Operative Traction Technique for an Intertrochanteric Femur Fracture in a Patient with Transfemoral Amputation: A Case Report.

CASE: A 53-year-old woman with a history of transfemoral amputation presented to the emergency department with an ipsilateral intertrochanteric femur fracture. Standard fracture tables that use a boot to pull traction are not helpful in these cases, which makes achieving adequate traction for reduction difficult. CONCLUSION: We describe a unique technique to manipulate an amputated extremity using 2 Schanz pins attached to a weight through a traction rope. This practical technique provided adequate skeletal traction for reduction and internal fixation in our case and can be performed on a standard radiolucent table without the need for special table attachments.

Trends in Orthopedic Device Innovation: An Analysis of 510(k) Clearances and Premarket Approvals From 2000 to 2019.

The objective of this study was to characterize recent trends in orthopedic device development across different subspecialty areas. Orthopedic 510(k) clearances, premarket approvals (PMAs; together, "authorizations"), and new market entrants from 2000 to 2019 were analyzed as markers of research and development activity. Data were extracted from the US Food and Drug Administration website and stratified into one of 9 "subspecialty" groups: spine, trauma, hip arthroplasty, knee arthroplasty, shoulder, hand/elbow, foot/ankle, cement/filler/graft, and other. Descriptive statistics were used to analyze the data. Growth rates were calculated from trailing 3-year averages. During the study period, there were 9906 orthopedic 510(k) clearances and 1409 PMAs, of which 61 were for original PMA submissions. The preponderance of 510(k) clearances were for devices used in spine (36%) and trauma (30%) surgery, followed by hip (11%) and knee (8%) arthroplasty. Annual 510(k) clearances for spine and trauma devices grew by 232% and 44%, respectively, whereas annual hip and knee arthroplasty clearances declined. Paralleling these findings, the influx of new manufacturers of orthopedic devices was greatest for the trauma surgery (438), spine surgery (383), and cement/filler/graft (181) markets. Spinal surgery and orthopedic trauma have become leading priorities in orthopedic product development during the past two decades. Meanwhile, hip and knee arthroplasty products have proportionally become a smaller category of new devices over time. These findings demonstrate changing priorities within orthopedic innovation. [Orthopedics. 2023;46(2):e98-e104.].

Use of Anatomic Radiographic Horizons for the Lateral Center-Edge Angle in the Classification of Hip Dysplasia.

BACKGROUND: The lateral center-edge angle of Wiberg (LCEA) and Tönnis angle (TA) rely on a "horizon" that functions as a reference point for measurements of hip dysplasia on weightbearing anteroposterior pelvis radiographs. There are 3 different horizons that are currently utilized depending on surgeon preference: (1) a line parallel to the radiographic floor (F), (2) a line that connects the inferior portions of the acetabular teardrops (ATs), or (3) a line that connects the ischial tuberosities (ITs). It is imperative to accurately assess the degree of hip dysplasia on initial workup to select the appropriate surgical intervention. PURPOSE: To assess how the choice of a radiographic horizon affects the measurements of the LCEA and TA. The secondary purpose was to assess how the horizon affected the classification of hips as either normal, borderline dysplastic, or dysplastic. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: The LCEA and TA were measured on all preoperative weightbearing anteroposterior pelvis radiographs for 186 consecutive patients who underwent hip preservation surgery between February 2016 and November 2020 (140 hip arthroscopic procedures, 46 combined hip arthroscopic procedures with periacetabular osteotomy), 3 times per hip, each time using an F, AT, and IT horizon. The Student t test was used to analyze the differences in the measurements of the LCEA and TA, and discordance rates in the dysplasia classification between horizons were quantified. RESULTS: For the entire study population, the mean LCEAF (23.4°± 7.4°) was significantly greater than the mean LCEAIT (23.1°± 7.2°) (95% CI, -0.634 to -0.003; P = .047) and mean LCEAAT (23.0°± 7.1°) (95% CI, -0.723 to -0.139; P = .004). There was no difference between the LCEAIT and LCEAAT (95% CI, -0.305 to 0.080; P = .251). When stratified by hip arthroscopic surgery, the mean LCEAF (26.3°± 5.6°) was significantly greater than the mean LCEAAT (25.8°± 5.3°) (95% CI, -0.845 to -0.162; P = .004). Overall, there was a 17.7% and 18.3% discordance rate in the dysplasia classification using the LCEAIT and LCEAAT compared with the LCEAF, respectively. There were no statistically significant differences between the mean TAIT, TAAT, and TAF for the entire study population, the arthroscopic surgery group, and the combined arthroscopic surgery and periacetabular osteotomy group. CONCLUSION: There was no statistical difference between the AT and IT horizons for LCEA measurements. The dysplasia classification was in better agreement between the 2 anatomic horizons compared with the F horizon. The TA was not affected by changes in the horizon.

Clinical parameters and radiographic resorption of a novel magnesium based bone void filler.

BACKGROUND: Bone voids can present challenging problems for the Orthopaedic surgeon, and are often treated with backfilling followed by structural stabilization. Recently, a magnesium based, and presumably resorbable, bone void filler (BVF) has been developed, but has limited longitudinal clinical data. Therefore, the purpose of this study was to investigate clinically relevant parameters and radiographic resorption characteristics of this novel magnesium based BVF (MgBVF) with long-term clinical data. METHODS: All patients who underwent surgery by a single surgeon in which MgBVF was utilized from 2019 to 2020 were retrospectively reviewed. Clinical parameters including evidence of infection, wound breakdown, and wound drainage were reviewed. Radiographic resorption, evidence of joint extrusion of BVF, heterotopic ossification, and subsidence was assessed at each post-operative visit. Those with less than 6 month follow up were excluded from radiographic analysis of resorption. Postoperative images at two weeks were compared to each subsequent radiograph during follow up, and reviewed by each of the three authors in blinded fashion. Interval radiographs were assigned a grade of radiographic resorption which corresponded to estimated percent resorption: grade 1 (0-25%), grade 2 (25-50%), grade 3 (50-75%), or grade 4 (75-100%). After 2 weeks, this process was repeated, and both inter and intraobserver reliability scores were calculated. RESULTS: Forty-two patients were identified for clinical review, and 18 for radiographic review. Average length of follow up was 209±113 days. Five patients experienced a postoperative complication: two wound infections, one delayed wound healing, one sterile serous drainage, and one catastrophic failure of the fixation construct. Four patients were noted to have postoperative joint subsidence of 2 mm or less. Average grade of resorption was found to be 1.5 ± 0.8, 1.7 ± 0.9, 2.9 ± 0.9, and 3.6 ± 0.6 at 6 weeks, 3 months, 6 months, and 1 year, respectively (p<0.001). Average kappa (intrarater reliability) was found to be 0.61, 0.41, 0.55, and 0.63 for each time interval, respectively. Interrater reliability increased form 0.19 at 6 weeks to 0.42 at 1 year. CONCLUSION: This novel MgBVF demonstrates clinically relevant resorption, provides structural support in challenging bone voids, and does not appear to significantly increase risk of complications, setting it apart from previously described BVF's.

Epidemiology of Tibial Fractures in Professional American Football Athletes From 2013 to 2019.

BACKGROUND: Lower extremity injuries occur with high frequency in National Football League (NFL) athletes and cause high burden to players and teams. Tibial fractures are among the most severe lower extremity injuries sustained in athletes and are associated with prolonged time loss from sport. PURPOSE: To determine the number of tibial fractures in NFL athletes from the 2013 to 2019 NFL seasons and describe athlete demographics, fracture characteristics, and details of injury onset. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of the NFL injury database was performed to identify all NFL athletes sustaining tibial fractures over the 2013 to 2019 NFL seasons. Athlete characteristics, injury characteristics, days missed, and treatment (operative vs nonoperative) were examined. Descriptive statistics were used to calculate means, standard deviations, ranges, and percentages. RESULTS: A total of 64 tibial fractures were identified in 60 athletes, resulting in a median loss of 74 days. Defensive secondary athletes had the highest number of injuries (n = 10; 16%), followed by running backs (n = 9; 14%), while 61% of these injuries occurred during NFL regular-season games, primarily between weeks 13 and 17. The most commonly reported activity during injury was athletes being tackled, with a direct impact to the tibia being the most common mechanism of injury. Lateral tibial plateau fractures were the most frequently reported, while distal tibial fractures resulted in the greatest number of days lost. The median time lost for injuries requiring surgery was 232 days compared with 56 days for injuries treated using conservative management. CONCLUSION: The highest proportion of tibial fractures were injuries to defensive secondary athletes and athletes being tackled while sustaining a direct impact to the leg, primarily to the lateral tibial plateau. Tibial fracture injuries were commonly sustained during NFL regular-season games, primarily during the final 4 weeks of the NFL regular season. Further investigations examining performance and career longevity in athletes sustaining tibial fractures are warranted to help improve the health and safety of NFL athletes.

Comparison of time to healing and major complications after surgical fixation of nondisplaced femoral neck stress fractures: A systematic review.

INTRODUCTION: There is no recent literature review comparing outcomes of fixation methods for nondisplaced stress fractures of the femoral neck. METHODS: A systematic review of the literature on operative fixation of femoral neck stress fractures was performed. Inclusion criteria consisted of diagnosis of nondisplaced femoral neck stress fractures, implants used for fixation, articles in English language or available English translation, all ages, and Level 1-5 evidence, documented time to healing, and incidence of complications. Statistical analysis was performed to compare outcomes. RESULTS: Eight studies with 13 subjects and 15 fractures undergoing operative fixation were included. Six fracture were compression sided, five were tension sided, and four were complete. Radiographic healing occurred on average at 32.7 ± 36.3 weeks (range 8-121 weeks). Four subjects were noted to have a metabolic disturbance. Six subjects did not participate in vigorous exercise. There were no complications. There was no significant difference in radiographic healing time between: cannulated screws or SHS ± osteotomy (p = 0.21); compression sided, tension sided, or complete fractures (p = 0.41); ages (p = 0.09); sex (p = 0.09) or individuals with or without metabolic disturbances (p = 0.92). There was no difference between use of cannulated screw fixation, SHS + osteotomy, and SHS alone based on the subject's age (p = 0.27) or cannulated screw vs SHS ± osteotomy given subject's age (p = 0.19) or sex (p = 1.0). Time to full weight bearing (FWB) did not significantly differ between implants (p = 0.22). However, >8 weeks restricted weight bearing had increased healing times (p = 0.002). DISCUSSION: Time to healing was not dependent on subjects' sex or age, fracture location, implant choice, or presence of metabolic abnormality. No complications were reported. Time to full weight bearing was not dependent on implant choice. However, restricted weight bearing beyond 8 weeks can lead to prolonged healing times. Fixation should be safe, effective and promote early weight bearing and mobilization.

Comparison of Infrapatellar and Suprapatellar Approaches for Intramedullary Nail Fixation of Tibia Fractures.

OBJECTIVE: To assess clinical, radiographic, and functional outcomes after intramedullary nail (IMN) fixation of tibia fractures with an infrapatellar approach compared to a suprapatellar approach. DESIGN: Retrospective chart review. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Two hundred four patients with 208 tibia fractures treated with intramedullary nailing between 2008 and 2018. METHODS: A retrospective chart review of tibia fractures was conducted. The clinical and functional outcomes of tibia fractures treated with IMN were compared between groups treated with an infrapatellar approach versus a suprapatellar approach. Multivariate models were created to control for confounding demographic, comorbidity, and injury-related confounders. MAIN OUTCOME MEASUREMENTS: Outcome measures included nonunion, malunion, and infection. Subjective functional patient outcomes were assessed using pain interference and physical function Patient-Reported Outcome Measurements Systems scores. RESULTS: There were 101 patients treated with infrapatellar nailing (49%) and 107 patients treated with suprapatellar nailing (51%). On multivariate analysis, suprapatellar nailing was independently associated with decreased risk of malunion (adjusted odds ratio, 0.165; 95% confidence interval, 0.054-0.501; P = 0.001) and decreased risk of postoperative knee pain (adjusted odds ratio, 0.272; 95% confidence interval, 0.083-0.891; P = 0.032). There was no difference in the rate of nonunion (P = 0.44), infection (P = 0.45), or Patient-Reported Outcome Measurements Systems pain interference or physical function scores. CONCLUSIONS: Suprapatellar IMN fixation of tibial shaft fractures is independently associated with lower risk of malunion and postoperative knee pain compared to the infrapatellar approach. However, there are no functional differences between approaches. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical Outcomes After Intramedullary Nailing of Intraarticular Distal Tibial Fractures: A Retrospective Review.

The objective of this study was to evaluate the clinical and functional outcomes of intra-articular distal tibial fractures after intramedullary nail (IMN) and independent fixation compared with extra-articular fracture controls. Methods: A retrospective chart review of distal tibial fractures treated with IMN was performed. Clinical outcomes were compared between fractures with and without intra-articular involvement. Outcomes included nonunion, malunion, ankle arthrosis, and infection. Patient-Reported Outcome Measurement System (PROMIS) scores were used to assess subjective outcomes. Results: Of the 135 distal tibial fractures, 87 extra-articular and 48 intra-articular, no significant difference was observed in the rate of ankle arthrosis between intra-articular and extra-articular fractures (2% versus 0%; P = 0.35). Similarly, no difference was observed in the postoperative rates of infection (8% versus 3%; P = 0.25), the rate of nonunion (17% versus 10%; P = 0.29), or the rate of malunion (10% versus 21%; P = 0.17). No notable difference was observed in PROMIS scores between groups. Conclusion: This study suggests that IMN is an acceptable method of fixation in select intra-articular distal tibial fractures. In the intra-articular group, low rates of ankle arthrosis were noted at intermediate follow-up, with no increase in nonunion, malunion, or infection compared with extra-articular fractures. Furthermore, PROMIS scores indicate similar functional outcomes in patients, regardless of intra-articular involvement.

Identifying a clinical decision tool to predict discharge disposition following operative treatment of hip fractures in the United States.

BACKGROUND: Post-discharge management following operative treatment of hip fractures continues to be performed on a case-by-case basis, with no uniform guidelines dictating management. Predicting discharge to post-acute care (PAC) facilities (i.e. skilled nursing facilities and inpatient rehabilitation facilities) can assist preoperative planning and potentially decrease length of stay secondary to disposition issues. The goal of this study was to develop a nomogram using easily identified variables to preoperatively predict discharge disposition following operative treatment of hip fractures. METHODS: Using the National Surgical Quality Improvement Program database, patients who underwent surgical intervention for hip fractures between 2012 and 2015 were identified. A multivariable logistic regression model was used to identify risk factors for discharge to a PAC facility, and a predictive nomogram was created based on these results. RESULTS: From 2012 to 2015, 33,371 hip fractures were identified: 13,336 (40%) femoral neck fractures, and 20,035 (60%) intertrochanteric femur fractures. Of the patients identified, 26,082 (78.2%) were discharged to a PAC while the remainder were discharged home with or without home health. 70% of patients were female and 92.4% were Caucasian. When accounting for comorbidities, using the American Society of Anesthesiologists (ASA) classification system, 6,122 patients (18.4%) had 'Mild Systemic Disease' (ASA 2), 20,872 (62.6%) patients had 'Severe Systemic Disease' (ASA 3), and 6,006 (18.1%) had 'Life Threatening Disease' (ASA 4/5). The majority of patients were brought in from a 'Home' setting, while 10.4% of patients were admitted from a 'Long-Term Care' setting. After controlling for confounding variables, older age and increasing ASA class were predictive of an increased risk of discharge to a PAC. Diabetes, dyspnea, congestive heart failure, and chronic obstructive pulmonary disease were not associated with an increased risk of discharge to a PAC. DISCUSSION: Discharge disposition following operative treatment of hip fractures can be reliably predicted using a nomogram with commonly identified preoperative variables. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Design, Observational Study.

Combined Surgical Approach to Young Adults with Hip Dysplasia and Concomitant Intra-Articular Pathology Using Intra-Abdominal Monitoring.

Background: Combined hip arthroscopy and periacetabular osteotomy (PAO) allows for treatment of intra-articular hip pathology with simultaneous correction of acetabular version and femoral head coverage in patients with symptomatic hip dysplasia. Currently, scant data is available to surgeons regarding optimal technique, sequence of repair, perioperative management, and the use of intra-abdominal monitoring in patients undergoing these combined procedures. The purpose of this study is to describe a two-surgeon, muscle-sparing, approach for sequential hip arthroscopy and PAO for the treatment of adults with acetabular dysplasia and concomitant intra-articular hip pathology. Methods: In this article, we present the indications for combined hip arthroscopy and PAO, in addition to patient set-up and positioning. A detailed discussion of hip arthroscopy and a muscle sparing PAO techniques are then presented, with overview of a novel intra-abdominal pressure monitoring technique and post-operative rehabilitation protocol. Results: Through technical refinement and experience, our indications and protocol for the treatment of patients with symptomatic acetabular dysplasia with concomitant intra-articular hip pathology involves a refined and reproducible, two surgeon procedure utilizing hip arthroscopy followed by PAO. The use of intra-abdominal monitoring allows for assessment of intra-peritoneal pressures to monitor for the development of abdominal compartment syndrome secondary to fluid extravasation. Conclusion: The performance of concomitant hip arthroscopy and PAO for concurrent hip dysplasia and intra-articular hip pathology represents an increasingly common approach in hip preservation surgery. The hip arthroscopy and muscle-sparing PAO protocol using intra-abdominal monitoring described here serves to further refine and advance the indications and technical aspects of this challenging procedure.Level of Evidence: V.

Comparison of Clinical Outcomes After Intramedullary Fixation of Tibia Fractures Caused by Blunt Trauma and Civilian Gunshot Wounds: A Retrospective Review.

OBJECTIVE: To assess the outcomes of patients who sustained blunt trauma tibia fractures compared with tibia fractures from civilian gunshot injuries when treated with intramedullary fixation. DESIGN: Retrospective chart review. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Two hundred and seven patients underwent intramedullary nailing for 211 tibia fractures. METHODS: A retrospective review of tibia fracture(s) treated with intramedullary fixation with comparison of closed, open, and gunshot wound (GSW) fracture outcomes. MAIN OUTCOME MEASUREMENTS: Outcomes included infection and nonunion. RESULTS: The infection rate in closed and GSW tibia fractures was significantly lower compared with the infection rate of open fractures (1% vs. 9% vs. 20%; P = 0.00005). Significantly lower rates of nonunion in closed fractures compared with open fractures and GSW fractures were appreciated (8% vs. 20% vs. 30%; P = 0.003). There was no difference in infection or nonunion between GSW fractures with small wounds, no exposed bone, and minimal comminution and closed injuries (P = 0.24, P = 0.60). Conversely, there was a significantly higher nonunion rate in GSW fractures with large wounds, exposed tibia, and comminution compared with blunt injuries (P = 0.0014). CONCLUSIONS: This study suggests that tibia fractures from civilian GSWs are heterogeneous injuries, and outcomes are dependent on the extent of soft-tissue injury, bone exposure, and bone loss. There are comparable infection rates in all fractures due to civilian GSWs and closed fractures, which are lower than high-grade open fractures. Tibia GSW fractures with exposed bone and comminution have higher complication rates and should be treated accordingly. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Scapular Body Fracture in the Athlete: A Systematic Review.

BACKGROUND: Scapular body fractures generally occur as a result of high-energy, direct trauma to the shoulder sustained in automobile accidents. While such mechanisms have been well described, little is known about scapular body fractures sustained during sporting activities. QUESTIONS/PURPOSES: We sought to systematically review the literature on scapular body fracture sustained during sporting activity, recording rates and mechanisms of injury, management strategies, and return-to-sport times. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we performed a systematic review of studies conducted between 1985 and 2017. Inclusion criteria were studies examining scapular body fractures sustained during sporting activity, fracture management, and patient outcomes. Exclusion criteria were studies on non-sporting-related fractures and those not reporting fracture management or patient outcomes. RESULTS: Nine studies encompassing ten cases of scapular body fracture sustained during sporting activity were identified, with acute trauma responsible for 70% of fractures. No patient sustained any associated injuries. Fractures were treated conservatively in 90% of cases, with no reported complications. Mean overall time to return to sport was 2.5 months, while no significant difference in return to sport was appreciated in athletes with acute versus fatigue fractures. CONCLUSION: Scapular body fractures in athletes occur primarily from muscle contraction against a resisted force in the upper extremity during contact sports. Unlike non-sporting fractures, these fractures usually involve low-energy mechanisms without associated injury and conservative treatment is usually successful.

Costs and Radiographic Outcomes of Rotational Ankle Fractures Treated by Orthopaedic Surgeons With or Without Trauma Fellowship Training.

INTRODUCTION: We evaluated the radiographic outcomes and surgical costs of surgically treated rotational ankle fractures in our health system between providers who had completed a trauma fellowship and those who had not. METHODS: We grouped patients into those treated by trauma-trained orthopaedic surgeons (TTOS) and non-trauma-trained orthopaedic surgeons (NTTOS). We graded the quality of fracture reductions and calculated implant-related costs of treatment. RESULTS: A total of 208 fractures met the inclusion criteria, with 119 in the TTOS group and 89 in the NTTOS group. Five patients lost reduction during the follow-up period. The adequacy of fracture reduction at final follow-up did not differ (P = 0.29). The median surgical cost was $2,940 for the NTTOS group and $1,233 for the TTOS group (P < 0.001). DISCUSSION: We found no notable differences in radiographic outcomes between the TTOS and NTTOS groups. Cost analysis demonstrated markedly higher implant-related costs for the NTTOS group, with the median surgical cost being more than twice that for the TTOS group. LEVEL OF EVIDENCE: Level III.

Heterotopic Ossification of the Inferior Pubic Ramus.

The hip is a common location for heterotopic ossification after surgical trauma, blunt trauma, or muscle injury. However, the region around the pubic rami is an unusual location for heterotopic bone formation. Here, we present a case of a young, active man in the Armed Forces Reserve with a large heterotopic bone involving the left inferior pubic ramus who underwent surgical excision through an unusual approach via the perineum. The patient had notable pain relief postoperatively and returned to his active duties 1 month after surgery without discomfort or functional limitation.

Prevalence and Management of Coracoid Fracture Sustained During Sporting Activities and Time to Return to Sport: A Systematic Review.

BACKGROUND: Coracoid fractures sustained during sporting activities are rare. Previous reports are limited to individual case reports, small case series, and retrospective analyses. PURPOSE: To systematically review the literature and identify coracoid fractures sustained during sporting activities to determine fracture prevalence, sporting activities/mechanisms, management, and time to return to sport. STUDY DESIGN: Systematic review. METHODS: A systematic review was conducted investigating all studies in the literature published between January 1970 and April 2017 that reported on athletes sustaining coracoid fractures during sporting activity. The systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and used PubMed, Biosis Previews, SPORTDiscus, PEDro, and EMBASE databases. Inclusion criteria were studies detailing (1) coracoid fractures with reported sporting activity causing injury, (2) fracture management (operative vs nonoperative), and (3) patient outcome. Exclusion criteria were (1) studies concerning fractures secondary to nonsporting activities (mechanical falls, motor vehicle accidents) and (2) studies not reporting fracture management or patient outcomes. Sporting activities, the presence or absence of associated acromioclavicular (AC) joint injury, fracture management, patient outcomes, and time to return to sport were analyzed. RESULTS: A total of 21 cases of coracoid fractures sustained during sporting activity were identified; acute trauma was responsible for 71% (n = 15/21) of fractures, and the remaining injuries were secondary to fatigue fractures. Concurrent AC joint injury was present in 60% (n = 9/15) of athletes sustaining acute trauma and in no athlete with fatigue fractures. Fractures were treated conservatively in 76% (n = 16/21) of patients, with only 19% (n = 3/16) of athletes reporting complications. Mean overall time to return to sport was 2.8 ± 2.0 months; no significant differences in return to sport were noted in athletes with traumatic versus fatigue fractures or those with or without AC joint injury. CONCLUSION: Coracoid fractures secondary to sporting activities are rare, occurring primarily from direct trauma with associated AC joint injury, and are treated successfully with nonoperative management. No difference in return to sport was found regardless of fracture mechanism, treatment, or the presence of associated AC joint injury.

Wide Variation of Surgical Cost in the Treatment of Periarticular Lower Extremity Injuries Between 6 Fellowship-Trained Trauma Surgeons.

OBJECTIVES: We hypothesized that negligible surgical material cost variation exists between traumatolgists for treatment of bimalleolar ankle and bicondylar tibial plateau fractures. DESIGN: Retrospective medical record review. SETTING: Academic level 1 Trauma Center; 2-year period. PATIENTS/PARTICIPANTS: Current Procedure Terminology codes for open treatment of bimalleolar ankle and bicondylar tibial plateau fractures identified patients. Patients who had operative treatment of other injuries under the same anesthetic session were excluded. Only definitive treatment procedures were analyzed. INTERVENTION: We analyzed the intraoperative material costs of these procedures and compared them between surgeons. This analysis was done with a newly developed proprietary program designed for inventory and cost analysis. MAIN OUTCOME MEASUREMENTS: Mean and median total case material costs were compared using one-way analysis of variance. Individual items that significantly increased costs were identified. RESULTS: We identified 88 bimalleolar ankle and 46 bicondylar tibial plateau fractures treated by 6 surgeons. The mean intraoperative material cost per bimalleolar ankle fracture was $1099. The least expensive surgeon's mean case cost was $613, which was significantly less than the most expensive surgeon's $2243 (P = 0.009). The median cost range was $598-$784. The top quartile of cases resulted in 57% of overall material cost for ankle fractures. The mean intraoperative material cost per bicondylar tibial plateau fracture was $3219 (range $1839-$4088, P = 0.064). The range of median costs ($1826-$3989) was significantly wider than for ankle fractures. Bone void fillers, locking plates, adjunctive external fixators, mini-fragment locking plates, cannulated screws, single-use taps, guidewires, and drill bits all substantially increased costs. CONCLUSION: This study demonstrated variation in intraoperative material cost between 6 traumatologists resulting from practice variations despite similar specialty training. The cost differences resulting from practice variation reveal potential savings through increased standardization of surgical care for similar injuries. We identified high-cost items, which could lead to cost savings if used only when they will have clinical benefit.

Comparison of modern locked plating and antiglide plating for fixation of osteoporotic distal fibular fractures.

BACKGROUND: Fractures in osteoporotic patients can be difficult to treat because of poor bone quality and inability to gain screw purchase. The purpose of this study is to compare modern lateral periarticular distal fibula locked plating to antiglide plating in the setting of an osteoporotic, unstable distal fibula fracture. METHODS: AO/OTA 44-B2 distal fibula fractures were created in sixteen paired fresh frozen cadaveric ankles and fixed with a lateral locking plate and an independent lag screw or an antiglide plate with a lag screw through the plate. The specimens underwent stiffness, cyclic loading, and load to failure testing. The energy absorbed until failure, torque to failure, construct stiffness, angle at failure, and energy at failure was recorded. RESULTS: The lateral locking construct had a higher torque to failure (p=0.02) and construct stiffness (p=0.04). The locking construct showed a trend toward increased angle at failure, but did not reach statistical significance (p=0.07). Seven of the eight lateral locking plate specimens failed through the distal locking screws, while the antiglide plating construct failed with pullout of the distal screws and displacement of the fracture in six of the eight specimens. CONCLUSION: In our study, the newly designed distal fibula periarticular locking plate with increased distal fixation is biomechanically stronger than a non-locking one third tubular plate applied in antiglide fashion for the treatment of AO/OTA 44-B2 osteoporotic distal fibula fractures. LEVEL OF EVIDENCE: V: This is an ex-vivo study performed on cadavers and is not a study performed on live patients. Therefore, this is considered Level V evidence.

Current Practice in the Management of Type I Open Fractures in Children: A Survey of POSNA Membership.

BACKGROUND: Treatment of pediatric type I open fractures is controversial. Centers have reported good success with emergency room (ER) treatment of low-energy (type I) open pediatric fractures. The purpose of this study was to ascertain the treatment preferences of pediatric orthopaedic surgeons for type I open fractures. We hypothesize that surgeons will have different treatment protocols and preferred location for these injuries. METHODS: A questionnaire was given to Pediatric Orthopaedic Society of North America (POSNA) members at the 2012 annual meeting. Demographic questions inquired about surgeon's practice environment and experience, whereas clinical questions queried opinions regarding the typical treatments and past experiences with open fractures. Clinical scenarios questioned preferred management of open fractures. RESULTS: A total of 181 surveys were collected from the 503 POSNA members in attendance (36%). Years in practice were well represented with 34%: <10 years, 37%: 10 to 19 years, and 29%: >20 years. Most respondents' practices comprised over 80% pediatric patients (86%), were academic (68%), and worked with residents (77%). After initial treatment of an open fracture, 86% of respondents admitted patients for intravenous antibiotics and 57% gave oral antibiotics. There was no consensus regarding the amount or type of irrigation preferred, use of antibiotics in the irrigation, or whether the bone ends are delivered during irrigation and débridement. Soft-tissue infections and delayed union were noted by 13% and 8%, respectively, of respondents in type I open fractures treated in the ER and in 16% and 30% treated in the operating room (OR). ER treatment was preferred in 19% to 31% of respondents for type I open fractures. When queried if level 1 evidence existed that demonstrated equivalent results between ER and OR management, 92% of respondents would change their practice. CONCLUSIONS: Treatment methods of type I open fractures are variable. Many surgeons prefer to treat type I open fractures in the ER as opposed to the traditional OR irrigation and débridement. On the basis of this survey, either children are going to the OR when ER treatment would be adequate or they may be receiving inadequate care when they avoid OR management. This survey establishes the equipoise necessary for a randomized, prospective trial comparing ER and OR management in the treatment of pediatric type I open fractures.

Allograft cortical strut for reconstruction of space-occupying bone lesions.

Space-occupying bone lesions present orthopedic surgeons with clinical and operative challenges. Multiple reconstructive procedures have proven successful for small bone lesions but lack the structural support necessary for reconstruction of larger lesions. This study reports the clinical outcomes of patients undergoing excision and reconstruction of large bone lesions with allograft cortical struts without additional internal fixation. This retrospective outcomes study reviewed patients who underwent surgical curettage and cortical strut allograft reconstruction of any space-occupying bone lesion. Clinical, surgical, and imaging data were collected. The primary outcome measures were lesion healing, graft incorporation, long-term pain, return to activity, and presence of complications/recurrences. Seventeen patients met the inclusion criteria. At least partial lesion healing and allograft incorporation was identified in 15 of 17 lesions. Of the 15 patients who did not sustain a recurrence, only 1 did not return to full activities. Mean lesion volume was 107 cc. Average follow-up was 19.6 months. Two recurrences were identified, and no other major complications were identified.