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Introduction: Postoperative infections are a leading cause of morbidity following fracture repair. The purpose of this study is to develop a risk score predicting fracture-related infection (FRI) that will require one versus multiple revision surgeries related to infection eradication and bone healing., Methods: This is a retrospective cohort study conducted at a single level I trauma center from 2013 to 2020. Adults with FRIs were identified through review of an institutional database on musculoskeletal infections maintained jointly by the infectious disease division and the orthopaedic surgery department. Inclusion criteria were surgically managed fracture of the humerus, olecranon, radius/ulna, clavicle, pelvis, femur, tibia/fibula, and calcaneus with an FRI and adequate documentation present in the electronic medical record. Exclusion criteria included infected chronic osteomyelitis from a non-fracture-related pathology and follow-up less than 6 months. Risk factors leading to multiple surgeries in FRIs, including demographics, comorbidities, injury characteristics, perioperative data, and microbiology, were recorded. Logistic regression was done to select variables predictive of multiple revision surgeries. Four prespecified methods of covariate selection were used., Results: Eighty-eight patients underwent one FRI revision surgery, whereas 208 patients underwent two or more revision surgeries. From multivariable logistic regression, age older than 45 years (P < 0.001), purulent drainage at infection presentation (P < 0.001), and incomplete bone union at infection presentation (P = 0.013) were all markedly associated with multiple revision surgeries. The model of best fit was used to generate the risk score (area under ROC curve = 0.789). Variables included in the final risk score were age ≥ 45 years, purulent drainage, incomplete bony union, and wound dehiscence at infection presentation., Conclusion: This study described a risk score for predicting multiple revision surgeries in patients with infection following fracture repair. Age older than 45 years, purulent drainage, and incomplete bony union at infection presentation were all markedly associated with multiple infection revision surgeries., Level of Evidence: III., (Copyright © 2025 by the American Academy of Orthopaedic Surgeons.)

There is growing concern over the safety of artificial turf when it comes to the incidence of player injuries. The artificial surfaces can withstand more play, are cheaper to maintain, and are more predictable. However, there is concern that this beneficial durability comes at the expense of the forgiveness of the surface, leading to more injuries. In this study, we aim to compare the incidence of in-game season-ending lower extremity injuries on natural and artificial playing surfaces in the National Football League (NFL) during the 2020, 2021, and 2022 seasons. For this study, we used publicly available data to determine and classify the specific injury, where the injury occurred, field surface type, and duration of recovery. All data were collected, and significance was determined using two-sample T -tests. Only in-game injuries were included in this study. Over the course of 2020, 2021, and 2022, there were 199 season-ending lower-extremity injuries. Of these, 79 occurred on natural turf (39.7%) and 120 on artificial turf (60.3%). Of the 891 games played in this three-year period, 396 were played on natural turf (44.4%) and 495 were played on artificial turf (55.6%). Natural turf saw an injury rate of 0.199 per game, and artificial turf saw 0.242 injuries per game. We determined that there is no significant difference in rates of season-ending lower-extremity injury between artificial and natural turf. Any perceived difference in injury rates could possibly be attributed to the increased amount of play on artificial surfaces and anecdotal evidence related to high profile cases. While there is no significant difference in incidence, surfaces should continue to be monitored and regulated for traits such as hardness, and player preferences should be considered for qualities that are not quantifiable., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 William F. McCormick et al.)

Objectives: To evaluate the outcomes of staged management with external fixation (ex-fix) before definitive fixation of distal femur fractures., Design: Retrospective cohort., Setting: Single Level I Trauma Center., Patient Selection Criteria: Adults treated operatively between 2004 and 2019 for distal femur fractures (OTA/AO 33A/33C) were identified using Current Procedural Terminology codes. Excluded cases were those with screw only fixation, acute distal femur replacement, 33B fracture pattern, no radiographs available, or did not have 6-months of follow-up., Outcome Measures and Comparisons: Postoperative complication rates including surgical site infection [SSI], reoperation to promote bone healing, final knee arc of motion <90 degrees, heterotopic ossification formation, and reoperation for stiffness were compared between patients treated with ex-fix before definitive fixation and those not requiring ex-fix., Results: A total of 407 patients were included with a mean follow-up of 27 months [median (IQR) of 12 (7.33) months] (range 6-192 months). Most patients were male (52%) with an average age of 48 (range: 18-92) years. Ex-fix was utilized in 150 (37%) cases and 257 (63%) cases underwent primary definitive fixation. There was no difference in SSI rates ( P = 0.12), final knee arc of motion <90 degrees ( P = 0.51), and reoperation for stiffness ( P = 0.41) between the ex-fix and no ex-fix groups. The 150 patients requiring ex-fix spent an average of 4.2 days (SD 3.3) in the ex-fix before definitive fixation. These patients were further analyzed by comparing the duration of time spent in ex-fix, <4 days (n = 82) and ≥4 days (n = 68). Despite longer time spent in ex-fix before definitive fixation, there was again no significant difference in any of the complication and reoperation rates when comparing the 2 groups, including final knee arc of motion <90 degrees ( P = 0.63), reoperation for stiffness ( P = 1.00), and SSI ( P = 0.79)., Conclusion: Ex-fix of distal femur fractures as a means of temporary stabilization before definitive open reduction internal fixation does not increase the risk of complications such as SSI, final knee arc of motion <90 degrees, or reoperations for bone healing or stiffness when compared with single-stage open reduction internal fixation of distal femur fractures., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To analyze demographics, comorbidities, fracture characteristics, presenting characteristics, microbiology, and treatment course of patients with fracture-related infections (FRIs) to determine risk factors leading to amputation., Design: Retrospective cohort., Setting: Single Level I Trauma Center (2013-2020)., Patient Selection Criteria: Adults with lower extremity (femur and tibia) FRIs were identified through a review of an institutional database. Inclusion criteria were operatively managed fracture of the femur or tibia with an FRI and adequate documentation present in the electronic medical record. This included patients whose primary injury was managed at this institution and who were referred to this institution after the onset of FRI as long as all characteristics and risk factors assessed in the analysis were documented. Exclusion criteria were infected chronic osteomyelitis from a non-fracture-related pathology and a follow-up of less than 6 months., Outcome Measures and Comparisons: Risk factors (demographics, comorbidities, and surgical, injury, and perioperative characteristics) leading to amputation in patients with FRIs were evaluated., Results: A total of 196 patients were included in this study. The average age of the study group was 44±16 years. Most patients were men (63%) and White (71%). The overall amputation rate was 9.2%. There were significantly higher rates of chronic kidney disease (CKD; P = 0.039), open fractures (P = 0.034), transfusion required during open reduction internal fixation (P = 0.033), Gram-negative infections (P = 0.048), and FRI-related operations (P = 0.001) in the amputation cohort. On multivariate, patients with CKD were 28.8 times more likely to undergo amputation (aOR = 28.8 [2.27 to 366, P = 0.010). A subanalysis of 79 patients with either a methicillin-sensitive Staphylococcus aureus or methicillin-resistant S. aureus (MRSA) infection showed that patients with MRSA were significantly more likely to undergo amputation compared with patients with methicillin-sensitive Staphylococcus aureus (P = 0.031). MRSA was present in all cases of amputation in the Staphylococcal subanalysis., Conclusions: Findings from this study highlight CKD as a risk factor of amputation in the tibia and femur with fracture-related infection. In addition, MRSA was present in all cases of Staphylococcal amputation. Identifying patients and infection patterns that carry a higher risk of amputation can assist surgeons in minimizing the burden on these individuals., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Bunionette deformity is an incredibly pervasive issue in our society with almost a quarter of individuals being affected by it. As it is so common, there are numerous techniques and approaches to correct the deformity. Currently, there is a growing trend that favors percutaneous osteotomy of the bunionette. As there are multiple osteotomy sites, there are anatomical considerations that must be made at each one. The purpose of this study was to investigate the anatomic structures at risk during distal osteotomy of bunionette deformity using a Shannon burr. Using 11 fresh cadaver specimens, the fifth metatarsal was accessed through a carefully marked portal. A Shannon burr was employed for the osteotomy. Dissections were performed to assess potential damage to critical structures, including the lateral dorsal cutaneous nerve (LDCN), abductor digiti minimi (ADM), and extensor digitorum longus (EDL). Measurements were taken from the osteotomy site to each structure. The distal osteotomy site was on average greater than 8 mm from the EDL and ADM, whereas it was 1.64 mm from the LDCN. The Shannon burr made contact with and transected the LDCN on 2 occasions. However, previous studies have highlighted potential anatomical variations of the LDCN that arise distally. The study underscored the challenges posed by minimally invasive approaches to treating bunionette deformity and highlighted the need for cautious consideration when using percutaneous methods. Level of Clinical Evidence: 5., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Extracorporeal membrane oxygenation (ECMO) plays a vital role in providing life support for patients with reversible cardiac or respiratory failure. Given the high rate of complications and difficulties associated with caring for ECMO patients, the goal of this study was to compare outcomes of orthopaedic surgery in polytrauma patients who received ECMO with similar patients who have not. This will help elucidate the timing and type of fixation that should be considered in patients on ECMO., Methods: A retrospective cohort was collected from the electronic medical record of two level I trauma centers over an 8-year period (2015 to 2022) using Current Procedural Terminology codes. Patients were matched with a similar counterpart not requiring ECMO based on sex, age, American Society of Anesthesiologists score, body mass index, injury severity score, and fracture characteristics. Outcomes measured included length of stay, number of revisions, time to definitive fixation, infection, amputation, revision surgery to promote bone healing, implant failure, bleeding requiring return to the operating room, and mortality., Results: Thirty-two patients comprised our ECMO cohort with a patient-matched control group. The ECMO cohort had an increased length of stay (40 versus 17.5 days, P = 0.001), number of amputations (7 versus 0, P = 0.011), and mortality rate (19% versus 0%, P = 0.024). When comparing patients placed on ECMO before definitive fixation and after definitive fixation, the group placed on ECMO before definitive fixation had significantly longer time to definitive fixation than the group placed on ECMO after fixation (14 versus 2.0 days, P < 0.001)., Conclusion: ECMO is a lifesaving measure for trauma patients with cardiopulmonary issues but can complicate fracture care. Although it is not associated with an increase in revision surgery rates, ECMO was associated with prolonged hospital stay and delays in definitive fracture surgery when initiated before definitive fixation., Level of Evidence: III., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Background: In anticipation of Food and Drug Administration (FDA) approval of the Total Posterior Spine (TOPS) system, the International Society for the Advancement of Spine Surgery (ISASS) conducted a study to estimate the work relative value units (RVUs) for facet arthroplasty. The purpose of this study was to establish a valuation of work RVU for Current Procedural Terminology (CPT) Code 0202T in the interim until the Relative Value Scale Update Committee (RUC) can determine an appropriate value. The valuation established from this survey will assist surgeons to establish appropriate procedure reimbursement from third-party payers., Methods: A survey was created and sent to 52 surgeons who had experience implanting the TOPS system during the investigational device exemption clinical trial. The survey included a patient vignette, a description of CPT Code 0202T along with a video of the TOPS system, and a confirmation question about the illustration's effectiveness. Respondents were asked to compare the work involved in CPT Code 0202T to 8 lumbar spine procedures. A Rasch analysis was performed to estimate the relative difficulty of CPT 0202T using the work RVUs of the comparable procedures., Results: Forty-one surgeons responded to the survey. Of all the procedures, CPT Code 0202T received the most responses for equal work compared with posterior osteotomy (46%) followed by transforaminal lumbar interbody fusion (41%). The results of the regression analysis indicate a work RVU for CPT 0202T of 39.47., Conclusion: The study found an estimated work RVU of 39.47 for CPT Code 0202T using Rasch analysis. As an alternative to this Rasch methodology, one may consider a crosswalk methodology to the work RVUs for transforaminal lumbar interbody fusion procedurally, not as an alternative code., Clinical Relevance: These recommendations are not a substitute for RUC methodology but serve as a reference for physicians and third-party payers to understand work RVU similarities for charge and payment purposes temporarily until RUC methodology provides accurate RVUs for the procedure., Competing Interests: Declaration of Conflicting Interests : The authors report no conflicts of interest in this work., (This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2024 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.)

Objectives: To analyze the relationship between patient resilience and patient-reported outcomes after orthopaedic trauma., Design: Retrospective analysis of prospectively collected data., Setting: Single Level 1 Trauma Center., Patient Selection Criteria: Patients were selected based on completion of the Patient-Reported Outcomes Measurement Information System (PROMIS) and Brief Resilience Scale (BRS) surveys 6 months after undergoing operative fracture fixation following orthopaedic trauma. Patients were excluded if they did not complete all PROMIS and BRS surveys., Outcome Measures and Comparisons: Resilience, measured by the BRS, was analyzed for its effect on patient-reported outcomes, measured by PROMIS Global Physical Health, Physical Function, Pain Interference, Global Mental Health, Depression, and Anxiety. Variables collected were demographics (age, gender, race, body mass index), injury severity score, and postoperative complications (nonunion, infection). All variables were analyzed with univariate for effect on all PROMIS scores. Variables with significance were included in multivariate analysis. Patients were then separated into high resilience (BRS >4.3) and low resilience (BRS <3.0) groups for additional analysis., Results: A total of 99 patients were included in the analysis. Most patients were male (53%) with an average age of 47 years. Postoperative BRS scores significantly correlated with PROMIS Global Physical Health, Pain Interference, Physical Function, Global Mental Health, Depression, and Anxiety ( P ≤ 0.001 for all scores) at 6 months after injury on both univariate and multivariate analyses. The high resilience group had significantly higher PROMIS Global Physical Health, Physical Function, and Global Mental Health scores and significantly lower PROMIS Pain Interference, Depression, and Anxiety scores ( P ≤ 0.001 for all scores)., Conclusions: Resilience in orthopaedic trauma has a positive association with patient outcomes at 6 months postoperatively. Patients with higher resilience report higher scores in all PROMIS categories regardless of injury severity. Future studies directed at increasing resilience may improve outcomes in patients who experience orthopaedic trauma., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The stability of the hindfoot greatly relies on the integrity of the talonavicular joint. Pathologies affecting this joint often necessitate fusion. Our study explores the risks posed to neurovascular and tendon structures during simulated percutaneous talonavicular joint preparation for fusion., Methods: In 9 fresh cadaver specimens, the talonavicular joint was accessed through two portals. A 2-mm Shannon burr was employed for joint surface preparation with distraction provided by a pin-based distractor. Dissections were performed to assess potential damage to critical structures, including the dorsalis pedis artery, superficial and deep peroneal nerves, extensor hallucis longus (EHL), and tibialis anterior (TA) tendons., Results: The dorsal portal site was found to be significantly closer to important structures compared to the medial portal site. The Shannon burr made contact with various structures, with a single transection identified for both deep and superficial peroneal nerve branches. During the dorsal portal site approach, potential injury to the EHL tendon was identified as concern., Conclusion: This study sheds light on the potential risks associated with percutaneous dorsal and medial joint preparation approaches using a Shannon burr.Level of Evidence:Level V, mechanism-based reasoning.., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

Introduction: This study aims to characterize radiographic features and fracture characteristics in femoral shaft fractures with associated femoral neck fractures, with the goal of establishing predictive indicators for the presence of ipsilateral femoral neck fractures (IFNFs)., Methods: A retrospective cohort was collected from the electronic medical record of three level I trauma centers over a 5-year period (2017 to 2022) by current procedural terminology (CPT) codes. Current CPT codes for combined femoral shaft and IFNFs were identified to generate our study group. CPT codes for isolated femur fractures were identified to generate a control group., Results: One hundred forty patients comprised our IFNF cohort, and 280 comprised the control cohort. On univariate, there were significant differences in mechanism of injury (P < 0.001), Orthopedic Trauma Association (OTA)/Arbeitsgemeinshaft fur Osteosynthesefragen (AO) classification (P = 0.002), and fracture location (P < 0.001) between cohorts. On multivariate, motor vehicle crashes were more commonly associated with IFNFs compared with other mechanism of injuries. OTA/AO 32A fractures were more commonly associated with IFNFs when compared with OTA/AO 32B fractures (adjusted odds ratio = 0.36, P < 0.001). Fractures through the isthmus were significantly more commonly associated with IFNFs than fractures more proximal (adjusted odds ratio = 2.52, P = 0.011)., Discussion: Detecting IFNFs in femoral shaft fractures is challenging. Motor vehicle crashes and motorcycle collisions, OTA/AO type 32A fractures, and isthmus fractures are predictive of IFNFs., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background: The objective of this study was to investigate the outcomes of COVID-19-positive patients undergoing orthopaedic fracture surgery using data from a national database of U.S. adults with a COVID-19 test for SARS-CoV-2., Methods: This is a retrospective cohort study using data from a national database to compare orthopaedic fracture surgery outcomes between COVID-19-positive and COVID-19-negative patients in the United States. Participants aged 18-99 with orthopaedic fracture surgery between March and December 2020 were included. The main exposure was COVID-19 status. Outcomes included perioperative complications, 30-day all-cause mortality, and overall all-cause mortality. Multivariable adjusted models were fitted to determine the association of COVID-positivity with all-cause mortality., Results: The total population of 6.5 million patient records was queried, identifying 76,697 participants with a fracture. There were 7,628 participants in the National COVID Cohort who had a fracture and operative management. The Charlson Comorbidity Index was higher in the COVID-19-positive group (n = 476, 6.2 %) than the COVID-19-negative group (n = 7,152, 93.8 %) (2.2 vs 1.4, p<0.001). The COVID-19-positive group had higher mortality (13.2 % vs 5.2 %, p<0.001) than the COVID-19-negative group with higher odds of death in the fully adjusted model (Odds Ratio=1.59; 95 % Confidence Interval: 1.16-2.18)., Conclusion: COVID-19-positive participants with a fracture requiring surgery had higher mortality and perioperative complications than COVID-19-negative patients in this national cohort of U.S. adults tested for COVID-19. The risks associated with COVID-19 can guide potential treatment options and counseling of patients and their families. Future studies can be conducted as data accumulates., Level of Evidence: Level III., Competing Interests: Declaration of Competing Interest The analyses described in this report were conducted with data or tools accessed through the NCATS N3C Data Enclave https://covid.cd2h.org and N3C Attribution & Publication Policy v 1.2-2020-08-25b supported by NCATS U24 TR002306 and NCATS UL1 TR003096. This research was possible because of the patients whose information is included within the data and the organizations (https://ncats.nih.gov/n3c/resources/data-contribution/data-transfer-agreement-signatories) and scientists who have contributed to the on-going development of this community resource [https://doi.org/10.1093/jamia/ocaa196/5893482]., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Thirty-two third-trimester amniotic fluid samples were studied according to the indication for amniocentesis, result of acetylcholinesterase (AChE) analysis, and outcome, in order to address the issue of the effectiveness of AChE testing late in gestation. The results indicate that third-trimester AChE analysis is less effective than second trimester in distinguishing open neural tube defects (ONTDs) and ventral wall defects (VWDs) from other abnormalities. False-positive results occurred in cases of isolated hydrocephaly (four of seven cases), polyhydramnios, and intrauterine growth retardation (IUGR). Caution is recommended in interpreting third-trimester AChE tests, particularly when neither an ONTD nor a VWD is observed by ultrasound.

Human chorionic gonadotropin and maternal serum alpha-fetoprotein (MSAFP) concentrations were measured in frozen maternal serum samples from 16 pregnancies with Down syndrome and from 614 unaffected pregnancies in women younger than 35. By using only maternal age and MSAFP level to determine Down syndrome risk, four of 16 (25%) Down syndrome pregnancies were identified, using risk estimates as a screening variable. This detection rate required performing amniocentesis on 4.8% of pregnancies with a normal outcome. By adding hCG level as a third risk parameter, ten of 16 (62.5%) Down syndrome pregnancies were detected. To achieve this detection rate, 4.7% of women under 35 would be recommended for amniocentesis. These results indicate that the estimation of risk for Down syndrome based on the addition of maternal hCG level to MSAFP level and maternal age will substantially improve the detection rate for Down syndrome, with no change in the amniocentesis rate. These findings are in agreement with other studies that suggest that hCG is a valuable addition to screening programs for Down syndrome.