Mortality Rates After Nonoperative Geriatric Hip Fracture Treatment: A Matched Cohort Analysis.

OBJECTIVE: To compare the mortality rate between geriatric patients with hip fracture treated nonoperatively and a matched cohort treated operatively. DESIGN: Retrospective Observational Matched Cohort Study. SETTING: Academic Level 1 Trauma Center. PATIENTS: Geriatric patients who sustained femoral neck and intertrochanteric/peritrochanteric fractures, excluding isolated greater trochanteric fractures. All patients older than 65 years with hip fractures over a 10-year period were identified. Operative patients were matched at a 2:1 ratio, when possible, to nonoperative patients based on Charlson Comorbidity Index and American Society of Anesthesiologists score. INTERVENTION: Nonoperative treatment or operative treatment (femoral neck fractures: cannulated screw fixation or hemiarthroplasty; intertrochanteric/peritrochanteric fractures: sliding hip screw or cephalomedullary nail fixation; or proximal femoral locking plate). MAIN OUTCOMES: Mortality calculated at 30 and 90 days, and 1-year after injury. Mortality was compared between groups using logistic regression while controlling for age, CVA/TIA, and dementia. RESULTS: Seven hundred seventy-two patients (171 nonoperative and 601 operative) were initially identified. After applying the matching algorithm, 128 nonoperative and 239 operative patients were included in the analysis. There were no significant differences in age, sex, Charlson Comorbidity Index, or American Society of Anesthesiologists score between the cohorts. Nonoperative patients had a significantly higher 1-year mortality rate than operative patients [46.1% vs. 18.0%, Odds Ratio (95% confidence interval): 3.85 (2.34-6.41), P < 0.001]. CONCLUSIONS: Geriatric patients with hip fracture treated nonoperatively had a 1-year mortality rate of 46.1%, more than double the rate among operative patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Treatment of Coxa Profunda With Open Surgical Hip Dislocation, Rim Resection, Cam Resection, and Labral Reconstruction.

Coxa profunda presents a unique challenge in surgical treatment approach given global acetabular overcoverage. Arthroscopic treatment can be fraught with difficulty obtaining hip distraction for safe arthroscopic instrumentation, and limited arthroscopic access may prevent sufficient osseous resection of the excess acetabular rim. Although hip arthroscopy use has increased markedly over the past decades for all types of hip pathology, coxa profunda may represent one unique indication for surgical hip dislocation. This technique describes open surgical hip dislocation, rim resection, femoral osteoplasty, and labral reconstruction using anterior tibialis allograft for coxa profunda with combined-type femoroacetabular impingement syndrome and labral ossification.

Combined Hip Arthroscopy and Periacetabular Osteotomy (PAO): Technical Focus on Arthroscopically Elevating the Iliocapsularis and Performing the Open PAO.

In this Technical Note, we discuss the combined hip arthroscopy and periacetabular osteotomy (PAO) for the treatment of symptomatic hip dysplasia, with a focus on the technique we use for the PAO. We identify modifications that can be made during the arthroscopic portion of the procedure to assist in the PAO dissection, including arthroscopic capsular closure and arthroscopic elevation of the iliocapsularis muscle off the capsule, which allows for expedited open exposure during the PAO.

Reduction techniques for intramedullary nailing of tibial shaft fractures: a comparative study.

OBJECTIVES: To assess the impact of various reduction techniques on postoperative alignment following intramedullary nail (IMN) fixation of tibial shaft fractures. DESIGN: Retrospective comparative study. SETTING: Level I trauma center. PATIENTS: Four hundred twenty-eight adult patients who underwent IMN fixation of a tibial shaft fracture between 2008 and 2017. INTERVENTION: IMN fixation with use of one or more of the following reduction techniques: manual reduction, traveling traction, percutaneous clamps, provisional plating, or blocking screws. MAIN OUTCOME MEASURES: Immediate postoperative coronal and sagittal plane alignment, measured as deviation from anatomic axis (DFAA); coronal and sagittal plane malalignment (defined as DFAA >5° in either plane). RESULTS: Four hundred twenty-eight patients met inclusion criteria. Manual reduction (MR) alone was used in 11% of fractures, and adjunctive reduction aids were used for the remaining 89%. After controlling for age, BMI, and fracture location, the use of traveling traction (TT) with or without percutaneous clamping (PC) resulted in significantly improved coronal plane alignment compared to MR alone (TT: 3.4°, TT+PC: 3.2°, MR: 4.5°, P = .007 and P = .01, respectively). Using TT+PC resulted in the lowest rate of coronal plane malalignment (13% vs 39% with MR alone, P = .01), and using any adjunctive reduction technique resulted in decreased malalignment rates compared to MR (24% vs 39%, P = .02). No difference was observed in sagittal plane alignment between reduction techniques. Intraclass correlation coefficient (ICC) results indicated excellent intraobserver reliability on both planes (both ICC>0.85), good inter-observer reliability in the coronal plane (ICC = 0.7), and poor inter-observer reliability in the sagittal plane (ICC = 0.05). CONCLUSIONS: The use of adjunctive reduction techniques during IMN fixation of tibia fractures is associated with a lower incidence of coronal plane malalignment when compared to manual reduction alone. LEVEL OF EVIDENCE: Therapeutic Level III.

Excision of Heterotopic Ossification around the Hip: Arthroscopic and Open Techniques.

Heterotopic ossification (HO) can occur as a complication of various pathologies affecting the hip including trauma, tendon avulsions, chronic injury, spinal cord injury, and soft-tissue disruption caused by surgery. When HO is present alongside intra-articular hip pathology such as femoroacetabular impingement syndrome (FAIS) or labral pathology, consideration should be made to combine the surgical excision of the HO with the FAIS decompression or labral repair if the location and size of the HO is appropriate for arthroscopic excision. Often times, the HO is located in such a position that any central compartment work can be completed before turning to the HO excision. If an open approach is required, the modified Gibson approach can be used for lateral hip access, whereas the Smith-Petersen approach provides anterior hip access. In this Technical Note we discuss arthroscopic techniques for excision of HO in the setting of concomitant FAIS, with discussion of when HO excision occurs in relation to cam decompression and labral repair, and mention tips on how to approach HO excision through an open approach.

3D-printed models for periacetabular osteotomy surgical planning.

The purpose of this study was to determine the feasibility and clinical benefits of using 3D-printed hemipelvis models for periacetabular osteotomy preoperative planning in the treatment of hip dysplasia. This retrospective study included 28 consecutive cases in 26 patients, with two bilateral cases, who underwent periacetabular osteotomy between January 2017 and February 2020 and had routine radiographs, CT and MR imaging. Of these, 14 cases [mean patient age 30.7 (SD 8.4) years, 11 female] had routine preoperative imaging, and 14 cases [mean patient age 28.0 (SD 8.7) years, 13 female] had routine preoperative imaging and creation of a full-scale 3D-printed hemipelvis model from the CT data. The expected surgical cuts were performed on the 3D-printed models. All patients underwent Bernese periacetabular osteotomy. Operative times, including time to achieve proper acetabular position and total periacetabular osteotomy time, fluoroscopy radiation dose and estimated total blood loss were compiled. ANOVA compared outcome variables between the two patient groups, controlling for possible confounders. On average, patients who had additional preoperative planning using the 3D-printed model had a 5.5-min reduction in time to achieve proper acetabular position and a 14.5-min reduction in total periacetabular osteotomy time; however, these changes were not statistically significant (P = 0.526 and 0.151, respectively). No significant difference was identified in fluoroscopy radiation dose or total blood loss. Detailed surgical planning for periacetabular osteotomy using 3D-printed models is feasible using widely available and affordable technology and shows promise to improve surgical efficiency.

Methicillin-Resistant Staphylococcus Aureus Carrier Rate in Orthopaedic Trauma Patients: A Prospective Cohort Study.

OBJECTIVES: To identify the methicillin-resistant Staphylococcus aureus (MRSA) carrier rate among surgical patients on an orthopaedic trauma service and to determine whether screening is an effective tool for reducing postoperative MRSA infection in this population. DESIGN: Prospective. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Two hundred forty-eight patients with operatively managed orthopaedic trauma conditions during the study period. Two hundred three patients (82%) had acute orthopaedic trauma injuries. Forty-five patients (18%) underwent surgery for a nonacute orthopaedic trauma condition, including 36 elective procedures and 9 procedures to address infection. INTERVENTION: MRSA screening protocol, preoperative antibiotics per protocol. MAIN OUTCOME MEASUREMENTS: MRSA carrier rate, overall infection rate, MRSA infection rate. RESULTS: Our screening captured 71% (175/248) of operatively treated orthopaedic trauma patients during the study period. The overall MRSA carrier rate was 3.4% (6/175). When separated by group, the acute orthopaedic trauma cohort had an MRSA carrier rate of 1.4% (2/143), and neither MRSA-positive patient developed a surgical site infection. Only one MRSA infection occurred in the acute orthopaedic trauma cohort. The nonacute group had a significantly higher MRSA carrier rate of 12.5% (4/32, P = 0.01), and the elective group had the highest MRSA carrier rate of 15.4% (4/26, P < 0.01). The odds ratio of MRSA colonization was 10.1 in the nonacute group (95% confidence interval, 1.87-75.2) and 12.8 for true elective group (95% confidence interval, 2.36-96.5) when compared with the acute orthopaedic trauma cohort. CONCLUSIONS: There was a low MRSA colonization rate (1.4%) among patients presenting to our institution for acute fracture care. Patients undergoing elective surgery for fracture-related conditions such as nonunion, malunion, revision surgery, or implant removal have a significantly higher MRSA carrier rate (15.4%) and therefore may benefit from MRSA screening. Our results do not support routine vancomycin administration for orthopaedic trauma patients whose MRSA status is not known at the time of surgery. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Urosymphyseal Fistulas Resulting From Endoscopic Treatment of Radiation-induced Posterior Urethral Strictures.

OBJECTIVE: To describe the inciting events leading to urosymphyseal fistulas (UFs) and pubic osteomyelitis (PO) in patients who had radiation-induced urethral strictures. METHODS: We retrospectively reviewed patients who underwent simultaneous pubic debridement, simple cystectomy, and urinary diversion for refractory UF and PO from 2014 to 2016. We investigated inciting events leading to UF, as well as patient presenting symptoms, diagnosis, management, and outcomes. RESULTS: Five patients were identified over a 2-year period. All patients had a previous history of radiation for prostate cancer. The median age was 67 years. All patients developed UF and PO after endoscopic intervention for urethral stricture. The number of endoscopic interventions per patient for stricture ranged from 1 to 7, including serial dilation, balloon dilation, and urethrotomy. Sterile urine cultures were obtained before all endoscopic interventions. All patients had pelvic pain with ambulation and recurrent urinary tract infections at presentation. Patients were diagnosed using a combination of retrograde urethrography and magnetic resonance imaging. Simultaneous pubic debridement with simple cystectomy and diversion was used for management in all cases. One patient died postoperatively with the remainder recovering well without PO or fistula recurrence, with a median follow-up of 16 months. CONCLUSION: UF can occur as a complication of endoscopic treatment of posterior urethral stricture in patients with a history of radiation therapy for prostate cancer. This study demonstrates that UF and PO may develop even with minimally traumatic procedures and sterile urine. All patients treated for posterior stricture must be considered at risk of development of fistulas and osteomyelitis.

Outcome of 28 open pilon fractures with injury severity-based fixation.

INTRODUCTION: Open pilon fracture management and treatment poses a significant challenge to orthopedic surgeons. The purpose of this study was to determine patient outcomes for open pilon fractures based on wound complication and infection rates, as well as subjective outcome instruments. MATERIALS AND METHODS: This was a retrospective consecutive case series of 28 fractures with Orthopaedic Trauma Association (OTA)-type 43-B and 43-C open pilon fractures. Mean length of follow-up was 36 months and minimum of 1 year. Ten fractures were Gustilo and Anderson grade IIIB, and the remaining fractures were grades I-IIIA. Patients were initially treated with spanning external fixation and staged wound debridement followed by osteosynthesis of the articular surface. Metaphyseal fixation was by either plate fixation or Ilizarov frame. The primary outcome was the incidence of deep tissue infection requiring surgery. Secondary outcomes included the incidence of other complications (nonunion, malunion, amputation) and functional outcomes (Short Musculoskeletal Functional Assessment Questionnaire and AAOS Foot and Ankle Questionnaire). RESULTS: Four patients developed deep tissue infections, three in the internal fixation group and one in the Ilizarov group, and all were treated successfully with staged debridement. There were two delayed unions required bone grafting, and infection-free union was ultimately achieved in all fractures. Two patients underwent arthrodesis secondary to post-traumatic arthritis, while no patients experienced malunions or amputations. CONCLUSIONS: The use of staged wound debridement in conjunction with either plate fixation or Ilizarov frame achieves low rates of wound infection and stable fixation after anatomic joint reconstruction for OTA-type 43-B and 43-C open pilon fractures.

Intraoperative angioembolization in the management of pelvic-fracture related hemodynamic instability.

BACKGROUND: This case series report discusses patients presenting with hemorrhage and hemodymanic compromise due to severe pelvic fractures and undergoing intraoperative angioembolization (IAE) with other resuscitative procedures. METHODS: We used portable digital subtraction fluoroscopy units for IAE in patients with severe pelvic hemorrhage and hemodynamic instability (5/03-4/09). Data was collected on demographics, injury severity, resource utilization, and outcomes at our Level 1 trauma center. RESULTS: There were 6,538 adult admissions with 912 having pelvic fractures and 65 of these undergoing pelvic angioembolization. Twelve hemodynamically compromised patients (10 males, 2 females) had intraoperative pelvic angiography (age: 22-79 years; mean 51.3 ± 17.4). Injury severity score (ISS) was 37.5 ± 8.4 (22-50). Mean emergency department (ED) length of stay (LOS) was 57.4 min ± 47.9 with 10 patients transported directly to the OR and 2 to the SICU prior to OR. Ten of 12 patients underwent exploratory laparotomy followed by angioembolization. Mortality was 50%. Among the 6 survivors (ISS 22 - 50), all had a pre-op CT scan, five had an initial base deficit <13, and four were transfused ≤ 6 units pre-incision/pre-procedure. Four of the 6 survivors had unilateral embolization. In contrast, all 6 non-survivors (ISS 29-41) required massive transfusion prior to OR (>6 units PRBCs) with 4 having a based deficit >13. Three of these patients bypassed CT and five underwent bilateral internal iliac embolization (BIIE). CONCLUSIONS: IAE for severe pelvic hemorrhage can be successfully performed concurrently with exploratory laparotomy, pelvic packing or other resuscitative procedures. Patients most likely to benefit have a base deficit <13, and do not require massive transfusion prior to IAE or suffer from a vertically unstable pelvis fracture.