Paul E. Matuszewski

Does Morbid Obesity Negatively Affect the Hospital Course of Patients Undergoing Treatment of Closed, Lower-Extremity Diaphyseal Long-Bone Fractures?

Obesity is prevalent in the developed world and is associated with significant costs to the health care system. The effect of morbid obesity in patients operatively treated for long-bone fractures of the lower extremity is largely unknown. The National Trauma Data Bank was accessed to determine if morbidly obese patients (body mass index >40) with lower extremity fractures have longer length of hospital stay, higher cost, greater rehabilitation admission rates, and more complications than nonobese patients. We identified patients with operatively treated diaphyseal femur (6920) and tibia (5190) fractures. Polytrauma patients and patients younger than 16 years were excluded. Morbidly obese patients were identified by ICD-9 and database comorbidity designation (femur, 131 morbidly obese; tibia, 75 morbidly obese). Patients meeting these criteria who were not morbidly obese were used as controls. Sensitivity analyses were performed to analyze patients with isolated trauma to the tibia or femur. Morbidly obese patients were more likely to be admitted to a subacute facility. Length of stay trended higher in morbidly obese patients. There was no significant relationship between obesity and inpatient mortality or inpatient complications. These trends held true when considering patients with multiple injuries and patients who had isolated long-bone injuries. Our study showed that morbidly obese patients may have greater rehabilitation needs following long-bone fractures in the lower extremity. Our study showed no difference in mortality or complications, although further studies are needed to confirm these findings.

Staged bone grafting following placement of an antibiotic spacer block for the management of segmental long bone defects.

Segmental long bone defects resulting from injury or surgical intervention are difficult problems to manage. Amputation, external fixators, vascularized fibular grafts, acute limb shortening, and various quantities of allograft and autograft have historically been the mainstays of treatment. Recently, the use of osteoinductive substances such as recombinant bone morphogenic proteins, and osteoconductive scaffolds such as calcium phosphate have found use in the treatment of these clinical situations. More recently, Masquelet described the use of a cement spacer placed within the osseous void followed by staged bone grafting within the induced biomembrane formed around the spacer as a potential treatment strategy to manage these large defects.This article describes a series of 11 patients for which we used this technique of staged bone grafting following placement of an antibiotic spacer to successfully manage osseous long bone defects ranging from 4 to 15 cm. The limbs were stabilized and aligned at the time of initial spacer placement with a plate and screw construct, intramedullary nail, or fine wire fixator. Osteoinductive substances including bone morphogenic protein-2 and platelet rich concentrate were used in addition to allograft to improve bony healing. In our series, osseous consolidation and full weight bearing was achieved in 10 of 11 patients. Two patients developed heterotopic ossification. There was 1 non-union and 1 infection, which occurred in the same patient. Staged bone grafting within an induced biomembrane created after the use of a cement spacer is a reasonable option in the management of both acute and delayed segmental long bone defects.

Current bacterial speciation and antibiotic resistance in deep infections after operative fixation of fractures.

Objectives: Infection after fracture fixation is a major source of morbidity. Information regarding bacterial speciation and antibiotic resistance is lacking. We attempted to determine the speciation and drug resistance profiles associated with fracture fixation infections. Design: Retrospective study. Setting: Level I trauma center. Patients: Two hundred eleven patients with 214 infections underwent surgery for postoperative infection from December 2006 to December 2010. Deep postoperative infections within 12 months of fixation were included. Intervention: None. Main Outcome Measurements: Incidence of each bacterial species and rate of clinically relevant resistance in Staphylococcus aureus, gram-negative rod (GNR), and Enterococcus species. The effect of timing of infection presentation and location of fracture on bacterial speciation was also investigated. Results: Fifty-six percent of infections had S. aureus present, with 58% of those (32% of all infections) being methicillin-resistant S. aureus. Thirty-two percent of infections had at least one GNR present, with only 4% of those being multidrug resistant. We found a marked increase in the rate of GNR infections of the pelvis, acetabulum, and proximal femur (63%) compared with other locations (27%), which was statistically significant (P = 0.0002). Conclusions: At our center, S. aureus and GNR are most often found in deep postoperative infections after fixation. Methicillin-resistant S. aureus is common in this population. Our GNR rate is high, but resistance in this group was low. The proportion of GNR infections in the pelvis, acetabulum, and proximal femur was high even in closed fractures. These data provide a modern snapshot of orthopaedic infections after fracture fixation and might be useful in designing future studies and protocols for antibiotic prophylactic treatment. We are considering the use of aminoglycosides in the treatment of closed fractures of the pelvis, acetabulum, and proximal femur. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Regional Variation in Human Supraspinatus Tendon Proteoglycans: Decorin, Biglycan, and Aggrecan

While tendons typically undergo primary tensile loading, the human supraspinatus tendon (SST) experiences substantial amounts of tension, compression, and shear in vivo. As a result, the functional roles of the extracellular matrix components, in particular the proteoglycans (PGs), are likely complex and important. The goal of this study was to determine the PG content in specific regions of the SST that exhibit differing mechanical function. The concentration of aggrecan, biglycan, and decorin was determined in six regions of the human SST using immunochemical techniques. We hypothesized that aggrecan concentrations would be highest in areas where the tendon likely experiences compression; biglycan levels would be highest in regions likely subjected to injury and/or active remodeling such as the anterior regions; decorin concentrations would be highest in regions of greatest tensile stiffness. Our results generally supported these hypotheses and demonstrated that aggrecan and biglycan share regional variability, with increased concentration in the anterior and posterior regions and smaller concentration in the medial regions. Decorin, however, was in high concentration throughout all regions. The data presented in this study represent the first regional measurements of PG in the SST. Together with our previous regional measurements of mechanical properties, these data can be used to evaluate SST structure–function relationships. With knowledge of the differences in specific PG content, their spatial variations in the SST, and their relationships to tendon mechanics, we can begin to associate defects in PG content with specific pathology, which may provide guidance for new therapeutic interventions.

Delay in surgical débridement of open tibia fractures: an analysis of national practice trends.

Background: Débridement and irrigation (D&I) of open tibia fractures less than 6 hours from the time of injury has been promoted as orthopaedic dogma despite limited evidence. The goal of this study was to determine the duration between emergency room presentation and D&I in open tibia fractures and to examine factors associated with delay in treatment. Methods: The National Trauma Data Bank Version 3.0 identified 6099 blunt trauma patients with open tibia fractures. Time was calculated from emergency room arrival to first D&I. Risk factors associated with delay in treatment greater than 6 hours and greater than 24 hours were then calculated using univariate and multivariate statistical methods. Results: Median time to D&I was 4.9 hours. Forty-two percent of patients with open tibia fractures experienced a delay in treatment of greater than 6 hours and 24% of patients experienced a delay to treatment of greater than 24 hours. Risk factors associated with greater than 6- and 24-hour delay on univariate and multivariate logistic regression were age, head or thoracic injury with Abbreviated Injury Score greater than 2, and presentation between 6 pm and 2 am. Level I and university hospitals carry a greater risk of delay that was independent of injury severity in multivariate analysis. Conclusions: A significant percentage of patients with open tibia fractures undergo their first surgical intervention of D&I greater than 6 hours after presentation to the emergency room. Patients with delayed D&I have more severe injuries, are treated at university or Level I centers, and present later in the day.

Distributions of types I, II and III collagen by region in the human supraspinatus tendon

Abstract The mechanical properties of the human supraspinatus tendon (SST) are highly heterogeneous and may reflect an important adaptive response to its complex, multiaxial loading environment. However, these functional properties are associated with a location-dependent structure and composition that have not been fully elucidated. Therefore, the objective of this study was to determine the concentrations of types I, II and III collagen in six distinct regions of the SST and compare changes in collagen concentration across regions with local changes in mechanical properties. We hypothesized that type I collagen content would be high throughout the tendon, type II collagen would be restricted to regions of compressive loading and type III collagen content would be high in regions associated with damage. We further hypothesized that regions of high type III collagen content would correspond to regions with low tensile modulus and a low degree of collagen alignment. Although type III collagen content was not significantly higher in regions that are frequently damaged, all other hypotheses were supported by our results. In particular, type II collagen content was highest near the insertion while type III collagen was inversely correlated with tendon modulus and collagen alignment. The measured increase in type II collagen under the coracoacromial arch provides evidence of adaptation to compressive loading in the SST. Moreover, the structure-function relationship between type III collagen content and tendon mechanics established in this study demonstrates a mechanism for altered mechanical properties in pathological tendons and provides a guideline for identifying therapeutic targets and pathology-specific biomarkers.

The Role of Elevated Lactate as a Risk Factor for Pulmonary Morbidity After Early Fixation of Femoral Shaft Fractures.

Objectives: To evaluate lactate levels before reamed intramedullary nailing (IMN) of femur fractures treated with early fixation. Design: Retrospective study. Setting: Three academic, tertiary care trauma centers. Patients: Age >=18 years, injury severity score >=17, admission lactate >= 2.5 mmol/L, elevated preoperative lactate = preoperative lactate >= 2.5 mmol/L. Intervention: Reamed IMN of femur fracture within 24 hours. Main Outcome Measure: Total duration of mechanical ventilation, pulmonary complications (PC) = duration of mechanical ventilation >=5 days. Results: Four hundred and fourteen patients identified; 294/414 (71.0%) with admission lactate >= 2.5 mmol/L. No difference in PC among the groups (86/294, 29.3% vs. 28/120, 23.3%; P = 0.22). Median admission lactate: 3.7 (interquartile range: 3.0–4.6); median preoperative lactate: 2.8 (interquartile range: 1.9–3.5). 184/294 (62.6%) demonstrated an elevated preoperative lactate (>= 2.5 mmol/L) before fracture fixation. No difference in elevated preoperative lactate and vent days (4.8 ± 9.9 vs. 3.9 ± 6.0, P = 0.41) or PC (50/86, 58.1% vs. 134/208, 64.4%; P = 0.31). There was no difference in PC when preoperative lactate was considered separately for a lactate >=3.0 (34/123, 27.6% vs. 52/171, 30.4%; P = 0.61), >=3.5 (21/79, 26.6% vs. 65/215, 30.2%; P = 0.54), or >=4.0 (14/50, 28.0% vs. 72/244, 29.5%; P = 0.83). Multivariable linear regression modeling demonstrated that admission lactate [coefficient of variation: 0.84, standard error: 0.33, 95% confidence interval (CI): 0.20–1.49] was correlated with duration of mechanical ventilation, after adjusting for emergency department Glasgow Coma Scale, age, chest Abbreviated Injury Scale (AIS) score, abdominal AIS, and admission glucose. Logistic regression demonstrated admission lactate was also significantly associated with PC (odds ratio: 1.26, 95% CI: 1.03–1.53) after controlling for age, admission Glasgow Coma Scale, chest AIS, abdominal AIS, admission pulse and admission glucose; preoperative lactate was not a risk factor (odds ratio: 0.84, 95% CI: 0.65–1.09) for PC. Conclusion: Median admission lactate of 3.7 mmol/L was associated with duration of mechanical ventilation >=5 days, whereas median preoperative lactate of 2.8 mmol/L was not, when multisystem trauma patients with a femoral shaft fracture were treated with reamed IMN within 24 hours after admission. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Prospective intraoperative syndesmotic evaluation during ankle fracture fixation: stress external rotation versus lateral fibular stress.

Objectives: We hypothesized that the method of stress external rotation more accurately reproduces the mechanism of injury, and therefore this diagnostic method more likely detects ankle instability than the fibular stress examination. Design: Prospective cohort comparison study. Setting: Level 1 trauma center. Patients: Twenty-eight consecutive patients with unstable ankle fractures presenting within 7 days from the time of injury. Previous ankle surgical history or age younger than 18 years was excluded. Intervention: Stress external rotation and lateral fibular stress examination was performed intraoperatively. Main Outcome Measure: Radiographic measurement of the tibiofibular clear space, tibiofibular overlap, and medial clear space were recorded. Results: After normalization of the fluoroscopic measurements, there was no difference in detecting changes in tibiofibular clear space or tibiofibular overlap. However, there was a significant difference in detecting medial clear space widening with stress external rotation. Compared with lateral fibular stress, stress external rotation demonstrated a 35% increase (P < 0.05) in medial clear space widening. This difference correlates with the 1–2-mm difference of additional widening with stress external rotation. Conclusions: Untreated instability impacts patient outcomes. The difference in widening with stress external rotation was significantly greater than lateral fibular stress and appreciable on standard fluoroscopic views. Stress external rotation radiographs are a more reliable indicator of mortise instability than traditional lateral fibular stress. Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Acute Operative Management of Humeral Shaft Fractures: Analysis of the National Trauma Data Bank

Advances in surgical techniques have increased the role of early surgical intervention for isolated diaphyseal humerus fractures. The goal of this study was to investigate the following: (1) the current trend of operative treatment; (2) factors that affect surgical treatment; and (3) the effect of surgical fixation on length of stay, complication rates, and hospital disposition. The National Trauma Data Bank from 2004 to 2006 was analyzed. All patients with multiple injuries that included closed humeral shaft fractures and all patients with isolated humeral shaft fractures were included. Of 2312 total closed humeral shaft fractures, 1662 had a documented procedure code. A total of 47% of patients underwent surgical treatment. Surgically treated patients were on average 3.5 years older than those treated nonoperatively (P=.007). A total of 49% of white patients underwent early surgery vs 39% of nonwhite patients (P<.001). The operative group had a mean Injury Severity Score of 8.33 vs 9.0 in the nonoperative group (P=.04). Treatment at a Level I trauma center decreased the likelihood of surgery compared with treatment at a non-Level I trauma center (45% vs 57%, P<.001). Mean length of stay was 4.6 days for operative treatment vs 3.9 days for nonoperative treatment (P=.02). Of patients who underwent surgery, 78% were discharged to home compared with 69% of those managed nonoperatively (P<.001). Acute operative management of humeral shaft fractures correlated with a lower Injury Severity Score, a decreased length of stay, and less rehabilitation placement. Furthermore, older patients, white patients, and patients treated at a non-Level I trauma center were more likely to undergo acute surgical management. The reasons for these disparities are unclear and warrant further investigation.

Fracture consolidation in a tibial nonunion after revascularization: a case report.

Poor vascularity can be a potential contributor in the development of fracture nonunion. There is little evidence in orthopaedic literature suggesting that poor vascularity alone may lead to the development of nonunion. Experimental models addressing the effects of ischemia on fracture healing have yielded conflicting views. The case presented here describes a patient who sustained a Type IIIC tibial shaft fracture requiring vascular repair and soft tissue coverage. The patient developed an aseptic, atrophic nonunion. In preparation for operative management of her nonunion, the patient underwent angioplasty in the lower extremity for stenotic vessels. Shortly thereafter, the patients nonunion went on to unite with no additional intervention, suggesting that revascularization alone resulted in this dramatic progress to union. Further prospective clinical studies may reveal a role for the use of vascular evaluation and intervention in the diagnosis and treatment of nonunion.