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Unlabelled: This study was performed to determine whether patients who sustain an intertrochanteric fracture have better outcomes when stabilized using a sliding hip screw or an intramedullary nail. A 20% sample of Part A and B entitled Medicare beneficiaries 65 years or older was used to generate a cohort of patients who sustained intertrochanteric femur fractures between 1999 and 2001. Two fracture implant groups, intramedullary nail and sliding hip screw, were identified using Current Procedural Terminology and International Classification of Diseases, 9th Revision codes. The cohort consisted of 43,659 patients. Patients treated with an intramedullary nail had higher rates of revision surgery during the first year than those treated with a sliding hip screw (7.2% intramedullary nail versus 5.5% sliding hip screw). Mortality rates at 30 days (14.2% intramedullary nail versus 15.8% sliding hip screw) and 1 year (30.7% intramedullary nail versus 32.5% sliding hip screw) were similar. Adjusted secondary outcome measures showed significant increases in the intramedullary nail group relative to the sliding hip screw group for index hospital length of stay, days of rehabilitation services in the first 6 months after discharge, and total expenditures for doctor and hospital services.Level Of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Recommendations for surgical treatment and expected outcomes differ for two unstable patterns of supination-external rotation ankle injuries. We compared the demographic characteristics and functional outcome following surgical stabilization between the two types of supination-external rotation type-4 fractures: distal fibular fracture with a deltoid ligament rupture and bimalleolar fracture.Methods: Demographic data on 456 patients in whom an unstable fracture of the ankle was treated surgically were entered into a database and the patients were prospectively followed. Two hundred and sixty-six of these patients sustained either a bimalleolar fracture or a lateral malleolar fracture with insufficiency of the deltoid ligament and widening of the medial clear space. No medial fixation was used in the patients with a deltoid ligament injury. All patients followed a similar postoperative protocol. The patients were followed clinically and radiographically at three, six, and twelve months after the surgery. Function was assessed with the Short Musculoskeletal Function Assessment and the American Orthopaedic Foot and Ankle Society score.Results: Bimalleolar fractures were more commonly seen in female patients, in those older than sixty years of age, and in patients with more comorbidities. There was no significant association between the fracture pattern and either diabetes or the length of the hospital stay. At a minimum of one year postoperatively, the patients with a bimalleolar fracture had significantly worse function, even after we controlled for all other variables. The overall complication rate, including elective hardware removal, was also higher in the group with a bimalleolar fracture (seventeen compared with nine patients).Conclusions: At one year after surgical stabilization of an unstable ankle fracture, most patients experience little or mild pain and have few restrictions in functional activities. However, the functional outcome for those with a bimalleolar fracture is worse than that for those with a lateral malleolar fracture and disruption of the deltoid ligament, possibly because of the injury pattern and the energy expended. [ABSTRACT FROM AUTHOR]

Background: In the United States, the Emergency Medical Treatment and Active Labor Act defines broad guidelines regarding interhospital transfer of patients who have sought care in the emergency department. However, patient transfers for nonmedical reasons are still considered a common practice. The purpose of this study was to evaluate the possible risk factors for hospital transfer in a population of patients unlikely to require transfer to a level-I center for medical reasons.Methods: A retrospective case-control national database study was performed with use of data from the National Trauma Data Bank (version 4.3). The study group consisted of patients with low Injury Severity Scores (< or =9) who were transferred to a level-I trauma center from another hospital. The controls were patients with low Injury Severity Scores who were treated at any hospital that was lower than a level-I trauma center and were not transferred. Hypothesized risk factors for hospital transfer were the age, gender, race, and insurance status of the patient; the time of day the transfer was received; and the number and type of comorbidities.Results: The total sample included 97,393 patients, 21% of whom were transferred to a level-I trauma center. The odds ratios adjusted for all risk factors indicated that transfer rates were higher for male patients compared with female patients (adjusted odds ratio = 1.46), children compared with seniors (3.54), blacks compared with whites (1.28), evening or night transfers compared with morning or afternoon transfers (2.25), patients with Medicaid compared with those with other types of insurance (2.02), and for those with one or more comorbidities compared with those with no comorbidity (2.79).Conclusions: These results suggest the need for prospective studies to further investigate the relationships between hospital transfer and medical and nonmedical factors. [ABSTRACT FROM AUTHOR]

Background: Ankle fractures are among the most common injuries treated by orthopaedic surgeons. However, very few investigators have examined the functional recovery following ankle fracture surgery and, to our knowledge, none have analyzed factors that may predict functional recovery. In this study, we evaluated predictors of short-term functional outcome following surgical stabilization of ankle fractures.Methods: Over three years, 232 patients who sustained a fracture of the ankle and were treated surgically were followed prospectively, for a minimum of one year. Trained interviewers recorded baseline characteristics, including patient demographics, medical comorbidities, and functional status according to the Short Musculoskeletal Function Assessment (SMFA). Laboratory findings, the American Society of Anesthesiologists (ASA) class, and operative findings were recorded from the chart during hospitalization. Follow-up information included the occurrence of complications or additional surgery, weight-bearing status, functional status according to the SMFA, and the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score. The data were analyzed to determine predictors of functional recovery at three months, six months, and one year postoperatively.Results: Complete follow-up data were available for 198 patients (85%). At one year, 174 (88%) of the patients had either no or mild ankle pain and 178 (90%) had either no limitations or limitations only in recreational activities. According to the AOFAS ankle-hindfoot score, 178 (90%) of the patients had > or = 90% functional recovery. A patient age of less than forty years was a predictor of recovery, as measured with the SMFA subscores, at six months after the ankle fracture. At one year, however, age was no longer a predictor of recovery. Patients who were younger than forty were more likely to recover > or = 90% of function (p = 0.004), and men were more likely than women to recover function (p = 0.02). ASA Class 1 or 2 (p = 0.03) and an absence of diabetes (p = 0.02) were also predictors of better functional recovery at one year. SMFA subscores were below average at baseline, indicating a healthy population. At three and six months postoperatively, all SMFA subscores were significantly higher than the baseline subscores (p < 0.001); however, at one year, the SMFA subscores were almost back to the baseline, normal level.Conclusions: One year after ankle fracture surgery, patients are generally doing well, with most experiencing little or mild pain and few restrictions in functional activities. They have a significant improvement in function compared with six months after the surgery. Younger age, male sex, absence of diabetes, and a lower ASA class are predictive of functional recovery at one year following ankle fracture surgery. It is important to counsel patients and their families regarding the expected functional recovery after an ankle injury. [ABSTRACT FROM AUTHOR]

Background: Pin-track infection remains one of the most troublesome complications of external fixation, in some cases compromising otherwise successful fracture treatment.Methods: One hundred and eighteen patients (120 wrists) who had been managed with the placement of an external fixation device for the treatment of a displaced, unstable, distal radial fracture were randomized into one of three treatment groups: (1) weekly dry dressing changes without pin-site care; (2) daily pin-site care with a solution of one-half normal saline solution and one-half hydrogen peroxide; and (3) treatment with the placement of chlorhexidine-impregnated discs (Biopatch) around the pins, with weekly changes of the discs by the treating surgeon. The patients were followed at weekly intervals until the external fixator was removed. Radiographs were made biweekly. The patients were evaluated with regard to (1) erythema, (2) cellulitis, (3) drainage, (4) clinical or radiographic evidence of pin-loosening, (5) the need for antibiotics, and (6) the need for pin removal before fracture-healing due to infection. Differences in complication rates among the three groups, with adjustment for patient age, gender, and the performance of an associated open procedure, were evaluated.Results: The average age of the patients was fifty-four years. Forty-seven wrists had an open procedure (either bone-grafting or open reduction and internal fixation) in addition to treatment with the external fixator. The fixators remained in place for an average of 5.9 weeks. Twenty-three patients (19%) had a complication related to the pin track, with twelve of these patients requiring oral antibiotics for the treatment of a pin-track infection. There were no significant differences among the three groups with regard to the prevalence of pin-site complications. The age of the patient was found to be significantly associated with an increased risk of postoperative pin-track complications (p = 0.04).Conclusions: We found a high rate of local wound complications around external fixation pin sites; however, most complications were minor and could be observed or treated with oral antibiotics. The prevalence of these complications was not decreased in association with the use of hydrogen peroxide wound care or chlorhexidine-impregnated dressings. On the basis of these results, we do not recommend additional wound care beyond the use of dry, sterile dressings for pin-track care after external fixation for the treatment of distal radial fractures. [ABSTRACT FROM AUTHOR]

Purpose : Hip fracture occurs frequently, resulting in considerable morbidity, mortality and utilization of healthcare resources. Technical advances in fracture fixation and surgical treatment have improved outcomes following hip fracture in the elderly. However, further improvement in outcomes of hip fracture patients may be possible with utilization of a clinical pathway designed to enhance outcomes in a standardized, cost-effective manner. This paper presents a clinical pathway for the treatment of hip fractures in the elderly with the above aims. Method : The clinical pathway presented is based on personal experience and literature pertaining to the treatment of the elderly hip fracture patient. It outlines a suggested algorithmic approach to the patient that begins with the initial evaluation, progresses on through pre-operative and operative management, and ends with post-operative rehabilitation and treatment. Results: The clinical pathway for the hip fracture patient in this paper is a working treatment algorithm that has been successful in personal experience. Conclusion : This treatment algorithm has been utilized successfully in personal experience. Further input from healthcare professionals may prove to enhance outcomes in a cost-effective, standardized manner. [ABSTRACT FROM AUTHOR]

Background: Operative treatment of tibial fractures in children requires implants that do not violate open physes while maintaining tibial length and alignment. Both elastic stable intramedullary nails and external fixation can be utilized. We retrospectively reviewed our experience with these two techniques to determine if one is superior to the other.Methods: We retrospectively reviewed the operative records and trauma registries of three institutions within our hospital system and identified thirty-five consecutive patients with open physes who had undergone operative treatment of a tibial fracture between April 1997 and June 2004. Four patients were excluded because they had been managed with locked intramedullary nails or with pins and plaster. Of the thirty-one remaining patients, sixteen had been managed with elastic stable intramedullary nails and fifteen had been managed with unilateral external fixation. The clinical and radiographic outcomes were compared. The functional outcomes were compared with use of the Pediatric Outcomes Data Collection Instrument. Complications related to treatment, such as malunion, delayed union, nonunion, infection, and the need for subsequent surgical treatment also were compared.Results: Thirty-one patients with thirty-one operatively treated tibial fractures were available for evaluation. Fifteen patients had been managed with external fixation. Seven of these patients had a closed fracture, and eight had an open fracture. There were seven healing complications in this group, including two delayed unions, three nonunions, and two malunions. Sixteen patients had been managed with elastic stable intramedullary nailing. Eleven patients had a closed fracture, and five had an open fracture. The mean time to union for the intramedullary nailing group (seven weeks) was significantly shorter than that for the external fixation group (eighteen weeks) (p < 0.01). The functional outcomes for the intramedullary nailing group were significantly better than those for the external fixation group in the categories of pain, happiness, sports, and global function (the mean of the mean scores of the first four categories) (p < 0.01 for these comparisons).Conclusions: When surgical stabilization of tibial fractures in children is indicated, we believe that the preferred method of fixation is with elastic stable intramedullary nailing. [ABSTRACT FROM AUTHOR]

Background: The expanding role of industrial support in biomedical research has resulted in both substantial interest and controversy in recent years. Our hypothesis was that, from 1985 to 2002, the role of industrial support in orthopaedic research increased, as documented by the research presented at the annual meetings of the American Academy of Orthopaedic Surgeons.Methods: We analyzed the frequency and types of self-reported conflicts of interest for all presentations at the annual meetings of the American Academy of Orthopaedic Surgeons in 1985, 1988, 1992, 1997, 1999, and 2002. Conflicts of interest were recorded directly from the final program for each meeting analyzed. The analysis focused on the scientific presentations, Instructional Course Lectures, symposia, poster exhibits, and scientific exhibits. Information about specific types of support received by authors was first required in 1988.Results: The incidence of conflicts of interest increased from 3% in 1985 to 39% in 2002 for scientific papers (p < 0.001); from 10% to 74%, respectively, for symposia (p < 0.001); from 22% to 60% for Instructional Course Lectures (p < 0.001); from 10% to 60% for scientific exhibits (p < 0.001); and from 9% in 1992 to 14% in 2002 for posters (p < 0.001). For presentations of all types, the incidence increased from 10% to 32% (p < 0.001). The types of conflict of interest also changed significantly from 1999 to 2002. In 1999, 73% of conflicts were documented as support directed to institutions and 27%, as support to individuals; in 2002, 57% were reported as support directed to institutions and 43%, as support to individuals (p < 0.01).Conclusions: The role of industrial support of orthopaedic research increased significantly between 1985 and 2002, as evidenced by the increase in the self-reported conflicts of interest for all types of presentations at the annual meetings of the American Academy of Orthopaedic Surgeons. In addition, the support directed to individuals, in contrast to that directed to institutions, increased significantly. [ABSTRACT FROM AUTHOR]

Background: Tape blisters after hip surgery can be a source of postoperative morbidity and can increase patient discomfort. The purpose of this prospective study was to compare two different types of tape to determine whether the type of tape influences the rate of blister formation.Methods: Ninety-nine patients (100 hips) were enrolled in the study. Patients were randomized into one of two treatment groups: one treated with a nonstretchable silk tape and one treated with a perforated, stretchable cloth tape. After surgery, the assigned tape was applied over the postoperative dressing with care not to produce skin tension. At the first dressing change, the presence or absence of blisters was recorded as were the number, size, location, and type of any blisters. The presence or absence of tape blisters was recorded at the time of each subsequent dressing change.Results: A tape blister developed on twenty-five hips in twenty-five patients. The risk of a blister developing was 41% (twenty of forty-nine patients) when the nonstretchable silk tape was used and 10% (five of fifty patients) when the perforated cloth tape was used (relative risk = 4.08, 95% confidence interval = 1.53 to 10.87, p = 0.005). We found no association between formation of tape blisters and the age or gender of the patient, number of medical comorbidities, smoking history, results of nutritional assessment, or type of surgery.Conclusions: The prevalence of tape blisters was significantly lower when perforated cloth tape was used than it was when nonstretchable silk tape was used. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to determine when patients recover the ability to safely operate the brakes of an automobile following operative repair of an ankle fracture.Methods: A computerized driving simulator was developed and tested. Eleven healthy volunteers were tested once to establish normal mean values (Group I), and a group of thirty-one volunteers with a fracture of the right ankle were tested at six, nine, and twelve weeks following operative repair (Group II). The subjects were tested with a series of driving scenarios (city, suburban, and highway). Scores on the Short Form Musculoskeletal Assessment were recorded at six, nine, and twelve weeks and were compared with the results of the driving test. We investigated the effect of the time of the visit and of the testing condition on the braking times.Results: The total braking time was 1079 msec for Group I and 1330, 1172, and 1160 msec for Group II at six, nine, and twelve weeks, respectively, postoperatively (p = 0.0094). The total braking time consistently improved for each of the driving scenarios at each successive data point (p = 0.05). The increase in the total braking time at six weeks meant an increase in the distance traveled by the automobile before braking of 22 ft (6.7 m) at 60 mph (96.6 km/hr), and the increase at nine weeks meant an increase of 8 ft (2.4 m) at 60 mph. The functional outcome improved at each successive visit, although no significant association was found between the functional scores and normalization of total braking time.Conclusion: By nine weeks, the total braking time of patients who have undergone fixation of a displaced right ankle fracture returns to the normal, baseline value. [ABSTRACT FROM AUTHOR]

Background: Delirium and pain are common following hip fracture. Untreated pain has been shown to increase the risk of delirium in older adults undergoing elective surgery. This study was performed to examine the relationship among pain, analgesics, and other factors on delirium in hip fracture patients.Methods: We conducted a prospective cohort study at four New York hospitals that enrolled 541 patients with hip fracture and without delirium. Delirium was identified prospectively by patient interview supplemented by medical record review. Multiple logistic regression was used to identify risk factors.Results: Eighty-seven of 541 patients (16%) became delirious. Among all subjects, risk factors for delirium were cognitive impairment (relative risk, or RR, 3.6; 95% confidence interval, or CI, 1.8-7.2), abnormal blood pressure (RR 2.3, 95% CI 1.2-4.7), and heart failure (RR 2.9, 95% CI 1.6-5.3). Patients who received less than 10 mg of parenteral morphine sulfate equivalents per day were more likely to develop delirium than patients who received more analgesia (RR 5.4, 95% CI 2.4-12.3). Patients who received meperidine were at increased risk of developing delirium as compared with patients who received other opioid analgesics (RR 2.4, 95% CI 1.3-4.5). In cognitively intact patients, severe pain significantly increased the risk of delirium (RR 9.0, 95% CI 1.8-45.2).Conclusions: Using admission data, clinicians can identify patients at high risk for delirium following hip fracture. Avoiding opioids or using very low doses of opioids increased the risk of delirium. Cognitively intact patients with undertreated pain were nine times more likely to develop delirium than patients whose pain was adequately treated. Undertreated pain and inadequate analgesia appear to be risk factors for delirium in frail older adults. [ABSTRACT FROM AUTHOR]