Is Flexion Gap Rectangular in Native Indian Knees? Results of an MRI Study.

BACKGROUND: The purpose of this study was to evaluate the flexion-gap of the native knees in the normal population and to assess any gender-specific variations in the flexion gap of the knees. METHODS: A total of 50 normal asymptomatic volunteers with normal knee radiographs were selected for MRI of the knee. The left knee was scanned in an open MRI using a T1-weighted sequence. Imaging was performed in neutral, passive varus and valgus stress at 90° of knee flexion by placing custom-made blocks on a special board consecutively below the distal part of the leg. RESULTS: The study population consisted of 26 males and 24 females with a mean age of 25.77 years. Under varus stress, the mean lateral flexion gap increased to 9.28 ± 1.53 mm and under valgus stress, the mean medial flexion gap increased to 2.75 ± 1.22 mm from neutral. The increase in the flexion gap on the lateral side was 5.28 ± 1.79 mm, which was significantly higher compared to that on the medial side. In gender-specific analysis, the mean lateral flexion gap was 10.21 mm in females and 8.46 mm in males under varus stress. CONCLUSION: The findings of the study indicate that the lateral soft tissues are more lax compared to the medial soft tissue structures and this laxity is higher in females as compared to males. The study provides evidence of the existing physiological variations of these soft tissue structures resulting in a trapezoidal flexion gap in the native knees rather than the recommended rectangular gap.

Acceptability and Feasibility of an Innovative Anesthesia Technique in a Low-Resource Setting at a Rural Community Ophthalmic Center: A Prospective Journey.

BACKGROUND: Ocular blindness and ocular morbidities are very much prevalent in pediatric age group in India. Mostly, these are all surgically amenable, provided they have access to safe anesthesia. Suboptimal facilities for conventional general anesthesia (GA) led to a different thought process. The combination of anesthetic and analgesic property of ketamine was utilized in a low-resource setting at a tertiary ophthalmic center for pediatric ophthalmic surgeries. AIMS: The aim of this study was to decipher whether this technique is acceptable and feasible. SETTINGS AND DESIGN: It was a prospective consecutive series at a rural eye center done over a period of 5 years. MATERIALS AND METHODS: Inclusion criterion was children undergoing eye surgeries between the ages of 7 and 18 years, who could be adequately counseled about the concept of painless intravenous cannulation and subsequent painless block. Intravenous anesthesia comprised of ketamine, in conjunction with peribulbar block. Complications of the technique, time to discharge, mean pain score, and patient and surgeon satisfaction score were documented. STATISTICAL ANALYSIS USED: Data were analyzed on Microsoft Excel. RESULTS: A total of 905 cases were conducted uneventfully without conversion to GA. No emergency resuscitation was required. The surgeon and the patient had a satisfying experience, with the technique being totally acceptable to them. CONCLUSIONS: Intravenous ketamine is an inexpensive and safe anesthetic technique when used in conjunction with regional block and is certainly a boon for minimal resource ophthalmic setup in rural India.

Preinjury Narcotic Use Does Not Affect Treatment for Compartment Syndrome.

OBJECTIVES: To determine the association of preinjury opioid use on incidence of fasciotomy after lower extremity trauma. DESIGN: Retrospective case-control study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: We identified 245 consecutive patients treated with fasciotomy for compartment syndrome of the lower extremity from 2011 to 2016. Of these, 115 were excluded for isolated vascular injury without fracture, age younger than 18 years, out-of-state residence, nontraumatic etiology, and/or incomplete opioid records. Three hundred ninety age- and sex-matched patients with tibial fractures not requiring fasciotomy were selected for comparison. INTERVENTION: Review of demographics, injury characteristics, and opioid prescriptions. MAIN OUTCOME MEASUREMENTS: Rate of preinjury narcotic use. RESULTS: There was no significant difference in chronic opioid use between patients requiring fasciotomy and those who did not (odds ratio = 0.80, 95% confidence interval: 0.43-1.50, P = 0.49). There was no significant difference in average morphine milligram equivalents (MME)/day (66.6 vs. 77.4, P = 0.68). There was no significant difference in active opioid use (odds ratio = 0.76, 95% confidence interval: 0.45-1.29, P = 0.30). There was no significant difference in average MME/day (69.3 vs. 75.6, P = 0.80) for active narcotic users. CONCLUSION: There were no differences in the rate or average MME/day of preinjury opioid use between patients with a tibia fracture treated with or without fasciotomy for compartment syndrome. These results indicate that pre-existing opioid use does not interfere with the accurate diagnosis of compartment syndrome in trauma patients. The diagnosis and treatment of compartment syndrome is not affected by preinjury narcotic use and potential associations with opiate-induced hyperalgesia. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A predictive model for increased hospital length of stay following geriatric hip fracture.

BACKGROUND: The purpose of this study was to identify the risk factors that are significantly associated with hospital length of stay (LOS) following geriatric hip fracture and to use these significant variables to develop a LOS calculator. MATERIALS AND METHODS: This was a retrospective study examining 614 patients treated for geriatric hip fracture between January 2000 and December 2009 at an urban, Level 1 trauma center. A negative binomial regression analysis was used to identify perioperative variables associated with hospital LOS. RESULTS: 614 patients met the inclusion criteria, presenting with a mean age of 78 (±10) years. The most common pre-operative comorbidity was hypertension, followed by diabetes and COPD. After controlling for all collected comorbidities as well as demographics and operative variables, hypertension (IRR: 1.10, p = 0.029) and disseminated cancer (IRR: 1.24, p = 0.007) were found to be significantly associated with LOS. In addition, two demographic/presenting variables, admission to the medicine service (IRR: 1.48, p < 0.001) and male sex (IRR: 1.09, p = 0.034), were shown to be independent risk factors for prolonged LOS. These variables were synthesized into a LOS formula, which estimated LOS to within 3 days of the true length of stay for 0.758 of the series (95% confidence interval: 0.661 to 0.855). CONCLUSIONS: This study identified several comorbidity and perioperative variables that were significantly associated with LOS following geriatric hip fracture surgery. The resulting LOS model may have utility in the risk stratification of orthopaedic trauma patients presenting with hip fracture.

Association Between 6-Week Postdischarge Risk Classification and 12-Month Outcomes After Orthopedic Trauma.

Importance: Numerous studies have demonstrated that long-term outcomes after orthopedic trauma are associated with psychosocial and behavioral health factors evident early in the patient's recovery. Little is known about how to identify clinically actionable subgroups within this population. Objectives: To examine whether risk and protective factors measured at 6 weeks after injury could classify individuals into risk clusters and evaluate whether these clusters explain variations in 12-month outcomes. Design, Setting, and Participants: A prospective observational study was conducted between July 16, 2013, and January 15, 2016, among 352 patients with severe orthopedic injuries at 6 US level I trauma centers. Statistical analysis was conducted from October 9, 2017, to July 13, 2018. Main Outcomes and Measures: At 6 weeks after discharge, patients completed standardized measures for 5 risk factors (pain intensity, depression, posttraumatic stress disorder, alcohol abuse, and tobacco use) and 4 protective factors (resilience, social support, self-efficacy for return to usual activity, and self-efficacy for managing the financial demands of recovery). Latent class analysis was used to classify participants into clusters, which were evaluated against measures of function, depression, posttraumatic stress disorder, and self-rated health collected at 12 months. Results: Among the 352 patients (121 women and 231 men; mean [SD] age, 37.6 [12.5] years), latent class analysis identified 6 distinct patient clusters as the optimal solution. For clinical use, these clusters can be collapsed into 4 groups, sorted from low risk and high protection (best) to high risk and low protection (worst). All outcomes worsened across the 4 clinical groupings. Bayesian analysis shows that the mean Short Musculoskeletal Function Assessment dysfunction scores at 12 months differed by 7.8 points (95% CI, 3.0-12.6) between the best and second groups, by 10.3 points (95% CI, 1.6-20.2) between the second and third groups, and by 18.4 points (95% CI, 7.7-28.0) between the third and worst groups. Conclusions and Relevance: This study demonstrates that during early recovery, patients with orthopedic trauma can be classified into risk and protective clusters that account for a substantial amount of the variance in 12-month functional and health outcomes. Early screening and classification may allow a personalized approach to postsurgical care that conserves resources and targets appropriate levels of care to more patients.

Are Cardiac Complications Associated With Other Adverse Events? A Look at 56,000 Orthopaedic Trauma Patients.

The purpose of this study was to identify those complications for which patients with adverse cardiac events are at risk within the 30-day postoperative period following treatment oforthopaedic trauma cases. This was a retrospective cohort study of orthopaedic trauma patients in the United States between 2006 and 2013. A total of 56,336 patients meeting any one of 89 CPT codes in the American College of Surgeons National Surgical Quality Improvement Program database were used. The main outcome measure was myocardial infarction or cardiac arrest within the 30-day postoperative period. Patients experiencing adverse cardiac events were at a significantly higher risk to have also developed deep surgical site infection, pneumonia, the need for reintubation, pulmonary emboli, a failure to wean off of ventilation, chronic and acute renal failure, urinary tract infection, stroke, deep venous thrombosis, sepsis, and shock. Cardiac complications in orthopaedic trauma patients are relatively uncommon (1.3%); however, cardiac complications are associated with greater risks of other complications, including pneumonia, stroke, and urinary tract infection. (Journal of Surgical Orthopaedic Advances 27(3):198-202, 2018).

Management of Femoral Defects Greater Than 5 cm Following Open Femur Fractures: A 12-Year Retrospective Review.

This study sought to evaluate the outcomes of patients with osseous defects exceeding 5 cm following open femur fractures. Size of the osseous defect, method of internal fixation (plate vs. intramedullary nail), patient demographics, medical comorbidities, and surgical complications were collected. Twenty-seven of the 832 open femur fracture patients had osseous defects exceeding 5 cm. Mean osseous defect size was 8 cm, and each patient had an average of four operations including initial debridement. Average time from injury to bone grafting was 123.7 days. The overall complication rate was 48.1% (n = 13). The most common complications were infection (26.0%, n = 7) and nonunion (41.0%, n = 11). Smoking, diabetes, ASA score, and defect size did not independently increase the risk of a complication. Management of open femur fractures with osseous defects greater than 5 cm is associated with high complication rate, driven primarily by infection and nonunion. (Journal of Surgical Orthopaedic Advances 27(3):203-208, 2018).

Opioid Prescribing Practices After Isolated Pilon Fractures.

The purpose of our study was to identify the opioid-prescribing practices after operative treatment of isolated pilon fractures at a level 1 trauma center. Patients ≥ 18 years of age with an operatively treated isolated pilon fracture between 2005 and 2015 were identified. Total morphine milligram equivalents (MMEs) were then calculated. Mean and standard deviations were calculated for patients without a history of opiate use and for patients with a history of opiate use within 1 year prior to injury. Data were obtained from the State Controlled Substance Monitoring Database. Seventy-two patients met our inclusion criteria; of these, 54% (39/72) were opiate exposed at the time of injury. Median MMEs prescribed were 2738 (range 375 to 12,360). Orthopedic providers prescribed 61% of all the MMEs (median 2010; range 113 to 6825), while nonorthopedic providers prescribed a median of 338 MMEs (range 0 to 10,080) (p < .05). Combined, patients with exposure 1 year before the injury received more MMEs (median 3600; range 840 to 12,360) than opiate-naive patients (median 2520; range 375 to 10,610) (p < .05). Twenty-eight (38.9%) patients continued using opiates for more than 6 months after their injury; 25% (7/28) were not previously exposed. There is great variability regarding the quantity of opiates being prescribed after isolated pilon fractures, and 39% of opiate prescriptions are coming from nonorthopedic prescribers. Opiate-exposed patients are more likely to be prescribed more opiates by orthopedists and outside physicians and for a longer duration. We believe that adequate pain control can be obtained by prescribing 40 pills of oxycodone 10 mg with a maximum of 1 additional refill. In cases in which a staged procedure is planned, an additional refill is expected (total of 3 refills).

Opioid Prescribing Practices by Orthopaedic Trauma Surgeons After Isolated Femur Fractures.

OBJECTIVE: The purpose of this retrospective study was to identify opioid prescribing practices, determine the number of morphine milliequivalents (MMEs) prescribed by orthopaedic/nonorthopaedic members to narcotic naive and previously exposed patients, and provide narcotic prescribing recommendations. METHODS: Patients older than 18 years with an isolated femur fracture sustained between 2013 and 2015 were identified using the CPT code 27506. Prescribing information was obtained from the State Controlled Substance Monitoring Database. Descriptive analysis of MMEs was then performed. Outliers and patients without prescriptions from orthopaedic providers were excluded to eliminate skewing of data. Mean and standard deviations were then calculated for patients without a history of opiates prescribed within 1 year of injury and for patients with a history of opiates prescribed within 1 year before the injury. RESULTS: Forty-five percent (40/88) of patients were opiate exposed at the time of injury. Previously exposed patients received 1491 MMEs (SD, 1044; median, 1350; range, 210-5140) and nonexposed patients received 1363 MMEs (SD, 977.2; median, 1260; range, 105-4935) from orthopaedic providers (P = 0.1473). Nonorthopedists prescribed 530 MMEs (SD, 780.7; median, 140; range, 0-3515) to previously exposed patients and 175 MMEs (SD, 393; median, 140; range, 0-1890) to patients without exposure (P < 0.0001). CONCLUSION: Patients with prior exposure are more likely to be prescribed more opiates after femoral shaft fracture treatment. We recommend a protocol of prescribing half the mean of MMEs currently prescribed by orthopedists equating to 47 (711 MMEs) pills of oxycodone 10 mg in up to 3 prescriptions.

Open treatment of ankle fracture as inpatient increases risk of complication.

BACKGROUND: Ankle fracture is one of the most common injuries treated by orthopaedic surgeons, and its incidence is only expected to rise with an aging population. It is also associated with often costly complications, yet there is little literature on risk factors, especially modifiable ones, driving these complications. The aim of this study is to reveal whether inpatient treatment after ankle fracture is associated with higher incidence of postoperative complications. As the USA moves towards a bundled payment healthcare system, it is imperative that orthopaedists maximize patient outcome and quality of care while also reducing overall costs. MATERIALS AND METHODS: We used the American College of Surgeons National Surgical Quality Improvement Program database to compare complication rates between inpatient and outpatient treatment of ankle fracture. We collected patient demographics, comorbidities, and postoperative complications from both groups, then compared treatments using a multinomial logistic regression model. RESULTS: We identified 7383 patients, with 2630 (36%) in the outpatient and 2630 (36%) in the inpatient group. Of these, 104 (4.0%) inpatients compared with 52 (2.0%) outpatients developed a complication (p < 0.001). CONCLUSIONS: Inpatients developed major complications including deep wound infection and pulmonary embolism, as well as minor complications such as pneumonia and urinary tract infection, at significantly greater rates. As reimbursement models begin to incorporate value-based care, orthopaedic surgeons need to be aware of factors associated with increased incidence of postoperative complications. LEVEL OF EVIDENCE: Level III retrospective comparative study.

Outcomes of Distal Femur Nonunions Treated With a Combined Nail/Plate Construct and Autogenous Bone Grafting.

In this study, we sought to retrospectively evaluate union and infection rates after treatment of distal femur nonunions using a combined nail/plate construct with autogenous bone grafting obtained from the ipsilateral femur using a reamer irrigator aspirator system. Ten (10) patients treated at a Level I trauma center for nonunion of a femoral fracture using a combined nail/plate construct from 2004 to 2014 were included in the study. Union rate and postoperative infection rates were recorded. Mean interval from index surgery to nonunion repair was 12 months (range 4-36 months). Follow-up at 24 months indicated that the entire cohort of 10 patients achieved clinical union and radiographic union based on radiograph union score in tibias (RUST) criteria. Treatment of distal femur nonunions with a combined nail/plate construct and autogenous bone grafting results in a high rate of union with a low complication rate.

Patients at Increased Risk of Major Adverse Events Following Operative Treatment of Distal Radius Fractures: Inpatient versus Outpatient.

Purpose The purpose of this study was to compare complication rates following inpatient versus outpatient distal radius fracture ORIF and identify specific complications that occur at increased rates among inpatients. Methods Using the 2005-2013 ACS-NSQIP, we collected patient demographics, comorbidities, surgical characteristics, and 30-day postoperative complications following isolated ORIF of distal radius fractures. A propensity score matched design using an 8-to-1 "greedy" matching algorithm in a 1:4 ratio of inpatients to outpatients was utilized. Rates of minor, major, and total complications were compared. A multinomial logistic regression model was then used to assess the odds of complications following inpatient surgery. Results Total 4,016 patients were identified, 776 (19.3%) of whom underwent inpatient surgery and 3,240 (80.3%) underwent outpatient surgery. The propensity score matching algorithm yielded a cohort of 629 inpatients who were matched with 2,516 outpatients (1:4 ratio). After propensity score matching, inpatient treatment was associated with increased rates of major and total complications but not with minor complications. There was an increased odds of major complications and total complications following inpatient surgery compared with outpatient surgery. There was no difference in odds of minor complications between groups. Conclusion Inpatient operative treatment of distal radius fractures is associated with significantly increased rates of major and total complications compared with operative treatment as an outpatient. Odds of a major complication are six times higher and odds of total complications are two and a half times higher following inpatient distal radius ORIF compared with outpatient. Quality improvement measures should be specifically targeted to patients undergoing distal radius fracture ORIF in the inpatient setting.

Damage Control Plating in Open Tibial Shaft Fractures: A Cheaper and Equally Effective Alternative to Spanning External Fixation.

The purpose of this study was to evaluate damage control plating (DCP) as an alternative to external fixation (EF) in the provisional stabilization of open tibial shaft fractures. Through retrospective analysis, the study found 445 patients who underwent operative fixation for tibial shaft fractures from 2008 to 2012. Twenty patients received DCP or EF before intramedullary nailing with a minimum follow-up of 3 months. Charts and radiographs were reviewed for postoperative complications. Hospital charges were reviewed for implant costs. Nine patients (45%) with DCP and 11 patients (55%) with EF were analyzed. There was no significant difference in the complication rates. The mean implant cost of DCP was $1028, whereas mean EF construct cost was $4204. Therefore, DCP resulted in significant cost savings with no difference in complication rates, making it a valuable alternative to EF for the provisional stabilization of open tibial shaft fractures.

Does Physician Reimbursement Correlate to Risk in Orthopaedic Trauma?

This study investigated whether current Medicare reimbursements for orthopaedic trauma procedures correlate with complications. A total of 18,510 patients representing 33 orthopaedic trauma procedures from 2005 to 2011 were studied. Adverse events and Medicare payments for each orthopaedic trauma procedure were collected. Linear regressions determined correlations between complications and Medicare payments for orthopaedic trauma procedures. A weak correlation between Medicare payments and complications was found for all procedures (r = .399, p = .021). A 1.0% increase in complications was associated with a payment increase of only $100. There were no correlations between complications and reimbursements for upper extremity (p = .878) and lower extremity (p = .713) procedures. A strong correlation (r = .808, p = .015) existed for hip and pelvic fractures, but a 1.1% increase in hip and pelvic complications correlated with only an increase of $100 in reimbursements. This study is the first to show that Medicare payments are not strongly correlated with complications, therefore demonstrating the potential risks of a bundled payment system for orthopaedic trauma surgeons.

Drivers of hospital length of stay in 56,000 orthopaedic trauma patients: The impact of postoperative cardiac events.

PURPOSE: To determine whether postoperative cardiac complications following orthopaedic trauma treatment are associated with longer lengths of stay. METHODS: This was a retrospective cohort study. We analyzed orthopaedic trauma patients in the United States for whom data was collected in the ACS-NSQIP database between the years of 2006 and 2013. The patient population included 56,217 orthopaedic trauma patients meeting any 1 of the 89 CPT codes selected in the ACS-NSQIP database. The main outcome measure was hospital length of stay following orthopaedic trauma treatment. RESULT: Of the 56,217 orthopaedic trauma patients, 749 (1.3%) developed postoperative adverse cardiac events. There was a significant difference in total length of stay (p < 0.001): patients with cardiac complications on average stayed 10.6 days compared to 5.2 days for patients who did not experience such cardiac complications. This amounted to a difference of $24,316 in total hospital costs. Through multiple linear regression modeling controlling for multiple patient and surgical factors, the presence of cardiac complications significantly added 1.5 days in total hospital stay (p < 0.05). CONCLUSION: Orthopaedic trauma patients sustaining postoperative cardiac events have significantly longer hospital lengths of stay when compared to those who do not develop cardiac complications. This difference amounts to significantly higher health care costs.

Predicting the post-operative length of stay for the orthopaedic trauma patient.

PURPOSE: Length of stay (LOS) is a major driver of cost and quality of care. A bundled payment system makes it essential for orthopaedic surgeons to understand factors that increase a patient's LOS. Yet, minimal data regarding predictors of LOS currently exist. Using the ACS-NSQIP database, this is the first study to identify risk factors for increased LOS for orthopaedic trauma patients and create a personalized LOS calculator. METHODS: All orthopaedic trauma surgery between 2006 and 2013 were identified from the ACS-NSQIP database using CPT codes. Patient demographics, pre-operative comorbidities, anatomic location of injury, and post-operative in-hospital complications were collected. To control for individual patient comorbidities, a negative binomial regression model evaluated hospital LOS after surgery. Betas (ß), were determined for each pre-operative patient characteristic. We selected significant predictors of LOS (p < 0.05) using backwards stepwise elimination. RESULTS: 49,778 orthopaedic trauma patients were included in the analysis. Deep incisional surgical site infections and superficial surgical site infections were associated with the greatest percent change in predicted LOS (ß = 1.2760 and 1.2473, respectively; p < 0.0001 for both). A post-operative LOS risk calculator was developed based on the formula: [Formula: see text]. CONCLUSIONS: Utilizing a large prospective cohort of orthopaedic trauma patients, we created the first personalized LOS calculator based on pre-operative comorbidities, post-operative complications and location of surgery. Future work may assess the use of this calculator and attempt to validate its utility as an accurate model. To improve the quality measures of hospitals, orthopaedists must employ such predictive tools to optimize care and better manage resources.

The risk of deep vein thrombosis in total joint patients compared to orthopaedic trauma patients: Need for new prevention guidelines.

BACKGROUND: The development of Deep Vein Thrombosis (DVT) is a major concern following orthopaedic surgery. No study has yet to compare the rate and risk factors for DVT between total joint and orthopaedic trauma patients. To evaluate if DVT prophylaxis for trauma should differ from total joints, we explored the rate and risk factors for DVT between both cohorts. METHODS: Using a CPT code search from 2005 to 2013 in the ACS-NSQIP database, 150,657 orthopaedic total joint patients and 44,594 orthopaedic trauma patients were identified. DVT complications, patient demographics, preoperative comorbidities, and surgical characteristics were collected for each patient. A chi-squared test was used to compare the risk factors for DVT between orthopaedic trauma and total joint patients. A multivariable logistic regression model was built to adjust for comorbidities for each cohort. RESULTS: The rate of DVT diagnosis in the total joint population was 0.8% (N = 1186) and 0.98% (N = 432) in the orthopaedic trauma population (p = 0.57). After controlling for individual comorbidities, dyspnea, peripheral vascular disease, and renal failure were significant risk factors for DVT in total joint patients (p < 0.05), whereas age, ascites and steroid use were significant risk factors for DVT in orthopaedic trauma patients (p < 0.05). CONCLUSIONS: Historically, the risks for DVT in total joints have been emphasized, yet based on our results, the incidence of DVT is the same for orthopaedic trauma. However, the risk factors varied. It is therefore important to consider specialty-specific DVT prophylaxis for orthopaedic trauma patients in order to improve care and reduce postoperative complications.

Higher Charlson Comorbidity Index Scores Are Associated With Increased Hospital Length of Stay After Lower Extremity Orthopaedic Trauma.

OBJECTIVES: The purpose of this study was to explore the relationship between preoperative Charlson Comorbidity Index (CCI) and postoperative length of stay (LOS) for lower extremity and hip/pelvis orthopaedic trauma patients. DESIGN: Retrospective. SETTING: Urban level 1 trauma center. PATIENTS/PARTICIPANTS: A total of 1561 patients treated for isolated lower extremity and pelvis fractures between 2000 and 2012. INTERVENTIONS: Surgical intervention for fractures MAIN OUTCOME MEASUREMENTS:: The main outcome metric was LOS. Negative binomial regression analysis was used to examine the association between CCI and LOS while controlling for significant confounders. RESULTS: One thousand five hundred sixty-one patients met the inclusion criteria, 1302 (83.4%) of which had lower extremity injuries and 259 (16.6%) experienced hip/pelvis trauma. A total of 1001 (64.1%) patients presented with a CCI score of 1 and stayed an average of 7.9 days. Patients with a CCI of 3 experienced a mean LOS of 1.2 days longer than patients presenting with a CCI of 1, whereas patients presenting with a CCI score of 5 stayed an average of 4.6 days longer. After controlling for age, race, American Society of Anesthesiologists score, sex, anesthesia type, and anesthesia time, a higher preoperative CCI was found to be associated with longer LOS for patients with lower extremity fractures (Incidence Rate Ratio: 1.04, P = 0.01). No significant association was found between CCI and LOS for patients with hip/pelvic fractures. CONCLUSIONS: This study demonstrated the potential utility of the CCI as a predictor of hospital LOS for lower extremity patients; however, the association may be small given the smaller Incidence Rate Ratio value. Further studies are needed to clarify the predictive value of the CCI for different types of orthopaedic injuries. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete.

Characterization of Synthesized and Commercial Forms of Magnesium Stearate Using Differential Scanning Calorimetry, Thermogravimetric Analysis, Powder X-Ray Diffraction, and Solid-State NMR Spectroscopy.

Magnesium stearate is the salt of a complex mixture of fatty acids, with the majority being stearate and palmitate. It has multiple crystalline forms and, potentially, an amorphous form. Magnesium stearate is used in the pharmaceutical manufacturing industry as a powder lubricant, and typically is added at low levels (∼1%) during the manufacturing process and blended for a relatively short time (∼5 min). Proper levels and mixing times are needed, as too short a mixing time or too small a quantity will result in improper lubrication, and too much can negatively impact dissolution rates. The complex mixture of multiple fatty acids and crystalline forms in magnesium stearate leads to variability between commercial sources, and switching between sources can impact both the amount of lubricant and mixing time needed for proper lubrication. In order to better understand the complex nature of magnesium stearate, a variety of analytical techniques were used to characterize both synthesized and commercial magnesium stearate samples. The results show that correlation among differential scanning calorimetry, thermogravimetric analysis, solid-state NMR spectroscopy, and other techniques provides a unique insight into the forms of magnesium stearate. Finally, the ability to monitor form changes of magnesium stearate in an intact tablet using solid-state NMR spectroscopy is shown.

Incidence and predictive risk factors of postoperative sepsis in orthopedic trauma patients.

BACKGROUND: Postoperative sepsis is associated with high mortality and the national costs of septicemia exceed those of any other diagnosis. While numerous studies in the basic orthopedic science literature suggest that traumatic injuries facilitate the development of sepsis, it is currently unclear whether orthopedic trauma patients are at increased risk. The purpose of this study was thus to assess the incidence of sepsis and determine the risk factors that significantly predicted septicemia following orthopedic trauma surgery. MATERIALS AND METHODS: 56,336 orthopedic trauma patients treated between 2006 and 2013 were identified in the ACS-NSQIP database. Documentation of postoperative sepsis/septic shock, demographics, surgical variables, and preoperative comorbidities was collected. Chi-squared analyses were used to assess differences in the rates of sepsis between trauma and nontrauma groups. Binary multivariable regressions identified risk factors that significantly predicted the development of postoperative septicemia in orthopedic trauma patients. RESULTS: There was a significant difference in the overall rates of both sepsis and septic shock between orthopedic trauma (1.6%) and nontrauma (0.5%) patients (p < 0.001). For orthopedic trauma patients, ventilator use (OR = 15.1, p = 0.002), history of pain at rest (OR = 2.8, p = 0.036), and prior sepsis (OR = 2.6, p < 0.001) were significantly associated with septicemia. Statistically predictive, modifiable comorbidities included hypertension (OR = 2.1, p = 0.003) and the use of corticosteroids (OR = 2.1, p = 0.016). CONCLUSIONS: There is a significantly greater incidence of postoperative sepsis in the trauma cohort. Clinicians should be aware of these predictive characteristics, may seek to counsel at-risk patients, and should consider addressing modifiable risk factors such as hypertension and corticosteroid use preoperatively. Level of evidence Level III.