Immediate weight bearing as tolerated (WBAT) correlates with a decreased length of stay post intramedullary fixation for subtrochanteric fractures: a multicenter retrospective cohort study.

BACKGROUND: Subtrochanteric femur fractures associate with a relatively high complication rate and are traditionally treated operatively with a period of limited weight bearing. Transitioning from extramedullary to intramedullary implants, there are increasing biomechanical and clinical data to support early weight bearing. This multicenter retrospective study examines the effect of postoperative weight bearing as tolerated (WBAT) for subtrochanteric femur fractures. We hypothesize that WBAT will result in a decreased length of stay (LOS) without increasing the incidence of re-operation. METHODS: This study assesses total LOS and postoperative LOS after intramedullary fixation for subtrochanteric fractures between postoperative weight bearing protocols across 6 level I trauma centers (n = 441). Analysis techniques consisted of multivariable linear regression and nonparametric comparative tests. Additional subanalyses were performed, targeting mechanism of injury (MOI), Winquist-Hansen fracture comminution, 20-year age strata, and injury severity score (ISS). RESULTS: Total LOS was shorter in WBAT protocol within the overall sample (7.4 vs 9.7 days; p < 0.01). Rates of re-operation were similar between the two groups (10.6% vs 10.5%; p = 0.99). Stratified analysis identified patients between ages 41-80, WH comminution 2-3, high MOI, and ISS between 6-15 and 21-25 to demonstrate a significant reduction in LOS as a response to WBAT. CONCLUSION: An immediate postoperative weight bearing as tolerated protocol in patients with subtrochanteric fractures reduced length of hospital stay with no significant difference in reoperation and complication rates. If no contraindication exists, immediate weight bearing as tolerated should be considered for patients with subtrochanteric femur fractures treated with statically locked intramedullary nails. LEVEL OF EVIDENCE: Therapeutic Level III.

Liposomal Bupivacaine Associated with Cost Savings during Postoperative Pain Management in Fragility Intertrochanteric Hip Fractures.

Background: Intertrochanteric hip fractures are among the most common and most expensive diagnoses in the Medicare population. Liposomal bupivacaine is a novel preparation of a commonly used analgesic agent that, when used intraoperatively, decreases narcotic requirements and hospital length of stay and increases the likelihood of discharge to home. The purpose of this investigation was to determine whether there was an economic benefit to utilizing intraoperative liposomal bupivacaine in patients with fragility intertrochanteric hip fractures in comparison to a group of patients who did not receive liposomal bupivacaine. Methods: This is a retrospective observational study performed at two academic medical centers. Fifty-six patients with intertrochanteric hip fractures treated with cephalomedullary nail implant who received standard hip fracture pain management protocol were compared to a cohort of 46 patients with intertrochanteric hip fractures who received additional intraoperative injections of liposomal bupivacaine. All other standards of care were identical. A cost analysis was completed including the cost of liposomal bupivacaine, operating room costs, and discharge destination. Statistical significance was set at p < 0.05. Results: Although the length of hospital stay was similar between the two groups (3.2 days vs. 3.8 days, p = 0.08), patients receiving intraoperative liposomal bupivacaine had a lower likelihood of discharge to a skilled nursing facility (84.8% vs. 96.4%, p = 0.002) and a longer operative time (73.4 minutes vs 67.2 minutes, p = 0.004). The cost-benefit analysis indicated that for an investment of $334.18 in the administration of 266 mg of liposomal bupivacaine, there was a relative saving of $1,323.21 compared to the control group. The benefit-cost ratio was 3.95, indicating a $3.95 benefit for each $1 spent in liposomal bupivacaine. Conclusions: Despite the increased initial cost, intraoperative use of liposomal bupivacaine was found to be a cost-effective intervention due to the higher likelihood of discharge to home during the postoperative management of patients with intertrochanteric hip fractures.

Kirschner wire prepared pilot holes improve screw pullout strength in synthetic osteoporotic-type bone.

OBJECTIVES: To compare the pullout strength and maximal insertional torque of pilot holes prepared with the traditional twist drill bit versus a smooth Kirschner wire. METHODS: Pilot holes were prepared using a drill press with either a 2.5 mm twist drill bit or a 2.5 mm smooth Kirschner wire into 2 distinct polyurethane foam densities representing severe and mild osteoporotic bone. 3.5 mm cortical and 4.0 mm cancellous screws were then inserted freehand into the prepared holes. All permutations of pilot hole type, screw size and foam density were tested for maximum pullout strength and maximum insertional torque. RESULTS: Kirschner wire prepared pilot holes resulted in significantly higher pullout load than drill bit holes in low density blocks (P < 0.001), but not in high density blocks (P = 0.232). There was no statistical difference (P > 0.05) for maximum insertional torque in the pilot hole preparation type. CONCLUSION: In severely osteoporotic bone, Kirschner wire pilot hole preparation may improve screw pullout strength.

Liposomial Bupivacaine for Postoperative Pain Control in Fragility Intertrochanteric Hip Fractures.

OBJECTIVES: To determine whether intraoperative liposomal bupivacaine reduces postoperative opioid requirements, pain scores, and length of stay (LOS) in patients with fragility intertrochanteric femur fractures in comparison with a group of patients who did not receive liposomal bupivacaine. DESIGN: Retrospective observational study. SETTING: Two academic medical centers. PATIENTS: One hundred two patients with intertrochanteric hip fracture treated with a cephalomedullary nail implant. INTERVENTION: Nonrandomized administration of liposomal bupivacaine in 2 cohorts of patients with similar injuries and treatment. MAIN OUTCOME MEASUREMENTS: Postoperative oral average morphine equivalents (MME) and average numerical pain rating score (NRS). Secondary endpoints included postoperative LOS, operative time, and home discharge. RESULTS: Forty-six patients received intraoperative liposomal bupivacaine and 56 patients did not. There was no significant difference between age, sex, and American Society of Anesthesiologist level between groups (P > 0.05). The liposomal bupivacaine group received significantly less MME (0.34 vs. 0.92 mg/h/kg, P = 0.04) and had significantly lower NRS (2.89 vs. 5.13, P = 0.04) in the first 24 hours after surgery. MME (1.18 vs. 1.37 mg/h/kg, P = 0.27) and NRS (3.61 vs. 5.51, P = 0.34) were similar at the 36-hour mark. The liposomal bupivacaine group had similar LOS (3.2 days vs. 3.8, P = 0.08), more home discharges (7 vs. 2, P = 0.001), and longer operative time (73.4 vs. 67.2 minutes, P = 0.004). CONCLUSIONS: Intraoperative liposomal bupivacaine use reduced opioid use and postoperative pain for the first 24 hours after fixation of intertrochanteric femur fractures. Significant increases in likelihood of discharge to home may present an opportunity for cost savings. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Fracture of a Carbon Fiber Reinforced Intramedullary Femoral Nail.

Carbon fiber reinforced implants have emerged as an alternative to traditional stainless steel and titanium implants because of the improved visibility on advanced imaging and excellent biomechanical strength. This can be advantageous in patients with concern about fracture healing, tumor recurrence, or additional imaging requirements. However, limited long-term data are available to present complications from the use of these implants. We present the case of a failure of a carbon fiber reinforced intramedullary femoral nail used in a closed distal femur fracture.

Nerve Blocks in the Geriatric Patient With Hip Fracture: A Review of the Current Literature and Relevant Neuroanatomy.

INTRODUCTION: Hip fracture is a common occurrence in the elderly population with high morbidity and mortality due to postoperative pain and opioid use. The goal of this article is to review the current literature on the neuroanatomy of the hip and the use of localized nerve block in controlling hip fracture pain. METHODS: A thorough search of MEDLINE/PubMed, Embase, and the Cochrane Database of Systematic Reviews was conducted using the search terms "hip fracture" and "fascia iliaca block (FICB)." An additional search was conducted utilizing multiple search terms including "hip fracture," "greater trochanter," "femur," "hip," "anatomy," "neuroanatomical," and "anatomic." Each search result was investigated for cadaveric studies on the innervation of the trochanteric region. RESULTS: Twenty-five clinical studies examining the use of FICBs in hip fracture patients were identified. These studies show that FICB is safe and effective in controlling perioperative pain. Additionally, FICB has been shown to decrease opioid requirement and opioid-related side effects. Neuroanatomical studies show that the hip capsule is innervated by contributions from the femoral, obturator, sciatic, and superior gluteal nerves. Imaging studies suggest that FICB anesthetizes these branches through localized spread along the fascia iliaca plane. Cadaveric evidence suggests that the greater trochanter region is directly innervated by a single branch from the femoral nerve. DISCUSSION: The proven efficacy of nerve blocks and their anatomic basis is encouraging to both the anesthesiologist and orthopedic surgeon. Their routine use in the hip fracture setting may improve patient outcomes, given the unacceptably high morbidity and mortality associated with opioid use. CONCLUSIONS: Localized nerve blocks, specifically FICB, have been shown to be safe and effective in managing acute hip fracture pain in geriatric patients, leading to decreased opioid use. Knowledge of the hip neuroanatomy may help guide future development of hip fracture pain blockade.

A Rare Presentation of Sciatic Palsy Due to Hematoma After Use of the Kocher-Langenbeck Approach to the Acetabulum.

CASE: A delayed sciatic palsy caused by compression due to hematoma formation is a rare complication of total hip arthroplasty. We report the case of a twenty-seven-year-old man who underwent open reduction and internal fixation of transverse and posterior wall acetabular fractures with posterior hip dislocation and had development of a delayed sciatic palsy due to the formation of a hematoma five days after the procedure. CONCLUSION: A patient who presents with a delayed-onset sciatic palsy with signs and symptoms of a hematoma after an acetabular surgery represents a surgical emergency. Early recognition and urgent decompression offers the best chance of nerve recovery.

Professional Demands and Job Satisfaction in Orthopaedic Trauma: An OTA Member Survey.

OBJECTIVES: The goal of this study was to examine the factors that affect career satisfaction in orthopaedic traumatologists. We hypothesize that the level of stress and career satisfaction in orthopaedic traumatology would be affected by increased number of call nights and work hours. DATA SOURCES: A 30-question survey was emailed to members of the OTA. The survey evaluated 5 critical areas: training/experience, practice characteristics, demands, stress management strategies, and satisfaction. STUDY SELECTION: After approval by the OTA research committee, all active and associate US members of the OTA were contacted. DATA EXTRACTION: The survey was open to the OTA members from July through November of 2012. DATA SYNTHESIS: Of 1031 members of the OTA, 263 members responded for an overall response rate of 25.5%. Most respondents were fellowship-trained (218, 82.9%) and predominantly young (<5 years in practice, 34.4%) or established surgeons (>15 years in practice, 28.5%). Most surgeons were married (229, 87.1%) and have not been divorced (226, 85.9%). Career satisfaction was statistically improved by belonging to larger practice (P = 0.016), decreased by work for more hours per week (P = 0.001), and improved by taking more call (P = 0.014). CONCLUSIONS: Career satisfaction among orthopaedic trauma surgeons was extremely high. Our results indicate that young surgeons may improve their job satisfaction and potentially prolong their career by limiting the numbers of hours worked, taking a consistent number of calls and joining a larger group. LEVEL OF EVIDENCE: Prognostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Radial neck fractures in children: experience from two level-1 trauma centers.

The aim of this study was to compare different treatment modalities for different severities of pediatric radial neck fractures in a large cohort of patients and determine prognostic factors. A retrospective, comparative study was conducted of all children treated for different severities of radial neck fractures at two level-1 pediatric trauma centers between 1990 and 2007. Pertinent data were collected, and the outcome was measured by the Tibone criteria. Several variables were compared to determine the prognostic value. Seventy-eight children were identified, 35 male and 43 female, at an average age of 7.8 years (range 3-15 years). Twenty-nine of the 78 (37%) children had associated injuries. Fracture patterns varied in their severity. Nineteen patients needed casting alone; 16 required closed reduction; of the children requiring surgery, 26 responded to percutaneous reduction and 17 were severe enough to need open reduction. Complications occurred in 28/78 (36%) children, 24 of which were related to stiffness. Seventeen of the 19 (89%) fractures that were amenable to casting alone had excellent or good outcomes, as did 11/16 (69%) in the closed reduction group. Among children treated operatively, 19/26 (73%) patients who underwent percutaneous reduction had an excellent or good outcome. Only 6/17 (35%) of the severe cases who underwent open reduction had an excellent or good outcome. The treatment method, essentially dictated by the severity of the cases, did correlate with the outcome (P=0.001). Compared with more severe fractures that required operative treatment, patients treated nonoperatively had a higher rate of excellent to good outcome (P=0.018). In particular, patients who underwent percutaneous reduction alone had improved outcomes versus open reduction (P=0.008). The outcome was not related to the presence of an associated injury (P=0.302). Initial fracture severity, as graded by the Judet classification, correlated with the outcome (P=0.004). Furthermore, age also expressed significance, as patients younger than 10 years of age tended to do better than those above 10 years of age (P=0.025). Children with less severe radial neck fractures amenable to nonoperative treatment fare well. Operative treatment of these fractures, particularly in severe cases when an open (not percutaneous) reduction is needed, is associated with a higher risk of poor outcome. Children over 10 years of age, especially those with more severe initial angulation, tend to fare worse. The presence of associated injuries does not appear to increase the risk of a poor outcome after treatment. There is a high rate of complications (36%), stiffness being the most common (24). This large bi-center retrospective study from two level-1 pediatric trauma centers emphasizes that in severe cases of radial neck fractures, open treatment does not necessarily decrease the risk of a poor outcome.

Pectus excavatum in blunt chest trauma: a case report.

INTRODUCTION: Blunt cardiac rupture is an exceedingly rare injury. CASE PRESENTATION: We report a case of blunt cardiac trauma in a 43-year-old Caucasian German mother with pectus excavatum who presented after a car accident in which she had been sitting in the front seat holding her two-year-old boy in her arms. The mother was awake and alert during the initial two hours after the accident but then proceeded to hemodynamically collapse. The child did not sustain any severe injuries. Intraoperatively, a combined one-cm laceration of the left atrium and right ventricle was found. CONCLUSION: Patients with pectus excavatum have an increased risk for cardiac rupture after blunt chest trauma because of compression between the sternum and spine. Therefore, patients with pectus excavatum and blunt chest trauma should be admitted to a Level I Trauma Center with a high degree of suspicion.