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Purpose: Determine if any fracture characteristics or radiographic parameters were predictive of fixation failure [FF] within 1 year following cephalomedullary nailing for intertrochanteric fractures., Methods: A consecutive series of intertrochanteric hip fracture patients (AO/OTA 31A) treated with a cephalomedullary nail were reviewed. Pre-fixation (neck-shaft angle [NSA], distance from ischial tuberosities to greater and lesser trochanters, integrity of lesser trochanter, and fracture angulation) and post-fixation (post-fixation NSA, posteromedial cortex continuity, lag screw position, tip to apex distance [TAD], and post-fixation angulation and translation) radiographic parameters were measured by blinded independent reviewers. The FF and non-FF groups were statistically compared. Logistic regression was performed to determine radiographic parameter correlates of FF., Results: Of 1249 patients, 23 (1.8%) developed FF within 1 year. The FF patients were younger than their non-FF counterparts (77.2 years vs 81.0 years, p=0.048), however there were no other demographic differences. The FF cohort did not differ in frequency of TAD over 25 mm (4.3% vs 9.6%, p=0.624) and had decreased mean TAD (13.6mm vs 16.3mm, p=0.021) relative to the non-FF cohort. The FF cohort had a higher rate of a post-fixation coronal plane NSA more than 10° different from the contralateral side (delta NSA>10°, 34.8% vs 13.7%, p=0.011) with the majority fixed in relative varus. For every 1° increase in varus compared to the contralateral side the odds of FF increased 7% (OR=1.065, 95%CI[1.005-1.130], p=0.034) on univariate analysis. On univariate logistic regression, patients with an absolute post-fixation NSA of 10° or more of varus compared to contralateral were significantly more likely to have a FF (OR=3.139, 95%CI[1.067-8.332], p=0.026)., Conclusion: Despite an acceptable TAD, post-fixation NSA in relative varus as compared to the contralateral side was significantly associated with failure in intertrochanteric hip fractures fixed with a cephalomedullary nail., Level of Evidence: Prognostic Level III., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Introduction: The purpose of this study was to assess the impact of COVID-19 on the cost of hip fracture care in the geriatric/middle-aged cohort, hypothesizing the cost of care increased during the pandemic, especially in COVID+ patients., Methods: Between October 2014 and January 2022, 2,526 hip fracture patients older than 55 years were analyzed for demographics, injury details, COVID status on admission, hospital quality measures, and inpatient healthcare costs from the inpatient admission. Comparative analyses were conducted between: (1) All comers and high-risk patients in the prepandemic (October 2014 to January 2020) and pandemic (February 2020 to January 2022) cohorts and (2) COVID+ and COVID- patients during the pandemic. Subanalysis assessed the difference in cost breakdown for patients in the overall cohorts, the high-risk quartiles, and between the prevaccine and postvaccine pandemic cohorts., Results: Although the total costs of admission for all patients, and specifically high-risk patients, were not notably higher during the pandemic, further breakdown showed higher costs for the emergency department, laboratory/pathology, radiology, and allied health services during the pandemic, which was offset by lower procedural costs. High-risk COVID+ patients had higher total costs than high-risk COVID- patients ( P < 0.001), most notably in room-and-board ( P = 0.032) and allied health ( P = 0.023) costs. Once the pandemic started, subgroup analysis demonstrated no change in the total cost in the prevaccine and postvaccine cohort., Conclusion: The overall inpatient cost of hip fracture care did not increase during the pandemic. Although individual subdivisions of cost signified increased resource utilization during the pandemic, this was offset by lower procedural costs. COVID+ patients, however, had notably higher total costs compared with COVID- patients driven primarily by increased room-and-board costs. The overall cost of care for high-risk patients did not decrease after the widespread administration of the COVID-19 vaccine., Level of Evidence: III., Competing Interests: All authors report no conflict of interest or financial disclosures., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Introduction: The purpose of this study is to identify optimal threshold hemoglobin (Hgb) and hematocrit (Hct) laboratory values to transfuse hip fracture patients., Methods: A consecutive series of hip fracture patients were reviewed for demographic, clinical, and cost data. Patients receiving an allogeneic transfusion of packed red blood cells (pRBCs) were grouped based on last Hct or Hgb (H&H) value before first transfusion. Multivariate logistic regressions of H&H quantile were performed to predict "good outcomes," a composite binary variable defined as admissions satisfying (1) no major complications, (2) length of stay below top tertile, (3) cost below median, (4) no mortality within 30 days, and (5) no readmission within 30 days. Odds ratios (OR) for "good outcomes" were calculated for each H&H quantile., Results: One thousand four hundred ninety-six hip fracture patients were identified, of which 598 (40.0%) were transfused with pRBCs. Patients first transfused at Hgb values from 7.55 to 7.85 g/dL ( P = 0.043, OR = 2.70) or Hct values from 22.7 to 23.8% ( P = 0.048, OR = 2.63) were most likely to achieve "good outcomes.", Discussion: The decision to transfuse patients should be motivated by Hgb and Hct laboratory test results, given that transfusion timing relative to surgery has been shown to not affect outcomes among patients matched by trauma risk score. Surgeons should aim to transfuse hip fracture patients at Hgb levels between 7.55 g/dL and 7.85 g/dL or Hct levels between 22.7% and 23.8%. These transfusion thresholds have the potential to lower healthcare costs without compromising quality, ultimately resulting in less costly, efficacious care for the patient., Level of Evidence: Level III., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Background: Many initiatives by medical and public health communities at the national, state, and institutional level have been centered around understanding and analyzing critical determinants of population health with the goal of equitable and nondisparate care. In orthopaedic traumatology, several studies have demonstrated that race and socioeconomic status are associated with differences in care delivery and outcomes of patients with hip fractures. However, studies assessing the effectiveness of methods to address disparities in care delivery, quality metrics, and complications after hip fracture surgery are lacking., Questions/purposes: (1) Are hospital quality measures (such as delay to surgery, major inpatient complications, intensive care unit admission, and discharge disposition) and outcomes (such as mortality during inpatient stay, within 30 days or within 1 year) similar between White and non-White patients at a single institution in the setting of a standardized hip fracture pathway? (2) What factors correlate with aforementioned hospital quality measures and outcomes under the standardized care pathway?, Methods: In this retrospective, comparative study, we evaluated the records of 1824 patients 55 years of age or older with hip fractures from a low-energy mechanism who were treated at one of four hospitals in our urban academic healthcare system, which includes an orthopaedic tertiary care hospital, from the initiation of a standardized care pathway in October 2014 to March 2020. The standardized 4-day hip fracture pathway is comprised of medicine comanagement of all patients and delineated tasks for doctors, nursing, social work, care managers, and physical and occupational therapy from admission to expected discharge on postoperative day 4. Of the 1824 patients, 98% (1787 of 1824) of patients who had their race recorded in the electronic medical record chart (either by communicating it to a medical provider or by selecting their race from options including White, Black, Hispanic, and Asian in a patient portal of the electronic medical record) were potentially eligible. A total of 14% (249 of 1787) of patients were excluded because they did not have an in-state address. Of the included patients, 5% (70 of 1538) were lost to follow-up at 30 days and 22% (336 of 1538) were lost to follow-up at 1 year. Two groups were established by including all patients selecting White as primary race into the White cohort and all other patients in the non-White cohort. There were 1111 White patients who were 72% (801) female with mean age 82 ± 10 years and 427 non-White patients who were 64% (271) female with mean age 80 ± 11 years. Univariate chi-square and Mann-Whitney U tests of demographics were used to compare White and non-White patients and find factors to control for potentially relevant confounding variables. Multivariable regression analyses were used to control for important baseline between-group differences to (1) determine the correlation of White and non-White race on mortality, inpatient complications, intensive care unit (ICU) admissions, and discharge disposition and (2) assess the correlation of gender, socioeconomic status, insurance payor, and the Score for Trauma Triage in the Geriatric and Middle Aged (STTGMA) trauma risk score with these quality measures and outcomes., Results: After controlling for gender, insurer, socioeconomic status and STTGMA trauma risk score, we found that non-White patients had similar or improved care in terms of mortality and rates of delayed surgery, ICU admission, major complications, and discharge location in the setting of the standardized care pathway. Non-White race was not associated with inpatient (odds ratio 1.1 [95% CI 0.40 to 2.73]; p > 0.99), 30-day (OR 1.0 [95% CI 0.48 to 1.83]; p > 0.99) or 1-year mortality (OR 0.9 [95% CI 0.57 to 1.33]; p > 0.99). Non-White race was not associated with delay to surgery beyond 2 days (OR = 1.1 [95% CI 0.79 to 1.38]; p > 0.99). Non-White race was associated with less frequent ICU admissions (OR 0.6 [95% CI 0.42 to 0.85]; p = 0.03) and fewer major complications (OR 0.5 [95% CI 0.35 to 0.83]; p = 0.047). Non-White race was not associated with discharge to skilled nursing facility (OR 1.0 [95% CI 0.78 to 1.30]; p > 0.99), acute rehabilitation facility (OR 1.0 [95% CI 0.66 to 1.41]; p > 0.99), or home (OR 0.9 [95% CI 0.68 to 1.29]; p > 0.99). Controlled factors other than White versus non-White race were associated with mortality, discharge location, ICU admission, and major complication rate. Notably, the STTGMA trauma risk score was correlated with all endpoints., Conclusion: In the context of a hip fracture care pathway that reduces variability from time of presentation through discharge, no differences in mortality, time to surgery, complications, and discharge disposition rates were observed beween White and non-White patients after controlling for baseline differences including trauma risk score. The pathway detailed in this study is one iteration that the authors encourage surgeons to customize and trial at their institutions, with the goal of providing equitable care to patients with hip fractures and reducing healthcare disparities. Future investigations should aim to elucidate the impact of standardized trauma care pathways through the use of the STTGMA trauma risk score as a controlled confounder or randomized trials in comparing standardized to individualized, surgeon-specific care., Level of Evidence: Level III, therapeutic study., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2022 by the Association of Bone and Joint Surgeons.)

Introduction: The purpose of this study was to assess how quality and volume of common orthopaedic care varies across private, municipal, and federal healthcare delivery systems (HDSs)., Methods: Hip and knee arthroplasty, knee and shoulder arthroscopy, and hip fracture repair were audited over a two-year period. Electronic medical records were reviewed for demographics, diagnosis, lengths of stay (LoSs), surgical wait times, inpatient complication, readmission, and revision surgery rates. Multivariate regression controlled for differences in age, sex, diagnosis, and Charlson Comorbidity Index to determine how HDS correlated with surgical wait time, length of stay, complication rates, readmission, and revision surgery., Results: The 5,696 included patients comprise 87.4% private, 8.6% municipal, and 4.0% federal HDSs. Compared with private HDS for arthroplasty, federal surgical wait times were 18 days shorter (95% CI = 9 to 26 days, P < 0.001); federal LoS was 4 days longer (95% CI = 3.6 to 4.3 days, P < 0.001); municipal LoS was 1 day longer (95% CI = 0.8 to 1.4, P < 0.001); municipal 1-year revision surgery odds were increased (odds ratio [OR] = 2.8, 95% CI = 1.3 to 5.4, P = 0.045); and complication odds increased for municipal (OR = 12.2, 95% CI = 5.2 to 27.4, P < 0.001) and federal (OR = 12.0, 95% CI = 4.5 to 30.8, P < 0.001) HDSs. Compared with private HDS for arthroscopy, municipal wait times were 57 days longer (95% CI = 48 to 66 days, P < 0.001) and federal wait times were 34 days longer (95% CI = 21 to 47 days, P < 0.001). Compared with private HDS for fracture repair, municipal wait times were 0.6 days longer (95% CI = 0.2 to 1.0, P = 0.02); federal LoS was 7 days longer (95% CI = 3.6 to 9.4 days, P < 0.001); and municipal LoS was 4 days longer (95% CI = 2.4 to 4.8, P < 0.001). Only private HDS fracture repair patients received bone health consultations., Discussion: The private HDS provided care for a markedly larger volume of patients seeking orthopaedic care. In addition, private HDS patients experienced reduced surgical wait times, LoSs, and complication odds for inpatient elective cases, with better referral patterns for nonsurgical orthopaedic care after hip fractures within the private HDS. These results may guide improvements for federal and municipal HDSs., (Copyright © 2022 by the American Academy of Orthopaedic Surgeons.)

Case: This case describes a 45-year-old man with documented history of untreated bilateral lower extremity psoriasis of equal severity who sustained a closed left tibial-fibular shaft fracture. After operative fixation with an intramedullary nail under a regional nerve block, the left lower extremity circumferential psoriatic plaque resolved throughout 1 year of follow-up with persistence of the contralateral limb disease., Conclusion: This case describes a rare outcome for a patient with bilateral leg psoriasis who experienced resolution of psoriatic plaques on the operated leg only after surgery. It is unknown which process: injury, anesthetic, surgery, or fracture healing mediated this unique finding., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B960)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

By the end of their training, all orthopaedic residents should be competent in understanding musculoskeletal research enough to navigate the literature and base clinical decisions on it. To accomplish this, the Accreditation Council for Graduate Medical Education requires involvement in scholarly activity. For those interested in academics and having additional involvement in research, there can be many benefits including professional achievement and intellectual /personal satisfaction. A number of potential career models exist for those interested in being engaged in musculoskeletal research, so trainees should seek the training and level of involvement in research that will help them achieve their individual academic goals. To that end, trainees should become involved with research early and identify research mentors in their field of interest (at home or from afar). Training programs and faculty members should create a milieu conducive to research productivity and support and equip trainees who have such aspirations., (Copyright © 2021 by the American Academy of Orthopaedic Surgeons.)

Introduction: This study compared costs, length of visit, and utilization trends for patients with fractures seen in an immediate care orthopaedic center (I-Care) versus the emergency department (ED) in a major metropolitan area., Methods: A retrospective chart review of consecutive patients seen on an outpatient basis in the ED and I-Care over a 6-month period was conducted. Patient demographics, procedures done, care category, estimated costs, and disposition information were included for statistical analysis. Within the low-acuity fracture care group, a cost-comparison analysis was conducted., Results: A total of 610 patients met inclusion criteria with 311 seen in I-Care and 299 in the ER. I-Care patients were more likely to have low-acuity injuries compared with ED patients (60.1% versus 18.1%, P < 0.001). The length of visit was longer for patients seen in the ED compared with I-Care (6.1 versus 1.43 hours, P value < 0.001). A cost analysis of low-acuity patients revealed that an estimated $62,150 USD could have been saved in healthcare costs by the initial diversion of low-acuity patients seen in the ER to I-Care during the study period., Discussion: These results suggest that the I-Care orthopaedic urgent care model is a more cost-effective and more efficient alternative to the ED for patients with fractures requiring procedural treatment and low-acuity patients managed on an outpatient basis., (Copyright © 2021 by the American Academy of Orthopaedic Surgeons.)

Background: Women have long been underrepresented in orthopaedic surgery; however, there is a lack of quantitative data on the representation of women in orthopaedic academic program leadership., Questions/purposes: (1) What is the proportion of women in leadership roles in orthopaedic surgery departments and residency programs in the United States (specifically, chairs, vice chairs, program directors, assistant program directors, and subspecialty division chiefs)? (2) How do women and men leaders compare in terms of years in position in those roles, years in practice, academic rank, research productivity as represented by publications, and subspecialty breakdown? (3) Is there a difference between men and women in the chair or program director role in terms of whether they are working in that role at institutions where they attended medical school or completed their residency or fellowship?, Methods: We identified 161 academic orthopaedic residency programs from the Accreditation Council for Graduate Medical Education (ACGME) website. Data (gender, length of time in position, length of time in practice, professorship appointment, research productivity as indirectly measured via PubMed publications, and subspecialty) were collected for chairs, vice chairs, program directors, assistant program directors, and subspecialty division chiefs in July 2020 to control for changes in leadership. Information not provided by the ACGME and PubMed was found using orthopaedic program websites and the specific leader's curriculum vitae. Complete data were obtained for chairs and program directors, but there were missing data points for vice chairs, assistant program directors, and division chiefs. All statistical analysis was performed using SPSS using independent t-tests for continuous variables and the Pearson chi-square test for categorical variables, with p < 0.05 considered significant., Results: Three percent (4 of 153) of chairs, 8% (5 of 61) of vice chairs, 11% (18 of 161) of program directors, 27% (20 of 75) of assistant program directors, and 9% (45 of 514) of division chiefs were women. There were varying degrees of missing data points for vice chairs, assistant program directors, and division chiefs as not all programs reported or have those positions. Women chairs had fewer years in their position than men (2 ± 1 versus 9 ± 7 [95% confidence interval -9.3 to -5.9]; p < 0.001). Women vice chairs more commonly specialized in hand or tumor compared with men (40% [2 of 5] and 40% [2 of 5] versus 11% [6 of 56] and 4% [2 of 56], respectively; X2(9) = 16; p = 0.04). Women program directors more commonly specialized in tumor or hand compared with men (33% [6 of 18] and 17% [3 of 18] versus 6% [9 of 143] and 11% [16 of 143], respectively; X2(9) = 20; p = 0.02). Women assistant program directors had fewer years in practice (9 ± 4 years versus 14 ± 11 years [95% CI -10.5 to 1.6]; p = 0.045) and fewer publications (11 ± 7 versus 30 ± 48 [95% CI -32.9 to -5.8]; p = 0.01) than men. Women division chiefs had fewer years in practice and publications than men and were most prevalent in tumor and pediatrics (21% [10 of 48] and 16% [9 of 55], respectively) and least prevalent in spine and adult reconstruction (2% [1 of 60] and 1% [1 of 70], respectively) (X2(9) = 26; p = 0.001). Women program directors were more likely than men to stay at the same institution they studied at for medical school (39% [7 of 18] versus 14% [20 of 143]; odds ratio 3.9 [95% CI 1.4 to 11.3]; p = 0.02) and trained at for residency (61% [11 of 18] versus 42% [60 of 143]; OR 2.2 [95% CI 0.8 to 5.9]; p = 0.01)., Conclusion: The higher percentage of women in junior leadership positions in orthopaedic surgery, with the data available, is a promising finding. Hand, tumor, and pediatrics appear to be orthopaedic subspecialties with a higher percentage of women. However, more improvement is needed to achieve gender parity in orthopaedics overall, and more information is needed in terms of publicly available information on gender representation in orthopaedic leadership., Clinical Relevance: Proportional representation of women in orthopaedics is essential for quality musculoskeletal care, and proportional representation in leadership may help encourage women to apply to the specialty. Our findings suggest movement in an improving direction in this regard, though more progress is needed., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2021 by the Association of Bone and Joint Surgeons.)

»: Tranexamic acid (TXA) is a drug used to control hemorrhage by preventing the breakdown of fibrin., »: TXA is a cost-effective treatment for trauma patients across a variety of economic settings., »: Concerns of TXA causing thromboembolic events (TEEs) in orthopaedic trauma patients are not supported by evidence., »: TXA has been shown to reduce blood loss in hip fracture surgery., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/A719)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

»: The induced membrane technique (IMT) takes advantage of an osteoinductive environment that is created by the placement of a cement spacer into a bone defect., »: Most commonly, a polymethylmethacrylate (PMMA) spacer has been used, but spacers made from other materials have emerged and achieved good clinical outcomes., »: The IMT has demonstrated good results for long-bone repair; however, more research is required in order to optimize union rates as well as delineate more precise indications and surgical timing., Competing Interests: Disclosure: The authors indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/A705)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Case: A 41-year-old man presented with a transverse patella fracture and proximal patellar tendon avulsion after a fall from standing. Disruption of the extensor mechanism of the knee at multiple points is rare. He was treated operatively for his patella fracture and patellar tendon avulsion but experienced early failure of the patellar tendon fixation requiring reoperation. Both components of injury ultimately healed, and he returned to function., Conclusion: This case describes a rare presentation of an uncommon injury pattern affecting the extensor mechanism. This is the first report to describe multifocal failure of the extensor chain from a low-energy mechanism., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B526)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: It is important to understand the current characteristics of orthopaedic surgery program leadership, especially in the current climate of modern medicine. The purpose of this report was to describe the demographic, academic, and geographic characteristics of current orthopaedic chairs and program directors (PDs)., Methods: Orthopaedic surgery residency programs were obtained from the Accreditation Council for Graduate Medical Education website and cross-referenced with the Electronic Residency Application Service, identifying 161 residency programs for the 2018 to 2019 cycle. All data were collected in January 2020 to best control for changes in leadership. Demographic and academic information were collected from public websites. For geographic analysis, the United States was divided into five regions, and training locations were categorized as appropriate., Results: A total of 153 chairs and 161 PDs were identified. 98.0% of chairs were men versus 88.8% of PDs (P = 0.001). Chairs had been in practice and in their current position for longer than PDs (26.4 vs 16.8 years [P < 0.005] and 9.1 vs 7.1 years [P = 0.014], respectively). Chairs had more publications and were more likely to be professors than PDs. PDs were more likely to remain at both the same region and institution that they trained in residency. The most common subspecialty was sports among chairs and trauma among PDs, although when compared with national averages orthopaedic trauma and orthopaedic oncology were the most overrepresented subspecialties., Conclusion: Orthopaedic chairs are more likely to be men, have had longer careers, and have more academic accomplishments than their PD counterparts. Geography appears to have an association with where our leaders end up, especially for PDs. Subspecialization does not notably influence leadership positions, although orthopaedic trauma and orthopaedic oncology surgeons are more commonly represented than expected. This report serves to identify the current state of orthopaedic leadership and may provide guidance for those who seek these leadership positions., (Copyright © 2020 by the American Academy of Orthopaedic Surgeons.)

Purpose: The ability to predict contracture development after elbow fracture would benefit patients and physicians. This study aimed to identify factors associated with the development of posttraumatic elbow joint contracture., Methods: A retrospective review of elbow fractures (AO/Orthopaedic Trauma Association [OTA] type 13 and 21) treated at one institution between 2011 and 2015 was performed. Data collected included demographics, injury information, treatment, and postoperative elbow range of motion (ROM). Multivariate logistic regression analyses were performed to identify factors associated with contracture development. Notable contracture was defined as an arc of motion less than 100° flexion/extension, which has been associated with reduced ability to perform activities of daily living., Results: A total of 278 patients at least 1 8 years of age underwent surgical repair of an elbow fracture or fracture-dislocation during the study period and had at least 6 months of postoperative follow-up. Forty-two (15.1%) developed a clinically notable elbow contracture, of whom 29 (69.0%) developed heterotopic ossification (HO). Multivariate analysis of preoperative variables demonstrated that AO/OTA 13-C fracture classification (odds ratio [OR], 13.7, P = 0.025), multiple noncontiguous fractures (OR, 3.7, P = 0.010), and ulnohumeral dislocation at the time of injury (OR, 4.9, P = 0.005) were independently associated with contracture development. At 6 weeks postoperatively, an arc of elbow ROM less than 50° flexion/extension (OR, 23.0, P < 0.0005) and the presence of HO on radiographs (OR, 6.7, P < 0.0005) were found to be independent risk factors for significant elbow stiffness., Discussion: Ulnohumeral dislocation, multiple noncontiguous fractures, AO/OTA 13-C fracture classification, limited elbow ROM at 6 weeks postoperatively, and the presence of radiographic HO at 6 weeks postoperatively are associated with contracture development after surgical elbow fracture repair. Patients with these risk factors should receive aggressive physical therapy and be counseled as to the possible development of a contracture requiring surgical intervention., (Copyright © 2020 by the American Academy of Orthopaedic Surgeons.)

Introduction: Burnout is an occupational hazard for physicians at all stages of training and medical practice. The purpose of the current study was to determine whether residency factors, with the use of an activity monitor, including the amount of exercise, have any impact on burnout among orthopaedic surgery residents in varying years of training., Methods: Orthopaedic residents at a single institution were recruited immediately before beginning a new clinical rotation and followed for four weeks. On enrollment, the participants were given a wrist-worn activity monitor (Fitbit Flex) and instructed on its use for tracking physical activity. REDCap was used to collect burnout levels (as assessed by using the Maslach Burnout Inventory and the Patient Health Questionnaire-9), which were completed a total of five times, once at enrollment and weekly during the study period., Results: Twenty-seven residents were enrolled, including 13 junior residents (interns and second years) and 14 senior residents (third, fourth, and fifth years). Seven residents were on fracture rotations, whereas 20 were not. As measured by using the Maslach Burnout Inventory, juniors were more emotionally exhausted (P = 0.01) and depersonalized (P = 0.027). No difference in the objective physical activity data as measured by using the Fitbit Flex and no difference in the self-reported hours of sleep were observed. Residents on orthopaedic trauma rotations also reported significantly higher rates of emotional exhaustion and depersonalization (P < 0.001) than other residents and were more physically active on average (P < 0.030)., Discussion: Although depersonalization and depression are common symptoms seen among orthopaedic surgery residents, this study demonstrated that quality of life improves markedly as they progress through their residency training. Residents on orthopedic trauma rotations have greater levels of emotional exhaustion and depersonalization. This pilot study suggests that burnout prevention programs should begin at the start of training to provide residents with strategies to combat and then reinforced while on orthopaedic trauma rotations., Level of Evidence: Level III Diagnostic Study.

Introduction: Students seek gap years to enhance knowledge and improve chances of professional success. Although many institutions offer research opportunities, no studies have examined outcomes after these experiences. This study evaluates a dedicated year of orthopaedic research on a cohort's ultimate orthopaedic surgery match rate., Methods: From 2001 to 2018, 129 learners spent a year with our Department of Orthopedic Surgery at a major academic medical center. The students were either completing a gap year after college, during or after medical school, or after an unsuccessful match. Participants were asked to respond to a survey, which included demographics, educational information, and metrics related to the program. For the subcohort of students who ranked orthopaedic surgery, the match rate was compared with the mean for the US orthopaedic surgery match rates from 2006 to 2018 using a chi-square analysis. In addition, a Mann-Whitney U test was used to compare the number of publications before and after the year., Results: One hundred three students (80%) returned completed questionnaires. Of all learners who applied to and ranked orthopaedic surgery, 91% matched into an orthopaedic surgery residency program. These results compared favorably with the US orthopaedic match from 2006 to 2018 (67.9%; P < 0.001), despite a 4-point lower United States Medical Licensing Examination (USMLE) Step 1 score for the research cohort. Finally, the research cohort had a greater percentage of women (23%) and minorities (40%) than the proportion of woman and minority practicing orthopaedic surgeons., Conclusion: Students who completed a gap year in research matched into orthopaedics at a higher rate than the national average, despite a lower Step score. Mentors may also target traditionally underrepresented groups to help increase the pool of diverse applicants.

Case: Two patients who developed radial nerve palsy at least 6 weeks after injury during nonoperative treatment of humeral shaft fractures. This complication was associated with external bracing, progressive varus angulation during treatment, and excess callus formation., Conclusion: Delayed radial nerve palsy may develop during nonoperative treatment of humeral shaft fractures when functional bracing fails to maintain alignment and stability at the fracture site.

Background: The purpose of this study was to compare narcotic use in the 90-day postoperative period across orthopaedic trauma, spine, and adult reconstruction patients and examine whether patient-reported pain scores at discharge correlate with narcotic use during the 90-day postoperative period., Methods: Electronic medical record query was done between 2012 and 2015 using diagnosis-related groups for spine, adult reconstruction, and trauma procedures. Demographics, length of stay (LOS), visual analog scale pain scores during hospitalization, and narcotics prescribed in the 90-day postoperative period were collected. Multivariate analysis and linear regression were done., Results: Five thousand thirty patients were analyzed. Spine patients had the longest LOS, highest mean pain during LOS, and were prescribed the most morphine in the 90-day postoperative period. Linear regression revealed that pain scores at discharge markedly influence the quantity of narcotics prescribed in the 90-day postoperative period., Discussion: Patient-reported pain at hospital discharge was associated with increased narcotic use in the 90-day postoperative period.

Introduction: The purpose of this study was to combine a validated middle-age and geriatric trauma risk assessment tool (STTGMA) with a novel cost-prediction tool to create an objective triage tool for elderly hip fractures that would guide value-based care initiatives., Methods: From October 2014 to January 2018, all patients aged ≥55 years who were admitted with a primary diagnosis of hip fracture to a single level 1 trauma center were enrolled. Upon evaluation in the emergency department, demographics, injury severity, and functional status were recorded to calculate the trauma triage score (STTGMARisk). A model to predict high-cost hip fracture patients was created using similar variables (STTGMACost)., Results: Three hundred sixty-one consecutive operative hip fracture patients were enrolled. Inpatient mortalities were skewed toward STTGMARisk3 with 21.4% of patients in this high-risk group ultimately expiring during their hospitalization. High-cost patients were correctly skewed to the STTGMACost2 and STTGMACost3 groups with 88.9% of all high-cost operatively treated hip fracture correctly triaged to these cohorts. Statistically significant variations were found in cost within each STTGMARisk group., Conclusions: A simple risk score calculated upon admission (STTGMARisk and STTGMACost) was able to be used as a triage tool not only to differentiate increased mortality risk but also to predict high-cost patients based on resource utilization in hip fracture patients., Level of Evidence: Prognostic, level II.

Compared with other proximal femoral fractures, subtrochanteric fractures are at a higher risk for nonunion because of the high deforming forces in this region, the associated increased risk of malreduction, and the risk of poor bone healing secondary to bisphosphonate use frequently associated with these fractures. Further understanding of nonunion of subtrochanteric fractures is of increasing importance given the rise in incidence of subtrochanteric hip fractures. Surgeons should be aware of risk factors for nonunion and techniques for prevention as well as surgical management and complications associated with surgical implantation devices. Surgeons should also consider using adjuncts including bone-grafting and biologic agents.

Case: This report reviews 2 cases of chronic lower extremity pain after traumatic tibial shaft fractures treated with intramedullary nail fixation. After examination and radiographic evaluation, clinical suspicion and pressure manometry were used to identify fascial herniation and indicate patients for fasciotomy, which ultimately relieved pain., Conclusions: Lower extremity fascial hernias typically present with nonspecific chronic pain. Ultrasonography and magnetic resonance imaging (MRI) can be used to confirm diagnosis. However, in patients with implanted hardware, MRI may be ineffective in detecting hernias because of artifact. Clinical suspicion and pressure manometry are effective ways of identifying patients with this etiology of chronic pain.

Introduction: Autogenous iliac crest bone graft (ICBG) is considered the benchmark graft for nonunion repair. However, ICBG harvest is invasive and may provide reduced benefit to elderly patients. The purpose of this study was to compare the clinical and functional outcomes of ICBG use in fixation of fracture nonunions between elderly and nonelderly patients., Methods: Over a 13-year period, 242 patients who underwent operative repair of a long bone fracture nonunion and received autogenous ICBG were enrolled in a prospective research registry and followed. Data collected included patient demographics, injury information, and nonunion management. All patients had a minimum of 12 months of postoperative follow-up. Patients at least 65 years of age were classified as elderly, whereas younger patients were classified as nonelderly. Functional outcomes were evaluated at routine intervals postoperatively using the short musculoskeletal function assessment (SMFA) and visual analog scale pain scores. Bony union was determined radiographically. All postoperative complications were recorded., Results: Of the 242 patients included, 44 were elderly and 198 were nonelderly. No differences were found between groups with respect to postoperative pain scores or SMFA scores. Furthermore, time to union, rate of union, and postoperative complication rate did not differ between groups. Multivariate linear regression demonstrated that older age was not associated with time to union, postoperative pain scores, or postoperative SMFA scores after controlling for possible confounding variables., Discussion: The use of ICBG in nonunion repair among elderly patients is as effective as use in younger patients with a long bone nonunion. Concerns of increased postoperative complications and decreased rate of union in elderly patients receiving ICBG for treatment of fracture nonunion should be alleviated. ICBG remains the benchmark graft for nonunion repair among all age groups.

Tibial plateau fracture is an injury commonly seen by those who treat trauma around the knee and/or sports-related injuries. In this video article, we present our protocol for surgical treatment of a tibial plateau fracture, which includes definitive fixation with use of a plate-and-screw construct, addressing of all associated soft-tissue injuries at the time of the surgical procedure, filling of any residual voids with bone cement, and early rehabilitation with weight-bearing beginning at 10 to 12 weeks postoperatively. The major steps of the procedure are (1) preoperative planning with digitally templated plates and screws, (2) patient positioning and setup, (3) anterolateral approach toward the proximal aspect of the tibia, (4) submeniscal arthrotomy, (5) booking open of the proximal aspect of the tibia at the fracture site, (6) tagging of the meniscus, (7) fracture reduction and placement of the Kirschner wire, (8) confirmation of reduction with C-arm image intensification, (9) internal fixation with a plate-and-screw construct, and (10) closure., (Copyright © 2019 by The Journal of Bone and Joint Surgery, Incorporated.)

Case: An 65-year-old immunocompetent female developed a Leclercia adecarboxylata infection following the repair of closed olecranon fracture. L. adecarboxylata is associated with polymicrobial infections, infections in immunocompromised patients and penetrating or open wounds. Following speciation, intravenous ceftriaxone was started. Two weeks later, the patient presented with leukopenia and neutropenia. Per infectious disease recommendations, the patient was switched to intravenous ertapenem with resolution of both infection and neutropenia. The olecranon fracture went on to heal fully., Conclusions: This case describes a rare postoperative monomicrobial infection with L. adecarboxylata in an immunocompetent host following musculoskeletal trauma and identifies L. adecarboxylata as a potential emerging hospital-acquired pathogen following orthopedic surgery.

Introduction: This study sought to assess and compare long-term functional and clinical outcomes in patients with tibial plateau fractures that are treated nonsurgically., Methods: Over a period of 8 years, 305 consecutive tibial plateau fractures were treated by three surgeons at a single institution and followed prospectively in an Institutional Review Board-approved study. Overall, 41 patients (13%) were treated nonsurgically and 37 were available for follow-up. Indications for nonsurgical management were minimal fracture displacement or preclusion of surgery because of comorbidities. A series of univariate retrospective analyses were used to identify individual risk factors potentially predictive of Short Musculoskeletal Functional Assessment scores., Results: Thirty-seven patients were included with a mean follow-up of 21 ± 14.9 months. Overall, 59% of patients (n = 22) attained good to excellent functional outcomes. In patients for whom surgery was precluded because of comorbidities, outcome scores were significantly poorer (38.8 ± 23.0 versus 12.7 ± 14.2; P = 0.001). Surgery precluded by a factor other than minimal fracture displacement predicted poor outcome (P = 0.002)., Discussion: Carefully selected patients with minimally displaced tibial plateau fractures can expect good to excellent outcomes when treated nonsurgically., Level of Evidence: Level III, retrospective comparative study.

The Accreditation Council of Graduate Medical Education requires that residency programs teach and assess trainees in six core competencies. Assessments are imperative to determine trainee competence and to ensure that excellent care is provided to all patients. A structured, direct observation program is feasible for assessing nontechnical core competencies and providing trainees with immediate constructive feedback. Direct observation of residents in the outpatient setting by trained faculty allows assessment of each core competency. Checklists are used to document residents' basic communication skills, clinical reasoning, physical examination methods, and medical record keeping. Faculty concerns regarding residents' professionalism, medical knowledge, fatigue, or ability to self-assess are tracked. Serial observations allow for the reinforcement and/or monitoring of skills and attitudes identified as needing improvement. Residents who require additional coaching are identified early in training. Progress in educational milestones is recorded, allowing an individualized educational program that ensures that future orthopaedic surgeons excel across all domains of medical and surgical competence.

Background: Bisphosphonate therapy for osteoporosis has been associated with atypical femoral fractures. To date, there have been few reports in the literature regarding the preoperative and postoperative courses of patients who have sustained bisphosphonate-associated complete atypical femur fractures., Objectives/purposes: The purposes of this study were to (1) characterize the preoperative course of patients who eventually presented with bisphosphonate-associated complete atypical femur fractures (duration of bisphosphonate treatment, pain history, risk of converting a nondisplaced fracture to a complete fracture); (2) evaluate the percentage of patients who achieved radiographic union of those fractures after treatment; and (3) determine the patients' recovery of function using the Short Musculoskeletal Functional Assessment., Methods: Thirty-three patients with 41 atypical, low-energy femur fractures associated with ≥ 5 years of bisphosphonate use were treated with intramedullary nailing between 2004 and 2011 at one center. The main outcome measurements were Short Musculoskeletal Functional Assessment for function and radiographic evaluation for fracture healing. Patients had been treated with bisphosphonates for an average of 8.8 years (range, 5-20 years) before presentation., Results: Patients reported a mean of 6 months of pain before presentation (range, 1-8 months). Sixty-six percent of patients with surgically treated complete fractures became pain-free and 98% were radiographically healed by 12 months. Sixty-four percent of patients who underwent intramedullary nailing reported a functional return to baseline within 1 year. Patients who reported major functional limitations at latest followup listed pain and apprehension as the major causes of their limitation., Conclusions: Patients with surgically treated bisphosphonate-associated complete femur fractures achieved generally reliable although delayed fracture healing if malaligned, and nearly two-thirds of patients returned to self-reported baseline function within 1 year., Level of Evidence: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Background: Prior studies have suggested that Asian patients and women may be more likely to sustain atypical femoral fractures in association with bisphosphonate use. However, they do not account for confounders such as asymptomatic patients who are long-term bisphosphonate users or patients sustaining osteoporotic fractures., Questions/purposes: The purpose of this study was to determine the differences in sex and racial association with atypical femoral fractures by comparing demographic characteristics of patients who sustained an atypical bisphosphonate-associated fracture with patients on long-term bisphosphonates without fractures and with patients who sustained osteoporotic fractures., Methods: Three groups from prospective registries were identified: (1) patients with atypical femur fractures associated with long-term bisphosphonate use (BFF) (n = 54); (2) patients on long-term bisphosphonates but with no associated fractures (BNF) (n = 119); and (3) patients with osteoporotic proximal femur fractures not associated with bisphosphonates (PFF) (n = 216). Age, sex, and self-reported race/ethnicity were documented and compared. Multivariate and univariate analyses were done as well as age- and sex-stratified analyses., Results: Age and sex distributions of the BFF and BNF patients were similar. There was a higher percentage of Asian patients in the BFF group (17%) than in the BNF group (3%; p = 0.004) as well as Hispanics (13% versus 3% in BNF; p = 0.011). Patients in the BFF group were younger than those in the PFF group (67.5 versus 78.4 years; p < 0.001) and had fewer males (7% versus 14%; p < 0.001)., Conclusions: These data suggest that Asians are at higher risk for atypical bisphosphonate-associated fractures. We recommend closer followup in Asian patients who are taking bisphosphonates., Level of Evidence: Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Objective Structured Clinical Examinations (OSCEs) have been used extensively in medical schools and residency programs to evaluate various skills, including the six core competencies outlined by the Accreditation Council for Graduate Medical Education (ACGME). Orthopaedic surgery residency programs will be required by the ACGME to assess residents on core competencies in the Milestone Project. Thus, it is important that evaluations be made in a consistent, objective manner. Orthopaedic residency programs can also use simulation models in the examination to accurately and objectively assess residents' skills as they progress through training. The use of these models will become essential as resident work hours are decreased and opportunities to observe skills become more limited. In addition to providing a method to assess competency, OSCEs are a valuable tool for residents to develop and practice important clinical skills. Here, we describe a method for developing a successful OSCE for use in orthopaedic surgical resident training.

Mastering rapidly evolving orthopaedic surgical techniques requires a lengthy period of training. Current work-hour restrictions and cost pressures force trainees to face the challenge of acquiring more complex surgical skills in a shorter amount of time. As a result, alternative methods to improve the surgical skills of orthopaedic trainees outside the operating room have been developed. These methods include hands-on training in a laboratory setting using synthetic bones or cadaver models as well as software tools and computerized simulators that enable trainees to plan and simulate orthopaedic operations in a three-dimensional virtual environment. Laboratory-based training offers potential benefits in the development of basic surgical skills, such as using surgical tools and implants appropriately, achieving competency in procedures that have a steep learning curve, and assessing already acquired skills while minimizing concerns for patient safety, operating room time, and financial constraints. Current evidence supporting the educational advantages of surgical simulation in orthopaedic skills training is limited. Despite this, positive effects on the overall education of orthopaedic residents, and on maintaining the proficiency of practicing orthopaedic surgeons, are anticipated.

Background: Locking plates have become a commonly used fixation device in the operative treatment of three- and four-part proximal humerus fractures. Examining function in patients treated nonoperatively and operatively should help determine whether and when surgery is appropriate in these difficult-to-treat fractures., Questions/purposes: We compared functional scores, ROM, and radiographs in patients with one-part proximal humerus fractures treated nonoperatively to those in patients with displaced three- and four-part proximal humerus fractures treated with open reduction and internal fixation using locking plates., Patients and Methods: We retrospectively reviewed 142 patients with proximal humerus fractures treated with a standardized treatment algorithm over a 6-year period. Three- and four-part fractures were treated surgically while one-part fractures were treated nonoperatively. Functional scores, ROM, and radiographs were used to evaluate outcomes. American Shoulder and Elbow Surgeons and SF-36 scores were obtained at 12 months. Of the 142 patients, 101 (51 with three- or four-part fractures and 50 with one-part fractures) had a minimum followup of 12 months (average, 19 months; range, 12-64 months)., Results: The fractures united in all patients. At 1 year, the patients with one-part fractures had better SF-36 physical and mental scores and American Shoulder and Elbow Surgeons scores than the three- and four-part fractures. Both groups had similar shoulder ROM. Nine patients treated operatively had complications, four of which were related to screw penetration into the joint., Conclusions: Patients with three- and four-part fractures should be advised of the likelihood of persistent functional impairment and a relatively higher risk of complications when treated operatively with locked plates., Level of Evidence: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Multiple studies have attempted to determine which attributes are predictive of success during residency as well as the optimal method of selecting residents who possess these attributes. Factors that are consistently ranked as being important in the selection of candidates into orthopaedic residency programs include performance during orthopaedic rotation, United States Medical Licensing Examination (USMLE) Step 1 score, Alpha Omega Alpha Honor Medical Society membership, medical school class rank, interview performance, and letters of recommendation. No consensus exists regarding the best predictors of resident success, but trends do exist. High USMLE Step 1 scores have been shown to correlate with high Orthopaedic In-Training Examination scores and improved surgical skill ratings during residency, whereas higher numbers of medical school clinical honors grades have been correlated to higher overall resident performance, higher residency interpersonal skills grading, higher resident knowledge grading, and higher surgical skills evaluations. Successful resident performance can be measured by evaluating psychomotor abilities, cognitive skills, and affective domain.

Distal radius fractures are the most common upper extremity fracture, representing one-sixth of all fractures treated in emergency departments nationwide. Beyond the initial reduction and immobilization of these fractures, providing proper followup to ensure maintenance of the reduction and identify complications is necessary for optimal recovery of forearm and wrist functions. We sought to identify the clinical and demographic factors that characterize patients with distal radius fractures who do not return for followup and to assess the underlying causes for their poor followup rates. Compared with patients who were compliant with followup, those lost to followup had lower Physical and Mental Health scores on the SF-36 forms, more often were treated nonoperatively, and more likely had not surpassed secondary education. However, we found no difference between these two groups based on age, gender, mechanism of injury, marital status, or hand dominance. Early identification of patients who potentially are noncompliant can result in additional measures being taken to ensure the patient's return to the treating hospital and physicians. This in turn will prevent complications attributable to lack of followup and allow more accurate assessment of results, thereby improving patient outcomes.

Unlabelled: There has been increased emphasis on validated, patient-reported functional outcomes after orthopaedic interventions for various conditions. The few reports on these types of outcomes after treatment of fracture nonunions are limited to specific anatomic sites, limited by small numbers, and retrospective. To determine whether successful healing of established long-bone nonunions resulted in improved functional outcomes and reduction in patient-reported pain scores, we prospectively followed 80 patients. These patients had a mean of 1.4 surgical procedures before enrollment and a mean of 18 months had elapsed from previous surgery until enrollment. Baseline data and functional scores were obtained before intervention. Seventeen of the 80 patients (21%) had positive intraoperative cultures. At a mean of 18.7 months (range, 12-36 months), 72 (90%) nonunions had healed. Patients with healed nonunions scored better on the Short Musculoskeletal Functional Assessment. Pain scores among all patients improved compared with baseline, but to a greater degree in patients who achieved healing by final followup. Our data suggest improvement in pain scores is seen in all patients after surgery, whereas successful internal fixation leads to improved function., Level of Evidence: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Partial articular fractures of the distal humerus commonly involve the capitellum and may extend medially to involve the trochlea. As the complex nature of capitellar fractures has become better appreciated, treatment options have evolved from closed reduction and immobilization and fragment excision to a preference for open reduction and internal fixation. The latter is now recommended to achieve stable anatomic reduction, restore articular congruity, and initiate early motion. More complex fracture patterns require extensile surgical exposures. The fractures are characterized by metaphyseal comminution of the lateral column and have associated ipsilateral radial head fracture. With advanced instrumentation, elbow arthroscopy may be used in the management of these articular fractures. Though limited to level IV evidence, clinical series reporting outcomes following open reduction and internal fixation of fractures of the capitellum, with or without associated injuries, have demonstrated good to excellent functional results in most patients when the injury is limited to the radiocapitellar compartment. Clinically significant osteonecrosis and heterotopic ossification are rare, but mild to moderate posttraumatic osteoarthrosis may be anticipated at midterm follow-up.

Treatment of intertrochanteric hip fracture is based on patient medical condition, preexisting degenerative arthritis, bone quality, and the biomechanics of the fracture configuration. A critical review of the evidence-based literature demonstrates a preference for surgical fixation in patients who are medically stable. Stable fractures can be successfully treated with plate-and-screw implants and with intramedullary devices. Although unstable fractures may theoretically benefit from load-sharing intramedullary implants, this result has not been demonstrated in the current evidence-based literature.

During the past 10 years, there has been a worldwide effort in all medical fields to base clinical health care decisions on available evidence as described by thorough reviews of the literature. Hip fractures pose a significant health care problem worldwide, with an annual incidence of approximately 1.7 million. Globally, the mean age of the population is increasing, and the number of hip fractures is expected to triple in the next 50 years. One-year mortality rates currently range from 14% to 36%, and care for these patients represents a major global economic burden. Surgical options for the management of femoral neck fractures are closely linked to individual patient factors and to the location and degree of fracture displacement. Nonsurgical management of intracapsular hip fractures is limited. Based on a critical, evidence-based review of the current literature, we have found minimal differences between implants used for internal fixation of displaced fractures. Cemented, unipolar hemiarthroplasty remains a good option with reasonable results. In the appropriate patient population, outcomes following total hip arthroplasty are favorable and appear to be superior to those of internal fixation.

The intramedullary nail or rod is commonly used for long-bone fracture fixation and has become the standard treatment of most long-bone diaphyseal and selected metaphyseal fractures. To best understand use of the intramedullary nail, a general knowledge of nail biomechanics and biology is helpful. These implants are introduced into the bone remote to the fracture site and share compressive, bending, and torsional loads with the surrounding osseous structures. Intramedullary nails function as internal splints that allow for secondary fracture healing. Like other metallic fracture fixation implants, a nail is subject to fatigue and can eventually break if bone healing does not occur. Intrinsic characteristics that affect nail biomechanics include its material properties, cross-sectional shape, anterior bow, and diameter. Extrinsic factors, such as reaming of the medullary canal, fracture stability (comminution), and the use and location of locking bolts also affect fixation biomechanics. Although reaming and the insertion of intramedullary nails can have early deleterious effects on endosteal and cortical blood flow, canal reaming appears to have several positive effects on the fracture site, such as increasing extraosseous circulation, which is important for bone healing.

Unlabelled: The management of periprosthetic fracture around the knee remains a challenging problem. The objective of this article was to review the general concepts, treatment algorithms, and the overall treatment outcomes of femoral and tibial periprosthetic fractures after total knee arthroplasty. This article aimed to highlight the deficiencies of the current classification systems that fail to provide a guideline for selection of appropriate treatment options. We proposed a new classification system for periprosthetic femoral fractures that takes into account the status of the prosthesis, the quality of distal bone stock, and the reducibility of the fracture. Type I fractures are those occurring in patients with good bone stock with the prosthesis being fixed and well positioned. Type IA fractures are either nondisplaced or easily reducible and can be treated conservatively. Type IB fractures are irreducible and require reduction and internal fixation. Type II fractures are defined as those occurring also in patients with good bone stock and being reducible, but either the components are loose or malpositioned. These fractures are treated by revision arthroplasty. Type III fractures are reducible or irreducible fractures that occur in patients with poor bone stock and in the vicinity of loose or malpositioned components. These fractures are treated by distal femoral replacement., Level of Evidence: Therapeutic study, level V (expert opinion). See Guidelines for Authors for a complete description of levels of evidence.

Unlabelled: We retrospectively reviewed the clinical and functional outcomes after operative fixation of ipsilateral fractures of the proximal ulna, radial head or neck, and radial head dislocation (Monteggia variant). Twenty of 25 patients who sustained this injury returned for followup at a mean of 2.3 years and were evaluated by an independent examiner. Radiographically, 17 of 20 fractures united after the index surgery. The three patients who had nonunions develop had Bado Type 2 fracture patterns. The fractures of two patients united after revision internal fixation, and bone grafting. Seven patients had heterotopic ossification develop and 14 of 20 patients had arthritic changes develop. The mean Broberg and Morrey score was 79.1 (range, 32.5-100) and the mean disability of the arm, shoulder and hand score was 64.1 (worse outcome than the general population). Eight of 20 patients required revision surgery (three for recurrent instability, three for nonunion of the ulna, one for radial head excision and hardware removal, and one for hardware removal alone). Nine of 20 patients had fair or poor outcomes according to the Broberg and Morrey scale. Physicians should counsel patients that functional impairment is common after these complex high-energy injuries., Level of Evidence: Prognostic study, Level IV (case series). See the Guideline for Authors for a complete description of levels of evidence.

Original studies at orthopaedic meetings are presented on the podium and in poster format. Publication of those studies in peer-reviewed journals is the standard of communicating scientific data to colleagues. Investigators of previous studies have reported publication rates, but never differentiated between the modes of presentation. We evaluated the annual meeting of the Orthopaedic Trauma Association from 1994-1998 and found that studies presented on the podium were 1.3 times more likely to be published than those presented in a poster format (67% versus 52%). The mean time to publication was similar, 21.6 months for poster presentations and 24.8 months for podium presentations. Podium presentations were more likely to be published in the Journal of Orthopaedic Trauma, Clinical Orthopaedics and Related Research, and the Journal of Bone and Joint Surgery (American and British editions). Our findings suggest different rates and distribution of publication between podium and poster presentations at an international trauma meeting. These findings should be considered when evaluating studies of interest at the Orthopaedic Trauma Association meeting.

Hip fractures are common injuries in the elderly and are associated with considerable morbidity and mortality. Although technical advances in the treatment of the elderly have resulted in improved fracture fixation and surgical outcomes, clinical pathways have been developed to further improve patient outcome while shortening hospital length of stay after hip fracture. We describe the clinical pathway used since 1990 at the Hospital for Joint Diseases. The outcomes of 747 patients treated before 1990 were compared with outcomes of 318 patients treated at our hospital after initiation of the clinical pathway. Use of the clinical pathway was associated with significant decreases in the acute care hospital length of stay, in-hospital mortality, and 1-year mortality.