Increasing Diversity in Orthopaedics: The Problem, Strategies, and Solutions.

It is important to educate and equip the orthopaedic community with tools to address health care disparities and improve orthopaedic specialty recruitment for racial minorities. How patients and providers are affected by systemic racism in healthcare and what that means in orthopaedic surgery, methods to identify bias and improve access to orthopaedic care for racial minorities, and how to structure a program and department environment to encourage and promote diversity are important topics of discussion.

Electric scooter injuries: Incidence and injury patterns at a level I trauma center.

PURPOSE: Electric scooters (e-scooters) have become an increasingly popular mode of public transportation in recent years. As the incidence of related injuries rises, it is important to understand specific fracture patterns unique to e-scooters and electric bikes (e-bikes) to help guide management. The purpose of this study was to review the prevalence and describe specific fracture patterns of e-scooter and e-bike related injuries at the busiest level 1 trauma center in the borough of Manhattan. METHODS: Chart review to determine mechanism of injury was performed on all patients for whom an orthopedic consult was requested from 1/1/2021 to 12/31/2021. All patients whose injuries were sustained due to an e-scooter or e-bike were further reviewed for demographics, injury characteristics including fracture pattern, and definitive injury management. Any patients who had an orthopedic consult placed for a reason other than an acute injury were excluded. Descriptive statistics are reported as frequency (percentage) for categorical variables and means for continuous variables. RESULTS: Of the 1815 orthopedic consults requested, 1357 (74.8%) were for acute injury management. Of those with acute injuries, 119 (8.8%) sustained 136 e-scooter or e-bike related injuries. There were 92 (77.3%) males at an average age of (33.8 ± 15.7) years. Approximately one-fifth of all patients presented in June 2021 (26, 21.8%). There was a 9.2% rate of open fractures. The 136 injuries were evenly split between the upper and lower extremities, with 57 (47.9%) upper extremity, 57 (47.9%) lower extremity injuries, and 5 (4.2%) concomitant upper and lower extremity injuries. The most common fracture patterns were ankle fractures (16, 11.7%), followed by tibial shaft (14, 10.2%), tibial plateau (13, 9.5%), and radial head fractures (11, 8.0%). There was a 33.3% incidence of associated posterior malleolar fractures in the spiral tibial shaft fractures, 31.0% of posterior malleolar involvement and 18.8% of isolated vertical medial malleolar fractures in the ankle fractures, and 61.5% of posterior comminution in the tibial plateau fractures. CONCLUSION: E-scooter and e-bike related injuries have a high incidence of tibial shaft fractures, ankle fractures, tibial plateau fractures, and radial head fractures. There should be a high index of suspicion for posterior and medial involvement in lower extremity fractures sustained due to e-scooter or e-bikes. Identifying specific fracture patterns seen in e-scooter and e-bike related mechanisms will help guide management of these injuries.

Decreasing Postoperative Opioid Prescriptions After Orthopedic Trauma Surgery: The "Lopioid" Protocol.

OBJECTIVE: To assess the effectiveness of a multimodal analgesic regimen containing "safer" opioid and non-narcotic pain medications in decreasing opioid prescriptions after surgical fixation in orthopedic trauma. DESIGN: Retrospective cohort study. SETTING: One urban, academic medical center. SUBJECTS: Patients with traumatic fracture from 2018 (n=848) and 2019 (n=931). METHODS: In 2019, our orthopedic trauma division began a standardized protocol of postoperative pain medications that included 50 mg of tramadol four times daily, 15 mg of meloxicam once daily, 200 mg gabapentin twice daily, and 1 g of acetaminophen every 6 hours as needed. This multimodal regimen was dubbed the "Lopioid" protocol. We compared patients who received this protocol with all patients from the prior year who had followed a standard protocol that included Schedule II narcotics. RESULTS: Greater mean morphine milligram equivalents were prescribed at discharge from fracture surgery under the standard protocol than under the Lopioid protocol (252.3 vs 150.0; P < 0.001), and there was a difference in the type of opioid medication prescribed (P < 0.001). There was a difference in the number of refills filled for patients discharged with opioids after surgical treatment between the standard and Lopioid cohorts (0.31 vs 0.21; P = 0.002). There were no differences in the types of medication-related complications (P = 0.710) or the need for formal pain management consults (P = 0.199), but patients in the Lopioid cohort had lower pain scores at discharge (2.2 vs 2.7; P = 0.001). CONCLUSIONS: The Lopioid protocol was effective in decreasing the amount of Schedule II narcotics prescribed at discharge and the number of opioid refills after orthopedic surgery for fractures.

A Level 1 Trauma Center's response to the COVID-19 pandemic in New York City: a qualitative and quantitative story.

BACKGROUND: The purpose of this study is to describe a Level 1 Trauma Center's orthopedic response to the COVID-19 pandemic, and to compare outcomes of acute fracture patients pre-COVID versus during the COVID-19 pandemic. METHODS: All inpatient fracture cases performed over a 5-month period were identified and retrospective chart review performed. Patients were divided into pre- and COVID-era groups based on when surgery was performed relative to March 16, 2020 (the date elective operations were ceased), and groups were statistically compared. Patients with a COVID test result were further sub-divided into COVID negative and positive groups, and statistically compared. Statistical analysis was performed using independent t-test for continuous variables and chi-square analysis for categorical variables. RESULTS: One hundred and nineteen patients were identified, 38% females with average age of 58 years. Average length of stay was 7 days with average time from injury to surgery of 3 days and average time from admission to surgery of 1.3 days. Overall in-hospital complication rate was 29.4%, and 30-day mortality and readmission rates were 2.5% and 5%, respectively. Sixty-nine patients comprised the pre-COVID group, and 50 in the COVID-era group. There was no significant difference with respect to length of stay, time from injury to surgery, time from admission to surgery, need for post-operative ICU stay, in-hospital complication rate, 30-day mortality rate and 30-day readmission rate. Thirty-four patients had COVID testing, with 24 negative and 10 positive. COVID-positive patients had longer time from injury to surgery (8.5 days vs. 2 days, p = 0.003) and longer time from admission to surgery (2.7 days vs. 1.2 days, p = 0.034). While more COVID-positive patients required ICU admission post-operatively (60% vs. 21%, p = 0.036), there was no difference in overall complication rate. CONCLUSIONS: Orthopedic care of acute fracture patients was not affected by a global pandemic. The response of our Level 1 Trauma Center's orthopedic department can guide other hospitals if and when new surges in COVID cases arise, in order to prevent compromising appropriate orthopedic care. LEVEL OF EVIDENCE: Prognostic III.

Persistent racial disparities in postoperative management after tibia fracture fixation: A matched analysis of US medicaid beneficiaries.

INTRODUCTION: Racial and ethnic disparities in orthopaedic surgery are well documented. However, the extent to which these persist in fracture care is unknown. This study sought to assess racial disparities in the postoperative surgical and medical management of patients after diaphyseal tibia fracture fixation. METHODS: Patients with surgically treated tibial shaft fractures from October 1, 2015, to December 31, 2020, were identified in the MarketScan® Medicaid Database. Exclusion criteria included concurrent fractures or amputation. Outcomes included 2-year postoperative complications, reoperation rates, and filled prescriptions. Surgically-treated Black and White cohorts were propensity-score matched using nearest-neighbor matching on patient demographics, comorbidities, fracture pattern and severity, and fixation type. Chi-square tests and survival analyses (Kaplan-Meier and Cox proportional hazard models) were conducted. RESULTS: 5,472 patients were included, 2,209 Black and 3,263 White patients. After matching, 2,209 were retained in each cohort. No significant differences in complication rates were observed in the matched Black vs White cohorts. Rates of reoperation, however, were significantly lower in Black as compared to White patients (28.5 % vs. 35.5 % rate, risk difference = 7.0 % (95 % confidence interval (CI): 4.2 % to 9.7 %)). Implant removal was also significantly lower in Black (17.9 %) vs. White (25.1 %) patients (Risk difference = 7.2 %, (95 %CI: 4.8 % to 9.6 %)). The adjusted hazard ratio comparing the reoperation rate in Black versus White patients was 0.77 (95 %CI: 0.69-0.82, p < 0.0001). Significantly lower proportions of Black vs White patients filled at least one prescription for benzodiazepine, antidepressants, strong opiates, or antibiotics at every time point post-index. DISCUSSION: Fewer resources were used in post-operative management after surgical treatment of tibial shaft fractures for Black versus White Medicaid-insured patients. These results may be reflective of the undertreatment of complications after tibia fracture surgery for Black patients and highlight the need for further interventions to address racial disparities in trauma care.

Early Weight-bearing Following Surgical Treatment of Ankle Fractures Without Trans-syndesmotic Fixation Is Safe and Improves Short-term Outcomes.

OBJECTIVES: The objective of this study was to ascertain outcome differences after fixation of unstable rotational ankle fractures allowed to weight-bear 2 weeks postoperatively compared with 6 weeks. DESIGN: Prospective case-control study. SETTING: Academic medical center; Level 1 trauma center. PATIENT SELECTION CRITERIA: Patients with unstable ankle fractures (OTA/AO:44A-C) undergoing open reduction internal fixation (ORIF) were enrolled. Patients requiring trans-syndesmotic fixation were excluded. Two surgeons allowed weight-bearing at 2 weeks postoperatively (early weight-bearing [EWB] cohort). Two other surgeons instructed standard non-weight-bearing until 6 weeks postoperatively (non-weight-bearing cohort). OUTCOME MEASURES AND COMPARISONS: The main outcome measures included the Olerud-Molander questionnaire, the SF-36 questionnaire, and visual analog scale at 6 weeks, 3 months, 6 months, and 12 months postoperatively and complications, return to work, range of ankle motion, and reoperations at 12 months were compared between the 2 cohorts. RESULTS: One hundred seven patients were included. The 2 cohorts did not differ in demographics or preinjury scores ( P > 0.05). Six weeks postoperatively, EWB patients had improved functional outcomes as measured by the Olerud-Molander and SF-36 questionnaires. Early weight-bearing patients also had better visual analog scale scores (standardized mean difference -0.98, 95% confidence interval [CI] -1.27 to -0.70, P < 0.05) and a greater proportion returning to full capacity work at 6 weeks (odds ratio = 3.42, 95% CI, 1.08-13.07, P < 0.05). One year postoperatively, EWB patients had improved pain measured by SF-36 (standardized mean difference 6.25, 95% CI, 5.59-6.92, P < 0.01) and visual analog scale scores (standardized mean difference -0.05, 95% CI, -0.32 to 0.23, P < 0.01). There were no differences in complications or reoperation at 12 months ( P > 0.05). CONCLUSIONS: EWB patients had improved early function, final pain scores, and earlier return to work, without an increased complication rate compared with those kept non-weight-bearing for 6 weeks. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Treatment of Segmental Bone Defects Biology and Treatment Options.

Segmental bone defects (SBD) are difficult to treat, requiring a comprehensive understanding of the bone and soft tissue injury. Defect size, fracture characteristics, and local and systemic biology all help dictate treatment options. Bone grafting with autograft or allograft, Masquelet technique, and bone transport with external or internal fixation can all be used successfully in the correct patient. When deciding on the best treatment option and addressing any complications throughout the process, it is important to always keep in mind the three principles of bone healing: sterility, stability, and biology. The goal of this review is to present the history of treatment for critical SBD, including the indications and challenges that have been addressed and current and emerging treatment options.

Diversity in orthopaedic trauma: where we are and where we need to be.

Diversity has multiple dimensions, and individuals' interpretation of diversity varies broadly. The Orthopaedic Trauma Association (OTA) leadership recognized the need to address issues of diversity within the organization and appointed the OTA Diversity Committee in 2020. The OTA Diversity Committee has produced a statement that was confirmed by the OTA's board of directors reflecting the organization's position on diversity: "The OTA promotes and values diversity and inclusion at all levels with the goal of creating an environment where every member has the opportunity to excel in leadership, education, and culturally-competent orthopaedic trauma care." The OTA Diversity Committee surveyed its 1907 OTA members in the United States and Canada to assess its membership's attitudes toward and interpretation of this important topic. METHODS: Two surveys were distributed. One 15-question survey was sent to 1907 OTA members with different membership categories in the United States and Canada requesting basic demographic information and asking how members felt about the degree to which women and underrepresented minorities (URM) are represented within the OTA and within its leadership. A second 11-question survey was sent to 30 past chairs of 2017-2019 OTA educational courses and meetings evaluating their criteria for choosing faculty for OTA courses. Comments were reviewed and summarized to identify recurring themes. RESULTS: Two hundred seven responses from the membership and 14 from course chairs were received from the 1907 surveys that were emailed to OTA members in the United States and Canada. The results reveal awareness of the limited female and URM representation within the OTA. However, there is disagreement in how or even whether this should be addressed at an organizational level. Review of comments from both surveys reveals a number of common themes on these important topics. CONCLUSION: The members and course chairs surveyed recognize that there is limited diversity at the OTA leadership and faculty level. Many members feel that the OTA would benefit from increasing female and URM representation in committees, within the leadership, and as faculty at OTA-sponsored courses. However, survey comments reveal that many members and course chairs feel it is not the organization's role to regulate diversity and that diversity initiatives themselves may introduce an unnecessary form of bias.

Modification of a Validated Risk Stratification Tool to Characterize Geriatric Hip Fracture Outcomes and Optimize Care in a Post-COVID-19 World.

OBJECTIVES: (1) To demonstrate how a risk assessment tool modified to account for the COVID-19 virus during the current global pandemic is able to provide risk assessment for low-energy geriatric hip fracture patients. (2) To provide a treatment algorithm for care of COVID-19 positive/suspected hip fractures patients that accounts for their increased risk of morbidity and mortality. SETTING: One academic medical center including 4 Level 1 trauma centers, 1 university-based tertiary care referral hospital, and 1 orthopaedic specialty hospital. PATIENTS/PARTICIPANTS: One thousand two hundred seventy-eight patients treated for hip fractures between October 2014 and April 2020, including 136 patients treated during the COVID-19 pandemic between February 1, 2020 and April 15, 2020. INTERVENTION: The Score for Trauma Triage in the Geriatric and Middle-Aged ORIGINAL (STTGMAORIGINAL) score was modified by adding COVID-19 virus as a risk factor for mortality to create the STTGMACOVID score. Patients were stratified into quartiles to demonstrate differences in risk distribution between the scores. MAIN OUTCOME MEASUREMENTS: Inpatient and 30-day mortality, major, and minor complications. RESULTS: Both STTGMA score and COVID-19 positive/suspected status are independent predictors of inpatient mortality, confirming their use in risk assessment models for geriatric hip fracture patients. Compared with STTGMAORIGINAL, where COVID-19 patients are haphazardly distributed among the risk groups and COVID-19 inpatient and 30 days mortalities comprise 50% deaths in the minimal-risk and low-risk cohorts, the STTGMACOVID tool is able to triage 100% of COVID-19 patients and 100% of COVID-19 inpatient and 30 days mortalities into the highest risk quartile, where it was demonstrated that these patients have a 55% rate of pneumonia, a 35% rate of acute respiratory distress syndrome, a 22% rate of inpatient mortality, and a 35% rate of 30 days mortality. COVID-19 patients who are symptomatic on presentation to the emergency department and undergo surgical fixation have a 30% inpatient mortality rate compared with 12.5% for patients who are initially asymptomatic but later develop symptoms. CONCLUSION: The STTGMA tool can be modified for specific disease processes, in this case to account for the COVID-19 virus and provide a robust risk stratification tool that accounts for a heretofore unknown risk factor. COVID-19 positive/suspected status portends a poor outcome in this susceptible trauma population and should be included in risk assessment models. These patients should be considered a high risk for perioperative morbidity and mortality. Patients with COVID-19 symptoms on presentation should have surgery deferred until symptoms improve or resolve and should be reassessed for surgical treatment versus definitive nonoperative treatment with palliative care and/or hospice care. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

Increased Mortality and Major Complications in Hip Fracture Care During the COVID-19 Pandemic: A New York City Perspective.

OBJECTIVES: To examine one health system's response to the essential care of its hip fracture population during the COVID-19 pandemic and report on its effect on patient outcomes. DESIGN: Prospective cohort study. SETTING: Seven musculoskeletal care centers within New York City and Long Island. PATIENTS/PARTICIPANTS: One hundred thirty-eight recent and 115 historical hip fracture patients. INTERVENTION: Patients with hip fractures occurring between February 1, 2020, and April 15, 2020, or between February 1, 2019, and April 15, 2019, were prospectively enrolled in an orthopaedic trauma registry and chart reviewed for demographic and hospital quality measures. Patients with recent hip fractures were identified as COVID positive (C+), COVID suspected (Cs), or COVID negative (C-). MAIN OUTCOME MEASUREMENTS: Hospital quality measures, inpatient complications, and mortality rates. RESULTS: Seventeen (12.2%) patients were confirmed C+ by testing, and another 14 (10.1%) were suspected (Cs) of having had the virus but were never tested. The C+ cohort, when compared with Cs and C- cohorts, had an increased mortality rate (35.3% vs. 7.1% vs. 0.9%), increased length of hospital stay, a greater major complication rate, and a greater incidence of ventilator need postoperatively. CONCLUSIONS: COVID-19 had a devastating effect on the care of patients with hip fracture during the pandemic. Although practice patterns generally remained unchanged, treating physicians need to understand the increased morbidity and mortality in patients with hip fracture complicated by COVID-19. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

Fixation of extra-articular distal humerus fractures using one locking plate versus two reconstruction plates: a laboratory study.

OBJECTIVE: To compare the strength and stiffness of standard double-plate fixation with that of a single-locking plate for comminuted extra-articular distal humeral fractures. MATERIALS: Eight matched pairs of humeri were used. One of each pair was fixed with two 3.5-mm standard reconstruction plates applied dorsally; the other was fixed with one precontoured locking plate applied to the posterior aspect of the lateral column. A 1-cm gap was created to simulate a distal fracture model with 100% metaphyseal comminution with no bony apposition. Stiffness testing of these constructs was performed in axial compression, anterior, posterior and lateral bending, and torsion. They were then cyclically loaded for 4000 cycles with 60 N in posterior bending and the stiffnesses retested. Finally, each construct was posteriorly loaded to failure to determine its ultimate strength. RESULTS: The double-plate construct was significantly stiffer than the one locking plate construct in anterior bending (39%; p = 0.02), posterior bending (23%; p = 0.04), and lateral bending (60%; p = 0.01). No significant stiffness differences were seen in axial compression and torsion (p = 0.64 and 0.25, respectively). After cyclic loading, all construct stiffnesses were relatively unchanged. Both construct types had similar failure strengths (p = 0.76) of approximately 400 N. CONCLUSIONS: Double-plating provides a more rigid fixation than a single-locked plate for fixation of extra-articular comminuted distal humeral fractures. This could be clinically relevant in situations with 100% comminution as seen in gun shot injuries.

Improving outcomes after pertrochanteric hip fractures.

Complex pertrochanteric fractures, such as those with reverse obliquity and subtrochanteric extension, represent a subset of hip fractures that sometimes is difficult to treat. Critical assessment of the available literature and a review of treatment indications, implant recommendations, and technical pitfalls will provide insight to physicians to enable better care of patients with these complex injuries.

Arm Fasciotomy Through Lateral Approach.

Acute compartment syndrome represents one of the few true orthopaedic emergencies. Timely management is essential to prevent permanent sequelae. This video describes a case of acute compartment syndrome of the arm. Relevant patient history, physical examination, and laboratory findings are discussed, and a presentation of the operative technique for arm fasciotomy through a lateral approach is highlighted. Diagnostic criteria for acute compartment syndrome and indications for fasciotomy are reviewed, with a discussion of published outcomes after fasciotomy.

Posttraumatic Heterotopic Ossification of the Hip.

INTRODUCTION: Posttraumatic heterotopic ossification (HO) of the hip frequently follows acetabular fracture and hip surgery and can become symptomatic, with significant pain and limited range of motion (ROM). Definitive treatment may require surgical excision, which can result in serious complications if not planned and executed appropriately. METHODS: Surgical excision of posttraumatic hip HO requires appropriate indications, preoperative planning, and intraoperative guidance using fluoroscopy to maximize excision of HO and minimize complications. This video presents a case of severe posttraumatic hip HO, indications and technique of surgical excision using fluoroscopic guidance, postoperative protocol, and the patient's clinical follow-up. RESULTS: Surgical excision along with appropriate postoperative HO prophylaxis and immediate mobilization resulted in significant improvement in hip ROM and return to activities of daily living without complications or recurrence. Intraoperative blood loss can be significant and should be appropriately planned for preoperatively. CONCLUSIONS: Posttraumatic hip HO can cause significantly limited hip ROM and pain with resulting disability. Surgical excision of posttraumatic hip HO in a preserved hip joint can be successful in restoring hip ROM and function. Appropriate postoperative HO prophylaxis can prevent recurrence.

Are outcomes of bimalleolar fractures poorer than those of lateral malleolar fractures with medial ligamentous injury?

BACKGROUND: Recommendations for surgical treatment and expected outcomes differ for two unstable patterns of supination-external rotation ankle injuries. We compared the demographic characteristics and functional outcome following surgical stabilization between the two types of supination-external rotation type-4 fractures: distal fibular fracture with a deltoid ligament rupture and bimalleolar fracture. METHODS: Demographic data on 456 patients in whom an unstable fracture of the ankle was treated surgically were entered into a database and the patients were prospectively followed. Two hundred and sixty-six of these patients sustained either a bimalleolar fracture or a lateral malleolar fracture with insufficiency of the deltoid ligament and widening of the medial clear space. No medial fixation was used in the patients with a deltoid ligament injury. All patients followed a similar postoperative protocol. The patients were followed clinically and radiographically at three, six, and twelve months after the surgery. Function was assessed with the Short Musculoskeletal Function Assessment and the American Orthopaedic Foot and Ankle Society score. RESULTS: Bimalleolar fractures were more commonly seen in female patients, in those older than sixty years of age, and in patients with more comorbidities. There was no significant association between the fracture pattern and either diabetes or the length of the hospital stay. At a minimum of one year postoperatively, the patients with a bimalleolar fracture had significantly worse function, even after we controlled for all other variables. The overall complication rate, including elective hardware removal, was also higher in the group with a bimalleolar fracture (seventeen compared with nine patients). CONCLUSIONS: At one year after surgical stabilization of an unstable ankle fracture, most patients experience little or mild pain and have few restrictions in functional activities. However, the functional outcome for those with a bimalleolar fracture is worse than that for those with a lateral malleolar fracture and disruption of the deltoid ligament, possibly because of the injury pattern and the energy expended.

Preoperative assessment of tibial nail length: accuracy using digital radiography.

This study was performed to determine if picture archiving communication systems can provide a more accurate method of determining implant length for intramedullary tibial nailing. Postoperative radiographs of 40 patients who underwent intramedullary nailing of their tibial shaft fractures using picture archiving communication systems were retrieved. In phase one and two of this investigation, tibial nail lengths were measured using "measuring distance" and "measure calibration" tools displayed on the respective digital systems. Phase 3 of this study involved 5 tibial Sawbones (Pacific Research Laboratories, Vashon, Wash) radiographically captured on the picture archiving communication systems with a radiograph marker of known length. Using the "measuring distance" and "measure calibration" tools in phases one and two did not result in accurate measurements. Of 40 digital radiographic images measured and calibrated with the on-screen ruler and using the digital system tools, 100% of our measurements were inaccurate. An average of 19.4-mm and 10.6-mm difference was noted in uncorrected measurements on anteroposterior (AP) and lateral views, respectively. An average 25.8 mm and 15.7 mm was noted in calibrated (corrected) measurements on AP and lateral views respectively. Digitally measured and calibrated lengths were an average 22 mm and 25 mm greater from the actual known length of the tibial nail, respectively. Phase 3 of our study presented the most accurate results in length determination of tibial nail length.

Superstorm Sandy's forgotten patient: a lesson in emergency preparedness in severe obesity.

Superstorm Sandy gained national attention in late 2012 after its impact on the Northeastern US. In New York City, thousands of residents lost power, and multiple hospitals were forced to evacuate. Bellevue Hospital Center (BHC), the nation's oldest public hospital, was forced to close for the first time in over 275 years. Two patients remained in BHC three days after the primary evacuation without water service and minimal power. Herein, we describe the challenges associated with evacuating a severely obese patient. Obesity management is challenging and at an institutional level must be addressed in emergency preparedness plans.