Complete Traumatic Trifocal Failure of the Extensor Mechanism of the Knee: A Case Report and Review of the Literature.

The unique case of a rare 3-level extensor mechanism failure in a 28-year-old male, involving a tibial tubercle avulsion fracture, a patellar tendon avulsion off the tibial tubercle fragment, and a severely comminuted patella fracture, and the surgical technique required to repair such an injury is presented. Focus is spent on the unique repair of a tendon injury when both proximal and distal bony attachments are damaged. Trifocal knee extensor mechanism is a rare clinical entity with minimal literature available-to date, this injury has only been reported in a retrospective review of combat-related injuries in military personnel. It is important to maintain an understanding of knee extensor mechanism anatomy and perform thorough investigation of high-energy knee injuries to ensure adequate treatment of all injuries. The outcome presented in this case shows that positive results after complex extensor mechanism injuries may be achieved, but limited data exists to elucidate optimum treatment. It is essential for surgeons to have firm grasp of techniques used to treat each segment of the extensor mechanism so that they may be combined when a patient presents with complex, multifocal injury.

Nonoperative Management of Proximal Tibiofibular Joint Synostosis after Tibial Intramedullary Nailing.

We report the case of a 28-year-old male semiprofessional basketball player who presented to an outside hospital with nonhealing stress fractures for which he underwent tibial intramedullary nailing (IMN). Two weeks after surgery, he developed pain proximal and lateral to the knee. As he returned to play, the pain worsened with jumping and lateral movement and improved with rest. He presented to our hospital one year after the operation with the same unresolved pain. Imaging one year after the surgery revealed proximal tibiofibular joint (TFJ) synostosis aligned with the drill path. Literature review showed that rare noncongenital cases of proximal TFJ synostosis cases were most often treated nonoperatively. However, two cases involved the removal of excessively protruding screws and two cases involved bone resection that resolved painful disruption of other joints, such as the ankle. The current patient had proper implant positioning and no other impacted joints, so he was managed without operative intervention. By the final 16-month postoperative follow-up, his symptoms had resolved completely. Although an unusual occurrence with limited data, we recommend nonoperative management for proximal TFJ synostosis caused by tibial nailing if implants are properly positioned and no other joints are affected.

Orthopaedic Physician Attire Influences Patient Perceptions in an Urban Inpatient Setting.

BACKGROUND: Prior research suggests that physician attire has an important effect on patient perceptions, and can influence the patient-physician relationship. Previous studies have established the effect of specialty, location, and setting on patient preferences for physician attire, and the importance of these preferences and perceptions on both the physician-patient relationship and first impressions. To date, no studies have examined the influence of attire in the inpatient orthopaedic surgery setting on these perceptions. QUESTIONS/PURPOSES: (1) Do differences in orthopaedic physician attire influence patient confidence in their surgeon, perception of trustworthiness, safety, how caring their physician is, how smart their surgeon is, how well the surgery would go, and how willing they are to discuss personal information with the surgeon? (2) Do patients perceive physicians who are men and women differently with respect to those endpoints? METHODS: Ninety-three of 110 patients undergoing orthopaedic surgery at an urban academic medical center participated in a three-part survey. In the first part, each patient was randomly presented 10 images of both men and women surgeons, each dressed in five different outfits: business attire (BA), a white coat over business attire (WB), scrubs alone (SA), a white coat over scrubs (WS), and casual attire (CA). Respondents rated each image on a five-point Likert scale regarding how confident, trustworthy, safe, caring, and smart the surgeon appeared, how well the surgery would go, and the patient's willingness to discuss personal information with the surgeon. In the second part, the respondent ranked all images, by gender, from the most to least confident based on attire. RESULTS: Pair-wise comparisons for women surgeons demonstrated no difference in patient preference between white coat over business attire compared with white coat over scrubs or scrubs alone, though each was preferable to business attire and casual attire (WS versus WB: mean difference [MD], 0.1 ± 0.6; 95% CI, 0.0-0.2; p = 1.0; WS versus SA: MD, 0.2 ± 0.7; 95% CI, 0-0.3; p = 0.7; WB versus SA: 0.1 ± 0.9; 95% CI, -0.1 to 0.2; p = 1.0). The same results were found when rating the surgeon's perceived intelligence, skill, trust, confidentiality, caring, and safety. In the pair-wise comparisons for male surgeons, white coat over scrubs was not preferred to white coat over business attire, scrubs alone, or business attire (WS versus WB: MD, -0.1 ± 0.6; 95% CI, 0-0.1; p = 1.0; WS versus SA: MD, 0 ± 0.4; 95% CI, -0.2 to 0; p = 1.0; WS versus BA: MD, 0.2 ± 0.8; 95% CI, 0-0.4; p = 0.6). WB and SA were not different (MD, 0.0 ± 0.6; 95% CI, -0.1 to 0.2; p = 1.0), though both were preferred to BA and CA (WB versus BA: MD, 0.3 ± 0.8; 95% CI, 0.1-0.5; p = 0.02; WB versus CA: 1.0 ± 1.0; 95% CI, 0.8-1.2; p < 0.01). We found no difference between SA and BA (MD, 0.3 ± 0.7; 95% CI, 0.1-0.4; p = 0.06). We found that each was preferred to CA (SA versus CA: 0.9 ± 1.0; 95% CI, 0.7-1.2; p < 0.01; BA versus CA: 0.7 ± 1.0; 95% CI, 0.5-0.9; p < 0.01), with similar results in all other categories. When asked to rank all types of attire, patients preferred WS or WB for both men and women surgeons, followed by SA, BA, and CA. CONCLUSIONS: Similar to findings in the outpatient orthopaedic setting, in the inpatient setting, we found patients had a moderate overall preference for physicians wearing a white coat, either over scrubs or business attire, and, to some extent, scrubs alone. Respondents did not show any difference in preference based on the gender of the pictured surgeon. For men and women orthopaedic surgeons in the urban inpatient setting, stereotypical physician's attire such as a white coat over either scrubs or business attire, or even scrubs alone may improve numerous components of the patient-physician relationship and should therefore be strongly considered to enhance overall patient care. LEVEL OF EVIDENCE: Level II, therapeutic study.

Comparison of Surgical Site Infections in Ankle Fracture Surgery With or Without the Use of Postoperative Antibiotics.

BACKGROUND: Surgeon preference has been replaced by an approach using evidence-based medicine in clinical decision making. The use of postoperative antibiosis in ankle fracture surgery is more common for inpatients but variable for outpatient surgery. Some surgeons prefer to prescribe 24 hours of oral antibiotics, whereas others give no antibiotics at all postoperatively. In this study, inpatients receiving 24 hours of intravenous antibiotics were compared to those patients receiving 24 hours of oral antibiotics and those receiving no postoperative antibiotics. METHODS: A total of 1442 patients with ankle fractures requiring operative fixation were retrospectively reviewed in this multicenter study. Demographic data including age, sex, and body mass index were collected. Clinical data including diabetes status, smoking status, hepatitis C virus (HCV) or human immunodeficiency virus (HIV) status, infection requiring additional antibiotics, and infection requiring return to operating room (RTOR) were compared across the groups. RESULTS: No differences in incidence of cellulitis or return to OR for infection were demonstrated between the 3 groups. No differences were noted among the groups for any risk factors for infection including body mass index, previous infection, smoking status, HCV/HIV status, or diabetes. The rates of cellulitis ( P = .402), infection requiring additional antibiotics ( P = .563), and infection requiring return to the operating room ( P = .878) showed no difference between the groups. CONCLUSION: The use of antibiotics postoperatively did not decrease the incidence of surgical site infection. The findings in this study suggest that the routine use of postoperative antibiotics after ankle fracture surgery is not beneficial. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

The Relative Effects of Manual Versus Automatic Exposure Control on Radiation Dose to Vital Organs in Total Hip Arthroplasty.

INTRODUCTION: Technologic advances have reduced medical radiation exposure while maintaining image quality. The purpose of this study was to determine the effects of the presence of total hip arthroplasty implants, compared with native hips, on radiation exposure of the most radiosensitive organs when manual and automatic exposure control settings are used. METHODS: Detection probes were placed at six locations (stomach, sigmoid colon, right pelvic wall, left pelvic wall, pubic symphysis, and anterior pubic skin) in a cadaver. Radiographs were obtained with the use of manual and automatic exposure control protocols, with exposures recorded. A total hip arthroplasty implant was placed in the cadaver, probe positioning was confirmed, and the radiographs were repeated, with exposure values recorded. RESULTS: The control probe placed at the stomach had values ranging from 0.00 mSv to 0.01 mSv in protocols with and without implants. With the manual protocol, exposures in the pelvis ranged from 0.36 mSv to 2.74 mSv in the native hip and from 0.33 mSv to 2.24 mSv after implant placement. The increases in exposure after implant placement, represented as relative risk, were as follows: stomach, 1.000; pubic symphysis, 0.818; left pelvic wall, 1.381; sigmoid colon, 1.550; right pelvic wall, 0.917; and anterior pubic skin, 1.015. With automatic exposure control, exposures in the pelvis ranged from 0.07 mSv to 0.89 mSv in the native hip and from 0.21 mSv to 1.15 mSv after implant placement. With automatic exposure control, the increases in exposure after implant placement, represented as relative risk, were as follows: stomach, 1.000; pubic symphysis, 1.292; left pelvic wall, 1.476; sigmoid colon, 2.182; right pelvic wall, 3.000; and anterior pubic skin, 1.378. DISCUSSION: The amount of radiation to which patients are exposed as a result of medical procedures or imaging, and whether exposure is associated with an increased risk of malignant transformation, are the subject of ongoing debate. We found that after insertion of a total hip arthroplasty implant, exposure values increased threefold at some anatomic locations and surpassed 1 mSv, the generally accepted threshold for concern. CONCLUSION: Radiation exposure to radiosensitive organs increased up to threefold after total hip implantation with automatic exposure control and up to approximately 1.5 times with the manual protocol. Doses were greater with manual exposures than with automatic exposure control (except at the control probe on the stomach, where exposure was negligible, as expected). However, after implant placement, doses increased more with automatic exposure control than with manual exposure. This difference can be attributed to increased scatter and the difficulty of dose modification because of the density of the implant. Current radiographic protocols should be reassessed to determine if the benefits of frequent radiographs outweigh the newly demonstrated risks.

Efficacy and Safety of Tranexamic Acid in Orthopaedic Fracture Surgery: A Meta-Analysis and Systematic Literature Review.

BACKGROUND: Tranexamic acid (TXA) is an antifibrinolytic drug that has been shown to be effective in reducing blood loss and the need for transfusions after several orthopaedic surgeries. However, the effectiveness of TXA use in orthopaedic fracture surgeries still remains unclear. The purpose of this meta-analysis was to review existing literature with interest in the effectiveness and safety of TXA treatment in reducing total blood loss and transfusion rates for patients who underwent surgery for fracture repairs. METHODS: An electronic literature search of PubMed, Embase, OVID, and the Cochrane Library was conducted to identify studies published before December 2016. All randomized controlled trials and cohort studies evaluating the efficacy of TXA during fracture repair surgeries were identified. Primary outcome measures included the number of patients receiving a blood transfusion and perioperative total blood loss. Data were analyzed using Comprehensive Meta-Analysis (CMA) statistical software. RESULTS: Seven studies encompassing 559 patients met the inclusion criteria for the meta-analysis. Our meta-analysis indicated that when compared with the placebo control group, the use of TXA in fracture surgeries significantly reduced total blood loss by approximately 330 mL (P = 0.009), reduced the transfusion rate with a relative risk of 0.54 (P < 0.001), and decreased the drop of hemoglobin by 0.76 g/dL (P < 0.001). There was no significant difference between the number of thromboembolic events among the study groups (P = 0.24). CONCLUSIONS: This study demonstrated that tranexamic acid may be used in orthopaedic fracture surgeries to reduce total blood loss, transfusion rates, and the drop in hemoglobin level, without increasing risk of venous thrombo-embolism. A limitation to these findings is the small number of studies available. Further studies need to be conducted to confirm these findings. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Physicians' Attire Influences Patients' Perceptions in the Urban Outpatient Orthopaedic Surgery Setting.

BACKGROUND: Previous work has established that physician attire influences patients' perceptions of their physicians. However, research from different specialties has disagreed regarding what kinds of physician attire might result in increased trust and confidence on the part of patients. QUESTIONS/PURPOSES: The purpose of this study was to investigate how surgeon attire affects patients' perceptions of trust and confidence in an urban orthopaedic outpatient setting. METHODS: Eighty-five of 100 patients solicited completed a three-part questionnaire in the outpatient orthopaedic clinic at an urban teaching hospital. In the first section, participants viewed eight images, four of a male surgeon and four of a female surgeon wearing a white coat over formal attire, scrubs, business attire, and casual attire, and rated each image on a five-level Likert scale. Participants were asked how confident, trustworthy, safe, caring, and smart the surgeon appeared, how well the surgery would go, and how willing they would be to discuss personal information with the pictured surgeon. The participant ranked all images from most to least confident in the second part and the last section obtained demographic information from the patients. Surveys were scored using a five-level Likert scale and a Friedman test was used to detect statistical significance when comparing all attires. For multiple pairwise comparisons, a Bonferroni correction was applied. RESULTS: The white coat on the male surgeon elicited modestly higher ratings in confidence (mean difference [MD], 0.367 ± 0.737; 95% CI, 0.202-0.532; p < 0.001), intelligence (MD, 0.216 ± 0.603; 95% CI, 0.077-0.356; p = 0.027), surgical skill (MD, 0.325 ± 0.658; 95% CI, 0.175-0.474; p < 0.001), trust (MD, 0.312 ± 0.613; 95% CI, 0.173-0.451; p < 0.001), ability to discuss confidential information (MD, 0.253 ± 0.742; 95% CI, 0.087-0.419; p = 0.023), caring (MD, 0.279 ± 0.655; 95% CI, 0.124-0.432; p = 0.006), and safety (MD, 0.260 ± 0.594; 95% CI, 0.125-0.395; p = 0.002) compared with business attire. Similarly, the white coat was preferred to casual attire in all categories (confidence: MD, 0.810 ± 0.921; smart: MD, 0.493 ± 0.801; surgical skill: MD, 0.640 ± 0.880; ability to discuss: MD, 0.564 ± 0.988; trust: MD, 0.545 ± 0.836; safety: MD, 0.581 ± 0.860; caring: MD, 0.479 ± 0.852; p < 0.001 for all comparisons). For the female surgeon, white coat and scrubs were not different, however the white coat was preferred to business attire in four of seven categories. Casual clothing was widely disliked in all categories for surgeons (men and women). When attire was compared for confidence on a scale, the white coat ranked higher than business (MD, 0.439 ± 1.491; p = 0.006) and casual attire (MD, 1.043 ± 2.054; p < 0.001), but not scrubs (MD, 0.169 ± 1.230; p = 1.000). CONCLUSIONS: In this urban outpatient orthopaedic practice, patients' preferences varied based on the sex of the pictured surgeon in the survey. Overall, however, modest preferences were observed for the white coat in terms of confidence, intelligence, trust, and safety. Furthermore patients are more willing to discuss personal information and believe that their surgery will go better if the surgeon wears a white coat or scrubs. These results are consistent with those of several studies in other settings and therefore may be generalizable in other locations and specialties. Given the increasing awareness and concern for physician-spread hospital infection, this study lends support to scrub attire over business or casual attire if physicians do not wear a white coat. LEVEL OF EVIDENCE: Level II, therapeutic study.

Management of Adult Elbow Fracture Dislocations.

Elbow fracture dislocations are complicated injuries that are difficult to manage and fraught with complications. A complete series of radiographs is typically complemented with CT scan to evaluate the elbow and assist preoperative planning. Typically, operative intervention is necessary and a systematic approach to the elbow injuries should be chosen. This article addresses the coronoid and proceeds to the radial head, lateral soft tissues, and finally the medial ligaments if elbow instability persists. With a focused, systematic surgical approach, improved outcomes have been demonstrated and patients may recover full function and range of motion in the affected elbow.

Management of the Morel-Lavallée Lesion.

Morel-Lavallée lesions are closed degloving injuries sustained during violent soft tissue shear that separate the subdermal fat from its strong underlying fascia. Lesions most often occur in the peritrochanteric region, and patients may have concomitant polytrauma. As a result, a hematoma develops that has a high rate of acute bacterial colonization and chronic recurrence. Conservative treatment outcomes are best for those managed acutely. However, diagnosis is often delayed or missed. Furthermore, there is no universally accepted treatment algorithm. Diagnosis and treatment depend on a surgeon's thorough understanding of the cause, pathophysiology, imaging characteristics, and treatment options of Morel-Lavallée lesions.

Application of Tranexamic Acid in Trauma and Orthopedic Surgery.

Tranexamic acid has gained recent interest in orthopedics and trauma surgery because of its demonstrated benefit in several clinical trials. It is inexpensive and effective at reducing blood loss and blood transfusion requirements without a significant increase in morbidity or mortality. The optimal timing, dosing, and route of administration in orthopedics are yet to be elucidated. Significant investigation of tranexamic acid use in joint replacement and spine surgery has promoted its incorporation into the everyday practice of many of these surgeons. The paucity of studies regarding its use in orthopedic trauma has limited its integration into a field that may stand to benefit most from the drug.

Nerve and tendon injury with percutaneous fibular pinning: a cadaveric study.

OBJECTIVE: The purposes of this study were to measure the average distance from a percutaneous pin in each quadrant of the distal fibula to the sural nerve and nearest peroneal tendon, and define the safe zone for percutaneous pin placement as would be used during surgery. METHOD: Ten fresh-frozen cadavers underwent percutaneous pin fixation into four quadrants of the distal fibula. The sural nerve and peroneal tendon were identified as they coursed around the lateral ankle. Distances from the K-wire in each quadrant to the anatomic structure of interest were measured. RESULTS: Average distances (mm) from the K-wire to the sural nerve in the anterolateral, anteromedial, posterolateral, and posteromedial quadrants were 19.1±8.9 (range, 5.1-35.5), 12.8±8.2 (range, 0.3-27.8), 12.6±6.8 (range, 3.0-27.8), and 5.9±5.5 (range, 0.1-19.9), respectively. Average distances from the K-wire to the nearest peroneal tendon in the anterolateral, anteromedial, posterolateral, and posteromedial quadrants were 15.7±4.4 (range, 9.5-23.1), 11.9±5.2 (range, 3.2-21.7), 6.3±3.9 (range, 0.1-14.4), and 1.0±1.6 (range, 0-5.6), respectively. CONCLUSIONS: Percutaneous pinning of distal fibula fractures is a successful treatment option with minimal complications. Our anatomical study found the safe zone of percutaneous pin placement to be in the anterolateral quadrant. The sural nerve can be as close as 5.1mm and the peroneal tendons as near as 15.7mm. In contrast, the posteromedial quadrant was associated with the greatest risk of injury to both the sural nerve and peroneal tendons.