Biomechanical properties of suprapectoral biceps tenodesis with double-anchor knotless luggage tag sutures vs. subpectoral biceps tenodesis with single-anchor whipstitch suture using all-suture anchors.

Background: As the use of all-suture anchors continues to increase, limited biomechanical data on the use of these anchors in various configurations for tenodesis of the long head biceps tendon (LHBT) exists. The aim of this study was to compare the biomechanical properties of a 2-anchor luggage tag suprapectoral biceps tenodesis (Sup-BT) vs. a single-anchor whipstitch subpectoral biceps tenodesis (Sub-BT) using all-suture anchors. The hypothesis was that the Sub-BT will have a higher ultimate load to failure and less creep relative to the Sup-BT construct. Methods: Eighteen fresh frozen cadaveric humeri were used. The specimens were randomly divided into 2 groups of 9; i) The Sup-BT were performed with 2 1.8 mm knotless all-suture anchors using a luggage-tag fixation configuration, ii) The Sub-BT were performed using a single 1.9 mm all-suture anchor and a whipstitch suture configuration with a tied knot. The humeri were tested on a hydraulic MTS machine where the specimens were preloaded at 5 N for 2 minutes and then cyclically loaded from 5 to 50 N for 1000 cycles at 1 Hz while maximum displacement was recorded with a motion system and markers attached to the bone and bicep tendon. The tendon was then tensioned at a rate of 1 mm/s to obtain the ultimate load to failure. CT scans of the specimens were used to calculate the bone mineral density at the site of the anchor/bone interface and video recordings were captured during load to failure to document all modes of failure. Results: There was no significant difference in the average load to failure of the Sup-BT and Sub-BT groups (197 N ± 45 N (SD), 164 N ± 68 N (SD) respectively; P = .122) or creep under fatigue between the Sup-BT vs. Sub-BT specimens (3.1 mm, SD = 1.5 vs. 2.2 mm, SD = 0.9; P = .162). The bone mineral density was statistically different between the 2 groups (P < .001); however, there were no observed failures at the anchor/bone interface and no correlation between failure load and bone mineral density. Conclusion: The ultimate load to failure and creep between a Sup-BT with 2 knotless all-suture anchors using a luggage tag suture configuration was equivalent to a Sub-BT with 1 all-suture anchor using a whipstitched suture configuration and a tied knot. Surgeons can perform either technique confidently knowing that they are biomechanically equivalent in a cadaver model at time zero, and they offer similar strength to other fixation methods cited in the literature.

Injury Risk in Collegiate Football Players With Generalized Joint Hypermobility: A Prospective Cohort Study Over 2 Years.

Background: Generalized joint hypermobility (GJH) has been identified as a risk factor for injury in various athletic patient populations. Purpose: To evaluate GJH as a predisposing risk factor for injury in a population of National Collegiate Athletic Association (NCAA) Division I football players. Study Design: Cohort study; Level of evidence, 2. Methods: The Beighton score was collected for 73 athletes during their preseason physical examinations in 2019. GJH was defined as a Beighton score ≥4. Athlete descriptive characteristics, including age, height, weight, and playing position, were recorded. The cohort was evaluated prospectively for 2 years, and the number of musculoskeletal issues, injuries, treatment episodes, days unavailable, and surgical procedures for each athlete during this period were recorded. These measures were compared between the GJH and no-GJH groups. Results: The mean Beighton score was 1.4 ± 1.5 for the 73 players; 7 players (9.6%) had a Beighton score indicating GJH. During the 2-year evaluation, there were 438 musculoskeletal issues, including 289 injuries. The mean number of treatment episodes per athlete was 77 ± 71 (range, 0-340), and the mean number of days unavailable was 67 ± 92 days (range, 0-432 days). There were 23 athletes who required 25 operations, the most common procedure being arthroscopic shoulder stabilization (n = 6). The number of injuries per athlete was not significantly different between the GJH and no-GJH groups (3.0 ± 2.1 vs 4.1 ± 3.0; P = .13), nor were there any between-group differences in the number of treatments received (74.6 ± 81.9 vs 77.2 ± 71.5; P = .47), days unavailable (79.6 ± 124.5 vs 65.3 ± 89.3; P = .61), or rates of surgery (43% vs 30%; P = .67). Conclusion: A preseason diagnosis of GJH did not place NCAA football players at a greater risk for injury during the 2-year study period. Based on the findings of this study, no specific preparticipation risk counseling or intervention is warranted for football players who are diagnosed with GJH as defined by the Beighton score.

Upper Extremity Injuries in CrossFit Athletes-a Review of the Current Literature.

PURPOSE OF REVIEW: Cross-discipline fitness, or CrossFit, has exploded in popularity during the last two decades. During this time, there have been a high volume of patients presenting to clinicians with a wide range of associated injuries. Given the high intensity, high repetition, and competitive nature of CrossFit training and competition, athletes are vulnerable to injury, particularly upper extremity injury. The rate of injury to the shoulder, elbow, and wrist in CrossFit is higher when compared to traditional weight-training and more comparable to elite-level gymnastics and Olympic-style lifting. Due to the growing popularity of CrossFit-style exercise and the relatively high rate of injury among its participants, clinicians are likely to encounter these athletes. The purpose of this review is to familiarize clinicians with CrossFit and the associated injuries they will likely encounter. RECENT FINDINGS: The medical literature focusing on CrossFit has demonstrated exponential growth, with the first article published in 2012 and 59 articles published in 2020. Although the body of literature is growing, there are no high-level studies focusing on CrossFit. The literature mainly consists of level IV and V studies, primarily consisting of case reports and case series. Recent studies have proven that CrossFit athletes are vulnerable to high rates of upper extremity injury and a few studies have identified risk factors for injury. Future high-level research is required to study modifiable risk factors, diagnostic criteria, and treatment options for these high-risk athletes in order to improve the safety of their sport. The CrossFit body of research is limited to level IV and V studies; however, the literature is clear, CrossFit athletes face a high rate of upper extremity injury. For this reason, clinicians must be familiar with CrossFit and its associated pathology. The goal of this review is to familiarize clinicians with CrossFit and the associated pathologies they will likely encounter.

Algorithm Improves Acetabular Fracture Radiograph Interpretation Among Inexperienced Practitioners.

Acetabular fractures are often first evaluated in the emergency department, where physicians with little experience reading pelvic radiographs may be required to make an accurate diagnosis and early management decisions. In this study, medical students classified radiographs of 20 acetabular fractures and repeated the exercise three weeks later with the aid of a previously described algorithm; half the students were given a lesson prior to using the algorithm. The pre-algorithm accuracy was 4/20 and the post-algorithm accuracy was 8.3/20 (p<0.01). The lesson provided no difference (p=0.5). This algorithm is therefore a useful reference to help classify and triage acetabular fractures.

Isolated Acetabuloplasty for Femoroacetabular Impingement: Favorable Patient-Reported Outcomes and Sustained Survivorship at Minimum 5-Year Follow-Up.

PURPOSE: To evaluate minimum 5-year outcomes and conversion rate to total hip arthroplasty (THA) for the treatment of femoroacetabular impingement (FAI) syndrome with an isolated acetabular osteoplasty. METHODS: Patients undergoing hip arthroscopy with an isolated acetabular osteoplasty from March 2009 to June 2014 for FAI syndrome with pincer and/or cam morphology and a labral tear were identified. Those who underwent femoroplasty or prior ipsilateral hip surgery or who had previous hip conditions, ipsilateral hip dysplasia, or a Tönnis grade higher than 2 were excluded. Patient-reported outcomes (PROs) collected included Patient-Reported Outcomes Measurement Information System (PROMIS) scores specific to physical functioning and pain interference, modified Harris Hip Score, International Hip Outcome Tool 12, Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sport-Specific Subscale, and Numeric Pain Rating Scale. Patients were also queried about secondary surgical procedures and conversion to THA. RESULTS: We identified 86 patients at minimum 5-year follow-up (average, 7.4 years). The average patient age was 39.8 ± 12.3 years, 70.9% of patients were female, and 7% of patients had Tönnis grade 2. The mean PRO scores were 52.0 ± 8.9 for the PROMIS physical functioning score, 39.6 ± 7.5 for the PROMIS pain interference score, 78.7 ± 12.0 for the modified Harris Hip Score, 73.3 ± 23.1 for the International Hip Outcome Tool 12 score, 89.9 ± 12.0 for the Hip Outcome Score-Activities of Daily Living, and 81.4 ± 21.0 for the Hip Outcome Score-Sport-Specific Subscale. Of the patients, 72.1% achieved the patient acceptable symptomatic state (PASS) according to previously established PASS scores for FAI syndrome treated with hip arthroscopy at minimum 5-year follow-up. The overall rate of revision arthroscopy was 3.5%, and the rate of conversion to THA was 5.8%. CONCLUSIONS: An isolated acetabular osteoplasty can provide sustained clinical benefits for the treatment of FAI syndrome with labral tears, with good to excellent PROs and PASS rates and a low rate of conversion to THA at minimum 5-year follow-up. LEVEL OF EVIDENCE: Level IV, case series.

Cast Saw Burn Prevention: An Evidence-Based Review.

Cast saw burns are an avoidable complication of cast removal and cast splitting. These iatrogenic injuries often lead to unacceptable clinical sequalae with significant financial and legal consequences. Therefore, a considerable body of research has been directed toward cast saw burn prevention. This review of currently published data provides clinicians with a summary of the literature to guide practice based on the best available evidence, with the goal of preventing iatrogenic cast saw burns. The PubMed database was queried for articles published from 1980 until present with the following key words: cast saw burns, cast saw blades, cast saws, orthopaedic education or surgical simulation. Relevant articles were reviewed and summarized. The prevention of cast saw burns involves awareness of clinical risk factors, maintenance of equipment, use of the proper technique, and the education of novice providers. By implementing evidence-based methods, orthopaedic surgeons and associated healthcare providers can aim to eliminate these preventable complications from their practice.

Partial rupture of the distal biceps brachii tendon: a magnetic resonance imaging analysis.

BACKGROUND: This study is the largest cohort of partial distal biceps brachii tendon ruptures in the literature that was analyzed according to rupture morphology of the long and short tendon heads. METHODS: Patients with partial distal biceps tendon ruptures were identified using an institutional enterprise data warehouse query at a single institution. A retrospective chart review was performed to record patient demographics, past medical history, and injury mechanism for each patient. Each patient's magnetic resonance images were reviewed to determine injury patterns, specifically the extent of long head (LH) and short head (SH) tendon involvement, and associated injuries. Rupture morphologies were correlated with mechanism of injury, diabetes status, and smoking history. RESULTS: Seventy-seven patients were included in the study. The average age was 52 years (±11.9, range: 23-90 years); 67% were male, with an average body mass index of 28.3 (±4.3). A smoking history was reported in 31.2% of patients and 5.2% were diabetic. The partial ruptures were caused by a traumatic mechanism in 57.1% of cases, 23.4% were atraumatic, and 19.5% had an unknown mechanism. The most common injury morphology was a partial LH rupture with an intact SH tendon (33.8%). Isolated complete ruptures of the LH represented the least common injury morphology. Injury morphology was significantly related to mechanism (P < .01). Traumatic ruptures had a higher percentage of SH involvement compared with the atraumatic group (77.3% vs. 37.7%, respectively). In contrast, atraumatic ruptures involved the LH tendon in 89% of cases, with only 37.7% of cases involving the SH tendon. Patients with a history of smoking were more likely to have an atraumatic mechanism (P = .01). A history of diabetes was unrelated to mechanism (P = .20). CONCLUSION: Partial ruptures of the distal biceps brachii tendon represent a spectrum of patterns with varying involvement of the LH and SH tendons. Injury morphology was significantly related to mechanism (P < .01). LH tendon involvement was seen in 88.9% of atraumatic cases, whereas SH tendon involvement was seen in 77.3% of traumatic cases. A more comprehensive understanding of partial rupture patterns is critical to further understand the risk factors that may preclude to worse clinical outcomes, and aid in deciding which patients would benefit from operative vs. nonoperative management.

Arthroscopy versus arthrotomy for the treatment of septic knee arthritis.

PURPOSE: To compare complications following arthroscopy and arthrotomy for treatment of septic knee arthritis. METHODS: Patients undergoing arthroscopy and arthrotomy for a diagnosis of septic knee arthritis were identified in National Surgical Quality Improvement Program and placed in a multivariate analysis to determine if type of surgery contributed to postoperative complications. RESULTS: Knee arthrotomy was associated with an increased risk for increased operative time [Parameter estimate 4.555 (95% CI:3.023-6.085); p < 0.0001], minor morbid events [OR 2.064 (95% CI: 1.447-2.943); p < 0.0001], and any morbidity [OR 2.285 (95% CI:1.527-3.419); p < 0.0001]. CONCLUSIONS: Knee arthrotomy was associated with a higher risk of complications.

Risk Factors for 30-Day Readmission following Knee Arthroscopy.

This study evaluates knee arthroscopy cases in a national surgical database to identify risk factors associated with readmission. The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2012 to 2016 for billing codes related to knee arthroscopy. International Classification of Diseases diagnostic codes were then used to exclude cases which involved infection. Patients were subsequently reviewed for readmission within 30 days. Univariate and multivariate analyses were then performed to identify risk factors associated with 30-day readmission. A total of 69,022 patients underwent knee arthroscopy. The overall 30-day complication rate was 1.75% and the 30-day readmission rate was 0.92%. On multivariate analysis, age > 60 years (odds ratio [OR], 1.29; 95% confidence interval [CI], 1.07-1.55), smoking (OR, 1.40; 95% CI, 1.15-1.70), recent weight loss (OR, 13.22; 95% CI, 5.03-34.73), chronic obstructive pulmonary disease (OR, 1.98; 95% CI, 1.39-2.82), hypertension (OR, 1.48; 95% CI, 1.23-1.78), diabetes (OR, 1.92; 95% CI, 1.40-2.64), renal failure (OR, 10.65; 95% CI, 2.90-39.07), steroid use within 30 days prior to the procedure (OR, 1.91; 95% CI, 1.24-2.94), American Society of Anesthesiologists (ASA) class ≥ 3 (OR, 1.69; 95% CI, 1.40-2.04), and operative time > 45 minutes (OR, 1.68; 95% CI, 1.42-2.00) were identified as independent risk factors for readmission. These findings confirm that the 30-day overall complication (1.75%) and readmission rates (0.92%) are low for knee arthroscopy procedures; however, age > 60 years, smoking status, recent weight loss, chronic obstructive pulmonary disease, hypertension, diabetes, chronic steroid use, ASA class ≥ 3, and operative time > 45 minutes are independent risk factors for readmission.

Risk factors for 30-day readmission following hip arthroscopy.

PURPOSE: Hip arthroscopy is known to be safe with low rates of postoperative complications. The purpose of this study is to evaluate hip arthroscopy cases in a national surgical database to identify risk factors associated with readmission. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2012 to 2016 for current procedural terminology billing codes related to hip arthroscopy. International Classification of Diseases diagnostic codes were used to exclude cases involving infection, fracture, or open procedures. Univariate and multivariate analyses were performed to identify risk factors associated with 30-day readmission. RESULTS: 1493 patients were identified who had undergone hip arthroscopy. The most common procedures were labral resection or chondroplasty (n = 589, 39.5%) and femoroplasty (n = 527, 35.3%). The 30-day complication rate was 1.7% and the most common complications following the procedure were bleeding (n = 12, 0.8%) superficial infections (n = 5, 0.3%), and returning to the operating room (n = 4, 0.3%). The 30-day readmission rate was 1.3%. On multivariate analysis, hypertension requiring anti-hypertensive medication (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.4-8.7) and chronic corticosteroid or immunosuppressant use (OR 7.2; 95% CI 1.9-26.7) were identified as independent risk factors for readmission. There was no difference in complication rates when hip arthroscopy was performed with isolated femoroplasty (n = 340), isolated acetabuloplasty (n = 103), both (n = 187) or neither (n = 863). CONCLUSION: These findings confirm that the 30-day readmission (1.3%) and complication rate (1.7%) are low for isolated hip arthroscopy procedures; however, hypertension and chronic steroid use are independent risk factors for readmission. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Deltoid ligament repair reduces and stabilizes the talus in unstable ankle fractures.

INTRODUCTION: Treatment of supination external rotation type IV (SER-IV) ankle injuries has focused on reduction and fixation of the fibula and syndesmosis (ORIF), not repair of the deltoid ligament. METHODS: Twenty-one ankles were analyzed with a motion capture system. Uninjured ankles were stressed and compared to ankles with SER-IV injuries, then with ORIF, and finally ORIF and deltoid repair. RESULTS: After deltoid ligament repair, talar coronal and axial rotation normalized to the uninjured state and were significantly reduced compared to ORIF alone. DISCUSSION: Deltoid ligament repair after an SER-IV ankle injury can help directly reduce and stabilize the tibiotalar joint.

Smoking as a Risk Factor for Readmission in Arthroscopic Surgery: A Propensity Matched Analysis.

The objective of this study was to perform a propensity matched analysis exploring smoking as a risk factor for readmission following hip, knee and shoulder arthroscopy. Patients undergoing knee, shoulder or hip arthroscopy between 2006-2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Patient's smoking was analyzed for its effect on 30-day readmission using multivariate regression adjusting for demographics and comorbidities. A propensity matched analysis control identified 19,732 non-smokers to serve as the control group. The readmission rate for the non-smoking cohort was 0.9% and 1.3% in the smoking group (p = 0.01). In a multivariate analysis adjusting for baseline characteristics and medical comorbidities, smoking status was associated with increased risk readmission (Odds Ratio: 1.37 [95% Confidence Interval: 1.133-1.657] p = 0.0012). This study suggests that smoking increases chances of readmission in all arthroscopic surgery. (Journal of Surgical Orthopaedic Advances 28(4):272-276, 2019).

Complete Intrasubstance Long Head Biceps Brachii Rupture with Successful Repair: A Case Report.

INTRODUCTION: Intrasubstance biceps brachii rupture is a rare injury. Non-operative management of this injury has demonstrated worse outcomes than early operative intervention. CASE REPORT: We report a case of a traumatic long head of the biceps brachii muscle belly rupture repaired primarily throughthe Kragh technique augmented with human dermal collagen matrix. The patient demonstrated full strength, an intact repair throughclinical exam and magnetic resonance imaging at 6-year follow-up. Dash scoring demonstrated 0 (no disability) out of 100 at this time. CONCLUSION: Repair of acute traumatic closed transection of the biceps brachii can be successfully repaired utilizing this technique with excellent post-operative function.

The Experiential Benefit of an Orthopedic Trauma Fellowship: An Analysis of ACGME Case Log Data From 2006 to 2017.

OBJECTIVE: The Accreditation Council for Graduate Medical Education (ACGME) has published orthopedic case log data since the 2006/2007 academic year. Here, we use this data to analyze the variability in orthopedic trauma case experience reported by orthopedic trainees and to better understand the impact of an orthopedic trauma fellowship on orthopedic surgical training. DESIGN, SETTING, AND PARTICIPANTS: Data were gathered from ACGME case log reports for orthopedic residents (reporting the cumulative case experience of graduating residents) and orthopedic trauma fellows (reporting the case experience of their fellowship year only) for all available years. RESULTS: The average orthopedic trauma fellow reported significantly more trauma cases in multiple body regions ("Pelvis/Hip", "Femur/Knee", and "Foot/Toes") and "Open Complex" reductions (as defined by the ACGME) in their 1 year of fellowship than the average resident reported in their 5 years of residency. CONCLUSION: On average, orthopedic trauma fellowships substantially increase the trauma case volumes of orthopedic trainees, especially with respect to lower extremity trauma.

Risk factors for complications following decompression of non-traumatic compartment syndrome.

PURPOSE: To investigate the rate of and risk factors for complications following non-traumatic compartment syndrome decompression. METHODS: The National Surgical Quality Improvement Program database was queried from 2006 to 2016 for non-traumatic compartment syndrome diagnosis codes. Multivariate analysis was performed to identify risk factors for 30-day complications and hospital readmissions. RESULTS: Overall complication, major complication, minor complication, and hospital readmission rates were 4.5%, 2.5%, 2.3%, and 2.0%, respectively. Active smoking was identified as a risk factor for post-operative complication (95%CI 1.19-9.24). CONCLUSION: The complication profile of non-traumatic compartment syndrome decompression is higher than that of traditional elective orthopaedic surgery. LEVEL OF EVIDENCE: IV.

Body Mass Index as a Risk Factor for 30-Day Postoperative Complications in Knee, Hip, and Shoulder Arthroscopy.

PURPOSE: To use the American College of Surgeons National Surgical Quality Improvement Program database to determine whether body mass index (BMI) is associated with 30-day postoperative complications following arthroscopic surgery. METHODS: Cases of elective knee, hip, and shoulder arthroscopy were identified. A retrospective comparative analysis was conducted, and the overall rates of morbidity, mortality, readmission, reoperation, and venothromboembolism (VTE) were compared using univariate analyses and binary logistic regressions to ascertain the adjusted effect of BMI, with and without diabetes, on morbidity, readmission, reoperation, and VTE. RESULTS: There were 141,335 patients who met the criteria. The most common complications were deep vein thrombosis (0.27%), superficial surgical site infection (0.17%), urinary tract infection (0.13%), and pulmonary embolism (0.11%). Obesity class III with diabetes was a risk factor for morbidity (odds ratio [OR] = 1.522; 95% confidence interval [CI], 1.101-2.103) and readmission (OR = 2.342; 95% CI, 1.998-2.745) following all procedures, while obesity class I was protective toward reoperation (OR = 0.687, 95% CI, 0.485-0.973). Underweight patients were at higher risk for morbidity following shoulder arthroscopy (OR = 3.776; 95% CI, 1.605-8.883), as were the class I obese (OR = 1.421; 95% CI, 1.010-1.998) and class II obese (OR = 1.726, 95% CI, 1.159-2.569). BMI did not significantly affect morbidity following knee arthroscopy. VTE risk factors included being overweight (OR = 1.474; 95% CI, 1.088-1.996) or diabetic with class I obesity (OR = 1.469; 95% CI, 1.027-2.101). CONCLUSIONS: Arthroscopic procedures are safe with very low complication rates. However, underweight and class I and class II obese patients are at higher risk for morbidity following shoulder arthroscopy, and diabetic patients with class III obesity are at higher risk for morbidity and readmission following all arthroscopy. Because BMI is a modifiable risk factor, these patients should be evaluated carefully before being considered for outpatient arthroscopic surgery. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Risk factors for admission after shoulder arthroscopy.

BACKGROUND: Shoulder arthroscopy is a common orthopedic procedure typically performed on an outpatient basis. Occasionally, patients require an unplanned hospital admission. An understanding of the incidence and risk factors for admission after shoulder arthroscopy may assist surgeons in determining which patients may be susceptible to unplanned admission after surgery. METHODS: All consecutive shoulder arthroscopy procedures performed during a 10-year period were reviewed. A 2:1 control-case matching technique was used. Univariate analysis was performed to identify differences between patients admitted after surgery and the control group. Multivariate analysis was performed to identify variables associated with admission. RESULTS: There were 5598 arthroscopic shoulder procedures performed, with 233 patients (4.2%) requiring admission. The most common reason for admission was respiratory monitoring. Risk factors for admission by multivariate analysis were chronic obstructive pulmonary disease (odds ratio [OR], 2.73; 95% confidence interval [CI], 1.51-4.95), diabetes (OR, 2.11; 95% CI, 1.28-3.48), obstructive sleep apnea (OR, 1.90; 95% CI, 1.13-3.21), age (OR, 1.02; 95% CI, 1.01-1.04), body mass index (OR, 1.04; 95% CI, 1.01-1.07), and operative time (OR, 1.01; 95% CI, 1.00-1.01). Regional with monitored anesthesia care decreased risk compared with general anesthesia and regional with general anesthesia (OR, 0.44; 95% CI, 0.30-0.63). CONCLUSION: Chronic obstructive pulmonary disease, obstructive sleep apnea, diabetes, increasing age, increasing body mas index, and increasing operative time were all risk factors for admission after shoulder arthroscopy. The absence of general anesthesia was found to decrease the risk of admission.

How Often Are Protocols Followed at Level I Trauma Centers?

This study analyzes adherence to an evidence-based protocol established at two level I trauma centers to determine its effect on clinical decision making. The centers' trauma databases were retrospectively studied and 51 patients with long bone fractures were identified who required revascularization and orthopaedic intervention and survived long enough to receive an index intervention. An arterial shunt was the protocol's first step; the preprotocol rate of shunting was 9.5%, while the postprotocol rate of shunting was 3.3%. The protocol's next step was external fixation; among the cases managed without a shunt, external fixation was the index intervention in 63.2% of the preprotocol cases and 31.0% of the postprotocol cases. Definitive vascular surgery was routinely performed before external fixation in 28.6% of the preprotocol cases and 56.7% of the postprotocol cases. This study demonstrates that this evidence-based protocol had no effect on the management of patients with combined orthopaedic and vascular injuries. Protocols should never supersede clinical judgment, but poor protocol adherence may represent a need for trauma centers to routinely review their protocols' compliance and efficacy. (Journal of Surgical Orthopaedic Advances 27(2):109-112, 2018).