A Cadaveric Study: Does Ankle Positioning Affect the Quality of Anatomic Syndesmosis Reduction?

OBJECTIVE: The objective of this study was to compare the quality of syndesmotic reduction with the ankle in maximal dorsiflexion versus neutral plantarflexion (normal resting position). METHODS: Baseline computed tomography (CT) imaging of 10 cadaveric ankle specimens from 5 donors was obtained with the ankles placed in normal resting position. Two fellowship-trained orthopaedic surgeons disrupted the syndesmosis of each ankle specimen. All ankles were then placed in neutral plantarflexion and were subsequently reduced with thumb pressure under direct visualization through an anterolateral approach and stabilized with one 0.062-inch K-wire placed from lateral to medial in a quadricortical fashion across the syndesmosis. Postreduction CT scans were then obtained with the ankle in normal resting position. This process was repeated with the ankles placed in maximal dorsiflexion during reduction and stabilization. Postreduction CT scans were then obtained with the ankles placed in normal resting position. All postreduction CT scans were compared with baseline CT imaging using mixed-effects linear regression with significance set at P < 0.05. RESULTS: Syndesmotic reduction and stabilization in maximal dorsiflexion led to increased external rotation of the fibula compared with baseline scans [13.0 ± 5.4 degrees (mean ± SD) vs. 7.5 ± 2.4 degrees, P = 0.002]. There was a tendency toward lateral translation of the fibula with the ankle reduced in maximal dorsiflexion (3.3 ± 1.0 vs. 2.7 ± 0.7 mm, P = 0.096). No other statistically significant differences between measurements of reduction with the ankle placed in neutral plantarflexion or maximal dorsiflexion compared with baseline were present (P > 0.05). CONCLUSIONS: Reducing the syndesmosis with the ankle in maximal dorsiflexion may lead to malreduction with external rotation of the fibula. There was no statistically significant difference in reduction quality with the ankle placed in neutral plantarflexion compared with baseline. Future studies should assess the clinical implications of ankle positioning during syndesmotic fixation.

Does Local Aqueous Tobramycin Injection Reduce Open Fracture-Related Infection Rates?

OBJECTIVES: To examine the effect of local aqueous tobramycin injection adjunct to perioperative intravenous (IV) antibiotic prophylaxis in reducing fracture-related infections (FRIs) following reduction and internal fixation of open fractures. DESIGN: Retrospective cohort study. SETTING: Single academic Level I trauma center. PATIENTS SELECTION CRITERIA: Patients with open extremity fractures treated with reduction and internal fixation with (intervention group) or without (control group) 80 mg of local aqueous (2 mg/mL) tobramycin injected during closure at the time of definitive fixation were identified from December 2018 to August 2021 based on population-matched demographic and injury characteristics. OUTCOME MEASURES AND COMPARISONS: The primary outcome was FRI within 6 months of definitive fixation. Secondary outcomes consisted of fracture nonunion and bacterial speciation. Differences in outcomes between the 2 groups were assessed and logistic regression models were created to assess the difference in infection rates between groups, with and without controlling for potential confounding variables, such as sex, fracture location, and Gustilo-Anderson classification. RESULTS: An analysis of 157 patients was performed with 78 patients in the intervention group and 79 patients in the control group. In the intervention group, 30 (38.5%) patients were women with a mean age of 47.1 years. In the control group, 42 (53.2%) patients were women with a mean age of 46.4 years. The FRI rate was 11.5% in the intervention group compared with 25.3% in the control group ( P = 0.026). After controlling for sex, Gustilo-Anderson classification, and fracture location, the difference in FRI rates between groups remained significantly different ( P = 0.014). CONCLUSIONS: Local aqueous tobramycin injection at the time of definitive internal fixation of open extremity fractures was associated with a significant reduction in FRI rates when administered as an adjunct to intravenous antibiotics, even after controlling for potential confounding variables. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Operative and Nonoperative Management of Elderly Fragility Pelvic Ring Fractures.

OBJECTIVES: To compare outcomes of nonoperative and percutaneous fixation of geriatric fragility lateral compression 1 (LC1) pelvic ring fractures. DESIGN: Retrospective. SETTING: Two level 1 trauma centers. PATIENT SELECTION CRITERIA: Included were patients who were 60 years or older with an isolated LC1 pelvic ring fracture managed nonoperatively or those who failed mobilization and were managed operatively with percutaneous sacral fixation. Patients with high-energy mechanisms of injury or polytrauma were excluded. OUTCOME MEASURES AND COMPARISONS: The primary outcome was pain as measured by using the visual analog scale (VAS) after treatment. Secondary outcomes included length of stay, discharge disposition, mortality, readmission rates, and complications. RESULTS: In total, 231 patients were included with a mean age of 79.5 years (range 60-100). One hundred eighty-five (80.0%) patients were female. Sixty-two (26.8%) patients received percutaneous sacral fixation after failed mobilization, and 169 (73.2%) were managed nonoperatively. In the operative group, the median time to surgery was hospital day 4. Nonoperative patients were older (81.5 ± 10.0 years vs. 74.2 ± 9.4 years, P < 0.01) and had a shorter hospital length of stay (4.8 ± 6.2 days) than the operative group (10.6 ± 9.5 days, P < 0.01). Patients in the operative group had more pain (VAS 7.9 ± 3.0) than those in the nonoperative group (VAS 6.6 ± 3.0) ( P = 0.01) on admission but had similar pain control postoperatively (VAS 4.4 ± 3.0) compared with the nonoperative group (VAS 4.5 ± 3.6) on the equivalent hospital day ( P = 0.91). Thus, patients in the operative group experienced more improvement in pain (VAS 3.3 ± 2.7) compared with the nonoperative group (VAS 1.9 ± 3.9) after treatment ( P = 0.02). Ninety-day mortality ( P = 0.21) and readmission rates ( P = 0.27) were similar for both groups. Two patients in the operative cohort sustained nerve injuries, whereas 1 patient in the nonoperative group had a nonunion and underwent surgery. CONCLUSIONS: Patients who undergo percutaneous surgical fixation for low-energy LC1 injuries have similar discharge disposition, mortality, complication rates, and readmission rates compared with patients treated nonoperatively. Percutaneous surgical fixation may provide significant pain relief for patients who failed conservative management. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does Scheduled Low-Dose Short-Term NSAID (Ketorolac) Modulate Cytokine Levels After Orthopaedic Polytrauma? A Secondary Analysis of a Randomized Clinical Trial.

OBJECTIVES: To determine whether scheduled low-dose, short-term ketorolac modulates cytokine concentrations in orthopaedic polytrauma patients. DESIGN: Secondary analysis of a double-blinded, randomized controlled trial. SETTING: Single Level I trauma center from August 2018 to October 2022. PATIENT SELECTION CRITERIA: Orthopaedic polytrauma patients between 18 and 75 years with a New Injury Severity Score greater than 9 were enrolled. Participants were randomized to receive 15 mg of intravenous ketorolac every 6 hours for up to 5 inpatient days or 2 mL of intravenous saline similarly. OUTCOME MEASURES AND COMPARISONS: Daily concentrations of prostaglandin E2 and interleukin (IL)-1a, IL-1b, IL-6, and IL-10. Clinical outcomes included hospital and intensive care unit length of stay, pulmonary complications, and acute kidney injury. RESULTS: Seventy orthopaedic polytrauma patients were enrolled, with 35 participants randomized to the ketorolac group and 35 to the placebo group. The overall IL-10 trend over time was significantly different in the ketorolac group ( P = 0.043). IL-6 was 65.8% higher at enrollment compared to day 3 ( P < 0.001) when aggregated over both groups. There was no significant treatment effect for prostaglandin E2, IL-1a, or IL-1b ( P > 0.05). There were no significant differences in clinical outcomes between groups ( P > 0.05). CONCLUSIONS: Scheduled low-dose, short-term, intravenous ketorolac was associated with significantly different mean trends in IL-10 concentration in orthopaedic polytrauma patients with no significant differences in prostaglandin E2, IL-1a, IL-1b, or IL-6 levels between groups. The treatment did not have an impact on clinical outcomes of hospital or intensive care unit length of stay, pulmonary complications, or acute kidney injury. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Nonoperative Treatment of Humeral Shaft Fractures With Immediate Functional Bracing Versus Coaptation Splinting and Delayed Functional Bracing: A Retrospective Study.

OBJECTIVES: To compare radiographic and clinical outcomes in nonoperative management of humeral shaft fractures treated initially with coaptation splinting (CS) followed by delayed functional bracing (FB) versus treatment with immediate FB. DESIGN: Retrospective cohort study. SETTING: Academic Level 1 Trauma Center. PATIENT SELECTION CRITERIA: Patients with closed humeral shaft fractures managed nonoperatively with initial CS followed by delayed FB or with immediate FB from 2016 to 2022. Patients younger than 18 years and/or with less than 3 months of follow-up were excluded. OUTCOME MEASURES AND COMPARISONS: The primary outcome was coronal and sagittal radiographic alignment assessed at the final follow-up. Secondary outcomes included rate of failure of nonoperative management (defined as surgical conversion and/or fracture nonunion), fracture union, and skin complications secondary to splint/brace wear. RESULTS: Ninety-seven patients were managed nonoperatively with delayed FB (n = 58) or immediate FB (n = 39). Overall, the mean age was 49.9 years (range 18-94 years), and 64 (66%) patients were female. The immediate FB group had less smokers ( P = 0.003) and lower incidence of radial nerve palsy ( P = 0.025), with more proximal third humeral shaft fractures ( P = 0.001). There were no other significant differences in demographic or clinical characteristics ( P > 0.05). There were no significant differences in coronal ( P = 0.144) or sagittal ( P = 0.763) radiographic alignment between the groups. In total, 33 (34.0%) humeral shaft fractures failed nonoperative management, with 11 (28.2%) in the immediate FB group and 22 (37.9%) in the delayed FB group ( P = 0.322). There were no significant differences in fracture union ( P = 0.074) or skin complications ( P = 0.259) between the groups. CONCLUSIONS: This study demonstrated that nonoperative treatment of humeral shaft fractures with immediate functional bracing did not result in significantly different radiographic or clinical outcomes compared to treatment with CS followed by delayed functional bracing. Future prospective studies assessing patient-reported outcomes will further guide clinical decision making. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Talar Neck Fractures With Associated Ipsilateral Foot and Ankle Fractures Have a Higher Risk of Avascular Necrosis.

OBJECTIVES: To determine if talar neck fractures with concomitant ipsilateral foot and/or ankle fractures (TNIFAFs) are associated with higher rates of avascular necrosis (AVN) compared with isolated talar neck fractures (ITNs). DESIGN: Retrospective cohort. SETTING: Single level I trauma center. PATIENT SELECTION CRITERIA: Skeletally mature patients who sustained talar neck fractures from January 2008 to January 2017 with at least 6-month follow-up. Based on radiographs at the time of injury, fractures were classified as ITN or TNIFAF and by Hawkins classification. OUTCOME MEASURES AND COMPARISONS: The primary outcome was the development of AVN based on follow-up radiographs, with secondary outcomes including nonunion and collapse. RESULTS: There were 115 patients who sustained talar neck fractures, with 63 (55%) in the ITN group and 52 (45%) in the TNIFAF group. In total, 63 patients (54.7%) were female with the mean age of 39 years (range, 17-85), and 111 fractures (96.5%) occurred secondary to high-energy mechanisms of injury. There were no significant differences in demographic or clinical characteristics between groups ( P > 0.05). Twenty-four patients (46%) developed AVN in the TNIFAF group compared with 19 patients (30%) in the ITN group ( P = 0.078). After adjusting for Hawkins classification and other variables, the odds of developing AVN was higher in the TNIFAF group compared with the ITN group [odds ratio, 2.43 (95% confidence interval, 1.01-5.84); ( P = 0.047)]. CONCLUSIONS: This study found a significantly higher likelihood of AVN in patients with talar neck fractures with concomitant ipsilateral foot and/or ankle fractures compared to those with isolated talar neck fractures after adjusting for Hawkins classification and other potential prognostic confounders. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.