Marilyn Heng

Introduction: Orthopaedic research informs clinical practice, making it critical to collect data that reflect diverse patient demographics, including race and ethnicity. Despite the importance of these variables in addressing healthcare disparities, race and ethnicity are often underreported in orthopaedic studies. The aim of this study was to evaluate the frequency of race and ethnicity reporting in high-impact orthopaedic journals and identify trends based on study characteristics. Methods: Original research published between January 1, 2018, and December 31, 2020, in Clinical Orthopaedics and Related Research (CORR), Journal of Bone and Joint Surgery , and Journal of Orthopaedic Trauma (JOT) was compiled for analysis. Data on publication date, study type, level of evidence, country, and demographic variables were collected. Reporting rates were compared with the US Census 2020 diversity index and the Historical Index for Ethnic Fractionalization for global reporting, creating a performance ratio (PR) to quantify underreporting or overreporting based on geographic diversity. Results: Among 1452 studies, 89.2% reported sex and 86.5% reported age, but only 18.9% included race and 6.1% included ethnicity. Reporting was highest in Level II studies (29.3% race, 10.2% ethnicity) and cross-sectional studies (31.0% race, 11.2% ethnicity). United States–based studies reported race and ethnicity more frequently (28.0%), with the highest PR in Hawaii, New Hampshire, and Washington DC. Internationally, Japan, Thailand, and Finland had the highest PR. Reporting varied by journal, with CORR leading in race reporting (23.9%) and JOT in ethnicity (8.0%). Discussion: Race and ethnicity are markedly underreported in orthopaedic research. Addressing this disparity through standardized guidelines and enforcement mechanisms is essential to improve research quality and identify healthcare inequities. Additional exploration of these variables can better characterize diverse patient populations and inform clinical practice.

Background: The ideal antibiotic prophylaxis for open fractures is unknown. We evaluated outcomes following different antibiotic prophylaxis regimens for open fractures. Methods: This is a secondary analysis of data from PREP-IT. Prophylactic antibiotics were defined as any intravenous antibiotic given on the day of admission. The outcomes were surgical site infection (SSI) within 90 days and reoperation within 1 year. Logistic regression and an instrumental variable analysis that leveraged site-level variation accounted for confounding. Subgroup variation was evaluated by stratifying by Gustilo-Anderson classification (Types I and II versus III). Results: Of the 3,331 included participants, the mean age was 45 ± 18 years, 63% were male, 73% were White, 21% were Black, 2% were Asian, and 10% were Hispanic. Cefazolin monotherapy (58% of patients), ceftriaxone monotherapy (10%), and cefazolin plus gentamicin (6%) were the most common regimens. In the instrumental variable analysis, the odds of infection did not significantly differ with ceftriaxone use (odds ratio [OR], 1.24; 95% confidence interval [CI], 0.70 to 2.20; p = 0.45) or cefazolin plus gentamicin use (OR, 0.25; 95% CI, 0.03 to 2.04; p = 0.20) compared with cefazolin monotherapy. There were no significant differences between the regimens with respect to infection when stratified by Gustilo-Anderson type. However, we did observe a nearly 3-fold increase in the odds of infection with ceftriaxone use compared with cefazolin monotherapy (OR, 2.73; 95% CI, 0.96 to 7.79; p = 0.06) in Type-I and II fractures, and a 75% decrease in the odds of infection with cefazolin plus gentamicin use (OR, 0.25; 95% CI, 0.03 to 2.02; p = 0.19) compared with cefazolin monotherapy in Type-III fractures. Conclusions: Among patients with open fractures, antibiotic prophylaxis with ceftriaxone monotherapy did not provide significant benefits compared with cefazolin monotherapy in preventing infection in Type-I and II fractures. The findings suggest that cefazolin plus gentamicin might reduce the odds of infection in Type-III fractures compared with cefazolin monotherapy, but this difference was not statistically significant. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Background: The purpose of this study was to describe the culture and speciation results of patients with surgical site infection (SSI) from the PREPARE and Aqueous-PREP studies from the PREP-IT Investigators. Methods: Patients with suspected SSI underwent collection of deep or organ tissue samples for culture. The culture positivity rate was estimated as a percentage along with the exact binomial 95% confidence interval (CI). Microbial species were reported as percentages. Comparisons between open and closed fractures were conducted with the Z-test for proportions. Significance was set at p < 0.05. Results: Among the 2 primary studies, a total of 484 cases (defined as an anatomic fracture area; some patients had multiple fractures, which were each defined as a case if they developed an infection) had culture samples taken from deep or organ tissue. The culture positivity rate was 96.7% (95% CI, 94.7% to 98.0% [468 of 484 cases]). There were no significant differences (p = 0.507) in culture positivity between open fractures (97.2% [95% CI, 94.5% to 98.6%]; 273 of 281 cases) and closed fractures (96.1% [95% CI, 92.4% to 98.0%]; 195 of 203 cases). There was information on microbial species in 84.4% (395) of 468 cases. For patients with positive cultures, 43.3% (171 of 395 cases) were polymicrobial infections. Open fractures (47.8% [111 of 232 cases]), compared with closed fractures (36.8% [60 of 163 cases]), were more likely to be polymicrobial (p = 0.029). Staphylococcus aureus microbes (methicillin-sensitive S. aureus, methicillin-resistant S. aureus, and coagulase-negative S. aureus) accounted for 43.3% (462 of 1,066) of all positive cultures. The median time to infection was 58.5 days (95% CI, 49.0 to 67.0 days). The median time to infection was not significantly different in cases of open fractures (61.0 days [95% CI, 51.0 to 71.0 days]) compared with closed fractures (54.0 days [95% CI, 43.0 to 67.0 days]) (hazard ratio [HR], 0.92 [95% CI, 0.72 to 1.12]). SSIs associated with gram-negative bacteria had a shorter median time to infection at 46.0 days (95% CI, 36.0 to 58.0 days) compared with SSIs not associated with gram-negative bacteria at 70.0 days (95% CI, 56.0 to 88.0 days) (HR, 1.79 [95% CI, 1.55 to 2.03]). There was also a shorter median time to infection for patients with polymicrobial infections (47.0 days [95% CI, 38.8 to 52.1 days]) compared with patients with monomicrobial infections (78.6 days [95% CI, 57.2 to 86.8 days]) (HR, 1.26 [95% CI, 1.03 to 1.49]). Conclusions: In patients with SSI, tissue samples yielded high rates of microbial culture results. There was a higher proportion of gram-negative organisms in open fractures. Gram-negative infections were also associated with earlier time to infection. Clinicians should not hesitate to take deep-tissue culture samples in patients with suspected SSI and should be prepared to encounter polymicrobial infections. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objective What is the effect of surgical or conservative treatment on the in-hospital outcomes of patients with combined fractures of the clavicle and ribs? Design Retrospective cohort study. Setting Two level-1 trauma centers and academic teaching hospitals in Boston, Massachusetts. Patients All adult patients with a clavicle fracture and ≥3 rib fractures admitted from 2016 to 2021. Intervention None. Main outcome measurements Nosocomial pneumonia, hospital length-of-stay (HLOS), ICU length-of-stay (ILOS), days on mechanical ventilation (DMV). Results 252 patients were included (212 conservative, 40 surgical; median age 62 years, 67% male). The median ISS and GCS scores were 17 and 15, respectively. Thirty-seven patients developed nosocomial pneumonia. For clavicle fixation (n = 26), the OR for pneumonia was 0.3 (95% CI 0.0–2.2), ILOS had a ß-coefficient of −2.6 (95% CI −5.9–0.8), and DMV a ß-coefficient of −3.6 (95% CI −12.0–4.8). For rib plating (n = 10), the OR for pneumonia was 1.4 (95% CI 0.2–8.6), HLOS had a ß-coefficient of 4.9 (95% CI −1.6–11.5), and ILOS a ß-coefficient of 4.1 (95% CI −0.4–8.6). For both surgeries (n = 4), the CIs were wide. Conclusion Clavicle fixation in patients with combined injuries of the clavicle and ribs did not improve nor worsen in-hospital outcomes; the orthopedic surgeon should make a patient-tailored treatment decision. Rib plating did not improve in-hospital outcomes in non-flail patients with a concomitant clavicle fracture. Guidelines on non-flail rib plating could profit from these findings in combination with previous and additional research. Level of evidence Level III, Therapeutic Study.

Background Targeted muscle reinnervation (TMR) is an effective surgical treatment of neuropathic pain for amputees. However, limited data exist regarding the early postoperative pain course for patients who undergo either primary (<14 days since amputation) or secondary (≥14 days) TMR. This study aims to outline the postoperative pain course for primary and secondary TMR during the first 6 postoperative months to aid in patient education and expectation management. Methods Patients were eligible if they underwent TMR surgery between 2017 and 2023. Prospectively collected patient-reported outcome measures of pain scores, Pain Interference, and Pain Intensity were analyzed. Multilevel mixed-effects models were utilized to visualize and compare pain courses between primary and secondary TMR patients. Results A total of 203 amputees were included, with 40.9% being primary and 59.1% being secondary TMR patients. Primary TMR patients reported significantly lower pain scores over the full 6-month postoperative trajectory (p < 0.001) compared with secondary TMR patients, with a difference of Δ −1.0 at the day of TMR (primary = 4.5, secondary = 5.5), and a difference of Δ −1.4 at the 6-month mark (primary = 3.6, secondary = 5.0). Primary TMR patients also reported significantly lower Pain Interference (p < 0.001) and Pain Intensity scores (p < 0.001) over the complete trajectory of their care. Conclusion Primary TMR patients report lower pain during the first 6 months postoperatively compared with secondary TMR patients. This may reflect how pre-existing neuropathic pain is more challenging to mitigate through peripheral nerve surgery. The current trends may assist in both understanding the postoperative pain course and managing patient expectations following TMR. Level of Evidence Therapeutic – IV.

Subtrochanteric femur fractures have a reputation as difficult orthopaedic injuries to treat. Strong deforming forces, including the hip musculature and high physiologic forces, must be counteracted to obtain and maintain reduction. Adding to the complexity is a wide variety of fracture morphologies that must be recognized to execute an appropriate surgical plan. The challenging nature of this injury is demonstrated by nonunion rates of 4% to 5%, but some series have reports of up to 15% and malunion rates of 10% to 15%. Improved outcomes have been shown to be dependent on appropriate reduction and stable fixation, which can be achieved with less surgical insult. The treating surgeon must have a thorough understanding of the injury characteristics and reduction techniques to appropriately execute minimally invasive techniques for these difficult fractures.

Purpose This study aimed to quantify the impact of pre-existing psychiatric illness on inpatient outcomes after major trauma and to assess acuity of psychiatric presentation as a predictor of outcomes. Methods A retrospective single-center cohort study identified adult trauma patients with an Injury Severity Score (ISS) ≥ 16 between January 2018 and December 2019. Bivariate analysis assessed patient characteristics, injury characteristics, and injury outcomes between patients with and without psychiatric comorbidity. A sub-group analysis explored further effects of psychiatric history and need for inpatient psychiatric consultation on outcomes. Results Of 640 patients meeting inclusion criteria, 99 patients (15.4%) had at least one psychiatric comorbidity. Patients with psychiatric comorbidity sustained distinct mechanisms of injury and higher in-hospital morbidity (44% vs. 26%, OR 1.97, 95% CI 1.17–3.3, p = 0.01), including pulmonary morbidity (31% vs. 21%, p < 0.01), neurologic morbidity (18% vs 7%, p < 0.01), and deep wound infection (8% vs. 2%, p < 0.01) than the control cohort. Psychiatric patients also had significantly greater median intensive care unit (ICU), length of stay (LOS) (1 day vs. 0 days, p = 0.04), median inpatient ward LOS (10 days vs. 7 days, p = 0.02), and median overall hospital LOS (16 days vs. 11 days, p < 0.01). In sub-group analysis, patients with a history of psychiatric illness alone had comparable outcomes to the control group. Conclusions Psychiatric comorbidity negatively impacts inpatient morbidity and inpatient LOS. This effect is most pronounced among acute psychiatric episodes with or without a history of mental illness.

Background and Objectives: To assess the impact of Gadolinium‐enhanced magnetic resonance imaging (MRI) sequences on Preoperative imaging evaluation and surgical planning parameters for osteosarcoma (OS) of the knee in pediatric and young adult patients.Methods: Thirty MRI scans of patients with OS about the knee were reviewed by five orthopedic oncologists. Key preoperative parameters (neurovascular bundle involvement, intra‐articular tumor extension, extent of intramedullary extension) and surgical plans were evaluated based on non‐contrast versus Gd contrast enhanced sequences. Assessment agreement, inter‐rater agreement, and intrarater agreement between pre and postcontrast images were evaluated via Kappa statistics.Results: Moderate agreement was seen between non and contrast‐enhanced assessment of neurovascular involvement and intra‐articular tumor extension. Intrarater reproducibility was substantial for neurovascular bundle involvement (precontrast Kappa: 0.63, postcontrast Kappa: 0.69). Intrarater reproducibility was also substantial for precontrast (Kappa: 0.70) and moderate for postcontrast (Kappa: 0.50) assessment of intra‐articular tumor extension. Planned resection length and choice of surgical approach were similar between sequences. The addition of Gd‐enhanced sequences improved the inter‐rater agreement across collected parameters.Conclusions: While some findings suggest that contrast enhanced sequences may not significantly alter the assessment of key preoperative planning parameters by orthopedic oncologists, they may help reduce variability among providers with differing experience levels.

Background: Tibial turnup-plasty is a rarely performed surgical option for large bone defects of the distal or entire femur and can serve as an alternative to hip disarticulation or high above-knee amputation. It entails pedicled transport of the ipsilateral tibia with or without the proximal hindfoot for use as a vascularized autograft. It is rotated 180° in the coronal or sagittal plane to the remaining proximal femur or pelvis, augmenting the functional length of the thigh. Prior reports consist of small case series with heterogeneous surgical techniques. Patient-reported outcome measures after the procedure have not been reported, and ambulatory status after the procedure is also unknown. Questions/purposes: (1) What proportion of patients underwent reoperation after tibial turnup-plasty? (2) What is the ambulatory status and what proportion of patients used a prosthesis after tibial turnup-plasty? (3) What are the Patient-Reported Outcome Measurement Information System (PROMIS) Global-10 mental and physical function scores after tibial turnup-plasty? Methods: A retrospective analysis was performed of 11 patients who underwent tibial turnup-plasty between 2003 and 2021 by a single orthopaedic oncology division in collaboration with a reconstructive plastic surgery team. Nine patients were men, with a median age of 55 years (range 34 to 75 years). All had chronic infections after arthroplasty or oncologic reconstructions, with a median number of 13 surgeries before turnup-plasty. All were considered to have no other surgical options other than hip disarticulation or high transfemoral amputation. All patients who were offered this possibility accepted it. Data of interest included patient demographics and comorbidities, surgical history that led to limb compromise, medical and surgical perioperative complications, date of prosthesis fitting, and functional capacity at the most recent follow-up interval based on ambulatory status and PROMIS Global-10 mental and physical function scores. The statistical analysis was descriptive. Results: The median number of reoperations after turnup-plasty was one (range 0 to 11). Of the six patients who underwent at least one reoperation, indications for surgery included wound infection (four patients), nonunion of the osteosynthesis site (two), heterotopic ossification (one), tumor recurrence (one), and flap hypoperfusion treated with local tissue revision (one). One patient underwent conversion to external hemipelvectomy for tumor recurrence. Ten of the 11 patients were ambulatory at the final follow-up interval with standard above-knee amputation prostheses. Two ambulated unassisted, four used a single crutch or cane, and four used two crutches or a walker. Of the nine patients for whom scores were available, the median PROMIS Global-10 physical and mental health scores were 48 (range 30 to 68) and 53 (range 41 to 68), both within the standard deviation of the population mean of 50. Conclusion: The tibial turnup-plasty is a complex surgical option for patients with large bone defects of the femur for whom there are no alternative surgeries capable of producing residual extremities with acceptable functional length. This should be viewed as a procedure of last resort to avoid a hip disarticulation or a high transfemoral amputation in patients who have typically undergone numerous prior operations. Although ambulation with a prosthesis within 1 year can be expected, almost all patients will require an assistive device to do so, and reoperations are frequent. Level of Evidence: Level IV, therapeutic study.