Intramedullary Fixation of Hand Fractures and Arthrodeses.

Intramedullary fixation has long been popular for fracture fixation in the upper extremity from the shoulder through the carpus. Recently, intramedullary fixation in the hand has gained increasing interest, specifically in the metacarpals and phalanges, corresponding with the development of improved cannulated headless screw technology. Along with the advantages of increased operative speed and less surgical dissection, which can promote rapid healing, many benefits exist, supporting their use despite some drawbacks. This article reviews the background and biomechanics of intramedullary fixation with a specific focus on cannulated headless screws, describes the application and techniques of intramedullary screw fixation in the hand, and details the associated outcomes and costs for metacarpal fractures, phalangeal fractures, and interphalangeal joint arthrodesis.

Interpersonal Interactions and Biases in Orthopaedic Surgery Residency: Do Experiences Differ Based on Gender?

BACKGROUND: Women residents are underrepresented in orthopaedic surgery. The causes of the deficit of women in orthopaedic surgery are multifactorial, but by identifying the perceptions of women in orthopaedic residency training and comparing them with the perceptions of men, we can improve our understanding of ways to enhance the recruitment of qualified and diverse candidates. QUESTIONS/PURPOSES: (1) What differences exist in the perceived experiences of residents identifying as women and men regarding professional, social, and personal interactions during residency training? (2) Are there differences in the percentage of women and men residents who have experienced harassment or discrimination in preresidency interviews, and are there differences in the type of harassment or discrimination experienced? METHODS: A survey was generated using Academy of Critical Care: Development, Evaluation, and Methodology guidelines. Two focus groups with seven attending orthopaedic surgeons who participate in the Collaborative Orthopaedic Education Research Group and who are experts on gender diversity in orthopaedics were held to improve survey validity. The survey included binary-response, Likert, and free-text questions on the perception of professional, social, and personal interactions held by the resident being surveyed. The questions focused on a respondent's perception of interactions with staff members, patients, resident colleagues, and attending surgeons, as well as sexual harassment. Program directors at 10 selected Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedic residency programs that participate in the Collaborative Orthopaedic Education Research Group shared the survey with residents at their institutions. There were 95 programs in the Collaborative Orthopaedic Education Research Group at the time this survey was distributed. In this program, directors or other interested teaching faculty in orthopaedic residency programs voluntarily participate to discuss and develop quality research on resident and fellow education. These 95 programs account for 46% of the ACGME-accredited programs in the United States at the time the survey was created and distributed. The 10 residency programs had a total of 232 enrolled residents; 15% (34) identified as women. This gender distribution models the national sample of orthopaedic residents. Survey reliability was assessed by calculating the Cronbach alpha after determining the variance in each relevant (nondemographic) survey item. The final survey was found to have excellent internal reliability (alpha = 0.95). Responses from residents identifying as women and those identifying as men were compared using Fisher exact tests for all categorical data, and two-tailed independent t-tests were used for all continuous data. Differences in each survey category (professional interactions, social interactions, personal interactions, and sexual harassment in preresidency interview experiences) were calculated. RESULTS: Women reported experiencing microaggressions (left undefined to the survey respondent, but generally considered to be subtle, stunning, often automatic, and nonverbal exchanges that are "put downs") at work more frequently than men did (40% [six of 15] versus 5% [four of 74]; p < 0.001). Specifically, women perceived being interrupted (53% [eight of 15] versus 5% [four of 75]); p < 0.001) by men colleagues, called by their first name (67% [10 of 15] versus 4% [3 of 72]; p < 0.001), and given administrative tasks (27% [four of 15] versus 1% [one of 75]; p = 0.004) more often than men. More women than men perceived that patients (33% [five of 15] versus 0 of 74 [0%]; p < 0.001) and hospital staff (27% [four of 15] versus 7% [five of 74]; p = 0.01) respected their opinion less than that of men. More women than men perceived that group humor negatively targeted their gender (47% [seven of 15] versus 1% [one of 75]; p < 0.001) and that criticism of their surgical skill was based on their gender rather than their ability (33% [five of 15] versus 5% [four of 78]; p = 0.005). In residency or subinternship interviews, 20% of women reported experiencing sexual harassment as defined by a listing of known types of harassment in the question stem, compared with 0% of men (p = 0.004). Women reported harassment in the form of verbal remarks of a sexual nature and obscene images in the workplace, whereas men did not report any form of harassment during interviews. CONCLUSION: These findings suggest that the greatest discrepancies in the perceived experiences of women and men residents lie in professional interactions, and women residents are more likely to experience sexual harassment and disparaging humor than men residents. CLINICAL RELEVANCE: Addressing these discrepancies, particularly in the professional setting, will help to create a more inclusive work environment and attract more women to orthopaedic surgery. Annual distribution of the survey used in this study by program directors to residents in their programs can help to identify discrepant perceptions that, coupled with the collection of objective data, can be targeted for improvement.

Failure of humeral shaft fixation: construct characteristics.

PURPOSE: Fixation failure following open reduction and internal fixation (ORIF) of humeral shaft fractures can be a challenging complication. We aimed to identify the modes of failure and characteristics of failed fixation constructs. METHODS: We queried our institutional database for patients > 18 years old with fixation failure after ORIF with single plate and screw constructs of humeral shaft fractures from 2006 to 2017. Demographics, fracture characteristics, fixation construct design and mode of failure were recorded. RESULTS: Twenty-three failures were identified. Mean age was 55.9 years (SD 19.2 years) with 15 (65%) women. Twelve patients (52%) had midshaft fractures; the remainder had distal-third shaft (8 pts, 35%) or proximal-third shaft (3 pts, 13%) fractures. Midshaft fractures were most commonly fixed through an anterolateral approach with plates and all non-locking screws (83%), while distal-third shaft fractures were fixed with a combination of locking and non-locking screws from a posterior approach. Distal-third shaft fractures failed by plate breakage (63%) or screw pullout (38%) and all midshaft failures occurred by screw pullout proximal (92%) or distal (8%) to the fracture. Resultant varus deformity occurred in 20 (87%) fractures. CONCLUSION: Screw pullout in midshaft fractures suggests that fixation to bone was insufficient or biomechanically disadvantageous. Varus moments contribute significantly to the failure of humeral shaft fracture ORIF. Plate breakage in distal fractures suggests high concentrations of stress over a narrow working length of constructs with inadequate plate strength. Recognizing how these constructs fail can aid proper implant selection and application for humeral shaft fracture. LEVEL OF EVIDENCE: Treatment level IV.

Biomechanical Comparison of Dual and Posterior Locking Plates in an Ex Vivo Comminuted Olecranon Fracture Model.

PURPOSE: Comminuted olecranon fractures are commonly fixed with posterior locking plates (PLPs). Though biomechanically validated, this method comes with risks of symptomatic implant prominence and wound breakdown. Dual locking plates (DLPs) placed on the medial and lateral surfaces of the olecranon theoretically avoid these risks and allow for fixation of proximal fracture fragments in multiple planes. A biomechanical comparison of DLP and PLP fixation would help to validate the use of DLPs in comminuted olecranon fractures. METHODS: Seven matched pairs of cadaveric upper extremities were evaluated with quantitative computed tomography scans to evaluate bone mineral density (BMD). Osteotomies simulating comminuted olecranon fractures (Mayo Type IIB) were created and the specimens were fixed either with variable angle PLPs or variable angle DLPs. The specimens were then cyclically loaded and loaded to failure. The ultimate strength, fracture displacement, and mechanism of failure were recorded and compared across groups. The correlation between BMD and ultimate strength was analyzed. RESULTS: The mean total BMD was 0.79 g/cm2 (SD, 0.14 g/cm2). No specimen failed during cyclic testing. Five of 7 PLP specimens and 5 of 7 DLP specimens failed by fracture through the proximal screws though in different planes (sagittal vs axial splits, respectively). The mean ultimate strengths of the PLP (1077 N [SD, 462 N]) and DLP (1241 N [SD, 506 N]) groups were similar. There was a linear relationship between ultimate strength and BMD (R2 = 0.33). CONCLUSION: Dual locking plates display biomechanical properties that suggest that they can be used in the fixation of comminuted olecranon fractures. Catastrophic failure of the fixation constructs occurs around stress risers at the proximal screws rather than due to displacement at the fracture itself. CLINICAL RELEVANCE: Dual locking plate constructs can be considered for use in the fixation of comminuted olecranon fractures.

Relevance of Diagnosed Depression and Antidepressants to PROMIS Depression Scores Among Hand Surgical Patients.

PURPOSE: We aimed to test the utility of screening for depressive symptoms in the hand surgical office focusing on chances of heightened depressive symptoms in patients with no history of diagnosed depression and by quantifying ongoing depressive symptoms among patients diagnosed with depression accounting for antidepressant use. The clinical importance of this study was predicated on the documented negative association between depressive symptoms and hand surgical outcomes. METHODS: This cross-sectional study analyzed 351 patients presenting to a tertiary hand center between April 21, 2016, and November 22, 2017. Adult patients completed self-administered Patient-Reported Outcomes Measurement Information System (PROMIS) Depression computer adaptive tests at registration. Health records were examined for a past medical history of diagnosed depression and whether patients reported current use of prescription antidepressants. Mean PROMIS Depression scores were compared by analysis of variance (groups: no diagnosed depression, depression without medication, depression with medication). Four points represented a clinically relevant difference in PROMIS Depression scores between groups and Depression scores greater than 59.9 were categorized as having heightened depressive symptoms. RESULTS: Sixty-two patients (18%) had been diagnosed with depression. Thirty-four of these patients (55%) reported taking antidepressant medications. The PROMIS Depression scores indicated greater current depressive symptoms among patients with a history of diagnosed depression when not taking antidepressants (11 points worse than unaffected) and also among patients taking antidepressants (7 points worse than unaffected). Heightened depressive symptoms were detected in all groups but were more prevalent among those diagnosed with depression (36% with no medication, 29% with antidepressant medication) compared with unaffected patients (7%). CONCLUSIONS: Depression screening for heightened depressive symptoms identifies 1 in 14 patients without diagnosed depression and 1 in 3 patients diagnosed with depression as having currently heightened depressive symptoms. Hand surgeons can use PROMIS Depression screening in all patients and using this to guide referrals for depression treatment to ameliorate one confounder of hand surgical outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Symptom prevalence study II.

Evaluation of Spanish Language Proficiency and Resources Available in Academic Pediatric Orthopaedic Centers.

INTRODUCTION: Given the rapidly increasing population of Spanish-speaking patients in the United States, medical providers must have the capability to effectively communicate both with pediatric patients and their caregivers. The purpose of this study was to query the Spanish language proficiency of pediatric orthopaedic surgeons, assess the educational resources available to Spanish-speaking patients and their families, and identify the barriers to care at academic pediatric orthopaedic centers. METHODS: The Web sites of medical centers within the United States that have pediatric orthopaedic surgery fellowships recognized by the Pediatric Orthopaedic Society of North America (POSNA) were accessed. Web sites were investigated for a health library as well as the availability of interpreter services. Profiles of attending surgeons within each Pediatric Orthopaedic Department were evaluated for evidence of Spanish proficiency as well as educational qualifications. Centers were contacted by phone to determine if the resources and physicians who could converse in Spanish were different than what was readily available online and if automated instructions in Spanish or a person who could converse in Spanish were available. RESULTS: Forty-six centers with 44 fellowship programs were identified. The profiles of 12 of 334 (3.6%) surgeons who completed pediatric orthopaedic fellowships indicated Spanish proficiency. Seventeen physicians (5.1%) were identified as proficient in Spanish after phone calls. Thirty-eight pediatric orthopaedic centers (82.6%) noted interpreter service availability online, although services varied from around-the-clock availability of live interpreters to interpreter phones. When contacted by phone, 45 of 46 centers (97.8%) confirmed the availability of any interpreter service for both inpatient and outpatient settings. Sixteen centers (34.8%) had online information on orthopaedic conditions or surgical care translated into Spanish. Twenty centers (43.5%) did not have automated phone messages in Spanish or live operators that spoke Spanish. CONCLUSIONS: There is a scarcity of surgical providers in pediatric orthopaedic centers proficient in Spanish, demonstrating a large discrepancy with the growing Hispanic population. Interpreter services are widely available, although there is variability in the services provided. Considerable barriers exist to Spanish-speaking patients who attempt to access care by phone or online.

What Patient-related Factors are Associated with an Increased Risk of Surgery in Patients with Stenosing Tenosynovitis? A Prospective Study.

BACKGROUND: Numerous patient-related risk factors have been identified as contributors to patient progression to operative treatment of stenosing tenosynovitis (STS). Identifying patients most at risk of undergoing surgery after receiving a corticosteroid injection would enable health care providers to identify patients most likely to benefit from nonsurgical treatment. QUESTIONS/PURPOSES: (1) What proportion of prospectively enrolled patients with a new diagnosis of STS did not require further intervention after a first, second, or third injection when offered up to three corticosteroid injections? (2) Which identifiable risk factors present at the initial evaluation in patients with STS are associated with the patient opting for surgical release after a trial of one, two, or three corticosteroid injections? METHODS: One hundred ninety-six patients with a presumed diagnosis of STS were evaluated between March 2014 and June 2015, and 160 patients with 186 affected fingers were prospectively enrolled after a new diagnosis of STS was made during the study period. STS was diagnosed by assessing for tenderness at the A1 pulley, passive or active triggering, and the absence of other confounding diagnoses. Only the affected finger received a corticosteroid injection, and these patients were followed up during the study period. Patients were followed for 2 years, and 135 of the 160 patients (84%) completed the final followup. Patients with recurrent symptoms were treated with up to three corticosteroid injections before undergoing A1 pulley release, although patients could elect to undergo surgery at any time. Bivariate comparisons and a multivariate logistic regression analysis were used for independent fingers (one per participant) to identify independent variables associated with progression to surgery after injection. The time between treatments (between injection and subsequent injection or between injection and surgery) for those with recurrent symptoms was also calculated. Information collected from the last time the patient could be contacted was carried forward in the analysis for all 160 patients. RESULTS: No further treatment was sought after the first, second, and third injections by 81 of 160 (51%), 16 of 45 (37%), and three of 10 patients (30%), respectively; 100 of 160 patients (63%) did not pursue further intervention. After the first, second, and third injections, 36 of 160 patients (23%), 17 of 43 patients (40%), and seven of 10 of patients, respectively, did not respond to treatment. After controlling for 21 potentially confounding patient- and disease-related variables, we found that only two risk factors at the initial presentation were protective against eventual progression to surgery: osteoarthritis in the fingers (odds ratio [OR], 0.26 [95% CI, 0.085-0.786]; p = 0.017) and a longer duration of symptoms (OR, 0.58 [95% CI, 0.38-0.89]; p = 0.012). There was no association between progression to surgery and hand dominance, finger type (thumb or other), whether the patient had diabetes, or whether the affected finger was one of multiple affected fingers. Patients who presented again for intervention (injection or surgery) did so at a mean of 153 ± 94 days. CONCLUSIONS: Although patients should be counseled that their risk of progressing to surgery after an initial corticosteroid injection is lower than for subsequently administered injections for recurrent symptoms, nonoperative treatment should not be bypassed for patients with any of the studied risk factors. LEVEL OF EVIDENCE: Level II, therapeutic study.

Utility of Prolotherapy for Upper Extremity Pathology.

Prolotherapy is a method of treatment of painful musculoskeletal conditions whereby a sclerosing agent is injected into an area of tendinosis or osteoarthritis to strengthen and repair painful connective tissue. It is a safe, effective, and relatively inexpensive nonsurgical treatment modality. This article provides a history of prolotherapy, discusses its proposed mechanisms of action, and provides a review of the existing literature on prolotherapy as a treatment for upper extremity pathologies, specifically, hand osteoarthritis, lateral epicondylitis, and rotator cuff disease.

Cost-Effective Management of Stenosing Tenosynovitis.

PURPOSE: Stenosing tenosynovitis (STS) is a common condition treated by hand surgeons. Limited evidence exists to support the nonsurgical management of STS. The purpose of this study was to prospectively evaluate a cohort of patients with STS, and to determine the strategy for treating patients with this condition that is most cost effective in terms of dollars reimbursed by payers. METHODS: Prospective data were collected on patients diagnosed with STS between March 2014 and September 2014. All patients were initially treated with a corticosteroid injection. Patients with persistent symptoms were given the option of injection or surgery. A maximum of 3 injections were offered. All patients were evaluated every 6 months through office appointments or phone calls. A cost analysis was performed in our cohort using actual reimbursement rates for injections, initial and established patient visits, and facility and physician fees for surgery, using the reimbursement rates from the 6 payers covering this patient cohort. Cost savings were calculated based on offering 1, 2, and 3 injections. RESULTS: Eighty-eight digits in 82 patients were followed for an average of 21.9 months (range, 18.7-22.7 mo) after an initial corticosteroid injection. Thirty-five digits went on to surgical release, whereas 53 digits were treated nonsurgically. Had all patients initially undergone surgery, the cost would have totaled $169,088.98 ($1,921 per digit). Offering up to 3 injections yielded a potential savings of $72,730 ($826 per digit) or 43% of the total cost. For the 33 patients who underwent more than 1 injection, offering a second injection yielded potential savings of $15,956 ($484 per digit, 22.7%), and for the 7 patients presenting a third time, a third injection saved $1,986 ($283 per digit, 14.5%). CONCLUSIONS: Based on the data from our cohort, the efficient way to treat STS in terms of health care dollars spent is to offer up to 3 injections before surgical release. The first injection had the highest component of cost savings, at $826 per digit. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analysis III.

Incidence, Timing, and Risk Factors for Secondary Revision After Primary Revision of Traumatic Digit Amputations.

PURPOSE: Primary revision amputation is the most common treatment method for traumatic digit amputations in the United States. Few studies have reported secondary revision rates after primary revision amputation. The primary aim of our study was to identify risk factors for secondary revision within 1 year of the index procedure. Secondarily, we describe the incidence and timing of complications requiring secondary revision. METHODS: Our institution's emergency department (ED) database was reviewed for traumatic digit amputations over a 6-year period. Patients were reviewed for demographic characteristics, comorbidities, site of treatment (ED versus operating room), and complications requiring secondary revision. Conditional Cox Proportional Hazard regression was used to model hazard of revision within 1 year of index procedure relative to site of initial management, mechanism of injury, injury characteristics, and patient demographics. RESULTS: Five hundred and thirty-seven patients with 677 digits were managed with primary revision amputation. Five hundred and eighty-six digits (86.6%) were revised in the ED, and 91 (13.4%) in the operating room. Ninety-one digits required secondary revision, including 83 within 1 year. No increased risk of secondary revision amputation within 1 year of the index procedure was observed for patients treated in the ED compared with the operating room. Relative to crush injuries, bite and sharp laceration amputations had 4.8 times and 2.6 times increased risk of secondary revision, respectively. The index finger had a 5.3-fold increased risk of revision with the thumb as the reference digit. Work-related injuries had a 1.9-fold increased risk of secondary revision compared with non-work-related injuries. CONCLUSIONS: No evidence was found indicating that traumatic digit amputations primarily revised in the ED had an increased risk of secondary revision. Patients may be counseled on the risk of secondary procedures based on the mechanism of injury, injury characteristics and demographics, as well as the timing of complications. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Pediatric Orthopedic Hoverboard Injuries: A Prospectively Enrolled Cohort.

Hoverboards pose a significant risk of musculoskeletal injury to pediatric riders. A prospectively enrolled cohort yielded 9 pediatric patients injured while riding hoverboards in 2016. Eight of the injuries involved the upper extremity, and one involved the lower extremity. No riders wore any safety equipment and injury patterns modeled those seen in skateboard riders.

Evaluation of Patient Education Materials From Large-Language Artificial Intelligence Models on Carpal Tunnel Release.

BACKGROUND: ChatGPT, an artificial intelligence technology, has the potential to be a useful patient aid, though the accuracy and appropriateness of its responses and recommendations on common hand surgical pathologies and procedures must be understood. Comparing the sources referenced and characteristics of responses from ChatGPT and an established search engine (Google) on carpal tunnel surgery will allow for an understanding of the utility of ChatGPT for patient education. METHODS: A Google search of "carpal tunnel release surgery" was performed and "frequently asked questions (FAQs)" were recorded with their answer and source. ChatGPT was then asked to provide answers to the Google FAQs. The FAQs were compared, and answer content was compared using word count, readability analyses, and content source. RESULTS: There was 40% concordance among questions asked by the programs. Google answered each question with one source per answer, whereas ChatGPT's answers were created from two sources per answer. ChatGPT's answers were significantly longer than Google's and multiple readability analysis algorithms found ChatGPT responses to be statistically significantly more difficult to read and at a higher grade level than Google's. ChatGPT always recommended "contacting your surgeon." CONCLUSION: A comparison of ChatGPT's responses to Google's FAQ responses revealed that ChatGPT's answers were more in-depth, from multiple sources, and from a higher proportion of academic Web sites. However, ChatGPT answers were found to be more difficult to understand. Further study is needed to understand if the differences in the responses between programs correlate to a difference in patient comprehension.

Pediatric thoracolumbar spine trauma.

Thoracolumbar spine trauma is an important cause of morbidity and mortality in pediatric patients. Special attention to this population is necessary because several unique features of the growing pediatric spine separate these patients from adult patients. These injuries are frequently associated with high-energy trauma and concurrent thoracic or abdominal injuries that require coordinated multidisciplinary care. Thoracolumbar spine trauma in pediatric patients may lead to compression fractures, burst fractures, flexion-distraction injuries (ie, Chance fracture), fracture-dislocation injuries, apophyseal fractures/herniations, and spinous process and transverse process fractures. Depending on the nature of the injury and the patient's level of skeletal maturity, thoracolumbar spinal injuries may have substantial ability to heal and remodel. Because the impact of thoracolumbar spinal injury on pediatric patients can be devastating, appropriate early diagnosis and management, as well as long-term follow-up, are imperative.

A 5-Year Update and Comparison of Factors Related to the Sex Diversity of Orthopaedic Residency Programs in the United States.

Female physicians have been historically underrepresented in orthopaedic surgery residencies. The purpose of this study was to determine whether sex diversity among orthopaedic residency programs and faculty is associated with an increased number of female residents matriculating into that program. In addition, we sought to analyze female resident matriculation trends in the past 5 years. Methods: The American Medical Association Fellowship and Residency Electronic Interactive Database was used to identify all allopathic orthopaedic surgery residency programs during the 2021 to 2022 academic year. The number of female residents and interns; the number of female faculty, professors, and associate professors; and the number of women in leadership positions were compared with data from the academic year 2016 to 2017. Continuous data were analyzed with independent t-tests, and significance was set at p < 0.05. Results: A total of 696 female residents (19.2%) were identified from 3,624 orthopaedic residents, an increase from 13.5% in 2016. Programs in the top quartile of female residents had 3 times the number of female residents per program when compared to other quartiles and almost double the number of female interns per program. Programs in the top quartile of female residents had a significantly greater number of female faculty per program than the lower quartiles; 5.76 vs. 4.18. Compared with 2016 to 2017, there were significant increases in female faculty per program from 2.77 to 4.54 along with female full professors from 0.274 to 0.694. These increases contribute to the overall growth in the number of women in leadership positions per program over the past 5 years to 1.01 from 0.35 (p < 0.001). Conclusion: In the past 5 years, the percentage of female residents has increased from 13.5% to 19.2%. Furthermore, women make up 22.1% of interns. Orthopaedic surgery residency programs with higher percentages of female faculty had higher numbers of female residents. By encouraging programs to promote female representation within leadership and residents, we may continue to see the gap in orthopaedic sex diversity close. Level of Evidence: III.

Chlorhexidine gluconate cleansing has no effect on the structural properties of human patellar tendon allografts.

PURPOSE: If an anterior cruciate ligament graft somehow becomes contaminated intraoperatively, soaking it in 4% chlorhexidine gluconate has been shown to be the most popular and efficacious method for sterilization before implantation. The purpose of this study was to evaluate the effects of a chlorhexidine soak on the structural properties of human patellar tendon allografts. METHODS: Sixteen human patellar tendon allografts were randomly split into 2 groups of 8. Grafts in 1 group were soaked in 4% chlorhexidine gluconate for 30 minutes, and the other grafts were kept moist in normal saline-soaked gauze. Data on preload width, preload thickness, elongation, ultimate tensile load, and stiffness were obtained through measurement and mechanical testing of the grafts. RESULTS: Graft donor ages ranged from 29 to 43 years. There was no difference in the mean values of graft dimensions of the chlorhexidine-exposed group versus the normal saline-exposed group before mechanical testing (width of 9.48 mm v 9.56 mm, P = .89; thickness of 4.01 mm v 4.57 mm, P = .34). Graft elongation was not statistically different between the groups (2.52 mm v 1.43 mm, P = .27). No statistically significant difference was noted between the ultimate tensile load (2,219 N v 1,878 N, P = .36) or stiffness (274.3 N/mm v 297.0 N/mm, P = .63) of the grafts in both groups. CONCLUSIONS: Structural properties of human patellar tendon allografts are not significantly affected by soaking in 4% chlorhexidine gluconate for 30 minutes. CLINICAL RELEVANCE: Surgeons wishing to treat an inadvertently contaminated graft intraoperatively with 4% chlorhexidine may do so without concern that such treatment will impact graft strength.

Effects of using a surgical clamp to hold tension while tying knots with commonly used orthopedic sutures.

PURPOSE: Tendon repairs are often performed under some degree of tension, and in these instances the use of a clamp to temporarily secure a knot following the first throw can lessen gap formation while subsequent suture throws are made. The effect of clamping on the ultimate tensile load, stiffness, elongation, and mechanism of failure of suture loops has not been investigated for several commonly used orthopedic sutures, and it was the purpose of this study to investigate this issue. METHODS: Seven different types/sizes of braided nylon or polyblend (PB) suture were uniformly tied around an isolated 35-mm glass cylinder in a laboratory setting using no clamp, a smooth needle holder, or a serrated clamp to hold a surgeon's knot following the first throw. Knots were secured with four alternating half-hitches with reversed posts, and the suture loops were then loaded on custom hooks in an MTS axial loading frame, preloaded, cycled, and loaded to failure. Elongation, ultimate tensile load (UTL), stiffness, and mechanism of failure were recorded. RESULTS: Six of seven suture loops tied with either clamp showed statistically significant but clinically minimal (<1 mm) increased elongation following cycling. The UTL of No. 2 ForceFiber suture loops tied with serrated clamps were reduced approximately 21% compared to those tied with no clamp (227 N vs. 289 N, P = 0.003) and approximately 18% compared to those tied with a smooth clamp (227 N vs. 278 N, P = 0.016). The use of clamps did not affect the UTL for the other six sutures. Clamp use also had no effect on suture loop stiffness for four suture types/sizes, but decreased stiffness for three. Suture loops tied with a serrated clamp were more likely to fail by untying compared to those tied without a clamp, but showed no difference in mechanism of failure from those tied with a smooth clamp. CONCLUSIONS: Biomechanical parameters of suture loops were not significantly affected when clamped during tying. Surgeons wishing to temporarily clamp a knot to keep it from slipping during the tying process may do this without concern for weakening the suture.

The effect of COVID-19 on adult traumatic orthopedic injuries: a database study.

PURPOSE: This study compares orthopedic injuries, procedures, and hospital outcomes of patients presenting to trauma centers in Pennsylvania before and during the COVID-19 pandemic. METHODS: A retrospective review of adult patients presenting to hospitals with Pennsylvania Trauma Systems Foundation (PTSF) designations was performed. All patients 18 years of age and older who presented with orthopedic injuries were included. Demographic information, injury and hospital stay details, and mortality were reviewed. Data were compared between the cohorts of patients presenting during April 2020 (COVID cohort) and April 2017, April 2018, and April 2019 (pre-COVID cohort). RESULTS: Overall, 14,858 patients were reviewed, and 9427 patients were included in this study. There were fewer orthopedic injuries (4868 vs. 6603 yearly mean) in the COVID cohort which led to fewer procedures (1763 vs. 2329 yearly mean). The COVID cohort had a significantly shorter mean hospital length of stay compared to the pre-COVID cohort (4.7 days versus 5.2 days, p = 0.01). A higher mortality rate was seen in the COVID cohort (n = 115, 6.1%) compared to the pre-COVID cohort (n = 305, 4.0%; p < 0.01). CONCLUSION: The characteristics of orthopedic injuries sustained by patients presenting to trauma centers during the COVID pandemic were not different from prior to the pandemic. However, there were decreases in the number of orthopedic injuries and procedures accompanied by a 50% increase in mortality seen in these patients during the pandemic. Resources should be appropriately marshalled to prevent rises in-hospital mortality for patients with orthopedic trauma treated during a pandemic. LEVEL OF EVIDENCE: Level III.

The Effect of COVID-19 on Pediatric Traumatic Orthopaedic Injuries: A Database Study.

INTRODUCTION: Stay-at-home orders and other social distancing restrictions had a profound effect on the lives of children during the pandemic. This study characterizes pediatric orthopaedic injuries and in-hospital outcomes during the COVID-19 pandemic and compares them with pre-COVID patterns. METHODS: A retrospective review of pediatric patients presenting to hospitals with Pennsylvania Trauma Systems Foundation designations was performed. All patients younger than 18 years who presented with orthopaedic injuries were included. Patient demographics, injuries, hospital stays, and mortality were compared between the COVID and pre-COVID cohorts. RESULTS: Overall, 1112 patients were included. During the pandemic, more injuries occurred at home (44.7% versus 54.9%, P = 0.01) and fewer at sporting areas, parks, and pools (7.8% versus 1.6%, P < 0.01) as well as at schools (3.4% versus 0.5%, P = 0.03). Injuries caused by child abuse were more prevalent during the pandemic (5.6% versus 11.0%, P < 0.01). Finally, the COVID cohort had a longer mean hospital length of stay (3.1 versus 2.4 days, P = 0.01), higher mean number of ICU days (1.0 versus 0.7 days, P = 0.02), and higher mortality rate (3.8% versus 1.3%, P = 0.02). DISCUSSION: Pediatric patients sustained injuries in differing patterns during the pandemic, but these led to worse hospital outcomes, including higher mortality rates.