Joey P. Johnson

An Evaluation of the Ota-ofc System in Clinical Practice: A Multi-center Study With 90 Days Outcomes

Objectives: The purpose of this study is to evaluate the predictive ability of the Orthopedic Trauma-Open Fracture Classification (OTA-OFC) system in regards to short-term (90 days) outcomes of amputation, infection necessitating intravenous antibiotics, and wound healing in clinical practice across multiple centers. Design: Prospective observational study. Setting: Academic and private practice. Patients/Participants: Patients with open fractures. Intervention: None. Main Outcome Measurements: OTA-OFC, amputations, IV antibiotics, and wound healing. Results: Three hundred seventy-three patients with a total of 419 open fractures were enrolled. Logistic regression to predict amputation demonstrated that arterial and skin injury were statistically significant contributors to the prediction of amputation. Bone loss and muscle injury were significant contributors to the prediction of readmission for IV antibiotics. None of the variables in the OTA-OFC were significant predictors of unhealed wounds. Conclusion: Our study demonstrates the predictive value of the OTA-OFC regarding the short-term (90 days) outcomes of amputation and infection necessitating IV antibiotics and is another step towards the validation of the OTA-OFC in widespread clinical practice. Level of Evidence: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Decreased infection rates following total joint arthroplasty in a large county run teaching hospital: a single surgeon's experience and possible solution.

Total joint arthroplasty is a common orthopaedic procedure producing valuable improvements in patients quality of life. A dreaded complication of this procedure is deep seated, periprosthetic infection. This complication can lead to multiple reoperations and upwards of

Analysis of mortality and fixation failure in geriatric fractures using quantitative computed tomography

100,000 of increased cost burden. At one 900 bed county run teaching hospital, with a historically high infection rate in total joints, the total joint service was closed and restarted using a new protocol, dropping infection rates from 12.9% to 1.9% (P = 0.007).

Isolated dorsal dislocations of the talonavicular and calcaneocuboid articulations (Chopart joints) from a low-energy mechanism

OBJECTIVES While osteoporosis has been shown to be a contributing factor in low energy fractures in the elderly, limited data exists regarding the correlation of bone mineral density (BMD) and T-Scores to mortality and failure of fracture fixation. This study seeks to determine the relationship between femoral neck BMD in elderly patients with typical geriatric fractures and mortality and fracture fixation failure using Quantitative Computed Tomography (QCT). MATERIALS AND METHODS Patients over the age of 65 who sustained fractures of the proximal humerus, distal radius, pelvic ring, acetabulum, hip, proximal tibia, and ankle who also underwent a CT scan that included an uninjured femoral neck were retrospectively reviewed. QCT was used to assess bone mineral density and T scores. Mortality and fixation failure were recorded. Standard descriptive statistics, as well as logistic regression were used to correlate BMD and mortality, and BMD and fixation failure. RESULTS Of the 173 patients initially screened, 150 met inclusion criteria. Patients who remained alive at the end of the study (LP) had significantly (P = .019) higher adjusted mean femoral neck BMD (0.502 g/cm2) than non-polytrauma patients who died (MNPT) (0.439 g/cm2) when controlling for age, time to mortality, follow up, CCI, and ASA. Patients who had fixation failure events (FE) had significantly (P = .002) lower adjusted mean femoral neck BMD (0.342 g/cm2) than patients without failure events (NE) (0.525 g/cm2) when controlling for age and time to radiographic follow-up. CONCLUSIONS Our study illustrates that QCT is a reliable method for the determination of femoral neck BMD in elderly patients with geriatric fractures. Furthermore, lower BMD/T-Scores are associated with increased mortality and fixation failures in this patient population.

Use of a Pin Distractor as an Aid for Fixation of Pronation-External Rotation Fibular Fractures

The transverse tarsal (Chopart) joints are defined as the talonavicular and calcaneocuboid articulations [1]. Dislocations of Chopart joints, although uncommon, have been reported from a variety of high-energy mechanisms, resulting in medial, lateral, plantar, or dorsal displacement [2]. In this article, we describe a case of isolated dorsal fracture dislocations of the talonavicular and calcaneocuboid articulations in a 25-yearold man after a low-energy missed-step mechanism. The mechanism of injury, diagnosis, andmanagement in the emergency department, operative intervention, and follow-up are discussed. Given the high rate of missed and delayed diagnosis of Chopart dislocations, emergency medicine physicians must be aware of this debilitating injury [3,4]. The transverse tarsal (Chopart) joints consist of the talonavicular and calcaneocuboid articulations [1]. The talonavicular joint derives its stability from the spring ligament, which consists of the superior medial calcaneonavicular and inferior calcaneonavicular ligament. The calcaneocuboid joint derives its support plantarly from the superficial and deep inferior calcaneocuboid ligaments and superiorly by the lateral limb of the bifurcate ligament. Reported isolated fracture dislocations of the Chopart joints, although rare, have been attributed to high-energy mechanisms given the inherent stability of these robust periarticular ligaments, and often have associated injuries in the polytrauma patient [5]. We describe the case of a 25-year-old man sustaining an isolated dorsal fracture dislocation of the Chopart joints resulting from a relatively lowenergy mechanism, missing a step while walking down stairs. A 25-year-old man was transferred from an outside hospital to our emergency department at a level 1 trauma center after missing a step while walking down stairs. The patient reported immediate pain in the left foot and an inability to bearweight on the extremity. Orthopedic surgery was consulted and evaluated the patient in the emergency department. No neurovascular deficits, signs of compartment syndrome, or associated injuries were found at the time of evaluation. Initial radiographs of the left foot revealed dorsal dislocations of the talonavicular and calcaneocuboid joints (Fig. 1A-C). The patient subsequently underwent conscious sedation in the emergency department, closed reduction of the traverse tarsal joints (Fig. 2), and application of a wellpadded plaster short-leg splint (Fig. 3). Postreduction radiographs revealed a persistent dorsal subluxation of the talonavicular joint (Fig. 4). A computed tomographic scan of the left footwas then obtained showing a comminuted fracture of the navicular and persistent subluxation of the talonavicular joint (Fig. 5A, B). The patient was admitted to the orthopedic surgery service and underwent open reduction internal fixation of the talonavicular joint. Postoperative radiographs showed a concentrically reduced talonavicular and calcaneocuboid joint with appropriately placed hardware (Fig. 6A–C). The patient returned to the http://dx.doi.org/10.1016/j.ajem.2015.12.054 0735-6757/© 2016 Elsevier Inc. All rights reserved. Please cite this article as: Harris AP, et al, Isolated dorsal dislocations of the low-energy mechanism, Am J Emerg Med (2016), http://dx.doi.org/10.101 orthopedic surgery floor and was discharged home without incident 2 days postoperatively with strict instruction to remain non–weight bearing. At 2-week follow-up, the incision was well healed and sutures were removed. The transverse tarsal (Chopart) joints include the talonavicular and calcaneocuboid joints. Main and Jowett [4] classified a series of 71 transverse tarsal joint injuries according to the direction of the deforming force and the resulting displacement: medial forces, longitudinal forces, lateral forces, plantar forces, and crush injury. In this series, only 2 cases of transverse tarsal joint dislocations were reported: pure plantar transverse tarsal joint dislocation and plantar subtalar dislocation associated with plantar dislocation of the talonavicular joint [4]. Current literature review reveals 2 cases of isolateddorsal transverse tarsal joint dislocations resulting from high-energy mechanisms including falls from height [2,6]. To the best of our knowledge, this is thefirst reported case of isolated dorsal transverse tarsal joint dislocation from a low-energy mechanism. Isolated dislocations of transverse tarsal joints are rare due to strong periarticular ligamentous structural support. The inferior calcaneocuboid ligament, calcaneonavicular (spring) ligament, and bifurcate ligament all confer stability to the transverse tarsal joints and are important to the support of the foot arch. For this reason, dislocations in the dorsal direction are infrequent, requiring disruption of these plantar ligaments [6]. As reported byWilson et al [7], transverse tarsal joint injuries occur in nearly 10% of polytrauma patients as a result of motor vehicle accidents, with 41% of these injuries having a delay in diagnosis. Emergency medicine physicians must have a high suspicion for these injuries when presented with a polytrauma patient for this reason. Initial radiographs of the foot should be obtained if there is suspicion for a foot injury. Further delineation of foot injuries may require a computed tomographic scan to detect small fractures, or possible dislocations that reduced prior to evaluation [8]. Any dislocations should be emergently reduced and immobilized tomitigate the consequences of delayeddiagnosis; avascular necrosis, osteoarthritis, or surgical intervention that may have been avoided (Figs. 2 and 3) [9]. Orthopedic surgery consultation should ensue, as studies have shown open reduction and internal fixation results in improved maintenance of the transverse tarsal joint reduction, especially when these joints are unstable after closed reduction [5,10]. Isolated dorsal transverse tarsal joint dislocations are rare injuries, but have been reported to occur in 10% of polytraumatized patients in motor vehicle accidents [7]. Emergency medicine physicians must be aware of this association with high-energy trauma and in rare cases of isolated dorsal dislocations to avoid a delay in diagnosis treatment. Although often seen in high-energy situations, our case report demonstrates that emergency medicine providers must remain vigilant, as these serious injuries can result from low-energymechanisms. All dislocations should be emergently reduced with covering of any open talonavicular and calcaneocuboid articulations (Chopart joints) from a 6/j.ajem.2015.12.054 Fig. 1. Injury radiographs demonstrating dorsal transverse tarsal joint dislocations on anteroposterior (A), lateral (B), and oblique views (C). Fig. 2. Reduction maneuver for transverse tarsal (Chopart) joints. 1. Place thumb over the navicular bone (C) and (B). 2. With contralateral hand, grab the talus and calcaneus as a unit (C). 3. Apply dorsal to plantar pressure on the navicular while stabilizing the talus. 2 A.P. Harris et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx wounds. Orthopedic surgery consultation should follow for further evaluation and treatment, as irreducible dislocations are an indication for urgent operative intervention; although stable, closed reductions may be managed nonoperatively or operatively on a delayed outpatient basis [10]. Andrew P. Harris MD Joey Johnson MD Gregory R. Waryasz MD Department of Orthopaedics, Alpert Medical School of Brown University, Providence, RI Corresponding author. Department of Orthopaedics, Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 02903 Tel.: + 1 401 444 4030; fax: + 1 401 444 6182 E-mail addresses: andrew_harris@brown.edu, aharri26@gmail.com http://dx.doi.org/10.1016/j.ajem.2015.12.054

Increased Incidence of Vascular Injury In Obese Patients with Knee Dislocations

Restoration of fibular length in pronation and other comminuted ankle fractures is key to good clinical outcomes and is often a challenging aspect of open reduction and internal fixation of the fibula. This article reports the use of a pin distractor to achieve appropriate fibular reduction in otherwise challenging ankle fractures. The authors describe the use of a pin distractor to obtain length and minimize the number of surgical assistants needed for these challenging ankle fractures. The authors find this technique particularly useful with pronation type and subacute ankle fractures. [Orthopedics. 2017; 40(1):e192-e194.].

Referral for Adolescent Idiopathic Scoliosis by Pediatric Primary Care Providers

Objectives: With rising rates of obesity in the United States, the burden of knee dislocations in this population remains unknown. This national epidemiologic study was designed to analyze the association of obesity with closed knee dislocation and vascular complications. Design: Retrospective cohort study. Setting: The deidentified Nationwide Inpatient Sample database was used to access the US inpatient data from 2000 to 2012. Patients/Participants: Patients with noncongenital closed knee dislocations were included. Examined variables included patient age, sex, vascular injury, and obesity status. Main Outcome Measures: Outcome measures included hospital length of stay, amputation, and inpatient hospitalization charge. Results: From 2000 to 2012, a total of 19,087 knee dislocations were identified, including 2265 in overweight/obese patients (11.9%). The annual incidence of knee dislocations reported in patients diagnosed as either obese or morbidly obese increased over the 13-year period (P < 0.0001). The overall average rate of vascular injury requiring intervention was 5.63%, whereas 7.2% of obese patients and 11.3% of morbidly obese patients with knee dislocations (P < 0.0001) sustained a vascular injury requiring intervention. The average length of stay and amputation rate for obese and morbidly obese patients who sustained a knee dislocation was not statistically different from nonobese patients when vascular injury was controlled. When patients with a vascular injury were excluded, obese and morbidly obese patients who sustained a knee dislocation had higher average cost of hospital stay than nonobese patients (P = 0.0262). Conclusions: This study demonstrates significant increases in costs of stay with obese patients sustaining knee dislocations when compared with normal weight knee dislocation patients. Vascular injuries were found to be far more common in obese and morbidly obese patient groups than nonobese patients. Providers should be on high alert when managing knee dislocations in obese patients because a significant number require prompt vascular intervention. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cobalt toxicity after revision to a metal-on-polyethylene total hip arthroplasty for fracture of ceramic acetabular component

This study sought to examine primary care physician opinions regarding referral practices for patients with adolescent idiopathic scoliosis (AIS) and to determine if curve severity at the time of referral is correlated with insurance status. A survey was distributed to pediatric primary care providers to determine referral practices. A chart review of patients referred to a pediatric spine specialist for AIS was performed. A total of 59.3% of respondents stated their referral threshold for AIS patients was <20°. The mean curve size in privately insured patients was 27° (range 6°-68°), whereas the mean curve size in the publicly insured group was 27.6° (range = 6°-58°; P = .9). Large disparities among referral practices exist among pediatric primary care providers, although insurance status did not seem to affect curve size at the time of referral. Encouraging education initiatives for pediatric primary care providers may encourage appropriate referral for AIS.

Unanticipated Admission Following Outpatient Rotator Cuff Repair: An Analysis of 18,061 Cases

Cobalt metallosis after revision metal-on-polyethylene total hip arthroplasty for catastrophic failure of ceramic components is uncommon but a potentially devastating complication. Common findings associated with heavy metal toxicity include cardiomyopathy, hypothyroidism, skin rashes, visual disturbances, hearing changes, polycythemia, weakness, fatigue, cognitive deterioration, and neuropathy. We report a case of a 57-year-old woman who presented with complaints of progressively worsening hip pain, fatigue, memory loss, lower extremity sensory loss, persistent tachycardia, and ocular changes 5 years after synovectomy and revision of a failed ceramic-on-ceramic total hip arthroplasty to metal-on-polyethylene components. A cobalt level of 788.1 ppb and chromium level of 140 ppb were found on presentation and subsequently decreased to 468.8 ppb and 105.9 ppb, respectively, 2 weeks after revision to a ceramic-on-polyethylene total hip arthroplasty. Improvement of symptoms accompanied this decrease in cobalt and chromium levels. Revision of failed ceramic arthroplasties with later-generation ceramics to avoid this potential complication is recommended.

Pubic Rami Fractures

The objective of this investigation was to examine the characteristics that place patients at risk for unanticipated inpatient admission after outpatient arthroscopic rotator cuff repair. This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program data sets from years 2012 to 2015. Patients were included in the study based on the presence of a primary Current Procedural Terminology code for rotator cuff repair (23410, 23412, 23420, and 29827). Only outpatient, nonemergent, and elective procedures performed on patients with American Society of Anesthesiologists classification of 4 or less were considered. The primary outcome variable was admission after outpatient surgery (defined as length of initial hospital stay >0). This study examined risk factors for unanticipated admission following rotator cuff repair, finding that age of 65 years or older, female sex, hypertension, body mass index of 35 kg/m2 or greater, American Society of Anesthesiologists classification of 2 or greater, and open surgical technique were significant predictors of admission, whereas monitored anesthesia care and regional anesthesia were associated with decreased odds of admission. Identifying patients with these characteristics will be critical in risk adjusting the anticipated cost of the episode of care in outpatient rotator cuff repair. [Orthopedics. 2018; 41(3):164-168.].