Orthopaedic Trauma Surgery Research Articles

A bibliometric analysis of clinical research on fracture-related infection

Background Infection following orthopaedic trauma surgery is increasingly recognized as one of the major research priorities with as primary goal, improving patient care. This increased interest has been anecdotally recognized through published research, research grants, and, finally, with the development of the fracture-related infection (FRI) consensus group. In 2017, the accepted consensus definition of FRI was published, which has been followed by consensus recommendations from both a surgical and medical perspective. A bibliometric analysis was performed to objectively describe the trends in published clinical research related to FRI. Methods The terms related to FRI were searched in the Web of Science database between 2000 and 2020. The characteristics of clinical research on FRI regarding the author, country, journal, institution, scientific output, top 100 most cited articles, and trend topics were analyzed using Bibliometrix and WPS Office. Results A total of 2597 records were eligible for inclusion in this bibliometric approach, with studies originating from 89 countries, including eight languages. The United States of America (USA) published the highest number of articles and citations. International collaborations were present between 72 countries, with the most active country being the USA. The most contributive institution was the University of California. The highest number of papers and citations were from the Injury-International Journal of the Care of the Injured and the Journal of Orthopaedic Trauma. The top 100 most cited articles were published in 27 different journals, with the number of citations ranging between 97 and 1004. The latest trend topics were related to the diagnosis of FRI. Conclusion The present bibliometric analysis shows the research characteristics and trends of FRI from multiple perspectives. The fact that there is an increasing number of studies being published on FRI shows the agreement among scientists and clinicians that standardization with respect to this topic is very important.

H-Index Predicts Academic Rank Among Full-time Academic Orthopaedic Trauma Surgeons Affiliated with Fellowship Programs

Objectives: The purpose was to investigate the association between Hirsch index (H-index) and academic rank among orthopaedic trauma surgeons affiliated with Orthopaedic Trauma Association (OTA) and Accreditation Council for Graduate Medical Education (ACGME) fellowship programs with academic appointments. Additional variables investigated included total number of publications and training program affiliation. Design: Database review. Participants: Orthopaedic trauma surgery faculty members at OTA and ACGME orthopaedic trauma surgery fellowship. Main outcome measurement: H-index, total number of publications, academic rank, and fellowship training pedigree. Results: The H-indices of 273 orthopaedic traumatologists from 57 fellowship programs were organized and calculated. There are strong correlations among total number of publications, citations, and H-index. Overall, there is a strong association with number of publications, number of citations, and H-index with higher academic rank. Overall, H-index was a stronger predictor of academic rank than total number of publications and citations. Appointment to the same program as an individual’s fellowship training program and orthopaedic subspeciality fellowship outside of traumatology were not associated with academic rank. Level of Evidence: IV, case series Key words: trauma, fellowship, academic rank, H-index

Sensors and digital medicine in orthopaedic surgery.

Digital health principles are starting to be evident in medicine. Orthopaedic trauma surgery is also being impacted —indirectly by all other improvements in the health ecosystem but also in particular efforts aimed at trauma surgery. Data acquisition is changing how evidence is gathered and utilized. Sensors are the pen and paper of the next wave of data acquisition. Sensors are gathering wide arrays of information to facilitate digital health relevance and adoption. Early adaption of sensor technology by the nonlegacy health environment is what has made sensor driven data acquisition so palatable to the normal health care system. As it applies to orthopaedic trauma, current sensor driven diagnostics and surveillance are nowhere near as developed as in the larger medical community. Digital health is being explored for health care records, data acquisition in diagnostics and rehabilitation, wellness to health care translation, intraoperative monitoring, surgical technique improvement, as well as some early-stage projects in long-term monitoring with implantable devices. The internet of things is the next digital wave that will undoubtedly affect medicine and orthopaedics. Internet of things (loT) devices are now being used to enable remote health monitoring and emergency notification systems. This article reviews current and future concepts in digital health that will impact trauma care.

The Effect of the COVID-19 Pandemic on Theatre Efficiency, Lessons to be Learned for Subsequent Waves.

This study aims to demonstrate the impact of the COVID-19 pandemic on providing trauma services at our district general hospital. We aim to identify the impact on specific areas of theatre delay to help optimize theatre efficiency and generate better protocols and improve patient flow for future pandemic waves. Patients who underwent orthopaedic trauma surgery at our hospital between July-August 2019 (pre-COVID-19) and 2020 (first UK wave of COVID-19) were identified retrospectively and grouped by year of operation. Type of operation was recorded, including time for sending, anaesthetic induction, surgical preparation, operating time, and time for transfer to recovery. The two groups were compared for analysis. Case numbers were similar in both 2019 and 2020 (215vs.213 operations), with a similar proportion being hip fractures (39.1% and 36.6%), respectively. Median sending time (40vs.23 minutes, P <0.00001) and induction time (13vs.8 minutes, P<0.00001) were increased in 2020, a 74% and 63% increase compared to 2019, respectively. Median surgical preparation time (35vs.37 minutes, P=0.06) and operating time (56vs.50 minutes, P=0.16) were not statistically significant. Transfer time in 2020 (16vs.13 minutes, P<0.00001) was significantly increased. Overall case time increased in 2020 (2:40vs.2:11, P<0.00001) by 29 minutes. COVID-19 had a significant impact on theatre efficiency in our hospital, causing multiple points of delay. As hospitals across the UK restart crucial elective services, focus should be given to maximizing theatre efficiency by providing rapid access COVID-19 testing for patients undergoing emergency surgery. We have proposed and implemented several steps for better theatre utilization.

Infected or Not Infected? Next-Generation DNA Sequencing Is Not the Answer...Yet: Commentary on an article by Roman M. Natoli, MD, PhD, et al.: "Poor Agreement Between Next-Generation DNA Sequencing and Bacterial Cultures in Orthopaedic Trauma Procedures".

Commentary Infections of the musculoskeletal system continue to be a vexing challenge for orthopaedic surgeons. Postoperative infections, particularly those in cases in which implants are used for fixation or reconstruction, are common complications in orthopaedic surgery. Metallic implants serve as a nidus for the formation of biofilm, on which bacteria can survive, colonize, and hide from the immune system1. The presence of a biofilm prevents systemic antibiotics from effectively eradicating pathogenic bacteria, leading to high rates of reoperation in which the wounds undergo irrigation, debridement, and implant removal. The infection rates in orthopaedic trauma and arthroplasty cases have been reported to range from 1% to 30%2,3. The diagnosis of a surgical site infection, particularly indolent infection, can be challenging4. The clinical signs can be subtle, often without fever or obvious purulence. Systemic markers are not always reliable, and tissue and fluid bacterial cultures can lack sensitivity5-7. Often, the diagnosis of surgical site infection is made by the treating surgeon on the basis of radiographic findings of implant loosening or new radiolucencies at the bone-implant interface. However, these findings also can be found in cases of aseptic loosening. Therefore, there is a critical need for sensitive and specific assays to identify and characterize pathogenic bacteria in orthopaedic surgical wounds. Assays that can detect bacterial DNA through highly sensitive molecular biology techniques have the potential to improve diagnostic accuracy. Next-generation DNA sequencing (NGS) is under investigation as a tool to diagnose infection by identifying the presence of bacterial DNA (specifically, the gene for 16S ribosomal RNA) and characterizing the bacterial species through DNA sequencing8. The potential advantages of NGS include the ability to identify the presence of bacteria with use of a very small sample. In addition, such techniques do not require the varied culture environments needed to identify specific bacterial species. Point-of-care NGS analysis of musculoskeletal tissue and implant biofilm, if accurate, would be a major advance in orthopaedic care. Natoli et al. report on a prospective study in which patients undergoing “clean” orthopaedic trauma procedures (i.e., procedures for the treatment of closed fractures, hardware removal, or nonunion management) had intraoperative tissue sent for both bacterial culture and NGS. The authors found very little correlation between bacterial cultures and NGS results. Only 3 of 9 positive culture cases were also positive on NGS, with common species in only 2 of the 3. The vast majority of bacteria identified by NGS were either nonpathogenic bacteria or bacteria that are infrequently associated with clinical infection. The authors also found no correlation between the diagnostic assay results and the outcome of clinical infection. Two of 9 patients who had positive cultures developed a clinical infection, only 1 of 27 patients with a positive NGS finding developed an infection, and the NGS speciation in the latter case did not match the culture results of the clinical infection. It should be noted that the study was not designed to follow patients for clinical infection, and therefore some infections may have been missed. It is clear from the data by Natoli et al., as well as data from the shoulder arthroplasty literature9,10 and lower extremity arthroplasty literature11, that NGS should not be considered as a substitute for, or even a complement to, bacterial cultures in clean trauma cases. NGS is extremely sensitive and can identify bacteria that are generally innocuous and clinically unimportant or that present at sufficiently low levels so as to not result in clinical infection. These “false positive” results could lead to overtreatment and increased morbidity. Nevertheless, advances that can address the limitations of conventional bacterial culturing methods are desperately needed. Further work on developing molecular biology techniques that can detect and characterize specific pathogenic bacteria with greater sensitivity than cultures would allow for a more accurate approach12. In addition, NGS can be studied in cases of clinic infection to determine the agreement between culture results showing pathogenic bacteria and specific NGS findings for these pathogens. In the meantime, the study by Natoli et al. takes an important step toward improving our understanding of the clinical utility and the limitations of NGS in the diagnosis of surgical site infections, specifically in orthopaedic trauma surgery.

Wearable technology in orthopedic trauma surgery – An AO trauma survey and review of current and future applications

The use of wearable sensors to track activity is increasing. Therefore, a survey among AO Trauma members was conducted to provide an overview of their current utilization and determine future needs and directions.A cross sectional expert opinion survey was administered to members of AO Trauma. Respondents were surveyed concerning their experience, subspeciality, current use characteristics, as well as future needs concerning wearable technology.Three hundred and thirty-three survey sets were available for analysis (Response Rate 16.2%). 20.7% of respondents already use wearable technology as part of their clinical treatment. The most prevalent technology was accelerometry combined with smartphones (75.4%) to measure general patient activity. To facilitate the use of wearable technology in the future, the most pressing issues were cost, patient compliance and validity of results.Wearable activity monitors are currently being used in trauma surgery. Surgeons employing these technologies mostly measure simple activity or activity associated parameters. Cost was the greatest perceived barrier to implementation. Further research, especially concerning the interpretation of the outcome values obtained, is required to facilitate wearable activity monitoring as an objective patient outcome measurement tool.

Strategies aimed at preventing long-term opioid use in trauma and orthopaedic surgery: a scoping review

BackgroundLong-term opioid use, which may have significant individual and societal impacts, has been documented in up to 20% of patients after trauma or orthopaedic surgery. The objectives of this scoping review were to systematically map the research on strategies aiming to prevent chronic opioid use in these populations and to identify knowledge gaps in this area.MethodsThis scoping review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. We searched seven databases and websites of relevant organizations. Selected studies and guidelines were published between January 2008 and September 2021. Preventive strategies were categorized as: system-based, pharmacological, educational, multimodal, and others. We summarized findings using measures of central tendency and frequency along with p-values. We also reported the level of evidence and the strength of recommendations presented in clinical guidelines.ResultsA total of 391 studies met the inclusion criteria after initial screening from which 66 studies and 20 guidelines were selected. Studies mainly focused on orthopaedic surgery (62,1%), trauma (30.3%) and spine surgery (7.6%). Among system-based strategies, hospital-based individualized opioid tapering protocols, and regulation initiatives limiting the prescription of opioids were associated with statistically significant decreases in morphine equivalent doses (MEDs) at 1 to 3 months following trauma and orthopaedic surgery. Among pharmacological strategies, only the use of non-steroidal anti-inflammatory drugs and beta blockers led to a significant reduction in MEDs up to 12 months after orthopaedic surgery. Most studies on educational strategies, multimodal strategies and psychological strategies were associated with significant reductions in MEDs beyond 1 month. The majority of recommendations from clinical practice guidelines were of low level of evidence.ConclusionsThis scoping review advances knowledge on existing strategies to prevent long-term opioid use in trauma and orthopaedic surgery patients. We observed that system-based, educational, multimodal and psychological strategies are the most promising. Future research should focus on determining which strategies should be implemented particularly in trauma patients at high risk for long-term use, testing those that can promote a judicious prescription of opioids while preventing an illicit use, and evaluating their effects on relevant patient-reported and social outcomes.

Peri- and Interprosthetic Femoral Fractures-Current Concepts and New Developments for Internal Fixation.

Treatment of peri- and interprosthetic fractures represents a challenge in orthopedic trauma surgery. Multiple factors such as osteoporosis, polymedication and comorbidities impede therapy and the rehabilitation of this difficult fracture entity. This article summarizes current concepts and highlights new developments for the internal fixation of periprosthetic fractures. Since the elderly are unable to follow partial weight bearing, stable solutions are required. Therefore, a high primary stability is necessary. Numerous options, such as new angular stable plate systems with additional options for variable angle screw positioning, already exist and are in the process of being further improved. Lately, individually produced custom-made implants are offering interesting alternatives to treat periprosthetic fractures.

Online consultation in an orthopedic trauma surgery outpatient clinic: is there a learning curve?

BackgroundIn the context of the German contact restrictions due to the COVID-19 pandemic of March 2020, an online-based consultation system was established in our university orthopedic outpatient department to maintain patient care. As a basis for contact-minimizing communication, this was continued after the contact restrictions were lifted. The aim of this prospective pilot study was to assess the effectiveness, technical feasibility, and patient flow in this system under lockdown conditions and in the period afterwards.MethodsThe evaluation took place from the beginning of the first lockdown on March 13, 2020, until May 31, 2021. For each patient encounter, the quality of the sound and video connections was documented. The outcomes of the consultations were recorded. Four categories were distinguished: 1) no follow-up necessary, 2) follow-up via online consultation, 3) referral for surgical therapy, and 4) follow-up in the outpatient clinic for physical examination.A comparison was made between an early cohort right after implementation of the online consultation and and a late cohort after establishment of the consultation.ResultsThere were 408 patient encounters via online consultation. A total of 360 (88%) consultations were uninterrupted. Initial presentations accounted for 124 (30%) consultations. In 75 (18%) patients, no further follow-up was necessary. Follow-up via online consultation was scheduled in 82 (20%) patients, direct referral for surgery was made in 86 (21%) patients, and a follow-up for physical examination was arranged in 165 (40%) patients. When comparing the early and late cohort, there was no difference in the duration of the conversation (p = 0.23). A significant difference was found in the type of further treatment. In the late cohort, conservative therapy was used more often (p < 0.01), resulting in a lower number of follow-up visits for clinical examination (p < 0.01).ConclusionWhile a definite decision for further procedure was possible solely by online consultation in a large percentage of cases, 40% of patients still needed an additional in-person consultation for physical examination. A learning curve could be observed regarding the selection of patients suited for online consultation. Overall, online consultation is a useful measure to manage patient volume and to visibly support direct doctor-patient contact.

297 Variations in Orthopaedic Trauma Presentation During COVID-19 Lockdown

IntroductionIn living memory there has never been a start to the year as 2020, due to Covid -19 Pandemic. Like every other surgical speciality, Orthopaedic trauma surgery faced significant challenges during this period in terms of numbers as well as variation in trauma patients’ presentation.AimThe purpose of our study is to analyse the numbers and variations in orthopaedic trauma and its presentations during the pandemic in comparison with 2018 and 2019.MethodsThe data for this audit was collected from orthopaedic register of Our lady of Lourdes Hospital, Ireland. Patients operated under orthopaedic trauma team in three months period (March, April & May) in 2018, 2019 and 2020 were selected for analysis and comparison.ResultsIn 2020, total number of surgeries were 32% less than the average of previous 2 years. (373 in 2020 vs 543 in 2019 and 551 in 2018). Similarly, the paediatric trauma surgeries dropped by 32 % in this period. Significantly lower proportion of sport related injuries, RTAs, and assaults presented in 2020. Higher proportion of trauma resulting from simple slip, falls from height and trampoline was observed in this period compared to previous two years. Slightly higher proportion of tibial pilon, calcaneum and peri-prosthetic fractures was noted as compared to previous years.ConclusionsSignificant reduction in total number of trauma cases as well as high energy trauma (Road Traffic Accidents, Sports Trauma) was observed due to limited mobility in pandemic, whereas higher proportion of low energy fractures occurred during this period of restrictions.

The Impact of COVID-19 Pandemic on the Surgical Treatment of Orthopedic Trauma in a Tertiary Hospital in Portugal

INTRODUCTION: The impact of the COVID-19 pandemic on orthopedic trauma surgery is not well characterized in the literature. We provided an evaluation of such impact in a tertiary hospital in Portugal.MATERIAL AND METHODS: Retrospective analysis of the patients admitted for surgical treatment due to acute orthopedic trauma from March to December of 2019 and March to December of 2020.RESULTS: A total of 794 patients in 2019 and 728 in 2020 were included. Although the mean time to surgery was shorter the hospital stay was longer in 2020. Infected patients had a longer hospital stay and longer time until surgery compared to non-infected. There was no significant difference between the mortality and need for treatment in the intensive care unit (ICU) in both years. There was a significant increase in the number of polytrauma patients treated in our institution in 2020 compared to 2019.CONCLUSION: Orthopedic trauma surgery was globally influenced by the pandemic. Safe and effective measures should be adopted in the treatment of trauma patients, to reduce the clinical and economic impact.

Analysis of the Effect of Comprehensive Nursing on Patients with Venous Thromboembolism of Lower Limbs after Traumatic Orthopedic Surgery

Analysis of the Effect of Comprehensive Nursing on Patients with Venous Thromboembolism of Lower Limbs after Traumatic Orthopedic Surgery

Bacteria-targeted fluorescence imaging of extracted osteosynthesis devices for rapid visualization of fracture-related infections

PurposeFracture-related infection (FRI) is a serious complication in orthopedic trauma surgery worldwide. Especially, the distinction of infection from sterile inflammation and the detection of low-grade infection are highly challenging. The objective of the present study was to obtain proof-of-principle for the use of bacteria-targeted fluorescence imaging to detect FRI on extracted osteosynthesis devices as a step-up towards real-time image-guided trauma surgery.MethodsExtracted osteosynthesis devices from 13 patients, who needed revision surgery after fracture treatment, were incubated with a near-infrared fluorescent tracer composed of the antibiotic vancomycin and the fluorophore IRDye800CW (i.e., vanco-800CW). Subsequently, the devices were imaged, and vanco-800CW fluorescence signals were correlated to the results of microbiological culturing and to bacterial growth upon replica plating of the imaged devices on blood agar.ResultsImportantly, compared to culturing, the bacteria-targeted fluorescence imaging of extracted osteosynthesis devices with vanco-800CW allows for a prompt diagnosis of FRI, reducing the time-to-result from days to less than 30 min. Moreover, bacteria-targeted imaging can provide surgeons with real-time visual information on the presence and extent of infection.ConclusionHere, we present the first clinical application of fluorescence imaging for the detection of FRI. We conclude that imaging with vanco-800CW can provide early, accurate, and real-time visual diagnostic information on FRI in the clinical setting, even in the case of low-grade infections.Graphical abstract

Augmentation of suture anchors with magnesium phosphate cement – Simple technique with striking effect

BackgroundSuture anchors have a large field of application in orthopedic trauma surgery like the refixation of patellar, quadriceps and Achilles tendon or the treatment of rotator cuff tears. The fixation of suture anchors in osteoporotic bone is difficult, a problem that becomes increasingly relevant in the elderly. MethodsTwo types of suture anchors: 1.) Titanium CorkScrew Fast Track II with a knotted eyelet and 2.) polyether ether ketone (PEEK) SwiveLock C with a knotless eyelet were chosen for evaluation in open cell bone blocks with densities of 5–20 pcf supplied by Sawbones AB. A pilot hole of 7 mm diameter and 20 mm depth was drilled in the bone blocks and filled with an experimental drillable magnesium phosphate cement (powder: 92.5 wt% Mg3(PO4)2, 7.5 wt% MgO, liquid: 25 wt% phytic acid (C6H18O24P6)). Anchors were then inserted into the cement and allowed to cure for 24 h (37 °C, 100% humidity) before pullout testing was conducted with a material testing machine. Suture anchors inserted in the blocks after predrilling and tapping served as control. ResultsThrough augmentation with magnesium phosphate cement pullout strength and stiffness of the suture anchors could be significantly increased in all bone blocks up to 22-fold. CorkScrew anchors failed by rupture of the eyelet with higher pullout strengths, whereas no failure of SwiveLock C anchors could be observed when reinforced with additional FibreWire at the tip. ConclusionsWe present a simple technique, whereby pullout strength of suture anchors can be significantly increased in bone with compromised density. The experimental resorbable and drillable magnesium phosphate cement proved to be effective in resisting tensile load, dispersing in the adjacent bone, and thus increasing the bone-anchor contact surface. Therefore, the experimental magnesium phosphate cement is a promising candidate for clinical application in the numerous scenarios mentioned.

Complications Associated with Administration of Post-operative Weight-Based Enoxaparin in Orthopaedic Trauma Patients.

BackgroundIn orthopedic-specific patients, limited evidence exists in regard to prophylactic weight-based enoxaparin dosing in the obese population. We examined the clinical outcomes of administering weight-based enoxaparin to obese orthopedic trauma patients.MethodsThis retrospective study involved 679 patients who underwent orthopedic trauma surgery and were admitted from 1/2016 to 6/2020 at a single institution. Of those patients, 156 patients met our inclusion criteria. Inclusion criteria included BMI>35 kg/m2 and received weight-based enoxaparin post-operatively (defined as any singular dose >40 mg at any time). Blood transfusion, documented hematoma, deep vein thrombosis (DVT), and return visits to the OR after the administration of weight-based enoxaparin were the primary endpoints assessed. Age, BMI, weight, injury severity score (ISS), sex, post-operative time to the first dose of enoxaparin, the total daily dose of enoxaparin, operating room (OR) blood loss, OR time, patient co-morbidities, and pre/post-operative hemoglobin were evaluated for a potential relationship with the primary endpoints.ResultsOne hundred and eighty-five surgeries were performed on a total of 156 patients. Thirty-six of the 185 (19%) surgeries required post-operative blood transfusion after weight-based enoxaparin was given. Higher ISS score, lower pre-operative hemoglobin, and lower post-operative hemoglobin were significant predictors of blood transfusion. Only increased post-operative time to the first dose of enoxaparin was significantly associated with DVT formation. Thirteen of the 156 patients (8.3%) had a post-operative hematoma after administration of enoxaparin, and four of the 13 patients required return to the OR for bleeding complications. ISS was the only significant predictor of post-operative hematoma formation.ConclusionPatients with a higher injury severity score are at an increased risk of adverse bleeding and may benefit from lower doses of enoxaparin administered earlier post-operatively.

Racial Differences in Orthopedic Trauma Surgery

Racial discrepancies among patients in the United States undergoing orthopedic trauma surgery have not been investigated. Issues relating to socioeconomic status and access to care have played a role in the health outcomes of racial groups. In orthopedic surgery, recent joint arthroplasty literature has shown significant racial differences in the use of elective joint arthroplasty. Furthermore, studies also suggest increased rates of early complication in racial minority groups. In general, little information exists on the postoperative outcomes of racial minority groups in orthopedic surgery. We retrospectively queried the National Surgical Quality Improvement Program database to identify patients undergoing orthopedic trauma surgery between 2008 and 2016. Patients of all ages who underwent orthopedic trauma surgery were identified using Current Procedural Terminology codes. Patients classified as either Black or White were included in the study. Demographic data, comorbidities, and basic surgical data were compared between the groups. Adverse outcomes in the initial 30 days postoperative were also examined. Higher frequencies of deep wound infection (0.5% vs 0.3%, P=.002) were noted among Black patients, with decreased mortality (0.3% vs 0.6%, P=.004) and postoperative transfusion (2.7% vs 3.8%, P<.001) rates, compared with White patients. Clear differences exist in the demographic, surgical, and outcome data between Black and White patients undergoing orthopedic trauma surgery. More epidemiological studies are required to further investigate racial differences in orthopedic trauma surgery. [Orthopedics. 2022;45(2):71-76.].

Contrast-enhanced ultrasound in the diagnostics of non-unions

Non-union represents asevere complication and amajor socioeconomic challenge in orthopedics and trauma surgery. Timely and reliable diagnostics are obligatory to be able to carry out the treatment of non-unions in apatient-specific and efficient manner. Contrast-enhanced ultrasound (CEUS) is an important interface between clinical signs, imaging investigations and the results of the paraclinical diagnostics, e.g. C‑reactive protein (CRP) and leukocyte count. It can display the microperfusion inside the non-union gap in real time and provide valuable information for exclusion of an infection or on the healing progress after revision surgery. An establishment of this diagnostic modality in routine orthopedic trauma surgery contributes to optimization of the treatment of non-unions.

Decreasing Postoperative Opioid Prescriptions After Orthopedic Trauma Surgery: The "Lopioid" Protocol.

To assess the effectiveness of a multimodal analgesic regimen containing "safer" opioid and non-narcotic pain medications in decreasing opioid prescriptions after surgical fixation in orthopedic trauma. Retrospective cohort study. One urban, academic medical center. Patients with traumatic fracture from 2018 (n=848) and 2019 (n=931). In 2019, our orthopedic trauma division began a standardized protocol of postoperative pain medications that included 50 mg of tramadol four times daily, 15 mg of meloxicam once daily, 200 mg gabapentin twice daily, and 1 g of acetaminophen every 6 hours as needed. This multimodal regimen was dubbed the "Lopioid" protocol. We compared patients who received this protocol with all patients from the prior year who had followed a standard protocol that included Schedule II narcotics. Greater mean morphine milligram equivalents were prescribed at discharge from fracture surgery under the standard protocol than under the Lopioid protocol (252.3 vs 150.0; P < 0.001), and there was a difference in the type of opioid medication prescribed (P < 0.001). There was a difference in the number of refills filled for patients discharged with opioids after surgical treatment between the standard and Lopioid cohorts (0.31 vs 0.21; P = 0.002). There were no differences in the types of medication-related complications (P = 0.710) or the need for formal pain management consults (P = 0.199), but patients in the Lopioid cohort had lower pain scores at discharge (2.2 vs 2.7; P = 0.001). The Lopioid protocol was effective in decreasing the amount of Schedule II narcotics prescribed at discharge and the number of opioid refills after orthopedic surgery for fractures.

Preoperative Opioid Informed Consent and Prescribing Practices in Children Undergoing Orthopaedic Trauma Surgery.

Introduction:This study sought to examine prescribing practices for pediatric patients undergoing orthopaedic trauma surgery and assess the effect of state-mandated preoperative informed consent for opioids.Methods:A retrospective single-institution cohort study was done between 2016 and 2018 for surgically managed isolated orthopaedic trauma with cohorting based on the presence of preoperative opioid consent. Analyses examined cohort demographic and procedural factors associated with the number of opioid doses prescribed.Results:A total of 1,793 patients met the study criteria. The proportion of patients prescribed opioids (P = 0.0378) and the number of doses (P < 0.001) were lower in consented patients. Differences were greater among those receiving solution (versus tablets). No cohort differences were observed in refill needs. Nonopioid medications prescribing increased. Multivariate analysis identified multiple factors, including preoperative opioid consent (P = 0.013) associated with fewer prescribed opioid doses.Discussion:After the implementation of preoperative opioid consenting, patients were prescribed fewer opioid doses after pediatric orthopaedic trauma surgery. The increased utilization of nonopioid therapies was also evident. These changes occurred despite a shorter length of hospital stay and without changes in the studied proxies of postoperative pain control. An increased awareness of opioid risks through formal consent discussion may help to facilitate reduced reliance on opioids for children in the postoperative period.

EFFECT OF TRANEXAMIC ACID ON FRACTURE HEALING IN RATS

ABSTRACTIntroduction In this study we investigated the effect of tranexamic acid (TXA) on fracture healing in an established animal model, when used to stop bleeding in orthopedic trauma surgery.Materials and Methods This study was a randomized, controlled, laboratory study. Eighteen Sprague-Dawley rats were randomly assigned to three groups, either receiving TXA intravenously (Group 1), TXA topically (Group 2), or isotonic TXA intravenously and TXA topically in the same amounts for the control group (Group 3). First, a Kirschner wire was inserted retrogradely into the femoral intramedullary canal. Then the femurs were fractured at the midshaft region with blunt guillotine. After 4 weeks, the rats were sacrified and the femurs harvested. Cortical bone volume, callus volume, and bone mineral density were calculated using computer tomography scans. Torsion tests were performed. Groups were compared by maximum torque to failure and callus stiffness.Results There were no statistical differences in torque to failure and stiffness between the 3 groups. There were no differences in mean total bone volume, callus volume, percent bone volume, or callus density between the groups.Conclusions A single dose of topical or intravenous TXA has no negative effect on fracture healing when used in traumatic femur fracture surgery in an animal model. Evidence level II; Randomized controlled experimental study.