Publications by authors named "Paul Tornetta"

239 Publications

Timing of Flap Coverage With Respect to Definitive Fixation in Open Tibia Fractures.

J Orthop Trauma 2021 Aug;35(8):430-436

Strong Memorial Hospital, Rochester, NY.

Objectives: We conducted a large, U.S wide, observational study of type III tibial fractures, with the hypothesis that delays between definitive fixation and flap coverage might be a substantial modifiable risk factor associated with nosocomial wound infection.

Design: A retrospective analysis of a multicenter database of open tibial fractures requiring flap coverage.

Setting: Fourteen level-1 trauma centers across the United States.

Patients: Two hundred ninety-six (n = 296) consecutive patients with Gustilo III open tibial fractures requiring flap coverage at 14 trauma centers were retrospectively analyzed from a large orthopaedic trauma registry. We collected demographics and the details of surgical care. We investigated the patient, and treatment factors leading to infection, including the time from various points in care to the time of soft-tissue coverage.

Intervention: Delay definitive fixation and flap coverage in tibial type III fractures.

Main Outcome Measurements: (1) Results of multivariate regression with time from injury to coverage, debridement to coverage, and definitive fixation to coverage in the model, to determine which delay measurement was most associated with infection. (2) A second multivariate model, including other factors in addition to measures of flap delay, to provide the estimate between delay and infection after adjustment for confounding.

Results: Of 296 adults (227 M: 69 F) with open Gustilo type III tibial fractures requiring flap coverage, 96 (32.4%) became infected. In the multivariate regression, the time from definitive fixation to flap coverage was most predictive of subsequent wound infection (odds ratio 1.04, 95% confidence interval 1.01 to 1.08, n = 260, P = 0.02) among the time measurements. Temporary internal fixation was not associated with an increased risk of infection in both univariate (P = 0.59) or multivariate analyses (P = 0.60). Flap failure was associated with the highest odds of infection (odds ratio 6.83, 95% confidence interval 3.26 to 14.27, P < 0.001).

Conclusion: Orthoplastic teams that are dedicated to severe musculoskeletal trauma, that facilitate coordination of definitive fixation and flap coverage, will reduce the infection rates in Gustilo type III tibial fractures.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000002033DOI Listing
August 2021

Are Narrative Letters of Recommendation for Medical Students Interpreted as Intended by Orthopaedic Surgery Residency Programs?

Clin Orthop Relat Res 2021 08;479(8):1679-1687

Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA, USA.

Background: Narrative letters of recommendation are an important component of the residency application process. However, because narrative letters of recommendation are almost always positive, it is unclear whether those reviewing the letters understand the writer's intended strength of support for a given applicant.

Questions/purposes: (1) Is the perception of letter readers for narrative letters of recommendation consistent with the intention of the letter's author? (2) Is there inter-reviewer consistency in selection committee members' perceptions of the narrative letters of recommendation?

Methods: Letter writers who wrote two or more narrative letters of recommendation for applicants to one university-based orthopaedic residency program for the 2014 to 2015 application cycle were sent a survey linked to a specific letter of recommendation they authored to assess the intended meaning regarding the strength of an applicant. A total of 247 unstructured letters of recommendation and accompanying surveys were sent to their authors, and 157 surveys were returned and form the basis of this study (response percentage 64%). The seven core members of the admissions committee (of 22 total reviewers) at a university-based residency program were sent a similar survey regarding their perception of the letter. To answer our research question about whether letter readers' perceptions about a candidate were consistent with the letter writer's intention, we used kappa values to determine agreement for survey questions involving discrete variables and Spearman correlation coefficients (SCCs) to determine agreement for survey questions involving continuous variables. To answer our research question regarding inter-reviewer consistency among the seven faculty members, we compared the letter readers' responses to each survey question using intraclass correlation coefficients (ICCs).

Results: There was a negligible to moderate correlation between the intended and perceived strength of the letters (SCC 0.26 to 0.57), with only one of seven letter readers scoring in the moderate correlation category. When stratifying the applicants into thirds, there was only slight agreement (kappa 0.07 to 0.19) between the writers and reviewers. There were similarly low kappa values for agreement about how the writers and readers felt regarding the candidate matching into their program (kappa 0.14 to 0.30). The ICC for each question among the seven faculty reviewers ranged from poor to moderate (ICC 0.42 to 0.52).

Conclusion: Our results demonstrate that the reader's perception of narrative letters of recommendation did not correlate well with the letter writer's intended meaning and was not consistent between letter readers at a single university-based urban orthopaedic surgery residency program.

Clinical Relevance: Given the low correlation between the intended strength of the letter writers and the perceived strength of those letters, we believe that other options such as a slider bar or agreed-upon wording as is used in many dean's letters may be helpful.
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http://dx.doi.org/10.1097/CORR.0000000000001691DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8277265PMC
August 2021

Impact of centre volume, surgeon volume, surgeon experience and geographic location on reoperation after intramedullary nailing of tibial shaft fractures

Can J Surg 2021 07 5;64(4):E371-E376. Epub 2021 Jul 5.

London Health Sciences Centre/University of Western Ontario: David W. Sanders, Mark D. Macleod, Timothy Carey, Kellie Leitch, Stuart Bailey, Kevin Gurr, Ken Konito, Charlene Bartha, Isolina Low, Leila V. MacBean, Mala Ramu, Susan Reiber, Ruth Strapp, Christina Tieszer; Sunnybrook Health Sciences Centre/University of Toronto: Hans Kreder, David J.G. Stephen, Terry S. Axelrod, Albert J.M. Yee, Robin R. Richards, Joel Finkelstein, Richard M. Holtby, Hugh Cameron, John Cameron, Wade Gofton, John Murnaghan, Joseph Schatztker, Beverly Bulmer, Lisa Conlan; Hôpital du Sacré-Coeur de Montréal: Yves Laflamme, Gregory Berry, Pierre Beaumont, Pierre Ranger, Georges-Henri Laflamme, Alain Jodoin, Eric Renaud, Sylvain Gagnon, Gilles Maurais, Michel Malo, Julio Fernandes, Kim Latendresse, Marie-France Poirier, Gina Daigneault; St. Michael’s Hospital/University of Toronto: Emil H. Schemitsch, Michael M. McKee, James P. Waddell, Earl R. Bogoch, Timothy R. Daniels, Robert R. McBroom, Robin R. Richards, Milena R. Vicente, Wendy Storey, Lisa M. Wild; Royal Columbian Hospital/University of British Columbia, Vancouver: Robert McCormack, Bertrand Perey, Thomas J. Goetz, Graham Pate, Murray J. Penner, Kostas Panagiotopoulos, Shafique Pirani, Ian G. Dommisse, Richard L. Loomer, Trevor Stone, Karyn Moon, Mauri Zomar; Wake Forest Medical Center/Wake Forest University Health Sciences, Winston-Salem, NC: Lawrence X. Webb, Robert D. Teasdall, John Peter Birkedal, David F. Martin, David S. Ruch, Douglas J. Kilgus, David C. Pollock, Mitchel Brion Harris, Ethan R. Wiesler, William G. Ward, Jeffrey Scott Shilt, Andrew L. Koman, Gary G. Poehling, Brenda Kulp; Boston Medical Center/Boston University School of Medicine: Paul Tornetta III, William R. Creevy, Andrew B. Stein, Christopher T. Bono, Thomas A. Einhorn, T. Desmond Brown, Donna Pacicca, John B. Sledge III, Timothy E. Foster, Ilva Voloshin, Jill Bolton, Hope Carlisle, Lisa Shaughnessy; Wake Medical Center, Raleigh, NC: William T. Ombremsky, C. Michael LeCroy, Eric G. Meinberg, Terry M. Messer, William L. Craig III, Douglas R. Dirschl, Robert Caudle, Tim Harris, Kurt Elhert, William Hage, Robert Jones, Luis Piedrahita, Paul O. Schricker, Robin Driver, Jean Godwin, Gloria Hansley; Vanderbilt University Medical Center, Nashville, Tenn.: William T. Obremskey, Philip J. Kregor, Gregory Tennent, Lisa M. Truchan, Marcus Sciadini, Franklin D. Shuler, Robin E. Driver, Mary Alice Nading, Jacky Neiderstadt, Alexander R. Vap; MetroHealth Medical Center, Cleveland: Heather A. Vallier, Brendan M. Patterson, John H. Wilber, Roger G. Wilber, John K. Sontich, Timothy A. Moore, Drew Brady, Daniel R. Cooperman, John A. Davis, Beth Ann Cureton; Hamilton Health Sciences, Hamilton, Ont.: Scott Mandel, R. Douglas Orr, John T.S. Sadler, Tousief Hussain, Krishan Rajaratnam, Bradley Petrisor, Mohit Bhandari, Brian Drew, Drew A. Bednar, Desmond C.H. Kwok, Shirley Pettit, Jill Hancock, Natalie Sidorkewicz; Regions Hospital, Saint Paul, Minn.: Peter A. Cole, Joel J. Smith, Gregory A. Brown, Thomas A. Lange, John G. Stark, Bruce Levy, Marc Swiontkowski, Julie Agel, Mary J. Garaghty, Joshua G. Salzman, Carol A. Schutte, Linda (Toddie) Tastad, Sandy Vang; University of Louisville School of Medicine, Louisville, Ky.: David Seligson, Craig S. Roberts, Arthur L. Malkani, Laura Sanders, Sharon Allen Gregory, Carmen Dyer, Jessica Heinsen, Langan Smith, Sudhakar Madanagopal; Memorial Hermann Hospital, Houston: Kevin J. Coupe, Jeffrey J. Tucker, Allen R. Criswell, Rosemary Buckle, Alan Jeffrey Rechter, Dhiren Shaskikant Sheth, Brad Urquart, Thea Trotscher; Erie County Medical Center/University of Buffalo, Buffalo, NY: Mark J. Anders, Joseph M. Kowalski, Marc S. Fineberg, Lawrence B. Bone, Matthew J. Phillips, Bernard Rohrbacher, Philip Stegemann, William M. Mihalko, Cathy Buyea; University of Florida – Jacksonville: Stephen J. Augustine, William Thomas Jackson, Gregory Solis, Sunday U. Ero, Daniel N. Segina, Hudson B. Berrey, Samuel G. Agnew, Michael Fitzpatrick, Lakina C. Campbell, Lynn Derting, June McAdams; Academic Medical Center, Amsterdam: J. Carel Goslings, Kees Jan Ponsen, Jan Luitse, Peter Kloen, Pieter Joosse, Jasper Winkelhagen, Raphaël Duivenvoorden; University of Oklahoma Health Science Center, Oklahoma City: David C. Teague, Joseph Davey, J. Andy Sullivan, William J.J. Ertl, Timothy A. Puckett, Charles B. Pasque, John F. Tompkins II, Curtis R. Gruel, Paul Kammerlocher, Thomas P. Lehman, William R. Puffinbarger, Kathy L. Carl; University of Alberta/University of Alberta Hospital, Edmonton: Donald W. Weber, Nadr M. Jomha, Gordon R. Goplen, Edward Masson, Lauren A. Beaupre, Karen E. Greaves, Lori N. Schaump; Greenville Hospital System, Greenville, SC: Kyle J. Jeray, David R. Goetz, Davd E. Westberry, J. Scott Broderick, Bryan S. Moon, Stephanie L. Tanner; Foothills General Hospital, Calgary: James N. Powell, Richard E. Buckley, Leslie Elves; Saint John Regional Hospital, Saint John, NB: Stephen Connolly, Edward P. Abraham, Donna Eastwood, Trudy Steele; Oregon Health & Science University, Portland: Thomas Ellis, Alex Herzberg, George A. Brown, Dennis E. Crawford, Robert Hart, James Hayden, Robert M. Orfaly, Theodore Vigland, Maharani Vivekaraj, Gina L. Bundy; San Francisco General Hospital: Theodore Miclau III, Amir Matityahu, R. Richard Coughlin, Utku Kandemir, R. Trigg McClellan, Cindy Hsin-Hua Lin; Detroit Receiving Hospital: David Karges, Kathryn Cramer, J. Tracy Watson, Berton Moed, Barbara Scott; Deaconess Hospital Regional Trauma Center and Orthopaedic Associates, Evansville, Ind.: Dennis J. Beck, Carolyn Orth; Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ont.: David Puskas, Russell Clark, Jennifer Jones; Jamaica Hospital, Jamaica, NY: Kenneth A. Egol, Nader Paksima, Monet France; Ottawa Hospital – Civic Campus: Eugene K. Wai, Garth Johnson, Ross Wilkinson, Adam T. Gruszczynski, Liisa Vexler.

Background: Tibial shaft fractures are the most common long-bone injury, with a reported annual incidence of more than 75 000 in the United States. This study aimed to determine whether patients with tibial fractures managed with intramedullary nails experience a lower rate of reoperation if treated at higher-volume hospitals, or by higher-volume or more experienced surgeons.

Methods: The Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) was a multicentre randomized clinical trial comparing reamed and nonreamed intramedullary nailing on rates of reoperation to promote fracture union, treat infection or preserve the limb in patients with open and closed fractures of the tibial shaft. Using data from SPRINT, we quantified centre and surgeon volumes into quintiles. We performed analyses adjusted for type of fracture (open v. closed), type of injury (isolated v. multitrauma), gender and age for the primary outcome of reoperation using multivariable logistic regression.

Results: There were no significant differences in the odds of reoperation between high- and low-volume centres (p = 0.9). Overall, surgeon volume significantly affected the odds of reoperation (p = 0.03). The odds of reoperation among patients treated by moderate-volume surgeons were 50% less than those among patients treated by verylow-volume surgeons (odds ratio [OR] 0.50, 95% confidence interval [CI] 0.28–0.88), and the odds of reoperation among patients treated by high-volume surgeons were 47% less than those among patients treated by very-low-volume surgeons (OR 0.53, 95% CI 0.30–0.93).

Conclusion: There appears to be no significant additional patient benefit in treatment by a higher-volume centre for intramedullary fixation of tibial shaft fractures. Additional research on the effects of surgical and clinical site volume in tibial shaft fracture management is needed to confirm this finding. The odds of reoperation were higher in patients treated by very-low-volume surgeons; this finding may be used to optimize the results of tibial shaft fracture management. Clinical trial registration: ClinicalTrials.gov, NCT00038129
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http://dx.doi.org/10.1503/cjs.004020DOI Listing
July 2021

Is There a Critical Radiographic Angle That Portends Poor Functional Outcome Scores in Nonoperative Treatment of Isolated Humeral Shaft Fractures?

J Surg Orthop Adv 2021 ;30(2):73-77

Saint Louis University, St. Louis, Missouri.

Our purpose was to evaluate radiographic alignment of nonoperatively treated humerus fractures and determine if there is a critical angle associated with worse outcomes. All patients with humeral shaft fractures that were prospectively followed as part of a larger multicenter trial were reviewed. These patients were selected for nonoperative management based on shared decision making. There were 80 patients that healed with adequate data. The receiver operating characteristic (ROC) had best fit with a sagittal radiographic angle of 10° (AUC: 0.731) and coronal angle of 15° (AUC: 0.580) at 1-year follow-up. We found increased or worse disabilities of the arm, shoulder and hand (DASH) scores with > 10° sagittal alignment or > 15° of coronal alignment. Poor DASH scores were observed at angles lower than previously accepted for nonoperative treatment. These findings are useful in decision making and patient guidance. (Journal of Surgical Orthopaedic Advances 30(2):073-077, 2021).
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June 2021

Operative vs. Nonoperative Treatment of Isolated Humeral Shaft Fractures: A Prospective Cohort Study.

J Surg Orthop Adv 2021 ;30(2):67-72

Saint Louis University, St. Louis, Missouri.

The purpose was to compare plate and screw fixation (open reduction internal fixation [ORIF]) and functional bracing (FB) of isolated humeral shaft fractures with treatment and patient-based outcomes. We performed a prospective trial of ORIF v. FB at 12 centers. Surgeons counseled patients on treatment options and a patient centered decision was made. We enrolled 179 patients, of which 6-month data was analyzed for 102 (39 female; 63 male). Forty-five were treated with ORIF and 57 with FB. We found no difference in the disability of the arm, shoulder and hand (DASH) score, visual analogue score (VAS) or elbow range of motion (ROM) at 6 months. However, 11% of the FB group developed nonunion. Complications in the ORIF group included a 2% infection and nonunion rate and 13% iatrogenic radial nerve dysfunction (RND). ORIF can be expected to result in higher union rates with the inherent risks of infection and RND. Finally, at 6 months, both groups demonstrated higher DASH scores than population norms, indicating a lack of full recovery. (Journal of Surgical Orthopaedic Advances 30(2):067-072, 2021).
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June 2021

Definitive fixation outcomes of open tibial shaft fractures: Systematic review and network meta-analysis.

J Orthop Trauma 2021 Mar 27. Epub 2021 Mar 27.

Department of Orthopaedic Surgery, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom. Department of Orthopaedic Surgery, Southmead Hospital, Bristol, United Kingdom. Department of Orthopaedic Surgery, The Royal National Orthopaedic Hospital, Stanmore, United Kingdom. Department of Orthopaedic Surgery, McMaster University, Ontario, Canada Department of Orthopaedic Surgery, Boston Medical Center, Boston, USA.

Objectives: To delineate if there were differences in outcomes between definitive fixation strategies in open tibial shaft fractures.

Data Sources: MEDLINE, EMBASE, CENTRAL, OpenGrey.

Study Selection: Randomized and Quasi-randomized studies analyzing adult patients (>18 years) with open tibial shaft fractures (AO-42), undergoing definitive fixation treatment of any type.

Data Extraction: Data regarding patient demographics, definitive bony/soft-tissue management, irrigation, type of antibiotics and follow up. Definitive intervention choices included unreamed intramedullary nailing (UN), reamed intramedullary nailing (RN), plate fixation, multiplanar, and uniplanar external fixation (EF). The primary outcome was unplanned reoperation rate. Cochrane risk of bias tool and GRADE systems were used for quality analysis.

Data Synthesis: A random-effects meta-analysis of head-to-head evidence, followed by a network analysis that modelled direct and indirect data was conducted to provide precise estimates (relative risks (RR) and associated 95% confidence intervals (95% CI)).

Results: In open tibial shaft fractures, direct comparison UN showed a lower risk of unplanned reoperation versus EF (RR 0.67, 95% CI 0.43 - 1.05, p=0.08, moderate confidence). In Gustilo type III open fractures, the risk reduction with nailing compared to EF was larger (RR 0.61, 95% CI 0.37 - 1.01, p=0.05, moderate confidence). UN had a lower reoperation risk compared to RN (RR 0.91, 95% CI 0.58 - 1.4, p=0.68, low confidence), however this was not significant and did not demonstrate a clear advantage.

Conclusion: Intramedullary nailing reduces the risk of unplanned reoperation by a third compared to EF, with a slightly larger reduction in type III open fractures. Future trials should focus on major complication rates and health-related quality of life in high-grade tibial shaft fractures.

Level Of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000002090DOI Listing
March 2021

Risk Factors Associated With Infection in Open Fractures of the Upper and Lower Extremities.

J Am Acad Orthop Surg Glob Res Rev 2020 12 8;4(12):e20.00188. Epub 2020 Dec 8.

From the Department of Orthopedic Surgery, Boston Medical Center, Boston, MA (Dr. Tornetta III); the University of Missouri School of Medicine, Columbia, MO (Dr. Della Rocca); the University of California San Francisco, San Francisco General Hospital, Orthopaedic Trauma Institute, San Francisco, CA (Dr. Morshed); the The CORE Institute, University of Arizona-Phoenix, Phoenix, AZ (Dr. Jones); the Department of Health Research Methods, Evidence, and Impact (Ms. Heels-Ansdell, Dr. Sprague, and Dr. Bhandari) and the Division of Orthopaedic Surgery, Department of Surgery (Dr. Sprague, Dr. Petrisor, Ms. Del Fabbro, Ms. Bzovsky, and Dr. Bhandari), McMaster University, Hamilton, Ontario, Canada; and the Department of Orthopaedic Surgery, Prisma Health-Upstate, Greenville, SC (Dr. Jeray).

Introduction: Open fractures are associated with a high risk of infection. The prevention of infection is the single most important goal, influencing perioperative care of patients with open fractures. Using data from 2,500 participants with open fracture wounds enrolled in the Fluid Lavage of Open Wounds trial, we conducted a multivariable analysis to determine the factors that are associated with infections 12 months postfracture.

Methods: Eighteen predictor variables were identified for infection a priori from baseline data, fracture characteristics, and surgical data from the Fluid Lavage of Open Wounds trial. Twelve predictor variables were identified for deep infection, which included both surgically and nonoperatively managed infections. We used multivariable Cox proportional hazards regression analyses to identify the factors associated with infection. Irrigation solution and pressure were included as variables in the analysis. The results were reported as adjusted hazard ratios (HRs), 95% confidence intervals (CIs), and associated P values. All tests were two tailed with alpha = 0.05.

Results: Factors associated with any infection were fracture location (tibia: HR 5.13 versus upper extremity, 95% CI 3.28 to 8.02; other lower extremity: HR 3.63 versus upper extremity, 95% CI 2.38 to 5.55; overall P < 0.001), low energy injury (HR 1.64, 95% CI 1.08 to 2.46; P = 0.019), degree of wound contamination (severe: HR 2.12 versus mild, 95% CI 1.35 to 3.32; moderate: HR 1.08 versus mild, 95% CI 0.78 to 1.49; overall P = 0.004), and need for flap coverage (HR 1.82, 95% CI 1.11 to 2.99; P = 0.017).

Discussion: The results of this study provide a better understanding of which factors are associated with a greater risk of infection in open fractures. In addition, it can allow for surgeons to better counsel patients regarding prognosis, helping patients to understand their individual risk of infection.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-20-00188DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7725249PMC
December 2020

Lack of Displacement of the Fibula is NOT Confirmation of Ankle Stability in SE Pattern Ankle Fractures.

J Orthop Trauma 2021 Apr 17. Epub 2021 Apr 17.

Boston Medical Center, Department of Orthopaedic Surgery, 850 Harrison Ave. Dowling 2 North, Boston, MA 02118.

Objectives: To evaluate and compare radiographic findings in SE2 injuries vs. stress (+) SE4 injuries.

Design: Retrospective.

Setting: Academic Level 1 Trauma Center.

Patients: 350 skeletally mature patients at a single level 1 trauma center who presented with an isolated, Lauge-Hansen type SER pattern, Weber B lateral malleolar fracture, OTA/AO 44-B.

Results: We reviewed 350 patients (185M: 165F) 18 - 95 years of age (avg 45) with isolated SE pattern lateral malleolar fractures. 109 had SE4 injuries (MCS=8.3mm). 241 ankles were stressed; 164 were unstable and 77 were stable (SE2). Avg MCS at presentation and on stress radiographs was 3.59mm for the SE2 (no widening) and 3.86mm and 5.94mm for the stress (+) SE4 group. The fibular displacement for the SE2, stress (+) SE4, and SE4 groups were: 1.5 (0-4.5), 3.5 (0 - 6.6), and 4.1 (0 - 30.5). 16/77 (20%) of SE2 and 24/164 (15%) of stress (+) SE4 fractures had NO displacement of the fibula on the lateral view. Similarly, 53/77 (68%) of SE2 and 91/164 (55%) of stress (+) SE4 had ≤2mm of fibular displacement. ≤2mm of fibular displacement on the lateral radiograph corresponded with a .69 sensitivity and only .37 positive predictive value for stable ankle mortise on stress exam.

Conclusions: Previous work indicated that patients with an isolated SE pattern fibula fracture, a normal MCS, and ≤2mm of fibular displacement on the lateral radiograph have a high rate of ankle stability, with a positive predictive value of approaching 97%. We were unable to confirm this finding as 15% of unstable ankles had 0mm and 55% had ≤ 2mm of fibular displacement. We conclude that stability may not be inferred from a lack of fibular displacement on the lateral view in this population of patients. If stability is to be determined, it must be tested irrespective of fibular displacement on the lateral radiograph.

Level Of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000002139DOI Listing
April 2021

The Use of Personality Assessment in Mentoring and to Aid in Self-reflection in Orthopaedic Surgery Residency Programs.

J Am Acad Orthop Surg 2021 07;29(13):545-552

From the Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, MA (Tornetta), Boston University School of Medicine, Boston, MA (Resad), and Pediatric Orthopaedics, Rush University Medical Center, Chicago, IL (Kogan).

Personality plays an important role in performance in medical education and mentorship. Personality assessment can aid in the ability to identify strengths and areas for development by understanding how one's personality influences their learning and interpersonal relationships. We sought to evaluate personality assessment as an effective tool in mentoring during orthopaedic residency in this prospective, cross-sectional study from two orthopaedic surgery residency programs using the Hogan Personality Inventory (HPI). Participants completed a survey regarding their experience with the assessment. Descriptive statistics were calculated, and two-sample t-tests were used to examine differences between groups. In total, thirty-four individuals completed the survey. Our results showed 82.4% reported that the HPI very accurately represented them and 58.8% reported better understanding potentially perceived strengths and weaknesses. In total, 75.7% and 72.7% were satisfied with their mentorship about development as a clinician and researcher, respectively. Significant differences were seen between participants who did and did not re-review their results, and participants who did and did-not believe their results profile was accurate. We conclude that personality assessments can be valuable in promoting introspection and strengthening relationships within orthopaedic surgery, particularly when they are valued and emphasized by the user. Our results suggest that use of the HPI provided participants with a better understanding of their perceived strengths and weaknesses as they progress through their orthopaedic residency training.
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http://dx.doi.org/10.5435/JAAOS-D-20-01345DOI Listing
July 2021

Recognizing Isolated Ulnar Fractures as Potential Markers for Intimate Partner Violence.

J Am Coll Radiol 2021 Apr 3. Epub 2021 Apr 3.

Professor and Chair of Orthopedic Surgery, Boston University Medical Center, Boston, Massachusetts; Professor of Orthopedic Surgery, Boston University Medical Center, Boston, Massachusetts.

Purpose: This study aimed to assess the incidence of intimate partner violence (IPV) in women with isolated ulnar fractures and compare the injury characteristics in victims of IPV with those who sustained the same fractures due to other causes.

Methods: Electronic health records from three level I trauma centers were queried to identify a cohort of women, aged 18 to 50, sustaining isolated ulnar fractures from 2005 to 2019. Radiographs were reviewed for fracture location, comminution, and displacement. Demographic data, number of visits to the emergency department, and documentation of IPV were also collected. Patients were stratified into four groups based on clinical chart review: confirmed IPV, possible IPV, not suspected for IPV, and not IPV. Historical imaging analysis for IPV prediction was also performed.

Results: There were 62 patients, with a mean age of 31 years (IPV: 12 confirmed, 8 possible, 8 suspected not IPV, 34 confirmed not IPV). Comparative analysis with and without suspected cases demonstrated IPV to be associated with nondisplaced fractures (95% versus 43%; P < .001 and 91% versus 44%; P = .012). Confirmed cases were also associated with homelessness (46% versus 0%; P < .001), and the number of documented emergency department visits (median 7.0; interquartile range 2.0-12.8 versus 1.0; interquartile range 1.0-2.0; P < .001). Formal documentation of IPV evaluation was completed in only 14 of 62 (22.5%) patients. Historical imaging analysis predicted IPV in 8 of 12 (75%) confirmed IPV cases.

Conclusion: Up to one-third of adult women sustaining isolated ulnar fractures may be the victims of IPV. Lack of displacement on radiographs, frequent emergency department visits, and homelessness would favor IPV etiology.
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http://dx.doi.org/10.1016/j.jacr.2021.03.006DOI Listing
April 2021

Gunshot Fractures of the Forearm: A Multicenter Evaluation.

J Orthop Trauma 2021 Apr 2. Epub 2021 Apr 2.

Department of Orthopaedic Surgery, Boston University Medical Center, Boston, MA Louisiana State University, Department of Orthopaedic Surgery, New Orleans, LA MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH Saint Louis University Hospital, St Louis, MO Wake Forest School of Medicine, Winston-Salem, NC Florida Orthopaedic Institute, Tampa, FL Department of Orthopedic Surgery, Hennepin County Medical Center, Minneapolis, MN Indiana University School of Medicine, Department of Orthopaedics, Indianapolis, IN Department of Orthopaedic Surgery and Sports Medicine, Harborview Medical Center, Seattle, WA.

Objectives: To evaluate a large series of open fractures of the forearm following gunshot wounds in order to determine complication rates and factors that may lead to infection, nonunion, or compartment syndrome.

Design: Multi-center retrospective review.

Setting: Nine Level 1 Trauma CentersPatients/Participants: 168 patients had 198 radius and ulna fractures due to firearm injuries. All patients were adults, had a fracture due to a firearm injury and at least one year clinical follow-up or follow-up until union. Average follow-up was 831 days.

Intervention: Most patients (91%) received antibiotics. Formal irrigation and debridement in the operating room was performed in 75% of cases along with either internal fixation (75%), external fixation (6%), or I&D without fixation (19%).

Main Outcome Measures: Complications including neurovascular injuries, compartment syndrome, infection and nonunion.

Results: Twenty-one percent of patients had arterial injuries and 40% had nerve injuries. Nine patients (5%) developed compartment syndrome. Seventeen patients (10%) developed infections, all in comminuted or segmental fractures. Antibiotics were not associated with a decreased risk of infection. Infections in the ulna were more common in fractures with retained bullet fragments and bone loss. Twenty patients (12%) developed a nonunion. Nonunions were associated with high velocity firearms and bone defect size.

Conclusions: Open fractures of the forearm from gunshot wounds are serious injuries that carry high rates of nonunion and infection. Fractures with significant bone defects are at increased risk of nonunion and should be treated with stable fixation and proper soft tissue handling. Ulna fractures are at particularly high risk for deep infection and septic nonunion and should be treated aggressively. Forearm fractures from gunshot wounds should be followed until union to identify long term complications.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000002056DOI Listing
April 2021

Resident Wellness During the COVID-19 Pandemic: A Nationwide Survey of Orthopaedic Residents.

J Am Acad Orthop Surg 2021 May;29(10):407-413

From the Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL (Nolte and Kogan), the Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, MA (Tornetta), the Department of Orthopaedic Surgery, Penn Medicine, Philadelphia, PA (Mehta), the University of Alabama at Birmingham, Birmingham, AL (Ponce), University of South Carolina Orthopaedics Center-Prisma Health Midlands, Columbia, SC (Grabowski and Spitnale), and the Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN (Turner).

Introduction: The COVID-19 pandemic has influenced the resident workforce to a particularly powerful and unexpected extent. Given the drastic changes to resident roles, expectations, and responsibilities, many valuable lessons regarding resident concerns and wellness can be garnered from this unique experience.

Methods: A voluntary survey was sent to 179 Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery residency program directors to distribute to their residents. Questions focused on issues that may have occurred, program's responses, and expectations of programs during the pandemic.

Results: In total, 507 residents completed the survey, and 10% reported being deployed to do nonorthopaedic-related care, with junior classes being more likely to receive this assignment (P < 0.001). The greatest concern for respondents was the possibility of getting family members sick (mean = 3.89, on scale of 1-5), followed by personally contracting the illness (mean = 3.38).

Discussion: The COVID-19 pandemic has resulted in numerous changes and novel sources of adversity for the orthopaedic surgery resident. Contrary to popular opinion, most residents are comfortable with the proposition of providing nonorthopaedic care. The possibility of bringing a pathogen to the home environment and infecting family members seems to be an overarching concern, and efforts to ensure resident and family safety are key.
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http://dx.doi.org/10.5435/JAAOS-D-20-01372DOI Listing
May 2021

The Statistical Fragility of Platelet-Rich Plasma in Rotator Cuff Surgery: A Systematic Review and Meta-analysis.

Am J Sports Med 2021 Mar 1:363546521989976. Epub 2021 Mar 1.

University of California at Irvine, Irvine, California, USA.

Background: The practice of evidence-based medicine relies on objective data to guide clinical decision-making with specific statistical thresholds conveying study significance.

Purpose: To determine the utility of applying the fragility index (FI) and the fragility quotient (FQ) analysis to randomized controlled trials (RCTs) evaluating the utilization of platelet-rich plasma (PRP) in rotator cuff repairs (RCRs).

Study Design: Systematic review and meta-analysis.

Methods: RCTs pertaining to the utilization of PRP in surgical RCRs published in 13 peer-reviewed journals from 2000 to 2020 were evaluated. The FI was determined by manipulating each reported outcome event until a reversal of significance was appreciated. The associated FQ was determined by dividing the FI by the sample size.

Results: Of the 9746 studies screened, 19 RCTs were ultimately included for analysis. The overall FI incorporating all 19 RCTs was only 4, suggesting that the reversal of only 4 events is required to change study significance. The associated FQ was determined as 0.092. Of the 43 outcome events reporting lost to follow-up data, 13 (30.2%) represented lost to follow-up >4.

Conclusion: Our analysis suggests that RCTs evaluating PRP for surgical RCRs may lack statistical stability with only a few outcome events required to alter trial significance. Therefore, we recommend the reporting of an FI and an FQ in conjunction with value analysis to carefully interpret the integrity of statistical stability in future comparative trials.

Clinical Relevance: Clinical decisions are often informed by statistically significant results. Thus, a true understanding of the robustness of the statistical findings informing clinical decision-making is of critical importance.
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http://dx.doi.org/10.1177/0363546521989976DOI Listing
March 2021

Imaging patterns of lower extremity injuries in victims of intimate partner violence (IPV).

Emerg Radiol 2021 Aug 24;28(4):751-759. Epub 2021 Feb 24.

Trauma Imaging Research and Innovation Center, Brigham and Women's Hospital, Boston, MA, USA.

Purpose: To describe the pattern and distribution of lower extremity injuries in victims of intimate partner violence (IPV).

Materials And Methods: A retrospective radiological review of 688 patients reporting IPV to our institution's violence intervention and prevention program between January 2013 and June 2018 identified 88 patients with 154 lower extremity injuries. All lower extremity injuries visible on radiological studies were analyzed. Concomitant, recurrent, and associated injuries were also collected, in addition to the demographic data.

Results: The injuries consisted of 103 fractures, 46 soft tissue injuries, and 5 dislocations. The foot was the most common site of injury representing 39% (60/154) of total injuries, 48% (49/103) of fractures, 17% (8/46) of soft tissue injuries, and 3 dislocations. The ankle was the second most common site of injury representing 30% (47/154) of total injuries, 20% (21/103) of fractures, and 57% (26/46) of soft tissue injuries. Recurrent injuries of the lower extremity were seen in 30% (26/88) of victims who had 74 recurrent injuries. The most common sites of recurrent injury were the foot and ankle, representing 72% (53/74) of recurrent injuries.

Conclusion: Recurrent injuries of the foot and ankle, synchronous craniofacial injuries, and upper extremity injuries in young women (<35 years) should prompt radiologists to consider IPV.
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http://dx.doi.org/10.1007/s10140-021-01914-5DOI Listing
August 2021

Prognostic factors for predicting health-related quality of life after intramedullary nailing of tibial fractures: a randomized controlled trial.

Bone Jt Open 2021 Jan 5;2(1):22-32. Epub 2021 Jan 5.

Division of Orthopaedic Surgery, London Health Sciences Centre and Western University, London, Ontario, Canada.

Aims: Using tibial shaft fracture participants from a large, multicentre randomized controlled trial, we investigated if patient and surgical factors were associated with health-related quality of life (HRQoL) at one year post-surgery.

Methods: The Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) trial examined adults with an open or closed tibial shaft fracture who were treated with either reamed or unreamed intramedullary nails. HRQoL was assessed at hospital discharge (for pre-injury level) and at 12 months post-fracture using the Short Musculoskeletal Functional Assessment (SMFA) Dysfunction, SMFA Bother, 36-Item Short Form 36 (SF-36) Physical, and SF-36 Mental Component scores. We used multiple linear regression analysis to determine if baseline and surgical factors, as well as post-intervention procedures within one year of fracture, were associated with these HRQoL outcomes. Significance was set at p < 0.01. We hypothesize that, irrespective of the four measures used, prognosis is guided by both modifiable and non-modifiable factors and that patients do not return to their pre-injury level of function, nor HRQoL.

Results: For patient and surgical factors, only pre-injury quality of life and isolated fracture showed a statistical effect on all four HRQoL outcomes, while high-energy injury mechanism, smoking, and race or ethnicity, demonstrated statistical significance for three of the four HRQoL outcomes. Patients who did not require reoperation in response to infection, the need for bone grafts, and/or the need for implant exchanges had statistically superior HRQoL outcomes than those who did require intervention within one year after initial tibial fracture nailing.

Conclusion: We identified several baseline patient factors, surgical factors, and post-intervention procedures within one year after intramedullary nailing of a tibial shaft fracture that may influence a patient's HRQoL.Cite this article: 2021;2(1):22-32.
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http://dx.doi.org/10.1302/2633-1462.21.BJO-2020-0150.R1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7842162PMC
January 2021

Combined Orthopaedic and Vascular Injuries with Ischemia: A Multicenter Analysis.

J Orthop Trauma 2021 Jan 21. Epub 2021 Jan 21.

Department of Orthopedic Surgery, Boston Medical Center, Boston University Medical School; Boston, MA Department of Orthopedic Surgery, Harborview Medical Center; Seattle, WA Department of Orthopedic Surgery, St. Louis University; St. Louis, MO Department of Orthopedic Surgery, Tampa General Hospital; Tampa, FL Department of Orthopedic Surgery, Lahey Hospital and Medical Center; Burlington, MA Department of Orthopedic Surgery, Case Western University; Cleveland, OH Department of Orthopedic Surgery, Indiana University Health West Hospital; Indianapolis, IN Department of Orthopedic Surgery, Washington University; St. Louis, MO Department of Orthopedic Surgery, LSU School of Medicine; New Orleans, LA.

Objectives: To review a large, multicenter experience to identify the current salvage and amputation rates of these combined injuries and where possible, the variables that predict amputation.

Design: Retrospective.

Setting: Nice trauma centers.

Patients: 199 patients presenting to 9 trauma centers with orthopaedic and vascular injuries resulting in ischemic limbs for whom the orthopaedic service was involved with the decision for salvage vs. amputation.

Results: We reviewed 199 patients, aged 17-85 years. 172 of the injuries were open. Thirty-eight (19%) were treated with amputation upon admission as they were deemed to be unsalvageable. Of the remaining 161 who had attempted salvage, 36 (30%) required late amputation. Closed injuries were successfully salvaged in 25/27 cases (93%). The highest rate of amputation was in tibia fractures with a combined amputation rate of 62%. In those attempted to be salvaged, 21/48 (44%) required amputation. The ischemia time for successful salvage was significantly less, p = 0.03. 124 patients had their definitive vascular repair prior to the bony reconstruction. There were 15 vascular complications, of which 13 (86%) had the definitive vascular repair performed prior to the definitive osseous repair, although this was not statistically significant.

Conclusions: In this series of combined orthopaedic and vascular injuries, we found a high rate of acute and late amputations. It is possible that other protocols, such as shunting and stabilizing the osseous injury prior to vascular repair may benefit limb salvage, although this needs more study.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000002067DOI Listing
January 2021

Spinal Anesthesia Associated With Increased Length of Stay Compared to General Anesthesia for Ankle Open Reduction Internal Fixation: A Propensity-Matched Analysis.

J Foot Ankle Surg 2021 Mar-Apr;60(2):350-353. Epub 2020 Nov 27.

Orthopaedic Surgeon, Chief, Chair, and Professor of Orthopaedic Surgery, Boston Medical Center, Boston, MA.

General and spinal anesthesia are both utilized for patients undergoing open reduction internal fixation of the ankle, but there are little data comparing early complication rates. The purpose of this study was to compare duration of surgery, length of stay, and rates of postoperative adverse events within 30 days in patients undergoing open reduction internal fixation of ankle fracture using spinal versus general anesthesia. Adult patients who underwent open reduction internal fixation of a closed ankle fracture from 2012 to 2016 were retrospectively identified from American College of Surgeons National Surgical Quality Improvement Program. Duration of surgery, length of stay, 30-day adverse events, and unplanned readmissions were compared between patients who received general anesthesia and spinal anesthesia. Propensity adjustment with respect to known risk factors for complications and adjunctive regional block was used to match patients. Of the 10,795 patients included after applying the inclusion and exclusion criteria, 9862 (91.36%) received general anesthesia and 933 (8.64%) received spinal anesthesia. Using propensity-scored matching, 841 patients in the spinal cohort were matched to 3364 patients in the general cohort. Spinal anesthesia was associated with increased length of stay (+0.5 days, 95% confidence interval 0.23-0.77, p < .001). There were no differences in the rates of major/minor complications, mortality, transfusions, unplanned readmissions, or duration of surgery. General anesthesia is predominantly used for fixation of ankle fractures. While spinal anesthesia is associated with lower complication rates in hip and knee surgery, we found that it is associated with increased length of stay in patients undergoing open reduction internal fixation of the ankle within 30 days of surgery.
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http://dx.doi.org/10.1053/j.jfas.2020.08.035DOI Listing
June 2021

A Reevaluation of the Risk of Infection Based on Time to Debridement in Open Fractures: Results of the GOLIATH Meta-Analysis of Observational Studies and Limited Trial Data.

J Bone Joint Surg Am 2021 02;103(3):265-273

Division of Orthopaedics, Dalhousie University, Halifax, Nova Scotia, Canada.

Background: Open fractures are one of the leading causes of disability worldwide. The threshold time to debridement that reduces the infection rate is unclear.

Methods: We searched all available databases to identify observational studies and randomized trials related to open fracture care. We then conducted an extensive meta-analysis of the observational studies, using raw and adjusted estimates, to determine if there was an association between the timing of initial debridement and infection.

Results: We identified 84 studies (18,239 patients) for the primary analysis. In unadjusted analyses comparing various "late" time thresholds for debridement versus "early" thresholds, there was an association between timing of debridement and surgical site infection (odds ratio [OR] = 1.29, 95% confidence interval [CI] = 1.11 to 1.49, p < 0.001, I2 = 30%, 84 studies, n = 18,239). For debridement performed between 12 and 24 hours versus earlier than 12 hours, the OR was higher in tibial fractures (OR = 1.37, 95% CI = 1.00 to 1.87, p = 0.05, I2 = 19%, 12 studies, n = 2,065), and even more so in Gustilo type-IIIB tibial fractures (OR = 1.46, 95% CI = 1.13 to 1.89, p = 0.004, I2 = 23%, 12 studies, n = 1,255). An analysis of Gustilo type-III fractures showed a progressive increase in the risk of infection with time. Critical time thresholds included 12 hours (OR = 1.51, 95% CI = 1.28 to 1.78, p < 0.001, I2 = 0%, 16 studies, n = 3,502) and 24 hours (OR = 2.17, 95% CI = 1.73 to 2.72, p < 0.001, I2 = 0%, 29 studies, n = 5,214).

Conclusions: High-grade open fractures demonstrated an increased risk of infection with progressive delay to debridement.

Level Of Evidence: Prognostic Level IV. See Instruction for Authors for a complete description of the levels of evidence.
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http://dx.doi.org/10.2106/JBJS.20.01103DOI Listing
February 2021

Management of pelvi-acetabular injuries: Global scenario and future trends.

J Clin Orthop Trauma 2020 Nov-Dec;11(6):961-962. Epub 2020 Oct 20.

Department of Orthopedic Surgery, Boston University School of Medicine, Boston, MA, 02118, USA.

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http://dx.doi.org/10.1016/j.jcot.2020.10.041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7656465PMC
October 2020

Intimate Partner Violence: A Primer for Radiologists to Make the "Invisible" Visible.

Radiographics 2020 Nov-Dec;40(7):2080-2097. Epub 2020 Oct 2.

From the Departments of Radiology (F.A., A.K., G.W.L.B., S.E.S., B.K.) and Orthopaedic Surgery (G.S.M.D.) and the Trauma Imaging Research and Innovation Center (B.K.), Brigham and Women's Hospital; and Department of Orthopaedic Surgery, Massachusetts General Hospital (M.B.H.), Harvard Medical School (J.L.), 75 Francis St, Boston, MA 02115; and Department of Orthopaedic Surgery, Boston Medical Center, Boston University Medical School, Boston, Mass (P.T.).

Intimate partner violence (IPV) is the physical, sexual, or emotional violence between current or former partners. It is a major public health issue that affects nearly one out of four women. Nonetheless, IPV is greatly underdiagnosed. Imaging has played a significant role in identifying cases of nonaccidental trauma in children, and similarly, it has the potential to enable the identification of injuries resulting from IPV. Radiologists have early access to the radiologic history of such victims and may be the first to diagnose IPV on the basis of the distribution and imaging appearance of the patient's currrent and past injuries. Radiologists must be familiar with the imaging findings that are suggestive of injuries resulting from IPV. Special attention should be given to cases in which there are multiple visits for injury care; coexistent fractures at different stages of healing, which may help differentiate injuries related to IPV from those caused by a stranger; and injuries in defensive locations and target areas such as the face and upper extremities. The authors provide an overview of current methods for diagnosing IPV and define the role of the radiologist in cases of IPV. They also describe a successful diagnostic imaging-based approach for helping to identify IPV, with a specific focus on the associated imaging findings and mechanisms of injuries. In addition, current needs and future perspectives for improving the diagnosis of this hidden epidemic are identified. This information is intended to raise awareness among radiologists, with the ultimate goal of improving the diagnosis of IPV and thus reducing the devastating effects on victims' lives. RSNA, 2020.
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http://dx.doi.org/10.1148/rg.2020200010DOI Listing
July 2021

The Fate of Patients After a Staged Nonunion Procedure for Known Infection.

J Orthop Trauma 2021 04;35(4):211-216

Department of Orthopaedic Surgery, Inova Fairfax Hospital, Falls Church, VA.

Objectives: To determine the factors associated with successful union and eradication of infection in the setting of staged procedures to treat obviously infected nonunions of long bones. We hypothesize that patients with positive intraoperative cultures obtained at the time of definitive surgery for infected nonunions are more likely to have persistent nonunion than those with negative cultures.

Design: Multicenter retrospective review.

Setting: Eight academic Level 1 trauma centers.

Patients/participants: Patients who underwent staged management for obviously infected nonunion of a long bone.

Main Outcome Measurements: For each patient, initial fracture management, management of retained implants, number of debridements, grafting, bacteriology, antibiotic course, bone defect management, soft-tissue coverage, and definitive surgery performed were reviewed.

Results: A total of 134 patients were treated with staged procedures for obviously infected nonunion of a long bone (mean age 49 years, 60% open fractures, and mean follow-up 22 months). During definitive procedures, 120 patients had intraoperative cultures taken with 43% having positive cultures. For culture-positive patients, 41 patients achieved eventual union and 10 had persistent nonunion. Of 69 culture-negative patients, 66 achieved eventual union and 3 had persistent nonunion. The number of patients with union versus persistent nonunion was statistically significant between culture-positive and culture-negative groups (P = 0.015).

Conclusions: Management of infected nonunion in long bones with staged treatments before definitive fixation are beneficial but ultimately less effective when performed in the setting of positive bacterial cultures at the time of definitive management.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001953DOI Listing
April 2021

What Is the Financial Impact of Orthopaedic Sequelae of Intravenous Drug Use on Urban Tertiary-care Centers?

Clin Orthop Relat Res 2020 10;478(10):2202-2212

P. Tornetta, Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA, USA.

Background: Orthopaedic sequelae such as skin and soft-tissue abscesses are frequent complications of intravenous drug use (IVDU) and comprise many of the most common indications for emergency room visits and hospitalizations within this population. Urban tertiary-care and safety-net hospitals frequently operate in challenging economic healthcare environments and are disproportionately tasked with providing care to this largely underinsured patient demographic. Although many public health initiatives have been instituted in recent years to understand the health impacts of IVDU and the spreading opioid epidemic, few efforts have been made to investigate its economic impact on healthcare systems. The inpatient treatment of orthopaedic sequelae of IVDU is a high-cost healthcare element that is critically important to understand within the current national context of inflationary healthcare costs.

Questions/purposes: (1) What were the total healthcare costs incurred and total hospital reimbursements received in the treatment of extraspinal orthopaedic sequelae of IVDU? (2) What were the total healthcare costs incurred and total hospital reimbursements received in the treatment of spinal orthopaedic sequelae of IVDU? (3) How did patient insurance status effect the economic burden of orthopaedic sequelae of IVDU?

Methods: An internal departmental record of all successive patients requiring inpatient treatment of orthopaedic sequelae of IVDU was initiated at Boston Medical Center (Boston, MA, USA) in 2012 and MetroHealth Medical Center (Cleveland, OH, USA) in 2015. A total of 412 patient admissions between 2012 to 2017 to these two safety-net hospitals (n = 236 and n = 176, respectively) for orthopaedic complications of IVDU were included in the study. These sequelae included cellulitis, cutaneous abscess, bursitis, myositis, tenosynovitis, septic arthritis, osteomyelitis, and epidural abscess. Patients were included if they were older than 18 years of age, presented to the emergency department for management of a musculoskeletal infection secondary to IVDU, and required inpatient orthopaedic treatment during their admission. Exclusion criteria included all patients presenting with a musculoskeletal infection not directly secondary to active IVDU. Patients presenting with an epidural abscess (Boston Medical Center, n = 36) were evaluated separately to explore potential differences in costs within this subgroup. A robust retrospective financial analysis was performed using internal financial databases at each institution which directly enumerated all true hospital costs associated with each patient admission, independent of billed hospital charges. All direct, indirect, variable, and fixed hospital costs were individually summed for each hospitalization, constituting a true "bottom-up" micro-costing approach. Labor-based costs were calculated through use of time-based costing; for instance, the cost of nursing labor care associated with a patient admission was determined through ascription of the median hospital cost of a registered nurse within that department (that is, compensation for salary plus benefits) to the total length of nursing time needed by that patient during their hospitalization. Primary reimbursements reflected the true monetary value received by the study institutions from insurers and were determined through the total adjusted payment for each inpatient admission. All professional fees were excluded. A secondary analysis was performed to assess the effect of patient insurance status on hospital costs and reimbursements for each patient admission.

Results: The mean healthcare cost incurred for the treatment of extraspinal orthopaedic sequelae of IVDU was USD 9524 ± USD 1430 per patient admission. The mean hospital reimbursement provided for the treatment of these extraspinal sequelae was USD 7678 ± USD 1248 per patient admission. This resulted in a mean financial loss of USD 1846 ± USD 1342 per patient admission. The mean healthcare cost incurred at Boston Medical Center for the treatment of epidural abscesses secondary to IVDU was USD 44,357 ± USD 7384 per patient. Hospital reimbursements within this subgroup were highly dependent upon insurance status. The median (range) reimbursement provided for patients possessing a unique hospital-based nonprofit health plan (n = 4) was USD 103,016 (USD 9022 to USD 320,123), corresponding to a median financial gain of USD 24,904 (USD 2289 to USD 83,079). However, the mean reimbursement for all other patients presenting with epidural abscesses (n = 32) was USD 30,429 ± USD 5278, corresponding to a mean financial loss of USD 5768 ± USD 4861. A secondary analysis demonstrated that treatment of extraspinal orthopaedic sequelae of IVDU for patients possessing Medicaid insurance (n = 309) resulted in a financial loss of USD 2813 ± USD 1593 per patient admission. Conversely, treatment of extraspinal orthopaedic sequelae for patients possessing non-Medicaid insurance (n = 67) generated a mean financial gain of USD 2615 ± USD 1341 per patient admission.

Conclusions: Even when excluding all professional fees, the inpatient treatment of orthopaedic sequelae of IVDU resulted in substantial financial losses driven primarily by high proportions of under- and uninsured people within this patient population. These financial losses may be unsustainable for medical centers operating in challenging economic healthcare landscapes. The development of novel initiatives and support of existing programs aimed at mitigating the health-related and economic impact of IVDU must remain a principal priority of healthcare providers and policymakers in coming years. Advocacy for the expansion of Medicaid accountable care organizations and national syringe service programs (SSPs), and the development of specialized outpatient wound and abscess clinics at healthcare centers may help to substantially alleviate the economic burden of the orthopaedic sequelae of IVDU.

Level Of Evidence: Level, IV, economic and decision analyses.
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http://dx.doi.org/10.1097/CORR.0000000000001330DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7491896PMC
October 2020

Surgical Hip Dislocation for Small Posterior Wall Fracture After Hip Subluxation.

J Orthop Trauma 2020 Aug;34 Suppl 2:S19-S20

Department of Orthopaedic Surgery, Boston Medical Center, Boston University Medical School, Boston, MA.

This case demonstrates a recognized association between an acetabular injury pattern and underlying morphology of the hip. In the patient discussed, hyperflexion of the hip results in the engagement of the present CAM lesion, and the resulting subluxation leads to a fracture of the posterior wall and instability of the hip. This combination of pathologies was addressed with a surgical dislocation approach to address both the CAM lesion and fix the posterior wall.
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http://dx.doi.org/10.1097/BOT.0000000000001833DOI Listing
August 2020

What is the Real Rate of Radial Nerve Injury After Humeral Nonunion Surgery?

J Orthop Trauma 2020 Aug;34(8):441-446

Department of Orthopaedic Surgery, San Francisco General Hospital, San Francisco, CA.

Objectives: To determine the radial nerve palsy (RNP) rate and predictors of injury after humeral nonunion repair in a large multicenter sample.

Design: Consecutive retrospective cohort review.

Setting: Eighteen academic orthopedic trauma centers.

Patients/participants: Three hundred seventy-nine adult patients who underwent humeral shaft nonunion repair. Exclusion criteria were pathologic fracture and complete motor RNP before nonunion surgery.

Intervention: Humeral shaft nonunion repair and assessment of postoperative radial nerve function.

Main Outcome: Measurements: Demographics, nonunion characteristics, preoperative and postoperative radial nerve function and recovery.

Results: Twenty-six (6.9%) of 379 patients (151 M, 228 F, ages 18-93 years) had worse radial nerve function after nonunion repair. This did not differ by surgical approach. Only location in the middle third of the humerus correlated with RNP (P = 0.02). A total of 15.8% of patients with iatrogenic nerve injury followed for a minimum of 12 months did not resolve. For those who recovered, resolution averaged 5.4 months. On average, partial/complete palsies resolved at 2.6 and 6.5 months, respectively. Sixty-one percent (20/33) of patients who presented with nerve injury before their nonunion surgery resolved.

Conclusion: In a large series of patients treated operatively for humeral shaft nonunion, the RNP rate was 6.9%. Among patients with postoperative iatrogenic RNP, the rate of persistent RNP was 15.8%. This finding is more generalizable than previous reports. Midshaft fractures were associated with palsy, while surgical approach was not.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001755DOI Listing
August 2020

Open Reduction Is Associated With Greater Hazard of Early Reoperation After Internal Fixation of Displaced Femoral Neck Fractures in Adults 18-65 Years.

J Orthop Trauma 2020 Jun;34(6):294-301

Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA.

Objectives: To determine (1) which factors are associated with the choice to perform an open reduction and (2) by adjusting for these factors, if the choice of reduction method is associated with reoperation.

Design: Retrospective cohort study with radiograph and chart review.

Setting: Twelve Level 1 North American trauma centers.

Patients: Two hundred thirty-four adults 18-65 years of age with an isolated, displaced, OTA/AO type 31-B2 or type 31-B3 femoral neck fracture treated with internal fixation with minimum of 6-month follow-up or reoperation. Exclusion criteria were pathologic fractures, associated femoral head or shaft fractures, and primary arthroplasty.

Intervention: Open or closed reduction technique during internal fixation.

Main Outcome: Cox proportional hazard of reoperation adjusting for propensity score for open reduction based on injury, demographic, and medical factors. Reduction quality was assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs.

Results: Median follow-up was 1.5 years. One hundred six (45%) patients underwent open reduction. Reduction quality was not significantly affected by open versus closed approach (71% vs. 69% acceptable, P = 0.378). The propensity to receive an open reduction was associated with study center; younger age; male sex; no history of injection drug use, osteoporosis, or cerebrovascular disease; transcervical fracture location; posterior fracture comminution; and surgery within 12 hours. A total of 35 (33%) versus 28 (22%) reoperations occurred after open versus closed reduction (P = 0.056). Open reduction was associated with a 2.4-fold greater propensity-adjusted hazard of reoperation (95% confidence interval 1.3-4.4, P = 0.004). A total of 35 (15%) patients underwent subsequent total hip arthroplasty or hemiarthroplasty.

Conclusions: Open reduction of displaced femoral neck fractures in nonelderly adults is associated with a greater hazard of reoperation without significantly improving reduction. Prospective randomized trials are indicated to confirm a causative effect of open versus closed reduction on outcomes after femoral neck fracture.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001711DOI Listing
June 2020

Interobserver Reliability in Imaging-Based Fracture Union Assessment-Two Systematic Reviews.

Authors:
Paul Tornetta

J Orthop Trauma 2020 01;34(1):e37-e38

Boston University Medical Center, Boston, MA.

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http://dx.doi.org/10.1097/BOT.0000000000001598DOI Listing
January 2020

Henry Versus Thompson Approach for Fixation of Proximal Third Radial Shaft Fractures: A Multicenter Study.

J Orthop Trauma 2020 Feb;34(2):108-112

Department of Orthopaedics, Louisiana State University, Kenner, LA.

Objective: To compare the volar Henry and dorsal Thompson approaches with respect to outcomes and complications for proximal third radial shaft fractures.

Design: Multicenter retrospective cohort study.

Patients/participants: Patients with proximal third radial shaft fractures ± associated ulna fractures (OTA/AO 2R1 ± 2U1) treated operatively at 11 trauma centers were included.

Intervention: Patient demographics and injury, fracture, and surgical data were recorded. Final range of motion and complications of infection, neurologic injury, compartment syndrome, and malunion/nonunion were compared for volar versus dorsal approaches.

Main Outcome: The main outcome was difference in complications between patients treated with volar versus dorsal approach.

Results: At an average follow-up of 292 days, 202 patients (range, 18-84 years) with proximal third radial shaft fractures were followed through union or nonunion. One hundred fifty-five patients were fixed via volar and 47 via dorsal approach. Patients treated via dorsal approach had fractures that were on average 16 mm more proximal than those approached volarly, which did not translate to more screw fixation proximal to the fracture. Complications occurred in 11% of volar and 21% of dorsal approaches with no statistical difference.

Conclusions: There was no statistical difference in complication rates between volar and dorsal approaches. Specifically, fixation to the level of the tuberosity is safely accomplished via the volar approach. This series demonstrates the safety of the volar Henry approach for proximal third radial shaft fractures.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001651DOI Listing
February 2020

In Response.

J Orthop Trauma 2019 12;33(12):626-627

Department of Orthopaedic Surgery, Boston University Medical Center, Boston, MA.

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http://dx.doi.org/10.1097/BOT.0000000000001647DOI Listing
December 2019
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