Early Weight-bearing Following Surgical Treatment of Ankle Fractures Without Trans-syndesmotic Fixation Is Safe and Improves Short-term Outcomes.

OBJECTIVES: The objective of this study was to ascertain outcome differences after fixation of unstable rotational ankle fractures allowed to weight-bear 2 weeks postoperatively compared with 6 weeks. DESIGN: Prospective case-control study. SETTING: Academic medical center; Level 1 trauma center. PATIENT SELECTION CRITERIA: Patients with unstable ankle fractures (OTA/AO:44A-C) undergoing open reduction internal fixation (ORIF) were enrolled. Patients requiring trans-syndesmotic fixation were excluded. Two surgeons allowed weight-bearing at 2 weeks postoperatively (early weight-bearing [EWB] cohort). Two other surgeons instructed standard non-weight-bearing until 6 weeks postoperatively (non-weight-bearing cohort). OUTCOME MEASURES AND COMPARISONS: The main outcome measures included the Olerud-Molander questionnaire, the SF-36 questionnaire, and visual analog scale at 6 weeks, 3 months, 6 months, and 12 months postoperatively and complications, return to work, range of ankle motion, and reoperations at 12 months were compared between the 2 cohorts. RESULTS: One hundred seven patients were included. The 2 cohorts did not differ in demographics or preinjury scores ( P > 0.05). Six weeks postoperatively, EWB patients had improved functional outcomes as measured by the Olerud-Molander and SF-36 questionnaires. Early weight-bearing patients also had better visual analog scale scores (standardized mean difference -0.98, 95% confidence interval [CI] -1.27 to -0.70, P < 0.05) and a greater proportion returning to full capacity work at 6 weeks (odds ratio = 3.42, 95% CI, 1.08-13.07, P < 0.05). One year postoperatively, EWB patients had improved pain measured by SF-36 (standardized mean difference 6.25, 95% CI, 5.59-6.92, P < 0.01) and visual analog scale scores (standardized mean difference -0.05, 95% CI, -0.32 to 0.23, P < 0.01). There were no differences in complications or reoperation at 12 months ( P > 0.05). CONCLUSIONS: EWB patients had improved early function, final pain scores, and earlier return to work, without an increased complication rate compared with those kept non-weight-bearing for 6 weeks. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Electric scooter injuries: Incidence and injury patterns at a level I trauma center.

PURPOSE: Electric scooters (e-scooters) have become an increasingly popular mode of public transportation in recent years. As the incidence of related injuries rises, it is important to understand specific fracture patterns unique to e-scooters and electric bikes (e-bikes) to help guide management. The purpose of this study was to review the prevalence and describe specific fracture patterns of e-scooter and e-bike related injuries at the busiest level 1 trauma center in the borough of Manhattan. METHODS: Chart review to determine mechanism of injury was performed on all patients for whom an orthopedic consult was requested from 1/1/2021 to 12/31/2021. All patients whose injuries were sustained due to an e-scooter or e-bike were further reviewed for demographics, injury characteristics including fracture pattern, and definitive injury management. Any patients who had an orthopedic consult placed for a reason other than an acute injury were excluded. Descriptive statistics are reported as frequency (percentage) for categorical variables and means for continuous variables. RESULTS: Of the 1815 orthopedic consults requested, 1357 (74.8%) were for acute injury management. Of those with acute injuries, 119 (8.8%) sustained 136 e-scooter or e-bike related injuries. There were 92 (77.3%) males at an average age of (33.8 ± 15.7) years. Approximately one-fifth of all patients presented in June 2021 (26, 21.8%). There was a 9.2% rate of open fractures. The 136 injuries were evenly split between the upper and lower extremities, with 57 (47.9%) upper extremity, 57 (47.9%) lower extremity injuries, and 5 (4.2%) concomitant upper and lower extremity injuries. The most common fracture patterns were ankle fractures (16, 11.7%), followed by tibial shaft (14, 10.2%), tibial plateau (13, 9.5%), and radial head fractures (11, 8.0%). There was a 33.3% incidence of associated posterior malleolar fractures in the spiral tibial shaft fractures, 31.0% of posterior malleolar involvement and 18.8% of isolated vertical medial malleolar fractures in the ankle fractures, and 61.5% of posterior comminution in the tibial plateau fractures. CONCLUSION: E-scooter and e-bike related injuries have a high incidence of tibial shaft fractures, ankle fractures, tibial plateau fractures, and radial head fractures. There should be a high index of suspicion for posterior and medial involvement in lower extremity fractures sustained due to e-scooter or e-bikes. Identifying specific fracture patterns seen in e-scooter and e-bike related mechanisms will help guide management of these injuries.

Increasing Diversity in Orthopaedics: The Problem, Strategies, and Solutions.

It is important to educate and equip the orthopaedic community with tools to address health care disparities and improve orthopaedic specialty recruitment for racial minorities. How patients and providers are affected by systemic racism in healthcare and what that means in orthopaedic surgery, methods to identify bias and improve access to orthopaedic care for racial minorities, and how to structure a program and department environment to encourage and promote diversity are important topics of discussion.

Treatment of Segmental Bone Defects Biology and Treatment Options.

Segmental bone defects (SBD) are difficult to treat, requiring a comprehensive understanding of the bone and soft tissue injury. Defect size, fracture characteristics, and local and systemic biology all help dictate treatment options. Bone grafting with autograft or allograft, Masquelet technique, and bone transport with external or internal fixation can all be used successfully in the correct patient. When deciding on the best treatment option and addressing any complications throughout the process, it is important to always keep in mind the three principles of bone healing: sterility, stability, and biology. The goal of this review is to present the history of treatment for critical SBD, including the indications and challenges that have been addressed and current and emerging treatment options.

Decreasing Postoperative Opioid Prescriptions After Orthopedic Trauma Surgery: The "Lopioid" Protocol.

OBJECTIVE: To assess the effectiveness of a multimodal analgesic regimen containing "safer" opioid and non-narcotic pain medications in decreasing opioid prescriptions after surgical fixation in orthopedic trauma. DESIGN: Retrospective cohort study. SETTING: One urban, academic medical center. SUBJECTS: Patients with traumatic fracture from 2018 (n=848) and 2019 (n=931). METHODS: In 2019, our orthopedic trauma division began a standardized protocol of postoperative pain medications that included 50 mg of tramadol four times daily, 15 mg of meloxicam once daily, 200 mg gabapentin twice daily, and 1 g of acetaminophen every 6 hours as needed. This multimodal regimen was dubbed the "Lopioid" protocol. We compared patients who received this protocol with all patients from the prior year who had followed a standard protocol that included Schedule II narcotics. RESULTS: Greater mean morphine milligram equivalents were prescribed at discharge from fracture surgery under the standard protocol than under the Lopioid protocol (252.3 vs 150.0; P < 0.001), and there was a difference in the type of opioid medication prescribed (P < 0.001). There was a difference in the number of refills filled for patients discharged with opioids after surgical treatment between the standard and Lopioid cohorts (0.31 vs 0.21; P = 0.002). There were no differences in the types of medication-related complications (P = 0.710) or the need for formal pain management consults (P = 0.199), but patients in the Lopioid cohort had lower pain scores at discharge (2.2 vs 2.7; P = 0.001). CONCLUSIONS: The Lopioid protocol was effective in decreasing the amount of Schedule II narcotics prescribed at discharge and the number of opioid refills after orthopedic surgery for fractures.

Diversity in orthopaedic trauma: where we are and where we need to be.

Diversity has multiple dimensions, and individuals' interpretation of diversity varies broadly. The Orthopaedic Trauma Association (OTA) leadership recognized the need to address issues of diversity within the organization and appointed the OTA Diversity Committee in 2020. The OTA Diversity Committee has produced a statement that was confirmed by the OTA's board of directors reflecting the organization's position on diversity: "The OTA promotes and values diversity and inclusion at all levels with the goal of creating an environment where every member has the opportunity to excel in leadership, education, and culturally-competent orthopaedic trauma care." The OTA Diversity Committee surveyed its 1907 OTA members in the United States and Canada to assess its membership's attitudes toward and interpretation of this important topic. METHODS: Two surveys were distributed. One 15-question survey was sent to 1907 OTA members with different membership categories in the United States and Canada requesting basic demographic information and asking how members felt about the degree to which women and underrepresented minorities (URM) are represented within the OTA and within its leadership. A second 11-question survey was sent to 30 past chairs of 2017-2019 OTA educational courses and meetings evaluating their criteria for choosing faculty for OTA courses. Comments were reviewed and summarized to identify recurring themes. RESULTS: Two hundred seven responses from the membership and 14 from course chairs were received from the 1907 surveys that were emailed to OTA members in the United States and Canada. The results reveal awareness of the limited female and URM representation within the OTA. However, there is disagreement in how or even whether this should be addressed at an organizational level. Review of comments from both surveys reveals a number of common themes on these important topics. CONCLUSION: The members and course chairs surveyed recognize that there is limited diversity at the OTA leadership and faculty level. Many members feel that the OTA would benefit from increasing female and URM representation in committees, within the leadership, and as faculty at OTA-sponsored courses. However, survey comments reveal that many members and course chairs feel it is not the organization's role to regulate diversity and that diversity initiatives themselves may introduce an unnecessary form of bias.

A Level 1 Trauma Center's response to the COVID-19 pandemic in New York City: a qualitative and quantitative story.

BACKGROUND: The purpose of this study is to describe a Level 1 Trauma Center's orthopedic response to the COVID-19 pandemic, and to compare outcomes of acute fracture patients pre-COVID versus during the COVID-19 pandemic. METHODS: All inpatient fracture cases performed over a 5-month period were identified and retrospective chart review performed. Patients were divided into pre- and COVID-era groups based on when surgery was performed relative to March 16, 2020 (the date elective operations were ceased), and groups were statistically compared. Patients with a COVID test result were further sub-divided into COVID negative and positive groups, and statistically compared. Statistical analysis was performed using independent t-test for continuous variables and chi-square analysis for categorical variables. RESULTS: One hundred and nineteen patients were identified, 38% females with average age of 58 years. Average length of stay was 7 days with average time from injury to surgery of 3 days and average time from admission to surgery of 1.3 days. Overall in-hospital complication rate was 29.4%, and 30-day mortality and readmission rates were 2.5% and 5%, respectively. Sixty-nine patients comprised the pre-COVID group, and 50 in the COVID-era group. There was no significant difference with respect to length of stay, time from injury to surgery, time from admission to surgery, need for post-operative ICU stay, in-hospital complication rate, 30-day mortality rate and 30-day readmission rate. Thirty-four patients had COVID testing, with 24 negative and 10 positive. COVID-positive patients had longer time from injury to surgery (8.5 days vs. 2 days, p = 0.003) and longer time from admission to surgery (2.7 days vs. 1.2 days, p = 0.034). While more COVID-positive patients required ICU admission post-operatively (60% vs. 21%, p = 0.036), there was no difference in overall complication rate. CONCLUSIONS: Orthopedic care of acute fracture patients was not affected by a global pandemic. The response of our Level 1 Trauma Center's orthopedic department can guide other hospitals if and when new surges in COVID cases arise, in order to prevent compromising appropriate orthopedic care. LEVEL OF EVIDENCE: Prognostic III.

Modification of a Validated Risk Stratification Tool to Characterize Geriatric Hip Fracture Outcomes and Optimize Care in a Post-COVID-19 World.

OBJECTIVES: (1) To demonstrate how a risk assessment tool modified to account for the COVID-19 virus during the current global pandemic is able to provide risk assessment for low-energy geriatric hip fracture patients. (2) To provide a treatment algorithm for care of COVID-19 positive/suspected hip fractures patients that accounts for their increased risk of morbidity and mortality. SETTING: One academic medical center including 4 Level 1 trauma centers, 1 university-based tertiary care referral hospital, and 1 orthopaedic specialty hospital. PATIENTS/PARTICIPANTS: One thousand two hundred seventy-eight patients treated for hip fractures between October 2014 and April 2020, including 136 patients treated during the COVID-19 pandemic between February 1, 2020 and April 15, 2020. INTERVENTION: The Score for Trauma Triage in the Geriatric and Middle-Aged ORIGINAL (STTGMAORIGINAL) score was modified by adding COVID-19 virus as a risk factor for mortality to create the STTGMACOVID score. Patients were stratified into quartiles to demonstrate differences in risk distribution between the scores. MAIN OUTCOME MEASUREMENTS: Inpatient and 30-day mortality, major, and minor complications. RESULTS: Both STTGMA score and COVID-19 positive/suspected status are independent predictors of inpatient mortality, confirming their use in risk assessment models for geriatric hip fracture patients. Compared with STTGMAORIGINAL, where COVID-19 patients are haphazardly distributed among the risk groups and COVID-19 inpatient and 30 days mortalities comprise 50% deaths in the minimal-risk and low-risk cohorts, the STTGMACOVID tool is able to triage 100% of COVID-19 patients and 100% of COVID-19 inpatient and 30 days mortalities into the highest risk quartile, where it was demonstrated that these patients have a 55% rate of pneumonia, a 35% rate of acute respiratory distress syndrome, a 22% rate of inpatient mortality, and a 35% rate of 30 days mortality. COVID-19 patients who are symptomatic on presentation to the emergency department and undergo surgical fixation have a 30% inpatient mortality rate compared with 12.5% for patients who are initially asymptomatic but later develop symptoms. CONCLUSION: The STTGMA tool can be modified for specific disease processes, in this case to account for the COVID-19 virus and provide a robust risk stratification tool that accounts for a heretofore unknown risk factor. COVID-19 positive/suspected status portends a poor outcome in this susceptible trauma population and should be included in risk assessment models. These patients should be considered a high risk for perioperative morbidity and mortality. Patients with COVID-19 symptoms on presentation should have surgery deferred until symptoms improve or resolve and should be reassessed for surgical treatment versus definitive nonoperative treatment with palliative care and/or hospice care. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

Increased Mortality and Major Complications in Hip Fracture Care During the COVID-19 Pandemic: A New York City Perspective.

OBJECTIVES: To examine one health system's response to the essential care of its hip fracture population during the COVID-19 pandemic and report on its effect on patient outcomes. DESIGN: Prospective cohort study. SETTING: Seven musculoskeletal care centers within New York City and Long Island. PATIENTS/PARTICIPANTS: One hundred thirty-eight recent and 115 historical hip fracture patients. INTERVENTION: Patients with hip fractures occurring between February 1, 2020, and April 15, 2020, or between February 1, 2019, and April 15, 2019, were prospectively enrolled in an orthopaedic trauma registry and chart reviewed for demographic and hospital quality measures. Patients with recent hip fractures were identified as COVID positive (C+), COVID suspected (Cs), or COVID negative (C-). MAIN OUTCOME MEASUREMENTS: Hospital quality measures, inpatient complications, and mortality rates. RESULTS: Seventeen (12.2%) patients were confirmed C+ by testing, and another 14 (10.1%) were suspected (Cs) of having had the virus but were never tested. The C+ cohort, when compared with Cs and C- cohorts, had an increased mortality rate (35.3% vs. 7.1% vs. 0.9%), increased length of hospital stay, a greater major complication rate, and a greater incidence of ventilator need postoperatively. CONCLUSIONS: COVID-19 had a devastating effect on the care of patients with hip fracture during the pandemic. Although practice patterns generally remained unchanged, treating physicians need to understand the increased morbidity and mortality in patients with hip fracture complicated by COVID-19. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

Free Tissue Transfer with Distraction Osteogenesis and Masquelet Technique Is Effective for Limb Salvage in Patients with Gustilo Type IIIB Open Fractures.

Osteocutaneous reconstruction can be challenging because of concomitant injuries and limited donor sites. There is a paucity of data on limb salvage outcomes following combined soft-tissue reconstruction and bone transport or Masquelet procedures. The authors reviewed a consecutive series of open tibia fracture patients undergoing soft-tissue reconstruction with either distraction osteogenesis or Masquelet technique. Endpoints were perioperative flap complications and bone union. Fourteen patients with Gustilo type IIIB open tibia fractures were included. Half of the group received muscle flaps and the remaining half received fasciocutaneous flaps. Ten patients (71.4 percent) underwent distraction osteogenesis and the remaining patients underwent Masquelet technique. Average bone gap length was 65.7 ± 31.3 mm (range, 20 to 120 mm). In the bone transport group, the average external fixation duration was 245 days (range, 47 to 686 days). In the Masquelet group, the average duration of the first stage of this two-stage procedure (i.e., time from cement spacer placement to bone grafting) was 95 days (range, 42 to 181 days). Bone union rate, as determined by radiographic evidence, was 85.7 percent. There was one complete flap failure (7.1 percent). One patient underwent below-knee amputation after failing bone transport and developing chronic osteomyelitis and subsequent infected nonunion. Our case series demonstrates that nonosteocutaneous flap methods of limb reconstruction are a viable option in patients with segmental long bone defects, with a bone union rate of 85 percent and a limb salvage rate over 90 percent in patients with Gustilo type IIIB fractures. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Arm Fasciotomy Through Lateral Approach.

Acute compartment syndrome represents one of the few true orthopaedic emergencies. Timely management is essential to prevent permanent sequelae. This video describes a case of acute compartment syndrome of the arm. Relevant patient history, physical examination, and laboratory findings are discussed, and a presentation of the operative technique for arm fasciotomy through a lateral approach is highlighted. Diagnostic criteria for acute compartment syndrome and indications for fasciotomy are reviewed, with a discussion of published outcomes after fasciotomy.

Comparing Radiographic Progression of Bone Healing in Gustilo IIIB Open Tibia Fractures Treated With Muscle Versus Fasciocutaneous Flaps.

OBJECTIVES: To investigate how muscle and fasciocutaneous flaps influence the progression of bone healing in acute Gustilo IIIB tibia fractures. DESIGN: Retrospective Chart Review. SETTING: Urban Academic Level I Trauma Center. PATIENTS/PARTICIPANTS: Between 2006 and 2016, 39 patients from a database of operatively treated long bone fractures met the inclusion criteria, which consisted of adults with acute Gustilo IIIB tibia shaft fracture requiring flap coverage and having at least 6 months of radiographic follow-up. INTERVENTION: Soft tissue coverage for patients with Gustilo IIIB open tibia fractures was performed with either a muscle flap or fasciocutaneous flap. MAIN OUTCOME MEASUREMENTS: A radiographic union score for tibia (RUST) fractures, used to evaluate fracture healing, was assigned to patients' radiographs postoperatively, at 3, 6, and 12 months from the initial fracture date. Mean RUST scores at these time points were compared between those of patients with muscle flaps and fasciocutaneous flaps. Union was defined as a RUST score of 10 or higher. RESULTS: There was a significant difference (P = 0.026) in the mean RUST score at 6 months between the muscle group (8.54 ± 1.81) and the fasciocutaneous group (6.92 ± 2.46). There was no significant difference in the mean RUST score at 3 months (P = 0.056) and at 12 months (P = 0.947) between the 2 groups. There was also significance in the number of fractures reaching union, favoring muscle flaps, at 6 months (P = 0.020). CONCLUSIONS: Patients with acute Gustilo IIIB tibia fractures who received muscle flaps have significantly faster radiographic progression of bone healing in the first 6 months than do patients who received fasciocutaneous flaps. Furthermore, according to radiographic evaluation, more Gustilo IIIB tibia fractures receiving muscle flaps reach union by 6 months than those flapped with fasciocutaneous tissue. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Posttraumatic Heterotopic Ossification of the Hip.

INTRODUCTION: Posttraumatic heterotopic ossification (HO) of the hip frequently follows acetabular fracture and hip surgery and can become symptomatic, with significant pain and limited range of motion (ROM). Definitive treatment may require surgical excision, which can result in serious complications if not planned and executed appropriately. METHODS: Surgical excision of posttraumatic hip HO requires appropriate indications, preoperative planning, and intraoperative guidance using fluoroscopy to maximize excision of HO and minimize complications. This video presents a case of severe posttraumatic hip HO, indications and technique of surgical excision using fluoroscopic guidance, postoperative protocol, and the patient's clinical follow-up. RESULTS: Surgical excision along with appropriate postoperative HO prophylaxis and immediate mobilization resulted in significant improvement in hip ROM and return to activities of daily living without complications or recurrence. Intraoperative blood loss can be significant and should be appropriately planned for preoperatively. CONCLUSIONS: Posttraumatic hip HO can cause significantly limited hip ROM and pain with resulting disability. Surgical excision of posttraumatic hip HO in a preserved hip joint can be successful in restoring hip ROM and function. Appropriate postoperative HO prophylaxis can prevent recurrence.

Management of Bone Defects in Orthopedic Trauma.

Treatment of traumatic bone defects is dictated by a multitude of clinical factors including the defect size, patient comorbidities, soft tissue condition, and the possibility of infection present in the defect. With a variety of treatment strategies described, it is critical to choose the approach that will maximize outcomes in addressing this difficult problem. When addressing small-scale defects, bone grafting is the primary treatment. For large-scale defects, there are two major options to consider: induced membrane technique and distraction osteogenesis. Choosing between these two techniques should be based on the associated soft tissue injury, the local vascularity, and the possibility of residual infection. This review will focus on the current management principles and strategies in the treatment of bone defects after orthopedic trauma and the existing literature to support each of these treatment options.

Operative Fixation of Rib Fractures Indications, Techniques, and Outcomes.

Rib fractures are extremely common injuries and vary in there severity from single nondisplaced fractures to multiple segmental fractures resulting in flail chest and respiratory compromise. Historically, rib fractures have been treated conservatively with pain control and respiratory therapy. However this method may not be the best treatment modality in all situations. Operative fixation of select rib fractures has been increasing in popularity especially in patients with flail chest and respiratory compromise. Newer techniques use muscle sparing approaches and precontoured locking plate technology to obtain stable fixation and allow improved respiration. Current reports shows that rib fracture fixation offers the benefits of improved respiratory mechanics and improved pain control in the severe chest wall injury with resultant improvement in patient outcomes by decreasing time on the ventilator, time in the intensive care unit, and overall hospital length of stay.

Two Cases of Retained Cement after Hip Hemiarthroplasty. Don't Forget the Basics.

Hemiarthroplasty as a treatment for femoral neck fractures is controversial with evolving understanding of its complications. One set of complications relates to the use of cement for these procedures. This case study presents two cases that were complicated by retained cement in the acetabulum that was identified in final intraoperative check with x-rays. In both cases, the incision was reopened and retained fragments were removed. We aim to remind the orthopaedic surgery community that this complication can occur even to the careful, experienced surgeon and to recommend the steps necessary to minimize the risk of its occurrence.