Allison L. Boden

The impact of prophylactic intraoperative vancomycin powder on microbial profile, antibiotic regimen, length of stay, and reoperation rate in elective spine surgery

BACKGROUND CONTEXTnThere is growing concern that the microbial profile of surgical site infection (SSI) in the setting of prophylactic vancomycin powder may favor more resistant and uncommon organisms.nnnPURPOSEnTo demonstrate the impact of prophylactic intraoperative vancomycin powder on microbial profile, antibiotic regimen, length of stay (LOS), and reoperation rate in spine surgical site infection.nnnSTUDY DESIGN AND/OR SETTINGnRetrospective cohort study.nnnPATIENT SAMPLEnthe study included 115 postoperative spine patients who were required to return to the operating room for SSI.nnnOUTCOME MEASURESnThe outcome measures were microbial profile, reoperation rate, antibiotic regimen, and LOS for patients with postoperative spine infection who either did (treated) or did not (untreated) receive prophylactic vancomycin powder during their index procedure.nnnMETHODSnA retrospective review of patients who underwent posterior thoracic and/or lumbar spine surgery between 2010 and 2017 was conducted. Those undergoing surgical treatment of SSI were identified, and patients were divided into two groups - those who were treated with intraoperative vancomycin (treated) and those who were not (untreated). The organism profile for each group was compared. The average LOS, reoperation rate, and number of patients requiring more than 1 antibiotic were calculated for each patient in both groups.nnnRESULTSnThere were 5,909 procedures performed. One hundred and fifteen SSIs were identified, resulting in a 1.9% infection rate. Prophylactic vancomycin powder was used in the index procedure for 42 of those cases. 23.8% of cultures in the vancomycin group were polymicrobial and 16.7% were gram-negative compared with 9.6% (p=0.039) and 4.1% (p=0.021) in the untreated group, respectively. In the vancomycin-treated group, 26.1% of patients underwent repeat irrigation and debridement compared with 38.4% in the untreated group (p=0.184). The percentage of patients in the treatment and untreated group who required more than 1 antibiotic was 26.0% and 26.1%, respectively (p=0.984). Mean LOS in the treatment group was 8.0 versus 7.9 for the untreated group (p=0.945) CONCLUSIONS: In this series, vancomycin powder was associated with a higher prevalence of gram-negative and polymicrobial organisms in patients that ultimately developed postoperative SSI. However, this did not adversely affect the need for multiple reoperations, antibiotic regimen, or LOS for these patients.

Risk Factors for Manipulation Under Anesthesia and/or Lysis of Adhesions After Anterior Cruciate Ligament Reconstruction

Background: In the currently published literature, a higher risk for developing arthrofibrosis after anterior cruciate ligament (ACL) reconstruction has been reported for female patients, adolescents, early surgery or concomitant procedures, and the use of a patellar tendon autograft. There is a lack of evidence regarding other graft choices or factors. Hypothesis: Multiple risk factors will play a significant role in the development of arthrofibrosis after ACL reconstruction. Specifically, we hypothesized that the risk of manipulation under anesthesia (MUA) and/or lysis of adhesions (LOA) would be affected by graft choice and patient demographic factors. Study Design: Case-control study; Level of evidence, 3. Methods: The charts of all patients who underwent ACL reconstruction over a 10-year period at a single academic institution were queried from an electronic medical record database and reviewed at a minimum of 6 months after ACL reconstruction, with the collection of demographic and surgical data. The relative risk for undergoing MUA and/or LOA was calculated for each analyzed risk factor. Results: A total of 2424 ACL reconstructions were included, with a chart review at a mean of 56.7 months after surgery (range, 7.6-124.0 months). The rate of MUA and/or LOA for arthrofibrosis was 4.5%. A statistically significantly increased relative risk was found for infection (5.45), hematoma requiring evacuation (3.55), ACL reconstruction with meniscal repair (2.83), use of a quadriceps tendon autograft (2.68), age <18 years (2.39), multiple concomitant procedures (1.69), contact injury (1.62), female sex (1.60), and surgery within 28 days of injury (1.53), and a statistically significantly decreased relative risk was found for revision ACL reconstruction (0.30), age >25 years (0.34), and use of a tibialis anterior allograft (0.36). In the multivariate regression model, the use of a quadriceps tendon autograft (P = .00007), infection (P = .00126), and concomitant meniscal repair (P = .00194) were independent risk factors, whereas revision ACL reconstruction (P = .0024) was an independent protective factor. Conclusion: Graft type, infection, concomitant meniscal repair, and primary reconstruction are significant risk factors for undergoing MUA or LOA after ACL reconstruction.

Biomechanical Evaluation of Standard Versus Extended Proximal Fixation Olecranon Plates for Fixation of Olecranon Fractures

Background: Small olecranon fractures present a significant challenge for fixation, which has resulted in development of plates with proximal extension. Olecranon-specific plates with proximal extensions are widely thought to offer superior fixation of small proximal fragments but have distinct disadvantages: larger dissection, increased hardware prominence, and the increased possibility of impingement. Previous biomechanical studies of olecranon fracture fixation have compared methods of fracture fixation, but to date there have been no studies defining olecranon plate fixation strength for standard versus extended olecranon plates. The purpose of this study is to evaluate the biomechanical utility of the extended plate for treatment of olecranon fractures. Methods: Sixteen matched pairs of fresh-frozen human cadaveric elbows were used. Of the 16, 8 matched pairs received a transverse osteotomy including 25% and 8 including 50% of the articular surface on the proximal fragment. One elbow from each pair was randomly assigned to a standard-length plate, and the other elbow in the pair received the extended-length plate, for fixation of the fracture. The ulnae were cyclically loaded and subsequently loaded to failure, with ultimate load, number of cycles, and gap formation recorded. Results: There was no statistically significant difference between the standard and extended fixation plates in simple transverse fractures at either 25% or 50% from the proximal most portion of the articular surface of the olecranon. Conclusion: Standard fixation plates are sufficient for the fixation of small transverse fractures, but caution should be utilized particularly with comminution and nontransverse fracture patterns.

Biomechanical Strength of Retrograde Fixation in Proximal Third Scaphoid Fractures

Background: Current techniques for fixation of proximal pole scaphoid fractures utilize antegrade fixation via a dorsal approach endangering the delicate vascular supply of the dorsal scaphoid. Volar and dorsal approaches demonstrate equivalent clinical outcomes in scaphoid wrist fractures, but no study has evaluated the biomechanical strength for fractures of the proximal pole. This study compares biomechanical strength of antegrade and retrograde fixation for fractures of the proximal pole of the scaphoid. Methods: A simulated proximal pole scaphoid fracture was produced in 22 matched cadaveric scaphoids, which were then assigned randomly to either antegrade or retrograde fixation with a cannulated headless compression screw. Cyclic loading and load to failure testing were performed and screw length, number of cycles, and maximum load sustained were recorded. Results: There were no significant differences in average screw length (25.5 mm vs 25.6 mm, P = .934), average number of cyclic loading cycles (3738 vs 3847, P = .552), average load to failure (348 N vs 371 N, P = .357), and number of catastrophic failures observed between the antegrade and retrograde fixation groups (3 in each). Practical equivalence between the 2 groups was calculated and the 2 groups were demonstrated to be practically equivalent (upper threshold P = .010). Conclusions: For this model of proximal pole scaphoid wrist fractures, antegrade and retrograde screw configuration have been proven to be equivalent in terms of biomechanical strength. With further clinical study, we hope surgeons will be able to make their decision for fixation technique based on approaches to bone grafting, concern for tenuous blood supply, and surgeon preference without fear of poor biomechanical properties.

Liquifying PLDLLA Anchor Fixation in Achilles Reconstruction for Insertional Tendinopathy

Insertional Achilles tendinopathy (IAT) is a frequent cause of posterior heel pain and is often associated with Haglund’s deformity. Surgical correction for refractory cases of IAT has been well studied; however, the method of tendon fixation to bone in these procedures remains controversial, and to date, no standard technique has been identified for tendon fixation in these surgeries. Often, after Haglund’s resection, there is large exposed cancellous surface for Achilles reattachment, which may require unique fixation to optimize outcomes. Previous studies have consistently demonstrated improved patient outcomes after Achilles tendon reconstruction with early rehabilitation with protected weight bearing, evidencing the need for a strong and stable anchoring of the Achilles tendon that allows early weight bearing without tendon morbidity. In this report, we highlight the design, biomechanics, and surgical technique of Achilles tendon reconstruction with Haglund’s deformity using a novel technique that utilizes ultrasonic energy to liquefy the suture anchor, allowing it to incorporate into surrounding bone. Biomechanical studies have demonstrated superior strength of the suture anchor utilizing this novel technique as compared with prior techniques. However, future research is needed to ensure that outcomes of this technique are favorable when compared with outcomes using traditional suture anchoring methods. Levels of Evidence: Level V: Operative technique

Comorbidities associated with poor outcomes following operative hammertoe correction in a geriatric population

Category: Lesser Toes Introduction/Purpose: Hammertoe deformities are one of the most common lesser foot deformities and are extremely prevalent in the geriatric population. When nonoperative treatment fails, surgical correction can improve functional status and pain. While complications following these surgeries are rare, older patients with comorbid conditions are often considered worse operative candidates due to an increased risk of adverse outcomes. The aim of this study is to determine if specific comorbidities or perioperative variables are associated with increased complications or unsuccessful outcomes following operative hammertoe correction in geriatric patients. Methods: Prospectively collected data was reviewed on 31 consecutive patients aged 60 or older who underwent operative correction of hammertoe deformity. Patient demographics, comorbidities, perioperative variables, and postoperative complications were recorded from their electronic medical records. Clinical outcomes were assessed utilizing preoperative and postoperative Visual Analogue Scale (VAS) and Short Form Health Survey Physical Component Score (SF-36 PCS) with a minimum of six-month follow-up. Data was examined using Fisher’s method and multivariable analysis. Results: 29.0% (9/31) of patients had a history of smoking, 61.2% (19/31) were on anticoagulant therapy, 19.4% (6/31) had osteoporosis, 16.1% (5/31) had rheumatoid arthritis, and 9.7% (3/31) had diabetes mellitus. The mean tourniquet and operative times were 65.7 (SE=6.2) and 95.4 (SE=7.4) minutes, respectively. Postoperative complications occurred in 12.9% (4/31) of patients with the most prevalent being wound infections that were treated with antibiotics in 9.7% (3/31). Impaired wound healing, joint nonunion, and the need for revision surgery each occurred in 3.2% (1/31) of patients. Mean 6-month improvement in VAS was 2.1 (SE=0.5) and mean improvement in SF-36 PCS was 10.2 (SE = 3.4). No significant association was found between comorbidities or perioperative variables and postoperative complications or improved outcomes. Conclusion: No specific comorbidities or perioperative variables were identified that increase the risk for unsuccessful surgical correction of hammertoe deformities. While comorbidities in the geriatric population have traditionally been thought to increase complication rates and lead to poor outcomes, further research in this area is warranted. Comorbidities should not necessarily be a deterrent for geriatric patients pursuing operative hammertoe correction.

Complication Rates and Short-Term Outcomes After Operative Hammertoe Correction in Older Patients:

Background: Hammertoe deformities are the most common lesser toe deformity. To date, no studies have looked at outcomes of operative management in the geriatric population, which may be at greater risk for complications or functional compromise because of comorbidities. Methods: Data on 58 patients undergoing operative correction of hammertoe deformities were prospectively collected. Clinical outcomes were assessed using preoperative and postoperative visual analogue scale (VAS) and Short Form Health Survey (SF-36) scores with a minimum of 6-month follow-up. Patients were divided into 2 groups on the basis of age at the time of surgery: younger than 65 and 65 and older. Complication rates and mean VAS and SF-36 improvement were compared. Forty-seven patients met inclusion criteria (7 men, 40 women), with 26 patients (37 toes) in the younger cohort and 21 patients (39 toes) in the older cohort. Results: Overall, patients demonstrated significant improvement from baseline to 6 and 12 months postoperatively in VAS (P < .001 and P < .001) and SF-36 (P < .001 and P < .001) scores. Mean improvement in VAS and SF-36 scores was not significantly different between the groups at 6 and 12 months postoperatively. Complications occurred in 13.5% and 10.3% of patients in the younger and older cohorts, respectively. Conclusions: Outcomes of operative correction of hammertoe deformities in older patients were similar to outcomes in younger patients after greater than 6 months of follow-up. Overall improvement in VAS and SF-36 was statistically significant for both cohorts. There was no associated increase in complications for older patients. Level of Evidence: Level, III comparative series.

The Effect of Season and Weather on Orthopaedic Trauma: Consult Volume Is Significantly Correlated with Daily Weather

Introduction On-call orthopedic clinicians have long speculated that daily consult volume is closely correlated with weather. While prior studies have demonstrated a relationship between weather and certain fracture types, the effect of weather on total orthopaedic consult volume has not yet been examined. The aim of this study was to investigate this relationship. Methods We retrospectively reviewed orthopaedic consult data from 405 consecutive days at an urban, level one trauma center. The number, mechanism of injury, and type of consult were collected, along with daily weather data (temperature, wind, and precipitation). Statistical analysis was then performed to determine the relationship between weather and orthopaedic trauma consults. Results A total of 4543 consults were received during the study period. There was a significant difference in total number of consults between months of the year (p<0.001). A post hoc analysis revealed that this was due to increased volume in the summer months relative to the winter months (i.e., August 13.7 consults/day; January 9.3 consults/day). Average daily temperature and consult volume were also positively correlated (p<0.001, r= 0.30). While there was no significant association between precipitation and total consult volume, when there was over 0.25 inches of rain, there were less penetrating trauma (p=0.034) and motorcycle collision consults (p=0.013). Conclusion Weather parameters, specifically average temperature and precipitation, were found to be associated with daily orthopedic consult type and volume. Additionally, consult volume varies significantly between months of the year. Because trauma centers are often resource scarce, this is an important relationship to understand for proper resource allocation.