Management of Femoral and Tibial Shaft Fractures in Chronic Spinal Cord Injury Patients.

OBJECTIVES: To compare outcomes and complications between non-operative and operative management of femur and tibia fractures in patients with paraplegia or quadriplegia from chronic spinal cord injury (SCI). METHODS: Design: Retrospective cohort study. SETTING: Three Level-1 Trauma centers. PATIENT SELECTION CRITERIA: All adult patients with paraplegia or quadriplegia due to a chronic SCI with operative or nonoperative treatment of a femoral or tibial shaft fracture from 01/01/2009 through 12/31/2019 were included. OUTCOME MEASURES AND COMPARISONS: Outcomes collected included range of motion, pain, return to baseline activity, extent of malunion and treatment complications (infection, pressure ulcers, nonunion, DVT/PE, stroke, amputation, death). Comparison between operative and nonoperative treatment were made for each outcome. RESULTS: Fifty-nine patients with acute lower extremity fracture in the setting of chronic SCI fulfilled inclusion criteria with a median age of 46 years in the operative group and 47 years in the non-operative group. Twelve patients (70.6%) in the nonoperative group were male with 32 (76.2%) male patients in the operative group. Forty-six patients (78%) presented as low energy trauma. Differences were seen between operative and non-operative management for pressure ulcers (19% vs 52.9%, p=0.009) and mean VAS pain score at first follow-up (1.19 vs 3.3, p=0.03). No difference was seen for rates of infection, nonunion, DVT/PE, stroke, amputation, death, return to baseline activity, and range of motion. CONCLUSIONS: Tibial and femoral shaft fractures commonly resulted from low energy mechanisms in patients with chronic SCI. Operative treatment seemed to decrease morbidity in these patients via lowered rates of pressure ulcers and decreased pain compared to non-operative management. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Patient Satisfaction Following Non-Operative Treatment of Geriatric Hip Fractures: A Case-Control Study.

Introduction: A minority of geriatric hip fracture patients pursue non-operative treatment. Compared with surgical patients, non-operative patients have higher mortality rates. However, patient satisfaction following non-operative vs operative treatment has not been investigated extensively. The purpose of this study was to compare satisfaction among non-operatively vs operatively treated hip fracture patients. Methods: We identified patients aged 60+ years with proximal femur fractures treated over a 10-year period. Excluded were patients with isolated greater/lesser trochanteric fractures. Patients or relatives were asked to complete a 6-question survey about their treatment satisfaction. Results: Survey responses from 56 operative and 28 non-operative patients were recorded. Overall, 91.1% of operative and 82.1% of non-operative patients were satisfied with their treatment course (P = 0.260). However, only 71.4% of non-operative patients were satisfied with treatment option explanations vs 83.9% of operative patients (P = 0.014). While only 64.3% of non-operative respondents were satisfied with the ultimate treatment outcome (vs 85.7% of operative patients, P = 0.025), 89.3% of patients in each cohort would choose the same treatment plan again. Discussion: Our findings highlight the complexity of defining patient satisfaction, particularly in a geriatric hip fracture population. Unlike previous studies, we chose a direct approach to quantifying patient satisfaction by asking participants specifically about satisfaction with treatment outcome and the overall treatment course. Additional survey questions were then included to assess factors considered important in treatment satisfaction, such as health care provider treatment explanations, post-treatment mobility, and palliative care service involvement. Conclusions: We identified significant differences between non-operatively and operatively treated geriatric hip fracture patients regarding satisfaction with the explanation of treatment options, and ultimate treatment outcomes. There was no significant difference in overall satisfaction with the treatment course or likelihood of choosing the same treatment again. Further research investigating patient satisfaction following geriatric hip fracture treatment is warranted.

Skin Antisepsis before Surgical Fixation of Extremity Fractures.

BACKGROUND: Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture). METHODS: In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications. RESULTS: A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups. CONCLUSIONS: Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).

The Role of Arthroscopy in Painful Shoulder Arthroplasty: Is Revision Always Necessary?

PURPOSE: To determine whether arthroscopy is an effective means to diagnose and treat postoperative pain in anatomic total shoulder arthroplasty (TSA) and reverse TSA patients. METHODS: A 2-year retrospective chart review of patients with a painful shoulder arthroplasty was performed. Patients included in the study had a painful shoulder after previous shoulder arthroplasty without gross signs of infection, severely elevated laboratory markers, implant loosening, or glenoid arthrosis after hemiarthroplasty. Visual analog scale scores, physical examination findings, laboratory studies, culture results, pathology reports, operative records, and postoperative treatment data were collected. RESULTS: The study cohort included 6 male and 7 female patients. Between 2016 and 2018, 7 TSA and 6 reverse TSA patients underwent arthroscopic debridement of adhesions and synovitis with tissue biopsy for cultures and fresh-frozen sections. We arthroscopically treated adhesive capsulitis, subacromial impingement, and acromioclavicular joint arthritis in 3 patients. Three patients required extensive debridement for profound synovitis. All 6 patients had negative findings of cultures and frozen sections, and none required revision arthroplasty. Their average follow-up period was 18.6 months (range, 9-32 months), with improvement in the mean visual analog scale score from 8.2 of 10 (range, 6-10) to 2.5 of 10 (range, 2-8). Two patients had arthroscopic cultures showing Cutibacterium acnes infection. Both required revision with an antibiotic spacer. Findings of cultures and fresh-frozen sections at revision were consistent with arthroscopic findings. Arthroscopic evaluation in 5 additional patients identified mechanical implant failure or a rotator cuff tear. CONCLUSIONS: Arthroscopy is a viable option to evaluate and treat painful shoulder arthroplasty. We were able to successfully treat 46% of patients (6 of 13) with arthroscopic procedures, preventing the need for revision arthroplasty. Arthroscopic frozen section and culture results had a 100% correlation with open frozen section and culture results in patients who had cultures obtained. LEVEL OF EVIDENCE: Level IV, case series.