Open Reduction Of Fractures Research Articles

Carpal Tunnel Release Performed during Distal Radius Fracture Surgery.

Background Carpal tunnel release (CTR) may be concomitantly performed along with distal radius fracture open reduction internal fixation (DRF ORIF) to prevent carpal tunnel syndrome; however, there is little to no literature investigating the rate, risk factors, and complications associated with CTR. Questions/Purposes The purpose was to determine (1) the rate of CTR performed at time of DRF ORIF, (2) factors associated with CTR, and (3) whether CTR was associated with any complications. Patients and Methods In this case-control study, adult patients who underwent DRF ORIF from 2014 to 2018 were identified from a national surgical database. Two cohorts were analyzed, (1) patients with CTR and (2) patients without CTR. Preoperative characteristics and postoperative complications were compared with determine factors associated with CTR. Results Of the 18,466 patients, 769 (4.2%) had CTR. Rates of CTR in patients with intra-articular fractures with two or three fragments were significantly higher than the rate of CTR for patients with extra-articular fractures. Underweight patients underwent CTR at a significantly lower rate compared with overweight and obese patients. The American Society of Anesthesiologists ≥3 was associated with a higher rate of CTR. Male and older patients were less likely to have CTR. Conclusion The rate of CTR at time of DRF ORIF was 4.2%. Intra-articular fractures with multiple fragments were strongly associated with CTR at time of DRF ORIF, while being underweight, elderly, and male were associated with lower rates of CTR. These findings should be considered when developing clinical guidelines to assess the need for CTR in patients undergoing DRF ORIF. This is a retrospective case control study and reflects level of evidence III.

Ninety-Day Emergency Department Visits After Ankle Fracture Surgery.

Emergency department (ED) visits after orthopaedic procedures such as ankle fracture open reduction and internal fixation (ORIF) have received less attention than other outcomes. This study analyzed 90-day ED visits after ankle fracture surgery in a national database to better characterize the incidence, timing, risk factors, and reasons. Ankle fractures undergoing ORIF were extracted from the PearlDiver M91Ortho 2010 to 2020Q3 data set. Patients were excluded for age younger than 18 years, presence of concomitant fractures, and <90 days of database follow-up. Patient age, sex, Elixhauser Comorbidity Index score, region of the country, and insurance plan were analyzed as predictors for 90-day ED utilization using multivariate logistic regression. Incidence of readmissions and incidence, timing, risk factors, and reasons for ED visits were determined. Of 87,662 ankle fracture ORIF patients identified, ED visits were noted within 90 days of surgery for 10,087 (11.5%) while 4,030 (4.6%) were readmitted. One ED visit was noted for 6,102 patients, two visits for 2,654, three visits for 787, and more than three visits for 544. The greatest weekly incidence of ED visits was observed in weeks 1 and 2, with 2.9% and 3.1% of the entire cohort visiting in each week respectively. Factors independently associated with 90-day ED utilization included younger age (odds ratio [OR] 1.21 per decade decrease, P < 0.001), greater Elixhauser Comorbidity Index score (OR 1.40 per two-point increase, P < 0.001), and Medicaid insurance (OR 1.92, P < 0.001). In the first two postoperative weeks, 71% of ED visits were attributed to issues directly involving the surgical site while in subsequent weeks, most visits did not involve the surgical site (65%). Many patients visit the ED after ankle fracture surgery. The greatest ED utilization was during the first two postoperative weeks, and reasons for visits were defined. These findings have implications for optimizing care pathways and targeting resource allocation.

Risk Factors for 30-Day Complications and Unplanned Reoperation Following Surgical Treatment of Distal Radius Fractures.

The purpose of this study was to identify demographic data, medical comorbidities, and perioperative factors that are associated with increased risk of overall surgical complications, wound complications, and reoperation within 30 days of open reduction and internal fixation (ORIF) of distal radius fractures. All adult patients undergoing ORIF of distal radius fractures in the National Surgical Quality Improvement Program database between 2005 and 2020 were identified. Patients were excluded for secondary procedures, open/infected injuries, or inpatient surgical setting. Demographic data, medical comorbidities, and perioperative data were examined for each patient, and patients were grouped by the presence or absence of any surgical complication. Univariate analysis and multivariate logistic regression were used to identify risk factors. A total of 20 301 patients from between 2005 and 2020 met the inclusion criteria, of which 219 complications (1.1% of cases) were identified. Following multivariate analysis, independent risk factors found to be associated with surgical complications included male sex, smoking, heart failure, longer operative time, and American Society of Anesthesiologists (ASA) classification of 3 or higher. Male sex, smoking, heart failure, prolonged operative time, and ASA status of 3 or higher are associated with an increased risk of surgical complications following ORIF of distal radius fractures. These complications, with the exception of heart failure, were also associated with an increased risk of wound complications. Finally, male sex, nonwhite race, smoking, dialysis, prolonged operative time, and 3 or higher ASA class were associated with reoperations. Understanding these risk factors allows surgeons to better predict and prevent complications in high-risk populations.

Cost minimization analysis of indication-specific osteosynthesis material in oral and maxillofacial surgery

PurposeFollowing the introduction of the Regulation (EU) 2017/745 by the European Parliament, any bioactive substance or surgical implant introduced into the human body must be documented. The regulation requires any implant to be traced back to the manufacturer. Lot numbers need to be available for every single medical implant. Also, the manufacturer is required by law to provide implants individually packaged and sterilized. Previously, model tray systems (MOS tray) were used for osteosynthesis in oral and maxillofacial surgery, in which the individual implants could not be registered separately. The new regulation made it impossible to use such processes during surgery anymore and a need for a change in the medical practice surged. We examined a possible solution for the new legislation. The aim of this prospective cohort study is to analyze the MOS tray systems to osteosynthesis materials prepackaged in sets. We record and evaluate parameters such as surgical time and documentation time. We perform a short cost analysis of our clinic. The primary aim is to determine how much time is gained or lost by the mandatory increased patient safety. The secondary aim is to describe change in costs.MethodsPatients that underwent standard surgical procedures in the clinic of oral and maxillofacial surgery of the faculty hospital Carl Gustav Carus in Dresden were included. We chose open reduction and internal fixation (ORIF) of anterior mandibular corpus fractures as well as mandibular advancement by means of bilateral sagittal split osteotomies (BSSO) as standardized procedures. Both of these procedures require two osteosynthesis plates and at least four screws for each plate. MOS trays were compared to prepackaged sterilized sets. The sets include a drill bit, two plates, and eight 5-mm screws.A total number of 40 patients were examined. We allocated 20 patients to the ORIF group and the other 20 patients to the BSSO group. Each group was evenly subdivided into a MOS tray group and a prepackaged group. Parameters such as the incision-suture time (IST) as well as the documentation time (DT) by the operating room (OR) staff to complete documentation for the implants are the main focus of investigation.ResultsFor open reduction, the incision-suture time was significantly different in favor of the MOS tray (p < 0.05). There was no difference in the BSSO groups. However, we observed a significantly different (p < 0.01) documentation time advantage for the prepackaged sets in both the ORIF and BSSO groups. On top of that, we find that by using the prepackaged kits, we are able to reduce sterilization costs by €11.53 per size-reduced container. Also, there is also a total cut of costs of €38.90 and €43.70, respectively, per standardized procedure for implant material.ConclusionsBy law, a change in the method of approaching surgery is necessary. For standardized procedures, the right choice of implants can lead to a reduction of documentation time and costs for implant material, sterilization, as well as utilizing less instruments. This in turn leads to lower costs for perioperative processing as well as provision of state-of-the-art implant quality implementing higher patient security.

Retrobulbar Hematoma after an open reduction of blow-out fracture of orbit

62 years old male patient who presented blunt trauma in his right eye with subsequent orbital fracture type impure blow-out who required open reduction of the facial fracture, who presented at the second postoperative day a retrobulbar hematoma with need for surgical intervention of urgency.

Lateral epicondyle osteotomy approach vs. olecranon osteotomy approach: an anatomic study of cadavers.

Exposure of the articular surface is the key to successful open reduction and internal fixation treatment for coronal shear fractures of the distal humerus. The olecranon osteotomy approach has previously been described as one of the most effective exposure approaches. Nevertheless, this approach cannot expose the anterior trochlea, and it is impossible to reduce and fix the capitellum under direct vision. The purpose of this study was to compare the exposure of the articular surface of the distal humerus between the lateral epicondyle osteotomy approach (group L) and the olecranon osteotomy approach (group O). Each approach was performed on 8 freshly frozen upper limbs of adult cadavers. After each approach was completed, a 0.5-mm Kirschner wire is inserted along the edge to mark the visible part of the articular surface. Then, the soft tissue of each elbow is removed, and a surface-scanning system is used to create a digital 3-dimensional model. The visible part of the articular surface obtained by each surgical approach was mapped and quantified using markers created by Kirschner wires. The lateral epicondyle osteotomy approach and the olecranon osteotomy approach exposed 0.8±0.0 and 0.6±0.0 of the distal humeral articular surface (P<.001), 1.0±0.0 and 0.3±0.1 of the capitellum (P<.001), 0.6±0.0 and 0.7±0.0 of the trochlea (P<.001), 0.7±0.0 and 0.5±0.1 of the anterior trochlea (P<.001), and 0.5±0.0 and 1.0±0.0 of the posterior trochlea, respectively (P<.001). Compared with the olecranon osteotomy approach, the lateral epicondyle osteotomy approach could more fully expose the total articular surface of the distal humerus, capitellum, and anterior trochlea, but the olecranon osteotomy approach could more fully expose the trochlea and posterior trochlea.

Open versus closed treatment for extracapsular fracture of the mandibular condyle.

Selection of treatment methods for mandibular condylar fractures remains controversial. In this study, we investigated treatment methods for condylar fractures to determine the indications for open or closed reduction. Patients and. Patients >12 years of age treated for mandibular condylar fractures with a follow-up period of ≥3 months were included in this study. The medical records of enrolled patients were reviewed for sex, age, fracture site, treatment method (open or closed reconstruction), postoperative intermaxillary fixation period, operation time, and complications. Radiological analysis of fracture fragment displacement and changes in ramal height difference was performed using computed tomography and panoramic radiography. A total of 198 patients was investigated, 48.0% (n=95) of whom underwent closed reduction and 52.0% (n=103) underwent open reduction. There was no significant correlation between reduction method and patient sex, age, or follow-up period. No statistically significant difference between the incidence of complications and treatment method was observed. None of the patients underwent open reduction of condylar head fracture. Binary logistic regression analysis showed that open reduction was significantly more frequent in patients with subcondylar fracture compared to in those with a fracture in the condylar head area. There was no statistically significant correlation between the groups and fracture fragment displacement. However, there was a significant difference between the treatment groups in amount of change in ramal height difference between the fractured and the nonfractured sides during treatment. No significant clinical differences were found between the open and closed reduction methods in patients with mandibular condylar fractures. According to fracture site, closed reduction was preferred for condyle head fractures. There was no significant relationship between fracture fragment displacement and treatment method.

Modified high-submandibular appraoch for open reduction and internal fixation of condylar fracture: case series report.

Recently a modified high-submandibular approach (HSMA) has been introduced for treatment of condylar fracture. This approach involves an incision line close to the mandibular angle and transmasseteric transection, leading to a low incidence of facial palsy and allowing good visualization of the condyle area, especially the condylar neck and subcondyle positions. This study reports several cases managed with this modified HSMA technique for treating condylar fractures. Six cases of condylar fractures treated with modified HSMA technique were reviewed. Three unilateral subcondylar fracture, 1 bilateral subcondylar fracture, 1 unilateral condylar neck fracture, 1 unlateral simultaneous condylar neck and subcondylar fracture cases were reviewed. All the cases were successfully treated without any major complication. Reduction, fixation, and osteosynthesis of condylar fractures via the modified HSMA technique enabled effective and stable treatment outcomes. Therefore, the described approach can be used especially for subcondylar and condylar neck fractures with minimal complications.

Can Frailty Indices Predict Surgical Risk in Open Reduction and Fixation of Facial Fractures?

PURPOSE: Facial fractures, often resulting from high impact trauma, necessitate surgical fixation with postoperative complications occurring in 3-30% of patients.1 Thus, risk prediction of unfavorable postoperative complications is essential for preoperative planning and postoperative management. Existing literature has linked smoking, alcohol use, age, BMI, and comorbidities to increased risk of adverse postoperative outcomes following facial fracture repair.1 More recently, frailty indices, including the Modified Five-Item Frailty Index (mFI-5) and the Modified Charlson Comorbidity Index (mCCI), have emerged as potentially more accurate predictors of surgical risk and 30-day postsurgical complications than their historical counterparts.2,3 The authors aimed to evaluate whether the mFI-5 and mCCI are stronger predictors of 30-day postoperative complications after open facial fracture reduction, versus historic risk proxies. METHODS: A retrospective review of the National Surgical Quality Improvement Program (NSQIP) database was performed of patients undergoing open facial fracture reduction from 2013-2019. Age, smoking, BMI, comorbidities, and American Society of Anesthesiologists (ASA) class were extracted, and mFI-5 and mCCI scores were calculated using this data. Univariate logistic regressions were performed (p<0.05). RESULTS: A total of 2,667 patients were analyzed, of which 2,131 (80%) were male. Most patients were nonfrail across both indices, with 86% (n=2,292) having an mFI-5 of 0, and 75% (n=1,994) having a mCCI of 0. Both mCCl score ≥2 (OR=2.19, p<0.001) and mFI-5 =1 (OR=1.96, p<0.001) were strong independent predictors of overall 30-day complication rate and complication severity. However, ASA class ≥3 was the strongest predictor (OR=3.60, p<0.001). Age was statically significant, but a low-impact, predictor of complications and complication severity (OR= 1.02, p<0.001). The only significant predictors of surgical site infections (SSI) were smoking (OR=1.56, p=0.042) and ASA class ≥3 (OR=2.37, p=0.013). An mFI-5 of 1 was also found to be a significant predictor of hospital readmission rates (7% vs 3% p<0.001). BMI was not associated with any increased risk. CONCLUSION: The mCCI and mFI-5 are significant independent predicators of total complications and complication severity following facial fracture repair. ASA class ≥3 was the strongest predictor of postoperative complications, likely attributable to concurrent multi-organ system trauma and its global impact on risk in facial fracture injury. An mFI-5 ≥1 was additionally predictive of increased readmission rates. Smoking increased risk of surgical site infections specifically but not overall complications. Newer frailty indices (mFI-5 and mCCI) predicted adverse postsurgical events more strongly than several historic risk proxies, offering potential utility as risk predictors during surgical planning. Further research should continue to clarify their predictive value. REFERENCES: 1. Perez D, Ellis E, 3rd. Complications of Mandibular Fracture Repair and Secondary Reconstruction. Semin Plast Surg. 2020;34(4):225-231. 2. Austin SR, Wong YN, Uzzo RG, Beck JR, Egleston BL. Why Summary Comorbidity Measures Such As the Charlson Comorbidity Index and Elixhauser Score Work. Med Care. 2015;53(9):e65-72. 3. Lee CC, Hunter WP, Hajibandeh JT, Peacock ZS. Does the Modified Frailty Index (mFI-5) Predict Adverse Outcomes in Maxillofacial Fracture Repair? J Oral Maxillofac Surg. 2021.

Association of Nerve Block and Opioid Administration for Patellar Surgery

Introduction: Multimodal pain control after orthopaedic surgery is a topic of growing interest in opioid-related risk mitigation. However, little evidence exists in the orthopaedic trauma setting. We aim to analyze the impact of perioperative peripheral nerve blocks (PNB) on opioid pain management in patients undergoing open reduction and internal fixation (ORIF) of patella fractures. Methods: This analysis included 47 patients with isolated patella fractures who underwent ORIF (2017-2021). Our dedicated PNB service provided 28 cases with PNBs. Extracted variables during hospitalization included demographic data, pain scores on visual analog scale (VAS), intra-, and postoperative opioid administration measured as morphine milligram equivalents (MME). Follow-up data included prescription refills, ED visits for pain within 90 days, and VAS pain scores. Chi-squared and logistic regression analyses were performed to evaluate the impact of PNB on opioid based pain management. Results: Patients with a PNB had lower average total MME (126.54±18.96) than those without a PNB (160.62±35.81); however, this was not statistically significant (p = 0.201). Use of PNB was not associated with total prescription refills, ED visits, or pain on VAS for all time points. However, at two-weeks follow-up, patients without PNB had 4x higher odds of receiving a refill (OR:4.13, CI:1.13-15.10). Subgroup analysis revealed no significant association between PNB timing (preoperative/postoperative) and intraoperative, postoperative, or total inpatient MME. Conclusion: With the observed inconsequential effect of PNB, findings suggest that opioid administration in the orthopaedic trauma population is multifaceted. Continued conscious prescribing practices with multimodal pain control should be encouraged to mitigate opioid-related risks.

Comparative study between preauricular retromandibular anteroparotid approach and retromandibular transparotid approach in open reduction and internal fixation of subcondylar fracture on facial nerve injury and parotid fistula

Background: Condyle fractures account for 17.5 percent to 50 percent of all mandibular fractures, although there are still many debates on whether to treat them close or open. There are several techniques of managing the mandibular condyle, each with its own set of benefits and drawbacks. Aim: compare the innovative preauricular transmasseteric anteroparotid approach (P-TMAP) to the usual retromandibular transparotid technique. Patients and methods: 20 cases, patients with an odd number (1,3,5,7,9,11,13,15,17,19) received a preauricular transmasseteric anteroparotid approach (study group), while patients with a double number (2,4,6,8,10,12,14,16,18,20) had a retromandibular transparotid approach (control group) (control group). Patients were closely monitored for six months. Results: Fractures were caused by a road traffic accident (RTA) in 6(60%) of the cases, interpersonal violence in 3(30%) of the cases and falling in 1(10%) of the cases in both groups. Immediate postoperative facial nerve affection was higher in the transparotid approach group (30%) than in the anteroparotid approach group (10%), but both groups exhibited no statistically significant difference three months after surgery. There were no parotid injuries in any of the cases in either group.

Résultats radiologiques des fractures bimalléolaires : importance du délai de la chirurgie et du type de reconstruction

ObjectiveThe goal of open reduction and internal fixation (ORIF) of bimalleolar ankle fractures is to reconstitute ankle anatomy. The most commonly used radiological parameters to assess adequacy of reduction are talocrural angle (TCA), medial clear space (MCS), tibiofibular overlap (TFO) and tibiofibular clear space (TFCS). There is little research about the radiological outcomes of surgery in bimalleolar fractures. We aimed at assessing the adequacy of ORIF and the factors involved in anatomical restoration (specifically time to surgery), postoperatively and at follow-up. MethodsTCA, MCS, TFO and TFCS were measured in preoperative and postoperative radiographs of 107 bimalleolar ankle fractures and in 83 follow-up radiographs, accounting for a total of 297 radiographs and 1182 measurements. Preoperative radiographs were categorized according to Danis-Weber classification. For all included cases, basic demographic data, dates of radiographs and surgery, and type of fixation used were acquired. Variables associated with postoperative and follow-up total anatomical reconstitution (i.e., when the four assessed radiological parameters were normalized), normalization of each radiological parameter, and improvement in the number of normalized radiological parameters were identified through univariable Cox regression analysis. ResultsIn our sample, 23.8% of the ankle fractures in postoperative radiographs and 28% in follow-up radiographs achieved a complete anatomical restoration. Type C fractures (hazard ratio [HR]=0.1, 95% confidence interval [CI]=0.02–0.7, P=0.021) were associated with lower chances of total anatomical reconstitution. The use of reconstruction plates (HR=0.1, 95% CI=0.03–0.7, P=0.014) and one third tubular plates (HR=0.2, 95% CI=0.03–0.8, P=0.026) decreased the chances of improving the number of normalized radiological parameters. Waiting days until surgery impaired total anatomical reconstitution (HR=0.8, 95% CI=0.6–0.9, P=0.012) and also reduced the chances of improving the number of normalized radiological parameters (HR=0.9, 95% CI=0.9–1.0, P=0.045). ConclusionThe radiological results for the treatment of bimalleolar fractures are time sensitive, and surgery should thus be performed as soon as possible, using adequate fixation materials, in order to achieve a better restoration of ankle anatomy. Level of evidenceIV, retrospective study.

Rotation of both X- and Y-axes is a predictive confounder of ulnar nerve injury and open reduction in pediatric lateral flexion supracondylar humeral fractures: A retrospective cohort study.

BackgroundRotation of the distal fragment often occurs in flexion-type supracondylar humerus fractures (SCHFs), potentially leading to ulnar nerve injury (UNI) and open reduction. We analyzed the correlation between the rotations and UNI or open reduction and then assessed the risk factors associated with these rotations.MethodsData of Wilkins type III lateral flexion SCHFs were collected over a 10-year time period (1 January 2012 to 31 December 2021) in Children's Hospital of Fudan University Anhui Hospital. We defined the rotation of the distal fragment on the coordinate axis as two types, IIIA (X-axis rotation) and IIIB (the rotation of both X- and Y-axes) on X-ray radiography. Demographic data, the incidence of the two-type rotation, odds ratios (ORs) of UNI and open reduction, and risk factors of the rotation of both X- and Y-axes were analyzed.ResultsTotally, 152 patients were found (50 with IIIA vs. 102 IIIB). The UNI rate was 13%, and the open reduction rate was 22%. The UNI rate of the IIIB was five-fold higher than that of the IIIA [OR, 5.143; 95% confidence interval (CI), 1.414–23.125; p = 0.019], and the open reduction rate of the IIIB was nearly five-fold higher than that of the IIIA (OR, 4.729, 95%CI, 1.584–14.495; p = 0.003). In these two types, patients with UNI had a higher risk of open reduction than those without UNI (OR, 9.816; 95%CI, 3.503–27.508; p = 0.001). In the multiple regression analysis, a high level of fracture was identified as a risk factor for the rotation of both X- and Y-axes.ConclusionType IIIB lateral flexion-type SCHFs have higher rates of UNI and open reduction, and a high level of fracture is a risk factor associated with this type.

Complications After Open Reduction and Internal Fixation for Distal Radius Fractures in Patients With and Without Rheumatoid Arthritis

Rheumatoid arthritis (RA) can have severe impact on patients' functional abilities and increase the risk of fragility fractures. Little is known about how patients with RA fare after operative management of distal radius fractures. The purpose of this study was to compare postoperative complications after surgical fixation in patients with RA and controls, hypothesizing that patients with RA would have higher levels of postoperative complications. Patients were identified using Current Procedural Terminology and International Classification of Diseases, Ninth and Tenth Revision, codes for open treatment of distal radius fractures and RA at 3 level 1 trauma centers over a 5-year period (2015-2019). Chart abstraction provided details regarding injuries and treatment. Age- and sex-matched controls were identified in a 2:1 ratio. Postoperative complications were classified according to the Clavien-Dindo-Sink classification system and divided into early (less than 90 days) and late groups. Sixty-four patients (21 with RA and 43 controls) were included. The patients were predominantly women, with a mean age of 62 years and a mean Charlson comorbidity index of 2.1. The RA medications at the time of injury included conventional synthetic disease-modifying antirheumatic drugs (5/21), biologic disease-modifying antirheumatic drugs (5/21), or chronic oral prednisone (6/21). Rheumatoid medications, except hydroxychloroquine, were withheld for 2-3 weeks after surgery. Rheumatoid patients were significantly more likely to sustain a complication compared with the control group, although this was no longer significant on adjusted analysis. Class I complications were the most common. The incidence of early versus late complications was similar between the groups. A high rate of early return to surgery for fixation failure occurred in the RA group compared with none in the control group. Patients with RA undergoing operative management of distal radius fractures are at risk of postoperative complications, particularly fracture fixation failure, necessitating return to the operative room. High levels of pain, stiffness, and mechanical symptoms were noted in the RA group. Prognostic IV.

Outcomes in Ankle Fracture Surgery: A Systematic Review and Meta-Analysis of Fibular Intramedullary Nail Fixation vs Open Reduction and Internal Fixation in Randomized Controlled Trials

Category: Trauma; Ankle; Ankle Arthritis; Diabetes Introduction/Purpose: What level I evidence exists to support the use of FNF for surgical management of ankle fractures in high risk patients? The purpose of this study was to compare clinical outcomes following fibular intramedullary nail fixation (FNF) and open reduction and internal fixation (ORIF) of ankle fractures. Methods: A systematic review of the current literature was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Certainty of evidence reported according to GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Our primary hypothesis was that patients undergoing FNF procedures to manage an ankle fracture would have significantly higher patient reported outcome scores (PROs) than patients undergoing ORIF. Primary study outcome measures were validated PROs. Secondary outcome measures included complication rate, secondary surgery rate, and bony union. Results: The primary outcome analysis revealed no evidence of a significant effect difference on Olerud and Molander Ankle Score (OMAS) PRO and no evidence of statistical heterogeneity. Secondary outcome analysis revealed a significant 0.30 (0.12-0.74 95CI) relative risk reduction for complications in FNF (P=0.008). No evidence of an effect difference for bony union. No evidence of reporting bias was appreciated. Sensitivity analyses did not significantly alter effect estimates. Conclusion: The quality of evidence is reasonably strong and likely sufficient to conclude: (1) there is likely no clinically important difference between FNF and ORIF up to 12 months post-operatively, as defined by OMS (moderate certainty); (2) surgeons may reasonably expect reduced complications in 14 out of every 100 patients treated with FNF (moderate certainty); (3) there is likely no difference in bony union (low certainty). Future studies should investigate more patient-centered outcomes and if short-term findings are durable over time if these findings apply to lower risk populations.

Prospective study on the functional and radiological outcome of open reduction and plating for intraarticular fractures of the calcaneum

Prospective study on the functional and radiological outcome of open reduction and plating for intraarticular fractures of the calcaneum

Older Age is Not a Contraindication for Surgical Treatment of Closed Calcaneal Fractures using the Sinus Tarsi Approach

Category: Hindfoot; Trauma Introduction/Purpose: The sinus tarsi (ST) approach for calcaneus fractures has gained popularity in recent years; however, the literature surrounding early complications rates based on age differences for this specific approach is lacking. The objective of this study was to determine if rates of early complications based on age varied for patients undergoing open reduction and internal fixation (ORIF) of calcaneus fractures using the ST approach. Methods: A retrospective review of patients undergoing ORIF for closed calcaneus fractures from 2012 to 2020 was performed. Inclusion criteria was based on an age greater than 18 years old, surgical management of a closed calcaneus fracture using a ST approach, requirement of a preoperative CT scan, and a minimum of 90 days follow-up. Patients were divided into two groups: those under the age of 50 and those over the age of 50. Measurement outcomes included wound dehiscence, superficial surgical site infection, deep infection, and implant removal. Results: A total of 175 patients (186 fractures) were included with 108 patients in the &lt;50 age group and 86 patients in the &gt;50 age group. Mean age was 34.8 and 58.7 years in the younger and older groups, respectively. The older group had similar rates of wound dehiscence (1.3% vs. 1.9%, P=0.761), superficial surgical site infection (1.3% vs. 0.9%, P=0.816), and deep infection (5.1% vs. 4.6%, P=0.876) as compared to the younger group. Eleven (10.2%) fractures in &lt;50 age group required implant removal compared to 13 (16.7%) fractures in the &gt;50 age group (P=0.193). Postoperative Gissane and Bohler angles were not significantly differnet between the two groups. Conclusion: Calcaneal fractures can be debilitating injuries, especially in the older patient population. The present study found that patients with intraarticular calcaneus fractures treated via the ST approach maintain similar early complication rates as compared to younger individuals.

Is It Safe to Prep the External Fixator in Situ During Staged ORIF of Pilon Fractures? A Retrospective Comparative Cohort Study

Category: Trauma; Ankle Introduction/Purpose: Pilon fractures usually result from high energy mechanisms and are associated with signifcant soft tissue injuries in addition to complex fracture patterns. Treatment typically involves staged management with initial placement of an external fixator and subsequent definitive internal fixation once soft tissues are amenable. The purpose of this study was to compare the risk of fracture-related infection (FRI) and unplanned re-operation after staged open reduction and internal fixation (ORIF) of pilon fractures between cases in which elements of the temporizing external fixator (ex-fix) were prepped into the surgical field and cases in which it was completely removed prior to definitive fixation. Methods: This was a multi-surgeon retrospective comparative cohort study on patients 18 years and older with pilon fractures who underwent operative treatment over a ten-year period between January 1, 2010 to January 1, 2020 at an academic-level 1 trauma center. Medical records and radiographic images were reviewed for each patient to assess demographics, clinical characteristics and surgical outcomes. The primary outcome measures were FRI and unplanned re-operation, including arthrodesis and amputation. All analyses were completed using JMP Software (Version 15.0, SAS Institute Inc., Cary, NC), and an alpha of 0.05 was used for statistical significance. Results: 133 patients underwent staged ORIF, 47 with retained elements of the ex-fix prepped in situ for definitive ORIF and 86 with the ex-fix entirely removed. The overall rate of FRI was 23.3% while the overall rate of unplanned re-operation was 11.3% (4.5% rate of arthrodesis and 6.8% rate of amputation). There was no difference in FRI between the group in which ex-fix was prepped in versus the group in which it was completely removed (23.4% vs 23.3%, p=0.985) and no difference in overall rate of unplanned re-operation (10.6% vs 11.6%, p=0.863). Assessing the subset of patients with FRI, those with ex-fix prepped in had a higher prevalence of infection with MRSA and MSSA (81.8% vs 40%, p=0.021). Using alpha=0.05, and power=0.8, a sample size of 42 patients with FRI post-ORIF (27 with ex-fix prepped in, and 15 with ex-fix removed) would be needed to detect a difference in MRSA/MSSA bacteriology. Conclusion: Although there were relatively high complication rates in this cohort of pilon fractures treated with staged ORIF, prepping in elements of the external fixator did not lead to a significant increase in rates of fracture-related infection nor unplanned re-operation, including arthrodesis and amputation. This study offers clinical support regarding a common practice used to assist in reduction and definitive fixation of distal tibial pilon fractures.

Evaluating the Association of Anesthesia Type with Postoperative Complications in Patients Undergoing Ankle Fracture Repair

Category: Ankle Introduction/Purpose: General and neuraxial anesthesia are both successful anesthesia techniques used in many orthopaedic procedures. Neuraxial anesthesia involves local anesthetics placed around the central nervous system (CNS) and spinal anesthesia is a subtype where the anesthetic is injected into intrathecal space. General anesthesia is usually recommended in ambulatory surgeries for its rapid onset of action. However, current literature shows contradicting complication profiles between these two anesthesia types. The purpose of this study was to compare the complications and length of hospital stay between patients who underwent general anesthesia versus neuraxial anesthesia during the repair of ankle fractures. Methods: Patients undergoing open reduction and internal fixation (ORIF) for ankle fracture from 2014 to 2018 were identified in the National Surgical Quality Improvement Program database. Patients were stratified into 2 cohorts: general anesthesia and neuraxial anesthesia. In this analysis, demographics data, comorbidities, and postoperative complications were collected and compared between the two cohorts. Bivariate analyses and multivariable logistical regression were performed. Results: Of 3,585 patients who underwent operative treatment for ankle fracture, 3,315 patients (92.5%) had general anesthesia and 270 (7.5%) had neuraxial anesthesia. Compared to patients who had general anesthesia, those who had neuraxial anesthesia were more likely to be older (58.0 vs 49.6 years old; p&lt;0.001), Caucasian (80.0% vs 71.9%; p=0.001), and have an ASA classification of III (38.1% vs 25.0%; p&lt;0.001). On bivariate analyses, patients who had neuraxial anesthesia were more likely to develop pulmonary complications (p=0.173) or extended length of stay more than 5 days (p=0.342) compared to the general anesthesia group. Following adjustment on multivariate analyses, the neuraxial anesthesia cohort no longer had increased likelihood of pulmonary complications or extended length of stay compared to the general anesthesia group. Conclusion: Prior studies have shown that neuraxial anesthesia methods are as effective as general anesthesia with fewer short- term outcomes. When compared to patients who underwent general anesthesia during ORIF for ankle fracture, neuraxial anesthesia patients experienced no significant increases in postoperative complications or extended length of hospital stay. In terms of the variables we explored in the NSQIP database, healthy ankle fracture patients could also benefit from neuraxial anesthetic methods, and they should be considered for this anesthetic type regardless of their lack of comorbidities that would make them high risk for general anesthesia.

Cost Efficiency of Ankle Fracture ORIF at an Ambulatory Surgical Center vs Hospital

Category: Ankle; Trauma Introduction/Purpose: Ankle fracture open reduction and internal fixation (ORIF) is one of the most commonly performed orthopaedic surgeries, which can be performed at a variety of surgical locations. However, there is very little data exploring the cost and efficiency of ankle fracture ORIF in different operative settings. Time-Driven Activity Based Costing (TDABC) is a novel accounting method used to accurately assign costs for various procedures by creating a process map of all personnel interactions as a patient moves through a care event. Further, it has been shown to more accurately allocate costs, as compared to traditional accounting systems. Our purpose is to evaluate cost and efficiency differences in ankle fracture ORIF at an outpatient ambulatory surgery center (ASC) versus a hospital setting. Methods: A prospective cohort study was performed at a single academic medical center involving four orthopaedic surgeons. Patients were enrolled with uni-, bi-, or tri-malleolar displaced ankle fractures undergoing ORIF. According to TD-ABC methodology, a process map was created for each peri-operative platform and hand-timed data was collected at each location (ASC=5, hospital=5) by a single observer. In addition, retrospective cost data was obtained from 181 surgical cases using our institution's existing cost accounting system (ASC=34, hospital=147). Average event times and care costs were calculated for both locations, and a process map outlining the steps of care was created for each surgical site, according to TDABC methodology. Data were analyzed to investigate the effects of surgical site on labor cost, efficiency, and provider time. Results: Overall, total direct cost was similar between locations (ASC=$10,837.43, hospital=$9,377.80; p=.114), although there were significantly higher direct costs in the hospital: perioperative/anesthesia (ASC=$2,532.61, hospital=$4,594.20; p&lt;.001), pharmacy (ASC=$112.18, hospital=$349.74; p&lt;.001), radiology (ASC=$17.67, hospital=$227.98; p&lt;.001), and therapy (ASC=$28.23, hospital=$130.91; p&lt;.001). However, medical supply costs, including implant costs, were significantly higher at the ASC (ASC=$7,835.14, hospital=$2,459.60; p&lt;.001). Preoperatively, nurse assessment of the patient was significantly quicker in the hospital (ASC=14.65 min, hospital=5.10 min; p=.030), while patient transport to the operating room was significantly quicker in the ASC (ASC=1.20 min, hospital=2.60 min; p=.014). Case duration was significantly longer in the ASC (ASC=138.60 min, hospital=56.60 min; p=.005), which may have been influenced by case complexity, as there were more tri-malleolar fractures (n=2) and concomitate ankle arthroscopies (n=3) in that cohort. Conclusion: Overall, direct costs appear to be lower at the ASC than the main hospital, although efficiency of care delivery seems similar. Generally, there were small differences in the care continuum between the main hospital and ASC, though areas where improvement could be obtained include preoperative nurse assessment of the patient and efficacy of regional nerve block administration. Going forward, larger studies will be needed to further investigate these results.