Use of single agent Cefotetan for Gustilo-Anderson type III open fracture prophylaxis.

INTRODUCTION: The prophylactic intravenous antibiotic regimen for Gustilo-Anderson Type III open fractures traditionally consists of cefazolin with an aminoglycoside plus penicillin for gross contamination. Cefotetan, a second-generation cephalosporin, offers a wide spectrum of activity against both aerobes and anaerobes as well as against Gram-positive and Gram-negative bacteria. Cefotetan has not been previously established within orthopedic surgery as a prophylactic intravenous agent. PATIENTS AND METHODS: Cefotetan monotherapeutic prophylaxis versus any other antibiotic regimen (standard/literature-supported and otherwise) was studied for patient encounters between September 2010 and December 2019 within a single Level 1 regional trauma center. Patient comorbidities, preoperative fracture characteristics, and in-hospital/operative metrics (including length of stay [LOS], number of antibiotic doses, and antibiotic costs [US$]) were included for analysis. Postoperative outcomes up to 1 year included rates of surgical site infection (SSI), deep infection necessitating return to the operating room (OR), non-union, prescribed outpatient antibiotics, hospital readmissions, and related returns to the emergency department (ED). Sensitivity analyses were also conducted to include standard/literature-supported antibiotic regimens as a nested random factor within the non-cefotetan cohort. RESULTS: The nested variable accounting for standard/literature-supported antibiotic regimens had no significant effect in any model for any outcome (for each, P ≥ 0.302). Thus, 1-year data for 138 Type III open fractures were included, accounting for only the binary effect of cefotetan (n = 42) versus non-cefotetan cohorts. The cohorts did not differ significantly at baseline. The cefotetan cohort received fewer in-house dose/day antibiotics (P < 0.001), was less likely to receive outpatient antibiotics in the following year (P = 0.023), had decreased return to the OR (35.7% versus 54.2%, P = 0.045), and demonstrated non-union rates of 16.7% versus 28.1% (P = 0.151). When adjusted for length of stay (LOS), the dose/day total costs for antibiotics were $8.71/day more expensive for the cefotetan cohort (P = 0.002). Type III open fractures incurred overall rates of SSI reaching 16.7% in the cefotetan cohort and 14.7% for non-cefotetan (P = 0.773). Deep infections necessitating return to the OR were 9.5% and 11.6%, respectively (P = 0.719). CONCLUSION: Cefotetan alone may provide superior antibiotic stewardship with similar infectious sequalae compared to more traditional antibiotic prophylaxis regimens for Gustilo-Anderson Type III open long bone fractures. LEVEL OF EVIDENCE: Level III Retrospective Cohort Study.

Knowledge of radiation exposure associated with common trauma imaging modalities among orthopaedic surgeons, emergency medicine physicians, and general surgeons in the United States.

BACKGROUND: Few contemporary studies have assessed physicians' knowledge of radiation exposure associated with common imaging studies, especially in trauma care. The purpose of this study was to assess the knowledge of physicians involved in caring for trauma patients regarding the effective radiation doses of musculoskeletal (MSK) imaging studies routinely utilized in the trauma setting. METHODS: An electronic survey was distributed to United States orthopaedic surgery, general surgery, and emergency medicine (EM) residency programs. Participants were asked to estimate the radiation dose for common imaging modalities of the pelvis, lumbar spine, and lower extremity, in terms of chest X-ray (CXR) equivalents. Physician estimates were compared to the true effective radiation doses. Additionally, participants were asked to report the frequency of discussing radiation risk with patients. RESULTS: A total of 218 physicians completed the survey; 102 (46.8%) were EM physicians, 88 (40.4%) were orthopaedic surgeons, and 28 (12.8%) were general surgeons. Physicians underestimated the effective radiation doses of nearly all imaging modalities, most notably for pelvic computed tomaography (CT) (median 50 CXR estimation vs. 162 CXR actual) and lumbar CT (median 50 CXR estimation vs. 638 CXR actual). There was no difference between physician specialties regarding estimation accuracy (P=0.133). Physicians who regularly discussed radiation risks with patients more accurately estimated radiation exposure (P=0.007). CONCLUSION: The knowledge among orthopaedic and general surgeons and EM physicians regarding the radiation exposure associated with common MSK trauma imaging is lacking. Further investigation with larger scale studies is warranted, and additional education in this area may improve care.

The Role of Far Cortical Endosteal Fixation for the Treatment of Medial Malleolus Fractures: A Biomechanical Study.

The traditional method for fixation of medial malleolus fractures has been with partially threaded (PT) lag screws extending beyond the physeal scar. The purpose of this study was to evaluate the biomechanical strength of an innovative method of fixation for medial malleolus fractures using a fully threaded (FT) lag screw that extends to the far endosteal cortex. Medial malleolus fractures were simulated in 12 matched cadaver pairs. A single PT 4.0-mm cancellous lag screw was placed in 1 ankle. The contralateral ankle of the same matched pair received an FT 3.5-mm cortical lag screw that extended to the far lateral tibial cortex and achieved endosteal purchase. Final torque of both screw configurations was recorded, and radiographs were taken to confirm appropriate screw placement. Average torque for the PT cancellous screws was 5.02 ± 2.34 in-lb. Average torque for the FT cortical screw was 7.63 ± 3.86 in-lb (p = .002). Visual and radiographic inspections revealed no displacement of the fracture site with use of the FT endosteal lag screw. Our results indicate superior biomechanical torque with far endosteal fixation with use of an FT cortical lag screw versus a traditional PT cancellous lag screw in a cadaver model. Far endosteal fixation is an alternative surgical option for medial malleolus fractures that provides added strength compared with PT lag screws and may obviate downsides associated with bicortical fixation.

Gun barrel view of the anterior pelvic ring for percutaneous anterior column or superior pubic ramus screw placement.

BACKGROUND: Traditionally, operative fixation of pelvic and acetabular injuries involves complex approaches and significant complications. Accelerated rehabilitation, decreased soft tissue stripping and decreased wound complications are several benefits driving a recent interest in percutaneous fixation. We describe a new fluoroscopic view to guide the placement of screws within the anterior pelvic ring. METHODS: Twenty retrograde anterior pelvic ring screws were percutaneously placed in ten cadaveric specimens. Arranging a standard C-arm in a position similar to obtaining a lateral hip image, with angles of 54° ± 2° beam to body, 75° ± 5° of reverse cantilever and 14° ± 6° of outlet, a gun barrel view of the anterior pelvic ring is identified. Fluoroscopic images were taken, and the hemipelvi were harvested to examine the dimensions of the anterior pelvic ring and inspected for any cortical or articular perforation. RESULTS: The minimum cranial-to-caudal distance in the anterior pelvic ring was 9 mm (range 6.5-12 mm), and the minimum anterior-to-posterior dimension was 9 mm (range 5-15 mm). All but 2 screws were completely confined within the osseous corridors. Identifiable on final fluoroscopic evaluation, one screw perforated the psoas groove and a second perforated the acetabular dome. Overall, 90 % of our screws were accurately and safely placed, upon the first attempt, within the anterior pelvic ring using the described gun barrel view. CONCLUSION: Employing either open reduction, or following a closed or percutaneous reduction, the anterior pelvic ring gun barrel view can reproducibly guide safe placement of anterior pelvic ring screw fixation. LEVEL OF EVIDENCE: IV.

Epidemiology of Fracture Nonunion in 18 Human Bones.

Importance: Failure of bone fracture healing occurs in 5% to 10% of all patients. Nonunion risk is associated with the severity of injury and with the surgical treatment technique, yet progression to nonunion is not fully explained by these risk factors. Objective: To test a hypothesis that fracture characteristics and patient-related risk factors assessable by the clinician at patient presentation can indicate the probability of fracture nonunion. Design, Setting, and Participants: An inception cohort study in a large payer database of patients with fracture in the United States was conducted using patient-level health claims for medical and drug expenses compiled for approximately 90.1 million patients in calendar year 2011. The final database collated demographic descriptors, treatment procedures as per Current Procedural Terminology codes; comorbidities as per International Classification of Diseases, Ninth Revision codes; and drug prescriptions as per National Drug Code Directory codes. Logistic regression was used to calculate odds ratios (ORs) for variables associated with nonunion. Data analysis was performed from January 1, 2011, to December 31, 2012. Exposures: Continuous enrollment in the database was required for 12 months after fracture to allow sufficient time to capture a nonunion diagnosis. Results: The final analysis of 309 330 fractures in 18 bones included 178 952 women (57.9%); mean (SD) age was 44.48 (13.68) years. The nonunion rate was 4.9%. Elevated nonunion risk was associated with severe fracture (eg, open fracture, multiple fractures), high body mass index, smoking, and alcoholism. Women experienced more fractures, but men were more prone to nonunion. The nonunion rate also varied with fracture location: scaphoid, tibia plus fibula, and femur were most likely to be nonunion. The ORs for nonunion fractures were significantly increased for risk factors, including number of fractures (OR, 2.65; 95% CI, 2.34-2.99), use of nonsteroidal anti-inflammatory drugs plus opioids (OR, 1.84; 95% CI, 1.73-1.95), operative treatment (OR, 1.78; 95% CI, 1.69-1.86), open fracture (OR, 1.66; 95% CI, 1.55-1.77), anticoagulant use (OR, 1.58; 95% CI, 1.51-1.66), osteoarthritis with rheumatoid arthritis (OR, 1.58; 95% CI, 1.38-1.82), anticonvulsant use with benzodiazepines (OR, 1.49; 95% CI, 1.36-1.62), opioid use (OR, 1.43; 95% CI, 1.34-1.52), diabetes (OR, 1.40; 95% CI, 1.21-1.61), high-energy injury (OR, 1.38; 95% CI, 1.27-1.49), anticonvulsant use (OR, 1.37; 95% CI, 1.31-1.43), osteoporosis (OR, 1.24; 95% CI, 1.14-1.34), male gender (OR, 1.21; 95% CI, 1.16-1.25), insulin use (OR, 1.21; 95% CI, 1.10-1.31), smoking (OR, 1.20; 95% CI, 1.14-1.26), benzodiazepine use (OR, 1.20; 95% CI, 1.10-1.31), obesity (OR, 1.19; 95% CI, 1.12-1.25), antibiotic use (OR, 1.17; 95% CI, 1.13-1.21), osteoporosis medication use (OR, 1.17; 95% CI, 1.08-1.26), vitamin D deficiency (OR, 1.14; 95% CI, 1.05-1.22), diuretic use (OR, 1.13; 95% CI, 1.07-1.18), and renal insufficiency (OR, 1.11; 95% CI, 1.04-1.17) (multivariate P < .001 for all). Conclusions and Relevance: The probability of fracture nonunion can be based on patient-specific risk factors at presentation. Risk of nonunion is a function of fracture severity, fracture location, disease comorbidity, and medication use.

Timing of C-arm drape contamination.

BACKGROUND: Surgical site infection remains a concern in orthopedic surgery, and contamination of C-arm covers is a potentially modifiable risk factor. METHODS: A single-cohort study was conducted using 30 consecutive patients undergoing operative fracture fixation. Cultures were obtained from the C-arm cover after initial draping and every 20 min thereafter. The total number of persons in the operating room (person-hours/h of study time) and the number of door openings were recorded. The C-arm position changes and the time to contamination were monitored. RESULTS: The median time from the start of the operation to contamination was 20 min. There was a 17% contamination rate on initial draping, 50% at 20 min, 57% at 40 min, and 80% by 80 min. The C-arms in five cases were not contaminated during the surgery. Time to contamination correlated significantly with lateral position changes (correlation [r]=0.64; p=0.003) but was not related to C-arm position changes (r=0.22; p=0.34), number of door openings (r=0.20; p=0.39), or person-hours/h (r=0.04; p=0.85). CONCLUSIONS: Contamination of the C-arm drape occurs often and early during surgery for orthopedic fractures. We recommend minimal contact with the C-arm to avoid contamination of the surgical field.

Biomechanical comparison of a proximal humeral locking plate using two methods of head fixation.

HYPOTHESIS: Locking plates have emerged as the implant of choice for stabilization of proximal humeral fractures. The biomechanical properties of a locked plating system using smooth pegs vs threaded screws for fixation of the humeral head were compared to test the hypothesis that there would be no biomechanical difference between pegs and threaded screws. MATERIALS AND METHODS: Sixteen pairs of fresh frozen cadaveric humeri were randomized to have a surgical neck gap osteotomy stabilized with a locked plate using threaded screws (n=8) or smooth pegs (n=8). The intact contralateral humerus served as a control. Each specimen was tested with simultaneous cyclic axial compression (40 Nm) and torsion (both +/-2 Nm and +/-5 Nm) for 6000 cycles. All specimens were loaded to failure. Interfragmentary motion and load-displacement curves were analyzed to identify differences between the groups. Our data were then compared to previously published forces across the glenohumeral joint to provide evidence based recommendations for postoperative use of the shoulder. RESULTS: There was a statistically significant difference between test specimens and their paired control (P < .001) in cyclic testing and load to failure. Differences between the smooth pegs and threaded screws were not statistically significant. DISCUSSION: There is no biomechanical difference between locked smooth pegs and locked threaded screws for proximal fragment fixation in an unstable 2-part proximal humeral fracture model. CONCLUSION: Our study contributes to the published evidence evaluating forces across the glenohumeral joint and suggests that early use of the affected extremity for simple activities of daily living may be safe. Use of the arm for assisted ambulation requiring a crutch, cane, walker, or wheelchair should be determined on a case-by-case basis.

Bladder incarceration following anterior external fixation of a traumatic pubic symphysis diastasis treated with immediate open reduction and internal fixation.

Anterior pelvic ring disruptions are often associated with injuries to the genitourinary structures with the potential for considerable resultant morbidity. Herniation of the bladder into the symphyseal region after injury with subsequent entrapment upon reduction of the symphyseal diastasis has seldom been reported in the literature. We report such a case involving bladder herniation and subsequent entrapment after attempted closed reduction with anterior pelvic external fixation immediately treated with open reduction and internal fixation along with a review of the literature.

Time-dependent contamination of opened sterile operating-room trays.

BACKGROUND: There are no clear guidelines for how long a sterile operating-room tray can be exposed to the open environment before the contamination risk becomes unacceptable. The purpose of this study was to determine the time until first contamination and the rate of time-dependent contamination of sterile trays that had been opened in a controlled operating-room environment. We also examined the effect of operating-room traffic on the contamination rate. METHODS: Forty-five sterile trays were opened in a positive-air-flow operating room. The trays were randomly assigned to three groups. All trays were opened with use of sterile technique and were exposed for four hours. Culture specimens were obtained immediately after opening and every thirty minutes thereafter during the study period. Group 1 consisted of fifteen trays that were opened and left uncovered in a locked operating room (i.e., one with no traffic). Group 2 was identical to Group 1 with the addition of single-person traffic flowing in and out of the operating room from a nonsterile corridor every ten minutes. Group 3 included fifteen trays that were opened, immediately covered with a sterile surgical towel, and then left uncovered in a locked operating room (i.e., one with no traffic). RESULTS: Three of the thirty uncovered trays (one left in the operating room with traffic and two left in the room with no traffic) were found to be contaminated immediately after opening. After those three trays were eliminated, the contamination rates recorded for the twenty-seven uncovered trays were 4% (one tray) at thirty minutes, 15% (four) at one hour, 22% (six) at two hours, 26% (seven) at three hours, and 30% (eight) at four hours. There was no difference in survival time (p = 0.47) or contamination rate (p = 0.69) between the uncovered trays in the room with traffic and those in the room without traffic. The covered trays were not contaminated during the testing period. The survival time for those trays was significantly longer (p = 0.03) and the contamination rate was significantly lower (p = 0.02) than those for the uncovered trays. CONCLUSIONS: Culture positivity correlated directly with the duration of open exposure of the uncovered operating-room trays. Light traffic in the operating room appeared to have no impact on the contamination risk. Coverage of surgical trays with a sterile towel significantly reduced the contamination risk.

Safe zone for anterior cortical perforation of the ulna during tension-band wire fixation: a magnetic resonance imaging analysis.

Placing K-wires obliquely through the anterior ulnar cortex is a common modification of traditional olecranon tension-band wiring. Wire tip protrusion, however, risks injury to adjacent neurovascular structures and may impede forearm rotation. This study examines the proximity of neurovascular structures to the anterior proximal ulnar cortex. The anatomy of 47 adult elbows was examined through magnetic resonance imaging. A radiologist measured the spatial relationship of 6 neurovascular structures to a mid-sagittal reference point 1.5 cm distal to the coronoid on the anterior surface of the ulna. Distance and angular measurements were made in the transverse plane of the reference point. Within a reasonable arc of K-wire placement, the ulnar artery and median nerve were at greatest risk yet were still beyond 10 mm from the anterior ulnar cortex. To avoid iatrogenic neurovascular injury during tension-band wiring of the olecranon, protrusion of wire tips beyond the anterior ulnar cortex should be no more than 1 cm at a distance of 1.5 cm distal to the coronoid.

Diagnosis and management of extremity compartment syndromes: an orthopaedic perspective.

More than 200,000 people in the United States are diagnosed annually with compartment syndrome. This condition is commonly established based on clinical parameters. Determining its presence, however, can be challenging in obtunded patients or those with an altered mental status. A delay in diagnosis and treatment of these injuries can result in significant morbidity. Surgical release of the enveloping fascia remains the acceptable standard treatment for compartment syndrome. This article reviews the evaluation and treatment of compartment syndrome.

Does open reduction increase the chance of infection during intramedullary nailing of closed tibial shaft fractures?

OBJECTIVE: To evaluate whether an open technique used to obtain reduction during intramedullary nailing of closed tibial shaft fractures increases the risk of infection, compared to closed reduction and nailing. SETTING: University level 1 trauma center. DESIGN: Retrospective database analysis. PATIENTS/PARTICIPANTS: One hundred seventeen patients with 119 fractures from our trauma database who had sufficient follow-up and met study criteria. The patients were grouped by open versus closed reduction. Only OTA fracture types 42 A to C were included in this study. INTERVENTION: Locked reamed intramedullary nailing for closed tibial shaft fractures accomplished through either open or closed reduction. MAIN OUTCOME MEASUREMENT: The presence or absence of infection as determined by the clinical presentation (erythema, warmth, purulent drainage, fevers, chills, increased pain at the fracture site), indicative laboratory work (complete blood count, erythrocyte sedimentation rate, C-reactive protein), and/or positive culture. RESULTS: There were 85 males and 32 females. The average age was 35.7 years; the average follow-up was 14.3 months. Of the 119 fractures, 79 had closed reduction whereas 40 had open reduction. The open reductions consisted of 13 with a formal incision (>1 cm in length), 22 with percutaneous incisions, and 5 with fasciotomies. There were no infections in the closed reduction group and 2 infections (5%) in the open reduction group. This difference was not statistically significant (P=0.1). The average time to union was 7.0 months in closed reductions and 7.3 months in open reductions. By latest follow-up, 107 fractures had reached union (89.9%), 1 had not (0.8%), and 11 were lost to final follow-up (9.2%). CONCLUSIONS: Limited open techniques can greatly facilitate the reduction of closed tibial shaft fractures but raise concern for infection through exposure of the fracture site. This study found that the rate of infection for open versus closed reductions was higher but not statistically different. Judicious use of open reduction techniques during intramedullary nailing of closed tibia fractures seems to have a minimal risk of infection.

Baseline compartment pressure measurements in isolated lower extremity fractures without clinical compartment syndrome.

BACKGROUND: The diagnosis of compartment syndrome is most commonly made by clinical examination. Direct compartmental measurements generally serve an adjunctive role in establishing the diagnosis, except when patients have an alteration in mental status. There is little known on what are the expected baseline elevations in compartments after the simple occurrence of a fracture when clinical compartment syndrome does not exist. Knowledge of such measurements might influence the utility of pressure measurements in diagnosing compartment syndrome. METHODS: A prospective analysis of compartment measurements was performed in 19 isolated lower extremity fractures with the opposite leg as the control. The patients had no clinical evidence of compartment syndrome, had no alteration in mental status, and underwent planned surgical treatment within 48 hours of injury. RESULTS: Average compartment measurements were 35.5 +/- 13.6 mm Hg (range 10 to 62 mm Hg) in the injured leg versus 16.6 +/- 7.5 mm Hg (range 3 to 40 mm Hg) in the control leg (p = 0.0001). Eighteen patients (95%) had at least one compartment measurement that exceeded a single threshold of 30 mm Hg and 12 patients (63%) exceeded a threshold of 45 mm Hg. Eleven patients (58%) had at least one compartment reading within 20 mm Hg of their diastolic pressure and 16 patients (84%) had one within 30 mm Hg of their diastolic pressure. Ten patients (53%) had a reading within 40 mm Hg of their mean arterial pressure (delta P) and eight patients (42%) had a reading within 30 mm Hg of the mean arterial pressure. No patient developed sequelae or required surgery related to an unrecognized compartment syndrome during a minimum 1-year follow-up. CONCLUSIONS: Based on our data, use of direct compartment measurements with existing thresholds and formulations to determine the diagnosis of compartment syndrome may not accurately reflect a true existence of the syndrome. A search for other quantitative measures to more accurately reflect the presence of compartment syndrome is warranted.