Intramedullary Nail Fixation for Metacarpal Fracture: A Case Report and Review of the Clinical and Biomechanical Evidence.

We present two cases of complex metacarpal fractures treated with an intramedullary locking nail. This is an emerging fixation method that minimizes tissue insult, provides sufficient stability, and allows early mobilization. Locking nails accommodate the capture of fractured fragments in complex unstable patterns and provide longitudinal and rotational stability. The described intrafocal technique is intended to improve coaxial placement of the wire into the medullary canal.

The Internal Joint Stabilizer of the Elbow: A Systematic Review of the Clinical and Biomechanical Evidence.

Purpose: The goal of surgical management for unstable elbow injuries is the restoration of joint concentricity and stability. After internal fixation, concerns may exist regarding instability or durability of the fixation construct. Historically, these scenarios were treated with options such as transarticular pinning or external fixation. Recently, an internal joint stabilizer (IJS) that allows postoperative mobilization was introduced. Our objective was to systematically review the literature to aggregate the clinical and biomechanical evidence for the IJS of the elbow. Methods: A systematic review of the PubMed and Google Scholar databases was performed, following the PRISMA guidelines. The search results were narrowed from 2015 through 2023 to coincide with the inception of the device being reviewed. Results: A total of nine retrospective reports on the IJS (N = 171) cases at a mean follow-up of 10.8 months were included. The pooled rate of implant failure was 4.4%, and recurrent instability was 4.1%. Additionally, the we included seven case reports and two biomechanical reports. Conclusions: The aggregate literature describes satisfactory clinical outcomes with low rates of recurrent instability and device failure for the IJS of the elbow. The limited biomechanical investigations conclude efficacy for stability profiles. Clinical relevance: Across a spectrum of unstable elbow cases, the IJS prevented recurrent instability during the early postoperative period. Notably, the device requires an additional procedure for removal, and the long-term impact of the retained devices is currently unclear.

The effect of the orthopaedic trauma association's (OTA) pain management guidelines on opioid prescriptions, pain control, and refills in outpatient orthopaedic trauma surgery.

PURPOSE: To determine the effect of the Orthopaedic Trauma Association (OTA) pain management guidelines for acute musculoskeletal injuries on opioid prescription sizes, pain control, and refills. METHODS: A prospective cohort study was performed at an academic urban level 1 trauma center. 90 patients undergoing outpatient orthopaedic trauma surgery were enrolled before and after the implementation of the OTA pain management guidelines. Adherence to guidelines, pain visual analog scale, and refills were recorded postoperatively and at the 2- and 6-week follow-up visit. RESULTS: After implementation of the guidelines, the number of patients receiving oxycodone decreased from 100 to 27%, with these patients receiving the less potent hydrocodone, instead. The discharge morphine equivalent dose (MED) decreased from a median (interquartile range) of 225 (169-300) to 140 mg (140-210) (p < 0.001). More patients required refills in the guidelines group (42% vs. 20%), resulting in no difference in total MED prescribed (210 (140-280) vs. 225 (169-307)). Adherence to the guidelines occurred in 66% of patients. As-treated analysis of patients with adherent and non-adherent prescriptions found no detectable difference in pain control, number of opioid pills used, or refills at the 2-week and 6-week follow-up. CONCLUSIONS: In the midst of a national opioid crisis, adoption of the OTA's pain management guidelines for orthopaedic trauma surgery warrants further research to determine if it's implementation can reduce the size, variability, and duration of opioid prescriptions. LEVEL OF EVIDENCE: Level II, prospective cohort.

The effect of regional anesthesia blocks on post-operative pain after ambulatory orthopedic trauma surgery.

PURPOSE: To determine if regional anesthesia had added benefit to general anesthesia, with or without local anesthesia, in controlling post-operative pain in outpatient orthopedic trauma surgery. METHODS: A retrospective review was performed of prospectively gathered data on 71 patients undergoing outpatient orthopedic trauma surgery. All patients received general anesthesia and an addition 52 patients received additional regional anesthesia. Regional vs. no regional anesthesia groups were compared in terms of post-anesthesia care unit (PACU) pain visual analog scores (VAS), PACU length of stay (LOS), opioid use, and pain control at two weeks. RESULTS: The regional anesthesia group not differ in demographics or proportion of patients receiving local anesthesia, but was less likely to be undergoing major procedures (13% vs. 37%, proportional difference (PD) - 23%; 95% confidence interval (CI) - 46% to - 0.4%). There were no detectable differences in PACU opioid requirements (median difference (MD) - 7.5 mg, CI - 8 to 0), PACU LOS (MD - 13 min, CI - 63 to 24), discharge pain VAS (MD 0, CI - 1 to 1), post-discharge pain VAS (MD 0, CI - 1 to 1), opioid refills (PD - 6%, CI - 31% to 18%), or patient-perceived pain control (PD - 24%, CI - 41% to 0%). On multivariate analysis, regional anesthesia was the only variable negatively associated with patient-perceived pain control at two weeks (Odds Ratio 0.15; 95% CI 0.03 to 0.8). CONCLUSIONS: Regional anesthesia did not improve post-operative opioid requirements, PACU LOS, or patient-reported pain in the immediate or short-term post-operative period.

Incidence of Surgical Site Infections and Acute Kidney Injuries After Topical Antibiotic Powder Application in Orthopaedic Trauma Surgery.

OBJECTIVES: To compare the incidence of deep surgical site infections (SSI) and acute kidney injuries (AKI) in patients who did and did not receive topical antibiotics during the open treatment of fractures. DESIGN: Retrospective comparative cohort. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Three hundred ninety-six patients undergoing open fixation of fractures. INTERVENTION: The topical antibiotic group included 78 (20%) patients. Vancomycin only was used in 28 (7%) patients with the median dose (interquartile range) of 1 g (1-2 g) and vancomycin/tobramycin was used in 48 (12%) patients with a median dose (interquartile range) of 2 g (1-2 g)/1.2 g (1.2-1.2 g). MAIN OUTCOME MEASUREMENTS: Deep SSI requiring debridement and AKI (>50% increase in creatinine compared with preoperative level). RESULTS: There was no detectable difference in SSI between the topical antibiotic and control groups (13% vs. 10%, odds ratio (OR) 1.3, 95% confidence interval (CI) 0.6 to 2.9). Variables associated with SSI on multivariate analysis included open fracture (OR 3.2, CI 1.5 to 6.5) and an American Society of Anesthesiologists classification of >2 (OR 2.7, CI 1.3 to 5.3). There was no detectable difference in AKI between the topical antibiotic and control groups (1 (2%) vs. 7 (5%); OR 0.3, CI 0.04 to 3). CONCLUSION: There was no detectable difference, with wide confidence intervals, in SSI and AKI between the topical antibiotic and control groups. Further studies need to be conducted to evaluate the relationship between topical antibiotics and clinical outcomes in orthopaedic trauma surgery. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Initial management of humeral shaft fractures with functional splints versus coaptation splints.

PURPOSE: Humerus shaft fractures are commonly acutely immobilized with coaptation splints (CS), which can be difficult to apply and poorly tolerated by the patient. Functional splints (FS), which work on the same principle as functional braces, are an alternative to CS. The purpose of this study was to directly compare CS and FS in terms of application and fracture reduction. METHODS: A retrospective review identified humeral shaft fractures managed nonoperatively with initial immobilization in a FS (n = 19) versus a CS (n = 15). In addition, 13 residents completed a blinded survey on splint application. RESULTS: The FS and CS groups did not differ in initial fracture angulation and translation on anteroposterior (AP) and lateral radiographs. Post-splint application, there was no clinically relevant difference in fracture angulation/translation between groups, and this persisted at the subsequent follow-up visit. All residents reported that the FS was easier to apply and took less time. CONCLUSION: This study results demonstrated the FS results in similar reductions in humeral shaft fractures as CS. A survey of residents found that the FS was easier to apply, took less time, and was better tolerated by patients. Subsequently, we prefer the FS over the CS for the acute management of humeral shaft fractures.

The effect of surgical pain severity, preoperative opioid use and patient characteristics on postoperative opioid prescriptions and refills in orthopedic surgery.

BACKGROUND: Excessive opioid prescriptions after orthopedic surgery are common. The purpose of this study was to examine the association between surgical severity, preoperative opioid use and patient characteristics with postoperative opioid prescriptions and refills. METHODS: Seventy-nine patients undergoing orthopedic surgeries were reviewed. Surgical pain severity was categorized as mild (n = 25), moderate (n = 26) and severe (n = 28). Patients were also categorized as opioid naïve (n = 57), experienced (n = 16) and tolerant (n = 6). Postoperative and refill prescriptions were reviewed to determine morphine equivalent dose (MED) prescribed. RESULTS: Mild, moderate and severe pain surgeries received a median (interquartile range) equivalent of 20 (0, 30), 53 (33, 80) and 60 (45, 80) oxycodone 5 mg tablets, respectively. Excessive opioid prescriptions (> 400 MED) were given to 37 (46%) patients. There was no difference in the total discharge MED between moderate and severe pain surgeries or between opioid naïve and opioid-experienced patients (p > 0.05). Variables associated with excessive postoperative opioid prescriptions on multivariate analysis-included severe pain surgery (odds ratio 7.7, 95% confidence interval 2 to 25; p < 0.01) and anesthetic block (odds ratio 4.5, 95% confidence interval 1.4 to 14; p < 0.01). Variables associated with opioid refill on multivariate analysis included an American Society of Anesthiologists Physical Status (ASA) score > I (odds ratio 11, 95% confidence interval: 1.3 to 92; p < 0.01) and preoperative pain VAS (odds ratio 1.2, 95% confidence interval 1.01 to 1.4; p = 0.02). CONCLUSION: The adoption of opioid prescription guidelines is warranted to differentiate between surgical severities and decrease the range and size of postoperative opioid prescriptions.

Just add water? Chlorhexidine's antimicrobial properties are minimally affected by dilution in saline compared to water.

BACKGROUND: Dilute chlorhexidine gluconate (CHG) in sterile water is an antiseptic solution approved for intraoperative wound irrigation by the United States Food and Drug Administration. In practice, however, CHG is commonly diluted with normal saline, which can result in its precipitation potentially reducing the antimicrobial effect. The purpose of this study was to determine if the antimicrobial properties of CHG are reduced after dilution with normal saline compared to sterile water. MATERIALS AND METHODS: Sterile paper disks were placed into undiluted 4% CHG (positive control), 0.05% CHG in sterile water, 0.05% CHG in normal saline, or normal saline alone (negative control) and then placed in triplicate onto the agar plates inoculated with Staphylococcus aureus. After incubating at 37 °C for 24 h, the diameter of the zone of inhibition around each disk was measured. RESULTS: The mean zone of inhibition for 4% CHG, 0.05% CHG in sterile water, 0.05% CHG in normal saline, and normal saline alone was 24 ± 0.6 mm, 16 ± 0.9 mm, 14 ± 0.5 mm, and 0 ± 0 mm, respectively (p < 0.01). The zone of inhibition for dilute CHG in normal saline was on average 2.5 mm less (95% CI 1.7-3.2 mm) than that of CHG in sterile water. CONCLUSIONS: Dilute CHG in normal saline, versus sterile water, retained its antimicrobial activity with a small reduction in the zone of inhibition. Surgeons and scientists should be aware of the interaction between normal saline and CHG. Future scientific studies need to control for what solution is used for dilution.

Foot and Ankle Related Sex-Specific Analysis Within High-Impact Journals.

BACKGROUND: The impact of patient sex on the prevalence of foot and ankle injuries has been established. Reporting of differences on treatment outcomes is lacking. The purpose of this study was to identify trends in sex-specific outcomes across high-impact journals over a 5-year time period. METHODS: Two independent investigators reviewed journal issues published during 2 calendar years (2011 and 2016) in the 5 highest-impact orthopedic foot and ankle/sports subspecialty journals (Foot & Ankle International [FAI], Foot and Ankle Surgery [FAS], American Journal of Sports Medicine [AJSM], Arthroscopy, and Knee Surgery, Sports Traumatology, Arthroscopy [KSSTA]). Studies were stratified into those that involved sex-specific analysis (SSA), where sex was a variable in a multifactorial statistical model, and those that only reported sex as a demographic characteristic or utilized sex-matched cohorts. RESULTS: A total of 473 studies evaluating a total of 273 128 patients met criteria. An average of 43.9% (119 967 patients) of the population were female. Only 16.7% (79/473) of studies included sex as variable in a statistical model. Thirteen percent (25/193) and 19.3% (54/280) of studies reported SSA in 2011 and 2016, respectively. FAI was the only journal demonstrating a significant improvement of reporting SSA from 2011 to 2016 (P < .002). Thirty percent (24/79) of studies that performed SSA demonstrated significant differences between male and female outcomes. CONCLUSION: Reporting of SSA in the orthopedic literature continued to be lacking. Only 16.7% of all articles evaluated in 2011 and 2016 performed SSA, with 30% of this subset reporting a statistically significant difference in outcomes. LEVEL OF EVIDENCE: Level III, comparative study.

Screws are at a safe distance from critical structures after superior plate fixation of clavicle fractures.

INTRODUCTION: Injuries to the critical structures underlying the clavicle are possible during open reduction and internal fixation (ORIF) and afterward secondary to prominent screws. The purpose of this study was to identify patients who received chest computerized tomography (CT) scans after clavicle ORIF to evaluate the distance between the screws and the subclavian vessels. METHODS: A retrospective review was performed at a single level-one trauma center. Nineteen patients with chest CT scans after superior plate fixation were included. Coronal CT reconstructions were analyzed to determine distances between the subclavian vessels and screw tips along with the prominence of the screws. Vessels within 15 mm of the screw were considered at risk. RESULTS: None of the screws (0/142) were within 15 mm of the subclavian vessels. Average screw prominence was 1.3 ± 1 mm (range, 0-3.6 mm). One of the 19 patients had a complication, a re-fracture requiring revision ORIF. The remaining 18 patients had no complications, including neurovascular or pulmonary, at the last follow-up. CONCLUSIONS: None of the screws were excessively prominent or within 15 mm of the subclavian vessels. Attentive superior plate fixation of the clavicle with screws is a safe technique. LEVEL OF EVIDENCE: Level IV, case series.

Physical and mental health inequalities among aging lesbian, gay, and bisexual Canadians: cross-sectional results from the Canadian Longitudinal Study on Aging (CLSA).

OBJECTIVE: International estimates suggest the presence of health inequalities among older sexual minorities (i.e., individuals who identify as lesbian, gay, or bisexual and are 65 years old or above). In this study, we investigated the presence of health inequalities among aging lesbian and bisexual females, as well as aging gay and bisexual males in Canada. METHODS: We used baseline data from the Canadian Longitudinal Study on Aging (CLSA) Tracking and Comprehensive cohorts to cross-sectionally compare self-reported physical and mental health indicators by sex and sexual orientation. Within our analysis sample of 51,208 Canadians 45 years old and over, 2% (n = 1057) of respondents identified as lesbian, gay, or bisexual. RESULTS: Compared to heterosexual female peers, lesbian and bisexual females had greater odds of heavy drinking (AOR = 1.8, 95% CI = 1.3-2.4) and being a former smoker (AOR = 1.5, 95% CI = 1.2-1.9). Gay and bisexual males had greater odds of reporting a diagnosis of cancer (AOR = 1.5, 95% CI = 1.0-1.9) and currently smoking (AOR = 1.5, 95% CI = 1.1-2.0), compared to heterosexual males. Female and male sexual minorities had greater odds of reporting mood disorders (including depression) and anxiety disorders relative to heterosexual peers of the same sex. CONCLUSION: These findings highlight the importance of considering both sex and sexual orientation when developing approaches to support the physical and mental health of a diverse aging population in Canada.