The use of liposomal bupivacaine in fracture surgery: a review.

Historically, opioids have played a major role in the treatment of postoperative pain in orthopedic surgery. A multitude of adverse events have been associated with opioid use and alternative approaches to pain relief are being investigated, with particular focus on multimodal pain management regimens. Liposomal bupivacaine (EXPAREL) is a component of some multimodal regimens. This formulation of bupivacaine encapsulates the local anesthetic into a multivesicular liposome to theoretically deliver a consistent amount of drug for up to 72 hours. Although the use of liposomal bupivacaine has been studied in many areas of orthopedics, there is little evidence evaluating its use in patients with fractures. This systematic review of the available data identified a total of eight studies evaluating the use of liposomal bupivacaine in patients with fractures. Overall, these studies demonstrated mixed results. Three studies found no difference in postoperative pain scores on postoperative days 1-4, while two studies found significantly lower pain scores on the day of surgery. Three of the studies evaluated the quantity of narcotic consumption postoperatively and failed to find a significant difference between control groups and groups treated with liposomal bupivacaine. Further, significant variability in comparison groups and study designs made interpretation of the available data difficult. Given this lack of clear evidence, there is a need for prospective, randomized clinical trials focused on fully evaluating the use of liposomal bupivacaine in fracture patients. At present, clinicians should maintain a healthy skepticism and rely on their own interpretation of the available data before widely implementing the use of liposomal bupivacaine.

The Opioid Risk Tool Correlates With Increased Postsurgical Opioid Use Among Patients With Orthopedic Trauma.

The aim of this study was to determine whether the Opioid Risk Tool (ORT), which has been validated in patients with chronic pain, relates to postoperative opioid consumption. The purpose was to investigate a tool that could help identify patients with orthopedic trauma at high risk for opioid abuse. Patients 18 to 80 years old presenting between May 2018 and August 2018 to UNC Hospitals with isolated orthopedic injuries that required surgical intervention were considered for inclusion. At 2 weeks postoperatively, the ORT was administered. At 6 weeks postoperatively, total morphine milligram equivalents (MME) was determined for each patient. Each patient was also categorized as either low risk (LR) or moderate to high risk (M-HR) based on the cumulative ORT score. Finally, opioid prescriptions provided after 6 weeks postoperatively was recorded. One hundred four patients met the inclusion criteria, and 42 completed the questionnaire. Thirty patients were categorized as LR and 12 patients as M-HR. Patients who were at M-HR consumed a significantly higher MME than LR patients (LR=406 [95% CI, 287-526]; M-HR=824 [95% CI, 591-1057]; P=.001). Linear regression analysis showed that for each additional risk factor, opioid consumption increased by 61 MME, and approximately 58% of the variation in opioid consumption could be explained by the ORT (beta=61, R2=0.58, P=.02). In this study, the ORT predicted which patients would have increased opioid consumption after orthopedic trauma surgery. Each additional risk factor correlated with increased opioid use. The ORT did not predict which patients would continue to receive opioid prescriptions after 6 weeks postoperatively. [Orthopedics. 2023;46(4):e219-e222.].

Locked Plating versus Nailing for Proximal Tibia Fractures: A Multicenter RCT.

OBJECTIVES: The main 2 forms of treatment for extraarticular proximal tibial fractures are intramedullary nailing (IMN) and locked lateral plating (LLP). The goal of this multicenter, randomized controlled trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN: Multicenter, randomized controlled trial. SETTING: 16 academic trauma centers. PATIENTS/PARTICIPANTS: 108 patients were enrolled. 99 patients were followed for 12 months. 52 patients were randomized to IMN, and 47 patients were randomized to LLP. INTERVENTION: IMN or lateral locked plating. MAIN OUTCOME MEASUREMENTS: Functional scoring including Short Musculoskeletal Functional Assessment, Bother Index, EQ-5Dindex and EQ-5DVAS. Secondary measures included alignment, operative time, range of motion, union rate, pain, walking ability, ability to manage stairs, need for ambulatory aid and number, and complications. RESULTS: Functional testing demonstrated no difference between the groups, but both groups were still significantly affected 12 months postinjury. Similarly, there was no difference in time of surgery, alignment, nonunion, pain, walking ability, ability to manage stairs, need for ambulatory support, or complications. CONCLUSIONS: Both IMN and LLP provide for similar outcomes after these fractures. Patients continue to improve over the course of the year after injury but remain impaired even 1 year later. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Fixation of humerus shaft fractures in polytrauma patients does not improve short-term outcomes.

BACKGROUND: Surgical fixation of humeral shaft fractures is widely considered a relative indication for polytraumatized patients to improve mobility and expedite care. This study aimed to determine whether operative treatment of humeral shaft fractures improves short term outcomes in polytrauma (PT] patients. METHODS: Using the National Trauma Data Bank, PT patients with humeral shaft fractures were identified from 2010-2015. Three PT groups were analyzed: Group 1 - PT with nonoperative humeral shaft fracture, Group 2 - PT with humeral fixation on Day 1, and Group 3 - PT with humeral fixation on Day 2+. Cox proportional hazards regression models were used to compare discharge timing and days on ventilator and in ICU between the three groups. RESULTS: There were 395 patients in Group 1, 1,346 in Group 2, and 1,318 in Group 3. There were no differences between the three groups when comparing Glasgow Coma Scale (p=0.3]; however, Injury Severity Score and Abbreviated Injury Scale were statistically different (p<0.001]. No differences were found in ICU or ventilator days between the three groups (p=0.2, p=0.5]. For Length of Stay, no difference was observed in Group 1 vs. Group 2 and Group 2 vs. Group 3. However, non-surgical patients were discharged 20% faster than those with Day 1 surgery (p=0.005]. Open fractures were treated one day earlier than closed fractures but discharged one day later (p<0.001]. CONCLUSIONS: This NTDB study demonstrates no differences in length of stay, days in the ICU or on the ventilator in patients with humeral shaft fractures treated non-operatively versus operative fixation. Overall, 44%-58% in all 3 groups had an ISS ≥ 14. Based on these results, we assert that fixation of the humeral shaft provides no short-term benefits in the multiply injured patient.

Serology and Comorbidities in Patients With Fracture Nonunion: A Multicenter Evaluation of 640 Patients.

INTRODUCTION: This multicenter cohort study investigated the association of serology and comorbid conditions with septic and aseptic nonunion. METHODS: From January 1, 2011, to December 31, 2017, consecutive individuals surgically treated for nonunion were identified from seven centers. Nonunion-type, comorbid conditions and serology were assessed. RESULTS: A total of 640 individuals were included. 57% were male with a mean age of 49 years. Nonunion sites included tibia (35.2%), femur (25.6%), humerus (20.3%), and other less frequent bones (18.9%). The type of nonunion included septic (17.7%) and aseptic (82.3%). Within aseptic, nonvascular (86.5%) and vascular (13.5%) nonunion were seen. Rates of smoking, alcohol abuse, and diabetes mellitus were higher in our nonunion cohort compared with population norms. Coronary artery disease and tobacco use were associated with septic nonunion (P < 0.05). Diphosphonates were associated with vascular nonunion (P < 0.05). Serologically, increased erythrocyte sedimentation rate, C-reactive protein, parathyroid hormone, red cell distribution width, mean platelet volume (MPV), and platelets and decreased absolute lymphocyte count, hemoglobin, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, and albumin were associated with septic nonunion while lower calcium was associated with nonvascular nonunion (P < 0.05). The presence of four or more of increased erythrocyte sedimentation rate, C-reactive protein, or red cell distribution width; decreased albumin; and age younger than 65 years carried an 89% positive predictive value for infection. Hypovitaminosis D was seen less frequently than reported in the general population, whereas anemia was more common. However, aside from hematologic and inflammatory indices, no other serology was abnormal more than 25% of the time. DISCUSSION: Abnormal serology and comorbid conditions, including smoking, alcohol abuse, and diabetes mellitus, are seen in nonunion; however, serologic abnormalities may be less common than previously thought. Septic nonunion is associated with inflammation, younger age, and malnourishment. Based on the observed frequency of abnormality, routine laboratory work is not recommended for nonunion assessment; however, specific focused serology may help determine the presence of septic nonunion.

Proximal tibia fracture dislocations: Management and outcomes of a severe and under-recognized injury.

INTRODUCTION: Proximal tibia fracture dislocations (PTFDs) are a subset of plateau fractures with little in the literature since description by Hohl (1967) and classification by Moore (1981). We sought to evaluate reliability in diagnosis of fracture-dislocations by traumatologists and to compare their outcomes with bicondylar tibial plateau fractures (BTPFs). METHODS: This was a retrospective cohort study at 14 level 1 trauma centers throughout North America. In all, 4771 proximal tibia fractures were reviewed by all sites and 278 possible PTFDs were identified using the Moore classification. These were reviewed by an adjudication board of three traumatologists to obtain consensus. Outcomes included inter-rater reliability of PTFD diagnosis, wound complications, malunion, range of motion (ROM), and knee pain limiting function. These were compared to BTPF data from a previous study. RESULTS: Of 278 submitted cases, 187 were deemed PTFDs representing 4% of all proximal tibia fractures reviewed and 67% of those submitted. Inter-rater agreement by the adjudication board was good (83%). Sixty-one PTFDs (33%) were unicondylar. Eleven (6%) had ligamentous repair and 72 (39%) had meniscal repair. Two required vascular repair. Infection was more common among PTFDs than BTPFs (14% vs 9%, p = 0.038). Malunion occurred in 25% of PTFDs. ROM was worse among PTFDs, although likely not clinically significant. Knee pain limited function at final follow-up in 24% of both cohorts. CONCLUSIONS: PTFDs represent 4% of proximal tibia fractures. They are often unicondylar and may go unrecognized. Malunion is common, and PTFD outcomes may be worse than bicondylar fractures.

Administration of Venous Thromboembolism Chemoprophylaxis Within 12 Hours of Pelvic and Acetabular Surgery Has No Effect on Estimated Blood Loss, Perioperative Change in Hemoglobin, or Need for Transfusion.

OBJECTIVE: To determine if preoperative administration of venous thromboembolism (VTE) chemoprophylaxis (PPx) before pelvic and acetabular fracture surgery affects estimated blood loss (EBL), perioperative change in hemoglobin (ΔHgb), or transfusion rates. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center, southeastern United States. PATIENTS/PARTICIPANTS: All pelvic and acetabular surgeries performed between April 2014 and February 2020. MAIN OUTCOME MEASUREMENTS: EBL, immediate and 24-hour postoperative ΔHgb, and intraoperative/postoperative transfusion. RESULTS: In all, 267 surgeries were included: 97 prechange and 170 postchange. Median injury severity score was 17 before versus 14 after the change. One surgeon retired and two started during the study, producing differences in acetabular approaches. Median surgical duration was longer postchange. Cohorts were otherwise similar. No differences were observed in EBL, ΔHgb, or transfusion rates. Rates of VTE and surgical site complications were unchanged. No VTE-related deaths occurred. In the as-treated analysis (63 patients given low-molecular-weight heparin <12 hours preoperatively vs. 190 patients not given PPx), no differences were observed. CONCLUSIONS: Administration of VTE PPx within 12 hours of pelvic and acetabular surgery had no effect on perioperative blood loss. This study is limited by changes in faculty, but it suggests that traumatologists need not advocate for holding VTE PPx before pelvic and acetabular trauma surgery. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Smith-Petersen Versus Watson-Jones Approach Does Not Affect Quality of Open Reduction of Femoral Neck Fracture.

OBJECTIVE: To compare immediate quality of open reduction of femoral neck fractures by alternative surgical approaches. DESIGN: Retrospective cohort study. SETTING: Twelve Level 1 North American trauma centers. PATIENTS: Eighty adults 18-65 years of age with isolated, displaced, OTA/AO type 31-B2 or -B3 femoral neck fractures treated with internal fixation. INTERVENTION: Thirty-two modified Smith-Petersen anterior approaches versus 48 Watson-Jones anterolateral approaches for open reduction performed by fellowship-trained orthopaedic trauma surgeons. MAIN OUTCOME: Reduction quality as assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs. RESULTS: No difference was observed in the rate of acceptable reduction by modified Smith-Petersen (81%) versus Watson-Jones (81%) approach (risk difference null, 95% confidence interval -17.4% to 17.4%, P = 1.00) with 90.4% panel agreement (Fleiss' weighted κ = 0.63, P < 0.01). Stratified analyses did not identify a significant difference in the rate of acceptable reduction between approaches when stratified by Pauwels angle, basicervical or transcervical fracture location, or posterior comminution. The Smith-Petersen approach afforded a better reduction when preoperative skeletal traction was not applied (RR = 1.67 [95% CI 1.10-2.52] vs. RR = 0.87 [95% CI 0.70-1.08], P = 0.006). CONCLUSIONS: No difference was observed in the quality of open reduction of displaced femoral neck fractures in young adults when a Watson-Jones anterolateral approach versus a modified Smith-Petersen anterior approach was performed by orthopaedic trauma surgeons. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Open Reduction Is Associated With Greater Hazard of Early Reoperation After Internal Fixation of Displaced Femoral Neck Fractures in Adults 18-65 Years.

OBJECTIVES: To determine (1) which factors are associated with the choice to perform an open reduction and (2) by adjusting for these factors, if the choice of reduction method is associated with reoperation. DESIGN: Retrospective cohort study with radiograph and chart review. SETTING: Twelve Level 1 North American trauma centers. PATIENTS: Two hundred thirty-four adults 18-65 years of age with an isolated, displaced, OTA/AO type 31-B2 or type 31-B3 femoral neck fracture treated with internal fixation with minimum of 6-month follow-up or reoperation. Exclusion criteria were pathologic fractures, associated femoral head or shaft fractures, and primary arthroplasty. INTERVENTION: Open or closed reduction technique during internal fixation. MAIN OUTCOME: Cox proportional hazard of reoperation adjusting for propensity score for open reduction based on injury, demographic, and medical factors. Reduction quality was assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs. RESULTS: Median follow-up was 1.5 years. One hundred six (45%) patients underwent open reduction. Reduction quality was not significantly affected by open versus closed approach (71% vs. 69% acceptable, P = 0.378). The propensity to receive an open reduction was associated with study center; younger age; male sex; no history of injection drug use, osteoporosis, or cerebrovascular disease; transcervical fracture location; posterior fracture comminution; and surgery within 12 hours. A total of 35 (33%) versus 28 (22%) reoperations occurred after open versus closed reduction (P = 0.056). Open reduction was associated with a 2.4-fold greater propensity-adjusted hazard of reoperation (95% confidence interval 1.3-4.4, P = 0.004). A total of 35 (15%) patients underwent subsequent total hip arthroplasty or hemiarthroplasty. CONCLUSIONS: Open reduction of displaced femoral neck fractures in nonelderly adults is associated with a greater hazard of reoperation without significantly improving reduction. Prospective randomized trials are indicated to confirm a causative effect of open versus closed reduction on outcomes after femoral neck fracture. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does Very High Surgeon or Hospital Volume Improve Outcomes for Hemiarthroplasty Following Femoral Neck Fractures?

BACKGROUND: This study evaluates whether very high-volume hip arthroplasty providers have lower complication rates than other relatively high-volume providers. METHODS: Hemiarthroplasty patients ≥60 years old were identified in the New York Statewide Planning and Research Cooperative System 2001-2015 dataset. Low-volume hospitals (<50 hip arthroplasty cases/y) and surgeons (<10 cases/y) were excluded. The upper and lower quintiles were compared for the remaining "high-volume" hospitals (50-70 vs >245) and surgeons (10-15 vs ≥60) using multivariable Cox proportional hazards regression. Multiple sensitivity analyses were performed treating volume as a continuous variable. RESULTS: In total, 48,809 patients were included. Very high-volume hospitals demonstrated slightly less pneumonia (6% vs 7%, hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.68-0.88, P < .0001). Very high-volume surgeons experienced slightly higher rates of inpatient morality (3% vs 2%, HR 1.30, 95% CI 1.06-1.60, P = .01), revision surgery (3% vs 3%, HR 1.24, 95% CI 1.02-1.52, P = .03), and implant failure (1% vs <1%, HR 1.80, 95% CI 1.10-2.96, P = .02). Sensitivity analyses did not significantly alter these findings but suggested that inpatient mortality may decline as surgeon volume approaches 30 cases/y before gradually increasing at higher volumes. CONCLUSION: A clinically meaningful volume-outcome relationship was not identified among very high-volume hemiarthroplasty surgeons or hospitals. Although prior evidence indicates that outcomes can be improved by avoiding very low-volume providers, these results suggest that complications would not be further reduced by directing all hemiarthroplasty patients to very high-volume surgeons or facilities. Future research investigating whether inpatient mortality changes with surgeon volume (particularly around 30 cases/y) in a different dataset would be valuable. LEVEL OF EVIDENCE: Prognostic Level III.

Do Hospital or Surgeon Volume Affect Outcomes After Surgical Management of Tibial Shaft Fractures?

OBJECTIVES: To determine whether hospital and surgeon volume are associated with outcomes after operative fixation of tibial shaft fractures. METHODS: Adults (≥18 year old) who underwent operative fixation of diaphyseal tibial fractures were identified in the New York Statewide Planning and Research Cooperative System data set from 2001 to 2015. Reoperation, nonunion, and other adverse event rates were compared across surgeon and hospital volume using multivariable Cox proportional hazards regression, adjusting for clinical and demographic factors. Low-volume providers (lowest 20%) were compared with high-volume providers (highest 20%). Low volume constituted <5 cases/year for hospitals and 1 case/year for surgeons. High volume constituted ≥40 cases/year for hospitals and ≥8 cases/year for surgeons. RESULTS: Nine thousand one hundred forty-seven patients were included. Relative to high-volume surgeons, low-volume surgeons experienced slightly higher rates of pneumonia [2% vs. 1%, hazard ratio (HR) 2.50, 95% confidence interval (CI) 1.38-4.53, P = 0.003], and respiratory failure (5% vs. 3%, HR 1.88, 95% CI 1.30-2.71, P = 0.001). Compared with high-volume hospitals, low-volume hospitals experienced slightly lower rates of compartment syndrome (1% vs. 3%, HR 0.45, 95% CI 0.24-0.85, P = 0.01) and fasciotomies (3% vs. 7%, HR 0.57, 95% CI 0.38-0.85, P = 0.005). The rates of all other reoperations and adverse events compared among hospitals and surgeons were not significantly different. CONCLUSIONS: We did not detect a clinically meaningful volume-outcome relationship for either surgeons or hospitals despite the use of a robust database with rigorous statistical methodology. Of note, these findings should not be applied to rare complex injuries such as those with extensive bone loss or articular extension, which are not well represented by this study population. Therefore, we conclude that typical tibial shaft fracture, including open or closed injuries, can be safely managed in the vast majority of orthopaedic settings and that this care does not necessarily require transfer to a specialty centers. Future research into orthopaedic volume-outcome relationships could be strengthened by the use of functional outcomes (which would likely require well-organized multicenter prospective registries). LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Closed Reduction Percutaneous Pinning of a Pediatric Supracondylar Distal Humerus Fracture.

Pediatric supracondylar humerus fractures are the most common type of fracture of the elbow in children. Treatment options for these fractures depend on the fracture type as well as the severity of the fracture; however, the standard of care is closed reduction and percutaneous pin fixation for Gartland type 2 and 3 fractures. Controversy exists regarding the ideal pin configuration, size, and number of pins for best stabilization. We present a technique video illustrating our method of lateral entry-pinning of a type 3 supracondylar humerus fracture using three 2.0-mm smooth pins.

Despite the Safety of Preoperative Cefazolin for Patients With Non-anaphylactic Penicillin Allergy, 20% of Practitioners Avoid Its Use.

Cefazolin is commonly used for surgical site infection prophylaxis due to its low cost and effective coverage. However, it is controversial to use cefazolin in patients with a penicillin allergy despite the cross-reactivity between cefazolin and penicillin being only 1%. Ample literature shows that it is safe to use cefazolin in patients with non-anaphylactic penicillin allergies. However, there is often hesitation by anesthesiologists or orthopedists when prescribing this medication in this population. The current authors sent a 16-question survey to all the residency programs in the United States in anesthesiology and orthopedics asking physicians affiliated with these programs to answer a series of questions about their demographics, prescribing patterns, and knowledge of the cross-reactivity between penicillin and cefazolin. A total of 146 responses in each group, with 82.9% (n=121) of orthopedists and 78.8% (n=115) of anesthesiologists preferring cefazolin for patients with non-anaphylactic penicillin allergies. However, only 57.5% of anesthesiologists and 41.1% of orthopedists knew the correct cross-reactivity between cephalosporins and penicillin. If a provider knew the correct cross-reactivity between cefazolin and penicillin, he or she had an increased odds of prescribing cefazolin to patients with nonanaphylactic penicillin allergies (orthopedics odds ratio [OR], 4.77, P<.01; anesthesiologists OR, 3.59, P<.01). Therefore, this study supports that further education of orthopedic and anesthesia providers about the cross-reactivity between cefazolin and penicillin would lead to more evidence-based, cost-effective care. [Orthopedics. 2019; 42(5):e437-e442.].

Proximal Humeral Locking Plates: A Cadaveric Study of 5 Versus 7 Metaphyseal Locking Screws.

The most common operative treatment of proximal humerus fractures is internal fixation with fixed-angle locking plates. Although this surgical technique has been refined, a significant failure rate remains. This study aimed to determine whether the number of locking screws in the humeral head affects the biomechanical strength and stability of the construct in bone from elderly individuals. Ten pairs of embalmed cadaveric humeri were osteotomized in a gap model and fixed with periarticular locking plates placed in the standard position. Five or 7 proximal locking screws were inserted. Mechanical testing was performed, and cyclic displacements and maximum force to failure were recorded. No significant difference was found between 5 and 7 locking screws in mean cyclic displacement on the medial (1.09 mm vs 1.12 mm, P=.834) or posterior (0.45 mm vs 0.42 mm, P=.791) sides of the fracture model. On testing to failure, 7 and 5 screws showed similar stiffness (336 N/mm vs 292 N/mm, P=.176), force at ultimate load (745 N vs 662 N, P=.309), and displacement at ultimate load (5.90 mm vs 4.36 mm, P=.080). All samples failed at diaphyseal fixation, and no screw cutout or varus collapse was observed. Results from this study suggest that there is no significant difference between 5 and 7 metaphyseal locking screws for stiffness of fixation of proximal humeral fractures in elderly patients. With the inherent possibility of screw penetration of the humeral head, fewer screws may lead to fewer complications. [Orthopedics. 2018; 41(5):306-311.].