Current Procedural Terminology Code Selection, Attitudes, and Practices of the Orthopaedic Surgery Resident Case Log: A Survey of Residents and Program Directors.

Introduction: The Accreditation Council for Graduate Medical Education Resident Case Log is one of the primary tools used to track surgical experience. Owing to the self-reported nature of case logging, there is uncertainty in the consistency and accuracy of case logging. The aims of this study are two-fold: to assess current resident case log Current Procedural Terminology (CPT) code selection and practices across orthopaedic surgery residencies and to understand current attitudes of both program directors (PD) and residents surrounding case logging. Methods: Residents and PDs from 18 residency programs received standardized, consensus-built surveys distributed through the Collaborative Orthopaedic Educational Research Group. Resident surveys additionally contained clinical orthopaedic subspecialties vignettes on sports, trauma, and spine. Each subspecialty section contained 4 clinical vignettes with stepwise increases in complexity/CPT coding procedures. Results: One hundred sixteen residents (response rate: 28.4%) and 16 PDs (response rate: 88.9%) participated. Formal case log training was reported by 53.0% of residents and 56.3% of PDs. A total of 7.8% of residents rated themselves "excellent" at applying CPT codes for the case log, while 0.0% PDs rated their residents' ability as "excellent." In total, 40.9% of residents and 81.3% of PDs responded that it was "extremely important" or "very important" to code accurately (p = 0.006). Agreement between resident CPT code selection and number of cases and procedures logged for each clinical vignette was conducted using Fleiss' kappa. As the clinical vignettes increased in complexity, there was a decreasing trend in kappa values from the first (least complex) to the last (most complex) clinical vignette. Conclusions: The inconsistent case logging practices, dubious outlook on case log accuracy and resident case logging ability and attitude, and lack of formal training signals a need for formal, standardized case log training. Enhanced case logging instruction and formalized educational training for PDs and residents would be a meaningful step toward capturing true operative experience, which would have a substantial impact on orthopaedic surgery resident education and assessment.

Gunshot Trauma Patients Have Higher Risk of PTSD Compared With Blunt Trauma and Elective Populations: A Retrospective Comparative Study of Outpatient Orthopaedic Care.

BACKGROUND: Posttraumatic stress disorder (PTSD) has been extensively studied in patients who have experienced natural disasters or military conflict, but there remains a substantial gap in knowledge about the prevalence of PTSD after civilian orthopaedic trauma, especially as related to firearms. Gun violence is endemic in the United States, especially in urban centers, and the mental impact is often minimized during the treatment of physical injuries. QUESTIONS/PURPOSES: (1) Do patients who experience gunshot wound (GSW) trauma have higher PTSD screening scores compared with patients with blunt or other trauma (for example, motor vehicle and motorcycle accidents or stab wounds) and those with elective conditions (for example, arthritis, tendinitis, or nerve compression)? (2) Are PTSD scores correlated with pain scores in patients with GSW trauma, those with non-GSW trauma, and patients with elective orthopaedic symptoms? METHODS: We performed a retrospective study of adults older than 18 years of age presenting to an orthopaedic clinic over an 8-month period between August 2021 and May 2022. All patients presenting to the clinic were approached for inclusion (2034 patients), and 630 new or postoperative patients answered study surveys as part of routine care. Patients were divided into three cohorts based on the orthopaedic condition with which they presented, whether gunshot trauma, blunt trauma, or elective orthopaedic symptoms. Overall, the results from 415 patients were analyzed, including 212 patients with elective orthopaedic symptoms, 157 patients with non-GSW trauma, and 46 patients with GSW trauma. Clinical data including demographic information were collected at the time of appointment and abstracted along with results from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, short screening questionnaire, which uses a 7-item scale scored from 0 to 7 (with higher scores representing worse symptoms), and from the numeric rating scale for pain (range 0 to 10). Both questionnaires were routinely administered by medical assistants at patient intake. The proportions of patients completing PTSD scoring were 45% (95) in the elective group, 74% (116) in the group with non-GSW trauma, and 85% (39) in the group with GSW trauma (p = 0.01). We compared the PTSD scores across the three groups and then dichotomized the scores as a negative versus positive screening result at a value of ≥ 4 with further comparative analysis. The correlation between pain and PTSD scores was also evaluated. RESULTS: Patients with GSW trauma had higher mean ± SD PTSD scores compared with those who had non-GSW trauma (4.87 ± 4.05 versus 1.75 ± 2.72, mean difference 3.21 [95% CI 1.99 to 4.26]; p < 0.001) and those who presented with elective conditions (4.87 ± 4.05 versus 0.49 ± 1.04, mean difference 4.38 [95% CI 3.50 to 5.26]; p < 0.001). When dichotomized for positive or negative PTSD screening results, patients with GSW trauma had a higher risk of having PTSD (64% [25 of 39]) compared with patients with non-GSW trauma (27% [31 of 116], relative risk 2.40 [95% CI 1.64 to 3.51]; p < 0.001) and compared with patients with elective conditions (4% [4 of 95], relative risk 15.22 [95% CI 5.67 to 40.87]; p < 0.001). Pain scores were correlated with PTSD scores only for patients with non-GSW trauma (ρ = 0.37; p < 0.0001). No correlation with pain scores was present for patients with GSW (ρ = 0.24; p = 0.16) or patients with elective conditions (ρ = -0.04; p = 0.75). CONCLUSION: In an orthopaedic clinic population, the prevalence of positive screening for PTSD was highest in the population sustaining gunshot trauma as compared with blunt or other trauma and elective orthopaedic conditions. Interestingly, pain scores correlated with PTSD screening only in the patients with non-GSW trauma. These differences suggest a substantial difference in the populations at risk of PTSD after trauma. Overall, the psychological impacts of gun trauma are poorly understood. The next step would be to prospectively study the differences and timelines of PTSD screening in patients with GSW trauma in comparison with patients with blunt or other trauma to better define the treatment needs in this population. LEVEL OF EVIDENCE: Level III, prognostic study.

Normothermia to Decrease Surgical Site Infection Risk: Silver Bullet or Fool's Gold? A Retrospective Cohort Study.

PURPOSE: Surgical site infection (SSI) is the leading cause of nosocomial infections among surgical patients in the United States. Currently, there is compelling evidence suggesting that temperature dysregulation in surgical patients may be a risk factor for the development of SSI. We examined the relationship between perioperative hypothermia (PH) and SSI in a population of surgical patients with diabetes mellitus (DM). METHODS: This retrospective cohort review was conducted on patients with a history of DM undergoing orthopaedic surgery at our institution between May 1, 2018, and April 1, 2022. Inclusion criteria were age older than 15 years, a history of DM or recent hemoglobin A1c concentration of ≥6.5%, and operation of at least 60 minutes under general anesthesia. Perioperative hypothermia was defined as an intraoperative temperature ≤ 35.5°C. Continuous variables were compared using the t-test and Wilcoxon rank-sum test. Categorical variables were compared using the chi-squared test. We constructed a multivariable logistic regression model to estimate SSI risk while controlling for demographic variables. RESULTS: A total of 236 patients were included in the final analysis. The overall incidence of SSI was 5.93%. 99 patients (42%) experienced PH. No difference was observed in the risk of SSI between the normothermic and hypothermic cohorts. Among the 99 patients who experienced PH, increasing HbA1c was associated with increasing risk of SSI (OR = 2.39, 95% CI = 1.12 to 5.32, P-value = 0.0222). The multivariable logistic regression model had good discriminatory ability (c-statistic 0.74, 95% CI: 0.61 to 0.89) and good predictive accuracy (sensitivity 64%, specificity 73%). DISCUSSION: PH is not an independent risk factor of SSI. However, in the presence of elevated HbA1c, PH may more than double the risk of SSI. Perioperative hypothermia may be an additive risk factor in the setting of poor glycemic control and potentially in the setting of other known risk factors.

AOA Critical Issues Symposium: Gun Violence as a Public Health Crisis.

ABSTRACT: Gun violence is an epidemic throughout the United States and is increasing around the world-it is a public health crisis. The impact of gun violence is not limited to the victims (our patients); it also extends to the physicians and caregivers who are taking care of these patients every day. Even more broadly, gun violence affects those living and going to work in potentially dangerous environments. The "vicarious trauma" that is experienced in these situations can have long-term effects on physicians, nurses, and communities. Importantly, socioeconomic disparities and community deprivation strongly correlate with gun violence. Systemic factors that are deeply ingrained in our society can increase concerns for these underrepresented patient populations and cause increased stressors with substantial health consequences, including delayed fracture-healing and poorer overall health outcomes. It is incumbent on us as physicians to take an active role in speaking up for our patients. The importance of advocacy efforts to change policy (not politics) and continue to push for improvement in the increasingly challenging environments in which patients and physicians find themselves cannot be overstated. Multiple national organizations, including many orthopaedic and general surgery associations, have made statements advocating for change. The American College of Surgeons, in collaboration with many other medical organizations, has supported background checks, registration, licensure, firearm education and training, safe storage practices, red flag laws, addressing mental health issues, and more research to better inform an approach going forward and to address the root causes of violence. We encourage the orthopaedic surgery community to stand together to protect each other and our patients, both physically and mentally, with agreement on these principles.

Ethical Considerations of Artificial Intelligence in Health Care: Examining the Role of Generative Pretrained Transformer-4.

The integration of artificial intelligence technologies, such as large language models (LLMs), in health care holds potential for improved efficiency and decision support. However, ethical concerns must be addressed before widespread adoption. This article focuses on the ethical principles surrounding the use of Generative Pretrained Transformer-4 and its conversational model, ChatGPT, in healthcare settings. One concern is potential inaccuracies in generated content. LLMs can produce believable yet incorrect information, risking errors in medical records. Opacity of training data exacerbates this, hindering accuracy assessment. To mitigate, LLMs should train on precise, validated medical data sets. Model bias is another critical concern because LLMs may perpetuate biases from their training, leading to medically inaccurate and discriminatory responses. Sampling, programming, and compliance biases contribute necessitating careful consideration to avoid perpetuating harmful stereotypes. Privacy is paramount in health care, using public LLMs raises risks. Strict data-sharing agreements and Health Insurance Portability and Accountability Act (HIPAA)-compliant training protocols are necessary to protect patient privacy. Although artificial intelligence technologies offer promising opportunities in health care, careful consideration of ethical principles is crucial. Addressing concerns of inaccuracy, bias, and privacy will ensure responsible and patient-centered implementation, benefiting both healthcare professionals and patients.

Are Social Deprivation and Low Traditional Health Literacy Associated With Higher PROMIS CAT Completion in Orthopaedic Surgery?

BACKGROUND: The Patient-Reported Outcomes Measurement Information System® (PROMIS®) may be used to assess an individual patient's perspective of their physical, mental, and social health through either standard or computer adaptive testing (CAT) patient questionnaires. These questionnaires are used across disciplines; however, they have seen considerable application in orthopaedic surgery. Patient characteristics associated with PROMIS CAT completion have not been examined within the context of social determinants of health, such as social deprivation or health literacy, nor has patient understanding of the content of PROMIS CAT been assessed. QUESTIONS/PURPOSES: (1) What patient demographics, including social deprivation, are associated with completion of PROMIS CAT questionnaires? (2) Is health literacy level associated with completion of PROMIS CAT questionnaires? (3) Do patients with lower health literacy have a higher odds of completing PROMIS CAT without fully understanding the content? METHODS: Between June 2022 and August 2022, a cross-sectional study was performed via a paper survey administered to patients at a single, urban, quaternary academic medical center in orthopaedic subspecialty clinics of foot and ankle, trauma, and hand/upper extremity surgeons. We considered all English-speaking patients aged 18 or older, including those with limited reading and/or writing abilities, as eligible provided they received an iPad in clinic to complete the PROMIS CAT questionnaire as part of their routine standard clinical care or they completed the questionnaire via a patient portal before the visit. In all, 946 patients were considered eligible during the study period and a convenience sample of 36% (339 of 946) of patients was approached for inclusion due to clinic time constraints. Fifteen percent (52 of 339) declined to participate, leaving 85% (287 of 339) of patients for analysis here. Median (range) age of study participants was 49 years (35 to 64). Fifty-eight percent (167 of 287) of study participants self-identified as non-Hispanic Black or African American and 26% (75 of 287) as non-Hispanic White. Even proportions were observed across education levels (high school graduate or less, 29% [82 of 287]; some college, 25% [73 of 287]; college graduate, 25% [71 of 287]; advanced degree, 20% [58 of 287]). Eighteen percent (52 of 287) of patients reported an annual income bracket of USD 0 to 13,000, and 17% (48 of 287) reported more than USD 120,000. Forty-six percent (132 of 287) of patients worked full-time, 21% (59 of 287) were retired, and 23% (66 of 287) were unemployed or on disability. The primary outcome of interest was self-reported PROMIS CAT questionnaire completion grouped as: fully completed, partially completed, or no part completed. Overall, self-reported PROMIS CAT questionnaire completion proportions were: 80% (229 of 287) full completion, 13% (37 of 287) partial completion, and 7% (21 of 287) no part completed. We collected the National Area Deprivation Index (ADI) score and the Brief Health Literacy Screening Tool (BRIEF) as part of the study survey to associate with level of completion. Additionally, patient understanding of PROMIS CAT was assessed through Likert-scaled responses to a study survey question that directly asked whether the patient understood all of the questions on the PROMIS CAT questionnaire. Responses to this question may have been limited by social desirability bias, and hence may overestimate how many individuals genuinely understood the questionnaire content. However, the benefit of this approach was it efficiently allowed us to estimate the ceiling effect of patient comprehension of PROMIS CAT and likely had a high degree of specificity for detecting lack of comprehension. RESULTS: ADI score adjusted for age was not associated with PROMIS CAT completion (partial completion OR 1.00 [95% CI 0.98 to 1.01]; p = 0.72, no part completed OR 1.01 [95% CI 0.99 to 1.03]; p = 0.45). Patients with lower health literacy scores, however, were more likely to not complete any part of their assigned questionnaires than patients with higher scores (no part completed OR 0.85 [95% CI 0.75 to 0.97]; p = 0.02). Additionally, 74% (26 of 35) of patients who did not fully understand all of the PROMIS CAT questionnaire questions still fully completed them-hence, 11% (26 of 229) of all patients who fully completed PROMIS CAT did not fully understand the content. Among patients self-reporting full completion of PROMIS CAT with health literacy data (99% [227 of 229]), patients with inadequate/marginal health literacy were more likely than patients with adequate health literacy to not fully understand all of the questions (21% [14 of 67] versus 8% [12 of 160], OR 3.26 [95% CI 1.42 to 7.49]; p = 0.005). CONCLUSION: Within an urban, socioeconomically diverse, orthopaedic patient population, health literacy was associated with PROMIS CAT questionnaire completion. Lower health literacy levels increased the likelihood of not completing any part of the assigned PROMIS CAT questionnaires. Additionally, patients completed PROMIS CAT without fully understanding the questions. This indicates that patient completion does not guarantee comprehension of the questions nor validity of their scores, even more so among patients with low health literacy. This is a substantive concern for fidelity of data gathered from PROMIS CAT. CLINICAL RELEVANCE: Clinical implementation of the PROMIS CAT in orthopaedic populations will benefit from further research into health literacy to increase questionnaire completion and to ensure that patients understand the content of the questions they are answering, which will increase the internal validity of the outcome measure.

Depression, anxiety, and post-traumatic stress disorder following upper versus lower extremity fractures.

INTRODUCTION: Orthopaedic trauma has been linked to major depressive disorder (MDD), generalized anxiety disorder (GAD), and post-traumatic stress disorder (PTSD). Post-injury rates of psychiatric diagnoses and their relationship to various injury characteristics are not well characterized. We aimed to determine the association between orthopaedic trauma and MDD, GAD, and PTSD diagnoses at 5-year follow-up. METHODS: A national insurance claims database was used to create upper extremity fracture (UEF) and lower extremity fracture (LEF) cohorts, with further stratification by isolated versus multiple fractures. Patient undergoing elective upper or lower extremity orthopaedic procedures served as controls. Rates of post-injury psychiatric diagnoses were calculated. Univariate logistic regression was conducted after matching in a 1:1 ratio based on relevant comorbidities such as psychiatric history. All significant variables were included in multivariate analysis. RESULTS: A total of 308,578 UEF patients and 360,510 LEF patients were identified. Within the UEF cohort, the diagnosis rates following either isolated or multiple fractures were identified: MDD (25% to 30%), GAD (10% to 11%), and PTSD (4%). LEF cohort rates were as follows: MDD (30% to 38%), GAD (11% to 14%), and PTSD (4% to 7%). Compared to non-injured controls, both the UEF and LEF cohorts were associated with higher rates of all psychiatric diagnoses. In comparing UEF and LEF cohorts, isolated UEF was associated with MDD, GAD, and PTSD; however, multiple UEF was associated with MDD and GAD, whereas multiple LEF was associated with PTSD. CONCLUSION: Psychiatric pathology is prevalent following orthopaedic trauma. Even after controlling for psychiatric history, orthopaedic trauma is independently associated with post-injury psychiatric diagnoses and may be more predictive of PTSD and GAD than of MDD. Upper extremity fractures may portend higher psychiatric risk. With negative stigma surrounding mental health and the early role of orthopaedic surgeons in providing care, it is imperative to normalize psychiatric care with patients and discuss warning symptoms that may indicate the onset of psychiatric disorders. LEVEL OF EVIDENCE: Prognostic, Level III.

ChatGPT's Ability to Assist with Clinical Documentation: A Randomized Controlled Trial.

INTRODUCTION: Clinical documentation is a critical aspect of health care that enables healthcare providers to communicate effectively with each other and maintain accurate patient care records. Artificial intelligence tools, such as chatbots and virtual assistants, have the potential to assist healthcare providers in clinical documentation. ChatGPT is an artificial intelligence conversational model that generates human-like responses to text-based prompts. In this study, we sought to investigate ChatGPT's ability to assist with writing a history of present illness based on standardized patient histories. METHODS: A blinded, randomized controlled study was conducted to compare the use of typing, dictation, and ChatGPT as tools to document history of present illness (HPI) of standardized patient histories. Eleven study participants, consisting of medical students, orthopaedic surgery residents, and attending surgeons, completed three HPIs using a different documentation technique for each one. Participants were randomized into cohorts based on the type of documentation technique. Participants were asked to interview standardized patients and document the patient's history of present illness using their assigned method. RESULTS: ChatGPT was found to be intermediate for speed; dictation was fastest, but produced markedly longer and higher quality patient histories based on Physician Documentation Quality Instrument score compared with dictation and typing. However, ChatGPT included erroneous information in 36% of the documents. Poor agreement existed on the quality of patient histories between reviewers. DISCUSSION: Our study suggests that ChatGPT has the potential to improve clinical documentation by producing more comprehensive and organized HPIs. ChatGPT can generate longer and more detailed documentation compared with typing or dictation documentation methods. However, additional studies are needed to investigate and address concerns regarding privacy, bias, and accuracy of information.

Bullet Fragment Retrieval During Intramedullary Nailing: A Report of 2 Cases.

CASE: Two young adult patients, 22 and 27 years, who sustained ballistic long bone fractures, presented for incarcerated, retained metallic fragments in the medullary canal, which blocked fixation. Owing to the presence and location of the fragments, each case required a bullectomy (removal of the metallic fragment) before intramedullary nail fixation because the projectile impeded the appropriate insertion of the intramedullary rod and, in one case, induced fracture malalignment. Attempts at removal using conventional tools did not provide adequate length or grasp of the retained projectile, necessitating the use of the novel technique. The Babcock Laparoscopic Endopath is an easy-to-use, ubiquitous tool that facilitates the removal of content within the intramedullary canal, including metallic or bony fragments. CONCLUSION: There is limited literature describing accessible, cost-effective techniques for the removal of intramedullary retained metallic foreign fragments when it is unremovable through conventional means. This article reports on a novel, minimally invasive technique for bullet removal from the intramedullary canal of the femur and tibia using the Babcock Laparoscopic Endopath, a tool typically used by urologists. Both patients were followed for at least 8 weeks postoperatively with no complications secondary to the procedure. The article describes the technique and advantages of using this readily available tool that is both flexible enough to navigate through the intramedullary canals as well as rigid enough to obtain and manipulate metallic objects.

Is Hand Therapy Associated With a Delay in Surgical Treatment in Thumb Carpometacarpal Arthritis?

PURPOSE: Thumb carpometacarpal (CMC) osteoarthritis (OA) causes functional disability and an increased health care burden in the aging population. The role of therapy in thumb CMC OA has been minimally analyzed in the literature. We hypothesized that patients treated with therapy for thumb CMC OA would demonstrate reduced rates of surgery for this diagnosis. METHODS: We queried a national insurance dataset for all patients with an International Classification of Diseases, Ninth Revision, or International Statistical Classification of Diseases, Tenth Revision, code for thumb CMC OA, with a minimum of 2 years of follow-up. A 2:1 propensity-matched cohort of patients with CMC OA who did not receive therapy versus a therapy cohort was created, with a minimum of two sessions of hand therapy for inclusion. The primary outcome was the rate of thumb CMC OA surgery occurring within 2 years of diagnosis; time to surgery and use of thumb CMC injections were secondary outcomes. Multivariable logistic regression analysis was used to identify the risk factors for undergoing surgical treatment. RESULTS: After matching, the therapy cohort comprised 14,548 patients, with a matched group of 28,930 patients who did not undergo therapy. In the overall sample, the rate of surgery within 2 years was 22.5%. Two-year surgical treatment rates were significantly higher for those who did not undergo therapy when compared with those who did (29.3% vs 13.1%). Patients treated with therapy had a significantly longer time to surgery, with no difference in the rate of surgery after one year. In multivariable regression of all included variables, lack of therapy intervention had the highest odds of surgery for thumb CMC OA (odds ratio 4.3). CONCLUSIONS: We present the findings of a large insurance database evaluating the association of therapy with rates of surgical treatment for thumb CMC arthritis. On average, those treated with therapy had longer times to surgery, and the 2-year surgery rates for patients diagnosed with thumb CMC arthritis were significantly higher in those who did not undergo therapy treatment. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

"Can You Feel It": An Early Experience with Simulated Vibration to Recreate Glenoid Reaming.

When developing educational simulators, meaningful haptic feedback is important. To our knowledge, no shoulder arthroplasty surgical simulator exists. This study focuses on simulating vibration haptics of glenoid reaming for shoulder arthroplasty using a novel glenoid reaming simulator. Methods: We validated a novel custom simulator constructed using a vibration transducer transmitting simulated reaming vibrations to a powered nonwearing reamer tip through a 3D-printed glenoid. Validation and system fidelity were evaluated by 9 fellowship-trained shoulder surgeon experts performing a series of simulated reamings. We then completed the validation process through a questionnaire focused on experts' experience with the simulator. Results: Experts correctly identified 52% ± 8% of surface profiles and 69% ± 21% of cartilage layers. Experts identified the vibration interface between simulated cartilage and subchondral bone (77% ± 23% of the time), indicating high fidelity for the system. An interclass correlation coefficient for experts' reaming to the subchondral plate was 0.682 (confidence interval 0.262-0.908). On a general questionnaire, the perceived utility of the simulator as a teaching tool was highly ranked (4/5), and experts scored "ease of instrument manipulation" (4.19/5) and "realism of the simulator" (4.11/5) the highest. The mean global evaluation score was 6.8/10 (range 5-10). Conclusions: We examined a simulated glenoid reamer and feasibility of haptic vibrational feedback for training. Experts validated simulated vibration feedback for glenoid simulation reaming, and the results suggested that this may be a useful additional training adjuvant. Level of Evidence: Level II, prospective study.

How do surgeons decide when to treat proximal humerus fractures with operative versus nonoperative management?

PURPOSE: The objective of this study was to determine the underlying factors that drive the decision for surgeons to pursue operative versus nonoperative management for proximal humerus fractures (PHF) and if fellowship training had an impact on these decisions. METHODS: An electronic survey was distributed to members of the Orthopaedic Trauma Association and the American Shoulder and Elbow Surgeons Society to assess differences in patient selection for operative versus nonoperative management of PHF. Descriptive statistics were reported for all respondents. RESULTS: A total of 250 fellowship trained Orthopaedic Surgeons responded to the online survey. A greater proportion of trauma surgeons preferred nonoperative management for displaced PHF fractures in patients over the age of 70. Operative management was preferred for older patients with fracture dislocations (98%), limited humeral head bone subchondral bone (78%), and intraarticular head split (79%). Similar proportions of trauma surgeons and shoulder surgeons cited that acquiring a CT was crucial to distinguish between operative and nonoperative management. CONCLUSION: We found that surgeons base their decisions on when to operate primarily on patient's comorbidities, age, and the amount of fracture displacement when treating younger patients. Further, we found a greater proportion of trauma surgeons elected to proceed with nonoperative management in patients older than the age of 70 years old as compared to shoulder surgeons.

Team Approach: The Unstable Trauma Patient.

¼ A multidisciplinary, integrated, and synergistic team approach to the unstable polytrauma patient is critical to optimize outcomes, minimize morbidity, and reduce mortality.¼ The use of Advanced Trauma Life Support protocols helps standardize the assessment and avoid missing critical injuries¼ Effective and open dialog with consulting specialists is paramount for effective team-based care.¼ Orthopaedic surgeons should play an important role in the rapid assessment of potentially life-threatening and/or limb-threatening injuries including pelvic ring disruption, open fractures with substantial blood loss, and dysvascular limbs.

Association of Pelvic Trauma With Rates of Cesarean Section, Sexual Dysfunction, and Genitourinary Dysfunction in a National Database.

INTRODUCTION: Pelvic fractures are severe injuries that can drastically affect a woman's quality of life through sexual dysfunction (SD), genitourinary dysfunction (GD), and increasing the potential need for future cesarean section (C-section). Limited research has captured long-term outcomes after pelvic fractures in women of childbearing age. This study aimed to determine the association between pelvic fractures and rates of C-section, SD, and GD. METHODS: All women of childbearing age who sustained a pelvic fracture were identified in a national insurance database. A comparison group of patients with lower extremity long-bone fractures was selected. Patients who gave birth after injury were additionally identified. A minimum of 5 years of follow-up was required for inclusion. Rates of C-section, SD, and GD were compared between cohorts. Multivariate logistic regression analysis was conducted with the inclusion of diabetes, tobacco, hypertension, obesity, and advanced maternal age. RESULTS: A total of 6,174 patients with pelvic fracture and 27,154 control fracture patients were identified. 434 patients with pelvic fracture (7.0%) and 1,258 control fracture patients (4.6%) gave birth after fracture. Patients with pelvic fracture had a significantly higher rate of C-section (50.0% versus 38.8%, P < 0.001), SD diagnosis (10.9% versus 8.8%, P < 0.001), and urinary retention diagnosis (3.5% versus 2.8%, P < 0.001). No significant difference in global GD diagnosis was identified. Multivariate analyses showed that pelvic fracture was associated with C-section (odds ratio [OR]: 1.78; 95% confidence interval [95% CI]: 1.42 to 2.23, P < 0.001), SD diagnosis (OR: 1.23; 95% CI: 1.12 to 1.35, P < 0.001), and urinary retention diagnosis (OR: 1.35; 95% CI: 1.15 to 1.57, P < 0.001). DISCUSSION: Pelvic fractures confer an intrinsic level of risk of C-section, SD, and urinary retention that is elevated beyond what would be expected from a traumatic lower extremity injury alone. Treating orthopaedic surgeons should actively counsel women regarding increased risks, openly discuss postinjury sequelae, and coordinate interspecialty care beyond initial treatment of acute trauma.

Firearm-Related Injuries-Wound Management, Stabilization, and Associated Injuries: A Critical Analysis Review.

¼: Gun violence-related and firearm-related injuries are a public health crisis with increasing rates, particularly among younger demographics, in the United States despite a decline in incidence worldwide. ¼: There exists limited high-quality evidence to guide the management of firearm-related orthopaedic injuries. ¼: Associated injuries (i.e., neurological and vascular) are common in ballistic injuries to the extremity. ¼: Where indicated, low-energy orthopaedic injuries can be managed successfully with standard fixation and management strategies with similar complications to closed fractures.

Isolated ballistic femoral condyle fractures: a case series of eighteen patients.

PURPOSE: Ballistic fractures of the femoral condyles are rare injuries with limited literature to help guide treatment. The purpose of this study is to report on the presentation, management, and outcomes for patients with isolated ballistic condylar fractures. METHODS: Eighteen patients between ages 16 and 65 with low-energy ballistic injuries isolated to the femoral condyles (OTA 33B) were included, 15 with CT imaging. Clinical records and imaging were reviewed, as well as treatment strategy. Fractures were classified by AO/OTA classification. Outcome and follow-up data were gathered at outpatient appointments and telephone calls. RESULTS: Of the 18 patients, 78% were treated operatively (61% with open reduction and internal fixation, 17% with removal of foreign body alone). There were two instances of traumatic vascular injury and no neurologic injuries. Furthermore, there were no identified infections. Only 58% of the patients had follow-up for more than 6 weeks with average KOOS Jr. Score of 50, and average VAS pain score of 5.2. CONCLUSIONS: Ballistic femoral condyle fractures are rare Orthopaedic injuries seen in relatively high frequency at our institution. Most (78%) were treated operatively and with few complications. These fractures are not easily classified according to common classification schemes and may benefit from more rigorous study to guide treatment and anticipate outcomes.

Surgical Outcomes, Trends, and Risk Factors of Distal Triceps Repairs.

BACKGROUND: Distal triceps ruptures are rare, and complete ruptures are commonly treated with surgery. Studies of patients in small cohorts with distal triceps tear have reported outcomes and risk factors; however, large-scale data are scant. This study seeks to determine current trends, outcomes, and risk factors of distal triceps tears. METHODS: Within a large insurance claims database, distal triceps repair patients were identified through Current Procedural Terminology coding with concomitant distal triceps International Classification of Diseases, 9th Revision/10th Revision diagnosis codes and 1-year active status before and after surgery. Demographics, total costs, 90-day complications, and revision rates within 1 year of index surgery were analyzed. Logistic regression was performed for revision and complication rates using sex, age, and comorbidities (anabolic steroid use, diabetes, ischemic heart disease, tobacco use, rheumatoid arthritis, and chronic kidney disease). RESULTS: A total of 8143 patients were included in the cohort. Male patients and patients aged 40 to 59 years comprised most of the study population. The postoperative complication rate was 5.8%, and the 1-year revision rate was 2.6%. Male sex, age >60 years, ischemic heart disease, rheumatoid arthritis, and chronic kidney disease were statistically significant risk factors for higher 90-day complication rates. Anabolic steroid use significantly increased the risk of surgical revision. CONCLUSIONS: Distal triceps repairs in this large cohort study occur most frequently in men aged 40 to 59 years. Complications are generally low, with age >60 years, male sex, ischemic heart disease, rheumatoid arthritis, and chronic kidney disease as risk factors for 90-day complications and prior anabolic steroid use as a risk factor for 1-year revision surgery. This information can help to improve education and expectations of this procedure.

Comparison of a Novel Modified All-Suture Construct versus Suspensory Suture-button Fixation in a Syndesmotic Injury Model.

OBJECTIVES: To biomechanically investigate a novel modified all-suture construct compared with commercially available suspensory button fixation for stabilization of the syndesmosis. METHODS: Eight matched pairs of cadaver lower limbs were obtained. We used a material testing machine and Optotrak optoelectronic 3D motion measurement system for testing. Syndesmotic injuries were simulated, and specimens were fixed with either a suspensory suture button or modified all-suture construct. Repaired specimens were then cyclically loaded for 500 cycles. Spatial relationship of the tibia and fibula were continuously monitored for the intact, destabilized, and repaired states. The results were analyzed using independent samples t test. RESULTS: There was no significant difference in sagittal or coronal plane translation between intact and either repair. Compared with the intact state, both repair techniques demonstrated significantly more external rotation of the fibula relative to the tibia and decreased construct stiffness. Cycling of the specimens did not significantly increase coronal or sagittal plane translation; however, external rotation of the fibula relative to the tibia increased and stiffness decreased with cycling for both repair techniques. CONCLUSIONS: Our data suggest that sagittal and coronal plane translation is no different from the intact state for both fixation techniques. However, rotation of the fibula relative to the tibia was increased, and construct stiffness was decreased compared with the intact state for both fixation techniques. These findings suggest that an all-suture construct could offer syndesmotic fixation comparable with proprietary suspensory button fixation in a cadaver model.

Bilateral femur fractures are associated with concomitant femoral neck fracture.

OBJECTIVE: The purpose of this study is to determine the rate of femoral neck fractures in patients who have sustained bilateral femur fractures compared to unilateral femur fractures. DESIGN AND SETTING: A retrospective review of an institutional trauma database was completed at a single level 1 trauma academic medical center. PATIENTS: All patients treated for a femur fracture between May 1, 2018 and December 31, 2020 were included. RESULTS: Twenty-one patients sustained bilateral femur fractures (11%) and 166 sustained unilateral femur fractures. Fifteen associated ipsilateral femoral neck fractures were identified. Eight of the 15 (53%) associated femoral neck fractures were observed in patients who sustained bilateral femur fractures. Eight of the 21 patients with bilateral femur fractures, 42 fractures in total, had an associated ipsilateral femoral neck fracture (38% of patients; 19% of fractures, respectively), while only seven of the 166 patients (4%) with a unilateral femur fracture had an associated femoral neck fracture (p < 0.001). Of the 208 femur fractures, 19 (9%) were open fractures. Ten of the 21 patients with bilateral femur fractures, 42 fractures in total, were identified to have an open femur fracture (48% of patients, 24% of fractures), while only nine of the 166 (5%) unilateral femur fractures were open (p < 0.001). CONCLUSIONS: Our results demonstrate an association between bilateral femur fractures, open femur fractures, and associated femoral neck fractures. Surgeons treating these injuries should maintain a high index of suspicion for associated ipsilateral proximal.

Gunshot-related lower extremity nerve injuries.

OBJECTIVE: The purpose of this study was to describe the frequency of nerve injury associated with lower extremity ballistic trauma, the associated skeletal and soft tissue injuries, and the rate of neurologic recovery. DESIGN AND SETTING: A retrospective review of an institutional trauma database was completed at a single level 1 trauma academic medical center. PATIENTS: This was an institutional review board approved retrospective cohort study of patients over 16 years of age presenting with ballistic-related traumatic injury to the lower extremities between May 2018 and May 2019. All patients identified with lower extremity ballistic trauma were included in this study. The rate of nerve palsy, associated skeletal injury, and operative fixation were recorded for each anatomic zone. Rates of associated concomitant vascular injury, fracture, and compartment syndrome were collected through a review of the electronic medical records. Chart review was performed to evaluate outcomes and nerve recovery. RESULTS: Twenty-one patients (21 extremities, 21/148, 14%) were diagnosed by attending physicians, fellowship-trained in orthopedic trauma, as having ballistic-related nerve injuries. Seventy-three percent of patients with a documented neurologic injury (11/15) demonstrated complete nerve recovery as measured by the MRC and sensory scale assessment at most recent follow-up, while the rest demonstrated no improvement in their neurologic deficits from presentation. The rate of associated vascular injury in patients with lower extremity nerve palsies was 38% (8/21). While the rate of vascular injury in the absence of neurologic injury was 3% (4/127). CONCLUSIONS: This series of lower extremity nerve injuries in a large sample of urban lower extremity ballistic trauma noted a high rate of concomitant nerve injuries. An associated diagnosis of a vascular injury appears to portend a higher risk of neurologic injury. Treating surgeons should have a high index of suspicion for associated vascular injury in patients presenting with a ballistic lower extremity nerve palsy.