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Hip hemiarthroplasty is a commonly performed orthopedic surgery, used to treat proximal femur fractures in the elderly population. Although hip hemiarthroplasty is frequently successful in addressing these injuries, complications can occur. Commonly seen complications include dislocation, periprosthetic fracture, acetabular erosion, and leg-length inequality. Less frequently seen complications include neurovascular injury and capsular interposition. This article presents a comprehensive review of the complications associated with the management of hip hemiarthroplasty. [ Orthopedics . 202x;4x(x):xx–xx.]

Background Intramedullary nail (IMN) fixation of the fibula in malleolar ankle fractures has been shown to result in less wound complications then plate fixation. Therefore, IMN fibula fixation may also be associated with lower rates of wound complications when used for higher-risk pilon fractures. The purpose of this study was to compare complications of fibula IMN fixation in pilon versus malleolar ankle fractures. Methods A retrospective cohort comparison was performed at an urban level one trauma center involving fibula fractures in 47 patients with AO/Orthopaedic Trauma Association (OTA) type 43 fractures and 48 patients with AO/OTA type 44 fractures being treated with fibula IMN fixation. Complications, fibula-specific complications, revision surgeries, and implant removals were reviewed. Results There was no detectable difference in complications (27% vs. 23%, 95% confidence interval of the odds ratio (CIOR) 0.5 to 3.2), fibular-specific complications (6% vs. 10%, CIOR 0.1 to 3.5), revision surgeries (4% vs. 4%, CIOR 0.1 to 7.5), or symptomatic fibula implant removals (13% vs. 21%, CIOR 0.1 to 1.6) between pilon and ankle fracture groups, respectively. There was one (2%) fibular nonunion and one wound complication (2%) in each of the fracture groups. Conclusion Fibula IMN fixation of pilon versus ankle fractures resulted in a similar number of complications. Comparative studies of fibula IMN and plate fixation are necessary to determine if the benefits of fibula IMN in ankle fractures extends to pilon fractures. Level of evidence Level III, retrospective cohort.

The purpose of this study was to determine if varus displacement of intertrochanteric femur fractures on injury radiographs is associated with screw cutout after fixation. A retrospective review performed at two urban level 1 trauma centers identified 334 patients with intertrochanteric femur fractures treated with either a cephalomedullary nail (CMN) or a sliding hip screw (SHS). Median patient age was 75 years, 69% were female and 46% had unstable fractures. Varus fracture displacement on injury radiographs, defined as the most proximal aspect of the femoral head being at or below the most proximal aspect of the greater trochanter, was present in 38% of patients. Screw cutout was recorded. Varus displacement was associated with unstable fracture patterns (62% vs. 37%, difference (D) 25%, 95% confidence interval (CI) 15–35%), female gender (77% vs. 64%, D 13%, CI 3–22%) and poor/adequate reductions (54% vs. 41%, D 13%, CI 2–23%). Cutout occurred in 9 (3%) patients, 8 of which had varus displacement. There was no detectable difference, with wide confidence intervals, between patients that did and did not experience cutout in terms of age, gender, unstable fractures, implants, tip-apex distance (TAD) or poor/adequate reductions. On univariate and multivariate analysis, varus displacement was the only variable associated with cutout. Patients with and without varus displacement had a cutout incidence of 6 and 0.5% (Odds ratio 13, CI 1.6–108). Intertrochanteric fractures presenting with varus displacement were more likely to experience cutout. This potential risk factor for cutout warrants further study. Level 3, retrospective cohort.

Background The majority of clavicle fractures are midshaft injuries, although fractures of the distal or medial fragment also occur. The aim of this study was to review the current evidence on these injuries to help inform future treatment plans. Methods We searched for studies comparing interventions for medial, midshaft, or distal clavicle fractures; however, we did not identify any comparative studies on medial fractures and performed a secondary search on this topic. We conducted Bayesian network meta-analyses, although this was not feasible with studies on medial fractures and we described their results qualitatively. Results For midshaft fractures, we found statistically significant improvements in function and time to radiographic union with plating, an elastic stable intramedullary nail (ESIN), and the Sonoma CRx intramedullary nail over nonoperative treatments. Both plating and an ESIN also showed significantly lower risks of nonunion and malunion relative to nonoperative methods. For distal fractures, a locking plate (LP) with or without coracoclavicular (CC) suturing yielded significantly better outcomes over K-wires with or without tension bands, CC suturing alone, an LP with a CC screw, a hook plate, and a sling. For medial fractures, plating may result in more favorable functional and union-related outcomes, although implant irritation may occur. In addition, K-wires, tension bands, and a screw with sutures demonstrated success when plating was technically not feasible in a few cases, whereas treatment with a sling may result in reduced function and a higher risk of complications relative to surgery. Conclusion This study can provide guidance on the management of medial, midshaft, and distal clavicle fractures. The current evidence suggests that plating, an ESIN, and a CRx intramedullary nail are all good options for midshaft fractures; an LP with or without CC suturing should be preferred for distal fractures; and plating is also acceptable for medial fractures, provided that the patient is deemed suitable for surgery and has the adequate bone stock and sufficiently sized medial fragment necessary to implant the device. Patient preferences for certain outcomes should be considered, which may result in different treatment recommendations.

Objectives To compare cell salvage (CS) volume, intraoperative blood loss, intraoperative blood transfusions, and operative time for acetabular fractures undergoing early (≤48 hours from admission) versus delayed fixation (>48 hours from admission). Design Retrospective. Setting Level one trauma center. Patients One hundred thirty-one patients with unilateral acetabular fractures involving at least one column. Intervention Open reduction and internal fixation performed through the anterior intrapelvic approach or posterior approach. Main outcome measurements CS volume, estimated blood loss (EBL), intravenous fluids (IVFs), intraoperative packed red blood cells (PRBCs), and operative time. Results Early versus delayed fixation through the posterior approach was associated with shorter operative times and less intraoperative PRBCs (140 vs. 301 mL, MD -161 mL, 95% confidence interval -25 to -296 mL) with no differences in CS, EBL, or IVF. Early versus delayed fixation through an anterior intrapelvic approach was more common in less severe fracture patterns with no differences in PRBCs, CS, EBL, or IVF. CS, through either approach, was successful in returning blood to 77% of patients for an average of 267 ± 168 mL (range, 105-900 mL). Conclusions Fixation of acetabular fractures within 48 hours of admission did not increase blood loss or intraoperative transfusions. CS was successful in returning an average of one unit of blood to a majority of patients. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objective:Needlestick and sharps injury (NSSI) is a common occupational hazard of orthopedic surgery training. The purpose of this study was to examine the incidence and surrounding circumstances of intraoperative NSSI in orthopedic surgery residents and fellows and to examine postexposure reporting.Design:A 35-question cross-sectional survey.Setting:The study was conducted by orthopedic surgery residents and faculty at a nonprofit regional hospital.Participants:The questionnaire was distributed to US allopathic orthopedic surgery residency and fellowship programs; 300 orthopedic surgery trainees participated in the survey.Results:Of 223 trainees who had completed at least 1 year of residency, 172 (77.1%) sustained an NSSI during residency, and 57 of 63 trainees (90.5%) who had completed at least 4 years sustained an NSSI during residency. The most common causes of NSSI were solid needles, followed by solid pins or wires. The surgical activity most associated with NSSI was wound closure, followed by fracture fixation. The type of surgery most frequently associated with NSSI was orthopedic trauma, followed by hip and knee arthroplasty. Of 177 trainees who had sustained a prior NSSI, 99 (55.9%) failed to report all events to their institution’s occupational health department.Conclusions:The incidence of NSSI during residency training is high, with >90% of trainees in their fifth year or later of training having received an injury during their training, with a mean of >4 separate events. Most trainees with an NSSI did not report all of their events, which implies that changes are needed in the incident reporting process universally.

Injuries to the critical structures underlying the clavicle are possible during open reduction and internal fixation (ORIF) and afterward secondary to prominent screws. The purpose of this study was to identify patients who received chest computerized tomography (CT) scans after clavicle ORIF to evaluate the distance between the screws and the subclavian vessels. A retrospective review was performed at a single level-one trauma center. Nineteen patients with chest CT scans after superior plate fixation were included. Coronal CT reconstructions were analyzed to determine distances between the subclavian vessels and screw tips along with the prominence of the screws. Vessels within 15 mm of the screw were considered at risk. None of the screws (0/142) were within 15 mm of the subclavian vessels. Average screw prominence was 1.3 ± 1 mm (range, 0–3.6 mm). One of the 19 patients had a complication, a re-fracture requiring revision ORIF. The remaining 18 patients had no complications, including neurovascular or pulmonary, at the last follow-up. None of the screws were excessively prominent or within 15 mm of the subclavian vessels. Attentive superior plate fixation of the clavicle with screws is a safe technique. Level IV, case series.

Bone grafts are the second most common tissue transplanted in the United States, and they are an essential treatment tool in the field of acute and reconstructive traumatic orthopaedic surgery. Available in cancellous, cortical, or bone marrow aspirate form, autogenous bone graft is regarded as the gold standard in the treatment of posttraumatic conditions such as fracture, delayed union, and nonunion. However, drawbacks including donor-site morbidity and limited quantity of graft available for harvest make autograft a less-than-ideal option for certain patient populations. Advancements in allograft and bone graft substitutes in the past decade have created viable alternatives that circumvent some of the weak points of autografts. Allograft is a favorable alternative for its convenience, abundance, and lack of procurement-related patient morbidity. Options include structural, particulate, and demineralized bone matrix form. Commonly used bone graft substitutes include calcium phosphate and calcium sulfate synthetics-these grafts provide their own benefits in structural support and availability. In addition, different growth factors including bone morphogenic proteins can augment the healing process of bony defects treated with grafts. Autograft, allograft, and bone graft substitutes all possess their own varying degrees of osteogenic, osteoconductive, and osteoinductive properties that make them better suited for different procedures. It is the purpose of this review to characterize these properties and present clinical evidence supporting their indications for use in the hopes of better elucidating treatment options for patients requiring bone grafting in an orthopaedic trauma setting.

Background The standard proximal interlocking screw (SS) configuration for antegrade intramedullary nail (IMN) fixation of femoral shaft fractures is lateral to medial or from the greater to less trochanter. Some authors argue for the routine use of the reconstruction screw (RS) configuration (oriented up the femoral neck) instead to prevent femoral neck complications. The purpose of this study was to compare a matched cohort of patients receiving these screw configurations and subsequent complications. Methods A retrospective review of two urban level-one trauma centers identified adults with isolated femoral shaft fractures undergoing antegrade IMN. Patients with RS and SS configurations were matched 1:1 by age, sex, fracture location, and AO classification in order to compare complications. Results 130 patients with femoral shaft fractures were identified. SS and RS configurations were used in 83 (64%) and 47 (36%) patients. 30 patients from each group were able to be matched for analysis. The RS and SS group did not differ in age, fracture location, AO classification, operative time, or number of distal interlocking screws. The RS group had fewer open fractures and were more likely to have two proximal screws. There were 7 complications, including 5 nonunions and 2 delayed unions, with no detectable difference between RS vs. SS groups (10% vs 13%, Proportional difference −3%, 95% confidence interval (CI) −30 to 14%, p = 0.1). There were no femoral neck complications in the entire cohort of 130 patients. On multivariate analysis none of the variables analyzed were independently associated with the development of complications. Conclusions In this matched cohort of patients with femoral shaft fractures undergoing antegrade IMN fixation, RS and SS configurations were associated with a similar number of complications and no femoral neck complications. The SS configuration remains the standard for antegrade IMN femoral shaft fixation. Level of evidence Level III, Retrospective cohort study.

BACKGROUND: Suprapatellar nailing of tibial fractures has not been shown to affect short-term knee outcomes, however long-term outcomes are unknown. The purpose of this study was to report long-term patient-reported knee outcomes after suprapatellar nailing. METHODS: Thirty-five adult patients with 37 tibial shaft fractures treated with suprapatellar nailing completed the Tegner-Lysholm Knee Score (TLKS) at an average of 5 years (range, 4–9 years) follow-up. RESULTS: The median TLKS was 98 (interquartile range, 85–100): Scores were considered excellent in 24 (68%), good in 3 (9%), fair in 3 (9%), and poor in 5 (14%). Based on patient responses, 28 (80%) patients did not have a limp, 32 (91%) ambulated without assistance, 22 (63%) were pain free, 29 (83%) had no knee instability, 30 (86%) endorsed no catching or locking, 27 (77%) could climb stairs with no issue, and 24 (69%) had no problems with squatting. Patients with poor/fair outcomes on the TLKS were more likely to have had a complication [3 (38%) vs. 1 (4%), difference 34%, 95% confidence interval 1–65%] and had no detectable difference in age, gender, open fracture, fracture classification, or worker’s compensation. CONCLUSION: At long-term follow-up a majority of patients undergoing suprapatellar nailing had good/excellent knee outcomes. Poor/fair knee outcomes were associated with the development of complications. LEVEL OF EVIDENCE: III, Retrospective cohort study.

The purpose of this study was to determine if varus displacement of intertrochanteric femur fractures on injury radiographs is associated with screw cutout after fixation.A retrospective review performed at two urban level 1 trauma centers identified 334 patients with intertrochanteric femur fractures treated with either a cephalomedullary nail (CMN) or a sliding hip screw (SHS). Median patient age was 75 years, 69% were female and 46% had unstable fractures. Varus fracture displacement on injury radiographs, defined as the most proximal aspect of the femoral head being at or below the most proximal aspect of the greater trochanter, was present in 38% of patients. Screw cutout was recorded.Varus displacement was associated with unstable fracture patterns (62% vs. 37%, difference (D) 25%, 95% confidence interval (CI) 15-35%), female gender (77% vs. 64%, D 13%, CI 3-22%) and poor/adequate reductions (54% vs. 41%, D 13%, CI 2-23%). Cutout occurred in 9 (3%) patients, 8 of which had varus displacement. There was no detectable difference, with wide confidence intervals, between patients that did and did not experience cutout in terms of age, gender, unstable fractures, implants, tip-apex distance (TAD) or poor/adequate reductions. On univariate and multivariate analysis, varus displacement was the only variable associated with cutout. Patients with and without varus displacement had a cutout incidence of 6 and 0.5% (Odds ratio 13, CI 1.6-108).Intertrochanteric fractures presenting with varus displacement were more likely to experience cutout. This potential risk factor for cutout warrants further study.Level 3, retrospective cohort.

Dynamization of fracture fixation constructs provides early rigidity for primary bone healing and late motion for secondary healing. A review of laboratory, animal, and clinical studies investigating the impact, and optimal timing, of dynamization is limited by lack of standardization across studies. However, in animal models, dynamization improves histologic and biomechanical properties compared with statically rigid or flexible controls. In animals, dynamization at 3 to 4 weeks showed improved histologic results. In clinical studies, it showed faster, stronger, and stiffer bone healing. Clinical success dynamizing external fixators and intramedullary nails suggests a role for late dynamization in other fixation types, such as bridge plating. [ Orthopedics . 2020;43(3):e125–e133.]

To evaluate variables associated with lag screw sliding after single-screw cephalomedullary nail (CMN) fixation of intertrochanteric femur fractures.Retrospective cohort study.Level-one trauma center.One hundred fifty-eight intertrochanteric fractures in patients older than 65 years with an average follow-up of 22 months.Single-screw CMN fixation.Lag screw sliding and revision surgeries.The average amount of lag screw sliding was 5 ± 5 mm (range, 0-21 mm). Lag screw sliding was greater with unstable fracture patterns (mean difference 2 mm, 95% confidence interval 0.4-3.5 mm, P = 0.01) and calcar gapping4 mm (mean difference 3.7 mm, 95% confidence interval 2-5 mm, P0.01). No association was found between lag screw sliding and age, female gender, implants, long versus short nails, distal interlock screw use, postoperative neck-shaft angle, or tip-apex distance (P0.05). Revision surgeries were performed in 6 (4%) patients. Indications included symptomatic lag screw removal (n = 2), avascular necrosis (n = 1), cutout (n = 1), loss of reduction (n = 1), and perimplant fracture (n = 1).Unstable fracture patterns are unavoidable; however, careful attention to calcar reduction and selection of dual-screw CMN implants may minimize lag screw sliding and its detrimental effects on outcomes.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Purpose Indications for removing orthopedic hardware on an elective basis varies widely. Although viewed as a relatively benign procedure, there is a lack of data regarding overall complication rates after fracture fixation. The purpose of this study is to determine the overall short-term complication rate for elective removal of orthopedic hardware after fracture fixation and to identify associated risk factors. Materials and methods Adult patients indicated for elective hardware removal after fracture fixation between July 2012 and July 2016 were screened for inclusion. Inclusion criteria included patients with hardware related pain and/or impaired cosmesis with complete medical and radiographic records and at least 3-month follow-up. Exclusion criteria were those patients indicated for hardware removal for a diagnosis of malunion, non-union, and/or infection. Data collected included patient age, gender, anatomic location of hardware removed, body mass index, ASA score, and comorbidities. Overall complications, as well as complications requiring revision surgery were recorded. Statistical analysis was performed with SPSS 20.0, and included univariate and multivariate regression analysis. Results 391 patients (418 procedures) were included for analysis. Overall complication rates were 8.4%, with a 3.6% revision surgery rate. Univariate regression analysis revealed that patients who had liver disease were at significant risk for complication (p = 0.001) and revision surgery (p = 0.036). Multivariate regression analysis showed that: 1) patients who had liver disease were at significant risk of overall complication (p = 0.001) and revision surgery (p = 0.039); 2) Removal of hardware following fixation for a pilon had significantly increased risk for complication (p = 0.012), but not revision surgery (p = 0.43); and 3) Removal of hardware for pelvic fixation had a significantly increased risk for revision surgery (p = 0.017). Conclusions Removal of hardware following fracture fixation is not a risk-free procedure. Patients with liver disease are at increased risk for complications, including increased risk for needing revision surgery following hardware removal. Patients having hardware removed following fixation for pilon fractures also are at increased risk for complication, although they may not require a return trip to the operating room. Finally, removal of pelvic hardware is associated with a higher return to the operating room.

Intertrochanteric hip fractures are common and costly. Intramedullary fixation has gained popularity as a means of stabilizing intertrochanteric hip fractures. This review article presents some of the controversies surrounding the treatment of intertrochanteric fractures using a cephalomedullary nail. These topics include nail length, the need for distal interlocking, proximal screw design, the number of proximal lag screws, and integrated proximal sliding lag screws.Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Importance Disability persists after hip fracture in older persons. Current rehabilitation may not be sufficient to restore ability to walk in the community. Objective To compare a multicomponent home-based physical therapy intervention (training) with an active control on ability to walk in the community. Design, Setting, and Participants Parallel, 2-group randomized clinical trial conducted at 3 US clinical centers (Arcadia University, University of Connecticut Health Center, and University of Maryland, Baltimore). Randomization began on September 16, 2013, and ended on June 20, 2017; follow-up ended on October 17, 2017. Patients aged 60 years and older were enrolled after nonpathologic, minimal trauma hip fracture, if they were living in the community and walking without human assistance before the fracture, were assessed within 26 weeks of hospitalization, and were not able to walk during daily activities at the time of enrollment. A total of 210 participants were randomized and reassessed 16 and 40 weeks later. Interventions The training intervention (active treatment) (n = 105) included aerobic, strength, balance, and functional training. The active control group (n = 105) received transcutaneous electrical nerve stimulation and active range-of-motion exercises. Both groups received 2 to 3 home visits from a physical therapist weekly for 16 weeks; nutritional counseling; and daily vitamin D (2000 IU), calcium (600 mg), and multivitamins. Main Outcomes and Measures The primary outcome (community ambulation) was defined as walking 300 m or more in 6 minutes at 16 weeks after randomization. The study was designed to test a 1-sided hypothesis of superiority of training compared with active control. Results Among 210 randomized participants (mean age, 80.8 years; 161 women [76.7%]), 197 (93.8%) completed the trial (187 [89.0%] by completing the 6-minute walk test at 16 weeks and 10 [4.8%] by adjudication of the primary outcome). Among these, 22 of 96 training participants (22.9%) and 18 of 101 active control participants (17.8%) (difference, 5.1% [1-sided 97.5% CI, −∞ to 16.3%]; 1-sidedP = .19) became community ambulators. Seventeen training participants (16.2%) and 15 control participants (14.3%) had 1 or more reportable adverse events during the intervention period. The most common reportable adverse events reported were falls (training: 6 [5.7%], control: 4 [3.8%]), femur/hip fracture (2 in each group), pneumonia (training: 2, control: 0), urinary tract infection (training: 2, control: 0), dehydration (training: 0, control: 2), and dyspnea (training: 0, control: 2). Conclusions and Relevance Among older adults with a hip fracture, a multicomponent home-based physical therapy intervention compared with an active control that included transcutaneous electrical nerve stimulation and active range-of-motion exercises did not result in a statistically significant improvement in the ability to walk 300 m or more in 6 minutes after 16 weeks. Trial Registration ClinicalTrials.gov Identifier:NCT01783704

Recent estimates suggest an annual incidence of greater than 125,000 femoral neck fractures. Surgical treatment is indicated for the majority of these fractures, which are estimated to double by the year 2050. Most displaced femoral neck fractures in elderly patients are treated with arthroplasty secondary to high complication rates associated with internal fixation. Traditional implants used for internal fixation, typically in elderly patients with stable fracture morphology and younger patients regardless of morphology, include the sliding hip screw (SHS), with or without a supplemental anti-rotation screw, and multiple cancellous lag screws. Complications have been reported with both of these fixation techniques, especially as they apply to treating displaced femoral neck fractures in the elderly. Yet, complications of nonunion, loss of fixation and osteonecrosis, among others, still frequently occur in stable patterns of femoral neck fracture treated with internal fixation. Accordingly, additional implants have been designed recently to improve outcomes and avoid such complications in this population. The Targon Femoral Neck Plate (Aesculap, Tuttlinger, Germany) has been used in Europe for the treatment of both displaced and nondisplaced femoral neck fractures by combining a side plate and multiple cancellous lag screws. Multiple studies have shown superior rates of both nonunion and osteonecrosis when compared to the SHS and multiple cancellous screws in both displaced and nondisplaced femoral neck fractures. This article details the design rationale, surgical technique and early postoperative results of a new hybrid implant used for the treatment of both displaced and nondisplaced femoral neck fractures.

Subtrochanteric femur fractures are significant injuries that despite surgery can lead to relatively high rates of nonunion, malunion, and subsequent poor clinical outcomes.

The diagnosis and treatment of ankle fractures has evolved considerably over the past two decades. Recent topics of interest have included indications for operative treatment of isolated lateral malleolus fractures, need for fixation of the posterior malleolus, utilization of the posterolateral approach, treatment of the syndesmosis, and the potential role of fibular nailing. In this update, we concisely review these topics and what to expect in the future literature.

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.

Nondisplaced or minimally displaced clavicle fractures are often considered to be benign injuries. These fractures in the trauma patient population, however, may deserve closer follow-up than their low-energy counterparts. We sought to determine the initial assessment performed on these patients and the rate of subsequent fracture displacement in patients sustaining high-energy trauma when a supine chest radiograph on initial trauma survey revealed a well-aligned clavicle fracture.We retrospectively reviewed the cases of trauma alert patients who sustained a midshaft clavicle fracture (AO/OTA type 15-B) with less than 100% displacement treated at a single level 1 trauma centre between 2005 and 2010. We compared fracture displacement on initial supine chest radiographs and follow-up radiographs. Orthopedic consultation and the type of imaging studies obtained were also recorded.Ninety-five patients with clavicle fractures met the inclusion criteria. On follow-up, 57 (60.0%) had displacement of 100% or more of the shaft width. Most patients (63.2%) in our study had an orthopedic consultation during their hospital admission, and 27.4% had clavicle radiographs taken on the day of admission.Clavicle fractures in patients with a high-energy mechanism of injury are prone to fracture displacement, even when initial supine chest radiographs show nondisplacement. We recommend clavicle films as part of the initial evaluation for all patients with clavicle fractures and early follow-up within the first 2 weeks of injury.Les fractures de la clavicule accompagnées d’un déplacement minime voire nul sont souvent considérées comme des blessures mineures. Toutefois, ces fractures méritent probablement un suivi plus étroit chez le patient polytraumatisé que chez le patient dont la blessure résulte d’un impact à faible énergie. Nous avons voulu analyser l’évaluation initiale de ces patients et le degré de déplacement subséquent des fractures chez les victimes d’un traumatisme à forte énergie dont la première radiographie du thorax en position couchée a initialement révélé une fracture de la clavicule présentant un bon alignement.Nous avons passé en revue de façon rétrospective les dossiers de patients polytraumatisés ayant fait l’objet d’une alerte, atteints d’une fracture de la clavicule (type 15-B selon la classification AO/OTA) accompagnée d’un déplacement inférieur à 100 % et traités dans un seul centre de traumatologie de niveau 1 entre 2005 et 2010. Nous avons comparé le déplacement des fractures entre les radiographies thoraciques initiales en position couchée et les radiographies de suivi. Les consultations en orthopédie et les types d’épreuves d’imagerie ont aussi été consignés.Quatre-vingt-quinze patients atteints d’une fracture de la clavicule répondaient aux critères d’inclusion. Au moment du suivi, 57 (60 %) présentaient un déplacement de 100 % ou plus du corps de la clavicule. La plupart des patients (63 %) de notre étude ont eu une consultation en orthopédie au cours de leur hospitalisation et 27 % avaient subi une radiographie de la clavicule le jour de leur admission.Les fractures de la clavicule chez des patients victimes d’un traumatisme à forte énergie sont sujettes au déplacement, et ce, même si les radiographies thoraciques initiales en position couchée ne montrent aucun déplacement. Nous recommandons la prise de clichés de la clavicule dans le cadre de l’évaluation initiale de tous les patients victimes d’une fracture de la clavicule et un suivi rapproché dans les 2 premières semaines suivant la fracture.

Background: Recombinant human bone morphogenetic protein-2 (rhBMP-2) applied on an absorbable collagen sponge improves open tibial fracture-healing as an adjunct to unreamed intramedullary nail fixation. We evaluated rhBMP-2 and a new, injectable calcium phosphate matrix (CPM) formulation in acute closed tibial diaphyseal fractures treated with reamed intramedullary nail fixation. Methods: Patients were randomized (1:2:2:1) to receive standard of care, which consisted of definitive fracture fixation within seventy-two hours of injury with a locked intramedullary nail after reaming; standard of care and injection with 1.0 mg/mL of rhBMP-2/CPM; standard of care and injection with 2.0 mg/mL of rhBMP-2/CPM; or standard of care and injection with buffer/CPM, to evaluate the activity of the CPM delivery matrix and provide for sponsor and investigator blinding. The co-primary end points of the study were the effects of rhBMP-2/CPM on the time to fracture union (based on blinded assessment of radiographs) and the time to return to normal function (based on blinded assessment of the time to full weight-bearing without pain at the fracture site) compared with standard of care alone. Results: Three hundred and sixty-nine patients were randomized and included in the intent-to-treat population. This study was terminated after an interim analysis (180 patients with six months of follow-up) revealed no shortening in the time to fracture union in the active treatment arms compared with the standard of care control (the SOC group). In the final primary analysis, the median time to radiographic fracture union was not significantly different for the SOC (13.1 weeks), 1.0-mg/mL rhBMP-2/CPM (13.0 weeks), 2.0-mg/mL rhBMP-2/CPM (15.9 weeks), or buffer/CPM (15.4 weeks) treatment groups. The median time to pain-free full weight-bearing was also not significantly different among the SOC (13.4 weeks), 1.0-mg/mL rhBMP-2/CPM (13.4 weeks), 2.0-mg/mL rhBMP-2/CPM (14.3 weeks), and buffer/CPM (16.4 weeks) treatment groups. Conclusions: In patients with closed tibial fractures treated with reamed intramedullary nailing, the time to fracture union and pain-free full weight-bearing were not significantly reduced by rhBMP-2/CPM compared with standard of care alone. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Although gunshot injuries are relatively common, there is little consensus about whether retained bullets or bullet fragments should be removed routinely or only in selected circumstances.We performed a systematic review of the literature to answer the following questions: (1) Is bullet and/or bullet fragment removal from gunshot injuries to the pelvis or extremities routinely indicated? And, if not, (2) what are the selected indications for removal of bullets and/or bullet fragments?A search of the English-language literature on the topic of gunshot injury and bullet removal was performed using the National Library of Medicine and MEDLINE(®) and supplemented by hand searching of bibliographies of included references. Studies were included if they provided clinical data on one or both of our study questions; included studies were evaluated using the levels of evidence rubric. Most studies on the subject were expert opinion (Level V evidence), and these were excluded; one Level III study and seven Level IV studies were included.No studies provided a rationale for routine bullet removal in all cases. The studies identified bullet fragment removal as indicated acutely for those located within a joint, the palm, or the sole. Chronic infection, persistent pain at the bullet site, and lead intoxication were reported as late indications for bullet removal.The evidence base for making clinical recommendations on the topic of bullet and bullet fragment removal after gunshot injury is weak. Level I and II evidence is needed to determine the indications for bullet removal after gunshot injury.

Reports linking long-term use of bisphosphonates (BPs) with atypical fractures of the femur led the leadership of the American Society for Bone and Mineral Research (ASBMR) to appoint a task force to address key questions related to this problem. A multidisciplinary expert group reviewed pertinent published reports concerning atypical femur fractures, as well as preclinical studies that could provide insight into their pathogenesis. A case definition was developed so that subsequent studies report on the same condition. The task force defined major and minor features of complete and incomplete atypical femoral fractures and recommends that all major features, including their location in the subtrochanteric region and femoral shaft, transverse or short oblique orientation, minimal or no associated trauma, a medial spike when the fracture is complete, and absence of comminution, be present to designate a femoral fracture as atypical. Minor features include their association with cortical thickening, a periosteal reaction of the lateral cortex, prodromal pain, bilaterality, delayed healing, comorbid conditions, and concomitant drug exposures, including BPs, other antiresorptive agents, glucocorticoids, and proton pump inhibitors. Preclinical data evaluating the effects of BPs on collagen cross-linking and maturation, accumulation of microdamage and advanced glycation end products, mineralization, remodeling, vascularity, and angiogenesis lend biologic plausibility to a potential association with long-term BP use. Based on published and unpublished data and the widespread use of BPs, the incidence of atypical femoral fractures associated with BP therapy for osteoporosis appears to be very low, particularly compared with the number of vertebral, hip, and other fractures that are prevented by BPs. Moreover, a causal association between BPs and atypical fractures has not been established. However, recent observations suggest that the risk rises with increasing duration of exposure, and there is concern that lack of awareness and underreporting may mask the true incidence of the problem. Given the relative rarity of atypical femoral fractures, the task force recommends that specific diagnostic and procedural codes be created and that an international registry be established to facilitate studies of the clinical and genetic risk factors and optimal surgical and medical management of these fractures. Physicians and patients should be made aware of the possibility of atypical femoral fractures and of the potential for bilaterality through a change in labeling of BPs. Research directions should include development of animal models, increased surveillance, and additional epidemiologic and clinical data to establish the true incidence of and risk factors for this condition and to inform orthopedic and medical management. © 2010 American Society for Bone and Mineral Research.

Introduction Certain patients with pilon fractures present with significant soft-tissue swelling or with a poor soft-tissue envelope typically not amenable to definitive fixation in the early time period. The objective of this study was to review the treatment of simple intra-articular fractures of the tibial plafond (Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type 43C1–C2) via intramedullary nailing (IMN) with the assessment of clinical and radiographic results and any associated complications. Materials and methods Retrospective clinical and radiological reviews of 31 patients sustaining AO/OTA type 43C distal tibial fractures treated with IMN were evaluated. Our main outcome measurement included achievable alignment in the immediate postoperative period and at the time of union along with complications or need for secondary procedures within the first year of follow-up. Results Seven patients were lost to follow-up. All the remaining patients achieved bony union at a mean union time of 14.1 ± 4.9 weeks with no evidence of malunion or malrotation. All patients were at full-weight-bearing status at 1-year follow-up. Complications were notable for one delayed union, one non-union, one patient with superficial wound drainage, two with deep infection, one with symptomatic hardware and one with deep vein thrombosis. Conclusion Simple articular fractures of the tibial plafond (AO/OTA type 43C) treated via IMN can achieve excellent alignment and union rates with proper patient selection and surgical indication. One should not hesitate to use additional bone screws or plating options to help achieve better anatomic reduction. However, larger, prospective randomised trials comparing plating versus nailing, in experienced hands, are needed to completely delineate the utility of this treatment modality.

Background : Although most medical centers are equipped for 24-h care, some middle of the night services may not be as robust as they are during daylight hours. This would have potential impact upon certain outcome measurements in trauma patients. The purpose of this paper was to assess the effect of patient arrival time at hospital emergency departments on in-hospital survival following trauma. Materials and Methods : Data of patients, 18 years of age or older, with no evidence that they were transferred to or from that center were obtained from the National Trauma Data Bank Version 7.0. Patients meeting the above criteria were excluded if there was no valid mortality status, arrival time information, injury severity score, or trauma center designation. The primary analyses investigated the association of arrival time and trauma center level on mortality. Relative risks of mortality versus patient arrival time and trauma level were determined after controlling for age, gender, race, comorbidities, injury, region of the country, and year of admission. Results : In total, 601,388 or 71.7% of the 838,284 eligible patients were retained. The overall in-hospital mortality rate was 4.7%. The 6 p.m. to 6 a.m. time period had a significantly higher adjusted relative risk for in-hospital mortality than the 6 a.m. to 6 p.m. time frame (ARR=1.18, P

To determine the cost-effectiveness of open reduction internal fixation (ORIF) of displaced, midshaft clavicle fractures in adults.Formal cost-effectiveness analysis based on a prospective, randomized, controlled trial.Eight hospitals in Canada (seven university-affiliated and one community hospital).One hundred thirty-two adults with acute, completely displaced, midshaft clavicle fractures.Clavicle ORIF versus nonoperative treatment.Utilities derived from SF-6D.The base case cost per quality-adjusted life-year (QALY) gained for ORIF was $65,000. Cost-effectiveness improved to $28,150/QALY gained when the functional benefit from ORIF was assumed to be permanent with cost per QALY gained falling below $50,000 when the functional advantage persisted for 9.3 years or more. In other sensitivity analyses, the cost per QALY gained for ORIF fell below $50,000 when ORIF cost less than $10,465 (base case cost $13,668) or the long-term utility difference between nonoperative treatment and ORIF was greater than 0.034 (base case difference 0.014). Short-term disutility associated with fracture healing also affected cost-effectiveness with the cost per QALY gained for ORIF falling below $50,000 when the utility of a fracture treated nonoperatively before union was less than 0.617 (base case utility 0.706) or when nonoperative treatment increased the time to union by 20 weeks (base case difference 12 weeks).The cost-effectiveness of ORIF after acute clavicle fracture depended on the durability of functional advantage for ORIF compared with nonoperative treatment. When functional benefits persisted for more than 9 years, ORIF had a favorable value compared with many accepted health interventions.

A previous hip fracture more than doubles the risk of a contralateral hip fracture. Pharmacologic and environmental interventions to prevent hip fracture have documented poor compliance. The purpose of this study was to examine the cost-effectiveness of prophylactic fixation of the uninjured hip to prevent contralateral hip fracture.: A Markov state-transition model was used to evaluate the cost and quality-adjusted life-years (QALYs) for unilateral fixation of hip fracture alone (including internal fixation or arthroplasty) compared with unilateral fixation and contralateral prophylactic hip fixation performed at the time of hip fracture or unilateral fixation and bilateral hip pad protection. Prophylactic fixation involved placement of a cephalomedullary nail in the uninjured hip and was initially assumed to have a relative risk of a contralateral fracture of 1%. Health states included good health, surgery-related complications requiring a second operation (infection, osteonecrosis, nonunion, and malunion), fracture of the uninjured hip, and death. The primary outcome measure was the incremental cost-effectiveness ratio estimated as cost per QALY gained in 2006 US dollars with incremental cost-effectiveness ratios below $50,000 per QALY gained considered cost-effective. Sensitivity analyses evaluated the impact of patient age, annual mortality and complication rates, intervention effectiveness, utilities, and costs on the value of prophylactic fixation.: In the baseline analysis, in a 79-year-old woman, prophylactic fixation was not found to be cost-effective (incremental cost-effectiveness ratio = $142,795/QALY). However, prophylactic fixation was found to be a cost-effective method to prevent contralateral hip fracture in: 1) women 71 to 75 years old who had 30% greater relative risk for a contralateral fracture; and 2) women younger than age 70 years. Cost-effectiveness was greater when the additional costs of prophylaxis were less than $6000. However, for most analyses, the success of prophylactic fixation was highly sensitive to the effectiveness and the relative morbidity and mortality of the additional procedure.: Prophylactic fixation with a cephalomedullary nail was not found to be cost-effective for the average older woman who sustained a hip fracture. However, it may be appropriate for select patient populations. The study supports the need for basic science and clinical trials investigating the effectiveness of prophylactic fixation for patient populations at higher lifetime risk for contralateral hip fracture.

Background: In the treatment of distal radial fractures, physicians often advocate internal fixation over cast treatment for potentially unstable fracture patterns, citing the difficulties of successful nonoperative treatment and a decrease in patient tolerance for functional deficiencies. This study was performed to evaluate whether early internal fixation or nonoperative treatment would be preferred for displaced, potentially unstable distal radial fractures that initially had an adequate reduction. Methods: A decision analytic model was created to compare early internal fixation with use of a volar plate and nonoperative management of a displaced, potentially unstable distal radial fracture with an acceptable closed reduction. To identify the optimal treatment, quality-adjusted life expectancy was estimated for each management approach. Data from the literature were used to estimate rates of treatment complications (e.g., fracture redisplacement with nonoperative treatment) and of treatment outcomes. Mean health-state utilities for treatment outcomes of painless malunion, functional deficit, and painful malunion were derived by surveying fifty-one adult volunteers with use of the time trade-off method. Sensitivity analysis was used to determine which model parameters would change the treatment decision over a plausible range of values. Results: Early internal fixation with volar plating was the preferred strategy in most scenarios over the ranges of parameters available, but the margins were small. The older patient (mean age, 57.8 years) who sustains a distal radial fracture can expect 0.08 more quality-adjusted life years (29.2 days) with internal fixation compared with nonoperative treatment. Sensitivity analysis revealed no single factor that changed the preferred option within the reported ranges in the base case. However, the group of patients sixty-five years or older, who had lower disutility for painful malunion, derived a very small benefit from operative treatment (0.01 quality-adjusted life year or 3.7 days) and would prefer cast treatment in some scenarios. Conclusions: Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature. This long-term gain in quality-adjusted life years outweighed the short-term risks of surgical complications, making early internal fixation the preferred treatment in most cases. However, the difference was quite small. Patients, especially those over sixty-four years old, who have lower disutility for the malunion and painful malunion outcome states may prefer nonoperative treatment. Level of Evidence: Economic and decision analysis Level II. See Instructions to Authors for a complete description of levels of evidence.

Background: Distal radial fractures are common and confer a considerable financial burden on the health-care system; however, controversy surrounds the optimal treatment of these injuries. This study was performed to determine (1) the rate of distal radial fractures in the U.S. Medicare population stratified by hospital referral region and (2) whether the type of fracture treatment is affected by patient age, race, sex, comorbidity, or hospital referral region. Methods: A 20% sample of Medicare Part-B claims from the years 1998 through 2004 was analyzed. Procedural codes for nonoperative treatment, percutaneous fixation, and open reduction and internal fixation of distal radial fractures were identified. These codes were then used to determine the overall rate of distal radial fracture. The rates of distal radial fracture were then evaluated according to hospital referral region and patient age, sex, comorbidity, and race. The types of treatment were determined and were also analyzed on the basis of hospital referral region and patient age, sex, comorbidity, and race. Regression analysis was performed with use of the above variables. Results: We identified 107,190 patients. The rate of distal radial fracture was 125 per 10,000 Medicare beneficiaries. The rate of the fracture in white individuals (136 per 10,000) was more than twice that in non-white individuals (fifty-nine per 10,000), and the rate in women (189 per 10,000) was 4.8 times higher than that in men (thirty-nine per 10,000). The overall fracture rate varied widely across the United States, from forty-seven per 10,000 beneficiaries in New Orleans, Louisiana, to 220 per 10,000 in Spartanburg, South Carolina. Treatment rates were similar across race, with the rate of nonoperative treatment being 84% for white beneficiaries compared with 83% for non-white beneficiaries, the rate of percutaneous fixation being 11% for white beneficiaries compared with 10% for non-white beneficiaries, and the rate of open treatment being 6% for white beneficiaries compared with 7% for non-white beneficiaries. There was variation across the country, with the rate of nonoperative treatment ranging from 60% in San Luis Obispo, California, to 96% in Covington, Kentucky; the rate of percutaneous fixation ranging from 2% in Boulder, Colorado, to 39% in San Luis Obispo, California; and the rate of open treatment ranging from 0.4% in Wilkes-Barre, Pennsylvania, to 25% in Great Falls, Montana. While the rates of percutaneous fixation and nonoperative treatment remained relatively stable, the overall rate of operative fixation nearly doubled from 5% in 1998 to 8% in 2004. Conclusions: There is wide variation in the rate of distal radial fractures across sex, age, race, and geographic region in the United States. There is also significant variation in the treatment of these fractures, driven mainly by age and region. Between 1998 and 2004, a strong trend toward more frequent operative fixation was apparent. While white individuals had more than twice as many fractures as did non-white individuals, there did not appear to be significant racial variation in the treatment of this injury. Clinical Relevance: The national and local variations in distal radial fractures and the ensuing treatment are key features in developing evidence-based medicine for this ubiquitous injury.

OBJECTIVE. Patient management choices in ankle fractures remain controversial because of ambiguities in assessing ankle stability and lack of information on the integrity of all supporting ligaments. Our objective was to use MRI to identify the range of ankle ligament injuries associated with a problematic subset of ankle fracture: isolated fibular fractures for which widened medial clear space is absent or minimal on standard ankle radiographs but evident on stress images.CONCLUSION. In our retrospective study of 19 patients, we have categorized ligament injury and found partial or complete tears in all cases in at least two of the four major ligament groups—usually the deltoid and syndesmosis groups. The anterior inferior tibiofibular ligament of the syndesmosis suffered complete interruption in every case. The posterior tibiotalar ligament of the deltoid group, a major contributor to stability, was generally injured but, unexpectedly, most of these tears were partial.

This study was performed to determine whether patients who sustain an intertrochanteric fracture have better outcomes when stabilized using a sliding hip screw or an intramedullary nail. A 20% sample of Part A and B entitled Medicare beneficiaries 65 years or older was used to generate a cohort of patients who sustained intertrochanteric femur fractures between 1999 and 2001. Two fracture implant groups, intramedullary nail and sliding hip screw, were identified using Current Procedural Terminology and International Classification of Diseases, 9th Revision codes. The cohort consisted of 43,659 patients. Patients treated with an intramedullary nail had higher rates of revision surgery during the first year than those treated with a sliding hip screw (7.2% intramedullary nail versus 5.5% sliding hip screw). Mortality rates at 30 days (14.2% intramedullary nail versus 15.8% sliding hip screw) and 1 year (30.7% intramedullary nail versus 32.5% sliding hip screw) were similar. Adjusted secondary outcome measures showed significant increases in the intramedullary nail group relative to the sliding hip screw group for index hospital length of stay, days of rehabilitation services in the first 6 months after discharge, and total expenditures for doctor and hospital services.Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Background: During the administration of the oral (Part II) examinations for the American Board of Orthopaedic Surgery over the past nine years, it has been observed that orthopaedic surgeons are opting more often for open treatment as opposed to percutaneous fixation of distal radial fractures. Evidence to support this change in treatment is thought to be deficient. The present study was designed to identify changes in practice patterns regarding operative fixation of distal radial fractures between 1999 and 2007 and to assess the results of those treatments over time. Methods: As a part of the certification process, Part II candidates submit a six-month case list to the American Board of Orthopaedic Surgery. In the present study, we searched the American Board of Orthopaedic Surgery Part II database to evaluate changes in treatment over time and to identify available outcomes and associated complications of open and percutaneous fixation of distal radial fractures. All distal radial fractures that had been treated surgically over a nine-year period (1999 to 2007) were reviewed. The fractures were categorized according to fixation method with use of surgeon self-reported surgical procedure codes. Comparisons of percentage treatment type by year were made. Utilization was analyzed by geographic region, and open and percutaneous fixation were compared with regard to complications and outcomes as self-reported by candidates during the online application process. Results: The proportion of fractures that were stabilized with open surgical treatment increased from 42% in 1999 to 81% in 2007 (p < 0.0001). Although the differences were small, surgeon-reported outcomes revealed that a higher percentage of patients who had been managed with percutaneous fixation had no pain and normal function but some deformity as compared with patients who had had open treatment. Patients who had been managed with percutaneous fixation had a higher overall complication rate (14.0% compared with 12.3%; p < 0.006) and a higher rate of infection (5.0% compared with 2.6%; p < 0.0001) than those who had been managed with open treatment. Patients who had had open treatment had a higher rate of nerve palsy and/or injury (2.0% compared with 1.2%; p = 0.001). No other differences in the reported complication rates were found between the two techniques. Conclusions: A striking shift in fixation strategy for distal radial fractures occurred over the past decade among younger orthopaedic surgeons in the United States. These changes occurred despite a lack of improvement in surgeon-perceived functional outcomes. Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

BACKGROUND: Few studies of hip fracture have large enough samples of men, minorities, and persons with specific comorbidities to examine differences in their mortality and functional outcomes. To address this problem, we combined three cohorts of hip fracture patients to produce a sample of 2692 patients followed for 6 months. METHOD: Data on mortality, mobility, and other activities of daily living (ADLs) were available from all three cohorts. We used multiple regression to examine the association of race, gender, and comorbidity with 6-month survival and function, controlling for prefracture mobility and ADLs, age, fracture type, cohort, and admission year. RESULTS: The mortality rate at 6 months was 12%: 9% for women and 19% for men. Whites and women were more likely than were nonwhites and men to survive to 6 months, after adjusting for age, comorbidities, and prefracture mobility and function. Whites were more likely than were nonwhites to walk independently or with help at 6 months compared to not walking, after adjusting for age, comorbidities, and prefracture mobility and function. Dementia had a negative impact on survival, mobility, and ADLs at 6 months. The odds of survival to 6 months were significantly lower for people with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and/or cancer. Parkinson's disease and stroke had negative impacts on mobility and ADLs, respectively, among survivors at 6 months. CONCLUSIONS: The finding of higher mortality and worse mobility for nonwhite patients with hip fractures highlights the need for more research on race/ethnicity disparities in hip fracture care. Language: en

Background: Controversy exists regarding the risks and benefits of ankle fracture treatment in elderly patients. The purpose of this study was to use the United States Medicare database to determine the complication rate for ankle fractures in elderly patients treated operatively and to compare it to fractures treated nonoperatively. Methods: We used the National Medicare Claims History System to study all enrollees who sustained ankle fractures between 1998 and 2001. A total of 33,704 patients were identified and their outcomes at numerous time points were evaluated. These outcomes included mortality, rate of repeat hospitalization, rate of medical and operative complications, and the rate of additional surgery. The predictor variables were either nonoperative or operative intervention. Covariates included patient age, gender, race, medical comorbidity status, and fracture type. Results: Patients treated nonoperatively had significantly higher mortality ( p < 0.05) than those treated operatively at all time periods except for 30 days. However, patients treated operatively had significantly higher rehospitalization rates ( p < 0.05) at all time periods studied. The medical and operative complication rates at all time periods were less than or equal to 2% for patients who had either operative or nonoperative treatment. In the group that had operative management, a relatively small number of patients had additional procedures. Eleven percent had removal of hardware. Less than 1% of all patients had revision of the internal fixation, arthroplasty, arthrodesis, or amputation. Conclusion: In properly selected cases, the complication rates of both operatively and nonoperatively treated elderly patients are low.

Many orthopaedic surgeons believe that obese patients have a higher rate of peri-operative complications and a worse functional outcome than non-obese patients. There is, however, inconsistency in the literature supporting this notion. This study was performed to evaluate the effect of body mass index (BMI) on injury characteristics, the incidence of complications, and the functional outcome after the operative management of unstable ankle fractures. We retrospectively reviewed 279 patients (99 obese (BMI ≥ 30) and 180 non-obese (BMI < 30) patients who underwent surgical fixation of an unstable fracture of the ankle. We found that obese patients had a higher number of medical co-morbidities, and more Orthopaedic Trauma Association type B and C fracture types than non-obese patients. At two years from the time of injury, however, the presence of obesity did not affect the incidence of complications, the time to fracture union or the level of function. These findings suggest that obese patients should be treated in line with standard procedures, keeping in mind any known associated medical co-morbidities.

Planning for surgical correction of lower-limb deformity requires assessment of the character and extent of the deformity. Deformity measurements are defined; however, the reliability of these measurements has not been evaluated. This study was conducted to assess the interobserver and intraobserver reliability of lower extremity deformity measurements in the frontal and sagittal planes. Anteroposterior and lateral lower extremity radiographs were evaluated using Paley technique. Statistical analysis included intraclass correlation coefficient (2,1), median absolute difference, range, and agreement within 3 and 5 degrees. Reliability was good to very good for all measurements except for the anterior distal tibial angle, which had moderate reliability. Intraobserver reliability was higher than interobserver reliability, and measurements in the frontal plane had better reliability than measurements in the sagittal plane. Overall, these measurements are a reliable method of assessing lower extremity deformity and should be used to guide treatment and monitor outcome.

OBJECTIVES: To examine unidentified heterogeneity in hip fracture patients that may predict variation in functional outcomes. DESIGN: Observational, longitudinal, multisite cohort study. SETTING: Three separate cohorts from five hospitals in the metropolitan New York area and eight hospitals in Baltimore. PARTICIPANTS: Two thousand six hundred ninety-two hip fracture patients treated at one of 13 hospitals and followed for 6 months postfracture. MEASUREMENTS: A mobility measure with three categories (independent (walks independently or with a device), limited independence (needs human assistance or supervision to walk 150 feet or one block or able only to walk indoors), and unable to walk) was developed for use with all three cohorts. A similar measure was developed for the other activities of daily living (ADLs): bathing, dressing, feeding, and using the toilet. Cluster analysis was used to form homogenous groups of patients based on baseline demographic characteristics, comorbid conditions, and baseline mobility and ADL independence. RESULTS: Seven homogeneous subgroups were identified based on prefracture age, health, and functional status, with measurably different 6-month functional outcomes. At least 90% of patients could be correctly classified into the seven groups using simple decision rules about age, ADLs, and dementia status at baseline. Dementia was the only comorbid condition that segmented the groups. CONCLUSION: The heterogeneous hip fracture population can be grouped into homogenous patient clusters based on prefracture characteristics. Differentially targeting services and interventions to these subgroups may improve functional status outcomes.

To evaluate factors associated with complications in a series of patients with proximal humerus fractures treated with locked plating.Retrospective chart review.Level 1 Trauma Center.A retrospective review was performed on patients older than 18 years of age treated with a locked plate for a proximal humerus fracture between June 2007 and December 2011 in order to identify any factors associated with failure. Patients had a minimum of 6 months of clinical follow-up.78 proximal humerus fractures in 78 patients were stabilized using a locked plate. Twenty-four patients were lost to follow-up, while 54 patients were available for 6-month minimum follow-up and comprised the study group. A healing complication occurred in 20 patients (37%) and consisted of loss of reduction (16), varus malunion (16), avascular necrosis (6) or implant penetration (1). Eleven of 54 patients (20%) required secondary surgery. Factors associated with a healing complication were number of fracture parts (p0.029), one or more comorbidities (p0.016), three or more comorbidities (p0.038), and varus malreduction (p0.001).An overall complication rate of 37% was found in patients stabilized using a locked plate after sustaining a proximal humerus fracture. Factors associated with healing complications included increased number of fracture parts, increasing number of comorbidities, and initial varus malreduction. Patient selection for locked plating after proximal humerus fracture should incorporate many factors with meticulous attention to surgical technique.

This study investigates the results of closed manipulations performed under anesthesia (MUA) to evaluate whether it is an effective means to treat posttraumatic knee arthrofibrosis.Retrospective review.Level I trauma center.Twenty-two patients with a mean age of 40 underwent closed MUA for posttraumatic knee arthrofibrosis. Injuries included fractures of the femur, tibia, and patella as well as ligamentous injuries and traumatic arthrotomies. The mean time from treatment to manipulation was 90 days. Mean follow-up after manipulation was 7 months.Closed knee MUA.Improvement of knee range of motion (ROM) arc was the primary outcome. Patient demographics were correlated with manipulation success using a 2-sample t test. A delay in manipulation of 90 days or greater was also evaluated in this fashion with regard to its role in predicting the benefit of MUA.The mean premanipulation ROM arc was 59 ± 25 degrees. The mean intraoperative arc of motion, achieved at the time of the manipulation was 123 ± 14 degrees. No complications occurred during the MUA procedure. At the most recent follow-up, the mean ROM arc was 110 ± 19 degrees. Tobacco use, associated injuries, elevated body mass index, open fracture, and advanced age did not impact manipulation efficacy. Additionally, manipulations performed 90 days or more after surgical treatment provided a benefit equaling those performed more acutely (P = 0.12).MUA is a safe and effective method to increase knee ROM in the setting of posttraumatic arthrofibrosis. Improvement in ROM was noted in all patients. A 90-day window between fracture fixation and manipulation did not impact ROM at final follow-up and may prevent fracture displacement during the MUA.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Determination of muscle viability during debridement is a subjective process with significant consequences. Evaluating muscle color, consistency, contractility, and capacity to bleed (the 4 Cs) was established by a study performed half a century ago. This work reinvestigates the utility of the 4 Cs using current histopathologic techniques.After institutional review board approval, 36 biopsies were prospectively collected at a level-1 trauma center from 20 patients undergoing a debridement for open fracture (81%), compartment syndrome (11%), infection (5%), or crush injury (3%). Surgeons graded the biopsies using the 4 Cs, and provided their overall impression as healthy, borderline, or dead. Blinded pathological analysis was performed on each specimen. A correlation between the 4 Cs and surgeon impression with histopathological diagnosis was sought through a univariate statistical analysis.The surgeon's impression was dead muscle in 25 specimens, borderline in 10, and healthy in 1. Pathological analysis of the 35 specimens considered as dead or borderline muscle by the surgeon demonstrated normal muscle or mild interstitial inflammation in 21 specimens (60%). Color (P = 0.07), consistency (P = 0.12), contractility (P = 0.51), capacity to bleed (P = 0.07), and surgeon impression (P = 0.50) were unable to predict histologic appearance.Neither the 4 Cs nor the surgeon's impression correlate with histological findings regarding muscle viability. In 72% of specimens, the treating surgeon's gross assessment differed from the histopathologic appearance. Although the fate of the debrided muscle remains unclear if left in situ, these results raise questions regarding current practices, including the possibility that surgeons are debriding potentially viable muscle.Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Item does not contain fulltext BACKGROUND: The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) has been extensively evaluated in groups of patients with osteoarthritis, yet not in patients with a femoral neck fracture. This study aimed to determine the reliability, construct validity, and responsiveness of the WOMAC compared with the Short Form-12 (SF-12) and the EuroQol 5D (EQ-5D) questionnaires for the assessment of elderly patients with a femoral neck fracture. METHODS: Reliability was tested by assessing the Cronbach alpha. Construct validity was determined with the Pearson correlation coefficient. Change scores were calculated from ten weeks to twelve months of follow-up. Standardized response means and floor and ceiling effects were determined. Analyses were performed to compare the results for patients less than eighty years old with those for patients eighty years of age or older. RESULTS: The mean WOMAC total score was 89 points before the fracture in the younger patients and increased from 70 points at ten weeks to 81 points at two years postoperatively. In the older age group, these scores were 86, 75, and 78 points. The mean WOMAC pain scores before the fracture and at ten weeks and two years postoperatively were 92, 76, and 87 points, respectively, in the younger age group and 92, 84, and 93 points in the older age group. Function scores were 89, 68, and 79 points for the younger age group and 84, 71, and 73 points for the older age group. The Cronbach alpha for pain, stiffness, function, and the total scale ranged from 0.83 to 0.98 for the younger age group and from 0.79 to 0.97 for the older age group. Construct validity was good, with 82% and 79% of predefined hypotheses confirmed in the younger and older age groups, respectively. Responsiveness was moderate. No floor effects were found. Moderate to large ceiling effects were found for pain and stiffness scales at ten weeks and twelve months in younger patients (18% to 36%) and in the older age group (38% to 53%). CONCLUSIONS: The WOMAC showed good reliability, construct validity, and responsiveness in both age groups of elderly patients with a femoral neck fracture who had been physically and mentally fit before the fracture. The instrument is suitable for use in future clinical studies in these populations. CLINICAL RELEVANCE: The results are based on two clinical trials. The questionnaires used concern pure, clinically relevant issues (ability to walk, climb stairs, etc.). Moreover, the results can be used for future research comparing clinical outcomes (or treatments) for populations with a femoral neck fracture.

PURPOSE Our experience with retrograde femoral nailing after periprosthetic distal femur fractures was that femoral components with deep trochlear grooves posteriorly displace the nail entry point resulting in recurvatum deformity. This study evaluated the influence of distal femoral prosthetic design on the starting point. METHODS One hundred lateral knee images were examined. The distal edge of Blumensaat's line was used to create a ratio of its location compared with the maximum anteroposterior condylar width called the starting point ratio (SPR). Femoral trials from 6 manufacturers were analyzed to determine the location of simulated nail position in the sagittal plane compared with the maximum anteroposterior prosthetic width. These measurements were used to create a ratio, the femoral component ratio (FCR). The FCR was compared with the SPR to determine if a femoral component would be at risk for retrograde nail starting point posterior to the Blumensaat's line. RESULTS The mean SPR was 0.392 ± 0.03, and the mean FCR was 0.416 ± 0.05, which was significantly greater (P = 0.003). The mean FCR was 0.444 ± 0.06 for the cruciate retaining (CR) trials and was 0.393 ± 0.04 for the posterior stabilized trials; this difference was significant (P < 0.001). CONCLUSIONS The FCR for the femoral trials studied was significantly greater than the SPR for native knees and was significantly greater for CR femoral components compared with posterior stabilized components. These findings demonstrate that many total knee prostheses, particularly CR designs, are at risk for a starting point posterior to Blumensaat's line.

Femoral neck fractures are a commonly encountered injury in orthopaedic practice and result in significant morbidity and mortality. It is essential that surgeons are able to recognize specific fracture patterns and patient characteristics that indicate the use of particular implants and methods to effectively manage these injuries. Use of the Garden and Pauwels classification systems has remained the practical mainstay of femoral neck fracture characterization that help dictate appropriate treatment. Operative options include in situ fixation, closed or open reduction and internal fixation, hemiarthroplasty, and total hip arthroplasty. Recent reports demonstrate diversity among orthopaedic surgeons in regard to the optimal treatment of femoral neck fractures and changing trends in management. The present discussion focuses on the current indications and methods for femoral neck fracture management to provide direction with respect to appropriate and effective care of these injuries.