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Background: The objective of this study was to determine whether talar neck fractures with proximal extension (TNPE) into the talar body are associated with higher rates of avascular necrosis (AVN) compared to isolated talar neck (TN) fractures. Methods: A retrospective review of patients sustaining talar neck fractures at a level I trauma center from 2008 to 2016 was performed. Demographic and clinical data were collected from the electronic medical record. Fractures were characterized as TN or TNPE based on initial radiographs. TNPE was defined as a fracture that originates on the talar neck and extends proximal to a line subtended from the junction of the neck and the articular cartilage dorsal to the anterior portion of the lateral process of the talus. Fractures were classified according to the modified Hawkins classification for analysis. The primary outcome was the development of AVN. Secondary outcomes included nonunion and collapse. These were measured on postoperative radiographs. Results: There were 137 fractures in 130 patients, with 80 (58%) fractures in the TN group and 57 (42%) in the TNPE group. Median follow-up was 10 months (interquartile range, 6-18 months). The TNPE group was more likely to develop AVN as compared to the TN group (49% vs 19%, P Conclusion: We found a higher rate of AVN, subsequent collapse, and nonunion in patients with TNPE compared to isolated TN fractures. Level of Evidence: Level III, retrospective cohort study.

To determine whether the use of a multimodal analgesic protocol reduced short-term and long-term opioid use in patients hospitalized after orthopaedic trauma.Retrospective pre-post intervention study.Regional, academic, Level 1 trauma center in Central Kentucky.Patients were hospitalized after orthopaedic injury before (n = 393) and after (n = 378) the implementation of a multimodal analgesic protocol.The intervention involved a multimodal analgesic protocol consisting of acetaminophen, ibuprofen/ketorolac, gabapentinoids, skeletal muscle relaxants, and standardized doses of opioids plus standardized pain management education before hospital discharge.End points included discharge opioid prescription, days' supply and daily morphine milligram equivalent (MME), and long-term opioid use after hospitalization. Opioid use in the 90 days before and after hospitalization was assessed using state prescription drug monitoring program data.Discharge opioid prescription rates were similar in the intervention and control cohorts [79.9% vs. 78.4%, odds ratio (OR) 1.30 (0.83-2.03), P = 0.256]. Patients in the intervention cohort received a shorter days' supply [5.7 ± 4.1 days vs. 8.1 ± 6.2 days, rate ratio 0.70 (0.65-0.76), P0.001] and lower average daily MME [34.8 ± 24.9 MME vs. 51.5 ± 44.0 MME, rate ratio 0.68 (0.62-0.75), P0.001]. The incidence of long-term opioid use was also significantly lower in the intervention cohort [7.7% vs. 12.0%, OR 0.53 (0.28-0.98), P = 0.044].Implementation of a multimodal analgesic protocol was associated with reductions in both short-term and long-term opioid use, including long-term opioid therapy, after orthopaedic trauma.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

To review and evaluate the validity of common perceptions and practices regarding radiation safety in orthopaedic trauma.Retrospective study.Level 1 trauma center.N/A.The intervention involved personal protective equipment.The main outcome measurements included radiation dose estimates.Surgeon radiation exposure estimates performed at the level of the thyroid, chest, and pelvis demonstrate an estimated total annual exposure of 1521 mR, 2452 mR, and 1129 mR, respectively. In all cases, wearing lead provides a significant reduction (90% or better) in the amount of radiation exposure (in both radiation risk and levels of radiation reaching the body) received by the surgeon. Surgeons are inadequately protected from radiation exposure with noncircumferential lead. The commonly accepted notion that there is negligible exposure when standing greater than 6 feet from the radiation source is misleading, particularly when cumulative exposure is considered. Finally, we demonstrated that trauma surgeons specializing in pelvis and acetabular fracture care are at an increased risk of exposure to potentially dangerous levels of radiation, given the amount of radiation required for their caseload.Common myths and misperceptions regarding radiation in orthopaedic trauma are unfounded. Proper use of circumferential personal protective equipment is critical in preventing excess radiation exposure.

To determine whether pre-existing psychiatric disorder is associated with potentially unnecessary fasciotomy.Retrospective cohort study.Academic Level-1 trauma center.All the patients with orthopaedic trauma undergoing leg fasciotomy at an academic Level I trauma center from 2006 to 2020.Pre-existing diagnosis of psychiatric disorder.Early primary wound closure and delayed primary wound closure.In total, 116 patients were included. Twenty-seven patients (23%) had a pre-existing diagnosis of psychiatric disorder with 13 having anxiety, 14 depression, 5 bipolar disorder, and 2 ADHD. Several patients had multiple diagnoses. Fifty-one patients (44%) had early primary closure (EPC), and 65 patients (56%) had delayed primary closure. Of patients with a psychiatric disorder, 52% received EPC compared with 42% of patients without a disorder, P = 0.38. This lack of a strong association did not seem to vary across specific psychiatric conditions. After adjusting for sex, age, injury type, and substance abuse, there was still no significant association between a psychiatric disorder and EPC with an odds ratio of 1.08 (95% CI, 0.43-2.75).Among patients with orthopaedic trauma undergoing emergent fasciotomy for acute compartment syndrome, a psychiatric disorder was not associated with a significantly increased rate of possibly unnecessary fasciotomy. Given the potential for a psychiatric condition to complicate the diagnosis of acute compartment syndrome, this data is somewhat reassuring; however, there remains a need for continued vigilance in treating patients with psychiatric conditions and research in this area.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objective To evaluate the efficacy of routine postoperative computed topography (CT) scan after percutaneous fixation of unstable pelvic ring injuries. Design Retrospective chart review. Setting Level I Trauma Center. Patients/participants A total of 362 consecutive patients underwent operative fixation of unstable pelvic ring injuries during the study period. Intervention Postoperative CT scan of the pelvis was obtained in 331 (91%) of the 362 patients treated operatively for unstable pelvic ring injuries. Main outcome measurements Revision surgery based on routine postoperative CT scan. Results Two patients (0.55%) returned to the operating room on the basis of postoperative CT scans due to malpositioned implants. There were no significant differences of age, sex, body mass index, Injury Severity Score, mechanism of injury, smoking status, or diabetes status between those who did and did not undergo revision surgery. A dysmorphic pelvis was identified in 154 (47%) patients. Both patients undergoing revision surgery were determined to have a dysmorphic pelvis while no patients with normal pelvic anatomy returned to the operating room based on postoperative CT (2/154, 1.3% vs. 0/177, 0%, P = 0.22). Conclusions Although there remains a role for postoperative CT scans in the appropriately selected patient, in the hands of experienced orthopaedic traumatologists, patients with adequate intraoperative fluoroscopy and a nondysmorphic pelvis may not require routine postoperative three-dimensional imaging. Level of evidence Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Alzheimer disease is a neurologic disorder characterized by the progressive cognitive decline. As the population continues to age, orthopaedic surgeons need to become familiar with surgical and nonsurgical treatment considerations in this complex population. Despite the advances in geriatric and dementia care, surgical and postoperative management of both elective and emergent surgery remain complex and controversial in this patient population. Appropriate perioperative and postoperative management can optimize outcomes, and the management can significantly affect the quality of life of patient and caregiver and limit disease burden. Any treatment decision should be guided first and foremost by the goals of care as agreed between the surgeon, other providers, and family. Surgical management must be demand matched to the patient accounting for the severity of disease, life expectancy, and the social support system. The authors conducted a literature review of Alzheimer dementia care in orthopaedic patients via a Pubmed search of relevant articles published since 1980.

Objective To assess the effectiveness of reducing contamination using 2 methods of C-Arm draping compared with traditional methods. Materials and methods The authors simulated an operating room using an extremity drape, commercially available C-Arm drapes, and C-Arm. A black light was placed above the field. A fluorescent powder was placed on the nonsterile portions of the field. Baseline light intensity was recorded by photo. The C-Arm was brought into the surgical field for orthogonal imaging for 15 cycles. A repeat photograph was taken to measure the increase in intensity of the fluorescent powder to assess degree of contamination. This was repeated 5 times for each configuration: standard C-Arm drape, a proprietary close-fitting drape, and a split drape secured to the far side with the split wrapped around the C-Arm receiver. Light intensity difference was measured and average change in intensity was compared. Results Compared with standard draping, the proprietary close-fitting drape resulted in a 71.3% decrease in contamination (4.84% vs. 16.90%, P = 0.101) that trended toward significance and the split drape resulted in a 99.5% decrease (0.09% vs. 16.90%, P = 0.017) that was statistically significant. Conclusion Far side contamination can be reduced by using a split drape connecting the operative table to the C-Arm receiver, effectively "sealing off" contaminants. The proprietary close-fitting drape may also decrease contamination, but this was not statistically significant in this study. Use of the split drape technique will help prevent contamination and may ultimately lead to decreased infection risk.

Comminuted extraarticular metaphyseal and diaphyseal fractures of the distal humerus frequently require operative fixation through a posterior approach. Most of the previously described approaches to the posterior humerus are dependent on large and extensile approaches. This video demonstrates open reduction and internal fixation of a comminuted metaphyseal distal humerus fracture through a minimally invasive posterior approach.

OBJECTIVE To determine whether suprapatellar nailing (SPN) over time can decrease operative time and radiation exposure when compared with infrapatellar nailing (IPN) of tibial shaft fractures. DESIGN Retrospective. SETTING Single, Level 1 trauma center. PATIENTS Extra-articular adult tibial shaft fractures treated with intramedullary nailing alone within a 7-year period. INTERVENTION Patients were treated with SPN or IPN techniques based on the discretion of the operating surgeon. MAIN OUTCOME MEASUREMENTS Operative time and radiation exposure. RESULTS Three hundred forty-one fractures (SPN: 177, IPN: 164) were included in the analysis. No differences in patient body mass index, sex, or open fracture incidence existed between the 2 groups. A significant difference in average operative time (IPN 130 minutes vs. SPN 110 minutes, P < 0.01), fluoroscopy time (IPN 159 minutes vs. SPN 143 minutes, P = 0.02), and radiation dose (IPN 8.6 mGy vs. SPN 6.5 mGy, P < 0.01) existed between IPN and SPN. Early tibias treated with SPN had similar operative times (P = 0.11), fluoroscopy time (P = 0.94), and radiation dose (P = 0.34) compared with IPN. Later SPN patients had significantly lower operative time (P = 0.03), fluoroscopy time (P < 0.01), and radiation dose (P < 0.013) compared with earlier SPN. Regression analysis revealed with the increased use of SPN, operative time, fluoroscopy time, and radiation dose significantly decreased (P = 0.018, 0.046, 0.011). CONCLUSIONS Tibia fractures treated with SPN have significantly decreased operative times and radiation exposure compared with those treated with IPN, after allowing time for the surgeon to gain sufficient experience with the technique. The surgeon should consider this when deciding to adopt this technique. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The early generations of proximal tibial locking plates demonstrated inferior results when compared to dual plating in bicondylar tibial plateau fractures with posteromedial fragments (PMF). Modern plates have multiple rows of locking screws and variable angle technology -which tote the ability to capture the PMF. The purpose of this study was to determine if the modern plates could capture the PMF in a large series of bicondylar tibial plateau fractures.Axial computer topography (CT) scans of 114 bicondylar tibial plateau fractures with PMF were analyzed. Five proximal tibia locking plates-in seven total configurations-were applied to radiopaque tibiae models. All possible screws were placed. Templates of screw trajectories were created based on the model CT scans. These were superimposed onto patient CT scan images to assess for screw penetration into the PMF. Number of screws fully within the PMF were recorded. Capture of the PMF was defined as having at least two screws within the fragment.On average, all plates were able to capture 81.6% of PMF with an average of 3.77 [95% Confidence Interval (CI): 3.47-4.07] screws. However, their ability to capture all fragments varied greatly, from 55.7%-95.2% in fixed angle constructs. Overall, variable angle constructs had a significantly higher capture rate (98.5% vs. 74.9%; p0.0001) and more screws in the PMF (5.88 [95% CI: 5.58-6.17] vs 2.93 [95% CI: 2.62-3.24]; p0.0001) when compared to fixed angle constructs.Newer generation locking plates vary greatly in their ability to capture the PMF. Variable angle technology dramatically increases the ability to capture the majority of PMFs. Prior biomechanical and clinical studies may yield substantially different results if repeated with these newer implants. Use of newer generation locked plates should not replace thorough preoperative planning.

Supracondylar femur fractures represent a challenging and common injury treated by many orthopedic surgeons. An array of surgical fixation options has been developed to help the treating surgeon restore normal anatomic alignment of these fractures, and lateral precontoured condylar femoral locking plates have become a common implant for most surgeons in treating these fractures. Although these precontoured plates provide significant benefit to the treating physician in regards to gaining appropriate bony fixation, common technical errors that may lead to malalignment when using these plates have been described. Avoiding these errors will help improve patient outcomes. Here, we describe a novel, inexpensive, and universally available technique that may aid the treating surgeon in restoring coronal alignment when treating distal femur fractures.

Background Early administration of antibiotics and wound coverage have been shown to decrease the deep infection risk in all patients with Type 3 open tibia fractures. However, it is unknown whether early antibiotic administration decreases infection risk in patients with Types 1, 2, and 3A open tibia fractures treated with primary wound closure. Questions/purposes (1) Does decreased time to administration of the first dose of antibiotics decrease the deep infection risk in all open tibia fractures with primary wound closure? (2) What patient demographic factors are associated with an increased deep infection risk in Types 1, 2, and 3A open tibia fractures with primary wound closure? Methods We identified 361 open tibia fractures over a 5-year period at a Level I regional trauma center that receives direct admissions and transfers from other hospitals which produces large variation in the timing of antibiotic administration. Patients were excluded if they were younger than 18 years, had associated plafond or plateau fractures, associated with compartment syndrome, had a delay of more than 24 hours from injury to the operating room, underwent repeat debridement procedures, had incomplete data, and were treated with negative-pressure dressings or other adjunct wound management strategies that would preclude primary closure. Primary closure was at the descretion of the treating surgeon. We included patients with a minimum follow-up of 6 weeks with assessment at 6 months and 12 months. One hundred forty-three patients with were included in the analysis. Our primary endpoint was deep infection as defined by the CDC criteria. We obtained chronological data, including the time to the first dose of antibiotics and time to surgical debridement from ambulance run sheets, transferring hospital records, and the electronic medical record to answer our first question. We considered demographics, American Society of Anesthesiologists classification, mechanism of injury, smoking status, presence of diabetes, and Injury Severity Score in our analysis of other factors. These were compared using one-way ANOVA, chi-square, or Fisher's exact tests. Binary regression was used to to ascertain whether any factors were associated with postoperative infection. Receiver operator characteristic curves were used to identify threshold values. Results Increased time to first administration of antibiotics was associated with an increased infection risk in patients who were treated with primary wound closure; the greatest inflection point on that analysis occurred at 150 minutes, when the increased infection risk was greatest (20% [8 of 41] versus 4% [3 of 86]; odds ratio 5.6 [95% CI 1.4 to 22.2]; p = 0.01). After controlling for potential confounding variables like age, diabetes and smoking status, none of the variables we evaluated were associated with an increased risk of deep infection in Type 1, 2, and 3A open tibia fractures in patients treated with primary wound closure. Conclusions Our findings suggest that in open tibia fractures, which receive timely antibiotic administration, primary wound closure is associated with a decreased infection risk. We recognize that more definitive studies need to be performed to confirm these findings and confirm feasibility of early antibiotic administration, especially in the pre-hospital context. Level of evidence Level III, therapeutic study.

CASE A 38-year-old woman presented with previously undiagnosed factor V Leiden (FVL), who suffered a complete superficial femoral arterial thrombosis after tourniquet use during the surgical repair of one of her bilateral tibial plafond fractures. This patient's injury eventually resulted in a below-knee amputation. CONCLUSION We recommend expanding hypercoagulable screening on patients with risk factors based on a detailed history and physical examination. We also recommend limiting or negating tourniquet use in patients with FVL or other hypercoagulable disorders.

CASE We present the case of a 26-year-old otherwise healthy man with an isolated tibial and fibular shaft fracture who developed signs of fat embolism syndrome (FES) within 6 hours of injury and prior to any operative treatment. CONCLUSION General orthopaedists and traumatologists should be aware that the onset of FES is not always delayed for several days, but can develop within 6 hours of injury. After initiation of appropriate management, including respiratory support, our patient did well. There was union of the fracture, and he was able to return to work at 3 months postinjury.

Background Bilateral asymmetric hip dislocation, with one hip dislocated posteriorly and with anterior dislocation of the contralateral hip, is a rare injury pattern. A total of 34 cases have been reported in English literature, but only 24 cases detail injury mechanism and patient demographic factors, 3 of which reported bilateral asymmetric hip dislocation in female patients. Only one report describes more than one example. We describe four patients with bilateral asymmetric hip dislocation, including one example in a female patient, which represents the largest case series to date. Pertinent anatomy, injury mechanism, treatment options, and prognosis are also discussed. Methods A literature review was conducted via PubMed using the term bilateral asymmetric dislocation. Review of additional reports cited by articles found by our search resulted in what we think to be an exhaustive list of cases reported to date.A medical record review of four patients treated at our institution, a Level I trauma center, was performed to compare our treatment methods and outcomes to those previously described. Results All four patients in our case series had satisfactory outcomes. Motor vehicle collision is the most common cause of bilateral asymmetric hip dislocation. Conclusion Timely, accurate reduction of bilateral asymmetric hip dislocation is recommended for optimal outcomes. An understanding of pertinent anatomy about the hip joint allows the orthopedic surgeon to perform a safe, timely reduction. In the absence of an associated acetabular fracture, conservative management with weight-bearing restrictions typically leads to good outcomes without complications such as aseptic necrosis of the femoral head. Level of evidence Therapeutic study, level V.

In contrast to open reduction internal fixation, percutaneous fixation is a relatively new option for operative fixation of acetabular fractures. The techniques for percutaneous insertion of anterior and posterior column screws have been previously described. For technical aspects of retrograde percutaneous posterior column screws, much attention has been paid to the proper start point. However, descriptions of proper trajectory and end point have not been as clearly delineated. Understanding of posterior column anatomy and its radiographic correlates are fundamental in the safe placement of this screw. Herein, we present technical advice for acquisition and interpretation of fluoroscopic images needed to ensure a safe trajectory and end point in retrograde percutaneous posterior column screw placement. We highlight our steps to ensure correct placement in a small series.

Surgical-site infection is a common form of noscomial infection that can occur in fractures following internal fixation. Treatment of these infections has traditionally included preserving stable implants via debridement and antibiotic administration while the fracture is healing. Recent evidence indicated that this algorithm results in less-than-optimal rates of fracture union and infection eradication. The premise for this study is that bacterial removal from fracture implants using the Versajet Hydrosurgery System (Smith & Nephew, Memphis, Tennessee) method is better compared with the bulb syringe and pressurized pulsatile lavage methods. Thirty-two stainless steel, 4-hole, nonlocking, 3.5-mm fracture plates were incubated with Staphylococus aureus and divided into 4 groups. Eight plates in each group underwent irrigation with 1 L of saline using a bulb syringe lavage, pressurized pulsatile lavage, or the Versajet Hydrosurgery System method. Eight plates underwent no irrigation method and served as a control group. The residual bacterial loads following irrigation were quantitatively cultured. Each of the experimental groups had significantly reduced levels of bacteria adherent to the plate following irrigation compared with the control group ( P =.0002). Furthermore, the Versajet Hydrosurgery System was most the effective at bacterial removal, followed by the pressurized pulsatile and bulb syringe lavage techniques ( P =.0002 to P =.0012, respectively). Novel approaches to eradicate bacteria from implants, such as hydrosurgery technology, while maintaining rigid stability of healing fracture, may improve clinical outcomes.

Approximately 15% of all patients admitted to trauma centers will have sustained blunt chest trauma. Of these patients, about one-third present with a unilateral or bilateral flail chest.1–5 Described as a chest injury with four or more consecutive ribs fractured at two or more sites, flail chest ca