Use of single agent Cefotetan for Gustilo-Anderson type III open fracture prophylaxis.

INTRODUCTION: The prophylactic intravenous antibiotic regimen for Gustilo-Anderson Type III open fractures traditionally consists of cefazolin with an aminoglycoside plus penicillin for gross contamination. Cefotetan, a second-generation cephalosporin, offers a wide spectrum of activity against both aerobes and anaerobes as well as against Gram-positive and Gram-negative bacteria. Cefotetan has not been previously established within orthopedic surgery as a prophylactic intravenous agent. PATIENTS AND METHODS: Cefotetan monotherapeutic prophylaxis versus any other antibiotic regimen (standard/literature-supported and otherwise) was studied for patient encounters between September 2010 and December 2019 within a single Level 1 regional trauma center. Patient comorbidities, preoperative fracture characteristics, and in-hospital/operative metrics (including length of stay [LOS], number of antibiotic doses, and antibiotic costs [US$]) were included for analysis. Postoperative outcomes up to 1 year included rates of surgical site infection (SSI), deep infection necessitating return to the operating room (OR), non-union, prescribed outpatient antibiotics, hospital readmissions, and related returns to the emergency department (ED). Sensitivity analyses were also conducted to include standard/literature-supported antibiotic regimens as a nested random factor within the non-cefotetan cohort. RESULTS: The nested variable accounting for standard/literature-supported antibiotic regimens had no significant effect in any model for any outcome (for each, P ≥ 0.302). Thus, 1-year data for 138 Type III open fractures were included, accounting for only the binary effect of cefotetan (n = 42) versus non-cefotetan cohorts. The cohorts did not differ significantly at baseline. The cefotetan cohort received fewer in-house dose/day antibiotics (P < 0.001), was less likely to receive outpatient antibiotics in the following year (P = 0.023), had decreased return to the OR (35.7% versus 54.2%, P = 0.045), and demonstrated non-union rates of 16.7% versus 28.1% (P = 0.151). When adjusted for length of stay (LOS), the dose/day total costs for antibiotics were $8.71/day more expensive for the cefotetan cohort (P = 0.002). Type III open fractures incurred overall rates of SSI reaching 16.7% in the cefotetan cohort and 14.7% for non-cefotetan (P = 0.773). Deep infections necessitating return to the OR were 9.5% and 11.6%, respectively (P = 0.719). CONCLUSION: Cefotetan alone may provide superior antibiotic stewardship with similar infectious sequalae compared to more traditional antibiotic prophylaxis regimens for Gustilo-Anderson Type III open long bone fractures. LEVEL OF EVIDENCE: Level III Retrospective Cohort Study.

Automating Patient-Reported Outcome Measures Following Hand Surgery.

PURPOSE: The purpose of this study was to assess the overall response rate of patients receiving electronic patient-reported outcome measures (ePROMs) following hand surgery and to determine the patient characteristics associated with responding. METHODS: A Health Insurance Portability and Accountability Act-compliant, web-based system was developed to automatically distribute ePROMs to patients undergoing hand surgery at five institutions with 22 surgeons. Patients who were at least 18 years old were eligible. The PROMs used were the visual analog scale (VAS) for pain and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH). After surgery, ePROMs along with a satisfaction questionnaire were electronically sent three, six, 12, 24, and 52 weeks after surgery. RESULTS: A total of 6458 patients were eligible. Of these, 80% were enrolled voluntarily. Among these, 70% completed ePROMs for at least one postoperative time point, whereas 30% did not complete any. Among responders, 28% completed all five time points, whereas 72% completed four or fewer time points. Incomplete responders were more likely to be insured by workers' compensation when compared to complete responders. Incomplete responders exhibited higher baseline QuickDASH scores and similar baseline VAS compared to complete responders. During the follow-up, incomplete responders demonstrated worse VAS and QuickDASH scores at all time points. Finally, in comparison with complete responders, incomplete responders were less likely to be satisfied with their surgery at all time points. CONCLUSIONS: This study demonstrates that automated email-based ePROM systems may be an effective method for survey distribution. Particularly for simple, outpatient surgeries, this study illustrates the potential for clinical use of the data obtained from these systems. CLINICAL RELEVANCE: Patient-reported outcome measures continue to have an expanding role in health care with the rise of valued-based systems. Electronic PROMs are a relatively unexplored medium that may offer a viable alternative to more effectively collecting these valuable patient metrics.

Trends and epidemiology of knee extensor mechanism injuries presenting to United States emergency departments from 2001 to 2020.

OBJECTIVES: Injuries to the native extensor mechanism (EM) of the knee are potentially disabling and often require surgical treatment. Large-scale, updated epidemiological data on these injuries is lacking. The objective of the current study was to examine recent trends in EM injuries presenting to United States (US) Emergency Departments (EDs) over the last 20 years using a nationally representative sample. METHODS: This study retrospectively analyzed the National Electronic Injury Surveillance System (NEISS) database to identify cases of EM injuries (defined as either a quadriceps tendon rupture, a patella fracture, or a patellar tendon rupture) presenting to EDs in the US from 2001 to 2020. RESULTS: During the study period, an estimated 214,817 EM injuries occurred in an at-risk population of 6,183,899,410 person-years for an overall incidence rate of 3.47 per 100,000 person-years. Patella fractures (PFs) were the most common injury type, representing 77.5% of all EM injuries (overall incidence rate: 2.69), followed by patellar tendon ruptures (PTRs; 13.5%; incidence: 0.48) and quadriceps tendon ruptures (QTRs; 9%; incidence: 0.31). Demographic characteristics and mechanisms of injury differed between injury types. Annual incidence rates increased significantly during the study period for all EM injury types, with PTRs demonstrating the largest relative increase (average annual percent increase: PF, 2.8%; PTR, 7.2%; QTR, 5.3%). Accounting for population growth yielded an increasing incidence of all EM injuries combined from 3.65 in 2001 to 4.9 in 2020. The largest relative increases in incidence rates were observed in older age groups. CONCLUSION: Extensor mechanism injuries of the knee are increasing in the US, which likely reflects an aging and more active population. These types of injuries are associated with substantial functional impairment and recent increases in incidence rates highlight the need for injury prevention and management strategies.

Funding has no effect on clinical outcomes of total joint arthroplasty emerging technologies: a systematic review of bibliometrics and conflicts of interest.

BACKGROUND: The use of new total joint arthroplasty technologies, including patient-specific implants/instrumentation (PSI), computer-assisted (CA), and robotic-assisted (RA) techniques, is increasing. There is an ongoing debate regarding the value provided and potential concerns about conflicts of interest (COI). METHODS: PRISMA guidelines were followed. PubMed, MEDLINE, and Web of Science databases were searched for total hip and knee arthroplasties, unicompartmental knee arthroplasties (UKA), PSI, CA, and RA. Bibliometric data, financial COI, clinical/functional scores, and patient-reported outcomes were assessed. RESULTS: Eighty-seven studies were evaluated, with 35 (40.2%) including at least one author reporting COI, and 13 (14.9%) disclosing industry funding. COI and industry funding had no significant effects on outcomes (P = 0.682, P = 0.447), and there were no significant effects of conflicts or funding on level of evidence (P = 0.508, P = 0.826). Studies in which author(s) disclosed COI had significantly higher relative citation ratio (RCR) and impact factor (IF) than those without (P < 0.001, P = 0.032). Subanalysis demonstrated RA and PSI studies were more likely to report COI or industry funding (P = 0.045). RA (OR = 6.31, 95% CI: 1.61-24.68) and UKA (OR = 9.14, 95% CI: 1.43-58.53) had higher odds of reporting favorable outcomes than PSI. CONCLUSIONS: Author COIs (about 40%) may be lower than previously reported in orthopedic technologies/techniques reviews. Studies utilizing RA and PSI were more likely to report COI, while RA and UKA studies were more likely to report favorable outcomes than PSI. No statistically significant association between the presence of COIs and/or industry funding and the frequency of favorable outcomes or study level of evidence was found. LEVEL OF EVIDENCE: Level V Systematic Review.

Effects of veterans' mental health service-connections on patient-reported outcomes following total joint arthroplasty.

Background: Studies report poor outcomes of elective orthopaedic surgeries among civilian patients receiving Workers' Compensation (WC). However, little is known about surgical outcomes in veterans receiving similar benefits through the Veterans Affairs (VA) service-connected (SC) disability compensation program. Methods: Veterans undergoing primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) at a VA Medical Center between 07/2019-12/2021 were analyzed by SC status. Outcomes were evaluated using Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR) and Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) scores collected preoperatively and at 2- and 12-months postoperatively. Repeated measures mixed models were used to test for the effect of SC on HOOS-JR/KOOS-JR scores, controlling for baseline age, sex, and Charlson Comorbidity Index (CCI). SC and baseline joint function (stratified into quartiles using baseline HOOS-JR/KOOS-JR scores) were analyzed for effects on achieving substantial clinical benefit (SCB) at 12-month follow-up. Results: The analysis included 67 hips and 142 knees. SC and non-SC (NSC) veterans had similar baseline HOOS-JR/KOOS-JR and CCI. HOOS-JR remained similar between groups through 12 months (79.9 ± 19.2 vs. 82.7 ± 18.8) as did KOOS-JR (70.4 ± 15.6 vs. 74.6 ± 15.3). The designation of any SC and mental health SC reached significance for KOOS-JR (P = 0.034 and P = 0.032, respectively). For HOOS-JR and KOOS-JR, baseline function score quartile significantly influenced final score (P < 0.001), with patients in the lowest quartiles (i.e., worst baseline function) exhibiting significantly greater improvements than patients in higher quartiles. Conclusions: Mental health SC and high preoperative functional status are variables that may have unfavorable influences on self-reported outcomes of TKA in veteran patients. SC status does not appear to influence the outcomes of THA or the likelihood of achieving SCB after either THA or TKA. Regardless of SC status, most veterans can expect significant clinical improvements after total joint arthroplasty.

Screw Thread Configuration Has No Effect on Outcomes of In Situ Fixation for Stable Slipped Capital Femoral Epiphysis.

BACKGROUND: No consensus exists regarding the optimal surgical management of slipped capital femoral epiphysis (SCFE). Treatment goals include avoiding slip progression and sequelae such as avascular necrosis (AVN). Factors associated with surgical implants merit further research. This study investigates the effect of screw thread configuration and the number of screws on surgical outcomes. METHODS: A total of 152 patients undergoing cannulated, stainless steel, in situ screw fixation of SCFE between January 2005 and April 2018 were included. Procedure laterality, screw number and thread configuration (partially threaded/fully threaded), bilateral diagnosis, Loder classification, final follow-up, patient demographics, and endocrinopathy history were analyzed. Primary outcomes were return to the operating room (ROR), AVN, hardware failure/removal, and femoroacetabular impingement (FAI). RESULTS: Most patients received a single (86.2%), partially threaded (81.6%) screw; most were unilateral (67.8%) and stable (79.6%). Mean follow-up was 2.0±2.7 years, with a 15.8% rate of ROR, 5.3% exhibiting AVN, 6.6% exhibiting FAI, and 9.2% experiencing hardware failure/removal. Number of screws was the sole predictor of ROR [odds ratio (OR)=3.35, 95% confidence interval (CI): 1.18-9.49]. Unstable SCFE increased the odds of AVN (OR=38.44; 95% CI: 4.35-339.50) as did older age (OR=1.43, 95% CI: 1.01-2.03). Female sex increased risk for FAI (OR=4.87, 95% CI: 1.20-19.70), and bilateral SCFE elevated risk for hardware failure/removal versus unilateral SCFE (OR=4.41, 95% CI: 1.39-14.00). Screw thread configuration had no significant effect on any outcome (for each, P ≥0.159). CONCLUSIONS: Rates of ROR, AVN, FAI, and hardware failure/removal did not differ between patients treated with partially threaded or fully threaded screws. The use of 2 screws was associated with an increased likelihood of ROR. These findings suggest that screw thread configuration has no impact on complication rates, whereas screw number may be an important consideration in SCFE fixation. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Patient-specific factors, but neither regional anesthesia nor hip-specific cryotherapy, predict postoperative opioid requirements after hip arthroscopy for femoroacetabular impingement (FAI) syndrome.

Background: We sought to determine whether regional nerve block, cryotherapy variant, or patient-specific factors predict postoperative opioid requirements and pain control following hip arthroscopy. Methods: 104 patients underwent hip arthroscopy with (n = 31) or without (n = 73) regional block and received cryotherapy with a universal pad [joint non-specific; no compression (n = 60)] or circumferential hip/groin wrap with intermittent compression (n = 44). Outcomes included total opioid prescription amounts, requests for refills, and unplanned clinical encounters for postoperative pain within 45 days of surgery. Multivariate modeling was used to determine the effect of perioperative regional nerve block and type of cryotherapy device on outcomes after adjusting for patient demographics, previous opioid use, mental health disorder history, and surgery length. Results: The average amount of 5 mg oxycodone pill equivalents prescribed within 45 days of surgery was 40.5 (SD 14.8); 36% requested refills, 20% presented to another physician, and 21% called the surgeon's office due to pain. Neither the hip-specific cryotherapy pad nor regional block was predictive of opioid amounts prescribed, refill requests, or unplanned clinical encounters due to pain. Refill requests within 45 days were more common with baseline opioid use (p < 0.001), increased age (p = 0.007), and mental health disorder history (p = 0.008). Total opioid amounts prescribed within 45 days were higher with workers compensation (p = 0.03), a larger initial opioid prescription (p < 0.001), baseline opioid use (p < 0.001), history of mental health disorder (p = 0.02), and increased age (p = 0.02). Together, these variables explained 61% of the variance in opioid amounts prescribed. Conclusion: Patient factors are strong predictors of postoperative opioid requirements after hip arthroscopy. Postoperative opioid prescription amounts, opioid refill requests, and pain-related calls or office visits were not affected by use of a perioperative regional nerve block or type of cryotherapy delivery system. Level of evidence: III, retrospective cohort study.

Virtual Interviews in the Era of COVID-19: Expectations and Perceptions of Orthopaedic Surgery Residency Candidates and Program Directors.

Orthopaedic surgery residency program directors (PDs) and candidates consider interviews to be central to the application process. In-person interviews are typical, but virtual interviews present a potentially appealing alternative. Candidate and PD expectations and perceptions of virtual interviews during the 2020/2021 orthopaedic surgery application cycle were assessed. METHODS: Candidates and PDs were surveyed electronically. Questions covered pre-virtual-interview and post-virtual-interview expectations and perceptions, and past in-person experiences (PDs and reapplicants) on the relative importance of application components, ability to assess fit, interview costs, and preferred interview mode. Identical questions allowed between-group comparisons. RESULTS: Responses included n = 29 PDs and n = 99 candidates. PDs reported diminished ability to assess candidate fit; social, clinical, and surgical skills; and genuine interest in the virtual context (each p ≤ 0.01). They placed greater importance on research and less on the interview in the virtual vs. in-person context (each p = 0.02). Most candidates (78%) reported fair/good ability to demonstrate potential and were better able to assess research opportunities than expected (p < 0.01). Candidates expected virtual interviews to increase the importance of research, transcripts, and recommendations (for each, p ≤ 0.02) and decrease the importance of the interview itself (p < 0.01). Compared with PDs, candidates overvalued research, United States Medical Licensing Examination scores, transcripts, and recommendations (each p ≤ 0.02) and may have slightly undervalued the virtual interview (p = 0.08). Most candidates (81%) and PDs (79%) preferred in-person interviews, despite both groups reporting monetary savings. CONCLUSIONS: Despite cost savings associated with virtual interviews, orthopaedic surgery residency PDs and candidates identified reduced abilities to assess candidate or program fit and displayed a preference for in-person interviews.

Inpatient and outpatient opioid requirements after total joint replacement are strongly influenced by patient and surgical factors.

AIMS: Currently, there is no single, comprehensive national guideline for analgesic strategies for total joint replacement. We compared inpatient and outpatient opioid requirements following total hip arthroplasty (THA) versus total knee arthroplasty (TKA) in order to determine risk factors for increased inpatient and outpatient opioid requirements following total hip or knee arthroplasty. METHODS: Outcomes after 92 primary total knee (n = 49) and hip (n = 43) arthroplasties were analyzed. Patients with repeat surgery within 90 days were excluded. Opioid use was recorded while inpatient and 90 days postoperatively. Outcomes included total opioid use, refills, use beyond 90 days, and unplanned clinical encounters for uncontrolled pain. Multivariate modelling determined the effect of surgery, regional nerve block (RNB) or neuraxial anesthesia (NA), and non-opioid medications after adjusting for demographics, ength of stay, and baseline opioid use. RESULTS: TKAs had higher daily inpatient opioid use than THAs (in 5 mg oxycodone pill equivalents: median 12.0 vs 7.0; p < 0.001), and greater 90 day use (median 224.0 vs 100.5; p < 0.001). Opioid refills were more likely in TKA (84% vs 33%; p < 0.001). Patient who underwent TKA had higher independent risk of opioid use beyond 90 days than THA (adjusted OR 7.64; 95% SE 1.23 to 47.5; p = 0.01). Inpatient opioid use 24 hours before discharge was the strongest independent predictor of 90-day opioid use (p < 0.001). Surgical procedure, demographics, and baseline opioid use have greater influence on in/outpatient opioid demand than RNB, NA, or non-opioid analgesics. CONCLUSION: Opioid use following TKA and THA is most strongly predicted by surgical and patient factors. TKA was associated with higher postoperative opioid requirements than THA. RNB and NA did not diminish total inpatient or 90-day postoperative opioid consumption. The use of acetaminophen, gabapentin, or NSAIDs did not significantly alter inpatient opioid requirements.Cite this article: Bone Joint Open 2020;1-7:398-404.

Dorsal Approach for Dorsal Impaction Distal Radius Fracture-Visualization, Reduction, and Fixation Made Simple.

Distal radius fractures with dorsal articular surface impaction comprise a difficult fracture pattern to operatively reduce using a standard volar approach. Distal radius open reduction internal fixation using a dorsal approach allows direct visualization and reduction. The surgical technique video presented demonstrates technical pearls for optimal visualization, reduction, and fixation.

Comparison of Local-Only Anesthesia Versus Sedation in Patients Undergoing Staged Bilateral Carpal Tunnel Release: A Randomized Trial.

Purpose: Carpal tunnel syndrome is a common disease treated operatively. During the operation, the patient may be wide-awake or sedated. The current literature has only compared separate cohorts. We sought to compare patient experience with both local-only anesthesia and sedation. Methods: Staged bilateral carpal tunnel release utilizing open or endoscopic technique was scheduled and followed through to completion of per-protocol analysis in 31 patients. Patients chose initial hand laterality and were randomized regarding initial anesthesia method: local-only or sedation. Data collection via questionnaires began at consent and continued to 6 weeks postoperatively from second procedure. Primary outcome measures included patient satisfaction and patient anesthesia preference. Results: At final follow-up, 6 weeks postoperatively, high satisfaction (30 of 31 patients per method) was reported with both types of anesthesia. Among these patients, 17 (54%) preferred local-only anesthesia, 10 (34%) preferred sedation, 2 had no preference, and 2 opted out of response. Although anesthesia fees were approximately $390 lower with local-only anesthesia, total costs for carpal tunnel release were not significantly different with respect to the anesthesia cohorts. Total time in surgical facility was approximately 26 minutes quicker with local-only anesthesia, largely due to shorter time in the post-anesthesia care unit. Scaled comparison of worst postoperative pain following the 2 procedures revealed no difference between local-only anesthesia and sedation. Conclusions: Patients reported equal satisfaction scores with carpal tunnel release whether performed under local-only anesthesia or with sedation. In addition, local-only anesthesia was indicated as the preference of patients in 59% of cases.