Perioperative allogenic blood transfusions are associated with increased fracture related infection rates, but not nonunion in operatively treated distal femur fractures.

INTRODUCTION: Distal femur fractures are common injuries that remain difficult for orthopedic surgeons to treat. High complication rates, including nonunion rates as high as 24% and infection rates of 8%, can lead to increased morbidity for these patients. Allogenic blood transfusions have previously been identified as risk factors for infection in total joint arthroplasty and spinal fusion surgeries. No studies have explored the relationship between blood transfusions and fracture related infection (FRI) or nonunion in distal femur fractures. METHODS: 418 patients with operatively treated distal femur fractures at two level I trauma centers were retrospectively reviewed. Patient demographics were collected including age, gender, BMI, medical comorbidities, and smoking. Injury and treatment information was also collected including open fracture, polytrauma status, implant, perioperative transfusions, FRI, and nonunion. Patients with less than three months of follow up were excluded. RESULTS: 366 patients were included in final analysis. One hundred thirty-nine (38%) patients received a perioperative blood transfusion. Forty-seven (13%) nonunions and 30 (8%) FRI were identified. Allogenic blood transfusion was not associated with nonunion (13% vs 12%, P = 0.87), but was associated with FRI (15% vs 4%, P<0.001). Binary logistic regression analysis identified a dose dependent relationship between number of perioperative blood transfusions and FRI: total transfusion ≥2 U PRBC RR= 3.47(1.29, 8.10, P = 0.02), ≥3 RR= 6.99 (3.01, 12.40, P<0.001), and ≥4 RR= 8.94 (4.03, 14.42, P<0.001). DISCUSSION: In patients undergoing operative treatment of distal femur fractures, perioperative blood transfusions are associated with increased risk of fracture related infection, but not the development of a nonunion. This risk association increases in a dose-dependent relationship with increasing total blood transfusions received.

External fixator pin placement during initial management of tibial plateau fractures: are there parameters to minimize pin-plate overlap?

PURPOSE: External fixator pin site overlap with definitive fixation implants (pin-plate overlap) has been identified as a risk factor for surgical site infection in tibial plateau fractures. Despite this, pin-plate overlap occurs in 24-38% of patients. This study sought to identify radiographic characteristics associated with pin-plate overlap to help minimize occurrences. METHODS: 283 patients at two Level I trauma centers were retrospectively reviewed. Radiographic measurements were recorded including fracture length, distance from fracture to proximal tibial pin site, and pin site distance-to-fracture (PSF) ratio. RESULTS: 70 (24.7%) cases of pin-plate overlap were identified. Pin-plate overlap was associated with increased fracture length (81.5 ± 32.1 mm vs 56.9 ± 26.1 mm, p < 0.001) and decreased distance from fracture to proximal tibial pin site (84.5 ± 37.1 mm vs 126.9 ± 35.8 mm). Pins placed greater than 100 mm and 150 mm from the fracture eliminated 36/70 (51%) and 67/70 (96%) pin-plate overlaps, respectively. Pins placed with a PSF ratio greater than 1.5 and 2.0 eliminated 47/70 (67%), and 57/70 (81%) of pin-plate overlaps, respectively. CONCLUSIONS: Longer fractures, pins closer to the fracture, and decreased PSF ratio were associated with overlap. Placing proximal tibial pins more than 100 mm from the fracture eliminated most pin-plate overlaps.

Purposeful Closed Reduction and Pinning in Unstable Slipped Capital Femoral Epiphysis Results in a Rate of Avascular Necrosis Comparable to the Literature Mean.

The standard treatment of stable slipped capital femoral epiphysis (SCFE) is generally accepted to be in situ pinning. Controversy exists regarding the treatment of unstable SCFE, including the role of a purposeful closed reduction or open reduction. The objective of this study was to investigate the rate of avascular necrosis (AVN) with purposeful closed reduction and in situ pinning of unstable SCFE. The authors retrospectively reviewed 221 patients with 302 SCFE hips treated with in situ pinning between 2000 and 2014. Forty-eight patients (50 hips) presented with an unstable SCFE. All unstable SCFEs were treated by a gentle reduction method with traction and hip internal rotation followed by pinning. Southwick angles were measured prior to reduction and at the first postoperative visit. No stable SCFEs developed AVN. Thirteen (26%) unstable SCFEs developed AVN. Avascular necrosis developed in 7 of 17 (41%) hips screened with magnetic resonance imaging vs 6 of 33 (18%) hips screened with plain radiographs alone. Mean change in Southwick angle was 28°±8° in the AVN group vs 18°±18° in the no AVN group (P=.18). Despite potentially inflating the rate with the use of early detection magnetic resonance imaging, the authors found an AVN rate comparable to that in the published literature with the use of gentle purposeful reduction on a fracture table, and no statistical differences in reduction amount between patients with and without AVN. Gentle purposeful reduction appears to be a reasonable low morbidity option in the treatment of unstable SCFE without a clear increase in risk of AVN. [Orthopedics. 2021;44(2):92-97.].

Posterolateral plating is a safe alternative for the treatment of distal tibial fractures.

INTRODUCTION: We assessed the outcome and safety of posterior plating of distal tibial fractures. METHODS: We conducted a retrospective case series at a Level I trauma center. Seventy-four consecutive patients with distal tibial fractures treated with anatomically contoured 3.5-mm T-shaped locking compression plate using a posterolateral approach from January 2008 through April 2018 were included in the study. The mean patient age was 48 years (range, 18-87 years). Fifty-nine percent of the patients were male patients, 47% of the fractures were open fractures; and 27% of the patients had multiple traumatic injuries. Eleven fractures were AO/OTA type 42, 22 were type 43A, and 41 were type 43C. Sixty-two (84%) patients were treated with initial spanning external fixation (median time, 23 days) and staged open reduction and internal fixation. The main outcome measure was unplanned reoperation to address implant failure, nonunion, deep surgical site infection, or symptomatic implant. RESULTS: Overall risk of unplanned reoperation was 15% (11 of 74 patients, 95% confidence interval, 9%-25%). Four (5%) reoperations were for nonunion, three (4%) were for surgical site infection, two (3%) were for infected nonunion, and two (3%) were for implant prominence. Loss of alignment >10 degrees occurred in one patient who underwent unplanned reoperation for nonunion. No plate breakage occurred. Median time to reoperation was 221 days (range, 22-436 days). Only one other complication was noted: wound dehiscence associated with the posterolateral approach, which was treated with irrigation and débridement and a 6-week regimen of oral antibiotics. CONCLUSIONS: Use of a posterolateral approach with a pre-contoured locking compression T-plate for the treatment of distal tibial fractures led to reasonable outcomes with an acceptable risk of unplanned reoperation, even with a high proportion of open fractures commonly staged with external fixation.

Percutaneous Plate Osteosynthesis of Ulnar Shaft Fractures: A Surgical Technique and Case Series.

Treatment of ulnar diaphyseal fractures can range broadly from nonoperative with immobilization to surgical intervention with a variety of implants or approaches. At a Level 1 trauma center, a series of ulnar shaft fractures have been treated using a percutaneous plating technique that is base beneath the extensor carpi ulnaris. This technique description illustrates relevant anatomy, important patient and injury characteristics, implant considerations, and potential outcomes and complications. The described treatment option provides an effective way of spanning comminuted fracture patterns without disrupting the surrounding biology while providing stable fixation. An associated patient series is included which enumerates associated injuries and describes limited follow-up. In the multiply injured trauma patient, such a fixation method also had potential benefits for their overall care and rehabilitation.

Results and Outcomes After Midshaft Clavicle Fracture: Matched Pair Analysis of Operative Versus Nonoperative Management.

This study evaluated patients with displaced clavicle fractures treated surgically vs nonoperatively. The authors hypothesized that functional outcomes would be no different. A retrospective comparative study was performed of 138 patients with closed midshaft clavicle fractures. Sixty-nine patients were treated operatively and matched for sex, age, and fracture pattern to 69 patients treated nonoperatively. Charts and radiographs were reviewed, and the American Shoulder and Elbow Surgeons survey was administered. A poor outcome was defined as a treatment complication or an American Shoulder and Elbow Surgeons score less than 60. There were 116 men and 22 women with a mean age of 37.7 years and fracture patterns of 15B-1 (n=78), 15B-2 (n=48), and 15B-3 (n=12). Thirty-seven percent were tobacco smokers, with 23 treated operatively and 28 nonoperatively. Ten (14.5%) initially nonoperative patients underwent plate fixation at a mean of 25.9 weeks (range, 7-48 weeks) because of persistent pain and motion at the fracture site. Fifteen (21.7%) of the 69 patients treated acutely with surgery had 16 complications, which resulted in secondary procedures in 11 patients (15.9%). Overall, poor outcomes occurred in 21 (30.4%) of 69 after fixation and in 19 (27.5%) of 69 in the nonoperative group. Unemployment (P=.05) and tobacco use (P=.03) were associated with poor outcome, irrespective of type of treatment. Initial nonoperative treatment presents a reasonable option for many patients. No differences in complications or poor outcomes were noted for surgical vs nonoperative treatment. Social factors proved to be greater predictors of outcome than other patient or injury features. Management of clavicle fractures should be individualized with assessment of patient expectations and activity level. Social factors should also be considered. [Orthopedics. 2018; 41(5):e689-e694.].

Early MRI Detection and Closed Bone Graft Epiphysiodesis May Alter the Course of Avascular Necrosis Following Unstable Slipped Capital Femoral Epiphysis.

BACKGROUND: Unstable slipped capital femoral epiphysis (SCFE) has an increased incidence of avascular necrosis (AVN). Early identification and surgical intervention for AVN may help preserve the femoral head. METHODS: We retrospectively reviewed 48 patients (50 hips) with unstable SCFE managed between 2000 and 2014. AVN was diagnosed based on 2 different postoperative protocols. Seventeen patients (17 hips) had a scheduled magnetic resonance imaging (MRI) between 1 and 6 months from initial surgery, and the remaining 31 patients (33 hips) were evaluated by plain radiographs alone. If AVN was diagnosed, we offered core decompression and closed bone graft epiphysiodesis (CBGE) to mitigate its affects. At final follow-up, we assessed progression of AVN using the Steinberg classification. RESULTS: Overall 13 hips (26%) with unstable SCFEs developed AVN. MRI revealed AVN in 7 of 17 hips (41%) at a mean of 2.5 months postoperatively (range, 1.0 to 5.2 mo). Six hips diagnosed by MRI received surgical intervention (4 CBGE, 1 free vascularized fibula graft, and 1 repinning due to screw cutout) at a mean of 4.1 months (range, 1.3 to 7.2 mo) postoperatively. None of the 4 patients treated with CBGE within 2 months postoperatively progressed to stage IVC AVN. The 2 patients treated after 4 months postoperatively both progressed to stage VC AVN.Plain radiographs demonstrated AVN in 6 of 33 hips (18%) at a mean of 6.8 months postoperatively (range, 2.1 to 21.1 mo). One patient diagnosed with stage IVB AVN at 2.4 months had screw cutout and received CBGE at 2.5 months from initial pinning. The remaining 5 were not offered surgical intervention. Five of the 6 radiographically diagnosed AVN, including the 1 treated with CBGE, progressed to stage IVC AVN or greater. CONCLUSIONS: Although all patients with positive MRI scans developed radiographic AVN, none of the 4 patients treated with CBGE within 2 months after pinning developed grade IVC or greater AVN. Early MRI detection and CBGE may mitigate the effects of AVN after SCFE. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Hexapod Stacked Transport for Tibial Infected Nonunions With Bone Loss: Long-Term Functional Outcomes.

OBJECTIVES: To analyze long-term functional outcomes in patients with posttraumatic infected tibial nonunions having undergone bone transport with hexapod external fixator. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Thirty-eight patients with infected nonunions of the tibia. INTERVENTION: Resection of nonunion with application of stacked hexapod external fixator for bone transport. MAIN OUTCOME MEASUREMENTS: Functional outcome was measured using the short Musculoskeletal Functional Assessment (sMFA). Parameters measured included age, sex, presence of diabetes, smoking, use of a free flap, bone defect size, length in frame, external fixation index, and direction of lengthening. RESULTS: The mean sMFA score for the entire group was 27.1. Average patient age was 46.8 ± 12.7 years, 74% patients were male, 8% were diabetic, and 29% were smokers. Seventeen patients had soft-tissue defects that required a free flap. Smokers had higher degrees of disability compared with nonsmokers (39 ± 16 vs. 22 ± 14, P = 0.011). Patients requiring adjunctive stabilization had worse functional scores compared with those who did not receive adjunctive stabilization (33 ± 17 vs. 22 ± 15, P = 0.049). Sixteen patients returned 2 sMFA surveys at different time points after completion of bone transport. Initial average sMFA score was 26.5 at a mean of 25.3 months; subsequent sMFA scores averaged 19.4 at a mean of 98.8 months. CONCLUSIONS: Stacked hexapod external fixator bone transport is a reliable technique for infected nonunion of the tibia with bone loss. Improved sMFA scores can be expected from 2 to 8 years, suggesting full recovery takes longer than previously anticipated. Limb salvage with hexapod bone transport is justified over time. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Hexapod Frame Stacked Transport for Tibial Infected Nonunions With Bone Loss: Analysis of Use of Adjunctive Stability.

OBJECTIVES: The stacked hexapod bone transport technique is an effective treatment for infected tibial nonunions with bone loss. The purpose of this study was to evaluate the patients' risk factors and timing for requiring adjunctive stabilization. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Seventy-five patients with infected posttraumatic nonunions of the tibia. INTERVENTION: Resection of nonunion with application of stacked hexapod frame for bone transport. MAIN OUTCOME MEASUREMENTS: Parameters measured included age, sex, diabetes, smoking, use of a free flap, bone defect size, length in frame, external fixation index, and direction of lengthening. Outcomes recorded: removal of frame, below knee amputation, or adjunctive stability. Further analysis evaluated location of nonunion, timing of adjunctive stabilization, and type of fixation. RESULTS: The average patient age was 45.7 ± 12.5 years, 76% patients were men, 11% were diabetic, and 44% were smokers. Forty two percent had soft tissue defects that required a free flap. Thirty-eight patients had removal of frame, whereas 36 patients required adjunctive stability of the hexapod frame. Patient receiving adjunctive stabilization had a longer length of time in the hexapod frame (P = 0.026) and were more likely to require a free flap (P = 0.053). Ninety-three percent docking site nonunions occurred after the removal of the frame (P = 0.032); whereas 79% regenerate nonunions occurred before the hexapod frame was removed (P = 0.029). CONCLUSIONS: The use of a hexapod frame for the infected tibial nonunions with bone loss is an effective method for achieving union and eradicating infection in a difficult orthopaedic patient population. Use of adjunctive stabilization is a reasonable technique to address delayed regenerate and docking site nonunions. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Factors Affecting Functional Outcomes After Clavicle Fracture.

INTRODUCTION: This study evaluated the effects that patient demographics, injury, and social characteristics have on functional outcomes after clavicle fracture. METHODS: After a mean follow-up of 56 months, 214 patients with a mean age of 44.4 years completed the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form. The effects that age, sex, fracture location, open fracture, associated injuries, tobacco use, employment status, and timing of surgery had on functional outcomes were assessed. RESULTS: The mean ASES score for the entire group of 214 patients was 80.5. Seventy-seven patients (36%) were treated surgically and 137 patients (64%) were treated nonsurgically. The mean ASES scores were 84.0 and 78.5, respectively, in the surgical and nonsurgical groups (P = 0.06). Patients with lateral fractures who were treated surgically had better ASES scores than those treated nonsurgically (91.3 versus 72.7, P = 0.011); this was also true of patients with isolated fractures (P = 0.02). Smokers in the surgical and nonsurgical groups had scores of 74.1 and 83.6, respectively (P = 0.003). Patients who were unemployed had the worst ASES scores regardless of surgical or nonsurgical treatment (70.5 and 86.1, respectively; P < 0.001). Surgical timing was not related to outcome; no difference in ASES scores was noted in patients treated surgically within ≤10 weeks versus those treated after 10 weeks after injury and in those treated within <20 weeks versus those treated >20 weeks after injury (both, P > 0.34). DISCUSSION: We identified factors associated with better functional outcomes, which could aid in developing treatment recommendations. Additionally, initial nonsurgical management of clavicle fractures may be reasonable because patients had similar functional outcomes even when surgery was delayed. LEVEL OF EVIDENCE: Level III retrospective comparative study.

Factors Associated With Narcotic Use After Clavicle Fractures.

Clavicle fractures are common in adults. Recent studies have shown that operative treatment of clavicle fractures has benefits in many situations. However, there is controversy about the indications. Data on social outcomes are limited. A total of 434 patients with 436 clavicle fractures treated both operatively and nonoperatively at a level 1 trauma center were identified. Narcotic use was recorded 2, 4, 6, 8, 10, 12, 14, and 16 weeks after injury for both treatment groups. Other descriptive data included age, sex, laterality, hand dominance, rib fractures, smoking, alcohol use, employment, long bone or spine fracture, open clavicle fracture, and mechanism of injury. Logistic regression analysis was performed to determine the independent predictors of narcotic use after clavicle fracture. Open reduction and internal fixation was performed in 105 fractures (24%), and 329 fractures were managed nonoperatively. A total of 154 patients (35%) reported some narcotic use 2 weeks after injury, and 15% were still using narcotics 16 weeks after injury. Narcotic use decreased over time in patients treated with open reduction and internal fixation (10% vs 15% after nonoperative management). Patients treated with open reduction and internal fixation reported reduced narcotic use at 16 weeks (odds ratio [OR], 0.454; P=.070). Concurrent rib fracture (OR, 5.668; P<.001), smoking (OR, 3.095; P=.013), unemployment (OR, 5.429; P<.0005), and long bone or spine fracture (OR, 6.761; P<.001) were predictors of narcotic use. Further studies of the social, economic, and financial outcomes of clavicle fracture and osteosynthesis are warranted. [Orthopedics. 2016; 39(5):e917-e923.].

Can Vascular Injury be Appropriately Assessed With Physical Examination After Knee Dislocation?

BACKGROUND: Knee dislocations are rare injuries with potentially devastating vascular complications. An expeditious and accurate diagnosis is necessary, as failing to diagnose vascular injury can result in amputation; however, the best diagnostic approach remains controversial. QUESTIONS/PURPOSES: We asked: (1) What patient factors are predictors of vascular injury after knee dislocation? (2) What are the diagnostic utilities of palpable dorsalis pedis or posterior tibial pulses, and the presence of an ankle-brachial index (ABI) of 0.9 or greater? METHODS: A database at a Level I trauma center was queried for patients with evidence of knee dislocation, demographic information (age at the time of injury, sex, Injury Severity Score, BMI, mechanism of injury), and the presence of open injury were recorded. One-hundred forty-one patients underwent screening at initial presentation, of whom 26 (24%) underwent early vascular exploration based on an abnormal physical examination. One-hundred five (91%) of the remaining 115 patients were available at a minimum followup of 6 months (mean, 19 ± 10 months). In total, 31 unique patients were excluded, including 10 patients (7%) who were lost to followup before 6 months. Among the 110 patients who met inclusion criteria, the mean age and SD was 37 ± 13 years, and the Injury Severity Score was 15 ± 9. There were 71 males (65%). Logistic regression was used to determine independent correlates of vascular injury. The vascular examination was reviewed for the presence of a palpable pulse in the dorsalis pedis artery, the presence of a palpable pulse in the posterior tibial artery, and whether the ABI in the dorsalis pedis was 0.9 or greater. Contingency tables were generated to assess the sensitivity, specificity, and accuracy of physical examination maneuvers. The physical examination was collectively regarded as "normal" when both pulses were palpable and the ABI was 0.9 or greater. The initial physical examination as just described was considered the diagnostic test being evaluated in this study; "positive" tests were evaluated by and confirmed at vascular surgery, and 6 months clinical followup without symptoms or progressive signs of vascular injury confirmed the absence of injury in the remainder of the patients. Contingency tables were generated again to assess the sensitivity, specificity, and accuracy of the combined physical examination. RESULTS: Increased BMI (odds ratio [OR], 1.077; 95% CI, 1.008-1.155; p = 0.033) and open injuries (OR, 3.366; 95% CI, 1.008-11.420; p = 0.048) were associated with vascular injury. No single physical examination maneuver had a 100% sensitivity for ruling out vascular injury. A normal physical examination (palpable pulses and ABI ≥ 0.9) had 100% sensitivity for ruling out vascular injury. CONCLUSIONS: Increased BMI and the presence of open dislocation are associated with a greater risk for vascular injury after knee dislocation. The combination of a palpable dorsalis pedis and posterior tibial pulse combined with an ABI of 0.9 or greater was 100% sensitive for the detection of vascular injury based on clinical followup at 6 months. LEVEL OF EVIDENCE: Level III, diagnostic study.

High-dose isoflavones do not improve metabolic and inflammatory parameters in androgen-deprived men with prostate cancer.

The profound hypogonadism that occurs with androgen deprivation therapy (ADT) for prostate cancer (PCa) results in complications such as diabetes and metabolic syndrome that predispose to cardiovascular disease. Because phytoestrogens have been associated with an improvement in metabolic parameters, we evaluated their role in men undergoing ADT. Our objective was to evaluate the effects of high-dose isoflavones on metabolic and inflammatory parameters in men undergoing ADT. This was a randomized, double-blind, placebo-controlled, 12-week pilot study. Participants were randomly assigned to receive 20 g of soy protein containing 160 mg of total isoflavones vs taste-matched placebo (20 g whole milk protein). The study was conducted at a tertiary care center in the United States. Thirty-three men (isoflavones = 17, placebo = 16) undergoing ADT for PCa completed this pilot study. Mean age in the 2 groups was 69 years and the majority of men were Caucasians. Mean duration of ADT in both groups was approximately 2 years (P = .70). The 2 groups were well matched at baseline. After 12 weeks of intervention, there was no significant difference in either metabolic or inflammatory parameters between the 2 groups. We found that high-dose isoflavones over a course of 12 weeks do not improve metabolic or inflammatory parameters in androgen-deprived men.

Vasoactive intestinal peptide-null mice demonstrate enhanced sweet taste preference, dysglycemia, and reduced taste bud leptin receptor expression.

OBJECTIVE: It is becoming apparent that there is a strong link between taste perception and energy homeostasis. Recent evidence implicates gut-related hormones in taste perception, including glucagon-like peptide 1 and vasoactive intestinal peptide (VIP). We used VIP knockout mice to investigate VIP's specific role in taste perception and connection to energy regulation. RESEARCH DESIGN AND METHODS: Body weight, food intake, and plasma levels of multiple energy-regulating hormones were measured and pancreatic morphology was determined. In addition, the immunocytochemical profile of taste cells and gustatory behavior were examined in wild-type and VIP knockout mice. RESULTS: VIP knockout mice demonstrate elevated plasma glucose, insulin, and leptin levels, with no islet beta-cell number/topography alteration. VIP and its receptors (VPAC1, VPAC2) were identified in type II taste cells of the taste bud, and VIP knockout mice exhibit enhanced taste preference to sweet tastants. VIP knockout mouse taste cells show a significant decrease in leptin receptor expression and elevated expression of glucagon-like peptide 1, which may explain sweet taste preference of VIP knockout mice. CONCLUSIONS: This study suggests that the tongue can play a direct role in modulating energy intake to correct peripheral glycemic imbalances. In this way, we could view the tongue as a sensory mechanism that is bidirectionally regulated and thus forms a bridge between available foodstuffs and the intricate hormonal balance in the animal itself.