Background: Phalanx fractures are common, and plate fixation can be used to treat difficult fractures. Major complications have been reported in up to 64% of phalanx fractures treated with plate fixation, with stiffness being the most common. Low-profile anatomic plates (LPAP) have been designed to decrease soft tissue irritation and postoperative stiffness. The objective of this study was to determine whether the use of LPAP has decreased complications in plate fixation of phalanx fractures. Methods: A retrospective chart review was performed of patients with phalanx fractures treated with open reduction and internal fixation (ORIF) using LPAP at a single institution from January 1, 2010, to January 25, 2018. Twenty-three patients with 23 phalanx fractures treated with LPAP were included. The primary outcome was the presence of a complication. Results: Of the 23 patients, 12 patients (52.2%) had a postoperative complication. Nine patients (39.1%) required return to the operating room, with 7 (30.4%) returning for removal of hardware and tenolysis/capsulotomy. Two patients (8.7%) had superficial infections, one requiring irrigation and debridement. The other infection resolved clinically after 2 courses of oral antibiotics, with the fracture going on to nonunion. One patient had delayed wound healing treated prophylactically with cephalexin; although the wound healed, the patient developed a boutonniere deformity requiring surgery. There were 2 malunions (8.7%), one requiring revision surgery and the other electing for nonoperative management. All but one fracture progressed to union. Conclusions: ORIF with LPAP consistently achieves fracture union for phalanx fractures, but it does not appear that LPAP reduce the high complication rate.

High complication rates have been reported using conventional plating systems to treat metacarpal fractures. This study investigated complication rates in metacarpal fractures treated with low-profile anatomic plates. A retrospective chart review was performed of patients with metacarpal fractures who were treated with open reduction and internal fixation using low-profile anatomic plates at a single institution from January 2010 to February 2017. Patients with concomitant tendon injury, open fractures, prior same metacarpal fracture, or thumb metacarpal fracture were excluded. A total of 79 patients with 110 metacarpal fractures were included. The primary outcome was the presence of a complication, defined as superficial or deep infection, delayed wound healing, delayed union, nonunion, major or minor extensor lag or stiffness 90 days postoperatively, or return to the operating room. Eleven fractures (10%) had 1 or more complications. Complications included 6 fractures (5%) with major extensor lag or stiffness, 4 fractures (4%) with minor extensor lag or stiffness, 1 fracture (1%) with delayed radiographic union that did not require operative intervention, and 1 fracture (1%) with return to the operating room for removal of hardware. In this retrospective study, treatment of metacarpal fractures with low-profile plate fixation resulted in a 10% overall complication rate and a 1% reoperation rate; this rate is significantly less than reported in previous literature prior to the widespread use of low-profile plates. This study suggests treatment of patients with metacarpal fractures using low-profile plating systems provides a reliable solution with acceptable complication rates. [ Orthopedics . 2021;44(1):e91–e94.]

Background: The purpose of this study was to investigate the impact of diabetes on complications after open trigger finger release compared with a cohort matched for age, sex, race, and body mass index class. Methods: A retrospective chart review was performed of diabetic patients who underwent trigger finger release at an academic institution within the past 10 years. Exclusion criteria included rheumatoid arthritis, malignancy, human immunodeficiency virus/acquired immunodeficiency syndrome, connective tissue disorders, or systemic steroid use. These patients were then matched by age, sex, race, and body mass index class to nondiabetic patients who underwent trigger finger release during the same period. One hundred thirty-seven patients met inclusion criteria and were matched with controls. Complications included superficial or deep infection, delayed wound healing, limited range of motion at 6 weeks, pain requiring medication at 6 weeks, and return to the operating room. Results: In adjusted analyses, diabetic patients had a significantly higher rate of all-cause complication following trigger finger release compared with matched nondiabetic controls at an odds ratio of 2.1. Diabetic patients also had a significantly higher rate of limitation in postoperative range of motion compared to the controls with an odds ratio of 2.4. Conclusion: This retrospective case-control study identified that diabetic patients undergoing trigger finger release are at increased risk of all-cause postoperative complications and, specifically, range of motion limitation when compared with similar patients without diabetes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

INTRODUCTION Heart failure is a leading cause of morbidity and mortality in hip fracture surgery. The impact of heart failure with preserved ejection fraction (HFpEF) is poorly understood in this population. We designed a study to evaluate national perioperative outcomes in hip fracture for patients with HFpEF. METHODS Patients with hip fracture undergoing total hip arthroplasty, hemiarthroplasty, or open/closed reduction with internal and external fixation from January 2005 to December 2013 were identified using the Nationwide Inpatient Sample. Inpatient outcomes during the index hospitalization were compared between patients without heart failure and with HFpEF. Heart failure with reduced ejection fraction was included as a secondary comparator. Perioperative major adverse cardiovascular and cerebrovascular events (MACCEs), defined as in-hospital all-cause death, acute myocardial infarction, and in-hospital cardiac arrest or acute ischemic stroke, were evaluated. RESULTS Among 2,020,712 hospitalizations for hip fracture surgery, perioperative MACCE occurred in 67,554 hospitalizations (3.3%), corresponding to an annual incidence of approximately 7,506 events after applying sample weights. Compared with patients without heart failure, patients with HFpEF experienced increased odds of MACCE, adjusted odds ratio [aOR], 1.69; 95% confidence interval (CI), 1.51 to 1.89. In comparison, the aOR of experiencing a MACCE event in the heart failure with reduced ejection fraction group was 1.75 (95% CI, 1.57 to 1.96). HFpEF was also associated with increased odds of acute respiratory failure (aOR, 1.71; 95% CI, 1.53 to 1.91) and acute renal failure (aOR, 1.52; 95% CI, 1.41 to 1.64). CONCLUSION HFpEF confers a significant perioperative risk of MACCE in patients undergoing hip fracture surgery.

Although volar locked plating (VLP) of distal radius fractures is common, complications remain a considerable concern for upper extremity specialists using modern techniques. Complications following VLP of DR fractures were recorded prospectively from January 2005 to January 2017. Fractures were characterized using the AO classification, and complications were described by severity. Severe complications required operative treatment and/or resulted in permanent impairment, moderate complications required nonoperative treatment, and mild complications resolved without intervention. The available Current Procedural Terminology data for uncomplicated VLP were used to calculate the complication rate. Statistical analysis compared severe and nonsevere complications. Thirty-seven patients (27 women; 39 radii) experienced complications following VLP of DR fractures, resulting in a complication rate of 13.2%. For those with complications, the mean age was 48.5 ± 13.5 years (range: 19-78 years) and the mean follow-up was 13.7 ± 9.0 months (range: 3-36 months). A majority (28/39: 71.8%) had type C fractures. The most common complications were hardware complication requiring removal (18) and malunion (6). There were only 3 tendon ruptures. There were 25 unplanned returns to the operating room in 24 radii (22 patients). The most common reason was removal of hardware (18). Patients with severe complications more commonly had AO type C fractures and required longer follow-up. Modern VLP of DR fractures has a complication rate of 13.2%. Hardware complication requiring removal was the most notable complication of VLP. Tendon rupture has become rare with modern techniques. AO type C fractures were associated with more severe complications.

Purpose: Diabetes mellitus (DM) is associated with increased rates of wound complications and reduced improvement in patient-reported outcomes across a wide range of surgical disciplines, although the impact of DM is less known after primary carpal tunnel release (CTR). This study’s hypothesis was that DM would be an independent risk factor for wound complications after CTR. Methods: This retrospective, matched, cohort study evaluated all diabetic patients with a preoperative hemoglobin A1c value within 90 days of open primary CTR at a single academic institution from 2007 to 2017. Records were reviewed to determine rates of superficial or deep surgical site infection and delayed wound healing or wound dehiscence. Additional procedures, bilateral procedures, and administration of perioperative antibiotics were also noted. We calculated unadjusted and adjusted odds ratios and 95% confidence intervals to determine differences in all-cause and specific wound complication rates between patients with and without DM. Results: Diabetic patients (n = 128) had an all-cause wound complication rate, surgical site infection rate, and delayed wound healing or wound dehiscence rate of 11 (8.6%), 5 (3.9%), and 6 (4.7%), respectively, compared with 8 (6.3%), 2 (1.6%), and 6 (4.7%), respectively, for nondiabetic patients (n = 128). Diabetes was not significantly associated with an increased rate of all-cause wound complications at an unadjusted odds ratio of 1.41 (range, 0.55–3.63). Rates of specific wound complications also did not differ significantly, although superficial surgical site infections were more common among patients with DM at an unadjusted odds ratio of 5.16 (range, 0.59–44.82). Conclusions: Adjusted all-cause wound complication rates did not differ significantly in a matched cohort series. Superficial surgical site infections occurred at a higher rate in patients with DM, although this difference was not statistically significant. The presence of DM is not a contraindication to proceed with CTR in symptomatic patients. Type of study/level of evidence: Therapeutic III. Key words: Carpal tunnel release, cohort, diabetes, surgical site infection, wound healing

BACKGROUND:An increased rate of complications has been demonstrated with increasing hemoglobin A1c value for a variety of orthopedic procedures, including arthroplasty and spine surgery. The authors investigated the effects of elevated hemoglobin A1c value on postoperative complications at the time of carpal tunnel release.METHODS:This retrospective, cohort study evaluated all diabetic patients with a preoperative hemoglobin A1c value within 90 days of primary, open carpal tunnel release at a single academic institution within the past 10 years. Binary hemoglobin A1c thresholds were tested for association with outcomes of superficial or deep infection, delayed wound healing, and persistent symptoms using chi-square analysis. Multivariable models with adjustment for baseline and operative factors were then constructed. Odds ratios and 95 percent confidence intervals were displayed.RESULTS:Hemoglobin A1c value greater than or equal to 7.8 percent was most strongly associated with an increased risk of all-cause wound healing complications (p = 0.049) at an odds ratio of 4.2 (95 percent CI, 1.0 to 17.7) in adjusted analyses. Six patients (4 percent) experienced delayed wound healing and five patients (4 percent) developed a superficial infection. Six patients (4 percent) reported persistent carpal tunnel syndrome symptoms.CONCLUSIONS:Diabetic patients undergoing open, primary carpal tunnel release with a hemoglobin A1c value of 7.8 percent or higher had a higher rate of postoperative wound complications compared to diabetic patients with improved preoperative glucose control. Diabetics with poor glycemic control should be counseled that their risk of postoperative complication is higher. Further work is needed to determine whether delaying surgery to optimize glucose control could result in a reduction of wound healing complications.CLINICAL QUESTION/LEVEL OF EVIDENCE:Risk, II.

Introduction Amputations secondary to high-energy open fractures and blast, ballistic, and crush injuries to the lower extremity are common challenges faced by military and civilian orthopaedic surgeons. A lack of consensus on domains to be measured and quality of prosthetic rendering pose methodological challenges to researchers and clinicians alike. We conducted a systematic review of the literature to summarize which domains of health, prosthetic fit, and prosthetic alignment are used to describe outcomes for lower extremity amputees secondary to trauma. Materials and methods A search of PubMed, Cochrane, and Embase was conducted including the keywords: Amputation, traumatic, transtibial, survey, and metric. Articles were selected based on whether the study assessed clinical outcomes following transtibial amputation following trauma. Experimental and observational comparative studies and case series were included. Study characteristics and results were extracted using standardized data forms. The number of unique measures recorded, the frequency of measure use, and the number outcome measures were validated and were compiled. Results Literature search ultimately resulted in 273 articles being included. A conceptual model was constructed to capture and organize the causal and temporal relationships between fit, alignment, and outcome. Of the 68 articles that used questionnaires to assess prosthetic fit, 37 used a questionnaire designed specifically for the study as opposed to a published or validated tool. Four validated tools were commonly used to capture patient satisfaction with a prosthesis: The OPUS, PEQ, TAPES, and the Socket Comfort Fit Score. Prosthetic alignment was assessed in 19 of 273 articles. One article validated the use of an alignment jig for quantification and prescription of prostheses. Totally, 8 of 19 articles assessing alignment used gait analysis and ground reaction forces to capture differences due to alterations in alignment. Discussion Choice of an appropriate outcome measure is critical in generating evidence to support treatment decisions for patients undergoing transtibial amputation after trauma. We found a large number of different tools being used across studies, making results difficult to compare. Prosthetic fit and comfort of the residual limb in the socket and the alignment of the socket and the shank of the prosthesis make up the foundation for the proposed conceptual model. In order to distinguish effects attributable to an intervention of interest vs the impact of the quality of the socket fitting, validation of a clinically objective scoring system to assess socket fit is necessary. Conclusion A large number of different tools are currently being used across studies to assess outcomes for transtibial amputees resulting from trauma, and there is a need for development and validation of a clinically objective scoring system to assess socket fit. Baumgartner R, Morshed S. Assessment Measures for Evaluation of Outcomes in Transtibial Amputees resulting from Trauma: A Systematic Review. The Duke Orthop J 2017;7(1):23-29.

OBJECTIVES:The use of fluoroscopy for indirect guidance in orthopaedic trauma surgery has increased. The purpose of this investigation was to assess how real-time visualization of radiation exposure impacts dose levels during orthopaedic trauma operations. DESIGN:Observational comparative study. SETTING:Level 1 trauma center orthopaedic trauma surgery operating room. PATIENTS/PARTICIPANTS:The participants in this study were 83 patients with fractures of the ankle, tibia, femur, or acetabulum receiving definitive surgical fixation of their fracture; children under 18 years of age were excluded from the study. Fellowship trained orthopaedic trauma surgeons, resident orthopaedic surgeons, radiology technicians, and scrub nurses involved in the operations on included fracture patients were also participants. INTERVENTION:Real-time radiation exposure feedback from the Philips DoseAware device. MAIN OUTCOME MEASUREMENTS:Radiation exposure from fluoroscopy compared between phase 1, during which participants were blinded to exposure levels, and phase 2, during which participants were able to see exposure levels in real time. RESULTS:Overall mean radiation exposure was decreased by 60% in phase 2 compared with phase 1 (P = 0.023). Mean surgeon (MS; average of primary and assistant surgeon) and mean nonsurgeon personnel (average of x-ray technician, scrub nurse, and patient) radiation exposures were decreased from phase 1 to phase 2, by 58% and 80%, respectively (MS, P = 0.034; mean nonsurgeon personnel, P = 0.043). From phase 1 to phase 2, MS radiation for femoral shaft fractures decreased by 80% or 162.0 μSv (P = 0.02) and by 81% or 128.9 μSv (P = 0.014) for acetabular fractures. DISCUSSION:Our data demonstrate that real-time visualization of radiation exposure during orthopaedic trauma operations can decrease radiation exposure in the highest exposure cases. Further research is necessary to determine whether the reduction in radiation exposure is sustained over time and to understand how real-time radiation exposure data mitigates exposure. LEVEL OF EVIDENCE:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.