•Stress-induced hyperglycemia has shown to correlate with a higher risk of infection and poorer outcomes.•This study presents and compares four different methods to predict infection based on glucose ...values.•Having an open fracture remains the most important predictor of infection.•Although none of these methods prove to be a driving factor for infection, we believe that they can be successfully applied to a broader orthopaedic population.
Identify a glucose threshold that would put patients with isolated bicondylar tibial plateau fractures at risk of early wound infection (i.e. < 90 days).
Retrospective review of medical records.
Academic American College of Surgeons (ACS) Level 1 trauma center.
Adult patients between 2010 and 2015 with an operatively treated isolated bicondylar tibial plateau fracture and at least three glucose measurements during their hospitalization.
To predict infection using four different methods: maximum preoperative blood glucose (PBG), maximum blood glucose (MGB), Hyperglycemic Index (HGI), and Time-Weighted Average Glucose (TWAG).
126/381 patients met our inclusion criteria. Fifteen (12%) patients had an open fracture and 30/126 (23%) developed an infection. Median glucose for each predictive method studied was 114 (IQR 101.2–137.8) mg/dL for PBG, 144 (IQR 119–169.8) mg/dL for MBG, 0.8 (IQR 0.20–1.60) mmol/L for HGI, and 120.4 (IQR 106.0–135.6) mg/dL for TWAG. As expected, infected patients had higher PBG, MGB, and TWAG. HGI was similar in both groups. None of these differences prove to be statistically significant (p > .05). Logistic regression models for all the methods showed that having an open fracture was the strongest predictor of infection.
It is well known that stress-induced hyperglycemia increases the risk of infection, we present and compare four models that have been used in other medical fields. In our study, none of the methods presented identified a glucose threshold that would increase the risk of infection in patients with bicondylar tibial plateau fractures.
Level of Evidence: Retrospective review, Level III. See Instructions for Authors for a complete description of levels of evidence.
This retrospective study aimed at identifying opiate prescribing practices, the number of morphine milligram equivalents (MMEs) prescribed by orthopaedic and nonorthopaedic providers in patients with ...operatively treated isolated lower extremity fractures, and provide opiate prescribing recommendations.
Patients older than 18 years with isolated lower extremity (unicondylar, bicondylar, tibial shaft, pilon, and ankle) fractures between 2005 and 2016 were identified. Prescribing information was obtained from the State Controlled Substance Monitoring Database. Descriptive statistics were calculated for each injury and plotted for MME use. Mann-Whitney and Wilcoxon tests were used for data analysis. To aid in clinical relevance, MMEs were converted to number of pills of oxycodone 10 mg (OC 10 mg).
Three hundred forty-one patients met our inclusion criteria. Mean age was 45 years; 56% (192/341) were men. Forty-seven percent (159/341) were prescribed opiates before their injury. Orthopaedic providers prescribed more opiates to patients with pilon fractures compared with unicondylar (P = 0.010), tibial shaft (P < 0.001), and ankle (P < 0.001) fractures. Bicondylar plateau fracture patients also received more opiates when compared with unicondylar (P = 0.001), tibial shaft (P < 0.001), and ankle (P < 0.001) fractures. Nonorthopaedic providers prescribed more opiates to patients with pilon fractures when compared with unicondylar (P = 0.006), bicondylar (P < 0.001), tibial shaft (P < 0.001), and ankle fractures (P = 0.006). Differences between orthopaedic and nonorthopaedic MMEs prescribed are significantly different for each injury type (<0.05).
Patients with pilon or bicondylar tibial plateau fractures are currently being prescribed more opiates when compared with other isolated fractures. We have developed an opiate prescription guideline based on what is being prescribed by orthopaedic providers.
To evaluate mechanical treatment failure in a large patient cohort sustaining a distal femur fracture treated with a distal femoral locking plate (DFLP).
This retrospective case-control series ...evaluated mechanical treatment failures of DFLPs.
The study was conducted at 8 Level I trauma centers from 2010 to 2017.
One hundred one patients sustaining OTA/AO 33-A and C distal femur fractures were treated with DFLPs that experienced mechanical failure.
The intervention included the treatment of a distal femur fracture with a DFLP, affected by mechanical failure (implant failure by loosening or breakage).
The main outcome measures included injury and DFLP details; modes and timing of failure were studied.
One hundred forty-six nonunions were found overall (13.4%) including 101 mechanical failures (9.3%). Failures occurred in different manners, locations, and times depending on the DFLPs. For example, 33 of 101 stainless steel (SS) plates (33%) failed by bending or breaking in the working length, whereas no Ti plates failed here ( P < 0.05). Eleven of 12 failures with titanium-Less Invasive Stabilization System (92%) occurred by lost shaft fixation, mostly by the loosening of unicortical screws (91%). Sixteen of 44 variable -angled-LCP failures (36%) occurred at the distal plate-screw junction, whereas only 5 of 61 other DFLPs (8%) failed this way ( P < 0.05). Distal failures occurred on average at 23.7 weeks compared with others that occurred at 38.4 weeks ( P < 0.05). Variable -angled-LCP distal screw-plate junction failures occurred earlier (mean 21.4 weeks).
Nonunion and mechanical failure occurred in 14% and 9% of patients, respectively, in this large series of distal femur fracture treated with a DFLP. The mode, location, presence of a prosthesis, and timing of failure varied depending on the characteristics of DFLP. This information should be used to optimize implant usage and design to prolong the period of stable fixation before potential implant failures occur in patients with a prolonged time to union.
Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
The purpose of this study was to compare 18-month clinical and patient-reported outcomes between patients with severe lower-limb injuries treated with a transtibial amputation or a hind- or midfoot ...amputation. Despite the theoretical benefits of hind- and midfoot-level amputation, we hypothesized that patients with transtibial amputations would report better function and have fewer complications.
The study included patients 18 to 60 years of age who were treated with a transtibial amputation (n = 77) or a distal amputation (n = 17) and who were enrolled in the prospective, multicenter Outcomes Following Severe Distal Tibial, Ankle, and/or Foot Trauma (OUTLET) study. The primary outcome was the difference in Short Musculoskeletal Function Assessment (SMFA) scores, and secondary outcomes included pain, complications, amputation revision, and amputation healing.
There were no significant differences between patients with distal versus transtibial amputation in any of the domains of the SMFA: dysfunction index distal versus transtibial, 31.2 versus 22.3 (p = 0.13); daily activities, 37.3 versus 26.0 (p = 0.17); emotional status, 41.4 versus 29.3 (p = 0.07); mobility, 36.5 versus 27.8 (p = 0.20); and bother index, 34.4 versus 23.6 (p = 0.14). Rates of complications requiring revision were higher for distal amputations but not significantly so (23.5% versus 13.3%; p = 0.28). One distal and no transtibial amputees required revision to a higher level (p = 0.18). A higher proportion of patients with distal compared with transtibial amputation required local surgical revision (17.7% versus 13.3%; p = 0.69). There was no significant difference between the distal and transtibial groups in scores on the Brief Pain Index at 18 months post-injury.
Surgical complication rates did not differ significantly between patients who underwent transtibial versus hind- or midfoot amputation for severe lower-extremity injury. The average SMFA scores were higher (worse), although not significantly different, for patients undergoing distal compared with transtibial amputation, and more patients with distal amputation had a complication requiring surgical revision. Of note, more patients with distal amputation required closure with an atypical flap, which likely contributed to less favorable outcomes.
Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
Current guidelines recommend low-molecular-weight heparin for thromboprophylaxis after orthopaedic trauma. However, recent evidence suggests that aspirin is similar in efficacy and safety. To ...understand patients' experiences with these medications, we compared patients' satisfaction and out-of-pocket costs after thromboprophylaxis with aspirin versus low-molecular-weight heparin.
This study was a secondary analysis of the PREVENTion of CLots in Orthopaedic Trauma (PREVENT CLOT) trial, conducted at 21 trauma centers in the U.S. and Canada. We included adult patients with an operatively treated extremity fracture or a pelvic or acetabular fracture. Patients were randomly assigned to receive 30 mg of low-molecular-weight heparin (enoxaparin) twice daily or 81 mg of aspirin twice daily for thromboprophylaxis. The duration of the thromboprophylaxis, including post-discharge prescription, was based on hospital protocols. The study outcomes included patient satisfaction with and out-of-pocket costs for their thromboprophylactic medication measured on ordinal scales.
The trial enrolled 12,211 patients (mean age and standard deviation SD, 45 ± 18 years; 62% male), 9725 of whom completed the question regarding their satisfaction with the medication and 6723 of whom reported their out-of-pocket costs. The odds of greater satisfaction were 2.6 times higher for patients assigned to aspirin than those assigned to low-molecular-weight heparin (odds ratio OR: 2.59; 95% confidence interval CI: 2.39 to 2.80; p < 0.001). Overall, the odds of incurring any out-of-pocket costs for thromboprophylaxis medication were 51% higher for patients assigned to aspirin compared with low-molecular-weight heparin (OR: 1.51; 95% CI: 1.37 to 1.66; p < 0.001). However, patients assigned to aspirin had substantially lower odds of out-of-pocket costs of at least $25 (OR: 0.15; 95% CI: 0.12 to 0.18; p < 0.001).
Use of aspirin substantially improved patients' satisfaction with their medication after orthopaedic trauma. While aspirin use increased the odds of incurring any out-of-pocket costs, it protected against costs of ≥$25, potentially improving health equity for thromboprophylaxis.
Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.
This multicenter cohort study investigated the association of serology and comorbid conditions with septic and aseptic nonunion.
From January 1, 2011, to December 31, 2017, consecutive individuals ...surgically treated for nonunion were identified from seven centers. Nonunion-type, comorbid conditions and serology were assessed.
A total of 640 individuals were included. 57% were male with a mean age of 49 years. Nonunion sites included tibia (35.2%), femur (25.6%), humerus (20.3%), and other less frequent bones (18.9%). The type of nonunion included septic (17.7%) and aseptic (82.3%). Within aseptic, nonvascular (86.5%) and vascular (13.5%) nonunion were seen. Rates of smoking, alcohol abuse, and diabetes mellitus were higher in our nonunion cohort compared with population norms. Coronary artery disease and tobacco use were associated with septic nonunion (P < 0.05). Diphosphonates were associated with vascular nonunion (P < 0.05). Serologically, increased erythrocyte sedimentation rate, C-reactive protein, parathyroid hormone, red cell distribution width, mean platelet volume (MPV), and platelets and decreased absolute lymphocyte count, hemoglobin, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, and albumin were associated with septic nonunion while lower calcium was associated with nonvascular nonunion (P < 0.05). The presence of four or more of increased erythrocyte sedimentation rate, C-reactive protein, or red cell distribution width; decreased albumin; and age younger than 65 years carried an 89% positive predictive value for infection. Hypovitaminosis D was seen less frequently than reported in the general population, whereas anemia was more common. However, aside from hematologic and inflammatory indices, no other serology was abnormal more than 25% of the time.
Abnormal serology and comorbid conditions, including smoking, alcohol abuse, and diabetes mellitus, are seen in nonunion; however, serologic abnormalities may be less common than previously thought. Septic nonunion is associated with inflammation, younger age, and malnourishment. Based on the observed frequency of abnormality, routine laboratory work is not recommended for nonunion assessment; however, specific focused serology may help determine the presence of septic nonunion.
Selecting the best treatment for patients with severe terminal lower-limb injury remains a challenge. For some injuries, amputation may result in better outcomes than limb salvage. This study ...compared the outcomes of patients who underwent limb salvage with those that would have been achieved had they undergone amputation.
This multicenter prospective observational study included patients 18 to 60 years of age in whom a Type-III pilon or IIIB or C ankle fracture, a Type-III talar or calcaneal fracture, or an open or closed blast/crush foot injury had been treated with limb salvage (n = 488) or amputation (n = 151) and followed for 18 months. The primary outcome was the Short Musculoskeletal Function Assessment (SMFA). Causal effect estimates of the improvement that amputation would have provided if it had been performed instead of limb salvage were calculated for the SMFA score, physical performance, pain, participation in vigorous activities, and return to work.
The patients who underwent limb salvage would have had small differences in most outcomes had they undergone amputation. The most notable difference was an improvement in the SMFA mobility score of 7 points (95% confidence interval CI = 2.0 to 10.7). Improvements were largest for pilon/ankle fractures and complex injury patterns.
Amputation should be considered a treatment option rather than a last resort for the most complex terminal lower-limb injuries.
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Opioid Prescribing Practices After Isolated Pilon Fractures Rodriguez-Buitrago, Andres; Attum, Basem; Enata, Nichelle ...
The Journal of foot and ankle surgery,
November-December 2018, 2018 Nov - Dec, 2018-11-00, 20181101, Volume:
57, Issue:
6
Journal Article
Peer reviewed
The purpose of our study was to identify the opioid-prescribing practices after operative treatment of isolated pilon fractures at a level 1 trauma center. Patients ≥ 18 years of age with an ...operatively treated isolated pilon fracture between 2005 and 2015 were identified. Total morphine milligram equivalents (MMEs) were then calculated. Mean and standard deviations were calculated for patients without a history of opiate use and for patients with a history of opiate use within 1 year prior to injury. Data were obtained from the State Controlled Substance Monitoring Database. Seventy-two patients met our inclusion criteria; of these, 54% (39/72) were opiate exposed at the time of injury. Median MMEs prescribed were 2738 (range 375 to 12,360). Orthopedic providers prescribed 61% of all the MMEs (median 2010; range 113 to 6825), while nonorthopedic providers prescribed a median of 338 MMEs (range 0 to 10,080) (p < .05). Combined, patients with exposure 1 year before the injury received more MMEs (median 3600; range 840 to 12,360) than opiate-naive patients (median 2520; range 375 to 10,610) (p < .05). Twenty-eight (38.9%) patients continued using opiates for more than 6 months after their injury; 25% (7/28) were not previously exposed. There is great variability regarding the quantity of opiates being prescribed after isolated pilon fractures, and 39% of opiate prescriptions are coming from nonorthopedic prescribers. Opiate-exposed patients are more likely to be prescribed more opiates by orthopedists and outside physicians and for a longer duration. We believe that adequate pain control can be obtained by prescribing 40 pills of oxycodone 10 mg with a maximum of 1 additional refill. In cases in which a staged procedure is planned, an additional refill is expected (total of 3 refills).
To assess the operative results of femoral neck fractures (FNFs) in young adults in a large multicenter series, specifically focusing on risk factors for treatment failure.
Large multicenter ...retrospective cohort series.
Twenty-six North American Level 1 trauma centers.
Skeletally mature patients younger than 50 years with displaced and nondisplaced FNFs treated between 2005 and 2017.
Operative repair of FNF.
The main outcome measure is treatment failure: nonunion and/or failed fixation, osteonecrosis, malunion, and need for subsequent major reconstructive surgery (arthroplasty or proximal femoral osteotomy). Logistic regression models were conducted to examine factors associated with treatment failure.
Of 492 patients with FNFs studied, a major complication and/or subsequent major reconstructive surgery occurred in 45% (52% of 377 displaced fractures and 21% of 115 nondisplaced fractures). Overall, 23% of patients had nonunion/failure of fixation, 12% osteonecrosis type 2b or worse, 15% malunion (>10 mm), and 32% required major reconstructive surgery. Odds of failure were increased with fair-to-poor reduction odds ratio (OR) = 5.29, 95% confidence interval (CI) = 2.41-13.31, chronic alcohol misuse (OR = 3.08, 95% CI = 1.59-6.38), comminution (OR = 2.63, 95% CI = 1.69-4.13), multiple screw constructs (vs. fixed-angle devices, OR = 1.95, 95% CI = 1.30-2.95), metabolic bone disease (OR = 1.77, 95% CI = 1.17-2.67), and increasing age (OR = 1.03, 95% CI = 1.01-1.06). Women (OR = 0.57, 95% CI = 0.37-0.88), Pauwels angle ≤50 degrees (type 1 or 2; OR = 0.64, 95% CI = 0.41-0.98), or associated femoral shaft fracture (OR = 0.19, 95% CI = 0.10-0.33) had lower odds of failure.
FNFs in adults <50 years old remain a difficult clinical and surgical problem, with 45% of patients experiencing major complications and 32% undergoing subsequent major reconstructive surgery. Risk factors for complications after treatment of displaced FNFs were numerous.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
To evaluate the effect of technical errors (TEs) on the outcomes after repair of femoral neck fractures in young adults.
Multicenter retrospective clinical study.
26 North American Level 1 Trauma ...Centers.
Skeletally mature patients younger than 50 years of age with 492 femoral neck fractures treated between 2005 and 2017.
Operative repair of femoral neck fracture.
The association between TE (malreduction and deviation from optimal technique) and treatment failure (fixation failure, nonunion, malunion, osteonecrosis, malunion, and revision surgery) were examined using logistic regression analysis.
Overall, a TE was observed in 50% (n = 245/492) of operatively managed femoral neck fractures in young patients. Two or more TEs were observed in 10% of displaced fractures. Treatment failure in displaced fractures occurred in 27% of cases without a TE, 56% of cases with 1 TE, and 86% of cases with 2 or more TEs. TEs were encountered less frequently in treatment of nondisplaced fractures compared with displaced fractures (39% vs. 53%, P < 0.001). Although TE(s) in nondisplaced fractures increased the risk of treatment failure and/or major reconstructive surgery (22% vs. 9%, P < 0.001), they were less frequently associated with treatment failure when compared with displaced fractures with a TE (22% vs. 69% P < 0.001).
TEs were found in half of all femoral neck fractures in young adults undergoing operative repair. Both the occurrence and number of TEs were associated with an increased risk for failure of treatment. Preoperative planning for thoughtful and well-executed reduction and fixation techniques should lead to improved outcomes for young patients with femoral neck fractures. This study should also highlight the need for educational forums to address this subject.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
