The effect of spanning external fixation on entrapped structures in tibial pilon fractures.

PURPOSE: Pilon fractures are often complex injuries involving severe soft tissue injury. Studies have shown pilon fractures may entrap soft tissue structures between fracture fragments. Staged fixation of pilon fractures with spanning external fixation (SEF) is important for soft tissue rest and plays an important role in the management of these injuries. While SEF has been shown to promote soft tissue rest prior to definitive fixation, no studies have shown the effect SEF has on entrapped structures (ES). The purpose of this study was to evaluate how SEF effects ES in pilon fractures. METHODS: A retrospective review of 212 pilon fractures treated at our institution between 2010 and 2022 was performed. Patients with a CT scan pre-SEF and post-SEF met inclusion criteria. CTs were reviewed to characterize ES in pre- and post-SEF imaging. RESULTS: Of the 19 patients with ES identified on CT pre-SEF, seven (36.8%) had full release of ES post-SEF and 12 (63.2%) had no release of ES. The posterior tibial tendon was the most commonly ES and remained entrapped in 62.5% of cases. Only 25% of 43-C3 fractures had release of ES post-SEF, while 100% of 43-C1 and 43-C2 fractures demonstrated complete release of ES post-SEF. CONCLUSION: Entrapped structures in pilon fractures are likely to remain entrapped post-SEF, with only one-third of our cohort demonstrating release. In 43-C3 patterns, if ES are identified on CT pre-SEF, surgeons should consider addressing these either through mini open versus open approaches at the time of SEF as they are likely to remain entrapped post-SEF.

Fracture blisters: predictors for time to definitive fixation in pilon fractures.

PURPOSE: Fracture blisters, a common soft-tissue complication of pilon fractures, are associated with post-operative wound infections, delays in definitive fixation, and alterations in surgical plan. The purpose of this study was to (1) identify the delay in surgery attributable to the presence fracture blisters and (2) investigate the relationship of fracture blisters to comorbidities and fracture severity. METHODS: Patients with pilon fractures at an urban level 1 Trauma center from 2010 to 2021 were identified. The presence or absence of fracture blisters was noted, along with location. Demographic information, time from injury to external fixator placement, and time to definitive open reduction internal fixation (ORIF) were collected. Pilon fractures were classified according to AO/OTA guidelines using CT imaging and plain radiographs. RESULTS: 314 patients with pilon fractures were available for analysis, eighty (25%) of whom were found to have fracture blisters. Patients with fracture blisters had longer time to surgery compared to those without fracture blisters (14.2 days vs 7.9 days, p < 0.001). A greater proportion of patients with fracture blisters had AO/OTA 43C fracture patterns, compared with those without fracture blisters (71.3% vs 53.8%, p = 0.03). Fractures blisters were less likely to be localized over the posterior ankle (12%, p = 0.007). CONCLUSION: The presence of fracture blisters in pilon fractures are associated with significant delays in time to definitive fixation and higher energy fracture patterns. Fracture blisters are less commonly located over the posterior ankle which may support the implementation of a staged posterolateral approach when managing these injures.

Do associated proximal fibula fractures help predict the severity of tibial plateau fractures?

PURPOSE: Proximal fibula fractures are often associated with tibial plateau fractures, but their relationship is poorly characterized. The purpose of this study was to better define the relationship between tibial plateau injury severity and presence of associated soft tissue injuries. METHODS: A retrospective review was performed on all operatively treated tibial plateau fractures at a Level 1 trauma center over a 5-year period. Patient demographics, injury radiographs, CT scans, operative reports and follow-up were reviewed. RESULTS: Queried tibial plateau fractures from 2014 to 2019 totaled 217 fractures in 215 patients. Fifty-two percent were classified as AO/OTA 41B and 48% were AO/OTA 41C. Thirty-nine percent had an associated proximal fibula fracture. The presence of a proximal fibula fracture had significant correlation with AO/OTA 41C fractures, as compared with AO/OTA 41B fractures (chi-square, p < 0.001). Of the patients with a lateral split depression type tibial plateau fracture, the presence of a proximal fibula fracture was associated with more articular comminution, measured by number of articular fragments (mean = 4.0 vs. 2.9 articular fragments, p = 0.004). There was also a higher rate of meniscal injury in patients with proximal fibula fractures (37% vs. 20%, p = 0.003). CONCLUSIONS: There was a significant relationship between the higher energy tibial plateau fracture type (AO/OTA 41C) and the presence of an associated proximal fibula fracture. The presence of a proximal fibula fracture with a tibial plateau fracture is an indicator of a higher energy injury and a higher likelihood of meniscal injury.

Automated Boluses and Delayed-Start Timers Prolong Perineural Local Anesthetic Infusions and Analgesia Following Ankle and Wrist Orthopedic Surgery: A Case-Control Series.

BACKGROUND Continuous peripheral nerve blocks can be administered as continuous infusion, patient-controlled boluses, automated boluses, or a combination of these modalities. MATERIAL AND METHODS Ten patients undergoing either ankle (5) or distal radius (5) open reduction and internal fixation received single-injection ropivacaine sciatic nerve block or infraclavicular brachial plexus block and catheter. Infusion pumps were set to begin administering additional ropivacaine 6 h following the initial block as automated boluses supplemented with patient-controlled boluses. RESULTS Patients had similar pain scores when compared to previously published controls; however, local anesthetic consumption was lower in the patients, resulting in increased infusion and analgesia duration by 1 or more days in each group. CONCLUSIONS For infraclavicular and popliteal sciatic catheters, automated boluses may provide a longer duration of analgesia than continuous infusions following painful hand and ankle surgeries, respectively.

Characterization of electric scooter injuries over 27 months at an urban level 1 trauma center.

BACKGROUND: Electric scooters (e-scooters) have become a widespread method of transportation. The purpose of this study is to provide risk stratification tools for modifiable risk factors associated with e-scooter injury morbidity. METHODS: Patients at an urban Level 1 Trauma center sustaining e-scooter injuries between November 2017 through March 2020 were identified. Primary outcomes of interest were major trauma, as defined by an Injury Severity Score (ISS) >15, or hospital admission. RESULTS: A total of 442 patients sustained orthopaedic (51%), facial (31%), cranial (13%), and chest/abdominal injuries (4.5%). Rate of helmet use was 2.5%, hospital admission was 40.7%, and intensive care was 3%. Patients with facial injuries were half as likely to sustain major trauma as compared to orthopaedic injuries (p < 0.05). Factors with higher likelihood of hospital admission included age > 40 years (OR 4.20, p < 0.01), alcohol or other substance intoxication (OR 4.14 and 9.87, p < 0.001), loss of consciousness (OR 2.72, p < 0.003), or transport to the hospital by ambulance (OR 4.47, p < 0.001). CONCLUSIONS: There is a substantial proportion of major trauma within e-scooter injuries. Modifiable risk factors for hospital admission include use of head protection and substance use while riding e-scooters.

Suture-method versus Through-the-needle Catheters for Continuous Popliteal-sciatic Nerve Blocks: A Randomized Clinical Trial.

BACKGROUND: The basic perineural catheter design has changed minimally since inception, with the catheter introduced through or over a straight needle. The U.S. Food and Drug Administration recently cleared a novel perineural catheter design comprising a catheter attached to the back of a suture-shaped needle that is inserted, advanced along the arc of its curvature pulling the catheter past the target nerve, and then exited through the skin in a second location. The authors hypothesized that analgesia would be noninferior using the new versus traditional catheter design in the first two days after painful foot/ankle surgery with a primary outcome of average pain measured with the Numeric Rating Scale. METHODS: Subjects undergoing painful foot or ankle surgery with a continuous supraparaneural popliteal-sciatic nerve block 5 cm proximal to the bifurcation were randomized to either a suture-type or through-the-needle catheter and subsequent 3-day 0.2% ropivacaine infusion (basal 6 ml/h, bolus 4 ml, lockout 30 min). Subjects received daily follow-up for the first four days after surgery, including assessment for evidence of malfunction or dislodgement of the catheters. RESULTS: During the first two postoperative days the mean ± SD average pain scores were lower in subjects with the suture-catheter (n = 35) compared with the through-the-needle (n = 35) group (2.7 ± 2.4 vs. 3.4 ± 2.4) and found to be statistically noninferior (95% CI, -1.9 to 0.6; P < 0.001). No suture-style catheter was completely dislodged (0%), whereas the tips of three (9%) traditional catheters were found outside of the skin before purposeful removal on postoperative day 3 (P = 0.239). CONCLUSIONS: Suture-type perineural catheters provided noninferior analgesia compared with traditional catheters for continuous popliteal-sciatic blocks after painful foot and ankle surgery. The new catheter design appears to be a viable alternative to traditional designs used for the past seven decades.

What Was the Change in Telehealth Usage and Proportion of No-show Visits for an Orthopaedic Trauma Clinic During the COVID-19 Pandemic?

BACKGROUND: In response to the coronavirus disease 2019 (COVID-19) pandemic, the Centers for Medicare and Medicaid Services pledged payment for telehealth visits for the duration of this public health emergency in an effort to decrease COVID-19 transmission and allow for deployment of residents and attending physicians to support critical-care services. Although the COVID-19 pandemic has vastly expanded telehealth use, no studies to our knowledge have analyzed the implementation and success of telehealth for orthopaedic trauma. This population is unique in that patients who have experienced orthopaedic trauma range in age from early childhood to late adulthood, they vary across the socioeconomic spectrum, may need to undergo emergent or urgent surgery, often have impaired mobility, and, historically, do not always follow-up consistently with healthcare providers. QUESTIONS/PURPOSES: (1) To what extent did telehealth usage increase for an outpatient orthopaedic trauma clinic at a Level 1 trauma center from the month before the COVID-19 stay-at-home order compared with the month immediately following the order? (2) What is the proportion of no-show visits before and after the implementation of telehealth? METHODS: After nonurgent clinic visits were postponed, telehealth visits were offered to all patients due to the COVID-19 stay-at-home order. Patients with internet access who had the ability to download the MyChart application on their mobile device and agreed to a telehealth visit were seen virtually between March 16, 2020 and April 10, 2020 (COVID-19) by three attending orthopaedic trauma surgeons at a large, urban, Level 1 trauma center. Clinic schedules and patient charts were reviewed to determine clinical volumes and no-show proportions. The COVID-19 period was compared with the 4 weeks before March 16, 2020 (pre-COVID-19), when all visits were conducted in-person. The overall clinic volume decreased from 340 to 233 (31%) between the two periods. The median (range) age of telehealth patients was 46 years (20 to 89). Eighty-four percent (72 of 86) of telehealth visits were postoperative and established nonoperative patient visits, and 16% (14 of 86) were new-patient visits. To avoid in-person suture or staple removal, patients seen for their 2-week postoperative visit had either absorbable closures, staples, or nonabsorbable sutures removed by a home health registered nurse or skilled nursing facility registered nurse. If radiographs were indicated, they were obtained at outside facilities or our institution before patients returned home for their telehealth visit. RESULTS: There was an increase in the percentage of office visits conducted via telehealth between the pre-COVID-19 and COVID-19 periods (0% [0 of 340] versus 37% [86 of 233]; p < 0.001), and by the third week of implementation, telehealth comprised approximately half of all clinic visits (57%; [30 of 53]). There was no difference in the no-show proportion between the two periods (13% [53 of 393] for the pre-COVID-19 period and 14% [37 of 270] for the COVID-19 period; p = 0.91). CONCLUSIONS: Clinicians should consider implementing telehealth strategies to provide high-quality care for patients and protect the workforce during a pandemic. In a previously telehealth-naïve clinic, we show successful implementation of telehealth for a diverse orthopaedic trauma population that historically has issues with mobility and follow-up. Our strategies include postponing long-term follow-up visits, having sutures or staples removed by a home health or skilled nursing facility registered nurse, having patients obtain pertinent imaging before the visit, and ensuring that patients have access to mobile devices and internet connectivity. Future studies should evaluate the incidence of missed infections or stiffness as a result of telehealth, analyze the subset of patients who may be more vulnerable to no-shows or technological failures, and conduct patient surveys to determine the factors that contribute to patient preferences for or against the use of telehealth. LEVEL OF EVIDENCE: Level III, therapeutic study.

Continuous Popliteal-Sciatic Blocks for Postoperative Analgesia: Traditional Proximal Catheter Insertion Superficial to the Paraneural Sheath Versus a New Distal Insertion Site Deep to the Paraneural Sheath.

We tested the hypothesis that during a continuous popliteal-sciatic nerve block, postoperative analgesia is improved with the catheter insertion point "deep" to the paraneural sheath immediately distal to the bifurcation between the tibial and common peroneal branches, compared with the traditional approach "superficial" to the paraneural sheath proximal to the bifurcation. The needle tip location was determined to be accurately located with a fluid bolus visualized with ultrasound; however, catheters were subsequently inserted without a similar fluid injection and visualization protocol (visualized air injection was permitted and usually implemented, but not required per protocol). The average pain (0-10 scale) the morning after surgery for subjects with a catheter inserted at the proximal subparaneural location (n = 31) was a median (interquartile) of 1.5 (0.0-3.5) vs 1.5 (0.0-4.0) for subjects with a catheter inserted at the distal supraparaneural location (n = 32; P = .927). Secondary outcomes were similarly negative.

Heterotopic ossification around the knee after tibial nailing and ipsilateral antegrade and retrograde femoral nailing in the treatment of floating knee injuries.

PURPOSE: Floating knee injuries are relatively uncommon injuries. We report the prevalence, location, and severity of heterotopic ossification (HO) around the knee in patients treated with antegrade tibial intramedullary nailing and ipsilateral antegrade versus retrograde femoral intramedullary nailing as well as how the severity of HO around the knee affects knee range of motion (ROM). METHODS: From 2004 to 2014, 26 floating knee injuries were included. Radiographs were reviewed to determine presence, location, and severity of HO. Post-operative knee ROM was determined. RESULTS: A significantly higher prevalence of HO around the knee was detected in the retrograde group (90%) compared to the antegrade group (43%) (p = 0.028). There was a trend for more HO into the patellar tendon occurring in 29% of patients in the antegrade group and 74% in the retrograde group (p = 0.069). The severity of HO was higher for the retrograde group 1.6 ± 1.0 compared to the antegrade group 0.4 ± 0.5 (p = 0.004). There was poor correlation between HO severity and knee ROM. CONCLUSIONS: Treatment of floating knee injuries with a retrograde femoral nail was demonstrated to result in a greater likelihood of developing HO and a greater severity of HO around the knee than if treated with an antegrade femoral nail. However, this increased severity of HO is unlikely to affect ROM. LEVEL OF EVIDENCE: III.

Approaches and fixation of the posterolateral fracture fragment in tibial plateau fractures: a review with an emphasis on rim plating via modified anterolateral approach.

PURPOSE: To review available approaches and fixation methods for posterolateral fracture fragment (PLF) in tibial plateau fracture, and to propose an algorithm to treat various types of plateau fractures which all involve the PLF. METHODS: This article reviews multiple surgical approaches for PLF and suggests an algorithm for suitable approach and fixation method according to PLF with combined plateau fracture. RESULTS: The modified anterolateral approach is a suitable single approach for fractures with a PLF combined with an anterolateral plateau fracture and for isolated posterolateral fracture fragments. For a multicolumn tibia plateau fracture involving the lateral, medial and posterior columns, dual approaches (modified anterolateral and posteromedial approach) can be used to access the entire plateau area. CONCLUSIONS: When considering approaches of this complex fracture pattern, one must consider local soft tissue condition, plateau fracture morphology, associated injuries, and fixation options. After review of multiple approaches described in the literature for PLF fixation, we can suggest an algorithm for the approach and fixation to treat tibial plateau fractures with posterolateral fracture fragments.

Anterior Tibial Artery Danger Zone During Anterolateral Plate Fixation of the Distal Tibia: A 3D Computed Tomography Angiogram Modeling Study.

OBJECTIVES: The objective of this study was to define the danger zone at which the anterior tibial artery (ATA) is at risk during anterolateral plating of the distal tibia using a novel 3D computed tomography angiography (CTA) modeling technique. METHODS: 116 patients (232 lower extremities) who underwent lower extremity CTAs between April 2020 and April 2022 were identified. Those with lower extremity trauma, evidence of a previously healed tibial fracture, or poor visualization of the ATA were excluded. The remaining 150 lower extremities (92 patients) were modeled with an anterolateral distal tibia plate using Sectra IDS7 software. The distance of the ATA from bony landmarks was measured perpendicular to the level at which the vessel intersected the plate. RESULTS: The ATA intersected the plate proximally at a mean distance of 10.5 cm (95% confidence intervals, 10.2-10.9) and at a mean distance of 4.6 cm (95% confidence intervals, 4.4-4.9) distally from the central tibial plafond. The ATA intersected with the plate as far distal as hole number 1 and as proximal as hole 14 of the plate. The greatest injury risk was associated with plate holes 3-8. In this region, the artery was at risk in 46-99 percent of specimens. CONCLUSIONS: The ATA is at risk when screws are placed percutaneously in an anterolateral distal tibia plate. The artery can be as close as 4.4 cm and as far as 10.9 cm proximal to the tibial plafond when crossing the plate, correlating to a risk of injury to the ATA at plate holes 1 through 14.

Patient Characteristics and Outcomes of Geriatric Ankle Fractures: Open Fracture Is the Key Risk Factor for Complications and Functional Decline.

OBJECTIVES: To determine whether open (O) or closed (C) geriatric ankle fractures had different patient characteristics or outcomes. METHODS: . DESIGN: Retrospective cohort study. SETTING: Urban Level 1 trauma center. PATIENT SELECTION CRITERIA: Patients, age 60 years and older, who underwent operative fixation of a rotational ankle fracture (OTA/AO 44A-C) between January 2012 and September 2021. OUTCOME MEASURES AND COMPARISONS: Morbidity, defined as 90-day reoperation, 90-day readmission, or loss of mobility, as well as 1-year mortality compared between patients with closed and open fractures. RESULTS: The open cohort was older (75 years vs. 68 years; P = 0.003) but had similar Charlson comorbidity indices (4.6 O vs. 4.0 C; P = 0.323) and preinjury rates of independent ambulation (70.4% O vs. 80.9% C; P = 0.363). There were higher rates of 1-year mortality (11% vs. 0%; P < 0.001), deep infection (14.8% vs. 3.9%; P = 0.019), and loss of mobility (64.7% vs. 23.0%; P < 0.001) in the open cohort. Multivariate regression identified open fracture as an independent predictor of 90-day reoperation (OR: 20.6; P = 0.022) and loss of mobility (OR: 5.1; P = 0.011). CONCLUSIONS: Despite having comorbidities and preinjury function similar to the closed geriatric ankle fracture cohort, open ankle fracture was independently predictive of greater loss of mobility. Nearly two-thirds of geriatric patients with open ankle fractures experienced a decline in functional independence, compared with 1 in 4 of those with closed fractures. Open fracture was associated with higher rates of deep infection, reoperation, and 1-year mortality. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Ultrasound-Guided Percutaneous Cryoneurolysis for Perioperative Analgesia Following Major Lower Extremity Amputation: A Randomized, Participant- and Observer-Masked, Sham-Controlled Pilot Study.

BACKGROUND: Extremity amputations are associated with pain in both the residual limb and the phantom limb. This pain, which is often debilitating, may be prevented by excellent perioperative pain control. Ultrasound-guided percutaneous cryoneurolysis is an analgesic modality offering pain control for weeks or months following surgery. This treatment has not been compared to the sham procedure for large nerves (e.g., femoral and sciatic) to provide preoperative analgesia. We therefore conducted a randomized, controlled pilot study to evaluate the use of this modality for the treatment of pain following amputation to (1) determine the feasibility of and optimize the study protocol for a subsequent definitive clinical trial; and (2) estimate analgesia and opioid reduction within the first postoperative weeks. METHODS: A convenience sample of seven patients undergoing lower extremity amputation were randomized to receive either active cryoneurolysis or a sham procedure targeting the sciatic and femoral nerves in a participant-masked fashion. This was a pilot study with a relatively small number of participants, and therefore the resulting data were not analyzed statistically. RESULTS: Compared to the participants who received sham treatment (n=3), those who underwent active cryoneurolysis (n=4) reported lower pain scores and decreased opioid consumption at nearly all time points between days one and 21 following amputation. CONCLUSIONS: Ultrasound-guided percutaneous cryoneurolysis of the femoral and sciatic nerves prior to lower extremity amputation appears feasible and potentially effective. The data from this pilot study may be used to power a definitive randomized clinical trial.

Safe and Effective Aspirations and Nerve Blocks for the On-Call Orthopaedic Surgeon.

The on-call orthopaedic surgeon is faced with a wide array of orthopaedic pathology for which intra-articular aspiration, injection, and/or nerve/hematoma block may be used. Efficient use of these diagnostic and therapeutic modalities affords better patient care and a more effective on-call period. Often, these interventions are the rate limiting factor in a reduction or diagnosis. In this review, we describe joint aspirations, saline load tests, hematoma blocks, and nerve blocks in detail to include their indications, techniques, related pharmacology, pearls, and pitfalls.

Review of perioperative outcomes and management of hip fracture patients on direct oral anticoagulants.

Anticoagulation use is common in elderly patients presenting with hip fractures and has been shown to delay time to surgery (TTS). Delays in operative treatment have been associated with worse outcomes in hip fracture patients. Direct oral anticoagulants (DOACs) comprise a steadily increasing proportion of all oral anticoagulation. Currently, no clear guidelines exist for perioperative management of hip fracture patients taking DOACs. DOAC use is associated with increased TTS, with delays frequently greater than 48 h from hospital presentation. Increased mortality has not been widely demonstrated in DOAC patients, despite increased TTS. Timing of surgery was not found to be associated with increased risk of transfusion or bleeding. Early surgery appears to be safe in patients taking DOACs presenting with a hip fracture, but is not currently widely accepted due to factors such as site-specific anesthesiologic protocols that periodically delay surgery. Direct oral anticoagulant use should not routinely delay surgical treatment in hip fracture patients. Surgical strategies to limit blood loss should be considered and include efficient surgical fixation, topical application of hemostatic agents, and the use of intra-operative cell salvage. Anesthesiologic strategies have utility in minimizing risk and a collaborative effort to minimize blood loss should be undertaken by the surgeon and anesthesiologist. Anesthesia team interventions include considerations regarding positioning, regional anesthesia, permissive hypotension, avoidance of hypothermia, judicious administration of blood products, and the use of systemic hemostatic agents.

The Influence of Industry Affiliation on Randomized Controlled Trials of Platelet-Rich Plasma for Knee Osteoarthritis.

BACKGROUND: Industry funding and corporate sponsorship have played a significant role in the advancement of orthopaedic research and technology. However, this relationship raises concerns for how industry association may bias research findings and influence clinical practice. PURPOSE: To determine whether industry affiliation plays a role in the outcomes of randomized controlled trials (RCTs) investigating platelet-rich plasma (PRP). STUDY DESIGN: Meta-analysis; Level of evidence, 2. METHODS: A search of the PubMed, Cochrane, and MEDLINE databases for RCTs published between 2011 and the present comparing PRP versus hyaluronic acid, corticosteroid, or placebo for the treatment of knee osteoarthritis was performed. To determine industry affiliation, the conflict of interest, funding, and disclosure sections of publications were assessed, and all authors were assessed through the American Academy of Orthopaedic Surgeons disclosure database and the Centers for Medicare & Medicaid Services open payments database. Studies were classified as industry affiliated (IA) or non-industry affiliated (NIA). The outcomes of each study were rated as favorable, analogous, or unfavorable according to predefined criteria. RESULTS: A total of 37 studies (6 IA and 31 NIA) were available for analysis. Overall, 19 studies (51.4%) reported PRP as favorable compared with other treatment options, while 18 studies (48.6%) showed no significant differences between PRP and other treatment methods. There was no significant difference in qualitative conclusions between the IA and NIA groups, with the IA group having 3 favorable studies and 3 analogous studies and the NIA group having 16 favorable studies and 15 analogous studies (P = .8881). When comparing IA versus NIA studies using 6- and 12-month Western Ontario and McMaster Universities Arthritis Index and International Knee Documentation Committee scores, there were no significant differences in outcomes. CONCLUSION: The results of this study demonstrated that qualitative conclusions and outcome scores were found to not be associated with industry affiliation. Although the results of this study suggest that there is no influence of industry involvement on RCTs examining PRP, it is still necessary to carefully evaluate pertinent commercial affiliations when reviewing recommendations from studies before adopting new treatment approaches, such as the use of PRP for knee osteoarthritis.

Comparing Propofol With Fentanyl and Midazolam for Sedation in Closed Reductions of Traumatic Hip Dislocations.

Traumatic native hip dislocations require prompt reduction of the dislocation to limit the risk of avascular necrosis and resultant hip arthrosis. Although closed reduction under sedation is frequently attempted, there is minimal evidence about which sedative agent is most safe and effective. The goal of this study was to compare the efficacy of propofol vs combination fentanyl/midazolam for closed reduction under sedation of traumatic native hip dislocations. This was a single-center retrospective review. The main outcome measures were the rate of successful closed reduction with propofol vs combination fentanyl/midazolam and time from the start of sedation to radiographic evidence of reduction. Fifty-four patients with traumatic native hip dislocations were identified. Closed reduction under sedation with propofol was successful in 11 of 14 attempts compared with 4 of 11 attempts with combination fentanyl/midazolam (P=.04). The fentanyl/midazolam group had 6.4 times the odds (95% CI, 1.1-37.7) of failed closed reduction compared with the propofol group. The median time to reduction in the propofol group was 14 minutes vs 45 minutes for the fentanyl/midazolam group (P=.18). Patients who had failed closed reduction with fentanyl/midazolam had a median time to reduction of 100 minutes. There was no difference in sedation-related complications between the 2 groups. We therefore conclude that sedation with propofol is significantly more effective than combination fentanyl/midazolam for closed reduction of native hip dislocations. To minimize unsuccessful reduction attempts and shorten total time to reduction, we recommend against the use of combination fentanyl/midazolam because of the high risk of failure. [Orthopedics. 2023;46(2):86-92.].

Ambulation Distance Within 72 Hours after Surgical Management Is a Predictor of 90-Day Ambulatory Capacity in Elderly Patients with Hip Fracture.

INTRODUCTION: The inability to mobilize after surgical intervention for hip fractures in the elderly is established as a risk factor for greater morbidity and mortality. Previous studies have evaluated the association between the timing and distance of ambulation in the postoperative acute care phase with postoperative complications. The purpose of this study was to evaluate the association between ambulatory distance in the acute postoperative setting and ambulatory capacity at 3 months. METHODS: Patients aged 65 and older who were ambulatory at baseline and underwent surgical intervention for hip fractures from 2014 to 2019 were retrospectively reviewed. Consistent with previous literature, patients were divided into two groups: those who were able to ambulate 5 feet within 72 hours after surgical fixation (early ambulatory) and those who were not (minimally ambulatory). RESULTS: One hundred seventy patients (84 early ambulatory and 86 minimally ambulatory) were available for analysis. Using a multivariable ordinal logistic regression model, variables found to be statistically significant predictors of ambulatory status at 3 months were the ability to ambulate five feet in 72 hours (P < 0.0001), ambulatory distance at discharge (P = 0.012), and time from presentation to surgery (P = 0.039). Patients who were able to ambulate 5 feet within 72 hours had 9 times the odds of being independent ambulators rather than a lower ambulatory class (cane, walker, and nonambulatory). Pertrochanteric fractures were less likely than femoral neck fractures to independently ambulate at 3 months (17.2% vs. 42.3%; P = 0.0006). DISCUSSION: Ambulating 5 feet within 72 hours after hip fracture surgery is associated with an increased likelihood of independent ambulation at 3 months postoperatively. This simple and clear goal may be used to help enhance postoperative mobility and independence while providing a metric to guide therapy and help counsel patients and families.

Falling from new heights: Traumatic fracture burden and resource utilization after border wall height increase.

BACKGROUND: San Diego County hospitals commonly care for patients injured by falls from the United States-Mexico border. From 2018 to 2019, the height of >400 miles of an existing border wall was raised. Prior work has demonstrated a 5-fold increase in traumatic border wall fall injuries after barrier expansion. We aimed to examine the impact of a barrier height increase on fracture burden and resource use. METHODS: We performed a retrospective review of patients admitted to a level 1 trauma center from 2016 to 2021 with lower extremity or pelvic fractures sustained from a border wall fall. We defined the pre-wall group as patients admitted from 2016 to 2018 and the post-wall group as those admitted from 2019 to 2021. We collected demographic and treatment data, hospital charges, weight-bearing status at discharge, and follow-up. RESULTS: A total of 320 patients (pre-wall: 45; post-wall: 275) were admitted with 951 lower extremity fractures (pre-wall: 101; post-wall: 850) due to border wall fall. Hospital resources were utilized to a greater extent post-wall: a 537% increase in hospital days, a 776% increase in intensive care unit days, and a 468% increase in operative procedures. Overall, 86% of patients were non-weight-bearing on at least 1 lower extremity at discharge; 82% were lost to follow-up. CONCLUSION: Traumatic lower extremity fractures sustained from border wall fall rapidly rose after the wall height increase. Hospital resources were used to a greater extent. Patients were frequently discharged with weight-bearing limitations and rarely received scheduled follow-up care. Policymakers should consider the costs of caring for border fall patients, and access to follow-up should be expanded.

Musculoskeletal injuries sustained at the California, USA: Baja California, Mexico border.

BACKGROUND: Individuals attempting to enter the USA from Mexico at non-authorized points along the border fence often sustain injuries requiring medical intervention. We evaluated characteristics of this patient population and their hospital care to better understand patient treatment needs. Given the high-velocity nature of these injuries, we hypothesized that higher pain scores would be associated with longer lengths of hospital stay. METHODS: In this cross-sectional study, we selected records of all patients from 2013 to 2019 who received care by the Orthopaedic Surgery department following an injury sustained at the California-Baja California border. We evaluated demographics, musculoskeletal injuries, procedures, length of hospital stay (LOS), follow-up, and pain scores via retrospective chart review. We used linear regression, adjusting for age and gender, to evaluate associations between pain scores and hospital LOS. RESULTS: Among all 168 patients, there were 248 total injuries comprised of 46% lower extremity, 15% upper extremity, 17% spine, and 4% pelvic injuries. Average age at injury was 33 ± 10, 74% were male, and 85% identified as Hispanic. Of this patient population, 68% underwent operative interventions, 26% sustained open injuries, and 21% required external fixation for initial injury stabilization. Thirteen percent were seen for follow-up after discharge. Spine (n = 42), pilon (n = 36), and calcaneus fractures (n = 25) were the three most common injury types. Average LOS for all patients was 7.8 ± 8.1 days. Pain scores were not significantly associated with LOS ( p = 0.08). However, for every surgical procedure performed, hospital LOS was increased by 5.16 ± 0.47 days (p < 0.001). CONCLUSION: Many injuries incurred by patients crossing the border were severe, requiring multiple surgical interventions and a prolonged LOS. The higher number of procedures was significantly associated with longer LOS in all operatively treated patients. Future studies are needed to determine how we can optimize care for this unique patient population and facilitate post-discharge care.