Paul S. Whiting

Adverse Events in Orthopaedics: Is Trauma More Risky? An Analysis of the NSQIP Data.

Objectives: As our healthcare system moves toward bundling payments, orthopaedic trauma surgeons will be increasingly benchmarked on perioperative complications. We therefore sought to determine financial risks under bundled payments by identifying adverse event rates for (1) orthopaedic trauma patients compared with general orthopaedic patients and (2) based on anatomic region and (3) to identify patient factors associated with complications. Design: Prospective. Setting: Multicenter. Patients/Participants: A total of 146,773 orthopaedic patients (22,361 trauma) from 2005 to 2011 NSQIP data were identified. Interventions: Minor and major adverse events, demographics, surgical variables, and patient comorbidities were collected. Main Outcome Measurements: Multivariate regressions determined significant risk factors for the development of complications. Results: The complication rate in the trauma group was 11.4% (2554/22,361) versus 4.1% (5137/124,412) in the general orthopaedic group (P = 0.001). When controlling for all variables, trauma was a risk factor for developing complications [odds ratio (OR): 1.69, 95% confidence interval (CI): 1.57–1.81]. After controlling for several patient factors, hip and pelvis patients were 4 times more likely to develop any perioperative complication than upper extremity patients (OR: 3.79, 95% CI: 3.01–4.79, P = 0.01). Lower extremity patients are 3 times more likely to develop any complication versus upper extremity patients (OR: 2.82, 95% CI: 2.30–3.46, P = 0.01). Conclusions: Our study is the first to show that orthopaedic trauma patients are 2 times more likely than general orthopaedic patients to sustain complications, despite controlling for identical risk factors. There is also an alarming difference in complication rates among anatomic regions. Orthopaedic trauma surgeons will face increased financial risk with bundled payments. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors for Deep Venous Thrombosis Following Orthopaedic Trauma Surgery: An Analysis of 56,000 patients

Background: Deep venous thrombosis (DVT) and pulmonary embolism (PE) are recognized as major causes of morbidity and mortality in orthopaedic trauma patients. Despite the high incidence of these complications following orthopaedic trauma, there is a paucity of literature investigating the clinical risk factors for DVT in this specific population. As our healthcare system increasingly emphasizes quality measures, it is critical for orthopaedic surgeons to understand the clinical factors that increase the risk of DVT following orthopaedic trauma. Objectives: Utilizing the ACS-NSQIP database, we sought to determine the incidence and identify independent risk factors for DVT following orthopaedic trauma. Patients and Methods: Using current procedural terminology (CPT) codes for orthopaedic trauma procedures, we identified a prospective cohort of patients from the 2006 to 2013 ACS-NSQIP database. Using Wilcoxon-Mann-Whitney and chi-square tests where appropriate, patient demographics, comorbidities, and operative factors were compared between patients who developed a DVT within 30 days of surgery and those who did not. A multivariate logistic regression analysis was conducted to calculate odds ratios (ORs) and identify independent risk factors for DVT. Significance was set at P < 0.05. Results: 56,299 orthopaedic trauma patients were included in the analysis, of which 473 (0.84%) developed a DVT within 30 days. In univariate analysis, twenty-five variables were significantly associated with the development of a DVT, including age (P < 0.0001), BMI (P = 0.037), diabetes (P = 0.01), ASA score (P < 0.0001) and anatomic region injured (P < 0.0001). Multivariate analysis identified several independent risk factors for development of a DVT including use of a ventilator (OR = 43.67, P = 0.039), ascites (OR = 41.61, P = 0.0038), steroid use (OR = 4.00, P < 0.001), and alcohol use (OR = 2.98, P = 0.0370). Compared to patients with upper extremity trauma, those with lower extremity injuries had significantly increased odds of developing a DVT (OR = 7.55, P = 0.006). The trend toward increased odds of DVT among patients with injuries to the hip/pelvis did not reach statistical significance (OR = 4.51, P = 0.22). Smoking was not found to be an independent risk factor for developing a DVT (P = 0.1217). Conclusions: This is the largest study to date using the NSQIP database to identify risk factors for DVT in orthopaedic trauma patients. Although the incidence of DVT was low in our cohort, the presence of certain risk factors significantly increased the odds of developing a DVT following orthopaedic trauma. These findings will enable orthopaedic surgeons to target at-risk patients and implement post-operative care protocols aimed at reducing the morbidity and mortality associated with DVT in orthopaedic trauma patients.

Suprapatellar Intramedullary Nail Technique Lowers Rate of Malalignment of Distal Tibia Fractures.

Objectives: To report on the immediate postoperative alignment of distal tibia fractures (within 5 cm of the tibial plafond) treated with suprapatellar intramedullary nail (IMN) insertion compared with the infrapatellar technique. Primary outcomes include alignment on both the anteroposterior and lateral radiographic views. Design: Retrospective cohort study. Setting: Two urban level I trauma centers. Patients: A total of 266 skeletally mature patients with a distal tibia fracture were treated with an IMN. One hundred thirty-two patients underwent this procedure through a suprapatellar technique. Intervention: Intramedullary nail placement. Main Outcome Measures: Alignment. Results: The 2 treatment groups were evenly matched with respect to age, gender, fracture grade, and the presence of open fracture. Within the suprapatellar group, the fibula was intact, fixed, and remained fractured in 6 (4.5%), 22 (16.7%), and 104 (78.8%) cases, respectively. The fibula was intact, repaired, and remained fractured in 9 (6.7%), 32 (23.9%), and 93 (69.4%) cases, respectively, in the infrapatellar group. There was no difference in the rate of fibular fixation between the groups (P = 0.2). Primary angular malalignment of ≥5 degrees occurred in 35 (26.1%) patients with infrapatellar IMN insertion and in 5 (3.8%) patients who underwent suprapatellar IMN insertion (P < 0.0001). Conclusions: This is the largest patient series directly comparing the suprapatellar with infrapatellar IMN insertion technique in the treatment of distal tibia fractures. In the treatment of distal tibia fractures, suprapatellar IMN technique results in a significantly lower rate of malalignment compared with the infrapatellar IMN technique. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Thromboembolic Disease After Orthopedic Trauma

Orthopedic trauma results in systemic physiologic changes that predispose patients to venous thromboembolism (VTE). In the absence of prophylaxis, VTE incidence may be as high as 60%. Mechanical and pharmacologic thromboprophylaxis are effective in decreasing rates of VTE. Combined mechanical and pharmacologic thromboprophylaxis is more efficacious for decreasing VTE incidence than either regimen independently. If pharmacologic thromboprophylaxis is contraindicated, mechanical prophylaxis should be used. Patients with isolated lower extremity fractures who are ambulatory, or those with isolated upper extremity trauma, do not require pharmacologic prophylaxis in the absence of other VTE risk factors.

Posterior Fixation of APC-2 Pelvic Ring Injuries Decreases Rates of Anterior Plate Failure and Malunion

BACKGROUND Biomechanical studies suggest that augmenting anterior fixation of the pelvic ring with posterior fixation increases stability. Prior clinical studies have assessed radiographic outcomes following plate fixation of the symphysis. However, to our knowledge, none have directly compared the radiographic and clinical outcomes of anterior plate fixation alone with the outcomes of such plate fixation with the addition of posterior percutaneous screw fixation in the treatment of a partially disrupted hemipelvis. We attempted to determine whether use of an anterior symphyseal plate alone is adequate to control sagittal and coronal plane rotation and prevent malunion of an anteroposterior compression type-2 (APC-2) pelvic ring injury. METHODS The records of all skeletally mature patients with a traumatic pelvic disruption treated from 2004 to 2014 with an anterior symphyseal plate with or without a posterior iliosacral screw were retrospectively reviewed. Patients with an APC-2 pelvic ring injury evidenced by computed tomography (CT) were included in the study and divided into 2 groups: (1) fixation of the symphysis with an anterior 3.5-mm 6-hole plate alone and (2) the same anterior fixation supplemented posteriorly with a percutaneous partially threaded 7.0 or 7.3-mm iliosacral screw. Postoperative CT scans were reviewed to assess the reduction of the pelvic ring and the position of all implants. The patients were followed for a minimum of 6 months or until the fixation failed. Examined data included demographic factors, type of and time to fixation failure, and presence of malunion. Univariate and multivariate statistical analyses were completed. RESULTS One hundred and thirty-four patients met the inclusion criteria. Ninety-two (69%) underwent combined anterior and posterior fixation, and 42 (31%) had anterior fixation alone. The average age and duration of follow-up were 38 years and 7.2 months, respectively. Anterior plate fixation failed in 5 patients (5%) in the combined-fixation group and in 17 patients (40%) in the anterior-only group (p < 0.0001). Malunion was identified in 1 patient (1%) in the combined group and in 15 (36%) in the anterior-only cohort (p < 0.0001). CONCLUSIONS Our study indicated that use of an anterior plate and a supplemental posterior screw for fixation of APC-2 pelvic ring injuries significantly decreases the rate of anterior plate failure and malunion compared with use of an anterior plate alone. The potential for selection and detection bias introduced by our study design limited the strength of this conclusion. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Patients at Increased Risk of Major Adverse Events Following Operative Treatment of Distal Radius Fractures: Inpatient versus Outpatient

Purpose The purpose of this study was to compare complication rates following inpatient versus outpatient distal radius fracture ORIF and identify specific complications that occur at increased rates among inpatients. Methods Using the 2005‐2013 ACS‐NSQIP, we collected patient demographics, comorbidities, surgical characteristics, and 30‐day postoperative complications following isolated ORIF of distal radius fractures. A propensity score matched design using an 8‐to‐1 “greedy” matching algorithm in a 1:4 ratio of inpatients to outpatients was utilized. Rates of minor, major, and total complications were compared. A multinomial logistic regression model was then used to assess the odds of complications following inpatient surgery. Results Total 4,016 patients were identified, 776 (19.3%) of whom underwent inpatient surgery and 3,240 (80.3%) underwent outpatient surgery. The propensity score matching algorithm yielded a cohort of 629 inpatients who were matched with 2,516 outpatients (1:4 ratio). After propensity score matching, inpatient treatment was associated with increased rates of major and total complications but not with minor complications. There was an increased odds of major complications and total complications following inpatient surgery compared with outpatient surgery. There was no difference in odds of minor complications between groups. Conclusion Inpatient operative treatment of distal radius fractures is associated with significantly increased rates of major and total complications compared with operative treatment as an outpatient. Odds of a major complication are six times higher and odds of total complications are two and a half times higher following inpatient distal radius ORIF compared with outpatient. Quality improvement measures should be specifically targeted to patients undergoing distal radius fracture ORIF in the inpatient setting.

A Novel Casting Technique for Tongue-Type Calcaneus Fractures With Soft Tissue Compromise:

Displaced calcaneal fractures encompass a spectrum of fracture patterns, many of which are associated with soft tissue complications. Displaced tongue-type calcaneal fractures often cause pressure on the posterior heel skin, particularly when treatment is delayed. Resultant partial- or full-thickness skin necrosis presents significant challenges to the treating surgeon. In this article, the authors report on a case of full-thickness skin necrosis associated with a displaced tongue-type calcaneus fracture. The authors describe the use of a specialized heel window casting technique, which eliminates posterior heel pressure and greatly facilitates soft tissue surveillance and local wound care. The article also reviews the literature on soft tissue complications associated with displaced calcaneus fractures.

Management of Distal Tibial Metaphyseal Fractures With the SIGN Intramedullary Nail in 3 Developing Countries.

Objectives: To evaluate the effectiveness of the Surgical Implant Generation Network (SIGN) intramedullary (IM) nail in distal tibial metaphyseal fractures. Design: Retrospective Case Series. Setting: Three Level I trauma centers in 3 different developing countries from 2009 to 2013. Patient/Participants: One hundred sixty patients with 162 distal tibial metaphyseal fractures (AO/OTA 43-A). Intervention: SIGN IM nailing was performed using hand reaming and without the use of an image intensifier. Main Outcome Measurements: The primary outcome measures were the rate of union and complications. The secondary outcome measures were the effect of open fractures on outcomes, effectiveness and safety of open reduction of closed fractures, and risk factors for the development of malalignment and possible solutions. Results: The average age of patients was 35.3 years. Seventy-nine percent were male. Sixty percent of the fractures were closed. The mean time to surgery was 4.1 days. Fracture union occurred in 97.3% of fractures with an average time to union of 105 days. Open reduction of closed fractures was performed in 51 fractures. Nonunion occurred in 3 patients (1.8%). Acceptable alignment (<5 degrees deformity) was found in 134 fractures (83%). Infection occurred in 14 patients (8.6%). Revision surgery was required in 10 fractures (6.2%). Conclusions: In developing settings, distal metaphyseal tibial fractures can be managed successfully with the SIGN IM nail. There is an increased risk for complications (P = 0.001) and infection (P = 0.0004) in open fractures. Open reduction of closed distal tibia fractures is safe and effective. Malalignment can be improved with fibula stabilization but indications remain unclear. For surgeons interested in international mission work, the SIGN IM nail is an effective tool in managing distal tibial fractures. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Response to “Letter Regarding: A Novel Casting Technique for Tongue-Type Calcaneus Fractures With Soft Tissue Compromise”

Dear Editor: We humbly read the comments from Drs Hsu, Lareau, and Born regarding the similarities between our technique published in “A Novel Casting Technique for Tongue-Type Calcaneus Fractures With Soft Tissue Compromise” and their 2013 publication, “Novel Posterior Splinting Technique to Avoid Heel Ulcers,” in Orthopedics. We sincerely apologize to the authors for our oversight in not properly citing their article, which represents the original description in the literature of this useful technique. This situation highlights 2 important lessons for the orthopaedic community. First, it is a reminder of the obligation that we have to perform a thorough literature review when preparing any manuscript, poster, or abstract for publication. We have a wealth of literature at our fingertips, including resources that are available through emerging open access publication forums. With an increasing number of available resources, there is a corresponding increase in the responsibility of authors to properly cite the contributions of others. Second, this discussion emphasizes the many applications of this particular technique to a variety of challenging clinical conditions. Along with Drs Hsu, Lareau, and Born, we hope that these 2 publications will reach a wide audience and provide orthopaedic surgeons with a useful technique to prevent and treat complex soft tissue problems about the heel.

2017@@@Damage Control Plating in Open Tibial Shaft Fractures: A Cheaper and Equally Effective Alternative to Spanning External Fixation@@@86: 93

Abstract The purpose of this study was to evaluate damage control plating (DCP) as an alternative to external fixation (EF) in the provisional stabilization of open tibial shaft fractures. Through retrospective analysis, the study found 445 patients who underwent operative fixation for tibial shaft fractures from 2008 to 2012. Twenty patients received DCP or EF before intramedullary nailing with a minimum follow-up of 3 months. Charts and radiographs were reviewed for postoperative complications. Hospital charges were reviewed for implant costs. Nine patients (45%) with DCP and 11 patients (55%) with EF were analyzed. There was no significant difference in the complication rates. The mean implant cost of DCP was