Perioperative nutritional status thought to be important, but poorly understood.

OBJECTIVES: Malnutrition has been shown to increase complications and leads to poor outcomes in surgical patients, but it has not been studied extensively in orthopedic trauma. This study's purpose is to determine the perspective and assessment of nutrition by orthopedic traumatologists. METHODS: A survey was created and distributed via REDCap to orthopedic traumatologists at 60 U.S. trauma centers. Out of 183 distributed surveys, 130 surgeons completed the survey (71%). The survey focused on the importance of nutrition and practice patterns in orthopedic trauma. RESULTS: Seventy-five percent of surgeons thought that nutritional status was "very important" to the final outcome of patients with orthopedic trauma injuries, 24% responded "somewhat important" and 1% responded "not important." Furthermore, 88% perform nutritional assessments; most surgeons (77%) utilize nutritional laboratory markers, with the most common markers being albumin, pre-albumin, transferrin and CRP. Additionally, 42% think trending the laboratory markers is important, and 50% are not sure if nutrition markers should be tested at multiple time points. Despite 75% of surgeons believing that nutrition is very important, only 8% discuss it with patients routinely. When asked what is more important for outcomes, nutrition or Vitamin D, almost three times as many surgeons thought nutrition was more important (29% vs 11%, respectively). CONCLUSIONS: While orthopedic traumatologists believe nutrition is an important determinant of patient outcomes, this study shows a clear lack of consensus and variability in practice regarding nutrition among surgeons. Orthopedic trauma surgeons need specific guidelines on how to assess and treat malnutrition in trauma patients.

Effect of Aspirin Versus Low-Molecular-Weight Heparin Thromboprophylaxis on Medication Satisfaction and Out-of-Pocket Costs: A Secondary Analysis of a Randomized Clinical Trial.

BACKGROUND: Current guidelines recommend low-molecular-weight heparin for thromboprophylaxis after orthopaedic trauma. However, recent evidence suggests that aspirin is similar in efficacy and safety. To understand patients' experiences with these medications, we compared patients' satisfaction and out-of-pocket costs after thromboprophylaxis with aspirin versus low-molecular-weight heparin. METHODS: This study was a secondary analysis of the PREVENTion of CLots in Orthopaedic Trauma (PREVENT CLOT) trial, conducted at 21 trauma centers in the U.S. and Canada. We included adult patients with an operatively treated extremity fracture or a pelvic or acetabular fracture. Patients were randomly assigned to receive 30 mg of low-molecular-weight heparin (enoxaparin) twice daily or 81 mg of aspirin twice daily for thromboprophylaxis. The duration of the thromboprophylaxis, including post-discharge prescription, was based on hospital protocols. The study outcomes included patient satisfaction with and out-of-pocket costs for their thromboprophylactic medication measured on ordinal scales. RESULTS: The trial enrolled 12,211 patients (mean age and standard deviation [SD], 45 ± 18 years; 62% male), 9725 of whom completed the question regarding their satisfaction with the medication and 6723 of whom reported their out-of-pocket costs. The odds of greater satisfaction were 2.6 times higher for patients assigned to aspirin than those assigned to low-molecular-weight heparin (odds ratio [OR]: 2.59; 95% confidence interval [CI]: 2.39 to 2.80; p < 0.001). Overall, the odds of incurring any out-of-pocket costs for thromboprophylaxis medication were 51% higher for patients assigned to aspirin compared with low-molecular-weight heparin (OR: 1.51; 95% CI: 1.37 to 1.66; p < 0.001). However, patients assigned to aspirin had substantially lower odds of out-of-pocket costs of at least $25 (OR: 0.15; 95% CI: 0.12 to 0.18; p < 0.001). CONCLUSIONS: Use of aspirin substantially improved patients' satisfaction with their medication after orthopaedic trauma. While aspirin use increased the odds of incurring any out-of-pocket costs, it protected against costs of ≥$25, potentially improving health equity for thromboprophylaxis. LEVEL OF EVIDENCE: Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

Deep Surgical Site Infection after Fracture Has a Profound Effect on Functional Outcomes.

Background: Fracture-related infection is one of the most challenging complications in orthopaedic trauma surgery. However, the effect of infection on functional and pain-related outcomes has not been well established. The aims of this study were to evaluate functional recovery for patients with fracture and a deep surgical site infection compared with patients with fracture without infection and to evaluate whether pain severity, social support, and preinjury mental health have a moderating effect on the magnitude and direction of the relationship between deep surgical site infection and functional recovery. Methods: This is a secondary retrospective cohort study using prospectively collected data from the VANCO trial (Local Antibiotic Therapy to Reduce Infection After Operative Treatment of Fractures at High Risk of Infection) and the OXYGEN (Supplemental Perioperative Oxygen to Reduce Surgical Site Infection After High Energy Fracture Surgery) trial. In this study, 2,116 patients with tibial plateau, pilon, or calcaneal fractures at high risk for infection were included. Patients were divided into cohorts of patients who experienced a deep surgical site infection and those who did not. The primary outcome measure was the functional outcome using the Veterans RAND 12-Item Health Survey (VR-12). Results: After controlling for covariates, deep surgical site infection was independently associated with functional outcome, with a 3.3-point reduction in the VR-12 Physical Component Score, and pain severity was independently associated with functional outcome, with a 2.5-point reduction in the VR-12 Physical Component Score. Furthermore, the Brief Pain Inventory pain severity demonstrated an important moderating effect on the relationship between infection and functional outcome. In patients with lower pain scores, infection had a large negative impact on functional outcome, whereas, in patients with higher pain scores, infection had no significant impact on functional outcome. Furthermore, the functional outcome in the entire cohort remains at only 61% of baseline. Conclusions: This study documents the negative impact of postoperative infection on functional recovery after injury, as well as the novel finding of pain severity as an important moderating factor. This study emphasizes not only the importance of developing effective interventions designed to reduce postoperative infection, but also the role that factors that moderate pain severity plays in limiting recovery of physical function. Level of evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A technique for introducing broad-spectrum topical antibiotics during open reduction and internal fixation of acetabular fractures.

Postoperative surgical site infections remain a significant and prevalent complication after open reduction and internal fixation of acetabular fractures. Local antibiotics have been shown to decrease risk of postoperative infection, although recent evidence is conflicting. We provide a consistent and replicable technique for delivering intraoperative broad-spectrum antibiotics in the form of a putty applied directly to surgical implants. With this technique, systemic levels of those antibiotics remain safe and stable.

Risk-stratified thromboprophylaxis effects of aspirin versus low-molecular-weight heparin in orthopedic trauma patients: A secondary analysis of the PREVENT CLOT trial.

BACKGROUND: The PREVENT CLOT trial concluded that thromboprophylaxis with aspirin was noninferior to low-molecular-weight heparin (LMWH) in preventing death after orthopedic trauma. However, it was unclear if these results applied to patients at highest risk of thrombosis. Therefore, we assessed if the effect of aspirin versus LMWH differed based on patients' baseline risk of venous thromboembolism (VTE). METHODS: The PREVENT CLOT trial enrolled 12,211 adult patients with fractures. This secondary analysis stratified the study population into VTE risk quartiles: low (<1%) to high (>10%) using the Caprini score. We assessed stratum-specific treatment effects using the win ratio method, in which each patient assigned to aspirin was paired with each assigned to LMWH. In each pair, we compared outcomes hierarchically, starting with death, then pulmonary embolism, deep vein thrombosis, and bleeding. The secondary outcome added patients' medication satisfaction as a fifth composite component. RESULTS: In the high-risk quartile (n = 3052), 80% had femur fracture, pelvic, or acetabular fractures. Thoracic (47%) and head (37%) injuries were also common. In the low risk quartile (n = 3053), most patients had a tibia fracture (67%), 5% had a thoracic injury, and less than 1% had head or spinal injuries. Among high risk patients, thromboembolic events did not differ statistically between aspirin and LMWH (win ratio, 0.94; 95% confidence interval [CI], 0.82-1.08, p = 0.42). This result was consistent in the low (win ratio, 1.15; 95% CI, 0.90-1.47, p = 0.27), low-medium (win ratio, 1.05; 95% CI, 0.85-1.29, p = 0.68), and medium-high risk quartiles (win ratio, 0.94; 95% CI, 0.80-1.11, p = 0.48). When medication satisfaction was considered, favorable outcomes were 68% more likely with aspirin (win ratio, 1.68; 95% CI, 1.60-1.77; p < 0.001). CONCLUSION: Thromboembolic outcomes were similar with aspirin or LMWH, even among patients at highest risk of VTE. Aspirin was favored if medication satisfaction was also considered. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.

Underweight patients experience higher inpatient complication and mortality rates following acetabular fracture.

PURPOSE: Underweight patients experience poor outcomes after elective orthopaedic procedures. The effect of underweight body mass index (BMI) on complications after acetabular fracture is not well-described. We evaluate if underweight status is associated with inpatient complications after acetabular fractures. METHODS: Adult patients (≥ 18 years) presenting with acetabular fracture between 2015 and 2019 were identified from Trauma Quality Program data. Adjusted odds (aOR) of any inpatient complication or mortality were compared between patients with underweight BMI (< 18.5 kg/m2) and normal BMI (18.5-25 kg/m2) using multivariable logistic regression and stratifying by age ≥ 65 years. RESULTS: The 1299 underweight patients aged ≥ 65 years compared to 11,629 normal weight patients experienced a 1.2-times and 2.7-times greater aOR of any complication (38.6% vs. 36.6%, p = 0.010) and inpatient mortality (7.9% vs. 4.2%, p < 0.001), respectively. The 1688 underweight patients aged 18-64 years compared to 24,762 normal weight patients experienced a 1.2-times and 1.5-times greater aOR of any inpatient complication (38.9% vs. 34.8%, aOR p = 0.006) and inpatient mortality (4.1% vs. 2.5%, p < 0.001), respectively. CONCLUSION: Underweight adult patients with acetabular fracture are at increased risk for inpatient complications and mortality, particularly those ≥ 65 years old. LEVEL OF EVIDENCE: Prognostic Level III.

Obesity classification predicts early complications and mortality after acetabular fracture.

INTRODUCTION: Obesity remains a global epidemic. The effect of obesity on the risk of complications after acetabular fracture is unknown. Here, we evaluate the effect of BMI on early complications and mortality after acetabular fracture. We hypothesize that the risk of inpatient complications and mortality will be greater in patients with high BMI when compared to those with normal BMI. METHODS: Adult patients with acetabular fracture were identified via the Trauma Quality Improvement Program data from 2015 to 2019. The primary outcome was overall complication rate with reference to normal-weight patients (BMI = 25-30 kg/m2). The secondary outcome was rates of death. The association of obesity class on the primary and secondary outcomes was assessed using Bonferroni-corrected multiple logistic regression models considering patient, injury, and treatment covariates. RESULTS: A total of 99,721 patients with acetabular fracture were identified. Class I obesity (BMI = 30-35 kg/m2) was associated with 1.2 greater adjusted relative risk (aRR; 95% confidence interval (CI) 1.1-1.3) of any adverse event, without significant increases in adjusted risk of death. Class II obesity (BMI = 35-40 kg/m2) was associated with aRR = 1.2 (95% CI 1.1-1.3) of any adverse event and aRR = 1.5 (95% CI 1.2-2.0) of death. Class III obesity (BMI ≥ 40 kg/m2) was associated with aRR = 1.3 (95% CI 1.2-1.4) of any adverse event and aRR = 2.3 (95% CI 1.8-2.9) of death. CONCLUSION: Obesity is associated greater risk of adverse events and death following acetabular fracture. Obesity severity classification scales with these risks.

The EMS stress view: occult pelvic instability revealed by pre-hospital pelvic binder placement.

PURPOSE: To describe and evaluate the serendipitous pelvic binder stress radiographs of lateral compression type (LC) pelvic ring injuries. METHODS: This was a retrospective case series performed at a single, level I academic trauma center from 2016 to 2018. All patients presenting with a minimally displaced LC pelvic ring injury were reviewed (< 10 cm displacement on static pelvic radiographs). Patients with X-rays (XR) in a pelvic binder (EMS stress) and with the pelvic binder removed were included. Pelvic ring stability was determined by attending surgeon evaluation of EMS stress radiographs versus static XR of the pelvis. Patients were treated non-operatively and allowed to weight bear or taken to the operating room for exam under anesthesia (EUA) and potential operative fixation. Clinical success of treatment was determined by evaluation of further displacement at the completion of their most recent follow-up. RESULTS: Thirty-seven patients of the initial 398 reviewed met inclusion criteria. Fourteen of 37 patients (38%) were categorized as stable with no significant pelvis displacement seen on EMS stress and were treated non-operatively without further sequelae (4.6 months mean follow-up). The remaining 23/37 (62%) were treated operatively. Occult instability was identified on EMS stress in 14 (61%) of those 23 patients and the remainder were determined to be unstable based upon fracture pattern or EUA. All patients went on to successful treatment without significant pelvic deformity (7.8 months mean follow-up). CONCLUSION: The EMS stress XR is a valuable, opportunistic evaluation in LC pelvic ring injuries. This evaluation is a useful diagnostic adjunct to alert the provider that additional stress imaging may be indicated to evaluate for occult pelvic ring instability.

Immediate Fixation of Acetabular Fractures Through an Anterior Approach Does Not Increase Morbidity or Mortality.

INTRODUCTION: Acetabular fractures requiring an anterior approach have historically been delayed, allowing a stable clot to form before creating large surgical exposures. The purpose of this study was to determine whether immediate fixation of acetabular fractures within 24 hours using an anterior approach demonstrates notable difference in blood loss, length of stay (LOS), complications, or mortality compared with acetabular fractures treated after 24 hours. METHODS: Ninety-three patients were optimized for surgery within 24 hours of injury. Thirty-two patients underwent fixation within 24 hours using an anterior approach to the acetabulum. Demographics, hours from injury to operating room, fracture classification, embolization, surgical approach, intraoperative cell salvage use, Charlson Comorbidity Index, American Society of Anesthesiologists class, Injury Severity Score, and Abbreviated Chest Injury Score were recorded. Estimated blood loss, transfusions, intensive care unit stay, total hospital LOS, complications, and mortality rates were compared. RESULTS: No statistically significant differences were observed in fracture classification, blood loss, or intraoperative transfusions between the immediate and delayed fixation groups. Six patients in the delayed group (9.8%) returned to the operating room for a complication compared with one patient (3.1%) in the immediate group ( P = 0.42). Three patients in the delayed group (4.9%) developed a surgical site infection compared with none (0%) in the immediate group ( P = 0.55). The immediate group had an average LOS of 7 days compared with 11 days in the delayed fixation group ( P = 0.01). No notable differences were observed in 30- or 90-day mortality rates. DISCUSSION: Medically optimized patients with acetabular fractures who undergo immediate fixation through an anterior approach do not seem to have an associated increase in blood loss, transfusions, or mortality. Prompt surgical management may also be associated with a shorter preoperative and postoperative LOS. LEVEL OF EVIDENCE: Therapeutic level III.

Aspirin or Low-Molecular-Weight Heparin for Thromboprophylaxis after a Fracture.

BACKGROUND: Clinical guidelines recommend low-molecular-weight heparin for thromboprophylaxis in patients with fractures, but trials of its effectiveness as compared with aspirin are lacking. METHODS: In this pragmatic, multicenter, randomized, noninferiority trial, we enrolled patients 18 years of age or older who had a fracture of an extremity (anywhere from hip to midfoot or shoulder to wrist) that had been treated operatively or who had any pelvic or acetabular fracture. Patients were randomly assigned to receive low-molecular-weight heparin (enoxaparin) at a dose of 30 mg twice daily or aspirin at a dose of 81 mg twice daily while they were in the hospital. After hospital discharge, the patients continued to receive thromboprophylaxis according to the clinical protocols of each hospital. The primary outcome was death from any cause at 90 days. Secondary outcomes were nonfatal pulmonary embolism, deep-vein thrombosis, and bleeding complications. RESULTS: A total of 12,211 patients were randomly assigned to receive aspirin (6101 patients) or low-molecular-weight heparin (6110 patients). Patients had a mean (±SD) age of 44.6±17.8 years, 0.7% had a history of venous thromboembolism, and 2.5% had a history of cancer. Patients received a mean of 8.8±10.6 in-hospital thromboprophylaxis doses and were prescribed a median 21-day supply of thromboprophylaxis at discharge. Death occurred in 47 patients (0.78%) in the aspirin group and in 45 patients (0.73%) in the low-molecular-weight-heparin group (difference, 0.05 percentage points; 96.2% confidence interval, -0.27 to 0.38; P<0.001 for a noninferiority margin of 0.75 percentage points). Deep-vein thrombosis occurred in 2.51% of patients in the aspirin group and 1.71% in the low-molecular-weight-heparin group (difference, 0.80 percentage points; 95% CI, 0.28 to 1.31). The incidence of pulmonary embolism (1.49% in each group), bleeding complications, and other serious adverse events were similar in the two groups. CONCLUSIONS: In patients with extremity fractures that had been treated operatively or with any pelvic or acetabular fracture, thromboprophylaxis with aspirin was noninferior to low-molecular-weight heparin in preventing death and was associated with low incidences of deep-vein thrombosis and pulmonary embolism and low 90-day mortality. (Funded by the Patient-Centered Outcomes Research Institute; PREVENT CLOT ClinicalTrials.gov number, NCT02984384.).

Do superficial infections increase the risk of deep infections in tibial plateau and plafond fractures?

PURPOSE: Open reduction internal fixation of tibial plateau and pilon fractures may be complicated by deep surgical site infection requiring operative debridement and antibiotic therapy. The management of superficial surgical site infection is controversial. We sought to determine whether superficial infection is associated with an increased risk of deep infection requiring surgical debridement after fixation of tibial plateau and pilon fractures. METHODS: This is a secondary analysis of data from the VANCO trial, which included 980 adult patients with a tibial plateau or pilon fracture at elevated risk of infection who underwent open reduction internal fixation with plates and screws with or without intrawound vancomycin powder. An association of superficial surgical site infection with deep surgical site infection requiring debridement surgery and antibiotics was explored after matching on risk factors for deep surgical site infection. RESULTS: Of the 980 patients, we observed 30 superficial infections (3.1%) and 76 deep infections (7.8%). Among patients who developed a superficial infection, the unadjusted incidence of developing a deep infection within 90 days was 12.8% (95% confidence interval [CI] 1.3-24.2%). However, after a 3:1 match on infection risk factors, the 90-day marginal probability of a deep surgical site infection after sustaining a superficial infection was 6.0% (95% CI - 6.5-18.5%, p = 0.35). CONCLUSION: Deep infection after superficial infection is uncommon following operative fixation of tibial plateau and pilon fractures. Increased risk of subsequent deep infection attributable to superficial infection was inconclusive in these data. LEVEL OF EVIDENCE: Prognostic Level II.

Early hip survival after open reduction internal fixation of acetabular fracture.

PURPOSE: To estimate survival of acetabular fracture repair by tracking patients across healthcare encounters. We hypothesized that hip survival estimated this way would be lower than reported by single-surgeon or single-center series not capturing censored reoperations. METHODS: Retrospective health insurance administrative database cohort study. All claimed healthcare encounters for employer-sponsored health insurance beneficiaries aged 18-65 years without pre-existing hip pathology with a newly diagnosed acetabular fracture were identified between October 1, 2015, through December 31, 2018. The intervention was open reduction internal fixation of acetabular fracture during index admission. The primary outcome was survival of the acetabular fracture repair to subsequent reoperation by arthroscopy, arthrotomy for drainage of infection, implant removal, revision acetabular fixation, hip arthroplasty, hip resection, or arthrodesis. RESULTS: 38 reoperation procedures on the fractured acetabulum in 852 patients occurred within 2 years (incidence 4.5%). Total hip arthroplasty (2.5%) and revision internal fixation (1.5%) accounted for most early reoperations. Multivariable Cox regression identified an association between reoperation and increasing patient age (hazard ratio = 1.4 per decade, p < 0.01). The prevalence of any mental health condition was 29%. CONCLUSIONS: Non-elderly adults with employer-sponsored insurance who sustain acetabular fractures have a greater burden of mental health disease than similarly insured patients without these injuries. Survival of the native acetabulum after fracture fixation exceeded 95% at 2 years and decreased with increasing patient age. LEVEL OF EVIDENCE: Level III, Prognostic Study.

Prospective Study Investigating the Prevalence and Evolution of Malnourishment in the Acute Orthopaedic Trauma Patient.

Background: Orthopaedic trauma surgeons believe that nutritional status is important. The primary aim of this study was to prospectively investigate the prevalence and progression of malnourishment in orthopaedic trauma patients and determine when and what labs should be ordered. The secondary aim was to determine if malnourished patients had increased complications. Methods: Prospective cohort study of orthopaedic trauma patients at a Level I trauma center. Assessment of nutritional status over the hospital course was performed using the Rainey MacDonald nutritional index (RMNI) and nutritional laboratory markers on admission, day 3, day 7, and 6 weeks post-op. Results: 98 patients were enrolled and included. On admission, 60%, 41%, and 38% of patients were malnourished based on albumin, prealbumin, and RMNI values, respectively, with 31% in severe acute-phase response (APR) as determined by CRP. By day 3, a significant increase in the percent of malnourished patients was noted based on the laboratory markers, 85%, 90%, and 80%, respectively, with 70% in severe APR. On day 7, values stabilized at 74%, 89%, 69%, with 56% in severe APR. At six weeks, malnourishment persisted in 13%, 19%, and 12% of patients, with 4% in severe APR. Older patients demonstrated a greater depression of nutritional markers throughout the hospital stay. Conclusion: The prevalence of malnourishment, based on serum nutritional markers, in the presence of acute orthopaedic injury is substantial, and it continues to rise during the acute hospital stay. Recommend obtaining prealbumin or albumin levels on hospital day 3 to assess nutritional status.

Novel Technique for Percutaneous Reduction of Displaced LCII Pelvic Ring Injury: A Case Report.

CASE: We present a case report of an elderly patient with a displaced lateral compression type II pelvic ring injury and describe a novel technique for maintaining a percutaneously obtained reduction during percutaneous fixation using a supra-acetabular Schantz pin attached to a mechanical limb positioner. CONCLUSION: The mechanical limb positioner used allows the surgeon to hold a multidirectionally obtained reduction of the hemipelvis with ease.

The 1-Year Economic Impact of Work Productivity Loss Following Severe Lower Extremity Trauma.

BACKGROUND: Severe lower extremity trauma among working-age adults is highly consequential for returning to work; however, the economic impact attributed to injury has not been fully quantified. The purpose of this study was to examine work and productivity loss during the year following lower extremity trauma and to calculate the economic losses associated with lost employment, lost work time (absenteeism), and productivity loss while at work (presenteeism). METHODS: This is an analysis of data collected prospectively across 3 multicenter studies of lower extremity trauma outcomes in the United States. Data were used to construct a Markov model that accumulated hours lost over time due to lost employment, absenteeism, and presenteeism among patients from 18 to 64 years old who were working prior to their injury. Average U.S. wages were used to calculate economic loss overall and by sociodemographic and injury subgroups. RESULTS: Of 857 patients working prior to injury, 47.2% had returned to work at 1 year. The average number of productive hours of work lost was 1,758.8/person, representing 84.6% of expected annual productive hours. Of the hours lost, 1,542.3 (87.7%) were due to working no hours or lost employment, 71.1 (4.0%) were due to missed hours after having returned, and 145.4 (8.3%) were due to decreased productivity while working. The 1-year economic loss due to injury totaled $64,427/patient (95% confidence interval [CI], $63,183 to $65,680). Of the 1,758.8 lost hours, approximately 88% were due to not being employed (working zero hours), 4% were due to absenteeism, and 8% were due to presenteeism. Total productivity loss was higher among older adults (≥40 years), men, those with a physically demanding job, and the most severe injuries (i.e., those leading to amputation as well as Gustilo type-IIIB tibial fractures and type-III pilon/ankle fractures). CONCLUSIONS: Patients with severe lower extremity trauma carry a substantial economic burden. The costs of lost productivity should be considered when evaluating outcomes.

Open Ankle Fractures: What Predicts Infection? A Multicenter Study.

OBJECTIVE: To identify the patient, injury, and treatment factors associated with an acute infection during the treatment of open ankle fractures in a large multicenter retrospective review. To evaluate the effect of infectious complications on the rates of nonunion, malunion, and loss of reduction. DESIGN: Multicenter retrospective review. SETTING: Sixteen trauma centers. PATIENTS: One thousand and 3 consecutive skeletally mature patients (514 men and 489 women) with open ankle fractures. MAIN OUTCOME MEASURES: Fracture-related infection (FRI) in open ankle fractures. RESULTS: The charts of 1003 consecutive patients were reviewed, and 712 patients (357 women and 355 men) had at least 12 weeks of clinical follow-up. Their average age was 50 years (range 16-96), and average BMI was 31; they sustained OTA/AO types 44A (12%), 44B (58%), and 44C (30%) open ankle fractures. The rate FRI rate was 15%. A multivariable regression analysis identified male sex, diabetes, smoking, immunosuppressant use, time to wound closure, and wound location as independent risk factors for infection. There were 77 cases of malunion, nonunion, loss of reduction, and/or implant failure; FRI was associated with higher rates of these complications (P = 0.01). CONCLUSIONS: Several patient, injury, and surgical factors were associated with FRI in the treatment of open ankle fractures. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Utility and Associated Charge of Anteroposterior Radiographs in Rotational Ankle Fractures During Postoperative Follow-Up: The Results of an Orthopaedic Trauma Association Survey.

OBJECTIVES: To evaluate the perceived utility and associated charges of the anteroposterior (AP) radiograph during rotational ankle fracture postoperative follow-up. DESIGN: Survey study with charge analysis using published data at 50 orthopaedic hospitals in the United States. SETTING: Not Applicable. PARTICIPANTS: Orthopaedic Trauma Association Members with an active email address who were invited and interested in answering a survey. RESULTS: Ninety-four percent of respondents stated that they did routinely obtain an AP radiograph during rotational ankle fracture follow-up. However, 57% thought that the AP view should be eliminated from standard follow-up and only 51% found this view useful after initial treatment. CHARGE ANALYSIS: The mean difference between a 2-view and 3-view ankle radiograph series was $102.00. Using this value and the assumption that each patient with a rotational ankle fracture gets 3 follow-up radiographs, there is the potential for a charge reduction of $306 per patient. Assuming over 134,000 rotational ankle fractures, a charge reduction of 41 million US dollars (USD) per year is possible if the AP image is routinely removed. Actual savings are likely to be less based on agreed on payer rates. Although less easy to quantify, there is also a potential reduction of radiation exposure, radiologists' interpretation time, and data storage. CONCLUSIONS: Routine AP radiographs should potentially be eliminated from routine postoperative ankle x-ray protocols based on this survey of experienced orthopaedic surgeons. If this specific radiograph is ordered on a case-by-case basis, then significant savings may occur.

The effect of proximal tibiofibular joint dislocation on knee mechanics: reduction and fixation matters.

PURPOSE: Proximal tibiofibular joint (PTFJ) dislocations are under-investigated injuries. There is scant basic science or clinical evidence to direct management. The purpose of this study was twofold; first to investigate the pathomechanics of PTFJ dislocation on knee mechanics. The second purpose was to evaluate knee mechanics following reduction and fixation. METHODS: Six cadaveric legs were tested on a mechanical platform. A 5 Nm external rotation force was applied to each knee and the external rotation and fibular translation was measured for several study conditions at 0°, 30°, and 90° of flexion. Conditions included: the native state, transection of the posterior PTFJ ligament, transection of the anterior and posterior ligaments, screw fixation, and suspensory fixation. Screw fixation was performed using a single quadricortical 3.5 mm screw. Suspensory fixation was performed using an Arthrex TightRope device RESULTS: Transection of the anterior and posterior ligaments increased external rotation by 4.3°, 5.9°, and 5.6°, at 0°, 30°, and 90° (p ≤ 0.001), respectively. Screw and suspensory fixation returned external rotation to a near native state with mild overconstraint. Complete transection of anterior and posterior ligaments resulted in pathologic anterior fibular translation of 1.51 mm (p = 0.001), 1 mm, (p = 0.02) and 0.44 mm (p = 0.69) for 0°, 30°, 90° of knee flexion. Screw and suspensory fixation restored native translation at all points with a small degree of overconstraint. CONCLUSION: Disruption of the PTFJ causes pathologic external rotation and anterior fibular translation. Fixation restores near native motion with minor overconstraint. Surgeons should consider reduction and fixation of PTFJ injuries to restore native knee mechanics.

Reduction and fixation of high-energy proximal tibiofibular joint dislocations: a technical trick.

We present our technique for screw stabilization and our clinical experience treating a series of patients presenting with proximal tibiofibular joint fracture-dislocations.

Long-term sequelae of septic arthritis after tibial plateau fracture fixation: does timing matter?

INTRODUCTION: Septic arthritis following surgical treatment of a tibial plateau fracture is a rare complication, but it does occur, and the impact on long-term function is relatively unknown. The purpose of this study was to determine the long-term sequelae of septic arthritis among patients treated with internal fixation for a tibial plateau fracture and to determine the effect of timing (early or late infection) on the rate of such sequela. MATERIALS AND METHODS: A retrospective comparative study was designed using the trauma database of a single level I academic trauma center. Patients who developed culture-positive septic knee arthritis after internal fixation of a tibial plateau fracture, with 1-year follow-up, were included in the study. The number of debridement procedures required was recorded. Rates of long-term complications and implant removal were identified. Complications rates were compared between patients who developed early (within 30 days of definitive fixation) and late (more than 30 days) septic arthritis. RESULTS: The mean number of debridement procedures per patient was six. Fourteen patients (88%) required implant removal, and thirteen (81%) developed knee arthritis. There was a significantly lower rate of complications in the early septic arthritis group compared to the late group (3 of 6 patients or 50%, vs 10 of 10 patients or 100%; p = 0.036). CONCLUSIONS: Patients who developed septic arthritis following internal fixation of a tibial plateau fracture were likely to endure long-term sequelae. Early infection and detection led to fewer complications. Surgeons treating infectious complications in tibial plateau fracture patients should specifically seek to rule out septic arthritis, anticipate that implant removal may be necessary, and counsel these patients appropriately regarding the anticipated natural history of their condition. LEVEL OF EVIDENCE: III.