Successful Outcomes With Nonoperative Treatment and Immediate Weightbearing Despite Stress-Positive Radiographs in Isolated Distal Fibula (OTA/AO 44B) Fractures.

OBJECTIVES: To determine whether a nonoperative management protocol results in equivalent outcomes in isolated OTA/AO 44B (Weber B) fractures without initial medial clear space (MCS) widening regardless of stress radiography findings. DESIGN: Prospective cohort. SETTING: Level 1 academic trauma center. PATIENT SELECTION CRITERIA: Nonoperatively managed patients with isolated OTA/AO 44B fractures and MCS ≤4 mm on initial non-weightbearing injury radiographs between from January 2018 and January 2022 were included. All patients underwent emergency department gravity stress radiographs and those with widening were considered the widening cohort and those without the non-widening cohort. OUTCOME MEASURE AND COMPARISONS: MCS measurements on weightbearing radiographs were obtained at first follow-up, 6 weeks, 12 weeks, and 6 months postinjury, were considered indicative of instability if >4 mm and were compared between cohorts.; American Orthopaedic Foot and Ankle Society ankle-hindfoot scores were also compared between cohorts. RESULTS: Sixty-nine patients were studied. None of the 38 patients (55%) with widening on gravity stress radiographs demonstrated widening with weightbearing radiographs at any time point. Mean MCS measurement differences between the 2 cohorts were statistically significant for all time points ( P = 0.012); however, with a model adjusted mean MCS value of 2.7 mm for the nonwidening cohort and 2.9 mm for the widening cohort, these are not clinically significant. There was no statistically significant difference in overall final American Orthopaedic Foot and Ankle Society scores between the 2 groups ( P = 0.451). In addition, statistical equivalence using Schuirmann 2 one-sided tests was achieved between the 2 groups. Both cohorts had mean American Orthopaedic Foot and Ankle Society scores representing excellent outcomes at the final follow-up. CONCLUSIONS: Patients with isolated OTA/AO 44B fractures without MCS widening on initial injury radiographs did not demonstrate instability on subsequent weightbearing radiographs and had equivalent outcomes regardless of gravity stress radiography findings when treated nonoperatively. Weightbearing radiographs at the initial follow-up appear to be a reliable assessment of ankle stability in these injuries and are an appropriate alternative to painful and time-consuming stress radiography. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Adherence to Antibiotic Recommendations and Infection Among Patients With Open Long-Bone Fractures: An Examination of Antibiotic Prioritization in Fracture Management.

Open fractures are at high risk of infection because of exposure of bone and tissue to the environment. Initiation of intravenous antibiotics is recommended within 1 hour of hospital arrival, although the presence of other severe injuries may lead to delays in fracture management. This retrospective study of adult patients with open long-bone fractures admitted to six level 1 trauma centers between January 1, 2018, and December 31, 2019, aimed to examine adherence to antibiotic recommendations. Associations between receiving recommendation-adherent antibiotics and patient and injury characteristics were investigated univariately and in adjusted regression analyses. The most common fracture locations among the 404 patients included were the tibia (43%) and fibula (26%). Fifty-eight percent of patients received recommendation-adherent antibiotics. After adjustment, patient demographics, comorbidities, cause of injury, and overall injury severity did not show significant associations with adherence to recommendations. Concomitant serious abdominal (adjusted odds ratio [AOR]=0.44) and spinal injuries (AOR=0.23) were associated with lower odds of receiving recommendation-adherent antibiotics. Additionally, fractures of certain locations were associated with increased odds of adherence (humerus: AOR=2.78; fibula: AOR=1.64), as were type 3 fractures (AOR=1.55). The overall infection rate was 4%, and adherence to antibiotic recommendations was not associated with infection (3% vs 5% for nonadherent, P=.34). Results suggest that although full recommendation adherence was somewhat low among this patient population, certain injury characteristics were predictive of adherence rates. Current antibiotic recommendations may benefit from consideration of how antibiotic initiation may fit into the prioritization of injury management, especially in patients with polytrauma with other severe injuries. [Orthopedics. 2023;46(1):54-58.].

Temporizing External Fixation vs Splinting Following Ankle Fracture Dislocation.

BACKGROUND: Closed reduction and splinting followed by outpatient management is standard of care for temporizing most ankle fractures. However, ankle fracture-dislocation potentially warrants a different approach based on the propensity for loss of reduction. The purpose of this study was to determine the rate of complications associated with closed reduction and splinting of unstable ankle fracture-dislocations. Further, we sought to determine the efficacy of immediate external fixation as an alternative to splinting in cases too swollen for acute operation. METHODS: This retrospective chart review analyzed all ankle-fracture dislocations that came through a large health care system from 2008 to 2018. Patients managed with acute open reduction internal fixation (ORIF) and open fractures were excluded. In patients managed late, the cohorts were divided into those temporized with closed reduction/splinting vs external fixation. Reduction quality and splint technique were additionally assessed in splinted patients. A total of 354 closed ankle fracture-dislocations were identified: 298 patients (84%) underwent ORIF within 48 hours and were excluded; 28 (15 female/13 male, average age 46.8 years) were placed in an external fixator and 28 (22 female/6 male, average age 57.2 years) were reduced, splinted, and discharged. RESULTS: At follow-up, 14 of the patients (50%) in the splint group developed loss of reduction and 5 of these patients (17.6%) developed anteromedial skin necrosis from skin tenting. None of the patients in the ex-fix group developed loss of reduction or skin necrosis. The rate of redislocation and the rate of development of skin necrosis was statistically higher in cases temporized with a splint versus an external fixator (P < .01 and P = .05, respectively). CONCLUSION: We found that in ankle fracture-dislocations not treated with acute ORIF, splint immobilization was associated with an increased risk of complications, including redislocation and skin necrosis, when compared to a temporizing external fixator. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Initial Experience With Percutaneous IM Rodding of the Humeri in Children With Osteogenesis Imperfecta.

BACKGROUND: To report a single-center surgical experience treating humeral deformity and fractures in children with osteogenesis imperfecta (OI) using the Fassier-Duval (FD) intramedullary elongating rods. METHODS: A retrospective review was conducted between December 2005 and July 2013 of all OI patients who underwent FD rodding with a minimum of 1-year follow-up. All patients were also being concurrently treated with bisphosphonates. RESULTS: Eighteen patients underwent internal fixation on a total of 35 humeri: 7 males and 11 females with an average age of 49 months. Thirty-five procedures were performed using FD rodding, with 5 utilizing only the male portion. Thirty procedures were primary FD implantation and 5 were revisions. Twelve patients had type III OI and 6 patients type IV OI. Indications for surgery included recurrent fracture, severe bowing deformity, and pain. Osteotomy methods included closed osteoclasis, percutaneous, or open osteotomies. Two patients required transfusions during their hospital stay. At our determined endpoint, 23 humeri (65.7%) had acceptable results with a mean follow-up time of 43 months (SD=27) with no revision. The remaining 12 humeri (34.3%) necessitated revision with a mean time to revision of 35 months (SD=29). Reasons for revision included: migration resulting in pain and functional difficulty (8.6%), migration with bowing (8.6%), and hardware failure secondary to trauma (8.6%). In addition, 2 revisions were required for nonunion (5.7%) and 1 for malunion (2.9%). To our knowledge, all other osteotomies performed during surgery resulted in bony union. CONCLUSIONS: The use of the FD system for correction of humeral deformity demonstrates a reasonable option to improve comfort and function in children with recurrent fractures and deformity secondary to OI. The FD system allows for decreased revision rates and less morbid instrumentation. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Is It Safe to Prep the External Fixator In Situ During Second-Stage Pilon Surgical Treatment?

OBJECTIVE: To evaluate the infection rate of our protocol of prepping the external fixator in situ during definitive second-stage pilon fracture open reduction internal fixation. DESIGN: Retrospective clinical investigation. SETTING: Academic Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Out of 229 patients with distal tibia fractures presenting to our institution from 1999 to 2014, 100 were treated in a 2-stage fashion utilizing this protocol. INTERVENTION: Prepping the external fixator into the surgical field during the second-stage/definitive open reduction internal fixation procedure. MAIN OUTCOME MEASUREMENT: The rates of deep and superficial infections after definitive fixation. RESULTS: The deep infection rate was 13%, and the superficial infection rate was 11%. CONCLUSIONS: Infection rates using this protocol are comparable to previously reported infection rates for two-stage surgical treatment of pilon fractures. This protocol provides the treating surgeon information about an alternative method to streamline definitive fixation. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Aortic Surgery for Abdominal Aortic Graft Infections.

BACKGROUND: Literature on postoperative outcomes following aortic surgery for aortic graft infection (AGI) is limited by relatively small sample sizes, resulting in lack of national benchmarks for quality of care. We report in-hospital outcomes following abdominal aortic surgery for AGI and identify factors associated with postoperative complications using the Nationwide Inpatient Sample (NIS) database. METHODS: Patients who underwent aortic graft resection for AGI were identified from the 2002 to 2008 NIS database, a multicenter database capturing 20% of all US admissions. Multivariable logistic regression analyses were performed. RESULTS: Among 394 patients (men: 73.4%) who underwent abdominal aortic surgery for AGI, 53% of the admissions were emergent/urgent. A significant trend for decreasing number of abdominal aortic surgery for AGIs per year was observed (Pearson r correlation: -.96; P = .0006). Over the same time span, a significant correlation was also seen with decrease in open and increase in endovascular aortic aneurysm repairs in the NIS database. In-hospital rates of overall postoperative morbidity and mortality were 68.3% and 19.8%, respectively. In-hospital rates of postoperative respiratory failure, renal failure, and cardiac arrest were 35.5%, 14.2%, and 8.9%, respectively. Median length of stay was 26 days, with median hospital charges being US$184 162. On multivariable analysis, increase in age per year (odds ratio [OR] 1.07; 95% confidence interval [CI]: 1.03-1.12) was independently associated with postoperative morbidity, while higher hospital volume for this procedure was protective (OR: 0.71; 95% CI: 0.56-0.89). No preoperative factors were independently associated with postoperative mortality. CONCLUSION: Incidence of abdominal aortic surgery for AGI has progressively declined over the span of our study in association with decreased open and increased endovascular aortic aneurysm repairs. Aortic surgery for AGI is associated with very high morbidity and mortality rates along with prolonged lengths of stay and elevated hospital charges. The outcomes of operations for AGI are better in younger patients and higher volume hospitals.

Theoretical study of Cl(-)RG (rare gas) complexes and transport of Cl- through RG (RG = He-Rn).

We present a systematic investigation of the accuracy of the various theories and basis sets that can be applied to study the interaction of Cl(-) ions with Ar atoms. It is conclusively shown that gaseous ion mobility can distinguish among theoretical ion-neutral interaction potentials. Based on the conclusions, high-level ab initio potential energy curves are obtained for all of the Cl(-)-RG (RG = He-Rn) complexes. Spectroscopic constants have been derived from these potentials and are compared to a range of theoretical and experimental data, to which they generally show good agreement. General trends are discussed in comparison to other halogen-rare gas complexes previously studied. The potentials also have been tested by using them to calculate transport coefficients for Cl(-) moving through a bath of RG atoms.