Laura S. Phieffer

Delayed unions of the tibia.

Delayed union of the tibia represents a diverse group of clinical problems that can at times be challenging for even the most experienced surgeon to treat. Early recognition and treatment can help patients avoid prolonged periods of pain and disability. Many factors have been associated with delayed union or nonunion; most of these factors are dictated by the injury and patient factors but others are within the surgeons control. Although high rates of union are obtained in many series of tibial fractures using simple treatment methods, nonunion is seen by all practitioners treating tibial fractures. Early intervention to prevent nonunion seems to be in the best interest of patients and surgeons. Treatment must take into account the biologic and mechanical factors contributing to delay in fracture union.

The impact of antiplatelet therapy on pelvic fracture outcomes

Introduction: Despite increasing use of antiplatelet agents (APA), little is known regarding the effect of these agents on the orthopedic trauma patient. This study reviews clinical outcomes of patients with pelvic fractures (Pfx) who were using pre-injury APA. Specifically, we focused on the influence of APA on postinjury bleeding, transfusions, and outcomes after Pfx. Methods: Patients with Pfx admitted during a 37-month period beginning January 2006 were divided into APA and non-APA groups. Pelvic injuries were graded using pelvic fracture severity score (PFSS)–a combination of Young–Burgess (pelvic ring), Letournel–Judet (acetabular), and Denis (sacral fracture) classifications. Other clinical data included demographics, co-morbid conditions, medications, injury severity score (ISS), associated injuries, morbidity/mortality, hemoglobin trends, blood product use, imaging studies, procedures, and resource utilization. Multivariate analyses for predictors of early/late transfusions, pelvic surgery, and mortality were performed. Results: A total of 109 patients >45 years with Pfx were identified, with 37 using preinjury APA (29 on aspirin [ASA], 8 on clopidogrel, 5 on high-dose/scheduled non-steroidal anti-inflammatory agents [NSAID], and 8 using >1 APAs). Patients in the APA groups were older than patients in the non-APA group (70 vs. 63 years, P < 0.01). The two groups were similar in gender distribution, PFSS and ISS. Patients in the APA group had more comorbidities, lower hemoglobin levels at 24 h, and received more packed red blood cell (PRBC) transfusions during the first 24 h of hospitalization (all, P < 0.05). There were no differences in platelet or late (>24 h) PRBC transfusions, blood loss/transfusions during pelvic surgery, lengths of stay, post-ED/discharge disposition, or mortality. In multivariate analysis, predictors of early PRBC transfusion included higher ISS/PFSS, pre-injury ASA use, and lower admission hemoglobin (all, P < 0.03). Predictors of late PRBC transfusion included the number of complications, gender, PFSS, and any APA use (all, P < 0.05). Mortality was associated with pelvic hematoma/contrast extravasation on imaging, number of complications, and higher PFSS/ISS (all, P < 0.04). Conclusions: Results of this study support the contention that preinjury use of APA does not independently affect morbidity or mortality in trauma patients with Pfx. Despite no clinically significant difference in early postinjury blood loss, pre-injury use of APA was associated with increased likelihood of receiving PRBC transfusion within 24 h of admission. Furthermore, multivariate analyses demonstrated that among different APA, only preinjury ASA (vs. clopidogrel or NSAID) was associated with early PRBC transfusions. Late transfusion was associated with the use of any APA, complications, higher PFSS, and need for pelvic surgery.

Early versus late reduction of a physeal fracture in an animal model.

This study was designed to determine whether delayed reduction of physeal fractures in an animal model causes growth disturbance, and whether final alignment is better in delayed or malreduced fractures. Salter 1 fractures of the proximal tibia were created in 41 immature rats randomized into five groups. The fractures were reduced as follows: group 1, immediately; group 2, 6 hours; group 3, 24 hours; group 4, 48 hours; and group 5, left malreduced. Both legs were analyzed for leg-length discrepancy, angular deformity, and evidence of radiographic bar. No radiographic physeal bar or leg-length discrepancy was seen among any of the groups. Angular deformity was greatest in group 5 and least in group 1. Immediate reduction resulted in the least angular deformity. Delayed reduction showed no evidence of physeal damage, physeal growth disturbance, or radiographic bar formation. Alignment was not improved in delayed reduction versus malreduced fractures.

Does Syndesmotic Injury Have a Negative Effect on Functional Outcome? A Multicenter Prospective Evaluation.

Objective: To evaluate the effect of syndesmotic disruption on the functional outcomes of Weber B, SE4 ankle fractures treated operatively. Setting: Multicenter trauma hospitals. Patients: Data were prospectively gathered during a previous, multicenter randomized trial including 242 patients (136 women, 106 men) from 9 trauma centers with operatively treated Weber B SE4 ankle fractures. There were 81 patients (35%) with syndesmotic instability confirmed intraoperatively after fibula fixation. Intervention: Functional evaluations were performed postoperatively at 6, 12, 26, and 52 weeks. The presence of symptomatic hardware and peroneal tendon discomfort was evaluated with 9–12 months of follow-up. Main Outcome Measures: Functional outcomes evaluated included Short Musculoskeletal Function Assessment (SMFA), Bother index, and American Orthopaedic Foot and Ankle Society (AOFAS) scores. The recovery curve of the 2 groups was analyzed using a mixed linear regression analysis for repeated measures and included gender and race in the model. Symptomatic hardware and peroneal tendon discomfort were compared between the 2 groups with a &khgr;2 analysis. Results: The adjusted mean linear regression analyses demonstrated that patients without a syndesmotic injury had better functional outcomes for some outcome measures. SMFA scores at 12 weeks were statistically lower in patients without syndesmotic injury (P = 0.02), but not at other visits. AOFAS scores were significantly higher (P = 0.0006), and Bother index trended toward lower results (P = 0.07) in patients without syndesmotic injury at all time points. Isolated analyses (T-tests) at 1 year demonstrated a difference in the SMFA (P = 0.04) and Bother index (P = 0.05), but not the AOFAS (P = 0.21). Men consistently demonstrated better recovery than women for all outcomes, whereas race was not significant for any measure. Symptomatic hardware and peroneal tendon irritation was not statistically different between the groups. Conclusions: The recovery curves after ankle fractures were different based on syndesmotic injury. However, the difference was at the limit of clinical significance. Syndesmotic injury has a slightly detrimental effect on outcomes of operatively treated Weber B SE4 fractures. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Head Trauma from Falling Increases Subsequent Emergency Department Visits More Than Other Fall-Related Injuries in Older Adults

To determine whether fall‐related injuries affect return to the ED after the initial visit.

Improving Operating Room Efficiency: First Case On-Time Start Project.

Background: Operating rooms (ORs) are costly to run, and multiple factors influence efficiency. The first case on-time start (FCOS) of an OR is viewed as a harbinger of efficiency for the daily schedule. Across 26 ORs of a large, academic medical center, only 49% of cases started on time in October 2011. Methods: The Perioperative Services Department engaged an interdisciplinary Operating Room Committee to apply Six Sigma tools to this problem. The steps of this project included (1) problem mapping, (2) process improvements to preoperative readiness, (3) informatics support improvements, and (4) continuous measurement and feedback. Results: By June 2013, there was a peak of 92% first case on-time starts across service lines, decreasing to 78% through 2014, still significantly above the preintervention level of 49% (p = .000). Delay minutes also significantly decreased through the study period (p = .000). Across 2013, the most common delay owners were the patient, the surgeon, the facility, and the anesthesia department. Conclusions: Continuous and sustained improvement of first case on-time starts is attributed to tracking the FCOS metric, establishing embedded process improvement resources and creating transparency of data. This article highlights success factors and barriers to program success and sustainability.

Fear of Falling Correlates with Subtle Neuromuscular Balance and Strength Deficits of Fragility Fracture Patients

Fragility fractures, or fractures occurring from a low-trauma event, are extremely prevalent among the elderly population worldwide and associated with significant mortality and morbidity. This study evaluated the relationship between FES-I Fear of Falling Survey results, self-reported activity restrictions via the SF-36 survey, and scores recorded by portable, inexpensive clinical assessment tools (CATs) during dynamic functional tasks. Low scores during these tasks may indicate functional deficits that put patients at risk for falls and subsequent fragility fractures. Forty-one subjects (20 fragility fracture patients, 21 controls without history of fragility fractures) over the age of 50 were recruited from three outpatient orthopaedic clinics. All subjects were administered a FES-I Fear of Falling Survey, a portion of an SF-36 survey, and tested using three different portable CATs: the Wii Balance Board, iPod Level Belt and Saehan Squeeze Hand Grip Dynamometer. There were several measured variables that showed a moderate correlation with Fear of Falling scores. Of note, correlations between FES-I scores and maximum hand grip strength for both the dominant hand (R= -0.302, p=0.069) and non-dominant hand (R= -0.309, p=0.059), as well as maximum anterior-posterior sway measured by the iPod Level Belt (R=0.320, p=0.056) were found to be marginally significant. In addition, the correlation between FES-I and average anterior-posterior sway was found to be significant (R=0.416, p=0.012). The Nintendo Wii and iPod Level Belt are relatively inexpensive, portable tools that can assess patients for subtle deficits during dynamic functional tasks. The results indicate that these tools can provide a more objective measure of a patient’s limitations during daily activities such as walking by assigning them a numerical value and correlating this value to physical deficits that impact balance and coordination. In the future, CATs may also have a role in predicting outcomes and in individualizing care, therapy, and at-home preventive measures.

Evaluation of a cleanser for petroleum-contaminated skin

BACKGROUND Extremity injuries contaminated with petroleum products pose clinical dilemmas. This project was designed to evaluate the efficacy of a dioctyl sulfosuccinate (DS) solution for cleansing petroleum-contaminated skin. METHODS One hundred Sprague-Dawley rats were subjected to a contamination protocol followed by a cleansing procedure. Four petroleum contaminants and five cleansing solutions were selected. The protocol consisted of shaving, initial punch biopsy, contamination, precleansing punch biopsy, standardized scrub protocol, and postcleansing punch biopsy. Biopsy samples were analyzed for petroleum residue using fluorometry. RESULTS The 10% DS solution had the highest reduction of crude oil, grease, and tar: 99.6 +/- 0.4% (mean +/- SD) contaminant reduction for crude oil, 99.8 +/- 0.2% for grease, and 99.8 +/- 0.2% for tar. The other cleansers showed less efficacy (p < 0.05). CONCLUSION Concentrated DS appears to be significantly more effective at cleaning petroleum products from skin than the commonly chosen surgical and commercial cleansers.

Targeting intracellular Staphylococcus aureus to lower recurrence of orthopaedic infection

Staphylococcus aureus is often found in orthopaedic infections and may be protected from commonly prescribed antibiotics by forming biofilms or growing intracellularly within osteoblasts. To investigate the effect of non‐antibiotic compounds in conjunction with antibiotics to clear intracellular and biofilm forming S. aureus causing osteomyelitis. SAOS‐2 osteoblast‐like cell lines were infected with S. aureus BB1279. Antibiotics (vancomycin, VAN; and dicloxacillin, DICLOX), bacterial efflux pump inhibitors (piperine, PIP; carbonyl cyanide m‐chlorophenyl hydrazone, CCCP), and bone morphogenetic protein (BMP‐2) were evaluated individually and in combination to kill intracellular bacteria. We present direct evidence that after gentamicin killed extracellular planktonic bacteria and antibiotics had been stopped, seeding from the infected osteoblasts grew as biofilms. VAN was ineffective in treating the intracellular bacteria even at 10× MIC; however in presence of PIP or CCCP the intracellular S. aureus was significantly reduced. Bacterial efflux pump inhibitors (PIP and CCCP) were effective in enhancing permeability of antibiotics within the osteoblasts and facilitated killing of intracellular S. aureus. Confocal laser scanning microscopy (CLSM) showed increased uptake of propidium iodide within osteoblasts in presence of PIP and CCCP. BMP‐2 had no effect on growth of S. aureus either alone or in combination with antibiotics. Combined application of antibiotics and natural agents could help in the treatment of osteoblast infected intracellular bacteria and biofilms associated with osteomyelitis.

Patellar tendon reconstruction with semitendinosus-gracilis autograft.

We present a case of a 24-year-old, otherwise healthy, man who sustained a right knee injury after a fall. A small, comminuted inferior pole patella fracture with medial and lateral retinacular tears was encountered that required a small, nonarticular partial patellectomy and patellar tendon repair. An uneventful postoperative course was complicated by a fall onto a flexed knee and rerupture of the patellar tendon at 3 months following surgery. Intraoperatively, a significant tissue void was seen in the area of the prior repair. The patellar tendon was reconstructed with semitendinosus and gracilis autograft. At 1 year follow-up, the patient had regained a normal gait, had no pain, and had full range-of-motion without extensor lag.