Psychiatric Diagnosis Does Not Influence Management or Resolution of Confirmed Fracture-Related Infection.

BACKGROUND: The purpose of this study was to determine if the presence of a standing Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, psychiatric diagnosis is associated with worse outcomes for patients who develop a confirmed fracture-related infection (FRI). MATERIALS AND METHODS: Included patients had open or closed fractures managed with internal fixation and had confirmed FRIs. Baseline demographics, injury information, and outcomes were collected via chart review. All patients who had a diagnosis of psychiatric illness, which included depression, bipolar disorder, anxiety disorder, and schizophrenia, were identified. Patients with and without a psychiatric diagnosis were statistically compared. RESULTS: Two hundred eleven patients were diagnosed with a confirmed FRI. Fifty-seven (27.0%) patients had a diagnosis of a psychiatric illness at the time of FRI diagnosis. Patients with a psychiatric diagnosis had a higher rate of smoking (56% vs 40%, P=.039) and drug use (39% vs 19%, P=.004) and a higher American Society of Anesthesiologists (ASA) classification (2.35±1.33 vs 1.96±1.22, P=.038); however, there were no other demographic differences. Clinical outcomes also did not differ between the groups, as patients with an FRI and a psychiatric diagnosis had a similar time to FRI diagnosis, similar confirmatory FRI characteristics, and a similar rate of reoperation. Furthermore, there was no difference between patients with FRI with and without a psychiatric diagnosis regarding rate of infection resolution (89% vs 88%, P=.718) or time to final follow-up (20.13±24.93 vs 18.11±21.81 months, P=.270). CONCLUSION: The presence of a psychiatric diagnosis does not affect clinical outcomes in the patient population with FRI. This is the first study exploring the impact of psychiatric illness on patient outcomes after a confirmed FRI diagnosis. [Orthopedics. 202x;4x(x):xx-xx.].

Pneumothorax After Superior Plating of Clavicle Fractures: Are the Concerns Warranted?

PURPOSE: The primary goal of this study was to determine the anatomic relationship between the clavicle and the apical lung segment. The secondary goal was to determine the incidence of pneumothorax (PTX) in patients who underwent clavicle ORIF to analyze the utility of postoperative chest radiographs. METHODS: Six hundred thirty-one patients with a midshaft clavicle fracture who underwent superior plating at a single institution were identified. Forty-two patients had a CT scan of the chest. Three points on the uninjured clavicle were defined: 2 cm from the medial end of the clavicle, the mid-point of the clavicle, and 2 cm from the lateral end of the clavicle. At each point, the distance from both the inferior cortex and the superior cortex of the clavicle to the apical lung segment was measured. All 631 patients who underwent Open Reduction and Internal Fixation had a postoperative chest radiograph to evaluate implant placement, restoration of clavicular length, and presence of PTX. RESULTS: From the lateral end of the clavicle, the mean distance of the lung was 60.0 ± 14.9 mm (20.1 to 96.1 mm) from the inferior cortex of the clavicle. At the mid-point, the mean distance of the lung was 32.3 ± 7.2 mm (20.4 to 45.5 mm) from the inferior cortex of the clavicle. At the medial end, the mean distance of the lung was 18.0 ± 5.5 mm (8.1 to 28.9 mm) from the inferior cortex of the clavicle. A review of postoperative radiographs for all 631 patients revealed none (0%) with a postoperative iatrogenic PTX. CONCLUSION: The risk of injury is minimal in all three zones. Postoperative chest radiographs after clavicle fracture repair to rule out PTX are unnecessary.

Thigh compartment syndrome: Outcomes in an urban level 1 trauma center.

INTRODUCTION: Thigh compartment syndrome (TCS) is a rare surgical emergency associated with a high risk of morbidity with mortality rates as high as 47 %. There is sparse literature discussing the management as well as outcomes of these injuries. The purpose of this study is to review a consecutive series of patients presenting to a single urban Level 1 trauma center with TCS to identify injury characteristics, clinical presentation, and outcomes associated with this injury. METHODS: A trauma database was queried for all patients with a diagnosis of TCS at a single level 1 urban trauma center between January 1, 2011 and December 31, 2021. Demographic and injury variables collected included age, sex, BMI, mechanism of injury, and creatine phosphokinase levels (CPK). Hospital quality measures including time from admission to surgery, length of both hospital and ICU stay, complications, and cost of care were collected. Descriptive statistics are reported as median [interquartile range] or N (percent). RESULTS: There were 14 patients identified with a diagnosis of TCS. All were men with an average age 33.5 [23.5 - 38] years and an average BMI of 26 [22.9-28.1]. The most common cause of injury was blunt trauma (71.4 %), and the remaining 28.6 % were gunshot wound injuries. Within the cohort, 6 (42.9 %) patients sustained a femoral shaft fracture, and 4 (28.6 %) patients sustained a vascular injury. The median initial CPK of patients within this cohort was 3405 [1232-5339] and reached a peak of 5271 [3013-13,266]. The median time from admission to diagnosis was 6.8 [0-236.9] hours. The median time from admission to the operating room was 8.2 [0.6-236.9] hours, and the median number of operating room visits was 3 [2 - 6]. Five patients (35.7 %) wounds were closed with split thickness skin grafting. There were 12 (85.7 %) patients who required ICU care. The median ICU length of stay was 7.5 days [4-15]. The median hospital length of stay was 16.5 days [13.25-38.0]. The median total charges for a patient with thigh compartment syndrome was $129,159.00 [$24,768.00 - $587,152.00]. The median direct variable cost for these patients was $86,106.00 For comparison, the median direct variable cost for patients with femur fractures without TCS at this institution was $8,497.28 [$1,903.52-$21,893.13]. No patients required readmission within 60 days. There were no mortalities. CONCLUSION: TCS is a rare and life-threatening injury associated with significant morbidity. Despite rapid diagnosis and fasciotomy, the majority of the patients have prolonged hospital courses, ICU lengths of stay, and significant costs of treatment. Providers can reference the outcomes reported in this study when caring for TCS patients.

The effect of traumatic head injuries on the outcome of middle-aged and geriatric orthopedic trauma patients.

BACKGROUND: The purpose of this study is to characterize the effects of head injuries amongst the middle-aged and geriatric populations on hospital quality measures, costs, and outcomes in an orthopedic trauma setting. METHODS: Patients with head and orthopedic injuries aged >55 treated at an academic medical center from October 2014-April 2021 were reviewed for their Abbreviated Injury Score for Head and Neck (AIS-H), baseline demographics, injury characteristics, hospital quality measures and outcomes. Univariate comparative analyses were conducted across AIS-H groups with additional regression analyses controlling for confounding variables. All statistical analyses were conducted with a Bonferroni adjusted alpha. RESULTS: A total of 1,051 patients were included. The mean age was 74 years, and median AIS-H score was 2 (range 1-6). While outcomes worsened and costs increased as AIS-H scores increased, the most drastic (and clinically relevant) rise occurs between scores 2-3. Patients who sustained a head injury warranting an AIS-H score of 3 experienced a significantly higher rate of major complications, need for ICU admission, inpatient and 1-year mortality with longer lengths of stay and higher total costs despite no differences in demographics or injury characteristics. Regression analysis found a higher AIS-H score was independently associated with greater mortality risk. CONCLUSION: AIS-H scores >2 correlate with significantly worse outcomes and higher hospital costs. Concomitant head injuries impact both outcomes and direct variable costs for middle-aged and geriatric orthopedic trauma patients. Clinicians, hospitals, and payers should consider the significant effect of head injuries on the hospitalization of these patients.

External fixation about the elbow: Indications and long-term outcomes.

Background: Operative management is often required for fractures of the elbow, with treatment goals aiming to restore stability, reduction, and early range of motion. The purpose of this study was to determine risk factors for necessitating the application of an external fixator, and to compare range of motion and functional outcomes between patients who required an elbow external fixator to those who did not. Hypothesis: We hypothesize that patients who require an external fixator will have worse elbow range of motion and functional outcomes when compared to those who did not. Patients and methods: This is a retrospective study of 391 patients who presented at a Level-I trauma center between March 2011 and January 2021 for operative management of a fracture/fracture-dislocation of the distal humerus (AO/OTA 13A-C) and/or proximal ulna and/or radius (AO/OTA 21A-C). A primary analysis was performed to determine risk factors for necessitating the application of an external fixator. A secondary analysis was performed comparing elbow range-of-motion and functional outcomes between cases and controls. Results: 391 patients were identified; 26 required external fixation (cases) and 365 did not (controls). Significant risk factors for necessitating placement of an external fixator included large BMI (OR = 1.087, 95 % CI = 1.007-1.173, p = 0.033), elbow dislocation (OR = 7.549, 95 % CI = 2.387-23.870, p = 0.001), open wound status (OR = 9.584, 95 % CI = 2.794-32.878, p < 0.001), and additional non-contiguous orthopaedic injury (OR = 9.225, 95 % CI = 2.219-38.360, p = 0.002). Elbow ROM was poorer in the external fixator group with regards to extension (-15°), flexion (+19.4°), and pronation (+14.3°) (p < 0.05). In addition, those who did not need external fixation had better functional scores (+20.4 points MEPI) (p < 0.05). Discussion: The use of external fixation about the elbow is associated with significantly worse initial injuries and results in poorer outcomes. These results can be used to inform the surgeon-patient discussion regarding treatment options and expected functional outcomes. Level of evidence: III.

Early Weight-bearing Following Surgical Treatment of Ankle Fractures Without Trans-syndesmotic Fixation Is Safe and Improves Short-term Outcomes.

OBJECTIVES: The objective of this study was to ascertain outcome differences after fixation of unstable rotational ankle fractures allowed to weight-bear 2 weeks postoperatively compared with 6 weeks. DESIGN: Prospective case-control study. SETTING: Academic medical center; Level 1 trauma center. PATIENT SELECTION CRITERIA: Patients with unstable ankle fractures (OTA/AO:44A-C) undergoing open reduction internal fixation (ORIF) were enrolled. Patients requiring trans-syndesmotic fixation were excluded. Two surgeons allowed weight-bearing at 2 weeks postoperatively (early weight-bearing [EWB] cohort). Two other surgeons instructed standard non-weight-bearing until 6 weeks postoperatively (non-weight-bearing cohort). OUTCOME MEASURES AND COMPARISONS: The main outcome measures included the Olerud-Molander questionnaire, the SF-36 questionnaire, and visual analog scale at 6 weeks, 3 months, 6 months, and 12 months postoperatively and complications, return to work, range of ankle motion, and reoperations at 12 months were compared between the 2 cohorts. RESULTS: One hundred seven patients were included. The 2 cohorts did not differ in demographics or preinjury scores ( P > 0.05). Six weeks postoperatively, EWB patients had improved functional outcomes as measured by the Olerud-Molander and SF-36 questionnaires. Early weight-bearing patients also had better visual analog scale scores (standardized mean difference -0.98, 95% confidence interval [CI] -1.27 to -0.70, P < 0.05) and a greater proportion returning to full capacity work at 6 weeks (odds ratio = 3.42, 95% CI, 1.08-13.07, P < 0.05). One year postoperatively, EWB patients had improved pain measured by SF-36 (standardized mean difference 6.25, 95% CI, 5.59-6.92, P < 0.01) and visual analog scale scores (standardized mean difference -0.05, 95% CI, -0.32 to 0.23, P < 0.01). There were no differences in complications or reoperation at 12 months ( P > 0.05). CONCLUSIONS: EWB patients had improved early function, final pain scores, and earlier return to work, without an increased complication rate compared with those kept non-weight-bearing for 6 weeks. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Is Postoperative Splinting Advantageous After Upper Extremity Fracture Surgery? Results From the Arm Splint Pain Improvement Research Experiment.

OBJECTIVES: The authors report no conflict of interest.To determine if short-term immobilization with a rigid long arm plaster elbow splint after surgery of the arm, elbow, or forearm results in superior outcomes compared with a soft dressing with early motion. DESIGN: Prospective Randomized Control Trial. SETTING: Academic Medical Center. PATIENT SELECTION CRITERIA: Patients undergoing operative treatment for a mid-diaphysis or distal humerus, elbow, or forearm fracture were consented and randomized according to the study protocol for postoperative application of a rigid elbow splint (10-14 days in a plaster Sugar Tong Splint for forearm fracture or a Long Arm plaster Splint for 10-14 for all others) or soft dressing and allowing immediate free range of elbow and wrist motion (range of motion [ROM]). OUTCOME MEASURES AND COMPARISONS: Self-reported pain (visual analog score or VAS), Healthscale (0-100, 100 denoting excellent health), and physical function (EuroQol 5 Dimension or EQ-5D) surveyed on postoperative days 1-5 and 14 were compared between groups. Patient-reported pain score (0-10, 10 denoting highest satisfaction) at week 6, time to fracture union, ultimate disabilities of the arm, shoulder, and hand score, and elbow ROM were also collected for analysis. Incidence of complications were assessed. RESULTS: Hundred patients (38 men to 62 women with a mean age of 55.7 years) were included. Over the first 5 days and again at postop day 14, the splint cohort reported a higher "Healthscale" from 0 to 100 than the nonsplint group on all study days ( P = 0.041). There was no difference in reported pain between the 2 study groups over the same interval ( P = 0.161 and 0.338 for least and worst pain, respectively), and both groups reported similar rates of treatment satisfaction ( P = 0.30). Physical function ( P = 0.67) and rates of wound problems ( P = 0.27) were similar. Additionally, the mean time to fracture healing was similar for the splint and control groups (4.6 ± 2.8 vs. 4.0 ± 2.2 months, P = 0.34). Ultimate elbow ROM was similar between the study groups ( P = 0.48, P = 0.49, P = 0.61, and P = 0.51 for elbow extension, flexion, pronation, and supination, respectively). CONCLUSIONS: Free range of elbow motion without splinting produced similar results compared with elbow immobilization after surgical intervention for a fracture to the humerus, elbow, and forearm. There was no difference in patient-reported pain outcomes, wound problems, or elbow ROM. Immobilized patients reported slightly higher "healthscale" ratings than nonsplinted patients and, however, reported similar rates of satisfaction. Both treatment strategies are acceptable after upper extremity fracture surgery. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Total Hip Arthroplasty is the Most Effective Treatment for Atraumatic Subchondral Insufficiency Fractures of the Femoral Head.

BACKGROUND: Subchondral insufficiency fracture of the femoral head (SIFH) is a relatively newly used diagnosisfollowing an insidious onset of hip pain in individuals without apparent antecedent trauma. The aim of this study was to investigate the outcomes of a consecutive series of patients with SIFH treated at one institution. METHODS: A total of 93 patients aged 23 to 91 years who were treated for SIFH in the outpatient clinics at one academic, urban medical center between August 2012 and August 2019 were identified. The diagnosis was made by magnetic resonance imaging or radiograph of the hip and was confirmed by a radiologist specialized in orthopedic surgery. Patient demographics, injury history, duration of pain, treatment type, and persistence of pain were recorded. RESULTS: Sixty-five (69.9%) patients with a mean age of 64.2 ± 9.4 years ultimately underwent total hip arthroplasty (THA). Twenty-eight (30.1%) patients chose no surgical intervention. Patients who underwent THA had less pain at their final follow-up appointment than patients who elected non-operative treatment (p < 0.001). At their final follow-up appointments, 92.9% of patients treated non-operatively reported pain, compared to only 13.8% of patients who underwent THA who had pain. Age, body mass index, and duration of pain prior to initial complaint did not affect presence of continued pain at final follow-up appointments, regardless of treatment type (p > 0.05). CONCLUSION: In the majority of patients, SIFH is often not sufficiently managed with non-operative treatments. Pain reported among patients with confirmed or suspected SIFH is usually severe and interferes with patients' ability to perform their activities of daily life. Total hip arthroplasty seems to be the most reliable method of treatment for this condition. Physicians who treat patients with SIFH should counsel them as to the expectations of recovery and the potential for poorer outcome if treated without THA.

Factors Associated With the Development of a Confirmed Fracture-Related Infection.

OBJECTIVES: To identify factors associated with the development of fracture-related infection (FRI) in patients who have undergone operative fixation of their fracture. DESIGN: Retrospective study. SETTING: Academic medical center. PATIENTS/PARTICIPANTS: Patients with peripheral extremity long-bone fractures and shoulder and pelvic girdle fractures who underwent operative repair. This included patients who had undergone fixation inside and outside of our institution. INTERVENTION: Chi-square, Fisher exact testing, analysis of variance (ANOVA), and t tests were used for analysis of data, as appropriate. Binomial logistic regression analysis was performed to determine risk factors of FRI. MAIN OUTCOME MEASUREMENTS: Demographics, fracture location, injury mechanism, open wound status, and wound complication type. RESULTS: One hundred ninety-three patients comprised the FRI cohort. Of those with confirmed signs of FRI, 36 (18.7%) had wound breakdown to bone or implant, 120 (62.1%) had a sinus track, and 170 patients (88.1%) had the confirmed presence of microorganisms in deep tissue samples obtained during operative intervention. Factors associated with development of an FRI were as follows: higher BMI; being of Black and Hispanic race; higher American Society of Anesthesiologists class; history of tobacco, alcohol, and drug use; and fractures of the lower extremity (foot, tibia, and femur/pelvis). The results of binary logistic regression demonstrated that treatment at an urban level I trauma center and drug use positively predicted the development of FRI. CONCLUSION: Our results demonstrate that higher BMI; being of Black or Hispanic race; higher American Society of Anesthesiologists; history of tobacco, alcohol, and drug use; and fractures of the foot, tibia, and femur/pelvis are all factors associated with development of FRI. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Monitored Anesthesia Care and Soft Tissue Infiltration with Local Anesthesia: An Anesthetic Option for High-Risk Patients with Hip Fractures.

SUMMARY: This review demonstrates the technique for monitored anesthesia care and soft tissue infiltration with local anesthesia as the only form of anesthesia for short cephalomedullary nailing in medically complex patients. Monitored anesthesia care is defined as providing sedation and analgesia that is titrated to a level that preserves spontaneous breathing and airway reflexes. Soft tissue infiltration refers to soft tissue infiltration with local anesthesia directly into the surgical site and is performed by the surgeon before the start of the procedure.

Acute Total Hip Replacement for Geriatric Acetabular Fracture: Anterior Intrapelvic Approach + Posterolateral Approach.

SUMMARY: This review describes the indications and technique for acute total hip arthroplasty in an incomplete both-column acetabular fracture in a geriatric patient.

Posteromedial Surgical Approach for Fixation of Haraguchi Type 2B Posterior Malleolar Fracture.

SUMMARY: A case of a 26-year-old man with a displaced medial malleolus fracture with extension into the posteromedial aspect of the posterior malleolus is presented. A CT scan of the ankle is obtained demonstrating a Haraguchi type 2B posterior malleolus fracture with a posteromedial and posterolateral fragment. The posteromedial fragment extends into the posterior colliculus of the medial malleolus and has a subchondral impaction fracture. There is also a 1 × 1 cm piece of the articular surface of the posterior malleolus that has flipped 90 degrees and lodged itself between the posterolateral fracture fragment. This video overview and case presentation demonstrates a posteromedial approach with fixation strategy for the posterior malleolus.

Effects of Intraoperative Local Pain Cocktail Injections on Early Function and Patient-Reported Outcomes: A Randomized Controlled Trial.

OBJECTIVE: To determine whether a perioperative pain cocktail injection improves postoperative pain, ambulation distance, and long-term outcomes in patients with hip fracture. DESIGN: Prospective, single-blinded, randomized controlled trial. SETTING: Academic Medical Center. PATIENTS/PARTICIPANTS: Patients with OTA/AO 31A1-3 and 31B1-3 fractures undergoing operative fixation, excluding arthroplasty. INTERVENTION: Multimodal local injection of bupivacaine (Marcaine), morphine sulfate (Duramorph), ketorolac (Toradol) given at the fracture site at the time of hip fracture surgery (Hip Fracture Injection, HiFI). MAIN OUTCOME MEASUREMENTS: Patient-reported pain, American Pain Society Patient Outcome Questionnaire (APS-POQ), narcotic usage, length of stay, postoperative ambulation, Short Musculoskeletal Function Assessment. RESULTS: Seventy-five patients were in the treatment group and 109 in the control group. Patients in the HiFI group had a significant reduction in pain and narcotic usage compared with the control group on postoperative day (POD) 0 ( P < 0.01). Based on the APS-POQ, patients in the control group had a significantly harder time falling asleep, staying asleep, and experienced increased drowsiness on POD 1 ( P < 0.01). Patient ambulation distance was greater on POD 2 ( P < 0.01) and POD 3 ( P < 0.05) in the HiFI group. The control group experienced more major complications ( P < 0.05). At 6-week postop, patients in the treatment group reported significantly less pain, better ambulatory function, less insomnia, less depression, and better satisfaction than the control group as measured by the APS-POQ. The Short Musculoskeletal Function Assessment bothersome index was also significantly lower for patients in the HiFI group, P < 0.05. CONCLUSIONS: Intraoperative HiFI not only improved early pain management and increased ambulation in patients undergoing hip fracture surgery while in the hospital, it was also associated with early improved health-related quality of life after discharge. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

One year later: How outcomes of hip fractures treated during the "first wave" of the COVID-19 pandemic were affected.

The purpose of this study was to assess the impact of COVID-19 on long-term outcomes in the geriatric hip fracture population. We hypothesize that COVID + geriatric hip fracture patients had worse outcomes at 1-year follow-up. Between February and June 2020, 224 patients > 55 years old treated for a hip fracture were analyzed for demographics, COVID status on admission, hospital quality measures, 30- and 90-day readmission rates, 1-year functional outcomes (as measured by the EuroQol- 5 Dimension [EQ5D-3L] questionnaire), and inpatient, 30-day, and 1-year mortality rates with time to death. Comparative analyses were conducted between COVID + and COVID- patients. Twenty-four patients (11%) were COVID + on admission. No demographic differences were seen between cohorts. COVID + patients experienced a longer length of stay (8.58 ± 6.51 vs. 5.33 ± 3.09, p < 0.01) and higher rates of inpatient (20.83% vs. 1.00%, p < 0.01), 30-day (25.00% vs. 5.00%, p < 0.01), and 1-year mortality (58.33% vs. 18.50%, p < 0.01). There were no differences seen in 30- or 90-day readmission rates, or 1-year functional outcomes. While not significant, COVID + patients had a shorter average time to death post-hospital discharge (56.14 ± 54.31 vs 100.68 ± 62.12, p = 0.171). Pre-vaccine, COVID + geriatric hip fracture patients experienced significantly higher rates of mortality within 1 year post-hospital discharge. However, COVID + patients who did not die experienced a similar return of function by 1-year as the COVID- cohort.

COVID-19 vaccination improved outcomes in the treatment of geriatric hip fractures between December 2020 and January 2022.

INTRODUCTION: Geriatric hip fracture patients are at high risk for perioperative morbidity and mortality from COVID-19. This study analyses the impact of COVID-19 vaccination on geriatric hip fracture outcomes. We hypothesise that having the COVID-19 vaccine improves outcomes for geriatric patients treated for hip fracture. METHODS: Between December 2020 and January 2022, 506 patients treated for hip fracture were analysed for demographics, hospital quality measures, and outcomes. Patients were grouped according to vaccine series administration status. During the study period, there were 329 (65%) unvaccinated patients (NV), 14 (3%) partially vaccinated (PV) patients, 138 (27%) fully vaccinated (FV) patients, and 25 (5%) patients received a booster shot (BV). Variables were compared using chi square, independent sample t-tests or ANOVA as appropriate. Multivariable logistic regression was used to independently assess the impact of vaccination. RESULTS: The rate of minor complications decreased if any vaccination status was achieved (NV: 37.99%, PV: 21.34%, FV: 28.26%, BV: 20.00%; p = 0.054). Vaccinated patients had a decreased need for Intensive Care Unit (ICU) level care (NV: 14.89%, PV: 7.14%, FV: 5.80%, BV: 8.00%; p = 0.038). There were no differences in inpatient or 30-day mortality, major complications, length of stay, home discharge, or readmission within 30 or 90 days. Vaccination against COVID-19 was independently protective against the need for ICU level care. Additionally, female gender and vaccination against COVID-19 decreased the rate of minor complications. Older age and higher comorbidity burden increased the rate of minor complications. DISCUSSION: In the hip fracture population, vaccination against COVID-19 was protective against the need for ICU level care and decreased overall minor complications. Larger studies are needed to determine if vaccination decreases mortality in this population. These findings have resource allocation implications including ICU bed availability during pandemics and patient outreach to improve vaccination status.

Improving Cephalad Lag Screw Placement in the Femoral Head During Cephalomedullary Nailing Using a Novel Augmented Reality System.

OBJECTIVES: To measure the effect of a novel augmented reality software designed to aid in lag screw placement into the femoral head for cephalomedullary nails. DESIGN: Retrospective cohort study. SETTING: Single Level I trauma center. PATIENTS: Between November 2017 and December 2020, 114 consecutive patients with a hip fracture that underwent repair with a cephalomedullary nail by one of 2 orthopaedic trauma surgeons were reviewed. Fracture classifications included OTA/AO 31-A1, 31-A2, 31-A3, and 31-B3. INTERVENTION: The first 57 patients underwent fracture repair without the software (control) and the subsequent 57 patients underwent repair with use of the augmented reality software (AR). MAIN OUTCOME MEASUREMENTS: Tip apex distance (TAD) and femoral head zone (AP: superior, center, inferior; Lateral: anterior, center, posterior) were measured using standardized techniques. RESULTS: The mean TAD was lower for the AR versus control cohort (10.7 ± 2.9 mm vs. 15.4 ± 3.8 mm; P < 0.001). TAD <10 mm for AR versus control: 25 (43.9%) versus 3 (5.3%), P < 0.001. TAD <15 mm for AR versus control: 50 (87.7%) versus 44 (77.2%), P < 0.001. On the AP view, center position was achieved in 50.9% versus 7.0% of cases for the AR versus control cohort, respectively. On the lateral view, center position was achieved in 68.4% versus 12.3% of cases for the AR versus control cohort, respectively. CONCLUSION: This study suggests that use of the novel augmented reality software for assistance in lag screw positioning within the femoral head improves overall TAD and ability to achieve the center-center position. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does mechanism of injury impact the outcome of operative fixation of geriatric proximal humerus fractures.

BACKGROUND: The purpose of this study is to determine the effects of energy mechanism on outcomes following repair of proximal humerus fractures (PHF) in the middle aged and geriatric population. METHODS: Two hundred sixty-nine patients who presented to our academic medical center between 2006 and 2020, and underwent operative treatment of a proximal humerus fracture were prospectively enrolled in an IRB-approved database. Patients above 55 were divided into high energy (motor vehicle accident, pedestrian struck, or fall > 2 stairs) or low energy mechanisms (fall from standing or < 2 stairs). Of 97 patients with complete documentation and follow-up, 72 were included in the low velocity (LV) group and 25 were included in the high velocity (HV) group. Demographic information, primary injury details, healing and time to union, range of motion (ROM), complications, and need for reoperation were assessed at initial presentation and subsequent follow-up appointments. RESULTS: Mean age, BMI, and gender were significantly different between the LV and HV cohorts (p = 0.01, 0.04, 0.01). OTA/AO fracture patterns were similar between the groups. (p = 0.14). Bony healing and complications occurred with similar frequency between groups (p = 1.00, 0.062). The most common complications in the LV and HV groups included avascular necrosis (9.7%, 16.0%), and screw penetration (4.2%, 12.0%), while the HV group also had rotator cuff issues including weakness and tendonitis (12.0%). There was no significant difference in need for reoperation between cohorts (p = 0.45). Time to healing, shoulder ROM, and DASH scores did not differ between each group. CONCLUSIONS: Energy and mechanism demonstrates similar outcomes in operatively treated proximal humerus fractures. These factors should not play a role in decisions for surgery in these patients and can help guide patient expectations.

Operative Fixation of Extra-articular Scapula Body Fracture Through a Modified Judet Approach.

SUMMARY: We present the case of a 53-year-old male laborer who slipped and fell on ice and had acute right shoulder pain. Plain radiographs and a computed tomography scan of the scapula were obtained that demonstrated a comminuted and displaced extra-articular scapula body fracture with approximately 2 cm of medialization of the glenoid. The anatomy, examination, diagnosis, and surgical approach options are reviewed. In this case, open reduction and internal fixation of the scapula is performed through a modified Judet approach. At the 3-month postoperative visit, radiographs demonstrated a healed scapula fracture. The patient was allowed to return to work as a laborer. A modified Judet approach can be performed for surgical fixation of comminuted and displaced extra-articular scapula body fractures with excellent clinical results.

Flexible Nailing of Pediatric Both Bone Forearm Fracture.

SUMMARY: This is the case of a 12-year-old boy presented with a displaced radial and ulnar shaft fracture. Historically, these fractures were managed conservatively with closed reduction and cast immobilization; however, there has been an increasing trend toward operative fixation. Malalignment is an indication for operative fixation of pediatric both bone forearm fractures. Flexible nailing was performed in this case because of the small incisions, minimal tissue disruption, shorter operative time, and ease of implant removal. Five years postoperatively, the patient's fracture was healed. Patient presented with an excellent clinical outcome including full range of motion and no pain. He had full strength of his arm and no deficits.