Delay of fixation increases 30-day complications and mortality in traumatic pelvic ring injuries.

PURPOSE: While decreased time to fixation in femur fractures improves mortality, it remains unclear if the same relationship exists for pelvic fractures. The National Trauma Data Bank (NTDB) is a data repository for trauma hospitals in the United States (injury characteristics, perioperative data, procedures, 30-day complications), and we used this to investigate early, significant complications after pelvic-ring injuries. METHODS: The NTDB (2015-2016) was queried to capture operative pelvic ring injuries in adult patients with injury severity score (ISS) ≥ 15. Complications included medical and surgical complications, as well as 30-day mortality. Multivariable logistic regression was used to investigate the association between days to procedure and complications after adjusting for demographic characteristics and comorbidities. RESULTS: 2325 patients met inclusion criteria. 532 (23.0%) sustained complications, and 72 (3.2%) died within the first 30 days. The most common complications were deep vein thrombosis (DVT) (5.7%), acute kidney injury (AKI) (4.6%), and unplanned intensive care unit (ICU) admission (4.4%). In a multivariate analysis, days to procedure was independently significantly associated with complications, with an adjusted odds ratio (95% confidence interval) of 1.06 (1.03-1.09, P < 0.001), best interpreted as a 6% increase in the odds of complication or death for each additional day. CONCLUSION: Time to pelvic fixation is a significant and modifiable risk factor for major complications and death. This suggests we should prioritize time to pelvic fixation on trauma patients to minimize mortality and major complications.

Radiographic bladder shift is a harbinger of intraoperative blood loss in acetabular surgical fixation.

PURPOSE: The purpose of this study was to characterize the relationship between a novel radiographic measurement on initial AP pelvis radiograph (termed "bladder shift," BS) to intraoperative blood loss (IBL) during acetabular surgical fixation. METHODS: All adult patients receiving unilateral acetabular fixation (Level 1 academic trauma; 2008-18) were reviewed. AP pelvis radiographs were reviewed for visible bladder outlines and then measured to determine the percentage deformation toward the midline. Hemoglobin & hematocrit data were then used to calculate quantitative blood loss between pre- and post- operative blood counts for data analysis. RESULTS: 371 patients with unilateral traumatic acetabular fractures requiring fixation were reviewed; 99 of these had visible bladder outlines, complete blood count and transfusion data (2008-2018; 66% associated patterns). Median bladder shift (BS) was 13.3%. Every 10% of bladder shift was associated with 123 mL greater IBL. Patients with full bladder shift to midline sustained a median 1.5L IBL (interquartile range [IQR] 0.8 to 1.6). Associated patterns had a threefold greater median BS (associated: 16.5% [15.4 to 45.9] vs. elementary: 5.6% [1.1 to 15.4], p < 0.05) and received intraoperative pRBC twice as frequently (57% vs. 24%, p < 0.01). CONCLUSIONS: Radiographic bladder shift is an easily available visual marker, in patients sustaining acetabular fractures, that may predict intraoperative hemorrhage and need for transfusions.

Acetabular fracture pattern is altered by pre-injury sacroiliac joint autofusion.

PURPOSE: Acetabular fracture shape is determined by the direction of force applied. We perceive an anecdotally observed connection between pre-existing autofused sacroiliac joints (aSIJ) and high anterior column (HAC) injuries. The purpose of this study was to compare variations in acetabular fracture patterns sustained in patients with and without pre-injury sacroiliac (SI) joint autofusion. METHODS: All adult patients receiving unilateral acetabular fixation (level 1 academic trauma; 2008-2018) were reviewed. Injury radiographs and CT scans were reviewed for fracture patterns and pre-existing aSIJ. Fracture types were subgrouped presence of HAC injury (includes anterior column (AC), anterior column posterior hemitransverse (ACPHT), or associated both column (ABC)). ANALYSIS: Logistic regression determined the association between aSIJ and HAC. RESULTS: A total of 371 patients received unilateral acetabular fixation (2008-2018); 61 (16%) demonstrated CT evidence of idiopathic aSIJ. These patients were older (64.1 vs. 47.4, p < 0.01), more likely to be male (95% vs. 71%, p < 0.01), less likely to be smokers (19.0% vs. 44.8%, p < 0.01), and were injured from lower energy mechanisms (21.3% vs. 8.4%, p = 0.01). The most common patterns with autofusion were ACPHT (n = 13, 21%) and ABC (n = 25, 41%). Autofusion was associated with greater odds of patterns involving a high anterior column injury (ABC, ACPHT, or isolated anterior column; OR = 4.97, p < 0.01). After adjusting for age, mechanism, and body mass index, the connection between autofusion and high anterior column injuries remained significant (OR = 2.60, p = 0.01). CONCLUSIONS: SI joint autofusion appears to change mode of failure in acetabular injuries; a more rigid posterior ring may precipitate a high anterior column injury. LEVEL OF EVIDENCE: Prognostic level III.

A Curricular Model for Simulation Within Orthopaedic Residency Training.

Introduction: American Board of Orthopaedic Surgery/American Council on GraduateMedical Education Residency Review Committee training requirements have necessitated the need for the adoption of simulation education into existing programmatic requirements. Current guidelines focus only on interns at a potentially significant cost to programs; both in total dollar amount and time. Methods: The authors aim to provide a model that can maximize utility for all resident levels, manage cost by maximizing the use of cadaveric material, and allow integration of varied industry support. Results: The Oregon Health & Science University Orthopaedic education program has developed a high-fidelity training curriculum that (1) is applicable to both junior and senior residents (2) has minimized the cost per resident with the reuse of cadaveric specimens and (3) has nurtured partnerships with industry stakeholders to reduce bias in training by collaborating with most major industry representatives. Conclusion: The simulation curriculum outlined in this manuscript may serve as a reference for other programs and institutions to develop their own residency educational curriculum models.

Salvage hip arthroplasty after failed fixation of proximal femur fractures.

We reviewed 46 patients who underwent salvage hip arthroplasty (SHA) for revision of failed cannulated screws (CS), sliding hip screws (SHS), or intramedullary nails (IMN). The primary objective was to determine differences in operative difficulty. SHA after failed femoral neck fixation was associated with lower intra-operative demands than after failed peri-trochanteric fractures. Similarly, analysis by the index implant found that conversion arthroplasty after failed CSs was associated with lower intra-operative morbidity than failed SHSs or IMNs; differences between SHS and IMN were not as clear. Importantly, intra-operative data in cases of failed SHSs were similar regardless of the original fracture type, showing the device played a larger role than the fracture pattern. Complications and revision surgery rates were similar regardless of fracture type or fixation device. Our results suggest that operative demands and subsequent patient morbidity are more dependent on the index device than the fracture pattern during SHA.

Surgeon-Estimated Blood Loss Is Discordant With Calculated Blood Loss in Acetabular and Pelvic Fracture Surgery.

OBJECTIVES: To compare blood loss as estimated by surgeon-estimated blood loss (EBL), the Gross formula, and the HB equation in open pelvic and acetabular surgery. DESIGN: Retrospective cohort study. SETTING: Single Level I academic trauma center. PATIENTS: We included 710 patients 18-89 years of age who underwent acetabular or pelvic surgery between 2008 and 2018 for the management of fracture. INTERVENTION: Surgical treatment for the management of acetabular or pelvic fracture and blood transfusion when deemed clinically appropriate in the perioperative setting. MAIN OUTCOME MEASURES: Surgeon EBL and calculated blood loss (using the Gross formula, a Gross formula derivative, and the HB equation with both Moore and Nadler blood volume estimations). RESULTS: One hundred ninety-two patients (27%) received intraoperative blood transfusions. Surgeon EBL significantly differed from all formulas except the Gross/Nadler and the modified Gross/Nadler calculations. Gross and HB calculation methods yielded similar results in the overall cohort but yielded significantly different results in the subgroup analysis. Use of a corrective transfusion factor mildly improved correlation of the Gross equation with EBL. At high levels of blood loss, surgeon EBL predictions became more discordant with calculated blood loss values. When assessing only patients who did not receive transfusions, concordance improved. CONCLUSION: Blood loss in pelvic and acetabular surgery is challenging to quantify, and this study demonstrates discordance between formula predictions and surgeon-estimated blood loss. At higher levels of blood loss, this discrepancy worsens. This exploratory study highlights the need for the development of improved methods of quantifying blood loss in orthopaedic trauma surgery. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Post Post-Mobilization Films for LC1 Pelvic Ring Injuries: Follow up Stress Imaging Demonstrates Minimal Utility.

OBJECTIVE: To assess the utility of outpatient postmobilization radiographs in the nonoperative treatment of lateral compression type I (LC1) (OTA/AO 61-B1) pelvic ring injuries. DESIGN: Retrospective series. SETTING: Academic, Level 1 trauma center, 2008-2018. PATIENTS/PARTICIPANTS: A series of 173 patients with nonoperatively treated LC1 pelvic ring injuries was identified. Of these, 139 received a complete set of outpatient pelvic radiographs with which to assess displacement. INTERVENTION: Outpatient pelvic radiographs to assess additional fracture displacement and potential need for surgical intervention. MAIN OUTCOME MEASUREMENTS: Rate of conversion to late operative intervention based on radiographic displacement. RESULTS: No patient in this cohort received late operative intervention. A majority of the patients sustained incomplete sacral fractures (82.6%) and unilateral rami fractures (75.1%), and 92.8% demonstrated less than 10 mm of displacement on their final radiographs. CONCLUSIONS: There is a low utility of repeat outpatient radiographs of stable, nonoperative LC1 pelvic ring injuries as they do not undergo late displacement. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Fracture Surgery in Patients With Escalating Hemoglobin A1C in the Setting of Unmanaged Diabetes.

OBJECTIVE: To determine whether there is a threshold of elevated hemoglobin A1C (HbA1c) above which the complication risk is so high that fracture fixation should be avoided. DESIGN: Retrospective cohort study. SETTING: Academic Level I trauma center. PATIENTS/PARTICIPANTS: A cohort of 187 patients with HbA1c values >7 and operatively treated extremity fractures. INTERVENTION: Surgical fixation of extremity fractures. MAIN OUTCOME MEASUREMENTS: Rate of major orthopaedic complication (loss of reduction, nonunion, infection, and need for salvage procedure). RESULTS: 34.8% demonstrated HbA1c > 9% and 12.3% with HbA1c > 11. Major complications occurred in 31.4%; HbA1c values were not predictive. We found no evidence of a clinically or statistically significant relationship between HbA1c and risk of major complication. The odds ratio for a one-point increase in HbA1c was 1.006 ( P = 0.9439), and the area under the receiver operating characteristic curve, which reflects the average probability that someone with a major complication will have a higher HbA1c than someone without, was 0.51 (95% confidence interval 0.42-0.61), equivalent to random chance. CONCLUSION: Diabetic patients with fracture demonstrated an extremely high overall rate of complications, with 30.5% experiencing a major complication. However, patients with extreme diabetic neglect did not have higher complication rates after extremity fracture fixation when compared with patients with controlled and uncontrolled diabetes. There was no correlation between rate of complication and level of HbA1c. In addition, there was no difference in complication rate between upper and lower extremity fractures or between fractures treated with open or percutaneous fixation. This suggests that fracture treatment decision-making should not be altered for patients with poor diabetic control, and that surgery is not contraindicated in patients with an extremely high HbA1c. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Distribution of Bacterial Species and Resistance Patterns in Surgical Site Infection after Prior Administration of Vancomycin and Tobramycin Intrawound Powdered Antibiotic Prophylaxis.

OBJECTIVE: Evaluate the species distribution and resistance patterns of bacterial pathogens causing surgical site infection (SSI) after operative fracture repair, with and without the use of intrawound powdered antibiotic (IPA) prophylaxis during the index surgery. DESIGN: Retrospective cohort study. SETTING: Academic, level 1 trauma center, 2018-2020. PATIENTS/PARTICIPANTS: Fifty-nine deep SSIs were identified in a sample of 734 patients with 846 fractures (IPA [n = 320], control [n = 526]; open [n = 157], closed fractures [n = 689]) who underwent orthopaedic fracture care. Among SSIs, 28 (48%) patients received IPA prophylaxis and 25 (42%) of the fractures were open. INTERVENTION: Intrawound powdered vancomycin and tobramycin. MAIN OUTCOME MEASUREMENTS: Distribution of bacterial species and resistance patterns causing deep surgical site infections requiring operative debridement. RESULTS: Zero patients developed infections caused by resistant strains of streptococci, enterococci, gram-negative enterics, Pseudomonas , or Cutibacterium species. The only resistant strains isolated were methicillin resistance (19%) and oxacillin-resistant coagulase-negative staphylococci (16%). There was no associated statistical difference in the proportion of bacterial species isolated, their resistance profiles, or rate of polymicrobial infections between the IPA and control group. Most (93%) cases using IPAs included vancomycin and tobramycin powders. There were 59 SSIs; 28 (9%) in the IPA cohort and 31 (6%) in the control cohort ( P = 0.13). CONCLUSION: The use of local antibiotic prophylaxis resulted in no measurable increase in the proportion of infections caused by resistant bacterial pathogens after operative treatment of fractures. However, the small sample size and limited time frame of these preliminary data require continued investigation into their role as an adjunct to SSI prophylaxis. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Reaming the intramedullary canal during tibial nailing does not affect in vivo intramuscular pH of the anterior tibialis.

Many investigations have evaluated local and systemic consequences of intramedullary (IM) reaming and suggest that reaming may cause, or exacerbate, injury to the soft tissues adjacent to fractures. To date, no study has examined the effect on local muscular physiology as measured by intramuscular pH (IpH). Here, we observe in vivo IpH during IM reaming for tibia fractures. Methods: Adults with acute tibia shaft fractures (level 1, academic, 2019-2021) were offered enrollment in an observational cohort. During IM nailing, a sterile, validated IpH probe was placed into the anterior tibialis (<5 cm from fracture, continuous sampling, independent research team). IpH before, during, and after reaming was averaged and compared through repeated measures ANOVA. As the appropriate period to analyze IpH during reaming is unknown, the analysis was repeated over periods of 0.5, 1, 2, 5, 10, and 15 minutes prereaming and postreaming time intervals. Results: Sixteen subjects with tibia shaft fractures were observed during nailing. Average time from injury to surgery was 35.0 hours (SD, 31.8). Starting and ending perioperative IpH was acidic, averaging 6.64 (SD, 0.21) and 6.74 (SD, 0.17), respectively. Average reaming time lasted 15 minutes. Average IpH during reaming was 6.73 (SD, 0.15). There was no difference in IpH between prereaming, intrareaming, and postreaming periods. IpH did not differ regardless of analysis over short or long time domains compared with the duration of reaming. Conclusions: Reaming does not affect IpH. Both granular and broad time domains were tested, revealing no observable local impact.

Role of single-dose intravenous iron therapy for the treatment of anaemia after orthopaedic trauma: protocol for a pilot randomised controlled trial.

INTRODUCTION: Orthopaedic trauma and fracture care commonly cause perioperative anaemia and associated functional iron deficiency due to a systemic inflammatory state. Modern, strict transfusion thresholds leave many patients anaemic; managing this perioperative anaemia is an opportunity to impact outcomes in orthopaedic trauma surgery. The primary outcome of this pilot study is feasibility for a large randomised controlled trial (RCT) to evaluate intravenous iron therapy (IVIT) to improve patient well-being following orthopaedic injury. Measurements will include rate of participant enrolment, screening failure, follow-up, missing data, adverse events and protocol deviation. METHODS AND ANALYSIS: This single-centre, pilot, double-blind RCT investigates the use of IVIT for acute blood loss anaemia in traumatically injured orthopaedic patients. Patients are randomised to receive either a single dose infusion of low-molecular weight iron dextran (1000 mg) or placebo (normal saline) postoperatively during their hospital stay for trauma management. Eligible subjects include adult patients admitted for lower extremity or pelvis operative fracture care with a haemoglobin of 7-11 g/dL within 7 days postoperatively during inpatient care. Exclusion criteria include history of intolerance to intravenous iron supplementation, active haemorrhage requiring ongoing blood product resuscitation, multiple planned procedures, pre-existing haematologic disorders or chronic inflammatory states, iron overload on screening or vulnerable populations. We follow patients for 3 months to measure the effect of iron supplementation on clinical outcomes (resolution of anaemia and functional iron deficiency), patient-reported outcomes (fatigue, physical function, depression and quality of life) and translational measures of immune cell function. ETHICS AND DISSEMINATION: This study has ethics approval (Oregon Health & Science University Institutional Review Board, STUDY00022441). We will disseminate the findings through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT05292001; ClinicalTrials.gov.

Locked Lateral Plating Versus Retrograde Nailing for Distal Femur Fractures: A Multicenter Randomized Trial.

OBJECTIVES: The 2 main forms of treatment for distal femur fractures are locked lateral plating and retrograde nailing. The goal of this trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN: Multicenter randomized controlled trial. SETTING: Twenty academic trauma centers. PATIENTS/PARTICIPANTS: One hundred sixty patients with distal femur fractures were enrolled. One hundred twenty-six patients were followed 12 months. Patients were randomized to plating in 62 cases and intramedullary nailing in 64 cases. INTERVENTION: Lateral locked plating or retrograde intramedullary nailing. MAIN OUTCOME MEASUREMENTS: Functional scoring including Short Musculoskeletal Functional Assessment, bother index, EQ Health, and EQ Index. Secondary measures included alignment, operative time, range of motion, union rate, walking ability, ability to manage stairs, and number and type of adverse events. RESULTS: Functional testing showed no difference between the groups. Both groups were still significantly affected by their fracture 12 months after injury. There was more coronal plane valgus in the plating group, which approached statistical significance. Range of motion, walking ability, and ability to manage stairs were similar between the groups. Rate and type of adverse events were not statistically different between the groups. CONCLUSIONS: Both lateral locked plating and retrograde intramedullary nailing are reasonable surgical options for these fractures. Patients continue to improve over the course of the year after injury but remain impaired 1 year postoperatively. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Methods of Quantifying Intraoperative Blood Loss in Orthopaedic Trauma Surgery: A Systematic Review.

OBJECTIVES: To collect and present the recently published methods of quantifying blood loss (BL) in orthopaedic trauma. DATA SOURCES: A systematic review of English-language literature in PubMed, Cochrane Library, and Scopus databases was conducted according to the PRISMA guidelines on articles describing the methods of determining BL in orthopaedic trauma published since 2010. STUDY SELECTION: English, full-text, peer-reviewed articles documenting intraoperative BL in an adult patient population undergoing orthopaedic trauma surgery were eligible for inclusion. DATA EXTRACTION: Two authors independently extracted data from the included studies. Articles were assessed for quality and risk of bias using the Cochrane Collaboration's tool for assessing risk of bias and ROBINS-I. DATA SYNTHESIS: The included studies proved to be heterogeneous in nature with insufficient data to make data pooling and analysis feasible. CONCLUSIONS: Eleven methods were identified: 6 unique formulas with multiple variations, changes in hemoglobin and hematocrit levels, measured suction volume and weighed surgical gauze, transfusion quantification, cell salvage volumes, and hematoma evacuation frequency. Formulas included those of Gross, Mercuriali, Lisander, Sehat, Foss, and Stahl, with Gross being the most common (25%). All formulas used blood volume estimation, determined by equations from Nadler (94%) or Moore (6%), and measure change in preoperative and postoperative blood counts. This systematic review highlights the variability in BL estimation methods published in current orthopaedic trauma literature. Methods of quantifying BL should be taken into consideration when designing and evaluating research.

Collagen X Longitudinal Fracture Biomarker Suggests Staged Fixation in Tibial Plateau Fractures Delays Rate of Endochondral Repair.

OBJECTIVES: To use a novel, validated bioassay to monitor serum concentrations of a breakdown product of collagen X in a prospective longitudinal study of patients sustaining isolated tibial plateau fractures. Collagen X is the hallmark extracellular matrix protein present during conversion of soft, cartilaginous callus to bone during endochondral repair. Previous preclinical and clinical studies demonstrated a distinct peak in collagen X biomarker (CXM) bioassay levels after long bone fractures. SETTING: Level 1 academic trauma facility. PATIENTS/PARTICIPANTS: Thirty-six patients; isolated tibial plateau fractures. INTERVENTION: (3) Closed treatment, ex-fix (temporizing/definitive), and open reduction internal fixation. MAIN OUTCOME MEASUREMENTS: Collagen X serum biomarker levels (CXM bioassay). RESULTS: Twenty-two men and 14 women (average age: 46.3 y; 22.6-73.4, SD 13.3) enrolled (16 unicondylar and 20 bicondylar fractures). Twenty-five patients (72.2%) were treated operatively, including 12 (33.3%) provisionally or definitively treated by ex-fix. No difference was found in peak CXM values between sexes or age. Patients demonstrated peak expression near 1000 pg/mL (average: male-986.5 pg/mL, SD 369; female-953.2 pg/mL, SD 576). There was no difference in peak CXM by treatment protocol, external fixator use, or fracture severity (Schatzker). Patients treated with external fixation (P = 0.05) or staged open reduction internal fixation (P = 0.046) critically demonstrated delayed peaks. CONCLUSIONS: Pilot analysis demonstrates a strong CXM peak after fractures commensurate with previous preclinical and clinical studies, which was delayed with staged fixation. This may represent the consequence of delayed construct loading. Further validation requires larger cohorts and long-term follow-up. Collagen X may provide an opportunity to support prospective interventional studies testing novel orthobiologics or fixation techniques. LEVEL OF EVIDENCE: Level II, prospective clinical observational study.

Is the Iliac Cortical Density Similarly Positioned in the Developing Pediatric Pelvis?

OBJECTIVES: The iliac cortical density (ICD) is a critical fluoroscopic landmark for pelvic percutaneous screw placement. Our purpose was to evaluate the ICD as a landmark in pediatrics and quantify the diameter of osseous pathways for 3 screw trajectories: iliosacral (IS) at S1 and transiliac-transsacral (TSTI) at S1 and S2. METHODS: Two hundred sixty-seven consecutive pelvic CT scans in children 0-16 years of age were analyzed. ICD and S1 vertebral heights were measured at multiple regions along S1. Their height and corresponding ratios, as well as osseous screw corridor dimensions were compared between age groups and by the dysmorphic status. RESULTS: In the nondysmorphic pelvises, S1 height, ICD height, and the ICD to S1 height ratio increased across age groups for all locations (P < 0.001). All 3 screw pathway diameters increased with age (P < 0.001). In the dysmorphic group, there was no increase in ICD to S1 height ratio with age. Except for the age 0-2 group, the ICD to S1 height ratios were significantly larger in the nondysmorphic group. In the dysmorphic group, S1 TSTI pathway remained narrow with age, whereas IS at S1 and TSTI at S2 had a significant increased diameter with age (P < 0.001). CONCLUSION: The ICD is a useful fluoroscopic landmark for percutaneous screw placement in the pediatric pelvis. For nondysmorphic pelvises, the ICD to S1 height ratio, as well as osseous corridors for IS, TSTI at S1, and TSTI at S2 screw trajectories increase significantly with age. The margin for safe screw placement in S1 is smaller for younger and dysmorphic pelvises.

Methamphetamines and Acetabular Reoperation Rates: Poor Outcomes From the Front Lines.

OBJECTIVES: To compare acetabular fracture reoperation rates within 1 year of surgery in methamphetamine ("meth") abusers and abstainers. DESIGN: Retrospective database analysis. SETTING: Level 1 academic trauma facility, 2008-2018. PATIENTS/PARTICIPANTS: Three hundred seventy-one patients who underwent unilateral traumatic acetabular open reduction internal fixation during the study period, 36 of whom abused methamphetamines through self-report or toxicology. One hundred four were excluded for indeterminate abuse histories. INTERVENTION: Open reduction internal fixation. MAIN OUTCOME MEASUREMENTS: Reoperation resulting from major surgical complications, including hematoma, seroma, deep wound infection, failure of fixation, or arthrosis with conversion to arthroplasty. RESULTS: More than 10% of our cohort used meth, representing patients who were a mean 8 years younger and sustained a higher rate of high-energy mechanisms than sober peers. Meth abusers had a greater than 2-fold reoperation rate at 90 days and 1 year compared with abstainers (17% vs. 7% and 25% vs. 11%, respectively). The adjusted odds ratio of 1-year reoperation in meth users was 3.2 (confidence interval 1.2-8.5, P = 0.03). The adjusted 1-year survival of native hip after acetabular fractures in meth users approaches 55%. CONCLUSIONS: Methamphetamine use is a nonmodifiable factor associated with a 3-fold increase in adjusted odds for 1-year reoperation after surgical fixation of acetabular fractures. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Methamphetamine in Orthopaedics: Considerations of an At-Risk Population.

¼: Methamphetamine use by orthopaedic trauma patients has risen to epidemic proportions. ¼: Perioperative methamphetamine use by orthopaedic trauma patients requires physicians to consider both medical and psychosocial factors during treatment. ¼: Behavioral and psychosocial effects of methamphetamine use present barriers to care. ¼: Patients who use methamphetamine face elevated rates of complications.

Does Resident Participation in the Surgical Fixation of Hip Fractures Increase Operative Time or Affect Outcomes?

BACKGROUND: Surgical fixation of hip fractures is a common procedure at teaching hospitals with resident support and in community hospitals. OBJECTIVE: We evaluated to what extent participation by residents in hip fracture fixation affects operative times or outcomes. SETTING: Operations were performed by three surgeons who operate at a teaching hospital with resident support, and at a community hospital without residents in the same metropolitan area. PARTICIPANTS: We performed a retrospective analysis of operative time and early post-operative outcomes on a series of 314 patients with hip fractures (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association A1-3, B1-3) treated with surgical fixation between April 2012 and March 2015; 177 patients at the community hospital, and 137 at the teaching hospital. METHODS: Multivariate regression assessed the effect of hospital type, adjusting for age, gender, American Society of Anesthesiologist classification, and Charlson comorbidity index. RESULTS: We found lower median operative time at the community hospital than the teaching hospital (46 minutes, 95% confidence interval [CI] = [43, 52] versus 75 minutes, 95% CI = [70, 81]) and lower estimated blood loss (177.3 mL, 95% CI=[158.6, 195.1] versus 234.8 mL, 95% CI = [196.4, 273.6]), but no differences in transfusion requirement, length of stay, or discharge to skilled nursing facility. Adjusted odds ratio for thirty-day mortality at the teaching hospital was 5.44 (95% CI = [1.22, 24.1]). CONCLUSION: We found longer operative times and elevated estimated blood loss with resident involvement in surgical fixation of hip fractures. There was a difference in 30-day mortality between the groups, although this cannot simply be attributed to resident involvement as there are many other factors related to mortality.

Smith-Petersen Versus Watson-Jones Approach Does Not Affect Quality of Open Reduction of Femoral Neck Fracture.

OBJECTIVE: To compare immediate quality of open reduction of femoral neck fractures by alternative surgical approaches. DESIGN: Retrospective cohort study. SETTING: Twelve Level 1 North American trauma centers. PATIENTS: Eighty adults 18-65 years of age with isolated, displaced, OTA/AO type 31-B2 or -B3 femoral neck fractures treated with internal fixation. INTERVENTION: Thirty-two modified Smith-Petersen anterior approaches versus 48 Watson-Jones anterolateral approaches for open reduction performed by fellowship-trained orthopaedic trauma surgeons. MAIN OUTCOME: Reduction quality as assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs. RESULTS: No difference was observed in the rate of acceptable reduction by modified Smith-Petersen (81%) versus Watson-Jones (81%) approach (risk difference null, 95% confidence interval -17.4% to 17.4%, P = 1.00) with 90.4% panel agreement (Fleiss' weighted κ = 0.63, P < 0.01). Stratified analyses did not identify a significant difference in the rate of acceptable reduction between approaches when stratified by Pauwels angle, basicervical or transcervical fracture location, or posterior comminution. The Smith-Petersen approach afforded a better reduction when preoperative skeletal traction was not applied (RR = 1.67 [95% CI 1.10-2.52] vs. RR = 0.87 [95% CI 0.70-1.08], P = 0.006). CONCLUSIONS: No difference was observed in the quality of open reduction of displaced femoral neck fractures in young adults when a Watson-Jones anterolateral approach versus a modified Smith-Petersen anterior approach was performed by orthopaedic trauma surgeons. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Open Reduction Is Associated With Greater Hazard of Early Reoperation After Internal Fixation of Displaced Femoral Neck Fractures in Adults 18-65 Years.

OBJECTIVES: To determine (1) which factors are associated with the choice to perform an open reduction and (2) by adjusting for these factors, if the choice of reduction method is associated with reoperation. DESIGN: Retrospective cohort study with radiograph and chart review. SETTING: Twelve Level 1 North American trauma centers. PATIENTS: Two hundred thirty-four adults 18-65 years of age with an isolated, displaced, OTA/AO type 31-B2 or type 31-B3 femoral neck fracture treated with internal fixation with minimum of 6-month follow-up or reoperation. Exclusion criteria were pathologic fractures, associated femoral head or shaft fractures, and primary arthroplasty. INTERVENTION: Open or closed reduction technique during internal fixation. MAIN OUTCOME: Cox proportional hazard of reoperation adjusting for propensity score for open reduction based on injury, demographic, and medical factors. Reduction quality was assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs. RESULTS: Median follow-up was 1.5 years. One hundred six (45%) patients underwent open reduction. Reduction quality was not significantly affected by open versus closed approach (71% vs. 69% acceptable, P = 0.378). The propensity to receive an open reduction was associated with study center; younger age; male sex; no history of injection drug use, osteoporosis, or cerebrovascular disease; transcervical fracture location; posterior fracture comminution; and surgery within 12 hours. A total of 35 (33%) versus 28 (22%) reoperations occurred after open versus closed reduction (P = 0.056). Open reduction was associated with a 2.4-fold greater propensity-adjusted hazard of reoperation (95% confidence interval 1.3-4.4, P = 0.004). A total of 35 (15%) patients underwent subsequent total hip arthroplasty or hemiarthroplasty. CONCLUSIONS: Open reduction of displaced femoral neck fractures in nonelderly adults is associated with a greater hazard of reoperation without significantly improving reduction. Prospective randomized trials are indicated to confirm a causative effect of open versus closed reduction on outcomes after femoral neck fracture. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.