Illicit drug and alcohol use and measures of musculoskeletal function and mental health in orthopaedic trauma patients.

Objectives: The objective of this study was to describe the relationship between positive toxicology screens and measures of preinjury mental health and physical function in an orthopaedic trauma population. Design: This was a cross-sectional study. Setting: Urban Level 1 trauma center. Patients: A total of 125 trauma patients gave written consent for this study. Main Outcome Measurements: Questionnaires such as, Patient Health Questionnaire-9, General Anxiety Disorder-7, PCL-5, and Short Musculoskeletal Function Assessment, were used to survey patients after surgical intervention. Results: Patient Health Questionnaire-9 (P = 0.05) and PCL-5 (P = 0.04) were not found to have significant differences between positive and negative toxicology screens. Both General Anxiety Disorder-7 (P = 0.004) and Short Musculoskeletal Function Assessment function (P = 0.006) were significantly higher in patients with positive toxicology screens. Conclusions: Positive toxicology seems to be associated with preinjury anxiety. Patient reported preinjury function was not adversely affected by the presence of illicit substances or alcohol, nor were levels of post-traumatic stress disorder and depression found to be higher in patients with positive toxicology screens. Level of Evidence: Level IV Cross-Sectional Study.

Anterior Intrapelvic Plating of the Sacroiliac Joint-A Cadaveric Quantification of Visualized Area with Case Series.

SUMMARY: The objective of this study was to quantitatively describe the area available on the sacrum for reduction and plating using the Anterior Intrapelvic approach and describe its use clinically in a case series. The area available for plate and screw placement on 5 cadavers was on average 1007 ± 231 mm3. The cranial/caudal dimension at greatest length was 39.78 ± 6.91 mm, and the greatest length medial to the sacroiliac joint was 30.91 ± 3.43 mm. The major anatomic restraints to visualization were the S1 nerve root and the external and internal iliac vessels. Large fragment plates had an area overlying the sacrum of 360 mm3, and all sacrum had an area for at least two plates. The exposure was succesfully used for reduction, fixation and direct inspection of neural elements in 4 patients, demonstrating the anterior intrapelvic approach can be expanded to the lateral sacrum.

Intraoperative monitoring of femoral head perfusion in adult femoral neck fractures.

OBJECTIVES: To validate a novel intraoperative method of quantifying femoral head perfusion in adult patients with femoral neck fractures and to determine whether the lack of a perfusion waveform correlates with the development of osteonecrosis, nonunion, or reoperation. DESIGN: Prospective cohort. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Nineteen patients with 20 acute femoral neck fractures treated with hip-preserving surgical fixation. All patients underwent intraoperative quantification of femoral head perfusion. INTERVENTION: Intraoperative quantification of femoral head perfusion pressure and waveform utilizing an intracranial pressure monitor. MAIN OUTCOME MEASUREMENTS: Radiographic union, avascular necrosis, revision surgery. RESULTS: Nineteen patients (8 male, 11 female, average age 56 ±â€Š21 years) with 20 femoral neck fractures were enrolled. Eight fractures were stable (Garden 1-2/OTA B1.1-1.3) and 12 were unstable (Garden 3-4/OTAB2.1-3.3). A waveform was present in 12 of 20 cases. The average pressures were systolic 36.8 mm Hg, diastolic 30.8 mm Hg, pulse pressure 6.0 mm Hg. A perfusion waveform was significantly associated with advanced age (P = 0.02) and accompanied by trend toward stable fracture patterns. There were 4 deaths during the 1-year follow-up period (20%), and there were 5 conversions to total hip arthroplasty (25%). There was no significant association between revision surgery or death with the absence of a waveform. CONCLUSIONS: Our study demonstrated the feasibility of a relatively low cost, minimally invasive, technique to quantify femoral head perfusion. In our limited sample, the absence of perfusion did not correlate with our main outcomes; however, the trend toward correlation with increased fracture displacement was as expected. A larger cohort of patients will be needed to detect a significant difference between those with and without a perfusion waveform with regards to our primary outcomes. Further study is needed to delineate the role such data may play in medical decision making at the time of index surgery. LEVEL OF EVIDENCE: Prognostic Level II.

Quantification and Comparison of Talar Exposure Utilizing a Posteromedial Approach and Medial Malleolar Osteotomy.

BACKGROUND: Fractures of the talus are a rare but challenging injury. This study sought to quantify the area of osseous exposure afforded by a posteromedial approach to the talus and medial malleolar osteotomy. METHODS: Five fresh-frozen cadaveric lower extremities were dissected using a posteromedial approach and medial malleolar osteotomy respectively. Following exposure, the talar surfaces directedly visualized were marked and captured using a calibrated digital image. The digital images were then analyzed using ImageJ software (National Institutes of Health) to calculate the surface area of the exposure. RESULTS: The average square area of talus exposed using the posteromedial approach was 9.70 cm2 (SD = 2.20, range 7.20-12.46). The average quantity of talar exposure expressed as a percentage was 9% (SD = 1.58, range 7.03-10.40). The average square area of talus exposed using a medial malleolar osteotomy was 14.32 cm2 (SD = 2.00, range 11.26-16.66). The average quantity of talar exposure expressed as a percentage was 12.94% (SD = 1.79, range 9.97-14.73). The posteromedial approach provided superior visualization of the posterior talus, whereas the medial malleolar osteotomy offered greater access to the medial body. CONCLUSION: The posteromedial approach and medial malleolar osteotomy allow for significant exposure of the talus, yielding 9.70 and 14.32 cm2, respectively. Given the differing portions of the talus exposed, surgeons may prefer to use the posteromedial approach for operative fixation of posterior process fractures and elect to use a medial malleolar osteotomy in cases requiring more extensive medial and distal exposure for neck or neck/body fractures. LEVEL OF EVIDENCE: Level IV.

Skeletal surveys lack efficacy in obtunded polytrauma patients.

OBJECTIVES: To evaluate if a skeletal survey protocol initiated after 48 hours of intubation will decrease time to diagnosis and the treatment of occult fractures in the obtunded polytrauma patient. DESIGN: Prospective cohort trial with a retrospective cohort comparison arm. SETTING: A single level 1 trauma center. PATIENTS: Forty-seven patients were identified prospectively for the skeletal survey protocol to screen for occult fractures. The results of the new protocol were compared to a retrospective comparison arm of 46 patients who would have met the same criteria. INTERVENTION: A skeletal survey protocol using 2-view x-rays of the patients' extremities to evaluate for any occult injuries after 48 hours of intubation in trauma patients with altered mental status and an unreliable tertiary examination. MAIN OUTCOME MEASURE: Time to diagnosis of delayed fractures and surgical intervention from date of admission. RESULTS: The average time to fracture diagnosis and time to surgical intervention in days was not statistically significant between the retrospective and prospective groups [fracture diagnosis: 1.6 ±â€Š5.1 (retrospective) versus 0.5 ±â€Š0.9 (prospective) (P = .159); time to initial surgery: 2.7 ±â€Š5.6 (retrospective) versus 1.1 ±â€Š1.7 (prospective) (P = .064); time to final surgery: 5.3 ±â€Š8.5 (retrospective) versus 2.4 ±â€Š3.0 (prospective) (P = .029)]. In addition, only 24% (4/17) of patients with a delayed fracture diagnosis required surgical intervention making most nonoperative. CONCLUSIONS: Given the inability to have a clinically or statistically significant impact on time to fracture diagnosis or subsequent treatment, we cannot advocate for the routine use of a skeletal survey protocol in obtunded polytrauma patients.Level of Evidence: Level III.

PET Imaging in Sarcoma.

PET imaging has been evaluated in five areas of sarcoma diagnosis and treatment: biopsy guidance, therapeutic monitoring, tumor detection and grading, tumor staging, and prognostication. Current evidence does not include any cost-benefit analysis showing a decreased number of invasive procedures from false-positive results. There is overlap from more conventional imaging and PET imaging without obvious added benefit from information gained from PET/computed tomography scanning. Use as a routine test in patients with sarcoma cannot be recommended. Use in specific histologic subtypes with differing patterns of metastasis or in monitoring those cases undergoing neoadjuvant chemotherapy needs further study before PET/computed tomography becomes standard of care for patients with sarcoma.

Orthopaedic trauma patients and depression: a prospective cohort.

OBJECTIVES: This study prospectively followed a cohort of orthopaedic trauma patients to identify risk factors that contribute to depression in patients with skeletal injuries. DESIGN: Prospective cohort study. SETTING: Level I trauma center. PATIENTS: One hundred ten orthopaedic trauma patients admitted as inpatients. INTERVENTION: None. MAIN OUTCOME MEASUREMENTS: Patient Health Questionnaire (PHQ-9) scores. RESULTS: One hundred ten patients were enrolled at the time of injury in which 22 patients had moderate-to-major depression and 36 patients had mild depression. Forty-eight patients completed the follow-up surveys that were taken, on average, 9 months after the date of injury. Factors that were significant for mild depression (PHQ-9 >4) at the time of injury included a history of illegal drug use (P = 0.037) and a lower Duke Social Support and Stress Scale (DUSOCS) support score (P = 0.002). The duke social support and stress scale score had a negative Pearson correlation coefficient with PHQ-9 (n = -0.18, P = 0.03). Factors that were significant for moderate-to-major depression (PHQ-9 >9) at the time of injury were a history of a psychiatric diagnosis (P = 0.0009) and unemployment at injury (P = 0.039). Both a history of psychiatric diagnosis and an elevated PHQ-9 score at the time of injury were predictors of having depression at 9 months (P = 0.02 and P = 0.001, respectively). Also, patients with Medicaid insurance had a significant increase in their depression scores at 9 months (P = 0.02). CONCLUSION: Depression was quite prevalent in our patient sample. A previous psychiatric diagnosis predisposed patients to depression. The socioeconomic status was also a predictive factor for increased depression scores at 9 months. Patients with a higher feeling of support from friends and family had an inverse correlation for depression. Employment also seems to have a protective effect against depression. Surprisingly, the severity of injury did not affect the depression score. Targeted consultation with a mental health care provider may obviate any morbidity that is associated with depression in an injured patient. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Radiographic predictors of compartment syndrome in tibial plateau fractures.

OBJECTIVES: The purpose of this article was to evaluate the relationship of radiographic features of tibial plateau fractures to the development of compartment syndrome. We hypothesized that the direction and degree of initial displacement of the femur on the tibia, and the amount of tibial widening (TW), were correlated with the development of compartment syndrome. DESIGN: Retrospective case-control study. SETTING: Single level 1 trauma center. PATIENTS: Retrospective evaluation of 158 patients with 162 plateau fractures. INTERVENTION: Grouping with and without compartment syndrome. MAIN OUTCOME MEASURES: The following data were obtained: age, sex, Schatzker and OTA/AO classification, open/closed status, TW, and femoral displacement (FD). A univariate statistical and a logistical regression analysis were performed to determine significance. RESULTS: The overall rate of compartment syndrome was 11%. Univariate analysis found both the TW and FD to be significant with respect to development of compartment syndrome (P < 0.05). Higher Schatzker (IV-VI) and OTA/AO grades were also correlated (P < 0.05) with increased incidence of compartment syndrome. Logistic regression found FD and Schatzker grade to be significant. CONCLUSIONS: Our study is the first to identify easily obtained radiographic parameters that correlate to the occurrence compartment syndrome. There may also be a relationship between TW and FD, as noted by regression result. This study helps to assess which patients with a fracture are at higher risk for developing a compartment syndrome. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Retrograde intramedullary nailing of open femoral shaft fractures: a retrospective case series.

BACKGROUND: Nailing of open femur fractures has been described, but the literature on this subject often used antegrade nailing techniques. A retrograde nailing technique carries the risk of contamination and infection of the knee, infection, and nonunion. The purpose of this study was to have a case series examining the intermediate term outcome of retrograde nailing of open femur fractures. METHODS: A retrospective review of all open femur fractures treated between 2008 and 2010 at a Level II trauma center was performed. Demographic and injury patterns were reviewed for the 35 patients who were treated with retrograde nailing. The main outcome measures evaluated were infection (knee or femur) and nonunion. RESULTS: There were 11 grade I, 18 grade II, and 6 grade IIIA fractures (no IIIB or IIIC injuries). Healing occurred in 34 of 35 fractures with 1 (3%) nonunion and 2 (6%) deep infections, both occurring in IIIA fractures. There were no cases of knee joint infections, but two patients (6%) developed arthrofibrosis requiring manipulation. Implant removal of a prominent screw was required in one patient. CONCLUSION: Early retrograde nailing of open femur fractures has infection and healing rates consistent with existing literature. There seems to be little risk for knee infection, but the increased incidence of arthrofibrosis requiring manipulation is higher than previously published. These findings suggest that early retrograde nailing may be considered an acceptable treatment option for open femur fractures. LEVEL OF EVIDENCE: IV, case series.