Nail Plate Constructs are Associated with Decreased Rates of Reoperation in Complex Distal Femur Fractures.

OBJECTIVES: To determine if nail plate constructs have lower rates of reoperation to promote bone healing than lateral locking plates in the treatment of distal femur fractures. DESIGN: Retrospective Cohort. SETTING: Single Level 1 trauma centerPatients/Participants: 312 consecutive patients treated operatively for native distal femur fractures (OTA/AO 33A or 33C). INTERVENTION: Reduction and fixation of distal femur fractures with either a lateral locked plate (LLP) or a nail plus plate construct (NPC). MAIN OUTCOME MEASURES: reoperation to promote bone healing at any time after definitive fixation. RESULTS: 279 fractures were treated with LLP and were compared with and 33 fractures treated with NPC constructs. Patient demographics, injury severity score (ISS), and frequency utilization of each construct between different types of OTA/AO classified distal femur fractures were similar. The reoperation rate to promote bone healing was 18.7% (51/273) for LLPs, and 3% (1/33) for NPC constructs. There was no significant difference in surgical site infection (SSI) (p = 0.67). CONCLUSIONS: Utilization of NPC technique demonstrated a significant decrease in rates of reoperation to promote bone healing compared to LLP alone in the treatment of OTA/AO 33A and 33C distal femur fractures. Augmented fixation with NPCs should be considered to treat complex distal femur fractures as it is associated with lower rates of reoperation to promote bone healing in comparison to LLP. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors for Nonunion of Distal Femur Fractures.

OBJECTIVES: To determine patient, fracture, and construct related risk factors associated with nonunion of distal femur fractures. DESIGN: Retrospective cohort study. SETTING: Academic Level I trauma center. PARTICIPANTS: Patients 18 years and older presenting with OTA/AO 33A and 33C distal femur fractures from 2004 to 2020. A minimum follow-up of 6 months was required for inclusion. OTA/AO 33B and periprosthetic fractures were excluded, 438 patients met inclusion criteria for the study. MAIN OUTCOMES: The primary outcome of the study was fracture nonunion defined as a return to the OR for management of inadequate bony healing. Patient demographics, comorbidities, injury characteristics, fixation type, and construct variables were assessed for association with distal femur fracture nonunion. Secondary outcomes include conversion to total knee arthroplasty, surgical site infection, and other reoperation. RESULTS: The overall nonunion rate was 13.8% (61/438). The nonunion group was compared directly with the fracture union group for statistical analysis. There were no differences in age, sex, mechanism of injury, Injury Severity Score, and time to surgery between the groups. Lateral locked plating characteristics including length of plate, plate metallurgy, screw density, and working length were not significantly different between groups. Increased body mass index [odds ratio (OR), 1.05], chronic anemia (OR, 5.4), open fracture (OR, 3.74), and segmental bone loss (OR, 2.99) were independently associated with nonunion. Conversion to total knee arthroplasty (TKA) ( P = 0.005) and surgical site infection ( P < 0001) were significantly more common in the nonunion group. CONCLUSION: Segmental bone loss, open fractures, chronic anemia, and increasing body mass index are significant risk factors in the occurrence of distal femoral nonunion. Lateral locked plating characteristics did not seem to affect nonunion rates. Further investigation into the prevention of nonunion should focus on fracture fixation constructs and infection prevention. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk of Acute Kidney Injury and Fracture-Related Infection After Antibiotic Prophylaxis With Piperacillin-Tazobactam in Open Fractures.

OBJECTIVES: To evaluate the effects of prophylactic piperacillin-tazobactam (PT) on inpatient acute kidney injury (AKI) and fracture-related infection (FRI) in patients with open fractures. SETTING: The study was conducted at a Level 1 trauma center. PATIENTS: We reviewed 358 Gustilo-Anderson type II and III open fractures at our institution from January 2013 to December 2017. INTERVENTION: Administration of PT (the PT group) or antibiotics other than PT (the historical control group) during the first 48 hours of arrival for open fracture antibiotic prophylaxis. MAIN OUTCOME MEASUREMENTS: The main outcome measurements were rates of inpatient AKI and FRI within six months after definitive fixation. RESULTS: There were 176 patients in the PT group and 182 patients in the historical control group. The PT group had worse American Society of Anesthesiologists class ( P = 0.004) and injury severity scores ( P < 0.001), a higher average number of debridements before closure/coverage ( P = 0.043), and higher rates of gross soil contamination ( P = 0.049) and staged procedures ( P = 0.008) compared with the historical control group.There was no difference in the rate of AKI between the PT and historical control groups (5.7% vs. 2.7%, P = 0.166) nor when stratified by Gustilo-Anderson fracture classification (type II: 5.8% vs. 3.6%, P = 0.702; type III: 5.6% vs. 2.0%, P = 0.283). There was no significant difference in the rate of FRI between the PT and historical control groups (23.6% vs. 19.6%, P = 0.469). CONCLUSION: The use of PT in prophylactic antimicrobial treatment in patients with Gustilo-Anderson type II and III open fractures does not increase the rate of AKI or FRI. We believe PT can be used as an effective monotherapy in these patients without an increased risk of renal injury, but future investigations are necessary. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Normalization of Elevated Blood Pressure After Anterior Cervical Discectomy and Fusion.

Perioperative change to the autonomic nervous system (ANS) in spine surgery is an uncommon occurrence but has a wide range of possible presentations including blood pressure, heart rate, and heart rate variability changes collectively referred to as dysreflexia. Increased sympathetic tone and decreased vagal output are believed to be the underlying causes of these autonomic manifestations and pose an important question as to effective treatment of these dysfunctions. Spinal nerve root decompression has shown to be a valuable tool in normalizing autonomic tone by increasing parasympathetic output, most notably to the cardiovascular system, leading to the resolution of the aforementioned cardiovascular complications. Here we report a patient with elevated blood pressure with complaints of upper extremity paresthesias. MRI showed nerve root compression, and anterior cervical discectomy was performed. Post-operatively the patient had a decrease in both systolic and diastolic blood pressure which was maintained two months after surgery and allowed for discontinuation of one anti-hypertensive medication.

An Abnormal Presentation of Pediatric Genu Varum, Managed by Bilateral Tibial and Fibular Osteotomies With External Spatial Frame Placement: A Case Report.

Genu varum is a common finding in the pediatric population with a large differential, including but not limited to Blount's disease, rickets, and physiologic bowing of the legs. Here we report a case of a 12-year-old Caucasian male who presented for an atraumatic stress fracture of the fifth metatarsal after an athletic event. Further evaluation showed significant genu varum with a Q angle of 9 degrees and medial knee joint space narrowing. The patient was unable to undergo conservative management due to early completion of puberty with relatively premature skeletal maturity. A bilateral tibial and fibular osteotomy with external spatial frame placement was performed successfully followed by six months of minor activity complicated by subclinical enoxaparin-induced purpura. The unique presentation of a stress fracture caused by compensatory mechanisms for the severe varus deformity, as well as the rarity of this procedure being performed on both legs simultaneously with good outcomes was the primary reason for the publication of this paper.

An Abnormal Presentation of Multiple Myeloma in Pregnancy: A Case Report.

Multiple myeloma (MM) is an uncommon hematologic malignancy in the general population and extremely rare in pregnant and peripartum women. Here we report a rare case of multiple myeloma in a 43-year-old African American woman at 24 weeks gestation who presented for severe flank pain and difficulty breathing. An elevated D-dimer was present on initial presentation and diagnoses of deep vein thrombosis and pulmonary embolism were ruled out via bilateral Doppler ultrasounds and CT scan. Lytic bone lesions, anemia, and elevated total protein were also noted and an iliac crest biopsy demonstrating monoclonal plasma cells confirmed the diagnosis of MM. She was started on steroids at 27 weeks gestation and delivered via c-section at 30 weeks gestation. Postpartum, a treatment regimen to allow for breastfeeding was discussed but was unable to be accommodated, and she was started on a multi-drug chemotherapy regimen. There have only been about 30 cases of multiple myeloma in pregnant women reported in the literature. The rarity and lack of information on the effects of multiple myeloma in pregnancy was the primary indication for publication of this case.

Financial Literacy in Orthopaedic Surgery Residents: A COERG Survey.

INTRODUCTION: Financial literacy is the individual ability and skill to make informed decisions in the management of resources within the financial marketplace to yield a lifetime of financial well-being. Residents across several subspecialties have demonstrated low levels of financial literacy, and it is thought that more financial education is needed during residency training. The purpose of this study is to perform a comprehensive evaluation on financial literacy and financial attitudes of orthopaedic surgery residents. The authors hypothesize that orthopaedic residents will have low levels of financial literacy and financial satisfaction. METHODS: A 46-question anonymous survey was administered through COERG (Collaborative Orthopaedic Educational Research Group) to 1028 orthopaedic surgery residents of all postgraduate year at 43 programs with broad national distribution. Resident demographics and survey responses regarding knowledge of finance and investment topics, application of financial principles, and personal financial status were compared. RESULTS: The survey response rate was 48% (494/1028). The average financial literacy score of all orthopaedic resident participants was 60.9% (±16.5%). A total of 35.5% of orthopaedic residents were satisfied with their current financial situation. Saving for retirement and lower loan burdens correlated with greater financial satisfaction in financial situation. Scores were higher in orthopaedic residents with greater childhood annual household income, no credit card debt, higher levels of parent education, and active retirement savings plans. CONCLUSIONS: Orthopaedic residents show significant deficits in overall financial and investment knowledge combined with a dissatisfaction with financial situations while in residency. Orthopaedic residency programs have the opportunity to implement program-sponsored training and financial resources to enhance the resident education experience.

Extended Antibiotic Coverage in the Management of Type II Open Fractures.

Background: Responsible antibiotic stewardship requires surgeons treating open fractures to use the narrowest appropriate antibiotic coverage possible to prevent infection. Because inter-observer agreement about the application of the Gustilo-Anderson open fracture classification is moderate at best, antibiotic selection can be overly aggressive. The purpose of this study was to evaluate the outcomes of Type II open fractures treated with gram-positive coverage only (GP) versus broad-spectrum antibiotic coverage (BS) with piperacillin-tazobactam (PT). Methods: A retrospective review of all Type II open fractures was performed at a single Level one trauma center over a 5-year period (2013-2017). All patients received prophylactic antibiotics on arrival on the basis of the best judgment of classification by the house officer on call. The final Gustilo-Anderson open fracture classification was assigned intra-operatively by the operating surgeon. Two groups were created, a GP antibiotic group (cefazolin and/or clindamycin) and a BS group (PT). A minimum of 3-month follow-up was required for inclusion. Patient demographics, cost of treatment, fracture-related infection (FRI) rates, and infecting bacteria were assessed. Results: The GP group contained 70 open fractures and the BS group contained 74 open fractures. Between the groups, there were no differences in age, sex, race, Body Mass Index, American Society of Anesthesiologists Class, or smoking status. There were no statistical differences in Injury Severity Score (ISS), fracture location, fixation method, or rates of staged management with external fixation. There was no difference in FRI rate between the GP and BS groups (8.6% versus 10.8%; p = 0.78). The bacteria responsible for FRI were similar in the GP and BS groups. The hospital charge for PT was 4.39 × the cost of cefazolin. Conclusions: The use of BS coverage in Type II open fractures does not result in a lower infection rate and adds significant cost to patient care. These data support the use of a GP-only antibiotic regimen for Type II open fractures.

A Safety and Cost Analysis of Outpatient Versus Inpatient Hindfoot Fusion Surgery.

Background. Hindfoot fusion procedures are increasingly being performed in the outpatient setting. However, the cost savings of these procedures compared with the risks and benefits has not been clearly investigated. The objective of this study was to compare patient characteristics, costs, and short-term complications between inpatient and outpatient procedures. Methods. This was a retrospective review of all patients who underwent inpatient and outpatient hindfoot fusion procedures by a single surgeon, at 1 academic institution, from 2013 to 2017. Data collected included demographics, operative variables, comorbidities, complications, costs, and subsequent reencounters. Results. Of 124 procedures, 34 were inpatient and 90 were outpatient. Between procedural settings, with the numbers available, there was no significant increase in complication rate or frequency of reencounters within 90 days. There were no significant differences in the number of patients with reencounters related to the index procedure within 90 days (P = .43). There were 30 reencounters within 90 days after outpatient surgery versus 4 after inpatient surgery (P = .05). The total number of emergency room visits in the outpatient group within 90 days was significantly higher compared with the inpatient group (P = .04). The average cost for outpatient procedures was US$4159 less than inpatient procedures (P < .0001). Conclusion. Outpatient hindfoot fusion may be a safe alternative to inpatient surgery, with significant overall cost savings and similar rate of short-term complications. On the basis of these findings, we believe that outpatient management is preferable for the majority of patients, but further investigation is warranted. Levels of Evidence: Level III.

Xeroderma pigmentosa: three new cases with an in depth review of the genetic and clinical characteristics of the disease.

Xeroderma pigmentosum (XP) is a rare autosomal recessive disorder characterized by hypersensitivity of the skin and eyes to UV-radiation as a result of a defect in one of eight genes. Seven genes (XPA-XPG) have a defect in Nucletoide Excision Repair (NER), while the eighth gene XPV has a defect in polymerase η, which is responsible for replication of UV-damaged DNA to produce corrected daughter strands. We present the varied clinical courses of three African-American female patients with XP. Additionally, we present a review of the literature that focuses on the various clinical manifestations as well as the genetic and molecular mechanisms underlying this disease.