Risk of Infection Following Gunshot Wound Fractures to the Foot and Ankle: A Multicenter Retrospective Study.

The purpose of this multicenter retrospective chart review was to describe demographics, fracture and wound characteristics, and treatments for foot and/or ankle fractures caused by gunshot wounds (GSWs) and identify factors that increase risk of infection in adults treated at 5 urban level 1 trauma centers in South and Midwest regions of the United States. A total of 244 patients sustained GSW-related fractures of the foot/ankle during 2007-2017, of whom 179 had ≥30 days of follow-up data after the initial injury. Most patients were male (95.1%; 232/244) with an average age of 31.2 years. On average, patients sustained 1.3 GSWs (range 1-5) to the foot/ankle. Most GSWs were categorized as low energy (85.1%; 171/201) and the majority (58.2%; 142/244) had retained bullet fragments. Antibiotics were administered at initial presentation to 78.7% (192/244) of patients and 41.8% (102/244) were managed operatively at the time of initial injury. Nerve injury, vascular injury, and infection were documented in, respectively, 8.6% (21/243), 6.6% (16/243), and 17.2% (42/244) of all cases. Multivariable analysis revealed that high-energy injuries and retained bullet fragments increased the risk of infection by 3-fold (odds ratio 3.09, 95% confidence interval 1.16-8.27, p = .025) and 3.5-fold (OR 3.48, 95% CI1.40-8.67; p = .008), respectively. Side of injury, primary injury region, and vascular injury were not significant predictors of infection risk. Further research should examine whether retained bullet fragments are directly associated with infection risk and support the development of guidelines regarding the management of patients with GSW-related fractures to the ankle/foot.

Midshaft clavicle fractures: is anterior plating an acceptable alternative to superior plating?

PURPOSE: The purpose of this study was to determine whether anterior plating is better tolerated than superior plating for midshaft clavicle fractures. METHODS: This was a prospective non-randomized observational cohort study following operative vs. non-operative management of clavicle fractures from 2003 to 2018 at 7 level 1 academic trauma centers in the USA. The subset of patients treated with plate and screws is the basis for this comparative study. Adults aged 18-85 with closed clavicle fractures displaced over 100% or shortened by more than 1.5 cm were eligible for enrollment. Patients were followed for 2 years following enrollment. Allowable fixation methods at the discretion of the surgeon consisted of anterior-inferior or superior plating. A total of 412 patients were enrolled. Of these, 192 patients received either superior or anterior plating for a displaced clavicle fracture with complete documented prospective research forms capturing type of plating technique. The primary outcome measure was hardware removal (HWR). Secondary outcomes were Disability of the Arm Shoulder and Hand (DASH) score and Visual Analog Pain (VAP) score, and satisfaction score (1 = high satisfaction; 5 = low satisfaction). RESULTS: There was no difference in HWR rates (7.1% superior 9/127; 6.2% anterior 4/65, p = 0.81), VAP score (mean 1.5 SD 1.0 superior; mean 1.7 SD 0.6 anterior, p = 0.21), DASH score (mean 7.5 SD 12.4 superior; mean 5.2 SD 15.2 anterior; p = 0.18) or satisfaction score (mean 1.6 SD 1.0 superior; mean 1.7 SD 0.60 anterior, p = 0.18). CONCLUSION: There is no difference in HWR rates or functional outcomes when using a superior vs. anterior plating technique.

Characterization of vitamin D deficiency and use of a standardized supplementation protocol in orthopaedic trauma patients.

PURPOSE: The objectives of this study were to assess the incidence of vitamin D deficiency in orthopaedic trauma patients, evaluate the safety and efficacy of a vitamin D supplementation protocol, and investigate the utility of vitamin D supplementation in reducing nonunions. METHODS: Three hundred seventy patients with operative tibia and/or fibula fractures were retrospectively reviewed. Both overall and matched cohorts were analysed. RESULTS: Ninety-eight per cent (n = 210) were found to have vitamin D insufficiency (serum 25(OH)D level < 30 ng/ml). There were no cases of vitamin D toxicity following vitamin D replacement. Median follow-up vitamin D level was 22.7 ng/mL. No statistical difference between union rates was found between either the two consecutive cohorts or matched cohorts. CONCLUSION: This vitamin D replacement protocol was a safe treatment for hypovitaminosis D, but post hoc analysis shows there would need to be over 1200 matched patients to achieve adequate power.

Overlapping Surgery for Distal Radius Fractures: Is It Safe?

Patients who underwent distal radius fracture (open reduction and internal fixation [ORIF]) at a Level 1 trauma center deemed "overlapping" (greater than 30 minutes overlap) were compared against consecutive cases. Unplanned return to surgery within 1 year was the primary outcome. Sixty-two patients were included in the overlapping group and 37 in the consecutive group. There was no difference in unplanned return to surgery 1 year following procedure with three cases (5%) in the overlapping group and one case (3%) in the consecutive group. There was a significant difference (p = 0.02) in procedure time between the overlapping group (151 + 54 minutes) and nonoverlapping group (126 + 35 minutes). There was no difference in infection, readmission, nonunion, malunion, deep infection, or superficial infection between groups. Based on a post-hoc power analysis with p < 0.05 and power at 80%, 2,691 patients would be needed to determine if there is truly no difference between groups. (Journal of Surgical Orthopaedic Advances 31(2):127-130, 2022).

Peri-implant fractures of the upper and lower extremities: a case series of 61 fractures.

PURPOSE: To assess outcomes for patients who sustained peri-implant fractures (PIFs). METHODS: Medical records of patients who sustained a PIF were reviewed for demographic, injury, outcome, and radiographic data. PIFs were classified using a reproducible system and stratified into cohorts based on fracture location. Clinical outcomes were evaluated for each cohort. RESULTS: Fifty-six patients with 61 PIFs with at least 6 months of follow-up were included. The mean age of the cohort was 60.4 ± 19.5 years. Twenty-two (36.1%) PIFs occurred in males, while 39 (63.9%) occurred in females. Fifty-two (85.2%) PIFs were sustained from a low-energy injury mechanism. PIFs were most often treated with plate/screw constructs (50.8%). Complications included: 6 (9.8%) nonunions, 5 of which were successfully treated to healing, 5 (8.2%) fracture related infections (FRI), and 1 (1.6%) hardware failure. Sixty (98.4%) PIFs ultimately demonstrated radiographic healing. CONCLUSION: PIFs are usually treated surgically and have a relatively high incidence of complications, with nonunion in femoral PIFs being the greatest. Despite this, the rate of ultimate healing is quite high.

Operative vs. Nonoperative Treatment of Isolated Humeral Shaft Fractures: A Prospective Cohort Study.

The purpose was to compare plate and screw fixation (open reduction internal fixation [ORIF]) and functional bracing (FB) of isolated humeral shaft fractures with treatment and patient-based outcomes. We performed a prospective trial of ORIF v. FB at 12 centers. Surgeons counseled patients on treatment options and a patient centered decision was made. We enrolled 179 patients, of which 6-month data was analyzed for 102 (39 female; 63 male). Forty-five were treated with ORIF and 57 with FB. We found no difference in the disability of the arm, shoulder and hand (DASH) score, visual analogue score (VAS) or elbow range of motion (ROM) at 6 months. However, 11% of the FB group developed nonunion. Complications in the ORIF group included a 2% infection and nonunion rate and 13% iatrogenic radial nerve dysfunction (RND). ORIF can be expected to result in higher union rates with the inherent risks of infection and RND. Finally, at 6 months, both groups demonstrated higher DASH scores than population norms, indicating a lack of full recovery. (Journal of Surgical Orthopaedic Advances 30(2):067-072, 2021).

Is There a Critical Radiographic Angle That Portends Poor Functional Outcome Scores in Nonoperative Treatment of Isolated Humeral Shaft Fractures?

Our purpose was to evaluate radiographic alignment of nonoperatively treated humerus fractures and determine if there is a critical angle associated with worse outcomes. All patients with humeral shaft fractures that were prospectively followed as part of a larger multicenter trial were reviewed. These patients were selected for nonoperative management based on shared decision making. There were 80 patients that healed with adequate data. The receiver operating characteristic (ROC) had best fit with a sagittal radiographic angle of 10° (AUC: 0.731) and coronal angle of 15° (AUC: 0.580) at 1-year follow-up. We found increased or worse disabilities of the arm, shoulder and hand (DASH) scores with > 10° sagittal alignment or > 15° of coronal alignment. Poor DASH scores were observed at angles lower than previously accepted for nonoperative treatment. These findings are useful in decision making and patient guidance. (Journal of Surgical Orthopaedic Advances 30(2):073-077, 2021).

High Energy Midfoot Fracture-Dislocations: Does Staged Treatment with External Fixation Help?

This study analyzes the outcomes of patients treated for high energy midfoot injuries with temporary stabilization (TS) prior to definitive operative fixation compared to a control group (C) treated initially with splint only. Three Level 1 trauma centers reduced and temporized high energy Lisfranc injuries. A matched control group was compared with the intervention group. Clinical parameters, complications and need for additional surgery were evaluated. There were 15 patients in group C and 29 patients with temporary stabilization (TS). Both the TS and C groups demonstrated no significant difference in the number of additional operations, infection rate, incidence of deep vein thrombosis (DVT), nonunion and need for orthotics postoperatively (p > 0.05). Staged treatment of high energy Lisfranc injuries in the TS group led to a delay in definitive fixation or arthrodesis while having a similar minimal complication rate relative to the controls. This is a Level III, Retrospective Case Control Study. (Journal of Surgical Orthopaedic Advances 29(3):154-158, 2020).

Surgical Telementoring Without Encumbrance: A Comparative Study of See-through Augmented Reality-based Approaches.

OBJECTIVE: This study investigates the benefits of a surgical telementoring system based on an augmented reality head-mounted display (ARHMD) that overlays surgical instructions directly onto the surgeon's view of the operating field, without workspace obstruction. SUMMARY BACKGROUND DATA: In conventional telestrator-based telementoring, the surgeon views annotations of the surgical field by shifting focus to a nearby monitor, which substantially increases cognitive load. As an alternative, tablets have been used between the surgeon and the patient to display instructions; however, tablets impose additional obstructions of surgeon's motions. METHODS: Twenty medical students performed anatomical marking (Task1) and abdominal incision (Task2) on a patient simulator, in 1 of 2 telementoring conditions: ARHMD and telestrator. The dependent variables were placement error, number of focus shifts, and completion time. Furthermore, workspace efficiency was quantified as the number and duration of potential surgeon-tablet collisions avoided by the ARHMD. RESULTS: The ARHMD condition yielded smaller placement errors (Task1: 45%, P < 0.001; Task2: 14%, P = 0.01), fewer focus shifts (Task1: 93%, P < 0.001; Task2: 88%, P = 0.0039), and longer completion times (Task1: 31%, P < 0.001; Task2: 24%, P = 0.013). Furthermore, the ARHMD avoided potential tablet collisions (4.8 for 3.2 seconds in Task1; 3.8 for 1.3 seconds in Task2). CONCLUSION: The ARHMD system promises to improve accuracy and to eliminate focus shifts in surgical telementoring. Because ARHMD participants were able to refine their execution of instructions, task completion time increased. Unlike a tablet system, the ARHMD does not require modifying natural motions to avoid collisions.

How Often Are Protocols Followed at Level I Trauma Centers?

This study analyzes adherence to an evidence-based protocol established at two level I trauma centers to determine its effect on clinical decision making. The centers' trauma databases were retrospectively studied and 51 patients with long bone fractures were identified who required revascularization and orthopaedic intervention and survived long enough to receive an index intervention. An arterial shunt was the protocol's first step; the preprotocol rate of shunting was 9.5%, while the postprotocol rate of shunting was 3.3%. The protocol's next step was external fixation; among the cases managed without a shunt, external fixation was the index intervention in 63.2% of the preprotocol cases and 31.0% of the postprotocol cases. Definitive vascular surgery was routinely performed before external fixation in 28.6% of the preprotocol cases and 56.7% of the postprotocol cases. This study demonstrates that this evidence-based protocol had no effect on the management of patients with combined orthopaedic and vascular injuries. Protocols should never supersede clinical judgment, but poor protocol adherence may represent a need for trauma centers to routinely review their protocols' compliance and efficacy. (Journal of Surgical Orthopaedic Advances 27(2):109-112, 2018).

A Retrospective Comparative Analysis of the Use of Implantable Bone Stimulators in Nonunions.

This study details the use of implantable bone stimulators in the setting of nonunion. A retrospective comparative analysis was used to evaluate the efficacy of implantable bone stimulators in achieving union in the setting of atrophic or oligotrophic nonunion by two fellowship-trained orthopaedic trauma surgeons. Initially, 72 patients underwent surgical intervention for nonunion. Twenty-one patients had an implantable bone stimulator placed at the time of nonunion surgery. Thirty-eight patients had a minimum of 1-year follow-up. An implantable bone stimulator was used in 13 patients and 25 patients did not have a bone stimulator. The use of implantable bone stimulators was found to be significantly associated with increased union rates (p = .042). (Journal of Surgical Orthopaedic Advances.

How High Can You Go?: Retrograde Nailing of Proximal Femur Fractures.

There are no data-supported recommendations on how proximal is too proximal for retrograde nailing (RGN). At six level 1 trauma centers, patients with femur fractures within the proximal one-third of the femur treated with RGN were included. This article describes a proximal segment capture ratio (PSCR) and nail segment capture ratio to evaluate RGN of proximal fractures. The study included 107 patients. The average follow-up was 44 weeks. There were two nonunions and three malunions. There was no significant difference between PSCR of 0.3 or less and need for secondary procedures or time to full weight bearing (p>.05). In this study, a smaller (< 0.3) PSCR was not associated with an increased number of complications. A higher Orthopaedic Trauma Association classification was predictive of malunion and increased time to union. These data demonstrate that retrograde nailing is safe and effective for the treatment of supraisthmal femur fractures.

Skeletal Traction for Isolated Femur Fractures Does Not Reduce Opioid Consumption.

OBJECTIVES: Isolated femoral shaft fractures can be treated preoperatively with skeletal traction (TXN) or maintenance of a position of comfort (COMF). The goal of this retrospective review was to determine whether preoperative opioid consumption differs significantly between these forms of treatment. DESIGN: Case-control retrospective study. SETTING: Two academic Level 1 trauma centers. PATIENT SELECTION CRITERIA: Patients presenting to the emergency department with isolated OTA/AO 32A-C femoral shaft fractures from 2017 to 2020. OUTCOME MEASURES AND COMPARISONS: The primary outcome was preoperative opioid consumption (morphine milligram equivalents) comparing patients treated with application of TXN or placed in a position of COMF. RESULTS: Two hundred and twenty patients were studied (COMF n = 167, TXN n = 53). Multivariate regression analysis revealed significantly greater preoperative opioid consumption in the emergency department for the TXN group compared with COMF (2.6 more morphine milligram equivalents [confidence interval, 0.23-4.96], P = 0.031). There was no difference in preoperative opioid consumption between groups on the hospital floor ( P = 0.811) nor during the entire preoperative course ( P = 0.486). The total preoperative rate of opioid consumption (morphine milligram equivalents/hour) did not differ ( P = 0.825). CONCLUSIONS: Patients with isolated femoral shaft fractures treated preoperatively with skeletal traction consumed more opioids in the emergency department compared with patients treated in a position of comfort, but no difference in opioid consumption was observed between groups for the entire preoperative course. A position of comfort may be considered as an acceptable alternative to skeletal traction for patients with isolated femur fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Multicenter, Prospective, Observational Study of Nonoperative Versus Operative Treatment for High-Energy Midshaft Clavicle Fractures.

OBJECTIVES: Evaluate if nonoperative or operative treatment of displaced clavicle fractures delivers reduced rates of nonunion and improved Disability of the Arm, Shoulder, and Hand (DASH) scores. DESIGN: Multicenter, prospective, observational. SETTING: Seven Level 1 Trauma Centers in the United States. PATIENT SELECTION CRITERIA: Adults with closed, displaced (100% displacement/shortened >1.5 cm) midshaft clavicle fractures (Orthopaedic Trauma Association 15.2) were treated nonoperatively, with plates and screw fixation, or with intramedullary fixation from 2003 to 2018. OUTCOME MEASURES AND COMPARISONS: DASH scores (2, 6 weeks, 3, 6, 12, and 24 months), reoperation, and nonunion were compared between the nonoperative, plate fixation, and intramedullary fixation groups. RESULTS: Four hundred twelve patients were enrolled, with 203 undergoing plate fixation, 26 receiving intramedullary fixation, and 183 treated nonoperatively. The average age of the nonoperative group was 40.1 (range 18-79) years versus 35.8 (range 18-74) in the plate group and 39.3 (range 19-56) in the intramedullary fixation group (P = 0.06). One hundred forty (76.5%) patients in the nonoperative group were male compared with 154 (75.9%) in the plate group and 18 (69.2%) in the intramedullary fixation group (P = 0.69). All groups showed similar DASH scores at 2 weeks, 12 months, and 24 months (P > 0.05). Plate fixation demonstrated better DASH scores (median = 20.8) than nonoperative (median = 28.3) at 6 weeks (P = 0.04). Intramedullary fixation had poorer DASH scores at 6 weeks, 3 months, and 6 months than plate fixation and worse DASH scores than nonoperative at 6 months (P < 0.05). The nonunion rate for nonoperative treatment (14.6%) was significantly higher than the plate group (0%) (P < 0.001). CONCLUSIONS: Operative treatment of displaced clavicle fractures provided lower rates of nonunion than nonoperative treatment. Except at 6 weeks, no difference was observed in DASH scores between plate fixation and nonoperative treatment. Intramedullary fixation resulted in worse DASH scores than plate fixation at 6 weeks, 3 months, and 6 months and worse DASH scores than nonoperative at 6 months. Implant removal was the leading reason for reoperation in the plate and intramedullary fixation groups, whereas surgery for nonunion was the primary reason for surgery in the nonoperative group. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Early Results of Orthopaedic Trauma and Anemia: Conservative Versus Liberal Transfusion Strategy.

INTRODUCTION: The purpose of this study was to determine whether it is safe to use a conservative packed red blood cell transfusion hemoglobin threshold (5.5 g/dL) compared with a liberal transfusion threshold (7.0 g/dL) for asymptomatic patients with musculoskeletal-injured trauma out of the initial resuscitative period. METHODS: This was a multicenter, prospective, nonblinded, randomized study done at three level 1 trauma centers. One hundred patients were enrolled. One patient was inappropriately enrolled, withdrawn from the study, and excluded from analysis leaving 99 patients (49 liberal and 50 conservative) with 30-day follow-up. After initial resuscitation, patients were enrolled and randomized to either a liberal or a conservative transfusion strategy. This strategy was followed throughout the index hospitalization. The primary outcome of the study was infection. Superficial infection was defined as clinical diagnosis of cellulitis or other superficial infection treated with oral antibiotics only. Deep infection was defined as clinical diagnosis of fracture-related infection requiring IV antibiotics and/or surgical débridement. RESULTS: Ninety-nine patients were successfully followed for 30 days with 100% follow-up during this time. Seven infections (14%) occurred in the liberal group and none in the conservative group ( P < 0.01). Five deep infections (10%) occurred in the liberal group and none in the conservative group ( P = 0.03). Three superficial infections (6%) occurred in the liberal and none in the conservative group, which was not a significant difference ( P = 0.1). No difference was observed in length of stay between groups. DISCUSSION: Transfusing young healthy asymptomatic patients with orthopaedic trauma for hemoglobin <7.0 g/dL increases the risk of infection. No increased risk of anemia-related complications was identified with a conservative transfusion threshold of 5.5 g/dL. DATA AVAILABILITY AND TRIAL REGISTRATION NUMBERS: Data are available on request. IRB protocol number is 1402557771. This study was registered with Clinicaltrials.gov identifier NCT02972593. LEVEL OF EVIDENCE: Level 2, unblinded prospective randomized multicenter study.

Orthopaedic Trauma and Anemia: Conservative versus Liberal Transfusion Strategy: A Prospective Randomized Study.

OBJECTIVES: To determine whether it is safe to use a conservative packed red blood cell transfusion hemoglobin (Hgb) threshold (5.5 g/dL) compared with a liberal transfusion threshold (7.0 g/dL) for asymptomatic musculoskeletal injured trauma patients who are no longer in the initial resuscitative period. METHODS: Design: Prospective, randomized, multicenter trial. SETTING: Three level 1 trauma centers. PATIENT SELECTION CRITERIA: Patients aged 18-50 with an associated musculoskeletal injury with Hgb less than 9 g/dL or expected drop below 9 g/dL with planned surgery who were stable and no longer being actively resuscitated were randomized once their Hgb dropped below 7 g/dL to a conservative transfusion threshold of 5.5 g/dL versus a liberal threshold of 7.0 g/dL. OUTCOME MEASURES AND COMPARISONS: Postoperative infection, other post-operative complications and Musculoskeletal Functional Assessment scores obtained at baseline, 6 months, and 1 year were compared for liberal and conservative transfusion thresholds. RESULTS: Sixty-five patients completed 1 year follow-up. There was a significant association between a liberal transfusion strategy and higher rate of infection (P = 0.01), with no difference in functional outcomes at 6 months or 1 year. This study was adequately powered at 92% to detect a difference in superficial infection (7% for liberal group, 0% for conservative, P < 0.01) but underpowered to detect a difference for deep infection (14% for liberal group, 6% for conservative group, P = 0.2). CONCLUSIONS: A conservative transfusion threshold of 5.5 g/dL in an asymptomatic young trauma patient with associated musculoskeletal injuries leads to a lower infection rate without an increase in adverse outcomes and no difference in functional outcomes at 6 months or 1 year. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Tranexamic Acid and Holding Venous Thromboembolism Prophylaxis Morning of Surgery Do Not Decrease Transfusion Requirements in Patients Undergoing Anterior Intrapelvic Approach for Acetabular Open Reduction and Internal Fixation.

INTRODUCTION: The objective of this study was to determine factors that may affect transfusion rates for patients requiring an anterior intrapelvic (AIP) approach for an acetabulum fracture. METHODS: This was a multicenter retrospective comparison study (3 trauma centers at two urban academic centers). Patients who had an AIP approach for an acetabulum fracture without other notable same-day procedures (irrigation and débridement and/or external fixation were only other allowed procedures) were included. One hundred ninety-five adult (18 and older) patients had adequate records to complete analysis with no preexisting coagulopathy. The main outcome evaluated was the number of units transfused at the time of surgery and up to 7 days after surgery. RESULTS: Factors that were found to affect intraoperative transfusion rates were older age, lower preoperative hematocrit, longer surgery duration, and requiring increased intraoperative intravenous fluids. Factors that did not affect transfusion rate included sex, body mass index, hip dislocation at the time of injury, fracture pattern, AIP approach alone or with lateral window ± distal extension, Injury Severity Score, preoperative platelet count, use of tranexamic acid, and venous thromboembolism prophylaxis received morning of surgery. When followed out through the remainder of a week after surgery, the results for any factor did not change. DISCUSSION: In this large multicenter retrospective study of patients requiring an AIP approach, tranexamic acid and use of venous thromboembolism prophylaxis (or holding it the morning of surgery) did not affect transfusion rates either during surgery or up to a week after surgery. Older age, lower preoperative hematocrit level, longer surgery time, and increased intraoperative intravenous fluids were associated with higher transfusion rates. DATA AVAILABILITY AND TRIAL REGISTRATION NUMBERS: Data are available on request. LEVEL OF EVIDENCE: Level 3, retrospective case-control study.

Early Treatment of Acetabular Fractures Using an Anterior Approach Increases Blood Loss but not Packed Red Blood Cell Transfusion.

OBJECTIVE: The objective of this study was to determine whether time from hospital admission to surgery for acetabular fractures using an anterior intrapelvic (AIP) approach affected blood loss. DESIGN: Retrospective review. SETTING: Three level 1 trauma centers at 2 academic institutions. PATIENT SELECTION CRITERIA: Adult (18 years or older) patients with no pre-existing coagulopathy treated for an acetabular fracture via an AIP approach. Excluded were those with other significant same day procedures (irrigation and debridement and external fixation were the only other allowed procedures). OUTCOME MEASURES AND COMPARISONS: Multiple methods for evaluating blood loss were investigated, including estimated blood loss (EBL), calculated blood loss (CBL) by Gross and Hgb balance methods, and packed red blood cell (PRBC) transfusion requirement. Outcomes were evaluated based on time to surgery. RESULTS: 195 patients were studied. On continuous linear analysis, increasing time from admission to surgery was significantly associated with decreasing CBL at 24 hours (-1.45 mL per hour by Gross method, P = 0.003; -0.440 g of Hgb per hour by Hgb balance method, P = 0.003) and 3 days (-1.69 mL per hour by Gross method, P = 0.013; -0.497 g of Hgb per hour by Hgb balance method, P = 0.010) postoperative, but not EBL or PRBC transfusion. Using 48 hours from admission to surgery to define early versus delayed surgery, CBL was significantly greater in the early group compared to the delayed group (453 [IQR 277-733] mL early versus 364 [IQR 160-661] delayed by Gross method, P = 0.017; 165 [IQR 99-249] g of Hgb early versus 143 [IQR 55-238] g Hgb delayed by Hgb balance method, P = 0.035), but not EBL or PRBC transfusion. In addition, in multivariate linear regression, neither giving tranexamic acid nor administering prophylactic anticoagulation for venous thromboembolism on the morning of surgery affected blood loss at 24 hours or 3 days postoperative ( P > 0.05). CONCLUSION: There was higher blood loss with early surgery using an AIP approach, but early surgery did not affect PRBC transfusion and may not be clinically relevant. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Hip Fracture Repair by the Post-Call Surgeon: A Multicenter Retrospective Review.

INTRODUCTION: The purpose of this study was to evaluate surgeons' ability to perform or supervise a standard operation with agreed-upon radiologic parameters after being on call. METHODS: We reviewed a consecutive series of patients with intertrochanteric hip fractures treated with a fixed angle device at 9 centers and compared corrected tip-apex distance and reduction quality for post-call surgeons versus those who were not. Subgroup analyses included surgeons who operated the night before versus not and attending-only versus resident involved cases. Secondary outcomes included union and perioperative complications. RESULTS: One thousand seven hundred fourteen patients were of average age 77 years. Post-call surgeons treated 823 patients and control surgeons treated 891. Surgical corrected tip-apex distance did not differ between groups: on-call 18 mm versus control 18 mm (P = 0.59). The Garden indices were 160° on the AP and 179° on the lateral in both groups. In 66 cases performed by surgeons who operated the night before, the TAD was 17 mm. No difference was noted in corrected tip-apex distance with and without resident involvement (P = 0.101). No difference was observed in pooled fracture-related complications (P = 0.23). CONCLUSION: Post-call surgeons demonstrated no difference in quality and no increase in complications when performing hip fracture repair the next day compared with surgeons who were not on call.

Chitosan Sponges Are Associated With Higher Rates of Wound Complications Compared to Calcium Sulfate Beads.

Background In this study, we aimed to determine if there is a difference in the rates of wound dehiscence, delayed union, nonunion, and unanticipated surgery after the use of bioabsorbable local antibiotic-delivery systems (LADS), specifically comparing antibiotic-impregnated calcium sulfate pellets (Osteoset-T, Wright Medical Technology Inc., Arlington, TN, USA, hereafter referred to as beads) and chitosan sponge (Sentrex BioSponge, Bionova Medical, Germantown, TN, USA, hereafter referred to as sponges) in the management of acute and chronic extremity wounds. Methodology We conducted a retrospective comparative cohort study in the setting of a level 1 trauma center. All patients who received either beads or sponges as an adjunct to surgical debridement from January 2010 to December 2017 were included, and 136 patients met the inclusion criteria. The intervention studied was extremity wounds that were treated with bioabsorbable LADS, either beads or sponges. The main outcome measurement was wound dehiscence and the need for unanticipated surgery. Results Of the 136 patients in the study cohort, 78% (106/136) were treated with beads, and 22% (30/136) were treated with sponges. Of the 136 patients, 50 (37%) experienced wound dehiscence, and 49 patients required unanticipated surgery. Overall, 62% (31/50) of patients with wound dehiscence and 67.4% (33/49) of patients requiring unanticipated surgery were seen in the bead cohort (p = 0.0001 and 0.025, respectively). However, in multivariable analyses, we found that the odds of having wound dehiscence and undergoing unanticipated surgery were, respectively, 4.9 (p = 0.001) and 2.8 (p = 0.021) times more likely to occur in the sponge than in the bead group. Conclusions Sentrex sponges appear to be associated with higher rates of wound dehiscence and the need for unanticipated surgery compared to Osteoset beads.