Rate of skin and nerve complications as a result of cutaneous traction with modern foam boots.

INTRODUCTION: Cutaneous traction is used to temporize lower extremity fractures and relies on friction between the skin and surrounding material to apply a longitudinal force. This circumferential compressive force can lead to pressure sores, skin sloughing, or compressive neuropathies. These complications have been reported in up to 11% of patients when the cutaneous traction relies on adhesive tapes, plaster, and rubber bandages being in immediate contact with the skin. The rates of these complications are not well documented when using modern foam boots. METHODS: A retrospective chart review was performed on all orthopedic trauma patients who suffered pelvic or lower extremity injuries between March 1st, 2020 and April 30th, 2021 at a single Level-1 trauma center. We included all patients with femoral fractures, axially unstable pelvic ring and/or acetabular fractures, and unstable hip dislocations temporized with the use of cutaneous traction. All patients had intact skin and lower extremity nerve function prior to application. RESULTS: There were 138 patients identified with 141 lower extremities. The average patient age was 50.7 (6-100) years. Mean traction weight of 9.8 (5-20) pounds. Average traction duration was 20.9 (2.3-243.5) hours. At the time of traction removal, there was 1 (0.7%) new skin wound and 0 nerve palsies. The new skin wound was a stage one heel pressure sore and did not require further treatment. CONCLUSION: Cutaneous traction with a modern foam boot was found to have a skin complication rate of 0.7% and a nerve palsy complication rate of 0% for an overall complication rate of 0.7%, which has not been previously established and is lower than historically reported complication rates of 11% when utilizing adhesive and plaster directly on skin. Foam boot Cutaneous traction may be considered a safe option for traction placement.

Early postoperative step count and walking time have greater impact on lower limb fracture outcomes than load-bearing metrics.

INTRODUCTION: Weight-bearing protocols for rehabilitation of lower extremity fractures are the gold standard despite not being data-driven. Additionally, current protocols are focused on the amount of weight placed on the limb, negating other patient rehabilitation behaviors that may contribute to outcomes. Wearable sensors can provide insight into multiple aspects of patient behavior through longitudinal monitoring. This study aimed to understand the relationship between patient behavior and rehabilitation outcomes using wearable sensors to identify the metrics of patient rehabilitation behavior that have a positive effect on 1-year rehabilitation outcomes. METHODS: Prospective observational study on 42 closed ankle and tibial fracture patients. Rehabilitation behavior was monitored continuously between 2 and 6 weeks post-operative using a gait monitoring insole. Metrics describing patient rehabilitation behavior, including step count, walking time, cadence, and body weight per step, were compared between patient groups of excellent and average rehabilitation outcomes, as defined by the 1-year Patient Reported Outcome Measure Physical Function t-score (PROMIS PF). A Fuzzy Inference System (FIS) was used to rank metrics based on their impact on patient outcomes. Additionally, correlation coefficients were calculated between patient characteristics and principal components of the behavior metrics. RESULTS: Twenty-two patients had complete insole data sets, and 17 of which had 1-year PROMIS PF scores (33.7 ± 14.5 years of age, 13 female, 9 in Excellent group, 8 in Average group). Step count had the highest impact ranking (0.817), while body weight per step had a low impact ranking (0.309). No significant correlation coefficients were found between patient or injury characteristics and behavior principal components. General patient rehabilitation behavior was described through cadence (mean of 71.0 steps/min) and step count (logarithmic distribution with only ten days exceeding 5,000 steps/day). CONCLUSION: Step count and walking time had a greater impact on 1-year outcomes than body weight per step or cadence. The results suggest that increased activity may improve 1-year outcomes for patients with lower extremity fractures. The use of more accessible devices, such as smart watches with step counters combined with patient reported outcome measures may provide more valuable insights into patient rehabilitation behaviors and their effect on rehabilitation outcomes.

Fewer Hip Dislocations With Anterior Total Hip Arthroplasty for Displaced Femoral Neck Fracture.

The primary goal of this study was to compare dislocation rates with an anterior approach vs a posterior approach for patients who underwent total hip arthroplasty (THA) for displaced femoral neck fracture. A retrospective review was conducted of patients who underwent THA for acute femoral neck fracture at the authors' level I trauma center. All patients had at least 1 year of follow-up. Modified Harris Hip Score (mHHS) and EuroQol 5D-5L score were obtained to assess hip function and overall quality of life at a minimum of 12 months postoperatively. The study population included 76 patients (posterior, 22; anterior, 54), with mean follow-up of 39 months (range, 12-125 months). Significantly more postoperative complications occurred in the posterior group compared with the anterior group (7 vs 4, respectively; P=.006). In addition, significantly more hip dislocations occurred in the posterior group compared with the anterior group (3 vs 1, respectively; P=.037). The study did not show a difference in mHHS (anterior, 82; posterior, 77; P=.411). The findings suggest that an anterior-based approach to THA may result in fewer complications than a posterior-based approach for patients who have displaced femoral neck fracture. Patients should be counseled on the higher perioperative risk after surgery compared with patients undergoing elective THA. Patients undergoing THA with an anterior approach for femoral neck fracture can expect to achieve good hip functional outcome and good quality of life 12 months after surgery. [Orthopedics. 2021;44(2):e248-e252.].

Effect of Statewide Social Distancing and Stay-At-Home Directives on Orthopaedic Trauma at a Southwestern Level 1 Trauma Center During the COVID-19 Pandemic.

OBJECTIVES: To compare orthopaedic trauma volume and mechanism of injury before and during statewide social distancing and stay-at-home directives. DESIGN: Retrospective. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: One thousand one hundred thirteen patients sustaining orthopaedic trauma injuries between March 17 and April 30 of years 2018, 2019, and 2020. INTERVENTION: Statewide social distancing and stay-at-home directives. MAIN OUTCOME MEASUREMENTS: Number of consults, mechanism of injury frequency, and type of injury frequency. RESULTS: During the COVID-19 pandemic, orthopaedic trauma consult number decreased. Injuries due to gunshot wounds increased and those due to automobile versus pedestrian accidents decreased. Time-to-presentation increased and length of stay decreased. Operative consults remained unchanged. CONCLUSIONS: Orthopaedic trauma injuries continued to occur during the COVID-19 pandemic at an overall decreased rate, however, with a different distribution in mechanism and type of injury. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Short Versus Long Cephalomedullary Nails for Fixation of Stable Versus Unstable Intertrochanteric Femur Fractures at a Level 1 Trauma Center.

The purpose of this study was to compare failure and complication rates associated with short cephalomedullary nail vs long cephalomedullary nail fixation for stable vs unstable intertrochanteric femur fractures. This study included 201 adult patients with nonpathologic intertrochanteric femur fractures without subtrochanteric extension (OTA 31-A1.1-3, 31-A2.1-3, 31-A3.1-3) who were treated with a short cephalomedullary nail (n=70) or a long cephalomedullary nail (n=131) and had at least 6 months of follow-up. Treatment groups were similar in terms of age, sex, and comorbidities. In the stable fracture group (N=81), there was no difference in total complications (adjusted P=.73), failure (adjusted P=.78), or mortality (adjusted P=.62) between short cephalomedullary nails and long cephalomedullary nails. Unstable fracture patterns were more likely to be treated with a long cephalomedullary nail than a short cephalomedullary nail (P=.01). In the unstable fracture group (N=120), there was no difference in total complications (adjusted P=.32) or failure (adjusted P=.31) between short cephalomedullary nails and long cephalomedullary nails. A cumulative mortality curve showed a trend toward increasing mortality in unstable fractures treated with short cephalomedullary nails. Traumatologists did not display a statistically significant preference between short cephalomedullary nails and long cephalomedullary nails when compared with nontraumatologists. [Orthopedics. 2019; 42(2):e202-e209.].

It's All About the Timing: When Do I Take This Injury to the Operating Room?

Over time, what was considered urgent or emergent in orthopaedic trauma has been revisited, and as awareness of factors associated with outcomes has increased, priorities have changed. There are multiple procedures performed urgently in the belief that early intervention allowed for better outcomes for the injury and the patient. Classic examples of conditions for which urgent intervention has been implemented include open fractures, femoral neck fractures in the young adult, talus fractures, and compartment syndrome. All of these conditions are considered nonurgent except for compartment syndrome, which requires urgent and timely intervention. Studies have demonstrated that these injuries need to be managed in a timely fashion but not necessarily in the middle of the night. Outcomes can be improved by measures such as early antibiotic administration for open fractures, closed reduction of talus fracture-dislocations, and anatomic reduction of femoral neck fractures. These measures are more important and useful than an emergent trip to the operating room by inexperienced surgeons with staff who may be unprepared. Orthopaedic surgeons should be familiar with open fractures and the timing of irrigation and débridement, the relative urgency of managing talus fractures, and the need for immediate reduction and fixation of femoral neck fractures. For each of these injuries, factors other than timing that affect outcomes will be described. Finally, the emergent nature of diagnosis and management of compartment syndrome must also be understood.

A Comparison of the Open Semi-extended Parapatellar Versus Standard Entry Tibial Nailing Techniques and Knee Pain: A Randomized Controlled Trial.

OBJECTIVE: To determine if an open, semi-extended, parapatellar tibial nailing technique (SEK) imparts any undue knee symptoms/pain compared with the traditional infrapatellar tibial nailing technique (FK). DESIGN: Randomized controlled trial. SETTING: Level 1 trauma center. PATIENTS: Forty-seven patients with OTA/AO 42A-C tibial shaft fractures were included in the study. INTERVENTION: Patients were randomized to treatment with either a SEK or an FK technique. MAIN OUTCOME: The main outcome was a symptoms subset of the International Knee Documentation Committee (SS-IKDC) pertaining to knee symptoms/pain. RESULTS: Final follow-up was collected at 1 year for 24 SEK and 23 FK patients. No significant differences were found between the groups in regards to demographics, injury, or surgery-related variables. The 2 techniques did have equivalent symptoms scores [mean for the difference (SEK - FK): 0.29, 90% confidence interval: -4.16 to 4.75] but did not have equivalent pain scores [mean for the difference (SEK - FK): 0.2, 90% confidence interval: -3.18 to 3.59]. When comparing demographic and injury-related variables to the SS-IKDC, only Kellgren-Lawrence classification was statistically significant (P = 0.026), where increasing presence of osteoarthritis was associated with lower scores. CONCLUSIONS: The results of this single-center randomized controlled trial show that SEK and FK techniques for tibial nailing are equivalent in regards to knee symptoms (defined as ±5 points on the SS-IKDC) but not specifically pain that showed trends toward decreasing knee pain with the open SEK technique. This randomized controlled trial demonstrates that the use of the open semi-extended, parapatellar technique for tibial nailing should not be associated with any higher likelihood of knee pain/symptoms than the traditional flexed knee, infrapatellar technique. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Ankle Fractures in Elderly Patients with Osteopenia and Neuropathy.

Ankle fractures are increasingly common in elderly patients given the number of aging individuals who remain active. The already difficult aspects of ankle fixation are amplified by the compromised soft-tissue envelope and bone quality present in elderly patients with an ankle fracture. In addition, elderly patients with an ankle fracture often have compromised neuroprotective mechanisms and are physically unable to follow postoperative protected weight-bearing protocols during ambulation. Surgeons should be aware of strategies to improve fixation and maintain the tibiotalar relationship during ambulation in elderly patients with an ankle fracture.

Periprosthetic Fractures About the Hip and Knee: Contemporary Techniques for Internal Fixation and Revision.

The number of periprosthetic fractures is expected to increase given the growing number of elderly individuals who are living longer and advances in technology that allow for total hip and knee arthroplasty in younger patients. Evolving technologies in combination with a better understanding of required total hip and knee reconstruction has allowed for continued improvements in applied fixation strategies and patient outcomes. Current fixation and revision options have led to reliable, reproducible management of periprosthetic fractures about the hip and knee, including proximal femur and supracondylar femur fractures, which are common, and fractures about an acetabular component and between proximal and distal hip and knee prostheses, which are rare. Orthopaedic surgeons should understand the most contemporary techniques, strategies, and formulas for the successful management of periprosthetic fractures about the hip and knee.

Radiographic Investigation of the Distal Extension of Fractures Into the Articular Surface of the Tibia (The RIDEFAST Study).

OBJECTIVE: To determine whether radiographic measurements are predictive of involvement of the distal tibia articular surface in tibial shaft fractures. DESIGN: Retrospective review. SETTING: Academic Level-I trauma hospital. PATIENTS: Two-hundred seventeen patients with tibial shaft fractures distal to the isthmus (OTA/AO: 42-A1-3; 42-B1-3; 42-C1-3; and 43-A1-3). INTERVENTION: Analysis of anteroposterior (AP) and lateral radiographs. The following parameters were measured: (1) angle between the predominant fracture line and the plane of the tibial plafond (α-angle), (2) length of the shaft fracture, (3) distance from the most inferior extent of the shaft fracture to the tibial plafond (DTP), (4) width of the tibial plafond, (5) width of the tibial isthmus, (6) ratio of fracture length to DTP (FTP), and (7) fibular fracture distance. MAIN OUTCOME MEASURE: Distal intra-articular involvement (DIA). RESULTS: A total of 217 patients were identified, 56 (26%) with DIA. The FTP ratio as measured on both the AP (odds ratio: 8.20, confidence interval, 4.26-17.22, P < 0.0001) and lateral radiographs (10.00, 4.78-23.23, <0.0001) was the most effective screening measurement for DIA. AP and lateral FTP ratios of 0.224 and 0.255, respectively, achieved a negative predictive value of 100%, eliminating the need for computed tomography in 16%-23% of injuries. CONCLUSION: Involvement of the distal articular surface in patients with distal tibial shaft fractures is significantly associated with fracture geometry and pattern. The FTP ratio may be used as an effective screening tool to rule out of intra-articular involvement. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Bone penetrance of locally administered vancomycin powder in a rat femur fracture model.

INTRODUCTION: Locally delivered, crystalline vancomycin has been suggested as a potential prophylactic measure against the development of deep and superficial surgical site infection. Clinical expectations regarding the duration and peak of drug concentration in local tissues following administration are unknown. Our goal was to develop concentration vs time curves for locally administered vancomycin powder in a high-energy, open femur fracture rat model in local tissues and to compare that data to two well performed similar, systemic administration studies. METHODS: After approval for animal research, 24 adult Sprague-Dawley rats sustained closed, midshaft femoral fracture under anesthesia. Fractures were caused via blunt guillotine with 750g metal rod dropped 50cm. Injured hindlimbs were surgically opened at fracture to simulate open injury and stabilized using 0.054 Kirschner wires. Vancomycin powder was administered using weight-based protocol (goal: 25mg/kg). Rats were sacrificed in groups of 4 at 4, 8, 24, 48, 72, 96h. Samples harvested included rat-tail venous blood prior to sacrifice, and femoral bone and anterior thigh soft-tissue were harvested post-mortem. High Performance Liquid Chromatography (HPLC) was performed on all samples. RESULTS: Concentration vs. time curves demonstrated that the surrounding soft-tissues demonstrated highest maximum concentration (1.5mg vancomycin/g muscle). Bone reached maximum average of 199µg vancomycin/g femur: approximately 13% of maximal soft-tissue absorption. Plasma reached maximum concentration of 1.8µg/mL plasma. All peaks at t=4h. Within 48h, average muscle vancomycin concentration dropped to 3µg/g muscle (0.2% maximum muscle concentration) and the average bone concentration dropped to 1.9µg/g femur (0.9% maximum bone concentration). Vancomycin was undetectable on all samples at 96h. Comparison to classical animal studies suggest local delivery to bone exceeds that of IV dosing for approximately 48h and may peak near concentrations of 102 multiples. CONCLUSIONS: Locally administered vancomycin provides drug delivery in excess of IV dosing for approximately 48h after intervention. Exponential decay demonstrates rapid removal of drug to near undetectable levels in bone, plasma, and local soft tissue thereafter in a rat model. Local delivery may generate concentrations exceeding that achievable by steady state systemic dosing for 48h.

External validation of the clinical indications of computed tomography (CT) of the head in patients with low-energy geriatric hip fractures.

INTRODUCTION: On evaluation of the clinical indications of computed tomography (CT) scan of head in the patients with low-energy geriatric hip fractures, Maniar et al. identified physical evidence of head injury, new onset confusion, and Glasgow Coma Scale (GCS)<15 as predictive risk factors for acute findings on CT scan. The goal of the present study was to validate these three criteria as predictive risk factors for a larger population in a wider geographical distribution. PATIENTS AND METHODS: Patients ≥65 years of age with low-energy hip fractures from 6 trauma centers in a wide geographical distribution in the United States were included in this study. In addition to the relevant patient demographic findings, the above mentioned three criteria and acute findings on head CT scan were gathered as categorical variables. RESULTS: In total 799 patients from 6 centers were included in the study. There were 67 patients (8.3%) with positive acute findings on head CT scan. All of these patients (100%) had at least one criteria positive. There were 732 patients who had negative acute findings on head CT scan with 376 patients (51%) having at least one criteria positive and 356 patients (49%) having no criteria positive. Sensitivity of 100% and negative predictive value of 100% was observed to predict negative acute findings on head CT scan when all the three criteria were negative. CONCLUSION: With the observed 100% sensitivity and 100% negative predictive value, physical evidence of acute head injury, acute retrograde amnesia, and GCS<15 can be recommended as a clinical decision guide for the selective use of head CT scans in geriatric patients with low energy hip fractures. All the patients with positive acute head CT findings can be predicted in the presence of at least one positive criterion. In addition, if these criteria are used as a pre-requisite to order the head CT, around 50% of the unnecessary head CT scans can be avoided.

Serial Radiographs Do Not Change the Clinical Course of Nonoperative Stable OTA/AO 44-B1 Ankle Fractures.

OBJECTIVE: To assess radiographic markers of ankle stability in stable OTA/AO 44-B1 ankle fractures. DESIGN: Retrospective review. SETTING: Academic Level-I trauma hospital. PATIENTS: One hundred thirty-four patients with stable OTA/AO 44-B1 (Danis-Weber B, Supination-External Rotation-II) ankle fractures. INTERVENTION: Analysis of mortise view radiographs at the time of initial evaluation and final follow-up. VARIABLES MEASURED: (1) medial clear space; (2) Mueller-Nose Distance. MAIN OUTCOME MEASURE: Change in radiographic measurements resulting in conversion to operative intervention. RESULTS: Patients followed up an average of 2.6 visits in our clinics (SD 1.06). Patients received an average of 11.2 individual radiographic images to evaluate their injury (SD 3.9, maximum 29). No patients progressed to surgery in this cohort. Mean medial clear space at the time of injury was 3.4 mm (SD 0.8) and was 3.3 mm (SD 0.7) at the time of final follow-up (P = 0.1). Mean Mueller-Nose measurement at the time of injury was 3.5 mm (SD 1.0) and was 3.5 mm (SD 0.8) at the time of final follow-up (P = 0.47). CONCLUSIONS: No patients with stable OTA/AO 44-B1 fractures proceeded to surgery for loss of tibiotalar reduction or any other cause. Radiographic relationships were conserved during the follow-up, and serial radiographs may not be needed when managing these patients. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Inflammatory cytokine response is greater in acute tibial plafond fractures than acute tibial plateau fractures.

The purpose of the study was to compare the inflammatory cytokine and matrix metalloproteinase (MMP) concentrations in synovial fluid after acute plafond fracture with acute tibial plateau fracture. Between December 2011 and August 2014, we prospectively enrolled patients with acute tibial plateau and plafond fractures. Synovial fluid aspirations were obtained from injured and uninjured joints. The concentrations of IL-1ß, IL-1RA, IL-6, IL-8, IL-10, MCP-1, TNF-α, MMP-1, -3, -9, -10, -12, and -13 were quantified using multiplex assays. A Bonferroni correction was used so that the adjusted alpha level for significance was p < 0.004. We enrolled 45 tibial plateau fractures and 19 plafond fractures. Mean patient age was 42 years (range, 20-60) and 64% were male patients. There were 24 low-energy (OTA 41B) plateau fractures and eight low-energy (OTA 43B) plafond fractures. There were 21 high-energy (6 OTA 41B3 and 15 OTA 41C) plateau fractures and 11 high-energy (OTA43C) plafond fractures. All cytokines and MMPs except MMP-13 were significantly elevated in plafond fractures compared to uninjured ankles. When comparing acutely injured joints, IL-8 (p < 0.001), IL-1ß (p = 0.002), and MMP-12 (p = 0.001) were significantly higher in plafond fractures compared to plateau fractures. Concentrations of IL-1RA (p = 0.008) and MCP-1 (p = 0.005) were higher in plafond fractures, and MMP-10 (p = 0.01) was higher in plateau fractures, but these differences did not reach significance. In conclusion, several cytokines and MMPs were significantly elevated in acute plafond fractures as compared to acute tibial plateau fractures. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2613-2619, 2017.

Obesity Is Associated With High Perioperative Complications Among Surgically Treated Intertrochanteric Fracture of the Femur.

OBJECTIVES: To document the complications among obese patients who underwent surgical fixation for intertrochanteric femur (IT) fractures and to compare with nonobese patients. DESIGN: Retrospective cohort study. SETTING: Four level I trauma centers. PATIENTS: 1078 IT fracture patients. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Patient and fracture characteristics, surgical duration, surgical delay intraoperative and postoperative complications, inpatient mortality, and length of stay. METHOD: A retrospective review at 4 academic level I trauma centers was conducted to identify skeletally mature patients who underwent surgical fixation of intertrochanteric fractures between June 2008 and December 2014. Descriptive data, injury characteristics, OTA fracture classification, and associated medical comorbidities were documented. The outcomes measured included in-hospital complications, length of stay, rate of blood transfusion, change in hemoglobin levels, operative time, and wound infection. RESULTS: Of 1078 unique patients who were treated for an IT fracture, 257 patients had a Body mass index (BMI) of 30 or greater. Patients with a high BMI (≥30) had a significantly lower mean age (73 vs. 77 years, P < 0.0001), higher percentage of high-energy injuries (18% vs. 9%, P = 0.0004), greater mean duration of surgery (96 vs. 86 minutes, P = 0.02), and higher mean length of stay (6.5 vs. 5.9 days, P = 0.004). The high-BMI group (n = 257) had significantly higher percentages of patients with complications overall (43% vs. 28%, P < 0.0001), respiratory complications (11% vs. 3%, P < 0.0001), electrolyte abnormalities (4% vs. 2%, P = 0.01), and sepsis (4% vs. 1%, P = 0.002). Patients with BMI ≥ 40 had a much higher rate of respiratory complications (18%) and wound complications (5%) than obese (BMI: 30-39.9) and nonobese patients (BMI < 30). CONCLUSION: Intertrochanteric hip fracture patients with a BMI of >30 kg/m are much more likely to sustain systemic complications including respiratory complications, electrolyte abnormalities, and sepsis. In addition, morbidly obese patients are more likely to sustain respiratory complications and wound infections than obese (BMI: 30-39.9 kg/m) and nonobese patients (BMI: < 30 kg/m). The findings from this study can help direct surgeons in the counseling to obese patients and their family, and perhaps increase hospital reimbursement for this group of patients. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Is This Autograft Worth It?: The Blood Loss and Transfusion Rates Associated With Reamer Irrigator Aspirator Bone Graft Harvest.

OBJECTIVES: To investigate the blood loss and transfusion rate associated with the use of reamer irrigator aspirator (RIA). DESIGN: Retrospective review. SETTING: Academic Level-I trauma hospital. PATIENTS: One hundred eight patients requiring bone graft harvest for surgical reconstruction of nonunion or failed arthrodesis. INTERVENTION: Bone graft harvest preformed via RIA or iliac crest bone graft (ICBG). MAIN OUTCOME MEASURE: Blood loss as measured by a change in preoperative and postoperative hematocrit (Hct). In addition, postoperative transfusion reported intraoperative blood loss, volume of graft harvested, and major complications. RESULTS: The average Hct drop was found to be 13.7 (4.1-27.4) in the RIA cohort of 61 patients and 7.36 (1.2-14.5) in the ICBG cohort of 47 patients (P = 0.013). Operative reports documented an average estimated blood loss of 674 mL (100-2000 mL) in the RIA cohort compared with 255 mL (50-1000 mL) in the ICBG cohort (P < 0.001). Twenty-seven patients (44%) required blood transfusion after RIA, whereas 10 patients (21%) required blood transfusion after ICBG (odds ratio 5.32, 95% confidence interval 2.2-6.3, P < 0.001). RIA procedures collected an average 53 mL (20-100 mL) of bone graft compared with 27 mL (15-50 mL) with ICBG. There was no significant difference between groups regarding age, sex, medical comorbidities, or postoperative major complications. CONCLUSIONS: This series demonstrated that 44% of patients undergoing RIA bone graft harvest required transfusion, with a mean Hct drop of 13.7 across all subjects, which is significantly greater than that associated with ICBG. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predictors of amputation in high-energy forefoot and midfoot injuries.

INTRODUCTION: High energy injuries to the midfoot and forefoot are highly morbid injury groups that are relatively unstudied in the literature. Patients sustaining injuries of this region are challenging to counsel at the time of injury because so little is known about the short and long term results of these injuries. The purpose of this study was to investigate injury specific factors that were predictive of amputation in patients sustaining high energy midfoot and forefoot injuries. PATIENTS AND METHODS: 137 patients with 146 injured feet [minimum of two fractures located in the forefoot and midfoot, excluding phalanges, talus, calcaneus, with a high energy mechanism]. RESULTS: 121 of 146 feet (83%) were treated operatively; 27 patients sustained 34 total surgical amputation events. 30-day amputation rate was 13.9% and 1-year amputation rate was 18.9%; 27 of 146 feet ultimately sustained amputation with 23 of 27 sustaining a below the knee amputation (BKA) and 17 of 23 (73.9%) received a BKA as their first amputation. Statistically significant predictors of amputation included the number of bones fractured in the foot (p=0.015), open injury to the plantar or dorsal surfaces of the foot, Gustilo grade, vascular injury, and complete loss of sensation to any surface of the foot (all p<0.001). Specific fracture patterns predictive of any amputation were fracture of all five metatarsals (p<0.001) and fracture of the first metatarsal (p=0.003). Presence of a dislocation or fracture of the distal tibia were not predictive of amputation. Midterm patient-reported-outcomes (N=51) demonstrated no difference in physical function for patients with and without amputations. CONCLUSIONS: High-energy forefoot and midfoot injuries are associated with a high degree of morbidity; 1/5th of patients sustaining these injuries proceeded to amputation within 1year. Injury characteristics can be used to counsel patients regarding severity and amputation risk.

The Role of Radiographs and Office Visits in the Follow-Up of Healed Intertrochanteric Hip Fractures: An Economic Analysis.

OBJECTIVES: The purpose of this study was to evaluate the role and the necessity of radiographs and office visits obtained during follow-up of intertrochanteric hip injuries. DESIGN: Retrospective study. SETTING: Two level I trauma centers. PATIENTS: Four hundred sixty-five elderly patients who were surgically treated for an intertrochanteric fracture of the femur at 2 level I trauma centers between January 2009 and August 2014 were retrospectively identified from orthopaedic trauma databases. INTERVENTION: Analysis of all healed intertrochanteric hip fractures, including demographic characteristics, quality of reduction, time of healing, number of office visits, number of radiographs obtained, and each radiograph for fracture alignment, implant position or any pathological changes. RESULTS: The surgical fixation of 465 fractures included 155 short nails (33%), 232 long nails (50%), 69 sliding hip screw devices (15%), 7 trochanteric stabilizing plates (1.5%), and 2 proximal femur locking plates (0.5%). The average fracture healing time was 12.8 weeks and the average follow-up was 81.2 weeks. Radiographs of any patient obtained after the fracture had healed did not reveal any changes, including fracture alignment or implant position and hardware failure. In 9 patients, pathological changes, including arthritis (3), avascular necrosis (3), and ectopic ossification (3) were noted. The average number of elective office visits and radiographs obtained after the fracture had healed were 2.8 (range: 1-8) and 2.6 (range: 1-8), respectively. According to Medicare payments to the institution, these radiographs and office visits account for a direct cost of $360.81 and $192, respectively, per patient. CONCLUSION: The current study strongly suggests that there is a negligible role for radiographs and office visits during the follow-up of a well-healed hip fracture when there is documented evidence of radiographic and clinical healing with acceptable fracture alignment and implant position. Implementation of this simple measure will help in reducing the cost of care and inconvenience to elderly patients. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Posterior Malleolar Fractures Associated With Tibial Shaft Fractures and Sequence of Fixation.

OBJECTIVES: The purpose of this study was to evaluate posterior malleolar injuries associated with nailed tibial fractures and to determine the quality of reduction based on the sequence of fixation in associated fracture patterns. DESIGN: Retrospective cohort study. PATIENTS: 1113 tibia fractures treated with an intramedullary nail at 3 level I trauma centers. INTERVENTION: Tibial shaft fractures with posterior malleolar injury were analyzed regarding type of fracture, mechanism of injury, energy of injury, fracture characteristic, surgical characteristics including sequence of fixation, obvious intraoperative displacement of the posterior malleolar fragment, and the quality of reduction. One group ("malleolus-first") consisted of patients in whom the posterior malleolus was fixed before tibial nailing and the other group ("tibia-first") included patients in whom tibial nailing was done before posterior malleolus fixation. OUTCOMES MEASURED: Intraoperative displacement, quality of reduction. RESULTS: Ninety-six of 1113 (9%) nailed tibial shaft fracture patients had a concomitant posterior malleolus fracture (9%). Of the 96 posterior malleolar fracture patients, 70 patients were operatively treated (73%). In the malleolus-first group (54 patients), intraoperative displacement of the posterior malleolar fragment was observed in 1 patient, and 1 case of poor reduction of the posterior malleolar fragment was observed (2%). In the tibia-first group (16 patients), obvious intraoperative displacement of the posterior malleolar fragment was observed in 5 patients (31%), and poor reduction of the posterior malleolar fragment was observed in 7 patients (44%). These percentages of patients with poor quality of reduction were statistically significantly different (p ≤ 0.01). CONCLUSION: Many low-energy tibia fractures with a spiral configuration do have an associated posterior malleolus fracture. In order to avoid intraoperative displacement and poor reduction, we recommend fixation of the posterior malleolar fragment before nailing of the tibia in associated fracture pattern. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Effect of Transiliac-Transsacral Screw Fixation for Pelvic Ring Injuries on the Uninjured Sacroiliac Joint.

OBJECTIVE: To evaluate the functional outcomes and pain in patients with unilateral posterior pelvic ring injuries treated with transiliac-transsacral screw fixation compared with unilateral iliosacral screw fixation. DESIGN: Retrospective comparative study. SETTING: Three academic level 1 trauma centers. PATIENTS/PARTICIPANTS: From a group of 866 patients with pelvic ring injuries treated surgically, 86 patients with unilateral pelvic ring injuries treated with transiliac-transsacral screws and 97 patients treated with unilateral iliosacral screws were identified. Thirty-six patients treated with transiliac-transsacral fixation and 26 patients treated with unilateral iliosacral screws met the inclusion criteria and participated. INTERVENTION: Patients were treated surgically for unstable pelvic ring injuries with either unilateral iliosacral screws or transiliac-transsacral screws at the discretion of the treating surgeon. MAIN OUTCOME MEASUREMENT: Majeed Pelvic Score. RESULTS: There was no significant difference in Majeed Pelvic Scores between patients treated with transiliac-transsacral screws and those treated with unilateral iliosacral screws (72.8 ± 23.7 vs. 70.4 ± 19.0, P = 0.66). There was no difference in side-specific Numeric Rating Scale pain scores between patients treated with transiliac-transsacral screws and those treated with unilateral iliosacral screws on the injured side (2.5 ± 3.1 vs. 2.0 ± 2.4, P = 0.46) or the uninjured side (1.7 ± 2.8 vs. 0.8 ± 1.7, P = 0.12). Mean follow-up was greater than 3 years with no difference between the groups (mean 1270 vs. 1242 days, P = 0.84). CONCLUSIONS: Treatment of unilateral pelvic ring injuries with transiliac-transsacral screws does not adversely affect or improve patient outcomes or subjective pain scores when compared with those treated with unilateral iliosacral screws. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.