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Fragility fractures are an enduring source of morbidity in the elderly with unfortunate frequency and rising costs. Although the predominant cause of fractures is generally understood to be falls, the exact stratification of the causes of fractures presenting to the emergency department has not yet been described in the literature. We sought out to stratify the primary products associated with fractures in the elderly, further describing the anatomic location of the fracture and setting of injury.We queried the National Electronic Injury Surveillance System database for all fractures in patients older than 65 years from January 1, 2000, to December 31, 2019. We analyzed demographic data, patient disposition, anatomic fracture location, and injury setting for the top 20 causes of fractures. Trends, proportions and distributions were analyzed using descriptive statistics.A total of 901,418 visits to the Emergency Department were reviewed. Of these, 216,657 (24%) were found to have fractures. The top 20 causes for fractures accounted for a total of 173,557 (19%) fractures. The average age in our population was 80.1 years (SD 8.7). Women constituted most of the patients (127,753 [74%]). Flooring (58,347 [33.6%]) was the most common product associated with the cause of fractures, with stairs/steps (29,804 [17.2%]) and bed/bed frames (19,004 [10.9%]) being the second and third most common, respectively. Lower extremity fractures (97,195 [56%]) were more common than upper extremity fractures (63,899 [37%]). The lower trunk (pelvis, femoral neck, and lower spine) was the most common anatomic location of fractures reported (64,132 [37.0%]). Most fractures occurred either at home (113,158 [65.2%]) or at a public setting (31,162 [18.0%]).Most products associated with fractures among mature adults were related to flooring, stairs, or bedding. This study offers a detailed understanding on the common products associated with fractures in mature adults and aids in discussing preventive measures for lowering fracture risk with patients, communities, and healthcare systems.

Background Previous studies have demonstrated the influence of heritable factors on the development of nontraumatic osteonecrosis of the femoral head (ONFH). We hypothesized that genetic variation is associated with an increased risk of ONFH, and that variants could be identified by a genomewide association study (GWAS). Methods Using data collected from the MyCode Community Health Initiative, we identified 118 adult patients with radiographically confirmed nontraumatic ONFH. Study patients were statistically compared with a control population of 56,811 unrelated individuals without a diagnosis of ONFH. A case-control GWAS was performed to identify single nucleotide variants (SNVs) associated with ONFH. Sensitivity analyses were performed to evaluate the association of the top SNVs with (cortico)steroid-associated ONFH and ONFH with femoral head collapse. Gene-based analyses were performed to identify potential causal genes. Results Of the 118 patients, 114 (96.6%) had bilateral ONFH at a median of 5 years of follow-up; 90.7% had at least one 3-week steroid prescription compared with 68.3% in controls. A GWAS identified 4 SNVs reaching genomewide significance. rs116468452 near CACNA1E was significantly associated with ONFH (p = 3.26 × 10, odds ratio [OR] = 5.6, 95% confidence interval [CI] = 3.21 to 9.76). rs10953090 in SAMD9 was significantly associated with ONFH in the steroid-exposed subset (p = 2.96 × 10, OR = 2.57, 95% CI = 1.84 to 3.58). rs112467115 in PI4K1B showed enhanced association in the collapsed subset (p = 7.82 × 10, OR = 4.5, 95% CI = 2.60 to 7.79). Gene-based analyses identified PPARGC1B as the only gene significantly associated with ONFH after Bonferroni correction (p = 1 × 10), with the lead SNV being rs78814834 (OR = 2.86, 95% CI = 1.87 to 4.38). Conclusions We identified 4 SNVs and 1 gene, PPARGC1B, associated with ONFH. Level of evidence Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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

Stemmed femoral implants are not universally used in revision total knee arthroplasty. The aim of this study was to evaluate whether the re-revision rate would be greater for revision total knees performed without stemmed femoral implants compared with revision total knees performed with stemmed femoral implants.All revision cases performed at a single institution between 2004 and 2011 were retrospectively reviewed. A total of 130 revision total knee arthroplasty procedures (63 Group 1; 67 Group 2) met the inclusion criteria.Revisions performed without femoral stems failed more often than revisions with femoral stems (44% vs 9%, p0.001) despite more severe pre-operative bone loss in groups that were revised with stems (p0.05).We recommend that femoral stems be used routinely in procedures where a femoral implant is revised following a prior total knee arthroplasty.

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

Objective: Evaluate cost of care of all-terrain vehicle (ATV) related injuries sustained by riders 16 years and younger in Pennsylvania. Methods: Population-based retrospective cohort design reviewing costs of care of 78 patients (

Obesity has been associated with lower function and more pain before and after total hip or knee replacement (THR or TKR). We examined the changes between preoperative and postoperative function and pain in a large representative U.S. cohort to determine if there was a relationship to obesity status.Preoperative and 6-month postoperative data on function (Short Form-36 Physical Component Summary [PCS] score), joint pain (Hip disability and Osteoarthritis Outcome Score and Knee injury and Osteoarthritis Outcome Score), and body mass index (BMI) were collected from a national sample of 2,040 patients who had undergone THR and 2,964 who had undergone TKR from May 2011 to March 2013. Preoperative and postoperative function and pain were evaluated according to BMI status, defined as under or of normal weight, overweight, obese, severely obese, or morbidly obese.Patients undergoing THR were an average of 65 years of age; 59% were women, 94% were white, and 14% were severely or morbidly obese. A greater obesity level was associated with a lower (worse) PCS score at baseline and 6 months postoperatively. Severely and morbidly obese patients had less postoperative functional gain than the other BMI groups. A greater obesity level was associated with more pain at baseline but greater postoperative pain relief, so the average postoperative pain scores did not differ significantly according to BMI status. Patients undergoing TKR had an average age of 69 years; 61% were women, 93% were white, and 25% were severely or morbidly obese. A greater obesity level was associated with a lower PCS score at baseline and 6 months. The postoperative gain in PCS score did not differ by BMI level. A greater obesity level was associated with worse pain at baseline but greater pain relief at 6 months, so the average pain scores at 6 month were similar across the BMI levels.Six months after total joint replacement (TJR), severely or morbidly obese patients reported excellent pain relief and substantial functional gain that was similar to the findings in other patients. While obesity is associated with a greater risk of early complications, obesity in itself should not be a deterrent to undergoing TJR to relieve symptoms.Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

The immunocompromised host is a particularly vulnerable population in whom routine and unusual infections can easily and frequently occur. Prosthetic devices are commonly used in these patients and the infections associated with those devices present a number of challenges for both the microbiologist and the clinician. Biofilms play a major role in device-related infections, which may contribute to failed attempts to recover organisms from routine culture methods. Moreover, device-related microorganisms can be difficult to eradicate by antibiotic therapy alone. Changes in clinical practice and advances in laboratory diagnostics have provided significant improvements in the detection and accurate diagnosis of device-related infections. Disruption of the bacterial biofilm plays an essential role in recovering the causative agent in culture. Various culture and nucleic acid amplification techniques are more accurate to guide directed treatment regimens. This chapter reviews the performance characteristics of currently available diagnostic assays and summarizes published guidelines, where available, for addressing suspected infected prosthetic devices.

The antiplatelet effect of clopidogrel on blood loss and perioperative complications after surgical intervention remains ambiguous. The purpose of this study was to determine if patients on clopidogrel before hemiarthroplasty for femoral neck fracture are predisposed to greater surgical bleeding and perioperative complications compared with those not taking clopidogrel before surgery.We conducted a review of our electronic medical record from 2006-2013 and identified 602 patients who underwent 623 hemiarthroplasty procedures for displaced femoral neck fracture, of which 54 cases (9%) were taking clopidogrel before hospital admission. Patient demographics and comorbidities, operative and surgical variables, and perioperative complications at 90 days were compared between the clopidogrel and nonclopidogrel user groups.The 2 groups of patients had similar baseline characteristics, but patients taking clopidogrel preoperatively were sicker with higher American Society of Anesthesiologists scores (P = .049) and age-adjusted Charlson index (P = .001). They also had a greater incidence of cerebrovascular disease (P = .01), chronic obstructive pulmonary disease (P = .03), diabetes (0.03), and malignancy (P.001). There was no significant difference between the 2 patient groups with respect to 90-day postoperative medical readmissions (P = .85), surgical readmissions (P = .26), infection (P = .99), and mortality (P = .89).Patients taking clopidogrel who present with a displaced femoral neck fracture can safely undergo a hemiarthroplasty while actively on clopidogrel without an increase in medical or surgical complications and mortality. We do not recommend delaying surgical intervention until the antiplatelet effects of clopidogrel subside.

BACKGROUND The treatment of interprosthetic femoral fractures is challenging because of several factors. Poor bone stock, advanced age, potential prosthetic instability, and limited fracture fixation options both proximally and distally can complicate standard femur fracture treatment procedures. The purpose of this report was to describe our experience treating interprosthetic femoral fractures, providing an emphasis on treatment principles and specific intraoperative management. METHODS All patients with fractures occurring between ipsilateral hip and knee prostheses between 2004 and 2010 were identified from a comprehensive database and included in this study. Patients had been treated using principles adapted from two isolated periprosthetic fracture classification systems, the Vancouver and Su classifications. The electronic medical record (including inpatient medical records, operative notes, outpatient medical records, and all radiographs) was reviewed for each patient and demographic and treatment-related variables as well as complications and outcomes were recorded. RESULTS Thirteen consecutive patients with interprosthetic fractures were included. Four fractures occurred around a clearly loose prosthesis, which were subsequently treated with long-stemmed revisions. The remaining 12 fractures were treated with a locked-plate construct. Two of nine patients (22.2%) died before fracture union. Follow-up averaged 28 months ± 4 months, with fracture union achieved at an average of 4.7 months ± 0.3 months. All patients returned to their self-reported preoperative ambulatory status except one who developed a loose hip prosthesis at 3-year follow-up after fracture union. CONCLUSIONS The principles for treatment of isolated periprosthetic fractures are useful to guide the fixation of interprosthetic fractures. Locked plating is an effective method for the treatment of interprosthetic femoral fractures. Bypassing the adjacent prosthesis by a minimum of two femoral diameters is a necessary technique to prevent a stress riser.

Monopotassium phosphate (MKP) is a potential option for fertigating phosphorus (P) in potato (Solanum tuberosum L.) when petioles are low in P and high in nitrogen (N); which is a situation where using ammonium polyphosphate (APP) could potentially result in excessive N application. Fertilizer trials were conducted in 2004–2006 with 0 or 56 kg P2O5 ha−1 fertigated as either APP or MKP as a supplement to the pre-plant P (112 or 224 kg P2O5 ha−1) broadcast applied to all plots. Supplemental P fertigation increased petiole P concentration, US No. 1 yield, and total yield over the control not receiving any in-season P fertilizer regardless of source. In addition, MKP increased tuber specific gravity. These results support previous studies showing that fertigated P can be used to increase potato yields when petiole P concentrations are low and that MKP is a viable substitute for APP fertilizer when fertigation is necessary.

Potato (Solanum tuberosum L.) has active surface roots that may enable phosphorus (P) fertigation. Fertilizer trials were conducted in 2002–2004 with 0 or 224 kg P2O5 ha−1 applied as incorporated pre-plant broadcast, in-season fertigation, or split application (half pre-plant and half in-season). All of the P fertilization treatments increased petiole P concentration over the untreated control in all three years of the trial, but only the pre-plant application resulted in significant increases in US No. 1 and Total yields. Both the pre-plant and the split application resulted in significant increases in Marketable yield (US No. 1 & 2). These results show that P fertilizer should be applied and incorporated prior to planting. Fertigated P does enter into the plant, but the relative efficiency of this method of application for P is poor with regard to important yield and quality parameters and application as such should be limited to “rescue” situations.

Potato (Solanum tuberosum L.) has surface roots with enhanced activity upon canopy closure that should allow application of phosphorus (P) via fertigation. Fertilizer trials were conducted in 2005–2006 with four pre-plant broadcast (0, 112, 224, or 336 kg P2O5 ha−1) and two split applied in-season fertigation (0 or 56 kg P2O5 ha−1) rates. Total and undersized tuber yield had a quadratic relationship with pre-plant P, increasing and then declining as pre-plant P fertilizer rate increased, with predicted yield peaks at 246 and 167 kg P2O5 ha−1, respectively. Marketable and US No. 1 yields increased linearly with increasing pre-plant P fertilizer rate. A trend for an increase in total yield as a function of in-season P fertilization was also measured. The P rate for maximum yield did not decline with in-season application, suggesting that this practice does not enhance P fertilizer use efficiency.

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

The authors describe the technique of blocking K-wires to facilitate the freehand percutaneous plating of periarticular tibia fractures. The blocking K-wires facilitate anatomic accuracy of plate placement, a limiting feature of percutaneous plating technique particularly in the absence of a plate-specific jig. The described technique is to be applied as part of a staged surgical protocol utilizing temporary external fixation and directed at the preservation of the periarticular soft-tissues of the tibia.

We propose that the classification commonly used in patients with osteomyelitis, the Gustilo classification, also is applicable to patients with open fractures as a method of identifying increased risk of infection because of comorbid medical illness. The records of 174 adult patients sustaining open fractures of long bones were retrospectively reviewed. Each patient was sorted into Class A, B, or C based on 14 immune system compromising factors. Class A has no compromising factors, Class B has one or two compromising factors, and Class C has more than three compromising factors. The association between class and infection was examined. The incidence of infection was 4%, 15%, and 30% in patients in Classes A, B, and C, respectively. Patients in Class B were 2.86 times more likely to have an infection, and patients in Class C were 5.72 times more likely to have an infection when both groups of patients were compared with patients in Class A. The Gustilo classification, location of fracture, and tobacco use are all factors associated with infection. Patients in Class B or C are at markedly increased risk of infection and may benefit from additional or alternative therapies that decrease the risk of infection. Level of evidence Prognostic study, Level II-1 (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Children with muscular dystrophy (MD) offer a unique opportunity to measure the effect of weakness on gait efficiency as they experience weakness not usually accompanied by other disabilities affecting gait. Oxygen consumption measurements were collected from eight patients with MD and eight patients with cerebral palsy (CP). A statistically significant difference in oxygen cost and oxygen consumption while walking between patients with CP and patients with MD was found despite their common inability to walk similar distances. Oxygen cost and oxygen consumption were elevated within the CP population, whereas all measurements for the MD population were within normal ranges. The measurements show that a patient can have normal oxygen cost and oxygen consumption while walking and yet be functionally limited because of weakness. Caution should be taken when using oxygen cost and oxygen consumption as sole outcome measures for patients with CP, because these measures may be insensitive to changes in strength.

A case of an angulated, greenstick fracture of the scapula mimicking scapular winging in a skeletally immature 12-year-old boy is described. The bony deformity was visualized with plain radiography. CT was helpful in exclusion of a thoracic injury or an underlying neoplasm. Closed reduction yielded satisfactory results. Based on this 1 case only, we recommend consideration of closed reduction in children with significantly angulated greenstick fractures of the scapula without underlying thoracic pathology.

Periprosthetic joint infection is a leading cause of failure after two-stage reimplantation. One cause of relapse may be persistent subclinical infection. Difficulty exists in detecting biofilm-forming infections. Sonication disrupts biofilm and has led to higher rates of positive intraoperative cultures.Our aims in this study were to determine (1) if sonication results were predictive of failure, including reinfection, at 2-year followup; and (2) whether sonication of antibiotic spacers at the time of reimplantation improves sensitivity of intraoperative cultures.We prospectively followed 36 consecutive patients undergoing two-stage reimplantation for periprosthetic hip or knee infection. Minimum followup was 19 months (mean, 29.9 months; range, 19–38 months). Results of intraoperative cultures and sonicated antibiotic spacers were analyzed.Positive sonication results were predictive of failure as defined by reinfection at 2-year followup. Among the 18 patients who had positive sonication results, reinfection developed in nine patients (50%) compared with two of 18 patients (11%) with negative sonication results (odds ratio, 8.0; 95% CI, 1.2–69.0). Sonication of antibiotic spacers improved the sensitivity of intraoperative cultures from 45% to 82%. [corrected].Sonication of antibiotic spacers appears to be useful in predicting failure attributable to recurrent infection after two-stage reimplantation. For patients with positive sonication cultures during reimplantation, more aggressive antimicrobial treatment may be indicated after reimplantation.Level III, diagnostic study. See the Instructions for Authors for a complete description of levels of evidence.

Objective: The aim of this study was to investigate the association of bisphosphonate exposure with low-energy, non-articular femur fractures.Methods: The electronic records of 106 patients over the age of 55 years who sustained low-energy non-articular femur fractures and were treated within an integrated health system were examined. Patients were identified through a prospective registry and all fractures were classified anatomically. Cases were matched with control patients without fracture, and prescription orders were examined to assess drug exposures. Conditional logistic regression tested for a significant association between bisphosphonate exposure and fracture.Results: Thirteen of the 106 cases (12%) and 76 of 804 controls (9%) received at least one year of prescriptions for bisphosphonates prior to fracture. Odds ratio for bisphosphonate exposure as a risk factor was 1.52 (95% confidence interval: 0.76 to 3.05), suggesting no statistically significant association (p=0.24). Results were similar when four-year exposure or alendronates only were studied.Conclusion: Bisphosphonate exposure was not associated with non-articular femur fracture in this case-control study. We suggest that the majority of low-energy, geriatric femur fractures are not associated with bisphosphonate exposure., Çalışma planı: Düşük enerjili eklem dışı femur kırığı olan ve entegre bir sağlık sistemi içinde tedavi edilen 55 yaşın üzerinde 106 hastanın elektronik kayıtları incelendi. Hastalar prospektif bir veritabanı üzerinden saptandı ve tüm kırıklar anatomik olarak sınıflandırıldı. Olgular kırığı olmayan kontrol grubu ile eşleştirilerek, reçeteler ilaca maruz kalma durumunu değerlendirmek için incelendi. Koşullu lojistik regresyon analizi ile bifosfonata maruz kalma ile kırık arasında anlamlı bir ilişki olup olmadığına bakıldı.Bulgular: Yüz altı olgunun 13’ü (%12) ve 804 kontrolün 76’sı (%9) kırık öncesinde en az bir yıl boyunca bisfosfonat kullanmıştı. Bir risk faktörü olarak bifosfonata maruz kalma olasılık oranının 1.52 (%95 güven aralığı: 0.76-3.05) olarak belirlenmesi istatistiksel olarak anlamlı bir ilişki olmadığını düşündürdü (p=0.24). Dört yıllık maruz kalma durumu ya da sadece alendronatlar incelendiği zaman benzer bulgular elde edildi.Çıkarımlar: Bu olgu-kontrol çalışmasında, bifosfonata maruz kalmanın eklem dışı femur kırığı ile ilişkisi saptanmadı. Biz düşük enerjili, geriatrik femur kırıklarının çoğunluğunun bifosfonata maruz kalma ile ilişkili olmadığını düşünüyoruz.

A 9-year-old boy sustained a previously unreported salter-Harris III coronal plane fracture of the anterior capitellum after a 20-foot fall from a tree. the fracture was diagnosed on x-ray and an MrI confirmed the fracture pattern. During surgical treatment, an anterolateral approach to the elbow allowed direct visualization of the fracture fragment, anatomic reduction, and fixation with a bioabsorbable pin. At one year follow-up the patient's range of motion and function was symmetric to the contralateral extremity. this paper reviews the literature regarding the epidemiology, classification, and management of the rare pediatric capitellar fracture.

To retrospectively compare the clinical outcomes in patients with pertrochanteric femur fractures without subtrochanteric extension (OTA 31-A1 and A2) after treatment with short or long cephalomedullary nails.Retrospective study.Academic level I trauma center.Two hundred eighty three adult patients presenting with simple or multifragmentary pertrochanteric femur fractures (OTA 31-A1 and A2) between 2004 and 2009 qualified for inclusion in this study.One hundred patients were treated with a short cephalomedullary nail and 183 with a long cephalomedullary nail.Patient demographics and medical comorbidities were recorded for each patient via an electronic medical record. Treatment-related variables including the American Society of Anesthesiologists (ASA) score, duration of surgery, volume of intraoperative blood loss, need for blood products, treatment-related complications, and mortality were recorded and compared between the short and long nail groups.There were no significant difference between treatment modalities, complication, and reoperation rates for the 2 groups. Treatment with a long nail resulted in subtle increases in procedure time and blood loss.No differences in the union and complication rates between the 2 groups were identified, suggesting that long nails offer no advantage compared with short nails for stabilizing simple and multifragmentary pertrochanteric femur fractures without subtrochanteric extension (OTA 31-A1 and A2).Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The study of genomics in orthopaedics has considerably lagged behind such study in other medical disciplines. Seminal work from other lines of medical research demonstrates the importance of genomic information in the evolution of personalized medicine. Common techniques for studying genome-phenotype associations include single nucleotide polymorphism, haplotype, and quantitative trait loci analysis. The few genome-based studies in major orthopaedic and related conditions have focused on osteoporosis, osteoarthritis, neuropathy and nerve compression, spinal deformity, trauma and inflammatory response, and pain and analgesia. The nascent field of orthogenomics, newly defined here as the application of genomic study to orthopaedic practice, has produced findings that could affect the practice of orthopaedics. However, more work is required, and the findings must be distilled and harnessed into applicable and achievable steps to improve clinical orthopaedic practice.

The purpose of this study was to examine the acute outcomes and mortality rates of an Advanced Trauma Life Support guideline approach for managing hemodynamically unstable pelvic ring injuries. We retrospectively reviewed the acute outcomes of 48 consecutive patients with hemodynamically unstable pelvic fractures. Patients underwent treatment via the advanced trauma life support protocol, with primary angiography based on trauma surgeon preference. Mean patient age was 51.2 years, with a mean injury severity score of 43.2±14.3. Mean systolic blood pressure was 74.8±16.1 mm Hg at presentation. Patients received an average of 7.0±6.6 units of red blood cells and 4.2±2.3 units of fresh frozen plasma in the first 6 hours. Fourteen patients underwent emergent angiography, and 12 patients were treated with embolization. Mean time to angiography was 3 hours and 55 minutes (range, 2–19 hours). Twenty patients died during hospitalization, with an overall mortality rate of 41.7%; 13 (27.1%) of them died within 24 hours. Advanced Trauma Life Support guidelines with angiography are not adequate for the management of hemodynamically unstable pelvic ring injuries and result in unacceptably high mortality rates compared with more specific approaches using transfusion protocols and interventions, such as pelvic packing.

Fractures of the femur above a total knee arthroplasty (TKA) are becoming increasingly common in the osteoporotic, aging populations of developed countries. Treatment of these fractures is complicated by the presence of a knee prosthesis, frequently limiting the bone available for distal fracture fixation. The recent application of minimally invasive surgical techniques and locked plate technology to this problem offers the promise of stable, fixed-angle fixation of small distal fracture fragments with limited surgical exposure. The purpose of this study is to report the clinical and radiographic outcomes of fracture fixation using this technique in patients with periprosthetic femur fractures above TKA.Fifty-three patients presenting with periprosthetic femur fractures above a TKA were treated with osteosynthesis. One patient was lost to follow-up resulting in 52 patients with complete data. Thirty-four patients were treated with plate fixation and 18 patients underwent retrograde intramedullary nail fixation (RIMN). Using a comprehensive electronic medical record, we recorded data regarding patient-related demographics, nature of the fractures, the operative treatment, and clinical and radiographic outcomes for all patients treated with osteosynthesis.Successful fracture healing occurred in 75% of patients (39 of 52). Mean operating time was 91.6 ± 6.8 minutes in the RIMN group and 87.4 ± 6.4 minutes in the locked plating (LP) group (P = 0.46). Mean intraoperative blood loss was 182 ± 31.6 mL in the RIMN group and 177.5 ± 23.4 mL in the LP group (P = 0.91). The mean time to bone union was 3.7 ± 0.30 months in the RIMN group and 4.0 ± 0.27 months in the LP group (P = 0.95). The most common cause of treatment failure was patient death within 6 months (9 patients [17%]); three of 18 were treated with a nail and 6 of 34 with a plate (P = 1.0). In the LP group, three (9%) sustained fracture nonunions, three (9%) sustained fracture malunions, and two (6%) sustained surgical site infections. In the RIMN group, one (6%) failed to unite as a result of infection and two (11%) developed fracture malunions. There were no significant differences between patients treated with LP and those treated with RIMN.Despite significant advances in surgical technique and implant design, the treatment of periprosthetic femur fractures above a TKA remains a challenge. LP using an indirect reduction technique is applicable to most patients and prosthetic designs and can provide similar favorable results as compared with treatment with a RIMN in periprosthetic femoral fractures.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background/Aims Dialysis and kidney transplantation adversely impact outcomes of total hip or knee arthroplasty (THA, TKA), but complication rates have not been reported for patients with less advanced stages of chronic kidney disease (CKD). Surgeons lack the data necessary to have informed discussions regarding anticipated outcomes of joint replacement for these patients.

Much has been written in the sports medicine literature regarding return to competition following anterior cruciate ligament reconstruction; however, little scientific work has been done regarding the return to competition following meniscal surgery or cartilage surgery. This article reviews the basic science of meniscal surgery and cartilage surgery in an attempt to promote rational rehabilitative protocols rooted in scientific investigation. A twofold approach is used. One approach is from a biologic standpoint; that is, when are the repaired tissues healed enough to withstand physiologic activity? The second approach is from a rehabilitative standpoint; when is the patient strong enough to play without recurrent injury?

Background Hip fracture patients experience high morbidity and mortality rates in the first post-operative year after discharge. We compared mortality, utilization, costs, pain and function between two prospective cohorts of hip fracture patients, both managed with identical perioperative protocols and one group subsequently managed via a “Patient-Centered Medical Home” (PCMH) primary care management model. Methods We analyzed 6 and 12-month outcomes from two matched cohorts of patients who were surgically treated for hip fracture from January 1, 2010 to June 30, 2011 at two hospitals (n = 194). Controls did not receive PCMH and were matched to cases on surgery date, sex, age, and comorbidities. Mortality and healthcare utilization were the primary outcomes studied, with medical costs, quality of life, pain and function at 12 months assessed as secondary outcomes in a subgroup. Survival analysis, regression and Student-t testing were used with p

Children with muscular dystrophy (MD) offer a unique opportunity to measure the effect of weakness on gait efficiency as they experience weakness not usually accompanied by other disabilities affecting gait. Oxygen consumption measurements were collected from eight patients with MD and eight patients with cerebral palsy (CP). A statistically significant difference in oxygen cost and oxygen consumption while walking between patients with CP and patients with MD was found despite their common inability to walk similar distances. Oxygen cost and oxygen consumption were elevated within the CP population, whereas all measurements for the MD population were within normal ranges. The measurements show that a patient can have normal oxygen cost and oxygen consumption while walking and yet be functionally limited because of weakness. Caution should be taken when using oxygen cost and oxygen consumption as sole outcome measures for patients with CP, because these measures may be insensitive to changes in strength.

Dynamic foot-pressure measurements are time-sensitive measurements of the pressures under the foot while walking. Historically, many methods are used to measure these pressures; however, current medical literature does not contain a method suitable for the evaluation of pediatric orthopaedic foot deformities. A method for the measurement of dynamic foot pressure for the treatment of pediatric orthopaedic foot deformities was defined in this study. We established the dynamic foot-pressure pattern of a normal population using this method. Dynamic foot-pressure measurements were collected from 54 normal subjects (108 feet). These measurements were divided into the following five segments: the heel, the lateral midfoot, the medial midfoot, the lateral forefoot, and the medial forefoot. Standard tables and graphs were created describing the normal progression of pressure across each segment of the foot while walking. These standard tables and graphs can be used as a reference with which clinical measurements can be compared. This method may be useful as a diagnostic measure of foot deformities and may increase the clinician's ability to measure changes in foot deformity resulting from treatment intervention.

Oxygen consumption measurements made on five repeated tests from five children with cerebral palsy (CP) and five nondisabled children of similar age and size were collected using the Cosmed K2 (Cosmed, Rome, Italy) oxygen-analysis system at free-walking velocity. Oxygen cost, oxygen consumption, and physiological cost index (PCI) were measured. There were no statistically significant differences in the percentage of variability of oxygen cost, oxygen consumption, or PCI between the disabled and nondisabled populations. Oxygen cost was the most reliable oxygen-use measurement with an average percentage of variability of 13.2% for the CP population and 13.9% for the nondisabled population. Physiological cost index was found be the least reliable measurement with the average percentages of variabilities of the disabled and nondisabled populations of 20.3 and 20.5%, respectively. Thus because of oxygen cost's relatively low variability, it was the most sensitive measurement of change in gait efficiency.