Comparison of reamed long and short intramedullary nail constructs in unstable intertrochanteric femur fractures: A biomechanical study.

OBJECTIVES: There is no definitive evidence to guide clinicians in their decision-making for implant choice regarding long or short intramedullary nails for unstable fracture patterns. Historically short nails were associated with higher rates of perisprothetic fractures which seem to have improved with newer designs. Long intramedullary nails have higher blood loss and time under anesthesia. The purpose of this study was to assess stability of long and short intramedullary nail constructs in unstable intertrochanteric fracture patterns to better elucidate if unstable intertrochanteric fractures are amenable to treatment with short intramedullary nails. METHODS: This study utilized composite model femurs which were assigned to either a comminuted or reverse obliquity fracture pattern, then subsequently assigned to implantation with either a long or short intramedullary nail. All the samples were reamed to the level of the distal femur and instrumented with the appropriate nail. Axial and torsional stiffness as well as axial load to failure values were determined using a servohydraulic loading system. RESULTS: Short nail constructs exhibited significantly greater axial stiffness in A1 fractures and torsional stiffness in A3 fractures when compared with long nails. There was no significant difference between axial load to failure between long nails and short nails. DISCUSSION: We found no significant difference in axial load to failure values between long and short intramedullary nail fixation in 2 unstable intertrochanteric fracture patterns in a composite femur model. Short nails exhibited greater stiffness in axial loads in the A1 pattern and torsional stiffness in the A3 pattern. This suggests short or long intramedullary nails could be appropriately employed for fixation of unstable intertrochanteric hip fracture patterns.

Not Further Specified: Unclassified Orthopedic Injuries in Trauma Registries, Cause for Concern?

BACKGROUND: Data accuracy is essential to obtaining correct results and making appropriate conclusions in outcomes research. Few have examined the quality of data that is used in studies involving orthopedic surgery. A nonspecific data entry has the potential to affect the results of a study or the ability to appropriately risk adjust for treatments and outcomes. This study evaluated the proportion of Not Further Specified (NFS) orthopedic injury codes found into two large trauma registries. MATERIALS: Data from the National Trauma Data Bank (NTDB) from 2011 to 2015 and from the Michigan Trauma Quality Improvement Program (MTQIP) 2011-2017 were used. We selected multiple orthopedic injuries classified via the Abbreviated Injury Scale, version 2005 (AIS2005) and calculated the percentage of NFS entries for each specific injury. RESULTS: There were a substantial proportion of fractures classified as NFS in each registry, 18.5% (range 2.4%-67.9%) in MTQIP and 27% (range 6.0%-68.5%) in the NTDB. There were significantly more NFS entries when the fractures were complex versus simple in both MTQIP (34.5% versus 9.6%, P < 0.001) and the NTDB (41.8% versus 15.7%, P < 0.001). The level of trauma center affected the proportion of NFS codes differently between the registries. CONCLUSIONS: The proportion of nonspecific entries in these two large trauma registries is concerning. These data can affect the results and conclusions from research studies as well as impact our ability to truly risk adjust for treatments and outcomes. Further studies should explore the reasons for these findings.

Modern Implant Options for the Treatment of Distal Femur Fractures.

Distal femur fractures occur in a periarticular fracture pattern and disproportionately afflict an aging population. Although the goals of treatment have not changed, the emergence of new surgical techniques and devices has recently been developed and refined to treat this challenging fracture pattern. Treatment options include open reduction and internal fixation with periarticular locking plates, intramedullary nails, or distal femur replacement. Despite rapid adoption, these modern solutions display a concerning complication rate, specifically from nonunion and malunion. The indications for each of these treatment strategies are not well defined and are the subject of current debate. As with the use of any orthopaedic implant, the knowledge of the strengths and weaknesses of each construct is paramount to successful treatment of these fractures. Recently, as the understanding of the biomechanics of distal femur fracture healing has improved, the literature has demonstrated clinical and theoretical improvements in the outcomes after distal femur fracture repair.

American College of Surgeons Committee on Trauma verification level affects trauma center management of pelvic ring injuries and patient mortality.

BACKGROUND: Pelvic ring fractures represent a complex injury that requires specific resources and clinical expertise for optimal trauma patient management. We examined the impact of treatment variability for this type of injury at Level I and II trauma centers on patient outcomes. METHODS: Trauma quality collaborative data (2011-2017) were analyzed. This includes data from 29 American College of Surgeons Committee on Trauma verified Level I and Level II trauma centers. Inclusion criteria were adult patients (≥16 years), Injury Severity Score of 5 or higher, blunt injury, and evidence of a partially stable or unstable pelvic ring fracture injury coding as classified using Abbreviated Injury Scale version 2005, with 2008 updates. Patients directly admitted, transferred out for definitive care, with penetrating trauma, or with no signs of life were excluded. Propensity score matching was used to create 1:1 matched cohorts of patients treated at Levels I or II trauma centers. Trauma center verification level was the exposure variable used to compare management strategies, resource utilization, and in-hospital mortality in univariate analysis. RESULTS: We selected 1,220 well-matched patients, from 1,768 total patients, using propensity score methods (610 Level I and 610 Level II cohort). There were no significant baseline characteristic differences noted between the groups. Patients with pelvic ring fractures treated at Level I trauma centers had significantly decreased mortality (7.7% vs. 11.6%, p = 0.02). Patients treated at Level II trauma centers were less likely to receive interventional angiography, undergo complicated definitive orthopedic operative treatment, and to be admitted to an intensive care unit. CONCLUSION: Admission with a partially stable or unstable pelvic ring injury to a Level I trauma center is associated with decreased mortality. Level II trauma centers had significantly less utilization of advanced treatment modalities. This variation in clinical practice highlights potential processes to emphasize in the appropriate treatment of these critically ill patients. LEVEL OF EVIDENCE: Economic/Decision, Level II.

Previous arthroscopic repair of femoro-acetabular impingement does not affect outcomes of total hip arthroplasty.

BACKGROUND: Total hip arthroplasty (THA) is commonly elected following failed arthroscopic treatment of femoro-acetabular impingement (FAI). The purpose of this study was to evaluate post-operative outcomes of primary THA in patients who had previously undergone arthroscopic treatment for FAI. METHODS: A retrospective, matched case-control study was conducted. The case group included 39 patients who underwent THA after previous hip arthroscopy for FAI. Thirty-nine patients who had a primary THA without previous hip arthroscopy served as a control group and were matched for age, sex and body mass index. Surgical outcomes were assessed based on inpatient hospital metrics and outpatient complication measures. Statistical analyses were performed to identify the significance of outcome variables between case and control groups. RESULTS: No statistically significant differences were observed between groups in terms of operative time, haemoglobin drop, intra-operative estimated blood loss, transfusion requirements, amounts of opioids provided, functional mobility assessments on post-operative days one and two, length of hospitalization, discharge location, emergency department visits, post-operative superficial or deep periprosthetic infection, revision rates for dislocation or formation of heterotopic bone (p-values = 0.1-0.8). A statistically significant difference was found between the walking scores on the third post-operative day (p = 0.015). CONCLUSIONS: These findings, while underpowered, are consistent with other previously published reports. Previous hip arthroscopy for FAI does not appear to impact post-operative outcomes of a subsequent THA. Larger datasets from different surgeons and centers are needed to further assess these conclusions. LEVEL OF EVIDENCE: Case-control level-III.

Variation in Optimal Sagittal Alignment of the Femoral Component in Total Knee Arthroplasty.

Accurate sagittal alignment of the femoral component in total knee arthroplasty is crucial for prosthesis longevity, improved function, and patient satisfaction. However, there is variation in the techniques used to attain optimal sagittal femoral component placement in total knee arthroplasty. Femoral component flexion in imageless navigation is based on the mechanical axis rather than the distal femoral anatomy, and there is significant variability in the anatomy of the distal femur. The purpose of this study was to accurately determine the mean distal femoral flexion angle of a representative population and whether variability of the distal femoral flexion angle correlates with race, femur length, or radius of curvature. The mean degree of distal femoral flexion was determined by assessing distal femoral anatomy on computed tomography scans of paired femurs of 1235 patients without evidence of previous fracture, deformity, or surgical implants. The mean±SD distal femoral flexion angle was 2.90°±1.52°, with 80.2% of knees within 3°±2°. Therefore, placing the component in 3° of flexion from the mechanical axis would attain a satisfactory position in most cases. However, further analysis of the patient data revealed 11.4% of Asians, 7.3% of African Americans, and 8.3% of whites had a distal femoral flexion angle greater than 5°. Additionally, the data revealed a moderately strong negative correlation between the distal femoral flexion and the overall radius of curvature of the femur. This preliminary study highlights the need for improved methods for selecting femoral component position in the sagittal plane when using navigation for total knee arthroplasty. [Orthopedics. 2017; 40(2):102-106.].

Own the Bone, a System-Based Intervention, Improves Osteoporosis Care After Fragility Fractures.

BACKGROUND: The goal of this study was to evaluate the effectiveness of the American Orthopaedic Association's Own the Bone secondary fracture prevention program in the United States. METHODS: The objective of this quality improvement cohort study was dissemination of Own the Bone and implementation of secondary prevention (osteoporosis pharmacologic and bone mineral density [BMD] test recommendations). The main outcome measures were the number of sites implementing Own the Bone and implementation of secondary prevention, i.e., orders for BMD testing and/or pharmacologic treatment. The 177 sites participating in the program were academic and community hospitals, orthopaedic surgery groups, and a health system; data were obtained from the first 125 sites utilizing its registry, between January 1, 2010, and March 31, 2015. It included all patients, aged 50 years or older, presenting with fragility fractures (n = 23,132) who were enrolled in the Own the Bone web-based registry. The interventions were education, development of program elements, dissemination, implementation, and evaluation of the Own the Bone program at participating sites. RESULTS: A growing number of institutions implemented Own the Bone (14 sites in 2005-2006 to 177 sites in 2015). After consultation, 53% of patients had a BMD test ordered and/or pharmacologic therapy for osteoporosis. CONCLUSIONS: The Own the Bone intervention has succeeded in improving the behaviors of medical professionals in the areas of osteoporosis treatment and counseling, BMD testing, initiation of pharmacotherapy, and coordination of care for patients who have experienced a fragility fracture.

Fat Thickness as a Risk Factor for Infection in Lumbar Spine Surgery.

Body mass index does not account for body mass distribution. This study tested the hypothesis that subcutaneous fat thickness is a better indicator than body mass index of the risk of surgical site infection in lumbar spine procedures performed through a midline posterior approach. Charts were reviewed for previously identified risk factors for surgical site infection (age, diabetes, smoking, obesity, albumin level, multilevel procedures, previous surgery, and operative time) in 149 adult patients who underwent lumbar spine procedures through a midline posterior approach. Subcutaneous fat thickness was measured with a novel automated technique. Regression analysis was used to determine associations between risk factors and fat thickness with surgical site infection. In the study group, 15 surgical site infections occurred (10.1%). Bivariate analysis showed a significant association between surgical site infection and body mass index (P=.01), obesity (P=.02), and fat thickness (P=.002). With multivariate analysis, body mass index and obesity did not show significance, but fat thickness remained significant (P=.026). For every 1-mm thickness of subcutaneous fat there was a 6% (odds ratio, 1.06; 95% confidence interval, 1.02-1.10) increase in the odds of surgical site infection, and patients with fat thickness of greater than 50 mm had a 4-fold increase in the odds of surgical site infection compared with those with fat thickness of less than 50 mm. Body mass index and fat thickness were moderately correlated (r2=0.44). These results confirm the hypothesis that local subcutaneous fat thickness is a better indicator than body mass index of the risk of surgical site infection in lumbar spine procedures. [Orthopedics. 2016; 39(6):e1124-e1128.].

Complicated Outcomes After Emergent Lower Extremity Surgery in Patients With Solid Organ Transplants.

The complications of emergent or urgent surgery in solid organ transplant recipients are unclear. The goal of this nonrandomized retrospective case study, conducted at a large public university teaching hospital, was to determine the following: (1) 90-day postsurgical complications in solid organ transplant recipients who undergo fracture surgery of the lower extremities; (2) 90-day and 1-year mortality rates for this cohort; (3) correlation of particular postsurgical complications with the 90-day or 1-year mortality rate; and (4) correlation of body mass index with the 90-day or 1-year mortality rate. Subjects included 36 solid organ transplant recipients who underwent surgical treatment for 37 emergent or urgent lower extremity fractures within 72 hours of presentation to the emergency department. Patients were followed for all medical and surgical complications for 90 days and for all-cause mortality for 1 year. Within 90 days of surgery, patients had complications that included acute renal failure (15, 40.5%), deep venous thrombosis (3, 8.1%), pulmonary embolus (2, 5.4%), pneumonia (7, 18.9%), superficial surgical site infection (3, 8.1%), and nonorthopedic sepsis (4, 10.8%). In addition, 3 (8.1%) and 5 (13.9%) patients died within 90 days and 1 year, respectively. Hospital readmission correlated with a higher 1-year mortality rate (odds ratio, 14.000; P=.016). Higher body mass index correlated with higher 90-day (odds ratio, 1.425; P=.035) and 1-year (odds ratio, 1.334; P=.033) mortality rates. Solid organ transplant recipients with lower extremity fracture have high 90-day and 1-year mortality rates and may have multiple complications within 90 days of treatment. [Orthopedics. 2016; 39(6):e1063-e1069.].

Open Reduction and Internal Fixation of the Tibial Plateau Through the Anterolateral Approach.

Fractures of the tibial plateau are challenging injuries to treat. The lateral tibial plateau is fractured more commonly than the medial plateau and the workhorse approach for these fractures is the anterolateral approach. This approach allows visualization of the lateral joint, metaphysis, and can be extensile if there is shaft extension. We present our technique for performing the anterolateral approach while treating a Schatzker III tibial plateau fracture. Special attention is given to performing a submeniscal arthrotomy to view the joint surface and judge the reduction. A femoral distractor is placed to assist with elevation the joint surface and visualization of the lateral plateau. A cortical window is created using a triple reamer from the sliding hip screw set. The reduction is performed and supported with cancellous bone chips. Finally, a lateral locking plate with rafting screws is placed. Knowledge of this approach and the strategies needed to address lateral and some bicondlar tibial plateau fractures are crucial to good patient outcomes.

Open Reduction and Internal Fixation of the Posteromedial Tibial Plateau via the Lobenhoffer Approach.

Posteromedial fractures of the tibial plateau are often encountered after high-energy injuries. They can be seen in isolation or in combination with lateral column fractures. These fractures must be recognized and stabilized independently of any lateral sided fracture to ensure the stability of the final construct. First described in 1997, the Lobenhoffer approach provides access to the posteromedial and posterior aspects of the proximal tibia, allowing for reduction and stabilization of fractures in this location with a posteromedial plate. We present our technique for this approach for the treatment of an isolated posteromedial tibial plateau fracture. The procedure is performed in the prone position. An interval between the gastrocnemius and pes anserine is developed and the fracture apex visualized. The reduction maneuver involves extension and valgus of the knee along with direct manipulation of the fracture fragment. A small fragment antiglide plate is then placed to stabilize the fracture. This relatively straightforward approach is of great use when treating complex tibial plateau fractures involving the medial and posterior columns.

Atypical femur fractures in patients receiving bisphosphonate therapy: etiology and management.

Osteoporosis is a growing problem that is projected to affect more than 50% of American adults by 2020. Bisphosphonate therapy is currently the primary mode of treating osteoporosis in this population. While bisphosphonate therapy has been successful in increasing bone mineral density, data has shown an increased risk of atypical femur fractures with prolonged therapy. Atypical femur fractures are characterized by low-energy or atraumatic injuries that occur in the subtrochanteric region. They originate on the medial cortex, travel transversely, and typically have little or no comminution. Conservative therapy is indicated for patients with incomplete fractures without prodromal symptoms. Patients with incomplete fractures and significant prodromal symptoms or visible fracture line on radiographs, those who have failed conservative management, and those with complete fractures should be treated with intramedullary nail fixation. Evaluation should involve imaging of the contralateral femur. Teriparatide therapy may be considered for patients without contraindications. While the incidence of these fractures is low, it is likely that these rates will increase with the aging population and increased prevalence of patients being treated with bisphosphonate therapy.

Publication Productivity of Early-Career Orthopedic Trauma Surgeons.

The goals of this study were to: (1) define the publication productivity of early-career orthopedic trauma surgeons over time; (2) compare the early-career publication productivity of recent orthopedic trauma fellowship graduates vs their more senior colleagues; and (3) determine the proportion of fellowship graduates who meet the Orthopaedic Trauma Association (OTA) publication criteria for active membership early in their careers. Orthopedic trauma fellowship graduates from 1982 to 2007 were analyzed. A literature search was performed for each fellow's publications for the 6-year period beginning the year of fellowship graduation. Publication productivity was compared between early and recent groups of graduates, 1987 to 1991 and 2003 to 2007, respectively. Fulfillment of OTA publication criteria was determined. Seventy-nine percent of graduates contributed to 1 or more publications. The recent group produced more total publications per graduate (4.06 vs 3.29, P=.01) and more coauthor publications (2.60 vs 2.04, P=.019) than the early group. The number of first-author publications did not differ between groups (1.46 vs 1.25, P=.26). A greater percentage of the recent group met current OTA publication criteria compared with the early group (51% vs 35%, P=.04). The findings showed that recent orthopedic trauma graduates had increased publication productivity compared with their more senior colleagues, although a proportion had not qualified for active OTA membership 6 years into their career. Overall, these data are encouraging and suggest that young orthopedic trauma surgeons remain committed to sustaining a high level of academic excellence.

A Computed Tomography Study of Gender Differences in Acetabular Version and Morphology: Implications for Femoroacetabular Impingement.

PURPOSE: To assess the prevalence of acetabular retroversion in a large population of patients with asymptomatic hips. Furthermore, we sought to identify gender differences in acetabular morphology to address the current thinking that retroversion and pincer-type femoroacetabular impingement (FAI) are more common in women. METHODS: We retrospectively reviewed morphologic features of acetabula from a consecutive series of trauma-protocol computed tomography scans of patients without pelvis injury. An automated algorithm determined the acetabular rim profile and center of the femoral head, normalized the frontal plane of the pelvis, and calculated version and coverage. We then compared male and female rim profiles, specifically focusing on version and acetabular wall coverage in the 1-o'clock (anterosuperior), 2-o'clock (central), and 3-o'clock (inferior) positions. RESULTS: Of 1,088 patients in the database, 878 had complete data (i.e., age, ethnicity, and body mass index) and were therefore included in the final analysis. Of these, 34.3% were women and 65.7% were men. Mean global acetabular version was 19.1° for men and 22.2° for women (P < .001). Mean acetabular version for men and women was 15.5° and 18.3°, respectively, in the 1-o'clock position; 21.5° and 24.0°, respectively, in the 2-o'clock position; and 20.2° and 24.3°, respectively, in the 3-o'clock position (P < .001 for all 3). True retroversion (<0°) was observed only in the 1-o'clock position. The prevalence of true acetabular retroversion in the 1-o'clock position for men and women was 4.3% and 3%, respectively (P = .36). CONCLUSIONS: Mean global and focal acetabular anteversion was greater in women, and the prevalence of focal cephalad retroversion in the 1-o'clock position was not significantly different compared with men. Acetabular retroversion and anterior overcoverage are not more prevalent in women in the anterosuperior acetabulum, where femoroacetabular impingement most commonly occurs. LEVEL OF EVIDENCE: Level III, diagnostic study.

Transsacral screw safe zone size by sacral segmentation variations.

Variations in sacral segmentation may preclude safe placement of transsacral screws for posterior pelvis fixation. We developed a novel automated 3D technique to determine the safe zone size for transsacral screws in the upper two sacral segments in 526 adult pelvis computed tomography scans. Safe zone sizes were then compared by gender and sacral segmentation variations (number of neuroforamen and the presence/absence of lumbosacral transitional vertebrae, ± LSTV). Ten millimeters was used as the safety threshold for a large screw. 3 (0.6%), 366 (70%), and 157 (30%) sacra had 3, 4, or 5 neuroforamen, respectively. Eighty-eight (17%) were +LSTV. Safe zone size depended on gender, number of neuroforamen in -LSTV sacra and presence of LSTV (p < 0.001) but not on the uni- or bilateral nature of the LSTV. 17% of -LSTV sacra were below the safety threshold in S1, 27% in S2, whereas 3% of +LSTV sacra were below in S1, 74% in S2. Of -LSTV sacra that cannot take an S1 screw safely, 77% can do so in S2, leaving only 4% of sacra that cannot accommodate a screw safely in either upper segment. The results demonstrate a predictable pattern of safe zone size based on gender and sacral segmentation variations.

Evidence-based protocol for prophylactic antibiotics in open fractures: improved antibiotic stewardship with no increase in infection rates.

BACKGROUND: Evidence-based guidelines for prophylactic antibiotic use in open fractures recommend short-course, narrow-spectrum antibiotics for Gustilo Grade I or II open fractures and broader gram-negative coverage for Grade III open fractures. No studies to date have assessed the impact of these guidelines on infection rates in open fractures. Infection rates before and after the new protocol implementation were examined. METHODS: A new protocol was implemented including antibiotic prophylaxis based on grade of open fracture: Grade I/II fractures, cefazolin (clindamycin if allergy); Grade III fractures, ceftriaxone (clindamycin and aztreonam if allergy) for 48 hours. Aminoglycosides, vancomycin, and penicillin were removed from the protocol. Data for 174 femur and tibia/fibula open fractures (101 preprotocol and 73 postprotocol) were analyzed. Patients who were moribund or managed at another institution for greater than 24 hours were excluded. The National Healthcare Safety Network risk index was used to provide risk adjustment. RESULTS: No significant differences in the study cohorts (preprotocol and postprotocol) were identified for demographics (age, 37.2 [14.8] years vs. 40.0 [17.9] years; male, 71.3% vs. 79.5%) or mechanism of injury (motor vehicle crash, 67.3% vs. 64.4%; other blunt, 28.7% vs. 32.9%; penetrating, 4.0% vs. 2.8%). After protocol implementation, the use of aminoglycoside and glycopeptide antibiotics was significantly reduced (53.5% vs. 16.4%, p = 0.0001). The skin and soft tissue infection rate per fracture event was 20.8% before and 24.7% after protocol implementation (p = 0.58). There was no statistically significant change after stratification for fracture grade, National Healthcare Safety Network risk index, or fracture site. The rate per fracture event of resistant gram-positive and gram-negative organisms (15.8% vs. 17.8%, p = 0.84) and methicillin-resistant Staphylococcus aureus (2.0% vs. 4.1%, p = 0.65) was not different. CONCLUSION: Implementation of an evidence-based protocol for open fracture antibiotic prophylaxis resulted in significantly decreased use of aminoglycoside and glycopeptide antibiotics with no increase in skin and soft tissue infection rates. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Variation in the femoral bow: a novel high-throughput analysis of 3922 femurs on cross-sectional imaging.

OBJECTIVES: To evaluate femoral radius of curvature in a large sample of computed tomography scans to definitively determine the relationship between radius of curvature and femoral length, age, gender, ethnicity, body mass index and cortical thickness. METHODS: A retrospective review was conducted of the electronic medical records and advanced imaging of 1961 patients who underwent pulmonary embolism protocol computed tomography scans between December 1999 and March 2010. The computed tomography scans were imported from the clinical picture archiving and communication system archive into a research image archive and analysis system. Each scan was processed by an automated system that algorithmically determined bony landmarks, adjusted for body position within the scanner and measured the radius of curvature. RESULTS: The mean medullary radius of curvature of 3922 femurs was 112 cm (SD = 26 cm). The mean anterior radius of curvature of the femurs was 145 cm (SD = 55 cm). There was a moderately strong positive correlation (0.36-0.39) between femoral length and radius of curvature (P < 0.0001) that was not affected by age, body mass index, cortical thickness, gender, or ethnicity. No significant relationship was found between either gender or ethnicity and radius of curvature independent of femoral length. CONCLUSIONS: Differences in radius of curvature based on ethnicity and gender exist primarily because of the variation in average height, and therefore femur length, that exists between ethnic groups and genders. These data may prove useful in the design of safer intramedullary implants that accommodate a greater spectrum of anatomic variation.

Analysis of the orthopedic in-training examination (OITE) musculoskeletal trauma questions.

OBJECTIVES: Residency program directors are responsible for providing assessment and feedback about resident performance and for developing a comprehensive resident curriculum in orthopedic surgery. One measure of resident knowledge is the Orthopedic In-Training Examination (OITE). Scores of the OITE examination have been found to correlate with the American Board of Orthopedic Surgery Part 1 Certifying Examination. The purpose of this study was to identify commonly tested orthopedic trauma topics, the taxonomic distribution of questions, and literature references in the OITE to aid curriculum development and individual test preparation. METHODS: The musculoskeletal trauma-related questions on the OITE during a 5-year period (2004-2008) were reviewed, and the number of questions, topics, taxonomic classification, and educational references associated with each question were analyzed. RESULTS: Nearly 30% of questions each year consist of musculoskeletal trauma-related topics. Femur, tibia, and hip fractures were the most commonly tested topics. The majority (65.6%) of musculoskeletal trauma questions tested recall of specific facts. Examiners referenced primary literature sources (74.9%) more than textbooks (25.1%). The Journal of Bone and Joint Surgery (American) and the Journal of Orthopaedic Trauma were cited most, accounting for 44.3% of all journal references. Forty-seven percent of the primary references were published within 5 years of the test administration. CONCLUSIONS: One method for assessing orthopedic knowledge is the OITE examination. Longitudinal analysis of trauma-related questions shows a consistent pattern of both topics and primary literature citation. This information may be used to help guide structured review for future OITE examinations and develop an orthopedic trauma curriculum for a residency program.

Do higher hospital-wide nurse staffing levels reduce in-hospital mortality in elderly patients with hip fractures: a pilot study.

BACKGROUND: There is increasing recognition that lower nurse staffing levels are associated with higher morbidity and mortality among medical and surgical patients. The degree to which this applies to elderly patients with hip fractures is unclear. QUESTIONS/PURPOSES: We conducted a pilot study using administrative data as an initial step in investigating the relationship between nurse staffing levels and in-hospital mortality among elderly patients with hip fractures. PATIENTS AND METHODS: We retrospectively reviewed administrative data for 13,343 patients 65 years or older with a primary diagnosis of hip fracture admitted to 39 Michigan hospitals between 2003 and 2006. We used logistic regression to calculate the change in predicted probability of in-hospital death conferred by differences in the hospitals' overall number of full-time equivalent registered nursing staff (FTE-RN) per patient day. Regression models controlled for patient age, gender, and comorbid conditions; hospital characteristics including teaching status, hip fracture volume, and income/racial composition of the hospital's zip code; and seasonal influenza. RESULTS: We found an association between hospital-wide nurse staffing levels and in-hospital mortality among patients with hip fractures. The odds of in-hospital mortality decreased by 0.16 for every additional FTE-RN added per patient day, even after controlling for covariates. This association suggests the absolute risk of mortality increases by 0.35 percentage points for every one unit decrease of FTE-RN per patient day, a 16% increase in the risk of death. CONCLUSIONS: Decreased hospital-wide nurse staffing levels are associated with increased in-hospital mortality among patients admitted with hip fractures. These observations indicate the need for further studies to characterize this relationship for staffing of units caring for patients with hip fractures. LEVEL OF EVIDENCE: Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Patterns of acetabular femoral head coverage.

The size and shape of the acetabulum and of the femoral head influence the injury tolerance of the hip joint. The aim of this study is to quantify changes in acetabular cup geometry that occur with age, gender, height, and weight. Anonymized computed tomography (CT) scans of 1,150 individuals 16+ years of age, both with and without hip trauma, were used to describe the acetabular rim with 100 equally spaced points. Bilateral measurements were taken on uninjured patients, while only the uninjured side was valuated in those with hip trauma. Multinomial logistic regression found that after controlling for age, height, weight, and gender, each 1 degree decrease in acetabular anteversion angle (AAA) corresponded to an 8 percent increase in fracture likelihood (p<0.001). Age, weight, and gender were found to influence anteversion angle significantly, with each 10 years in age increasing AAA by 1.07 degrees, each 10 kg of weight decreasing AAA by 0.45 degrees, and being female resulting in 1.42 degrees greater AAA than males. Height was not found to relate significantly to AAA after other anthropometric factors were controlled for. Height, age, and weight, however, correlated with femoral head radius, thus establishing a relationship with acetabular rim size independent of rim shape. A parametric model of the 3D acetabular rim landmark points is reported, allowing for the creation of individualized acetabular geometry for any given age, gender, height, and weight. A custom-built tool to produce such geometry programmatically is also provided.