The past few decades have seen an alarming rise in opioid use in the United States, and the negative consequences from diversion of opioids for nontherapeutic use are dramatically increasing. A ...significant number of orthopaedic patients are at risk for repercussions from both therapeutic and nontherapeutic opioid use. Orthopaedic surgeons are the third highest prescribers of opioid prescriptions among physicians in the United States. Thus, it is important for orthopaedic surgeons to understand the detrimental effects of opioid abuse on individuals and society and to recognize objective measures to identify patients at risk for nontherapeutic opioid use. These measures include elements of the patient history, recognition of aberrant behaviors, prescription drug monitoring programs, and opioid risk-assessment tools.
The COVID-19 pandemic has presented challenges to healthcare systems, including the cancellation and then staged resumption of elective procedures. The orthopaedic trauma community has continued to ...provide care to patients with acute musculoskeletal injuries that cannot be delayed in all scenarios. This article summarizes and provides relevant information (orthopaedic trauma service, outpatient fracture clinic, inpatient surgery) to the practicing orthopaedic traumatologist on maximizing outcomes while limiting exposure during the pandemic. LEVEL OF EVIDENCE:: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.
To report on the immediate postoperative alignment of distal tibia fractures (within 5 cm of the tibial plafond) treated with suprapatellar intramedullary nail (IMN) insertion compared with the ...infrapatellar technique. Primary outcomes include alignment on both the anteroposterior and lateral radiographic views.
Retrospective cohort study.
Two urban level I trauma centers.
A total of 266 skeletally mature patients with a distal tibia fracture were treated with an IMN. One hundred thirty-two patients underwent this procedure through a suprapatellar technique.
Intramedullary nail placement.
Alignment.
The 2 treatment groups were evenly matched with respect to age, gender, fracture grade, and the presence of open fracture. Within the suprapatellar group, the fibula was intact, fixed, and remained fractured in 6 (4.5%), 22 (16.7%), and 104 (78.8%) cases, respectively. The fibula was intact, repaired, and remained fractured in 9 (6.7%), 32 (23.9%), and 93 (69.4%) cases, respectively, in the infrapatellar group. There was no difference in the rate of fibular fixation between the groups (P = 0.2). Primary angular malalignment of ≥5 degrees occurred in 35 (26.1%) patients with infrapatellar IMN insertion and in 5 (3.8%) patients who underwent suprapatellar IMN insertion (P < 0.0001).
This is the largest patient series directly comparing the suprapatellar with infrapatellar IMN insertion technique in the treatment of distal tibia fractures. In the treatment of distal tibia fractures, suprapatellar IMN technique results in a significantly lower rate of malalignment compared with the infrapatellar IMN technique.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Despite advances in management, open fractures are at an elevated risk for deep fracture-related infection (FRI). Time to systemic antibiotic (ABX) administration and intraoperative topical ...administration of ABX powder have been used to decrease FRI risk. The purpose of this study was to determine whether topical application of antibiotic powder to type III open lower extremity fractures immediately on presentation to the emergency department (ED) reduces the rate of FRI.
Prospective cohort compared with retrospective historical control.
Level I trauma center.
Application of 1 g of vancomycin and 1.2 g of tobramycin powder directly to open fracture wounds on presentation to the ED.
Patients with type III open lower extremity fractures treated from July 1, 2019, to September 17, 2022, who received topical ABX powder in the ED were compared with patients from a 4-year historical cohort from July 1, 2015, to June 30, 2019, who were treated without topical ABX powder.
Development of a FRI within 6 months of follow-up. Patient demographics, injury characteristics, and postoperative data were analyzed as risk factors for FRI.
Sixty-six patients received topical ABX powder in the ED and were compared with 129 patients who were treated without topical ABX powder. The rate of FRI in the trial group was 6/66 (9.09%) versus 22/129 (17.05%) in the control cohort ( P = 0.133). Multivariate analysis demonstrated higher body mass index as a risk factor for development of FRI ( P = 0.036).
No statistically significant difference in rates of FRI in open lower extremity fractures treated with immediate topical ABX administration in the ED versus standard-of-care treatment without topical ABX was found. These findings may have been limited by insufficient power. Further large-scale study is warranted to determine the significance of topical antibiotic powder application in the ED.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Controversy remains regarding the optimal management of tarsometatarsal (Lisfranc) fracture dislocations. Open reduction and internal fixation (ORIF) and ORIF with primary arthrodesis (PA) have been ...described in the treatment of these injuries, although adverse sequelae remain problematic. Previous work has yielded small cohorts with heterogenous results. We aimed to describe the outcomes of Lisfranc fracture dislocations managed with ORIF and/or PA to identify risk factors for complications, such as nonunion and revision surgery.
A retrospective review of 206 consecutive tarsometatarsal fracture dislocations that underwent surgical repair between 2015 and 2021 was performed. Time to radiographic union was noted. Complications were recorded, including revision surgery, infection, symptomatic implant removal, posttraumatic arthritis, secondary arthrodesis, and nonunion. A comparative subgroup analysis of outcomes by treatment modality (ie, PA versus ORIF) and by injury severity (isolated injury versus concomitant lower extremity fracture) were performed. Logistic regression analysis was performed to assess factors associated with revision surgery.
104 patients met the inclusion criteria with a mean 13-month follow-up. Ninety-three (n = 93) patients underwent ORIF, and 11 patients underwent PA. Radiographic union was achieved in 94.2% of cases (98/104) at an average 106 days. Complications included superficial infection (3.8%), deep infection (7.7%), symptomatic implant removal (19.2%), posttraumatic arthritis (12.5%), secondary arthrodesis (4.8%), and nonunion (2.9%). No difference existed in the complication rates between those who underwent ORIF and those who underwent PA ( P = 0.50). Revision surgery rates were similar between patients who sustained isolated injuries and those with concomitant lower extremity fractures ( P = 0.31). Risk factors for revision surgery included open fractures (OR 4.01, P = 0.042) and previous psychiatric illness (OR 5.77, P = 0.016).
The vast spectrum of injury in Lisfranc fracture dislocations makes uniform treatment challenging. In this large consecutive series, few failed to achieve union or required secondary arthrodesis. Open fractures and previous psychiatric illness portended worse clinical outcomes. ORIF without PA remains a viable treatment in these injuries.
Level III, retrospective cohort study.
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