Serology and Comorbidities in Patients With Fracture Nonunion: A Multicenter Evaluation of 640 Patients.

INTRODUCTION: This multicenter cohort study investigated the association of serology and comorbid conditions with septic and aseptic nonunion. METHODS: From January 1, 2011, to December 31, 2017, consecutive individuals surgically treated for nonunion were identified from seven centers. Nonunion-type, comorbid conditions and serology were assessed. RESULTS: A total of 640 individuals were included. 57% were male with a mean age of 49 years. Nonunion sites included tibia (35.2%), femur (25.6%), humerus (20.3%), and other less frequent bones (18.9%). The type of nonunion included septic (17.7%) and aseptic (82.3%). Within aseptic, nonvascular (86.5%) and vascular (13.5%) nonunion were seen. Rates of smoking, alcohol abuse, and diabetes mellitus were higher in our nonunion cohort compared with population norms. Coronary artery disease and tobacco use were associated with septic nonunion (P < 0.05). Diphosphonates were associated with vascular nonunion (P < 0.05). Serologically, increased erythrocyte sedimentation rate, C-reactive protein, parathyroid hormone, red cell distribution width, mean platelet volume (MPV), and platelets and decreased absolute lymphocyte count, hemoglobin, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, and albumin were associated with septic nonunion while lower calcium was associated with nonvascular nonunion (P < 0.05). The presence of four or more of increased erythrocyte sedimentation rate, C-reactive protein, or red cell distribution width; decreased albumin; and age younger than 65 years carried an 89% positive predictive value for infection. Hypovitaminosis D was seen less frequently than reported in the general population, whereas anemia was more common. However, aside from hematologic and inflammatory indices, no other serology was abnormal more than 25% of the time. DISCUSSION: Abnormal serology and comorbid conditions, including smoking, alcohol abuse, and diabetes mellitus, are seen in nonunion; however, serologic abnormalities may be less common than previously thought. Septic nonunion is associated with inflammation, younger age, and malnourishment. Based on the observed frequency of abnormality, routine laboratory work is not recommended for nonunion assessment; however, specific focused serology may help determine the presence of septic nonunion.

Complications With Surgical Treatment of Pediatric Supracondylar Humerus Fractures: Does Surgeon Training Matter?

INTRODUCTION: National trends reveal increased transfers to referral hospitals for surgical management of pediatric supracondylar humerus (SCH) fractures. This is partly because of the belief that pediatric orthopaedic surgeons (POs) deliver improved outcomes compared with nonpediatric orthopaedic surgeons (NPOs). We compared early outcomes of surgically treated SCH fractures between POs and NPOs at a single center where both groups manage these fractures. METHODS: Patients ages 3 to 10 undergoing surgery for SCH fractures from 2014 to 2020 were included. Patient demographics and perioperative details were recorded. Radiographs at surgery and short-term follow-up assessed reduction. Primary outcomes were major loss of reduction (MLOR) and iatrogenic nerve injury (INI). Complications were compared between PO-treated and NPO-treated cohorts. RESULTS: Three hundred and eleven fractures were reviewed. POs managed 132 cases, and NPOs managed 179 cases. Rate of MLOR was 1.5% among POs and 2.2% among NPOs (P=1). Rate of INI was 0% among POs and 3.4% among NPOs (P=0.041). All nerve palsies resolved postoperatively by mean 13.1 weeks. Rates of reoperation, infection, readmission, and open reduction were not significantly different. Operative times were decreased among POs (38.1 vs. 44.6 min; P=0.030). Pin constructs were graded as higher quality in the PO group, with a higher mean pin spread ratio (P=0.029), lower rate of "C" constructs (only 1 "column" engaged; P=0.010) and less frequent crossed-pin technique (P<0.001). Multivariate analysis revealed minimal positive associations only for operative time with MLOR (odds ratio=1.021; P=0.005) and INI (odds ratio=1.048; P=0.009). CONCLUSIONS: Postsurgical outcomes between POs and NPOs were similar. Rates of MLOR were not different between groups, despite differences in pin constructs. The NPO group experienced a marginally higher rate of INI, though all injuries resolved. Pediatric subspecialty training is not a prerequisite for successfully treating SCH fractures, and overall value of orthopaedic care may be improved by decreasing transfers for these common injuries. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

How Much Opioid Do Kids Actually Need? A Prospective Study of Analgesic Prescribing and Postdischarge Opioid Use Among Pediatric Patients With Operative Fractures.

BACKGROUND: Analgesic guidelines are lacking for most operative pediatric fractures, and little is known about postdischarge opioid use or pain control. We hypothesized that opioid/acetaminophen/non-steroidal anti-inflammatory drugs (NSAID) prescribing would vary, pain would be well controlled, and postdischarge opioid use would be low. METHODS: This prospective cohort study included nonpolytraumatized patients aged 17 years and below with operative fractures at a level 1 trauma center from August 1, 2019 to March 31, 2021. Supracondylar humerus fractures were excluded since they have been studied extensively. Information regarding injury/surgery/analgesics were collected. Discharged patients were called on postoperative days (POD) 1/3/5. Parents/guardians were asked about analgesic use and pain over the preceding 2 days. Complications, pain control, and opioid refills were recorded after first follow-up. RESULTS: All 100 eligible patients were included. Mean age was 10.1 years (range: 1.8 to 17.8 y). Common fracture types were humeral condyle/epicondyle (28%), radius/ulna (15%), and femoral shaft (13%). Opioids were prescribed to 95% of patients with mean 14 doses (range: 2 to 45). Acetaminophen/NSAIDs were prescribed to 74% and 60% of patients, respectively. Eleven patients were excluded from telephone follow-up (7 non-English speaking, 3 prohibitive social situations, 1 inpatient POD1 to 5). Telephone follow-up was completed for 87/89 eligible patients (98%). Mean pain scores declined from 3.7/10 POD1 to 2.4/10 POD5. Opioids were taken by 50% POD1, 20% POD5. Acetaminophen/NSAID was given before opioid 82% of the time. By POD5, mean total doses of opioid taken postdischarge was 2.3; mean proportion of prescribed opioid doses taken was 22%; and 97% of patients took ≤8 opioid doses postdischarge. Two patients were evaluated early due to poor pain control which improved with cast changes. Pain was well controlled or absent at follow-up in 97% of patients. CONCLUSIONS: Pain is consistently well controlled after operative pediatric fractures. Nearly all were prescribed opioids, while acetaminophen/NSAIDs were inconsistently prescribed and used. Opioid prescriptions are written for 4 to 5 times the amount needed. Prescribing ≤8 doses of opioid is adequate for acute pain through POD5 in 97% of patients. Poorly controlled pain should prompt early evaluation for possible complications. LEVEL OF EVIDENCE: Level II-prospective comparative study.

Pain Control and Medication Use in Children Following Closed Reduction and Percutaneous Pinning of Supracondylar Humerus Fractures: Are We Still Overprescribing Opioids?

BACKGROUND: The purpose of this 2-part study is to determine opioid prescribing patterns and characterize actual opioid use and postoperative pain control in children following discharge after closed reduction and percutaneous pinning of a supracondylar humerus fracture. METHODS: A retrospective study was conducted from 2014 to 2016 to determine pain medication prescribing patterns at a single level 1 trauma center. Next, a prospective, observational study was conducted from 2017 to 2018 to determine actual pain medication use and pain scores in the acute postoperative period. Data were collected through telephone surveys performed on postoperative day 1, 3, and 5. Pain scores were collected using a parental proxy numerical rating scale (0 to 10) and opioid use was recorded as the number of doses taken. RESULTS: From 2014 to 2016, there were 126 patients who were prescribed a mean of 47 doses of opioid medication at discharge. From 2017 to 2018, telephone questionnaires were completed in 63 patients. There was no significant difference (P>0.05) in pain ratings or opioid use by fracture type (Gartland), age, or sex. Children required a mean of 4 doses of oxycodone postoperatively. There were 18 (28%) patients who did not require any oxycodone. On average, pain scores were highest on postoperative day 1 (average 5/10) and decreased to clinically unimportant levels (<1) by postoperative day 5. Acetaminophen and ibuprofen were utilized as first-line pain medications in only 25% and 9% of patients, respectively. Two of 3 patients who used >15 oxycodone doses experienced a minor postoperative complication. CONCLUSIONS: Pediatric patients have been overprescribed opioids after operative treatment of supracondylar humerus fractures at our institution. Families who report pain scores >5 of 10 and/or persistent opioid use beyond postoperative day 5 warrant further clinical evaluation. Two of 3 pain outliers in this study experienced a minor postoperative complication. With appropriate parental counseling, satisfactory pain control can likely be achieved with acetaminophen and ibuprofen for most patients. If oxycodone is prescribed for breakthrough pain, then the authors recommend limiting to <6 doses. LEVEL OF EVIDENCE: Level IV-observational, cohort study.

An Evidence-Based Algorithm for Determining Venous Thromboembolism Prophylaxis After Degenerative Spinal Surgery.

BACKGROUND: Although venous thromboembolism (VTE) is a potentially serious and life-threatening complication, there is no widely accepted protocol to guide VTE prophylaxis in adult degenerative spinal surgery, and pharmacologic overtreatment may result in hemorrhagic complications. Previously, we published the VTE Prophylaxis Risk/Benefit Score, an evidence-based algorithm that balances the risk and consequences of thrombotic versus hemorrhagic complications by taking consideration of patient-related risks, procedure-related risks, and the risk of neurological compromise to guide VTE prophylaxis. To objective of this study was to validate the VTE Prophylaxis Risk/Benefit Score. METHODS: From January 1, 2016, to December 31, 2017, VTE Prophylaxis Risk/Benefit Scores and corresponding prophylaxes were prospectively assigned. When indicated, chemoprophylaxis was dosed 24 to 36 hours postoperatively to allow for adequate surgical hemostasis. Patients were retrospectively evaluated for immediate and short-term complications. The Fisher exact test compared incidence of complications by VTE prophylaxis. Multinomial logistic regression modeled the probability of complication by prophylaxis type, demographics, and comorbidities. Significance was set at P < .05. RESULTS: Of the 266 patients who met inclusion criteria, 79.3% were given mechanical prophylaxis alone and 20.7% were given combined mechanical and chemical prophylaxis. Complications including VTE (0.38%), delayed wound healing or infection (2.26%), and hematoma (0.75%) were observed at rates similar to or lower than previously published studies with increased utilization of chemoprophylaxis. Use of chemoprophylaxis and continuation of perioperative aspirin were significantly associated with the development of a hemorrhagic complication. No patient developed persistent neurologic deficit from hematoma or pulmonary embolism. CONCLUSIONS: The VTE Prophylaxis Risk/Benefit Score comprehensively considers the risk of thrombotic, wound, and bleeding complications and is an effective tool for determining appropriate thromboprophylaxis in adult degenerative spinal surgery. LEVEL OF EVIDENCE: 3.