Incidence of acute Deep Vein Thrombosis in pediatric and adolescent orthopedic trauma hospitalized patients and effect of rivaroxaban treatment.

OBJECTIVE: Deep vein thrombosis (DVT) provoked by orthopedic trauma is increasing in pediatric hospitalized patients. The purpose of our study is to identify the prevalence of acute DVT in pediatric and adolescent orthopedic trauma hospitalized patients and focus on evaluating the anticoagulation strategies and the clinical outcomes after a confirmed acute DVT. METHODS: Patients (age ≤18 years) with a confirmed acute DVT admitted for orthopedic trauma between September 2017 and December 2023 were included. Patients were classified into the non-anticoagulation (NA), the in-hospital anticoagulation (IHA), and the in-and-out-of-hospital anticoagulation (IOHA) groups based on their anticoagulation regimen. Efficacy outcomes were the venous thromboembolism (VTE) recurrence within 3 months and change in thrombus burden by repeat imaging at 2 weeks after discharge compared with baseline. Safety outcomes were major bleeding (MB) and clinically relevant non-major bleeding (CRNMB) within 3 months. RESULTS: Of the 11,206 pediatric and adolescent orthopedic trauma inpatients, 94(median age,16 [15, 18] years) were diagnosed with acute DVT, with an incidence of 0.84 %, of which 8(8.5 %) received NA, 41(43.6 %) received IHA, and 45(47.9 %) received IOHA. After the diagnosis of DVT, of patients who received anticoagulation, 97.9 % were treated with rivaroxaban as an oral anticoagulant, and 71.7 % received an LMWH course of ≥5 days before starting rivaroxaban therapy. With a median anticoagulation course of 22(8, 37.3) days, the duration in the IOHA was significantly longer than the IHA (37 days vs. 8 days, p = 0.000). No patients experienced recurrent VTE and MB at 3 months, and 1 received IOHA had a CRNMB event (0 % vs. 0 % vs. 2.2 %, p = 1.000). Thrombus resolution was significantly higher in patients who received anticoagulation therapy (IOHA 91.1 % vs. IHA 80.5 % vs. NA 37.5 %, P = 0.002), and thrombus-no relevant change was significantly lower in patients who received the IOHA strategy compared with the other groups (4.4 % vs. 19.5 % vs. 62.5 %, P = 0.000). CONCLUSIONS: A rivaroxaban-predominant IOHA strategy significantly reduced the thrombotic burden without increasing the risk of bleeding for the treatment of DVT in adolescents with orthopedic trauma. Duration of anticoagulation therapy <6 weeks appears appropriate for adolescent orthopedic trauma-related DVT.

Management of Suspected Peripheral Vascular Injuries in Orthopedic Trauma.

OBJECTIVE: In orthopedic trauma, identification of extremity trauma combined with vascular injury is challenging. Missed diagnosis may result in amputation or even death. The purpose of this study was to investigate whether physical examination combined with handheld vascular ultrasound Doppler examination could be an effective method of screening for peripheral vascular injury and to explore the characteristics of vascular injuries in orthopedic trauma patients. METHODS: Retrospective analysis of patients in the emergency department of orthopedic trauma in our hospital from January 2022 to October 2023. Physical examination combined with handheld vascular ultrasound Doppler examination was used as a screening method for suspected vascular injuries. Patients with suspected vascular injury would undergo further angiography and receive multidisciplinary treatment. Angiography was used as the gold standard for diagnosing vascular injuries. Patient demographics, mechanism of injury, location and type of injury, angiographic results, surgical notes, and early treatment outcome data were recorded. RESULTS: A total of 55 cases (58 limb injuries) with suspected vascular injury were ultimately included. Angiography revealed that 53 cases (55 limbs, positive rate 94.8%) were considered to have confirmed vascular injuries. Forty-three were male (81.1%) and 10 were female (18.9%), with mean age 44.1 ± 16.6 years. The main mechanism of injury was traffic accident (30, 56.7%). Most common site of vascular injuries was knee joint (30/55, 54.5%), and popliteal artery (23, 47.9%) was the most commonly injured blood vessel. After multidisciplinary collaborative treatment, overall patient mortality was 3.8% (2/53), and limb survival rate among surviving patients was 81.1% (43/53) in our study. CONCLUSION: In orthopedic trauma, "Hard signs" and "soft signs" combined with handheld vascular ultrasound Doppler examination were effective ways to screen for suspected vascular injuries. Most limbs had associated fractures or dislocations at the site of vascular injury. Collaboration of vascular surgery, microsurgery and orthopedic trauma may help improve patients' prognosis.

The Effect of COVID-19 Infection on Clinical Outcomes in Patients Undergoing Surgical Repair of Humerus Fractures.

Introduction Limited research exists on the association between coronavirus 2019 (COVID-19) infection and outcomes following surgical fixation for humerus fractures. The objective of this study was to evaluate the effects of COVID-19 on the clinical outcomes of patients undergoing humerus fracture surgery. Methods Approval to utilize insurance claim data from the Change Healthcare dataset was obtained from the Datavant COVID-19 Research Database. Patients older than 55 years old who underwent humerus fracture surgery from April 1, 2020, to March 1, 2022, were included in the analysis. COVID-19 status, comorbidities, and adverse events were identified using the International Classification of Diseases, 10th Revision (ICD-10) diagnostic codes. Propensity score matching with age, sex, and comorbidities was completed to create a 1:10 matched COVID-19-negative cohort. Univariate and multivariate logistic regressions were performed to assess the association of COVID-19 positivity with perioperative adverse events. Results A total of 18,365 patients underwent humerus fracture surgery in this study, of which 132 (0.72%) tested positive for COVID-19. Univariate analysis found that COVID-19-positive patients were at higher risk for myocardial infarction (5.30% vs. 1.74%, p = 0.015) and acute kidney injury (28.79% vs. 12.50%, p < 0.001) when compared to the 1:10 matched COVID-19-negative cohort. In addition, multivariate logistic regression found that COVID-19-positive patients had higher odds of experiencing any adverse event (2.57; 95% CI: 1.69-3.91; p < 0.001) or a minor adverse event (2.44; 95% CI: 1.57-3.79; p < 0.001). Conclusion COVID-19-positive patients have increased odds of experiencing adverse events after undergoing humerus fracture surgery in comparison to a matched COVID-19-negative control. Findings from this study stress the importance of using COVID-19 status as a factor in predicting outcomes following orthopedic surgery in this patient population.

Exploring an innovative decellularization protocol for porcine nerve grafts: a translational approach to peripheral nerve repair.

Introduction: Peripheral nerves are frequently affected by lesions caused by traumatic or iatrogenic damages, resulting in loss of motor and sensory function, crucial in orthopedic outcomes and with a significant impact on patients' quality of life. Many strategies have been proposed over years to repair nerve injuries with substance loss, to achieve musculoskeletal reinnervation and functional recovery. Allograft have been tested as an alternative to the gold standard, the autograft technique, but nerves from donors frequently cause immunogenic response. For this reason, several studies are focusing to find the best way to decellularize nerves preserving either the extracellular matrix, either the basal lamina, as the key elements used by Schwann cells and axons during the regenerative process. Methods: This study focuses on a novel decellularization protocol for porcine nerves, aimed at reducing immunogenicity while preserving essential elements like the extracellular matrix and basal lamina, vital for nerve regeneration. To investigate the efficacy of the decellularization protocol to remove immunogenic cellular components of the nerve tissue and to preserve the basal lamina and extracellular matrix, morphological analysis was performed through Masson's Trichrome staining, immunofluorescence, high resolution light microscopy and transmission electron microscopy. Decellularized porcine nerve graft were then employed in vivo to repair a rat median nerve lesion. Morphological analysis was also used to study the ability of the porcine decellularized graft to support the nerve regeneration. Results and Discussion: The decellularization method was effective in preparing porcine superficial peroneal nerves for grafting as evidenced by the removal of immunogenic components and preservation of the ECM. Morphological analysis demonstrated that four weeks after injury, regenerating fibers colonized the graft suggesting a promising use to repair severe nerve lesions. The idea of using a porcine nerve graft arises from a translational perspective. This approach offers a promising direction in the orthopedic field for nerve repair, especially in severe cases where conventional methods are limited.

Experimental and virtual testing of bone-implant systems equipped with the AO Fracture Monitor with regard to interfragmentary movement.

Introduction: The management of fractured bones is a key domain within orthopedic trauma surgery, with the prevention of delayed healing and non-unions forming a core challenge. This study evaluates the efficacy of the AO Fracture Monitor in conjunction with biomechanical simulations to better understand the local mechanics of fracture gaps, which is crucial for comprehending mechanotransduction, a key factor in bone healing. Through a series of experiments and corresponding simulations, the study tests four hypotheses to determine the relationship between physical measurements and the predictive power of biomechanical models. Methods: Employing the AO Fracture Monitor and Digital Image Correlation techniques, the study demonstrates a significant correlation between the surface strain of implants and interfragmentary movements. This provides a foundation for utilizing one-dimensional AO Fracture Monitor measurements to predict three-dimensional fracture behavior, thereby linking mechanical loading with fracture gap dynamics. Moreover, the research establishes that finite element simulations of bone-implant systems can be effectively validated using experimental data, underpinning the accuracy of simulations in replicating physical behaviors. Results and Discussion: The findings endorse the combined use of monitoring technologies and simulations to infer the local mechanical conditions at the fracture site, offering a potential leap in personalized therapy for bone healing. Clinically, this approach can enhance treatment outcomes by refining the assessment precision in trauma trials, fostering the early detection of healing disturbances, and guiding improvements in future implant design. Ultimately, this study paves the way for more sophisticated patient monitoring and tailored interventions, promising to elevate the standard of care in orthopedic trauma surgery.

Functional Outcome of Lower Limb Long Bone Trauma Management in Pregnant Mothers: A Prospective Study of 30 Cases From a Tertiary Care Centre in North India.

INTRODUCTION: The occurrence of orthopedic injuries during pregnancy carries considerable morbidity and mortality for both the mother and fetus. Successful care of lower limb fractures during pregnancy requires a multidisciplinary approach. Both operative and non-operative treatments must be taken into account by the treating orthopedic physician. There is limited literature available on the management of these lower limb fractures in pregnancy, and peri-operative management of this obstetric and orthopedic trauma is largely unclear. Trauma during pregnancy is a common cause of non-obstetrical maternal death, having a significant public health burden to both the mother and child. The aims and objectives of this study were to review the common causes of lower limb long bone trauma during pregnancy and their functional outcome in terms of morbidity and mortality. This study evaluates various operative and conservative methods of treatment to provide a comprehensive management approach to pregnant patients with lower limb trauma. MATERIALS AND METHODS: A prospective study on functional outcomes of 30 pregnant females who were admitted with lower limb long bone fractures from 2017 to 2021 was done. The patients were randomly selected intra-operatively for various procedures based on the surgeon's preference. All patients were followed for two years or till union occurred, and the radiographic union score for tibial (RUST) and modified radiographic union score for tibial (mRUST) fracture criteria were used to assess bony union clinico-radiologically.  Results: During this study, the mean age of patients was 27 years (range 19-38), having right-side (53.33%) predominance with road traffic accidents (n=22) and falls (n=6) as the most common causes of injury. Two cases of domestic violence were also reported. In our study, the maximum number of cases was 17-25 weeks of their gestation; 12 (40%) patients had tibial fractures, and 18 (60%) had femoral fractures. Six tibial fractures were handled conservatively, while all femoral fractures required surgical intervention. Out of 18 femoral fractures, which were treated surgically, dynamic compression plating was done in 15 (83.33%) patients, while interlock nailing was done in three patients. Six tibial fractures have been operated upon, two (66.66%) with dynamic compression plating and four (33.33%) with an interlocking nail. CONCLUSION: A multidisciplinary approach in terms of both operative and non-operative methods must be taken into account for treating pregnant mothers by the orthopedic physician while carefully weighing the benefits and risks of both procedures. Based on the pattern and displacement of the fracture, many prenatal fractures can be treated conservatively. Another alternative that is frequently safe is to postpone the surgical procedure until childbirth. The physiologic changes associated with pregnancy and any potential dangers to the fetus must be taken into account by the orthopedic surgeon when fractures necessitate surgical intervention. The surgeon is responsible for the patient's correct placement, the C-arm's use, the radiation dose, and the intra-operative fetal monitoring, as well as the danger brought on by anesthetics, antibiotics, analgesics, and anticoagulants.

Disparities Exist in the Experience of Financial Burden Among Orthopedic Trauma Patients: A Systematic Review.

PURPOSE OF REVIEW: There are substantial costs associated with orthopedic injury and management. These costs are likely not experienced equally among patients. At the level of the healthcare and hospital systems, disparities in financial burden and patient demographics have already been identified among orthopedic trauma patients. Accordingly, disparities may also arise at the level of the patient and how they experience the cost of their care. We sought to determine (1) how patient demographics are associated with financial burden/toxicity and (2) if patients experience disproportionate financial burden/toxicity and social support secondary to their economic standing. RECENT FINDINGS: It has been described that there is an inequitable experience in clinical and economic outcomes in certain socioeconomic demographics leading to disparities in financial burden. It has been further reported that orthopedic injury, management, and outcomes are not experienced equitably among all demographic and socioeconomic groups. Ten articles met inclusion criteria, among which financial burden was disproportionately experienced amid orthopedic trauma patients across age, gender, race, education, and marital status. Financial hardship was also unequally distributed among different levels of income, employment, insurance status, and social deprivation. Younger, female, non-White, and unmarried patients experience increased financial burden. Patients with less education, lower income, limited or no insurance, and greater social deprivation disproportionately experienced financial toxicity compared to patients of improved economic standing. Further investigation into policy changes, social support, and barriers to appropriate care should be addressed to prevent unnecessary financial burden and promote greater patient welfare.

Management of the Mangled Extremity.

Mangled extremities represent one of the most challenging injuries. They indicate the need for a comprehensive trauma assessment to rule out coexisting injuries. Treatment options include amputation and attempts at limb salvage. Although both have been associated with chronic disability, new surgical techniques and evolving rehabilitation options offer hope for the future.

Perioperative nutritional status thought to be important, but poorly understood.

OBJECTIVES: Malnutrition has been shown to increase complications and leads to poor outcomes in surgical patients, but it has not been studied extensively in orthopedic trauma. This study's purpose is to determine the perspective and assessment of nutrition by orthopedic traumatologists. METHODS: A survey was created and distributed via REDCap to orthopedic traumatologists at 60 U.S. trauma centers. Out of 183 distributed surveys, 130 surgeons completed the survey (71%). The survey focused on the importance of nutrition and practice patterns in orthopedic trauma. RESULTS: Seventy-five percent of surgeons thought that nutritional status was "very important" to the final outcome of patients with orthopedic trauma injuries, 24% responded "somewhat important" and 1% responded "not important." Furthermore, 88% perform nutritional assessments; most surgeons (77%) utilize nutritional laboratory markers, with the most common markers being albumin, pre-albumin, transferrin and CRP. Additionally, 42% think trending the laboratory markers is important, and 50% are not sure if nutrition markers should be tested at multiple time points. Despite 75% of surgeons believing that nutrition is very important, only 8% discuss it with patients routinely. When asked what is more important for outcomes, nutrition or Vitamin D, almost three times as many surgeons thought nutrition was more important (29% vs 11%, respectively). CONCLUSIONS: While orthopedic traumatologists believe nutrition is an important determinant of patient outcomes, this study shows a clear lack of consensus and variability in practice regarding nutrition among surgeons. Orthopedic trauma surgeons need specific guidelines on how to assess and treat malnutrition in trauma patients.

Urinary bladder matrix versus dermal regeneration template for lower extremity wound coverage.

PURPOSE: To compare dermal regenerative template (DRT), with and without split-thickness skin-grafting (STSG), and urinary bladder matrix (UBM) for coverage of lower extremity wounds. METHODS: A retrospective review of 56 lower extremity wounds treated with either DRT and STSG (DRT-S) (n = 18), DRT only (n = 17), or UBM only (n = 21). Patient characteristics, comorbidities, American Society of Anesthesiology (ASA) classification, injury characteristics, wound characteristics, use of negative pressure wound therapy, surgical details, postoperative care, and failure of primary wound coverage procedure were documented. RESULTS: The DRT group, compared to the DRT-S group, was older [median difference (MD) 17.4 years, 95% confidence interval (CI) 9.1-25.7; p = 0.0008], more diabetic (proportional difference (PD) 54.2%, CI 21.2-76.1%; p = 0.002), had smaller wounds (MD - 91.0 cm2, CI - 125.0 to - 38.0; p = 0.0008), more infected wounds (PD 49.0%, CI 16.1-71.7%; p = 0.009), a shorter length of stay after coverage (MD - 5.0 days, CI - 29.0 to - 1.0; p = 0.005), and no difference in primary wound coverage failure (41.2% vs. 55.6%; p = 0.50). The UBM group, compared to the DRT group, was younger (MD - 6.8 years; CI - 13.5 to - 0.1; p = 0.04), had fewer patients with an ASA > 2 (PD - 35.0%, CI - 55.2% to - 7.0%; p = 0.02), diabetes (PD - 49.2%, CI - 72.4% to - 17.6%; p = 0.003), and had no difference in primary wound coverage failure (36.4% vs. 41.2%; p = 1.0). Failure of primary wound coverage was found to only be associated with larger wound surface areas (MD 22.0 cm2, CI 4.0-90.0; p = 0.01). CONCLUSIONS: DRT and UBM coverage had similar rates of primary wound coverage failure for lower extremity wounds. LEVEL OF EVIDENCE: Diagnostic, Level III.

The State of Local Antibiotic Use in Orthopedic Trauma.

Fracture-related infections are a challenging complication in orthopedic trauma that often necessitates multiple surgeries. Early administration of systemic antibiotics and surgical intervention remains the gold standard of care, but despite these measures, treatment failures can be as high as 35%. For these reasons, the introduction of local antibiotics at the site of at-risk fractures has increased over the past decade. This review looks at the various measures being used clinically including local antibiotic powder, polymethylmethacrylate, biodegradable substances, antibiotic-coated implants, and novel methods such as hydrogels and nanoparticles that have the potential for use in the future.

The Impact of the City of Miami's Decision to Revoke Electric Scooter Company Permits on Orthopedic Trauma at a Level I Trauma Center.

BACKGROUND: Since the introduction of electric-scooter (e-scooter) mobile applications, there has been a marked increase in e-scooter-related injury. On January 19, 2022, the City of Miami revoked permits to five major mobile applications for violation of safety protocols. OBJECTIVES: The purpose of our study was to assess the effects of this notice on the orthopedic patients seen at our corresponding Level I trauma center. METHODS: Institutional Review Board approval was obtained for this study. A retrospective chart review was performed including all patients with orthopedic injuries at our Level I trauma center between July 19, 2021 and July 19, 2022. These dates include 6 months prior to and after the major e-scooter operators ceased use in Miami. SPSS statistical software version 28.0.0 (SPSS, IBM, Armonk, NY) was utilized for all statistical analysis. RESULTS: There were 2558 patients in the prenotice cohort, and 2492 patients in the postnotice cohort. After the notice, there was a significant decrease in the number of patients that presented to our institution due to injuries caused by e-scooters (2.8% vs. 1.8% patients; p = 0.021). Patients with injuries caused by e-scooters had a significantly lower age (38 vs. 42, respectively; p = 0.034) and were more likely to be male (79.3% vs. 67.4% male, respectively; p = 0.007) than patients with other orthopedic injuries. CONCLUSION: This study demonstrates that the 2022 notice revoking the major mobile application operators from the City of Miami resulted in a significant decrease in the number of orthopedic cases due to e-scooter-related injury at the corresponding Level I trauma center.

Incidence and factors associated with deep vein thrombosis among hospitalized adult patients at Hawassa university comprehensive specialized hospital Hawassa city, Sidama, Ethiopia: retrospective cohort study.

PURPOSE: Deep vein thrombosis is a public health problem with substantial morbidity and mortality globally. In Ethiopia, death due to complications of DVT is very significant however its incidence, risk factors, and preventive methods are not well studied. To assess the incidence and factors associated with deep vein thrombosis among hospitalized adult patients at Hawassa University Comprehensive Specialized Hospital, Hawassa, Ethiopia. METHOD: Intuitional-based retrospective study design was employed in July1-August 30, 2022 in 660 randomly selected patients' record cards. The patients' record cards were reviewed from 2012 to 2014 at Hawassa University Compressive Specialized Hospital. The data entry and analysis were done by using Epi Info and SPSS version 24. After adjusting covariates at a 95% confidence interval, an independent variable with a P value < 0.05 was declared significantly associated with deep vein thrombosis. An odds ratio was calculated to measure the strength of the relationship independent variable and deep vein thrombosis. RESULTS: The overall incidence of DVT was 10.6% [95% CI: 8.5%, 13.1%]. After adjusting for covariates, orthopedic trauma; AOR = 2.6 (95% CI (1.2-5.4), corona virus; AOR = 2.5 (95%CI (1.07-5.1), and hospital stay > 15 days; AOR = 2.2 (95% CI (1.25-3.94) were significantly associated with deep vein thrombosis. CONCLUSION: DVT incidence is high among hospitalized patients. An orthopedic trauma, a recent infection of the coronavirus, and a hospital stay above 15 days were a risk to acquire deep vein thrombosis. Early identification and detection of patients at high risk of developing DVT and provision of prophylaxis are recommended.

Socioeconomic status is associated with greater hazard of post-discharge mortality than race, gender, and ballistic injury mechanism in a young, healthy, orthopedic trauma population.

OBJECTIVES: To explore the utility of legacy demographic factors and ballistic injury mechanism relative to popular markers of socioeconomic status as prognostic indicators of 10-year mortality following hospital discharge in a young, healthy patient population with isolated orthopedic trauma injuries. METHODS: A retrospective cohort study was performed to evaluate patients treated at an urban Level I trauma center from January 1, 2003, through December 31, 2016. Current Procedure Terminology (CPT) codes were used to identify upper and lower extremity fracture patients undergoing operative fixation. Exclusion criteria were selected to yield a patient population of isolated extremity trauma in young, otherwise healthy individuals between the ages of 18 and 65 years. Variables collected included injury mechanism, age, race, gender, behavior risk factors, Area Deprivation Index (ADI), and insurance status. The primary outcome was post-discharge mortality, occurring at any point during the study period. RESULTS: We identified 2539 patients with operatively treated isolated extremity fractures. The lowest two quartiles of socioeconomic status (SES) were associated with higher hazard of mortality than the highest SES quartile in multivariable analysis (Quartile 3 HR: 2.2, 95% CI: 1.2-4.1, p = 0.01; Quartile 4 HR: 2.2, 95% CI: 1.1-4.3, p = 0.02). Not having private insurance was associated with higher mortality hazard in multivariable analysis (HR 2.0, 95% CI: 1.3-3.2, p = 0.002). The presence of any behavioral risk factor was associated with higher mortality hazard in univariable analysis (HR: 1.8, p < 0.05), but this difference did not reach statistical significance in multivariable analysis (HR: 1.4, 95%: 0.8-2.3, p = 0.20). Injury mechanism (ballistic versus blunt), gender, and race were not associated with increased hazard of mortality (p > 0.20). CONCLUSION: Low SES is associated with a greater hazard of long-term mortality than ballistic injury mechanism, race, gender, and medically diagnosable behavioral risk factors in a young, healthy orthopedic trauma population with isolated extremity injury.

Antibiotic Prophylaxis for Grade 3 Open Fractures: A Retrospective Comparison of Ceftriaxone Plus Vancomycin Versus Cefazolin Plus Gentamicin.

Background: Because of the established path of bacterial entry and contamination-associated mechanisms, grade 3 open orthopedic fractures represent a substantial infection risk. The Eastern Association for the Surgery of Trauma (EAST) guidelines recommended covering Staphylococcus aureus and adding aminoglycoside gram-negative coverage. Local institutional guidelines rely on ceftriaxone for gram negative coverage and add methicillin-resistant Staphylococcus aureus coverage with vancomycin. Patients and Methods: The electronic health records of adults admitted for a grade 3 open fracture between January 1, 2016, and October 31, 2021, were retrospectively reviewed. Patients who received cefazolin and gentamicin (CZ+GM) or ceftriaxone and vancomycin (CRO+VA) as prophylaxis were included. We recorded the rate of a composite treatment failure outcome of receipt of antibiotic agents, infection-related hospitalization, or subsequent debridement for injury-site skin and soft tissue infection or osteomyelitis. The presence of acute kidney injury (AKI) was also evaluated. Results: There were 65 patients included in the CZ+GM group and 53 patients in the CRO+VA group. Patients in the CZ+GM group were younger (mean 42.6 compared with 50.6 years; p = 0.02). Otherwise, there were no significant differences between groups' demographics, mechanism and site of injury, timeline of care, or surgical interventions. More patients in the CZ+GM arm met the composite treatment failure outcome, but it was not statistically significant (45% vs. 32%; p = 0.2). There were similar rates of treatment failure at 30 days (21% vs. 26%; p = 0.5) and for only osteomyelitis (8% vs. 9%; p = 1). Conclusions: The trend in numerically lower treatment failure rates in the CRO+VA group across outcomes provides sufficient evidence to continue the current local recommendations. Given our sample size, type 2 error may have occurred, and studies with greater power should analyze this question.

A technique for introducing broad-spectrum topical antibiotics during open reduction and internal fixation of acetabular fractures.

Postoperative surgical site infections remain a significant and prevalent complication after open reduction and internal fixation of acetabular fractures. Local antibiotics have been shown to decrease risk of postoperative infection, although recent evidence is conflicting. We provide a consistent and replicable technique for delivering intraoperative broad-spectrum antibiotics in the form of a putty applied directly to surgical implants. With this technique, systemic levels of those antibiotics remain safe and stable.

Fracture related infection (FRI) of the upper extremity correlates with poor bone and soft tissue healing.

PURPOSE: The purpose of this study was to evaluate the specific course and complication profile following the development of FRI in the upper extremity. METHODS: An IRB-approved retrospective review was conducted on a consecutive series of operatively managed patients within an academic medical center between 1/2010 and 6/2022. Included patients met the following criteria: (1) upper extremity fracture definitively treated with internal fixation (2) development of criteria for suggestive or confirmatory FRI (as per the FRI Consensus Group) and (3) age ≥ 18 years. Baseline demographics, medical history, injury information, infection characteristics, hospital quality measures, and outcomes were recorded. A 3:1 propensity-matched control cohort of patients without FRI was obtained using the same dataset. Univariable analysis was performed to compare the outcomes (rate of nonunion, time to bone healing, need for soft tissue coverage, patient reported joint stiffness at final follow-up) of the FRI vs Non-FRI cohorts. RESULTS: Of 2827 patients treated operatively for an upper extremity fracture, 43 (1.53%) met criteria for suggestive of confirmatory FRI. The successful propensity match (43 FRI, 129 Non-FRI) revealed no differences in demographics, baseline health status, or fracture location. FRI patients underwent more reoperations (p < 0.001), experienced an increased rate of removal of hardware (p < 0.001), and were admitted more frequently following index operation (p < 0.001). The FRI cohort had higher rates of fracture nonunion (p = 0.003), and a prolonged mean time to bone healing in months (8.37 ± 7.29 FRI vs. 4.14 ± 5.75 Non-FRI, p < 0.001). Additionally, the FRI cohort had a greater need for soft tissue coverage throughout their post-operative fracture treatment (p = 0.014). While there was no difference in eventual bone healing (p = 0.250), FRI patients experienced a higher incidence of affected joint stiffness at final follow-up (p < 0.001). CONCLUSION: Patients who develop an FRI of the upper extremity undergo more procedures and experience increased complications throughout their treatment, specifically increased joint stiffness. Despite this, ultimate outcome profiles are similar between patients who experience FRI and those who do not following operative repair of an upper extremity fracture. LEVEL OF EVIDENCE: III.

Integrating Psychosocial Care into Orthopedic Settings: A Qualitative Study of Provider Perspectives.

Introduction: Approximately 50% of persons with orthopedic injuries experience psychosocial distress (e.g., depression, anxiety), which can predict chronic pain and disability. Offering psychosocial services in orthopedic settings can promote patient recovery. This study explores health care professionals' perceptions of and recommendations regarding integrated psychosocial care for orthopedic settings. Methods: We conducted 18 semi-structured focus groups with 79 orthopedic health care professionals (e.g., surgeons, residents, nurses) across three Level I Trauma Centers. This secondary data analysis used the evidence-based Rainbow Model of Integrated Care framework to structure hybrid inductive-deductive qualitative data analysis. Results: Orthopedic health care professionals identified potential benefits to psychosocial service integration across all dimensions of integration (i.e., clinical, professional, organizational, system, functional, and normative). These benefits included increased patient satisfaction with care, decreased burden on medical providers to manage patient distress, and decreased healthcare utilization costs. They also identified barriers (e.g., fast-paced clinic flow, mental health stigma) and offered recommendations to address barriers across dimensions of integration. Conclusion: Integrated psychosocial care for orthopedic trauma patients has the potential to improve patient recovery and long-term physical and mental health outcomes. This work identifies strategies to inform the development and implementation of initiatives to integrate psychosocial services within orthopedic settings.

Comparison of different intervention methods to reduce the incidence of venous thromboembolism: study protocol for a cluster-randomized, crossover trial.

BACKGROUND: Venous thromboembolism (VTE) remains a priority challenge among orthopedic trauma patients. It is crucial to further improve the prophylaxis against VTE in routine orthopedic treatment. This study aims to compare the efficacy of two low molecular weight heparin (LMWH) regimens and additional intermittent pneumatic compression in preventing VTE among orthopedic trauma patients. METHODS AND ANALYSIS: This is a cluster-randomized crossover clinical study conducted in four hospitals in Shanghai from December 2019 to December 2023. The unit of randomization is orthopedic wards, and each ward will define a cluster. All clusters will implement four diverse intervention measures and one control measure in a given random sequence. Perioperative orthopedic trauma patients aged ≥ 18 years with stable vital signs, Caprini score > 2, and no contraindication of anticoagulation or intermittent pneumatic compression (IPC) devices will be eligible. The sample size will be determined to be 2590, considering cluster effect, period effect, and interactions. We will generally use the intention-to-treat (ITT) at the subject level for each outcome. For the primary outcome of the study, the incidence of VTE will be presented as risk ratio and 95% CIs. Generalized estimating equation (GEE) will be deployed to compare differences and adjust cluster effect, period effect, and interaction among interventions and periods if applicable. DISCUSSION: VTE is a complication that cannot be underestimated after major orthopedic surgery. Early identification, early assessment, and early prevention can significantly reduce the incidence of VTE. Most guidelines recommend both medical and physical prevention, and we hope to demonstrate how they would affect the incidence among perioperative orthopedic patients. We want to explore if there is a difference between the two types of LWMH with or without an IPC device to provide more evidence for future guidelines and prevent more patients from the threat of VTE. ETHICS AND DISSEMINATION: The study received approval from the IRB of the coordinating center and all participating hospitals. Findings will be disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION: ChiCTR1900027659. Registered on 17 November 2019.

Trends in the Utilization of Computed Tomography in Operative Treatment of Distal Radius Fractures.

Purpose: To identify patient, surgeon, and injury characteristics associated with preoperative computed tomography (CT) scan utilization for operative distal radius fractures (DRF). In addition, we aimed to determine if preoperative CT was associated with treatment methods other than isolated volar-locked plating (VLP). Methods: We retrospectively reviewed all operatively treated adult DRFs within our health care system from 2016 to 2020. Baseline demographics, injury, treatment characteristics, and the fellowship training of the 44 included surgeons were recorded. We compared cases with and without a preoperative CT, and an adjusted logistic regression model was generated to determine the odds of having a preoperative CT. Results: A total of 1,204 operatively treated DRFs performed by 44 surgeons were included. CT utilization increased during the study period. Intra-articular fractures accounted for 76% of cases, and preoperative CT scans were ordered in 243 of 1240 cases (20%). Overall, isolated VLP was used in 83% of cases. Cases with a preoperative CT were more likely to be treated with an alternative method of fixation (such as dorsal plating). The adjusted logistic regression model demonstrated that male sex (OR 1.62; 95% CI: 1.16, 2.26), intra-articular fractures (OR 3.11; 95% CI: 1.87, 5.81), and associated fractures (OR 2.69; 95% CI: 1.82, 3.98) had a significantly increased odds of having a preoperative CT. Fellowship training was not associated with increased CT utilization overall, but hand surgeons were more likely to use a CT in Orthopaedic Trauma Association-C3 fractures. Conclusions: Patient and injury characteristics are associated with CT utilization in operative DRFs. Preoperative CTs are associated with alternative fixation approaches, as cases with a CT were more likely to use fixation methods other than isolated VLP. The costs and benefits of CT scans must be carefully weighed against whether this modality adds value or improves outcomes in treating DRFs. Level of evidence: Prognostic II.