Comparison of Patient Demographics and Risk of Surgical Site Infections Following Open Reduction and Internal Fixation of Trimalleolar Ankle Fractures: A Nationwide Analysis of a Private Payor.

Surgical site infections (SSIs) are a notable complication following open reduction and internal fixation (ORIF) for ankle fractures. The purpose of this study was to (1) compare baseline demographics of patients who did and did not develop SSIs within 90 days following ORIF for trimalleolar ankle fractures and (2) identify risk factors associated with SSIs in this setting. A retrospective analysis from 2010 to 2020 was completed using a national administrative database. The study group consisted of patients who underwent ORIF for trimalleolar ankle fractures and developed SSIs within 90 days postoperatively. Patients without SSIs served as the comparison cohort. Baseline demographics of the two cohorts were compared utilizing Pearson's Chi-Square Analyses. A multivariate binomial logistic regression model determined the association of various comorbidities on developing SSIs in this setting. Out of a total sample of 22,118 patients, 1000 individuals (4.52%) developed SSIs. The study revealed that the SSI cohort exhibited a greater burden of comorbidities, as evidenced by significant differences in various individual comorbidities and average Elixhauser-Comorbidity Indices scores. The most strongly associated risk factors for the development of SSIs following ORIF for trimalleolar ankle fractures were peripheral vascular disease (OR: 1.53, p < .0001), diabetes mellitus (OR: 1.26, p = .0010), iron deficiency anemia (OR: 1.24, p = .0010), male sex (OR: 1.22, p = .0010), and tobacco use (OR: 1.15, p = .0010). This study identified several patient risk factors that were associated with developing SSIs after ORIF for trimalleolar ankle fractures, recognizing potential patient-directed interventions that may reduce the rate of SSIs in this setting.

Comparison of patient demographics and patient-specific risk factors for readmissions following open reduction and internal fixation for acetabular fractures.

PURPOSE: Acetabular fractures are highly complex injuries often resulting from high-energy trauma. The gold standard treatment for these injuries has become open reduction internal fixation (ORIF). The purpose of this study is to further this understanding and investigate how (1) patient demographics and (2) patient-specific risk factors affect 90-day readmission rates. METHODS: A retrospective, nationwide query of private insurance database from January 1st, 2010 to October 31st, 2020 was performed using ICD-9, ICD-10, and CPT codes. Patients who underwent acetabular ORIF and were readmitted within 90 days following index procedure were included, patients who were not readmitted served as controls. Patients were divided by demographics and specific risk factors associated with readmission. RESULTS: The query yielded a total of 3942 patients. Age and sex were found to be non-significant contributing risk factors to 90-day readmissions. Data also showed that statistically significant comorbidities included arrhythmia, cerebrovascular disease, coagulopathy, fluid and electrolyte abnormalities, and pathologic weight loss. CONCLUSION: This study illustrated how several patient-specific risk factors may contribute to increased 90-day readmission risk following acetabular ORIF. A heightened awareness of these comorbidities in patients requiring acetabular ORIF is required to improve patient outcomes and minimize rates of readmission. Further investigation is needed to improve patient outcomes, and increase awareness of potential post-operative complications in these higher-risk patient populations.

Social determinants of health in patients undergoing hemiarthroplasty: are they associated with medical complications, healthcare utilization, and payments for care?

INTRODUCTION: Social determinants of health (SDOH) have previously been shown to impact orthopedic surgery outcomes. This study assessed whether greater socioeconomic disadvantage in patients undergoing hemiarthroplasty following femoral neck fracture was associated with differences in (1) medical complications, (2) emergency department (ED) utilization, (3) readmission rates, and (4) payments for care. METHODS: A US nationwide database was queried for hemiarthroplasties performed between 2010 and 2020. Area Deprivation Index (ADI), a validated measure of socioeconomic disadvantage reported on a scale of 0-100, was used to compare two cohorts of greater and lesser deprivation. Patients undergoing hemiarthroplasty from high ADI (95% +) were 1:1 propensity score matched to a comparison group of lower ADI (0-94%) while controlling for age, sex, and Elixhauser Comorbidity Index. This yielded 75,650 patients evenly distributed between the two cohorts. Outcomes studied were 90-day medical complications, ED utilizations, readmissions, and payments for care. Multivariate logistic regression models were utilized to calculate odds ratios (ORs) of the relationship between ADI and outcomes. p Values < 0.05 were significant. RESULTS: Patients of high ADI developed greater medical complications (46.74% vs. 44.97%; OR 1.05, p = 0.002), including surgical site infections (1.19% vs. 1.00%; OR 1.20, p = 0.011), cerebrovascular accidents (1.64% vs. 1.41%; OR 1.16, p = 0.012), and respiratory failures (2.27% vs. 2.02%; OR 1.13, p = 0.017) compared to patients from lower ADIs. Although comparable rates of ED visits (2.92% vs. 2.86%; OR 1.02, p = 0.579), patients from higher ADI were readmitted at diminished rates (10.57% vs. 11.06%; OR 0.95, p = 0.027). Payments were significantly higher on the day of surgery ($7,570 vs. $5,974, p < 0.0001), as well as within 90 days after surgery ($12,700 vs. $10,462, p < 0.0001). CONCLUSIONS: Socioeconomically disadvantaged patients experience increased 90-day medical complications and payments, similar ED utilizations, and decreased readmissions. These findings can be used to inform healthcare providers to minimize disparities in care. LEVEL OF EVIDENCE: III.

Antegrade Flexible Nailing for Pediatric Metaphyseal-diaphyseal Junction Distal Radius Fracture, is it Safe?

Fractures involving the distal radius metaphyseal-diaphyseal junction (MDJ) present a unique challenge for pediatric orthopedic surgeons. These fractures are too proximal for percutaneous K -wire fixation and too distal for retrograde flexible nailing. The purpose of this study was to: (1) determine the safety of a described antegrade approach from the posterior interosseous nerve (PIN); (2) assess the efficacy of antegrade nailing in cases of distal MDJ fractures; and (3) describe a standardized lateral approach to the proximal radius. A cadaveric study was performed using 10 adult forearms. Anterograde flexinail was introduced at the proximal radius based on the described "safe zone". Distal MDJ fractures were created using osteotomes. We evaluated the distance between the entry point to the PIN in addition to the quality of the reduction for the fracture. The average distance between the entry point and piercing instrument to the PIN was 5.4 cm (range: 4.7 to 6.0 cm). When grouped based on sex, the average distance was significantly further for males (5.8 cm, range: 5.2 to 6.0 cm) versus females (4.9 cm, range: 4.7 to 5.2 cm), P =0.004. Fracture reduction was not maintained after the introduction of the antegrade flexible nail across the fracture site. For all specimens, >25% displacement was seen on the anterior-posterior imaging. Our modified lateral approach to the starting point in the proximal radius is safe as long as the entry point for antegrade flexible nailing stays proximal to the radial tuberosity during the lateral approach to the proximal radius while the elbow is flexed and the forearm pronated.

Comparison of patient demographics, utilization trends, and costs of total ankle arthroplasty and ankle fusion in the United States from 2010 to 2019.

INTRODUCTION: Contemporary studies evaluating utilization and trends of total ankle arthroplasty (TAA) and ankle fusion (AF) for tibiotalar osteoarthritis are sparse. Therefore, the purpose of this study was to utilize a nationwide administrative claims database from 2010 to 2019 to compare: (1) baseline demographics; (2) utilization, (3) in-hospital length of stay (LOS), and (4) costs of care. METHODS: Using the PearlDiver database, a retrospective query from January 1st, 2010 to December 31st, 2019 was performed for all patients who underwent TAA and AF for tibiotalar osteoarthritis. Baseline demographics, comorbidities, and geographic utilization were compared using Pearson Chi-square analyses. Linear regression was used to compare differences in procedure utilization and in-hospital LOS during the study interval. Reimbursements between the two cohorts during the study interval were compared. A p value less than 0.05 was statistically significant. RESULTS: In total, 14,248 patients underwent primary TAA (n = 5544) or AF (n = 8704). Patients undergoing AF were generally younger (< 60) with greater comorbidity burden driven by hypertension, diabetes mellitus, obesity, and tobacco use compared to TAA patients (p < 0.0001). Over the study interval, TAA utilization remained constant (912 vs 909 procedures; p = 0.807), whereas AF utilization decreased by 42.5% (1737 vs 998 procedures; p = 0.0001). Mean in-hospital LOS for patients undergoing TAA decreased (2.5 days vs. 2.0 days, p = 0.0004), while AF LOS increased (2.6 days vs. 3.5 days, p = 0.0003). Reimbursements for both procedures significantly declined over the study interval (TAA: $4559-$2156, AF: $4729-$1721; p < 0.013). CONCLUSION: TAA utilization remained constant, while AF utilization declined by 42.5% from 2010 to 2019. There was divergence in the LOS for TAA versus AF patients. Both procedures significantly declined by over 50% in reimbursements over the study interval.

Utilization Trends of Total Ankle Arthroplasty and Ankle Fusion for Tibiotalar Osteoarthritis: A Nationwide Analysis of the United States Population.

Introduction: Studies evaluating utilization and trends of total ankle arthroplasty (TAA) and ankle fusion (AF) are sparse. The purpose of this study was to use a nationwide administrative claims database to compare baseline demographics between TAA and ankle arthrodesis and to determine whether patients who had a TAA have increased rates of: (1) utilization, (2) in-hospital length of stay (LOS), and (3) costs of care. Methods: PearlDiver, a nationwide claims database was queried from 2005 to December 2013 for all patients who underwent primary TAA or AF for the treatment of osteoarthritis of the ankle and foot. Baseline demographics of age, sex, geographic distribution, and the prevalence of comorbidities comprising the Elixhauser comorbidity index (ECI) were compared between patients who had TAA and AF. Linear regression was used to compare differences in utilization and in-hospital LOS between the 2 cohorts during the study interval. Annual charges and reimbursement rates for TAA were assessed during the study period. A P value less than .05 was considered to be statistically significant. Results: A total of 21 433 patients undergoing primary TAA (n = 7126) and AF (n = 14 307) were included. Patients undergoing TAA had significantly greater ECI driven by arrythmias, congestive heart failure, diabetes mellitus, electrolyte/fluid disorders, iron deficiency anemia than patients undergoing AF (P < .001). From 2005 to 2013, TAA utilization increased from 21.5% to 49.4% of procedures (P < .0001). There was reduced in-hospital LOS over the time interval for patients with TAA compared with AF (2.15 days vs. 3.11 days, P < .0001). Total ankle arthroplasty reimbursements remained stable while charges per patient increased significantly from $40 203.48 in 2005 to doubling by the end of 2013 to $86 208.59 (P < .0001). Conclusion: This study demonstrated increased use of TAA compared to AF showing decreased in-hospital LOS and increased cost of care with stagnant reimbursement rates.Level of Evidence: Level III.

Sleep Apnea and Postoperative Medical Complications and Health Care Expenditures Following Open Reduction and Internal Fixation of Bimalleolar Ankle Fractures.

INTRODUCTION: Sleep Apnea (SA) is a common sleep disorder that increases postoperative morbidity. There is limited research on how SA influences outcomes following operative fixation of ankle fractures. Therefore, the aim of this study was to determine whether patients who undergo surgical fixation for bimalleolar ankle fractures have higher rates of medical complications and health care expenditures. METHODS: A retrospective review from January 1, 2005 to March 31, 2014 was conducted using the parts A and B Medicare Data from PearlDiver database. Patients with and without SA on the day of the primary open reduction and internal fixation (ORIF) of their bimalleolar ankle fractures were queried using the International Classification of Diseases, Ninth Revision codes. Welch'st-tests were used to compare costs of care. A multivariate binomial logistic regression model was used to calculate the odds ratio (OR) of adverse events. A P-value <.001 was considered statistically significant. RESULTS: There were 20 560 patients (SA = 3150; comparison cohort = 17 410) who underwent ORIF for bimalleolar ankle fractures during the study period. Sleep apnea patients were found to have significantly higher rates and odds of 90-day medical complications (21.42% vs 7.47%, OR: 3.11, P < .0001) and 90-day costs of care ($7213.12 vs $5415.79, P < .0001). CONCLUSION: This research demonstrates an increased risk of postoperative medical complications and health care costs among patients with SA undergoing ORIF for bimalleolar ankle fractures. LEVEL OF EVIDENCE: Therapeutic, Level IV: Retrospective.

Pediatric Snakebites: Comparing Patients in Two Geographic Locations in the United States.

BACKGROUND: Management of children with snakebites may vary based on subjective criteria, geographic, and climatic factors. We reviewed the incidence and management of snakebite injuries in children at two tertiary referral centers in separate geographic and climatic location to assess differences in management and outcomes of these patients. METHODS: After institutional review board approval, a retrospective chart review was performed for patients ≤18 years with snakebite injuries at emergency departments (ED) of two American College of Surgeons verified trauma centers (2006-2013). One center is in southeast US and experiences a sub-tropical climate whereas the other is in southwest US and experiences a semi-arid climate. Demographic and clinical parameters were extracted. RESULTS: A total of 108 patients (59% male), median age of 9 y (1 y-17 y), were included. Snake type was identified by bystanders in 55.5% cases; copperhead was the most common (37%) subtype. Approximately 30% of patients received antivenom. One quarter of all patients were discharged from the ED. Two patients received surgical intervention in the first 48 hours after presentation. Compared to patients who sustained a snakebite in semi-tropical regions, patients in semi-arid areas had shorter bite-to-ED time, presented directly to the referral center, were more frequently bitten by a rattlesnake, had longer lengths of hospital stay, required antivenom more frequently and at higher doses, and were more frequently admitted to the ICU. No differences were seen in gender, age at presentation, severity of wound, location of bite, abnormalities in coagulation profile or rate of admission to hospital amongst the two sites. CONCLUSIONS: Patients sustaining snakebites in semi-arid climates were more commonly exposed to dangerous snake types, resulting in higher antivenom requirement, as well as longer hospital stays and need for intensive monitoring. Although no fatalities were reported in our study, our data supports early transfer of snakebite victims to higher levels of care, especially in semi-arid or high-risk areas.

Unstable Ankle Fracture Fixation Using Locked Fibular Intramedullary Nail in High-Risk Patients.

Open reduction internal fixation is the gold standard for unstable ankle fracture fixation; however, complications in patients with multiple medical comorbidities are common. Intramedullary nail fixation of the fibula can help to mitigate these difficulties. A retrospective chart review was performed on all patients who underwent fixation for unstable ankle fracture between January 2015 and March 2016 at our level I trauma center. Comorbidities in the patient sample included were one or several of diabetes, renal disease, hypertension, advanced age with osteoporosis, hemorrhagic blisters, and alcoholism. The primary outcomes studied were wound complications, infections, and hardware failure or failure of fixation. Eighteen patients with a mean age of 61 years underwent fibular intramedullary nail fixation, all of whom were considered at high risk for postoperative complications. Patients presented with Weber B or C fracture patterns. All patients had syndesmotic fixation through the nail by one or two 3.5-mm tricortical screws. A medial malleolus was added if needed for stability. The average follow-up time was 291.1 (range 9 to 14 months) days. The prescribed range of time to weightbearing was 2 to 6 weeks. All patients maintained reduction of the fracture and had no wound complications. No syndesmotic screws broke postoperatively, although most patients to failed comply with the postoperative non-weightbearing restrictions. Intramedullary nailing of the fibula with syndesmotic intranail fixation is minimally invasive, quick, and provides adequate fixation strength. It offers a viable treatment option for patients at high risk for complications or who are suspected to have difficulty with follow-up or compliance.

Management of displaced midshaft clavicle fractures in adolescent patients using intramedullary flexible nails: A case series.

INTRODUCTION: Clavicle fractures are common injuries in adolescent patients. In this study we present our technique and results for treating non-comminuted displaced midshaft clavicle fractures using flexible intra medullary nails. METHODS: A retrospective review of prospectively collected data using the electronic medical record was performed. Adolescent patients presenting to a level one pediatric trauma center with acute displaced non comminuted clavicular shaft fractures who were treated with intra medullary flexible nails were included in this study. RESULTS: Seven adolescent patients with non-comminuted displaced mid shaft clavicle fractures were treated with flexible nails over a period of five and half years with an average follow up time of 10 months. The average age was 14.6 years (range 14-16), and a 2 mm nail was used in all cases. Closed reduction was obtained in five cases with only two cases needing open reduction to pass the nail. One patient had skin breakdown over the nail entry and had the nail removed in clinic two months after surgery, all other patients healed with no complication. Sports and full shoulder activity were allowed when radiographic healing was seen at an average 8 weeks. Implant removal was performed four of the seven patients. CONCLUSION: Flexible intramedullary nailing is an effective minimally invasive method for the treatment of displaced midshaft clavicle fractures in the adolescent population. The surgeon should be aware that a 2 mm nail is likely the optimal diameter, and the nail is difficult to pass beyond the lateral 2-3 cm of the distal segment due to canal narrowing, but passage further than this is not necessary to achieve stability and union. Following these pearls will allow the surgeon to successfully perform the procedure.

The impact of acute compartment syndrome on the outcome of tibia plateau fracture.

BACKGROUND: Acute compartment syndrome (ACS) is often associated with tibial plateau fractures and is a limb-threatening injury. Staged management through fasciotomy with delayed definitive fixation can prevent muscle necrosis and increase limb salvage rates. This procedure opens a large area for potential contamination and infection in the lower extremity. Recent studies have shown an increased risk of infection following fasciotomy and staged management for tibial plateau fractures. This study reports the rate of infection, delayed union, and nonunion in patients with this injury pattern. METHODS: This study was a retrospective chart review, which received institutional review board approval. It surveyed patient radiographs, clinical notes, and operating room reports from a level I trauma center between 2010 through 2016. RESULTS: The results demonstrated that 23 out of 221 consecutive patients with ACS of the lower extremity presented with tibial plateau fracture over a 65-month period. Of these 23 patients, four were lost to follow-up or died. Nineteen patient charts were surveyed, 63% were male (12/19) and 37% were female (7/19). One patient developed deep infection (5.3%). Three patients experienced delayed union (15.8%), and their fractures eventually achieved union without intervention. The mean time to union was 14 weeks. Schatzker type V/VI fractures were the most prevalent type of fractures seen among patients. CONCLUSION: The infection rate found is lower than in other recently published studies. The incidence of delayed union or nonunion of the fracture was also lower than in other publications in the literature. Early decompression through double- or single-incision fasciotomy does not increase the risk of infection or nonunion of the fracture. The delayed union rates found in this study are lower than those in previous studies. LEVEL OF EVIDENCE: Level IV prognostic.

Open Supracondylar-Intercondylar Fractures of the Femur Treatment With Taylor Spatial Frame.

OBJECTIVES: To evaluate the Taylor spatial frame (TSF) for primary and definitive fixation of open supracondylar-intracondylar femoral (SIF) fractures. DESIGN: Retrospective. SETTING: Level I trauma center. PATIENTS: Subset of 20 SIF open fractures treated with TSF extracted from a consecutive series of 80 SIF fractures treated between 2007 and 2013. INTERVENTION: Eighteen (90%) fractures underwent definitive fixation with the TSF; 2 were treated primarily within 24 hours of injury. Mean time interval between primary treatment and secondary TSF was 5 days. MAIN OUTCOME MEASUREMENTS: Clinical and radiological. RESULTS: Complete union was obtained in 17 (85%) fractures without additional surgery at an average of 33 weeks. Three nonunions and 1 malunion occurred. No deep infection occurred. Results based on Association for the Study and Application of the Method of Ilizarov criteria: 37% excellent, and 63% good for bone outcomes; 5% excellent, 58% good, and 37% fair for functional outcomes. Neer knee scores were 21% excellent, 68% good, and 11% fair. The mechanical lateral distal femoral angle and anatomic posterior distal femoral angle values were within normal range in 80% and 90% of patients, respectively. Abnormal mechanical axis deviation was observed in 4 (20%) cases (2 had associated tibia fractures). CONCLUSIONS: Primary and definitive fixation with the TSF are effective. Advantages include continuity of device until union, reduced risk of infection, early mobilization, restoration of primary defect caused by bone loss, easy and accurate application, convertibility and versatility, and improved union rate and range of motion for SIF open fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Bone grafting via reamer-irrigator-aspirator for nonunion of open Gustilo-Anderson type III tibial fractures treated with multiplanar external fixator.

INTRODUCTION: The purpose of this investigation was to evaluate the outcomes following reamer-irrigator-aspirator (RIA) autogenous bone grafting (ABG) of high-grade open tibia fracture nonunions stabilized via multiplanar external fixation. METHODS: We retrospectively reviewed all patients with Gustilo-Anderson type III open tibia fractures treated with multiplanar external fixation and who underwent RIA ABG for nonunion at our institutional Level 1 Trauma Center between 2008 and 2015. All patients between 15 and 65 years of age with a minimum of six-month follow-up were included. The primary outcomes of interest were achievement of union, time to union, and incidence of revision surgery. Complications and all-cause reoperation were recorded as secondary endpoints. RESULTS: Fifteen patients met the inclusion criteria with a mean age of 41.1 ± 14.0 years. RIA ABG was harvested from the femur in all cases, with a mean volume of 34 ± 15 mL. At an average follow-up of 13.3 ± 6.8 months, all patients achieved union, including two who required repeat RIA ABG. One patient experienced a femoral shaft fracture four months following RIA that required intramedullary fixation. The average time to union was 6.0 ± 6.3 months. Twelve patients (80%) went on to union within six months and 13 (86.7%) within one year. Five patients experienced a total of six post-operative complications including three deep infections, one refracture through the nonunion site, and one gradual varus deformity. Two patients in this series required a subsequent RIA autografting procedure secondary to persistent nonunion despite initial RIA. CONCLUSION: We found that RIA ABG offered a reliable solution to nonunion of Gustilo-Anderson type III open tibial fractures treated with multiplanar external fixation, circumventing the need to change the method of fixation.

Plantar and Pedal Puncture Wounds in Children: A Case Series Study From a Single Level I Trauma Center.

OBJECTIVES: The purpose of this study was to describe our experience in treatment of pediatric patient presenting with pedal puncture wound to our level I trauma center and describe our results for the need for hospitalization and/or surgery for these patients. METHODS: Children and adolescents 18 years and younger presenting with pedal puncture wounds from September 2009 to December of 2013 were retrospectively studied. Exclusion criteria included adult patients, wounds related to animal bites, lacerations associated with a motor vehicle collision or all-terrain vehicle accidents, gunshot wounds, degloving injuries, or injuries resulting in complex lacerations to the foot. RESULTS: A total of 147 children presented to emergency department (ED) with a pedal puncture wound. Average age was 9.8 years. Prophylactic antibiotic therapy was administered in 107 cases (72.8%). Fifteen patients (10%) were treated with intravenous or intramuscular antibiotics in the ED or after hospital admission, 81 patients (55%) were treated with oral medications (prescribed for them to be taken after discharge), and 35 patients (24%) received topical antibiotic treatment. Of the 147 patients included in the study, 9 patients (6%) required the need for hospitalization. Two patients were admitted for parenteral antibiotic treatment only, and 7 patients required formal surgical debridement in the operating room in addition to parenteral antibiotic therapy. CONCLUSIONS: The majority of pediatric patients with pedal puncture wounds were treated in the ED with only a small percentage of patients requiring admission for either parenteral antibiotic treatment or formal surgical debridement.

Prophylactic Intramedullary Rodding Following Femoral Lengthening in Congenital Deficiency of the Femur.

INTRODUCTION: Femoral fracture after lengthening of congenital femoral deficiency (CFD) is a common complication with a high incidence, up to 50%. The purpose of this study is to determine whether prophylactic intramedullary Rush rodding after lengthening for CFD is an effective method to prevent femoral fracture and to assess any complications that may result. METHODS: Forty-five femoral lengthenings (43 CFD patients) were performed using external fixation. At the time of frame removal (except for 3 cases, 8 d later), prophylactic intramedullary Rush rods were inserted. Special reaming techniques were developed to pass a Rush rod through the solid regenerate bone and past sclerotic pin sites. Mean age at time of rodding was 6.9 years (range, 2.9 to 14.2 y). Mean duration of treatment with external fixation was 184 days (range, 146 to 461 d). Mean follow-up was 4.2 years (range, 1.3 to 8.2 y). This group of cases was compared with a historical cohort of 95 femoral lengthening procedures for CFD without prophylactic intramedullary rodding after frame removal previously performed at the same institute by the same surgeons. RESULTS: Eight cases (18%) developed fracture despite intramedullary rodding (1 case with relatively high-energy trauma, 3 cases during physical therapy, and 4 cases spontaneously). Only 4 of these fractures required intervention. Fractures were more common when a 3.18 mm Rush rod was used (28%) compared with 4.76 mm (8.3%). Patients with prophylactic rodding had a significantly lower incidence of femur fracture rodding than those who did not (18% vs. 34%, respectively; P=0.04). Three out of 45 Rush rods (7%) developed infection that were treated by debridement and removal of the rod, and all healed uneventfully without residual or recurrent infection. There were no cases of avascular necrosis. CONCLUSIONS: Prophylactic intramedullary rodding is a safe and effective method to prevent femoral fractures after CFD lengthening. Use of 4.76 mm rod is preferred. The risk of infection is acceptable, when compared with the risk of fracture, loss of length, and angulation. LEVEL OF EVIDENCE: Level III-a retrospective comparative study.

A New Technique for Obtaining Bone Graft in Cases of Distal Femur Nonunion: Passing a Reamer/Irrigator/Aspirator Retrograde Through the Nonunion Site.

Bone grafting is one of the most common orthopedic procedures. We conducted a study to assess the possibility of passing a Reamer/Irrigator/Aspirator (RIA; DePuy Synthes) retrograde through the nonunion site in distal femur cases. This technique would avoid the complications and discomfort associated with a separate entry site for RIA. All patients with a distal femur nonunion treated with RIA bone grafting between 2009 and 2013 were included in the study. Nonunions were mobilized with excision of fibrous tissues. The distal part was angulated into varus, and then the guide wire was passed from the nonunion site laterally. Five patients had a RIA passed retrograde through the nonunion site. Mean age of these patients was 40.4 years (range, 22-66 years). Mean reamer size was 13.4 mm (mode, 14 mm), producing an average bone graft volume of 33 mL. There were no intraoperative or postoperative fractures. In 1 case, the reamer shaft broke. Passing a RIA retrograde through the nonunion site in distal femur cases is reproducible, and the technique avoids the discomfort and pain associated with a separate entry point as well as the complication of eccentric reaming of the proximal and distal part of the femoral canal.

New Technique for Tibiotalar Arthrodesis Using a New Intramedullary Nail Device: A Cadaveric Study.

Introduction. Ankle arthrodesis is performed in a variety of methods. We propose a new technique for tibiotalar arthrodesis using a newly designed intramedullary nail. Methods. We proposed development of an intramedullary device for ankle arthrodesis which spared the subtalar joint using a sinus tarsi approach. Standard saw bones models and computer assisted modeling and stress analysis were used to develop different nail design geometries and determine the feasibility of insertion. After the final design was constructed, the device was tested on three cadaveric specimens. Results. Four basic nail geometries were developed. The optimal design was composed of two relatively straight segments, each with a different radius of curvature for their respective tibial and talar component. We successfully implemented this design into three cadaveric specimens. Conclusion. Our newly designed tibiotalar nail provides a new technique for isolated tibiotalar fusion. It utilizes the advantages of a tibiotalar calcaneal nail and spares the subtalar joint. This design serves as the foundation for future research to include compression options across the tibiotalar joint and eventual transition to clinical practice.

Pediatric pelvic pyomyositis: initial MRI can be misleading.

Pelvic pyomyositis is an infection of the skeletal muscles around the hip joint. Fever, hip pain, limp, and leukocytosis are common; however, the clinical picture is often vague. MRI is the current gold-standard imaging for pyomyositis. No studies in the current literature have reported an unremarkable initial MRI in a patient with symptomatic pyomyositis. An adolescent female presented with symptomatic pelvic pyomyositis, but admission MRI was normal. A follow-up MRI indicated development of pelvic pyomyositis. The patient was successfully managed nonoperatively. The initial MRI in pyomyositis can be misleading. Patients should be admitted and MRI should be repeated, as indicated clinically.

Ilio-Sacral (IS) Screw Fixation for Sacral and Sacroiliac Joint (SIJ) Injuries in Children.

BACKGROUND: Treatment of sacral fractures and sacroiliac joint (SIJ) disruption with percutaneous ilio-sacral (IS) screw fixation had become a more popular treatment option. There has been no study that specifically assessed IS fixation in children. The purpose of this study is present our results with fixation of the sacral fractures and SIJ disruption using IS screw in children 18 years old and younger. METHODS: This is a retrospective review chart for children with sacral fracture or SIJ disruption who were treated by IS fixation in the period from 2000 to 2012. The patients were assessed for the following (age, sex, type of injury, associated injuries, surgery, complications, postoperative return of function, healing of the injury, and return to function). RESULTS: In the studied period (2000 to 2012), 11 patients who had either sacral fracture (4 patients) or SIJ (7 patients) disruption were treated by IS screws. The average age of these patients was 14 years (range, 6 to 17 y). Six patients had 1 screw and 5 patients had 2 screws. Eight patients had their entire fixation in S1, and 3 patients had 1 screw in S1 and 1 screw in S2. All screws were cannulated and were inserted over a guidewire with fluoroscopy and/or navigation guidance. Five patients had added anterior fixation of the pelvis. One patient was lost for follow-up. All patients (except 1) achieved healing of their injuries with no displacement or implant failure with return of function. One patient had failure of fixation and needed revision. One patient had neurological complication related to screw insertion. CONCLUSIONS: IS screws can be safely used to treat sacral fractures and SIJ injuries in children. This was feasible in children as young as 6 years old. The complications of the procedure were minimal with good stability obtained by IS screws.

Outcomes of trochanteric external fixation for geriatric inter-trochanteric hip fractures.

INTRODUCTION: Trochanteric fractures are a leading cause of disability among the elderly. Internal fixation is the gold standard treatment. However, it may be challenging in the high-risk population. We present our results using external fixator in trochanteric fractures in the elderly. PATIENTS AND METHODS: During 2005-2012, twenty-three high-risk elderly patients (average age 70 years) with trochanteric fracture were managed using percutaneous external fixation (EF). RESULTS: At one year follow-up, 86% returned to pre-fracture ambulatory status. Average time to fixator removal was 14 weeks. There were no cases of pin loosening, breakage, or penetration of femoral head. CONCLUSION: Advantages of EF include avoidance of delay, use of local/regional anesthesia, and shorter duration of surgery, blood loss and hospital stay. EF is an acceptable alternative in this patient population, given the associated co-morbidities and especially due to limited resources in developing countries.