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INTRODUCTION: Postoperative fracture site infection can lead to notable patient morbidity, increase cost of care, and further contribute to healthcare disparities globally. Dogma suggests surgical blades as a vehicle for introducing bacteria into the surgical site; however, there is a paucity of literature to support this claim. This study uses advanced DNA sequencing to detect bacterial DNA on surgical blades used in upper extremity fracture surgeries. METHODS: This was a prospective study, conducted at a high-volume level 1 trauma center. All acute, closed upper extremity fractures requiring surgical stabilization were consecutively enrolled in a prospective fashion. The primary end point was the presence of bacterial DNA on the surgical blade using next-generation sequencing (NGS). At the time of surgery, two blades were sterilely opened. One blade served as the control while the other was used for the initial skin incision. Two negative control blades were opened directly into a sterile container. Two positive control blades were used for skin incision through known infections. All samples were sent for NGS analysis. RESULTS: Forty patients were enrolled in this study. The median age was 33.5 years, and 30% were female; the median body mass index was 26.52. Humerus fractures were the most common injury (N = 17, 42.5%), followed by clavicle fractures (13, 32.5%) and radius/ulna fractures (10, 25.0%). NGS analysis revealed no contamination of test blades used for skin incision. Three control blades tested positive for bacterial DNA. Negative control blades tested negative for bacterial DNA (0/2); the positive control blades resulted positive for bacterial DNA contamination (2/2). CONCLUSION: Surgical blades used for skin incision in the upper extremity are not contaminated with bacterial DNA as analyzed by NGS. This finding challenges previous surgical dogma regarding surgical blade contamination and supports that the same surgical blade can safely be used for deeper dissection. LEVEL OF EVIDENCE: Level II study: IRB approval-IRB#848938.
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Sequenciamento de Nucleotídeos em Larga Escala , Infecção da Ferida Cirúrgica , Humanos , Estudos Prospectivos , Infecção da Ferida Cirúrgica/prevenção & controle , Infecção da Ferida Cirúrgica/microbiologia , Feminino , Masculino , Adulto , Pessoa de Meia-Idade , Fraturas Ósseas/cirurgia , DNA Bacteriano/análise , Adulto Jovem , Extremidade Superior/cirurgia , Extremidade Superior/lesões , Contaminação de Equipamentos , Estudos de Coortes , Fraturas do Úmero/cirurgiaRESUMO
INTRODUCTION: Matching into an orthopaedic surgery residency consistently reinforces a competitive landscape, challenging the applicants and programs. A group of orthopaedic surgery residency programs implemented video prompts asking applicants to respond to a standardized question by video recording. Assessing the impact of this video on the decision to offer an interview can help guide programs and applicants through the interview process. METHODS: Twenty residency applications to one institution requiring video prompts were randomly selected and deidentified. Thirteen experienced faculty from various orthopaedic surgery programs served as applicant reviewers. The reviewers evaluated the electronic residency application service (ERAS) application and determined whether they would grant the applicant an interview ("no," "maybe," or "yes") before and after watching the video prompt. The reviewer also scored the impact of the applicant's dress, facial presentation, and video background distractions on their evaluation of the video. Multivariable logistic regressions were conducted using a group of applicants where interview status was not impacted by the video compared with the group of applicants where the interview status changed after video review. An alpha value of 0.05 was used to define significance. RESULTS: The video prompt impacted the decision to offer an interview 29.3% of the time; 15.8% were switched from "yes" or "maybe" to "no" and 13.5% were switched from "no" or "maybe" to "yes." For the positively impacted applicants, facial presentation score was significantly higher (P = 0.005). No recorded variables were associated with decreased chance of interview. DISCUSSION: Video prompts impacted the decision to offer interviews to orthopaedic surgery applicants approximately one-third of the time, with a similar number of applicants being positively and negatively impacted. Facial presentation score was associated with increased chance of interview, and no variables were associated with decreased chance of interview. Thus, the answer to the videos presumably negatively impacted applicants.
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BACKGROUND: Periprosthetic fractures can be devastating complications after total joint arthroplasty (TJA). The management of periprosthetic fractures is complex, spanning expertise in arthroplasty and trauma. The purpose of this study was to examine and project trends in the operative treatment of periprosthetic fractures in the United States. METHODS: A large, public and private payer database was queried to capture all International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes for periprosthetic femoral and tibial fractures. Statistical models were created to assess trends in treatment for periprosthetic fractures and to predict future surgical rates. An alpha value of 0.05 was used to assess significance. A Bonferroni correction was applied where applicable to account for multiple comparisons. RESULTS: In this study, from 2016 to 2021, 121,298 patients underwent surgical treatment for periprosthetic fractures. There was a significant increase in the total number of periprosthetic fractures. The incidence of periprosthetic hip fractures rose by 38% and that for periprosthetic knee fractures rose by 73%. The number of periprosthetic fractures is predicted to rise 212% from 2016 to 2032. There was a relative increase in open reduction and internal fixation (ORIF) compared with revision arthroplasty for both periprosthetic hip fractures and periprosthetic knee fractures. CONCLUSIONS: Periprosthetic fractures are anticipated to impose a substantial health-care burden in the coming decades. Periprosthetic knee fractures are predominantly treated with ORIF rather than revision total knee arthroplasty (TKA), whereas periprosthetic hip fractures are predominantly treated with revision total hip arthroplasty (THA) rather than ORIF. Both periprosthetic knee fractures and periprosthetic hip fractures demonstrated increasing trends in this study. The proportion of periprosthetic hip fractures treated with ORIF relative to revision THA has been increasing. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Fraturas Periprotéticas , Reoperação , Humanos , Fraturas Periprotéticas/epidemiologia , Fraturas Periprotéticas/cirurgia , Fraturas Periprotéticas/etiologia , Estados Unidos/epidemiologia , Reoperação/estatística & dados numéricos , Feminino , Fixação Interna de Fraturas/tendências , Fixação Interna de Fraturas/métodos , Fixação Interna de Fraturas/estatística & dados numéricos , Masculino , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/estatística & dados numéricos , Artroplastia de Quadril/tendências , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/estatística & dados numéricos , Idoso , Incidência , Pessoa de Meia-Idade , Fraturas do Fêmur/cirurgia , Fraturas do Fêmur/epidemiologia , Fraturas do Fêmur/etiologia , Fraturas da Tíbia/cirurgia , Fraturas da Tíbia/epidemiologiaRESUMO
INTRODUCTION: Intensive care unit risk stratification models have been utilized in elective joint arthroplasty; however, hip fracture patients are fundamentally different in their clinical course. Having a critical care risk calculator utilizing pre-operative risk factors can improve resourcing for hip fracture patients in the perioperative period. METHODS: A cohort of geriatric hip fracture patients at a single institution were reviewed over a three-year period. Non-operative patients, periimplant fractures, additional procedures performed under the same anesthesia period, and patients admitted to the intensive care unit (ICU) prior to surgery were excluded. Pre-operative laboratory values, Revised Cardiac Risk Index (RCRI), and American Society of Anesthesiologists (ASA) scores were calculated. Pre-operative ambulatory status was determined. The primary outcome measure was ICU admission in the post-operative period. Outcomes were assessed with Fisher's exact test, Kruskal-Wallis test, logistic regression, and ROC curve. RESULTS: 315 patient charts were analyzed with 262 patients meeting inclusion criteria. Age ≥ 80 years, ASA ≥ 4, pre-operative hemoglobin < 10 g/dL, and a history of CVA/TIA were found to be significant factors and utilized within a "training" data set to create a 4-point scoring system after reverse stepwise elimination. The 4-point scoring system was then assessed within a separate "validation" data set to yield an ROC area under the curve (AUC) of 0.747. Score ≥ 3 was associated with 96.8 % specificity and 14.2 % sensitivity for predicting post-op ICU admission. Score ≥ 3 was associated with a 50 % positive predictive value and 83 % negative predictive value. CONCLUSION: A hip fracture risk stratification scoring system utilizing pre-operative patient specific values to stratify geriatric hip patients to the ICU post-operatively can improve the pre-operative decision-making of surgical and critical care teams. This has important implications for triaging vital hospital resources. LEVEL OF EVIDENCE: III (retrospective study).
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Cuidados Críticos , Avaliação Geriátrica , Fraturas do Quadril , Unidades de Terapia Intensiva , Humanos , Fraturas do Quadril/cirurgia , Feminino , Masculino , Idoso de 80 Anos ou mais , Medição de Risco/métodos , Idoso , Avaliação Geriátrica/métodos , Estudos Retrospectivos , Fatores de Risco , Cuidados Pós-Operatórios/métodosRESUMO
BACKGROUND: Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture). METHODS: In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications. RESULTS: A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups. CONCLUSIONS: Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).
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Anti-Infecciosos Locais , Clorexidina , Fixação de Fratura , Fraturas Ósseas , Iodo , Infecção da Ferida Cirúrgica , Humanos , 2-Propanol/administração & dosagem , 2-Propanol/efeitos adversos , 2-Propanol/uso terapêutico , Anti-Infecciosos Locais/administração & dosagem , Anti-Infecciosos Locais/efeitos adversos , Anti-Infecciosos Locais/uso terapêutico , Antissepsia/métodos , Canadá , Clorexidina/administração & dosagem , Clorexidina/efeitos adversos , Clorexidina/uso terapêutico , Etanol , Extremidades/lesões , Extremidades/microbiologia , Extremidades/cirurgia , Iodo/administração & dosagem , Iodo/efeitos adversos , Iodo/uso terapêutico , Cuidados Pré-Operatórios/efeitos adversos , Cuidados Pré-Operatórios/métodos , Pele/microbiologia , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Fraturas Ósseas/cirurgia , Estudos Cross-Over , Estados UnidosRESUMO
INTRODUCTION: The effect of spinal versus general anesthesia on the risk of postoperative delirium or other outcomes for patients with or without cognitive impairment (including dementia) is unknown. METHODS: Post hoc secondary analysis of a multicenter pragmatic trial comparing spinal versus general anesthesia for adults aged 50 years or older undergoing hip fracture surgery. RESULTS: Among patients randomized to spinal versus general anesthesia, new or worsened delirium occurred in 100/295 (33.9%) versus 107/283 (37.8%; odds ratio [OR] 0.85; 95% confidence interval [CI] 0.60 to 1.19) among persons with cognitive impairment and 70/432 (16.2%) versus 71/445 (16.0%) among persons without cognitive impairment (OR 1.02; 95% CI 0.71 to 1.47, p = 0.46 for interaction). Delirium severity, in-hospital complications, and 60-day functional recovery did not differ by anesthesia type in patients with or without cognitive impairment. DISCUSSION: Anesthesia type is not associated with differences in delirium and functional outcomes among persons with or without cognitive impairment.
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Disfunção Cognitiva , Delírio , Fraturas do Quadril , Humanos , Delírio/etiologia , Complicações Pós-Operatórias , Disfunção Cognitiva/complicações , Anestesia Geral/efeitos adversos , Fraturas do Quadril/complicações , Fraturas do Quadril/cirurgiaRESUMO
Humanitarian crises create opportunities for both in-person and remote aid. Durable, complex, and team-based care may leverage a telemedicine approach for comprehensive support within a conflict zone. Barriers and enablers are detailed, as is the need for mission expansion due to initial program success. Adapting a telemedicine program initially designed for critical care during the severe acute respiratory syndrome coronavirus 2 pandemic offers a solution to data transfer and data analysis issues. Staffing efforts and grouped elements of patient care detail the kinds of remote aid that are achievable. A multiprofessional team-based approach (clinical, administrative, nongovernmental organization, government) can provide comprehensive consultation addressing surgical planning, critical care management, infection and infection control management, and patient transfer for complex care. Operational and network security create parallel concerns relevant to avoid geolocation and network intrusion during consultation. Deliberate approaches to address cultural differences that influence relational dynamics are also essential for mission success.
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The opioid epidemic in the United States has forced care providers to seek out alternatives to narcotic analgesics. Physicians involved in trauma care, including orthopaedic trauma surgeons, often have patients requiring significant amounts of these medications, especially in the perioperative period, given the acuity and severity of their injuries. Modalities such as local infiltration of fractures with anesthetic agents during operative treatment may provide some benefit to this population by decreasing postoperative pain and narcotic usage. However, prior data suggest that these agents are chondrotoxic, which may impede secondary fracture healing. The purpose of this study was to investigate the hypothesis that local anesthetics decrease secondary bone healing and callus formation in stabilized murine femur fractures through chondrocyte apoptosis. Male C57BL/6 mice underwent intramedullary stabilization and fracture of bilateral femurs followed by immediate infiltration of the fracture site with local anesthetic agents. Femurs were dissected at 10- and 20-days post-fracture and evaluated by [Formula: see text]CT and histological analysis. No significant differences were seen in callus size or mineralization between controls and fractures treated with a local anesthetic. When the callus was analyzed histologically, local anesthetic agents appeared to increase cartilage density. Therefore, infiltration of local anesthetics during operative treatment of fracture as part of a multimodal approach to pain control does not appear to significantly affect callus formation in a preclinical model, although subclinical molecular effects may be present. Local infiltrative analgesia with local anesthetics may be used as an adjunct for perioperative pain control during femur fracture surgery without a significant effect on secondary bone healing.
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BACKGROUND: Suicide and depression among orthopaedic surgeons have recently emerged as rising concerns. Prior research has suggested that orthopaedic surgeons have the highest prevalence of suicide among surgical specialties. We sought to determine the factors associated with depression and suicidal ideation (SI) in orthopaedics, including subspecialty. METHODS: A survey including demographic questions, the Beck Depression Inventory, and the Columbia-Suicide Severity Rating Scale was administered electronically via a listserv to the orthopaedic subspecialties of trauma, adult reconstruction, hand and upper extremity, shoulder and elbow, foot and ankle, spine, pediatrics, sports medicine, and oncology. The responses were quantified according to previously published criteria. The associations of demographic factors, training, and current practice environment with depression and suicidality were assessed using Fisher exact tests. Reverse stepwise multivariable logistic regression models were developed to identify factors associated with depression and SI. RESULTS: The responses were obtained from 661 board-certified, practicing orthopaedic surgeons. In this study, 156 surgeons (23.6%) endorsed some level of active SI in their lifetime, 200 surgeons (30.3%) reported either active or passive SI in their lifetime, and 33 surgeons (5%) reported that, on at least 1 occasion in their lifetime, they had experienced active SI with a specific plan and intention to harm themselves. Gender, relationship status, having children, and residency and/or current practice region were significantly associated with depression and/or SI. Younger age, divorce, adult reconstruction and foot and ankle subspecialties, and attending residency in the Western U.S. were found on multivariable testing to be associated with symptoms of depression and SI (odds ratios, 1.03 [per 1-year decrease in age] to 8.28). CONCLUSIONS: Symptoms of depression and suicidality are not uncommon among orthopaedic surgeons, and variation by gender, relationship status, and geographic location are supported by prior research. Based on our results, depression and/or SI likely affect someone close to you or someone with whom you work. The normalization of discussions surrounding emotional well-being, depression, and SI is imperative.
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Cirurgiões Ortopédicos , Ortopedia , Suicídio , Adulto , Criança , Depressão/diagnóstico , Humanos , Cirurgiões Ortopédicos/educação , Ortopedia/educação , Ideação SuicidaRESUMO
SUMMARY: Historically, the traditional pathways into plastic surgery required board eligibility in a surgical specialty such as general surgery, orthopedics, urology, neurosurgery, otolaryngology, or ophthalmology. This requirement resulted in plastic surgery residents who had served as chief residents before plastic surgery training. Their maturity emotionally and surgically allowed them to immediately concentrate on the new language and principles of plastic surgery. They had led others and were capable of leading themselves in a new surgical discipline. Today, medical students typically match into surgical specialties directly out of medical school and need to spend their time learning basic surgical skills and patient care because of the contracted time afforded to them. Formal leadership training has historically been limited in surgical training. The authors set out to delineate the creation, implementation, and perceptions of a leadership program within a surgical residency and provide guideposts for the development of engaged, conscious, and dedicated leaders within the residencies they lead.
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Currículo , Internato e Residência/métodos , Liderança , Cirurgia Plástica/educação , Humanos , Internato e Residência/organização & administração , Pennsylvania , Cirurgia Plástica/organização & administraçãoRESUMO
OBJECTIVES: To compare risk of reoperation for femoral neck fracture patients undergoing fixation with cancellous screws (CSs) or sliding hip screws based on surgeon fellowship (trauma-fellowship-trained vs. non-trauma-fellowship-trained). DESIGN: Retrospective review of Fixation using Alternative Implants for the Treatment of Hip fractures data. SETTING: Eighty-one centers across 8 countries. PATIENTS/PARTICIPANTS: Eight hundred nineteen patients ≥50 years old with low-energy hip fractures requiring surgical fixation. INTERVENTION: Patients were randomized to CS or sliding hip screw group in the initial dataset. MAIN OUTCOME MEASUREMENTS: The primary outcome was risk of reoperation. Secondary outcomes included death, serious adverse events, radiographic healing, discharge disposition, and use of ambulatory devices postoperatively. RESULTS: There was no difference in risk of reoperation between the 2 surgeon groups (P > 0.05). Patients treated by orthopaedic trauma surgeons were more likely to be overweight/obese and have major medical comorbidities (P < 0.05). There was a higher risk of serious adverse events, higher likelihood of radiographic healing, and higher odds of discharge to a facility for patients treated by trauma-fellowship-trained surgeons (P < 0.05). CONCLUSIONS: Based on these data, risk of reoperation for low-energy femoral neck fracture fixation is equivalent regardless of fellowship training. The higher likelihood of radiographic healing noted in the trauma-trained group does not seem to have a major clinical implication because it did not affect risk of reoperation between the 2 groups. Patient-specific factors present preinjury, such as body habitus and medical comorbidities, may account for the lower odds of discharge to home and higher risk of postoperative medical complications for patients treated by orthopaedic trauma surgeons. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Fraturas do Colo Femoral , Fraturas do Quadril , Parafusos Ósseos , Bolsas de Estudo , Fraturas do Colo Femoral/cirurgia , Fixação Interna de Fraturas , Fraturas do Quadril/cirurgia , Humanos , Pessoa de Meia-Idade , Reoperação , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVES: The aim of this study was to determine the educational value of a national virtual fracture conference implemented during the COVID-19 disruption of resident education. DESIGN: Survey study. SETTING: National virtual conference administered by the Orthopaedic Trauma Association. PARTICIPANTS: Attendees of virtual fracture conference. INTERVENTION: Participation at a national virtual fracture conference. MAIN OUTCOME MEASURE: Surveys of perception of quality and value of virtual conferences relative to in-person conferences. RESULTS: Ninety-six percent of participants rated the virtual fracture conference as similar or improved educational quality relative to conventional in-person fracture conference. Participants also felt they learned as much (35%) or more (57%) at each virtual fracture conference compared to the amount learned in-person. The quality of interpersonal interactions at both the resident-faculty level and faculty-faculty level was also perceived to be overall superior to those at participants' own institutions. Learners felt they were more likely to engage the primary literature as well. Overall, 100% of participants were likely to recommend virtual conference to their colleagues and 100% recommended continuing this conference even after COVID-19 issues resolve. CONCLUSIONS: We found that learners find significant educational value in a national virtual fracture conference compared to in-person fracture conferences at their own institution. COVID-19 has proven to be a disruptor not only in health care but in medical education as well, accelerating our adoption of innovative and novel resident didactics. LEVEL OF EVIDENCE: Therapeutic Level III.
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INTRODUCTION: Ankle fractures are the most common fracture of the foot and ankle treated at trauma hospitals in the United States, costing millions of dollars yearly. The purpose of this study was to determine whether a standardized care pathway led to a difference in the direct and indirect costs of surgical fixation of ankle fractures at one Level I Trauma Center and tertiary care medical center. METHODS: We analyzed cost, volume, length of stay, and collections for surgical treatment of ankle fractures in inpatient and outpatient settings by the orthopaedics and podiatry departments during fiscal years 2016 to 2018. Based on these data, we compared projected costs and collections across a 5-year period with the procedure being done by a single department (orthopaedics only and podiatry only). RESULTS: Total costs per case fell by 18% in the orthopaedics department and 8% in the podiatry department over the 3-year period. The podiatry department spent an average of $1,296 (46%) more per case than the orthopaedics department, driven by increased average supply costs. Both departments had significantly decreased direct costs (P = 0.0039 orthopaedics and P = 0.033 podiatry) in the outpatient setting. The orthopaedics department also had significantly lower average supply costs than the podiatry department (P = 0.045) and significantly decreased total costs in the outpatient setting (P = 0.0084). DISCUSSION: The orthopaedics department performed a higher volume of cases at a lower cost per case than the podiatry department. These savings were driven by a standardized ankle fracture treatment pathway that we propose decreased direct and supply costs. Our results suggest that surgical treatment of ankle fracture cases using a standardized care pathway is economically advantageous because of limiting variations in care and creating manageable workflows.
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Fraturas do Tornozelo , Fraturas do Tornozelo/cirurgia , Custos e Análise de Custo , Custos de Cuidados de Saúde , Humanos , Pacientes Internados , Estudos Retrospectivos , Centros de Traumatologia , Estados UnidosRESUMO
OBJECTIVES: This study compares outcomes for patients with displaced femoral neck fractures undergoing hemiarthroplasty (HA) or total hip arthroplasty (THA) by surgeons of different fellowship training. DESIGN: Retrospective review of HEALTH trial data. SETTING: Eighty clinical sites across 10 countries. PATIENTS/PARTICIPANTS: One thousand four hundred forty-one patients ≥50 years with low-energy hip fractures requiring surgical intervention. INTERVENTION: Patients were randomized to either HA or THA groups in the initial data set. Surgeons' fellowship training was ascertained retrospectively, and outcomes were compared. MAIN OUTCOME MEASUREMENTS: The main outcome was an unplanned secondary procedure at 24 months. Secondary outcomes included death, serious adverse events, prosthetic joint infection (PJI), dislocation, discharge disposition, and use of ambulatory devices postoperatively. RESULTS: There was a significantly higher risk of PJI in patients treated by surgeons without fellowship training in arthroplasty (P = 0.01), surgeons with unknown fellowship training (P = 0.03), and surgeons with no fellowship training (P = 0.02) than those treated by an arthroplasty-trained surgeon. There were significantly higher odds of being discharged to a facility rather than home in patients who underwent surgery by a surgeon with no fellowship training compared with arthroplasty-fellowship-trained surgeons (P = 0.03). CONCLUSIONS: Arthroplasty for hip fracture can be performed by all orthopaedic surgeons with equivalent reoperation rates. Infection prevention strategies and use of "care pathways" by arthroplasty-fellowship-trained surgeons may account for the lower risk of PJI and higher rate of discharge to home. The authors advocate for the use of evidence-based infection prevention initiatives and standardized care pathways in this patient population. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Artroplastia de Quadril , Fraturas do Colo Femoral , Hemiartroplastia , Fraturas do Quadril , Artroplastia de Quadril/efeitos adversos , Fraturas do Colo Femoral/cirurgia , Fraturas do Quadril/cirurgia , Humanos , Reoperação , Estudos RetrospectivosRESUMO
BACKGROUND: Controversy continues regarding appropriate indications for posterior malleolus fracture fixation in unstable rotational trimalleolar ankle injuries, with limited data comparing gait in operatively treated trimalleolar ankle fractures vs control populations. The purpose of this study was to evaluate the effect of trimalleolar ankle fracture fixation on gait parameters in the early postoperative period as compared to a healthy control population. METHODS: Adult patients having undergone operative treatment of isolated trimalleolar ankle fractures were eligible for inclusion. A total of 10 patients met the inclusion criteria and participated in the analysis. Patients were evaluated using standard parameters of human gait 6 months after their index procedures, with gait values compared to a population of 17 non-age-matched healthy control subjects in addition to literature values of healthy populations of younger and older subjects. RESULTS: Significant differences were noted between the spatiotemporal gait parameters of healthy control subjects and patients who had undergone operative treatment of trimalleolar ankle fractures. However, within the fracture group itself, no differences were found between patients with or without posterior malleolar fixation for any of the tested gait parameters. When patients were compared to literature values of younger and older healthy control populations, they were found to have gait patterns more similar to older rather than younger individuals. CONCLUSION: Operative fixation of trimalleolar ankle fracture does not restore normal gait function in the early postoperative period. Fixation of the posterior malleolus in particular also does not appear to improve gait characteristics. Patients who undergo surgery for these injuries demonstrate gait patterns similar to those of healthy older adults. LEVEL OF EVIDENCE: Level II, Therapeutic (prospective cohort study).
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OBJECTIVE: To determine whether intramedullary nail (IMN) size and its relation to the canal diameter [nail-canal (NC) diameter] impacts the union rate or time to union in the treatment of femoral shaft fractures. DESIGN: Retrospective review. SETTING: Two Level 1 and 1 Level 2 trauma centers. PATIENTS: Two hundred eighty-seven patients met the criteria and were included in the study. INTERVENTION: Patients were treated with either an antegrade or retrograde IMN. Comparisons were first performed comparing 10- versus 11- versus 13-mm nails. Patients were then divided into 3 groups based on the difference between the size of the femoral canal at the isthmus and the IMN (NC diameter). Group 1: <1.0 mm, group 2: >1.0 and <2.0 mm, and group 3: >2.0 mm. MAIN OUTCOME MEASUREMENTS: Nonunion rates, mean time to union. RESULTS: Two hundred eighty-seven patients with a minimum of 12-month follow-up, who were treated with size with IMN for femoral shaft fractures, were assessed for fracture characteristics, time to union, and union rate. When comparing IMN size, no statistical difference was found when comparing time to union or overall union rate. When comparing NC diameter, no significant difference was found in union rate and time to union when comparing between the groups. CONCLUSION: Similar rate of union and time to union were exhibited regardless of nail size or NC diameter. This can correlate to the standard utilization of a reamed, titanium 10-mm IMN with 5.0-mm interlocking screws in the treatment of femoral shaft fractures, offering potentially less reaming, shorter operative times, and removing unnecessary stock from inventory. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Fraturas do Fêmur , Fixação Intramedular de Fraturas , Pinos Ortopédicos , Fraturas do Fêmur/diagnóstico por imagem , Fraturas do Fêmur/cirurgia , Fêmur , Consolidação da Fratura , Humanos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
A critical component in the evaluation of a patient with a periprosthetic hip fracture is determination of stem stability. Failure to critically evaluate preoperative radiographs and subsequently intraoperative stem position may result in an incorrect treatment algorithm and early catastrophic failure of the implant construct. In 2018, this is becoming a larger issue as demand for revision total hip arthroplasty increases. Several factors contribute to the type of implant used in these fractures and depend on age, activity level, comorbidities, and available bone stock. The purpose of this article is to review the evaluation of periprosthetic hip fractures around a loose stem and provide tips and tricks for their management to allow for a successful, long-lasting outcome.
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Artroplastia de Quadril/efeitos adversos , Fraturas do Fêmur/cirurgia , Fêmur/cirurgia , Fixação Interna de Fraturas/métodos , Fraturas Periprotéticas/cirurgia , Fraturas do Fêmur/diagnóstico , Fêmur/diagnóstico por imagem , Humanos , Fraturas Periprotéticas/diagnóstico , Radiografia , ReoperaçãoRESUMO
There currently exists an array of operative strategies to manage Lisfranc injuries. Modular fixation systems present surgeons with a choice between fully threaded solid cortical (FSC) and partially threaded cannulated cancellous (PCC) bone screws when using a transarticular screw approach. It is currently unknown how screw design influences fixation strength in Lisfranc reconstructions. The purpose of this study was to evaluate the biomechanical differences of FSC and PCC screws using a cadaveric model of a simulated Lisfranc injury and controlled benchtop experiments. Ten matched pairs of cadaveric feet received an acute Lisfranc injury and were repaired with FSC or PCC screws. Diastasis was measured between the medial and intermediate cuneiforms and the first and second metatarsals during simulations of partial weight bearing. Three-point bending and axial pull-out tests were performed to characterize screw mechanics that could not be measured within the cadaveric model. Screw design did not affect cuneiform or metatarsal diastasis. Neither screw loosening nor deformation was observed following cadaveric testing. Bending tests indicated FSC screws had higher ultimate strength, but there was no significant difference in yield load. Partially threaded cannulated cancellous bone screws exhibited superior axial pull-out strength. Fully threaded solid cortical and PCC screws provide equal amounts of fixation strength during partial weight bearing and similar resistance to deformation under bending loads. Partially threaded cannulated cancellous screws may simplify the operative procedure and minimize nonoptimal screw placement. If a clinician so desires, PCC screws may be used in lieu of FSC screws without sacrificing fixation strength. [Orthopedics. 2018; 41(2):e222-e227.].
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Parafusos Ósseos , Fixação Interna de Fraturas/instrumentação , Fraturas Ósseas/cirurgia , Ossos do Metatarso/lesões , Ossos do Metatarso/cirurgia , Idoso , Idoso de 80 Anos ou mais , Fenômenos Biomecânicos , Cadáver , Desenho de Equipamento , Falha de Equipamento , Feminino , Fixação Interna de Fraturas/métodos , Humanos , Masculino , Teste de Materiais/métodos , Pessoa de Meia-Idade , Suporte de CargaRESUMO
OBJECTIVES: The suprapatellar approach for medullary nailing of the tibia is increasing. This requires intra-articular passage of instruments, which theoretically places the knee at risk of postoperative sepsis in the setting of open fracture. We hypothesized that the risk of knee sepsis is similar after suprapatellar or infrapatellar nailing of open tibia fractures. DESIGN: Retrospective, multicenter. SETTING: Three urban level 1 trauma centers. PATIENTS: All patients treated with medullary nailing for open diaphyseal tibia fractures (OTA 42) from 2009 to 2015. Patients younger than 18 years of age and with less than 12 weeks of follow-up were excluded. We identified 289 fractures in 282 patients. INTERVENTION: Suprapatellar (SP) or infrapatellar (IP) medullary nailing of open tibia fractures. MAIN OUTCOME MEASUREMENT: Occurrence of ipsilateral knee sepsis, defined as presence of a positive culture from knee aspiration or arthrotomy. Deep infection requiring operative debridement, superficial infection requiring antibiotic therapy alone, and all-cause reoperation were also recorded. RESULTS: IP nailing was used for 142 fractures. There were 20 infections (14.1%), of which 14 (9.8%) were deep. Fourteen tibias (9.8%) required reoperation for noninfectious reasons for 28 total reoperations (19.7%). SP nailing was used in 147 fractures. There were 24 infections (16.2%), of which 16 (10.8%) were deep. Fourteen additional tibias (9.5%) required reoperation for noninfectious reasons for a total of 30 reoperations (20.4%). There were no differences in the rates of infection, deep infection, or reoperation between groups. There were 2 cases of knee sepsis after SP nailing (1.4%) but zero cases after IP nailing (P = 0.5). CONCLUSIONS: There was no significant difference in the rate of knee sepsis with SP or IP approaches. The risk of knee sepsis after SP nailing of open fractures is low, but present. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Artrite Infecciosa/etiologia , Fixação Intramedular de Fraturas/efeitos adversos , Fraturas Expostas/cirurgia , Fraturas da Tíbia/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Fraturas Expostas/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Patela , Estudos Retrospectivos , Tíbia , Fraturas da Tíbia/complicações , Adulto JovemRESUMO
CASE: A 65-year-old woman sustained a closed segmental humeral shaft fracture with a complete radial nerve palsy. Radial nerve neurotmesis was found during acute surgical exploration and fixation. Treatment included a 2-cm shortening osteotomy of the humeral shaft and osteosynthesis in order to obtain a tension-free primary end-to-end repair of the radial nerve. CONCLUSION: Tension-free primary nerve repair can be technically challenging with humeral shaft fractures. A shortening osteotomy of the humeral shaft and osteosynthesis are feasible to achieve tension-free neurorrhaphy without nerve-grafting.