing factor for excessive light duty, high rates of LIMDU utilization, and ultimately medical separation of service members. Overall, in all patients who had scaphoid nonunions, the average time to diagnosis was 42.1 days with 35% of patients presenting with negative initial imaging. A delayed diagnosis subgroup was identified and notable for a higher rate of initial negative X-rays, an average of 139.7 days until diagnosis, and a 33% PEB rate. In total, 77% of patients with a delay in diagnosis of more than 30 days had an initial negative X-ray. An evidence-based algorithm for diagnosing occult scaphoid fractures may prevent delays in diagnosis, thus increasing the readiness of active duty service members.

Percutaneous Pedicle Screws in the Obese: Should the Skin Incision Be More Lateral?

OBJECTIVE: To determine if the skin incision for lumbar percutaneous pedicle screws should be more lateral in the obese patient. METHODS: This was a retrospective radiographic analysis of 30 obese and non-obese lumbar spine computed tomography (CT) radiographs comparing the depth of soft tissue along the anatomic axis of the pedicle at L4 and L5. RESULTS: The average distance from the pedicle trajectory on the skin to the lateral border of the pedicle at L4 was 1.4 cm and 3.8 cm in the non-obese and obese groups, respectively. The average distance from the pedicle trajectory on the skin to the lateral border of the pedicle at L5 was 2.1 cm and 4.3 cm in the non-obese and obese groups, respectively; both these differences reached statistical significance, p <0.05. CONCLUSIONS: This radiographic study supports a more lateral start point for percutaneous pedicle screws in obese patients to maintain an anatomic trajectory when inserting percutaneous pedicle screws into the lumbar spine at L4 and L5. If a skin incision is made at only 1 cm lateral to the pedicle in the obese patient, the surgeon often has to place significant traction on the skin edge to lateralize their instrumentation to achieve an appropriate angle of insertion. By making a more lateral skin incision, less manipulation of the skin and soft tissues is needed to maintain an anatomic trajectory of the pedicle screw. Decreasing soft tissue manipulation may decrease wound and instrumentation complications in this at-risk population.

Extravasation of fluid in arthroscopic shoulder surgery requiring prolonged intubation: a case report.

BACKGROUND: Shoulder arthroscopy is a safe and effective procedure with a low complication rate. Although rare, there are potentially life-threatening risks such as fluid extravasation causing airway compromise. CASE PRESENTATION: We report the case of a 65-year-old female treated with an arthroscopic rotator cuff repair who had significant extravasation of arthroscopic fluid causing severe facial and neck swelling. Overnight intubation was required for respiratory monitoring until the edema had resolved enough to allow safe extubation. CONCLUSION: This case highlights the risk factors and clinical course of a patient with airway compromise caused by extravasation of fluid during shoulder arthroscopy. Although shoulder arthroscopy is a safe procedure, surgeon familiarity with the risk factors for this complication and close monitoring can aid in its identification and allow for appropriate treatment.