External Fixation Before Planned Conversion to Internal Fixation in Orthopaedic Trauma: Controversies and Current Trends.

External fixation is a widely used technique for a myriad of bone fractures and pathologies in all extremities. Despite its widespread use, controversies and unknowns still exist. This review article seeks to discuss current literature surrounding pin insertion technique, pin-site care, intraoperative use during conversion to definitive fixation, the relationship of pin sites to definitive fixation, and pin-site management after removal for temporary external fixation.

Comparison of direct surgical cost and outcomes for unstable elbow injuries: internal joint stabilizer versus external fixation.

Background: Unstable elbow injuries sometimes require External fixation (ExF) or an Internal Joint Stabilizer (IJS) to maintain joint reduction. No studies have compared the clinical outcomes and surgical costs of these 2 treatment modalities. The purpose of this study was to determine whether clinical outcome and surgical encounter total direct costs (SETDCs) differ between ExF and IJS for unstable elbow injuries. Methods: This retrospective study identified adult patients (aged ≥ 18 years) with unstable elbow injures treated by either an IJS or ExF between 2010 and 2019 at a single tertiary academic center. Patients postoperatively completed 3 patient-reported outcome measures (the Disability of the Arm, Shoulder, and Hand, the Mayo Elbow Performance score, and EQ-5D-DL). Postoperative range of motion was measured in all patients, and complications tallied. SETDCs were determined and compared between the 2 groups. Results: A total of 23 patients were identified, with 12 in each group. Clinical and radiographic follow-up for the IJS group averaged 24 months and 6 months, respectively, and for the ExF group, 78 months and 5 months, respectively. The 2 groups had similar final range of motion, the Mayo Elbow Performance score, and 5Q-5D-5L scores; ExF patients had better the Disability of the Arm, Shoulder, and Hand scores. IJS patients had fewer complications and were less likely to require additional surgery. The SETDCs were similar between the 2 groups, but the relative contributors to cost differed significantly between the groups. Conclusions: Patients treated with an ExF or IJS had similar clinical outcomes, but complications and second surgeries were more likely in ExF patients. The overall SETDC was also similar for ExF and IJS, but relative contributions of the cost subcategories differed.

Pregnancy During Orthopaedic Surgery Residency: The Iowa Experience.

Family planning is a challenge for physicians at all stages of their careers, but particularly difficult during residency. Residency commonly occurs during prime childbearing years and is associated with long work hours and inflexible schedules. A commonly cited deterrent for women entering orthopaedic surgery is the inability to achieve a healthy and fulfilling work-life balance.1 Further, those women who pursue starting a family during residency have been shown to have higher rates of pregnancy-related complications including infertility with complications rates as high as 30%.2,3 In a recent AAOS article, a call to action for modified policies to prioritize the health of pregnant orthopaedic surgeons and their unborn children was made to decrease the overall risk to women who wish to have children during residency and early practice.4 The University of Iowa has a history of attracting women into the orthopedic training program. We asked past graduates of the University of Iowa Orthopedic Residency program who had children during residency to share their personal experiences and opinions. We asked past graduates to answer five questions surrounding their pregnancy during residency. We have included the good, the bad, and the ugly with real-life testimonies in hopes that despite the statistics, women in our field considering pregnancy will find comfort in those that have been through it. Four prior residents were kind enough to share their experiences. Dr. Sarah Schippers (SS) completed residency in 2021 and is currently finishing a hand and upper extremity fellowship and will soon be starting private practice in Kansas. She shares on her experience regarding two pregnancies during residency. Dr. Tina Hajewski (TH) completed residency in 2021 and is also currently finishing a spine fellowship and will soon be starting private practice in Washington, sharing on her experience having two children during residency. Dr. Elizabeth Weldin (EW) completed residency in 2018 and is a current hand and upper extremity attending in Oklahoma and shares her experience having a child during residency and the contrast to having children during practice. Finally, Dr. Heather Campion (HW) completed residency in 2012 and is a current hand and upper extremity attending in Oregon and shares her experience as being the first Iowa orthopaedic resident to have a child during residency. Level of Evidence: V.

Agricultural Trauma Causing Open Fractures: Is Antibiotic Coverage Against Anaerobic Organisms Indicated?

OBJECTIVE: To compare deep infection rate and causative organisms in open fractures of the lower extremity from agricultural trauma with similar injuries in nonagricultural trauma. DESIGN: Retrospective. SETTING: Two tertiary care institutions. METHODS: Open lower extremity fractures sustained between 2003 and 2018 caused by agriculture-related trauma in adult patients were reviewed. A nonagriculture open fracture control group (NAG) was identified for comparison. Patient demographics and injury characteristics were assessed. Outcomes included occurrence of deep infection and causative organisms. RESULTS: One hundred seventy-eight patients were identified in the agriculture (AG) (n = 89) and control (NAG) (n = 89) groups. Among patients with agricultural injury, farm machinery was the most common mechanism in 69 (77.5%) of them. Open injuries of the foot (38.2%) and tibial shaft injuries (25.8%) were the most common in the AG and NAG groups, respectively. Deep infection was seen in 21% of patients in the AG group compared with 10% in the NAG group (P < 0.05). In the AG group, anaerobic infection occurred in 44% of patients with deep infection compared with 9.1% in the NAG group (P < 0.05). The most common anaerobic organisms included enterococci, Pseudomonas aeruginosa, and Clostridium perfringens. CONCLUSIONS: This study supports that open fractures due to agricultural trauma have a high infection rate, with anaerobic infection occurring at higher rates than in injuries due to nonagricultural trauma. Prophylactic treatment with antibiotics directed against anaerobes is indicated in these injuries. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Failure of Orthopaedic Residents to Voluntarily Participate in a Laboratory Skills Training.

INTRODUCTION: Arthroscopy simulation is increasingly used in orthopaedic residency training. The implementation of a curriculum to accommodate these new training tools is a point of interest. We assessed the use of a high-fidelity arthroscopy simulator in a strictly voluntary curriculum to gauge resident interest and educational return. METHODS: Fifty-eight months of simulator use data were collected from a single institution to analyze trends in resident use. Comparable data from two additional residency programs were analyzed as well, for comparison. Orthopaedic residents were surveyed to gauge interest in continued simulation training. RESULTS: Average annual simulator use at the study institution was 27.7 hours (standard deviation = 26.8 hours). Orthopaedic residents spent an average of 1.7 hours practicing on the simulation trainer during the observation period. A total of 21% of residents met or exceeded a minimum of 3 hours of simulation time required for skill improvement defined by literature. Most (86%) of the residents agreed that the simulator in use should become a mandated component of a junior resident training. CONCLUSION: Although surgical simulation has a role in orthopaedic training, voluntary simulator use is sporadic, resulting in many residents not receiving the full educational benefits of such training. Implementation of a mandated simulation training curriculum is desired by residents and could improve the educational return of surgical simulators in residency training.

Time and Clerical Burden Posed by the Current Electronic Health Record for Orthopaedic Surgeons.

INTRODUCTION: The electronic health record (EHR) has become an integral part of modern medical practice. The balance of benefit versus burden of a required EHR remains inconclusive, with many studies identifying increasing physician burnout and less face-to-face patient contact because of increasing documentation demands. Few studies have investigated EHR burden in orthopaedic surgery practice. This study aimed to characterize and compare EHR usage patterns and time allocation within EHR between orthopaedic surgeons, other surgeons, and medicine physicians at an academic medical center. METHODS: EHR usage was digitally tracked within a large academic medical center. EHR usage data were compiled for all physicians seeing outpatients from April 2018 to June 2019. The tracking metrics included time spent answering messages, typing notes, reviewing laboratories and imaging, reading notes, and placing orders. Physicians were subdivided between orthopaedic surgeons, other surgeons, and nonsurgeon/medical specialties. Statistical comparisons using a two-sample t-test were done between orthopaedic surgeon EHR usage patterns and other surgeons, in addition to orthopaedic surgeons versus nonsurgeons. RESULTS: One thousand sixty physicians including 28 full-time orthopaedic surgeons, 134 other surgeons, and 898 nonsurgical medicine physicians met inclusion criteria. Orthopaedic surgeons saw on average 31 patients per office day compared with other surgeons at 18 patients per office day (P < 0.01) and nonsurgeons at 12 patients per office day (P < 0.01). Orthopaedic surgeons received more EHR messages while also being more efficient at answering EHR messages compared with other surgeons and nonsurgeons (P < 0.01). EHR tasks, including answering messages, placing orders, chart review, writing notes, and reviewing imaging, consumed 58% of an orthopaedic surgeon's scheduled office day with the largest contribution from required note writing. DISCUSSION: In academic orthopaedic practice, EHR use has surpassed face-to-face patient time, consuming 58% of orthopaedic surgeons' clinical days. With the previously shown correlation between EHR burden and physician burnout, targeted interventions to increase efficiency and off-load EHR burden are necessary to sustain a successful orthopaedic practice.

Does Anterior Impaction Affect Radiographic Outcomes of Pilon Fractures?

Background: The outcomes of pilon fractures are multifactorial. Anterior articular impaction requires sagittal plane correction (anterior distal tibia angle (ADTA)) with articular reduction. However, there is a risk of avascular necrosis of the articular fragments and postoperative tibiotalar arthritis. The purpose of this study was to determine if the presence of anterior impaction affects radiographic alignment after definitive fixation. Methods: Retrospective cohort study of patients who underwent operative management for pilon fractures at two academic, level 1 trauma centers between September 2005-September 2016. Fractures were categorized as having anterior impaction or no anterior impaction after review of preoperative radiographic and computer tomography imaging. Patient demographics and postoperative time to union was recorded. Quality of reduction was measured using (ADTA) (degrees), lateral distal tibia angle (LDTA) (degrees), and lateral talar station (LTS) (millimeters) from postoperative radiographs. Statistical analysis compared fracture patterns with anterior impaction to those without. Results: 208 patients met inclusion criteria. 132 fractures (63.4%) were determined to have anterior impaction. Cohorts were similar in demographics and medical comorbidities (p>0.05). Mean ADTA, LTDA, and LTS for the anterior impaction group 83.5°, 89.7°, and 2.4mm versus 84.6°, 89.9°, and 2.0mm in the group without anterior impaction. Cohorts significantly differed in ADTA(p=0.01), but not LDTA(p=0.12) or LTS(p=0.44). No significant differences were found between cohorts with infection (>0.05), nonunion(p=0.76), unplanned reoperation(p=0.56), or amputation(p=0.34). Conclusion: This study demonstrated no significant differences in the coronal or sagittal plane alignment when comparing definitively fixed pilon fractures with and without anterior impaction. Additional studies are needed to evaluate the longterm clinical impact of failing to restore ADTA. Level of Evidence: III.

Patient specific predictive factors of vertebral artery injury following blunt cervical spine trauma.

OBJECTIVE: Determine patient and injury characteristics predictive of vascular injury (VAI) in blunt cervical spine (BCS) trauma to identify high-risk patients and propose an alternative screening protocol. METHODS: Patients presenting between 2014 and 2018 with BCS injury and cervical spine CT imaging were included. Demographics and injury characteristics of BCS injuries were collected. Univariate and multivariate analyses to determine risk factors for VAI were performed. Once factors associated with greater odds of VAI were identified, this information was used to create an alternative protocol for indicating CTA in patients who sustained BCS injury. RESULTS: A total of 475 patients were included. CTA of the neck was performed in 55.5% patients. In patients who received CTA, 18.2% had a contraindication to receiving anti-platelet therapy, and 25% were already receiving anti-coagulation therapy as an outpatient medication. VAI was found in 13.2% patients. In patients with VAI, 48.5% were already receiving anti-coagulation as outpatient medication. Acute kidney injury was found in 10.5% patients who had received CTA. Factors associated with greater odds of having VAI included transverse foramen involvement(p = 0.0001), subluxation/displacement/dislocation of fracture(p = 0.03), high energy mechanism(p = 0.02), SLIC score > 4(p = 0.04), and concomitant lumbar spine injury(p = 0.03). Using Modified Hawkeye Protocol, 40.2% of patients were indicated to receive a CTA, and 17 VAI were identified. Compared to Denver Criteria, CTAs were performed in 73 less patients(p = 0.04). CONCLUSIONS: Updated protocols utilizing evidence-based clinical parameters to predict chance of VAI may avoid unnecessary advanced imaging and contrast load to patients in the setting of BCS trauma.

Identifying Barriers: Current Breastfeeding Policy in Orthopedic Surgery Residency.

BACKGROUND: Family planning is a challenge for physicians at all stages of their careers but can be particularly difficult during residency. As the field of orthopedic surgery strives to increase diversity and recruit exceptional female candidates, barriers to entry should be identified. For many women, successful family planning including pregnancy, breast-feeding, and childcare, presents a daunting endeavor during residency training and a difficult topic to broach with superiors when planning future careers. Prospective residents often look to websites to obtain information regarding potential residency programs. We sought to identify current breast-feeding policies available at orthopedic residency programs via a thorough review of individual programs websites. METHODS: Residency program websites from 178 ACGME-accredited orthopedic surgery residencies were reviewed to determine currently available departmental lactation policies and facilities. Region and number of female staff and residents were recorded and organized into a central database. Descriptive analyses to determine programs with available resources was performed. Logistic regression to determine association between region and number of programs written policy available was also performed. RESULTS: 178 ACGME-accredited orthopedic surgery programs were reviewed. Five (2.8%) programs were found to have written breastfeeding policies available on the orthopedic surgery residency website. Thirty-six (20%) programs provided links to institutional GME websites which gave written lactation policies. Dedicated lactation facilities were mentioned for 3 (1.7%) programs. The average number of female attendings per program was two (range 0-19), and the average number of female residents per program was three (range 0-14). The odds of a program having a written breastfeeding policy increased along with an increasing number of female attendings, OR 1.1 (CI 1.03-1.24, p=0.01). Programs in the Southwest region of the U.S. were found to have a higher association with presence of a written breastfeeding policy, OR 3.7 (CI 1.01-13.4, p=0.04). CONCLUSION: Scarce information is available to prospective orthopedic surgery residents regarding breast-feeding policies and available lactation facilities. Only 2.8% of current programs have website information discussing breastfeeding support. Ensuring available breastfeeding support for female orthopedic surgeon trainees and the transparency of these policies by orthopedic departments could contribute to an improved perception of childbearing during residency.Level of Evidence: IV.

Radiographic Evaluation of Proximal Femoral Nutrient Arteries After Total Hip Arthroplasty With a Short Femoral Stem.

BACKGROUND: The use of less invasive approaches and broach only press-fit femoral stems in total hip arthroplasty (THA) may increase the risk for periprosthetic fracture. Proximal femoral nutrient arteries (FNAs) can be mistaken for fractures after THA. Description of FNAs in relation to THA implants is important to better distinguish between FNAs and periprosthetic fractures. The purpose of this study was to evaluate the frequency, location, and morphology of FNAs visible on radiographs after primary THA with a broach-only stem design. METHODS: A retrospective cohort study was performed. Patients ≥18 years who underwent primary THA with a cementless, broach-only stem, and had 6-week follow-up radiographs were included. Patient demographics were recorded. Anteroposterior and lateral radiographs at 6 weeks postoperatively were assessed for the presence of FNA; if present, measurements of vessel location and morphology were obtained. Descriptive statistics were reported. Univariate and multivariate analyses were performed to identify patient characteristics associated with the radiographic presence of perforating vessel. RESULTS: A total of 378 hips were evaluated (332 patients). FNAs were identified radiographically in 46.3% (175 hips/378 hips). All FNAs were found to be unicortical, most observed in the posterior and lateral cortices. Gender, age, BMI, stem position, and surgical approach did not correlate with a presence of FNA on radiograph. CONCLUSION: FNA was seen on postoperative radiographs in 46% of patients after THA with one broach-only stem design. The FNA was unicortical and present on preoperative radiographs. Surgeons should consider this when evaluating postoperative radiographs.

Nonoperative Treatment of a Pathologic Proximal Tibia Fracture in the Setting of Previous Total Knee Arthroplasty: A Case Report.

CASE: We present the case of a super obese 51-year-old woman with a pathologic fracture of the proximal tibia in the setting of a previous total knee arthroplasty. Imaging demonstrated an osteolytic lesion distal to the keel and pathologic fracture of the proximal tibia. Nonoperative treatment with a 12-week course of nonweight-bearing resulted in fracture healing and ossification of osteolysis. CONCLUSION: Pathologic fractures of the tibia secondary to osteolysis are frequently treated surgically. Patients may benefit from nonoperative management, even in the setting of super morbid obesity and significant osteolysis about the tibial component.

The Prevalence of Abnormal Spinopelvic Relationships in Patients Presenting for Primary Total Hip Arthroplasty.

BACKGROUND: The prevalence of an abnormal spinopelvic relationship in patients presenting for primary total hip arthroplasty (THA) is not well known. The purpose of this study was to identify the prevalence of abnormal spinopelvic relationships in patients presenting for primary THA. METHODS: A retrospective chart review of 338 consecutive, nonselected patients undergoing primary THA from the practice of 2 fellowship-trained adult reconstruction surgeons was performed (J.E.O. and T.S.B.). Sitting and standing radiographs were measured for lumbar lordosis (LL), pelvic incidence (PI), sacral slope (SSstand), and pelvic tilt; the sacral slope was also measured on sitting radiographs (SSsit). Patients were assessed for the presence of spinopelvic imbalance, defined as PI-LL>10°, and decreased spinopelvic motion, defined as SSstand-SSsit< 10°. Descriptive statistics were reported. RESULTS: A cohort of 338 patients was identified; 110 were excluded. In total, 228 unique patients underwent measurement. One hundred one of 228 patients (44.3%) in the cohort were female. The mean age of the cohort was 60.0 ± 13 years, with the mean body mass index of 31 ± 7 mg/kg2. Spinopelvic imbalance (PI-LL > 10°) was present in 142 of 228 patients (62.3%). Decreased motion at the spinopelvic junction (SSstand-SSsit < 10°) was present in 78 of 228 patients (34.2%). Fifty (21.9%) patients had both spinopelvic imbalance and decreased spinopelvic motion. CONCLUSIONS: In a cohort of 228 patients presenting for primary THA, the prevalence of spinopelvic imbalance was 62.3%, the prevalence of decreased spinopelvic motion was 34.2%, and the prevalence of both spinopelvic imbalance and decreased spinopelvic motion was 22%. Hip surgeons are likely to encounter patients with abnormal spinopelvic relationships.

Escherichia hermannii as the sole cause of osteomyelitis in a patient with an open tibial shaft fracture.

Escherichia hermannii is a rare monomicrobial cause of infection in humans. E. hermannii has never before been reported as the sole isolate from an infected open tibia fracture. We present a case of E. hermannii infection after a type III open tibia fracture. The patient was initially treated with irrigation and debridement, open reduction internal fixation and primary wound closure. However, after 8 weeks, he developed a draining wound and infection at the fracture site. He required a repeat debridement, hardware removal, external fixation and 6 weeks of intravenous ceftriaxone for treatment. At 2-year follow-up, he remains infection free, asymptomatic and continues to work with excellent functional outcomes. This case adds to the growing literature that evidences E. hermannii as an organism that can be pathogenic, virulent and cause monomicrobial infection.

Effectiveness of Nonoperative Treatment of the Symptomatic Accessory Navicular in Pediatric Patients.

Background: Initial management of symptomatic accessory navicular in pediatric patients is nonoperative. However, efficacy of nonoperative treatment has not been studied or established. If nonoperative treatment is frequently unsuccessful or does not give lasting pain relief, surgery could be offered as first line treatment. This study retrospectively reviewed outcomes of pediatric patients treated nonoperatively for symptomatic accessory naviculae in an effort to provide clinicians success rates for their discussion of treatment options with patients and their families. Methods: A retrospective analysis of pediatric patients diagnosed and treated nonoperatively for a symptomatic accessory navicular bone at Cincinnati Children's Hospital Medical Center between dates August 1st, 2006 and August 24th, 2016 was performed. Outcome measures consisted of complete pain relief, partial relief without operative intervention, or need for operative intervention. Radiographic imaging for each patient was also used to identify the type of accessory navicular and presence of concurrent pes planus. Results: A total of 169 patients were included, with 226 symptomatic accessory naviculae. Average age at diagnosis was 11.8 years, with majority females (78%). Type 2 accessory naviculae were most frequent (72.7%), with Type 1 and Type 3 in 9.7% and 17.4%, respectively. Average number of nonoperative trials was 2.1, with 28% experiencing complete pain relief, 30% requiring surgical intervention, and 41% that experienced partial pain relief and did not require surgical intervention, and were recommended as needed (PRN) follow-up based on clinical improvement. Of those that achieved complete pain relief, the average length of non-operative treatment was 8.0 months. Conclusions: The results of this study can be used by clinicians to frame discussions surrounding treatment options for symptomatic accessory navicular bones with both patients and their families.Level of Evidence: III.