Does the type of lower extremity fracture affect long-term opioid usage? A meta-analysis.

INTRODUCTION:  Patients recovering from musculoskeletal trauma have a heightened risk of opioid dependence and misuse, as these medications are typically required for pain management. The purpose of this meta-analysis was to examine the association between fracture type and chronic opioid use following fracture fixation in patients who sustain lower extremity trauma. MATERIALS AND METHODS: A meta-analysis was performed using PubMed and Web of Science to identify articles reporting chronic opioid use in patients recovering from surgery for lower extremity fractures. 732 articles were identified using keyword and MeSH search functions, and 9 met selection criteria. Studies were included in the final analysis if they reported the number of patients who remained on opioids 6 months after surgery for a specific lower extremity fracture (chronic usage). Logistic regressions and descriptive analyses were performed to determine the rate of chronic opioid use within each fracture type and if age, year, country of origin of study, or pre-admission opioid use influenced chronic opioid use following surgery. RESULTS: Bicondylar and unicondylar tibial-plateau fractures had the largest percentage of patients that become chronic opioid users (29.7-35.2%), followed by hip (27.8%), ankle (19.7%), femoral-shaft (18.5%), pilon (17.2%), tibial-shaft (13.8%), and simple ankle fractures (2.8-4.7%).Most opioid-naive samples had significantly lower rates of chronic opioid use after surgery (2-9%, 95% CI) when compared to samples that allowed pre-admission opioid use (13-50%, 95% CI). There were no significant associations between post-operative chronic opioid use and age, year, or country of origin of study. CONCLUSIONS:  Patients with lower extremity fractures have substantial risk of becoming chronic opioid users. Even the lowest rates of chronic opioid use identified in this meta-analysis are higher than those in the general population. It is important that orthopedic surgeons tailor pain-management protocols to decrease opioid usage after lower extremity trauma.

Double microvascular free flap reconstruction for bilateral lower extremity injury in a paediatric patient.

Many challenges have been described by microsurgeons in paediatric free flaps. With the advancement in microsurgical expertise, it is now possible to achieve excellent results. We present a case of a female child with car-tyre friction injury of bilateral feet with associated extradural haemorrhage who underwent emergency bilateral anterolateral thigh flap. A secondary tendon reconstruction of the left foot was performed at 6 months. No complications were observed in the postoperative period after both procedures and good functional recovery was achieved at 1 year follow-up. The problems unique to this case were the presence of head injury and bilateral extremity injury in the paediatric patient. The technical details of planning, execution, difficulties and recommendations to minimise the risk in such cases are discussed. To the best of our knowledge, this is the only case report of bilateral lower limb paediatric emergency free flap with associated head injury.

The impact of fasciotomy on inpatient outcomes in lower leg fracture management.

BACKGROUND: While lower extremity fractures are common injuries, concomitant compartment syndrome can lead to significant implications and surgical release (fasciotomy) is essential. The aim of this study was to identify potential predictors of compartment release and risk factors related to complications. Using a large nationwide cohort, this study compared patients suffering from lower extremity fractures with and without compartment syndrome during their primary in-hospital stay following trauma. METHODS: A retrospective analysis was conducted using the prospective surgical registry of the working group for quality assurance in surgery in Switzerland, which collects data from nearly 85% of all institutions involved in trauma surgery. Inclusion criteria Patients who underwent surgical treatment for tibia and/or fibula fractures between January 2012 and December 2022 were included in the study. Statistics Statistical analysis was performed using Chi-square, Fisher's exact test, and t test. Furthermore, a regression analysis was conducted to determine the independent risk factors for fasciotomy and related complications. In the present study, a p value less than 0.001 was determined to indicate statistical significance due to the large sample size. RESULTS: The total number of cases analyzed was 1784, of which 98 underwent fasciotomies and 1686 did not undergo the procedure. Patients with fasciotomies were identified as significantly younger (39 vs. 43 years old) and mostly male (85% vs. 64%), with a significantly higher American Society of Anesthesiologists (ASA) score (ASA III 10% vs. 6%) and significantly more comorbidities (30% vs. 20%). These patients had significantly longer duration of surgeries (136 vs. 102 min). Furthermore, the total number of surgical interventions, the rate of antibiotic treatment, and related complications were significantly higher in the fasciotomy group. Sex, age, comorbidities, and fracture type (both bones fractured) were identified as relevant predictors for fasciotomy, while ASA class was the only predictor for in-hospital complications. Outcomes Patients who underwent fasciotomy had a significantly longer hospital stay (18 vs. 9 days) and a higher complication rate (42% vs. 6%) compared to those without fasciotomy. While fasciotomy may have played a role, other factors such as variations in patient characteristics and injury mechanisms may also contribute. Additionally, in-house mortality was found to be 0.17%, with no patient death recorded for the fasciotomy group. CONCLUSIONS: Fasciotomy is vital. The knowledge about the further course is, however, helpful in resource allocation. We found significant differences between patients with and without fasciotomy in terms of age, sex, complication rate, length of stay, comorbidities, duration of operations, and use of antibiotics during their primary in-hospital stay. While the severity of the underlying trauma could not be modulated, awareness of the most relevant predictors for fasciotomy and related complications might help mitigate severe consequences and avoid adverse outcomes.

The association of pre-existing mental health conditions and patient outcomes after lower extremity orthopaedic trauma: a scoping review.

INTRODUCTION: Existing research has established a correlation between post-traumatic mental health conditions, including anxiety and depression, and various aspects of recovery, such as pain exacerbations, reduced functional recovery, and lowered patient satisfaction. However, the influence of pre-existing mental health conditions on orthopaedic trauma outcomes has not been thoroughly investigated. The objective of this study was to systematically review literature addressing the association between pre-existing mental health conditions and patient outcomes following surgical interventions for lower extremity fractures in non-geriatric populations. METHODS: A systematic literature review was conducted using Medline, Embase, and Scopus databases following PRISMA-ScR guidelines to select studies that examined lower extremity orthopaedic trauma outcomes in relation to pre-existing mental health conditions. Studies that evaluated patients with surgically treated lower extremity fractures and a history of mental health conditions such as anxiety, depression, or mood disorders were included. Studies with a mean patient age above 65 years of age were excluded to focus on non-geriatric injury patterns. RESULTS: The systematic review identified 12 studies investigating the relationship between surgical outcomes of orthopaedic lower extremity fractures and pre-existing mental health disorders in non-geriatric populations. Studies included patients with pelvis, femur, tibia, and ankle fractures. A majority (83%) of these studies demonstrated that patients with pre-existing mental health diagnoses had inferior functional outcomes, heightened pain levels, or an increase in postoperative complications. DISCUSSION: The presence of pre-existing mental health conditions, particularly anxiety and depression, may predispose orthopaedic trauma patients to an elevated risk of suboptimal functional outcomes, increased pain, or complications after surgical intervention for lower extremity fractures. Future research should focus on interventions that mitigate the impact of mental health conditions on orthopaedic outcomes and patient wellness in this population.

Risk assessment in delayed free flap reconstruction for severe lower extremity trauma.

PURPOSE: This study aims to identify serum biomarkers that contribute to vascular thrombosis and complete flap failure in delayed reconstruction with free flaps, as well as to develop a scoring system of risk assessment including these biomarkers. METHODS: A retrospective review of the database was conducted for lower extremity open fractures reconstructed between 7 and 90 days from injury, from March 2014 to February 2022. We investigated changes in platelet count (PLT), D-dimer, creatine phosphokinase (CPK), and C-reactive protein (CRP) and then, developed a risk assessment system including these biomarkers as risk factors. RESULTS: A total of 62 free flaps were enrolled, and vascular thrombosis occurred in 14 flaps (22.6%), 9 of which (14.5%) developed complete flap failure. The risk assessment score was set to a maximum of 6 points for 6 items: age ≤ 40 years, time from injury to coverage ≥ 14 days, zone of injury from middle to distal leg, D-dimer on the day of injury ≥ 60 µg/mL, maximum value of CPK ≥ 10,000 U/L, and maximum value of CRP ≥ 25 mg/dL. The best cutoff score was 3 in the vascular thrombosis model (sensitivity: 0.79, specificity: 0.77) and 4 in the complete flap failure model (sensitivity: 0.78, specificity: 0.92). CONCLUSIONS: Our risk assessment system showed that the risk of vascular thrombosis was high at ≥ 3 points and that of complete flap failure was high at ≥ 4 points. Significantly, elevated levels of D-dimer, CPK, and CRP require more caution during reconstruction using free flaps.

Antibiotic administration within 1 hour for open lower extremity fractures is not associated with decreased risk of infection.

BACKGROUND: Open fractures have a high risk of infection with limited data correlating timing of prophylactic antibiotic administration and rate of subsequent infection. The Trauma Quality Improvement Program has established a standard of antibiotic administration within 1 hour of arrival, but there is a lack of adequately powered studies validating this quality metric. We hypothesize that open femur and/or tibia fracture patients undergoing orthopedic surgery have a decreased risk of infectious complications (osteomyelitis, deep and superficial surgical site infection) if antibiotics are administered within 1 hour of presentation compared with administration after 1 hour. METHODS: The 2019 Trauma Quality Improvement Program was queried for adults with isolated (Abbreviated Injury Scale <1 for the head/face/spine/chest/abdomen/upper extremity) open femur and/or tibia fractures undergoing orthopedic surgery. Transfer patients were excluded. Patients receiving early antibiotics (EA) within 1 hour were compared with patients receiving delayed antibiotics (DA) greater than 1 hour from arrival. RESULTS: Of 3,367 patients identified, 2,400 (70.4%) received EA. Patients receiving EA had a higher rate of infections compared with DA (1.1% vs. 0.2%, p = 0.011). After adjusting for age, comorbidities, injury severity, nerve/vascular trauma to the lower extremity, washout of the femur/tibia performed in <6 hours, blood transfusion, and admission vitals, patients in the EA group had a similar associated risk of surgical site infection/osteomyelitis compared with the DA cohort ( p = 0.087). These results remained in subset analyses of patients with only femur, only tibia, and combined femur/tibia open fractures (all p > 0.05). CONCLUSION: In this large national analysis, approximately 70% of isolated open femur or tibia fracture patients undergoing surgery received antibiotics within 1 hour. After adjusting for known risk factors of infection, there was no association between timing of antibiotic administration and infection. Reconsideration of the quality metric of antibiotic administration within 1 hour for open fractures appears warranted. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Clostridium difficile colitis portends poor outcomes in lower extremity orthopaedic trauma surgery.

INTRODUCTION: Clostridium difficile is the most common cause of healthcare-associated infectious diarrhea and colitis, and carries the potential for high morbidity, particularly in frail patient populations. The purpose of this study was to utilize a large nationally representative database in order to report 1.) the incidence of CDC in patients with operative lower extremity fractures, 2.) risk factors for the development of CDC, 3.) the association of CDC with length of stay (LOS), readmission, and 30-day mortality rates. METHODS: The ACS-NSQIP (2015-2019) was queried for patients who underwent surgical fixation of lower extremity fractures. A backward elimination multivariate regression model was used to identify risk factors for CDC. Chi squared and multivariate regression that controlled for preoperative variables and comorbidities were used to compare outcomes in patients with and without CDC. RESULTS: 95,532 patients were included, 681 (0.71%) of whom developed CDC. Risk factors for CDC were advanced age, ASA class ≥ 3, smoking, dialysis, anemia, hypoalbuminemia, preoperative SIRS, preoperative wound infections, preoperative sepsis, and the use of spinal anesthesia or MAC/IV sedation. Patients with CDC had significantly increased 30-day mortality rates (10.6% vs 4.4%; OR 1.80, 95% CI 1.41-2.31), readmission (34.2% vs 7.5%; OR 5.13, 95% CI 4.36-6.05, and length of stay (7.5 days vs 5.3 days) compared to patients without CDC. CONCLUSION: The incidence of CDC in lower extremity orthopedic trauma patients was 0.71%. An occurrence of CDC was associated with approximately a 2.5 times increase in 30-day mortality, five times the readmission rate, and a longer hospital stay compared to patients without CDC. Mitigating the spread of c. diff through improved antibiotic stewardship and prompt treatment of CDC is paramount to decreasing the burden this infection imposes on orthopedic trauma patients and the healthcare system.

Identifying Patients at Risk for Venous Thromboembolic Events After Isolated Upper Extremity Trauma: A Predictive Scale.

Previous studies have defined risk factors for development of venous thromboembolisms (VTEs) among patients with lower extremity orthopedic trauma. Limited data exist on this risk after upper extremity orthopedic trauma. A total of 269,137 incidents of upper extremity orthopedic trauma (fractures of the clavicle, scapula, humerus, elbow, or lower arm) were identified in the State Inpatient Database for 4 states included in the analysis (California, Florida, New York, and Washington) from 2006 to 2014. These patients were split into 2 cohorts, a derivation cohort (California and New York) and a validation cohort (Florida and Washington). Univariate and multivariate logistic regression analyses of risk factors for VTE within 90 days of discharge in the derivation group were used to develop the Thromboembolic Risk after Upper Extremity Trauma (TRUE-T) scale. Linear regression was used to determine fit of the TRUE-T scale to the 2 cohorts. We found that 2.61% of patients in the derivation cohort and 2.72% of patients in the validation cohort had a VTE within 90 days of discharge. Risk factors associated with increased rates of VTE were age older than 40 years, Medicare payer, anemia, chronic lung disease, coagulopathy, heart failure, malignancy, obesity, renal failure, head injury, chest injury, abdominal injury, rib fracture, humerus fracture, elbow fracture, and closed reduction. Application of the TRUE-T scale to the validation cohort showed an R2 value of 0.88. The patient factors, concomitant injuries, and fracture treatment modalities included in the TRUE-T scale can be used to identify patients at increased risk for VTE after upper extremity orthopedic trauma. [Orthopedics. 2022;45(6):345-352.].

Lower-leg injury and knee arthroscopy have distinct effects on coagulation.

It is unknown how lower-leg injury and knee arthroscopy, both associated with venous thromboembolism (VTE), affect coagulation. To study the effect of (1) lower-leg trauma and (2) knee arthroscopy on coagulation, plasma samples of the Prevention of Thrombosis following CAST immobilization (POT-CAST, #NCT01542762) and Prevention of Thrombosis following Knee Arthroscopy (POT-KAST, #NCT01542723) trials were used, which were collected shortly after lower-leg trauma and before/after (<4 hours) knee arthroscopy. For aim 1, 1204 lower-leg injury patients were compared with preoperative samples of 1001 controls. Mean differences/ratios (if ln-retransformed because of skewedness) were adjusted for sex, age, body mass index, comorbidity, malignancy, and oral contraceptives using linear regression. For aim 2, perioperative mean changes of 715 arthroscopy patients were calculated. Plasma levels of fibrinogen, factor (F)VIII, FIX, FXI, von Willebrand Factor (VWF), and D-dimer were measured in all individuals. Parameters of underlying mechanisms (tissue factor, interleukin-6 [IL-6], myeloperoxidase DNA, cell-free DNA) were measured in random subsets. In lower-leg injury patients, coagulation parameter levels increased, especially FVIII, VWF, and D-dimer, that is, adjusted mean differences: FVIII 26.8% (95% confidence interval [CI], 23.7-29.9), FIX 13.8% (95% CI, 11.9-15.6), FXI 5.1% (95% CI, 3.3-7.0), VWF 29.8% (95% CI, 26.0-33.6), fibrinogen 32.5 mg/dL (95% CI, 25.8-39.2), and D-dimer (mean ratio) 3.3 (95% CI, 3.1-3.6). Remaining parameters were unchanged, except for increased IL-6 levels. After arthroscopy, all parameters decreased. Lower-leg trauma is associated with increased procoagulant factor levels in contrast to knee arthroscopy. This suggests that, in both situations, different pathways are involved in development of VTE.

Epidemiology of paediatric lower extremity fractures in a tertiary care center in Switzerland.

PURPOSE: About 20% of all fractures in children occur at the lower extremity. This study aims to investigate the epidemiology and injury pattern of lower extremity fractures within the pediatric population consulting a tertiary referral hospital in Switzerland. METHODS: Study population included all patients up to 16 years presenting with a lower extremity fracture over a period of one year. Recorded data were age, gender, side, season of the year, mechanism, type of fracture and applied treatment. RESULTS: Fractures of the lower extremity represent 23% of all fractures with a mean age of 9 years and 6 months. The tibia, with 94 fractures (38%), represents the most frequently injured bone. Peak incidence is seen in winter and 24% of tibia shaft fractures were due to board sports. Overall, 82% of fractures were treated by cast with or without closed reduction, and only 18% requested surgery. CONCLUSION: Board sports seems to be a leading cause of tibial shaft fracture in our region. Nevertheless, only 18% of fractures had recourse to an orthopedic surgeon, hence the importance of the teaching quality of pediatric residents for conservative fracture treatment.

Effect of Tourniquet Use During Surgical Treatment of Open Fractures.

BACKGROUND: We sought to evaluate whether tourniquet use, with the resultant ischemia and reperfusion, during surgical treatment of an open lower-extremity fracture was associated with an increased risk of complications. METHODS: This is a retrospective cohort study of 1,351 patients who had an open lower-extremity fracture at or distal to the proximal aspect of the tibia and who participated in the FLOW (Fluid Lavage of Open Wounds) trial. The independent variable was intraoperative tourniquet use, and the primary outcome measures were adjudicated unplanned reoperation within 1 year of the injury and adjudicated nonoperative wound complications. RESULTS: Unplanned reoperation and nonoperative wound complications were roughly even between the no-tourniquet (18.7% and 19.1%, respectively) and tourniquet groups (17.8% and 20.8%) (p = 0.78 and p = 0.52). Following matching, as determined by model interactions, tourniquet use was a significant predictor of unplanned reoperation in Gustilo Type-IIIA (odds ratio, 3.60; 95% confidence interval, 1.16 to 11.78) and IIIB fractures (odds ratio, 16.61; 95% confidence interval, 2.15 to 355.40). CONCLUSIONS: The present study showed that tourniquet use did not influence the likelihood of complications following surgical treatment of an open lower-extremity fracture. However, in cases of severe open fractures, tourniquet use was associated with increased odds of unplanned reoperation; surgeons should be cautious with regard to tourniquet use in this setting. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Occult deep vein thrombosis in lower limb trauma requiring microsurgical reconstruction-A retrospective cohort study.

BACKGROUND: Delayed microsurgical reconstruction of lower extremity trauma is associated with increased risk of free flap loss, frequently following failure of the venous anastomosis. This has been attributed to thrombocytosis, but occult deep vein thrombosis (DVT) may contribute to this risk. METHODS: We performed a retrospective cohort study of consecutive patients presenting to our service with lower limb injuries requiring microsurgical reconstruction between 2013 and 2017, and examined venous Duplex ultrasound reports, operation notes and free flap outcomes. RESULTS: A total of 165 free flap reconstructions for lower limb trauma were performed for 162 limbs in 158 patients. Seventy-two limbs (44.4%) underwent preoperative venous Duplex ultrasound identifying occult DVT in 14 (19.4%) patients. Occult DVT was identified intraoperatively in a further 7 cases. Bilateral lower limb injuries (p = 0.0002), the level of injury at or above the knee (p < 0.0001), multiple levels of injury within the affected limb (p = 0.0008) and critical care admission (p = 0.0008) were significant risk factors for DVT. All 7 cases of DVT diagnosed intraoperatively prompted a change in the surgical plan for the recipient vein; however, preoperative identification of occult DVT also lead to an adjustment in the microsurgical plan in 4 out of 14 cases. CONCLUSIONS: Prevalence of DVT is high in severe lower limb injury, potentially increasing the risk of free flap loss. Preoperative identification of occult DVT may influence the microsurgical plan and mitigate for this risk.

End-stage renal disease increases risk of postoperative complications after lower extremity fracture.

INTRODUCTION: End-stage renal disease (ESRD) leads to multiple systemic effects and patients suffer from multiple comorbidities including fractures. While previous studies have examined complications following hip fracture surgery in ESRD patients, there are no studies evaluating other lower extremity fractures. This study aimed to identify postoperative complication risk in patients with ESRD who had lower extremity fractures. METHODS: Using our database from 2000 to 2015 at two level-one trauma centres, we collected data on patients over age 40, who had lower extremity fractures and surgical fixation. Diagnosis of ESRD was made before the injury. Each ESRD patient was matched by two non-ESRD patients regarding age, gender, American Society of Anaesthesiologists (ASA) score, and AO/OTA fracture classification. Postoperative outcomes were non-union, mechanical failure, and infection. The number of outcome events was compared between the ESRD and non-ESRD cohorts. RESULTS: A total of 195 patients (65 ESRD patients matched to 130 non-ESRD patients) were identified. Median follow-up was 31 months (12-141 months). Patients with ESRD were 3.6 time more likely to have at least one postoperative complication (mechanical failure, non-union, or infection) compared to non-ESRD patients (9/65 vs. 5/130, p = 0.02). In particular, mechanical failure was eight times higher among ESRD patients compared to non-ESRD patients (8/65 vs. 2/130, p < 0.01). CONCLUSIONS: ESRD was associated with higher rates of complications, especially mechanical failure, after lower extremity fracture surgeries.

Evaluation of the efficacy of commercial and noncommercial tourniquets for extremity hemorrhage control in a perfused cadaver model.

BACKGROUND: Tourniquets are a critical tool in the immediate response to life-threatening extremity hemorrhage; however, the optimal tourniquet type and effectiveness of noncommercial devices remain unclear. Our aim was to evaluate the efficacy of five tourniquets in a perfused-cadaver model. METHODS: This prospective study used a perfused-cadaver model with standardized superficial femoral artery injury bleeding at 700 mL/min. Five tourniquets were tested: combat application tourniquet; rapid application tourniquet system; Stretch, Wrap, And Tuck Tourniquet; an improvised triangle bandage windlass; and a leather belt. Forty-eight medical students underwent a practical hands-on demonstration of each tourniquet. Using a random number generator, they placed the tourniquets on the bleeding cadaver in random order. Time to hemostasis, time to secure devices, estimated blood loss, and difficulty rating were assessed. A one-way repeated measures analysis of variance was used to compare efficacy between the tourniquets in achieving the outcomes. RESULTS: The mean ± SD participant age was 25 ± 2.6 years, and 29 (60%) were male. All but one tourniquet was able to stop bleeding, but the rapid application tourniquet system had a 4% failure rate. Time to hemostasis and estimated blood loss did not differ significantly (p > 0.05). Stretch, Wrap, And Tuck Tourniquet required the longest time to be secured (47.8 ± 17.0 seconds), whereas the belt was the fastest (15.2 ± 6.5 seconds; p < 0.001). The improvised windlass was rated easiest to learn and apply, with 22 participants (46%) assigning a score of 1. CONCLUSION: Four of five tourniquets evaluated, including both noncommercial devices, effectively achieved hemostasis. A standard leather belt was the fastest to place and was able to stop the bleeding. However, it required continuous pressure to maintain hemostasis. The improvised windlass was as effective as the commercial devices and was the easiest to apply. In an emergency setting where commercial devices are not available, improvised tourniquets may be an effective bridge to definitive care.

The Application of Ultra-High-Frequency Ultrasound in Dermatology and Wound Management.

The management of lower extremity wounds is frequently performed by means of clinical examination, representing a challenge for the clinician due to the various conditions that can potentially enter differential diagnosis. Several diagnostic techniques are available in the dermatologist's arsenal as a support to diagnosis confirmation, including dermoscopy and ultrasonography. Recently, a novel ultrasonographic technique involving the use of ultra-high ultrasound frequencies has entered the scene, and appears a promising tool in the diagnostic workup of skin ulcerative lesions. The focus of this review is to discuss the potential role of ultra-high-frequency ultrasonography in the diagnostic workup of wounds in the light of the current applications of the technique.

A rat model of orthopedic injury-induced hypercoagulability and fibrinolytic shutdown.

BACKGROUND: Postinjury hypercoagulability occurs in >25% of injured patients, increasing risk of thromboembolic complications despite chemoprophylaxis. However, few clinically relevant animal models of posttraumatic hypercoagulability exist. We aimed to evaluate a rodent model of bilateral hindlimb injury as a preclinical model of postinjury hypercoagulability. METHODS: Forty Wistar rats were anesthetized with isoflurane: 20 underwent bilateral hindlimb fibula fracture, soft tissue and muscular crush injury, and bone homogenate injection intended to mimic the physiological severity of bilateral femur fracture. Twenty sham rats underwent anesthesia only. Terminal citrated blood samples were drawn at 0, 6, 12, and 24 hours (n = 5 per timed group) for analysis by native thromboelastography in the presence and absence of taurocholic acid to augment fibrinolysis. Plasminogen activator inhibitor 1 and α-2 antiplasmin levels in plasma were assessed via enzyme-linked immunosorbent assay. RESULTS: Injured rats became hypercoagulable relative to baseline by 6 hours based on thromboelastography maximal amplitude (MA) and G (p < 0.005); sham rats became hypercoagulable to a lesser degree by 24 hours (p < 0.005). Compared with sham animals, injured rats were hypercoagulable by MA and G within 6 hours of injury, remained hypercoagulable by MA and G through at least 24 hours (all p < 0.01), and showed impaired fibrinolysis by taurocholic acid LY30 at 12 hours (p = 0.019) and native LY30 at 24 hours (p = 0.045). In terms of antifibrinolytic mediators, α-2 antiplasmin was elevated in trauma animals at 24 hours (p = 0.009), and plasminogen activator inhibitor 1 was elevated in trauma animals at 6 hours (p = 0.004) and 12 hours (p < 0.001) when compared with sham. CONCLUSIONS: Orthopedic injury in rodents induced platelet and overall hypercoagulability within 6 hours and fibrinolytic impairment by 12 to 24 hours, mimicking postinjury hypercoagulability in injured patients. This rodent model of orthopedic injury may serve as a preclinical testing ground for potential therapies to mitigate hypercoagulability, maintain normal fibrinolysis, and prevent thromboembolic complications.

In-Hospital Morbidity and Mortality of Traumatic Lower-Extremity Amputations.

Traumatic lower-extremity amputations often result in complications and surgical revisions. The authors report the in-hospital morbidity and mortality of traumatic lower-extremity amputations at a metropolitan level I trauma center for a large rural region and compare below-knee (BK) vs higher-level amputation complications. They retrospectively reviewed 168 adult patients during a 10-year period (2005 to 2015) who had a traumatic injury to the lower extremity that required an amputation. Main outcome measurements included amputation level, complication rates, intensive care unit (ICU) admission rates, length of stay, total trips to the operating room (OR), and Injury Severity Score (ISS). A total of 95 patients had through-knee/above-knee (TK/AK) amputations, and 73 patients had BK amputations. The majority of injuries occurred in the non-urban setting. The TK/AK group had higher ICU admission rates (76% vs 35%, P<.0001), longer overall hospital length of stay (22.0 vs 15.5 days, P=.01), more total OR trips (6.5 vs 5.0, P=.04), and higher ISS (17.0 vs 11.5, P<.0001). A complication was experienced by 64% of all patients during the initial hospitalization. The TK/AK group had higher complication rates than the BK group, including wound infection, pulmonary embolus, rhabdomyolysis, compartment syndrome, and death. Patients with TK/AK traumatic amputations have a greater burden of injury with higher complication rates, increased ICU admissions, increased length of stay, and increased ISS and require more return trips to the OR compared with patients with BK amputations. [Orthopedics. 2020;43(6):e561-e566.].

Orthopaedic Trauma-Induced Pyoderma Gangrenosum: A Case Report.

CASE: We present a case of a 60-year-old polytraumatized man who developed postoperative pyoderma gangrenosum (PG) after his initial stabilization procedures, mimicking a postoperative infection. This caused a delay in diagnosis, leading to progression of his wounds and a delay in initiation of the appropriate treatment. Once his PG was appropriately treated, his clinical status and wounds improved. He underwent successful wound coverage by plastic surgery and has been recovering from his injuries. CONCLUSION: Prompt identification and initiation of treatment for postoperative PG is critical to avoid exacerbation of wounds and subsequent morbidity to the patient.

Symptoms of adjustment disorder and smoking predict long-term functional outcome after ankle and lower leg fracture.

OBJECTIVE: To examine the psychological, social, behavioural and injury-related factors impacting functional outcome in patients with ankle or lower limb fracture one year post-operation. METHODS: In this prospective study 66 patients with ankle or lower leg fracture were recruited and followed up one year post-operation. Possible associations between predictors and functional outcome were explored by regression analyses. Functional outcome was assessed with the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Score. RESULTS: Linear regression models revealed that smoking and elevated symptoms of adjustment disorder were associated with lower functional outcome one year post-operation. Fracture type, depressive symptoms and quality of relationship had no effect on functional outcome. A second linear regression revealed that preoccupations were correlated with functional outcome. CONCLUSION: Smoking and symptoms of adjustment disorder, specifically preoccupations, are associated with functional outcome one year post-operation in patients recovering from ankle or lower leg fractures. The results support the notion that differences in functional recovery are attributable to psychological and behavioural factors rather than to fracture type. Psychological, fracture-specific, symptoms play a role in functional recovery rather than general affective symptoms.