Ketorolac and bone healing: a review of the basic science and clinical literature.

Although the efficacy of ketorolac in pain management and the short duration of use align well with current clinical practice guidelines, few studies have specifically evaluated the impact of ketorolac on bony union after fracture or surgery. The purpose of this study was to review the current basic science and clinical literature on the use of ketorolac for pain management after fracture and surgery and the subsequent risk of delayed union or nonunion. Animal studies demonstrate a dose-dependent risk of delayed union in rodents treated with high doses of ketorolac for 4 weeks or greater; however, with treatment for 7 days or low doses, there is no evidence of risk of delayed union or nonunion. Current clinical evidence has also shown a dose-dependent increased risk of pseudoarthrosis and nonunion after post-operative ketorolac administration in orthopedic spine surgery. However, other orthopedic subspecialities have not demonstrated increased risk of delayed union or nonunion with the use of peri-operative ketorolac administration. While evidence exists that long-term ketorolac use may represent risks with regard to fracture healing, insufficient evidence currently exists to recommend against short-term ketorolac use that is limited to the peri-operative period. LEVEL OF EVIDENCE V: Narrative Review.

The geriatric distal femur fracture: nail, plate or both?

Surgical fixation of distal femur fractures in geriatric patients is an evolving topic. Unlike hip fractures, treatment strategies for distal femur fractures are ill-defined and lack substantive high-quality evidence. With an increasing incidence and an association with significant morbidity and mortality, it is essential to understand existing treatment options and their supporting evidence. Current fixation methods include the use of either retrograde intramedullary nails, or plate and screw constructs. Due to the variability in fracture patterns, the unique anatomy of the distal femur, and the presence or absence or pre-existing implants, decision-making as to which method to use can be challenging. Recent literature has sought to describe the advantages and disadvantages of each, however, there is currently no consensus on a standard of care, and little randomized evidence is available that directly compares intramedullary nails with plating. Future randomized studies comparing intramedullary nails with plating constructs are necessary in order to develop a standard of care based on injury characteristics.

Comparison of true blood loss between short and long cephalomedullary nail fixation of geriatric hip fractures, a retrospective cohort study.

PURPOSE: Existing literature is discrepant on the differences in blood loss and need for transfusion between short and long cephalomedullary nails used for extracapsular geriatric hip fractures. However, prior studies used the inaccurate estimated rather than the more accurate 'calculated' blood loss based on hematocrit dilution (Gibon in IO 37:735-739, 2013, Mercuriali in CMRO 13:465-478, 1996). This study sought to clarify whether use of short nails is associated with clinically meaningful reductions in calculated blood loss and resultant need for transfusion. METHODS: A retrospective cohort study using bivariate and propensity score-weighted linear regression analyses was conducted examining 1442 geriatric (ages 60-105) patients undergoing cephalomedullary fixation of extracapsular hip fractures over 10 years at two trauma centers. Implant dimensions, pre and postoperative laboratory values, preoperative medications, and comorbidities were recorded. Two groups were compared based on nail length (greater or less than 235 mm). RESULTS: Short nails were associated with a 26% reduction in calculated blood loss (95% confidence interval: 17-35%; p < 10-14) and a 24-min (36%) reduction in mean operative time (95% confidence interval: 21-26 min; p < 10-71). The absolute reduction in transfusion risk was 21% (95% confidence interval: 16-26%; p < 10-13) yielding a number needed to treat of 4.8 (95% confidence interval: 3.9-6.4) with short nails to prevent one transfusion. No difference in reoperation, periprosthetic fracture, or mortality was noted between groups. CONCLUSION: Use of short compared to long cephalomedullary nails for geriatric extracapsular hip fractures confers reduced blood loss, need for transfusion, and operative time without a difference in complications.

Are resident research projects correlated to future subspecialty choice in orthopaedic surgery? A ten-year retrospective review of a single centre's experience.

AIM: To determine (1) frequency of resident research projects being in the same orthopaedic subspecialty that they ultimately choose for fellowship and practice; (2) percentage of research projects that were published. METHODS: Resident Thesis Day programs were independently assessed by two reviewers from 2010 to 2020. Reviewers classified projects based on orthopaedic subspecialty: Spine, Joints, Trauma, Hand, Foot and Ankle, Sports, Pediatrics, Oncology, and Shoulder Elbow. Presenting residents' fellowship subspecialty, current practice specialty, and geographic state of current practice were collected using internet searches. Correlation of residents who completed a thesis day project in the same subspecialty as their fellowship and current practice was calculated. RESULTS: A total of 81 resident physicians, 11 (13.6%) female, were included. In the entire cohort, 50.6% did a thesis day project in a different field than their current or projected subspecialty. Of those who completed, or are currently completing fellowship, 33 (52.4%) did their thesis day project in the same subspecialty as their fellowship. Of the current residents who have matched into fellowship, 46.7% did a thesis day project in the same subspecialty. A total of 51 (63.0%) projects were published. CONCLUSION: The majority of resident research projects were published, and about 50% of orthopaedic residents went on to complete a fellowship and practice in the same subspecialty as their research project. As residents often spend a considerable amount of time and effort on their projects, these findings may help tailor resident education and research curriculums to focus more on research principles than specific orthopedic content.

Validation of a prospective mortality prediction score for hip fracture patients.

PURPOSE: Although mortality prediction tools are the subject of significant interest as components of comprehensive hip fracture protocols, few have been applied or validated to prospectively inform ongoing patient management. Five regional hospitals are currently generating real-time mortality risk scores for all adults at the time of admission using available laboratory and comorbidity data (Cowen et al. J Hosp Med 9(11):720-726, 2014). Although results for aggregated conditions have been published, the primary aim of this study is to determine how well prospectively calculated scores predict mortality for hip fracture patients specifically. METHODS: Using a five-hospital database, 1376 patients who were prospectively scored on admission were identified from January 2013 to April 2017, cross-referencing ICD9/10 diagnosis and procedure codes for AO/OTA 31A1 through 31B3 fractures. Prospective mortality scores have been previously divided into 5 risk categories to facilitate ease of clinical use. Vital status was determined from hospital data, Social Security and Michigan Death Indices. RESULTS: Prospective scores demonstrated good mortality prediction, with AUCs of 0.80, 0.73, 0.74 and 0.74 for in hospital, 30-, 60- and 90-day mortality, respectively. Patients in the top 2 mortality risk categories represented 30% (410/1376) of the cohort and accounted for 78% (25/32) of the inpatient and 59% (57/97) of the 30 day deaths. CONCLUSIONS: Implementation of this real-time mortality risk tool is feasible and valid for the prediction of short- to medium-term mortality risk for hip fracture patients, and potentially offers valuable information to guide ongoing patient management decisions such as admitting service or level of care.

Vertical shear pelvic injury: evaluation, management, and fixation strategies.

Vertical shear pelvic ring fractures are rare and account for less than 1% of all fractures. Unlike severely displaced antero-posterior compression and lateral compression pelvic fractures, patients' mortality is lower. Nevertheless, patients must be managed acutely using well-defined ATLS protocols and institution-specific protocols for haemodynamically unstable pelvic ring fractures. The definitive treatment of vertical shear pelvic fractures is however more controversial with a paucity of literature to recommend the ideal reduction and fixation strategy. While the majority of injuries can be reduced and fixed in a closed manner, orthopaedic traumatologists should be familiar with the contraindications to those techniques as well as options such as tension band plating and lumbo pelvic fixation. Our paper reviews the acute management, associated injuries and definitive reduction and fixation strategies of vertical shear pelvic fractures. In addition, we propose a treatment algorithm for the selection of the most appropriate fixation technique.

Age and dressing type as independent predictors of post-operative infection in patients with acute compartment syndrome of the lower leg.

PURPOSE: The purpose of this study was to determine independent factors, including timing of fasciotomy, that confer an increased risk of post-operative surgical site infection (SSI) in patients presenting with acute compartment syndrome (ACS) of the lower extremity. METHODS: A retrospective analysis was performed on a consecutive cohort of 53 adult patients requiring fasciotomy for lower-extremity fractures complicated by ACS presenting to a single Level I trauma center over a seven-year study period. The primary outcome measure was the incidence of SSI (as defined by the CDC) occurring within 12 months of fasciotomy. Explanatory variables including site of ACS, time of injury, time of fasciotomy, operative findings, and requirement for additional soft tissue coverage procedures were recorded for all patients. Multivariate regression was used to determine independent predictors of post-operative SSI. RESULTS: post-operative SSI was detected in 16 (30.2%) patients. Compared to infection-free patients, patients with post-operative SSI had a significantly higher median age (52.0 vs. 37.0 years, p = 0.010), frequency of intra-operative myonecrosis at time of fasciotomy (31.2% vs. 5.4%, p = 0.021), and requirement for negative-pressure wound therapy [NPWT] (93.7% vs. 45.9%, p = 0.002). Multivariate logistic regression analysis confirmed that requirement for NPWT (odds ratio [OR], 17.10; 95% confidence interval [CI], 1.78-164.0; p = 0.014) and increasing age (OR, 1.07; 95% CI, 1.01-1.14; p = 0.037) were independent predictors of post-operative SSI. Timing of fasciotomy following injury was not independently related to the risk of SSI. CONCLUSIONS: ACS occurs on a spectrum of disease severity that evolves variably over time. Increasing age of the patient and requirement for NPWT following fasciotomy are independent predictors of post-operative SSI following emergent fasciotomy for ACS. Further studies are required to inform optimal treatment strategies in such patients. LEVEL OF EVIDENCE: Therapeutic, Level III.

Factors associated with adverse postoperative outcomes in patients with long bone post-traumatic osteomyelitis.

AIMS: To evaluate short-term clinical and functional outcomes following operative treatment of long bone post-traumatic osteomyelitis (PTOM). METHODS: We retrospectively analyzed a consecutive cohort of 142 adult patients undergoing operative treatment of long bone PTOM at our Level I trauma center over a 10-year study period. In addition to subjective patient evaluations, surveyed postoperative outcomes included incidence of residual infection, fracture malunion or nonunion, and requirement for limb amputation. All included patients had a minimum follow-up of 12 months postoperatively. RESULTS: Patients suffering an adverse postoperative outcome tended to have a higher incidence of polymicrobial infection (25.4 vs. 11.4%, p = 0.042) and requirement for skin grafting (58.1 vs. 37.9%, p = 0.024) and free-flap procedures (43.6 vs. 19.5%, p = 0.003) compared to those achieving complete healing. Sequential administration of parenteral and oral antibiotic therapies was associated with a reduced incidence of adverse postoperative outcome (p = 0.047). DISCUSSION: Patients with long bone PTOM and extensive soft tissue defects often fail to develop complete remission of their symptoms by 12 months postoperatively. Sequential administration of parenteral and oral antibiotics may help to limit infection recurrence. Further research is required to inform optimal treatment strategy.

Diagnostic accuracy of various modalities relative to open bone biopsy for detection of long bone posttraumatic osteomyelitis.

BACKGROUND: Long bone posttraumatic osteomyelitis (PTOM) is a relatively common complication following surgical fixation of open fractures. There is a lacking consensus on ideal strategies for diagnostic evaluation of long bone PTOM. While open bone biopsy and culture is considered the 'gold diagnostic standard,' its cost and invasiveness are often prohibitive and have prompted the search for alternate diagnostic methods. OBJECTIVE: To evaluate the sensitivity and specificity of various diagnostic modalities relative to open bone biopsy and culture for the detection of long bone PTOM. DESIGN: Retrospective cohort study; Level of Evidence, III. SETTING: Urban Level I trauma center and safety-net institution. PATIENTS/PARTICIPANTS: A consecutive cohort of 159 adult patients presenting with long bone PTOM at our Level I trauma center between January 1, 2004, and December 31, 2013, were retrospectively identified. All included patients fulfilled diagnostic criteria for PTOM (as defined by the Center for Disease Control and Prevention) that involved a long bone (femur, fibula, tibia, humerus, radius, and ulna). Patients with diabetic foot infection, septic arthritis, osteomyelitis of the spine/pelvis/hand, or insufficient medical records were excluded. MAIN OUTCOME MEASUREMENTS: Sensitivity and specificity of deep wound culture, soft tissue histopathologic examination, and elevated levels of acute phase reactants [C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and leukocyte count (WBC)] were determined using findings of open bone biopsy and culture as a reference standard. RESULTS: The most common pathogen isolated on open bone culture was staphylococci, contributing to 89 (57%) of 159 cases of long bone PTOM (p < 0.001). Relative to open bone biopsy and culture as the gold diagnostic standard, soft tissue histopathology demonstrated a sensitivity of 69.8% [95% confidence interval (CI) 53.7-82.3%] and specificity of 38.9% (95% CI 18.3-63.9%) for the detection of long bone PTOM. Deep wound culture exhibited a lower sensitivity of 66.0% (95% CI 56.1-74.8%) and specificity of 28.1% (95% CI 12.9-49.5%), a difference that was statistically significant (p = 0.021). Among inflammatory markers, elevated levels of CRP and ESR were equally sensitive for the detection of PTOM compared to open bone biopsy and culture, while WBC was significantly less sensitive (sensitivity 33.2%; 95% CI 25.3-43.7; p < 0.001). CONCLUSION: Soft tissue histopathologic examination and deep wound culture are relatively poor substitutes for the diagnosis of long bone PTOM compared to open bone biopsy and culture. The accurate identification of causative pathogens underlying long bone PTOM is critical for diagnosis and choice of antibiotic treatment. Future studies investigating the use of higher-resolution diagnostic methods are merited.

Development, implementation and evaluation of a patient handoff tool to improve safety in orthopaedic surgery.

OBJECTIVE: To develop, implement and test the effect of a handoff tool for orthopaedic trauma residents that reduces adverse events associated with the omission of critical information and the transfer of erroneous information. DESIGN: Components of this project included a literature review, resident surveys and observations, checklist development and refinement, implementation and evaluation of impact on adverse events through a chart review of a prospective cohort compared with a historical control group. SETTING: Large teaching hospital. PARTICIPANTS: Findings of a literature review were presented to orthopaedic residents, epidemiologists, orthopaedic surgeons and patient safety experts in face-to-face meetings, during which we developed and refined the contents of a resident handoff tool. The tool was tested in an orthopaedic trauma service and its impact on adverse events was evaluated through a chart review. The handoff tool was developed and refined during the face-to-face meetings and a pilot implementation. Adverse event data were collected on 127 patients (n = 67 baseline period; n = 60 test period). INTERVENTION: A handoff tool for use by orthopaedic residents. MAIN OUTCOME MEASUREMENTS: Adverse events in patients handed off by orthopaedic trauma residents. RESULTS: After controlling for age, gender and comorbidities, testing resulted in fewer events per person (25-27% reduction; P < 0.10). CONCLUSIONS: Preliminary evidence suggests that our resident handoff tool may contribute to a decrease in adverse events in orthopaedic patients.

Transarticular plating for acute posterior sternoclavicular joint dislocations: a valid treatment option?

BACKGROUND: Restoration of the sternoclavicular joint after posterior dislocation is important for upper limb function. The proximity of neuro-vascular mediastinal structures makes open reduction and internal fixation (ORIF) a high-risk procedure. The ideal treatment strategy is still debated. Our aim is to review the treatment of acute posterior sternoclavicular joint dislocation with a locking compression plate. MATERIALS AND METHODS: We present our experience of transarticular plating using a locking compression plate for the treatment of three consecutive patients with posterior sternoclavicular dislocation (SCD). Our primary outcome measure was objective functional outcome using DASH (disability of the arm, shoulder and hand) and PROMIS (patient-reported outcomes measurement information system) questionnaires. All patients had a minimum follow-up of six months, and serial radiographs were reviewed to evaluate maintenance of reduction. RESULTS: All three patients presented a posterior SCD with instability refractory to closed reduction. In all three patients, we opted for surgical management using open reduction and fixation with a locking compression plate and allowed early mobilization at two weeks postoperatively. No complications were encountered during follow-up. Good functional outcomes were evidenced by DASH scores of 7.5, 20 and 30, and PROMIS scores were 53.8, 53.8 and 38.1 in each patient, respectively. CONCLUSION: Our experience of transarticular plating using a locking compression plate for posterior SCD is positive, as it allows early mobilization and resulted in good functional outcomes.

Atypical femur fractures in patients receiving bisphosphonate therapy: etiology and management.

Osteoporosis is a growing problem that is projected to affect more than 50% of American adults by 2020. Bisphosphonate therapy is currently the primary mode of treating osteoporosis in this population. While bisphosphonate therapy has been successful in increasing bone mineral density, data has shown an increased risk of atypical femur fractures with prolonged therapy. Atypical femur fractures are characterized by low-energy or atraumatic injuries that occur in the subtrochanteric region. They originate on the medial cortex, travel transversely, and typically have little or no comminution. Conservative therapy is indicated for patients with incomplete fractures without prodromal symptoms. Patients with incomplete fractures and significant prodromal symptoms or visible fracture line on radiographs, those who have failed conservative management, and those with complete fractures should be treated with intramedullary nail fixation. Evaluation should involve imaging of the contralateral femur. Teriparatide therapy may be considered for patients without contraindications. While the incidence of these fractures is low, it is likely that these rates will increase with the aging population and increased prevalence of patients being treated with bisphosphonate therapy.

An observational case series of HIV-positive patients treated with open reduction internal fixation for a closed lower extremity fracture.

OBJECTIVES: The purpose of this study was to investigate the influence of immune deficiency status of HIV-positive patients on postoperative complication such as surgical site infection and nonunions. DESIGN: Retrospective observational cohort study: Level III. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Consecutive adult HIV-positive patients with closed fractures who underwent operative treatment between January 1, 2001 and December 31, 2012. MAIN OUTCOME AND MEASUREMENTS: postoperative complication including infection and fracture nonunion. RESULTS: A total of 42 HIV-positive patients with closed fractures who underwent surgical fracture fixation were identified during the 12-year study time window. Of these, 18 patients were excluded due to incomplete medical records (n = 16) or open fractures (n = 2). The remaining 24 patients with closed fracture treated surgically (19 males and 5 females; mean age 45.1 ± 10.5 years; age range 20-67 years) were included in the study. Within a 6-month period from the time of injury, 16 patients had a CD4+ cell count >200 and five patients had a CD4+ cell count <200 (CD4+ cell count was not available in three patients). Twenty-two patients (91.6 %) were on antiretroviral therapy at the time of injury. Only one patient, with associated end-stage renal failure and diabetes mellitus, developed a postoperative infection (4.2 %). All patients achieved fracture union within 180 days postoperatively, without the need for surgical revisions. CONCLUSIONS: Our study suggests that HIV infection does not seem to correlate with a higher risk for the development of postoperative complication related to surgical site infection and fracture nonunions after operative fixation of closed fractures.

Operative Management of Atypical Femur Fractures.

VIDEO AVAILABLE AT: https://ota.org/education/ota-online-resources/video-library-procedures-techniques/operative-management-atypical#/+/0/score,date_na_dt/desc/.

Comparison of Outcomes at Midterm Follow-up of Operatively and Nonoperatively Treated Isolated Weber B Ankle Fractures.

OBJECTIVES: A novel protocol was previously presented for nonoperative management of Weber B (OTA/AO 44B) ankle fractures with criteria of medial clear space <7 mm on gravity stress (GS) radiographs and ipsilateral superior clear space and contralateral GS medial clear space within 2 mm. This study recruited an operative cohort for comparison of outcomes. DESIGN: Retrospective cohort study. SETTING: Level 1 academic center. PATIENT SELECTION CRITERIA: The recruited operative cohort consisted of patients who may have been considered for the nonoperative protocol, but underwent surgery instead. OUTCOME MEASURES AND COMPARISONS: Kellgren-Lawrence scale for evaluation of arthritis, American Orthopedic Foot and Ankle Society Hindfoot, Olerud Molander Ankle, Lower Extremity Functional Scale (LEFS), and PROMIS (physical function, depression, pain interference) scores for the current operative cohort were compared with that of the original nonoperative cohort. RESULTS: There were 20 patients in the operative cohort and 29 in the original nonoperative cohort. Mean follow-up was 6.9 and 6.7 years, respectively. The following outcome scores were better for the nonoperative cohort compared with the operative, respectively: LEFS, 75.2 and 68.1 ( P = 0.009); Olerud Molander Ankle, 94.1 and 89.0 ( P = 0.05); American Orthopedic Foot and Ankle Society, 98.5 and 91.7 ( P = 0.0003); PROMIS Physical Function, 58.2 and 50.4 ( P = 0.01); PROMIS Pain Interference, 42.2 and 49.7 ( P = 0.004). The PROMIS Depression, 42.8 and 45.4 ( P = 0.29), was not different between groups. All patients achieved union of their fracture. Surgical complications included implant removal (15%), SPN neurapraxia (5%), and delayed wound healing (5%). CONCLUSIONS: In carefully selected patients with isolated Weber B fractures, nonoperative management may be considered because it can lead to equivalent or superior outcomes with none of the risks typically associated with surgical intervention. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The rate of disuse osteopenia in admitted, non-weight-bearing patients.

Disuse osteopenia is a well-recognized consequence of prolonged physical inactivity, but its rate after orthopaedic injuries necessitating non-weight-bearing is not well studied. The purpose of this study was to estimate the rate of disuse osteopenia at the lumbar spine and proximal femur in patients with lower extremity trauma admitted to the hospital. We performed a retrospective chart review of patients with lower extremity trauma with a period of strict non-weight-bearing between completion of two computed tomography (CT) scans. The radiodensity of the proximal femur or lumbar vertebrae was measured from the earliest and latest available CT scans within the non-weight-bearing timeframe. The change in estimated bone mineral density (eBMD) was calculated as a proxy for disuse osteopenia. A total of 189,111 patients were screened, with 17 patients in the proximal femur group and 15 patients in the lumbar spine group meeting inclusion and exclusion criteria. The average rate of change in eBMD of the proximal femur was a decrease of 7.54 HU/day, 95% confidence interval (CI) [3.65, 11.43]. The average rate of change in eBMD of the lumbar spine was an increase of 1.45 HU/day, 95% CI [-3.15, 6.06]. In admitted, non-weight-bearing orthopaedic trauma patients, our novel study suggests that the proximal femur experiences disuse osteopenia during periods of non-weight-bearing, although this finding was not observed at the lumbar spine. The clinical significance of this data underscores the important consideration of disuse osteopenia by all physicians when caring for patients that may require non-weight-bearing restrictions.

Full Reversal of Anticoagulants Before Cephalomedullary Fixation of Geriatric Hip Fractures May Not Be Necessary.

OBJECTIVES: To examine the relationship between anticoagulant and antiplatelet drugs and surgical blood loss for geriatric patients undergoing cephalomedullary nail fixation of extracapsular proximal femur fractures. DESIGN: Multicenter, retrospective, cohort study using bivariate and multivariable regression analyses. SETTING: Two Level-1 trauma centers. PATIENTS: One thousand four hundred forty-two geriatric (ages 60-105 years) patients undergoing isolated primary intramedullary fixation of nonpathologic extracapsular hip fractures from 2009 to 2018 including 657 taking an antiplatelet drug alone (including aspirin), 99 taking warfarin alone, 37 taking a direct oral anticoagulant (DOAC) alone, 59 taking an antiplatelet drug and an anticoagulant, and 590 taking neither. INTERVENTION: Cephalomedullary nail fixation. MAIN OUTCOME MEASUREMENTS: Blood transfusion and calculated blood loss. RESULTS: More patients taking antiplatelet drugs required a transfusion than controls (43% vs. 33%, P < 0.001), whereas patients taking warfarin or DOACs did not (35% or 32% vs. 33%). Median calculated blood loss was increased in patients taking antiplatelet drugs (1275 mL vs. 1059 mL, P < 0.001) but not in patients taking warfarin or DOACs (913 mL or 859 mL vs. 1059 mL). Antiplatelet drugs were independently associated with an odds ratio of transfusion of 1.45 [95% confidence interval (CI), 1.1-1.9] in contrast with 0.76 (95% CI, 0.5-1.2) for warfarin and 0.67 (95% CI, 0.3-1.4) for DOACs. CONCLUSIONS: Geriatric patients taking warfarin (incompletely reversed) or DOACs lose less blood during cephalomedullary nail fixation of hip fractures than those taking aspirin. Delaying surgery to mitigate anticoagulant-related surgical blood loss may be unwarranted. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Compartment Syndrome After Tibial Intramedullary Nail Removal and Intramedullary Debridement: A Case Report.

CASE: A 45-year-old man who sustained an open tibial shaft fracture treated with intramedullary (IM) nailing 9 years earlier presented with persistent pain and concern for occult infection. He underwent tibial nail removal and debridement with reamer-irrigator-aspirator. Postoperative course was complicated by acute compartment syndrome. CONCLUSION: This is a unique case of postoperative compartment syndrome after IM debridement and tibial hardware removal. A high index of suspicion should be prioritized in patients who complain of severe or unexpected pain to mitigate delays in diagnosis and aid in early treatment.

Preoperative Comorbidities Associated With Early Mortality in Hip Fracture Patients: A Multicenter Study.

OBJECTIVE: Multiple comorbidities in hip fracture patients are associated with increased mortality and complications. The goal of this study was to characterize the relationship between specific patient factors including comorbidities and outcomes in geriatric hip fractures, including length of stay, unplanned ICU admission, discharge disposition, complications, and mortality. METHODS: This is a retrospective review of a trauma database from five Level 1 and Level 2 trauma centers of patients with hip fractures of the femoral neck and intertrochanteric region who underwent treatment using hip pinning, hemiarthroplasty, total hip arthroplasty, cephalomedullary nailing, or dynamic hip screw fixation. Mortality was the primary outcome variable (including in-hospital mortality, 30-day mortality, 60-day mortality, and 90-day mortality). Secondary outcome variables included in-hospital adverse events, unplanned transfer to the ICU, postoperative length of stay, and discharge disposition. Regression analyses were used for evaluation of relationships between comorbidities as independent variables and primary and secondary outcomes as dependent variables. RESULTS: Two thousand three hundred patients were included. The mortality was 1.8%, 7.0%, 10.9%, and 14.1% for in-hospital, 30-day, 60-day, and 90-day mortality, respectively. Diabetes and cognitive impairment present on admission were associated with mortality at all-time intervals. COPD was the only comorbidity that signaled in-hospital adverse event with an odds ratio of 1.67 (P = 0.012). No patient factors, time to surgery, or comorbidities signaled unplanned ICU transfer. Patients with renal failure and COPD had longer hospital stays after surgery. CONCLUSION: Geriatric hip fractures continue to have high short-term morbidity and mortality. Identifying patients with increased odds of early mortality and adverse events can help teams optimize care and outcomes. Patients with diabetes, cognitive impairment, renal failure, and COPD may benefit from continued and improved medical optimization during the perioperative period as well as being more closely managed by a medicine team without delaying time to the operating room.

Operative Technique for Sacral Insufficiency Fractures Causing Spinopelvic Dissociation: A Case Report.

CASE: We present a case of a 54-year-old man with atraumatic, U-type sacral insufficiency and L5 compression fractures leading to spinopelvic dissociation, inability to ambulate, and bowel/bladder compromise. The patient underwent L3-4 percutaneous pedicle screw fixation with bilateral iliac bolts and percutaneous iliosacral screw fixation. Postoperatively, the patient had return of bowel/bladder function and independent ambulation at 2.5 years. CONCLUSION: Atraumatic spinopelvic dissociation is an underappreciated pathology in older patients. Here, we describe the result of our preferred treatment strategy, triangular osteosynthesis, to preserve function and independence. Despite optimal, prompt treatment, these injuries pose a difficult rehabilitation process for patients.