The Effect of Adverse Events on Orthopaedic Surgeons: A Review.

The purpose of this review was to evaluate the effect of adverse events (AEs) on orthopaedic surgeons, illustrate common ways orthopaedic surgeons deal with AEs, and describe solutions to reduce the negative effect of AEs and prevent them from recurring. AEs are common in orthopaedic surgery and increase the risk of depression, anxiety, and suicide. Orthopaedic surgeons may experience negative effects after AEs even when they are not at fault. AEs are linked to moral injury, second victim syndrome, burnout, and disruptive physician behaviors. Many surgeons deal with AEs in isolation out of fear of a negative effect on their professional reputation, potentially leading to increased psychological distress and unhealthy coping mechanisms. Healthy ways to address AEs and improve the well-being of surgeons include destigmatizing psychological stress after AEs and creating a culture of receptivity and peer support.

Variables Associated With Loss of Fixation of Retrograde Rami Screws in Minimally Displaced Lateral Compression Type 1 Pelvic Ring Injuries.

OBJECTIVES: To evaluate variables associated with loss of fixation of retrograde rami screws in the treatment of stress-positive minimally displaced lateral compression type 1 (LC1) injuries. DESIGN: Retrospective comparative study. SETTING: Level 1 trauma center. PATIENT SELECTION CRITERIA: Stress-positive minimally displaced (<1 cm) LC1 pelvic ring injuries treated with retrograde rami screws. OUTCOME MEASURES AND COMPARISONS: Loss of fixation, defined as >5 mm of pelvic fracture displacement based on the radiographic tear-drop distance or >5 mm of implant displacement on follow-up radiographs; revision surgery for loss of fixation. RESULTS: Thirty-eight patients with 40 retrograde rami screws were analyzed. Median patient age was 64 years (interquartile range 42.5-73.3 years), 71.1% (n = 27/38) were female, and 52.6% (n = 20/38) of injuries were secondary to low-energy mechanisms. Loss of fixation occurred in 17.5% (n = 7/40) of screws with 10% (n = 4/40) requiring revision surgery. On univariate analysis, patients who had a loss of fixation were more likely to have greater dynamic displacement on stress radiographs (22.0 vs. 15.2 mm; median difference 5.6 mm, confidence interval [CI] -19.2 to 10.3; P = 0.04), unicortical rami screws (71.4% vs. 9.1%; proportional difference 62.3%, CI 8.8%-22.6%; P = 0.001), and partially threaded rami screws (71.4% vs. 21.2%; proportional difference 50.2%, CI 10.0%-77.6%; P = 0.01). The remaining variables had no observed association ( P ≥ 0.05) with loss of fixation, including age, sex, body mass index, energy of injury mechanism, tobacco use, American Society of Anesthesiologist score, sacral fracture type, distal rami fractures, rami comminution, number of sacral screws, fully threaded sacral screws, transsacral screws, or rami screw diameter. On multivariate analysis, only unicortical rami screws ( P = 0.01) remained associated with loss of fixation. CONCLUSIONS: Retrograde rami screws had a high rate of loss of fixation in minimally displaced LC1 pelvic ring injuries, and this was associated with unicortical screws. These screws should be avoided when possible. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Use of 3D Printing Technology in Fracture Management: A Review and Case Series.

SUMMARY: Three-dimensional (3D) offers exciting opportunities in medicine, particularly in orthopaedics. The boundaries of 3D printing are continuously being re-established and have paved the way for further innovations, including 3D bioprinting, custom printing refined methods, 4D bioprinting, and 5D printing potential. The quality of these applications have been steadily improving, increasing their widespread use among clinicians. This article provides a review of the current literature with a brief introduction to the process of additive manufacturing, 3D printing, and its applications in fracture care. We illustrate this technology with a case series of 3D printing used for correction of complex fractures/nonunion. Factors limiting the use of this technology, including cost, and potential solutions are discussed. Finally, we discuss 4D bioprinting and 5D printing and their potential role in fracture surgery.

Acute Fixation Protocol for High-Energy Tibial Pilon Fractures Decreases Time to Fixation and Lowers Operative Costs Without Affecting Wound Complications and Reoperations.

OBJECTIVES: To determine whether an acute fixation protocol for high-energy tibial pilon fractures increases the rate of wound complications. DESIGN: Retrospective comparative study. SETTING: Urban level 1 trauma center. PATIENTS/PARTICIPANTS: One hundred forty-seven patients with OTA/AO 43B and 43C high-energy tibial pilon fractures treated with open reduction and internal fixation (ORIF). INTERVENTION: Acute (<48 hours) versus delayed ORIF protocols. MAIN OUTCOME MEASUREMENT: Wound complications, reoperations, time to fixation, operative costs, and hospital length of stay (LOS). Patients were compared by protocol, regardless of ORIF timing, for an intention-to-treat analysis. RESULTS: Thirty-five and 112 high-energy pilon fractures were treated under the acute and delayed ORIF protocols, respectively. In the acute ORIF protocol group, 82.9% of patients received acute ORIF versus 15.2% of patients in the standard delayed protocol group. The 2 groups had no observed difference (OD) in the rate of wound complications (OD -5.7%, confidence interval (95% CI) -16.1% to 7.8%; P = 0.56) or reoperations (OD -3.9%, 95% CI, -14.1% to 9.4%; P = 0.76). The acute ORIF protocol group had a shorter LOS (OD -2.0, 95% CI, -4.0 to 0.0; P = 0.02) and lower operative costs (OD $-2709.27, 95% CI, -3582.02 to -1601.16; P < 0.01). On multivariate analysis, wound complications were associated with open fractures (odds ratio 3.36, 95% CI, 1.06-10.69; P = 0.04) and an American Society of Anesthesiologists score >2 (odds ratio 3.68, 95% CI, 1.07-12.67; P = 0.04). CONCLUSION: This study suggests that an acute fixation protocol for high-energy pilon fractures decreases time to definitive fixation, lowers operative costs, and shortens hospital LOS without affecting wound complications or reoperations. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

An Acute Fixation Protocol for High-Energy Tibial Plateau Fractures Decreases Time to Fixation and Lowers Operative Costs Without Affecting Wound Complications and Reoperations.

OBJECTIVES: To investigate whether an acute fixation protocol for high-energy tibial plateau fractures increases the rate of wound complications. DESIGN: Retrospective comparative study. SETTING: Urban level 1 trauma center. PATIENTS/PARTICIPANTS: One hundred thirty-four patients with high-energy tibial plateau fractures (OTA/AO 41B/C [Schatzker VI/V/VI]) treated with open reduction and internal fixation (ORIF). INTERVENTION: Utilization of an acute ORIF (<48 hours) versus delayed ORIF protocol. MAIN OUTCOME MEASURE: Primary outcomes: wound complications (wound dehiscence/necrosis, superficial/deep infections) and reoperations. Secondary outcomes: total operative costs and hospital length of stay. RESULTS: Overall, 83.9% (26/31) of patients received definitive fixation within 48 hours under the acute ORIF protocol versus 18.4% (19/103) of patients treated under the standard delayed protocol with no observed differences in the rate of wound complications (proportional difference (PD) -4.6%, confidence interval (CI) -17.2% to 11.3%; P = 0.78) or reoperations (PD 2.0%, CI, 13.0% to 12.5%; P = 1.00). The acute ORIF protocol lowered operative costs (median difference (MD) $-2.563.00, CI, 3021.00 to -1661.00; P < 0.001) and hospital length of stay (MD 4.0 days, CI, 6.0-1.0; P = 0.001). On multivariate analysis, wound complications were associated with increasing age (odds ratio (OR) 1.05, CI, 1.01-1.10; P = 0.01) and tobacco use (OR 3.75, CI, 1.19-11.82; P = 0.02). CONCLUSION: An acute ORIF protocol for high-energy tibial plateau fractures decreased time to fixation and lowered operative costs without increasing the risk of wound complications or reoperations. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for complications within 30 days of operatively fixed periprosthetic femur fractures.

Background: With a rising number of periprosthetic femur fractures (PPFFs) each year, the primary objective of our study was to quantify risk factors that predict complications following operative treatment of PPFFs. Methods: A retrospective cohort study of 231 patients with a periprosthetic femur fracture was conducted at an Academic, Level 1 Trauma Center. The main outcome measurement of interest was complications, as defined by the ACS-NSQIP, within 30 days of surgery. Results: 56 patients had 96 complications. Bivariate analyses revealed ASA score, preoperative ambulatory status, length of stay, discharge disposition, time from admission to surgery, length of surgery, perioperative change in hemoglobin, Charlson comorbidity index, cerebral vascular accident/transient ischemic attack, chronic obstructive pulmonary disease, diabetes mellitus, and receipt of a blood transfusion were associated with development of a complication (p < 0.1). Multivariate logistic regression showed length of stay (OR 1.11, 95% CI 1.03-1.19; p = 0.006), receipt of a blood transfusion (OR 2.48, 95% CI 1.14-5.42; p = 0.02), and diabetes mellitus (OR 2.17, 95% CI 1.03-4.56; p = 0.04) remained independently predictive of complication. Conclusions: Length of stay, receipt of a blood transfusion, and diabetes were associated with increased perioperative risk for developing a complication following operative treatment of periprosthetic femur fractures. Methods to decrease length of stay or transfusion rates may mitigate complication risk in these patients. Level of Evidence: Prognostic, Level III.

Retrograde intramedullary nailing below a hip arthroplasty prosthesis: a viable fixation option for periprosthetic and interprosthetic femur fractures.

BACKGROUND: Periprosthetic femur fractures (PPFF) distal to a femoral stem are traditionally treated with open reduction and internal fixation (ORIF) with plate and screws. To our knowledge, no studies exist comparing outcomes following ORIF vs retrograde intramedullary nails (RIMN) for this injury. METHODS: This is a retrospective comparison of PPFFs distal to a femoral stem treated by ORIF (n = 17) vs RIMN (n = 13). The primary outcome was unplanned re-operation. RESULTS: There was no difference in unplanned re-operation (17.6 vs 23.1%, p > 0.99), infection, nonunion, refracture, and alignment between groups. The RIMN group had shorter surgical time (89 vs 157 min, p < 0.01), less blood loss (137 vs 291 ml, p = 0.03), and greater obesity. CONCLUSION: RIMN is a potential option for operative fixation of PPFF distal to a femoral stem worthy of additional study.

Is "Early Total Care" a Safe and Effective Alternative to "Staged Protocol" for the Treatment of Schatzker IV-VI Tibial Plateau Fractures in Patients Older Than 50 Years?

OBJECTIVES: To compare "Early Total Care" (ETC) with "Staged Protocol" (SP) for the treatment of Schatzker IV-VI tibial plateau fractures in patients older than 50 years regarding safety and effectiveness. DESIGN: Retrospective cohort study. SETTING: An academic level 1 US trauma center. PATIENTS/PARTICIPANTS: Eighty-one patients older than 50 years with Schatzker grade IV-VI tibial plateau fractures were included. INTERVENTION: Fifty-three patients were treated under SP with immediate external fixation followed by definitive internal fixation. Twenty-eight patients were treated under ETC with immediate internal fixation. MAIN OUTCOME MEASUREMENTS: Comparison of perioperative findings, time to bony and clinical union, soft-tissue and bony complications, radiological outcome, and secondary procedures. RESULTS: The 2 groups were comparable without significant difference regarding age, sex, side of involvement, body mass index, smoking status, American Society of Anesthesiologist classification, associated injuries, comorbidities, follow-up duration, and fracture classification. No statistically significant difference was found regarding the perioperative complications, quality of reduction, time to union, Rasmussen score at union or at the final follow-up, soft-tissue/bony complications, and the rate of the secondary procedures. CONCLUSION: ETC seems to be a safe, efficacious, and effective alternative to the SP for the treatment of some Schatzker IV-VI fractures in patients older than 50 years. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Preoperative Use of Clopidogrel Does Not Affect Outcomes for Femoral Neck Fractures Treated With Hemiarthroplasty.

BACKGROUND: The antiplatelet effect of clopidogrel on blood loss and perioperative complications after surgical intervention remains ambiguous. The purpose of this study was to determine if patients on clopidogrel before hemiarthroplasty for femoral neck fracture are predisposed to greater surgical bleeding and perioperative complications compared with those not taking clopidogrel before surgery. METHODS: We conducted a review of our electronic medical record from 2006-2013 and identified 602 patients who underwent 623 hemiarthroplasty procedures for displaced femoral neck fracture, of which 54 cases (9%) were taking clopidogrel before hospital admission. Patient demographics and comorbidities, operative and surgical variables, and perioperative complications at 90 days were compared between the clopidogrel and nonclopidogrel user groups. RESULTS: The 2 groups of patients had similar baseline characteristics, but patients taking clopidogrel preoperatively were sicker with higher American Society of Anesthesiologists scores (P = .049) and age-adjusted Charlson index (P = .001). They also had a greater incidence of cerebrovascular disease (P = .01), chronic obstructive pulmonary disease (P = .03), diabetes (0.03), and malignancy (P < .001). There was no significant difference between the 2 patient groups with respect to 90-day postoperative medical readmissions (P = .85), surgical readmissions (P = .26), infection (P = .99), and mortality (P = .89). CONCLUSION: Patients taking clopidogrel who present with a displaced femoral neck fracture can safely undergo a hemiarthroplasty while actively on clopidogrel without an increase in medical or surgical complications and mortality. We do not recommend delaying surgical intervention until the antiplatelet effects of clopidogrel subside.

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.

What Orthopaedic Operating Room Surfaces Are Contaminated With Bioburden? A Study Using the ATP Bioluminescence Assay.

BACKGROUND: Contaminated operating room surfaces can increase the risk of orthopaedic infections, particularly after procedures in which hardware implantation and instrumentation are used. The question arises as to how surgeons can measure surface cleanliness to detect increased levels of bioburden. This study aims to highlight the utility of adenosine triphosphate (ATP) bioluminescence technology as a novel technique in detecting the degree of contamination within the sterile operating room environment. QUESTIONS/PURPOSES: What orthopaedic operating room surfaces are contaminated with bioburden? METHODS: When energy is required for cellular work, ATP breaks down into adenosine biphosphate (ADP) and phosphate (P) and in that process releases energy. This process is inherent to all living things and can be detected as light emission with the use of bioluminescence assays. On a given day, six different orthopaedic surgery operating rooms (two adult reconstruction, two trauma, two spine) were tested before surgery with an ATP bioluminescence assay kit. All of the cases were considered clean surgery without infection, and this included the previously performed cases in each sampled room. These rooms had been cleaned and prepped for surgery but the patients had not been physically brought into the room. A total of 13 different surfaces were sampled once in each room: the operating room (OR) preparation table (both pre- and postdraping), OR light handles, Bovie machine buttons, supply closet countertops, the inside of the Bair Hugger™ hose, Bair Hugger™ buttons, right side of the OR table headboard, tourniquet machine buttons, the Clark-socket attachment, and patient positioners used for total hip and spine positioning. The relative light units (RLUs) obtained from each sample were recorded and data were compiled and averaged for analysis. These values were compared with previously published ATP benchmark values of 250 to 500 RLUs to define cleanliness in both the hospital and restaurant industries. RESULTS: All surfaces had bioburden. The ATP RLUs (mean ± SD) are reported for each surface in ascending order: the OR preparation table (postdraping; 8.3 ± 3.4), inside the sterilized pan (9.2 ± 5.5), the inside of the Bair Hugger™ hose (212.5 ± 155.7), supply closet countertops (281.7 ± 236.7), OR light handles (647.8 ± 903.7), the OR preparation table (predraping; 1054 ± 387.5), the Clark-socket attachment (1135.7 ± 705.3), patient positioners used for total hip and spine positioning (1201.7 ± 1144.9), Bovie machine buttons (1264.5 ± 638.8), Bair Hugger™ buttons (1340.8 ± 1064.1), tourniquet machine buttons (1666.5 ± 2144.9), computer keyboard (1810.8 ± 929.6), and the right side of the OR table headboard (2539 ± 5635.8). CONCLUSIONS: ATP bioluminescence is a novel method to measure cleanliness within the orthopaedic OR and can help identify environmental trouble spots that can potentially lead to increased infection rates. Future studies correlating ATP bioluminescence findings with microbiology cultures could add to the clinical utility of this technology. CLINICAL RELEVANCE: Surfaces such as the undersurface of the OR table headboard, Bair Hugger™ buttons, and tourniquet machine buttons should be routinely cleansed as part of an institutional protocol. Although correlation between ATP bioluminescence and clinical infection was not evaluated in this study, it is the subject of future research. Specifically, evaluating microbiology samples taken from these environmental surfaces and correlating them with increased bioburden found with ATP bioluminescence technology can help promote improved surgical cleaning practices.

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.

Concomitant Venous Thrombosis and Pulmonary Embolism After Hip Arthroscopy in a Patient With Heterozygous Factor V Leiden Deficiency.

As hip arthroscopy becomes more prevalent, it is imperative to identify potential risks associated with this procedure. In this article, we report a case of deep vein thrombosis (DVT) and pulmonary embolism that developed after hip arthroscopy in a moderate-risk patient with heterozygous factor V Leiden deficiency. The patient concomitantly developed DVT and pulmonary embolism during a 5-day course of treatment with subcutaneous enoxaparin. The American College of Chest Physicians and American Academy of Orthopaedic Surgeons guidelines on postarthroplasty DVT prophylaxis do not address thromboprophylaxis in hip arthroscopy. Guidelines on managing venous thromboembolism after hip arthroscopy are needed. With complications increasing, protocols should be implemented to address the potential risks of this popular procedure.

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.

Reverse Oblique and Transverse Intertrochanteric Femoral Fractures Treated With the Long Cephalomedullary Nail.

OBJECTIVE: To evaluate the healing rate, complications, role of reduction and screw placement, and the 1-year mortality in the treatment of reverse oblique and transverse intertrochanteric femoral fractures treated with the long cephalomedullary nail. DESIGN: Retrospective review. SETTING: Two different Level-1 trauma centers: Geisinger Medical Center and the University of Utah. PATIENTS: One hundred forty-eight patients with intertrochanteric fractures (AO/OTA class 31-A3) eligible for review. All patients had a minimum of 12 months of follow-up and were available for radiologic checks and assessment of outcomes and complications. INTERVENTION: Long cephalomedullary nail. MAIN OUTCOME MEASURES: Medical records were reviewed for reoperation, demographic parameters, length of hospital stay, estimated blood loss, and need for transfusion. Mortality rates at 1 month, 6 months, and 1 year were also recorded. Patients were followed clinically and radiographically at 6 weeks, 3 months, 6 months, 12 months, and yearly as needed. RESULTS: The average age of patients was 69.9 (range, 19-95) years. Average length of follow-up was 53 (range, 12-148) months. The average surgical time was 71.8 (range, 26-229) minutes. Twenty-four patients (16%) required blood transfusions, and the average transfusion required was 205.1 mL (range, 20-800). Five different long nail designs were used to treat the patients. One patient (0.6%) experienced an intraoperative complication. Eighteen patients (12%) sustained postoperative complications. Twelve (8%) patients required reoperations. One-year mortality rates were 10.1%. CONCLUSIONS: Long cephalomedullary nails remain the preferred treatment option for the treatment of 31-A3-type fractures, demonstrating acceptable complication rates, low reoperation rates, and high rates of healing. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Impact of chronic kidney disease stage on lower-extremity arthroplasty.

End-stage renal disease and dialysis is commonly associated with poor outcomes after joint replacement surgery. The goal of this study was to evaluate postoperative complications in patients with less advanced chronic kidney disease undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). Patients who underwent THA or TKA between 2004 and 2011 with stage 1, 2, or 3 chronic kidney disease were retrospectively reviewed via an electronic medical record. The authors compared 377 patients who had stage 1 to 2 chronic kidney disease with 402 patients who had stage 3 chronic kidney disease. No significant differences in 90-day readmission or revision rates were found between the stage 1 to 2 and stage 3 patient groups. For patients with stage 3 chronic kidney disease, the overall mortality rate was greater than that in patients with stage 1 to 2 chronic kidney disease. However, when adjusted for comorbid disease, no significant increases were seen in joint infection, readmission, or early revision between patients with stage 1 to 2 chronic kidney disease vs patients with stage 3 chronic kidney disease. The overall incidence of infection was high (3.5%) but far less than reported for patients with end-stage renal disease, dialysis, and kidney transplant. In conclusion, patients with stage 1, 2, or 3 chronic kidney disease may have a higher than expected rate of prosthetic joint infection (3.5%) after total joint arthroplasty. Patients with stage 3 chronic kidney disease are at higher risk for postoperative mortality compared with those with lesser stages of kidney disease.

Techniques for the surgical treatment of distal tibia fractures.

Surgical management of extra-articular distal tibia fractures has evolved because of the high rate of complications with conventional techniques and the technically challenging aspects of the surgery. Open reduction and internal fixation with plating or nailing remain the gold standards of treatment, and minimally invasive techniques have reduced wound complications and increased healing. Adequate reduction and stabilization as well as appropriate soft tissue management are imperative to achieving good outcomes in these fractures.

The learning styles of orthopedic residents, faculty, and applicants at an academic program.

BACKGROUND: To train surgeons effectively, it is important to understand how they are learning. The Kolb Learning Style Inventory (LSI) is based on the theory of experiential learning, which divides the learning cycle into 4 stages: active experimentation (AE), abstract conceptualization (AC), concrete experience, and reflective observation. The purpose of this investigation was to assess the learning styles of orthopedic residents, faculty, and applicants at an east-coast residency program. METHODS: A total of 90 Kolb LSI, Version 3.1 surveys, and demographic questionnaires were distributed to all residency applicants, residents, and faculty at an academic program. Data collected included age, sex, type of medical school (MD or DO), foreign medical graduate status, and either year since college graduation, postgraduate year level (residents only), or years since completion of residency (faculty only). Seventy-one completed Kolb LSI surveys (14 residents, 14 faculty members, and 43 applicants) were recorded and analyzed for statistical significance. RESULTS: The most prevalent learning style among all participants was converging (53.5%), followed by accommodating (18.3%), diverging (18.3%), and assimilating (9.9%) (p = 0.13). The applicant and resident groups demonstrated a high tendency toward AE followed by AC. The faculty group demonstrated a high tendency toward AC followed by AE. None of the 24 subjects who were 26 years or under had assimilating learning styles, in significant contrast to the 12% of 27- to 30-year-olds and 18% of 31 and older group (p < 0.01). CONCLUSIONS: The majority of applicants, residents, and faculty in the orthopedic residency program were "convergers." The converging learning style involves problem solving and decision making, with the practical application of ideas and the use of hypothetical-deductive reasoning. Learning through AE decreased with age, whereas learning through AC increased.

The reporting of functional outcome instruments in the Journal of Orthopaedic Trauma over a 5-year period.

OBJECTIVES: Orthopaedic journals, such as the Journal of Orthopaedic Trauma, frequently publish studies reporting functional outcome instruments, but little information has been provided regarding the validity and overall strength of these instruments. This study analyzes the trends in reported functional outcome instruments in articles published in the Journal of Orthopaedic Trauma over a 5-year period and examines the utilization rate, "overall" strength, and validity of these functional outcome instruments for the populations being studied. METHODS: Articles that were published in the Journal of Orthopaedic Trauma from January 2006 to December 2010 were reviewed, and each article was assigned to 1 of 4 different categories, based on the subspecialty focus and body region. The total number of articles reporting the use of functional outcome instruments, articles with at least 1 functional outcome instrument found in the AO Handbook, and the total number of functional outcome instruments reported were recorded. Each functional outcome instrument was assigned to 1 of 3 categories (generic, nonvalidated, validated), and each validated instrument was also examined to determine whether the category of interest for which it was used was one in which it was previously validated in. RESULTS: A total of 171 articles (34%) of the articles initially reviewed met the inclusion criteria. The average number of articles per year that reported functional outcome instruments was 56% (range, 47%-65%), and the average number of articles that reported at least 1 validated outcome instrument was 51% (range, 44%-61%). The average percentage of validated scores that were appropriately used within the category of interest was 23% (range, 13%-41%). CONCLUSIONS: Even though the 56% utilization rate of functional outcome instruments in The Journal of Orthopaedic Trauma is much higher than other journals, it is still low given the importance of measuring and attaining excellent functional outcomes. It is clear that future effort should be given to validating outcome measures for correct evaluation of orthopaedic trauma patients.