Fracture or Not: An Easily Mistaken Benign Finding in a Tuberous Sclerosis Patient.

Tuberous sclerosis (TSC) is a rare autosomal dominant disorder that can affect multiple organ systems, including the brain, heart, lungs, and skin. Cutaneous manifestations are common, including ungual fibromas, however, these may be mistaken for other pathologies. Here, we present the case of a 14-year-old with TSC complaining of traumatic left little finger pain. Radiographic evaluation revealed cortical scalloping of the nailbed, concerning for a non-displaced fracture. Given the history of TSC, however, this defect may have also represented a periungual fibroma. The patient subsequently underwent conservative management and an eight-month radiographic follow-up showed no osseous remodeling, supporting the diagnosis of periungual fibroma. It is imperative for clinicians to understand the cutaneous manifestations of TSC to aid in proper diagnosis and avoidance of unnecessary treatment. In this case, interval follow-up confirmed the diagnosis and excluded fracture.

How Do Standing Neutral, Supine Lateral, Standing Flexion, and Standing Extension Radiographs Compare in Detecting the Presence and Magnitude of Stable and Dynamic Spondylolisthesis?

BACKGROUND: Clinical guidelines recommend standing radiographs as the most appropriate imaging for detecting degenerative spondylolisthesis, although reliable evidence about the standing position is absent. To our knowledge, no studies have compared different radiographic views and pairings to detect the presence and magnitude of stable and dynamic spondylolisthesis. QUESTIONS/PURPOSES: (1) What is the percentage of new patients presenting with back or leg pain with stable (3 mm or greater listhesis on standing radiographs) and dynamic (3 mm or greater listhesis difference on standing-supine radiographs) spondylolisthesis? (2) What is the difference in the magnitude of spondylolisthesis between standing and supine radiographs? (3) What is the difference in the magnitude of dynamic translation among flexion-extension, standing-supine, and flexion-supine radiographic pairs? METHODS: This cross-sectional, diagnostic study was performed at an urban, academic institution between September 2010 and July 2016; 579 patients 40 years or older received a standard radiographic three-view series (standing AP, standing lateral, and supine lateral radiographs) at a new patient visit. Of those individuals, 89% (518 of 579) did not have any of the following: history of spinal surgery, evidence of vertebral fracture, scoliosis greater than 30°, or poor image quality. In the absence of a reliable diagnosis of dynamic spondylolisthesis using this three-view series, patients may have had flexion and extension radiographs, and approximately 6% (31 of 518) had flexion and extension radiographs. A total of 53% (272 of 518) of patients were female, and the patients had a mean age of 60 ± 11 years. Listhesis distance (in mm) was measured by two raters as displacement of the posterior surface of the superior vertebral body in relation to the posterior surface of the inferior vertebral body from L1 to S1; interrater and intrarater reliability, assessed with intraclass correlation coefficients, was 0.91 and 0.86 to 0.95, respectively. The percentage of patients with and the magnitude of stable spondylolisthesis was estimated on and compared between standing neutral and supine lateral radiographs. The ability of common pairs of radiographs (flexion-extension, standing-supine, and flexion-supine) to detect dynamic spondylolisthesis was assessed. No single radiographic view or pair was considered the gold standard because stable or dynamic listhesis on any radiographic view is often considered positive in clinical practice. RESULTS: Among 518 patients, the percentage of patients with spondylolisthesis was 40% (95% CI 36% to 44%) on standing radiographs alone, and the percentage of patients with dynamic spondylolisthesis was 11% (95% CI 8% to 13%) on the standing-supine pair. Standing radiographs detected greater listhesis than supine radiographs did (6.5 ± 3.9 mm versus 4.9 ± 3.8 mm, difference 1.7 mm [95% CI 1.2 to 2.1 mm]; p < 0.001). Among 31 patients, no single radiographic pairing identified all patients with dynamic spondylolisthesis. The listhesis difference detected between flexion-extension was no different from the listhesis difference detected between standing-supine (1.8 ± 1.7 mm versus 2.0 ± 2.2 mm, difference 0.2 mm [95% CI -0.5 to 1.0 mm]; p = 0.53) and flexion-supine (1.8 ± 1.7 mm versus 2.5 ± 2.2 mm, difference 0.7 mm [95% CI 0.0 to 1.5]; p = 0.06). CONCLUSION: This study supports current clinical guidelines that lateral radiographs should be obtained with patients in the standing position, because all cases of stable spondylolisthesis of 3 mm or greater were detected on standing radiographs alone. Each radiographic pair did not detect different magnitudes of listhesis, and no single pair detected all cases of dynamic spondylolisthesis. Clinical concern for dynamic spondylolisthesis may justify standing neutral, supine lateral, standing flexion, and standing extension views. Future studies could identify and evaluate a set of radiographic views that provides the greatest capacity to diagnose stable and dynamic spondylolisthesis. LEVEL OF EVIDENCE: Level III, diagnostic study.

Systemic Complications of Obesity in Operative Acetabular Fractures.

OBJECTIVE: To determine the effect of obesity on rates of systemic complications in operatively treated acetabular fractures. DESIGN: Retrospective Case-Control study. SETTING: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: All patients with acetabular fractures managed operatively from January 2015 to December 2019. Patients were divided into groups based on their body mass index (BMI) (normal weight = BMI <25 kg/m2, overweight = BMI 25-30, obese = BMI 30-40, and morbidly obese = BMI >40). INTERVENTION: Operative management of an acetabular fracture. MAIN OUTCOME MEASUREMENT: Systemic complications, including mortality, sepsis, pneumonia, acute respiratory distress syndrome, deep vein thrombosis, pulmonary embolism, or venous thrombotic event. RESULTS: A total of 428 patients were identified. One hundred nine patients (25.4%) were in normal weight, 133 (31.1%) were overweight, 133 (31.1%) were obese, and 53 (12.4%) were morbidly obese. The rate of systemic complications was 17.5%, and overall mortality rate was 0.005%. There were no significant differences between the different BMI groups in all-cause complications or any individual complications. When the morbidly obese group was compared with all other patients, there were also no significant differences in all-cause complications or any individual complications. CONCLUSION: In conclusion, in this study, there was no association with increasing BMI and inpatient systemic complications after operative management of acetabular fractures. As we continue to refine our understanding of how obesity affects outcomes after acetabular fracture surgery, other indices of obesity might prove more useful in predicting complications. In the obese population, there are well-documented risks of postoperative infections and challenges in obtaining an anatomic reduction, but the fear of postoperative systemic complications should not deter surgeons from undertaking operative management of acetabular fractures in the obese population. Because the prevalence of obesity in trauma patients continues to increase, it is incumbent on us to continue to improve our understanding of optimal treatment for our patients. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Extended Antibiotic Coverage in the Management of Type II Open Fractures.

Background: Responsible antibiotic stewardship requires surgeons treating open fractures to use the narrowest appropriate antibiotic coverage possible to prevent infection. Because inter-observer agreement about the application of the Gustilo-Anderson open fracture classification is moderate at best, antibiotic selection can be overly aggressive. The purpose of this study was to evaluate the outcomes of Type II open fractures treated with gram-positive coverage only (GP) versus broad-spectrum antibiotic coverage (BS) with piperacillin-tazobactam (PT). Methods: A retrospective review of all Type II open fractures was performed at a single Level one trauma center over a 5-year period (2013-2017). All patients received prophylactic antibiotics on arrival on the basis of the best judgment of classification by the house officer on call. The final Gustilo-Anderson open fracture classification was assigned intra-operatively by the operating surgeon. Two groups were created, a GP antibiotic group (cefazolin and/or clindamycin) and a BS group (PT). A minimum of 3-month follow-up was required for inclusion. Patient demographics, cost of treatment, fracture-related infection (FRI) rates, and infecting bacteria were assessed. Results: The GP group contained 70 open fractures and the BS group contained 74 open fractures. Between the groups, there were no differences in age, sex, race, Body Mass Index, American Society of Anesthesiologists Class, or smoking status. There were no statistical differences in Injury Severity Score (ISS), fracture location, fixation method, or rates of staged management with external fixation. There was no difference in FRI rate between the GP and BS groups (8.6% versus 10.8%; p = 0.78). The bacteria responsible for FRI were similar in the GP and BS groups. The hospital charge for PT was 4.39 × the cost of cefazolin. Conclusions: The use of BS coverage in Type II open fractures does not result in a lower infection rate and adds significant cost to patient care. These data support the use of a GP-only antibiotic regimen for Type II open fractures.

Anatomic structures at risk in anteroposterior screw fixation of posterior malleolar fractures: A cadaver study.

INTRODUCTION: Percutaneous anterior-posterior (AP) screw is an option for posterior malleolus fracture fixation when the fracture fragment can be reduced indirectly by the mean of ligamentotaxis. However, anterior anatomic structures could be injured during screw placement. MATERIALS AND METHODS: Eleven below-knee cadavers were employed for the placement of AP screws in an attempt of fixing assumed Haraguchi Type-I posterior malleolar fractures. Three entry points were selected as medial to the anterior tibial tendon (ATT), lateral to the ATT, and lateral to the extensor digitorum longus (EDL). Three AP screws were placed under guidance of fluoroscopy. After dissection, measurements were made (mm) from each screw to nearby structures. Distances were calculated and damage to structures was documented. RESULTS: Mean, minimum, and maximum distances from the medial screw to the greater saphenous vein, TA, EHL, anterior tibial artery (ATA), and deep peroneal nerve (DPN), were 18.1 (12-25) mm, 2.0 (0-5) mm, 13.6 (9-20) mm, 16.6 (9-25) mm, and 20.1 (12-27) mm. From the middle screw to the ATA, DPN, TA, EHL, and EDL, were 1.2 (0-3) mm, 4.9 (3-9) mm, 3.8 (1-7) mm, 0.4 (0-2) mm, and 13.6 (10-18) mm. From the lateral screw to the superficial peroneal nerve (SPN), EDL, DPN, and ATA, were 10.8 (0-16) mm, 1.2 (0-4) mm, 15.9 (11-25) mm, 19 (15-27) mm. The SPN was found partially cut by the lateral screw on 1 specimen. CONCLUSIONS: Lateral and middle percutaneous AP screw placement put certain anatomic structures at-risk of injury. Medial screw placement did not result in appreciable damage to adjacent structures. Entry point of AP screws should be selected with respect to posterior malleolar fracture and anatomic structures. LEVEL OF EVIDENCE: IV.

Civilian Ballistic Tibia Shaft Fractures Compared With Blunt Tibia Shaft Fractures: Open or Closed?

OBJECTIVES: To identify a group of ballistic tibia fractures, report the outcomes of these fractures, and compare them with both closed and open tibia fractures sustained by blunt mechanisms. We hypothesized that ballistic tibia fractures and blunt open fractures would have similar outcomes. DESIGN: Retrospective cohort study. SETTING: A single Level-1 trauma center. PATIENTS/PARTICIPANTS: Adult patients presenting with ballistic (44), blunt closed (179), or blunt open (179) tibia fractures. INTERVENTION: Intramedullary stabilization of tibia fracture. MAIN OUTCOMES: Unplanned reoperation, soft tissue reconstruction, nonunion, compartment syndrome, and fracture-related infection. RESULTS: Compared with the blunt closed group, the ballistic fracture group required more operations (P < 0.01), had a higher occurrence of soft tissue reconstruction (P < 0.01), and higher incidence of compartment syndrome (P = 0.02). Ballistic and blunt closed groups did not significantly differ in rates of unplanned reoperation (P = 0.67), nonunion (11.4% vs. 4.5%, P = 0.08), or deep infection (9.1% vs. 5.6%, P = 0.49). In comparison to the blunt open group, the ballistic group required a similar number of operations (P = 0.12), had similar rates of unplanned reoperation (P = 0.10), soft tissue reconstruction (P = 0.56), nonunion (11.4% vs. 17.9%, P = 0.49), and fracture-related infection (9.1% vs. 10.1%, P = 1.0) but a higher incidence of compartment syndrome (15.9% vs. 5.0%, P = 0.02). CONCLUSIONS: Ballistic tibia fractures require more surgeries and have higher rates of soft tissue reconstruction than blunt closed fractures and seem to have outcomes similar to lower severity open fractures. We found a significantly higher rate of compartment syndrome in ballistic tibia fractures than both open and closed blunt fractures. When treating ballistic tibia fractures, surgeons should maintain a high level of suspicion for the development of compartment syndrome and counsel patients that ballistic tibia fractures seem to behave like an intermediate category between closed and open fractures sustained through blunt mechanisms. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Elective spine surgery with continuation of clopidogrel anti-platelet therapy: Experiences from the community.

PURPOSE: This retrospective study aimed to assess the feasibility of continuing clopidogrel therapy during the perioperative period in elective cervical and thoracolumbar surgery. METHODS: After IRB approval, medical records of patients requiring one or two-level surgery over a two-year period (2015-2017) while receiving clopidogrel were reviewed for relevant outcomes. Over the same period, a control group of patients not receiving clopidogrel perioperatively was formed. RESULT: In total, 136 patients were included: 37 clopidogrel and 99 control, with a mean age of 64.8 years. Between clopidogrel and control respectively, operative time was 86.7 min and 86.7 min (p = 0.620); blood loss was 127.0 cc and 117.5 cc (p = 0.480); drain output was 171.2 cc and 190.7 cc (p = 0.354); length of stay was 1.8 days and 1.5 days (p = 0.103). Two clopidogrel patients and 1 control patient had complications. Two clopidogrel patients and 1 control patient were readmitted within 30 days. CONCLUSIONS: Remaining on clopidogrel therapy during elective spine surgery results in no difference in operative time, blood loss, drain output, length of stay, or readmission. Precaution should be taken in cervical procedures as the drain output in clopidogrel patients was increased and complications in this region can be severe.

Thrombin Hemostatic Matrix Reduces Heterotopic Ossification in Acetabular Fractures Fixed Through the Kocher-Langenbeck Approach.

OBJECTIVE: To determine whether an injectable thrombin product [thrombin hemostatic matrix (THM)] at closure of a Kocher-Langenbeck approach reduces the risk of heterotopic ossification (HO) formation after an acetabular fracture. DESIGN: Case control. SETTING: Two Level 1 trauma centers. PATIENTS: Patients with operatively treated acetabulum fractures fixed through Kocher-Langenbeck from 2013 to 2018. INTERVENTION: Records were reviewed for demographics, history of traumatic brain injury, HO medication or radiation prophylaxis, THM (Surgiflo, Ethicon, Bridgewater New Jersey) administration, and length of follow-up. Radiographs were reviewed for dislocation, fracture, Letournel and Orthopaedic Trauma Association classifications, HO, and Brooker grade if applicable. Patients receiving HO prophylaxis (eg, nonsteroidal anti-inflammatory drugs and radiation) were excluded. Remaining patients were divided into 2 groups: THM administration (intervention) and no THM. Continuous variables were compared using t-tests and categorical variables with chi-square or Fisher's exact tests. MAIN OUTCOME MEASUREMENTS: Risk ratios for the association between HO occurrence and THM administration. RESULTS: Three-hundred and twenty-eight acetabular fractures met inclusion criteria (126 intervention, 202 control) in patients with a mean age of 38.7 ± 15.9 years; 62.2% were male, and 42.1% were African American. Traumatic brain injury and posterior dislocation rates were equivalent between groups (P = 0.505, 0.754, respectively). HO rate in the control group was 42.6% compared with 21.4% in the THM group (P < 0.001). Booker grade 3/4 in control group was 17.3% versus 3.2% in the THM group (P < 0.001). Patients receiving THM had a 50% reduced risk of HO (95% confidence interval 0.35-0.73) compared to those who did not; adjustment for age, gender, ethnicity, and traumatic brain injury did not meaningfully change the association (risk ratio 0.46; 95% confidence interval 0.29-0.73; P < 0.001). CONCLUSION: The use of a surgiflo product at closure of a KO approach may reduce the risk of HO formation by 50% after an acetabular fracture. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Postoperative aspirin use and its effect on bone healing in the treatment of ankle fractures.

BACKGROUND: There is hesitancy to administer nonsteroidal anti-inflammatories (NSAIDs) within the postoperative period following fracture care due to concern for delayed union or nonunion. However, aspirin (ASA) is routinely used for chemoprophylaxis of deep vein thrombosis (DVT) and is gaining popularity for use after treatment of ankle fractures. The current study examines the incidence of nonunion of operative ankle fractures and risk of DVT in patients who did and did not receive postoperative ASA. METHODS: A retrospective chart review was performed on all patients treated between 2008 and 2018 for ankle fractures requiring operative fixation by three Foot and Ankle fellowship trained orthopaedic surgeons at a single institution. Demographics, preoperative comorbidities, and postoperative medical and surgical complications were compared between patients who did and did not receive ASA postoperatively. For both groups, union was evaluated by clinical exam as well as by radiograph, for those with 6-week, 12-week, or 24-week follow-up. RESULTS: Five-hundred and six patients met inclusion criteria: 152 who received ASA and 354 who did not. Radiographic healing at six weeks was demonstrated in 95.9% (94/98) and 98.6% (207/210) respectively (p-value .2134). There was no significant difference in time to radiographic union between groups. The risk of postoperative DVTs in those with and without ASA was not significantly different (0.7% (1/137) vs 1.2% (4/323), respectively; p-value .6305). CONCLUSION: Postoperative use of ASA does not delay radiographic union of operative ankle fractures or affect the rate of postoperative DVT. This is the first and largest study to examine the effect of ASA on time to union of ankle fractures. LEVEL OF EVIDENCE: III.

Reamed Versus Unreamed Intertrochanteric Femur Fractures, Is It Time?

OBJECTIVES: This study compares the intraoperative and postoperative outcomes of the traditional technique of femoral canal reaming to placement of an unreamed 10-mm nail. DESIGN: Retrospective cohort study. SETTING: Academic Level I Trauma Center, Southeastern US. PATIENTS/PARTICIPANTS: Intertrochanteric femur fractures treated with a CMN (January 2016-December 2018) were retrospectively identified. Inclusion criteria were as follows: low-energy mechanism, at least 60 years of age, and long CMN. Exclusion criteria were as follows: short CMN, polytrauma, and subtrochanteric fractures. OUTCOME MEASUREMENTS: Records were reviewed for demographics, hematologic markers, transfusion rates, operative times, and postoperative complications. Variables were assessed with a χ or Student T-test. Significance was set at 0.05. RESULTS: Sixty-five patients were included (37 reamed and 28 unreamed), with a mean age of 76.2 years and mean body mass index of 25.1. Between the reamed and unreamed groups, respectively, mean nail size was 11.0 (SD 1.1) and 10.0 (SD 0.0), P < 0.001; mean blood loss was 209.1 mL (SD 177.5) and 195.7 mL (SD 151.5), P = 0.220; 55% (21/38), and 43% (12/28) were transfused, P = 0.319; operative time was 98.2 (SD 47.3) and 81.5 minutes (SD 40.7); P = 0.035. Changes in hemoglobin/hematocrit were not significant between the study groups. Two patients from the reamed group experienced implant failure due to femoral head screw cut out and returned to the operating room. Two patients from the unreamed group returned to operating room for proximal incision infection, without implant removal. One reamed patient and 2 unreamed patients died before 6-month follow-up. CONCLUSIONS: Unreamed CMNs for geriatric intertrochanteric femur fractures provide shorter operative times with no difference in perioperative complications. Both reamed and unreamed techniques are safe and effective measures for fixation of these fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Unique "Reverse" Crescent Fragment in an Anterior-Posterior Compression Fracture: A Case Report.

CASE: We describe a patient with an anterior-posterior compression type pelvic fracture sustained after a motorcycle crash, with pubic symphysis disruption and a "reverse" crescent fragment. The injury force ruptured the anterior sacroiliac ligaments and travelled posterior medially, creating a complete Denis zone 2 sacral fracture, rather than rupturing the posterior sacroiliac ligaments as would be expected. The patient underwent open reduction and internal fixation of the pubic symphysis and closed reduction and percutaneous pinning of the right sacroiliac joint. CONCLUSIONS: This case presents a unique "reverse" crescent fragment not previously described in the literature as an anterior-posterior compression type III variant.

Comparison of Adductor Canal Block and Femoral Nerve Block for Early Ambulation After Primary Total Knee Arthroplasty: A Randomized Controlled Trial.

PURPOSE: The purpose of this study was to assess the efficacy of adductor canal block (ACB) as compared to femoral nerve block (FNB) in ambulation distance, opioid consumption, and physical therapy participation on postoperative days (PODs) 1 and 2 after total knee arthroplasty (TKA). We hypothesized ACB would have increased the ambulation distance and decreased the opioid consumption in comparison to FNB. METHODS: All elective TKAs at a single institution, age 18 and older, without existing neurologic or anatomic deficit in the operative limb, were considered. Participants were randomized 1:1 to receive either an ACB (AC group) or a FNB (FN group), in addition to standard care. Visual analog pain scores (VAS) and oral morphine equivalents (OMEs) were recorded preoperatively, in post-anesthesia care unit (PACU), and on PODs 1 and 2. Postoperative ambulation distance was recorded on PODs 1 and 2. Patient satisfaction with analgesia and physical therapist-rated participation in therapy sessions was obtained as well.  Results: From 2014 to 2015, 84 participants were recruited: 41 in FN, and 43 in AC. On POD 1, mean ambulation distances in AC and FN were 70.2 and 48.5 ft, respectively (p = 0.045). On POD 2, mean ambulation distances in AC and FN were 129.0 and 106.4 ft, respectively (p = 0.225). VAS, OME, satisfaction, and physical therapy participation were not significantly different. CONCLUSIONS: Ambulation after TKA is superior with ACB on the first POD, but there is no difference in VAS scores, OME, patient satisfaction, or ambulation on POD 2.

Diagnosis can predict opioid usage and dependence in reverse shoulder arthroplasty.

INTRODUCTION: Reverse shoulder arthroplasty (RSA) has seen exponential growth over the past 2 decades. In addition, the recent focus on opioid usage and dependence has led to an increased understanding of the risk factors that lead to dependence. The purpose of this study was to examine associations between diagnosis and opioid consumption and dependence in RSA. METHODS: A retrospective review was performed of 441 patients who had undergone a primary RSA from 2012 to 2016. Demographics were collected and patients were categorized based on top 4 diagnoses: glenohumeral osteoarthritis (n = 129), irreparable rotator cuff tear (n = 85), rotator cuff arthropathy (RCA) (n = 184), and proximal humerus fracture (n = 69). Opioid consumption within 90 days surrounding surgery was recorded from Prescription Drug Monitoring Programs. Logistic regression was performed. RESULTS: Baseline characteristics for sex (P = .0001), ethnicity (P = .04), age (P = .01), and preoperative opioid use (P = .029) were significantly different. Patients with osteoarthritis had the lowest preoperative total morphine equivalents (TMEs) at 22.82 compared with fractures (53.36, P = .02) and RCA (46.54, P = .02). There was no significant difference in preoperative opioid dependence based on diagnosis (P = .16); however, postoperatively, the RCA group had the highest dependence at 40.3% (P = .03). In addition, there were no significant differences postoperatively in TMEs prescribed (P = .197). The preoperatively dependent patients were 8 times more likely to remain dependent regardless of diagnosis. CONCLUSION: Patients with fractures consume the highest amounts of opioids surrounding surgery. Surgeons should tailor their preoperative education and pain management protocols accordingly based on diagnoses for RSA. In addition, increased awareness and protocols need to be implemented for preoperative opioid-dependent patients regardless of diagnosis.

Is Use of Bone Cement for Treatment of Second Metatarsal Stress Fractures Safe? A Case Report.

Metatarsal stress fractures are common injuries of the foot and can be a source of chronic pain without appropriate management. Conservative management is first line, but surgery may be indicated in athletes, cases of nonunion, and fractures of the fifth metatarsal. We report a case of a 34-year-old female who presented to clinic for intractable pain of the left foot secondary to a stress fracture of the left second metatarsal, which had been previously treated with injectable acrylic bone cement. Calcium sulfate hydroxyapatite cement has a multitude of applications in orthopedic surgery, but to our knowledge no studies have documented its use in the treatment of metatarsal stress fractures. Our findings suggest that injectable calcium sulfate hydroxyapatite cement is not a suitable stand-alone treatment in fractures of the second metatarsal.