Disconnected: Electronic Patient-Reported Outcome Measure Collection in Orthopaedic Patients is Less Successful Than In-Person Collection at an Urban Safety Net Trauma Center.

OBJECTIVES: Electronic patient-reported outcome measure (E-PROM) collection is a technological advancement that has the potential to facilitate PROM collection in orthopaedic trauma. The purpose of this study was to compare E-PROM versus in-person PROM collection. DESIGN: This is a retrospective comparative study. SETTING: Urban Level I trauma center. PATIENTS/PARTICIPANTS: One hundred and fifty consecutive operative orthopaedic trauma patients. INTERVENTION: The Percent of Normal single assessment numerical evaluation and patient-reported outcomes measurement information system physical function were collected through automated e-mails from an online patient-engagement platform (PatientIQ, Chicago, IL) 2-week, 6-week, 3-month, and 6-month postoperatively. The Percent of Normal was also administered to patients in clinic at the same time intervals. MAIN OUTCOME MEASUREMENTS: Completion of PROMs; Loss to follow-up. RESULTS: The median clinical follow-up time was 4 months (interquartile range: 1.3-6 months), and 42.7% (64/150) were lost to follow-up. Loss to follow-up was associated with a more disadvantaged area deprivation index [observed difference, 7.0, 95% confidence interval, 1.0 to 13.0; P = 0.01] and noncommercial/no insurance (observed difference 34.8%, confidence interval, 20.9%-45.5%; P < 0.0001). In-person PROM collection was more successful than E-PROM collection at all intervals [2-week (51.3% vs 20.7), 6-week (46.7% vs 20.0%), 3-month (50.0% vs 18.7%), and 6-month (38.0% vs 18.7%), P < 0.0001]. Patients who completed 3-month E-PROMs had longer clinical follow-up (5.2 vs. 3.0 months, P = 0.004) and a trend of being less likely to be lost to follow-up (28.6% vs 45.9%, P = 0.13). CONCLUSION: E-PROMs were less successful than in-person PROM collection in trauma patients at an urban safety net trauma center. LEVEL OF EVIDENCE: Diagnostic Level III.

Institution of same-day total joint replacement at an urban safety net hospital during the COVID-19 pandemic.

Background: Increasingly, total hip and total knee replacements are being performed at outpatient ambulatory surgery centers. The purpose of this study was to investigate the feasibility and safety of instituting a same-day surgery program for hip and knee replacement at an urban, safety net hospital. Methods: Retrospective review of a prospectively collected registry for all patients scheduled for same-day total joint replacement at a safety net hospital was performed. Medical records were reviewed for patient demographics, same-day hospital admissions, and 30-day emergency room/hospital admissions. Results: 131 same-day total joint replacements were identified, including 76 knees and 55 hips. Median ASA was 3, and median Charlson comorbidity score was 2. Rate of same-day surgery for total joint replacements increased from 4.5% in September 2020 to 100% in September 2021. On major patient outcomes, 3.8% of patients (n = 5) required conversion to inpatient admission. Rate of 30-Day Emergency Department (ED) visits was 13.0% (n = 17). Most common complaints included postoperative pain (n = 10), incision drainage/edema/hematoma (n = 9), and cellulitis (n = 2). 30-Day Hospital Readmissions occurred in 1.5% of patients (n = 2). Conclusion: Same-day hip and knee replacement can be performed safely at a safety net hospital. Unlike dedicated high-volume orthopedic hospitals or outpatient surgery centers, urban safety net hospitals face a different set of challenges and must care for a wide variety of patients who do not plan for their illness and/or may not be able to pay for their care. Outpatient total joint replacement may extend total joint replacement to patients who might not have access otherwise.

The Antibiotic Cement Bead Rouleaux: A Technical Trick to Maximize the Surface Area to Volume Ratio of Cement Beads to Improve the Elution of Antibiotics.

SUMMARY: The use of antibiotic-impregnated cement as a local antibiotic delivery system is well-established as an adjunctive treatment for chronic osteomyelitis. Because the elution of antibiotics is a surface area phenomenon, the geometry of the cement is an important consideration. The antibiotic cement bead rouleaux technique is a simple and efficient method of bead fabrication that requires only 10 minutes of preparation time and readily available operating room supplies. The discoid structure of the beads provides 3 times the surface-area-to-volume ratio of a spherical bead, which facilitates antibiotic elution. Given the speed and ease of fabrication, along with optimized geometry, the antibiotic cement bead rouleaux is a useful addition to the surgeon's repertoire.

Urinary Bladder Matrix Grafting: A Simple and Effective Alternative to Flap Coverage for Wounds in High-Risk Orthopaedic Trauma Patients.

SUMMARY: Complex traumatic and/or infected wounds and their sequelae are a significant burden for high-volume trauma centers. Local or free flap coverage options are well described; however, they may be high risk in poor hosts with multiple comorbidities and active infections. In addition, flap coverage can result in delays in wound coverage depending on specialist availability. Porcine urinary bladder matrix grafting has been shown to be a simple definitive wound coverage option that can be performed without delay in multiple patient populations for wounds that would otherwise require flap coverage. The purpose of this article was to describe a technique for urinary bladder matrix grafting and report on a series of orthopaedic trauma patients treated with this technique.

History of pelvic fracture management: a review.

High-energy pelvic fractures represent potentially life-threatening injuries due to the risk of acute exsanguinating retroperitoneal hemorrhage. The first report of a severe pelvic ring disruption dates back to Charles Hewitt Moore's seminal publication from 1851. Significant advantages in the understanding of injury mechanisms and treatment concepts of pelvic ring injuries evolved in the 20(th) century, and provided the basis to current classification-guided treatment and life-saving "damage control" concepts. However, there is a paucity of reports in the current literature focused on the historic background on the treatment of pelvic ring injuries. The present review was designed to summarize the history and evolution of our current understanding of the mechanisms and management strategies for severe pelvic ring injuries (excluding acetabular fractures which represent a different entity outside of the scope of this article).

Optimizing Stability in Femoral Neck Fracture Fixation.

Optimizing stability of femoral neck fracture fixation is important in obtaining a successful outcome. The mechanical problems and strategies for achieving optimal stability differ depending on patients' age and degree of osteoporosis. Femoral neck fractures in younger adults usually result from high-energy trauma and have a vertical fracture pattern. Strategies for optimizing fixation stability in this group include placing additional screws at right angles to the fracture plane and medial buttress plate augmentation. In elderly patients, screw position relative to the intact cortical femoral neck bone is of critical importance. Additional strategies for optimizing fixation stability in this group include the concept of length stable fixation, use of adjunctive calcium phosphate cement, and use of novel fixed angle fixation implants.

Current Treatment Strategies for Patella Fractures.

Patella fractures can be caused by excessive tension through the extensor mechanism or a direct impact. Non-displaced fractures with an intact extensor mechanism can be treated nonoperatively. Surgical treatment is recommended for fractures that either disrupt the extensor mechanism or have greater than 2 to 3 mm of step-off and greater than 1 to 4 mm of displacement. Tension band fixation is the most commonly employed surgical technique; however, this can be technically demanding, especially in multifragmentary fractures. Symptomatic hardware is the most common complication following operative treatment. Functional impairment remains common after treatment of patella fractures. The purpose of this article is to review current treatment strategies to help optimize the management of patients with such patella fractures.

Local antibiotic therapy strategies in orthopaedic trauma: Practical tips and tricks and review of the literature.

The use of local antibiotics for the prevention of infection in the setting of open fractures and as part of the treatment of osteomyelitis is well established. Antibiotics are most commonly incorporated into polymethylmethacrylate (PMMA) cement, which can then be formed into beads, moulded to fit a bone defect or used to coat a guide wire or IM nail. Newer delivery vehicles and techniques are being evaluated to improve upon these methods. Many factors influence how local antibiotics are applied. Treatment strategies are challenging to standardise due to the variability of clinical presentations. The presence of hardware, upper versus lower extremity, healed versus non-healed fracture and quality of soft tissues overlying the affected bone, as well as patients' comorbidities all need to be considered. Despite the accepted use of local antibiotic therapy in orthopaedic trauma, high-quality evidence regarding the use of local antibiotics is lacking. Indications, techniques, dosages, types of antibiotics, elution properties and pharmacokinetics are poorly defined in the clinical setting. The purpose of our manuscript is to review current strategies and provide practical tips for local application of antibiotics in orthopaedic trauma. We focus on delivery vehicles, types of antibiotics, dosage recommendations when mixed with PMMA and indications.

Ipsilateral femoral neck and shaft fractures: current diagnostic and treatment strategies.

Associated ipsilateral femoral neck fractures have been reported to occur in 1% to 9% of femoral shaft fractures. The associated femoral neck fracture is often nondisplaced, and the diagnosis is delayed or missed in up to one-third of cases. It is essential to carefully evaluate the femoral neck in all patients sustaining high-energy femoral shaft fractures. Although there are a number of different implant options available for management of this challenging injury, most authors recommend that priority be given to anatomic reduction and optimal stabilization of the femoral neck fracture because nonunion, malunion, or avascular necrosis of this injury is more difficult to successfully treat.

Dental disease and periprosthetic joint infection.

➤ The number of patients with end-stage osteoarthritis is increasing, and treatment with hip and knee arthroplasty is expected to increase over the next several decades. ➤ Dental disease has long been anecdotally associated with increased periprosthetic joint infections, although case-control studies do not support this relationship. ➤ While most recent guidelines for the prevention of endocarditis have favored treatment of fewer patients, the most recent recommendations for prevention of periprosthetic joint infection have increased the number of patients who would receive antibiotics before a dental procedure. ➤ Antibiotics given before a dental procedure decrease the risk of bacteremia from the oral cavity, but this is of uncertain clinical importance. ➤ The number of patients who would require antibiotics before dental procedures to prevent one periprosthetic joint infection greatly outnumbers the number of patients who would experience an adverse event associated with antibiotics given before a dental procedure.

Surgical site infection after open reduction and internal fixation of tibial plateau fractures.

OBJECTIVE: The aim of this study was to identify risk factors for surgical site infections and to quantify the contribution of independent risk factors to the probability of developing infection after definitive fixation of tibial plateau fractures in adult patients. METHODS: A retrospective analysis was performed at a level I trauma center between January 2004 and December 2010. Data were collected from a review of the patient's electronic medical records. A total of 251 consecutive patients (256 cases) were divided into two groups, those with surgical site infections and those without surgical site infections. Preoperative and perioperative variables were compared between these groups, and risk factors were determined by univariate analyses and multivariate logistic regression. Variables analyzed included age, gender, smoking history, diabetes, presence of an open fracture, presence of compartment syndrome, Schatzker classification, polytrauma status, ICU stay, time from injury to surgery, use of temporary external fixation, surgical approach, surgical fixation, operative time, and use of a drain. RESULTS: The overall rate of surgical site infection after ORIF of tibial plateau fractures during the 7 years of this study was 7.8% (20 of 256). The most common causative pathogens was Staphylococcus aureus (n=15, 75%). Independent predictors of surgical site infection identified by multivariate analyses were open tibial plateau fracture (odds ratio=3.9; 95% CI=1.3-11.6; p=0.015) and operative time (odds ratio=2.7; 95% CI=1.6-4.4; p<0.001). The presence of compartment syndrome (odds ratio=3.4; 95% CI=0.7-15.9; p=0.119), use of temporary external fixation (odds ratio=0.5; 95% CI=0.2-1.7; p=0.298), and ICU stay (odds ratio=1.0; 95% CI=1.0-1.1; p=0.074) were not determined to be independent predictors of surgical site infection. CONCLUSIONS: Both open fracture and operative time are independent risks factors for postoperative infection.

A cascade of preventable complications following a missed femoral neck fracture after antegrade femoral nailing.

BACKGROUND: Occult femoral neck fractures associated with femoral shaft fractures are frequently missed and may lead to adverse outcomes. CASE PRESENTATION: A 46-year old female presented to our institution with increasing groin pain one month after antegrade intramedullary nailing of a femoral shaft fracture at an outside hospital. Radiographic evaluation revealed a displaced ipsilateral femoral neck fracture, adjacent to the piriformis starting point of the nail. A revision fixation of the femoral shaft and neck fracture was performed. The patient sustained a series of complications requiring multiple revision surgeries, including a total hip arthroplasty. Despite the cascade of complications, the patient had an uneventful long-term recovery, without additional complications noted at one-year follow-up. CONCLUSION: This case report illustrates the necessity of increased awareness with a high level of suspicion for the presence of associated femoral shaft and neck fractures in any patient undergoing antegrade femoral nailing. Arguably, the cascade of complications presented in this paper could have been prevented with early recognition and initial stabilization of the occult femoral neck fracture. Standardized diagnostic protocols include "on table" pelvic radiographs to rule out associated femoral neck fractures. The diagnosis must be enforced in case of equivocal radiographic findings, either by computed tomography scan or magnetic resonance imaging.

Heterotopic ossification in the reaming tract of a percutaneous antegrade femoral nail: a case report.

INTRODUCTION: Heterotopic ossification is a rare complication of musculoskeletal injuries, characterized by bone growth in soft tissues. Percutaneous antegrade intramedullary nailing represents the 'gold standard' for the treatment of femur shaft fractures. Minor bone growth is frequently seen around the proximal end of reamed femoral nails (so-called 'callus caps'), which are asymptomatic and lack a therapeutic implication. The occurrence of excessive, symptomatic heterotopic ossification around the entry site of an antegrade femoral nail is rarely described in the literature. CASE PRESENTATION: We present the case of a 28-year-old Caucasian woman who developed extensive heterotopic ossification around the reaming seeds of a reamed femoral nail. She developed severe pain and significantly impaired range of motion of the hip joint, requiring revision surgery for heterotopic ossification resection and adjunctive local irradiation. She recovered full function of the hip and remained asymptomatic at her two-year follow-up appointment. CONCLUSIONS: Severe heterotopic ossification represents a rare but potentially detrimental complication after percutaneous femoral nailing of femur shaft fractures. Diligent care during the reaming procedure, including placement of a trocar to protect from osteogenic seeding of the soft tissues, may help decrease the risk of developing heterotopic ossification after reamed antegrade femoral nailing.

Incidence and pattern of technical complications in balloon-guided osteoplasty for depressed tibial plateau fractures: a pilot study in 20 consecutive patients.

BACKGROUND: Inflation bone tamps are becoming increasingly popular as a reduction tool for depressed tibial plateau fractures. A number of recent publications have addressed the technical aspects of balloon inflation osteoplasty. However, no study has yet been published to describe the technical limitations, intraoperative complications, and surgical bailout strategies for this new technology. METHODS: Observational retrospective study of all patients managed with inflatable bone tamps for depressed tibial plateau fractures between October 1, 2010 and December 1, 2012. The primary outcome parameter was the rate of complications, which were stratified into "minor" and "major" depending on the necessity for altering the surgical plan intraoperatively, and based on the risk for patient harm. This study was approved by the Institutional Review Board of the State of Colorado. RESULTS: A consecutive series of 20 patients were managed by balloon inflation osteoplasty for depressed tibial plateau fractures during the 15 months study period. The mean age was 42.8 years (range 20-79), with 9 females and 11 males. A total of 13 patients sustained an adverse intraoperative event (65%), with three patients sustaining multiple technical complications. Minor events (n = 8) included the burst of a balloon with extrusion of contrast dye, and the unintentional posterior wall displacement during balloon inflation. Major events (n = 5) included the intra-articular injection of calcium phosphate in the knee joint, and the inability to elevate the depressed articular fragment with the inflatable bone tamp. CONCLUSION: The observed intraoperative complication rate of 65% reflects a steep learning curve for the use of inflation bone tamps to reduce depressed tibial plateau fractures. Specific surgical bailout options are provided in this article, based on our early anecdotal experience in a pilot series of 20 consecutive cases. Patients should be advised on the benefits and risks of this new technology as part of the shared decision-making process during the informed consent.

The reliability of measurement of tissue pressure in compartment syndrome.

BACKGROUND: Although there is general agreement as to the pathophysiology and treatment of compartment syndrome and the importance of intramuscular pressure measurements, there are many methods described to obtain these measurements. Variations in experimental measurements using current electronic monitoring, needle, and catheter devices of 18 to 22 mmHg are reported and are enough to cause errors in clinical decision-making that could result in significant clinical consequences. Current unacceptable reliability has been reported with the use of bevel-tipped needles and the clinical Whitesides technique. Because this is contrary to the authors' cumulative clinical and research experience with various methods when properly used (with the small required saline flush to assure a fluid continuum between tissue and the pressure monitor), this study was designed to clarify these problems. Although the two Whitesides techniques (original and clinical) are not in current use where digital methods are available, the clinical method is still used in the Third World. METHODS: To eliminate comparative errors, a laboratory compartment syndrome model was devised to allow simultaneous testing of different devices in the same area of fusiform muscle against increasing intramuscular pressure using the same transducer and monitor. Slit catheters, side-ported bevel-tipped needles, and 18-gauge bevel-tipped needles were compared against each other. The two Whitesides methods using a capillary meniscus and a mercury manometer were compared against a current electronic transducer method using identical 18-gauge bevel-tipped needles and varying diameter capillary tubing. RESULTS: The side-ported needle, slit catheter, and 18-gauge bevel-tipped needle were found to measure equivalent pressure when compared statistically with each other in pairs. The original Whitesides method using a 1.25-mm capillary tube and the digital transducer method using 18-gauge bevel-tipped needles was also found to measure equivalent pressure. The clinical Whitesides method using current plastic intravenous tubing of 3.0-mm internal diameter fails to produce an obvious capillary meniscus, leading to diminished reliability in the measured pressure. CONCLUSIONS: The slit catheter, side-ported bevel-tipped needle, or an 18-gauge needle, when appropriately used with current electronic transducer monitoring, may be used clinically with confidence. When digital methods are not available, the original Whitesides method using 1.25-mm glass capillary tubing is an accurate alternative but requires preplanning. When only 3-mm tubing is available, this method is relatively useful when electronic means are not available by averaging several consecutive measurements.

Modality of wound closure after total knee replacement: are staples as safe as sutures? A retrospective study of 181 patients.

BACKGROUND: Surgical site wound closure plays a vital role in post-operative success. This effect is magnified in regard to commonly performed elective procedures such as total knee arthroplasty. The use of either sutures or staples for skin re-approximation remains a contested subject, which may have a significant impact on both patient safety and surgical outcome. The literature remains divided on this topic. METHODS: Two cohorts of patients at a level one trauma and regional referral center were reviewed. Cohorts consisted of consecutive total knee arthroplasties performed by two surgeons who achieved surgical wound re-approximation by either staples or absorbable subcuticular sutures. Outcome variables included time of surgery, wound dehiscence, surgical site infection per Center for Disease Control criteria and repeat procedures for debridement and re-closure. RESULTS: 181 patients qualified for study inclusion. Staples were employed in 82 cases (45.3% of total) and sutures in 99 cases (54.7%). The staples group had no complications while the sutures group had 9 (9.1%). These consisted of: 4 infections (2 superficial, one deep, one organ/space); three patients required re-suturing for dehiscence; one allergic type reaction to suture material; and one gout flare resulting in dehiscence. The mean surgical time with sutures was 122.3 minutes (sd = 33.4) and with staples was 114 minutes (sd = 24.4). CONCLUSION: This study demonstrated significantly fewer complications with staple use than with suture use. While all complications found in this study cannot be directly attributed to skin re-approximation method, the need for further prospective, randomized trials is established.

Correlation between muscle oxygenation and compartment pressures in acute compartment syndrome of the leg.

BACKGROUND: Near-infrared spectroscopy estimates soft-tissue oxygenation approximately 2 to 3 cm below the skin. The purpose of the present study was to evaluate muscle oxygenation in the setting of an acute compartment syndrome of the leg and to determine if near-infrared spectroscopy is capable of detecting perfusion deficits. METHODS: Fourteen patients with unilateral lower extremity trauma were enrolled after the diagnosis of an acute compartment syndrome was made clinically and confirmed with intracompartmental pressure measurements. Lower extremity muscle compartments were evaluated with near-infrared spectroscopy, and near-infrared spectroscopy values of the uninjured, contralateral leg of each patient were used as internal reference values. The compartment perfusion gradient was calculated as the diastolic blood pressure minus the intracompartmental pressure. RESULTS: Intracompartmental pressures ranged from 21 to 176 mm Hg (mean, 79 mm Hg) and exceeded 30 mm Hg in all compartments but two (both in the same patient). Thirty-eight compartments had a perfusion gradient of < or = 10 mm Hg (indicating ischemia). Among ischemic compartments, near-infrared spectroscopy values in the anterior, lateral, deep posterior, and superficial posterior compartments of the injured limbs were decreased by an average 10.1%, 10.1%, 9.4%, and 16.3% in comparison with the corresponding compartments of the uninjured leg. Differences in near-infrared spectroscopy values (the near-infrared spectroscopy value for the injured leg minus the near-infrared spectroscopy value for the uninjured leg) were positively correlated with compartment perfusion gradient within each compartment (r = 0.82, 0.65, 0.67, and 0.62, for the anterior, lateral, deep posterior, and superficial posterior compartments, respectively; p < 0.05 for all). CONCLUSIONS: Normalized near-infrared spectroscopy values decrease significantly with decreasing lower limb perfusion pressures. Near-infrared spectroscopy may be capable of differentiating between injured patients with and without an acute compartment syndrome.

Near-infrared spectroscopy in lower extremity trauma.

BACKGROUND: Near-infrared spectroscopy measures the percentage of hemoglobin oxygen saturation in the microcirculation of tissue up to 3 cm below the skin. The purpose of this study was to describe the measurable response of normal tissue oxygenation in the leg after acute trauma with use of this technique. METHODS: Twenty-six patients with acute unilateral tibial fractures and twenty-five uninjured volunteer control subjects were enrolled. Near-infrared spectroscopy measurements were obtained for both legs in all four compartments: anterior, lateral, deep posterior, and superficial posterior. The twenty-six injured legs were compared with twenty-five uninjured legs (randomly selected) of the volunteer control group, with the contralateral limb in each patient serving as an internal control. RESULTS: The mean tissue oxygenation for each compartment in the injured legs was 69% (anterior), 70% (lateral), 74% (deep posterior), and 70% (superficial posterior). In the control (uninjured) legs, the average tissue oxygenation percentage in each compartment was 54%, 55%, 60%, and 57%, respectively. Repeated-measures analysis revealed that near-infrared spectroscopy values averaged 15.4 percentage points (95% confidence interval, 12.2 to 18.6 percentage points) higher for injured legs than for uninjured legs, controlling for the value of the contralateral limb (p < 0.0001). CONCLUSIONS: Tibial fracture produces a predictable increase in tissue oxygenation as measured by near-infrared spectroscopy. The corresponding compartment of the contralateral leg can provide strong utility as an internal control value when evaluating the hyperemic response to injury.

Sagittal profile of the elderly.

Little is known about the natural history of spinal alignment as it ages into the eighth and ninth decades. Fifty asymptomatic volunteers 70-85 years of age (mean 76 years) without any history of spine pain, trauma, or deformity were radiographed in the standing lateral position, from C7 to the pelvis including the hips. Measurements included segmental angulations, kyphosis, lordosis, and C7 plumb line balance. In addition, measurements of sagittal pelvic balance were made (pelvic incidence, tilting, sacral slope, and S1 overhang). Average kyphosis was 52 degrees (range 29 degrees to 79 degrees); the average lordosis was -57 degrees (range -96 degrees to -20 degrees). The C7 plumb line on average fell 40 mm anterior to the posterosuperior corner of S1. The anterior positioning of C7 was also positively correlated with age and decreasing lordosis. This provides further data into the natural history of the aging spine.