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Objectives: This study explored the hypothesis that social determinants of health, including racial and economic differences, may impact orthopaedic trauma outcomes in patients undergoing open reduction and internal fixation of humeral shaft fractures., Design: Retrospective., Setting: Single, academic, tertiary level I trauma center., Patient Selection Criteria: Adults with midshaft humerus fractures (Orthopaedic Trauma Association/Association of Osteosynthesis 12) were treated operatively with plate fixation from May 2011 to May 2021 with a minimum follow-up of 9 months., Outcome Measures and Comparisons: Radiographic fracture healing, complication rates, and patient-reported outcomes were investigated. Social determinants of health were assessed using the Area Deprivation Index (ADI). Demographics, complication rates, and patient-reported clinical outcomes were compared between the first and fourth ADI quartiles., Results: One hundred ninety-six patients fit the study criteria. The average age of the cohort was 47 years with 100 women (51%). Comparisons of the least deprived quartile (n = 49) with the most deprived quartile (n = 49) yielded similar sex distribution (59% vs. 43% females, P = 0.15), fewer non-White patients (8% vs. 51%, P < 0.01), older average age (51 vs. 43 years, P = 0.05), similar body mass index (30.5 vs. 31.8, P = 0.45), and higher Charlson Comorbidity Index (2.2 vs. 1.1, P = 0.03). While nonunion rates were similar ( P = 0.20) between groups, the most deprived quartile had 2.3 times greater odds of postoperative complications ( P = 0.04). Patients in the most deprived group exhibited higher Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference scores ( P < 0.01) and PROMIS Depression (D) scores ( P = 0.01), with lower PROMIS Physical Function scores ( P < 0.01) at 6-month follow-up than the least deprived cohort. The most deprived cohort had 3 times higher odds of missing scheduled appointments within the first postoperative year ( P < 0.01), resulting in a significantly higher no-show rate ( P < 0.01) than the least deprived cohort. Regression analysis including several demographic and injury factors identified that ADI was significantly associated with the occurrence of any missed appointments ( P < 0.01), no-show rates ( P = 0.04), and experiencing one of the following postoperative complications during recovery: nonunion, radial nerve injury, or dysfunction ( P = 0.03)., Conclusions: Patients experiencing greater resource deprivation faced increased odds of complications, missed appointments, and poorer PROMIS outcomes following humeral shaft fracture fixation. These findings suggest that baseline socioeconomic disparities predict unfavorable postoperative outcomes even given favorable baseline health status according to the Charlson Comorbidity Index score., Level of Evidence: Prognostic, Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To test the hypothesis that primary osteosynthesis of humeral shaft fractures may lead to more favorable clinical, functional, and patient-reported outcomes than fixation following a trial of nonoperative management., Design: Retrospective cohort review., Setting: Academic level I trauma center., Patient Selection Criteria: Adult patients who presented with humeral shaft fractures and ultimately underwent open reduction and internal fixation (ORIF) from May 2011 to May 2021. Patients who underwent ORIF within 2 weeks of injury were grouped into the primary osteosynthesis cohort, and patients who underwent ORIF >4 weeks from the date of injury were grouped into the trial of nonoperative cohort., Outcome Measures and Comparisons: Postoperative complications, elbow arc of motion, time to radiographic union, and patient-reported outcomes were investigated and compared between the primary osteosynthesis and trial of nonoperative management cohorts., Results: One hundred twenty-seven patients fit the study criteria, 84 underwent primary osteosynthesis and 43 trialed initial nonoperative treatment. No differences were found in patient demographics between the primary osteosynthesis and trial of nonoperative management cohorts, including age (53 ± 19 vs. 57 ± 18; P = 0.25), sex (39% vs. 44% male, 61% vs. 56% female; P = 0.70), and Body Mass Index (BMI) (30 ± 6 vs. 32 ± 9; P = 0.38). The average time to operative intervention in the primary osteosynthesis group was 4 days (0-14 days) and 105 days (28-332 days) in the trial of nonoperative treatment group ( P < 0.01). No differences were found with regard to intraoperative blood loss, total operative time, time to radiographic union (determined using the Radiographic Union Scores for Humeral scoring system), or overall complication rates, including primary and secondary radial nerve injuries ( P = 0.23 and 0.86, respectively). Patients reported similar patient-reported outcomes measurement information system pain interference ( P = 0.73), depression (D) ( P = 0.99), and physical function ( P = 0.66) scores at their 6-month postsurgical follow-up visits., Conclusions: Patients who attempted a trial of nonoperative management for humeral shaft fractures before ORIF had similar clinical, functional, and patient-reported outcomes as those who underwent primary osteosynthesis., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Syndesmotic injury alters joint mechanics, which may fail to be restored unless an anatomic reduction is obtained., Methods: A minimally invasive method of measuring joint forces was utilized that does not require significant dissection or intraarticular placement of sensory instruments. Steinmann pins were placed in the tibia and talus of eight fresh-frozen human cadaveric lower extremities and a baseline joint reaction force was determined. A syndesmotic injury was created and reduction (anatomic and anterior malreduction) performed with one or two quadricortical screws and joint reaction forces were measured after the injury and subsequent repairs., Findings: Baseline mean tibiotalar joint reaction force was 31.4 (SD 7.3 N) and syndesmotic injury resulted in a 35% decrease (mean 20.3, SD 8.4 N, p < 0.01). Fixation of the injury using one or two syndesmotic screws resulted in significant increase compared to the injury state (mean 28.7, SD3.9 N, and mean 28.3, SD 6.4 N, p < 0.05), however there was no significant difference between the two methods of fixation. Malreduction of the fibula also increased joint reaction force compared to the injury state (mean 31.5, SD 5.2 N, p < 0.01), however a significant difference was not detected between malreduction and anatomic reduction., Interpretation: The present study demonstrates that syndesmotic injury decreases joint reaction force within the tibiotalar joint, suggesting ankle joint instability. Tibiotalar force was restored with anatomic reduction with either a 1 or 2 quadricortical syndesmotic screws. Furthermore, anterior malreduction restored joint reaction force to levels similar to those observed at baseline and with anatomic reduction., Level of Evidence: Level V: biomechanical/cadaver study., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Talar head fractures represent a rare subtype of injury to the talus. Clinical series of talar head fractures are nonexistent in the current literature, and treatment of these injuries is based on expert opinion. Many authors recommend a single-incision approach to open reduction and internal fixation of talar head fractures; however, we have found that a 2-incision approach allows for optimal visualization while facilitating proper implant placement. We present a description of our technique and our clinical experience treating 8 of these rare injuries.

Objectives: To assess the healing and radiographic outcomes of displaced and comminuted talar neck fractures treated with medial position screws augmented with lateral minifragment plate fixation., Design: Retrospective case series., Setting: Two level I trauma centers., Patients: The records of 26 patients with displaced and comminuted talar neck fractures who underwent open reduction and internal fixation with medial-sided position screws augmented with lateral minifragment plates., Intervention: Surgery consisted of medial and lateral approaches to the talus, fixation with a laterally placed minifragment plate, and screw construct augmenting sagittal-plane-oriented, medial-sided position screws., Main Outcome Measurements: The incidences of nonunion, malunion, avascular necrosis, post-traumatic arthritis, and symptomatic implants., Results: Nonunion occurred in 3/26 (11.5%) displaced and comminuted talar neck fractures. There were no instances of malunion. Avascular necrosis developed in 7/26 (27%) cases. Post-traumatic arthritis was the most common complication affecting 10/26 (38%) tali. The subtalar joint was most commonly affected. There were no instances of hardware removal due to symptomatic medial impingement., Conclusions: Lateral minifragment plate fixation augmenting medially placed sagittal plane position screws provides a length stable construct that prevents talar neck shortening and malunion. Medial position screws can help avoid secondary surgeries for removal of symptomatic implants due to medial impingement as is common with medially based minifragment plates. This fixation strategy should be considered in the setting of displaced and comminuted talar neck fractures., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Patients who undergo internal fixation of ankle fractures commonly have postoperative imaging performed immediately after surgery. As these patients typically are typically immobilized, radiographs provide limited visualization. The purpose of this study was to evaluate the utility and quality of formal radiographs performed immediately following ankle fracture surgery., Methods: Ankle fractures undergoing open reduction and internal fixation at a single institution from January 1, 2011, to January 1, 2013, were reviewed. Intraoperative and formal postoperative radiographs were evaluated using defined parameters. The postoperative images were compared with the intraoperative fluoroscopic images in terms of quality. Postoperative complications were evaluated in terms of fracture displacement, hardware malpositioning, and need for return to the operating room. A total of 411 patients with 413 ankle fractures underwent surgical fixation, with 271 patients undergoing formal postoperative radiographs., Results: Twenty-eight patients (10.3%) had 3 good quality postoperative views of the ankle, with the lateral (35.2%) and mortise (41.3%) views least commonly performed with good technique. None of the patients without radiographs had a complication that could have been detected earlier using postoperative radiographs. No patients required return to the operating room based on immediate postoperative radiographs. Postoperative radiographs cost $191 per patient., Conclusion: The routine use of formal postoperative radiographs prior to discharge from the hospital did not provide additional value to the patient or orthopedic surgeon. The quality of these images was generally inferior to the quality of those obtained and saved intraoperatively due to malrotation and overlying cast material. To reduce cost and radiation exposure, formal postoperative radiographs should be obtained only in specific circumstances, such as increasing postoperative pain, marginal fixation, or instability., Level of Evidence: Level III, retrospective cohort study., (© The Author(s) 2015.)