Radiographic Measurements Correlate to Isolated Posterolateral Corner (PLC) Injury in a Novel Cadaveric Model.

INTRODUCTION:  Injury to the posterolateral corner (PLC) of the knee often requires surgical reconstruction. There remains no consensus on treatment for PLC injury, and, therefore, it is imperative to have a reproducible injury model to improve the general knowledge of PLC injuries. A novel cadaveric model of isolated PLC injury is proposed and evaluated using radiographic parameters as well as gross dissection. MATERIAL AND METHODS:  All protocols were reviewed by the Human Investigation and Research Committee of the home institution and were approved. Translational force in a defined posterior and lateral direction was applied to cadaveric native knees to induce PLC injury. Varus and recurvatum stress fluoroscopic imaging was obtained of each specimen before and after the injury model. Lateral joint distance and recurvatum angle after stress was measured on each image via picture archiving and communication software (PACS) imaging software. After the injury model, injured structures were assessed via saline loading and gross dissection. Any specimens found to be fractured were excluded from the analysis of stress radiography. RESULTS:  A total of 12 knees underwent testing and 6/12 successfully induced PLC injury without fracture. The lateral capsule was torn in every specimen. The popliteofibular ligament (PFL) was torn in 83% of specimens and the fibular collateral ligament (FCL) in 66.7% of specimens. The median lateral gapping after injury under varus stress radiography was 5.39 mm and the median recurvatum angle after injury was 14.25°. Radiographic parameters had a direct relationship with a number of structures injured. CONCLUSIONS:  This is the first successful cadaver model of PLC injury. The lateral capsule was injured in every specimen emphasizing the importance of this structure to the PLC.

Accuracy of self-reported opioid use in orthopaedic trauma patients.

PURPOSE: Opioids have long been a mainstay of treatment for pain in patients with orthopaedic injuries, but little is known about the accuracy of self-reported narcotic usage in orthopaedic trauma. The purpose of this study is to evaluate the accuracy of self-reported opioid usage in orthopaedic trauma patients. METHODS: A retrospective review of all new patients presenting to the orthopaedic trauma clinic of a level 1 trauma centre with a chief complaint of recent orthopaedic-related injury over a 2-year time frame was conducted. Participants were administered a survey inquiring about narcotic usage within the prior 3 months. Responses were cross-referenced against a query of a statewide prescription drug monitoring program system. RESULTS: The study comprised 241 participants; 206 (85.5%) were accurate reporters, while 35 (14.5%) were inaccurate reporters. Significantly increased accuracy was associated with hospital admission prior to clinic visit (ß = - 1.33; χ2 = 10.68, P < 0.01; OR: 0.07, 95% CI 0.01-0.62). Decreased accuracy was associated with higher pre-visit total morphine equivalent dose (MED) (ß = 0.002; χ2 = 11.30, P < 0.01), with accurate reporters having significantly lower pre-index visit MED levels compared to underreporters (89.2 ± 208.7 mg vs. 249.6 ± 509.3 mg; P = 0.04). An Emergency Department (ED) visit prior to the index visit significantly predicted underreporting (ß = 0.424; χ2 = 4.28, P = 0.04; OR: 2.34, 95% CI 1.01-5.38). CONCLUSION: This study suggests that most new patients presenting to an orthopaedic trauma clinic with acute injury will accurately report their narcotic usage within the preceding 3 months. Prior hospital admissions increased the likelihood of accurate reporting while higher MEDs or an ED visit prior to the initial visit increased the likelihood of underreporting.

Primary Hemiarthroplasty for the Treatment of Basicervical Femoral Neck Fractures.

Purpose Basicervical femoral neck fractures are uncommon injuries that occur at the extracapsular base of the femoral neck at its transition with the intertrochanteric line. Controversy remains in the orthopedic literature as to the optimal method of treatment for this fracture type given the inherent instability and greater rate of implant failure with traditional fixation constructs. The purpose of this study is to quantify the incidence and preferred treatment methods of basicervical hip fractures at a single, regional, Level 1 trauma center and to identify differences in postoperative complications between treatment options. Methods The present study is a retrospective case series from a single regional health network, including 316 patients with hip fractures. Basicervical femoral neck fractures were identified. Reoperation rates within 90 days, implant failures or nonunions, postoperative ambulation distances and range of motion, and discharge dispositions were compared across patients grouped by surgical treatment with either cephalomedullary nail, sliding hip screw, or hemiarthroplasty (HA). Results Basicervical femoral neck fractures represented 6.6% of this study population. The cephalomedullary nail group demonstrated rates of implant failure and return to the operating room within 90 days of 40% (4/10) and 20% (2/10), respectively. No patients who underwent hemiarthroplasty experienced a failure of fixation or return to the operating room. Conclusions This study suggests a much lower rate of fixation failure or need for reoperation with hemiarthroplasty treatment compared to cephalomedullary nail construct for basicervical femoral neck fractures and may be an underutilized treatment method for this fracture type. The promising results seen with this case series should encourage further investigation into HA as a primary treatment for these uncommon, yet challenging, fractures.

Increased risk of hip fracture mortality associated with intraoperative hypotension in elderly hip fracture patients is related to under resuscitation.

BACKGROUND: As the US and world population ages, hip fractures are increasingly more common. The mortality associated with these fractures remains high both in the immediate postoperative period and at one year. Perioperative resuscitation in this population is of key interest to prevent organ injury and mortality. Our objectives were to evaluate the effect of fluid resuscitation and hemodynamic status in the form of mean arterial pressure (MAP) on inpatient mortality of hip fracture patients. METHODS: An institutional database was queried to compare elderly hip fracture patients that sustained in-hospital mortality to a matched control cohort. Pre-, intra-, and post-operative intravenous fluid (IVF) administration and MAP were extracted from the electronic medical record. Time from hospital presentation to the OR was also recorded. RESULTS: 1,114 total hip fractures were identified during the two-year study period, 16 of which suffered inpatient mortalities. The mortality cohort was then matched with a control of 394 hip fracture patients for the same period based on age, sex, and Charlson Comorbidity Index (CCI). Conditional logistical regression analysis found odds ratios (OR) indicating that longer time between presentation and surgery (OR per additional hour: 1.05; 95% CI: 1.01-1.08) and lower intraoperative minimum MAP (OR per 5 mmHg decrease: 0.77; 95% CI: 0.61-0.97) were associated with significantly increased odds of mortality. There was also a marginal relationship between greater intraoperative IVF administration and reduced odds of mortality (OR per 500 cc additional fluid: 0.61; 95% CI: 0.37-1.00). CONCLUSION: Extended time from presentation to surgery and intraoperative hypotension were associated with increased likelihood of inpatient mortality in an elderly hip fracture cohort, with a possible additional effect of under-resuscitation. Further investigation into a safe intraoperative minimum MAP should be pursued. LEVEL OF EVIDENCE: Level III.

Differences between intertrochanteric and femoral neck fractures in resuscitative status and mortality rates.

INTRODUCTION: Hip fracture mortality remains a challenge for orthopedic surgeons. The purpose of this study was to compare resuscitative mean arterial pressures (MAPs), intravenous fluid (IVF) administration, and mortality rates between intertrochanteric (IT) and femoral neck (FN) fracture patients. HYPOTHESIS: We hypothesized that IT fracture patients would receive less aggressive fluid resuscitation than FNF patients given the perceived less invasive nature of intra-medullary nails compared with hemiarthroplasty. MATERIALS AND METHODS: An institutional database was queried to identify all hip fractures managed surgically over a 2-year period. Preoperative and intraoperative MAPs and IVF administration, as measures of resuscitation, were compared between IT fracture patients treated with open reduction internal fixation and FN fracture patients treated with hemiarthroplasty. RESULTS: Six hundred and ninety-eight hip fractures, including 531 IT and 167 FN fractures, were analyzed. There were no differences between IT and FN fracture cohorts for age, sex distribution, or Charlson Comorbidity Index scores. IT fracture patients were found to have lower MAP upon admission (103.7±20.1 vs. 107.8±18.4mmHg; p=0.026), and lower average, minimum, and maximum MAP values preoperatively and intraoperatively. Despite lower MAPs, IT fracture patients received less total IVF (581.9±472.5 vs. 832.9±496.5cc; p<0.001) and lower IVF rates intraoperatively (306.5±256.8 vs. 409.8±251.0 cc/h; p<0.001). IT fracture patients experienced higher 30-day (7.9% vs. 3.6%; p=0.040) and 90-day (10.6% vs. 5.4%; p=0.035) mortality rates and trended towards higher inpatient mortality (3.0% vs. 0.6%; p=0.088). Multivariate regression demonstrated IT pattern to be independently predictive of 30-day mortality with 2.459 increased odds relative to FN fracture (p=0.039). DISCUSSION: IT fracture patterns are associated with decreased perioperative MAP values, yet received lower perioperative IVF rates. IT fracture patients suffered higher 30- and 90-day mortality rates, despite similar age and comorbidities. LEVEL OF EVIDENCE: III; retrospective cohort study.

Variability of orthopedic physician fracture location identification: Implications for bone stimulator treatment.

INTRODUCTION: Aseptic non-union is a significant complication in approximately 5% of long-bone fractures. External bone stimulation treatment is often attempted before more invasive surgical interventions. Bone stimulators can have favorable results, but have a limited 1.7cm therapeutic radius. This study evaluated the accuracy by which clinicians locate a fracture on a cadaveric model. This has implications for the clinician's ability to accurately counsel patients on daily bone stimulator placement. Additionally, physicians (orthopedic attending surgeons and residents) were compared with pre-clinical (M1 and M2) medical students to evaluate if higher levels of training improved accuracy. HYPOTHESIS: Orthopedic physicians and pre-clinical medical students will localize a radiographic fracture within 1.7cm less than 100% of the time, which represents the ideal consistency for patient care. Furthermore, orthopedic physicians will achieve a higher percentage accuracy than pre-clinical medical students. MATERIALS AND METHODS: The sample included 20 orthopedic physicians and 16 pre-clinical medical students. Upper (radius) and lower (tibia) extremity cadaver models were prepared by inducing a single, transverse diaphyseal fracture. Plain reference radiographs of each model were obtained. Participants placed a radiopaque marker onto each model at the perceived fracture location, and radiographs were taken to document placement. Perpendicular marker-to-fracture distance was measured to the nearest mm along each bone's long axis using the PACS system. RESULTS: Placement within the therapeutic radius was achieved by 70-80% of physicians, and 69-75% of medical students. In the remaining participants, improper placement distances were lower among physicians than among medical students (radius: 2.1±0.5 vs. 3.6±0.9cm, p=0.02; tibia: 2.6±0.5 vs 3.5±0.5cm, p=0.89). DISCUSSION: In two cadaveric fracture models, up to 30% of orthopedic surgeons perceived a fracture location to be outside a bone stimulator's 1.7cm therapeutic radius. This finding suggests that physicians and their patients may benefit from additional methods for specifying the location of a non-union before commencing daily bone stimulator treatment. LEVEL OF EVIDENCE: Level IV, prospective cohort study-evidence from a well-designed prospective cohort study.

Long-Term Survival of Metastatic Bladder Cancer Treated With Chemotherapy, Radiation, and Arthroplasty: A Case Report.

CASE: A 64-year-old man suffered a pathologic left femoral neck fracture. Biopsy demonstrated metastatic urothelial cancer with a nonmuscle invasive bladder cancer primary confirmed by cystoscopy. The patient underwent hemiarthroplasty, chemotherapy, radiation, and eventually, a conversion to total hip arthroplasty. Today, over a decade from the initial surgery, the patient remains alive and highly functional. To our knowledge, this is the only report of bone metastatic bladder cancer with over 10-year survival. CONCLUSION: Combined chemotherapy, radiation, and surgical resection of metastasis with reconstruction may confer a survival benefit in bony oligometastatic bladder cancer.

Effects of the Ohio Opioid Prescribing Guidelines on Total Joint Arthroplasty Postsurgical Prescribing and Refilling Behavior of Surgeons and Patients.

BACKGROUND: The opioid epidemic has been declared a public health crisis, with thousands of Americans dying from overdoses each year. In 2017, Ohio passed the Opioid Prescribing Guidelines (OPG) limiting narcotic prescriptions for acute pain. The present study sought to evaluate the effects of OPG on the prescribing behavior of orthopedists following total knee arthroplasty (TKA) and total hip arthroplasty (THA). METHODS: An institutional database was queried to compare morphine equivalent dose (MED) prescribed at discharge, acute follow-up (<90 days), and chronic follow-up (>90 days) pre-OPG and post-OPG. Cases were identified over a 2-year period starting 1 year before OPG implementation. RESULTS: Nine orthopedic surgeons performed 1160 TKAs (692 pre-OPG, 468 post-OPG) and 834 THAs (530 pre-OPG, 304 post-OPG). Total MED for TKA and THA dropped post-OPG (1602.6 ± 54.3 vs 1145.8 ± 66.1, P < .01; 1302.3 ± 47.0 vs 878.3 ± 62.2, P < .01). Much of the total MED decrease was accounted for by the decrease in discharge MED, which was the largest in magnitude (904.8 ± 16.4 vs 606.2 ± 20.0, P < .01; 948.4 ± 19.6 vs 630.6 ± 25.9, P < .01). Seven of the 9 surgeons statistically reduced mean MED prescribed at discharge following OPG. The percentage of patients receiving new narcotic scripts at acute follow-up increased post-OPG for both TKA (41.5% vs 47.2%, P = .05) and THA (18.3% vs 25.7%, P = .01). CONCLUSION: Orthopedists reduced total MED prescribed after TKA and THA following the onset of OPG. The majority of this decrease is explained by decreased MED at discharge. Conversely, the post-OPG period saw slightly more new narcotic scripts written during acute follow-up.

Polymicrobial infection with Kluyvera species secondary to pressure necrosis of the hand, a case report.

Kluyvera is a rare infection in the upper extremity. Originally identified as an opportunistic pathogen, the virulence of Kluyvera has been debated. An elderly male presented with multiple pressure sores after being found down for an unknown time period. A hand abscess bacterial culture grew Kluyvera species as part of a polymicrobial infection. Despite multiple debridements, antibiotics and wound care, his clinical course ultimately was unsatisfactory and eventually fatal.

Minimal Invasive Fixation Can Decrease Infection Rates in Diabetic and Obese Patients With Severe Ankle Fracture and Syndesmotic Injury.

BACKGROUND: Ankle fractures involving syndesmosis disruption cause severely unstable joint conditions. Traditional invasive operations put certain patient groups at an increased risk of infection. There is limited literature discussing the outcomes of minimally invasive fixation of severe ankle fractures including syndesmotic injury, as clinicians may be tempted to treat these difficult cases with open reduction internal fixation (ORIF). METHODS: A retrospective case-control study was conducted on patients treated at a level one trauma center. Patients were divided into 2 groups based on presence of diabetes and/or obesity (body mass index ≥30.0 kg/m2). Those with either comorbidity were defined as high infection risk patients and placed in a comorbidity group. Patients were further divided into subgroups based on the operation's invasiveness; either traditional ORIF or percutaneous cannulated screw fixation. RESULTS: Comorbid patients (N = 67) were more likely to sustain Weber C fractures compared to noncomorbid patients (N = 43) (59.70% to 37.21%, P = .019). Additionally, patients receiving minimally invasive fixation procedures experienced fewer infections than those receiving ORIF (0 vs 11 incidences, P = .01), without effect on union rates, fracture reduction, pain, need for revision surgery, or time to full weightbearing. CONCLUSIONS: Diabetic and obese patients are at an increased risk of experiencing severe ankle fractures. The use of minimally invasive fixation methods can reduce the risk of postoperative infection without sacrificing other surgical outcomes, even with fractures involving syndesmotic injury. LEVELS OF EVIDENCE: Therapeutic, Level III: Retrospective comparative study.

Iliopsoas Abscess Presenting With Sacral Fracture and Gluteal Abscess: A Clinical Conundrum.

Abscess of the iliopsoas muscle is a rare condition that requires a high degree of clinical suspicion for diagnosis. High mortality rates highlight the need for prompt recognition. We report the case of a 26-year-old man, with a history of intravenous drug use, who was referred from an outside facility with sacral fracture and gluteal abscess. Sacral trauma occurred 3 weeks before presentation, with progressive worsening of buttock pain. The patient was treated with irrigation and débridement of the gluteal abscess. Follow-up MRI revealed a communicating iliopsoas abscess that initially had been undiagnosed. After a prolonged hospital stay requiring additional irrigation and débridement procedures, the patient was discharged in a stable condition. Five-month follow-up has demonstrated no evidence of recurrence of infection. To our knowledge, this is the first reported case of Staphylococcus aureus gluteal abscess with pelvic extension into the iliopsoas secondary to sacral trauma and intravenous drug use.

Prediction of Mortality in Nonagenarians Following the Surgical Repair of Hip Fractures.

BACKGROUND: The purpose of this study is to report on the mortality of nonagenarians who underwent surgical treatment for a hip fracture, specifically in regards to preexisting comorbidities. Furthermore, we assessed the effectiveness of the Deyo score in predicting such mortality. METHODS: Thirty-nine patients over the age of 90 who underwent surgical repair of a hip fracture were retrospectively analyzed. Twenty-six patients (66.7%) suffered femoral neck fractures, while the remaining 13 (33.3%) presented with trochanteric type fractures. Patient charts were examined to determine previously diagnosed patient comorbidities as well as living arrangements and mobility before and after surgery. RESULTS: Deyo index scores did not demonstrate statistically significant correlations with postoperative mortality or functional outcomes. The hazard of in-hospital mortality was found to be 91% (p = 0.036) and 86% (p = 0.05) less in patients without a history of congestive heart failure (CHF) and chronic pulmonary disease (CPD), respectively. Additionally, the hazard of 90-day mortality was 88% (p = 0.01) and 81% (p = 0.024) less in patients without a history of dementia and CPD, respectively. The hazard of 1-year mortality was also found to be 75% (p = 0.01) and 80% (p = 0.01) less in patients without a history of dementia and CPD, respectively. Furthermore, dementia patients stayed in-hospital postoperatively an average of 5.3 days (p = 0.013) less than nondementia patients and only 38.5% returned to preoperative living conditions (p = 0.036). CONCLUSIONS: Nonagenarians with a history of CHF and CPD have a higher risk of in-hospital mortality following the operative repair of hip fractures. CPD and dementia patients over 90 years old have higher 90-day and 1-year mortality hazards postoperatively. Dementia patients are also discharged more quickly than nondementia patients.

Examining Attachment Avoidance and Attachment Anxiety Across Eight Sessions of Couple Therapy.

This study examined initial levels of attachment anxiety and avoidance, as well as their patterns of change, across eight sessions of couple therapy. Participants were 461 couples in a treatment-as-usual setting. Dyadic latent growth modeling was used to determine whether couples started therapy at similar levels of attachment anxiety and avoidance and whether attachment anxiety and avoidance changed. An actor partner interdependence model was used to see whether partner attachment anxiety was related to avoidance. Results showed relative stability of attachment anxiety and avoidance over the course of therapy, with the only change being a slight decline in attachment anxiety among women. Results showed that a person's attachment anxiety was not related to their partner's avoidance and vice versa.

Testing the Clinical Implications of Planned Missing Data Designs.

Assessment is a core element of evidence-based practice, but thorough formal assessment can place a significant burden on clients. We evaluated the clinical viability of using planned missing data designs to reduce client burden. Data come from an archival dataset with 1342 participants. Although significant differences were found in scores with planned missing data versus real scores, the effect sizes for the differences were generally small. Scores with missing data had sensitivity and specificity scores generally above .90 when predicting real scores over clinical cutoffs and improvement in real scores. These findings offer useful information to agencies and researchers looking for ways to collect more data without losing its immediate clinical utility.

The development of a reliable change index and cutoff for the Revised Dyadic Adjustment Scale.

The Revised Dyadic Adjustment Scale (RDAS; Busby, Crane, Larson, & Christensen, 1995) is a measure of couple relationship adjustment that is often used to differentiate between distressed and non-distressed couples. While the measure currently allows for a determination of whether group mean scores change significantly across administrations, it lacks the ability to determine whether an individual's change in dyadic adjustment is clinically significant. This study addresses this limitation by establishing a cutoff of 47.31 and reliable change index of 11.58 for the RDAS by pooling data across multiple community and clinical samples. An individual whose score on the RDAS moves across the cutoff changes by 12 or more points can be classified as experiencing clinically significant change.