Iatrogenic open humeral shaft fractures following functional bracing.

INTRODUCTION: The treatment of closed humeral shaft fractures tends to be successful with functional bracing. Treatment failure due to iatrogenic conversion to an open fracture has not been described in the literature. We present a case series of patients that experienced open humeral shaft fractures after initially being treated with functional bracing for closed humeral shaft fractures and describe what factors are associated with this complication. MATERIALS AND METHODS: This was a retrospective case series performed at three level 1 trauma centers across North America. All nonoperatively treated humeral shaft fractures were reviewed from 2001 to 2023. Patients were included if they sustained a humeral shaft fracture, > 18 years old, were initially treated non-operatively with functional bracing which subsequently converted to an open fracture. Eight patients met inclusion criteria. All included patients were eventually treated with irrigation, debridement, and open reduction and internal fixation. Outcomes assessed included mortality rate, time until the fracture converted from closed to open, need for further surgery, and bony union. Descriptive statistics were used in analysis. RESULTS: The eight included patients on average were 65 ± 21.4 years old and had a body mass index (BMI) of 25.6 ± 5.2. Six patients were initially injured due to a fall. Time until the fractures became open on average was 5.2 ± 3.6 weeks. Three patients (37.5%) died within 1.8 ± 0.6 years after initial injury. The average Charlson Comorbidity Index (CCI) score was 4.5 ± 3.4. Three patients (37.5%) had dementia. Common characteristics among this cohort included a history of visual disturbances (50.0%), cerebrovascular accident (50.0%), smoking (50.0%), and alcohol abuse (50.0%). CONCLUSION: Conversion from a closed to open humeral shaft fracture after functional bracing is a potentially devastating complication. Physicians should be especially cognizant of patients with a low BMI, history of falling or visual disturbance, dementia, age ≥ 65, decreased sensorimotor protection, and significant smoking or alcohol history when choosing to use functional bracing as the final treatment modality. LEVEL OF EVIDENCE: IV.

Audio Distraction for Traction Pin Insertion: A Prospective Randomized Controlled Study.

BACKGROUND: Insertion of a skeletal traction pin in the distal femur or proximal tibia can be a painful and unpleasant experience for patients with a lower-extremity fracture. The purpose of this study was to determine whether providing patients with audio distraction (AD) during traction pin insertion can help to improve the patient-reported and the physician-reported experience and decrease pain and/or anxiety during the procedure. METHODS: A prospective randomized controlled trial was conducted at 2 level-I trauma centers. Patients ≥18 years of age who were conscious and oriented and had a medical need for skeletal traction were included. Patients were randomized to receive AD or not receive AD during the procedure. All other procedure protocols were standardized and were the same for both groups. Surveys were completed by the patient and the physician immediately following the procedure. Patients rated their overall experience, pain, and anxiety during the procedure, and physicians rated the difficulty of the procedure, both on a 1-to-10 Likert scale. RESULTS: A total of 54 patients met the inclusion criteria. Twenty-eight received AD and 26 did not. Femoral fractures were the most common injury (33 of 55, 60.0%). Baseline demographic characteristics did not differ between the 2 groups. The overall patient-reported procedure experience was similar between the AD and no-AD groups (3.9 ± 2.9 [95% confidence interval (CI), 3.1 to 4.7] versus 3.5 ± 2.2 [95% CI, 2.9 to 4.1], respectively; p = 0.55), as was pain (5.3 ± 3.2 [95% CI, 4.4 to 6.2] versus 6.1 ± 2.4 [95% CI, 5.4 to 6.8]; p = 0.28). However, anxiety levels were lower in the AD group (4.8 ± 3.3 [95% CI, 3.9 to 5.7] versus 7.1 ± 2.8 [95% CI, 6.3 to 7.9]; p = 0.007). Physician-reported procedure difficulty was similar between the groups (2.6 ± 2.0 [95% CI, 2.1 to 3.1] versus 2.8 ± 1.7 [95% CI, 2.3 to 3.3]; p = 0.69). CONCLUSIONS: AD is a practical, low-cost intervention that may reduce patient anxiety during lower-extremity skeletal traction pin insertion. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Intrawound Vancomycin Powder in Primary Total Hip Arthroplasty: A Prospective Quality Control Study.

BACKGROUND: The purpose of this retrospective analysis of a prospective quality control project was to determine whether the use of intrawound vancomycin powder (IVP) decreases the rate of periprosthetic joint infection (PJI) within 90 days following primary total hip arthroplasty (THA). METHODS: From October 2021 to September 2022, a prospective quality control project was undertaken in which 10 high-volume THA surgeons alternated between using and not using IVP each month while keeping other perioperative protocols unchanged. A retrospective analysis of the project was performed to compare the group of patients who received IVP to the group of patients who did not. The primary outcome was a culture positive infection within 90 days following primary THA. Secondary outcomes included gram-positive culture, overall reoperation rate, wound complications, readmission, and wound complications within 90 days post-operatively. A total of 1,193 primary THA patients were identified for analysis. There were 523 (43.8%) patients who received IVP and were included in the IVP group, while 670 (56.2%) did not and were included in the non-IVP group. Age, body mass index, and sex were similar between the 2 groups (P > .25). RESULTS: The IVP group had a higher rate of culture positive joint infections (1.7 [0.8, 3.2] versus 0.3% [0.04, 1.1], P = .01) than the non-IVP group. All PJI's were found to have gram positive bacteria in both groups. The IVP group had a higher overall reoperation rate than the non-IVP group (6.1 [4.2, 8.5] versus 2.4% [1.4, 3.9], P < .01). The IVP group had a higher reoperation rate for any wound complication compared to non-IVP patients (2.7 [1.5, 4.5] versus 0.7% [0.2, 1.7], P < .01). The overall readmission rate (6.1 [4.2, 8.5] versus 2.8% [1.7, 4.4], P < .01), as well as readmission for suspected infection (2.1 [1.1, 3.7] versus 0.6% [0.02, 1.5], P = .03), were higher in the IVP group. CONCLUSIONS: The use of IVP in primary THA was associated with a higher rate of PJI, overall reoperation, reoperation for wound complications, and readmission in a prospective quality control project. Until future prospective randomized studies determine the safety and efficacy of IVP in THA conclusively, we advocate against its utilization.

Preoperative Function Affects Ability to Achieve One-Year Minimum Clinically Important Difference for Patients Undergoing Total Knee Arthroplasty.

Background: Minimum clinically important difference (MCID) values are commonly used to measure treatment success for total knee arthroplasty (TKA). MCID values vary according to calculation methodology, and prior studies have shown that patient factors are associated with failure to achieve MCID thresholds. The purpose of this study was to determine if anchor-based 1-year Knee Injury and Osteoarthritis Outcome Score Joint Replacement (KOOS-JR) MCID values varied among patients undergoing TKA based on patient-specific factors. Methods: This was a retrospective review of patients undergoing TKA from 2017-2018. Patients without baseline or 1-year KOOS-JR or Patient-Reported Outcome Measurement Information System Global Health data or that underwent procedures other than primary TKA were excluded. MCIDs were calculated and compared between patient groups according to preoperative characteristics. Results: Among the included 976 patients, 1-year KOOS-JR MCIDs were 26.6 for men, 28.2 for women, 30.7 for patients with a diagnosis of anxiety and/or depression, and 26.7 for patients without a diagnosis. One-year MCID values did not differ significantly according to gender (P = .379) or mental health diagnosis (P = .066), nor did they correlate with body mass index (ß = -0.034, P = .822). Preoperative KOOS-JR decile demonstrated an inverse relationship with 1-year MCID values and attainment of MCID. Conclusions: The proportion of patients attaining KOOS-JR MCID values demonstrated an inverse relationship with preoperative baseline function. Future investigation may identify patient factors that allow surgeons to better capture patient satisfaction with their procedure despite failure to attain a 1-year MCID.

Clostridium difficile Infection Prior to Total Hip Arthroplasty Independently Increases the Risk of Periprosthetic Joint Infection.

BACKGROUND: Periprosthetic joint infection (PJI) following total hip arthroplasty (THA) is associated with major morbidity. There may be a link between the gut microbiome and an individual's overall immune system. A Clostridium difficile (C. difficile) infection portends poor gut microbiome health and has been previously associated with increased 90-day complication rates in total joint arthroplasty (TJA). The purpose of this study was to determine the effect of a previous history of C. difficile infection within 2 years of undergoing THA on PJI within 2 years postoperatively. METHODS: Patients undergoing THA from 2010 to 2021 were identified in a patient claims database (n = 770,075). Patients who had active records 2 years before and after THA as well as a history of C. difficile infection within 2 years prior to THA (n = 1,836) were included and propensity matched to a control group using age, sex, and Elixhauser comorbidity index. The primary outcome was the 2-year incidence of postoperative PJI. The exposed C. difficile infection cohort was stratified into 4 groups based on the time proximity of the C. difficile infection. Chi-square tests and logistic regressions were used to compare the groups. RESULTS: A C. difficile infection anytime within 2 years prior to total hip arthroplasty was independently associated with higher odds of PJI (OR [odds ratio]: 1.49 [95% CI (confidence interval) 1.09 to 2.02, P = .014]). Proximity of C. difficile infection to arthroplasty was associated with increased risk of PJI (infection 0 to 3 months before THA: OR 2.01 [95% CI 1.23 to 3.20], infection 3 to 6 months before THA: OR 1.84 [95% CI 1.06 to 3.04], infection 6 to 12 months before THA: OR 1.10 [95% CI 0.65 to 1.77], infection 1 to 2 years before THA: OR 1.40 [95% CI 0.94 to 2.06]). CONCLUSIONS: A C. difficile infection prior to THA is an independent risk factor for PJI. Proximity of C. difficile infection is associated with increased risk of PJI. Future investigations should evaluate how to adequately optimize patients prior to THA and pursue strategies to determine appropriate timing for proceeding with THA.

Outcomes of Name-brand Versus Generic Cephalomedullary Nail Fixation for Intertrochanteric and Subtrochanteric Fractures: A Matched Cohort Study.

This study aims to compare 90-day and 6-month outcomes and implant costs of intertrochanteric and subtrochanteric fracture fixation using cephalomedullary nails (CMNs) from a single name-brand company to fixation using generic CMNs. This was a retrospective matched cohort study. All CMN procedures for a single surgeon in a single US metropolitan institution from 2021 to 2022 were identified using current procedural terminology codes. Nearest neighbor 1:1 matching was conducted between the name-brand and generic cohorts controlling for (1) age, (2) American Society of Anesthesiologists score, and (3) Charlson Comorbidity Index. A total of 50 patients were successfully matched (25 namebrand versus 25 generic). The average implant cost per case for the name-brand group was $3,587 versus $1,615 for the generic group. Cost of disposables averaged $109 for the generic implant sets versus $916 for the name-brand (P < 0.001). Overall, a cost savings of 61% could be generated per case with the use of generic implants and disposables. Fixation of intertrochanteric and subtrochanteric fractures using generic CMNs produces similar outcomes compared with using name-brand CMNs for approximately half the implant cost.

Improved Patient-reported Outcomes in Patients Aged 16 and Younger at Two Years After Anterior Cruciate Ligament Reconstruction Despite Relatively High Rates of Reinjury and Repeat Surgery.

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) in adolescent patients, particularly those aged 16 and under, are increasingly common procedure that lacks robust clinical and patient-reported outcome (PRO) data. The purpose of this study was to report 2-year PROs of patients receiving ACLR aged 16 or younger using the single assessment numerical evaluation (SANE) and knee injury and osteoarthritis outcome score (KOOS). Secondary aims included characterizing treatment characteristics, return to sport (RTS), and clinical outcomes. METHODS: The institutional PRO database was queried for patients receiving ACLR from 2009 to 2020. Patients aged older than 16, revision procedures, concomitant ligament repairs/reconstructions, and patients without full outcome data at 2 years were excluded. Outcomes over 2 years after ACLR included SANE, KOOS, reinjuries, reoperations, and time to RTS. RESULTS: A total of 98 patients were included with an average age of 15.0 years. Most patients were females (77.6%). Bone-tendon-bone autograft (69.4%) was the most used. Average RTS was 8.7 months (range: 4.8 to 24.0 mo), with 90% of patients eventually returning to sport. A total of 23 patients (23.5%) experienced a reinjury and 24.5% (n = 24) underwent reoperation. Timing to RTS was not associated with reinjury, but patients who returned between 9.5 and 13.7 months did not sustain reinjuries. Mean KOOS and SANE scores at 2 years were 87.1 and 89.1, respectively, with an average improvement of +18.4 and +22.9, respectively. Change in KOOS was negatively impacted by reinjury to the anterior cruciate ligament graft and reoperation (anterior cruciate ligament failure: +10.0 vs 19.3, P = 0.081, respectively; reoperation: +13.2 vs +20.1, P = 0.051, respectively), though these did not reach statistical significance. CONCLUSION: Patients experienced improved SANE and KOOS scores after ACLR. Rates of reinjury and reoperation were relatively high and negatively impacted PRO scores but were not associated with the timing of RTS. Adolescent patients should be counseled regarding the risk of subsequent ipsilateral and contralateral knee injury after ACLR. LEVEL OF EVIDENCE: Level IV-case series.

Use of a Continuous Intracompartmental Pressure Monitoring Device During Fasciotomy.

A 52-year-old man presented with a bicondylar tibial plateau fracture and acute compartment syndrome. Continuous compartment pressure monitoring was used while the patient was treated with fasciotomies and application of an external fixator. The intraoperative pressure reading in the anterior compartment decreased from 105 mm Hg to 50 mm Hg after skin and subcutaneous tissue incision. Pressure continued to decrease to 10 mm Hg after all 4 compartments were released. The patient underwent staged open reduction and internal fixation and healed both fracture and fasciotomy incisions without complication. To our knowledge, this is the first report of continuous pressure changes during the different stages of a compartment release. Future studies could expand on use of this technology to gain information on compartment pressures during release and how single release affects pressures in other compartments. [Orthopedics. 2024;47(2):e98-e101.].

Autograft patellar bone-tendon-bone use does not increase operative time in anterior cruciate ligament reconstruction.

Background: Anterior cruciate ligament reconstruction (ACLR) is a common procedure that has been shown to have relatively good outcomes amongst various graft types. Operative time in ACLR has been found to influence outcomes and cost. The purpose of this study was to evaluate the association of operative time in primary arthroscopically performed anterior cruciate ligament reconstruction (ACLR) and graft type while controlling for confounders that influence time. Methods: All patients who received ACLR between 2018 and 2022 were included in this retrospective cohort study. Exclusion criteria consisted of age (≤16 years), revisions, concomitant ligament reconstruction or tendon repairs, or other simultaneously performed procedures that could potentially add substantial variation in operative time. The primary outcome was operative time. Graft types included allograft, bone-tendon-bone (BTB) autograft, hamstring tendon (HS) autograft and quadriceps tendon (QT) autograft. Results: A total of 1813 primary ACLRs were included. The average operative time was 98.9 ± 33.0 min. Graft utilization varies considerably among surgeons. The most used graft type was BTB autograft (42.6%) followed by HS autograft (32.3%) and allograft (21.4%). Only 68 cases (3.8%) used a QT autograft. Seven of the 15 included surgeons primarily used BTB autograft. One surgeon predominately used QT autograft. No difference in operative time was observed among the autograft types (p = 0.342). Allograft ACLR was significantly faster by 27-33 min compared to using BTB autograft, HS autograft, or QT autograft (p < 0.001). Conclusion: Operative time did not vary by type of autograft selected. Allograft ACLR was performed approximately 30 min faster than autograft ACLR. Further studies examining the effect on patient outcomes of reduced operative time and minimizing graft harvest morbidity in ACLR is important to more accurately determine the cost-effectiveness of allograft ACLR.

The Minimum Clinically Important Difference for the Patient-Rated Wrist Evaluation in Surgical Fixation of Distal Radius Fractures: Does Hand Dominance Make a Difference?

BACKGROUND: Distal radius fractures (DRFs) are common orthopaedic injuries. They can be treated in many ways, but the volar locking plate (VLP) is more frequent. Currently, there is limited information regarding the minimum clinically important difference (MCID) in surgically treated DRFs. The purpose of this study was to calculate MCID values for the Patient-Reported Wrist Evaluation (PRWE) in the setting of VLP-treated DRFs. METHODS: A retrospective review was conducted for patients with isolated, surgically-treated DRFs with a VLP. Exclusions included any concomitant procedure other than a carpal tunnel release, skeletal immaturity, polytrauma, open fracture, or missing PRWE data. MCID was calculated using PRWE, an overall health question, and the anchor-based method. RESULTS: A total of 131 patients were identified. Approximately 54.2% injured their dominant hand. AO/OTA classification 23C was the most common (n=89, 67.9%). Average baseline, 6-week, and 12-week PRWE were 71.8 ± 19.6, 34.3 ± 20.1, and 21.2 ± 18.0 respectively. This corresponds to an average change from baseline PRWE at 6 weeks and 12 weeks of -37.5 ± 23.4 and -50.6 ± 22.3, respectively. Average MCID values for 6 weeks and 12 weeks were 43.1 ± 18 and 56.0 ± 20.0, respectively (p<0.001). Hand dominance did not correlate with MCID value (rs = 0.084 at six weeks, rs = 0.099 at 12 weeks). MCID value additionally did not correlate with sex, AO/OTA classification, smoking status, ASA score, or BMI. Treatment at a level 1 trauma center and diagnosis of anxiety and/or depression correlated with a higher 6-week MCID value (rs = 0.308 and rs = 0.410, respectively). Increasing age weakly correlated with higher 12-week MCID value (rs = 0.352). CONCLUSIONS: This study demonstrated an MCID calculation using an overall health anchor. MCID value varied with follow-up time and correlated weakly with age, diagnosis of anxiety and/or depression, and treatment facility, but it did not correlate with injury of the dominant hand. Future research should analyze how to apply MCID and identify successful treatment in the setting of DRF care.

A Case Series of Surgically Treated Distal Radius Fractures: Implant Costs and Their Effect on Patient Outcomes.

INTRODUCTION: Distal radius fractures (DRFs) are common injuries, warranting a need to analyze the cost of treatment. The purpose of this study was to analyze the effect of implant costs on patient-reported outcomes in DRFs. METHODS: A PRO registry was retrospectively reviewed for isolated, surgically treated DRF patients. A total of 140 patients met criteria to be included in this study. Implant cost was obtained from the chargemaster database. RESULTS: The average total implant cost was $1,289.67 ± 215.32. The average Patient-rated Wrist Evaluation scores preoperatively, at 6 weeks, and at 12 weeks were 70.8 ± 20.1, 36.6 ± 21.1, and 22.8 ± 18.0, respectively. No statistically significant relationships were observed between cost and Patient-rated Wrist Evaluation scores at 6 weeks or 12 weeks (r = -0.05, P = 0.59; r = -0.04, P = 0.64, respectively). Implant costs were shown to not be affected by fracture complexity (AO/OTA classification: 23A = $1,335.50, 23B = $1,246.86, and 23C = $1,293.14). DISCUSSION: The total cost of implants did not influence patient outcomes indicating that patients receive no additional benefit from more costly constructs.

Implant cost variation in surgically treated distal radius fractures.

Aims & objectives: The purpose of this study was to evaluate for cost variation in distal radius fractures (DRFs) treated with a volar locking plate (VLP) and to identify key factors that affect the total construct cost. Materials & methods: A retrospective case series was conducted for a single healthcare system. A total of 140 patients with a DRF treated with a VLP from May 2014 to December 2021 were identified. Patients were excluded for polytrauma, open fractures, and skeletal immaturity. Results: Most patients were female (n = 120, 85.7%) and were on average 59 ± 13.7 years old. Patients most often injured their dominant hand (n = 75, 53.6%) and presented with an AO/OTA 23C fracture (n = 93, 66.4%). Twenty-two surgeons were included with fellowship training in hand or trauma and orthopaedic or plastic surgery residency. Orthopaedic hand-trained surgeons treated the highest proportion of 23C fractures (69.8%). Ninety patients (64.3%) were treated at a surgery center. The average cost was $1289.67 ± $215.32 (range: $857.83-$2156.95). The most expensive fixation constructs used a variable angle locking screw ($1316.75 ± $264.99) or a multidirectional threaded peg ($1321.67 ± $192.94). Multivariable regression analysis revealed none of the study variables to be significant contributors to construct cost (all p-values >0.27). Conclusions: Surgically treated DRFs with a VLP demonstrated similar total implant costs regardless of fracture pattern, surgeon specialty, or treatment facility. Contrary to previous literature, VLPs showed minimal cost variation, although some surgeons were able to decrease the overall cost by reducing the number of screws used.