Evaluation of distal tibia slope in pilon fractures after surgical fixation.

INTRODUCTION: Alteration of sagittal alignment during fracture fixation directly impacts ankle motion in dorsiflexion and plantarflexion. Previously research measured the anterior distal tibia angle (ADTA) in a normal healthy population. The null hypothesis for this study is that ADTA is restored to normal range following unstable pilon fractures. The aim of this study is to identify the range of the ADTA in distal tibia fractures after surgical fixation, compared to a previously published normal population. MATERIAL AND METHODS: A retrospective review of operative distal tibia fractures (AO/OTA classification 43A and 43C - 43B were excluded due to lower likelihood of fracture changing the ADTA) was performed. ADTA on lateral radiograph was measured as the angle relative to the tibia shaft. RESULTS: 100 patients with post-operative radiographs that met inclusion criteria were analyzed. The average ADTA was 6.9° (⌠=4.62°) with a maximum slope of 19.2° (i.e. anterior orientation) and a minimum of -3.3° (i.e. posterior orientation). The uninjured population had an average ADTA of 6.0° (range -2.0°-14°, ⌠=3.0°). CONCLUSION: This analysis shows the average distal tibia sagittal alignment in the post-surgical group is similar to a normal, uninjured population. Large alterations in ADTA would directly impact the ankle in the plane of motion (i.e. negative ADTA would decrease ankle dorsiflexion). Considering ADTA as an objective intra-operative parameter optimizes sagittal plane alignment.

Wearable Sensors in Other Medical Domains with Application Potential for Orthopedic Trauma Surgery-A Narrative Review.

The use of wearable technology is steadily increasing. In orthopedic trauma surgery, where the musculoskeletal system is directly affected, focus has been directed towards assessing aspects of physical functioning, activity behavior, and mobility/disability. This includes sensors and algorithms to monitor real-world walking speed, daily step counts, ground reaction forces, or range of motion. Several specific reviews have focused on this domain. In other medical fields, wearable sensors and algorithms to monitor digital biometrics have been used with a focus on domain-specific health aspects such as heart rate, sleep, blood oxygen saturation, or fall risk. This review explores the most common clinical and research use cases of wearable sensors in other medical domains and, from it, derives suggestions for the meaningful transfer and application in an orthopedic trauma context.

Postoperative pain score does not correlate with injury severity in isolated tibial plateau fractures.

PURPOSE: Appropriate management of acute postoperative pain is critical for patient care and practice management. The purpose of this study was to determine whether postoperative pain score correlates with injury severity in tibial plateau fractures. METHODS: A retrospective review of prospectively collected data was completed at a single academic level one trauma center. All adult patients treated operatively for tibial plateau fractures who did not have concomitant injuries, previous injury to the ipsilateral tibia or knee joint, compartment syndrome, inadequate follow-up, or perioperative regional anesthesia were included (n = 88). The patients were split into groups based on the AO/OTA fracture classification (B-type vs C-type), energy mechanism, number of surgical approaches, need for temporizing external fixation, and operative time as a proxy for injury severity. The primary outcome measure was the visual analog scale (VAS) pain score (average in the first 24 h, highest in the first 24 h, two- and six-week postoperative appointments). Psychosocial and comorbid factors that may affect pain were studied and controlled for (history of diabetes, neuropathy, anxiety, depression, PTSD, and previous opioid prescription). Additionally, opioid use in the postoperative period was studied and controlled for (morphine milligram equivalents (MME) administered in the first 24 h, discharge MME/day, total discharge MME, and opioid refills). RESULTS: VAS scores were similar between groups at each time point except the two-week postoperative time point. At the two-week postoperative time point, the absolute difference between the groups was 1.3. The groups were significantly different in several injury and surgical variables as expected, but were similar in all demographic, comorbid, and postoperative opioid factors. CONCLUSIONS: There was no clinical difference in postoperative pain between AO/OTA 41B and 41C tibial plateau fractures. This supports the idea of providers uncoupling nociception and pain in postoperative patients. Providers should consider minimizing extended opioid use, even in more severe injuries.

Dysphagia is associated with increased mortality risk after hip fracture surgery.

PURPOSE: This study aims to explore the prevalence of dysphagia, as well as mortality associated with dysphagia in the elderly population receiving surgical treatment for a hip fracture. METHODS: A retrospective cohort study was completed at an academic level 1 tertiary care center. Patients older than or equal to 65 admitted with a hip fracture diagnosis from January 2015 to December 2020 (n = 617) were included. The main outcome was the prevalence of dysphagia and association with mortality. Secondary analysis included timing of dysphagia and contributions to mortality. RESULTS: Fifty-six percent of patients had dysphagia, and the mortality rates were higher in patients with dysphagia (8.9%) versus those without dysphagia (2.6%), chi-square p = 0.001, and odds ratio 3.69 (CI 1.6-8.5). Mortality rates in patients with acute dysphagia were also higher (12.4%) than those with chronic dysphagia (5%) and chi-squared p = 0.02. Mortality rates in patients with a perioperative dysphagic event (13.9%) were higher than those with non-perioperative dysphagia (4%) and chi-squared p = 0.001. Mortality rates in patients who had acute perioperative dysphagia (21.2%) were higher than those with chronic dysphagia that presented perioperatively (6.8%) and chi-squared p = 0.006. CONCLUSIONS: This study demonstrates high rates of dysphagia in the elderly hip fracture population and a significant association between dysphagia and mortality. Timing and chronicity of dysphagia were relevant, as patients with acute perioperative dysphagia had the highest mortality rate. Unlike other identified risk factors, dysphagia may be at least partially modifiable. More research is needed to determine whether formal evaluation and treatment of dysphagia lowers mortality risk.

Traumatic brain injury is common and undertreated in the orthopaedic trauma population.

INTRODUCTION: Traumatic brain injuries (TBIs) can be difficult to diagnose and are often marginalized when compared to more obvious physical injuries. Despite this, recognition and early treatment can lead to improved outcomes. Even mild TBIs have the potential to cause significant long-term consequences for patients, which may affect their physical recovery from orthopaedic injuries. The objective of this study was to examine the incidence and treatment of TBI within the orthopaedic trauma population. METHODS: Inclusion criteria were all patients presenting after an acute trauma with an orthopaedic surgery consult over a continuous 3 month timeframe (n = 187). A retrospective review was completed at an academic tertiary referral trauma center. The primary outcome was the rate of TBI. Secondary outcomes included rate of TBI listed as a discharge diagnosis and rate of follow up plan. Several secondary variables were noted and their associations with TBI evaluated. RESULTS: 27 % of the 187 patients had an acute TBI. 61 % of TBI patients had the diagnosis listed in their discharge summary. 6 % had a follow up plan. The positive TBI group was associated with more high energy injuries (p = 0.032), average limbs involved (p = 0.007), upper extremity injury (p < 0.001), bilateral lower extremity injury (p = 0.004), and Injury Severity Score (p < 0.001). 82 % of patients with an acute TBI had an occupational therapy consult and 39 % had a neurosurgery consult. 24 % of patients with a TBI were admitted to the orthopaedic primary service. CONCLUSIONS: Patients presenting after an acute trauma with orthopaedic injuries have high rates of TBI, but low rates of diagnosis and treatment. This lack of diagnosis and treatment can negatively impact recovery from orthopaedic injuries. Orthopaedic providers should be aware of the diagnostic criteria and initial treatment steps for TBI to ensure prompt and effective treatment, which has been shown to improve outcomes.

Evaluation of a 30-day-mortality risk calculator for patients undergoing surgical fixation of fragility hip fractures.

INTRODUCTION: Hip fractures often occur in medically complex patients and can be associated with high perioperative mortality. Mortality risk assessment tools that are specific to hip fracture patients have not been extensively studied. The objective of this study is to evaluate a recently published 30-day mortality risk calculator (Hip Fracture Estimator of Mortality Amsterdam [HEMA]) in a group of patients treated at a university health system. MATERIALS & METHODS: 625 patients treated surgically for hip fractures between 2015 and 2020 at our institution were retrospectively reviewed. Patients younger than age 65, periprosthetic fractures, revision procedures, and fractures treated non-operatively were excluded. Univariate and multivariate analyses were used to determine significant relationships between variables and 30-day mortality after surgery. Additional patient-specific risk factors not included in the original risk calculator were also evaluated. RESULTS: The observed 30-day mortality was 5.6%. HEMA score was significantly associated with 30-mortality, though our cohort had significantly lower mortality rates in high-risk patients than expected based on the HEMA tool. In analyzing patient characteristics not included in HEMA score, history of dementia and elevated troponin were significantly associated with 30-day mortality. DISCUSSION: The HEMA score reliably stratifies risk for 30-day mortality after hip fracture, though overestimates mortality in high-risk patients treated at a tertiary care center with a multidisciplinary team. The HEMA score may be enhanced by considering additional variables, including troponin level and history of dementia. LEVEL OF EVIDENCE: IV.

"Bring Your Own Device"-A New Approach to Wearable Outcome Assessment in Trauma.

Background and Objectives: Outcome data from wearable devices are increasingly used in both research and clinics. Traditionally, a dedicated device is chosen for a given study or clinical application to collect outcome data as soon as the patient is included in a study or undergoes a procedure. The current study introduces a new measurement strategy, whereby patients' own devices are utilized, allowing for both a pre-injury baseline measure and ability to show achievable results. Materials and Methods: Patients with a pre-existing musculoskeletal injury of the upper and lower extremity were included in this exploratory, proof-of-concept study. They were followed up for a minimum of 6 weeks after injury, and their wearable outcome data (from a smartphone and/or a body-worn sensor) were continuously acquired during this period. A descriptive analysis of the screening characteristics and the observed and achievable outcome patterns was performed. Results: A total of 432 patients was continuously screened for the study, and their screening was analyzed. The highest success rate for successful inclusion was in younger patients. Forty-eight patients were included in the analysis. The most prevalent outcome was step count. Three distinctive activity data patterns were observed: patients recovering, patients with slow or no recovery, and patients needing additional measures to determine treatment outcomes. Conclusions: Measuring outcomes in trauma patients with the Bring Your Own Device (BYOD) strategy is feasible. With this approach, patients were able to provide continuous activity data without any dedicated equipment given to them. The measurement technique is especially suited to particular patient groups. Our study's screening log and inclusion characteristics can help inform future studies wishing to employ the BYOD design.

Regional anesthesia provides limited decreases in opioid use following distal tibia and ankle fracture surgery.

PURPOSE: Regional anesthesia (RA) is used for pain control, but its impacts on the orthopedic trauma population are not well known. This study evaluated the impact of peripheral nerve blocks after distal tibia and ankle fracture repair on opioid use and pain scores and quantified the magnitude and duration of any changes. METHODS: This retrospective cohort study included patients treated operatively for distal tibia and ankle fractures over a 5-year period, both with and without peripheral nerve blocks. Total inpatient 5 mg oxycodone equivalents (OEs) used in the post-operative period, from 0-24, 24-48, to 48-72 h and maximum visual analog scale (VAS) pain ratings from 0-24, 24-48, to 48-72 h were recorded. RESULTS: 540 non-polytrauma patients and 183 polytrauma patients were included. Patients in the non-polytrauma group who received nerve blocks required fewer opioids on post-operative day (POD) 1 compared to the non-nerve block group (4.8 [95% CI 4.2-5.4] vs. 10.5 [95% CI: 9.2-11.8]; p < 0.001) and had lower VAS scores on POD1 (5.0 [95% CI 4.6-5.4] vs. 7.7 [95% CI: 7.3-8.1]; p < 0.001). However, there were no differences between these groups on POD2 or POD3 and no differences at any timepoints in the polytrauma group. CONCLUSION: Patients with isolated distal tibia and ankle fractures who receive peripheral nerve blocks demonstrate modest reductions in inpatient opioids and pain scores on POD1. However, there are no clear benefits beyond this point. Furthermore, polytrauma patients do not experience any reductions in opioid consumption or pain scores.

Serology and Comorbidities in Patients With Fracture Nonunion: A Multicenter Evaluation of 640 Patients.

INTRODUCTION: This multicenter cohort study investigated the association of serology and comorbid conditions with septic and aseptic nonunion. METHODS: From January 1, 2011, to December 31, 2017, consecutive individuals surgically treated for nonunion were identified from seven centers. Nonunion-type, comorbid conditions and serology were assessed. RESULTS: A total of 640 individuals were included. 57% were male with a mean age of 49 years. Nonunion sites included tibia (35.2%), femur (25.6%), humerus (20.3%), and other less frequent bones (18.9%). The type of nonunion included septic (17.7%) and aseptic (82.3%). Within aseptic, nonvascular (86.5%) and vascular (13.5%) nonunion were seen. Rates of smoking, alcohol abuse, and diabetes mellitus were higher in our nonunion cohort compared with population norms. Coronary artery disease and tobacco use were associated with septic nonunion (P < 0.05). Diphosphonates were associated with vascular nonunion (P < 0.05). Serologically, increased erythrocyte sedimentation rate, C-reactive protein, parathyroid hormone, red cell distribution width, mean platelet volume (MPV), and platelets and decreased absolute lymphocyte count, hemoglobin, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, and albumin were associated with septic nonunion while lower calcium was associated with nonvascular nonunion (P < 0.05). The presence of four or more of increased erythrocyte sedimentation rate, C-reactive protein, or red cell distribution width; decreased albumin; and age younger than 65 years carried an 89% positive predictive value for infection. Hypovitaminosis D was seen less frequently than reported in the general population, whereas anemia was more common. However, aside from hematologic and inflammatory indices, no other serology was abnormal more than 25% of the time. DISCUSSION: Abnormal serology and comorbid conditions, including smoking, alcohol abuse, and diabetes mellitus, are seen in nonunion; however, serologic abnormalities may be less common than previously thought. Septic nonunion is associated with inflammation, younger age, and malnourishment. Based on the observed frequency of abnormality, routine laboratory work is not recommended for nonunion assessment; however, specific focused serology may help determine the presence of septic nonunion.

Use of Wearable Technology to Measure Activity in Orthopaedic Trauma Patients: A Systematic Review.

Background: Patient-Reported Outcome Measures (PROMs) are widely used for measurement of functional outcomes after orthopaedic trauma. However, PROMs rely on patient collaboration and suffer from various types of bias. Wearable Activity Monitors (WAMs) are increasingly used to objectify functional assessment. The objectives of this systematic review were to identify and characterise the WAMs technology and metrics currently used for orthopaedic trauma research. Methods: PubMed and Embase biomedical literature search engines were queried. Eligibility criteria included: Human clinical studies published in the English language between 2010 and 2019 involving fracture management and WAMs. Variables collected from each article included: Technology used, vendor/product, WAM body location, metrics measured, measurement time period, year of publication, study geographic location, phase of treatment studied, fractures studied, number of patients studied, sex and age of the study subjects, and study level of evidence. Six investigators reviewed the resulting papers. Descriptive statistics of variables of interest were used to analyse the data. Results: One hundred and thirty-six papers were available for analysis, showing an increasing trend of publications per year. Accelerometry followed by plantar pressure insoles were the most commonly employed technologies. The most common location for WAM placement was insoles, followed by the waist. The most commonly studied fracture type was hip fractures followed by fragility fractures in general, ankle, "lower extremity", and tibial fractures. The rehabilitation phase following surgery was the most commonly studied period. Sleep duration, activity time or step counts were the most commonly reported WAM metrics. A preferred, clinically validated WAM metric was not identified. Conclusions: WAMs have an increasing presence in the orthopaedic trauma literature. The optimal implementation of this technology and its use to understand patients' pre-injury and post-injury functions is currently insufficiently explored and represents an area that will benefit from future study. Systematic review registration number: PROSPERO ID:210344. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-022-00629-0.

Wearable technology in orthopedic trauma surgery - An AO trauma survey and review of current and future applications.

The use of wearable sensors to track activity is increasing. Therefore, a survey among AO Trauma members was conducted to provide an overview of their current utilization and determine future needs and directions. A cross sectional expert opinion survey was administered to members of AO Trauma. Respondents were surveyed concerning their experience, subspeciality, current use characteristics, as well as future needs concerning wearable technology. Three hundred and thirty-three survey sets were available for analysis (Response Rate 16.2%). 20.7% of respondents already use wearable technology as part of their clinical treatment. The most prevalent technology was accelerometry combined with smartphones (75.4%) to measure general patient activity. To facilitate the use of wearable technology in the future, the most pressing issues were cost, patient compliance and validity of results. Wearable activity monitors are currently being used in trauma surgery. Surgeons employing these technologies mostly measure simple activity or activity associated parameters. Cost was the greatest perceived barrier to implementation. Further research, especially concerning the interpretation of the outcome values obtained, is required to facilitate wearable activity monitoring as an objective patient outcome measurement tool.

Risk Factors for Infection and Revision Surgery following Patellar Tendon and Quadriceps Tendon Repairs: An Analysis of 3,442 Patients.

Disruption of the extensor mechanism is debilitating with surgical repair being the accepted treatment. The incidence of infection and reoperation after extensor mechanism repair are not well reported in the literature. Thus, the objective of the current study was to (1) determine the incidence of surgical site infection and reoperation within 1 year of primary extensor mechanism repair and (2) identify independent risk factors for infection and reoperation following patellar and quadriceps tendon repair. A retrospective review of the 100% Medicare Standard Analytic files from 2005 to 2014 was performed to identify patients undergoing isolated patellar tendon repair and quadriceps tendon repair. Diagnosis of infection within 1 year of operative intervention and revision repair were assessed. Extensor mechanism injuries in the setting of total knee arthroplasty and polytrauma were excluded. Multivariate logistic regression analysis was performed to evaluate risk factors for postoperative infection and reoperation within 1 year. Infection occurred in 6.3% of patients undergoing patellar tendon repair and 2.6% of patients undergoing quadriceps tendon repair. Diabetes mellitus (odds ratio [OR] = 1.89, p = 0.005) was found to be an independent risk factor for infection following patellar tendon repair. Reoperation within 1 year occurred in 1.3 and 3.9% following patellar tendon and quadriceps tendon repair, respectively. Age less than 65 years (OR = 2.77, p = 0.024) and obesity (OR = 3.66, p = 0.046) were significant risk factors for reoperation after patellar tendon repair. Hypertension (OR = 2.13, p = 0.034), hypothyroidism (OR = 2.01, p = 0.010), and depression (OR = 2.41, p = 0.005) were significant risk factors for reoperation after quadriceps tendon repair. Diabetes mellitus was identified as a risk factor for infection after patellar tendon repair. Age less than 65 years, peripheral vascular disease, and congestive heart failure were risk factors for infection after quadriceps tendon repair. The current findings can be utilized to counsel patients regarding preoperative risk factors for postoperative complications prior to surgical intervention for extensor mechanism injuries.

Proximal tibia fracture dislocations: Management and outcomes of a severe and under-recognized injury.

INTRODUCTION: Proximal tibia fracture dislocations (PTFDs) are a subset of plateau fractures with little in the literature since description by Hohl (1967) and classification by Moore (1981). We sought to evaluate reliability in diagnosis of fracture-dislocations by traumatologists and to compare their outcomes with bicondylar tibial plateau fractures (BTPFs). METHODS: This was a retrospective cohort study at 14 level 1 trauma centers throughout North America. In all, 4771 proximal tibia fractures were reviewed by all sites and 278 possible PTFDs were identified using the Moore classification. These were reviewed by an adjudication board of three traumatologists to obtain consensus. Outcomes included inter-rater reliability of PTFD diagnosis, wound complications, malunion, range of motion (ROM), and knee pain limiting function. These were compared to BTPF data from a previous study. RESULTS: Of 278 submitted cases, 187 were deemed PTFDs representing 4% of all proximal tibia fractures reviewed and 67% of those submitted. Inter-rater agreement by the adjudication board was good (83%). Sixty-one PTFDs (33%) were unicondylar. Eleven (6%) had ligamentous repair and 72 (39%) had meniscal repair. Two required vascular repair. Infection was more common among PTFDs than BTPFs (14% vs 9%, p = 0.038). Malunion occurred in 25% of PTFDs. ROM was worse among PTFDs, although likely not clinically significant. Knee pain limited function at final follow-up in 24% of both cohorts. CONCLUSIONS: PTFDs represent 4% of proximal tibia fractures. They are often unicondylar and may go unrecognized. Malunion is common, and PTFD outcomes may be worse than bicondylar fractures.

National Evaluation of Social Determinants of Health in Orthopedic Fracture Care: Decreased Social Determinants of Health Is Associated With Increased Adverse Complications After Surgery.

OBJECTIVES: To assess the individual impact of social determinants of health disparities (SDHD) on surgical outcomes following orthopaedic trauma surgery. DESIGN: Retrospective Cohort Study. SETTING: Mariner Claims Database. PATIENTS: Inclusion criteria were patients 18-85 years of age, undergoing surgery for hip fractures or ankle fractures from 2010 to 2018. INTERVENTION: Patients were divided based on SDHD using International Classification of Diseases 9 and International Classification of Diseases 10 codes. Those with SDHD were propensity-score matched with those who did not have any disparities with respect to age, gender, Charlson comorbidity index, tobacco use, and obesity (body mass index >30 kg/m2). OUTCOMES: Ninety-day major medical complications, infection, readmission, and revisions within 1 year. RESULTS: Patients with educational deficiencies had increased rates of readmission and major complications compared with those without disparities following hip and ankle fracture management. Moreover, economic disparities were associated with an increased risk of readmission and revision following hip fracture surgery and infection and readmission following ankle fracture surgery. DISCUSSION/CONCLUSIONS: This study emphasizes the large impact of SDHD on patients' outcomes following surgery and the importance of proper follow-up interventions to optimize patient care. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intramedullary nailing of extra-articular distal tibial fractures.

AIMS: The aim of this study was to determine the immediate post-fixation stability of a distal tibial fracture fixed with an intramedullary nail using a biomechanical model. This was used as a surrogate for immediate weight-bearing postoperatively. The goal was to help inform postoperative protocols. METHODS: A biomechanical model of distal metaphyseal tibial fractures was created using a fourth-generation composite bone model. Three fracture patterns were tested: spiral, oblique, and multifragmented. Each fracture extended to within 4 cm to 5 cm of the plafond. The models were nearly-anatomically reduced and stabilized with an intramedullary nail and three distal locking screws. Cyclic loading was performed to simulate normal gait. Loading was completed in compression at 3,000 N at 1 Hz for a total of 70,000 cycles. Displacement (shortening, coronal and sagittal angulation) was measured at regular intervals. RESULTS: The spiral and oblique fracture patterns withstood simulated weight-bearing with minimal displacement. The multifragmented model had early implant failure with breaking of the distal locking screws. The spiral fracture model shortened by a mean of 0.3 mm (SD 0.2), and developed a mean coronal angulation of 2.0° (SD 1.9°) and a mean sagittal angulation of 1.2° (SD 1.1°). On average, 88% of the shortening, 74% of the change in coronal alignment, and 75% of the change in sagittal alignment occurred in the first 2,500 cycles. No late acceleration of displacement was noted. The oblique fracture model shortened by a mean of 0.2 mm (SD 0.1) and developed a mean coronal angulation of 2.4° (SD 1.6°) and a mean sagittal angulation of 2.6° (SD 1.4°). On average, 44% of the shortening, 39% of the change in coronal alignment, and 79% of the change in sagittal alignment occurred in the first 2,500 cycles. No late acceleration of displacement was noted. CONCLUSION: For spiral and oblique fracture patterns, simulated weight-bearing resulted in a clinically acceptable degree of displacement. Most displacement occurred early in the test period, and the rate of displacement decreased over time. Based on this model, we offer evidence that early weight-bearing appears safe for well reduced oblique and spiral fractures, but not in multifragmented patterns that have poor bone contact. Cite this article: Bone Joint J 2021;103-B(2):294-298.

Use of Standardized Language for C-arm Fluoroscopy Improves Intraoperative Communication and Efficiency.

INTRODUCTION: Intraoperative fluoroscopy is a ubiquitous tool in orthopaedic surgery. However, many orthopaedic surgeons and radiology technologists are not taught standard terminology to communicate with one another. Breakdown of communication leads to inefficiencies. Simulation studies have demonstrated that a common language for C-arm movements may reduce time to capture the desired images and number of radiographs required. Our objective was to investigate the effect of a standardized language protocol for intraoperative C-arm fluoroscopy on communication as perceived by the surgeon and radiology technologists. METHODS: Our study intervention was the implementation of a common C-arm fluoroscopy terminology education protocol. To evaluate the efficacy of this protocol, a survey was administered to orthopaedic surgeons and radiology technologists after procedures involving the use of intraoperative fluoroscopy. Study end points were measured using a 5-point Likert scale and included effectiveness of communication, need for obtaining repeat radiographs, need to correct the C-arm position, and confusion noted during surgery. This survey was administered before and after the study intervention. RESULTS: The study intervention resulted in a statistically significant improvement in the mean perceived quality of intraoperative communication between the surgeon and the radiology technologist (0.398 [0.072, 0.725], P = 0.017). There was also a reported decrease in confusion in the operating room (-0.572 [-0.880, -0.263], P < 0.001), movement correction of the C-arm fluoroscope (-0.592 [-0.936, -0.248], P = 0.001), and need for repeat radiographs (-0.782 [-1.158, -0.406], P < 0.001) after the implementation of a standardized fluoroscopy language. CONCLUSION: A standardized fluoroscopy language protocol improves intraoperative communication between orthopaedic surgeons and radiology technologists.

Harris Heel View is Inadequate to Visualize Screw Prominence of the Medial Calcaneus: A Case Report and Cadaveric Evaluation.

CASE: A 58-year-old man sustained multiple right foot injuries during a motor vehicle accident that included a calcaneus fracture requiring open reduction and internal fixation (ORIF). The procedure was complicated by a prominent implant inferior to the sustentaculum, which necessitated a return to the operating room. Commonly used fluoroscopic views do not adequately image this area. A cadaveric study was undertaken to identify the optimal 2-dimensional fluoroscopic view that evaluates prominent implants at the medial calcaneus. CONCLUSION: The sustentaculum tunnel view gives a reliable image of prominent medial implants, and use of this technique may limit complications after calcaneus ORIF.

Treatment Algorithm for Surgical Site Infections Following Extensor Mechanism Repair.

¼: Despite general agreement regarding techniques for extensor mechanism repair, there is very limited guidance in the literature for the management of surgical site infections (SSIs) that may occur after these procedures. ¼: Early or mild superficial SSIs, such as cellulitis, can be managed on an outpatient basis while monitoring for improvement, with escalated intervention if the symptoms do not resolve within 1 week. ¼: Deep SSIs should be managed more aggressively with surgical irrigation and debridement (I&D), including the knee joint, depending on the results of the aspiration, removal of all braided nonabsorbable suture (if necessary) with immediate or delayed exchange with monofilament suture, and the administration of parenteral antibiotics based on culture results and an infectious disease consult. ¼: Arthrocentesis should be performed early to monitor for the spread of infection to the joint space, and diagnosis of a septic knee joint should be immediately followed by arthroscopic or open I&D. ¼: For refractory cases (i.e., wound coverage issues or persistent infections despite multiple attempts at debridement), a consult with a plastic surgeon for consideration of a gastrocnemius flap is recommended, and surgeons should remain suspicious of the possibility of the contiguous spread of osteomyelitis.

Simultaneous Use of Kocher-Langenbeck and Lateral Window Approaches for Transverse Acetabular Fracture Open Reduction and Internal Fixation: A Case Report.

CASE: An otherwise healthy 39-year-old man presented after a fall from 30 feet with a right transverse, transtectal acetabular fracture. The fracture was not reducible with an isolated anterior or posterior approach. A simultaneous combined approach was used in the lateral decubitus position. The fracture was appropriately reduced and stabilized. CONCLUSIONS: This combined approach with the patient in the lateral decubitus position was effective without requiring repositioning of the patient during surgery. This technique may be helpful for reduction of challenging transverse acetabular fractures.

A Locked Sacroiliac Joint Dislocation Requiring Open Reduction: A Case Report.

CASE: Vertically unstable pelvic ring injuries are often associated with sacroiliac (SI) joint subluxations or dislocations. The following report describes an irreducible SI joint dislocation where the ilium was locked in a position superior to the sacrum. This injury was refractory to initial closed reduction techniques and ultimately required an open reduction. CONCLUSIONS: This report demonstrates the limitations of closed manipulation for some vertically unstable pelvic ring injuries. It is critical to have a strong understanding of the anatomy and typical manipulations to succeed in both closed and open SI joint reduction attempts.