Evaluation of Intraoperative Fluoroscopic Techniques to Estimate Femoral Rotation: A Cadaveric Study.

OBJECTIVES: To compare three fluoroscopic methods for determining femoral rotation. METHODS: Native femoral version was measured by computed tomography in 20 intact femurs from 10 cadaveric specimens. Two Steinmann pins were placed into each left femur above and below a planned transverse osteotomy which was completed through the diaphysis. Four surgeons utilized the true lateral (TL), neck-horizontal angle (NH), and lesser trochanter profile (LTP) techniques to correct the injured femur's rotation using the intact right femur as reference, yielding 120 measurements. Accuracy was assessed by comparing the angle subtended by the two Steinmann pins before and after manipulation and comparing against version measurements of the right femur. RESULTS: Absolute mean rotational error in the fractured femur compared to its uninjured state was 6.0° (95% CI, 4.6-7.5), 6.6° (95% CI, 5.0-8.2), and 8.5° (95% CI, 6.5-10.6) for the TL, NH, and LTP techniques, respectively, without significant difference between techniques ( p = 0.100). Compared to the right femur, absolute mean rotational error was 6.6° (95% CI, 1.0-12.2), 6.4° (95% CI, 0.1-12.6), and 8.9° (95% CI, 0.8-17.0) for the TL, NH, and LTP techniques, respectively, without significant difference ( p = 0.180). Significantly more femurs were malrotated by >15° using the LTP method compared to the TL and NH methods (20.0% vs 2.5% and 5.0%, p = 0.030). Absolute mean error in estimating femoral rotation of the intact femur using the TL and NH methods compared to CT was 6.6° (95% confidence interval [CI], 5.1-8.2) and 4.4° (95% CI, 3.4-5.4), respectively, with significant difference between the two methods ( p = 0.020). CONCLUSIONS: The true lateral (TL), neck-horizontal angle (NH), and the lesser trochanter profile (LTP) techniques performed similarly in correcting rotation of the fractured femur, but significantly more femurs were malrotated by >15° using the LTP technique. This supports preferential use of the TL or NH methods for determining femoral version intraoperatively.

Patient Satisfaction Scores Are a Poor Metric of Orthopedic Care.

Patient satisfaction scores are a popular metric used to evaluate orthopedic care. There is little consistency with how satisfaction is described in the orthopedic literature. Online physician reviews are a growing trend that directly and indirectly affect a surgeon's reputation. There is little correlation of higher satisfaction with improved surgical outcomes, so rating surgical care may be misguided and possibly dangerous. Patient satisfaction is an important part of the patient-centered care model, so rating systems should directly reflect quality. More research is needed to determine the relationship between patient satisfaction and the delivery of quality care. [Orthopedics. 2022;45(3):e127-e133.].

Triceps Tenotomy as an Alternative Exposure for Fixation of OTA/AO 13-C Fractures: A Technical Trick.

SUMMARY: Intra-articular fractures of the distal humerus present challenges to treating physician and patient alike. The olecranon osteotomy is accepted as the standard exposure for intra-articular distal humerus fractures; nevertheless, complications such as nonunion and implant prominence are common. In this article, we describe the clinical outcomes and anatomic features of the triceps tenotomy as an alternative method of exposure for internal fixation of intra-articular distal humerus fractures. The olecranon osteotomy approach affords greater exposure of the distal humerus articular surface; however, there was no difference in quality of fracture reduction, progression to fracture union, posttraumatic arthrosis, or implant failure between approaches in our series. The osteotomy approach resulted in a greater need for reoperation (15% vs. 46%, respectively); largely as a result of olecranon implant-related complications. In summary, the triceps tenotomy offers an alternative exposure for intra-articular distal humerus fracture fixation with comparable clinical outcomes to the olecranon osteotomy technique.

The Cost of Malnutrition in Total Joint Arthroplasty.

BACKGROUND: Malnutrition is a known risk factor for complications and adverse outcomes after elective total joint arthroplasty (TJA), but little is known about the burden this risk factor places on the healthcare system. The purpose of this study was to evaluate the 90-day impact of malnutrition on medical and surgical complications and understand the increase in global reimbursements associated with TJA in malnourished patients. METHODS: We queried a combined private-payer and Medicare database from 2007 to 2016 for TJA using International Classification of Diseases, 9th revision and Current Procedural Terminology codes. Patients with serum albumin level of <3.5 g/dL were gender, age, and mean Elixhauser Comorbidity Index matched against a cohort with a normal serum albumin level. Odds ratios and confidence intervals were calculated for complications at 90 days postoperatively. Mean index and 90-day global reimbursements were calculated for the two matched groups and compared using P-values. RESULTS: 3053 protein malnourished patients receiving TJA were identified, and 12,202 matched protein nourished patients receiving TJA served as controls. At 90 days, the malnourished groups had increased risk for failure of multiple organ systems, periprosthetic joint infection, and reoperation. The mean 90-day increase in reimbursement was $3875 associated with performing a TJA on a protein malnourished patient (P < .001). CONCLUSION: This study demonstrates an association between malnourished patients and postoperative complications as well as significantly increased reimbursements. Understanding the reimbursement increases at 90 days for TJA in protein malnourished patients is important in the era of bundled payments.

Does the Coexistence of Multiple Segmental Rib Fractures in Polytrauma Patients Presenting With "Major" Vertebral Fracture Affect Care and Acute Outcomes?

OBJECTIVE: To determine whether operating on "major" vertebral fractures leads to premature abortion of surgery and/or other acute cardiopulmonary complications. DESIGN: Retrospective review. CLINICAL SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS AND INTERVENTION: We retrospectively queried our institutional Trauma Rregistry for all cases presenting with concomitant rib fractures and surgically managed vertebral fractures. MAIN OUTCOME MEASUREMENTS: The main outcomes included the surgical outcome (aborted vs. successfully performed), total and Intensive Care Unit length of stay (LOS), adverse discharge, mortality, and functional outcomes. RESULTS: We found 57 cases with concomitant segmental rib fractures and surgically managed vertebral fractures. Seven patients (12%) received a rib fixation, of which 1 received before vertebral fixation and 6 after. Importantly, 4 vertebral fixation cases (7.02%) had to be aborted intraoperatively because of the inability to tolerate prone positioning for surgery. For case-control analysis, we performed propensity score matching to obtain matched controls, that is, cases of vertebral fixation but no rib fractures. On matched case-control analysis, patients with concomitant segmental rib fractures and vertebral fractures were found to have higher Intensive Care Unit LOS [median = 3 days (Inter-Quartile Range = 0-9) versus. 8.4 days, P = 0.003], whereas total LOS, frequency of complete, incomplete or functional spinal cord injury, discharge to rehab, and discharge to nursing home were found to be similar between the 2 groups. CONCLUSION: Our findings demonstrate that segmental rib fractures with concomitant vertebral fractures undergoing surgical treatment represent a subset of patients that may be at increased risk of intraoperative cardio-pulmonary complications and rib fixation before prone spine surgery for cases in which the neurological status is stable is reasonable. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.