Search

Radiographic imaging is integral to the diagnosis and treatment of orthopedic injuries. Previous studies have shown that orthopedists consistently underestimate the price of implants, but their knowledge of imaging charges is unknown. This study evaluated whether orthopedic residents and faculty could accurately estimate charges of imaging modalities at their respective institutions. A survey with 10 common imaging studies was sent to 8 academic level I trauma centers. Participants estimated the total charge of each imaging modality. This was compared with the actual charge at their institution. Seven centers produced 162 responders: 74 faculty and 88 residents. The differences between the estimated cost and the billing charge were calculated and broken down by training level and imaging modality. Overall, imaging charges were underestimated by 31% ( P P =.69). There was greater than 1000% variation in charges between institutions. Orthopedists across training levels underestimate hospital charges associated with common imaging studies, and there is a large variation in charges between centers. Awareness of charges is important because charges affect clinical decision making and are relevant to practicing both cost-conscious and clinically sound medicine. [ Orthopedics . 2019; 42(5):e454–e459.]

Hardware-related complications can occur when plate fixation is used to stabilize osteoporotic fractures involving the olecranon. The use of an additional nonlocking screw, placed retrograde into the proximal fracture segment, may improve stability under load. The purpose of this study was to conduct a biomechanical comparison of olecranon repair constructs with and without this additional retrograde screw. Nine matched pairs of elderly fresh-frozen cadaveric upper extremities were used. Two-part olecranon fractures were modeled, and fracture stabilization was performed. Olecranon plates were implanted either with the standard surgical technique (CTRL) or with an additional retrograde screw (EXPT). Dynamic extensions of increasingly loaded forearms were performed, and comparisons of sustained cycles, maximum load, and total work were made. Relative motion of bone segments was tracked, and modes of failure were assessed. Seventy-eight percent of specimens from the CTRL group failed due to relative fragment displacement exceeding 3 mm, while 78% of EXPT specimens failed due to instantaneous catastrophic failure. There were no significant differences in terms of number of survived cycles, maximum load, or work performed between the groups. The addition of a retrograde screw in this plating technique changes the failure mode from fracture displacement to catastrophic failure. The use of a 3.5-mm retrograde screw in the relatively small proximal ulnar fragment should be avoided, but screws with a smaller diameter may still have potential to improve fixation. Further biomechanical and clinical research is necessary to improve strategies for plate fixation of olecranon fractures in the elderly population. [ Orthopedics . 2019; 42(1):e74–e80.]

Geriatric acetabular, pelvis, and subtrochanteric femur fractures are poorly understood and rapidly growing clinical problems. The purpose of this study was to describe the epidemiologic trends of these injuries as compared with traditional fragility fractures about the hip. From 1993 to 2010, the Nationwide Inpatient Sample (NIS) recorded more than 600 million Medicare-paid hospital discharges. This retrospective study used the NIS to compare patients with acetabular fractures (n=87,771), pelvic fractures (n=522,831), and subtrochanteric fractures (n=170,872) with patients with traditional hip fractures (intertrochanteric and femoral neck, n=3,495,742) with regard to annual trends over an 18-year period in incidence, length of hospital stay, hospital mortality, transfers from acute care institutions, and hospital charges. Traditional hip fractures peaked in 1996 and declined by 25.7% by 2010. During the same 18-year period, geriatric acetabular fractures increased by 67%, subtrochanteric femur fractures increased by 42%, and pelvic fractures increased by 24%. Hospital charges, when controlling for inflation, increased roughly 50% for all fracture types. Furthermore, transfers from outside acute care hospitals for definitive management stayed elevated for acetabular fractures as compared with traditional hip fractures, suggesting a greater need for tertiary care of acetabular fractures. Geriatric acetabular fractures are rapidly increasing, whereas traditional hip fractures continue to decline. Patients with these injuries are more likely to be transferred from their hospital of presentation to another acute care institution, possibly increasing costs and complications. This is likely related to their complexity and the lack of consensus regarding optimal management. [ Orthopedics. 2014; 37(3):151–157.]

The radius of curvature of femoral intramedullary nails does not match the average radius of curvature of the human femur. Anterior cortical breach of the distal femur during nail placement has been reported in certain fracture patterns, in femora with a smaller radius of curvature, and at the starting point of the nail. The authors describe a novel technique used to prevent anterior cortical disruption of the femur using multiple percutaneously placed Steinmann pins. This technique ensures safe passage of medullary reamers and the femoral nail.

Proximal humerus fractures are relatively common, with treatment dependent on fracture-specific, patient-specific, and surgeon-specific factors. This study sought to identify preferences among shoulder specialists and orthopedic traumatologists in the treatment of proximal humerus fractures. An anonymous Internet survey of fellowship-trained shoulder surgeons and traumatologists was conducted with radiographs and select computed tomography images of 15 unique displaced proximal humerus fractures. Participants were asked to classify each case according to Neer criteria and choose management from a list of options. Groups were analyzed using chi-square test for independence, paired t test, and Fleiss' kappa within and between each group. Among shoulder surgeons, there were a total of 19 cases selected for nonoperative management, 204 cases selected for open reduction and internal fixation (ORIF), and 122 cases selected for arthroplasty. Among traumatologists, there were 44 cases selected for nonoperative management, 234 for ORIF, and 67 for arthroplasty. Fleiss' kappa for intraobserver agreement on treatment choice was 0.26 for shoulder surgeons and 0.18 for traumatologists, and chi-square test for independence was significant between the 2 groups ( P t test of the average treatment proportions was significant for nonoperative management and arthroplasty ( P =.003) but not significant for differences in rates of ORIF. These results confirm poor consistency in Neer classification among surgeons and suggest that shoulder surgeons were more likely to consider arthroplasty for treatment and that traumatologists were more likely to use ORIF or to manage patients nonoperatively. These variations in care may translate to differences in outcome and cost. [ Orthopedics. 2016; 39(3):e509–e513.]

Advances in surgical techniques have increased the role of early surgical intervention for isolated diaphyseal humerus fractures. The goal of this study was to investigate the following: (1) the current trend of operative treatment; (2) factors that affect surgical treatment; and (3) the effect of surgical fixation on length of stay, complication rates, and hospital disposition. The National Trauma Data Bank from 2004 to 2006 was analyzed. All patients with multiple injuries that included closed humeral shaft fractures and all patients with isolated humeral shaft fractures were included. Of 2312 total closed humeral shaft fractures, 1662 had a documented procedure code. A total of 47% of patients underwent surgical treatment. Surgically treated patients were on average 3.5 years older than those treated nonoperatively ( P =.007). A total of 49% of white patients underwent early surgery vs 39% of nonwhite patients ( P P =.04). Treatment at a Level I trauma center decreased the likelihood of surgery compared with treatment at a non-Level I trauma center (45% vs 57%, P P =.02). Of patients who underwent surgery, 78% were discharged to home compared with 69% of those managed nonoperatively ( P Orthopedics. 2015; 38(6):e485–e489.]

Vascular injuries in conjunction with low-energy geriatric hip fractures, although uncommon, can be life-threatening. Furthermore, vascular injuries are usually iatrogenic, related to malpositioning of percutaneous reduction aids, aberrant drilling, or poorly sized implants. The authors describe an older woman who had a low-energy pertrochanteric hip fracture. She was noted preoperatively to have an isolated decrease in hemoglobin of 4.7 g/dL in the 2.5 days before surgery. Fracture reduction was performed with closed and percutaneous techniques with the limb free-legged on a radiolucent flat-top table. On reduction of the distal fragment (which was translated proximal and medial), extremely brisk bleeding was noted from the fracture site. Vascular control was obtained with subvastus exposure through the fracture site to gain access to the medial aspect of the thigh. A pulsatile traumatic laceration in the profunda femoral artery was identified, and the ends were ligated. The fracture was then fixated internally. Careful analysis of preoperative imaging showed the distal fracture fragment in immediate proximity to the calcified profunda femoral artery, transecting it at the time of injury and resulting in the significant increase in hemoglobin noted preoperatively. This case is an unusual vascular injury associated with a very common geriatric fracture pattern. To the authors’ knowledge, there are only 2 cases in the English language literature of acute vascular injury as a result of a proximal femur fracture fragment. Given the routine nature of geriatric hip fractures, the orthopedic surgeon must be familiar with the appropriate diagnosis and management of this major complication. [ Orthopedics . 2015; 38(1):e75–e79.]

Management of geriatric hip fractures in a protocol-driven center can improve outcomes and reduce costs. Nonetheless, this approach has not spread as broadly as the effectiveness data would imply. One possible explanation is that operating such a center is not perceived as financially worthwhile. To assess the economic viability of dedicated hip fracture centers, the authors built a financial model to estimate profit as a function of costs, reimbursement, and patient volume in 3 settings: an average US hip fracture program, a highly efficient center, and an academic hospital without a specific hip fracture program. Results were tested with sensitivity analysis. A local market analysis was conducted to assess the feasibility of supporting profitable hip fracture centers. The results demonstrate that hip fracture treatment only becomes profitable when the annual caseload exceeds approximately 72, assuming costs characteristic of a typical US hip fracture program. The threshold of profitability is 49 cases per year for high-efficiency hip fracture centers and 151 for the urban academic hospital under review. The largest determinant of profit is reimbursement, followed by costs and volume. In the authors’ home market, 168 hospitals offer hip fracture care, yet 85% fall below the 72-case threshold. Hip fracture centers can be highly profitable through low costs and, especially, high revenues. However, most hospitals likely lose money by offering hip fracture care due to inadequate volume. Thus, both large and small facilities would benefit financially from the consolidation of hip fracture care at dedicated hip fracture centers. Typical US cities have adequate volume to support several such centers.

Resident participation in the Political Action Committee (PAC) is important for professional advocacy and for ensuring access to quality musculoskeletal care. The following questions were asked: Would faculty contribution-matching increase donation rates and amounts among orthopedic surgery residents at a single institution? What barriers do residents self-identify that prevent or delay PAC participation? How do residents perceive a faculty contribution-matching program? Residents at 1 institution were encouraged to participate in the PAC before and after the introduction of a faculty contribution-matching program. In addition, telephone follow-up was performed and resident perceptions were assessed regarding the program and barriers to participation. Rates of participation, amounts donated, and perceptions are reported. Resident participation in the PAC increased from 10% to 95% following the introduction of a faculty contribution-matching program. The second group of residents contributed 67 cents for every dollar given by the first group. Significant barriers identified included time constraints and an inability to access the PAC Web portal. Ninety-four percent of the initial nonresponders said that they made joining the PAC a priority after learning about the faculty contribution-matching program. They specifically cite giving greater attention to an issue that the faculty value. Four months after the initial e-mail, 100% of residents had contributed. Residents believe that professional activism is important but ascribe it a lower priority than other professional duties. Residency programs might facilitate resident involvement in the PAC by instituting faculty contribution-matching and by assisting junior residents with their American Association of Orthopaedic Surgeons login information.

The objective of this study was to compare retrograde intramedullary femoral nailing with supracondylar locked screw-plate fixation for the treatment of periprosthetic femur fractures following total knee arthroplasty. Time to union and full weight bearing were the primary study outcomes, with perioperative blood loss, need for transfusion, need for revision surgery, and infection being the secondary outcomes. A retrospective review of 63 patients who sustained Rorabeck Type II periprosthetic femoral fractures was undertaken. Patients were pooled from 3 academic institutions between 2001 and 2009. Patients eligible for the study were identified from the electronic medical record using an IDX query of International Classification of Diseases 9 and Current Procedural Terminology codes for fixation of femur fracture with intramedullary implant or plate and screws. In the series, 35 patients were treated with intramedullary femoral nailing and 28 with a locked screw-plate. The 2 groups were compared for radiographic union at 6, 12, 24, and 36 weeks. At 36 weeks, radiographic union was significantly greater in the locked screw-plate group. Time to full weight bearing was not significantly different. A greater perioperative transfusion rate was observed in the locking plate group, but it also had an overall lower rate of reoperation, for any reason, compared with the intramedullary femoral nailing group. The results support the use of a laterally based locked plate in the treatment of Rorabeck type II distal femur periprosthetic fractures.

Segmental long bone defects resulting from injury or surgical intervention are difficult problems to manage. Amputation, external fixators, vascularized fibular grafts, acute limb shortening, and various quantities of allograft and autograft have historically been the mainstays of treatment. Recently, the use of osteoinductive substances such as recombinant bone morphogenic proteins, and osteoconductive scaffolds such as calcium phosphate have found use in the treatment of these clinical situations. More recently, Masquelet described the use of a cement spacer placed within the osseous void followed by staged bone grafting within the induced biomembrane formed around the spacer as a potential treatment strategy to manage these large defects. This article describes a series of 11 patients for which we used this technique of staged bone grafting following placement of an antibiotic spacer to successfully manage osseous long bone defects ranging from 4 to 15 cm. The limbs were stabilized and aligned at the time of initial spacer placement with a plate and screw construct, intramedullary nail, or fine wire fixator. Osteoinductive substances including bone morphogenic protein-2 and platelet rich concentrate were used in addition to allograft to improve bony healing. In our series, osseous consolidation and full weight bearing was achieved in 10 of 11 patients. Two patients developed heterotopic ossification. There was 1 non-union and 1 infection, which occurred in the same patient. Staged bone grafting within an induced biomembrane created after the use of a cement spacer is a reasonable option in the management of both acute and delayed segmental long bone defects.

Femoral neck fractures are common in the elderly; however, agreement on classification and treatment varies. It was hypothesized that computed tomography (CT) would increase agreement for Garden Classification and treatment plan over plain radiographs alone. This article presents results of an online survey completed by 32 respondents at a single institution. The survey was comprised of 5 elderly patients with femoral neck fractures using plain radiographs and CT images. Cases were randomly presented in 3 formats: (1) plain radiograph, (2) CT, and (3) plain radiograph and CT together. Patients were described as low-energy trauma, 65 years or older, and cleared for surgery. Garden Classification and treatment plans were queried. A single case was repeated for intraobserver reliability. Kappa was calculated for inter- and intraobserver reliability. The addition of CT and modification of the Garden Classification (nondisplaced vs displaced) improved interobserver agreement in all cases. Participants were 1.7× more likely ( P =.042) to change their Modified Garden Classification when CT was added to plain radiograph compared to plain radiograph added to CT. Treatment agreement was slight to fair. Intraobserver agreement varied from slight to moderate. The rate of arthoplasty recommendations was similar across attending subspecialties; however, arthroplasty-trained surgeons were 20 to 60 times more likely to recommend total hip arthroplasty ( P =.009) over hemiarthroplasty compared to nonarthroplasty-trained surgeons. The addition of CT to plain radiograph after femoral neck fracture improves Garden Classification agreement. However, treatment agreement was not impacted by CT. Factors other than improved classification agreement appeared to direct surgeons’ treatment recommendations.

Obesity is prevalent in the developed world and is associated with significant costs to the health care system. The effect of morbid obesity in patients operatively treated for long-bone fractures of the lower extremity is largely unknown. The National Trauma Data Bank was accessed to determine if morbidly obese patients (body mass index >40) with lower extremity fractures have longer length of hospital stay, higher cost, greater rehabilitation admission rates, and more complications than nonobese patients. We identified patients with operatively treated diaphyseal femur (6920) and tibia (5190) fractures. Polytrauma patients and patients younger than 16 years were excluded. Morbidly obese patients were identified by ICD-9 and database comorbidity designation (femur, 131 morbidly obese; tibia, 75 morbidly obese). Patients meeting these criteria who were not morbidly obese were used as controls. Sensitivity analyses were performed to analyze patients with isolated trauma to the tibia or femur. Morbidly obese patients were more likely to be admitted to a subacute facility. Length of stay trended higher in morbidly obese patients. There was no significant relationship between obesity and inpatient mortality or inpatient complications. These trends held true when considering patients with multiple injuries and patients who had isolated long-bone injuries. Our study showed that morbidly obese patients may have greater rehabilitation needs following long-bone fractures in the lower extremity. Our study showed no difference in mortality or complications, although further studies are needed to confirm these findings.

The purpose of the levels of evidence system is to provide a framework for critical evaluation of orthopedic literature. This rating system is based on guidelines from the Oxford Centre for Evidence-Based Medicine and is currently in use in several orthopedic surgery journals. The purpose of this study was to investigate resident knowledge of the levels of evidence criteria used in classification of clinical articles. Thirty-eight residents from 5 orthopedic surgery training programs, from year-in-training 3 to 5, determined the levels of evidence rating of 10 blinded articles representing all levels of evidence types in the orthopedic literature. Residents were then provided with a levels of evidence information sheet and asked to re-rate each article. The mean percentage correct for the initial rating was 29.5% and for the post-education rating was 41.3%, with significant improvement after levels of evidence education (P