Risk Factors for Early Postoperative Morbidity and Mortality following Extremity Metastatic Pathologic or Impending Fracture Fixation.

Background: As cancer survivorship continues to improve, the perioperative morbidity and mortality following surgical treatment of metastatic bone disease become an increasingly important consideration. The objective of this study is to identify risk factors for early postoperative complications and mortality following extremity prophylactic fixation and pathologic fracture stabilization. Methods: A single-centre retrospective review of 185 patients (226 total surgeries) who underwent prophylactic fixation or pathologic fracture stabilization for extremity metastatic bone disease between 2005 and 2020 was performed. Skull, spine, pelvic, and revision surgeries along with diagnosis of primary bone neoplasm were excluded. Univariate, multivariate, and subgroup analyses were performed to identify predictors and independent risk factors for 30-day postoperative morbidity and mortality. Results: Primary cancers included lung (n = 41), breast (n = 36), multiple myeloma (n = 35), prostate (n = 16), lymphoma (n = 11), renal cell carcinoma (n = 10), and other (n = 36). The 30-day postoperative complication and mortality rates were 32.30% (n = 73) and 17.26% (n = 39), respectively. The most common complications were pulmonary-related, cardiac events, surgical site infection, sepsis, and thromboembolism. Pathologic fracture, presence of extra-skeletal metastases, longer surgical duration, and blood transfusion requirements were associated with 30-day postoperative complications overall. A past medical history for cardiac disease was also associated with systemic but not local surgical complications. Pathologic fracture, presence of extra-skeletal metastases, lung cancer, blood transfusion requirements, and increasing pack-year smoking history were predictors for 30-day mortality. In the multivariate analysis, pathologic fracture (p=0.016) and presence of extra-skeletal metastases (p=0.029) were independent predictors of complications. For mortality, pathologic fracture (p=0.014), presence of extra-skeletal metastases (p=0.0085), and increased blood transfusion requirements (p=0.048) were independent risk factors. Conclusions: The findings of this study provide additional guidance for perioperative risk assessment and patient counselling. Additionally, improving clinical assessment tools to identify and quantify patients at risk of pathologic fractures becomes increasingly important given the significant morbidity and mortality associated with pathologic fracture treatment.

High-Energy Transsyndesmotic Ankle Fracture Dislocation-Does Deltoid Ligament Repair Influence the Progression of Posttraumatic Arthritis in Logsplitter Injuries?

OBJECTIVE: To determine the effect of deltoid ligament repair on the development of posttraumatic arthritis in logsplitter ankle injuries. DESIGN: Retrospective cohort. SETTING: Academic, Level I trauma center. PATIENT SELECTION CRITERIA: Patients ≥18 years of age with logsplitter injuries (OTA/AO 44B, 44C) treated with open reduction internal fixation (ORIF) with or without deltoid ligament repair from January 2008 to October 2021. OUTCOME MEASURES AND COMPARISON: The rate of posttraumatic arthritis (PTOA) development at the final follow-up (minimum 6 months) after ORIF was evaluated using the Kellgren-Lawrence scale. The achievement of acceptable reduction indicated by articular reduction <2 mm, and a medial clear space ≤4 mm was assessed at 6 weeks postoperatively with weight-bearing radiographs. The effect of deltoid ligament repair on the development of PTOA was investigated. RESULTS: Fifty-nine patients aged 49.1 ± 17.2 years met inclusion criteria with a mean follow-up of 16.6 months (range = 6 to 96). Twenty-six of 59 patients (44%) had developed PTOA at the final follow-up. Acceptable reduction was achieved in 83.1% (49/59) of fractures. The acceptable reduction rate in fractures undergoing deltoid ligament repair was 100% versus 78% in those without deltoid ligament repair (13/13 vs. 36/46, P = 0.017). The rate of PTOA development was significantly lower in patients who underwent deltoid ligament repair (15%) than those who did not (52%), P = 0.026. Patients who underwent deltoid ligament repair had a significantly reduced rate of PTOA development leading to arthrodesis compared with those who did not (0% vs. 17%, P = 0.013). CONCLUSIONS: Logsplitter injuries resulted in a high rate of development of posttraumatic arthritis. An acceptable reduction is required to minimize the risk of development of PTOA and progression to arthrodesis. Deltoid ligament repair during ORIF may facilitate acceptable reduction and decrease the rate of PTOA and progression to arthrodesis in these injuries. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Factors Predictive of Early Complications Following Total Ankle Arthroplasty.

Background: The safety of outpatient total ankle arthroplasty (TAA), and factors predictive of early complications are poorly understood. The objective of this study was to determine the frequency of early complications in patients undergoing outpatient TAA compared to a matched inpatient TAA cohort. Factors predictive of early complications following TAA are elucidated. Methods: A retrospective review of prospectively collected data from the 2011-2018 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was performed. An unadjusted analysis comparing complication rates in outpatient, and inpatient TAA was performed followed by a propensity score-matched cohort analysis. A multivariate logistic regression model was then used to identify significant independent predictors for complications, reoperation, and readmission following TAA. Results: A total of 1487 patients (198 outpatient, 1289 inpatient) undergoing TAA were included in the study. Inpatient TAA was associated with increased 30-day readmission compared with outpatient TAA (3.54% vs 0.51%, P = .032) in a matched cohort analysis. Thirty-eight (2.6%) patients had a minor complication, with 16 (1.1%) patients having a major complication after TAR. Nineteen (1.3%) patients underwent reoperation, and 42 (2.8%) patients were readmitted within 30 days of the index TAR. Multivariate analysis identified factors predictive of early complications to include length of stay (LOS) >2 days, smoking, hypertension, bleeding disorders, and diabetes mellitus. Conclusion: From this relatively limited data set, outpatient TAA appears to be safe for management of end-stage ankle arthritis in select patients. Inpatient status was associated with an increased rate of 30-day readmission following TAA. Postoperative length of stay >2 days, smoking, hypertension, bleeding disorders, and diabetes mellitus were identified to be associated with early postoperative complications following TAA in this cohort. Level of Evidence: Level III, retrospective cohort study.

Early radiographic outcomes following deltoid ligament repair in bimalleolar equivalent ankle fractures.

BACKGROUND: Indications for deltoid ligament repair in bimalleolar equivalent ankle fractures are unclear. This study compared radiographic outcomes in bimalleolar equivalent ankle fractures undergoing open reduction internal fixation (ORIF) +/- deltoid ligament repair. METHODS: A retrospective review of 1024 ankle fractures was performed. Bimalleolar equivalent injuries treated with ORIF +/- deltoid ligament repair were included. Radiographic assessment was performed preoperatively, and at three months postoperatively. RESULTS: One hundred and forty-seven ankle fractures met inclusion criteria with 46 undergoing deltoid ligament repairs. There was a significant decrease in medial clear space (1.93 ± 0.65 mm vs. 2.26 ± 0.64 mm, p = 0.01), and tibiofibular clear space (3.89 ± 1.20 mm vs. 4.87 ± 1.37 mm, p = 0.0001) at 3 months postoperative in the deltoid repair group compared to the no repair group. When syndesmotic fixation was performed, there were no differences between groups. CONCLUSION: Deltoid ligament repair in bimalleolar equivalent ankle fractures resulted in reduced medial clear space, and tibiofibular clear space in the early postoperative period. These differences were small and remained within established normal limits. LEVEL OF CLINICAL EVIDENCE: Level III, retrospective cohort study.

Short Versus Long InterTAN Fixation for Geriatric Intertrochanteric Hip Fractures: A Multicentre Head-to-Head Comparison.

OBJECTIVE: To determine if geriatric intertrochanteric hip fracture patients achieve equivalent postoperative functional status after management with either a short (180-200 mm) or a long (260-460 mm) InterTAN intramedullary device. DESIGN: Retrospective review of a prospective randomized control trial. SETTING: Four Level I Trauma Centers. PATIENTS/PARTICIPANTS: One hundred eight patients with OTA/AO classification 31A-1 and 31A-2 intertrochanteric hip fractures were included in the study. INTERVENTION: Internal fixation using an IT device. MAIN OUTCOMES MEASURES: Primary outcomes included Functional Independence Measure and Timed Up and Go. Secondary outcomes included blood loss, surgical time, length of stay, adverse events, and mortality. RESULTS: Seventy-one short and 37 long IT patients met study inclusion criteria. Demographics were similar between groups. There was no difference in Functional Independence Measure or Timed Up and Go scores between the 2 IT groups at any of the time points collected. Mean operative time was lower in the short IT group than in the long IT group (60 vs. 73 minutes; P = 0.021). A higher proportion of long IT patients had reamed constructs (95% vs. 48% short IT, P < 0.001). Postoperative blood loss was significantly higher in the long IT group without a significant influence on the number of patients requiring transfusion (P = 0.582) or average units transfused (P = 0.982). There was no significant difference in the proportion of postoperative adverse events between the 2 cohorts despite a higher number of peri-implant femur fractures in the short IT group than in the long IT group (5 vs. 1, P = 0.350). CONCLUSIONS: Postoperative functional status was not influenced by the length of IT device in the management of geriatric intertrochanteric hip fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Multicenter Randomized Control Trial Comparing a Novel Intramedullary Device (InterTAN) Versus Conventional Treatment (Sliding Hip Screw) of Geriatric Hip Fractures.

OBJECTIVES: To compare outcomes in elderly patients with intertrochanteric hip fractures treated with either the sliding hip screw (SHS) or InterTAN intramedullary device (IT). DESIGN: Prospective, randomized, multicenter clinical trial. SETTING: Five level 1 trauma centers. PATIENTS: Two hundred forty-nine patients 55 years of age or older with AO/OTA 31A1 (43) and OA/OTA 31A2 (206) fractures were prospectively enrolled and followed for 12 months. INTERVENTION: Computer generated randomization to either IT (n = 123) or SHS (n = 126). MAIN OUTCOME MEASUREMENTS: The Functional Independence Measure (FIM) and the Timed Up and Go test (TUG) were used to measure function and motor performance. Secondary outcome measures included femoral shortening, complications, and mortality. RESULTS: Demographics, comorbidities, preinjury FIM scores and TUG scores were similar between groups. Patients (17.2%) who received an IT had limb shortening greater than 2 cm compared with 42.9% who received an SHS (P < 0.001). To determine the importance of preinjury function and fracture stability, we analyzed the subgroup of patients with the ability to walk 150 m independently preinjury and an OA/OTA 31A-2 fracture (n = 70). In this subgroup, patients treated with SHS had greater shortening and demonstrated poorer FIM and TUG scores compared with patients treated with an IT. CONCLUSIONS: Overall, most patients with intertrochanteric femur fractures can expect similar functional results whether treated with an intramedullary or extramedullary device. However, active, functional patients have an improved outcome when the InterTAN is used to treat their unstable intertrochanteric fracture. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Functional and radiographic results of patients with syndesmotic screw fixation: implications for screw removal.

OBJECTIVE: Screw fixation of the injured syndesmosis restores stability but may reduce motion. The purpose of this study is to determine whether functional outcomes and radiographic results after ankle fracture are affected by the status of the syndesmosis screw. DESIGN: Retrospective review of a consecutive clinical series. SETTING: Level 1 academic trauma center. PATIENTS: One hundred six adults were reviewed radiographically; mean follow up was 15 months (range, 4-30 months). Seventy-six of the 106 patients completed formal functional testing; mean follow up was 23 +/- 13 months (range, 12-32 months). INTERVENTION: Open reduction and internal fixation, including fixation of the tibiofibular syndesmosis. MAIN OUTCOME MEASUREMENTS: Patients with intact, broken or loose, or removed syndesmosis screws were compared. Functional outcomes were measured using the Lower Extremity Measure and the Olerud Molander ankle score. Radiologic review included tibiofibular clear space, tibiofibular overlap, and medial clear space. RESULTS: Functional outcomes were improved in patients with fractured, loosened, or removed screws compared with those with intact screws. The Lower Extremity Measure score for patients with intact screws was 70 +/- 6 compared with 85 +/- 3 for fractured, loosened, or removed screws (P = 0.01). The Olerud Molander ankle score for patients with intact screws was 47 +/- 8.0 compared with 64 +/- 4 for fractured, loosened, or removed screws (P = 0.04). There was no difference in outcome comparing fractured, loosened, and removed screws. The tibiofibular clear space was narrowed in patients with intact screws compared with removed, fractured, or loose screws. The tibiofibular clear space for intact screws was 3.1 +/- 0.2 compared with 4.1 +/- 0.2 for removed, fractured, or loosened screws (P = 0.005). There was no difference in outcome comparing large and small fragment screws. CONCLUSIONS: An intact syndesmosis screw was associated with a worse functional outcome compared with loose, fractured, or removed screws. However, there were no differences in functional outcomes comparing loose or fractured screws with removed screws. Screw removal is unlikely to benefit patients with loose or fractured screws but may be indicated in patients with intact syndesmosis screws.

Functional outcome and persistent disability after isolated fracture of the femur.

BACKGROUND: The purpose of this study was to assess the functional outcome and causes of persistent disability in patients with isolated femoral shaft fractures treated at an academic level-1 trauma centre. METHODS: We prospectively enrolled 40 consecutive skeletally mature patients with isolated, nonpathologic diaphyseal femur fractures. All patients underwent fracture reduction and fixation using an antegrade locked intramedullary nail. We measured functional outcome using the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index and the Short Musculoskeletal Functional Assessment (SMFA). We obtained visual analog scores for pain in the groin, buttock, thigh and knee 6 months after the injury. RESULTS: Joint-related and musculoskeletal outcome scores improved gradually from the baseline assessment to the 6-month review. Mean scores (and standard deviations [SDs]) on the WOMAC index improved gradually from 57 (23) to 24 (22) for pain, from 57 (25) to 30 (20) for stiffness and from 70 (21) to 21 (23) for function (p < 0.001). The mean SMFA score (and SD) improved from 64 (13) to 25 (20) (p = 0.024). We noted no further improvements in functional outcome measures from the 6-month to the 12-month assessment (p > 0.21). Patients reported more pain in the knee than in other anatomic locations; the mean pain scores (and SDs) were 3.7 (3.1) in the knee, 2.5 (2.7) in the thigh, 1.7 (2.7) in the buttock and 1.0 (1.7) in the groin (p = 0.003). We noted correlations between knee pain and WOMAC pain (rho = 0.748, p < 0.001), function (rho = 0.701, p < 0.001) and SMFA (rho = 0.733, p < 0.001). We noted weaker correlations between thigh, groin and buttock pain and functional outcomes, with rho scores ranging from 0.2 to 0.55. CONCLUSION: Recovery from femur fractures occurs most rapidly in the first 6 months after injury. Residual deficits in functional outcome were still measurable 12 months after injury. Knee pain was the most common and most severe source of patient discomfort 12 months after isolated femur fractures, and demonstrated moderate to good correlation with general and joint-specific functional outcome measures.

Quieting Weinberg 5C: a case study in hospital noise control.

Weinberg 5C of Johns Hopkins Hospital is a very noisy hematological cancer unit in a relatively new building of a large medical campus. Because of the requirements for dealing with immuno-suppressed patients, options for introducing sound absorbing materials are limited. In this article, a case study of noise control in a hospital, the sound environment in the unit before treatment is described, the chosen noise control approach of adding custom-made sound absorbing panels is presented, and the impact of the noise control installation is discussed. The treatment of Weinberg 5C involved creating sound absorbing panels of 2-in.-thick fiberglass wrapped in an anti-bacterial fabric. Wallpaper paste was used to hold the fabric to the backing of the fiberglass. Installation of these panels on the ceiling and high on corridor walls had a dramatic effect. The noise on the unit (as measured by the equivalent sound pressure level) was immediately reduced by 5 dB(A) and the reverberation time dropped by a factor of over 2. Further, this drop in background noise and reverberation time understates the dramatic impact of the change. Surveys of staff and patients before and after the treatment indicated a change from viewing the unit as very noisy to a view of the unit as relatively quiet.

Comminuted talar neck fractures: a mechanical comparison of fixation techniques.

OBJECTIVE: To compare the mechanical performance of 3 fixation techniques for comminuted talar neck fractures. DESIGN: In vitro biomechanical study. SETTING: Bioengineering research laboratory. PARTICIPANTS: Thirty previously frozen human cadaveric tali were osteotomized across the talar neck. A wedge of bone 2 cm long and extending 50% of the medial to lateral and superior to inferior dimension of the talus was removed to create an unstable, comminuted fracture. INTERVENTION: The specimens were randomized to one of 3 fixation groups. The first group was fixed with 3 anterior-to-posterior screws. The second group was fixed with 2 cannulated screws inserted from posterior to anterior. The third group was fixed with 1 screw from anterior to posterior and a medially applied blade plate. Specimens were embedded in acrylic cement and mounted on an Instron mechanical testing machine. Loading was applied in the dorsal-medial direction to failure. MAIN OUTCOME MEASURES: For each specimen, the load-displacement curve, yield point, and 3 mm displacement point were recorded in response to controlled dorsal-medial loading to failure. Stiffness was calculated as the linear portion of the slope of the load (kN) versus displacement (mm) curve. Statistical analysis of the data was conducted using analysis of variance. RESULTS: The mean yield point of each of the fixation techniques tested exceeded 1.4 kN. No statistically significant difference was found between the fixation methods, even when variations in age and sex were considered. CONCLUSIONS: The mean yield point of the fixation techniques tested exceeds the theoretical stress across the talar neck during active motion. Anterior plate fixation provided equivalent stability to posterior screw fixation.

High tibial osteotomy with use of the Taylor Spatial Frame external fixator for osteoarthritis of the knee.

BACKGROUND: High tibial osteotomy (HTO) is used to treat medial compartment osteoarthritis of the knee in active patients with varus alignment. In this study we review the clinical and radiographic outcomes associated with the Taylor Spatial Frame (Smith & Nephew), and its use in HTOs, and we include an illustrative case report. METHODS: In 7 patients with medial compartment osteoarthritis of the knee and varus alignment, the Taylor Spatial Frame was applied to the tibia in the operating room and a proximal tibial osteotomy was performed. Patients followed a computer-generated turning schedule until the desired correction was achieved. The frame was removed when the osteotomy site had healed. The lower extremity measure (LEM) was used to assess physical function. Clinical outcome measures relating to the Taylor Spatial Frame included latency, time to correction, time in the frame, number of residual corrections and complications. Radiographic outcomes included preoperative Resnick grades of osteoarthritis, pre- and post-correction limb alignment and tibial slope measurements. RESULTS: Average (and standard deviation) LEM grade at a mean 41 (14) months follow-up after correction was 94% (5%). Average latency was 8 days, time to correction was 15 days, time in the frame was 23 weeks and number of residual corrections was 1.3. Complications were similar to those for external fixators. Radiographic correction goals were met in all patients. CONCLUSION: The Taylor Spatial Frame is a valuable asset when using HTO to treat medial compartment osteoarthritis of the knee.

Intraoperative diagnosis of syndesmosis injuries in external rotation ankle fractures.

OBJECTIVE: This study was designed to compare intraoperative fluoroscopic stress testing, static radiographs, and biomechanical criteria for the diagnosis of distal tibiofibular syndesmotic instability associated with external rotation type ankle fractures. DESIGN: Prospective, consecutive series. SETTING: Academic level 1 trauma center. PATIENTS/PARTICIPANTS: Thirty-eight skeletally mature patients with unstable unilateral external rotation ankle fractures were prospectively recruited. INTERVENTION: Before surgery, the treating surgeon detailed the operative treatment plan, including need for syndesmotic fixation. In pronation-external rotation injuries, biomechanical criteria were applied to predict syndesmotic instability. Ankles were examined using intraoperative fluoroscopic external rotation stress tests. The contralateral uninjured limb was used as a control. A 7.2-Nm force was applied for the external rotation stress examination. Stress testing was performed after lateral malleolar fixation and repeated after medial and syndesmotic fixation. MAIN OUTCOME MEASURES: The incidence of syndesmotic instability was determined based on radiographic clear space measurements and compared with previously published criteria. RESULTS: Intraoperative fluoroscopy detected unpredicted syndesmotic instability in 37% of ankles. In supination-external rotation (OTA 44B) injuries, unpredicted syndesmosis instability was found in 10 of 30 patients (33%). In pronation-external rotation injuries (OTA 44C), 4 of 7 patients (57%) were associated with syndesmosis disruption not predicted by biomechanical criteria. In bimalleolar fractures, syndesmosis fixation improved stability compared with rigid bimalleolar fixation alone (P < 0.01). CONCLUSIONS: Preoperative radiographs and biomechanical criteria are unable to routinely predict the presence or absence of syndesmosis instability. Rigid bimalleolar fixation was frequently not sufficient to stabilize syndesmotic disruption. Intraoperative stress fluoroscopy is a valuable tool for detection of unstable syndesmotic injuries.

Morbidity resulting from the treatment of tibial nonunion with the Ilizarov frame.

OBJECTIVE: To determine the sources and magnitude of residual morbidity after successful treatment of tibial nonunion using the Ilizarov device and techniques. DESIGN: A retrospective cohort study. SETTING: A level 1 trauma centre. PATIENTS: Sixteen patients with healed tibial nonunion. INTERVENTION: Application of the Ilizarov device and techniques to obtain union of a previous ununited tibial fracture. MAIN OUTCOME MEASURES: Patient satisfaction and sources of morbidity through clinical review and a visual analogue scale. Two disease-specific outcome measurement scales were used to assess ankle dysfunction. Radiographs were examined to determine the presence of arthrosis. RESULTS: Residual pain was present in over 90% of patients at a mean follow-up of 39 months: in 80% the worst pain was in the ankle, less than 10% felt the worst pain in the knee or at the fracture site. Mean ankle osteoarthritis scores were 3.4 for pain and 4.0 for disability, compared with 0.76 and 0.90 respectively for age-matched controls. Mean ankle-hindfoot scores were between 64 and 100. CONCLUSION: Ankle pain with disability is the major source of residual disability after successful use of the Ilizarov device for the treatment of tibial nonunion.