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STUDY DESIGN Case-control study. OBJECTIVE To analyze patient complaints, potential risk and malpractice events involving orthopaedic spine surgeons over a 10-year period. SUMMARY OF BACKGROUND DATA Unsolicited patient complaints may be associated with risk management and malpractice events. METHODS We analyzed patient complaint, potential risk event and malpractice event data for 6 orthopaedic spine surgeons over a 10-year period. Patient complaints were analyzed and classified according to the Patient Complaint Analysis System (PCAS). Baseline demographics were recorded for patients with complaints as well as the surgeons. A control group consisting of all patients seen by the 6 surgeons during the study period was created to identify patient and physician risk factors for formal patient complaints. Event rates (for complaints, risk and malpractice events) were calculated by dividing the number of events by the total number of unique patients seen. RESULTS There were 214 complaint designations among 202 patients with formal complaints, resulting in a complaint rate of 0.79%. Patients were most likely to complain about Access and Availability (35%) followed by Care and Treatment (32%). Of the 68 complaints regarding care and treatment, 34 were related to dissatisfaction with surgical outcome. Complications were identified in 26 / 34 cases. The malpractice event rate ranged from 0.06%-0.65%. Patients who had surgery (P

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.

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.

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

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.

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.

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.

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

Background: Glucocorticoids, the recommended first line treatment of steroid sensitive nephrotic syndrome (SSNS), are notorious for causing osteoporosis. There are very few studies from tropical countries looking at the lasting effects of a short course of glucocorticoids in SSNS. The objective is to study the effect of glucocorticoids and its dose on Vitamin D levels and biochemical markers of calcium metabolism in children with SSNS and to formulate a criterion to administer prophylactic calcium and vitamin D supplementation to such patients.Methods: A cross-sectional case-control study was conducted on 30 children with SSNS in remission and 30 healthy controls. Serum levels of 25 hydroxycholecalciferol [25(OH)D], calcium, phosphorous, albumin, alkaline phosphatase (ALP) and intact parathyroid (PTH) were measured. Total glucocorticoid exposure during the illness was summarized.Results: Children with SSNS had significantly lower height [median-100.00 (interquartile range {IQR}- 14.5) vs. controls [115.50 (17.5)] cm; P= 0.0003. Serum ALP levels was significantly higher in the cases [median 264 (IQR-80.7)] IU/L vs. controls [median 234 (IQR- 132)] IU/L; P= 0.028. Though hypovitaminosis D was universal in the study cohort; children with SSNS had worse Vitamin D status (76.7%) than healthy controls (50%). Levels of serum calcium, phosphorous, vitamin D and PTH were not significantly different between the two groups, nor were they related to total cumulative dose of steroid. Vitamin D levels showed no significant co-relation with number of relapses, age, calcium, phosphate, ALP, or PTH levels.Conclusions: Children with SSNS may benefit from routine measurement of 25 (OH) D and prophylactic supplementation with calcium and Vitamin D.

BACKGROUND Orthopaedic surgeons are at a high risk of sustaining a percutaneous or mucocutaneous exposure to blood and body fluids. The Center for Disease Control and Prevention recommends a wash with soap and water and notification of the concerned hospital authorities after any percutaneous/mucocutaneous exposure, but a systematic amenability with these guidelines is not always seen. This cross-sectional study was undertaken to determine current knowledge and practices of orthopaedic surgeons in case of a percutaneous sharp injury exposure, emphasizes the immediate first aid steps taken after an exposure, the degree of reporting, and to explore the reasons for noncompliance. Finally, we sought to create awareness about the prevailing Center for Disease Control and Prevention guidelines after any exposure to blood or body fluids. MATERIALS AND METHODS We conducted a cross-sectional survey using an anonymous prepared questionnaire. The study population included exclusively orthopaedic surgeons, including residents, fellows, and attending physicians at 4 US institutions. The questionnaire was also available online on the OTA Web site as a part of survey monkey. The questionnaire comprised 9 multiple choice questions, and more than 1 response could be given for some questions. The questions addressed previous needle stick/sharp injury exposure, number of times that had happened, whether reported to the hospital administration, reason for nonreporting, and risk perception for transmission of blood-borne pathogens (human immunodeficiency virus, HBsAg, and hepatitis C virus). The questions were also asked based on what should be done in four different clinical settings based on respondents risk perception. RESULTS Of fifty eight attendings, 7 fellows, 45 residents, and 7 respondents who did not indicate their position participated in the survey for a total of 117 respondents. Out of 99, 24 had sustained it once, 18 twice, 11 three times, and 35 at least 4 times. When questioned about informing the incident to the hospital administration, 38% had always reported the incident, 33% had never reported the incident, and the remaining 29% had not reported it every time. Of note, 87% gave the correct response about the risk of transmission of human immunodeficiency virus after an exposure. On questioning about the risk of hepatitis B transmission, from an HBsAg- and HBeAg-positive source, 13% gave the correct response, whereas from HBsAg-positive and HBeAg-negative source, 30% gave the correct response. Regarding transmission of hepatitis C virus from a positive source, 36% responded correctly. The surgeons seemingly attempted to risk stratify their exposure, and they were more likely to report their exposure in the higher risk scenarios. CONCLUSIONS This study demonstrates that orthopaedic surgeons of all levels of training are at high risk of occupational exposure to blood-borne pathogens. Moreover, despite the level of training, the majority of surgeons do not follow the recommended steps, although we do not know the reasons for such behavior. Also, there is a low awareness of the significant risk of hepatitis transmission among orthopaedic surgeons treating a population with a high prevalence of undiagnosed hepatitis.

Brown-Séquard's syndrome (BSS) is caused by hemisection or hemicompression of the cord leading to ipsilateral motor deficit and contralateral sensory loss. Cervical disc herniation has been reported to be a rare cause of Brown-Séquard's syndrome. We describe a rare case of multilevel cervical disc herniation presenting as BSS. The condition was confirmed by MRI scan. Cervical corpectomy, decompression, and fusion gave a satisfying result. Pertinent literature has been reviewed.