Ashley E. Levack

Tranexamic acid in hip fracture patients: a protocol for a randomised, placebo controlled trial on the efficacy of tranexamic acid in reducing blood loss in hip fracture patients

Introduction There is a high incidence of blood transfusion following hip fractures in elderly patients. Tranexamic acid (TXA) has proven efficacy in decreasing blood loss in general trauma patients as well as patients undergoing elective orthopaedic surgery. A randomised controlled trial will measure the effect of TXA in a population of patients undergoing hip fracture surgery. Methods This is a double-blinded, randomised placebo-controlled trial. Patients admitted through the emergency room that are diagnosed with an intertrochanteric or femoral neck fracture will be eligible for enrolment and randomised to either treatment with 1 g of intravenous TXA or intravenous saline at the time of skin incision. Patients undergoing percutaneous intervention for non-displaced or minimally displaced femoral neck fractures will not be eligible for enrolment. Postoperative transfusion rates will be recorded and blood loss will be calculated from serial haematocrits. Ethics and dissemination This protocol was approved by the Institutional Review Board (IRB) and is registered with clinicaltrials.gov. The findings of the trial will be disseminated through peer-reviewed journals and conference presentations. Trial registration number NCT01940536.

Validating the Patient Reported Outcomes Measurement Information System (PROMIS) computerized adaptive tests for upper extremity fracture care

BACKGROUND Computerized adaptive testing (CAT) for patient-reported outcomes (PROs) is a developing area within orthopedic surgery. Our objective was to validate the Patient Reported Outcomes Measurement Information System (PROMIS) CATs for upper extremity fracture care. We sought to correlate PROMIS with legacy PROs and to investigate floor and ceiling effects. METHODS Patients who underwent open reduction and internal fixation of upper extremity trauma were prospectively enrolled. Legacy PROs included the visual analog scale for pain, the Disabilities of the Arm, Shoulder and Hand questionnaire, the University of California-Los Angeles Shoulder Rating Scale, the Mayo Elbow Performance Score, and the 36-Item Short Form Health Survey. PROMIS CATs included Physical Function (PROMIS PF), PROMIS Pain Interference (PROMIS Pain), and PROMIS Upper Extremity (PROMIS UE). Correlations between the PROs were calculated as were the absolute and relative floor and ceiling effect. RESULTS The study prospectively enrolled 174 patients with upper extremity trauma. There was moderate to high correlation between PROMIS UE CAT and legacy upper extremity-specific PROs (ρ = 0.42-0.79), and high correlation between the PROMIS PF CAT and the 36-Item Short Form Health Survey Physical Component Summary (ρ = 0.71, P < .001). The visual analog scale for pain, University of California-Los Angeles Shoulder Rating Scale, Constant Score, and Mayo Elbow Score demonstrated a significant absolute ceiling effect (20.5%-23.7%), whereas the PROMIS PF, PROMIS UE, and PROMIS Pain CATs demonstrated no absolute ceiling effect. CONCLUSION PROMIS PF, Pain, and UE correlate well with legacy PROs in a upper extremity trauma population, with less absolute floor or ceiling effects. This study provides preliminary evidence for the utility of PROMIS CATs in upper extremity trauma patients.

The Use of Fibular Allograft in Complex Periarticular Fractures Around the Knee

Although the use of fibular strut allografts in proximal humerus fractures has gained popularity, their use in other types of fractures is less well described. Fibular allografts have recently been used in the repair of complex periarticular fractures of the proximal tibia and distal femur. Fibular allografts can be inserted in a variety of manners to achieve goals specific to each individual fracture pattern. In the proximal tibia, insertion through a fracture line or cortical window facilitates joint surface elevation, prevents subsidence and enhances overall construct stability. In distal femoral fractures, including complex periarticular fractures, insertion through the fracture or cortical window permits indirect reduction of the medial cortex and provides necessary medial column support. An additional option in distal femur fractures includes fibula insertion as an intramedullary nail, allowing enhanced fixation in short distal fracture segments. In all cases, the use of a fibular allograft augments poor bone stock and provides improved screw purchase and construct stability when combined with conventional plating methods. Here we present a series of cases at our institution illustrating an array of novel techniques utilizing endosteal fibular allografts in the fixation of complex periarticular fractures about the knee.

Computerized Adaptive Testing for Patient Reported Outcomes in Ankle Fracture Surgery.

Background: Advantages of using computerized adaptive testing (CAT) include decreased survey-burden, diminished floor and ceiling effect, and improved ability to detect the minimal clinical significant difference (MCID) among patients. The goal of this study was to compare the legacy patient-reported outcome measures (PROMs) to the Patient-Reported Outcomes Measurement Information System (PROMIS) scores in terms of ability to detect clinically significant changes in patients who have undergone surgery for ankle fractures. Methods: Patients who underwent osteosynthesis for an unstable ankle fracture between 2013-2016 and completed legacy outcome scores (Foot and Ankle Outcome Score [FAOS], Olerud and Molander Ankle Score [OMAS], and Weber Score) along with the PROMIS Physical Function (PF) and PROMIS Lower Extremity (LE) CATs postoperatively were included. Correlation between the scores at 3-month, 6-month, and 1-year intervals, as well as floor and ceiling effects, in addition to MCIDs were calculated for each instrument. A total of 132 patients were included in the study. Results: There was no observed floor or ceiling effect in either the PROMIS PF or the PROMIS LE scores. Clinically significant changes in the PROMIS LE score were detected in patients between 6-month and 12-month postoperative visits (P = .0006), whereas the reported OMAS score and Weber scores did not identify a clinically significant difference between patients at their 6-month and 12-month visit. Conclusion: The results of this study indicate that the PROMIS LE was superior for evaluating patients following ankle fracture surgery in terms of lower floor and ceiling effects and greater ability to distinguish clinically significant changes in patients between time points following surgery. Level of Evidence: Level III, comparative study.

Periprosthetic Joint Infection in Patients with Inflammatory Joint Disease: Prevention and Diagnosis

Purpose of ReviewPeriprosthetic joint infection (PJI) is a devastating complication that can occur following total joint arthroplasty (TJA), causing significant morbidity and often requiring revision surgery. This goal of this manuscript is to review the current evidence for the prevention and diagnosis of PJI in patients with inflammatory arthritis.Recent FindingsPatients with inflammatory arthritis have a higher risk of PJI after TJA; however, there are several preventive, diagnostic, and therapeutic measures that can be optimized to lower the burden of PJI in this population. This manuscript will review the current evidence and clinical practice recommendations that support specific features of preoperative evaluation, perioperative medication management, and surgical planning in inflammatory arthritis patients undergoing TJA. Evidence and recommendations for the diagnosis of PJI in this patient population will also be reviewed.SummaryDespite increased research efforts directed towards PJI, specific approaches directed at the inflammatory arthritis patient population remain surprisingly limited. Optimization strategies such as adequately managing disease-modifying medications, treating preoperative anemia, encouraging smoking cessation, and improving weight management are strongly encouraged before entering the perioperative period. If PJI does occur in the inflammatory arthritis patient, establishing the diagnosis is challenging, since guidelines were created from investigations of PJI in primarily patients without inflammatory arthritis. Future prospective research is required to better guide clinicians in preventing and diagnosing PJI in inflammatory arthritis patients undergoing TJA.

Current Options and Emerging Biomaterials for Periprosthetic Joint Infection

Purpose of ReviewInfection in the setting of total joint arthroplasty, referred to as periprosthetic joint infection (PJI), is a devastating complication requiring prolonged and costly treatment. The unique environment around an artificial joint and ability of surrounding tissues to sequester bacteria collectively make prevention, diagnosis, and treatment of this condition challenging. In light of the unique pathogenesis of PJI, this review explores the limitations of contemporary treatments and discusses novel treatment options.Recent FindingsRecent advancements in local antibiotic delivery platforms for preventing and treating PJI include titanium nanotube arrays, synthetic polymers, resorbable hydrogels, and cyclodextrin-based drug delivery options. In particular, cyclodextrins have facilitated great advancements in other clinical disorders and have demonstrated early promise as a future option in the arena of PJI.SummaryNovel treatment modalities for PJI optimize the implant surfaces to prevent bacterial biofilm formation or provide prolonged intra-articular antibiotic dosing to eradicate bacteria.

Soft Tissue Repair in Supination-External Rotation IV Ankle Fractures

Achieving optimal functional outcomes while preventing posttraumatic ankle arthritis in patients with unstable ankle fractures remains challenging for orthopedic surgeons. The rate of syndesmotic malreduction is alarmingly high after transsyndesmotic screw fixation. The senior author introduced an alternative to transsyndesmotic screw fixation with anatomic approach to bone and ligament repair. Here we review the development of this approach and present the technique of repairing soft tissue structures in unstable ankle fractures.