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Arthroplasty has become the standard of care for displaced femoral neck fractures in the geriatric cohort. However, details regarding optimal implant design and fixation strategy continue to be debated. We sought to determine whether cemented or press-fit hemiarthroplasties were more advantageous in terms of revision surgery, contralateral hip fractures, hospital length of stay, mortality rates, and survival.All geriatric fragility hip fractures at a level 1 trauma center (2014 to 2019) were retrospectively reviewed for the fracture pattern, fixation methodology, and outcome, yielding 707 femoral neck fractures treated with hemiarthroplasty (309 cemented and 398 press fit). The final follow-up was either date of death or final encounter. Major end points were revision surgery, contralateral fracture, and death. A Z-score test of two proportions was used for dichotomous variables, and a two-tailed t -test was used for continuous variables. Cox proportional hazard was used for revision surgery-free survival between groups, adjusting for age, sex, and American Society of Anesthesiologists status.Patients who underwent press-fit hemiarthroplasty had a significantly higher rate of revision surgery (7.8% vs 3.9%; P = 0.006). Press-fit cases had a trend toward a decreased risk of contralateral fracture (13% vs 9.8%; P = 0.12), although this did not reach significance. Both groups had similar length of stay ( P = 0.08) and death rates ( P = 0.39). Of those who died, there was a trend toward longer survival in patients who received a press-fit hemiarthroplasty (413 vs 615 days; P0.001). There was a trend toward longer survival without repeat surgery in the cemented group without reaching significance (hazard ratio, 0.66 [0.34 to 1.23]; P = 0.201).In this study, we found a markedly longer survival time after press-fit hemiarthroplasty, which we believe reflects surgeons' tendencies to cement the femoral prosthesis in patients with more comorbidities. However, press-fit hemiarthroplasties were more likely to result in repeat procedures on the same hip. Displaced geriatric femoral neck fractures may benefit from a cemented rather than press-fit hemiarthroplasty.

Objectives To establish the reliability of two radiographic union scoring systems for non-operative humeral shaft fractures. Design Retrospective medical record review. Patients identified had humeral shaft fractures and radiographs at various follow-up time points which were graded according to the both the standard (RUST) and modified radiographic union scoring systems (mRUST). Setting A single North American Level-1 Trauma center in Connecticut, including emergency department and clinic follow-up visitsPatients/Participants: 45 adult patients (162 image sets) met the following inclusion criteria: diaphyseal humerus fracture, initial non-operative management, and greater than 2 weeks of follow-up with imaging. Intervention All 162 image sets of AP and lateral radiographs were scored and divided into four tiers based on increasing score. AP and lateral image sets were randomly selected from each tier for a total of 50 that were then scored by 7 different reviewers using both the RUST and mRUST systems. Main outcome measurements The Intraclass correlation coefficients for the cortical and system scores for the RUST and mRUST systems. Results Interobserver reliability was 0.795 for the RUST system and 0.801 for mRUST. Intra-observer reliability of 0.909 for RUST and 0.949 for mRUST. For mRUST, 92% of values were within +/- 1 point from each other. Conclusions The RUST and mRUST systems can be applied to humeral shaft fractures with excellent reliability. They have the potential to assist in the diagnosis of humeral shaft union by providing an objective and standardized method to assess healing of bone over time. Level of evidence III, Diagnostic Study.

Introduction Pronation abduction (PA) ankle fractures are often associated with a medial tension failure wound. Though this injury pattern was defined based on the mechanism of injury, there is a paucity of literature evaluating risk factors for understanding which patients will sustain an open PA fracture. Furthermore, how patients with these types of fractures perform relative to other open ankle fractures has not been established. We hypothesized that open PA fractures are associated with obesity and increased number of reoperations. Methods All patients at a single level one trauma center who received operative treatment for an ankle fracture between February 2012 to January 2019 were retrospectively identified using Current Procedural Terminology (CPT) codes. Patients with open PA ankle fractures were identified. Demographic data, body mass index, medical comorbidities, time to surgery, and reoperations were compared between open PA ankle fractures and other open ankle fracture subtypes. Results There were 22 open PA ankle fractures and 35 other open ankle fracture subtypes. The open PA fracture group had a significantly higher median and average BMI and percentage of patients with obesity. There was no difference in number of patients requiring reoperation between the two groups. When reoperation was required, patients with open PA ankle fractures were found to undergo significantly more reoperations and were significantly more likely to require arthrodesis or below knee amputation. Conclusions Open PA ankle fractures are more often associated with obesity (BMI > 30 kg/m2) than are other open ankle fractures caused by a different mechanism. When reoperation does occur, patients with open PA ankle fractures require more reoperations and are more likely to require arthrodesis or below knee amputation that patients with other open ankle fracture subtypes. Early identification of those patients or injuries at increased risk of complications can help ensure optimal outcomes.

INTRODUCTION: The coronavirus 2019 (COVID-19) pandemic disease has imposed an unprecedented degree of stress on healthcare systems. This study aimed to understand whether COVID-19 positivity is associated with an increased risk of adverse outcomes after geriatric hip fracture surgery. METHODS: From a national administrative claims data set, patients who underwent hip fracture surgery from April 1, 2020, to December 1, 2020 were selected for analysis. COVID-19-positive status was assessed by the emergency International Classification of Diagnoses, 10th Revision, COVID-19 code within 2 weeks before the surgery. Demographic, comorbidity, and 30-day postoperative adverse event information were extracted. Logistic regression before and after 10:1 propensity matching was performed to identify patient risk factors associated with the occurrence of postoperative adverse events. RESULTS: Of 42,002 patients who underwent hip fracture surgery, 678 (1.61%) were identified to be positive for COVID-19 infection. No significant differences in age, sex, and procedure type were found between COVID-19-positive and COVID-19-negative groups, but the COVID-19-positive patients demonstrated a higher incidence of several comorbidities. These differences were no longer significant after matching. After matching, the COVID-19-positive group had a higher incidence of any, serious, and minor adverse events (P < 0.001 for all). Controlling for preoperative variables, COVID-19 positivity was associated with an increased risk of experiencing any adverse events (odds ratio [OR] = 1.62, 95% confidence interval [95% CI] = [1.37 to 1.92], P < 0.001), serious adverse events (OR = 1.66, 95% CI = [1.31 to 2.07], P < 0.001), and minor adverse events (OR = 1.59, 95% CI = [1.34 to 1.89], P < 0.001). DISCUSSION: After matching and controlling for confounding variables, COVID-19-positive hip fracture patients had increased odds of multiple postoperative events. Clinicians caring for this vulnerable geriatric population should be mindful of this risk to improve the care for these patients during the ongoing global pandemic.

Case A 58-year-old man presented with entrapment of the flexor hallucis longus (FHL) tendon between fractured fragments of the talar body. The patient was successfully treated with atypical operative approaches to release the tendon and reduce the fracture. At the 1-year follow-up, the patient remained asymptomatic with the ability to extend and flex of all toes. This case illustrates a unique surgical approach for this presentation. Conclusions With proper utilization of positioning and fluoroscopy, posterior talar body fractures with entrapment of the FHL can be stabilized and corrected with dual use of medial-sided approaches.

Osteogenesis imperfecta is a genetic disease resulting in abnormal collagen formation, with multiple clinical manifestations. Advancements in medical and surgical treatments have prolonged the life expectancy of these patients in recent decades. As a result, orthopedic surgeons are likely to be faced with the challenge of performing arthroplasty in these patients on a more frequent basis. Here, we describe a patient with osteogenesis imperfecta and subsequent severe osteoarthritis prompting primary total knee arthroplasty. This rare case presents an opportunity to explore special considerations unique to this patient population, including comorbid bone defects, the need for using extramedullary guides, careful alignment of prostheses to accommodate abnormalities in limb axes, and equipment utilization. Keywords: Osteogenesis imperfecta, Total knee arthroplasty

Advancements in medical and radiation oncology have improved the prognosis for many cancers during the past few decades. As a result, physicians are challenged with managing a greater burden of disease for a longer time. In orthopaedics, bone loss secondary to metastatic tumor places patients at risk of impending and pathologic fractures. These events limit functional independence, lessen the quality of life, and place a financial burden on patients and their families. Thus, it is important for clinicians to be aware of measures capable of mitigating cancer-induced bone loss.

Advances in the surgical approach to thoracic aortic aneurysm repairs have led to the increasing use of one-lung ventilation. Today’s practice of cardiothoracic and vascular anesthesia requires a clear understanding of the techniques available for lung separation and the technical skills necessary to employ them. In this article, we discuss and evaluate the options for one-lung ventilation in thoracic aortic aneurysm repair with regard to preoperative, intraoperative, and postoperative management.

Objective: To develop queuing and simulation-based models to understand the relationship between ICU bed availability and operating room schedule to maximize the use of critical care resources and minimize case cancellation while providing equity to patients and surgeons. Design: Retrospective analysis of 6-month unit admission data from a cohort of cardiothoracic surgical patients, to create queuing and simulation-based models of ICU bed flow. Three different admission policies (current admission policy, shortest-processing-time policy, and a dynamic policy) were then analyzed using simulation models, representing 10 yr worth of potential admissions. Important output data consisted of the “average waiting time,” a proxy for unit efficiency, and the “maximum waiting time,” a surrogate for patient equity. Setting: A cardiothoracic surgical ICU in a tertiary center in New York, NY. Patients: Six hundred thirty consecutive cardiothoracic surgical patients admitted to the cardiothoracic surgical ICU. Interventions: None. Measurements and Main Results: Although the shortest-processingtime admission policy performs best in terms of unit efficiency (0.4612 days), it did so at expense of patient equity prolonging surgical waiting time by as much as 21 days. The current policy gives the greatest equity but causes inefficiency in unit bed-flow (0.5033 days). The dynamic policy performs at a level (0.4997 days) 8.3% below that of the shortest-processing-time in average waiting time; however, it balances this with greater patient equity (maximum waiting time could be shortened by 4 days compared to the current policy). Conclusions: Queuing theory and computer simulation can be used to model case flow through a cardiothoracic operating room and ICU. A dynamic admission policy that looks at current waiting time and expected ICU length of stay allows for increased equity between patients with only minimum losses of efficiency. This dynamic admission policy would seem to be a superior in maximizing case-flow. These results may be generalized to other surgical ICUs. (Crit Care Med 2013; 41:414–422)

Patients in the cardiothoracic intensive care unit (CTICU) are subject to numerous physical and mental stresses. While most of these cannot be completely eliminated, intensivists have many tools in their armamentarium to alleviate patients' pain and suffering. This chapter will consider the importance of analgesia and sedation in the CTICU and the relevant consequences of over- or under-treatment. We will examine the tools available for monitoring and titrating analgesia and sedation in critically ill patients. The major classes of medications available will be reviewed, with particular attention to their clinical effects, metabolism and excretion, and hemodynamic characteristics. Lastly, experimental evidence will be assessed regarding the best strategies for treatment of pain and agitation in the CTICU, including use of non-pharmacologic adjuvants.

Fibrous dysplasia is proliferation of fibrous tissue within the bone marrow causing osteolytic lesions and pathologic fractures. Recently, second generation bisphosphonates have shown promise in the treatment of patients with fibrous dysplasia. In the current study, six patients with fibrous dysplasia were treated with either oral alone or oral and intravenous bisphosphonates. The participants were observed for changes in N-telopeptide, pain score, and radiographic changes. In the current study, the combination bisphosphonate therapy diminished pain, prevented fractures, lowered N-telopeptide values, and led to partial resolution of fibrous dysplasia lesions.