Low-Dose Short-Term Scheduled Ketorolac Reduces Opioid Use and Pain in Orthopaedic Polytrauma Patients: A Randomized Clinical Trial.

OBJECTIVE: To determine whether scheduled low-dose, short-term ketorolac is associated with reduced length of stay, opioid use, and pain in orthopaedic polytrauma patients. DESIGN: Double-blinded, randomized controlled trial. SETTING: One Level 1 trauma center. PATIENTS: From August 2018 to October 2022, 70 orthopaedic polytrauma patients between 18-75 years-old with a New Injury Severity Score (NISS) > 9 were randomized. 70 participants were enrolled, with 35 randomized to the ketorolac group and 35 to the placebo group. INTERVENTION: 15 mg of intravenous (IV) ketorolac every 6 hours for up to 5 inpatient days or 2 mL of IV saline in a similar fashion. MAIN OUTCOME MEASUREMENTS: Length of Stay (LOS), Morphine Milligram Equivalents (MME), Visual Analogue Scale (VAS), and Complications. RESULTS: Study groups were not significantly different with respect to age, BMI, and NISS (p>0.05). Median LOS was 8 days (interquartile range [IQR], 4.5 to 11.5) in the ketorolac group compared to 7 days (IQR, 3 to 10) in the placebo group (p = 0.275). Over the 5-day treatment period, the ketorolac group experienced a 32% reduction in average MME (p = 0.013) and a 12-point reduction in baseline-adjusted mean VAS (p = 0.037) compared to the placebo group. There were no apparent short-term adverse effects in either group. CONCLUSION: Scheduled low-dose, short-term IV ketorolac was associated with significantly reduced inpatient opioid use and pain in orthopaedic polytrauma patients with no significant difference in LOS and no apparent short-term adverse effects. The results support the use of scheduled low-dose, short-term IV ketorolac for acute pain control among orthopaedic polytrauma patients. Further studies are needed to delineate lasting clinical effects and potential long-term effects, such as fracture healing. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Comparison of post-op opioid use and pain between short and long cephalomedullary nails in elderly intertrochanteric fractures.

PURPOSE: It remains unknown if cephalomedullary nail (CMN) length has an impact on pain and opioid use following fixation. Given the lack of level I evidence favoring a specific CMN length to prevent adverse surgical outcomes, we investigated if CMN length impacts acute postoperative pain and opioid use. The authors hypothesize that the use of longer CMNs results in increased pain scores and morphine milligram equivalents (MME) intake during the 0-24 h (h) and 24-36 h postoperative period. METHODS: A retrospective chart review was performed from 2010 to 2020 of patients ≥ 65 years-old who underwent CMN for IT fractures and fractures with subtrochanteric extension (STE). We compared patients who received short and long CMNs using numeric rating scale (NRS) pain scores and MME intake at 0-24 h and 24-36 h postoperatively. RESULTS: 330 patients receiving short (n = 155) and long (n = 175) CMNs met criteria. CMN length was found to not be associated with higher pain scores in the early postoperative phase. However, patients with long CMNs received higher MME from 0-24 h (25.4% estimated mean increase, p value = 0.02) and 24-36 h (22.3% estimated mean increase, p value = 0.04) postoperatively, even after adjusting for covariates, gender, and age. CONCLUSION: Patients with long CMNs received greater MME postoperatively. Additionally, differences in pain and MME were not significantly different between patients with and without STE, suggesting our findings were not influenced by this pattern. These results suggest longer CMNs are associated with higher acute postoperative opioid intake among patients with IT fractures. LEVEL OF EVIDENCE: Therapeutic level III.

Functional Outcomes of Primary Arthrodesis (PA) Versus Open Reduction and Internal Fixation (ORIF) in the Treatment of Lisfranc Injuries.

OBJECTIVES: To determine whether primary arthrodesis (PA) or open reduction and internal fixation (ORIF) results in better functional outcomes through patient-reported outcome measures (PROMs). Reoperation rates and surgical characteristics among the 2 groups are evaluated as well. DESIGN: A retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS: Eighty-one patients treated using PA or ORIF for Lisfranc injuries between January 2010 and January 2019. MAIN OUTCOME MEASUREMENTS: PROMs were collected using the validated Foot and Ankle Ability Measure questionnaire. Follow-up ranged from 1 to 10 years posttreatment. RESULTS: Two hundred patients underwent ORIF, and 72 patients underwent PA. Eighty-one of 272 patients responded to the questionnaire. The Foot and Ankle Ability Measure revealed activities of daily living subscores for PA and ORIF of 69.78 ± 18.61 and 73.53 ± 25.60, respectively ( P = 0.48). The Sports subscores for PA (45.81 ± 24.65) and ORIF (56.54 ± 31.13) were not significantly different ( P = 0.11). Perceived levels of activities of daily living ( P = 0.32) and Sports ( P = 0.81) function, compared with preinjury levels, were also not significantly different between the 2 groups. Rates of reoperation were nearly identical for PA (28.1%) and ORIF (30.6%) ( P = 1.00). CONCLUSION: Our results suggest that neither PA nor ORIF is superior regarding functional outcomes or rates of reoperation in the surgical treatment of Lisfranc injuries when appropriately triaged by the treating surgeon. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Association of Talar Neck Fractures With Body Extension and Risk of Avascular Necrosis.

BACKGROUND: The objective of this study was to determine whether talar neck fractures with proximal extension (TNPE) into the talar body are associated with higher rates of avascular necrosis (AVN) compared to isolated talar neck (TN) fractures. METHODS: A retrospective review of patients sustaining talar neck fractures at a level I trauma center from 2008 to 2016 was performed. Demographic and clinical data were collected from the electronic medical record. Fractures were characterized as TN or TNPE based on initial radiographs. TNPE was defined as a fracture that originates on the talar neck and extends proximal to a line subtended from the junction of the neck and the articular cartilage dorsal to the anterior portion of the lateral process of the talus. Fractures were classified according to the modified Hawkins classification for analysis. The primary outcome was the development of AVN. Secondary outcomes included nonunion and collapse. These were measured on postoperative radiographs. RESULTS: There were 137 fractures in 130 patients, with 80 (58%) fractures in the TN group and 57 (42%) in the TNPE group. Median follow-up was 10 months (interquartile range, 6-18 months). The TNPE group was more likely to develop AVN as compared to the TN group (49% vs 19%, P < .001). Similarly, the TNPE group had a higher rate of collapse (14% vs 4%, P = .03) and nonunion (26% vs 9%, P = .01). Even after adjusting for open fracture, Hawkins fracture type, smoking, and diabetes, AVN still remained significant for the TNPE group as compared to the TN group with an odds ratio of 3.47 (95% CI, 1.51-7.99). CONCLUSION: We found a higher rate of AVN, subsequent collapse, and nonunion in patients with TNPE compared to isolated TN fractures. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Masquelet Technique for the Tibia: A Systematic Review and Meta-Analysis of Contemporary Outcomes.

OBJECTIVE: To systematically review outcomes of the Masquelet "induced membrane" technique (MT) in treatment of tibial segmental bone loss and to assess the impact of defect size on union rate when using this procedure. DATA SOURCES: PubMed, EBSCO, Cochrane, and SCOPUS were searched for English language studies from January 1, 2010, through December 31, 2019. STUDY SELECTION: Studies describing the MT procedure performed in tibiae of 5 or more adult patients were included. Pseudo-arthrosis, nonhuman, pediatric, technique, nontibial bone defect, and non-English studies were excluded, along with studies with less than 5 patients. Selection adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. DATA EXTRACTION: A total of 30 studies with 643 tibiae were included in this meta-analysis. Two reviewers systematically screened titles or abstracts, followed by full texts, to ensure quality, accuracy, and consensus among authors for inclusion or exclusion criteria of the studies. In case of disagreement, articles were read in full to assess their eligibility by the senior author. Study quality was assessed using previously reported criteria. DATA SYNTHESIS: Meta-analysis was performed with random-effects models and meta-regression. A meta-analytic estimate of union rate independent of defect size when using the MT in the tibia was 84% (95% CI, 79%-88%). There was no statistically significant association between defect size and union rate ( P = 0.11). CONCLUSIONS: The MT is an effective method for the treatment of segmental bone loss in the tibia and can be successful even for large defects. Future work is needed to better understand the patient-specific factors most strongly associated with MT success and complications. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Does prophylactic local tobramycin injection lower open fracture infection rates?

Objective: To determine whether local aqueous tobramycin injection in combination with systemic perioperative IV antibiotic prophylaxis will reduce the rate of fracture-related infection (FRI) after open fracture fixation. Other Outcomes of Interest: (1) To compare fracture nonunion rates and report differences between treatment and control groups and (2) compare bacterial speciation and antibiotic sensitivity among groups that develop FRI. Design: Phase 3 prospective, randomized clinical trial. Setting: Two level 1 trauma centers. Participants: Six hundred subjects (300 in study/tobramycin group and 300 in control/standard practice group) will be enrolled and assigned to the study group or control group using a randomization table. Patients with open extremity fractures that receive definitive internal surgical fixation will be considered. Intervention: Aqueous local tobramycin will be injected into the wound cavity (down to bone) after debridement, irrigation, and fixation, following closure. Main Outcome Measurements: Outcomes will look at the presence or absence of FRI, the rate of fracture nonunion, and determine speciation of gram-negative and Staph bacteria in each group with a FRI. Results: Not applicable. Conclusion: The proposed work will determine whether local tobramycin delivery plus perioperative standard antibiotic synergism will minimize the occurrence of open extremity FRI. Level of Evidence: Level 1.

Outcomes of Reamed Intramedullary Nailing for Lower Extremity Diaphyseal Fractures in COVID-Positive Patients: A Multi-institutional Observational Study.

OBJECTIVE: To determine if reamed intramedullary nailing (IMN) of tibial and femoral shaft fractures exacerbated the hypercoagulable state of COVID infection, resulting in increased thromboembolic and pulmonary complications. DESIGN: Retrospective chart review. SETTING: Eleven Level I trauma centers. PATIENTS: From January 1, 2020, to December 1, 2022, 163 patients with orthopaedic trauma and COVID positivity and 36 patients with tibial and femoral shaft fractures were included. INTERVENTION: Reamed IMN. MAIN OUTCOME MEASURES: Incidence of postoperative thromboembolic and respiratory complications. RESULTS: Thirty-six patients with a median age of 52 years (range, 18-92 years; interquartile range, 29-72 years) met criteria. There were 21 and 15 patients with femoral and tibial shaft fractures. There were 15 patients sustaining polytrauma; of which, 10 had a new injury severity score of >17. All patients underwent reamed IMN in a median of 1 day (range, 0-12 days; interquartile range = 1-2 days) after injury. Two patients developed acute respiratory distress syndrome (ARDS) and 3 pneumonia. No patients had pulmonary embolism, deep vein thrombosis, or died within 30 days. CONCLUSION: In this multi-institutional review of COVID-positive patients undergoing reamed IMN, there were no thromboembolic events. All patients developing pulmonary complications (ARDS or pneumonia) had baseline chronic obstructive pulmonary disease, were immune compromised, or sustained polytraumatic injuries with new injury severity score of >20. Given this, it seems reasonable to continue using reamed IMN for tibial and femoral shaft fractures after evaluation for COVID severity, comorbidities, and other injuries. LEVELS OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

An Off-Label Use of a Tensioned Proximal Humerus Plate for Tibiotalar Fusion: A Case Report.

CASE: A 70-year-old man presented with a left pilon fracture after a 10-foot fall from a ladder. The severe amount of comminution, joint destruction, and impaction from this injury eventually resulted in a tibiotalar fusion. Owing to multiple tibiotalar fusion plates not being long enough to span the extent of the fracture, a tensioned proximal humerus plate was used as an alternative. CONCLUSION: We do not endorse the off-label use of a tensioned proximal humerus plate for all tibiotalar fusions; however, we do believe that this is a useful technique in certain situations with large zones of distal tibial comminution.