Keith Baldwin

Does timing to operative debridement affect infectious complications in open long-bone fractures? A systematic review

BACKGROUND Existing guidelines recommend emergency surgical debridement of open fractures within six hours after injury. The aim of this study was to systematically review the association between time to operative debridement of open fractures and infection. METHODS Searches of the MEDLINE, EMBASE, and Cochrane computerized literature databases and manual searches of bibliographies were performed. Randomized controlled trials and cohort studies (retrospective and prospective) evaluating the association between time to operative debridement and infection after open fractures were included. Descriptive and quantitative data were extracted. A meta-analysis of patient cohorts who underwent early or delayed debridement was performed with use of a random effects model. RESULTS The initial search identified 885 references. Of the 173 articles inspected further on the basis of the title, sixteen (six prospective and ten retrospective cohort studies with a total of 3539 open fractures) were included. No significant difference in the infection rate was detected between open fractures debrided early or late according to any of the time thresholds used in the included studies. Sensitivity analyses demonstrated no difference in infection rate between early and late debridement in subgroups defined according to the Gustilo-Anderson classification, level of evidence, depth of infection, or anatomic location. CONCLUSIONS The data did not indicate an association between delayed debridement and higher infection rates when all infections were considered, when only deep infections were considered, or when only more severe open fracture injuries were considered. On the basis of this analysis, the historical “six-hour rule” has little support in the available literature. It is important to realize that additional carefully conducted studies are needed and that elective delay of treatment of patients with open fractures is not recommended

Results and Performance After Microfracture in National Basketball Association Athletes

Background Microfracture technique is commonly used to treat symptomatic chondral lesions of the knee. Performance outcomes and attrition rates associated with this injury/surgery in National Basketball Association athletes are unclear. Hypothesis National Basketball Association players undergoing microfracture for symptomatic chondral lesions of the knee will have demonstrable differences in performance compared with preinjury and with matched controls. Study Design Case control study; Level of evidence, 3. Methods We evaluated 24 National Basketball Association players who underwent microfracture between 1997 and 2006. Descriptive data and performance data for the first full season preceding and following the index surgery were collected. Data were obtained from 48 matched controls. Univariate/multivariate statistical methods were used to assess change in performance and return to play. Results Thirty-three percent (8 of 24) of National Basketball Association athletes who underwent microfracture surgery never returned to play in the National Basketball Association. Fourteen players returned to play in the National Basketball Association for >1 season. Within-group comparisons revealed that points scored (P = .008) and minutes played (P = .045) were reduced postoperatively. No performance variables were significantly different when averaged over 40 minutes of play. When compared with controls, cases experienced a significant decline in points per game (P = .013). Multiple regression analysis revealed that cases were 8.15 times less likely to remain in the National Basketball Association than controls (P = .005) after the index year. Conclusion Players undergoing microfracture for knee chondral injuries are at risk for not returning to the National Basketball Association postoperatively. With the exception of points per game, athletes returning exhibited similar performance postoperatively compared with matched controls.

Use of Medical Comorbidities to Predict Complications After Hip Fracture Surgery in the Elderly

BACKGROUND Comorbidities before and complications following hip fracture surgery can impact the return of function. We hypothesized that the American Society of Anesthesiologists (ASA) classification of medical comorbidities is a useful surrogate variable for the patients general medical condition and would be a strong predictor of perioperative medical complications following hip fracture surgery. METHODS A retrospective review of the cases of 197 elderly patients who had undergone operative management of a hip fracture was performed. The ASA class, data regarding perioperative medical and surgical complications, and demographic data were obtained. Medical complications were defined as those requiring intervention by an internist or medical specialist. Differences in complication rates among the ASA classes were determined. RESULTS Medical complications were more common in patients in ASA class 3 (p < 0.001) and those in class 4 (p = 0.001) than in those in class 2. Patients in ASA class 3 had a 3.78 times greater chance of having a medical complication than did those in class 2 (p < 0.001). Patients in ASA class 4 had a 7.39 times greater chance of having medical complications than did those in class 2 (p = 0.001). No significant relationship was identified between the ASA class and surgical complications. CONCLUSIONS The ASA class is strongly associated with medical problems in the perioperative period following hip fracture surgery in the elderly. Patients identified as being at higher risk (in ASA class 3 or 4) preoperatively should be closely managed medically so that perioperative medical complications can be managed and evolving medical issues can be addressed in a timely fashion.

Anterior Cruciate Ligament Tears in Children and Adolescents A Meta-analysis of Nonoperative Versus Operative Treatment

Background: Debate regarding the optimal initial treatment for anterior cruciate ligament (ACL) injuries in children and adolescents has not resulted in a clear consensus for initial nonoperative treatment or operative reconstruction. Hypothesis/Purpose: The purpose of this meta-analysis was to systematically analyze aggregated data from the literature to determine if a benefit exists for either nonoperative or early operative treatment for ACL injuries in the pediatric patient. The hypothesis was that combined results would favor early operative reconstruction with respect to posttreatment episodes of instability/pathological laxity, symptomatic meniscal tears, clinical outcome scores, and return to activity. Study Design: Meta-analysis. Methods: A literature selection process included the extraction of data on the following clinical variables: symptomatic meniscal tears, return to activities, clinical outcome scores, return to the operating room, and posttreatment instability/pathological laxity. A symptomatic meniscal tear was defined as occurring after the initial presentation, limiting activity, and requiring further treatment. Instability/pathological laxity was defined for the sake of this study as having an episode of giving way, a grade ≥2 Lachman/pivot-shift test result, or a side-to-side difference of >4 mm as measured by the KT-1000 arthrometer. All studies were evaluated using a formal study quality analysis. Meta-analysis was conducted for aggregated data in each category. Results: Six studies (217 patients) comparing operative to nonoperative treatment and 5 studies (353 patients) comparing early to delayed reconstruction were identified. Three studies reported posttreatment instability/pathological laxity; 13.6% of patients after operative treatment experienced instability/pathological laxity compared with 75% of patients after nonoperative treatment (P < .01). Two studies reported symptomatic meniscal tears; patients were over 12 times more likely to have a medial meniscal tear after nonoperative treatment than after operative treatment (35.4% vs 3.9%, respectively; P = .02). A significant difference in scores between groups was noted in 1 of 2 studies reporting International Knee Documentation Committee (IKDC) scores (P = .002) and in 1 of 2 studies reporting Tegner scores (P = .007). Two studies reported return to activity; none of the patients in the nonoperative groups returned to their previous level of play compared with 85.7% of patients in the operative groups (P < .01). Study quality analysis revealed that the majority of the studies were inconsistent in reporting outcomes. Conclusion: Meta-analysis revealed multiple trends that favor early surgical stabilization over nonoperative or delayed treatment. Patients after nonoperative and delayed treatment experienced more instability/pathological laxity and inability to return to previous activity levels than did patients treated with early surgical stabilization.

Child abuse and orthopaedic injury patterns: analysis at a level I pediatric trauma center.

Background Child abuse is a serious threat to the physical and psychosocial well-being of the pediatric population. Musculoskeletal injuries are common manifestations of child abuse. There have been multiple studies that have attempted to identify the factors associated with, and the specific injury patterns seen with musculoskeletal trauma from child abuse, yet there have been no large studies that have used prospectively collected data and controlled comparisons. The purpose of our study was to describe the patterns of orthopaedic injury for child abuse cases detected in the large urban area that our institution serves, and to compare the injury profiles of these victims of child abuse to that of general (accidental) trauma patients seen in the emergency room and/or hospitalized during the same time period. Methods This study is a retrospective review of prospectively collected information from an urban level I pediatric trauma center. Five hundred cases of child abuse (age birth to 48 mo) were identified by membership in our institutions Suspected Child Abuse and Neglect database collected between 1998 and 2007. These cases were compared against 985 general trauma (accidental) control patients of the same age group from 2000 to 2003. Age, sex, and injury type were compared. Results Victims of child abuse were on average younger than accidental trauma patients in the cohort of patients under 48 months of age. There was no difference in sex distribution between child abuse and accidental trauma patients. When the entire cohort of patients under 48 months were examined after adjusting for age and sex, the odds of rib (14.4 times), tibia/fibula (6.3 times), radius/ulna (5.8 times), and clavicle fractures (4.4 times) were significantly higher in child abuse versus accidental trauma patients. When regrouping the data based on age, in patients younger than 18 months of age, the odds of rib (23.7 times), tibia/fibula (12.8 times), humerus (2.3 times), and femur fractures (1.8 times) were found to be significantly higher in the child abuse group. Yet, in the more than 18 months age group, the risk of humerus (3.4 times) and femur fractures (3.3 times) was actually higher in the accidental trauma group than in the child abuse group. Conclusions Patients who present to an urban level I pediatric trauma center and are victims of abuse are generally younger, and have an equal propensity to be male or female. It is important for the clinician to recognize that the age of the patient (younger or older than 18 mo and/or walking age) is an important determinant in identifying injury patterns suspicious for abuse. Patients below the age of 18 months who present with rib, tibia/fibula, humerus, or femur fractures are more likely to be victims of abuse than accidental trauma patients. Yet, when patients advance in age beyond 18 months, their presentation with long bone fractures (ie, femur and humerus) is more likely to be related to accidental trauma than child abuse. Level of Evidence level III, prognostic study.

Comparison of hemiarthroplasty and reverse arthroplasty for treatment of proximal humeral fractures: a systematic review.

BACKGROUND Complex proximal humeral fractures that are not amenable to surgical fixation represent a difficult treatment problem. The purpose of this systematic review was to critically examine the outcomes of reverse shoulder arthroplasty and hemiarthroplasty (with use of a fracture-specific stem) for the treatment of proximal humeral fractures. METHODS A systematic review of the literature was performed by means of a search of electronic databases. Two reviewers independently assessed the methodological quality and extracted relevant data from each included study. When outcomes data were similar among studies, the data were pooled by means of frequency-weighted values to generate summary outcomes. RESULTS Fourteen studies fulfilled all inclusion and exclusion criteria and were included. Patients were followed for a frequency-weighted mean of 43.5 months in the reverse arthroplasty group and 31.1 months in the hemiarthroplasty group (p = 0.228). Subjective outcomes (including the Constant score, Constant pain subscore, and American Shoulder and Elbow Surgeons [ASES] score) and range-of-motion parameters (including active forward elevation, abduction, and external rotation) were similar between the two groups. Compared with hemiarthroplasty, reverse arthroplasty was associated with 4.0 times greater odds of a postoperative complication. CONCLUSIONS The compiled data and frequency-weighted means demonstrated improvement in function, pain, and range of motion after reverse arthroplasty and hemiarthroplasty. Patients and physicians should consider projected functional outcomes, implant costs, and complication rates when selecting an appropriate arthroplasty technique for this indication.

Hip Arthroscopy for Labral Tears: Review of Clinical Outcomes With 4.8-Year Mean Follow-Up

Background Arthroscopy of the hip joint is a relatively new diagnostic and therapeutic option for labral tears. Purpose More data are needed to characterize the utility and effectiveness of hip arthroscopy and identify patient-related factors that might predict functional outcome. Study Design Case series; Level of evidence, 4. Methods This retrospective study with prospective follow-up examined the clinical outcomes of 52 consecutive patients undergoing hip arthroscopy for labral tears. Outcomes measures included clinical outcome and the modified Harris hip score. Any complications associated with the procedure were recorded. Exclusion criteria included age younger than 18 years or prior ipsilateral hip surgery. Results Mean patient age was 42 years. Mean follow-up was 4.8 years. Twenty-one patients (40.4%) had a traumatic cause of the labral tears. Eight patients (15.4%) had possible secondary gain issues. Four (7.7%) patients suffered transient nerve palsies; in 1 case, the guide wire broke during initial cannulation. Three patients (5.8%) went on to total hip arthroplasty after hip arthroscopy. On multivariate analysis, left-sided surgery, a higher preoperative activity level, and duration of symptoms greater than 18 months were found to be positive predictors of good or excellent outcomes. Smoking and secondary gain issues were significant negative predictors of good or excellent outcomes. Only prior level of activity was a significant positive predictor of return to activity after surgery. A traumatic cause of the labral tear was a significant negative predictor of return to activity. Chondromalacia and osteoarthritis were not significant predictors of negative outcome. Postoperative modified Harris hip score improved 40% from 56.8 preoperatively to 80.4 (P < .001). No cases of patients with secondary gain issues achieved good or excellent outcomes. Overall percentage of good or excellent outcomes was 56%, or 66% when those with secondary gain issues were excluded; 84% of patients were able to return to sports or equivalent level of preoperative recreational activity. Neither preoperative radiographic osteoarthritis nor grade of intraoperative chondromalacia predicted postoperative outcome. Conclusion This series supports the hypothesis that hip arthroscopy provides safe and reliable improvement of labral symptoms in the majority of patients.

Adjunctive vancomycin powder in pediatric spine surgery is safe.

Study Design. Therapeutic level II cohort study. Objective. To evaluate the safety of adjunctive local application of vancomycin powder (VP) for infection prophylaxis in posterior instrumented thoracic and lumbar spine wounds in pediatric patients weighing more than 25 kg. Summary of Background Data. Spine surgeons have largely turned to vancomycin prophylaxis in an attempt to decrease the incidence of late surgical site infection and acute surgical site infection from methicillin-resistant Staphylococcus aureus. In adult patients, the adjunctive local application of VP with an intravenous cephalosporin has been shown to decrease postsurgical wound infection rates significantly; however, the safety of VP as an adjunct in pediatric spine surgery has not been reported. Methods. We reviewed data collected under a systematic protocol specifically designed to monitor the safety profile of VP. We measured changes in creatinine and systemic vancomycin levels after intrawound application of 500 mg of unreconstituted VP during spine deformity correction surgery in patients weighing more than 25 kg (patients also received routine intravenous cephalosporin prophylaxis). Laboratory values were measured preoperatively and on postoperative days 1 and 4. Any adverse reactions and infections through available follow-up (2–8 mo) were recorded. Results. Eighty-seven consecutive pediatric patients with spinal deformity weighing more than 25 kg who received intraoperative VP during a 9-month period were identified. Sixty-three percent of the patients in this series had adolescent idiopathic scoliosis, 15% congenital scoliosis, 15% neuromuscular scoliosis, and 5% spondylolisthesis. The average change in creatinine levels between the preoperative and postoperative day 1 draw was −0.03 and between the preoperative and postoperative day 4 draw was −0.075. The postoperative systemic vancomycin levels remained undetectable. None of the patients experienced nephrotoxicity or red man syndrome. Three of the 87 patients developed a surgical site infection. Conclusion. In this cohort there were no clinically significant changes in creatinine level or systemic vancomycin level caused by use of intraoperative VP. Level of Evidence: 2

Scapula fractures: a marker for concomitant injury? A retrospective review of data in the National Trauma Database.

BACKGROUND Many series have found that certain associated injuries occur with greater frequency in patients with scapula fractures than in patients without scapula fractures. However, several of the published series were limited by lack of a control group, inclusion of a patient population limited to the catchment area of one hospital, or inadequate control for injury severity. The goal of this study was to determine whether there was a relationship between scapula fractures and concomitant injury and which injuries related simply to the increased injury severity observed in this patient population. METHODS This series was a retrospective case control database analysis. Patients were identified through the National Trauma Database from 1994 to 2002 from trauma centers across the United States. Diagnosis code (ICD-9) 811.0 was used to identify 9,453 scapular fractures, whereas the 2,728 patients in the control group were selected by random number generation. After data extraction to a database, each patient was examined for concomitant diagnoses. The binomial distribution was used to compare cases and controls, as well as different diagnostic groups before adjusting for injury severity. The Bonferroni correction was applied to correct for the multiple null hypotheses. After univariate analysis, the data were analyzed with logistic regression using injury severity score as a covariate. RESULTS After statistical adjustment for multiple tests, there was not a statistically significant difference in injury rates for patients with different types of scapula fractures. However, there were many injuries that showed increased frequency in patients with scapula fractures compared with patients without this injury. Interestingly, when injury severity was statistically adjusted for, many of these differences disappeared. CONCLUSIONS After adjustment for injury severity, upper extremity, thoracic, and pelvic ring injuries were associated with greater frequency in patients with scapular fracture. The majority of other injuries found to occur frequently in the unadjusted patient population were likely because the injury severity is higher in patients with scapula fractures. LEVEL OF EVIDENCE III.

Current Data Do Not Support Routine Use of Patient-Specific Instrumentation in Total Knee Arthroplasty

The purpose of this systematic review and meta-analysis is to compare patient-specific instrumentation (PSI) versus standard instrumentation for total knee arthroplasty (TKA) with regard to coronal and sagittal alignment, operative time, intraoperative blood loss, and cost. A systematic query in search of relevant studies was performed, and the data published in these studies were extracted and aggregated. In regard to coronal alignment, PSI demonstrated improved accuracy in femorotibial angle (FTA) (P=0.0003), while standard instrumentation demonstrated improved accuracy in hip-knee-ankle angle (HKA) (P=0.02). Importantly, there were no differences between treatment groups in the percentages of FTA or HKA outliers (>3 degrees from target alignment) (P=0.7). Sagittal alignment, operative time, intraoperative blood loss, and cost were also similar between groups (P>0.1 for all comparisons).