Low Mortality of Orthopedic Trauma Patients With Asymptomatic COVID-19: A Level I Trauma Center Pandemic Experience.

Background: Early (2020) reports on mortality in patients with coronavirus disease 2019 (COVID-19) who underwent orthopedic surgery ranged from 20.5% to 56%, but these studies included elderly patients with multiple comorbidities. The mortality rate for younger and asymptomatic COVID-19-positive patients undergoing orthopedic surgery after high-energy trauma is underreported. The purpose of this study was to compare the 30-day mortality of asymptomatic COVID-19-positive patients and COVID-19-negative patients surgically treated for orthopedic trauma at a Level I trauma center during the coronavirus pandemic. A secondary objective was to compare the patients' postoperative hospital course and length of stay. Methods: This study is a single-center retrospective review of all patients who underwent an orthopedic surgical procedure at a Level I trauma center during a 3-month period early in the COVID-19 pandemic. All patients received a preoperative nasopharyngeal swab to determine COVID-19 infection status. Preoperative demographic variables, perioperative and postoperative mortality within 30 days, length of stay, and intensive care unit days were compared between COVID-19-positive and COVID-19-negative patients. Results: Of the 471 total patients, 13 were COVID-19-positive and 458 were COVID-19-negative prior to surgery. The average age of all patients was 40.5 ± 19.8 years. The mortality rate in the COVID-19-positive group was 0% vs 0.7% in the COVID-19-negative group, with no significant difference between groups (P=0.77). The COVID-19-positive group vs the COVID-19-negative group had no significant difference in hospital length of stay (7.4 days vs 4.4 days, respectively, P=0.12). Conclusion: Asymptomatic COVID-19-positive orthopedic trauma patients treated with surgery at a Level I trauma center in a 3-month period during the COVID-19 pandemic had a 0% mortality rate, and we found no differences between COVID-19-positive and COVID-19-negative patients with respect to mortality and hospital length of stay.

Case report: unique failure of a Synthes TFNA fenestrated lag screw in a peritrochanteric nonunion.

Background: Intertrochanteric femur fractures are a common orthopaedic injury that are often treated surgically. Cephalomedullary nails (CMN) are frequently the implant of choice for intertrochanteric femur fractures, resulting in low complication rates. Implant failure is a rare but reported complication. Common locations of failure include the proximal nail aperture, distal screw holes, and implant shaft. In this case report, we describe a CMN failure pattern through fenestrated cephalic screw holes. Case: A 70-year-old female sustained an OTA 31A-2.2 peritrochanteric fracture during a motor vehicle collision. She was treated the following day with a Synthes Trochanteric Fixation Nail-Advanced CMN utilizing a fenestrated cephalic screw. There were no intraoperative complications. She was made non-weight bearing for 8 weeks after the procedure due to ipsilateral foot fractures. At 6 months follow-up she was noted to have a delayed union. 11 months postoperatively she suffered a ground level fall and the cephalic lag screw failed through its fenestrations, resulting in varus collapse of her fracture at the femoral neck. The patient then underwent nail extraction and salvage total hip arthroplasty. Conclusion: Cephalomedullary nail implant failure is presented with implant fracture propagation through a fenestrated cephalic screw. Cephalomedullary lag screw failure is rare and can be difficult to manage. It is important to monitor new implants for unique failure mechanisms.

Improved Radiation Exposure Monitoring of Orthopaedic Residents After Institution of a Personalized Lead Protocol.

Radiation exposure of orthopaedic residents should be accurately monitored to monitor and mitigate risk. The purpose of this study was to determine whether a personalized lead protocol (PLP) with a radiation monitoring officer would improve radiation exposure monitoring of orthopaedic surgery residents. Materials and Methods: This was a retrospective case-control study of 15 orthopaedic surgery residents monitored for radiation exposure during a 2-year period (March 2017 until February 2019). During the first 12-month period (phase 1), residents were given monthly radiation dosimeter badges and instructed to attach them daily to the communal lead aprons hanging outside the operating rooms. During the second 12-month period (phase 2), a PLP (PLP group) was instituted in which residents were given lead aprons embroidered with their individual names. A radiation safety officer was appointed who placed the badges monthly on all lead aprons and collected them at the end of the month, whereas faculty ensured residents wore their personalized lead apron. Data collected included fluoroscopy use time and radiation dosimeter readings during all orthopaedic surgeries in the study period. Results: There were 1,252 orthopaedic surgeries using fluoroscopy during phase 1 in the control group and 1,269 during phase 2 in the PLP group. The total monthly fluoroscopy exposure time for all cases averaged 190 minutes during phase 1 and 169 minutes during phase 2, with no significant difference between the groups (p < 0.45). During phase 1, 73.1% of the dosimeters reported radiation exposure, whereas during phase 2, 88.7% of the dosimeters reported radiation exposure (p < 0.001). During phase 1, the average monthly resident dosimeter exposure reading was 7.26 millirems (mrem) ± 37.07, vs. 19.00 mrem ± 51.16 during phase 2, which was significantly higher (p < 0.036). Conclusions: Institution of a PLP increased the compliance and exposure readings of radiation dosimeter badges for orthopaedic surgery residents, whereas the actual monthly fluoroscopy time did not change. Teaching hospitals should consider implementing a PLP to more accurately monitor exposure. Level of Evidence: 3.

Implant Selection for Proximal Humerus Fractures.

Proximal humerus fractures (PHF) are a common orthopedic injury; however, their treatment remains largely controversial with evidence supporting a wide array of treatments. Although many injuries can be treated nonoperatively, there has been much debate about surgical management of PHF. A detailed review of the literature was performed relative to operative management options specifically related to implant choices. Although no definitive answers are available regarding best practice, there is literature to guide operative decision-making and implant selection based on both patient- and surgeon-specific factors.

Waist-Hip Ratio Surrogate Is More Predictive Than Body Mass Index of Wound Complications After Pelvic and Acetabulum Surgery.

OBJECTIVES: To determine whether a novel surrogate of waist-hip ratio (WHR) is more predictive of wound complications after pelvis or acetabulum stabilization than body mass index (BMI) and describe the method of measuring a WHR proxy (WHRp). DESIGN: Retrospective review. SETTING: One Level 1 Trauma Center. PATIENTS: One hundred sixty-one patients after operative repair of pelvis and acetabulum fractures. INTERVENTION: Operative stabilization of a pelvic ring injury or acetabular fracture. MAIN OUTCOME MEASUREMENTS: Infection (pin, superficial, and deep) and wound healing complication. METHODS: We retrospectively reviewed 161 subjects after operative repair of pelvic and acetabular fractures. Primary outcome was any wound complication. BMI was acquired from medical records. WHRp was derived from anteroposterior and lateral computed tomography scout images. BMI and WHRp results were analyzed as continuous and categorical variables. BMI was grouped into high-risk categories of ≥30 and ≥40. WHRp data were grouped utilizing the WHO's high-risk profile for females (>0.85) and males (>0.90). An alternative optimal WHR was also assessed. Covariate analysis included demographic data, Injury Severity Score, mechanism, tobacco use, presence and types of open approach, injury type, associated injuries and comorbidities, failure of fixation, and thromboembolism. RESULTS: The mean follow-up was 15.9 months. Twenty-four (15%) patients developed wound complications. Increasing BMI (P < 0.007) and WHRp (P < 0.001) as continuous variables and female sex (P < 0.009) were associated with wound complications. Applying unadjusted continuous data to a receiver operating characteristic curve revealed a greater area under the curve for WHRp than for BMI (P < 0.001). The optimal predictive WHRp was ≥1.0 (P < 0.001, odds ratio 43.11). The receiver operating characteristic curve from adjusted data demonstrated a greater area under the curve for WHRp ≥1.0 (0.93) compared with BMI ≥30 (0.78) or ≥40 (0.75) and WHO WHRp (0.82). Computed tomography generated WHRp demonstrated excellent interrater reliability (0.99). CONCLUSION: The WHRp of ≥1.0 was more predictive than BMI of wound complications after operative treatment of pelvis and acetabulum fractures. In our series, WHRp calculated using scout images performed sufficiently well to predict wound complications. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.