Journal of Orthopaedic Trauma

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Impact of Skin Suture Pattern on Incision Perfusion Using Intraoperative Laser Angiography: A Randomized Clinical Trial of Patients With Ankle Fractures

imageObjectives:
To assess which skin suture pattern—simple, vertical mattress, horizontal mattress, Allgöwer–Donati (AD), or running subcuticular—enables the greatest degree of perfusion as measured by indocyanine green laser angiography after ankle fracture surgery.
Design:
Prospective, randomized.
Setting:
Level 1 Academic Trauma Center.
Patients/Participants:
Seventy-five patients undergoing ankle fracture surgery were prospectively randomized to 1 of 5 skin suture patterns (n = 15 per cohort). Patient demographics and operative parameters were similar between groups.
Main Outcome Measurements:
Skin perfusion was assessed intraoperatively after skin closure using indocyanine green laser angiography and quantified in fluorescence units. Two perfusion values were collected: (1) mean incision perfusion was the mean of 10 points along the incision and (2) mean perfusion impairment was the perfusion difference between the incision and the skin adjacent to it. We also collected a postoperative patient scar assessment score.
Results:
Running subcuticular closure had significantly better mean incision perfusion than all other closure patterns. Mean perfusion impairment also favored running subcuticular closure, which was significantly lower than all other suture patterns except AD. We found no patient perceived cosmetic differences between the 5 suture pattern types.
Conclusions:
Running subcuticular suture pattern resulted in the greatest incision perfusion than simple, horizontal mattress, vertical mattress, and AD techniques after ankle fracture fixation.
Level of Evidence:
Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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https://journals.lww.com/jorthotrauma/Fulltext/2020/10000/Impact_of_Skin_Suture_Pattern_on_Incision.8.aspx

Effect of Wound Closure Technique in Proximal Femoral Fractures: A Prospective Cohort Study

imageObjectives:
To compare the effect of different wound closure techniques on wound drainage, postoperative length of stay, and complications in patients with proximal femoral fractures, including femoral neck fractures (31A fractures) and peritrochanteric fractures (31B fractures).
Design:
Prospective cohort study.
Setting:
Footscray Hospital, Western Health, Victoria, Australia; an acute teaching hospital.
Patients and Participants:
All inpatients receiving surgery for proximal femoral fractures at our facility between May 2016 and August 2017. A total of 486 consecutive patients who presented during the study period were included in the study.
Intervention:
Three cohorts of consecutive patients were assigned to use either skin staples, monofilament absorbable subcuticular sutures (Monocryl), or, sutures with the addition of 2-octylcyanoacrylate (OCA) (Monocryl and Dermabond), respectively, for skin closure according to when the patients entered the study.
Main Outcome Measurements:
The primary outcome of interest was prolonged wound drainage measured using a standardized technique after postoperative day 3. Secondary outcomes included inpatient length of stay and overall complications.
Results:
We found a statistically significant increase in prolonged wound drainage in the staples cohort compared with the subcuticular sutures cohort and the sutures and OCA cohort (21.1% vs. 8.5% vs. 4.4%, P < 0.001). Inpatient length of stay was also significantly increased in the staples cohort (5.83 days vs. 4.78 days vs. 5.5 days, P = 0.005). There were no statistically significant differences between the 3 cohorts when comparing incidence of any medical complications, withholding of thromboprophylactic agents, or usage of topical negative pressure dressings.
Conclusions:
In patients with proximal femoral fractures, closure with staples has the highest rate of prolonged wound drainage and length of stay. Subcuticular sutures in combination with OCA result in the lowest incidence of prolonged wound drainage.
Level of Evidence:
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

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https://journals.lww.com/jorthotrauma/Fulltext/2020/10000/Effect_of_Wound_Closure_Technique_in_Proximal.9.aspx

Dual Antiplatelet Therapy and Surgical Timing in Geriatric Hip Fracture

imageObjective:
To determine how timing of surgery affects transfusion, major complications, and mortality in patients who sustain a geriatric hip fracture while taking dual antiplatelet therapy (DAPT; typically aspirin and clopidogrel).
Design:
Retrospective cohort study.
Setting:
University-affiliated Level 1 Trauma Center.
Patients:
Patients 65 years of age or older on DAPT with a geriatric hip fracture were investigated at a single institution between 2002 and 2017. Demographic and perioperative data were collected from patient records, institutional databases, and national hip fracture registry.
Intervention:
Fixation or arthroplasty.
Main Outcome Measurement:
Transfusion, major complications, and 30-day mortality.
Results:
Of the 6724 patients sustaining a geriatric hip fracture, 122 patients were taking DAPT on admission. Timing of surgery did not influence transfused units (incidence rate ratio 1.00, 95% confidence interval: 0.87–1.15, P = 0.968) but did affect major complications (time modeled as quadratic term; odds ratios ranging from 0.20 to 7.91, ptime = 0.001, ptime*time<0.001) and 30-day mortality (odds ratio 1.32, 95% confidence interval: 1.03–1.68, P = 0.030).
Conclusion:
Surgical delay does not change the need for transfusion of hip fracture patients on DAPT, but it is associated with increased probabilities of major complications and 30-day mortality.
Level of Evidence:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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https://journals.lww.com/jorthotrauma/Fulltext/2020/10000/Dual_Antiplatelet_Therapy_and_Surgical_Timing_in.10.aspx

Treatment of Tibial and Femoral Bone Defects With Bone Transport Over an Intramedullary Nail

imageObjectives:
To evaluate the results of the bone transport over an intramedullary nail (BTON) technique for the treatment of segmental bone defects.
Design:
Retrospective review of case series.
Setting:
Level 1 trauma center.
Patients/Participants:
We included 40 patients who underwent reconstruction of the lower limb with BTON technique between 2000 and 2018. The technique was performed in the tibial segments in 21 patients and in the femoral segments in 19 patients.
Intervention:
The surgical technique was performed in 2 stages for patients with infected nonunion. Infection was eradicated in all patients at the first stage. For the BTON at the second stage, monolateral external fixators and circular external fixators were used for femoral and tibial defects, respectively. In cases of defects without any infection, debridement with a single-stage BTON was performed.
Main Outcome Measurements:
Complications as well as radiological and clinical results were evaluated according to the criteria of Paley–Maar.
Results:
Minor complications occurred in 11 patients: pin site problems (9), cellulitis (1), and skin detachment due to Schanz screw (1). Major complications occurred in 8 patients: docking site nonunion (4), early consolidation and Schanz screw failure (1), knee flexion contracture (1), and ankle equinus contracture (2). Four patients had osteomyelitis as residual sequelae. Bone score was excellent in 27 patients. Excellent functional results were obtained in 31 patients.
Conclusions:
The BTON technique is associated with low cost because of the short treatment period, low complication risk, and rapid rehabilitation and is not limited by the amount of bone transport.
Level of Evidence:
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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https://journals.lww.com/jorthotrauma/Fulltext/2020/10000/Treatment_of_Tibial_and_Femoral_Bone_Defects_With.11.aspx

Complications of Methamphetamine Use in Orthopaedic Trauma

imageObjectives:
To determine whether methamphetamine (MA) users are at an increased risk for complications compared to matched controls in the setting of orthopaedic trauma.
Design:
Retrospective cohort study.
Setting:
Academic Level-1 Trauma Center.
Patients:
MA users and matched controls.
Intervention:
MA use.
Main Outcome Measurements:
Infection, Deep Vein Thrombosis (DVT), and nonunion.
Results:
Five hundred sixty-seven patients were included in our study (189 MA users, 378 matched controls). On univariate analysis, MA users had a higher incidence of DVT (3.2% vs. 0.5%), but no statistically significant difference in infection or nonunion rates. MA users also had a higher incidence of intensive care unit admission (36.0% vs. 27.8%), leaving the hospital against medical advice (9.0% vs. 2.1%), nonadherence to weightbearing precautions (18.8% vs. 7.3%), and a higher incidence of loss of follow-up (47.1% vs. 30.4%). However, MA users had a lower incidence of surgical treatment for orthopaedic injuries (51.9% vs. 65.9%). When surgical treatment was pursued, more trips to the operating room were required for orthopaedic injuries in the MA group (2.6 vs. 1.5 trips). On multivariate analysis, MA users continued to demonstrate a higher incidence of DVT and a lower incidence of operative management, but more trips to the operating room when surgical management was pursued, a higher admission rate to the intensive care unit, and a greater incidence of loss of follow-up.
Conclusions:
MA use is associated with increased inpatient and outpatient complications.
Level of Evidence:
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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https://journals.lww.com/jorthotrauma/Fulltext/2020/10000/Complications_of_Methamphetamine_Use_in.12.aspx

Laser-Assisted Indocyanine Green Angiography in the Management of Open Ankle Fractures: A Technical Trick

imageSummary:
Open ankle and pilon fractures in patients with poor soft-tissue quality represent a challenge for the treating orthopaedic surgeon. Occasionally, the typical transverse medial wound is very cephalad and does not allow for the proper visualization of the fracture. It is difficult to decide how to extend these open wounds to get access to the fracture while minimizing disruption of the blood supply to the skin. We describe the use of a new tool, laser-assisted indocyanine green angiography, to assist in incision planning for the definitive treatment of these injuries.

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https://journals.lww.com/jorthotrauma/Fulltext/2020/10000/Laser_Assisted_Indocyanine_Green_Angiography_in.13.aspx

Are Hospitals Safe? A Prospective Study on SARS-CoV-2 Prevalence and Outcome on Surgical Fracture Patients: A Closer Look at Hip Fracture Patients

imageObjectives:
To describe clinical characteristics of fracture patients, including a closer look to hip fracture patients, and determine how epidemiological variables may have influenced on a higher vulnerability to SARS-CoV-2 infection, as the basis for the considerations needed to reintroduce elective surgery during the pandemic.
Design:
Longitudinal prospective cohort study.
Setting:
Level I Trauma Center in the East of Spain.
Patients/Participants:
One hundred forty-four consecutive fracture patients 18 years or older admitted for surgery.
Intervention:
Patients were tested for SARS-CoV-2 with either molecular and/or serological techniques and screened for presentation of COVID-19.
Main Outcome Measurements:
Patients were interviewed and charts reviewed for demographic, epidemiological, clinical, and surgical characteristics.
Results:
We interviewed all patients and tested 137 (95.7%) of them. Three positive patients for SARS-CoV-2 were identified (2.1%). One was asymptomatic and the other 2 required admission due to COVID-19-related symptoms. Mortality for the whole cohort was 13 patients (9%). Significant association was found between infection by SARS-CoV-2 and epidemiological variables including: intimate exposure to respiratory symptomatic patients (P = 0.025) and intimate exposure to SARS-CoV-2-positive patients (P = 0.013). No association was found when crowding above 50 people was tested individually (P = 0.187). When comparing the 2020 and 2019 hip fracture cohorts we found them to be similar, including 30-day mortality. A significant increase in surgical delay from 1.5 to 1.8 days was observed on the 2020 patients (P = 0.034).
Conclusions:
Patients may be treated safely at hospitals if strict recommendations are followed. Both cohorts of hip fracture patients had similar 30-day mortality.
Level of Evidence:
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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https://journals.lww.com/jorthotrauma/Fulltext/2020/10000/Are_Hospitals_Safe__A_Prospective_Study_on.14.aspx

Usefulness of PCR Screening in the Initial Triage of Trauma Patients During COVID-19 Pandemic

imageBackground:
Hospitals worldwide have postponed all nonessential surgery during the COVID-19 pandemic, but non-COVID-19 patients are still in urgent need of care. Uncertainty about a patient's COVID-19 status risks infecting health care workers and non-COVID-19 inpatients. We evaluated the use of quantitative reverse transcription polymerase chain reaction (RT-qPCR) screening for COVID-19 on admission for all patients with fractures.
Methods:
We conducted a retrospective cohort study of patients older than 18 years admitted with low-energy fractures who were tested by RT-qPCR for SARS-CoV-2 at any time during hospitalization. Two periods based on the applied testing protocol were defined. During the first period, patients were only tested because of epidemiological criteria or clinical suspicion based on fever, respiratory symptoms, or radiological findings. In the second period, all patients admitted for fracture treatment were screened by RT-qPCR.
Results:
We identified 15 patients in the first period and 42 in the second. In total, 9 (15.8%) patients without clinical or radiological findings tested positive at any moment. Five (33.3%) patients tested positive postoperatively in the first period and 3 (7.1%) in the second period (P = 0.02). For clinically unsuspected patients, postoperative positive detection went from 3 of 15 (20%) during the first period to 2 of 42 (4.8%) in the second (P = 0.11). Clinical symptoms demonstrated high specificity (92.1%) but poor sensitivity (52.6%) for infection detection.
Conclusions:
Symptom-based screening for COVID-19 has shown to be specific but not sensitive. Negative clinical symptoms do not rule out infection. Protocols and separated areas are necessary to treat infected patients. RT-qPCR testing on admission helps minimize the risk of nosocomial and occupational infection.
Level of Evidence:
Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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https://journals.lww.com/jorthotrauma/Fulltext/2020/10000/Usefulness_of_PCR_Screening_in_the_Initial_Triage.15.aspx

Early Orthopaedic Trauma Outcomes in COVID-19 Infected Patients: A Case Series

imageSummary:
Orthopaedic trauma presents a unique and complex challenge in the initial phase of the coronavirus 2019 (COVID-19) global crisis. Little is currently known about the surgical practices in orthopaedic emergencies in the early days of the COVID-19 outbreak (1). This is a retrospective case series of 10 orthopaedic trauma patients who underwent fracture fixation in March 2020. Of the 10 patients testing COVID-19 positive, there were a total of 16 long bone fractures, 5 pelvic ring fractures, and 1 lumbar burst fracture. There were 7 (70%) males in this cohort. Two (20%) of the COVID-positive patients did not develop fever, leukocytosis, respiratory insufficiency, or positive imaging findings and were younger (average age 25.5 years) with fewer comorbidities (average 0.5) compared with the 8 symptomatic COVID-19–positive patients (56.6 years with 1.88 comorbidities). Advancement of COVID-19 pathogenesis with lung opacities and prolonged intubation occurred in all 5 patients who remained on ventilation postoperatively (range 9 hours–11 days). At the time of most recent follow-up, all patients survived, 1 continues to require ventilation support, 1 remains admitted without ventilation support, and 8 (80%) were discharged to home.
Level of Evidence:
Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

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https://journals.lww.com/jorthotrauma/Fulltext/2020/10000/Early_Orthopaedic_Trauma_Outcomes_in_COVID_19.16.aspx

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