Delayed Presentation of Bowel Injury Associated with Pelvic Fragility Fracture in Patient with Bladder Sling: A Case Report.

CASE: An 85-year-old woman with a history of bladder mesh sling placement sustained a pelvic fracture and extraperitoneal bladder rupture after a ground-level fall. The patient underwent cystorrhaphy and percutaneous anterior column screw placement. Free air was identified on abdominal computed tomography scan on postoperative day 5. Exploratory laparotomy revealed a sigmoid colon perforation and extensive bowel adhesions to the anterior pelvis. CONCLUSION: This is the first report describing bowel injury and associated bladder rupture in a pelvic fragility fracture related to a prior bladder mesh sling. This case highlights the importance of obtaining a thorough surgical history when treating pelvic injuries.

Return to Play Rates Following Operative Ankle Fractures Differ Between High- and Low-Performing National Football League Athletes.

This study investigated predictive factors for return to play among National Football League athletes after operative treatment of ankle fractures and the impacts of these injuries on career longevity and player performance. Athletes who underwent surgery to repair ankle fractures from the 2013 to 2017 seasons were identified from injury reserve lists and press releases. Demographics and season metrics were collected before and after the injury. Statistical analysis assessed for differences in recorded variables between injured and uninjured players. Thirty-one players met study inclusion criteria. Twenty-two (71%) athletes successfully returned to play. Players who did not return showed no significant differences (P>.05) in position, age, body mass index, number of games or seasons played preinjury, or snaps per game the season prior to injury and had a significantly lower (42.6%, P=.013) preinjury season approximate value (SAV) compared with returning players. Returning athletes showed no significant differences (P>.05) in SAV or snaps per game compared with their preinjury season or with uninjured controls. A high preinjury SAV is associated with successful return to play. No difference in game time or performance metrics was detectable between returning players and uninjured controls, or between preinjury and postinjury seasons. [Orthopedics. 2024;47(1):22-27.].

Direct Oral Anticoagulants: How Do These Drugs Work, How to Monitor, and What Is Their Role in Orthopaedic Surgery.

Postoperative venous thromboembolism is a major adverse event associated with orthopaedic surgery. With the addition of perioperative anticoagulation and antiplatelet therapy, the rates of symptomatic venous thromboembolism have dropped to 1% to 3%, and as such, practicing orthopaedic surgeons must be familiar with these medications, including aspirin, heparin, or warfarin, and the use of direct oral anticoagulants (DOACs). DOACs are increasingly being prescribed due to their predictable pharmacokinetics and increased convenience, as they do not require routine monitoring, and 1% to 2% of the general population is currently anticoagulated. Although the introduction of DOACs has yielded additional treatment options, this has also led to confusion and uncertainty regarding treatment, specialized testing, and when and what reversal agents are appropriate. This article provides a basic overview of DOAC medications, their suggested use in the perioperative setting, effects on laboratory testing, and consideration for when and how to use reversal agents in orthopaedic patients.

Serial Surgical Debridement and Fixation of Chronic Pelvis Instability Secondary to Pubic Symphysis and Sacroiliac Osteomyelitis: A Case Report.

Introduction: Chronic global pelvic instability can be due to many different etiologies with infection being an uncommon cause. We present a case of chronic global pelvis instability secondary to osteomyelitis involving both the anterior and posterior ring, a rare and challenging problem with no standard treatment. Case Presentation: A 57-year-old female with a history of intravenous drug use presented with global pelvis instability in the setting of pubic symphysis and posterior sacroiliac osteomyelitis with multiple-associated abscesses. She was managed with serial surgical debridement's X4 and combined anterior and posterior fixation/fusion, with resolution of her infection and instability. Conclusions: This is the first reported case of chronic pelvis instability secondary to anterior and posterior pelvic ring osteomyelitis that was successfully treated with serial debridement and combined anterior and posterior fixation/fusion.

Interviewing in the Wake of COVID-19: How Orthopaedic Residencies, Fellowships, and Applicants Should Prepare for Virtual Interviews.

On May 7, 2020, the Coalition for Physician Accountability's released "Medical Students in the Class of 2021: Moving Across Institutions for Post Graduate Training," which comprises official recommendations on keeping programs and medical students safe during the upcoming match cycle with the challenges posed by COVID-19. In these recommendations, away rotations are discouraged, and all programs are compelled to commit to virtual interviews. Unlike employers and applicants in other industries, orthopaedic residency/fellowship programs and candidates seeking those positions have not routinely conducted virtual interviews. Without in-person interviews, applicants may perceive a limited ability to demonstrate their qualifications, judge program culture, and gauge ultimate program compatibility. Likewise, programs may perceive the inability to evaluate a candidate in real time, physically show program strengths, and ultimately judge applicant compatibility. Careful preparation and execution of a virtual interview can overcome these perceived limitations, whereas benefits, such as decreased cost for both programs and applicants, can make virtual interviews appealing. The purpose of this review was to help define a virtual interview, illustrate the benefits, and offer tips to both programs and applicants on how to prepare and perform optimally on an interview day.

Extraction of a Bent Tibial Nail After Refracture: A Case Report.

CASE: A 65-year-old man previously treated by intramedullary nailing for a left tibial shaft fracture presented 6 years later with an open refracture of his left tibia after a motorcycle accident. Treatment required extraction of the bent nail before revision nailing. CONCLUSIONS: Extraction of deformed intramedullary devices is a skill that will continue to be demanded of orthopaedic surgeons. In this case, standard extraction though the entry point proved successful. Standard extraction offers the safest form of removal and should be contemplated before considering more morbid methods of extraction while examining the fracture's morphology and the device's deformity.

What Orthopaedic Surgeons Need to Know: The Basic Science Behind Opioids.

On October 26, 2017, US president, Donald J. Trump, declared the opioid epidemic a national public health emergency. This declaration opened the door to government funding for programs geared toward studying and treating opioid addiction; however, part of the responsibility to slow the epidemic falls on physicians. Orthopaedic surgeons prescribed the third-highest number of narcotic prescriptions among all physician groups, and therefore, they have a major role to play in decreasing the use of opioids. Although restricting prescriptions is part of the solution, orthopaedic surgeries are often painful, and opioid medications, along with other multimodal nonopioid medications, allow patients to control pain and improve function, especially in the short term. Therefore, to successfully manage pain and opioid prescriptions, orthopaedic surgeons should know the basic science behind these powerful medications. Understanding the basic mechanism of action of opioid and nonopioid medication classes, knowing what oral morphine equivalent are, and knowing which nonopioid drugs can amplify or weaken the potency of opioids will help orthopaedic surgeons become more informed prescribers and leaders in helping control the opioid epidemic.

Impact of orthopaedic candidate interview timing on successful matching.

INTRODUCTION: The impact of the interview date on matching in orthopaedic surgery residency is unknown. MATERIALS AND METHODS: A retrospective review of interviewed applicants for a first-year orthopaedic surgery residency was conducted to determine the likelihood of matching based on being interviewed early versus late at our program. The United States Medical Licensing Examination (USMLE) scores were compared between early and late interviewees. RESULTS: Between 2012 and 2016, 316 candidates interviewed for residency positions. Twenty matched at our program and 230 at other institutions. No difference existed in USMLE scores. Late interviewees had significantly higher chances of matching at our center, but not nationwide in orthopaedic surgery (p = 0.025 and p = 0.58, respectively). CONCLUSION: Later applicant interview was associated with greater chance of matching at our institution, but did not impact the candidate's ability to match in orthopaedic surgery at other programs.

Scientific publication misrepresentation among orthopaedic residency applicants.

BACKGROUND: The predictors of erroneous publication reporting among orthopaedic surgery residency applicants have not been established. METHODS: A retrospective analysis of the reported scholarly activity of candidates who applied to our orthopaedic surgery department for a first-year residency position in 2017 was conducted to determine the incidence of scientific publication misrepresentation and analyze its association with pre-residency criteria. RESULTS: Out of 510 candidates, 264 (51.8%) applicants included accepted, in-press, or published scholarly activity on their resumes. The incidence of misrepresentation was 20.5%, and did not differ statistically based on the candidates' academic performance (United States Medical Licensing Examination - USMLE - steps 1 and 2 scores), Alpha Omega Alpha (AOA) membership, immigration status, or or additional academic degrees (p > 0.05). CONCLUSIONS: Misrepresentation is a persistent problem among residency training program applicants, and did not correlate with an applicant's academic performance, AOA membership, immigration status, or additional advanced academic degrees.

Thromboelastography for the Orthopaedic Surgeon.

Evaluation of coagulation is vital in the care of the orthopaedic patients, particularly in the subspecialties of trauma, spine, arthroplasty, and revision surgery resulting from blood loss and coagulopathies. Although conventional tests (prothrombin time/international normalized ratio, activated partial thromboplastin time, platelet count, and fibrinogen) are most commonly used, others like thromboelastography (TEG) are also available to the orthopaedic surgeons. TEG is a blood test developed in the 1950s, which provides a snapshot of a patient's coagulation profile by evaluating clot formation and lysis. Recently, TEG has been used to assess traumatic coagulopathy. The coagulation parameters measured by the TEG are reaction time (R-time), time to reach a certain clot strength (K-value), speed of fibrin build up (α-angle), maximum clot amplitude, and percentage decrease of clot in 30 minutes (LY30). Using these values, traumatologists have developed a better, faster, and more accurate overview of a patient's resuscitation and more successfully direct blood product use. However, many orthopaedic surgeons-despite performing surgical procedures that risk notable blood loss and postoperative clotting complications-are unaware of the existence of the TEG blood test and the critical information it provides. Increasing awareness of the TEG among orthopaedic surgeons could have a notable effect on numerous aspects of musculoskeletal care.

Does CT Angiography Matter for Patients with Cervical Spine Injuries?

BACKGROUND: Cervical injury can be associated with vertebral artery injury. This study was performed to determine the impact of computed tomography (CT) angiography of the head and neck on planning treatment of cervical spine fracture, if these tests were ordered appropriately, and to estimate cost and associated exposure to radiation and contrast medium. METHODS: This retrospective review included all patients who underwent CT of the cervical spine and CT angiography of the head and neck from January 2010 to August 2011 at one institution. Patients were divided into those with and those without cervical spine fracture seen on CT of the cervical spine. We determined if the CT angiography of the head and neck was positive for vascular injury in the patients with a cervical fracture. Vascular injury treatment and alterations in surgical fracture treatment due to positive CT angiography of the head and neck were recorded. A scan was deemed appropriate if it had been ordered per established institutional protocol. RESULTS: Of the 381 patients who underwent CT angiography of the head and neck, 126 had a cervical injury. Sixteen of the CT angiography studies were appropriately ordered for non-spinal indications, and twenty-three were inappropriately ordered. The CT angiography was positive for one patient for whom the imaging was off protocol and one for whom the indication was non-spinal. Nineteen patients had positive CT angiography of the head and neck; no patient underwent surgical intervention for a vascular lesion. Eleven patients underwent surgical intervention for a cervical fracture; the operative plan was changed because of vascular injury in one case. The CT angiography was positive for eleven of forty-eight patients who had sustained a C2 fracture; this group accounted for eleven of the nineteen positive CT angiography studies. Noncontiguous injuries occurred in nineteen patients; three had positive CT angiography of the head and neck. The approximate charge for the CT angiography was $3925, radiation exposure was approximately 4000 mGy/cm, and contrast-medium load was approximately 100 mL. CONCLUSIONS: Positive CT angiography of the head and neck rarely altered surgical treatment of cervical spine injuries. This study supports the findings in the literature that C1-C3 spine injuries have an increased association with vertebral artery injury. CT angiography of the head and neck ordered off protocol had a low likelihood of being positive. Strict adherence to protocols for CT angiography of the head and neck can reduce costs and decrease unnecessary exposure to radiation and contrast medium. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.