Technical Factors Contributing to Nonunion in Supracondylar Distal Femur Fractures Treated With Lateral Locked Plating: A Risk-Stratified Analysis.

OBJECTIVE: To identify technical factors associated with nonunion after operative treatment with lateral locked plating. DESIGN: Retrospective cohort study. SETTING: Ten Level I trauma centers. PATIENT SELECTION CRITERIA: Adult patients with supracondylar distal femur fractures (OTA/AO type 33A or C) treated with lateral locked plating from 2010 through 2019. OUTCOME MEASURES AND COMPARISONS: Surgery for nonunion stratified by risk for nonunion. RESULTS: The cohort included 615 patients with supracondylar distal femur fractures. The median patient age was 61 years old (interquartile range: 46 -72years) and 375 (61%) were female. Observed were nonunion rates of 2% in a low risk of nonunion group (n = 129), 4% in a medium-risk group (n = 333), and 14% in a high-risk group (n = 153). Varus malreduction with an anatomic lateral distal femoral angle greater than 84 degrees, was associated with double the odds of nonunion compared to those without such varus [odds ratio, 2.1; 95% confidence interval (CI), 1.1-4.2; P = 0.03]. Malreduction by medial translation of the articular block increased the odds of nonunion, with 30% increased odds per 4 mm of medial translation (95% CI, 1.0-1.6; P = 0.03). Working length increased the odds of nonunion in the medium risk group, with an 18% increase in nonunion per 10-mm increase in working length (95% CI, 1.0-1.4; P = 0.01). Increased proximal screw density was protective against nonunion (odds ratio, 0.71; 95% CI, 0.53-0.92; P = 0.02) but yielded lower mRUST scores with each 0.1 increase in screw density associated with a 0.4-point lower mRUST (95% CI, -0.55 to -0.15; P < 0.001). Lateral plate length and type of plate material were not associated with nonunion. ( P > 0.05). CONCLUSIONS: Malreduction is a surgeon-controlled variable associated with nonunion after lateral locked plating of supracondylar distal femur fractures. Longer working lengths were associated with nonunion, suggesting that bridge plating may be less likely to succeed for longer fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Injuries Common to the Brazilian Jiu-Jitsu Practitioner.

BACKGROUND: Brazilian jiu-jitsu (BJJ) is a martial art that focuses on ground combat, emphasizing skill over strength and submission over striking. The purpose of this study is to evaluate the nature of injuries affecting practitioners of BJJ in the settings of competition, training, and conditioning. METHODS: An online survey was created to collect demographic and injury-specific information. This survey was distributed to the 234 schools in the United States registered with the International Brazilian Jiu-Jitsu Federation (IBJJF). The survey was also distributed to local BJJ schools and at local tournaments in the Greater New York City area. Data from a total of N=56 participants were recorded for this survey. RESULTS: The majority of participants were male (n=44, 78.6%) and amateur competitors (n=29, 51.8%) with an average duration of BJJ training of 6.9 ± 5.9 years. The majority of participants (82.1%) train at least six hours per week and compete in an average of 4.6 ± 2.5 competitions per year. The most common injuries were to the finger/hand (78.6%) and knee (61.5%). The most commonly reported fracture was of the hand/fingers (n=6). Of the 156 total injuries reported, 133 (85.3%) occurred during practice or training rather than in competition and 76 (48.7%) required medical attention. Few injuries required surgical intervention. CONCLUSIONS: This study provides novel information regarding injury characteristics of BJJ practitioners with respect to the level of training and use of protective equipment that can guide expectations and management for this unique group of athletes. Amateur BJJ practitioners are the most commonly injured, and largely experience injuries of the upper extremities during training or conditioning rather than during competition.

Salvage of a recalcitrant humeral shaft septic nonunion using a linked nail-plate fixation construct with intercalary allograft.

Open humeral shaft fractures comprise approximately 2% of all fractures of the humerus. Nearly 20% of open humeral shaft fractures will develop deep infection, increasing the risk of nonunion regardless of treatment method. Recalcitrant septic nonunion of the humeral shaft is a complex and challenging problem. Operative treatment should aim to eradicate infection, address bony defects, and establish a stable construct that affords early motion. We describe the case of a 38-year-old male with a recalcitrant humeral shaft septic nonunion following fixation of an open humeral shaft fracture. Management of the infection consisted of periodic surgical debridement and IV antibiotics, resulting in a 10 cm segmental defect. Definitive fixation was achieved using the combination of an antegrade intramedullary nail, intercalary femoral shaft allograft, compression plating, and autologous bone graft. In addition to achieving bony union, the patient regained his pre-injury ROM and function, which was clinically sustained at 2-year follow-up.

The "Double Washer" Technique Is an Effective Strategy for Bicortical Fixation in Periprosthetic Fractures About a Femoral Stem: A Technical Trick and Case Series.

SUMMARY: Periprosthetic fractures about the hip and knee are challenging injuries to treat for the orthopaedic surgeon. The pre-existing femoral implant and poor bone quality provide for difficulties in achieving stable fixation. We present a surgical technique and clinical series of 5 patients describing the use and outcomes of a 3.5 screw with a "double washer" technique to achieve bicortical fixation around a femoral prosthesis.

Radiographic Humerus Union Measurement (RHUM) Demonstrates High Inter- and Intraobserver Reliability in Assessing Humeral Shaft Fracture Healing.

BACKGROUND: Orthopedic surgeons use radiographs to determine degrees of fracture healing, guide progression of clinical care, and assist in determining weight bearing and removal of immobilization. However, no gold standard exists to determine the progression of healing of humeral shaft fractures treated non-operatively. PURPOSE: The purpose of this study was to determine whether a scale comparable to the modified Radiographic Union Score for Tibial (RUST) fractures applied to non-operatively treated humeral shaft fractures can increase interobserver reliability in determining fracture healing. METHODS: A retrospective review was undertaken by three orthopedic traumatologists and one musculoskeletal radiologist, who evaluated 50 sets of anteroposterior and lateral radiographs, presented at random, of non-operatively treated humeral shaft fractures at various stages of healing from 17 patients. The radiographs were scored using a modified RUST scale called the Radiographic Humerus Union Measurement (RHUM). Observers were blinded to the time from injury. After a 4-week washout period, observers again scored the same radiographs. Observers classified each fracture as either healed or not healed based on the combination of radiographs. Inter- and intraobserver reliability of the RHUM were determined using an intraclass correlation coefficient (ICC). Interobserver reliability of determining a healed fracture was calculated using Cohen's kappa (κ) statistics. A receiver operator characteristic curve was conducted to determine the RHUM score predictive of a fracture being considered healed. RESULTS: ICC demonstrated almost perfect interobserver reliability (ICC, 0.838; ICC 95% CI, 0.765 to 0.896) and intraobserver reliability (ICC range, 0.822 to 0.948) of the RHUM. κ demonstrated substantial agreement between observers in considering a fracture healed (κ = 0.647). Receiver operating characteristic (ROC) curve demonstrated that a RHUM of 10 or higher is an excellent predictor of the observer considering the fracture healed (area under the ROC curve = 0.946, specificity = 0.957, 95% CI specificity, 0.916 to 0.979). CONCLUSIONS: This cortical scoring system has excellent interobserver reliability in humeral shaft fractures treated non-operatively. Consistent with previous cortical scoring systems, a RHUM score of 10 or above can be considered radiographically healed.

A Novel Tripod Percutaneous Reconstruction Technique in Periacetabular Lesions Caused by Metastatic Cancer.

BACKGROUND: Metastatic lesions in the periacetabular region can cause pain and immobility. Symptomatic patients are often treated surgically with a total hip replacement using various modified Harrington methods. These open surgical procedures confer inherent risks. Prolonged recovery and potential complications may delay adjuvant radiation and systemic therapy. METHODS: We describe a novel technique for acetabular reconstruction. Three large-bore cannulated screws are placed percutaneously under fluoroscopy in a tripod configuration to reinforce the mechanical axes of the acetabulum. Increased stability improves pain control and permits weight-bearing. RESULTS: Twenty consecutive patients with periacetabular metastases were treated using the tripod technique. Eighteen patients (90%) had Harrington class-III lesions, and 2 patients had Harrington class-II lesions. The mean surgical time was 2.3 hours. Sixteen patients (80%) were able to get out of bed on postoperative day 1. At 3 months postoperatively, there was significant improvement in pain as documented on their visual analog scale (p < 0.01) and in functionality as measured by the Eastern Cooperative Oncology Group score (p < 0.01). The mean follow-up time was 7 months (range, 0.6 to 20 months). At the most recent follow-up, only 3 among the 16 surviving patients were using opioids chronically for pain. Total hip arthroplasty was performed in 4 patients (20%) in a staged fashion using the previously placed screws as support for a cemented cup and obviating the need for a cage device. Of the 16 patients, 15 could walk either independently (6 patients) or using an ambulatory aid (9 patients). Eight patients with the primary tripod reconstruction survived >6 months postoperatively. They were found to have either new bone formation filling the defects or healing of the pathological fractures. There has been no implant loosening or failure. CONCLUSIONS: The tripod technique is a novel application to provide safe and effective pain relief in the context of periacetabular metastatic disease. It can be easily converted to support a cemented acetabular cup for a total hip replacement should disease progression occur. This technique provides an alternative to open surgery as currently practiced in these patients. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Radiographic union score for tibia fractures predicts success with operative treatment of tibial nonunion.

BACKGROUND: The purpose of this study is to evaluate the ability of preoperative and postoperative radiographic union scores for tibia fractures (RUST) to predict treatment success of tibia fracture nonunion. MATERIALS AND METHODS: Patients presenting for operative treatment of tibia fracture nonunion were enrolled in a prospective data registry. Enrolled patients were followed at regular intervals for 12 months. Preoperative and 12 week postoperative radiographs were reviewed and scored using the RUST criteria. Postoperative time to union was determined by clinical and radiographic measures. Multivariate regressions were conducted to predict time to union using preoperative and postoperative RUST while controlling for treatment method. Receiver operating characteristic (ROC) curve was conducted to determine the accuracy of preoperative RUST in predicting failure of treatment. RESULTS: Sixty-eight patients with aseptic tibia fracture nonunion treated operatively were identified. Sixty-one patients achieved union. Mean preoperative RUST was 7.5 (SD 1.4). Mean postoperative RUST was 9.2 (SD 1.4). Multivariate linear regressions demonstrated that preoperative (p = 0.043) and postoperative (p = 0.007) RUST are significant predictors of time to union after tibia fracture nonunion surgery. ROC curve demonstrated preoperative RUST below 7 was a good predictor of developing persistent tibia fracture nonunion (AUC = 0.83, Sensitivity = 1.000, Specificity = 0.745). CONCLUSIONS: RUST preoperatively and postoperatively predicts outcome after nonunion surgery. RUST can be used as part of the complete clinical picture to shape patient expectations and guide treatment.

Distally based anterolateral thigh flap: an underutilized option for peri-patellar wound coverage.

Wound coverage in the supra-patellar area presents a significant challenge for orthopaedic and reconstructive surgeons due to the need for preservation of knee joint function but the paucity of regional soft tissue flaps available. While many orthopaedic and reconstructive surgeons make use of the rotational gastrocnemius flap for coverage of peri-patellar defects, this flap has certain limitations. The goal of this study was to report a single-centre experience with the use of the distally based anterolateral thigh flap (ALT) and review the current literature on the use of the ALT for peri-patellar defects. In this report, both a single-centre experience using distally based anterolateral thigh (ALT) island flaps for supra-patellar wound coverage and the existing literature on this topic were reviewed. A systematic literature review was performed to assess the use of the ALT for peri-patellar wounds. Five patients with a mean age of 69 underwent a distally based ALT flap for coverage of peri-patellar defects. Four out of 5 flaps survived at the end of their respective follow-up. Based on this combined experience, the distally based reverse-flow anterolateral thigh island flap represents a useful but relatively underutilized option for appropriately selected supra-patellar wounds due to minimal donor site morbidity, multiple flap components, and predictable pedicle anatomy. The flap's major weakness is its potentially unreliable venous drainage, requiring delay or secondary venous outflow anastomosis. Given the ALT flap's favourable profile, the authors recommend consideration for its use when managing a peri-patellar coverage wound issue.

A Comparison of Assessment Tools: Is Direct Observation an Improvement Over Objective Structured Clinical Examinations for Communications Skills Evaluation?

BACKGROUND: Evaluation of resident physicians' communications skills is a challenging task and is increasingly accomplished with standardized examinations. There exists a need to identify the effective, efficient methods for assessment of communications skills. OBJECTIVE: We compared objective structured clinical examination (OSCE) and direct observation as approaches for assessing resident communications skills. METHODS: We conducted a retrospective cohort analysis of orthopaedic surgery resident physicians at a single tertiary care academic institution, using the Institute for Healthcare Communication "4 Es" model for effective communication. Data were collected between 2011 and 2015. A total of 28 residents, each with OSCE and complete direct observation assessment checklists, were included in the analysis. Residents were included if they had 1 OSCE assessment and 2 or more complete direct observation assessments. RESULTS: There were 28 of a possible 59 residents (47%) included. A total of 89% (25 of 28) of residents passed the communications skills OSCE; only 54% (15 of 28) of residents passed the direct observation communications assessment. There was a positive, moderate correlation between OSCE and direct observation scores overall (r = 0.415, P = .028). There was no agreement between OSCE and direct observation in categorizing residents into passing and failing scores (κ = 0.205, P = .16), after adjusting for chance agreement. CONCLUSIONS: Our results suggest that OSCE and direct observation tools provide different insights into resident communications skills (simulation of rare and challenging situations versus real-life daily encounters), and may provide useful perspectives on resident communications skills in different contexts.

Ultralow-Dose CT (REDUCTION Protocol) for Extremity Fracture Evaluation Is as Safe and Effective as Conventional CT: An Evaluation of Quality Outcomes.

OBJECTIVES: To assess clinical and hospital quality outcomes of patients receiving the previously reported Reduced Effective Dose Using Computed Tomography In Orthopaedic Injury (REDUCTION) imaging protocol. DESIGN: Retrospective Chart review. SETTING: Level I Trauma Center and affiliated Tertiary Care Hospital Center. PATIENTS/PARTICIPANTS: Fifty patients who received this protocol for acute traumatic fracture evaluation and met the inclusion criteria were compared with a cohort of 50 patients matched for age and fracture type who previously received conventional CT scanning for acute traumatic fracture evaluation. INTERVENTION: Reduced Effective Dose Using Computed Tomography In Orthopaedic Injury (REDUCTION) protocol for diagnostic fracture evaluation. MAIN OUTCOME MEASURES: Estimated effective radiation doses were calculated and compared using Digital Imaging and Communications in Medicine (DICOM) information from all included studies. Patient outcomes between groups were compared with time to fracture union as the primary outcome. Secondary outcome measures included the presence of complication defined as infection, malunion, nonunion, failure of nonoperative treatment, painful implants, and implant failure. Other secondary quality outcomes that were recorded included readmission within 30 days and hospital length of stay. Functional quality measures included joint range of motion. Statistical analyses were conducted to identify significant differences between cohorts (significance designated as P < 0.05). RESULTS: Patient characteristics between cohorts were not significantly different with respect to age, sex, body mass index, comorbidities, injury mechanism, or injury location. Fractures of the elbow, hip, knee, and foot/ankle were evaluated. Mean clinical follow-up was 9.5 ± 4.9 months for the REDUCTION cohort and 12.4 ± 5.3 months for the conventional CT cohort. Mean estimated effective dose for all REDUCTION scans was 0.15 milliSieverts (mSv) as compared to 1.50 mSv for the conventional CT cohort (P = 0.037). Preoperative diagnosis was confirmed intraoperatively in 49/50 cases in the REDUCTION cohort compared with 48/50 cases in the conventional CT cohort (P = 0.79). Outcomes including time to union, range of motion, complications, readmission, treatment failure, reoperation, and length of stay were not significantly different between groups. CONCLUSIONS: The REDUCTION protocol represents ultralow-dose CT developed for minimizing radiation exposure to patients presenting with traumatic fractures. This protocol resulted in a 10-fold reduction in radiation exposure. No difference in clinical or hospital quality outcomes was detected between patients who received this protocol as compared to those receiving automated dose CT. The REDUCTION protocol is a safe and effective method of performing CT for extremity fractures with significantly reduced radiation risk. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Results after radial head arthroplasty in unstable fractures.

BACKGROUND: Whereas most radial head fractures are stable injuries, they sometimes occur as part of complex injury patterns with associated elbow instability. Radial head arthroplasty has been favored in patients with unreconstructable radial head fractures and unstable elbow injuries. The purpose of this study was to review radiographic outcomes, functional outcomes, and complications after radial head arthroplasty for radial head fracture in unstable elbow injuries. METHODS: This study was a retrospective review of radial head fractures treated with radial head arthroplasty by a single surgeon during a 15-year period. Demographics of the patients, injury details, operative reports, radiographic and clinical outcomes, and any complications were recorded. Patients were divided into stable and unstable elbow injury groups. RESULTS: A total of 68 patients were included. There were 50 unstable fractures that were compared with 18 stable fractures. Patients with unstable radial head fractures with associated elbow dislocation achieved mean flexion and mean forearm rotational arc of motion similar to that of patients with stable radial head fractures. However, supination loss was greater in the unstable group than in the stable fracture group, with a mean difference of 10°. Radiographic outcomes and complication rates did not differ between injury groups. There was no observed decrease in implant longevity in patients with unstable elbow injuries. CONCLUSIONS: Radial head arthroplasty is an effective option for treatment of unstable elbow injuries, with recovery of functional elbow range of motion and no difference in complication rate or implant survivorship compared with those patients with stable injuries.

The Use of Liposomal Bupivacaine Administered With Standard Bupivacaine in Ankle Fractures Requiring Open Reduction Internal Fixation: A Single-Blinded Randomized Controlled Trial.

OBJECTIVES: To determine the efficacy of liposomal bupivacaine compared to placebo for postoperative pain control in patients undergoing operative fixation of ankle fractures. DESIGN: Prospective single-blinded randomized control trial. SETTING: Academic Medical Center. PATIENTS/PARTICIPANTS: After Institutional Review Board (IRB) approval, 76 patients who sustained an acute ankle fracture (OTA/AO 44A-C) requiring operative fixation met inclusion criteria. INTERVENTION: Patients were randomly assigned to 1 of 2 groups, control (local intraoperative sterile saline injection under general anesthesia) or interventional (local intraoperative liposomal bupivacaine and bupivacaine injection under general anesthesia). Injections were administered in a standardized fashion and included injection of a 1:1 mixture of a 40 mL solution consisting of 1.3% Exparel and sterile saline (interventional) or a 40 mL injection of normal saline (control) into the surrounding periosteal, peritendinous, surrounding muscles and subcutaneous tissue of the surgical incision(s). MAIN OUTCOME MEASUREMENTS: Pain medications administered and pain according to the Visual Analogue Scale was recorded at scheduled postoperative time points: 4, 24, 48, 72, and 336 hours (14 days). RESULTS: Thirty-nine patients were randomized to the control group and 37 to the interventional group (mean age = 42 ± 15 years), with no statistically significant differences between groups with regards to severity of injury and patient demographics. Pain scores were significantly lower in the interventional group versus control up to 2 weeks after surgery. Percocet ingestion at 4 hours was significantly lower in the interventional group (0.7 vs. 1.3, P = 0.004), while it approached significance at 48 hours postoperatively (2.8 vs. 3.69, P = 0.07). No other significant differences were noted for Percocet ingestion postoperatively at other time points assessed. The overall satisfaction with pain control was not statistically different between the 2 groups (P = 0.93). CONCLUSION: Local intraoperative infiltration of liposomal bupivacaine administered with standard bupivacaine for ankle fractures requiring Open Reduction Internal Fixation (ORIF) affords improved pain relief in the immediate postoperative period resulting in a reduction in Percocet ingestion, with resultant effects seen up to 2 days postoperatively. Continued investigation of this drug for use with extremity fractures is warranted. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Operative repair of proximal humerus fractures in septuagenarians and octogenarians: Does chronologic age matter?

BACKGROUND: With an expected doubling of the geriatric population within the next thirty years it is becoming increasingly important to determine who among the elderly population benefit from orthopaedic interventions. This study assesses post-operative outcomes in patients aged seventy or greater who sustained a proximal humerus fracture and were treated surgically as compared to a younger geriatric cohort to determine if there is a chronologic age after which post-operative outcomes significantly decline. METHODS: A retrospective chart review was conducted for 201 patients who sustained fractures of the proximal humerus (OTA 11A-C) and were treated operatively by open reduction and internal fixation. Data from 132 independent, active patients aged fifty-five or older was identified and analyzed. Forty-seven patients age 70 or older were compared to 78 patients aged 55-69. Average length of follow-up was 19.5 months. All complications were recorded. Univariate and multivariate analysis was conducted to assess for differences between groups. RESULTS: 95% of patients achieved fracture union within 6 months. No significant differences were found between cohorts with regard to gender, fracture severity, or CCI (p = 0.197, p = 0.276, p = 0.084, respectively). Functional outcome scores, shoulder range of motion, and complications rates for patients aged 70 and older were not significantly different from patients aged 55-69. There were 10 complications in the older elderly cohort (21%), 6 of which required re-operation and 13 complications in the young elderly cohort (17%), 8 of which required re-operation. CONCLUSIONS: Operative fracture repair using locked plating of the proximal humerus in septuagenarians and octogenarians can provide for excellent long-term outcomes in appropriately selected patients. These patients tend to have long term functional outcome scores, post-operative range of motion, and complication rates that are comparable to younger geriatric patients. Physicians should not exclude patients for repair of proximal humerus fractures based on chronological age cutoffs.

Surgical Fracture Repair in Chronic Renal Failure Patients on Hemodialysis An Analysis of Complications and Hospital Quality Measures.

In end stage renal disease (ESRD) patients on hemodialysis (HD), it is known that renal bone disease has a negative impact on postoperative complication rate of fracture repair compared to non-ESRD patients. Previous studies have examined complications following surgical hip fracture repair in ESRD patients on HD. However, there is paucity of information outside of hip fracture repair. This study was undertaken to investigate complications associated with surgical fracture repair in ESRD patients on hemodialysis and to compare quality measures with a control group for various fracture types. Data of all consecutive ESRD patients on HD was collected prospectively starting in 2013. Charts of 2,558 ESRD patients on HD from 2010 to 2013 were also reviewed. Thirty-four patients who underwent surgical fracture repair were included in the study. Additionally, 1,000 patients without ESRD who underwent fracture repair were also identified, and a random sample of 267 patients was selected for inclusion as a control group. Primary outcomes were major complications as defined by the Clavien-Dindo complication rating system for orthopaedic surgery. Secondary outcomes were minor complications, defined by the same method. Demographic information and hospital quality measures, such as hospital length of stay (LOS) and discharge disposition, were also collected. There were no differences between the two groups in terms of BMI, ethnicity, or gender distribution. The ESRD patients were older than control patients (62.6 versus 46.8 years; p > 0.01). Overall, the complication rate in the ESRD group was 14.7% compared to 3% in the control group (p < 0.05) while the rate of major complications was similar (5.8% versus 2.2%, p = 0.2). The rate of minor complications was higher in the ESRD group though this did not reach statistical significance (8.8% versus 1%, p = 0.07). Median LOS was significantly higher in the ESRD group (15.9 versus 6.4 days; p < 0.01), and patients in the ESRD group were less likely to be discharged to home (29.4% versus 78%; p < 0.01). Surgical fracture repair in ESRD patients can be performed with similar major complication rate as a control group. However, the higher rate of minor complications and poorer hospital quality measures in the ESRD group must be taken into account as we move toward "pay for performance" and bundled payment initiatives for orthopaedic trauma patients.

Current Practices Regarding Perioperative Management of Patients With Fracture on Antiplatelet Therapy: A Survey of Orthopedic Surgeons.

OBJECTIVE: There continues to be controversy over whether operative delay is necessary for patients on antiplatelet therapy, particularly for elderly patients with hip fractures. This study sought to assess current clinical practices of orthopedic surgeons regarding perioperative management of these patients. METHODS: A 12-question, Web-based survey was distributed to orthopedic surgeons via e-mail. Questions regarding timing of surgery assumed patients were on antiplatelet therapy and assessed attitudes toward emergent and nonemergent orthopedic cases as well as operative delay for specific closed fracture types. Responses were compared using unpaired, 2-tailed Student t tests for continuous variables and Pearson chi-square tests with odds ratios (ORs) and 95% confidence intervals (CIs) for categorical variables. Statistical significance was defined as a P value <.05. RESULTS: Overall 67 orthopedic surgeons responded. Fifty-two percent (n = 35) of the respondents described their practice as academic. Thirty-nine percent (n = 25) of the surgeons indicated that no delay was acceptable for urgent but nonemergent surgery, and 78% (n = 50) reported no delay for emergent surgery was acceptable. Sixty-eight percent (n = 46) of respondents felt patients on antiplatelet therapy with closed hip fractures did not require operative delay. Surgeons who opted for surgical delay in hip fractures were more likely to delay surgery in other lower extremity fracture types (OR = 16.4, 95% CI 4.48-60.61, P < .001). Sixty-four percent (n = 41) of the surgeons indicated there was no protocol in place at their institution. CONCLUSIONS: There continues to be wide variability among orthopedic surgeons with regard to management of patients with fracture on antiplatelet therapy. Over a quarter of surgeons continue to opt for surgical delay in patients with hip fracture. This survey highlights the need to formulate and better disseminate practice management guidelines for patients with fracture on antiplatelet therapy, particularly given the aging population in the United States.

Comparison of Short-Term Outcomes of Geriatric Distal Femur and Femoral Neck Fractures: Results From the NSQIP Database.

PURPOSE: To compare and contrast postoperative complications in the geriatric population following open reduction and internal fixation (ORIF) for (DF) fractures relative to femoral neck (FN) fractures. METHODS: Patients aged 65 years and older in the American College of Surgeons National Surgical Quality Improvement Program database who underwent ORIF for FN fractures or DF fractures from 2005 to 2012 were identified. Differences in rates of any adverse events (AAEs), serious adverse events (SAEs), infectious complications, and mortality between groups were explored using univariate and multivariate analyses. RESULTS: The DF cohort had a higher proportion of females (81.95% vs 71.35%, P < .001), were younger (79.41 ± 7.93 vs 82.11 ± 7.26 years old, P < .001), and had a lower age adjusted modified Charlson comorbidity index score (4.22 ± 1.32 vs 4.49 ± 1.35, P = .02). Cases with DF and FN did not differ in AAE (20.05% vs 20.20%, P = .94), SAE (12.03% vs 13.19%, P = .51), infectious complication (4.26% vs 4.22%, P = .97), hospital length of stay (7.32 ± 6.73 days vs 7.02 ± 10.67 days, P = .59), or mortality rates (4.51% vs 5.99%, P = .23). Multivariate analyses revealed that fracture type did not impact AAE (P = .28), SAE (P = .58), infectious complications (P = .83), or mortality (P = .85) rates. CONCLUSION: Postoperative morbidity and mortality of geriatric patients who sustain DF and FN fractures treated operatively were comparable. This information can be used when risk stratifying and prognosticating for elderly patients undergoing these procedures.

A mammalian melanopsin in the retina of a fresh water turtle, the red-eared slider (Trachemys scripta elegans).

A mammalian-like melanopsin (Opn4m) has been found in all major vertebrate classes except reptile. Since the pupillary light reflex (PLR) of the fresh water turtle takes between 5 and 10 min to achieve maximum constriction, and since photosensitive retinal ganglion cells (ipRGCs) in mammals use Opn4m to control their slow sustained pupil responses, we hypothesized that a Opn4m homolog exists in the retina of the turtle. To identify its presence, retinal tissue was dissected from seven turtles, and total RNA extracted. Reverse transcriptase-polymerase chain reactions (RT-PCRs) were carried out to amplify gene sequences using primers targeting the highly conserved core region of Opn4m, and PCR products were analyzed by gel electrophoresis and sequenced. Sequences derived from a 1004-bp PCR product were compared to those stored in GenBank by the basic local alignment search tool (BLAST) algorithm and returned significant matches to several Opn4ms from other vertebrates including chicken. Quantitative real-time PCR (qPCR) was also carried out to compare expression levels of Opn4m in different tissues. The normalized expression level of Opn4m in the retina was higher in comparison to other tissue types: iris, liver, lung, and skeletal muscle. The results suggest that Opn4m exists in the retina of the turtle and provides a possible explanation for the presence of a slow PLR. The turtle is likely to be a useful model for further understanding the photoreceptive mechanisms in the retina which control the dynamics of the PLR.