Publications by Year: 2024

PURPOSE: Rheumatoid arthritis (RA) can have severe impact on patients' functional abilities and increase the risk of fragility fractures. Little is known about how patients with RA fare after operative management of distal radius fractures. The purpose of this study was to compare postoperative complications after surgical fixation in patients with RA and controls, hypothesizing that patients with RA would have higher levels of postoperative complications.

METHODS: Patients were identified using Current Procedural Terminology and International Classification of Diseases, Ninth and Tenth Revision, codes for open treatment of distal radius fractures and RA at 3 level 1 trauma centers over a 5-year period (2015-2019). Chart abstraction provided details regarding injuries and treatment. Age- and sex-matched controls were identified in a 2:1 ratio. Postoperative complications were classified according to the Clavien-Dindo-Sink classification system and divided into early (less than 90 days) and late groups.

RESULTS: Sixty-four patients (21 with RA and 43 controls) were included. The patients were predominantly women, with a mean age of 62 years and a mean Charlson comorbidity index of 2.1. The RA medications at the time of injury included conventional synthetic disease-modifying antirheumatic drugs (5/21), biologic disease-modifying antirheumatic drugs (5/21), or chronic oral prednisone (6/21). Rheumatoid medications, except hydroxychloroquine, were withheld for 2-3 weeks after surgery. Rheumatoid patients were significantly more likely to sustain a complication compared with the control group, although this was no longer significant on adjusted analysis. Class I complications were the most common. The incidence of early versus late complications was similar between the groups. A high rate of early return to surgery for fixation failure occurred in the RA group compared with none in the control group.

CONCLUSIONS: Patients with RA undergoing operative management of distal radius fractures are at risk of postoperative complications, particularly fracture fixation failure, necessitating return to the operative room. High levels of pain, stiffness, and mechanical symptoms were noted in the RA group.

TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

PURPOSE: "Grit" is defined as the perseverance and passion for long-term goals. Thus, grittier patients may have a better function after common hand procedures; however, this is not well-documented in the literature. Our purpose was to assess the correlation between grit and self-reported physical function among patients undergoing open reduction internal fixation (ORIF) for distal radius fractures (DRFs).

METHODS: Between 2017 and 2020, patients undergoing ORIF for DRFs were identified. They were asked to complete the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire before surgery and at 6 weeks, 3 months, and 1 year after surgery. The first 100 patients with at least 1-year follow-up also completed the 8-question GRIT Scale, a validated measure of passion and perseverance for long-term goals measured on a scale of 0 (least grit) to 5 (most grit). The correlation between the QuickDASH and GRIT Scale scores was calculated using Spearman rho (ρ).

RESULTS: The average GRIT Scale score was 4.0 (SD, 0.7), with a median of 4.1 (range, 1.6-5.0). The median QuickDASH scores at the preoperative, 6-week postoperative, 6-month postoperative, and 1-year postoperative time points were 80 (range, 7-100), 43 (range, 2-100), 20 (range, 0-100), and 5 (range, 0-89), respectively. No significant correlation was found between the GRIT Scale and QuickDASH scores at any time.

CONCLUSIONS: We found no correlation between self-reported physical function and GRIT levels in patients undergoing ORIF for DRFs, suggesting no correlation between grit and patient-reported outcomes in this context. Future studies are needed to investigate the influence of individual differences in character traits other than grit on patient outcomes, which may help better align resources where needed and further the ability to deliver individualized, quality health care.

TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

BACKGROUND:  Older and frailer patients are increasingly undergoing free or pedicled tissue transfer for lower extremity (LE) limb salvage. This novel study examines the impact of frailty on postoperative outcomes in LE limb salvage patients undergoing free or pedicled tissue transfer.

METHODS:  The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2010-2020) was queried for free and pedicled tissue transfer to the LE based on Current Procedural Terminology and the International Classification of Diseases9/10 codes. Demographic and clinical variables were extracted. The five-factor modified frailty index (mFI-5) was calculated using functional status, diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension. Patients were stratified by mFI-5 score: no frailty (0), intermediate frailty (1), and high frailty (2 + ). Univariate analysis and multivariate logistic regression were performed.

RESULTS:  In total, 5,196 patients underwent free or pedicled tissue transfer for LE limb salvage. A majority were intermediate (n = 1,977) or high (n = 1,466) frailty. High frailty patients had greater rates of comorbidities-including those not in the mFI-5 score. Higher frailty was associated with more systemic and all-cause complications. On multivariate analysis, the mFI-5 score remained the best predictor of all-cause complications-with high frailty associated with 1.74 increased adjusted odds when compared with no frailty (95% confidence interval: 1.47-2.05).

CONCLUSION:  While flap type, age, and diagnosis were independent predictors of outcomes in LE flap reconstruction, frailty (mFI-5) was the strongest predictor on adjusted analysis. This study validates the mFI-5 score for preoperative risk assessment for flap procedures in LE limb salvage. These results highlight the likely importance of prehabilitation and medical optimization prior to limb salvage.

PURPOSE: Current estimates suggest that 1-2 million men in the United States have osteoporosis, yet the majority of osteoporosis literature focuses on postmenopausal women. Our aim was to understand men's awareness and knowledge of osteoporosis and its treatment.

METHODS: Semistructured interviews were conducted with 20 male patients >50 years old who sustained a low-energy distal radius fracture. The goal was to ascertain patients' knowledge of osteoporosis, its management, and experience discussing osteoporosis with their primary care physicians (PCP).

RESULTS: Participants had little knowledge of osteoporosis or its treatment. Many participants regarded osteoporosis as a women's disease. Most participants expressed concern regarding receiving a diagnosis of osteoporosis. Several patients stated that they believe osteoporosis may have contributed to their fracture. Families, friends, or mass media served as the primary information source for participants, but few had good self-reported understanding of the disease itself. The majority of participants reported never having discussed osteoporosis with their PCPs although almost half had received a dual x-ray absorptiometry scan. Participants expressed general interest in being tested/screened and generally were willing to undergo treatment despite the perception that medication has serious side effects. One patient expressed concern that treatment side effects could be worse than having osteoporosis.

CONCLUSION: Critical knowledge gaps exist regarding osteoporosis diagnosis and treatment in at-risk male patients. Specifically, most patients were unaware they could be osteoporotic because of the perception of osteoporosis as a women's disease. Most patients had never discussed osteoporosis with their PCP.

CLINICAL RELEVANCE: Male patients remain relatively unaware of osteoporosis as a disease entity. Opportunity exists for prevention of future fragility fractures by improving communication between patients and physicians regarding osteoporosis screening in men following low-energy distal radius fractures.

Necrotizing soft tissue infection (NSTI) is a feared and potentially morbid postoperative complication requiring prompt surgical intervention. Cutaneous conditions that mimic NSTI have been reported and rarely occur in the postoperative period. Sweet syndrome, also known as acute febrile neutrophilic dermatosis, is a dermatologic condition characterized by fever, neutrophil-predominant leukocytosis, and painful skin lesions. Necrotizing Sweet syndrome (NSS) is an aggressive variant that causes a clinical appearance of localized skin necrosis and histologic evidence of necrotic foci extending to the deep aspects of the soft tissues and involving fascia and/or skeletal muscle. Necrotizing Sweet syndrome can be easily mistaken for NSTI. Contrary to infection, Sweet syndrome and NSS are worsened by surgical intervention due to the phenomenon of pathergy and readily respond to corticosteroid treatment. We present the case of a 54-year-old woman who developed NSS following an uncomplicated fasciectomy for Dupuytren disease.

Nonunion is a common and costly problem. Unfortunately, there is no widely agreed upon and standardized definition for nonunion. The evaluation of bony union should start with a thorough history and physical examination. The clinician should consider patient-dependent as well as patient-independent characteristics that may influence the rate of healing and evaluate the patient for physical examination findings suggestive of bony union and infection. Radiographs and clinical examination can help confirm a diagnosis of union. When the diagnosis is in doubt, however, advanced imaging modalities as well as laboratory studies can help a surgeon determine when further intervention is necessary.

OBJECTIVES: To compare clinical and radiographic outcomes after retrograde intramedullary nailing (rIMN) versus locked plating (LP) of "extreme distal" periprosthetic femur fractures, defined as those that contact or extend distal to the anterior flange.

DESIGN: Retrospective review.

SETTING: Eight academic level I trauma centers.

PATIENT SELECTION CRITERIA: Adult patients with periprosthetic distal femur fractures at or distal to the anterior flange (OTA/AO 33B-C[VB1]) treated with rIMN or LP.

OUTCOME MEASURES AND COMPARISONS: The primary outcome was reoperation to promote healing or to treat infection (reoperation for elective removal of symptomatic hardware was excluded from this analysis). Secondary outcomes included nonunion, delayed union, fixation failure, infection, overall reoperation rate, distal femoral alignment, and ambulatory status at final follow-up. Outcomes were compared between patients treated with rIMN or LP.

RESULTS: Seventy-one patients treated with rIMN and 224 patients treated with LP were included. The rIMN group had fewer points of fixation in the distal segment (rIMN: 3.5 ± 1.1 vs. LP: 6.0 ± 1.1, P < 0.001) and more patients who were allowed to weight-bear as tolerated immediately postoperatively (rIMN: 45%; LP: 9%, P < 0.01). Reoperation to promote union and/or treat infection was 8% in the rIMN group and 16% in the LP group ( P = 0.122). There were no significant differences in nonunion ( P > 0.999), delayed union ( P = 0.079), fixation failure ( P > 0.999), infection ( P = 0.084), or overall reoperation rate ( P > 0.999). Significantly more patients in the rIMN group were ambulatory without assistive devices at final follow-up (rIMN: 35%, LP: 18%, P = 0.008).

CONCLUSIONS: rIMN of extreme distal periprosthetic femur fractures has similar complication rates compared with LP, with a possible advantage of earlier return to weight-bearing. Surgeons can consider this treatment strategy in all fractures with stable implants and amenable prosthesis geometry, even extreme distal fractures.

LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

PURPOSE: Low-velocity gunshot fractures (LVGFs) are a common type of gunshot-induced trauma with the potential for complications such as infection and osteomyelitis. The effectiveness of antibiotic therapy in LVGFs remains uncertain, leading to ongoing debate about the appropriate treatment. In this review, we evaluate recent updates on the current understanding of antibiotic therapy in LVGFs, how previous studies have investigated the use of antibiotics in LVGFs, and the current state of institutional policies and protocols for treating LVGFs with antibiotics.

METHODS: We conducted a review of PubMed, Embase, and Web of Science databases to identify studies that investigated the use of antibiotics in LVGFs after the last review in 2013. Due to the lack of quantitative clinical trial studies, we employed a narrative synthesis approach to analyze and present the findings from the included primary studies. We categorized the outcomes based on the anatomical location of the LVGFs.

RESULTS: After evaluating 67 publications with the necessary qualifications out of 578 abstracts, 17 articles were included. The sample size of the studies ranged from 22 to 252 patients. The antibiotics used in the studies varied, and the follow-up period ranged from three months to ten years. The included studies investigated the use of antibiotics in treating LVGFs at various anatomic locations, including the humerus, forearm, hand and wrist, hip, femur, tibia, and foot and ankle.

CONCLUSION: Our study provides updated evidence for the use of antibiotics in LVGFs and highlights the need for further research to establish evidence-based guidelines. We also highlight the lack of institutional policies for treating LVGFs and the heterogeneity in treatments among institutions with established protocols. A single-dose antibiotic approach could be cost-effective for patients with non-operatively treated LVGFs. We suggest that a national or international registry for gunshot injuries, antibiotics, and infections could serve as a valuable resource for collecting and analyzing data related to these important healthcare issues.

BACKGROUND: Although dual mobility total hip arthroplasty has become increasingly common in recent years, limited remains known on dual mobility in surgical oncology. This university-based investigation compared dislocation and revision rates of DMs, conventional total hip arthroplasty (THA), and hemiarthroplasties (HAs) for oncological hip reconstruction.

METHODS: An institutional tumor registry was used to identify 221 patients undergoing 45 DMs, 67 conventional THAs, and 109 HAs, performed for 17 primary hip tumors and 204 hip metastases between 2010 and 2020. The median age at surgery was 65 years, and 52% were female. The mean follow-up was 2.5 years. Kaplan-Meier survivorship curves and log-rank tests were done to compare dislocation and revision rates among all 221 patients, after a one-to-one propensity match, based on age, sex, tumor type (metastasis, primary tumor), and tumor localization (femur, acetabulum).

RESULTS: The 5-year survivorship free of dislocation was 98% in DMs, 66% in conventional THAs ( P = 0.03; all P values compared with DMs), and 97% among HAs ( P = 0.48). The 5-year survivorship free of revision was 69% in DMs, 62% in conventional THAs ( P = 0.68), and 92% in HAs ( P = 0.06). After propensity matching, the 5-year survivorship free of dislocation was 42% in 45 conventional THAs ( P = 0.027; compared with all 45 DMs) and 89% in 16 matched HAs ( P = 0.19; compared with 16 DMs with femoral involvement only). The 5-year survivorship free of revision was 40% in matched conventional THAs ( P = 0.91) and 100% in matched HAs ( P = 0.19).

CONCLUSIONS: DMs showed markedly lower rates of dislocation than conventional THAs, with overall revision rates remaining comparable among different designs. DMs should be considered the option of choice for oncological hip reconstruction if compared with conventional THAs. HAs are a feasible alternative when encountering femoral disease involvement only.

LEVEL OF EVIDENCE: III.