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Background: The quality of evidence of the orthopedic literature has been often called into question. The fragility index (FI) has emerged as a means to evaluate the robustness of a significant result. Similarly, reverse fragility index (RFI) can be used for nonsignificant results to evaluate whether one can confidently conclude that there is no difference between groups. The analysis of FI and RFI in proximal humerus fracture (PHF) management is of particular interest, given ongoing controversy regarding optimal management and patient selection. The aim of this study was to report the FI, RFI and quality of the evidence in the proximal humerus fracture literature., Methods: A systematic review was conducted based on the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines, which utilized EMBASE, MEDLINE and Cochrane Library databases. Inclusion criteria included randomized controlled clinical trials related to the management of proximal humerus fractures, published from 2000 to 2020 with dichotomous outcome measures and 1:1 allocation. The FI and RFI were calculated by successively changing one nonevent to an event for each outcome measure until the result was made nonsignificant or significant, respectively. The fragility quotient, (FQ), calculated by dividing the FI by the total sample size, was calculated as well., Results: There were 25 studies that met our criteria with 48 outcome measures recorded. A total of 21 studies had at least one fragile result, with ten studies including a fragile result in the conclusion of the abstract. A total of 31 outcome measures had nonsignificant results and the median RFI was found to be 4, with 71% greater than number of patients lost to follow up. Seventeen outcomes had significant results, with a median FI of 1, with 65% greater than or equal to the number patients lost to follow up. A total of 18 of 25 studies (72%) included a power analysis. In particular, ten studies reported a statistical analysis of complication rates, 90% of which were fragile. The median FQ was found to be 0.037., Conclusions: The literature on PHF management is frequently fragile. Outcome measures are often fragile, particularly with regards to comparing complication rates and reoperation rates in treatment arms. Comparing to the studies in other subspecialties PHF RCTs are relatively more fragile and underpowered. Standardized reporting of FI, FQ and RFI can help the reader to reliably draw conclusions based on the fragility of outcome measures., (© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To assess longer-term (> 5 years) function and outcome in patients treated with anatomic locking plates for proximal humerus fractures., Methods: This retrospective cohort study was conducted at an urban, academic level 1 trauma center and an orthopedic specialty hospital. Patients treated operatively for proximal humerus fractures with an anatomic locking plate by three orthopedic trauma surgeons and two shoulder surgeons from 2003 to 2015 were reviewed. Patient demographics and injury characteristics, disabilities of the arm, shoulder, and hand (DASH) scores, complications, secondary surgeries, and shoulder range of motion were compared at 1 year and at latest follow-up., Results: Seventy-five of 173 fractures were eligible for analysis. At a minimum 5 years and a mean of 10.0 ± 3.2 years following surgery, DASH scores did not differ from one-year compared to long-term follow-up (16.3 ± 17.4 vs. 15.1 ± 18.2, p = 0.555). Shoulder motion including: active forward flexion (145.5 vs. 151.5 degrees, p = 0.186), internal rotation (T10 vs. T9, p = 0.204), and external rotation measurements (48.4 vs. 57.9, p = 0.074) also did not differ from one year compared to long-term follow-up. By one year, all fractures had healed. After 1-year post-operatively, four patients underwent reoperation, but none for AVN or screw penetration., Conclusions: Patient-reported functional outcome scores and shoulder range of motion are stable after one year following proximal humerus fracture fixation, and outcomes do not deteriorate thereafter. After one-year, long-term follow-up of fixed proximal humerus fractures may be unnecessary for those without symptoms., (© 2021. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Patients with psychiatric comorbidities represent a significant subset of those sustaining pilon fractures. The purpose of this study is to examine the association of psychiatric comorbidities (PC) in patients with pilon fractures and clinical outcomes., Methods: A multi-institution, retrospective review was conducted. Inclusion/exclusion criteria were skeletally mature patients with a tibia pilon fracture (OTA Type 43B/C) who underwent definitive fracture fixation utilizing open reduction internal fixation (ORIF) with a minimum of 24 weeks of follow-up. Patients were stratified into two groups for comparison: PC group and no PC group., Results: There were 103 patients with pilon fractures that met the inclusion/exclusion criteria of this study. Of these patients, 22 (21.4%) had at least one psychiatric comorbidity (PC) and 81 (78.6%) did not have psychiatric comorbidities (no PC). There was a higher percentage of female patients (PC: 59.1% vs no PC: 25.9%, p=0.0.005), smokers (PC: 40.9% vs no PC: 16.0%, p=0.02), and drug users (PC: 22.7% vs no PC: 8.6%, p=0.08) amongst PC patients. Fracture comminution (PC: 54.5% vs no PC: 32.1%, p=0.05) occurred more frequently in PC patients. The PC group had a higher incidence of weightbearing noncompliance (22.7% vs 7.5%, p=0.04) and reoperation (PC: 54.5% vs no PC: 29.6%, p=0.03)., Conclusion: Patients with psychiatric comorbidities represent a significant percentage of pilon fracture patients and appear to be at higher risk for postoperative complication. Risk factors that may predispose patients in the PC group include smoking/substance use, weightbearing noncompliance, and fracture comminution. Level of Evidence: III ., (Copyright © The Iowa Orthopaedic Journal 2022.)

Introduction: The purpose of this study was to assess the hospital quality measures and outcomes of operative hip fracture patients before and after implementation of an anesthesiology department protocol assigning decision for a preoperative transthoracic echocardiogram (TTE) to the hospitalist co-managing physician., Materials and Methods: Demographics, injury details, hospital quality measures, and outcomes were reviewed for a consecutive series of patients presenting to our institution with an operative hip fracture. In May of 2019, a new protocol assigning the responsibility to indicate a patient for preoperative TTE was mandated to the co-managing hospitalist at the institution. Patients were split into pre-protocol and post-protocol cohorts. Linear regression modeling and comparative analyses were conducted with a Bonferroni adjusted alpha as appropriate., Results: Between September 2015 and June 2021, 1002 patients presented to our institution and were diagnosed with a hip fracture. Patients in the post-protocol cohort were less likely to undergo a preoperative echocardiogram, experienced a shorter time (days) to surgery, shorter length of stay, an increase in amount of home discharges, and lower complication risks for urinary tract infection and acute blood loss anemia as compared to those in the pre-protocol cohort. There were no differences seen in inpatient or 30-day mortality. Multivariable linear regression demonstrated a patient's comorbidity profile (Charlson Comorbidity Index (CCI)) and their date of presentation (pre- or post-protocol), were both associated with (P<0.01) a patients' time to surgery., Conclusion: A standardized preoperative work flow protocol regarding which physician evaluates and determines which patients require a preoperative TTE allows for a streamlined perioperative course for hip fracture patients. This allows for a shortened time to surgery and length of stay with an increase in home discharges and was associated with a reduced risk of common index hospitalization complications including UTI and anemia., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Objective: To identify the patient, injury, and treatment factors associated with an acute infection during the treatment of open ankle fractures in a large multicenter retrospective review. To evaluate the effect of infectious complications on the rates of nonunion, malunion, and loss of reduction., Design: Multicenter retrospective review., Setting: Sixteen trauma centers., Patients: One thousand and 3 consecutive skeletally mature patients (514 men and 489 women) with open ankle fractures., Main Outcome Measures: Fracture-related infection (FRI) in open ankle fractures., Results: The charts of 1003 consecutive patients were reviewed, and 712 patients (357 women and 355 men) had at least 12 weeks of clinical follow-up. Their average age was 50 years (range 16-96), and average BMI was 31; they sustained OTA/AO types 44A (12%), 44B (58%), and 44C (30%) open ankle fractures. The rate FRI rate was 15%. A multivariable regression analysis identified male sex, diabetes, smoking, immunosuppressant use, time to wound closure, and wound location as independent risk factors for infection. There were 77 cases of malunion, nonunion, loss of reduction, and/or implant failure; FRI was associated with higher rates of these complications (P = 0.01)., Conclusions: Several patient, injury, and surgical factors were associated with FRI in the treatment of open ankle fractures., 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 © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: The purpose of this study is to evaluate the relationship between patients' own health expectations and treatment outcomes following surgical repair of proximal humerus fractures., Hypothesis: Patients' health expectations will correlate with treatment outcomes following surgical repair of proximal humerus fractures., Material and Methods: Over a 14-year period, 247 patients with a displaced proximal humerus fracture who underwent ORIF with locking compression plates were prospectively followed at one academic institution. Minimum follow-up period was 12 months. Patient-reported functional outcome data for the latest follow up visit (12 months and greater) was obtained from Disabilities of Arm, Shoulder, and Hand (DASH) questionnaires. Survey responses regarding health expectations were recorded at 3-month follow-up and converted to dichotomous variables. Two groups were identified: the high expectations and the low expectations groups. Statistical analysis comparing the two groups and their functional and clinical outcomes was performed using the independent t-test, using p<0.05 for significance. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated to further statistically characterize the relationship between health expectations at 3 months and long-term outcomes., Results: One hundred and eighty-five (75.0%) patients available for analysis with a mean follow-up length of 24.8 months. The cohort included 124 (67%) females and 61 (33%) males and the average age at time of injury was 59.5 years. Eighty-six (46.5%) patients had low expectations for their overall health and 99 (53.5%) patients had high expectations for their health. No significant differences were seen between groups in regards to age, gender, follow-up length, Charlson Comorbidity Index (CCI), smoking and tobacco use, fracture pattern (OTA and Neer classifications), early complications (p>0.05), fracture healing, and avascular necrosis. The mean DASH score at the latest follow up for patients with low expectations was 31.42±22.8 whereas the mean for those with high expectations was 16.76±20.2 (p<0.0005). The mean forward flexion of the shoulder for patients with low expectations was 137.8±31.5 degrees as compared to 148.5±26.3 degrees (p<0.05). The positive predictive value of good expectations correlating with good outcomes was 71.7%., Discussion: Patients with high expectations for their health early following injury had better outcomes in the long term. These high expectations also appeared to have an optimal influence on range of shoulder motion. This data suggests attitudinal and psychological factors that affect patient health expectations early on in the course of treatment may also influence patients' functional and clinical outcomes., Level of Evidence: II; Retrospective Study., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Background: Historically, clavicle fracture repairs have been performed with patients under general anesthesia. However, in the past few years, the combination of an interscalene brachial plexus block and a modified superficial cervical plexus block has been described to provide adequate anesthesia for clavicle fracture surgery, with the added benefit of postoperative analgesia. In March 2013, members of our anesthesiology department began using this block with sedation for a subset of patients undergoing clavicle fracture fixation., Methods: This study was a retrospective review of patients who underwent clavicle fracture repair at a single institution between June 2014 and November 2017. The decision on the type of anesthesia (regional vs. general) was made jointly by the patient, anesthesiologist, and surgeon. Demographic data, relevant perioperative times, and intraoperative pain medication consumption were recorded, and comparisons of these variables were made between the regional and general anesthesia groups., Results: A total of 110 patients with 110 fractures were included. Of these patients, 52 received only regional anesthesia with the combined block whereas 58 received general anesthesia with an interscalene brachial plexus block. No major anesthetic-related complications were noted in any patients, and there were no cases in which regional anesthesia had to be converted to general anesthesia because of block failure. The anesthesia start time was significantly longer in the general anesthesia group (29 minutes vs. 20 minutes, P = .022), as was the total case time (164 minutes vs. 131 minutes, P < .001). Patients in the general anesthesia group required significantly more intraoperative fentanyl to be administered (207 μg vs. 141 μg, P = .002)., Conclusion: Regional anesthesia using a combined brachial plexus and modified superficial cervical plexus block is a reliable, efficacious technique. The combined block appears to be a reasonable alternative to general anesthesia with an interscalene brachial plexus block, and it may have benefits regarding the anesthesia start time and total case time., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Introduction: Nonunion of a femoral periprosthetic fracture is a rare occurrence in orthopedic practice. Failure of a periprosthetic fracture to heal can lead to substantial disability and pain for patients as well as the potential need for component revision. Relatively little literature exists describing their management and outcome., Methods: Eleven patients with femoral periprosthetic fracture nonunion who presented for tertiary care were enrolled in a prospective data registry. Patients were considered to have developed nonunion following failure of progression in radiographic and clinical healing for a 6-month period. All patients were seen at standard postoperative intervals, and outcomes were recorded using the Short Musculoskeletal Function Assessment (SMFA), visual analog scale (VAS) for pain, physical examination, and radiographic examination. Preoperative radiographs were reviewed for classification., Results: Eleven patients had periprosthetic femoral fracture nonunion associated with prior hip (five patients) or knee (six patients) arthroplasty and were included in our study. Mean follow-up time was 30 months. Mean age at time of nonunion surgery was 64.5 years (range: 41.8 to 78.2 years). All patients underwent removal of previous fracture hardware at time of nonunion surgery. Ten (91%) of 11 received autogenous iliac crest bone grafting at time of nonunion surgery. Ten (91%) of the 11 patients went on to union without further intervention. Mean time to union was 7.9 months (SD: 8.0). The one patient that developed a persistent nonunion was complicated by infection requiring multiple irrigation and debridement procedures and total hip explant. The mean improvement in total SMFA score from baseline to final follow-up was 22.6 (p = 0.030). The greatest functional improvement was in the bothersome index at 28.0 (p = 0.028). The mean improvement in VAS pain score from baseline to final follow-up was 4.5 (p = 0.013)., Discussion: Periprosthetic fracture nonunions can be successfully treated with operative intervention aimed at compression plating with bone graft and retention of primary components. In addition, successful periprosthetic nonunion repair improves function and pain in these patients.

Background: The number of individuals turning to cycling for physical activity and commuting has been expanding across the US. However, studies have demonstrated that when compared to motor vehicle accidents, cyclists in major cities have a significantly increased risk of injuries requiring hospitalizations. The purpose of this study was to assess if a correlation exists between the growing cyclist volume in a densely populated metropolitan city and prevalence of clavicle fractures requiring inpatient hospital admissions., Hypothesis: A correlation exists between the increased number of cyclists and the increasing number of clavicle fractures requiring inpatient hospital admissions., Methods: Patients who sustained a clavicle fracture that required an inpatient admission were identified using the New York Statewide Planning and Research Cooperative System (SPARCS). The location of hospital admission was screened using New York City (NYC) hospital county codes, as only clavicle fractures presenting to NYC hospitals were included in the analysis. This study was exempt from Institutional Review Board (IRB) approval. Public transportation data was available through the Department of Transportation (DOT) and The Decennial Census. These databases are publicly available and are performed to assess if New Yorkers are using cycling as a mode of transportation. The cycling data included the following information in a given year: the number of people in NYC who use a bicycle as their primary mode of commuting to work, the number of daily cycling trips, total bicycle protected bike lane mileage, midtown Manhattan cycling counts and East River Bridge cycling counts. Spearman's correlation analysis was conducted between the numbers of patients with clavicle fractures per year and the described data for that specific year. Additionally, the number of bicycle-share program miles traveled per month and total number of cycling trips that month were obtained from the public bicycle-sharing program database from June 2013 through June 2015. Spearman's correlation analysis was conducted between the numbers of patients with clavicle fractures per month and total bicycle-sharing miles and trips traveled per month., Results: The increasing daily cycling trips in NYC has a strong correlation with the increasing number of clavicle fractures in NYC (rs = .979, p < 0.001). The increasing use of a bicycle as transportation to work has a strong positive correlation with the increasing number of clavicle fractures in NYC (rs = .988, p < 0.001). There was a strong positive correlation between the mileage of bicycle lanes in NYC and the number of clavicle fractures (rs = .867, p = 0.001). A strong positive correlation exists between NYC clavicle fracture number and public bicycle-sharing miles (rs = .819, p < 0.001) and trips (rs = .811, p < 0.001)., Conclusion: There are many physical benefits to cycling. Cycling, as a means of transportation, has been encouraged to decrease CO2 emissions from vehicular transportation. These benefits do not come without risks, as this study shows a correlation between increased cycling and clavicle fractures., Clinical Relevance: Physicians and public health officials should be aware of the dangers of cycling in major cities in order to create safer routes for this environmentally beneficial route of transportation.

Fracture-related infections (FRIs) are among the most common complications following fracture fixation, and they have a huge economic and functional impact on patients. Because consensus guidelines with respect to prevention, diagnosis, and treatment of this major complication are scarce, delegates from different countries gathered in Philadelphia in July 2018 as part of the Second International Consensus Meeting (ICM) on Musculoskeletal Infection. This paper summarizes the discussion and recommendations from that consensus meeting, using the Delphi technique, with a focus on FRIs. A standardized definition that was based on diagnostic criteria was endorsed, which will hopefully improve reporting and research on FRIs in the future. Furthermore, this paper provides a grade of evidence (strong, moderate, limited, or consensus) for strategies and practices that prevent and treat infection. The grade of evidence is based on the quality of evidence as utilized by the American Academy of Orthopaedic Surgeons. The guidelines presented herein focus not only on the appropriate use of antibiotics, but also on practices for the timing of fracture fixation, soft-tissue coverage, and bone defect and hardware management. We hope that this summary as well as the full document by the International Consensus Group are utilized by those who are charged with musculoskeletal care internationally to optimize their management strategies for the prevention and treatment of FRIs.

Background . The incidence and risk factors of wound-healing complications following rotational ankle fracture surgery are well documented in the literature. However, there is a paucity regarding management options following these complications. The goal of this study was to provide a descriptive analysis of one surgeon's experience managing wound complications in patients who have undergone ankle fracture surgery. Methods . A total of 215 patients who were operatively treated for an unstable ankle were retrospectively identified. Patient demographics, medical histories, initial injury characteristics, surgical interventions, and clinical follow-up were collected. Twenty-five of these patients developed postoperative wound problems. Results . Of the original cohort of 215 patients, 25 (11.6%) developed wound-healing complications. Their average age was 53.6 ± 18.0 years; there were 12 males (48.0%). Connective tissue/inflammatory disease (odds ratio [OR] 3.9), cardiovascular disease (OR 3.6), and active smoking (OR 3.3) were associated with an increased likelihood of developing postoperative wound complications. With regard to injuries, open fractures (OR 17.9) had the highest likelihood of developing postoperative complications, followed by type 44-C (OR 2.8) and trimalleolar fractures (OR 2.0). Conclusion . Wound complications following open treatment of ankle fractures occurred with an incidence of 11.6% in this series, of which only about half required operative intervention. A third of wounds were managed by orthopaedics in conjunction with plastic surgery. Levels of Evidence: Level III: Retrospective comparative study.

Introduction: Approximately half of all hip fractures are intertrochanteric femur fractures. This video demonstrates the technique of repair of an unstable intertrochanteric hip fracture using a cephalomedullary device., Methods: The patient is an 88-year-old woman presenting with an intertrochanteric hip fracture secondary to a low-energy injury. The patient was indicated for surgery due to the unstable nature of the fracture., Results: This video demonstrates the cephalomedullary nailing technique for the repair of an unstable intertrochanteric hip fracture after a low-energy injury. Anatomical reduction and stable fixation were obtained with this technique., Conclusions: The case demonstrates a cephalomedullary technique of intertrochanteric fracture fixation using a cephalomedullary nail. The technique has significant advantages including minimal intraoperative blood loss, shorter operative times, potential for more biological healing with a load-sharing device, and low infection rate.

Musculoskeletal infections (MSKI) remain the bane of orthopedic surgery, and result in grievous illness and inordinate costs that threaten healthcare systems. As prevention, diagnosis, and treatment has remained largely unchanged over the last 50 years, a 2nd International Consensus Meeting on Musculoskeletal Infection (ICM 2018, https://icmphilly.com) was completed. Questions pertaining to all areas of MSKI were extensively researched to prepare recommendations, which were discussed and voted on by the delegates using the Delphi methodology. The questions, including the General Assembly (GA) results, have been published (GA questions). However, as critical outcomes include: (i) incidence and cost data that substantiate the problems, and (ii) establishment of research priorities; an ICM 2018 research workgroup (RW) was assembled to accomplish these tasks. Here, we present the result of the RW consensus on the current and projected incidence of infection, and the costs per patient, for all orthopedic subspecialties, which range from 0.1% to 30%, and $17,000 to $150,000. The RW also identified the most important research questions. The Delphi methodology was utilized to initially derive four objective criteria to define a subset of the 164 GA questions that are high priority for future research. Thirty-eight questions (23% of all GA questions) achieved the requisite > 70% agreement vote, and are highlighted in this Consensus article within six thematic categories: acute versus chronic infection, host immunity, antibiotics, diagnosis, research caveats, and modifiable factors. Finally, the RW emphasizes that without appropriate funding to address these high priority research questions, a 3rd ICM on MSKI to address similar issues at greater cost is inevitable., (© 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

Currently, clinical determination of pathologic fracture risk in the hip is conducted using measures of defect size and shape in the stance loading condition. However, these measures often do not consider how changing lesion locations or how various loading conditions impact bone strength. The goal of this study was to determine the impact of defect location on bone strength parameters in both the sideways fall and stance-loading conditions. We recruited 20 female subjects aged 48-77 years for this study and performed MRI of the proximal femur. Using these images, we simulated 10-mm pathologic defects in greater trochanter, superior, middle, and inferior femoral head, superior, middle, and inferior femoral neck, and lateral, middle, and medial proximal diaphysis to determine the effect of defect location on change in bone strength by performing finite element analysis. We compared the effect of each osteolytic lesion on bone stiffness, strength, resilience, and toughness. For the sideways fall loading, defects in the inferior femoral head (12.21%) and in the greater trochanter (6.43%) resulted in the greatest overall reduction in bone strength. For the stance loading, defects in the mid femoral head (-7.91%) and superior femoral head (-7.82%) resulted in the greatest overall reduction in bone strength. Changes in stiffness, yield force, ultimate force, resilience, and toughness were not found to be significantly correlated between the sideways fall and stance-loading for the majority of defect locations, suggesting that calculations based on the stance-loading condition are not predictive of the change in bone strength experienced in the sideways fall condition. While stiffness was significantly related to yield force (R 2  > 0.82), overall force (R 2  > 0.59), and resilience (R 2  > 0.55), in both, the stance-loading and sideways fall conditions for most defect locations, stiffness was not significantly related to toughness. Therefore, structure-dependent measure such as stiffness may not fully explain the post-yield measures, which depend on material failure properties. The data showed that MRI-based models have the sensitivity to determine the effect of pathologic lesions on bone strength., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Little evidence regarding the extent of recovery of radial nerve lesions with associated humerus trauma exists. The aim of this study is to examine the incidence and resolution of types of radial nerve palsy (RNP) in operative and nonoperative humeral shaft fracture populations., Materials and Methods: Radial nerve lesions were identified as complete (RNPc), which included motor and sensory loss, and incomplete (RNPi), which included sensory-only lesions. Charts were reviewed for treatment type, radial nerve status, RNP resolution time, and follow-up time. Descriptive statistics were used to document incidence of RNP and time to resolution. Independent-samples t-test was used to determine significant differences between RNP resolution time in operative and nonoperative cohorts., Results: A total of 175 patients (77 operative, 98 nonoperative) with diaphyseal humeral shaft injury between 2007 and 2016 were identified and treated. Seventeen out of 77 (22.1%) patients treated operatively were diagnosed preoperatively with a radial nerve lesion. Two (2.6%) patients developed secondary RNPc postoperatively. Eight out of 98 (8.2%) patients presented with RNP postinjury for nonoperatively treated humeral shaft fracture. All patients who presented with either RNPc, RNPi, or iatrogenic RNP had complete resolution of their RNP. No statistically significant difference was found in recovery time when comparing the operative versus nonoperative RNPc, operative versus nonoperative RNPi, or RNPc versus RNPi patient groups., Conclusions: All 27 (100%) patients presenting with or developing radial nerve palsy in our study recovered. No patient required further surgery for radial nerve palsy. Radial nerve exploration in conjunction with open reduction and internal fixation (ORIF) appears to facilitate speedier resolution of RNP when directly compared with observation in nonoperative cases, although not statistically significantly so. These findings provide surgeons valuable information they can share with patients who sustain radial nerve injury with associated humerus shaft fracture or nonunion., Level of Evidence: Level III treatment study.

Objective: To compare the incidence of venous thromboembolism (VTE) among patients with pelvic and/or lower extremity fractures directly admitted to our institution versus those transferred from an outside hospital for definitive management., Design: Retrospective cohort., Setting: Tertiary care orthopaedic hospital., Patients: Six hundred ninety patients who received definitive care for a lower extremity fracture at our institution between 2010 and 2017., Intervention: Interfacility transfer for definitive management of pelvic or lower extremity fracture., Main Outcome Measurements: VTE incidence and time to surgery., Results: The interfacility transfer (TR) group comprised 126 patients, and the direct admission (DA) group comprised 564 patients. TR patients had a significantly higher incidence of VTE compared with the DA group: 9.5% versus 0.7%, respectively (P < 0.001). Time to surgery was also longer in the TR group compared with the DA group: 3.05 ± 3.00 days versus 2.16 ± 2.42 days, respectively (P = 0.005). Demographics for TR and DA did not significantly differ with regard to age, sex, length of stay, or American Society of Anesthesiologist score. In the TR group, no complete and explicit documentation regarding thromboprophylaxis administration while at the outside facility was found., Conclusions: Patients undergoing interfacility transfer for definitive management of pelvic and lower extremity fractures are at a significantly increased risk of the development of VTE., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction: To aid implementing an ethics curriculum in an orthopaedic residency program, the American Academy of Orthopaedic Surgeons (AAOS) created 14 ethics scenarios. Because delivery of this curriculum could be burdensome, an online module-based curriculum might be optimal., Methods: Two cohorts of orthopaedic residents participated: cohort I completed 14 online ethics modules converted from the 14 AAOS ethics scenarios. For each module, we gave a multiple-choice assessment immediately before the module, immediately afterward, and 3 months afterward. Cohort II completed only the 14-module assessments at similar time intervals without any educational content., Results: Cohort I demonstrated improvement in 3-month postmodule assessment scores in 11 of the 14 modules, 3 of which had statistical differences in baseline scores for cohort I and cohort II. We observed no statistical difference in scores within cohort II on repeat testing., Discussion: This study demonstrates that 11 of the 14 AAOS ethics scenarios, converted to online modules, teach ethical concepts to orthopaedic residents. Orthopaedic residency programs may find it valuable to engage their residents in the ethics scenarios created by the AAOS to complement their ethics curriculum.

Objectives: To assess the role self-reported treatment for a psychiatric diagnosis may play in long-term functional outcomes after operatively managed tibial plateau fractures., Design: Prospective cohort study., Setting: Academic medical center., Patients: Over an 11-year period, patients were screened and identified on presentation to the emergency department or in the clinical office for inclusion in an IRB-approved registry. A total of 245 patients were included in the study. Twenty-one patients reported treatment for a psychiatric diagnosis., Intervention: Surgical repair of tibial plateau fractures., Main Outcome Measure: Patients were divided into 2 cohorts; 1 cohort being those who self-reported receiving treatment of a psychiatric diagnosis (PI); the other group being those who did not self-report receiving treatment of a psychiatric diagnosis (NPI). Three-month, 6-month, and long-term outcomes (mean = 18 months) were evaluated using the Short Musculoskeletal Function Assessment (SMFA), pain scores, and postoperative complications (infection, VTE, nonunion, and necessity for secondary operations)., Results: Pain scores were higher in patients who self-reported receiving treatment for a psychiatric diagnosis (P = 0.012). Long-term functional outcomes as measured by the SFMA were demonstrated to be worse in patients who self-reported treatment for a psychiatric diagnosis (P = 0.034). No differences existed between groups in regards to postoperative complications. Multiple linear regression analysis revealed that being treated for diagnosis of a mental health illness was an independent predictor of worse functional outcomes at long-term follow-up [B = 8.874, 95% confidence interval (CI) = 0.354-17.394, P = 0.041]., Conclusions: Mental health plays a crucial role in long-term outcomes after operative fixation of tibial plateau fractures. Patients who have been diagnosed with a mental health illness have significantly worse outcomes at long-term follow-up., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Purpose To determine if 3-T magnetic resonance (MR) imaging of proximal femur microarchitecture can allow discrimination of subjects with and without fragility fracture who do not have osteoporotic proximal femur bone mineral density (BMD). Materials and Methods Sixty postmenopausal women (30 with and 30 without fragility fracture) who had BMD T scores of greater than -2.5 in the hip were recruited. All subjects underwent dual-energy x-ray absorptiometry to assess BMD and 3-T MR imaging of the same hip to assess bone microarchitecture. World Health Organization Fracture Risk Assessment Tool (FRAX) scores were also computed. We used the Mann-Whitney test, receiver operating characteristics analyses, and Spearman correlation estimates to assess differences between groups, discriminatory ability with parameters, and correlations among BMD, microarchitecture, and FRAX scores. Results Patients with versus without fracture showed a lower trabecular plate-to-rod ratio (median, 2.41 vs 4.53, respectively), lower trabecular plate width (0.556 mm vs 0.630 mm, respectively), and lower trabecular thickness (0.114 mm vs 0.126 mm) within the femoral neck, and higher trabecular rod disruption (43.5 vs 19.0, respectively), higher trabecular separation (0.378 mm vs 0.323 mm, respectively), and lower trabecular number (0.158 vs 0.192, respectively), lower trabecular connectivity (0.015 vs 0.027, respectively) and lower trabecular plate-to-rod ratio (6.38 vs 8.09, respectively) in the greater trochanter (P < .05 for all). Trabecular plate-to-rod ratio, plate width, and thickness within the femoral neck (areas under the curve [AUCs], 0.654-0.683) and trabecular rod disruption, number, connectivity, plate-to-rod ratio, and separation within the greater trochanter (AUCs, 0.662-0.694) allowed discrimination of patients with fracture from control subjects. Femoral neck, total hip, and spine BMD did not differ between and did not allow discrimination between groups. FRAX scores including and not including BMD allowed discrimination between groups (AUCs, 0.681-0.773). Two-factor models (one MR imaging microarchitectural parameter plus a FRAX score without BMD) allowed discrimination between groups (AUCs, 0.702-0.806). There were no linear correlations between BMD and microarchitectural parameters (Spearman ρ, -0.198 to 0.196). Conclusion 3-T MR imaging of proximal femur microarchitecture allows discrimination between subjects with and without fragility fracture who have BMD T scores of greater than -2.5 and may provide different information about bone quality than that provided by dual-energy x-ray absorptiometry. © RSNA, 2018.

Introduction: The operative management of tibial plateau fractures is challenging and post-operative complications do occur. The purpose of this study was three-fold. 1). To report complications and unplanned outcomes in patients who had sustained tibial plateau fractures and were operatively managed 2). To report predictors of these post-operative events 3). To report if differences in clinical outcomes exist in patients who sustained a post-operative event., Methods: Over 11 years, all tibial plateau fractures were prospectively followed. Clinical outcomes were assessed using the validated Short Musculoskeletal Functional Assessment (SMFA) score. Demographics, initial injury characteristics, surgical details and post-operative events were prospectively recorded. Student's t-tests were used for continuous variables and chi-squared analysis was used for categorical variables. Binary logistic regression and multivariate linear regression were conducted for independent predictors of post-operative events and complications and functional outcomes, respectively., Results: 275 patients with 279 tibial plateau fractures were included in our analysis. Ten patients (3.6%) sustained a deep infection. Six patients (2.2%) developed a superficial infection. One patient (0.4%) presented with early implant failure. Two patients (0.7%) developed a fracture nonunion. Eight patients (2.9%) developed a venous thromboembolism. Seventeen patients (6.2%) went on to re-operation for symptomatic implant removal. Nine patients (3.3%) underwent a lysis of adhesions procedure. Univariate analysis demonstrated bicondylar tibial plateau fractures (P<0.001), Moore fracture-dislocations (P=0.005), open fractures (P=0.022), and compartment syndrome (P=0.001) to be associated with post-operative complications and unplanned outcomes. Long-term functional outcomes were worse among patients who developed a post-operative complication or unplanned outcome (P=0.031)., Conclusion: Orthopaedic trauma surgeons should be aware of complications and unplanned outcomes following operatively managed tibial plateau fractures, along with having the knowledge of factors that are associated with development of post-operative events., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objectives: To determine the efficacy of liposomal bupivacaine compared to placebo for postoperative pain control in patients undergoing operative fixation of ankle fractures., Design: Prospective single-blinded randomized control trial., Setting: Academic Medical Center., Patients/participants: After Institutional Review Board (IRB) approval, 76 patients who sustained an acute ankle fracture (OTA/AO 44A-C) requiring operative fixation met inclusion criteria., Intervention: Patients were randomly assigned to 1 of 2 groups, control (local intraoperative sterile saline injection under general anesthesia) or interventional (local intraoperative liposomal bupivacaine and bupivacaine injection under general anesthesia). Injections were administered in a standardized fashion and included injection of a 1:1 mixture of a 40 mL solution consisting of 1.3% Exparel and sterile saline (interventional) or a 40 mL injection of normal saline (control) into the surrounding periosteal, peritendinous, surrounding muscles and subcutaneous tissue of the surgical incision(s)., Main Outcome Measurements: Pain medications administered and pain according to the Visual Analogue Scale was recorded at scheduled postoperative time points: 4, 24, 48, 72, and 336 hours (14 days)., Results: Thirty-nine patients were randomized to the control group and 37 to the interventional group (mean age = 42 ± 15 years), with no statistically significant differences between groups with regards to severity of injury and patient demographics. Pain scores were significantly lower in the interventional group versus control up to 2 weeks after surgery. Percocet ingestion at 4 hours was significantly lower in the interventional group (0.7 vs. 1.3, P = 0.004), while it approached significance at 48 hours postoperatively (2.8 vs. 3.69, P = 0.07). No other significant differences were noted for Percocet ingestion postoperatively at other time points assessed. The overall satisfaction with pain control was not statistically different between the 2 groups (P = 0.93)., Conclusion: Local intraoperative infiltration of liposomal bupivacaine administered with standard bupivacaine for ankle fractures requiring Open Reduction Internal Fixation (ORIF) affords improved pain relief in the immediate postoperative period resulting in a reduction in Percocet ingestion, with resultant effects seen up to 2 days postoperatively. Continued investigation of this drug for use with extremity fractures is warranted., Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To identify the association between social and moderate alcohol consumption and functional outcomes after surgical management of orthopaedic fractures., Design: Prospective cohort study., Setting: Level 1 trauma center., Patients/participants: Seven hundred eighty-four patients who were operatively treated for an isolated orthopaedic fracture were prospectively followed. Patients were categorized into groups according to self-reported drinking frequencies based on NIAAA guidelines., Main Outcome Measurements: SMFA scores at baseline, 3, 6, and 12 months postoperatively; postoperative complications; and subsequent operations., Results: There were 367 (46.8%) abstinent, 327 (41.7%) social, 52 (6.6%) moderate, and 38 (4.8%) heavy drinkers. Mean SMFA scores of social and moderate drinkers were significantly lower than those of abstinent patients at 3-, 6-, and 12-month follow-ups, denoting better functional outcomes (social: 24.3 vs. 30.5, P = 0.001; 14.8 vs. 21.5, P < 0.005; and 10.1 vs. 18.8, P < 0.005); (moderate: 18.3 vs. 30.5, P = 0.001; 9.7 vs. 21.5, P = 0.001; and 5.4 vs. 18.8, P < 0.005). Multiple linear regression revealed that social drinking and baseline SMFA scores were the only statistically significant independent predictors of lower SMFA scores at 12 months after surgery., Conclusions: Social to moderate drinking may have a protective effect on functional outcomes at 3, 6, and 12 months after surgery. Social drinking may also have a protective effect on postoperative complications and reoperation rates. Further studies should be performed to fully appreciate the clinical effect of social and moderate drinking after operative treatment of orthopaedic fractures., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Patient care is 1 of the 6 core competencies defined by the Accreditation Council for Graduate Medical Education (ACGME). The physical examination (PE) is a fundamental skill to evaluate patients and make an accurate diagnosis. The purpose of this study was to investigate 3 different methods to teach PE skills and to assess the ability to do a complete PE in a simulated patient encounter., Design: Prospective, uncontrolled, observational., Setting: Northeastern academic medical center., Participants: A total of 32 orthopedic surgery residents participated and were divided into 3 didactic groups: Group 1 (n = 12) live interactive lectures, demonstration on standardized patients, and textbook reading; Group 2 (n = 11) video recordings of the lectures given to Group 1 and textbook reading alone; Group 3 (n = 9): 90-minute modules taught by residents to interns in near-peer format and textbook reading., Results: The overall score for objective structured clinical examinations from the combined groups was 66%. There was a trend toward more complete PEs in Group 1 taught via live lectures and demonstrations compared to Group 2 that relied on video recording. Near-peer taught residents from Group 3 significantly outperformed Group 2 residents overall (p = 0.02), and trended toward significantly outperforming Group 1 residents as well, with significantly higher scores in the ankle (p = 0.02) and shoulder (p = 0.02) PE cases., Conclusions: This study found that orthopedic interns taught musculoskeletal PE skills by near-peers outperformed other groups overall. An overall score of 66% for the combined didactic groups suggests a baseline deficit in first-year resident musculoskeletal PE skills. The PE should continue to be taught and objectively assessed throughout residency to confirm that budding surgeons have mastered these fundamental skills before going into practice., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Fracture of the metaphyseal region of the distal ulna is an uncommon injury that has been reported to occur concomitantly with distal radius fracture. We aimed to report the incidence and types of distal ulnar head and neck fractures associated with distal radius fractures and compare outcomes in operatively versus non-operatively treated patients., Methods: Over a 5-year period a distal radius fracture registry was maintained at our institution. Eleven of 512 consecutive patients had metaphyseal distal ulna fractures in association with distal radius fractures and at least 1-year follow-up. Baseline radiographs and functional data were obtained, and patients were followed at 1-week, 2-week, 3-week, 6-week, 3-month, 6-month, 1-year, and 2-year intervals. Patients were split into two treatment groups: Group 1 consisted of five non-operatively treated patients, and Group 2 consisted of six operatively treated patients., Results: Four separate fracture patterns were observed: simple transverse or oblique fracture of the ulnar neck just proximal to the ulnar head, fracture of the neck region with concomitant fracture of the tip of the ulnar styloid, simple fracture of the ulnar head, and comminuted fracture of the ulnar head. There were no statistical differences between the two groups with regard to flexion, extension, supination, pronation, and functional outcomes., Conclusions: Ulnar fracture patterns observed did not easily fall into previously described categories, and we have proposed a new classification system. Simple fractures of the ulnar neck or head often do not require operative fixation.

The purpose is to identify risk factors of functional outcome following proximal humerus open reduction and internal fixation. Patients treated for proximal humerus fractures with open reduction and internal fixation were enrolled in a prospective data registry. Patients were evaluated for function using the Disability of the Arm, Shoulder and Hand score for 12 months and as available beyond 12 months. Univariate analyses were conducted to identify variables associated with functional outcome. Significant variables were included in a multivariate regression predicting functional outcome. Demographics and minimum of 12 month follow-up were available for 129 patients (75%). Multiple regression demonstrated postoperative complication (B=8.515 p=0.045), education level (B=-6.269p<0.0005), age (B=0.241p=0.049) and Charlson Comorbidity Index (B=6.578, p=0.001) were all significant predictors of functional outcome. Orthopaedic surgeons can use education level, comorbidities, age, and postoperative complication information to screen patients for worse outcomes, establish expectations, and guide care.

Rumpel-Leede phenomenon is a rare clinical sign involving the appearance of purpura after application of a tourniquet or in noninvasive arterial blood pressure monitoring. This sign has been most commonly associated with hypertensive and diabetic microvascular fragility and thrombocytopenia. We describe a case of Rumpel-Leede phenomenon in an otherwise healthy patient with positive laboratory markers for Sjögren disease, a previously undescribed relationship. We aim to inform physicians of this potential complication in patients with Sjögren disease and suggest special consideration be given to patients with autoimmune diseases with secondary vascular or dermal manifestations.

Background: Operation choice is a complex decision in the surgical management of proximal humerus fractures. Recently, there has been an increase in the use of total shoulder arthroplasty (TSA) for complex fracture patterns., Hypothesis: Patients with proximal humerus fractures who receive TSA are more likely to have higher hospital charges and a prolonged length of stay relative to patients receiving hemiarthroplasty (HA), open reduction with internal fixation (ORIF) or closed reduction with internal fixation (CRIF)., Materials and Methods: A statewide electronic database was used to identify 13,316 hospital admissions from 2000-2011 were a proximal humerus fracture was surgically managed in an effort to determine the effect of operation choice on cost and length of stay. A univariate analysis was preformed to examine overall trends in surgical management. Additionally, a periodic, multivariate logistic regression analysis was used to determine how operation choice affected the odds of a high cost hospital stay or a prolonged length of stay after controlling for age, comorbidity burden, gender, and insurance type., Results: After controlling for confounding factors, patients receiving total shoulder arthroplasty (TSA) were 2.25 times more likely to have high total hospital charges than patients receiving HA and 3.21 times more likely than patients receiving ORIF. Additionally, TSA was found to be a significant negative predictor of prolonged length of stay (pLOS). HA, ORIF and CRIF did not significantly predict pLOS., Discussion: The use of TSA for acute proximal humerus fractures is associated with increased hospital costs despite a shorter length of stay when compared to other operative choices. As reverse total shoulder arthroplasty becomes more popular for treatment of this injury, it is important that functional outcomes be interpreted in the context of relative cost trade-offs., Level of Evidence: Level IV., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

The literature on the effect of ulnar styloid fractures (USFs) on concomitant distal radius fractures (DRFs) is mixed. We conducted a study to determine if associated ipsilateral USFs affect outcomes of DRFs. We retrospectively evaluated 315 DRFs treated (184 operatively, 131 nonoperatively) over a 7-year period. Concomitant USFs were identified. Mean follow-up was 12 months. Disabilities of the Arm, Shoulder, and Hand (DASH) and 36-Item Short Form Health Survey (SF-36) outcome scores, and grip strength and wrist range of motion data, were collected. Statistical analysis was performed with Student t test and analysis of variance. Incidence of concomitant USF and DRF was higher (P < .0002) in the operative group (64.6%) than in the nonoperative group (39.1%). Patients with USFs had worse mean (SD) pain score, 1.80 (2.43) versus 0.80 (1.55) (P = .0001), DASH score, 17.03 (18.94) versus 9.21 (14.06) (P = .001), and SF-36 score, 77.16 (17.69) versus 82.68 (16.10) (P = .022). In the operative group, patients with USFs had more pain and poorer DASH Functional scores than patients without USFs. Results were similar in the nonoperative group. There was no difference in healing time between intra-articular and extra-articular fractures or between presence and absence of USFs. Concomitant occurrence of USFs and DRFs-which is associated with worse pain scores and lower functioning compared with USFs without DRFs-should prompt clinicians to counsel patients about delayed recovery.

Objective: There continues to be controversy over whether operative delay is necessary for patients on antiplatelet therapy, particularly for elderly patients with hip fractures. This study sought to assess current clinical practices of orthopedic surgeons regarding perioperative management of these patients., Methods: A 12-question, Web-based survey was distributed to orthopedic surgeons via e-mail. Questions regarding timing of surgery assumed patients were on antiplatelet therapy and assessed attitudes toward emergent and nonemergent orthopedic cases as well as operative delay for specific closed fracture types. Responses were compared using unpaired, 2-tailed Student t tests for continuous variables and Pearson chi-square tests with odds ratios (ORs) and 95% confidence intervals (CIs) for categorical variables. Statistical significance was defined as a P value <.05., Results: Overall 67 orthopedic surgeons responded. Fifty-two percent (n = 35) of the respondents described their practice as academic. Thirty-nine percent (n = 25) of the surgeons indicated that no delay was acceptable for urgent but nonemergent surgery, and 78% (n = 50) reported no delay for emergent surgery was acceptable. Sixty-eight percent (n = 46) of respondents felt patients on antiplatelet therapy with closed hip fractures did not require operative delay. Surgeons who opted for surgical delay in hip fractures were more likely to delay surgery in other lower extremity fracture types (OR = 16.4, 95% CI 4.48-60.61, P < .001). Sixty-four percent (n = 41) of the surgeons indicated there was no protocol in place at their institution., Conclusions: There continues to be wide variability among orthopedic surgeons with regard to management of patients with fracture on antiplatelet therapy. Over a quarter of surgeons continue to opt for surgical delay in patients with hip fracture. This survey highlights the need to formulate and better disseminate practice management guidelines for patients with fracture on antiplatelet therapy, particularly given the aging population in the United States.

Objective: To characterize the timing, indications, and "success rates of secondary interventions, dynamization and exchange nailing, in a large series of tibial nonunions" (dynamization and exchange nailing are types of secondary interventions)., Setting: Retrospective multicenter analysis from level 1 trauma hospitals., Patients: A total of 194 tibia fractures that underwent dynamization or exchange nailing for delayed/nonunion., Intervention: Records and radiographs to characterize demographic data, fracture type, and cortical contact after tibial nailing were gathered. The radiographic union score for tibias (RUST) and the timing of intervention and time to union were calculated., Main Outcome Measures: The primary outcome was success of either intervention, defined as achieving union, with the need for further intervention defining failure. Other outcomes included RUST scores at intervention and union, and timing to intervention and union for both techniques. Two-tailed t tests and Fisher exact with P set at <0.05 for significance were used as indicated., Results: A total of 194 tibia fractures underwent dynamization (97) or exchange nailing (97). No statistical differences were found between groups with demographic characteristics. The presence of a fracture gap (P = 0.01) and comminuted fractures (P = 0.002) was more common in the exchange group. The success rates of the interventions and RUST scores were not different when performed before versus after 6 months; therefore, data were pooled. The RUST scores at the time of intervention were not different for successful or failed dynamizations (7.13 vs. 7.07, P = 0.83) or exchanges (6.8 vs. 7.3, P = 0.37). Likewise, the time to successful versus failed dynamization (165 vs. 158 days, P = 0.91) or exchange nailing (224 vs. 201 days, P = 0.48) was not different. No cortical contact or a gap was a statistically negative factor for both exchange nails (P = 0.09) and dynamizations (P = 0.06). When combined, the success in the face of a gap was 78% versus 92% when no gap was present (P = 0.02)., Conclusions: Previous literature has few reports of the success rates of secondary interventions for tibial nonunions. The indications for dynamization and exchange were similar. Comminuted fractures, and fractures with no cortical contact or "gap" present after intramedullary nailing, favored having an exchange nail performed over dynamization. Fracture gap was also found to be a negative prognostic factor for both procedures. Overall, this study demonstrates high rates of union for both interventions, making them both viable options., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

There is no consensus on surgical fixation and treatment of proximal humerus fractures, even though they are common fractures with several fixation techniques. This retrospective study quantifies the outcomes of patients who sustained a proximal humerus fracture and were treated with open reduction and internal fixation by at a single academic center between December 2010 and December 2014 using the Equinoxe® proximal humerus locking plate. Following enrollment, injury and surgical data was recorded. Forty-nine patients (31 female, 18 male) with 50 fractures were identified who met the inclusion criteria. Mean follow-up period was 16.8 months (range: 6 to 44 months). Mean age was 60.7 years with no significant difference in mean age by gender. Mean age-adjusted Charlson Comorbidity Index (CCI) was 2.9 (range: 0 to 6). The overall complication rate was 10% (N = 5) with the most common complication being osteonecrosis (N = 3). Four patients required reoperation. At final follow-up, mean active forward flexion for the cohort was 140.8º ± 30.1º, mean passive forward flexion was 155.7º ± 25.2º, and mean active external rotation was 50.1º ± 17.9º. For patients with postoperative complications, mean active forward flexion was 106.0º ± 23.0º, mean passive forward flexion was 136.7º ± 23.1º, and mean active external rotation was 34.2º ± 24.4. Active forward flexion and external rotation were significantly different in the presence of a complication (p = 0.005 and p = 0.038, respectively). Mean DASH score for the cohort was 19.1 ± 20.9. Mean DASH score for patients who developed complications or underwent reoperations was 34.2 ± 24.3. This study demonstrates that the Equinoxe® proximal humerus locking plate provides stable fracture treatment with excellent clinical results and a low complication rate when performed by experienced orthopaedic traumatologists.

Objective: To determine the reliability of the Radiographic Union Scale for Tibia (RUST) score and a new modified RUST score in quantifying healing and to define a value for radiographic union in a large series of metadiaphyseal fractures treated with plates or intramedullary nails., Design: Healing was evaluated using 2 methods: (1) evaluation of interrater agreement in a series of radiographs and (2) analysis of prospectively gathered data from 2 previous large multicenter trials to define thresholds for radiographic union., Intervention: Part 1: 12 orthopedic trauma surgeons evaluated a series of radiographs of 27 distal femur fractures treated with either plate or retrograde nail fixation at various stages of healing in random order using a modified RUST score. For each radiographic set, the reviewer indicated if the fracture was radiographically healed. Part 2: The radiographic results of 2 multicenter randomized trials comparing plate versus nail fixation of 81 distal femur and 46 proximal tibia fractures were reviewed. Orthopaedic surgeons at 24 trauma centers scored radiographs at 3, 6, and 12 months postoperatively using the modified RUST score above. Additionally, investigators indicated if the fracture was healed or not healed., Main Outcome Measures: The intraclass correlation coefficient (ICC) with 95% confidence intervals was determined for each cortex, the standard and modified RUST score, and the assignment of union for part 1 data. The RUST and modified RUST that defined "union" were determined for both parts of the study., Results: ICC: The modified RUST score demonstrated slightly higher ICCs than the standard RUST (0.68 vs. 0.63). Nails had substantial agreement, whereas plates had moderate agreement using both modified and standard RUST (0.74 and 0.67 vs. 0.59 and 0.53)., Union: The average standard and modified RUST at union among all fractures was 8.5 and 11.4. Nails had higher standard and modified RUST scores than plates at union. The ICC for union was 0.53 (nails: 0.58; plates: 0.51), which indicates moderate agreement. However, the majority of reviewers assigned union for a standard RUST of 9 and a modified RUST of 11, and >90% considered a score of 10 on the RUST and 13 on the modified RUST united., Conclusions: The ICC for the modified RUST is slightly higher than the standard RUST in metadiaphyseal fractures and had substantial agreement. The ICC for the assessment of union was moderate agreement; however, definite union would be 10 and 13 with over 90% of reviewers assigning union. These are the first data-driven estimates of radiographic union for these scores.

Purpose: To evaluate the within-day and between-day measurement reproducibility of in vivo 3D MRI assessment of trabecular bone microarchitecture of the proximal femur., Materials and Methods: This Health Insurance Portability and Accountability Act (HIPPA)-compliant, Institutional Review Board (IRB)-approved study was conducted on 11 healthy subjects (mean age = 57.4 ± 14.1 years) with written informed consent. All subjects underwent a 3T MRI hip scan in vivo (0.234 × 0.234 × 1.5 mm) at three timepoints: baseline, second scan same day (intrascan), and third scan 1 week later (interscan). We applied digital topological analysis and volumetric topological analysis to compute the following microarchitectural parameters within the femoral neck: total bone volume, bone volume fraction, markers of trabecular number (skeleton density), connectivity (junctions), plate-like structure (surfaces), plate width, and trabecular thickness. Reproducibility was assessed using root-mean-square coefficient of variation (RMS-CV) and intraclass correlation coefficient (ICC)., Results: The within-day RMS-CVs ranged from 2.3% to 7.8%, and the between-day RMS-CVs ranged from 4.0% to 7.3% across all parameters. The within-day ICCs ranged from 0.931 to 0.989, and the between-day ICCs ranged from 0.934 to 0.971 across all parameters., Conclusion: These results demonstrate high reproducibility for trabecular bone microarchitecture measures derived from 3T MR images of the proximal femur. The measurement reproducibility is within a range suitable for clinical cross-sectional and longitudinal studies in osteoporosis., (© 2015 Wiley Periodicals, Inc.)

Objective: To evaluate the effect of syndesmotic disruption on the functional outcomes of Weber B, SE4 ankle fractures treated operatively., Setting: Multicenter trauma hospitals., Patients: Data were prospectively gathered during a previous, multicenter randomized trial including 242 patients (136 women, 106 men) from 9 trauma centers with operatively treated Weber B SE4 ankle fractures. There were 81 patients (35%) with syndesmotic instability confirmed intraoperatively after fibula fixation., Intervention: Functional evaluations were performed postoperatively at 6, 12, 26, and 52 weeks. The presence of symptomatic hardware and peroneal tendon discomfort was evaluated with 9-12 months of follow-up., Main Outcome Measures: Functional outcomes evaluated included Short Musculoskeletal Function Assessment (SMFA), Bother index, and American Orthopaedic Foot and Ankle Society (AOFAS) scores. The recovery curve of the 2 groups was analyzed using a mixed linear regression analysis for repeated measures and included gender and race in the model. Symptomatic hardware and peroneal tendon discomfort were compared between the 2 groups with a χ analysis., Results: The adjusted mean linear regression analyses demonstrated that patients without a syndesmotic injury had better functional outcomes for some outcome measures. SMFA scores at 12 weeks were statistically lower in patients without syndesmotic injury (P = 0.02), but not at other visits. AOFAS scores were significantly higher (P = 0.0006), and Bother index trended toward lower results (P = 0.07) in patients without syndesmotic injury at all time points. Isolated analyses (T-tests) at 1 year demonstrated a difference in the SMFA (P = 0.04) and Bother index (P = 0.05), but not the AOFAS (P = 0.21). Men consistently demonstrated better recovery than women for all outcomes, whereas race was not significant for any measure. Symptomatic hardware and peroneal tendon irritation was not statistically different between the groups., Conclusions: The recovery curves after ankle fractures were different based on syndesmotic injury. However, the difference was at the limit of clinical significance. Syndesmotic injury has a slightly detrimental effect on outcomes of operatively treated Weber B SE4 fractures., Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Introduction: Osteoporosis is a disease of weak bone. Our goal was to determine the measurement reproducibility of magnetic resonance assessment of proximal femur strength., Methods: This study had institutional review board approval, and written informed consent was obtained from all subjects. We obtained images of proximal femur microarchitecture by scanning 12 subjects three times within 1 week at 3T using a high-resolution 3-D FLASH sequence. We applied finite element analysis to compute proximal femur stiffness and femoral neck elastic modulus., Results: Within-day and between-day root-mean-square coefficients of variation and intraclass correlation coefficients ranged from 3.5 to 6.6 % and 0.96 to 0.98, respectively., Conclusion: The measurement reproducibility of magnetic resonance assessment of proximal femur strength is suitable for clinical studies of disease progression or treatment response related to osteoporosis bone-strengthening interventions.

Osteoporosis is a disease of poor bone quality. Bone mineral density (BMD) has limited ability to discriminate between subjects without and with poor bone quality, and assessment of bone microarchitecture may have added value in this regard. Our goals were to use 7 T MRI to: (1) quantify and compare distal femur bone microarchitecture in women without and with poor bone quality (defined clinically by presence of fragility fractures); and (2) determine whether microarchitectural parameters could be used to discriminate between these two groups. This study had institutional review board approval, and we obtained written informed consent from all subjects. We used a 28-channel knee coil to image the distal femur of 31 subjects with fragility fractures and 25 controls without fracture on a 7 T MRI scanner using a 3-D fast low angle shot sequence (0.234 mm × 0.234 mm × 1 mm, parallel imaging factor = 2, acquisition time = 7 min 9 s). We applied digital topological analysis to quantify parameters of bone microarchitecture. All subjects also underwent standard clinical BMD assessment in the hip and spine. Compared to controls, fracture cases demonstrated lower bone volume fraction and markers of trabecular number, plate-like structure, and plate-to-rod ratio, and higher markers of trabecular isolation, rod disruption, and network resorption (p < 0.05 for all). There were no differences in hip or spine BMD T-scores between groups (p > 0.05). In receiver-operating-characteristics analyses, microarchitectural parameters could discriminate cases and controls (AUC = 0.66-0.73, p < 0.05). Hip and spine BMD T-scores could not discriminate cases and controls (AUC = 0.58-0.64, p ≥ 0.08). We conclude that 7 T MRI can detect bone microarchitectural deterioration in women with fragility fractures who do not differ by BMD. Microarchitectural parameters might some day be used as an additional tool to detect patients with poor bone quality who cannot be detected by dual-energy X-ray absorptiometry (DXA).

Background: Lower extremity injuries secondary to low-energy gunshot wounds are frequently seen in the civilian populations of urban areas. Although these wounds have fewer complications than high-energy gunshot injuries, the functional and psychological damage is still significant making appropriate timely orthopaedic treatment and follow-up imperative., Purpose: The purpose of this study is to present our outcomes in the treatment of low-energy gunshot wounds in a civilian population at an urban, level one trauma center in patients treated by a standard protocol., Methods: One hundred and thirty three patients who sustained 148 gunshot wound injuries were treated at our level one trauma center between January 1(st), 2009 and October 1(st), 2011. Following IRB approval, we extracted information from medical records regarding hospital course, length of stay and type of operative or non-operative treatment. If available, injury and post-operative radiographs were also reviewed. Patients were contacted by telephone to obtain Short Musculoskeletal Function Assessment (SMFA) surveys, pain on a scale of 0-10 and for the determination of any adverse events related to their shooting., Results: There were 125 men (94.0%) and 8 women (6.0%) with an average age of 27.1 years (range 15.2-56.3). Seventy-six patients (57.1%) did not have any health insurance upon admission. The average length of stay in the hospital was 4.5 days (range 0.0-88.0). Fifty-one gun shots (34.5%) resulted in fractures of the lower extremities. Patients underwent a total of 95 lower extremity-related procedures during their hospitalization. Twenty-two patients (16.5%) experienced a complication related to their gunshot wounds. 38% of the cohort was available for long-term functional assessment At a mean 23.5 months (range 8-48) of follow up, patients reported mean Functional and Bothersome SMFA scores of 19.6 (SD 15.9) and 10.9 (SD 15.6) suggesting that these patients have poorer function scores than the general population. These patients still had pain related to their gunshot injury with an average pain score of 2.16 (range 0-8)., Conclusions: Gunshot injuries to the extremities may involve bone, soft tissue, and neurovascular structures. Execution of appropriate therapeutic methods in such situations is critical for treating surgeons given the potential for complications. At our level one trauma center, gunshot victims were predominantly young, uninsured adult men. Complications included infection, compartment syndrome, and arterial injuries. Functional data collected demonstrated that patients continued to have difficulties with ADL's at long-term follow-up.

Purpose: High-resolution imaging of deeper anatomy such as the hip is challenging due to low signal-to-noise ratio (SNR), necessitating long scan times. Multi-element coils can increase SNR and reduce scan time through parallel imaging (PI). We assessed the feasibility of using a 26-element receive coil setup to perform 3 Tesla (T) MRI of proximal femur microarchitecture without and with PI., Materials and Methods: This study had institutional review board approval. We scanned 13 subjects on a 3T scanner using 26 receive-elements and a three-dimensional fast low-angle shot (FLASH) sequence without and with PI (acceleration factors [AF] 2, 3, 4). We assessed SNR, depiction of individual trabeculae, PI performance (1/g-factor), and image quality with PI (1 = nonvisualization to 5 = excellent)., Results: SNR maps demonstrate higher SNR for the 26-element setup compared with a 12-element setup for hip MRI. Without PI, individual proximal femur trabeculae were well-depicted, including microarchitectural deterioration in osteoporotic subjects. With PI, 1/g values for the 26-element/12-element receive-setup were 0.71/0.45, 0.56/0.25, and 0.44/0.08 at AF2, AF3, and AF4, respectively. Image quality was: AF1, excellent (4.8 ± 0.4); AF2, good (4.2 ± 1.0); AF3, average (3.3 ± 1.0); AF4, nonvisualization (1.4 ± 0.9)., Conclusion: A 26-element receive-setup permits 3T MRI of proximal femur microarchitecture with good image quality up to PI AF2., (© 2013 Wiley Periodicals, Inc.)

Purpose: To demonstrate the feasibility of performing bone microarchitecture, high-resolution cartilage, and clinical imaging of the hip at 7T., Materials and Methods: This study had Institutional Review Board approval. Using an 8-channel coil constructed in-house, we imaged the hips of 15 subjects on a 7T magnetic resonance imaging (MRI) scanner. We applied: 1) a T1-weighted 3D fast low angle shot (3D FLASH) sequence (0.23 × 0.23 × 1-1.5 mm(3) ) for bone microarchitecture imaging; 2) T1-weighted 3D FLASH (water excitation) and volumetric interpolated breath-hold examination (VIBE) sequences (0.23 × 0.23 × 1.5 mm(3) ) with saturation or inversion recovery-based fat suppression for cartilage imaging; 3) 2D intermediate-weighted fast spin-echo (FSE) sequences without and with fat saturation (0.27 × 0.27 × 2 mm) for clinical imaging., Results: Bone microarchitecture images allowed visualization of individual trabeculae within the proximal femur. Cartilage was well visualized and fat was well suppressed on FLASH and VIBE sequences. FSE sequences allowed visualization of cartilage, the labrum (including cartilage and labral pathology), joint capsule, and tendons., Conclusion: This is the first study to demonstrate the feasibility of performing a clinically comprehensive hip MRI protocol at 7T, including high-resolution imaging of bone microarchitecture and cartilage, as well as clinical imaging., (Copyright © 2013 Wiley Periodicals, Inc.)

Objectives: There is substantial variation in the classification and management of scapula fractures. The first purpose of this study was to analyze the interobserver reliability of the OTA/AO classification and the New International Classification for Scapula Fractures. The second purpose was to assess the proportion of agreement among orthopaedic surgeons on operative or nonoperative treatment., Design: Web-based reliability study., Setting: Independent orthopaedic surgeons from several countries were invited to classify scapular fractures in an online survey., Participants: One hundred three orthopaedic surgeons evaluated 35 movies of three-dimensional computerized tomography reconstruction of selected scapular fractures, representing a full spectrum of fracture patterns., Main Outcome Measurements: Fleiss kappa (κ) was used to assess the reliability of agreement between the surgeons., Results: The overall agreement on the OTA/AO classification was moderate for the types (A, B, and C, κ = 0.54) with a 71% proportion of rater agreement (PA) and for the 9 groups (A1 to C3, κ = 0.47) with a 57% PA. For the New International Classification, the agreement about the intraarticular extension of the fracture (Fossa (F), κ = 0.79) was substantial and the agreement about a fractured body (Body (B), κ = 0.57) or process was moderate (Process (P), κ = 0.53); however, PAs were more than 81%. The agreement on the treatment recommendation was moderate (κ = 0.57) with a 73% PA., Conclusions: The New International Classification was more reliable. Body and process fractures generated more disagreement than intraarticular fractures and need further clear definitions.

Controversy exists among the orthopedic community regarding the treatment of gunshot injuries. No consistent treatment algorithm exists for treatment of low energy gunshot wound (GSW) trauma. The purpose of this study was to critically examine the wound contamination following low velocity GSW based upon bullet caliber and clothing fiber type found within the injury track. Four types of handguns were fired at ballistic gel from a 10-foot distance. Various clothing materials were applied (denim, cotton, polyester, and wool) circumferentially around the tissue agar in a loose manor. A total of 32 specimens were examined. Each caliber handgun was fired a minimum of 5 times into a gel. Regardless of bullet caliber there was gross contamination of the entire bullet track in 100% of specimens in all scenarios and for all fiber types. Furthermore, as would be expected, the degree of contamination appeared to increase as the size of the bullet increased. Low velocity GSWs result in significant contamination regardless of bullet caliber and jacket type. Based upon our results further investigation of low velocity GSW tracks is warranted. Further clinical investigation should focus on the degree to which debridement should be undertaken.

Introduction: Operative fixation of displaced inferior pole patella fractures has now become the standard of care. This study aims to quantify clinical, radiographic and functional outcomes, as well as identify complications in a cohort of patients treated with non-absorbable braided suture fixation for inferior pole patellar fractures. These patients were then compared to a control group of patients treated for mid-pole fractures with K-wires or cannulated screws with tension band wiring., Methods: In this IRB approved study, we identified a cohort of patients who were diagnosed and treated surgically for a displaced patella fracture. Demographic, injury, and surgical information were recorded. All patients were treated with a standard surgical technique utilizing non-absorbable braided suture woven through the patellar tendon and placed through drill holes to achieve reduction and fracture fixation. All patients were treated with a similar post-operative protocol and followed up at standard intervals. Data were collected concurrently at follow up visits. For purpose of comparison, we identified a control cohort with middle third patella fractures treated with either k-wires or cannulated screws and tension band technique. Patients were followed by the treating surgeon at regular follow-up intervals. Outcomes included self-reported function and knee range of motion compared to the uninjured side., Results: Forty-nine patients with 49 patella fractures identified retrospectively were treated over 9 years. This cohort consisted of 31 females (63.3%) and 18 males (36.7%) with an average age of 57.1 years (range 26-88 years). Patients had an average BMI of 26.48 (range 19-44.08). Thirteen patients with inferior pole fractures underwent suture fixation and 36 patients with mid-pole fractures underwent tension band fixation (K-wire or cannulated screws with tension band). In the suture cohort, one fracture failed open repair (7.6%), which was revised again with sutures and progressed to union. Of the 36 fractures repaired with a tension band fixation, 11 underwent secondary surgery due to hardware pain or fixation failure (30.6%). At one year, no difference was seen in knee range of motion between cohorts. All fractures healed radiographically. Those patients who required reoperation or removal of hardware had significantly diminished range of motion about their injured knee (p > 0.005)., Conclusions: Patients who sustain inferior pole patella fractures have limited options for fracture fixation. Suture repair is clinically acceptable, yielding similar results to patella fractures repaired with metal implants. Importantly, patients undergoing suture repair appear to have fewer hardware related postoperative complications than those receiving wire fixation for midpole fractures.

Background: The quality of reduction of the syndesmosis is an important factor in the outcome of ankle fractures associated with a syndesmotic injury. The purpose of this study was to directly compare the accuracy of syndesmotic reductions obtained using intraoperative standard fluoroscopic techniques against reductions obtained using three-dimensional imaging of the Iso-C3D fluoroscope., Methods: We prospectively reviewed imaging studies of patients who were diagnosed as having preoperative or intraoperative evidence of syndesmotic diastasis (on the basis of the fluoroscopic Cotton test and/or a manual external rotation stress test) who underwent syndesmotic fixation at one of two level-I trauma centers. Center A used intraoperative computed tomography (CT) imaging to assess reduction (≤2 mm), while Center B assessed reduction under standard fluoroscopic imaging. Postoperative alignment was assessed in a standardized manner, measuring anterior fibular distance, posterior fibular distance, and the anterior translation distance. Measurements were taken on the injured side and the uninjured side and compared between the groups on postoperative axial CT scans., Results: A total of thirty-six patients in both centers met our inclusion criteria and were included in the data analysis. Despite utilization of the Iso-C(3D), a high rate of malreductions was noted in both groups. Anterior translation distance malreductions occurred in 31% of the sixteen patients in Center A and 25% of the twenty patients in Center B (p = 0.72). The number of anterior fibular distance malreductions was similar, with a rate of 38% in Center A and 30% in Center B (p = 0.73). A significant difference among the centers (p = 0.03) was noted, however, when the posterior fibular distance data was analyzed, with 6% being malreduced by >2 mm in Center A and 40% in Center B., Conclusions: The results of our study support previous investigations that have cited high rates of syndesmotic malreductions and demonstrate that the addition of advanced intraoperative imaging techniques does not help to reduce the rate of malreductions in this cohort.

'Skiving' is commonly used to refer to the condition when the subchondral plate is disrupted and the overlying cartilage physically displaced without the screw tip entering the joint. In this study we sought to define radiographic parameters of skiving and compare radiographs with computed tomography (CT) for accuracy in determining joint skiving. Cadaveric specimens of the distal radius were implanted with a volar plate and screws. Arthrotomies were performed to definitively assess the positions of the screws. Standard and anatomic tilt radiographs as well as CT were performed. Orthopaedic surgeons and radiologists evaluated the images and reported whether screw penetration or skiving had occurred. For screws which penetrated or skived, measurements were made to record the distances from the screw tips to the subchondral plate. Sensitivity, specificity and percent correct interpretations were 53%, 83%, 60% respectively for radiographs; and 100%, 72%, 69% for CT. Screws penetrating the articular surface protruded an average 2.3 mm (range 2-2.6 mm) from the subchondral plate and those skiving protruded 1.4 mm (range 1-1.8 mm). This study shows that articular skiving can occur with penetration of the subchondral plate of up to 1.8 mm. CT has a greater sensitivity and lower specificity in determining skiving compared to radiographs.

Background: Treatment of tibial stress fractures in elite dancers is centered on rest and activity modification. Surgical intervention in refractory cases has important implications affecting the dancers' careers., Hypothesis: Refractory tibial stress fractures in dancers can be treated successfully with drilling and bone grafting or intramedullary nailing., Study Design: Case series; Level of evidence, 4., Methods: Between 1992 and 2006, 1757 dancers were evaluated at a dance medicine clinic; 24 dancers (1.4%) had 31 tibial stress fractures. Of that subset, 7 (29.2%) elite dancers with 8 tibial stress fractures were treated operatively with either intramedullary nailing or drilling and bone grafting. Six of the patients were followed up closely until they were able to return to dance. One patient was available only for follow-up phone interview. Data concerning their preoperative treatment regimens, operative procedures, clinical union, radiographic union, and time until return to dance were recorded and analyzed., Results: The mean age of the surgical patients at the time of stress fracture was 22.6 years. The mean duration of preoperative symptoms before surgical intervention was 25.8 months. Four of the dancers were male and 3 were female. All had failed nonoperative treatment regimens. Five patients (5 tibias) underwent drilling and bone grafting of the lesion, and 2 patients (3 tibias) with completed fractures or multiple refractory stress fractures underwent intramedullary nailing. Clinical union was achieved at a mean of 6 weeks and radiographic union at 5.1 months. Return to full dance activity was at an average of 6.5 months postoperatively., Conclusion: Surgical intervention for tibial stress fractures in dancers who have not responded to nonoperative management allowed for resolution of symptoms and return to dancing with minimal morbidity.

Background: This study investigated which variables influence patients' return to sports after operative fixation of an unstable ankle fracture., Materials and Methods: Over a 5-year period, 488 patients underwent surgical repair of an unstable ankle fracture. 243 patients preoperatively identified themselves as participating in vigorous activity. Clinical evaluation, functional outcome scores, and radiographic findings were reviewed retrospectively., Results: At 3 months postoperatively, only 3% of all patients had returned to full sports. At 6 months, 14% of patients had returned, while at one year, only 24% of patients had returned. Younger age was predictive of return to sports by 3 months (p = 0.02), 6 months (p = 0.02) and 12 months (p = 0.0001). Males were more likely to return to sports at 6 (p = 0.001) and 12 months (p = 0.040). At 1 year, 88% of recreational athletes had returned to sports, while only 11.6% of competitive athletes had returned to sports (p = 0.043). At 12 months, bimalleolar injuries were more likely to return to sports than unimalleolar ankle fractures (p = 0.042). Furthermore, patients without an associated syndesmotic injury were more likely to return to athletic activities at 12 months (p = 0.011). A patient with an ASA of one or two was ten times more likely to return to sports versus a patient with an ASA of three or four (odds ratio > 10, p = 0.010)., Conclusion: Predictors of return to sporting activities at one year include younger age, male gender, no or mild systemic disease, and a less severe ankle fracture. Negative predictors include older age, female gender, and the presence of severe medical comorbidities.

Periprosthetic femoral fractures associated with well-fixed total hip or total knee prostheses present a challenging management problem as these injuries typically occur in osteoporotic bone. Conventional management entails extensive periosteal stripping to allow for plate fixation. We reviewed a consecutive series of patients who sustained fractures associated with a well fixed total knee prosthesis, a total hip prosthesis, or both. Twenty four patients with a mean age of 69.4 years were included. All patients underwent fixation via percutaneous insertion techniques with a first generation locking plate and screws (LISS--Less Invasive Skeletal Stabilization, Synthes, Paoli, PA). Three patients sustained fractures distal to a well-fixed total hip prosthesis, eighteen fractures occurred above a well-fixed total knee femoral component, and three were interprosthetic. The mean length of time from the index procedure to fracture was 76 months, range (2-172 months). Blood loss was minimal in each case, with a mean operative time of 90 min (range 60-120 min). Twenty one of twenty four went on to unite at a mean 6.2 months (range 3-19 months). Three patients underwent further surgery. One failure of fixation was encountered. Percutaneous fixation is technically demanding as it requires stable fixation without direct visualisation of the fracture site or the entire fixation device. Our results suggest percutaneous fixation with the LISS plate is an effective although technically demanding method of treatment. Complication rates were comparable to existing reports of this treatment method, and appear to be improved over traditional methods of fixation.