Skin Antisepsis before Surgical Fixation of Extremity Fractures.

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.).

A 2-Year Outcomes and Complications of Various Techniques of Lumbar Discectomy: A Multicentric Prospective Study.

STUDY DESIGN: Prospective Study. OBJECTIVES: There are numerous techniques for performing lumbar discectomy, each with its own rationale and stated benefits. The authors set out to evaluate and compare the perioperative variables, results, and complications of each treatment in a group of patients provided by ten hospitals and operated on by experienced surgeons. METHODS: This prospective study comprised of 591 patients operated between February-2017 to February-2019. The procedures included open discectomy, microdiscectomy, tubular microdiscectomy, interlaminar endoscopic lumbar discectomy, transforaminal endoscopic lumbar discectomy and Destandau techniques with a follow-up of minimum 2 years. VAS (Visual Analogue Score) for back and leg pain, ODI (Oswestry Disability Index), duration of surgery, hospital stay, length of scar, operative blood loss and peri-operative complications were recorded in each group. RESULTS: Post-operatively, there was a significant improvement in the VAS score for back pain as well as leg pain, and ODI scores spanning all groups, with no significant distinction amongst them. When compared to open procedures (open discectomy and microdiscectomy), minimally invasive surgeries (tubular discectomy, interlaminar endoscopic lumbar discectomy, transforaminal endoscopic lumbar discectomy, and Destandau techniques) reported shorter operative time, duration of hospital stays, better cosmesis, and lower blood loss. Overall, the complication rate was reported to be 8.62%. Complication rates differed slightly across approaches. CONCLUSION: Minimally invasive surgeries have citable advantages over open approaches in terms of perioperative variables. However, all approaches are successful and provide comparable pain relief with similar functional outcomes at long term follow up.

Artificial Intelligence in Orthopaedic Surgery: Can a Large Language Model "Write" a Believable Orthopaedic Journal Article?

ABSTRACT: ➢ Natural language processing with large language models is a subdivision of artificial intelligence (AI) that extracts meaning from text with use of linguistic rules, statistics, and machine learning to generate appropriate text responses. Its utilization in medicine and in the field of orthopaedic surgery is rapidly growing.➢ Large language models can be utilized in generating scientific manuscript texts of a publishable quality; however, they suffer from AI hallucinations, in which untruths or half-truths are stated with misleading confidence. Their use raises considerable concerns regarding the potential for research misconduct and for hallucinations to insert misinformation into the clinical literature.➢ Current editorial processes are insufficient for identifying the involvement of large language models in manuscripts. Academic publishing must adapt to encourage safe use of these tools by establishing clear guidelines for their use, which should be adopted across the orthopaedic literature, and by implementing additional steps in the editorial screening process to identify the use of these tools in submitted manuscripts.

Operative and Nonoperative Treatment of Humeral Shaft Fractures: A Cost-Effectiveness Analysis.

BACKGROUND: Decision-making with regard to the treatment of humeral shaft fractures remains under debate. The cost-effectiveness of these treatment options has yet to be established. This study aims to compare the cost-effectiveness of operative treatment with that of nonoperative treatment of humeral shaft fractures. METHODS: We developed a decision tree for treatment options. Surgical costs included the ambulatory surgical fee, physician fee, anesthesia fee, and, in the sensitivity analysis, lost wages during recovery. We used the Current Procedural Terminology codes from the American Board of Orthopaedic Surgery to determine physician fees via the U.S. Centers for Medicare & Medicaid Services database. The anesthesia fee was obtained from the national conversion factor and mean operative time for included procedures. We obtained data on mean wages from the U.S. Bureau of Labor and data on weeks missed from a similar study. We reported functional data via the Disabilities of the Arm, Shoulder and Hand (DASH) scores obtained from existing literature. We used rollback analysis and Monte Carlo simulation to determine the cost-effectiveness of each treatment option, presented in dollars per meaningful change in DASH score, utilizing a $50,000 willingness-to-pay (WTP) threshold. RESULTS: The cost per meaningful change in DASH score for operative treatment was $18,857.97 at the 6-month follow-up and $25,756.36 at the 1-year follow-up, by Monte Carlo simulation. Wage loss-inclusive models revealed values that fall even farther below the WTP threshold, making operative management the more cost-effective treatment option compared with nonoperative treatment in both settings. With an upward variation of the nonoperative union rate to 84.17% in the wage-exclusive model and 89.43% in the wage-inclusive model, nonoperative treatment instead became more cost-effective. CONCLUSIONS: Operative management was cost-effective at both 6 months and 1 year, compared with nonoperative treatment, in both models. Operative treatment was found to be even more cost-effective with loss of wages considered, suggesting that an earlier return to baseline function and, thus, return to work are important considerations in making operative treatment the more cost-effective option. LEVEL OF EVIDENCE: Economic and Decision Analysis Level III . See Instructions for Authors for a complete description of levels of evidence.

Outcomes of associated both-column acetabular fractures with and without a posterior wall fracture- A retrospective observational cohort study.

Aims & objectives: Our study sought to determine if posterior wall (PW) involvement in associated both-column acetabular fractures (ABCAFs) is associated with different clinical outcomes, primarily rate of conversion to total hip arthroplasty (THA), in comparison to ABCAFs with no PW involvement. Materials & methods: This retrospective observational cohort study was performed at two academic Level 1 trauma centers. Two study groups were identified. The first study group consisted of 18 patients who sustained an ABCAF with PW involvement (+PW). The second study group consisted of 26 patients who sustained an ABCAF with no PW involvement (-PW). All patients achieved a minimum 12-months of follow-up and/or received a THA conversion procedure at a time remote to their index open reduction internal fixation (ORIF) procedure. The primary outcome of this study was subsequent conversion to THA on the injured hip. The secondary outcome was the presence of post-operative pain at ≥6 months and/or complications. Results: No difference in rate of conversion to THA between + PW (n = 4, 22.2%) and -PW (n = 3, 11.5%) groups was demonstrated (p = 0.419). Similarly, no differences were seen between groups regarding complication rate (p = 0.814) and post-operative pain (p = 0.142). Conclusion: Involvement of the PW does not appear to create worse clinical outcomes in comparison to no involvement in ABCAFs particularly as it relates to ipsilateral joint replacement.

Use of a Six-Item Modified Frailty Index to Predict 30-day Adverse Events, Readmission, and Mortality in Older Patients Undergoing Surgical Fixation of Lower Extremity, Pelvic, and Acetabular Fractures.

INTRODUCTION: This is a retrospective study evaluating the use of a new six-item modified frailty index (MF-6) to predict short-term outcomes of patients receiving surgery for lower extremity fractures. METHODS: Patients older than 65 years undergoing open reduction and internal fixation for lower extremity, pelvic, and acetabulum fractures were identified from the American College of Surgeons National Surgical Quality Improvement Program. The MF-6 was calculated by assigning one point for each of six common conditions. Multivariable analysis was used to compare patients with an MF-6 of <3 and ≥3. Outcome measures included complications, mortality, readmission, revision surgery, and length of stay. An area under the curve receiver operator analysis was conducted to compare the MF-6 with MF-5, an existing five-item frailty index. RESULTS: Nine thousand four hundred sixty-three patients were included. Patients with an MF-6 of ≥3 were at markedly higher risk of discharge destination other than home (Exp[B] = 2.09), mortality (Exp[B] = 2.48), major adverse events (Exp[B] = 2.16), and readmission (Exp[B] = 1.82). Receiver-operating curve analysis demonstrated an area under the curve of 0.65 for mortality, 0.62 for major adverse events, and 0.62 for discharge destination other than home, all of which outperformed the MF-5. DISCUSSION: The MF-6 was correlated with a 30-day postoperative incidence of infectious complications, readmission, and discharge destination. MF-6 scores can be used to risk-stratify patient populations as shifts to value-based care continue to develop.

"Insert flipping technique:" An effective way of restoring segmental lordosis and disc height with tall bullet cages.

Study Design: The study design was a retrospective study. Objective: The objectives of the present study are dual; to describe a simple and effective way of restoring intervertebral disc (IVD) height by the "Insert Flip Technique" of cage insertion and to demonstrate effective restoration of IVD height and segmental lordosis (SL) and their influence on the functional outcome postoperatively. Methods: IVD height and SL were recorded pre- and postoperatively. Each motion segment was instrumented with pedicle screws to allow segmental stabilization. Patients were called for follow-up at 6 weeks, 3 months, and 1 year postoperatively and were assessed clinically for back pain and leg pain (VAS and Oswestry Disability Index scores recorded).The bullet cages are designed such that they are lordotic in the superior-inferior plane and neutral in the mediolateral plane. Usually, the cage is inserted with superior and inferior surfaces of the cage impacting against superior and inferior end plates of the adjacent vertebral body. However, with the proposed technique, the cages were inserted such that the narrower mediolateral surfaces of the cage engaged with superior and inferior vertebral end plates. The cage was then flipped within the disc space such that the superior-inferior surfaces of the bullet cage impacted against the superior and inferior end plates of the vertebral body to create desired lordosis. Results: There was a significant improvement seen in the postoperative Cobb's angle and disc height after placement of a tall bullet cage compared to the preoperative Cobb's angle and disc height. Conclusion: This modification of technique helped in gaining lordosis with taller bullet cages in minimally invasive surgery transforaminal lumbar interbody fusion with no/minimal complication and also reduced the need for bone resection during insertion of the cage.

The current status and surgical outcome of the minimally invasive techniques for lumbar interbody fusion in India: A systematic review and meta-analysis.

Objective: The global shift of trends to minimally invasive spine (MIS) surgery for lumbar degenerative diseases has become prominent in India for few decades. We aimed to assess the current status of MIS techniques for lumbar interbody fusion and their surgical outcomes in the Indian population. Materials and Methods: A systematic review (following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines) was performed using PubMed and Google Scholar till November 2020. The primary (visual analog scale [VAS] and oswestry disability index [ODI] scores; intraoperative blood loss; duration of surgery; duration of hospital stay, and fusion rate) and secondary (wound-associated complications and dural tear/cerebrospinal fluid (CSF) leak) outcomes were analyzed using Review Manager 5.4 software. Results: A total of 15 studies comprising a total of 1318 patients were included for analysis. The pooled mean of follow-up duration was 26.64 ± 8.43 months (range 5.7-36.5 months). Degenerative spondylolisthesis of Myerding grade I/II was the most common indication, followed by lytic listhesis, herniated prolapsed disc, and lumbar canal stenosis. The calculated pooled standard mean difference (SMD) suggested a significant decrease in postoperative ODI scores (SMD = 5.53, 95% confidence interval [CI] = 3.77-7.29; P < 0.01) and VAS scores (SMD = 6.50, 95% CI = 4.6-8.4; P < 0.01). The pooled mean blood loss, duration of postoperative hospital stay, duration of surgery, and fusion rate were 127.75 ± 52.79 mL, 4.78 ± 3.88 days, 178.59 ± 38.69 min, and 97.53% ± 2.69%, respectively. A total of 334 adverse events were recorded in 1318 patients, giving a complication rate of 25.34%. Conclusions: Minimally invasive transforaminal lumbar interbody fusion (TLIF) is the most common minimally invasive technique employed for lumbar interbody fusion in India, while oblique lumbar interbody fusion is in the initial stages. The surgical and outcome-related factors improved significantly after MIS LIF in the Indian population.

What Do Orthopedic Trauma Surgeons Want and Expect from Anesthesiologists?

From the orthopedic trauma surgeon's perspective, successful injury management hinges on fracture fixation and restoration of patient mobility in a safe and expeditious manner. Management of critically injured polytrauma patients and shared decisions regarding regional anesthetics presents a myriad of challenges for orthopedic trauma surgeons and anesthesiologists alike. As the populations age, the typical patient sustaining traumatic orthopedic injuries are increasingly frail and elderly. This trend in demographics has mandated that care for orthogeriatric patients is coordinated by multidisciplinary teams working in concert on medically complex cases to a common end. In this article, we highlight opportunities for improved communication and care integration between orthopedic trauma surgeons and anesthesiologists.

Single versus dual incision approaches for dual plating of bicondylar tibial plateau fractures have comparable rates of deep infection and revision surgery.

OBJECTIVES: The use of one midline incision versus dual medial/lateral incisions for dual plating of bicondylar tibial plateau (BTP) fractures is controversial. This study aimed to compare rates of infection and secondary surgery in patients treated with dual plating for a BTP fracture using a single versus double incisions. DESIGN: Retrospective cohort study. SETTING: Two Level-1 trauma centers. PATIENTS/PARTICIPANTS: Patients > 18 years with a closed AO/OTA 41-C BTP fracture without compartment syndrome treated with a single midline or dual incision (lateral with medial or posteromedial) approach for dual plating. INTERVENTION: Dual plating through either a single anterior incision, or dual medial/lateral incisions. MAIN OUTCOME MEASUREMENTS: Rates of deep infection and reoperation were compared using Chi-square analysis (p-value of < 0.05). RESULTS AND CONCLUSIONS: In total 636 AO/OTA 41-C BTP fractures treated between 1/1/01 and 12/31/18 were identified and assessed. After exclusions for limited follow up, other techniques, open fracture and the need for fasciotomies, 346 patients were studied. Of these 254 had been treated with a single plate / single approach technique while 92 had been dual plated, 41 through a single anterior incision while 51 had dual plating through separate lateral and medial or posteromedial incisions. For these 92 fractures, there was no significant difference in the rate of deep infection (22.0% vs 23.5%, s=0.858) or reoperation (31.7% vs 31.4%, p=0.973) between the single and dual incision groups. Injuries that had been treated with single plating via a single incision had comparably lower rates of deep infection (10.2% vs. 22.8%, p=0.003) and reoperation (12.2% vs. 31.5%, p<0.001). There were no significant differences in any demographic parameters between patients undergoing single versus dual plating. Although retrospective, not randomized and subject to single surgeon bias these data suggest that these complications are more based on injury than the approach. LEVEL OF EVIDENCE: III.

Comparative Outcomes and Surgical Timing for Operative Fragility Hip Fracture Patients during the COVID-19 Pandemic: A Retrospective Cohort Study.

The COVID-19 pandemic had wide-reaching effects on healthcare delivery, including care for hip fractures, a common injury among older adults. This study characterized factors related to surgical timing and outcomes, length-of-stay, and discharge disposition among patients treated for operative hip fractures during the first wave of the COVID-19 pandemic, compared to historical controls. A retrospective, observational cohort study was conducted from 16 March-20 May 2020 with a consecutive series of 64 operative fragility hip fracture patients at three tertiary academic medical centers. Historical controls were matched based on sex, surgical procedure, age, and comorbidities. Primary outcomes included 30-day mortality and time-to-surgery. Secondary outcomes included 30-day postoperative complications, length-of-stay, discharge disposition, and time to obtain a COVID-19 test result. There was no difference in 30-day mortality, complication rates, length-of-stay, anesthesia type, or time-to-surgery, despite a mean time to obtain a final preoperative COVID-19 test result of 17.6 h in the study group. Notably, 23.8% of patients were discharged to home during the COVID-19 pandemic, compared to 4.8% among controls (p = 0.003). On average, patients received surgical care within 48 h of arrival during the COVID-19 pandemic. More patients were discharged to home rather than a facility with no change in complications, suggesting an opportunity for increased discharge to home.

Efficacy of Accessory Facet Views in the Detection of Occult Patellar Malreduction: A Biomechanical Analysis.

A simulated fracture model was used to determine the ability of the medial and lateral patellar facet views in detecting magnitudes of articular displacement. Transverse patellar fractures were simulated in ten patients. Medial and lateral translation of the distal fragment were evaluated in 1 mm increments and rotational malalignment along the longitudinal axis of the patella was evaluated in 5 mm increments. In comparison to the true lateral view, the utilization of the medial and lateral patellar facet views considerably improves detection of occult articular surface malreduction.

Multimodal Applications of 3D-Navigation in Single-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion: Impacts on Precision, Accuracy, Complications, and Radiation Exposure.

BACKGROUND: Three-dimensional (3D)-navigation in minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is an evolving procedure. It is used not only for its accuracy of pedicle screw fixation but also for other major steps in transforaminal lumbar interbody fusion. Multimodal outcomes of this procedure are very limited in the literature. The purpose of this study was to examine the application of 3D-navigation in minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). METHODS: Patients who underwent single-level MI-TLIF using 3D-navigation between January 2017 and July 2019 were evaluated for navigation setting time, radiation exposure, volume of nucleus pulposus excised, cage placement, accuracy of pedicle screw placement, and cranial facet-joint violation. RESULTS: One hundred and two patients with a mean age of 60.2 years met the inclusion criteria. The mean presetting time of navigation was 46.65 ± 9.45 minutes. Radiation exposure, fluoroscopy use, and fluoroscopy time were 15.54 ± 0.65 mGy, 4.43 ± 0.87 Gy.cm², and 97.6 ± 11.67 seconds, respectively. The mean amount of nucleus pulposus excised from all quadrants was quantified. The cage was centrally placed in 87 patients, with 95.4% showing a Grade 0 pedicle breach and 94.6% showing Grade 0 cranial facet-joint violation. CONCLUSION: Registration and setting up 3D-navigation takes additional time. The amount of exposure to the patient is much less compared to routine computed tomography, and, importantly, the operating team is protected from radiation. Navigated MI-TLIF has high rates of accuracy with regard to placement of percutaneous pedicle screws and cages with the added advantage of protection of the cranial facet-joint.

A Systematic Review of the Management of Upper Extremity Orthopaedic Injuries in Epileptic Patients.

Background: During seizures, injury of the upper extremities may occur. Standardized guidelines are deficient for diagnosis and perioperative care. Methods: PubMed, Embase, Cochrane, Scopus, and Web of Science databases were systematically screened using predefined search terms. Results: Of the 59 patients included, 36 (61.0%) involved a posterior shoulder dislocation. Associated fractures were observed in 34 (57.6%) cases with surgical procedures performed in 30 (50.8%) patients. Functional outcomes were reported in 44 patients, with over half (23 of 44, [52.2%]) endorsing range of motion deficits. Conclusion: Standardized guidelines, to guarantee timely management of injury in post-seizure patients, are needed with a customized treatment approach that accommodates the various aspects of their condition.

Can Partially Threaded Cannulated Screws Be Better Designed to Maximize Purchase in the Sacrum?

Sacroiliac screw fixation involves the use of cannulated, partially or fully threaded screws. Current partially threaded screws have standardized thread lengths involving a small portion of the screw regardless of its overall length. Forty uninjured computed tomography images were evaluated for distances from the lateral iliac cortex to the lateral sacral cortex at the first and second sacral segments. No difference in measurements were observed for gender, age, or body mass index. Using a smooth segment value of 32 mm, a significant increase in thread lengths is achievable allowing for a novel sacroiliac screw design to achieve greater purchase in the sacrum.

Cervical facet joint effusion: A sign of instability in cervical degenerative spondylolisthesis.

Aims: The aim of this study was to trace the association between cervical facet joint effusion and cervical degenerative spondylolisthesis (CDS). CDS has not received as much attention as its lumbar counterpart. Identification of features of instability on magnetic resonance imaging (MRI) is crucial to avoid missing presence of CDS. Materials and Methods: The authors retrospectively reviewed cervical spine MRI scans and upright lateral flexion-extension radiographs of 17 consecutive patients at a single institution between January 2017 and June 2018 that revealed CDS. Presence of cervical facet joint effusion and CDS was recorded. Data were analyzed to deduce possibility of an association between cervical facet joint effusion and CDS. Results: Seventeen patients fulfilled the inclusion criteria of cervical spondylotic myelopathy associated with CDS. Out of these, 10 patients revealed facet joint effusion at C3-C4 (4 patients) and C4-C5 (6 patients) levels. The mean age of patients was 65.8 years (49-79) and M:F was 2.2:1. Amount of facet joint effusion varied and ranged from 1.6 mm to 4.7 mm on the axial images. Ten patients (58.82%) demonstrated facet joint effusion associated with mobile CDS. Seven patients (41.17%) with CDS and without facet effusion did not demonstrate mobility of more than 0.5 mm in flexion-extension radiographs. Conclusion: The current study acknowledges the association of "cervical facet effusion" and CDS. Clinically measurable facet joint effusion on MRI suggests the need for further attempts to diagnose CDS.

Racial Differences in Orthopedic Trauma Surgery.

Racial discrepancies among patients in the United States undergoing orthopedic trauma surgery have not been investigated. Issues relating to socioeconomic status and access to care have played a role in the health outcomes of racial groups. In orthopedic surgery, recent joint arthroplasty literature has shown significant racial differences in the use of elective joint arthroplasty. Furthermore, studies also suggest increased rates of early complication in racial minority groups. In general, little information exists on the postoperative outcomes of racial minority groups in orthopedic surgery. We retrospectively queried the National Surgical Quality Improvement Program database to identify patients undergoing orthopedic trauma surgery between 2008 and 2016. Patients of all ages who underwent orthopedic trauma surgery were identified using Current Procedural Terminology codes. Patients classified as either Black or White were included in the study. Demographic data, comorbidities, and basic surgical data were compared between the groups. Adverse outcomes in the initial 30 days postoperative were also examined. Higher frequencies of deep wound infection (0.5% vs 0.3%, P=.002) were noted among Black patients, with decreased mortality (0.3% vs 0.6%, P=.004) and postoperative transfusion (2.7% vs 3.8%, P<.001) rates, compared with White patients. Clear differences exist in the demographic, surgical, and outcome data between Black and White patients undergoing orthopedic trauma surgery. More epidemiological studies are required to further investigate racial differences in orthopedic trauma surgery. [Orthopedics. 2022;45(2):71-76.].

Hematoma Formation After Hip Corticosteroid Injection in a Patient with Chronic Myelomonocytic Leukemia: A Case Report.

CASE: We present a 70-year-old woman with history of chronic myelomonocytic leukemia with a right thigh hematoma after a corticosteroid hip injection. Aspiration of the hematoma was attempted, but she developed a significant transfusion requirement with paresthesias in a lateral femoral cutaneous nerve distribution, prompting transfer. Imaging demonstrated no active extravasation, and she was managed conservatively. At 8-month follow-up, she had a persistent consolidated hematoma on the right side, and she subsequently died of complications of her cancer. CONCLUSION: This case demonstrates an unusual complication from a common nonoperative modality, as well as important coagulopathies that must be considered in patients with leukemia.

Should Q-CT Be the Gold Standard for Detecting Spinal Osteoporosis?

STUDY DESIGN: Prospective comparative study. OBJECTIVE: Refinement of the guidelines for screening of osteoporosis and considering quantitative computed tomography (Q-CT) for detecting spinal osteoporosis. SUMMARY OF BACKGROUND DATA: Spinal osteoporosis is often underestimated and under-evaluated due to either lack of availability of the diagnostic modality or lack of awareness about the possibility of overestimation by dual X-ray absorptiometry (DXA) scan. There is a need for reconsidering osteoporosis evaluation with a site specific and patient specific inclination. METHODS: Post-menopausal women that underwent bone mineral density (BMD) evaluation from January-2018 to December-2020 with either Q-CT or DXA were evaluated. Comparison studies of the distribution of age and T-scores of the bone densities obtained from the two study groups: age-matched, sex-matched, and common skeletal site of interest (L1-4 vertebrae) were performed. Mann-Whitney U test, correlation and regression analyses were performed and bell curves were plotted. RESULTS: Of the 718 women evaluated, 447 underwent Q-CT and 271 underwent DXA. There was no significant difference among the age distribution of the two study groups (P-value > 0.05). The mean and mode T-scores obtained by Q-CT and DXA were found to be -2.71, -3.8 and -1.63, -1.7 respectively. A highly significant difference in the T-scores was observed in the Q-CT and DXA groups (P-value < 0.0001). Among those who were screened by Q-CT, 58.16% were osteoporotic, 37.58% were osteopenic, and 4.25% were normal. The respective percentages in the DXA group were 30.63%, 49.82%, and 19.55%. CONCLUSION: Q-CT provides more precise estimation of cancellous bone mineral density than DXA. With the reliance on DXA for spinal BMD estimation being questionable, new standards have to be established for spinal osteoporosis evaluation. Q-CT can be a better alternative to replace DXA as the gold standard for the evaluation of spinal osteoporosis.Level of Evidence: 2.

Is It Safe to Prep the External Fixator In Situ During Staged ORIF of Bicondylar Tibial Plateau Fractures? A Retrospective Comparative Cohort Study.

OBJECTIVES: To compare the risk of deep infection and unplanned reoperation after staged open reduction internal fixation (ORIF) of bicondylar tibial plateau (BTP) fractures whether elements of the temporizing external fixator were prepped into the surgical field or completely removed before definitive fixation. DESIGN: Retrospective comparative cohort study. SETTING: Two academic Level 1 trauma centers. PATIENTS/PARTICIPANTS: One hundred forty-seven OTA/AO 41-C (Schatzker 6) BTP fractures treated with a 2-stage protocol of acute spanning ex-fix followed by definitive ORIF between 2001 and 2018. INTERVENTION: Seventy-eight fractures had retained elements of the original ex-fix prepped in situ during surgery for definitive internal fixation, and 69 had the ex-fix construct completely removed before prepping and draping. MAIN OUTCOME MEASURES: Deep infection and unplanned reoperation. RESULTS: Among 147 patients treated with staged ORIF, the overall deep infection rate was 26.5% and the reoperation rate was 33.3%. There were high rates of deep infection (26.9% vs. 26.1%, P = 0.909) and unplanned reoperation (30.8% vs. 36.2%, P = 0.483) in both groups, but no difference whether the ex-fix was prepped in or completely removed. Within the retained ex-fix group, there was no difference in infection with retention of the entire ex-fix compared with only the ex-fix pins (28.1% vs. 26.1%, P = 0.842). CONCLUSIONS: We observed high complication rates in this cohort of OTA/AO 41C BTP fractures treated with staged ORIF, but prepping in the ex-fix did not lead to a significant increase in rates of infection or reoperation. This study provides the treating surgeon with clinical data about a common practice used to facilitate definitive fixation of unstable BTP fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.