Objectives: To determine whether primary arthrodesis (PA) or open reduction and internal fixation (ORIF) results in better functional outcomes through patient-reported outcome measures (PROMs). Reoperation rates and surgical characteristics among the 2 groups are evaluated as well. Design: A retrospective cohort study. Setting: Level 1 trauma center. Patients: Eighty-one patients treated using PA or ORIF for Lisfranc injuries between January 2010 and January 2019. Main Outcome Measurements: PROMs were collected using the validated Foot and Ankle Ability Measure questionnaire. Follow-up ranged from 1 to 10 years posttreatment. Results: Two hundred patients underwent ORIF, and 72 patients underwent PA. Eighty-one of 272 patients responded to the questionnaire. The Foot and Ankle Ability Measure revealed activities of daily living subscores for PA and ORIF of 69.78 ± 18.61 and 73.53 ± 25.60, respectively (P = 0.48). The Sports subscores for PA (45.81 ± 24.65) and ORIF (56.54 ± 31.13) were not significantly different (P = 0.11). Perceived levels of activities of daily living (P = 0.32) and Sports (P = 0.81) function, compared with preinjury levels, were also not significantly different between the 2 groups. Rates of reoperation were nearly identical for PA (28.1%) and ORIF (30.6%) (P = 1.00). Conclusion: Our results suggest that neither PA nor ORIF is superior regarding functional outcomes or rates of reoperation in the surgical treatment of Lisfranc injuries when appropriately triaged by the treating surgeon. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Background: The objective of this study was to determine whether talar neck fractures with proximal extension (TNPE) into the talar body are associated with higher rates of avascular necrosis (AVN) compared to isolated talar neck (TN) fractures. Methods: A retrospective review of patients sustaining talar neck fractures at a level I trauma center from 2008 to 2016 was performed. Demographic and clinical data were collected from the electronic medical record. Fractures were characterized as TN or TNPE based on initial radiographs. TNPE was defined as a fracture that originates on the talar neck and extends proximal to a line subtended from the junction of the neck and the articular cartilage dorsal to the anterior portion of the lateral process of the talus. Fractures were classified according to the modified Hawkins classification for analysis. The primary outcome was the development of AVN. Secondary outcomes included nonunion and collapse. These were measured on postoperative radiographs. Results: There were 137 fractures in 130 patients, with 80 (58%) fractures in the TN group and 57 (42%) in the TNPE group. Median follow-up was 10 months (interquartile range, 6-18 months). The TNPE group was more likely to develop AVN as compared to the TN group (49% vs 19%, P < .001). Similarly, the TNPE group had a higher rate of collapse (14% vs 4%, P = .03) and nonunion (26% vs 9%, P = .01). Even after adjusting for open fracture, Hawkins fracture type, smoking, and diabetes, AVN still remained significant for the TNPE group as compared to the TN group with an odds ratio of 3.47 (95% CI, 1.51-7.99). Conclusion: We found a higher rate of AVN, subsequent collapse, and nonunion in patients with TNPE compared to isolated TN fractures. Level of Evidence: Level III, retrospective cohort study.
Case Avascular necrosis (AVN) of the talus in a 45-year-old female following subchondroplasty with calcium phosphate bone filler for treatment of anterolateral and posteromedial talar dome bone marrow lesions (BMLs). The patient subsequently presented as consultation, 18 months postoperatively, with AVN of the talus. After failing conservative management, the patient underwent a total ankle arthroplasty at 46 months after subchondroplasty with resolution of pain. Conclusion There are few studies that have reported on the safety of subchondroplasty of the talus. Given the tenuous blood supply to the talar body and poor patient outcomes associated with AVN, caution should be taken before extrapolating the generally positive results of subchondroplasty in the knee. Level of Evidence: Level IV
Objective: To determine whether local aqueous tobramycin injection in combination with systemic perioperative IV antibiotic prophylaxis will reduce the rate of fracture-related infection (FRI) after open fracture fixation.Other Outcomes of Interest: (1) To compare fracture nonunion rates and report differences between treatment and control groups and (2) compare bacterial speciation and antibiotic sensitivity among groups that develop FRI.Design: Phase 3 prospective, randomized clinical trial.Setting: Two level 1 trauma centers.Participants: Six hundred subjects (300 in study/tobramycin group and 300 in control/standard practice group) will be enrolled and assigned to the study group or control group using a randomization table. Patients with open extremity fractures that receive definitive internal surgical fixation will be considered.Intervention: Aqueous local tobramycin will be injected into the wound cavity (down to bone) after debridement, irrigation, and fixation, following closure.Main Outcome Measurements: Outcomes will look at the presence or absence of FRI, the rate of fracture nonunion, and determine speciation of gram-negative and Staph bacteria in each group with a FRI.Results: Not applicable.Conclusion: The proposed work will determine whether local tobramycin delivery plus perioperative standard antibiotic synergism will minimize the occurrence of open extremity FRI.Level of Evidence: Level 1.
Objective:To determine whether pre-existing psychiatric disorder is associated with potentially unnecessary fasciotomy.Design:Retrospective cohort study.Setting:Academic Level-1 trauma center.Patients:All the patients with orthopaedic trauma undergoing leg fasciotomy at an academic Level I trauma center from 2006 to 2020.Intervention:Pre-existing diagnosis of psychiatric disorder.Main Outcome Measurements:Early primary wound closure and delayed primary wound closure.Results:In total, 116 patients were included. Twenty-seven patients (23%) had a pre-existing diagnosis of psychiatric disorder with 13 having anxiety, 14 depression, 5 bipolar disorder, and 2 ADHD. Several patients had multiple diagnoses. Fifty-one patients (44%) had early primary closure (EPC), and 65 patients (56%) had delayed primary closure. Of patients with a psychiatric disorder, 52% received EPC compared with 42% of patients without a disorder, P = 0.38. This lack of a strong association did not seem to vary across specific psychiatric conditions. After adjusting for sex, age, injury type, and substance abuse, there was still no significant association between a psychiatric disorder and EPC with an odds ratio of 1.08 (95% CI, 0.43–2.75).Conclusions:Among patients with orthopaedic trauma undergoing emergent fasciotomy for acute compartment syndrome, a psychiatric disorder was not associated with a significantly increased rate of possibly unnecessary fasciotomy. Given the potential for a psychiatric condition to complicate the diagnosis of acute compartment syndrome, this data is somewhat reassuring; however, there remains a need for continued vigilance in treating patients with psychiatric conditions and research in this area.Level of Evidence:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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