Comparison of Short-Arm Immobilization and Long-Arm Immobilization in Conservatively Managed Distal Radius Fractures: A Meta-Analysis and Systematic Review.

Distal radius fractures are often treated conservatively with immobilization. Immobilizing above the elbow limits forearm rotation, though recent literature has suggested the effects on radiographic or functional outcomes may be negligible. This systematic review and meta-analysis aimed to analyze the radiographic and functional outcome scores of distal radius fractures managed with short-arm (SA) immobilization and long-arm (LA) immobilization. An electronic systematic search was performed of the PubMed and EMBASE databases from inception to October 5, 2022. All randomized controlled trials (RCTs) involving patients with acute distal radius fractures undergoing nonoperative treatment (involving application/maintenance of immobilization) comparing above-elbow versus below-elbow constructs were included. The outcomes of interest were changes in radiographic parameters (loss of volar tilt [VT], radial height [RH], and radial inclination [RI]), loss of reduction, requirement for surgery, and patient-reported functional outcomes (Disabilities of the Arm, Shoulder, or Hand [DASH] or Quick DASH survey). The Cochrane Risk of Bias Tool 2.0 was used for study quality assessment. The effect size of the interventions was assessed using random effect models to calculate mean differences (MDs) for continuous variables and odds ratios (ORs) for categorical variables. Standardized mean difference (SMD) was calculated for patient-reported functional outcome scores. Nine studies involving 983 cases were included, including 497 SA and 486 LA. No statistically significant differences were observed with regards to VT (P = 0.83), RH (P = 0.81), RI (P = 0.35), loss of reduction (P = 0.33), requirement for surgery (P = 0.33), or patient-reported functional outcomes (P = 0.10). There was no difference in radiographic outcomes, need for surgery, or functional scores among patients treated with SA and LA immobilization. Utilizing SA immobilization is a safe option for conservative management of distal radius fractures and the benefits of mitigating complications associated with LA immobilization may supersede the theoretical limited forearm rotational stability observed with SA immobilization. Further study is required to determine the optimal method of SA immobilization.

Outcomes of hip fracture surgery during the COVID-19 pandemic.

PURPOSE: To investigate if changes to hospital operational models during the COVID-19 pandemic negatively impacted overall time to surgery (TtS) as well as morbidity and mortality rates of hip fractures (HFx). METHODS: 416 patients treated for OTA 31 fractures at a single institution between January 2019 and November 2020 were reviewed. TtS as well as morbidity and mortality rates were obtained from pre-pandemic and pandemic groups. RESULTS: 263 patients were treated pre-pandemic and 153 were treated during the pandemic. There were no significant differences in median TtS, readmission rates (p = 0.134), reoperation rates (p = 0.052), 30-day (p = 0.095) and 90-day (p = 0.22) mortality rates. CONCLUSION: Reallocation of hospital resources in response to the COVID-19 pandemic did not negatively impact surgical timing or complications. TtS for HFx remains a challenge and often requires multidisciplinary care, which is complicated by a pandemic. However, this study demonstrates HFx standard of care can be maintained despite COVID-19 obstacles to treatment efficiency and efficacy.

Implant Removal Due to Infection After Open Reduction and Internal Fixation: Trends and Predictors.

Background: Implant removal due to infection is one of the major causes failure following open reduction and internal fixation (ORIF). The aim of this study was to determine trends and predictors of infection-related implant removal following ORIF of extremities using a nationally representative database. Methods: Nationwide Inpatient Sample data from 2006 to 2017 was used to identify cases of ORIF following upper and lower extremity fractures, as well as cases that underwent infection-related implant removal following ORIF. Multivariate analysis was performed to identify independent predictors of infection-related implant removal, controlling for patient demographics and comorbidities, hospital characteristics, site of fracture, and year. Results: For all ORIF procedures, the highest rate of implant removal due to infection was the phalanges/hand (5.61%), phalanges/foot (5.08%), and the radius/ulna (4.85%). Implant removal rates due to infection decreased in all fractures except radial/ulnar fractures. Tarsal/metatarsal fractures (odds ratio (OR)=1.45, 95% confidence interval (CI): 1.02-2.05), and tibial fractures (OR=1.82, 95% CI: 1.45-2.28) were identified as independent predictors of infection-related implant removal. Male gender (OR=1.67, 95% CI: 1.49-1.87), Obesity (OR=1.85, 95% CI: 1.34-2.54), diabetes mellitus with chronic complications (OR=1.69, 95% CI: 1.13-2.54, P<0.05), deficiency anemia (OR=1.59, 95% CI: 1.14-2.22) were patient factors that were associated with increased infection-related removals. Removal of implant due to infection had a higher total charge associated with the episode of care (mean: $166,041) than non-infection related implant removal (mean: $133,110). Conclusion: Implant removal rates due to infection decreased in all fractures except radial/ulnar fractures. Diabetes, liver disease, and rheumatoid arthritis were important predictors of infection-related implant removal. The study identified some risk factors for implant related infection following ORIF, such as diabetes, obesity, and anemia, that should be studied further to implement strategies to reduce rate of infection following ORIF.

Acute Correction of Leg Length Discrepancy and Severe Femoral Malalignment: A Case Report.

Introduction: Approximately 70% of the population have a leg length discrepancy, with 2 cm being the threshold for surgical treatment. Although there are reports of patient outcomes after incremental leg-lengthening, there is a paucity of data regarding acute lengthening procedures. We present a unique case of acute leg lengthening and correction of severe malalignment in an adult patient after femoral malunion treated with multiple modified Sofield-Millar osteotomies and intramedullary nailing, a technique that has only previously been performed in pediatric long bone deformities. To the author's knowledge, there have been no previous reports of acute lengthening in an adult patient to correct for such a severe deformity in a single operation. Case Report: A 48-year-old woman with a 35-year history of a right femur fracture malunion presented with a 5 cm leg length discrepancy and severe malalignment associated with pain and ambulatory dysfunction. Multiple modified Sofield-Millar osteotomies followed by placement of an intramedullary nail were performed and resulted in successful acute correction of limb length discrepancy and anatomical alignment. There was a complete union of bone with callus formation at osteotomy sites at 9 months postoperatively, and the patient reported minimal pain and improved ambulation. The patient was followed for 2 years postoperatively and experienced an improvement in ambulatory function with no pain. No post-operative complications were observed. Conclusion: Multiple modified Sofield-Millar osteotomies with intramedullary nailing were utilized for successful acute correction of limb length discrepancy and severe malalignment with improvement in pain and ambulatory function in this case of femoral leg length discrepancy in an adult patient.

Treatment of Femoral Shaft Fractures in Patients with Klippel-Trénaunay Syndrome: A Report of 2 Cases.

CASES: Long-bone fractures in patients with Klippel-Trénaunay syndrome (KTS), a rare disorder of the venous, lymphatic, and capillary system, are difficult to treat with many complications. Two patients diagnosed with KTS presented with closed femoral shaft fractures after low-energy falls. Conservative treatment, open reduction internal fixation, and intramedullary nailing resulted in painful nonunions. Ultimately, both patients achieved pain relief and the ability to ambulate after en bloc resection and reconstruction. CONCLUSIONS: These cases demonstrate the challenges in achieving bony union when treating long-bone fractures in KTS. The feasibility of undergoing extensive resection and reconstruction to regain function is best approached with a multidisciplinary team.

Management of Pediatric Femur Fracture Using 90-90 Traction.

SUMMARY: This video discusses treatment of pediatric femur fractures using 90-90 traction, followed by delayed spica casting. This study details the treatment of a 2-year-old girl with a subtrochanteric femur fracture featuring a 4-cm acute shortening and severe malalignment. The patient was placed in 90-90 traction in the operative setting. When adequate callous was observed radiographically, the patient was treated with a spica cast in the hospital on day 16. She was noted to have obtained uneventful healing of the fracture with no functional deficits, as detailed during serial office visits.

Management of long bone fractures in patients with cerebral fat embolism syndrome.

Fat embolism syndrome (FES) is a rare complication associated with long bone fractures. Intramedullary nailing is the gold standard for treating patients with these injuries and early surgical intervention can prevent FES. However, there is a paucity of data on managing these patients once FES has developed. The purpose of this study is to present 3 unique cases of polytrauma patients with long bone fractures who underwent fixation with Taylor Spatial Frame, open reduction and internal fixation, or submuscular plating for treatment of these injuries. All 3 patients had complete cognitive and physical recovery.

Surgical Fixation of Sacral Fractures in the Elderly Population: Are There Predictors of Outcome? An Analysis of Return to Ambulation and Residential Living Status.

INTRODUCTION: Recent literature suggests that surgical fixation of elderly sacral fractures may reduce time to mobilization and ultimately self-sufficiency. However, it is unclear if predictors of success exist in this subpopulation. The objective of this study was to characterize relative change in ambulation and residential living statuses (pre-injury vs. post-surgery) of elderly patients who received surgical fixation of sacral fractures, as well as determine whether or not demographics and injury characteristics influence these findings. METHODS: Fifty-four elderly patients (≥60 years old) receiving percutaneous screw fixation of sacral fractures were retrospectively reviewed. All fractures were traumatic in nature; insufficiency fractures were excluded. Patient and surgical demographic data, as well as 1-year mortality status, was reported. Primary study endpoints included relative change in patient ambulation and residential living statuses (pre-injury to post-surgery). Statistical analyses were performed to assess relative change in ambulation/living status from pre-injury to post-surgery and to determine if predictors of outcome existed. RESULTS: Of the 54 patients who met inclusion criteria, 4 expired prior to discharge, 2 expired post-discharge, and 4 were lost to follow-up. Of those patients discharged, 95.7% regained some form of ambulation at last follow-up (mean: 22.4 ± 18.9 weeks). Of patients living independent pre-injury, 94.9% would eventually return to independent home living. Neither time-to-surgery, concomitant orthopaedic injury, Charlson Comorbidity Index, or injury mechanism were predictors of final ambulation or residential status (p ≥ 0.07). Mortality at 1-year was 11.1%. DISCUSSION: Operative fixation supported a high rate of return to pre-injury ambulation and residential living status. However, there did not appear to be measures predictive of final functional status. Further efforts with larger, prospective cohorts are warranted.

Arthroscopic-Assisted Reduction of Tibial Plateau Fractures.

Arthroscopic reduction of tibial plateau fractures have been gaining in popularity. Advantages include accurate diagnosis and treatment of joint pathology, minimally invasive soft tissue dissection, quicker recovery of joint motion, and anatomic reduction of joint surface. Success depends on accurate fracture selection. With arthroscopic-assisted reduction of tibial plateau fractures, patient set-up is similar to standard knee arthroscopy, but the C-arm is used to aid with fracture reduction and fixation. Outcomes are comparable or even improved when compared with standard procedures, and morbidity with arthroscopic reduction can often be lower with decreased rates of infection, wound complications, and thromboembolism.

Comparison of Hand Drills for the Insertion of Skeletal Traction Pins.

Skeletal traction pins are inserted as part of emergent stabilization of lower extremity fractures. The purpose of this study is to compare two drill options: a reusable store-bought drill and a single-use, sterilely packaged drill. The reusable drill and disposable drill were compared by having volunteers insert traction pins within a foam bone, fully encased, knee joint model using both systems. The two drill types were evaluated on three measures: user satisfaction, time required for insertion of the pins, and cost. The disposable drill received a statistically significant higher user satisfaction score and a statistically significant faster time to pin insertion. The per-use cost of the disposable system was found to be higher. For skeletal traction pin insertion, the disposable, single-use drill was found to be superior to the reusable drill in user satisfaction and time required for traction pin insertion. Institutional cost analysis favors the disposable system because of the more predicable charge capture, while the per-use cost of the disposable system remains higher. (Journal of Surgical Orthopaedic Advances 27(4):274-276, 2018).

Head-on Allograft Transplantation: A Unique Case Report Where a Large Piece of Femoral Bone was Extruded from One Patient's Body and Impaled Another Patient's Tibia.

INTRODUCTION: Open femoral fractures are relatively uncommon occurrences, with few reports addressing their management. They are caused by high-energy mechanisms, and bone loss is a possible, but infrequent occurrence. We present a case in which two friends, 20- and 21-year-old males, were involved in a motorcycle collision. A large piece of bone was ejected from one patient's femur as a bony projectile and impaled the other patient's tibia, resulting in an open tibial plateau fracture. This is the first case in the English literature, to the best of our knowledge, in which a piece of bone was ejected from one patient, causing a fracture in another. CASE REPORT: Two males, in their mid-twenties, were involved in a head-on motorcycle collision. Both patients sustained open fractures to their lower extremities. A large piece of bone was ejected from one patient's femur and impaled the other patient's tibia, causing an open tibial plateau fracture. The patient who provided the bony projectile underwent retrograde intramedullary nail fixation. The segmental piece of bone was not replanted, and he went on to heal without negative sequelae at 2-year follow-up. CONCLUSION: To the best of our knowledge, this is the first case documented in the English literature in which an ejected piece of bone from one person caused a fracture in another fracture. Management of extruded bone segments should be considered on a case-by-case basis.

Intrapleural Penetration of a Clavicle Fracture: An Indication for Operative Fixation.

INTRODUCTION: Clavicle fractures are common injuries treated by orthopedic surgeons, with most injuries managed nonoperatively. Operative fixation of clavicle fractures is indicated in specific clinical scenarios such as open injuries, ipsilateral shoulder trauma, or fractures with associated neurovasculature compromise. Operative fixation is not widely accepted for closed injuries and is typically reserved for instances of failed closed treatment with resultant nonunion or delayed union. Among the complications associated with clavicle fractures, pneumothorax has not been commonly reported. We report a case of a severely displaced clavicle fracture requiring operative repair through plate fixation to achieve union of the fracture as well as resolve the pneumothorax. CASE REPORT: A 22-year-old intoxicated male with no past medical history was admitted to the trauma bay in stable condition after being involved in a motor vehicle accident. On the primary survey, the patient was noted to be tachypneic with decreased breath sounds over his right hemithorax. Radiographic studies of his chest demonstrated a right proximal third clavicle fracture with inferior displacement with associated partial pneumothorax; the patient was also noted to have a right femoral shaft fracture. Neurovascular examinations of his extremities were normal. A chest thoracostomy tube was inserted and placed under suction. Computerized tomography studies later revealed that the fractured clavicle had penetrated the pleura and caused the partial lung collapse. The patient was initially placed in a sling and underwent intramedullary nailing of his femur on the day of presentation. Given the severe displacement of his clavicle fracture into the lung tissue resulting in pneumothorax, there was significant concern for nonunion and lack of resolution of the pneumothorax. 2 days after stabilization of his right femur fracture, the patient underwent open reduction with internal fixation of his right clavicle. Follow-up radiographs showed a healed clavicle fracture and resolved pneumothorax. CONCLUSION: Closed clavicle fractures typically heal uneventfully. Low energy, minimally displaced clavicle fractures can be managed nonoperatively, but high energy, significantly displaced injuries may require operative repair. Specifically, if these injuries result in pneumothorax, physicians shoulder consider operative repair for both treatment of the bony defect as well resulting pneumothorax.

The Effect of Opioids, Alcohol, and Nonsteroidal Anti-inflammatory Drugs on Fracture Union.

The estimated rate of fracture nonunion is between 5% and 10%, adding significant cost to the health care system. The cause of fracture nonunion is multifactorial, including the severity of the injury, patient factors resulting in aberrancies in the biology of fracture, and the side effects of pain control modalities. Minimizing surgeon-controlled factors causing nonunion is important to reduce the cost of health care and improve patient outcomes. Opioids, alcohol, and nonsteroidal anti-inflammatory drugs have been implicated as risk factors for fracture nonunion. Current literature was reviewed to examine the effects of opioids, alcohol, and nonsteroidal anti-inflammatory drugs on fracture union.

Lower Limb Morel-Lavallée Lesion Treated With Short-Stretch Compression Bandaging.

Morel-Lavallée lesions (MLLs) classically occur in the greater trochanteric region, lateral thigh, buttocks, and back. A high percentage of large MLLs require surgical intervention, which comes with an increased risk of skin necrosis and infection. We report a rare case of a large MLL that was successfully treated with compression. The lesion was created when the patient, a 66-year-old man, sustained a low-velocity crush injury. Extending from the medial distal thigh to the proximal medial calf, the MLL was nonoperatively treated with the short-stretch compression bandaging that is used in lymphedema management. The MLL resolved successfully and without complication or the need for surgical intervention.

Bleeding disorders in orthopedic surgery.

With increasing recognition of the complications related to coagulopathies, it is of paramount importance for all orthopedic surgeons to possess a basic knowledge of common bleeding disorders. The evaluation of the coagulopathic patient requires a careful history, physical examination, and laboratory evaluation. Bleeding disorders commonly include quantitative and qualitative platelet and coagulation factor disorders and coagulation inhibitors. The management of these coagulopathies that can be encountered in elective and nonelective practice is often ignored. With appropriate knowledge and a multidisciplinary approach with hematologists and cardiologists, surgeons can perform minor and major orthopedic procedures safely and effectively.

Extraordinary military medical care of a pediatric patient with penetrating pelvic trauma: a case report.

Modern military medicine is an ever advancing field, capable of remarkable feats. We present the case of a 16-year-old Iraqi female with a single gunshot wound to the pelvis with extensive rectal injury who survived despite the odds. Using "damage control" techniques, this patient survived despite a reported 30% mortality associated with such wounds. During the course of her stay, she was cared for by a multidisciplinary team whose integrated efforts led to survival and complete closure of 2 of 3 wounds prior to discharge. The case demonstrates the success of modern military medical measures applied to a malnourished pediatric civilian in an austere environment. In addition to being noteworthy as an extraordinary case of survival, this case raises questions about the implications of practicing short-term modern medicine on a population that will have to be reintegrated into a primitive medical establishment, possibly before definitive care is complete.

Long-term results after combined medial meniscal allograft transplantation and anterior cruciate ligament reconstruction: minimum 8.5-year follow-up study.

PURPOSE: The purpose of this study was to evaluate the long-term results after medial meniscal allograft transplantation combined with anterior cruciate ligament (ACL) reconstruction. TYPE OF STUDY: Retrospective clinical outcome study. METHODS: Between 1990 and 1992, 9 medial meniscal allograft transplantations were performed in symptomatic knees with a previous total or near-total medial meniscectomy. One of the 9 patients required transplant removal postoperatively because of a presumed low-grade infection versus immune reaction. The remaining 8 patients were evaluated, with an average follow-up time of 9.7 years. All 8 patients underwent an ACL reconstruction. One patient also had a staged high tibial osteotomy. RESULTS: All 8 patients were evaluated with the standard International Knee Documentation Committee (IKDC) form with no normal scores: 1 had a nearly normal score, 4 had abnormal scores, and 3 severely abnormal scores. The IKDC symptoms evaluation produced 2 normal scores, 5 nearly normal scores, and 1 abnormal score. The IKDC function test showed 5 normal scores, 1 nearly normal score, and 2 abnormal scores. Six of the 8 patients were extremely pleased with the function of the knee and were active in recreational sports. All 8 patients would recommend the procedure to a friend and would undergo the procedure again given similar circumstances. CONCLUSIONS: The findings of this study agree with several other studies with shorter follow-up times that medial meniscal allograft transplantation can significantly improve knee function in symptomatic medial meniscus-deficient knees. The addition of a ligament-stabilizing procedure probably improved the results in this patient population. LEVEL OF EVIDENCE: Level IV, Case Series.