All-suture fixation of syndesmotic injuries: a case series.

BACKGROUND: To retrospectively evaluate the clinical outcomes of patients treated for syndesmotic injuries with an all-suture construct technique and compare their patient reported outcome scores with historically published outcomes of syndesmotic injuries fixed with suspensory suture buttons. METHODS: This was a retrospective case series of patients treated at a Level 1 Trauma Center from May 1, 2018, to June 30, 2022. Ten patients aged 18 and older with unstable syndesmotic injuries treated with all-suture repair. Patients were excluded if they were treated with trans-osseous screws, had previous failed syndesmotic fixation, or suspensory suture button fixation. Patient-reported outcomes including Visual Analog Scale (VAS) pain scores, American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores, and complications were recorded. RESULTS: In the patients with 6 weeks or more of radiographic follow-up (N = 9), there was no evidence of nonunion, loss of fixation, hardware complication, or whitling of the fibula by the suture. At final follow-up average VAS pain scores were 1.5 out of 10 (range 0-4; SD 1.2), AOFAS ankle and hindfoot scores averaged 89.6 out of 100 (range 86-100; SD 6.1). The pain subscale of the AOFAS score averaged 37.5 out of 40 (range 35-40; SD 2.5). The functional subscale of the AOFAS score averaged 46 out of 50 (range 44-50; SD 3.0). Stiffness was reported in one patient at their follow-up visits, which resolved with continued physical therapy. There were no superficial or deep infections. CONCLUSIONS: In conclusion, this case series presents the first clinical outcomes of an all-suture fixation technique for treatment of unstable syndesmotic ankle injuries. Our results suggest that the all-suture fixation technique results in similar patient reported outcomes when compared with historically reported patient reported outcomes of suspensory suture button fixation, and low rates of complication or hardware failure.

Civilian Ballistic Arthrotomies: Infection Rates and Operative Versus Nonoperative Management.

OBJECTIVES: The purpose of this study was to determine whether a significant difference existed in the rate of infection after ballistic traumatic arthrotomy managed operatively compared with those managed without surgery. DESIGN: Retrospective cohort study. SETTING: Academic Level I Trauma Center. PATIENT SELECTION CRITERIA: Patients with ballistic traumatic arthrotomies of the shoulder, elbow, wrist, hip, knee, or ankle who received operative or nonoperative management. OUTCOME MEASURES AND COMPARISONS: The rates of infection and septic arthritis in those who received operative or nonoperative management. RESULTS: One hundred ninety-five patients were studied. Eighty patients were treated nonoperatively (Non-Op group), 16 patients were treated with formal irrigation and debridement in the operating room (I&D group), and 99 patients were treated with formal I&D and open reduction and internal fixation (ORIF) (I&D + ORIF group). Patients in all 3 groups received local wound care and systemic antibiotics. No patients in the Non-Op or I&D group developed an infection. Six patients in the I&D + ORIF group developed extra-articular postoperative infections requiring additional interventions. CONCLUSIONS: The infection rate in the I&D + ORIF group was consistent with the infection rates reported in orthopaedic literature after fixation alone. In addition, none of the infections were cases of septic arthritis. This suggests that traumatic arthrotomy does not increase the risk for infection beyond what is expected after fixation alone. Importantly, the Non-Op group represented a series of 80 patients who were treated nonoperatively without developing an infection, indicating that I&D may not be necessary to prevent infection after ballistic arthrotomy. The results suggest that septic arthritis after civilian ballistic arthrotomy is a rare complication regardless of the choice of treatment. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Axial Plane Deformity: How to Avoid It and How to Correct It.

Malreductions in the axial plane (ie, length and rotation) are common when managing long bone fractures. Careful attention to detail during the initial treatment can prevent these malreductions. Various fluoroscopy-based techniques exist for the prevention of malrotation and limb-length discrepancy during surgery for fracture. If malreductions do occur, a systematic clinical and radiographic evaluation can provide the necessary information to correct rotational malreduction and limb-length discrepancy.

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.

Radiographic detection of lateral plateau involvement in medial tibial plateau fractures (AO/OTA 41-B1.2, 1.3, 3.2 and 3.3).

PURPOSE: To assess the accuracy of radiographs in detecting the lateral plateau involvement of medial tibial plateau fractures as well as describe the impact of CT on preoperative planning for this specific fracture morphology. METHODS: Radiograph and CT imaging of patients with a Schatzker type IV tibial plateau fractures (AO/OTA 41-B1.2, B1.3 h, B2.2. B3.2, and B3.3) between January 2013 and July 2017 were reviewed by three trauma fellowship-trained orthopedic surgeons to identify fractures of the medial condyle with an intact anterolateral articular surface. RESULTS: Lateral plateau involvement was identified in 16 (37%) radiographs and 26 (61%) CT images (p = 0.051). Radiographic detection of lateral plateau involvement demonstrated a sensitivity of 62% and specificity of 100%, and radiographs were able to predict the recommendation for surgical intervention for lateral plateau involvement with a positive predictive value (PPV) of 75% and a negative predictive value (NPV) of 60% compared to recommendations based on CT imaging. Radiographs predicted a need for a separate surgical approach with PPV of 63% and NPV of 70% when compared to recommendations based on CT images. CONCLUSIONS: Radiographs are reliable in ruling in lateral plateau involvement of medial plateau fractures, but occult lateral articular extension may only be identified in CT imaging for some cases. Surgical planning may be impacted by CT imaging for this fracture morphology, but further study is warranted to evaluate the correlation between preoperative planning and clinical outcomes. LEVEL OF EVIDENCE: III.

Management of Segmental Tibial Bone Defects With a Motorized Intramedullary Bone Transport Nail: A Case Review With Follow-Up.

SUMMARY: Large segment bone defects of the tibia are challenging problems. Although caused by a wide range of conditions, tibial critical bone loss defects often require complex reconstructive plans with prolonged inability to weight-bear on the effected extremity. Reconstruction options frequently require harvesting of autograft leading to further morbidity. Distraction osteogenesis allows reconstruction of large segmental defects of the tibia while avoiding donor site morbidity. Historically, distraction osteogenesis of tibia was most reliably performed with circler ring external fixation. This process allowed early weight-bearing but unfortunately has considerable drawbacks. Negative effects include pin tract irritation and inability to wear normal clothes. The advent of the bone transport nail now allows management of tibial critical bone loss defects through distraction osteogenesis negating the need for external fixation. This new technique allows treatment of large segmental tibial defects by means of distraction osteogenesis with an all-internal device avoiding the negative effects of external fixation while simultaneously allowing early weight-bearing.

Injury and treatment patterns of ballistic pelvic fractures by anatomic location.

INTRODUCTION: Pelvic ballistic injuries threaten critical gastrointestinal, vascular, and urinary structures. We report the treatment patterns and injury profiles of ballistic pelvic fractures and the association between location of ballistic fractures of the pelvis and visceral injuries. METHODS: A prospectively collected database at an academic level I trauma center was reviewed for clinical and radiographic data on patients who sustained one or more ballistic fractures of the pelvis. Main outcomes compared included: procedures with orthopedic surgery, emergent surgery, concomitant intrapelvic injuries, and mortality. RESULTS: Eighty-six patients were included. Eight patients (9.3%) underwent surgical debridement with orthopedic surgery, no ballistic pelvic fractures required surgical stabilization. The anatomical locations of ballistic pelvic fractures included: 10 (14.7%) anterior ring, 13 (19.1%) posterior ring, 27 (39.7%) anterior column, and 18 (20.9%) posterior column. There was a statistically significant association between anterior ring and rectal injury. The association between anterior ring injury and bladder injury approached significance. CONCLUSIONS: This case series included 86 patients with a ballistic fracture of the pelvis, none requiring pelvic ring surgical stabilization. The unpatterned behavior of these injuries demands a high suspicion for visceral injury, with special attention to the rectum and bladder in the setting of anterior ring involvement. LEVEL OF EVIDENCE: IV.

Despite Growing Number of Women Surgeons, Authorship Gender Disparity in Orthopaedic Literature Persists Over 30 Years.

BACKGROUND: The most recent demographic data reveal that only 6.5% of practicing orthopaedic surgeons are women, and as far as we know, only two women have held chair positions in academic orthopaedic programs in the United States. Furthermore, orthopaedic surgery is the least gender-diverse speciality recognized by the Accreditation Council for Graduate Medical Education. The factors that contribute to the lack of gender diversity in orthopaedics remain ill-defined. A lag in publication productivity may be a barrier to career advancement for women orthopaedic surgeons, but this has not been well studied. QUESTIONS/PURPOSES: (1) What is the proportion of orthopaedic studies published in six major orthopaedic journals by women first or senior authors from 1987 to 2017? (2) Did men and women orthopaedic surgeons publish in equal proportions during the study period (measured in 5-year intervals)? (3) Are there differences in the characteristics (such as study type or subject focus) of orthopaedic publications authored by women and those authored by men? (4) Has the increased proportion of practicing women orthopaedic surgeons been matched by an equal increase in authorship by women orthopaedic surgeons during the study timeframe? METHODS: A cross-sectional analysis was designed to characterize trends in authorship of orthopaedic studies by women over time. All publications from the first issue of each of six major orthopaedic journals were evaluated at seven time points (1987, 1992, 1997, 2002, 2007, 2012, and 2017). Characteristics of each first and senior author (including gender, academic degree, and specialty), and study category of each publication were collected. Articles for which this information was not available were excluded (35 of 1073, or 3.3% of published studies, no difference in proportion of excluded studies between journals). The proportions of women and men authors were compared at the seven time points and for six study categories (basic science, case report/technique article, clinical medicine, economics/practice management, editorial content [including true editorials, letters to the editor, commentaries, and book reviews] and review/meta-analysis) using a Fisher's exact test or chi-squared analysis. We compared the rates of change of women authorship, practicing women orthopaedic surgeons, and women orthopaedic residents during the study period using an ANOVA and Tukey's honestly significant difference (HSD) post-hoc test with Cohen's D measure of effect size. RESULTS: From 1987 to 2017, only 1.7% (15 of 880) of senior authors and 4.4% (46 of 1038) of first authors of orthopaedic publications were women orthopaedic surgeons. Based on population proportions (that is, percent of practicing women orthopaedic surgeons compared with men), the proportion of women senior authors was less than would be expected at each time point after 1987 compared with men. There were no differences between the types of studies authored by women or men. Finally, during the study period, the rate of growth of women senior authorship was less than the rates of growth of both practicing women orthopaedic surgeons (d = 5.3, 95% CI, 4.8-5.6; p = 0.023) and women first authorship (d = -4.3, 95% CI -4.6 to -3.6, p = 0.030; estimated mean 3.3, p = 0.013). CONCLUSIONS: Women orthopaedic surgeons published a small proportion of academic orthopaedic research from 1987 to 2017, and women senior authors consistently published less than would be expected based on their population proportion compared with men orthopaedic surgeons. Furthermore, the growth of practicing women orthopaedic surgeons has not been matched by growth in senior authorship by women over the same timeframe. CLINICAL RELEVANCE: This discrepancy warrants further exploration because a low rate of publication may negatively impact the career advancement of women orthopaedic surgeons and contribute to the overall lack of gender diversity in orthopaedics. We suggest that journals and publishers review their editorial processes to ensure blinding of author names during peer review and editorial decision-making, and to disclose those review processes to authors. We also suggest that institutions encourage women trainees and junior faculty to participate in mentorship programs and specialty societies that promote academic productivity.

Street Smarts and a Scalpel: Emotional Intelligence in Surgical Education.

OBJECTIVE: To evaluate trends of emotional intelligence (EI) in surgical education and to compare the incorporation of EI in surgical education to other fields of graduate medical education. DESIGN: A MEDLINE search was performed for publications containing both "surgery" and "emotional intelligence" with at least one term present in the title. Articles were included if the authors deemed EI in surgical education to be a significant focus. A separate series of MEDLINE searches were performed with the phrase "emotional intelligence" in any field and either "surg*," "internal medicine," "pediatric," "neurology," "obstetric," "gynecology," "OBGYN," "emergency," or "psychiat*" in the title. Articles were included if they discussed resident education as the primary subject. Next, a qualitative analysis of the articles was performed, with important themes from each article noted. SETTING: Lehigh Valley Health Network in Allentown, PA. RESULTS: Eight articles addressed surgical resident education and satisfied inclusion criteria with 0, 1, and 7 articles published between 2001 and 2005, 2005 and 2010, and 2010 and 2015, respectively. The comparative data for articles on EI and resident education showed the following : 8 in surgery, 2 in internal medicine, 2 in pediatrics, 0 in neurology, 0 in OBGYN, 1 in emergency medicine, and 3 in psychiatry. CONCLUSIONS: Integration of EI principles is a growing trend within surgical education. A prominent theme is quantitative assessment of EI in residents and residency applicants. Further study is warranted on the integration process of EI in surgical education and its effect on patient outcomes and long-term job satisfaction.