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Background: Delayed wound closure is often used after open reduction and internal fixation (ORIF) of both-bone forearm fractures to reduce the risk of skin necrosis and subsequent infection caused by excessive swelling. However, no studies we are aware of have evaluated factors associated with the use of delayed wound closure after ORIF., Questions/purposes: (1) What proportion of patients undergo delayed wound closure after ORIF of adult both-bone forearm fractures? (2) What factors are associated with delayed wound closure?, Methods: The medical records of all patients who underwent ORIF with plate fixation for both-bone fractures by the adult orthopaedic trauma service at our institution were considered potentially eligible for analysis. Between January 2010 and April 2022, we treated 74 patients with ORIF for both-bone forearm fractures. Patients were excluded if they had fractures that were fixed more than 2 weeks from injury (six patients), if their fracture was treated with an intramedullary nail (one patient), or if the patient experienced compartment syndrome preoperatively (one patient). No patients with Gustilo-Anderson Type IIIB and C open fractures were included. Based on these criteria, 89% (66 of 74) of the patients were eligible. No further patients were excluded for loss of follow-up because the primary endpoint was the use of delayed wound closure, which was performed at the time of ORIF. However, one further patient was excluded for having bilateral forearm fractures to ensure that each patient had a single fracture for statistical analysis. Thus, 88% (65 of 74) of patients were included in the analysis. These patients were captured by an electronic medical record search of CPT code 25575. The mean ± SD age was 34 ± 15 years and mean BMI was 28 ± 7 kg/m 2 . The mean follow-up duration was 4 ± 5 months. The primary endpoint was the use of delayed wound closure, which was determined at the time of definitive fixation if tension-free closure could not be achieved. All surgeons used a volar Henry or modified Henry approach and a dorsal subcutaneous approach to the ulna for ORIF. Univariate logistic regression was used to identify which factors might be associated with delayed wound closure. A multivariable logistic regression analysis was then performed for male gender, open fractures, age, and BMI., Results: Twenty percent (13 of 65) of patients underwent delayed wound closure, 18% (12 of 65) of which occurred in patients who had high-energy injuries and 14% (nine of 65) in patients who had open fractures. Being a man (adjusted odds ratio 9.9 [95% confidence interval 1 to 87]; p = 0.04) was independently associated with delayed wound closure, after adjusting for open fractures, age, and BMI., Conclusion: One of five patients had delayed wound closure after ORIF of both-bone forearm fractures. Being a man was independently associated with greater odds of delayed wound closure. Surgeons should counsel all patients with these fractures about the possibility of delayed wound closure, with particular attention to men with high-energy and open fractures. Future larger-scale studies are necessary to confirm which factors are associated with the use of delayed wound closure in ORIF of both-bone fractures and its effects on fracture healing., Level of Evidence: Level III, therapeutic study., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2023 by the Association of Bone and Joint Surgeons.)

Background: Pain management after foot and ankle surgery must surmount unique challenges that are not present in orthopaedic surgery performed on other parts of the body. However, disparate and inconsistent evidence makes it difficult to draw meaningful conclusions from individual studies., Questions/purposes: In this systematic review, we asked: what are (1) the patterns of opioid use or prescription (quantity, duration, incidence of persistent use), (2) factors associated with increased or decreased risk of persistent opioid use, and (3) the clinical outcomes (principally pain relief and adverse events) associated with opioid use in patients undergoing foot or ankle fracture surgery?, Methods: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for our review. We searched PubMed, Embase, Scopus, Cochrane, and Web of Science on October 15, 2021. We included studies published from 2010 to 2021 that assessed patterns of opioid use, factors associated with increased or decreased opioid use, and other outcomes associated with opioid use after foot or ankle fracture surgery (principally pain relief and adverse events). We excluded studies on pediatric populations and studies focused on acute postoperative pain where short-term opioid use (< 1 week) was a secondary outcome only. A total of 1713 articles were assessed and 18 were included. The quality of the 16 included retrospective observational studies and two randomized trials was evaluated using the Methodological Index for Non-Randomized Studies criteria and the Jadad scale, respectively; study quality was determined to be low to moderate for observational studies and good for randomized trials. Mean patient age ranged from 42 to 53 years. Fractures studied included unimalleolar, bimalleolar, trimalleolar, and pilon fractures., Results: Proportions of postoperative persistent opioid use (defined as use beyond 3 or 6 months postoperatively) ranged from 2.6% (546 of 20,992) to 18.5% (32 of 173) and reached 39% (28 of 72) when including patients with prior opioid use. Among the numerous associations reported by observational studies, two or more preoperative opioid prescriptions had the strongest overall association with increased opioid use, but this was assessed by only one study (OR 11.92 [95% confidence interval (CI) 9.16 to 13.30]; p < 0.001). Meanwhile, spinal and regional anesthesia (-13.5 to -41.1 oral morphine equivalents (OME) difference; all p < 0.01) and postoperative ketorolac use (40 OME difference; p = 0.037) were associated with decreased opioid consumption in two observational studies and a randomized trial, respectively. Three observational studies found that opioid use preoperatively was associated with a higher proportion of emergency department visits and readmission (OR 1.41 to 17.4; all p < 0.001), and opioid use at 2 weeks postoperatively was associated with slightly higher pain scores compared with nonopioid regimens (β = 0.042; p < 0.001 and Likert scale 2.5 versus 1.6; p < 0.05) in one study., Conclusion: Even after noting possible inflation of the harms of opioids in this review, our findings nonetheless highlight the need for opioid prescription guidelines specific for foot and ankle surgery. In this context, surgeons should utilize short (< 1 week) opioid prescriptions, regional anesthesia, and multimodal pain management techniques, especially in patients at increased risk of prolonged opioid use., Level of Evidence: Level III, therapeutic study., Competing Interests: The authors certify that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2022 by the Association of Bone and Joint Surgeons.)

Temporary internal distraction (TID) is a surgical technique that can be utilized to correct severe scoliotic deformities. It allows the correction of severe curves (i.e., exceeding 90° to 100°) while minimizing the risk of neurologic injury associated with large corrections 1,2 ., Description: TID can be performed as a single or staged procedure. During the first part, cephalad anchors are placed on the spine or ribs, and caudad anchors are placed on the spine or pelvis. Temporary distraction rods are inserted, osteotomies and/or releases are performed, and iterative distractions are utilized for the duration of the procedure. If adequate correction is achieved, the final fusion may be completed at this time. If not, a staged approach may be performed: the wound is closed and the patient is returned to the operating room 1 to 3 weeks later, at which time the temporary rods are removed, further distraction is performed, and the final fusion instrumentation is placed. Around 80% to 90% cumulative correction of the major coronal angle should be achievable., Alternatives: The mainstay of treatment for large scoliotic curves is typically surgical correction and fusion. The main alternative to TID is traditional halo-gravity traction followed by fusion 3-5 . In rare cases, nonoperative treatment may be appropriate if comorbidities and/or prognoses that preclude surgery exist., Rationale: Halo traction is an effective adjunct for the treatment of large scoliotic curves; nonetheless, it has several disadvantages. First, halo traction requires a prolonged hospital stay with restriction of mobility and interference with daily activities. Second, this procedure may be less effective in cases of lumbar deformity, in which halo traction achieves limited tensile forces. Third, this procedure is associated with several risks, such as cranial nerve injuries and pin track complications 3-6 . Finally, halo traction is contraindicated for certain conditions, such as cervical instability.TID, on the other hand, involves the application of iterative corrective forces directly to the area of deformity, allowing a stronger correction 1 . TID takes advantage of the viscoelastic nature of the spine to achieve a higher percent correction compared with halo traction, with a low risk of neurologic injury 1,2 . TID also avoids the prolonged hospital stay, mobility restriction, and complications associated with halo traction. When performed as a staged procedure, TID allows accurate assessment of neurologic function with the patient awake and moving.TID is most effective for severe scoliotic multisegment deformities rather than short rigid curves, which are better treated by osteotomies., Expected Outcomes: This procedure provides satisfactory outcomes and a low risk of complications. In our retrospective case series, TID resulted in a mean major coronal angle correction of 53% after the first distraction and 80% to 90% after definitive fusion 1 . The overall percent correction was higher than that reported for halo traction 1 .The major risks of TID include infection and spinal injury. The risk of infection is decreased by antibiotic prophylaxis, perioperative nutritional optimization, and careful soft-tissue handling and wound closure. The risk of spinal cord injury is decreased by intraoperative neuromonitoring. Neuromonitoring changes occur in around 40% of cases, but these are almost always reversible and seldom lead to neurologic deficits if detected and appropriately treated, as described below 2 .Although risks exist, no complications have occurred among the 32 cases we presented in our series 1,2 ., Important Tips: Temporary anchors should be expected to loosen during distraction. Therefore, temporary anchors must be placed strategically so as to not jeopardize the purchase of the final implants.Gradual corrections must be performed over time, utilizing the viscoelastic nature of the spine to minimize risk of neurologic injury.Accurate neuromonitoring is essential for this procedure.If neuromonitoring changes occur, distraction must be stopped and the correction attained must be decreased., Acronyms and Abbreviations: TID = temporary internal distractionLIV = lowest instrumented vertebraAP = anteroposteriorTP = transverse processSAI = sacral-alar-iliacMAP = mean arterial pressureTPN = total parenteral nutritionVCR = vertebral column resectionJIS = juvenile idiopathic scoliosisAIS = adolescent idiopathic scoliosis., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSEST/A379)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: Out-of-pocket (OOP) costs for medical and surgical care can result in substantial financial burden for patients and families. Relatively little is known regarding OOP costs for commercially insured patients receiving orthopaedic surgery. The aim of this study is to analyze the trends in OOP costs for common, elective orthopaedic surgeries performed in the hospital inpatient setting., Methods: This study used an employer-sponsored insurance claims database to analyze billing data of commercially insured patients who underwent elective orthopaedic surgery between 2014 and 2019. Patients who received single-level anterior cervical diskectomy and fusion (ACDF), single-level posterior lumbar fusion (PLF), total knee arthroplasty (TKA), and total hip arthroplasty (THA) were identified. OOP costs associated with the surgical episode were calculated as the sum of deductible payments, copayments, and coinsurance. Monetary data were adjusted to 2019 dollars. General linear regression, Wilcoxon-Mann-Whitney, and Kruskal-Wallis tests were used for analysis, as appropriate., Results: In total, 10,225 ACDF, 28,841 PLF, 70,815 THA, and 108,940 TKA patients were analyzed. Most patients in our study sample had preferred provider organization insurance plans (ACDF 70.3%, PLF 66.9%, THA 66.2%, and TKA 67.0%). The mean OOP costs for patients, by procedure, were as follows: ACDF $3,180 (SD = 2,495), PLF $3,166 (SD = 2,529), THA $2,884 (SD = 2,100), and TKA $2,733 (SD = 1,994). Total OOP costs increased significantly from 2014 to 2019 for all procedures (P < 0.0001). Among the insurance plans examined, patients with high-deductible health plans had the highest episodic OOP costs. The ratio of patient contribution (OOP costs) to total insurer contribution (payments from insurers to providers) was 0.07 for ACDF, 0.04 for PLF, 0.07 for THA, and 0.07 for TKA., Conclusion: Among commercially insured patients who underwent elective spinal fusion and major lower extremity joint arthroplasty surgery, OOP costs increased from 2014 to 2019. The OOP costs for elective orthopaedic surgery represent a substantial and increasing financial burden for patients., (Copyright © 2022 by the American Academy of Orthopaedic Surgeons.)