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Formal patient complaints and malpractice events involving orthopedic trauma surgeons (OTSs) can have substantial career implications. Our purpose was to analyze formal patient complaints, risk events, and malpractice events against OTSs during a 10-year period. We reviewed all formal patient complaints within our institution's patient advocacy database involving 9 fellowship-trained OTSs throughout a decade. Complaints were categorized using the Patient Complaint Analysis System. Potential risk and malpractice events involving the OTSs were recorded. A control group of all patients seen by the surgeons during the study period was created. Demographics between patients with complaints and the control group were analyzed, as were malpractice, risk, and complaint rates between the surgeons. Of 33,770 patients, 136 filed a formal complaint (0.40%). There were 29 malpractice claims and 2 malpractice lawsuits. The care and treatment domain accounted for the highest percentage of complaints (36%), followed by the access and availability domain (26%). Results of the logistic regression analysis indicated that private insurance (odds ratio, 1.58) and operative treatment (odds ratio, 3.65) were significantly associated with complaints. Despite statistically significant differences in the rates of complaint and risk events between surgeons, malpractice events did not differ. The rate of patient complaints within a large orthopedic trauma practice during a 10-year period was 0.40%. Patients with private insurance and those treated operatively were more likely to file a complaint. Whereas complaint rates among surgeons varied, there was no significant difference in the rate of malpractice events. Understanding patient complaint rates and categorizations may allow surgeons to target areas for improvement. [ Orthopedics . 2023;46(2):121–127.]

Whereas prior studies have aimed to define the utility of routine radiographs for the closed treatment of upper extremity fractures, it remains uncertain whether routine radiographs influence management decisions for nonoperative treatment of proximal humerus fractures (PHFs). The purpose of this investigation was to assess the utility of routine radiographic monitoring of closed PHFs in elderly patients initially indicated for nonoperative treatment. We identified all patients 65 years and older who had a PHF from 2016 to 2019. We excluded cases of pathologic fractures or periprosthetic fractures, nonunion, malunion, cases with insufficient follow-up, and cases for which surgery was indicated either in the emergency department or at the first orthopedic visit. After applying these exclusion criteria, 402 cases remained. We recorded baseline demographics and fracture descriptions and noted any conversion to operative treatment after the initial office visit. Two-part fractures were most common (56%). Of the 402 fractures indicated for nonoperative treatment, 21 (5%) were converted to operative management during the follow-up period. Nine fractures (2%) were converted to operative management within 30 days of the first office visit. Eight cases (2%) were converted to operative treatment more than 120 days after the initial office visit: 6 due to nonunion and 2 due to posttraumatic arthritis. For patients 65 years and older who undergo initial nonoperative treatment of a PHF, routine follow-up radiographs do not appear to alter management decisions. Given the risk and cost associated with routine radiographs, surgeons should consider forgoing these images in the absence of clinical concern. [ Orthopedics. 202x;4x(x):xx–xx.]

Open fractures in the elderly are distinct compared to younger populations. The purpose of this study is to follow a series of open fractures of the lower extremity in the geriatric population to better prognosticate outcomes.We performed a retrospective chart review of patients over the age of 65 years old who were treated for an open, lower extremity fracture across two level I trauma medical systems. Patients were included if they had documented wound healing problems in the postoperative period, or 6 months of follow-up, or if they had a definitive radiographic outcome. Sixty-four patients were included of an average age of 76.23, of whom 73.4% were female.The fracture types were midshaft femur in 3, distal femur in 9, patella in 2, proximal tibia in 3, proximal fibula in 1, midshaft tibia in 14, distil tibia in 8, ankle in 23, and talar neck/calcaneus in 1. Forty-two fractures were the result of low energy mechanism and 22 fractures were from high energy mechanism. Fourteen fractures were type 1, 32 were type 2, 11 were type 3A, 6 were type 3B, and 1 was type 3C. At final follow-up, 13 wounds were well healed, 39 wounds were healed following a delay of more than 6 weeks to achieve healing, 3 were infected, 3 had been treated with amputation, 2 had chronic ulceration, 2 with active draining, and 2 had draining sinuses.Open lower extremity fractures are serious injuries with high rates of morbidity. Such risks are even higher in the geriatric population, particularly with regard to wound healing. This study provides important prognostic information in counseling geriatric patient with an open lower extremity fracture, as well as informs treatment in terms of wound surveillance and care in the postoperative period.

OBJECTIVE To identify the patient, injury and treatment factors associated with an acute infection during the treatment of open ankle fractures in a large multi-center retrospective review. To evaluate the effect of infectious complications on the rates of nonunion, malunion, and loss of reduction. DESIGN Multi-center Retrospective Review. SETTING Sixteen Trauma Centers. PATIENTS One thousand and three 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 1,003 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). CONCLUSION Several patient, injury and surgical factors were associated with fracture-related infection in the treatment of open ankle fractures. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objectives To determine the radial nerve palsy (RNP) rate and predictors of injury after humeral nonunion repair in a large multicenter sample. Design Consecutive retrospective cohort review. Setting Eighteen academic orthopedic trauma centers. Patients/participants Three hundred seventy-nine adult patients who underwent humeral shaft nonunion repair. Exclusion criteria were pathologic fracture and complete motor RNP before nonunion surgery. Intervention Humeral shaft nonunion repair and assessment of postoperative radial nerve function. Main outcome Measurements: Demographics, nonunion characteristics, preoperative and postoperative radial nerve function and recovery. Results Twenty-six (6.9%) of 379 patients (151 M, 228 F, ages 18-93 years) had worse radial nerve function after nonunion repair. This did not differ by surgical approach. Only location in the middle third of the humerus correlated with RNP (P = 0.02). A total of 15.8% of patients with iatrogenic nerve injury followed for a minimum of 12 months did not resolve. For those who recovered, resolution averaged 5.4 months. On average, partial/complete palsies resolved at 2.6 and 6.5 months, respectively. Sixty-one percent (20/33) of patients who presented with nerve injury before their nonunion surgery resolved. Conclusion In a large series of patients treated operatively for humeral shaft nonunion, the RNP rate was 6.9%. Among patients with postoperative iatrogenic RNP, the rate of persistent RNP was 15.8%. This finding is more generalizable than previous reports. Midshaft fractures were associated with palsy, while surgical approach was not. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES To evaluate the rate of, and reasons for, conversion of closed treatment of humeral shaft fractures using a fracture brace, to surgical intervention. DESIGN Multicenter, retrospective analysis. SETTING Nine Level 1 trauma centers across the United States. PATIENTS A total of 1182 patients with a closed humeral shaft fracture initially managed nonoperatively with a functional brace from 2005 to 2015 were reviewed retrospectively from 9 institutions. INTERVENTION Functional brace. MAIN OUTCOME MEASUREMENTS Conversion to surgery. RESULTS A total of 344 fractures (29%) ultimately underwent surgical intervention. Reasons for conversion included nonunion (60%), malalignment beyond acceptable parameters (24%), inability to tolerate functional bracing (12%), and persistent signs of radial nerve palsy requiring exploration (3.7%). Univariate comparisons showed that females and whites were significantly (P < 0.05) more likely to be converted to surgery. The multivariate logistic regression identified females as being 1.7 times more likely and alcoholics to be 1.4 times more likely to be converted to surgery (P < 0.05). Proximal shaft as well as comminuted, segmental, and butterfly fractures were also linked to a higher rate of conversion. CONCLUSIONS This large multicenter study identified a 29% surgical conversion rate, with nonunion as the most common reason for surgical intervention after the failure of functional brace. These results are markedly different than previously reported. These results may be helpful in the future when counseling patients on the choice between functional bracing and surgical intervention in managing humeral shaft fractures. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Femoral neck fractures in children are rare injuries resulting from high-energy trauma. Different methods of treatment, lack of standard management protocols, and the high risk of complications make this injury one of the biggest challenges that an orthopaedic surgeon can face. This review focuses on the general aspects of the pediatric femoral neck fracture management as well as its complications and possible solutions.

The role of routine clinical and radiographic follow-up after clavicle fractures are healed was evaluated.A retrospective study performed in two level-1 trauma centers included 246 adults with healed clavicle fractures treated surgically between 2000 and 2013 and at least 24-month follow-up. Based on radiographs, changes in fracture alignment or implant position from union to final follow-up were documented. The average reimbursement for a follow-up clinical visit and a clavicle radiograph was estimated.Mean time to union and mean time of follow-up were of 4.8 and 31.4 months, respectively. No changes in implant position or fracture alignment occurred after the fracture had healed. The amount reimbursed to our institution for two clinical visits and two clavicle radiographs was approximately $300 to $540.Once clavicle fractures are healed, further radiographic imaging does not provide any notable information. Limiting routine follow-up is safe and could be cost-effective for the healthcare system.Level-III retrospective cohort study.

With the increasing number of total knee arthroplasties (TKAs) being performed, the incidence of periprosthetic fractures adjacent to a TKA is rising. Minimally invasive plate osteosynthesis (MIPO) has proven to be successful for the biological fixation of many fractures. Advances in surgical instrumentation and techniques made MIPO possible for more complex fractures. Periprosthetic fractures are always complicated by problems of soft tissue incisions, scarring, and, of course, the arthroplasty components. MIPO techniques may be particularly suited to these injuries and may make the surgical repair of these fractures safer and more reliable. In this review, case examples are used to define the indications, preoperative planning, implant selection, complications, limitations, and challenges of MIPO for the treatment of periprosthetic fractures about the knee. When considering MIPO for any fracture, we recommend prioritizing an acceptable reduction with biological fixation and resorting to mini-open or open approach when necessary to achieve it. Awareness of the learning curve of the surgical technique, advances in implant designs, the tips and tricks involved, and the limitations of the MIPO is of paramount importance from the orthopaedic surgeon's perspective.

Objectives To report on the final displacement after in situ percutaneous pinning for Garden type 1 and 2 fractures in height, femoral neck fracture collapse, and loss of offset. Design Retrospectively reviewed case series. Setting Three Academic Medical Centers. Boston University Medical Center (Level 1 Trauma Center), Lahey Hospital and Medical Center (Level 2 Trauma Center), and Geisinger Medical Center (level 2 Trauma Center). Patients/participants One hundred thirty skeletally mature patients with 130 fractures (78 garden 1 and 52 garden 2) who were treated between January 2000 and January 2014 at participating hospitals with percutaneous pinning with a cannulated screw system to successful union after sustaining an intracapsular femoral neck fracture without complete displacement. Intervention In situ percutaneous pinning with 3 cannulated, partially threaded screws in an inverted triangle orientation. Main outcome measurements Femoral neck fracture collapse (mm), femoral height shortening (mm), and femoral offset shortening (mm). Results A total of 130 patients (81F, 49M), average age 72 years, sustained 78 Garden 1 and 52 Garden 2 femoral neck fractures. Maximal collapse occurred in the plane of the femoral neck. Thirty-three of 78 (42%) Garden 1 fractures and 33/52 (63%) Garden 2 fractures demonstrated >10 mm fracture collapse. The range of displacements was 0-39 mm as measured along the plane of the femoral neck. Conclusions Garden 1 fractures collapse less frequently than Garden 2 fractures, but both have high rates of fracture collapse when treated to union with in situ percutaneous pin fixation. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Introduction Proximal tibia fracture dislocations (PTFDs) are a subset of plateau fractures with little in the literature since description by Hohl (1967) and classification by Moore (1981). We sought to evaluate reliability in diagnosis of fracture-dislocations by traumatologists and to compare their outcomes with bicondylar tibial plateau fractures (BTPFs). Methods This was a retrospective cohort study at 14 level 1 trauma centers throughout North America. In all, 4771 proximal tibia fractures were reviewed by all sites and 278 possible PTFDs were identified using the Moore classification. These were reviewed by an adjudication board of three traumatologists to obtain consensus. Outcomes included inter-rater reliability of PTFD diagnosis, wound complications, malunion, range of motion (ROM), and knee pain limiting function. These were compared to BTPF data from a previous study. Results Of 278 submitted cases, 187 were deemed PTFDs representing 4% of all proximal tibia fractures reviewed and 67% of those submitted. Inter-rater agreement by the adjudication board was good (83%). Sixty-one PTFDs (33%) were unicondylar. Eleven (6%) had ligamentous repair and 72 (39%) had meniscal repair. Two required vascular repair. Infection was more common among PTFDs than BTPFs (14% vs 9%, p = 0.038). Malunion occurred in 25% of PTFDs. ROM was worse among PTFDs, although likely not clinically significant. Knee pain limited function at final follow-up in 24% of both cohorts. Conclusions PTFDs represent 4% of proximal tibia fractures. They are often unicondylar and may go unrecognized. Malunion is common, and PTFD outcomes may be worse than bicondylar fractures.

Introduction Ankle fractures are one of the most prevalent musculoskeletal injuries, with a significant number requiring surgical treatment. Postoperative complications requiring additional interventions frequently occur during the early postoperative period. We hypothesize that there is a limited need for routine clinical and radiographic follow-up once the fracture is deemed healed. Methods IRB approval was obtained at four academic trauma centers. A retrospective chart review was done to identify adults with healed unimalleolar and bimalleolar ankle fractures treated surgically with at least 12 months of follow-up. Based on postoperative radiographs, changes in fracture alignment and implant position from radiographic union to final follow-up were documented. The average reimbursement for a final follow-up clinic visit and a set of ankle radiographs were estimated. Results A total of 140 patients met inclusion criteria. The mean age at injury was 49.5 years, and 67.9% of patients were female. The mean time to healing was 82.2 days (±33.5 days). After radiographic healing, one patient had radiographic changes but was asymptomatic and full weight bearing at their final follow-up. On average, our institution was reimbursed $46 to $49 for a follow-up clinic visit and $364 to $497 for a set of ankle radiographs. Conclusion Given the average time to healing, there is limited utility in routine radiographic and clinical follow-up beyond 16 weeks in asymptomatic patients. In our series, this would result in a savings of $950 to $1,200 per patient. However, after ankle fractures were deemed healed, 0.7% patients had radiographic evidence of a change in implant position. Documenting this change did not modify the immediate course of fracture treatment. Surgeons will need to balance the need for routine follow-up with the potential economic benefits in reducing costs to the healthcare system.

Open reduction and internal fixation is the treatment of choice for intra-articular distal humerus fractures. The goal of treatment is to achieve an anatomic reduction with a fixation stable enough to allow for an early range of motion of the elbow. This chapter uses a clinical case to illustrate how to approach patients with this type of injury and highlights a few key elements for success in treating these fractures.

The treatment of osteoporotic fractures continues to challenge orthopedic surgeon. The fragility of the underlying bone in conjunction with the need for specific implants led to the development of explicit surgical techniques in order to minimize implant failure related complications, morbidity and mortality. From the patient's perspective, the existence of frailty, dementia and other medical related co-morbidities induce a complex situation necessitating high vigilance during the perioperative and post-operative period. This update reviews current principles and techniques essential to successful surgical treatment of these injuries.

OBJECTIVES To compare "Early Total Care" (ETC) with "Staged Protocol" (SP) for the treatment of Schatzker IV-VI tibial plateau fractures in patients older than 50 years regarding safety and effectiveness. DESIGN Retrospective cohort study. SETTING An academic level 1 US trauma center. PATIENTS/PARTICIPANTS Eighty-one patients older than 50 years with Schatzker grade IV-VI tibial plateau fractures were included. INTERVENTION Fifty-three patients were treated under SP with immediate external fixation followed by definitive internal fixation. Twenty-eight patients were treated under ETC with immediate internal fixation. MAIN OUTCOME MEASUREMENTS Comparison of perioperative findings, time to bony and clinical union, soft-tissue and bony complications, radiological outcome, and secondary procedures. RESULTS The 2 groups were comparable without significant difference regarding age, sex, side of involvement, body mass index, smoking status, American Society of Anesthesiologist classification, associated injuries, comorbidities, follow-up duration, and fracture classification. No statistically significant difference was found regarding the perioperative complications, quality of reduction, time to union, Rasmussen score at union or at the final follow-up, soft-tissue/bony complications, and the rate of the secondary procedures. CONCLUSION ETC seems to be a safe, efficacious, and effective alternative to the SP for the treatment of some Schatzker IV-VI fractures in patients older than 50 years. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Posterior wall acetabular fractures involving a large portion the wall's width and with extensive comminution are difficult fractures to manage operatively. Cortical substitution with a pelvic reconstruction plate and supplemental spring plates has been the traditional means of fixation for these fractures. This option, however, requires the use of multiple, unlinked plates and provides no reliable option for peripheral fixation in comminuted fragments. We describe a novel technique for operative fixation of large, comminuted posterior wall fractures using a single distal tibia pilon plate with the option for peripheral locking screw fixation and report on a series of 20 consecutive patients treated with this method.

Objective To compare the volar Henry and dorsal Thompson approaches with respect to outcomes and complications for proximal third radial shaft fractures. Design Multicenter retrospective cohort study. Patients/participants Patients with proximal third radial shaft fractures ± associated ulna fractures (OTA/AO 2R1 ± 2U1) treated operatively at 11 trauma centers were included. Intervention Patient demographics and injury, fracture, and surgical data were recorded. Final range of motion and complications of infection, neurologic injury, compartment syndrome, and malunion/nonunion were compared for volar versus dorsal approaches. Main outcome The main outcome was difference in complications between patients treated with volar versus dorsal approach. Results At an average follow-up of 292 days, 202 patients (range, 18-84 years) with proximal third radial shaft fractures were followed through union or nonunion. One hundred fifty-five patients were fixed via volar and 47 via dorsal approach. Patients treated via dorsal approach had fractures that were on average 16 mm more proximal than those approached volarly, which did not translate to more screw fixation proximal to the fracture. Complications occurred in 11% of volar and 21% of dorsal approaches with no statistical difference. Conclusions There was no statistical difference in complication rates between volar and dorsal approaches. Specifically, fixation to the level of the tuberosity is safely accomplished via the volar approach. This series demonstrates the safety of the volar Henry approach for proximal third radial shaft fractures. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

To analyze the outcomes of tibial shaft fractures treated with a lateral parapatellar approach in the semiextended position for intramedullary nail insertion.Prospective cohort study.Level I trauma center.Seventy patients treated from March 2012 to July 2015 with intramedullary nailing (IMN) using an extraarticular lateral parapatellar approach in the semiextended position were reviewed. Patients were clinically and radiographically checked at a minimum follow-up of 24 months, and the following data were recorded: fracture healing, any residual deformity, nail-apex distance, range of motion of the treated knee together with the contralateral side, knee functional outcome, and residual knee pain.Twenty-four months after surgery, all patients were clinically and radiographically healed, with 2 cases of malalignment (angular deformity10 degrees). The average range of motion of the treated knee was 0-130.6 degrees (±8.6 degrees) compared with 0-131.1 degree (±7.9 degrees) of the contralateral. Lysholm knee score was excellent for 57 patients, good for 11, and fair for 2. The mean residual pain was 0.6 (±1.1) according to the visual analogue scale.The described technique represents an effective option for IMN of tibial fractures. It is suitable for all tibial fractures, including proximal and distal. The results of our series demonstrate the effectiveness of this technique with nearly complete recovery of knee function and negligible incidence of anterior knee pain at a minimum follow-up of 24 months.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Ankle fractures are increasingly common in elderly patients given the number of aging individuals who remain active. The already difficult aspects of ankle fixation are amplified by the compromised soft-tissue envelope and bone quality present in elderly patients with an ankle fracture. In addition, elderly patients with an ankle fracture often have compromised neuroprotective mechanisms and are physically unable to follow postoperative protected weight-bearing protocols during ambulation. Surgeons should be aware of strategies to improve fixation and maintain the tibiotalar relationship during ambulation in elderly patients with an ankle fracture.

Introduction Care gaps have been identified in the treatment of osteoporosis after the occurrence of a fragility hip fracture. HiROC (High Risk Osteoporosis Clinic) is a fracture liaison service implemented at our institution. In ProvenCare geriatric hip fracture care program at our institution pre-set orders for the inpatient HiROC consults were prescribed. We hypothesized that there will be a significant increase in the rate of enrollment of patients in the HiROC program after the integration of the pre-set orders. Patients and methods The trauma database at a level-I trauma center was reviewed retrospectively for the charts of patients >50 years of age with fragility intertrochanteric fractures. Patients not treated under the geriatric hip fracture care program and patients treated under the geriatric hip fracture care program were identified and reviewed for the enrollment in HiROC and subsequent follow up. Results Out of 589 patients treated before the implementation of ProvenCare, 443 patients (75%) were enrolled in HiROC at the index consult. In comparison, out of 153 patients treated after the implementation of ProvenCare, 131 patients (85.6%) were enrolled in HiROC at the index consult. The difference between the two groups was statistically significant (p = 0.008). Conclusion Our experience shows that the occurrence of a fragility intertrochanteric fracture can be effectively utilized for the detection and initiation of treatment of osteoporosis. With the implementation of pre-set orders in the geriatric hip fracture care program significantly better enrollment can be achieved.

The purpose of this study was to evaluate the role and the necessity of radiographs and office visits obtained during follow-up of intertrochanteric hip injuries.Retrospective study.Two level I trauma centers.Four hundred sixty-five elderly patients who were surgically treated for an intertrochanteric fracture of the femur at 2 level I trauma centers between January 2009 and August 2014 were retrospectively identified from orthopaedic trauma databases.Analysis of all healed intertrochanteric hip fractures, including demographic characteristics, quality of reduction, time of healing, number of office visits, number of radiographs obtained, and each radiograph for fracture alignment, implant position or any pathological changes.The surgical fixation of 465 fractures included 155 short nails (33%), 232 long nails (50%), 69 sliding hip screw devices (15%), 7 trochanteric stabilizing plates (1.5%), and 2 proximal femur locking plates (0.5%). The average fracture healing time was 12.8 weeks and the average follow-up was 81.2 weeks. Radiographs of any patient obtained after the fracture had healed did not reveal any changes, including fracture alignment or implant position and hardware failure. In 9 patients, pathological changes, including arthritis (3), avascular necrosis (3), and ectopic ossification (3) were noted. The average number of elective office visits and radiographs obtained after the fracture had healed were 2.8 (range: 1-8) and 2.6 (range: 1-8), respectively. According to Medicare payments to the institution, these radiographs and office visits account for a direct cost of $360.81 and $192, respectively, per patient.The current study strongly suggests that there is a negligible role for radiographs and office visits during the follow-up of a well-healed hip fracture when there is documented evidence of radiographic and clinical healing with acceptable fracture alignment and implant position. Implementation of this simple measure will help in reducing the cost of care and inconvenience to elderly patients.Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background. The Trimed Medial Malleolar Sled is a newer device designed to treat medial malleolus fracture. The purpose of this study was to compare the outcome of medial malleolar fractures treated with the sled and conventional malleolar screws. Methods. After obtaining an institutional review board approval, we conducted a retrospective study to identify all skeletally mature patients who sustained an ankle fracture with medial malleolar involvement treated with the sled and we identified a matched cohort treated with conventional malleolar screws. The patients were divided into 2 groups: group A included patients treated with malleolar screws and group B included patients treated with the sled device. The outcomes measured included rate of union, implant removal, and pain over the implant site. Results. Eighty-five medial malleolar ankle fractures were divided into 2 groups: group A included patients (n = 64) treated with malleolar screws and group B included patients (n = 21) treated with the sled device. In group A (n = 64), 62 patients (96.8%) achieved radiological union with a mean union rate of 11 weeks and 10 (15%) patients underwent repeat surgery for implant removal of which 3 patients (4.6%) had pain specifically over the medial implant. In group B (n = 21), all of the patients (100%) achieved radiological union with a mean union rate of 10.8 weeks and 3 patients (14.2%) underwent repeat surgery of which 1 (4.7%) was related to the medial pain. There is no significant difference between the groups for the outcomes measured, including rate of union ( P = .93), visual analog scale score for pain ( P = .07), implant removal ( P = .41), and pain over the implant site ( P = .88). Conclusion. Based on the data from our study, we conclude that there are no major differences between the sled devices and conventional screws relating to union rate and complications. Levels of Evidence: Level III: Observational study

Successful results of osteoarticular allografts in reconstruction of periarticular bone defect after tumor resection encouraged its utilization in post-traumatic defects. Here we describe a case of post-traumatic skeletal defect in a 4 year-old girl treated with osteoarticular allograft reconstruction. Due to severity of the associated soft tissue injury and contamination at presentation staged treatment with antibiotic spacer followed by the reconstruction was carried out. At the end of one year the patient achieved 'Musculoskeletal tumor society' functional score of 27 points and radiographic score of 93%. Reconstruction immediately after healing of soft tissues prevented development of any varus or valgus deformity of the knee. Our case demonstrates utility of osteoarticular allograft in a pediatric post-traumatic skeletal defect.

Objectives The purpose of this study was to evaluate posterior malleolar injuries associated with nailed tibial fractures and to determine the quality of reduction based on the sequence of fixation in associated fracture patterns. Design Retrospective cohort study. Patients 1113 tibia fractures treated with an intramedullary nail at 3 level I trauma centers. Intervention Tibial shaft fractures with posterior malleolar injury were analyzed regarding type of fracture, mechanism of injury, energy of injury, fracture characteristic, surgical characteristics including sequence of fixation, obvious intraoperative displacement of the posterior malleolar fragment, and the quality of reduction. One group ("malleolus-first") consisted of patients in whom the posterior malleolus was fixed before tibial nailing and the other group ("tibia-first") included patients in whom tibial nailing was done before posterior malleolus fixation. Outcomes measured Intraoperative displacement, quality of reduction. Results Ninety-six of 1113 (9%) nailed tibial shaft fracture patients had a concomitant posterior malleolus fracture (9%). Of the 96 posterior malleolar fracture patients, 70 patients were operatively treated (73%). In the malleolus-first group (54 patients), intraoperative displacement of the posterior malleolar fragment was observed in 1 patient, and 1 case of poor reduction of the posterior malleolar fragment was observed (2%). In the tibia-first group (16 patients), obvious intraoperative displacement of the posterior malleolar fragment was observed in 5 patients (31%), and poor reduction of the posterior malleolar fragment was observed in 7 patients (44%). These percentages of patients with poor quality of reduction were statistically significantly different (p ≤ 0.01). Conclusion Many low-energy tibia fractures with a spiral configuration do have an associated posterior malleolus fracture. In order to avoid intraoperative displacement and poor reduction, we recommend fixation of the posterior malleolar fragment before nailing of the tibia in associated fracture pattern. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intramedullary devices are used increasingly to treat intertrochanteric femur fractures, especially those with unstable patterns. In spite of the considerable use of nails in the management of these fractures, opinions differ about the correct length of intramedullary nail. Long nails were developed to address the risk of diaphyseal fracture associated with earlier short nail designs and to extend the indications for use to include diaphyseal and subtrochanteric fractures. Several recent studies, however, have found no differences between modern short nails and long nails with regard to union and complication rates. In the absence of existing guidelines, the treating surgeon's preference and fracture characteristics continue to influence the decision of whether to use short nails or long nails. The surgeon needs to consider the fracture configuration and related factors, including whether osteoporosis is present and the cost and risk of revision surgery, when selecting the appropriate nail length.

Sonication is a new technology that uses high-frequency sound waves to mechanically dislodge bacteria adherent in biofilms. Unlike arthroplasty, its role in orthopaedic trauma has not been described. The goal of this study was to explore the utility of sonication in orthopaedic trauma.Retrospective review.Level I trauma center.One hundred forty-six sonicated metallic orthopaedic devices from September 2010 to May 2013 were included. Patients were divided into 3 groups: clinically infected, elective implant removals, and nonunion.Sonication culture results were retrospectively reviewed for all patients undergoing implant removal.Sonication results were the primary study outcome and were considered positive for culture growth if equal to or greater than 20 colony-forming units per plate.In 32 patients with clinical infection, tissue cultures were positive in 30 (94%) and negative in 2 (6%). In contrast, sonication cultures were positive in 19 patients (59%) and did not identify additional organisms. Of the 72 patients who underwent elective implant removal, 52 had pain. Sonication cultures were positive in 5 of these 52 patients (10%) and in 0 of 20 patients with no pain. Sonication culture results were negative in all 42 patients who underwent nonunion surgery.Sonication of orthopaedic trauma implants in patients with clinically apparent infection or "aseptic" nonunion offered negligible additional information. Sonication demonstrated a positive microbiologic yield in a subset of patients with painful implants; further research is required to better establish the frequency of subclinical infection and to determine the diagnostic role of traditional cultures and sonication.Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

On evaluation of the clinical indications of computed tomography (CT) scan of head in the patients with low-energy geriatric hip fractures, Maniar et al. identified physical evidence of head injury, new onset confusion, and Glasgow Coma Scale (GCS)15 as predictive risk factors for acute findings on CT scan. The goal of the present study was to validate these three criteria as predictive risk factors for a larger population in a wider geographical distribution.Patients ≥65 years of age with low-energy hip fractures from 6 trauma centers in a wide geographical distribution in the United States were included in this study. In addition to the relevant patient demographic findings, the above mentioned three criteria and acute findings on head CT scan were gathered as categorical variables.In total 799 patients from 6 centers were included in the study. There were 67 patients (8.3%) with positive acute findings on head CT scan. All of these patients (100%) had at least one criteria positive. There were 732 patients who had negative acute findings on head CT scan with 376 patients (51%) having at least one criteria positive and 356 patients (49%) having no criteria positive. Sensitivity of 100% and negative predictive value of 100% was observed to predict negative acute findings on head CT scan when all the three criteria were negative.With the observed 100% sensitivity and 100% negative predictive value, physical evidence of acute head injury, acute retrograde amnesia, and GCS15 can be recommended as a clinical decision guide for the selective use of head CT scans in geriatric patients with low energy hip fractures. All the patients with positive acute head CT findings can be predicted in the presence of at least one positive criterion. In addition, if these criteria are used as a pre-requisite to order the head CT, around 50% of the unnecessary head CT scans can be avoided.

Introduction: The United States has the highest population of inmates in the world (per capita and total). Musculoskeletal disorders are included within the 10 most frequent medical reports of prisoners; however, the literature about them is limited. The purpose of this study is to describe the epidemiology and complications of traumatic musculoskeletal injuries. To our knowledge, this is the first report of musculoskeletal trauma and complications in the prison population. Methods: A list of all traumatic orthopaedic injuries and complications, except for spine, was sent to the billing contractor of the Pennsylvania state prison system based on the Current Procedure Terminology, and it was queried over a 3-year period. Results: Five hundred seventy-six patients met the criteria. The hand and wrist was the most commonly injured region (65%), followed by foot and ankle (20%). Metacarpal fracture represented 22% of all injuries. A low complication rate was noted among all surgical procedures. Infection was seen in 1.15% of hand surgeries and in 2% of ankle surgeries. In addition, a low incidence of nonunion was recorded (1.5%). Nonsurgical management was the chosen method of treatment in 64% of all injuries. Conclusion: In this prison population with musculoskeletal injuries, upper extremity injuries and nonsurgical treatment are more prevalent and low energy injuries are more common. Contrary to popular belief, there is a trend toward low infection and complication rates after orthopaedic treatment. Further studies are necessary to best identify the patterns of injuries and the best way to treat inmates with orthopaedic injuries.

Osteoporosis poses many challenges for the management of fractures in a patient population commonly affected by multiple medical comorbidities such as diabetes, peripheral vascular disease, hypertension, and various inflammatory conditions, including malignancies (primary, metastatic, and secondary). These conditions, as well as some of their treatments, can exacerbate existing osteoporosis, further increasing the risk of fractures, and the likelihood of complications associated with their operative management. The design, development, and widespread use of locked plating systems have been critical components to addressing the stabilization of these fractures, which are often comminuted, with extensive involvement of the metaphysis, and commonly also have articular extension. These implant systems allow for decreased strain at the screw-bone interface, which has improved outcomes when used in metaphyseal fractures in osteoporotic bone. However, these systems also result in stiffer constructs, which can concentrate stress and increase the incidence of periprosthetic fractures. This discussion of the biology and biomechanics of osteoporosis, as it affects fracture healing and surgical implant selection, explains the rationale for methods of augmentation used in conjunction with commonly used surgical implant systems and provides clinical examples of their use in comminuted metaphyseal fractures in several anatomic locations in older patients with poor bone quality.

Basic science and experimental research on stem cells has increased exponentially in the last decade. Our present knowledge about stem cell biology is better than ever before. This new paradigm shift in research has been reflected in the field of orthopaedic surgery. Various experimental models have suggested a potential application of stem cells for different orthopaedic conditions, and early clinical results of stem cell use have been encouraging. These cells can be easily isolated, processed and made available for clinical use. From healing of bone defects caused by trauma, tumor or infection to cartilage defects, nerve, tendon and ligament healing, stem cell use has the potential to revolutionize orthopaedic practice. The purpose of this article is to orient a general orthopaedic surgeon towards the current use and clinical applications of stem cell based therapy in orthopaedics and to provide a complete overview of the clinical advances in this field.

Objective To define the role of head computed tomography (CT) scans in the geriatric population with isolated low-energy femur fractures and describe the pertinent clinical variables which are associated with positive CT findings with the objective to decrease the number of unnecessary CT scans performed. Design Retrospective review. Setting Level I trauma centre. Patients Eleven hundred ninety-two (1192) patients sustaining a femur fracture following a low-energy fall. Main outcome measurement Pertinent clinical variables that were associated with CTs that yielded positive findings. Results Two hundred fifty patients (21%) underwent a head CT scan as part of their evaluation. Of these patients, 83% suffered proximal femur fractures, 11% shaft fractures and 6% distal fractures. The majority of the patients were evaluated by the emergency department (ED) with only 18% (44/250) being evaluated by the trauma team. Average patient age was 83 years (range 65–99 years). One hundred seventy-three patients (69%) were on some form of antiplatelet medication or anticoagulation. Of the 250 patients who underwent head CT scan, 16 (6%) patients had acute findings (haemorrhage – 15, infarct – 1), and none of the patients required neurosurgical intervention. Conclusion None of the patients with a traumatic injury required a neurosurgical invention after sustaining a low energy fall (0/1192). Head CT scans should have a limited role in the work-up of this patient population and should be reserved for patients with a history and physical findings that support head trauma. Level of evidence: Prognostic level III. See instructions for authors for a complete description of levels of evidence.

To evaluate the healing rate, complications, role of reduction and screw placement, and the 1-year mortality in the treatment of reverse oblique and transverse intertrochanteric femoral fractures treated with the long cephalomedullary nail.Retrospective review.Two different Level-1 trauma centers: Geisinger Medical Center and the University of Utah.One hundred forty-eight patients with intertrochanteric fractures (AO/OTA class 31-A3) eligible for review. All patients had a minimum of 12 months of follow-up and were available for radiologic checks and assessment of outcomes and complications.Long cephalomedullary nail.Medical records were reviewed for reoperation, demographic parameters, length of hospital stay, estimated blood loss, and need for transfusion. Mortality rates at 1 month, 6 months, and 1 year were also recorded. Patients were followed clinically and radiographically at 6 weeks, 3 months, 6 months, 12 months, and yearly as needed.The average age of patients was 69.9 (range, 19-95) years. Average length of follow-up was 53 (range, 12-148) months. The average surgical time was 71.8 (range, 26-229) minutes. Twenty-four patients (16%) required blood transfusions, and the average transfusion required was 205.1 mL (range, 20-800). Five different long nail designs were used to treat the patients. One patient (0.6%) experienced an intraoperative complication. Eighteen patients (12%) sustained postoperative complications. Twelve (8%) patients required reoperations. One-year mortality rates were 10.1%.Long cephalomedullary nails remain the preferred treatment option for the treatment of 31-A3-type fractures, demonstrating acceptable complication rates, low reoperation rates, and high rates of healing.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Intramedullary implant has emerged as the workhorse in the management of intertrochanteric fracture, especially unstable intertrochanteric in recent times. A number of factors including fracture specific such as stable or unstable, integrity of greater trochanter, and lateral buttress, and patient s

A Lisfranc injury sustained by an adult male while playing football is the clinical case used to describe how to address patients in whom a Lisfranc injury is suspected. First a complete set of X-rays should be taken including but not limited to AP, oblique, and lateral views of the affected foot. Patients with subtle lesions could benefit from additional imaging to aid the diagnosis. Better clinical outcomes are obtained when patients with acute unstable Lisfranc injuries are treated with ORIF. Screws, plates, or interosseous sutures can be used for fixation and have comparable stability. Regardless of which implants are used, an anatomic reduction is the main determinant for achieving good results. Posttraumatic arthritis is the most common complication of Lisfranc injuries. Patients with pure ligamentous injuries do well with primary arthrodesis but, despite the lack of strong evidence, the use of interosseous sutures may be advantageous when treating these types of injuries, especially in athletes.

OBJECTIVES To determine whether a difference in plate position for fixation of acute, displaced, midshaft clavicle fractures would affect the rate of secondary intervention. DESIGN Retrospective Comparative Study. SETTING Two academic Level 1 Regional Trauma Centers. PATIENTS Five hundred ten patients treated surgically for an acutely displaced midshaft clavicle fracture between 2000 and 2013 were identified and reviewed retrospectively at a minimum of 24 months follow-up (F/U). Fractures were divided into 2 cohorts, according to plate position: Anterior-Inferior (AI) or Superior (S). Exclusion criteria included age

To document the complications among obese patients who underwent surgical fixation for intertrochanteric femur (IT) fractures and to compare with nonobese patients.Retrospective cohort study.Four level I trauma centers.1078 IT fracture patients.None.Patient and fracture characteristics, surgical duration, surgical delay intraoperative and postoperative complications, inpatient mortality, and length of stay.A retrospective review at 4 academic level I trauma centers was conducted to identify skeletally mature patients who underwent surgical fixation of intertrochanteric fractures between June 2008 and December 2014. Descriptive data, injury characteristics, OTA fracture classification, and associated medical comorbidities were documented. The outcomes measured included in-hospital complications, length of stay, rate of blood transfusion, change in hemoglobin levels, operative time, and wound infection.Of 1078 unique patients who were treated for an IT fracture, 257 patients had a Body mass index (BMI) of 30 or greater. Patients with a high BMI (≥30) had a significantly lower mean age (73 vs. 77 years, P0.0001), higher percentage of high-energy injuries (18% vs. 9%, P = 0.0004), greater mean duration of surgery (96 vs. 86 minutes, P = 0.02), and higher mean length of stay (6.5 vs. 5.9 days, P = 0.004). The high-BMI group (n = 257) had significantly higher percentages of patients with complications overall (43% vs. 28%, P0.0001), respiratory complications (11% vs. 3%, P0.0001), electrolyte abnormalities (4% vs. 2%, P = 0.01), and sepsis (4% vs. 1%, P = 0.002). Patients with BMI ≥ 40 had a much higher rate of respiratory complications (18%) and wound complications (5%) than obese (BMI: 30-39.9) and nonobese patients (BMI30).Intertrochanteric hip fracture patients with a BMI of30 kg/m are much more likely to sustain systemic complications including respiratory complications, electrolyte abnormalities, and sepsis. In addition, morbidly obese patients are more likely to sustain respiratory complications and wound infections than obese (BMI: 30-39.9 kg/m) and nonobese patients (BMI:30 kg/m). The findings from this study can help direct surgeons in the counseling to obese patients and their family, and perhaps increase hospital reimbursement for this group of patients.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Tibial shaft fractures distal to total knee arthroplasty are rare, but they are likely to become more common with the increasing number of arthroplasty procedures being performed. These fracture patterns have been treated in the past either with closed reduction and casting/bracing or with open reduction internal fixation using plates. Weight-bearing precautions in the elderly patient population can affect patient disposition, and weight bearing on extramedullary fixation can lead to early hardware failure. We present a series of nailing techniques that can be used for tibial fractures distal to a well-fixed total knee arthroplasty that avoids the tibial baseplate, provides stable fracture fixation, and allows for early weight bearing.

Surgical management of extra-articular distal tibia fractures has evolved because of the high rate of complications with conventional techniques and the technically challenging aspects of the surgery. Open reduction and internal fixation with plating or nailing remain the gold standards of treatment, and minimally invasive techniques have reduced wound complications and increased healing. Adequate reduction and stabilization as well as appropriate soft tissue management are imperative to achieving good outcomes in these fractures.

OBJECTIVES Orthopaedic journals, such as the Journal of Orthopaedic Trauma, frequently publish studies reporting functional outcome instruments, but little information has been provided regarding the validity and overall strength of these instruments. This study analyzes the trends in reported functional outcome instruments in articles published in the Journal of Orthopaedic Trauma over a 5-year period and examines the utilization rate, "overall" strength, and validity of these functional outcome instruments for the populations being studied. METHODS Articles that were published in the Journal of Orthopaedic Trauma from January 2006 to December 2010 were reviewed, and each article was assigned to 1 of 4 different categories, based on the subspecialty focus and body region. The total number of articles reporting the use of functional outcome instruments, articles with at least 1 functional outcome instrument found in the AO Handbook, and the total number of functional outcome instruments reported were recorded. Each functional outcome instrument was assigned to 1 of 3 categories (generic, nonvalidated, validated), and each validated instrument was also examined to determine whether the category of interest for which it was used was one in which it was previously validated in. RESULTS A total of 171 articles (34%) of the articles initially reviewed met the inclusion criteria. The average number of articles per year that reported functional outcome instruments was 56% (range, 47%-65%), and the average number of articles that reported at least 1 validated outcome instrument was 51% (range, 44%-61%). The average percentage of validated scores that were appropriately used within the category of interest was 23% (range, 13%-41%). CONCLUSIONS Even though the 56% utilization rate of functional outcome instruments in The Journal of Orthopaedic Trauma is much higher than other journals, it is still low given the importance of measuring and attaining excellent functional outcomes. It is clear that future effort should be given to validating outcome measures for correct evaluation of orthopaedic trauma patients.

There is broad recognition that the healthcare crisis in the United States is going to require a response and change in clinical practice. The management structure of Geisinger Health System is unique, and this has the potential to change the dynamics of surgeon-administration alignment.Our goal is to summarize and clarify the relationship between orthopaedic surgeons and the healthcare system at Geisinger, evaluate the positive and negative aspects, and consider which components may be reproducible.This overview arises from a review of management publications, discussions with orthopaedic attendings and administrators, and personal observations and comparison with my previous 15-year university-based practice.The Geisinger Health System has always been physician-run. The overall efficiency and pragmatic approach found at Geisinger relies heavily on changing surgeon behavior to match what is optimal for the system rather than the individual. This approach appears to bring greater stability and more consistent outcomes, but only by removing what some see as the art of medicine and at the loss of perceived provider autonomy. Despite the rigid demands placed on the surgeon, the system remains adaptable to change and appears to retain faculty at a high rate.The Geisinger System is unique in its ability to control an insurance plan, multiple hospitals, and a large physician group. Through clear protocols and behavioral pressure, it demands surgeon alignment with the system as a whole and in return provides a stable work environment. It is not ideal for all surgeons and it is unclear whether it can be reproduced in a less structured setting.

A 50-year-old gentleman presented with pain in his left tibia-fibula. He had sustained a closed segmental tibia-fibula fracture (Fig. 20.1a, b) following a motor vehicular accident one and a half years ago and had undergone open reduction and internal fixation with a reamed statically locked intramedullary nail for the tibia and plate osteosynthesis for the fibula. On presentation, he complained of 8/10 pain in the lower third tibia and anteriorly at the site of the distal interlocks that was aggravated with weight bearing. He also complained of frequent cramps in his left calf. He denied fever, chills or drainage from left lower extremity. He was nondiabetic, nonsmoker, and denied any other significant past medical or surgical illnesses. A focused clinical examination of the left lower extremity documented 10° diminished knee flexion and ankle dorsiflexion. He had multiple surgical scars that had healed with primary intention with no draining sinus or soft tissue compromise. The overlying skin seemed supple without any adhesions to the underneath structures. He had tenderness anteriorly over the fracture site and over the distal interlocking screws. He had normal capillary refill bilaterally with no motor or sensory deficits in his left lower extremity.