Traumatic Scapula Fracture with Intrathoracic Interposition: A Case Report and Review of Literature.

Introduction: Scapula fractures are infrequently operated on due to the high union rate and well-preserved motion despite a large degree of angular deformity. Scapula fractures with intrathoracic interposition are rare and typically require open reduction due to an increased risk of pleural injury from the interposed segment. While there are several reports of intrathoracic interposition of scapular fractures requiring open reduction, only one case involved subsequent fragment fixation in an adult. Case Report: Here, we present a 60-year-old male truck driver who fell from a 3-foot height and sustained a comminuted scapula body fracture with intrathoracic interposition of the lateral column adjacent to the pleural space. Following open reduction and internal fixation of the displaced fragment, the patient had satisfactory pain relief and no respiratory compromise during the acute hospital admission. The patient returned to full work duties without limitations or functional deficits as a heavy laborer. Conclusion: This case report describes a unique case and operative indication for open reduction and internal fixation of scapula fractures. Following open reduction of the interposed fragment, internal fixation should be considered to reduce the risk of further displacement and to optimize post-operative outcomes.

Bilateral Intertrochanteric Femur Fractures in a Paraplegic Patient: A Case Report.

Bilateral intertrochanteric (IT) femur fractures are rare, and appropriate evaluation and treatment can vary depending on concurrent patient comorbidities. Even less has been described for patients with bilateral IT fractures with pre-existing paraplegia. This case report describes the unique case of a 72-year-old paraplegic female who presented with bilateral IT femur fractures due to a wheelchair accident. The patient was treated with single-stage bilateral cephalomedullary nail fixation so she could effectively transfer to and from the wheelchair with less pain and a greater chance of fracture union. At the last follow-up, the patient's pain had resolved and she was able to transfer as effectively and safely as her pre-injury baseline. Single-stage cephalomedullary fixation of bilateral IT femur fractures is indicated in the paraplegic population to relieve pain and improve effective safe transfers for daily activities.

Chemical prophylaxis and venous thromboembolism following elective spinal surgery: A systematic review and meta-analysis.

Background: Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a potentially devastating complication after surgery. Spine surgery is associated with an increased risk of postoperative bleeding, such as spinal epidural hematomas (SEH), which complicates the use of anticoagulation. Despite this dilemma, there is a lack of consensus around perioperative VTE prophylaxis. This systematic review investigates the relationship between chemoprophylaxis and the incidence rates of VTE and SEH in the elective spine surgical population. Methods: A comprehensive literature search was performed using PubMed, Embase, and Cochrane databases to identify studies published after 2,000 that compared VTE chemoprophylaxis use in elective spine surgery. Studies involving patients aged < 18 years or with known trauma, cancer, or spinal cord injuries were excluded. Pooled incidence rates of VTE and SEH were calculated for all eligible studies, and meta-analyses were performed to assess the relationship between chemoprophylaxis and the incidences of VTE and SEH. Results: Nineteen studies met our eligibility criteria, comprising a total of 220,932 patients. The overall pooled incidence of VTE was 3.2%, including 3.3% for DVT and 0.4% for PE. A comparison of VTE incidence between patients that did and did not receive chemoprophylaxis was not statistically significant (OR 0.97, p=.95, 95% CI 0.43-2.19). The overall pooled incidence of SEH was 0.4%, and there was also no significant difference between patients that did and did not receive chemoprophylaxis (OR 1.57, p=.06, 95% CI 0.99-2.50). Conclusions: The use of perioperative chemoprophylaxis may not significantly alter rates of VTE or SEH in the elective spine surgery population. This review highlights the need for additional randomized controlled trials to better define the risks and benefits of specific chemoprophylactic protocols in various subpopulations of elective spine surgery.

Learning curve for imageless robotic-assisted total knee arthroplasty in non-fellowship trained joint replacement surgeons.

Introduction: Robotic-assisted total knee arthroplasty (RA-TKA) has become increasingly popular, although an associated learning curve can be a deterrent for some surgeons. Prior studies have addressed this learning curve in fellowship-trained arthroplasty surgeons, however the learning curve among non-fellowship-trained surgeons remains unclear. The objective of this study was to investigate the learning curve for imageless RA-TKA related to operative time and rates of complications among two non-arthroplasty-trained orthopedic surgeons. Methods: This retrospective case series included 200 RA-TKA consecutive cases performed by two non-arthroplasty-trained orthopedic surgeons (100 each). Cases were divided into 2 cohorts for each surgeon: the first 50 consecutive cases and the second 50 cases. These cohorts were then compared to assess for trends in each surgeon as well as in both surgeons combined. Mean operative times were compared, as were hospital length of stay, complications, readmission, and reoperations. Results: For both surgeons, the mean operative time significantly decreased from the first 50 cases to the next 50 cases (116.5 vs 108.4 min for surgeon 1, P = 0.031; 125.7 vs 109.1 min for surgeon 2, P = 0.001). No significant differences were found among length of stay, complications, readmissions, or reoperations between cohorts. Conclusion: General orthopedic surgeons can expect to optimize operative time within 50 cases, while not carrying associated risks of related complications during the early learning period.

Evaluating the utility of post-reduction imaging for simple hip joint dislocations: Is computed tomography always necessary?

Introduction: Following closed reduction of hip dislocations, computed tomography (CT) is considered standard of care to identify occult fractures or intra-articular loose bodies that may be missed on X-ray. The purpose of this study was to evaluate the sensitivity of post-reduction X-rays and the usefulness of subsequent post-reduction CT imaging. Methods: All patients presenting to our hospital system for traumatic hip dislocations from 2013 to 2022 were retrospectively reviewed. Participants were included if they had a simple dislocation of a native hip, underwent closed reduction, and received post-reduction X-ray and CT imaging. A sensitivity analysis was performed for the detection of associated fractures and intraarticular loose bodies by post-reduction X-ray, using CT as a reference standard. Results: Thirty-five subjects with a mean age of 26 years were included. Post-reduction CT revealed 6 fractures and 3 loose bodies, whereas post-reduction X-ray identified 3/6 (50%) fractures and 3/3 (100%) loose bodies. Four cases received operative management, all of which were identified by X-ray. Post-reduction X-ray had a sensitivity of 67% for identifying pathology that was subsequently found on CT, and a sensitivity of 100% for identifying pathology requiring surgery. Of the 13 cases with pre-reduction CT scans, none had new findings identified on post-reduction CT. Conclusions: Post-reduction X-rays are effective in the evaluation of acute pathology associated with closed reduction of traumatic hip dislocations, especially for cases requiring operative management. Our findings suggest that if a fracture or loose body was not identified on post-reduction X-ray, a post-reduction CT added no value in surgical decision-making and was not necessary.

Multiligament Knee Reconstruction of the ACL, PLC, and ALL in a Floating Knee: A Case Report.

Introduction: Ipsilateral fracture of the femur and tibia, known by the moniker "floating knee," is a serious injury that primarily results from high-energy trauma. Up to 53% of patients with floating knee injuries have concurrent ligamentous injuries, with the anterior cruciate ligament (ACL) as the most commonly affected ligament. Approximately 10% of multi-ligament knee injuries consist of injuries to both the ACL and posterolateral corner (PLC); however, the literature reporting the management of this patient population is sparse, particularly, with a lack of consensus on the timing and protocol of surgical treatment. Well-characterized treatment guidelines are needed for patients with concomitant floating knee and multi-ligament knee injuries. Case Report: A 26-year-old, previously healthy male involved in a high-speed motor vehicle collision presented with upper and lower extremity, skull, and facial fractures, sacropelvic dissociation, and epidural hematoma. Here we describe a rare instance of a floating knee with a multi-ligament knee injury treated through early reconstruction of the ACL, PLC, and anterolateral ligament following stabilization of long bone fractures. Post-injury day 18, the patient underwent single-stage reconstruction of his multi-ligament knee injury. The timing of this was chosen to allow for capsular scar formation to aid in arthroscopy. Conclusion: Our surgical algorithm consists of allograft reconstruction using an all-inside ACL technique and a modified anatomical PLC technique. We recommend early (1-3 weeks) surgical treatment of multi-ligament knee injuries for patients without a closed head injury; however, an individualized treatment approach should be sought, considering the severity of ligamentous injuries, pre-injury activity level, extent of soft-tissue damage, and the activity goals of the patient post-injury. In patients with floating knee injuries, the proposed surgical algorithm here may be utilized for successful multi-ligament knee injury reconstruction.

So much nuance: A qualitative analysis of parental perspectives on child passenger safety.

OBJECTIVE: To explore barriers and facilitators to optimal child restraint system (CRS) use for diverse parents of newborn infants and to obtain input from parents on the use of technology-assisted remote car seat checks as tools for promoting optimal CRS use. METHODS: Parents were recruited using purposive sampling. Interviews were conducted with English- or Spanish-speaking parents with a full term newborn and regular access to a car. Interviews were conducted by phone, and recorded and transcribed verbatim. Interviews were conducted until thematic saturation was reached. Data were organized for analysis using Atlas.ti, and codes grouped by theme using constant comparison. RESULTS: 30 parents were enrolled. Barriers and facilitators to optimal CRS use were classified into three themes, as were thoughts on the pros and cons regarding remote car seat checks. Themes on barriers and facilitators included motor vehicle and CRS features (such as age and size of the motor vehicle and presence of the Lower Anchors and Tethers for Children LATCH system), resources (availability, accessibility, and accuracy of resources), and parental factors (parental emotions and characteristics). Themes related to pros and cons of remote car seat checks included the ability (and challenge) of remote car seat checks to identify and correct errors, the potential use of remote car seat checks in certain situations (such as CRS transitions and periods of growth), and convenience of remote car seat checks (including increased availability and ease of access). Subthemes with further detail were arranged within each theme identified. CONCLUSION: From a parent perspective, there are several identified barriers and facilitators of optimal CRS use. Although car seat checks were identified as a resource, in-person accessibility was an issue, and there were mixed opinions on technology-assisted remote car seat checks. These results provide a foundation for additional study on targeted interventions, including remote interventions for which there is an increased need due to the COVID-19 pandemic.