Does Fracture Pattern Really Predict Displacement of LC1 Sacral Fractures?

BACKGROUND: Operative management of minimally displaced lateral compression type-1 (LC1) pelvic ring injuries remains controversial. We aimed to assess the proportion of LC1 pelvic fractures that displaced following nonoperative management as a function of specific ring fracture patterns, and we quantified the magnitude of this displacement. METHODS: A retrospective review of the billing registry of a level-I trauma center was performed. Two hundred and seventy-three patients with a high-energy LC1 pelvic ring fracture and <5 mm of sacral displacement were included. The fracture pattern was characterized with use of computed tomography (CT) scans and radiographs. Absolute and interval pelvic ring displacement were quantified with use of previously described methodology. RESULTS: Thirty-five pelvic ring injuries (13%) were displaced. The rate of displacement was 31% (15 of 49) for LC1 injuries involving a complete sacral fracture and bilateral ramus fractures, 12% (7 of 58) for injuries involving a complete sacral fracture and a unilateral ramus fracture, and 10% (5 of 52) for injuries involving an incomplete sacral fracture and bilateral ramus fractures. In displaced injuries, the average interval displacement was 4.2 mm (95% confidence interval [CI], 1.8 to 6.8) and the final displacement was 9.9 mm ± 4.2 mm. CONCLUSIONS: Our study suggests that fracture characteristics can be used to predict the likelihood of displacement of LC1 fractures that are treated without surgery. To our knowledge, the present study is the first to describe the magnitude of displacement that may occur in association with LC1 pelvic ring injuries that are treated nonoperatively; however, further studies are needed to determine the clinical impact of this displacement. LEVEL OF EVIDENCE: Diagnostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Effects of Delayed Hip Fracture Surgery on Severely Ill Patients: Defining the Time to Medical Optimization.

BACKGROUND: Patients with multiple comorbidities often have delayed hip fracture surgery due to medical optimization. The goal of this study is to identify the allowable time for medical optimization in severely ill hip fracture patients. METHODS: The 2016-2019 NSQIP database was used to identify patients over age 60 with ASA classification scores 3 and 4 for severe and life-threatening systemic diseases. Patients were divided into immediate (<24 hours), early (24-48 hours), or late (>48 hours) groups based on time to surgery (TTS). Risk-adjusted multivariable logistic regressions were conducted to compare relationships between 30-day postoperative outcomes and TTS. RESULTS: 43,071 hip fracture cases were analyzed for the purposes of this study. Compared to patients who underwent surgery immediately, patients who had surgeries between 24 and 48 hours were associated with higher rates of pneumonia (OR 1.357, CI 1.194-1.542), UTIs (OR 1.155, CI 1.000-1.224), readmission (OR 1.136, CI 1.041-1.240), postoperative LOS beyond 6 days (OR 1.249, CI 1.165-1.340), and mortality (OR 1.205, CI 1.084-1.338). Patients with surgeries delayed beyond 48 hours were associated with higher rates of CVA (OR 1.542, CI 1.048-2.269), pneumonia (OR 1.886, CI 1.611-2.209), UTIs (OR 1.546, CI 1.283-1.861), readmission (OR 1.212, CI 1.074-1.366), postoperative LOS beyond 6 days (OR 1.829, CI 1.670-2.003), and mortality (OR 1.475, CI 1.286-1.693) compared to patients with immediate surgery. DISCUSSION: Severely ill patients with the hip fracture may have a 24-hour window for medical optimization. Hip fracture surgery performed beyond 48 hours is associated with higher complication rates and mortality among those who are severely ill. Further prospective studies are warranted to examine the effects of early surgical intervention among severely ill patients.

Heterotopic Ossification Prophylaxis in Acetabular Fracture Surgery: A Systematic Review.

Heterotopic ossification (HO) following acetabular fracture surgery is relatively common. The purpose of this study was to perform a systematic review of the literature regarding HO rates following acetabular surgery and the effectiveness of the various prophylactic measures taken to prevent its occurrence. A search of PubMed, MEDLINE, and Cochrane Database of Systematic Reviews was performed using the search terms ("Acetabular" OR "Acetabulum") AND ("Heterotopic Ossification" OR "HO" OR "Ectopic Ossification"). Inclusion criteria included articles published in English reporting on HO in acetabular fracture surgery. Descriptive statistics were calculated with categorical data presented as frequency with percentages and continuous data as means. Standard weighted means were calculated for all parameters. Sixty-six articles were included in this study with a total of 5,028 patients. HO was identified in 1,511 (30%) of fractures. Indomethacin (27%) and radiation therapy (24%) demonstrated decreased rates of HO formation versus no prophylaxis (36%). In particular, rates of severe HO formation were substantially decreased with radiation therapy (3%) and indomethacin (7%) compared to no prophylaxis (18%). Indomethacin and radiation therapy both appear to decrease HO formation and severity without substantially increasing surgical morbidity. (Journal of Surgical Orthopaedic Advances 32(4):217-224, 2023).

Risk factors for loss to follow up of pelvis and acetabular fractures.

INTRODUCTION: Pelvic and acetabular fracture incidence is increasing worldwide for more than four decades. There is currently no evidence examining risk factors for loss to follow up in patients with these injuries. METHODS: Patients presenting with pelvic and/or acetabular fractures at our institution between 2015 and 2020 were included. Demographic, injury, treatment, and follow up information was included. Excluded patients were those who sustained a pathologic fracture, has a course of treatment prior to transfer to our centre, or expired prior to discharge. RESULTS: 446 patients, 263 with a pelvic ring injury, 172 with an acetabular fracture, and 11 with combined injuries were identified. 271 (61%) of patients in our cohort followed up in Orthopaedic clinic (p = 0.016). With an odds ratio of 2.134, gunshot wound mechanism of injury was the largest risk factor for loss to follow up (p = 0.031) followed by male sex (OR= 1.859) and surgery with general trauma surgery (OR=1.841). The most protective risk factors for follow up with Orthopaedic surgery were operatively treated pelvic and acetabular fractures (OR=0.239) and Orthopaedic Surgery as the discharging service (OR=0.372). DISCUSSION: Numerous risk factors exist for loss to follow up including male sex, ballistic mechanism, and discharging service. Investigation into interventions to improve follow up in these patients are warranted.

Orthopaedic Surgery Residency Program Websites: A Five-Year Update and the Rise of Social Media.

Objective  The importance of online information in the form of residency program websites has been well documented. With the rise of popularity of social media, another potential vital source of online information distribution exists. We aimed to examine the changes in orthopaedic surgery residency program websites and determine the use of social media by these programs. Methods A list of orthopaedic residency programs was obtained. Websites were then assessed for presence of numerous criteria. The presence of a social media account on Instagram, Twitter, and Facebook platforms was then determined. Results One hundred ninety-five websites out of 197 programs were identified. The most commonly present criterion was resident rotation schedule with 187 (96%) listings. Meanwhile, information on virtual sessions for prospective applicants was the least present at 26 (13%). Out of the 33 criteria assessed, websites contained an average of 20.4 criteria. Approximately half of the programs were noted to have a social media presence. Conclusion Website utilization and accessibility have improved over time as the importance of online information has continued to grow in the orthopaedic surgery residency application process. In order to increase their online presence, numerous programs have recently created or enhanced the profiles on social media platforms which may reach more users than websites alone.

Determining the Impact of the COVID-19 Pandemic on Hand Surgery Fellowship Education.

The purpose of this study is to report the impact of COVID-19 on hand surgery fellow learning and preparedness for practice. A multi-dimensional questionnaire was distributed to current hand fellows and fellowship directors across the United States. Survey questions included fellowship location, institutional response, impact on practice, education and job search. Thirty-two hand surgery fellows and 14 fellowship directors completed the survey. Of fellows, 59% reported a greater than 75% decrease in case volume. Mean hours worked per week per fellow decreased by 52%. All fellowship directors and 94% of fellows did not expect COVID-19 to impact their ability to graduate, and nearly all fellows felt prepared to start practice after fellowship training. However, many fellows expressed concern about job opportunities. The work hours and exposure of hand surgery fellows to elective surgical cases have been adversely impacted by COVID-19. Nevertheless, current hand fellows feel prepared to enter practice. (Journal of Surgical Orthopaedic Advances 31(1):048-052, 2022).

Incidence, risk factors and clinical implications of postoperative urinary tract infection in geriatric hip fractures.

INTRODUCTION: Postoperative urinary tract infection (UTI) is common in geriatric patients; however, little is known about the impact of UTI in orthopedic trauma. The present study was designed to determine the risk factors and clinical impact of postoperative urinary tract infection (UTI) in acute geriatric hip fractures. PATIENTS AND METHODS: Geriatric patients (≥65 years of age) undergoing hip fracture surgery were identified within the American College of Surgeons National Surgical Quality Improvement Program between 2016 and 2019. Patients presenting with UTI at the time of surgery were excluded. Baseline characteristics and outcomes were compared between patients with and without postoperative UTI. Multivariate logistic regression was performed, controlling for potential confounders. RESULTS: A total of 46,263 patients included in the study. Overall, 1,397 (3.02%) patients had postoperative UTI. Patients who developed postoperative UTI had higher rates of pneumonia (6.44% vs. 3.76%, p < 0.001), DVT (2.22% vs. 1.04%, p < 0.001), sepsis (7.73% vs. 0.62%, p < 0.001), and more frequently experienced postoperative hospital lengths of stay exceeding 6 days (37.94% vs. 20.33%, p < 0.001). Hospital readmission occurred more frequently in patients with postoperative UTI (24.55% vs. 7.85%, p < 0.001), but surprisingly, these patients had a lower mortality rate (1.36% vs. 2.2%, p < 0.001). Adjusted analysis demonstrated the following variables associated with postoperative UTI: age ≥ 85 (OR = 1.37, 95%CI = 1.08 - 1.73), ASA class ≥ 3 (OR = 1.59, 95%CI = 1.21 - 2.08,), chronic steroid use (OR = 1.451, 95%CI = 1.05 - 1.89), blood transfusion (OR = 1.24, 95%CI = 1.05 - 1.48), and >2 days delay from admission to operation (OR = 1.37, 95%CI = 1.05 - 1.79). Postoperative UTI was significantly associated with sepsis (OR = 7.65, 95%CI = 5.72 - 10.21), postoperative length of stay >2 days (OR = 1.83, 95%CI = 1.07 - 3.13), and readmission (OR = 3, 95%CI = 2.54 - 3.55). CONCLUSIONS: In our study, postoperative UTI was found in 3% of geriatric hip fracture patients. Predictors of postoperative UTI were age ≥ 85, ASA class ≥ 3, chronic steroid use, blood transfusion, and time to operation > 2 days from admission. Results showed that postoperative UTI is independently associated with sepsis, postoperative length of stay beyond 2 days, and hospital readmission. To diminish the risk of UTI and its consequences, we recommend operating geriatric hip fractures in 24-48 hours after admission.

Comparison of Extramedullary and Intramedullary Implants for Stable Intertrochanteric Fractures: Have We Swung the Pendulum Too Far the Other Way?

INTRODUCTION: Although intramedullary implants are commonly used to treat stable intertrochanteric (IT) fractures, there is a lack of evidence to demonstrate their superiority over extramedullary implants in treating these fractures. The purpose of this study was to compare short-term outcomes (<30 days) between intramedullary and extramedullary implants in patients with closed nondisplaced stable IT fractures. METHODS: Patients with closed nondisplaced stable IT fractures were identified from the American College of Surgeons National Surgical Quality Improvement Program database between 2016 and 2019. Patients who either underwent extramedullary implant or intramedullary implant fixation were selected for this analysis. Postoperative outcomes included transfusion, surgical complications (stroke, myocardial infarction, venous thromboembolism, pneumonia, renal failure/insufficiency, surgical site infection, urinary tract infections, and sepsis), weight-bearing on postoperative day 1, discharge destination, place of residence at 30 days after the operation, days from operation to discharge, readmission related to the index procedure, any readmission, revision surgery, and mortality. RESULTS: Of the 3,244 cases identified for the study, 2,521 (77.7%) underwent intramedullary nailing (IMN). Based on adjusted multivariable analysis, surgical complications between the two intervention groups were not statistically significantly (odds ratio [OR] 1.142; confidence interval [CI], 0.838 to 1.558; P = 0.4). However, patients who underwent IMN were associated with higher rates of blood transfusions (OR, 1.35, CI, 1.042 to 1.748, P = 0.023), more likely discharged to a place other than home (OR, 1.372, CI, 1.106 to 1.700, P = 0.004), and more likely to get readmitted (OR, 1.783, CI, 1.157 to 2.75, P = 0.009). Patients treated with IMN were associated with lower postoperative length of stay (OR 0.982, CI 0.967 to 0.998, P = 0.030). DISCUSSION: Our study found that extramedullary implants were associated with lower transfusions rates, lower readmissions, and better patient disposition. We recommend surgeons to consider extramedullary implants when treating stable IT fractures, especially if the patient is anemic or at high risk for hospital readmission. LEVEL OF EVIDENCE: Level III. Retrospective cohort study.

Clinical Outcomes and Surgical Complications Among Patients with Bleeding Disorders After Acute Hip Fracture Surgery.

OBJECTIVE: To compare short-term (≤30 days) outcomes of hip fracture between patients with and without bleeding disorders. DESIGN: Retrospective database review. SETTING: The study setting included hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS: Patients with acute hip fractures were identified from the National Surgical Quality Improvement Program database between 2016 and 2019. INTERVENTION: Open reduction internal fixation or hemiarthroplasty. MAIN OUTCOME MEASUREMENTS: Mortality, readmission, reoperation, length of stay, and complication were main outcome measurements. RESULTS: There were 63,718 patients undergoing hip surgery, and 16.0% had a bleeding disorder. After adjusting for confounders, multivariable regression models showed that cases with bleeding disorders were associated with higher rates of transfusion [odds ratio (OR) 1.404; confidence interval (CI), 1.335-1.479], myocardial infarction (OR 1.367; CI, 1.190-1.572), pneumonia (OR 1.193; CI, 1.078-1.321), renal failure (OR 1.843; CI, 1.363-2.491), surgical site infections (OR 1.429; CI, 1.185-1.175), sepsis (OR 1.25; CI, 1.034-1.511), and readmission (OR 1.314; CI, 1.224-1.408). However, bleeding disorders were not associated with mortality (OR 0.947; CI, 0.866-1.036) or reoperation (OR 1.061; CI, 0.925-1.220). CONCLUSIONS: Hip fracture surgery in patients with bleeding disorders is not associated with higher risks of short-term mortality or reoperation. However, special consideration should be taken when calculating preoperative risks of complications among bleeding disorder patients. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Geriatric Nutritional Risk Index Is an Independent Predictor of Adverse Outcomes for Total Joint Arthroplasty Patients.

BACKGROUND: Malnutrition affects patient outcomes after total joint arthroplasty (TJA). Although hypoalbuminemia has been used as a surrogate, there is no unanimous method for screening and assessing malnutrition. This study aimed to determine if malnutrition, as defined by the Geriatric Nutritional Risk Index (GNRI), is independently correlated with short-term (<30 days) postoperative complications and prognosis in patients undergoing TJA. METHODS: The 2016-2019 American College of Surgeons National Surgical Quality Improvement Program was queried for all patients aged >65 years who underwent TJA. Based on GNRI value, patients were divided into 3 groups: normal nutrition (GNRI >98), moderate malnutrition (GNRI 92-98), and severe malnutrition (GNRI <92). After adjusting for potential confounders, multivariable regression models were used to analyze the association between GNRI and patient outcomes. RESULTS: A total of 191,087 patients were included in the study. Prevalence of malnutrition based on body mass index (<18.5 kg/m2), albumin (<3.5 mg/dL), and GNRI (≤98) was 0.41% (784), 4.17% (7975), and 15.83% (30,258). Adjusted analysis showed that compared with normal nutrition, moderate and severe malnutrition status were associated with a higher rate of transfusion, readmission, and postoperative length of stay over 8 days (P < .05). Severe malnutrition was also associated with pneumonia, surgical site infection, urinary tract infection, sepsis, and revision surgery (P < .05). CONCLUSION: Malnutrition, as defined by GNRI, is an independent predictor of adverse outcomes after TJA, including 30-day readmission, revision surgery, and increased length of stay. GNRI can be used to routinely screen and assess patient nutritional status before TJA and counsel patients and families appropriately. LEVEL OF EVIDENCE: Level 3: Retrospective Cohort Study.

Techniques for predicting and avoiding unintentional biplanar movements during iliosacral screw placement.

The technique for placing iliosacral screws typically involves the surgeon using an inlet and outlet view as the primary means for assessing the anteroposterior and craniocaudal position of the guidewire, respectively. However, because these views are rarely, if ever, orthogonal to one another, this technique will inevitably lead to unintentional biplanar movements. These unintentional movements, in turn, require correction, which can increase operating room and fluoroscopic time. Here we calculate the degree and magnitude of these unintentional movements. Additionally, we provide a simple technique for minimizing or eliminating them altogether.

A Current Update on Pelvifemoral Conditions That Should be in the Differential Diagnosis for Patients With Lower Extremity Radiculopathy.

Patients presenting to an outpatient spine clinic frequently report symptoms of low back pain with associated buttock, groin, and lower extremity pain. While many of these individuals suffer from lumbar spine radiculopathy, a number of different orthopedic pathologies can mimic these symptoms. Management depends substantially on a detailed history and physical examination, in addition to working from a broad list of differential diagnoses when evaluating these patients. It is imperative that spine practitioners have a comprehensive understanding of the differential diagnoses that may mimic those originating from the lumbar spine, especially when a patient's symptoms are atypical from classic radicular pain. Misdiagnosis can lead to unnecessary testing and treatment, while delaying an accurate clinical assessment and treatment plan. This review highlights common orthopedic diagnoses that may present similar to lumbar spine pathologies and the evidence-based evaluation of these conditions.

The Quadrilateral Plate in Acetabular Fracture Surgery: What Is It and When Should It Be Addressed?

The quadrilateral plate (QP) is the relatively flat surface of bone in the true pelvis lying directly medial to the acetabulum. This surface is frequently involved in acetabular fractures. Elderly individuals, in particular, commonly sustain anterior column fractures with incomplete or complete posterior hemitransverse fracture lines with associated QP comminution. If QP fracture lines propagate through the superior weight-bearing surface of the acetabulum, the femoral head may displace medially, leading to poor outcomes if not addressed. Fortunately, the collective work of many orthopaedic surgeons has resulted in numerous effective methods for approaching, reducing, and stabilizing the QP and the diverse family of fractures which affect it. A thorough understanding of the QP, its anatomy, radiology, and techniques for fixation, is required to optimize patient outcomes.

Assessing the Early Impact of the COVID-19 Pandemic on Spine Surgery Fellowship Education.

STUDY DESIGN: This was a cross-sectional study. OBJECTIVE: The objective of this study is to report the impact of COVID-19 on spine surgery fellow education and readiness for practice. SUMMARY OF BACKGROUND DATA: COVID-19 has emerged as one of the most devastating global health crises of our time. To minimize transmission risk and to ensure availability of health resources, many hospitals have cancelled elective surgeries. There may be unintended consequences of this decision on the education and preparedness of current surgical trainees. MATERIALS AND METHODS: A multidimensional survey was created and distributed to all current AO Spine fellows and fellowship directors across the United States and Canada. RESULTS: Forty-five spine surgery fellows and 25 fellowship directors completed the survey. 62.2% of fellows reported >50% decrease in overall case volume since cancellation of elective surgeries. Mean hours worked per week decreased by 56.2%. Fellows reported completing a mean of 188.4±64.8 cases before the COVID-19 crisis and 84.1% expect at least an 11%-25% reduction in case volume compared with previous spine fellows. In all, 95.5% of fellows did not expect COVID-19 to impact their ability to complete fellowship. Only 2 directors were concerned about their fellows successfully completing fellowship; however, 32% of directors reported hearing concerns regarding preparedness from their fellows and 25% of fellows were concerned about job opportunities. CONCLUSIONS: COVID-19 has universally impacted work hours and case volume for spine surgery fellows set to complete fellowship in the middle of 2020. Nevertheless, spine surgery fellows generally feel ready to enter practice and are supported by the confidence of their fellowship directors. The survey highlights a number of opportunities for improvement and innovation in the future training of spine surgeons. LEVEL OF EVIDENCE: Level III.

Factors Influencing Subspecialty Choice of Orthopedic Residents: Effect of Gender, Year in Residency, and Presumptive Subspecialty.

Background: Subspecialty training is a common part of orthopedic surgical training. The factors which influence resident subspecialty choice have important residency design and workforce implications. Our objective was to present survey data gathered from orthopedic residents regarding their fellowship plans and relative importance of factors which influence those plans. Methods: An anonymous online survey tool was developed and distributed to orthopedic residents through their program directors at academic institutions across the country with orthopedic surgery residency programs. Results: 227 residents completed the survey. 97% planned to pursue fellowship training after residency. The most common presumptive subspecialties were sports (29.7%), joints (17.3%) and shoulder/ elbow (12.8%). The majority of senior residents (57%) reported that their subspecialty choice had changed during residency. When making their choice of subspecialty, residents were most influenced by their experiences working on the subspecialty service in question, their experiences working with a mentor, and intellectual interest. The factors influencing their choice were affected by gender, residency year and presumptive subspecialty. Conclusions: The most critical factors influencing subspecialty choice of orthopedic residents included experiences in rotations as a resident, intellectual interest and mentors in certain subspecialties. Factors influencing subspecialty choice changes over the course of residency and differ between male and female residents. This information may be useful for residency design, mentorship structuring, career counseling and for addressing subspecialty surpluses or shortages which arise in the future.Level of Evidence: IV.

Outcomes of Expandable Prostheses for Primary Bone Malignancies in Skeletally Immature Patients: A Systematic Review and Pooled Data Analysis.

BACKGROUND: Osteosarcoma and other primary bone malignancies are relatively common in skeletally immature patients. Current literature features case series with disparate complication rates, making it difficult for surgeons to educate patients on outcomes after limb salvage with expandable prostheses. This study aims to provide an update on complication rates, mortality, and functional outcomes in patients who undergo limb salvage with expandable prostheses for primary bone malignancies. METHODS: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An exhaustive PubMed/Medline and Cochrane search of peer-reviewed published literature from 1997 to 2017 was performed, yielding a total of 1350 studies. After multiple rounds of review for inclusion and exclusion criteria, 28 retrospective studies were included. All were level IV evidence of case series and retrospective studies. Overall, this included 634 total patients and 292 patients with individual patient data. The primary outcomes studied were complication rates, mortality, and Musculoskeletal Tumor Society (MSTS) functional score. Secondary outcomes included complication rate subtypes, number of lengthening procedures, mean amount lengthened, and prevalence of limb length discrepancies. RESULTS: A total of 292 patients with individual patient data averaged 10.1 years at the surgery and had a mean follow-up of 67 months. Two hundred sixteen patients (74%) had tumors of the distal femur. MSTS scores averaged 80.3 and overall mortality was 22%. Patients with distal femur tumors averaged 4.4 lengthening procedures and 43 mm lengthened. Leg length discrepancy (LLD) was 36% overall, which increased with longer periods of follow-up (P<0.001). Overall complication and revision rate was 43%, increasing to 59% in patients with 5 to 10 years of follow-up, and 89% in patients with >10 years of follow-up. Minimally invasive prostheses had lower rates of complications than noninvasive prostheses (P=0.024), specifically mechanical complications (P=0.028), mostly because of increased rates of lengthening and device failure in the noninvasive models (21% vs. 4%, P=0.0004). CONCLUSIONS: Despite its limitations, which include entirely heterogenous and retrospective case series data, this systematic review provides clinicians with pooled summary data representing the largest summary of outcomes after reconstruction with expandable prostheses to date. This analysis can assist surgeons to better understand and educate their patients and their families on functional outcomes, mortality, and complication rates after limb-sparing reconstruction with expandable prostheses for primary bone malignancies. LEVEL OF EVIDENCE: Level IV-retrospective case series with pooled data.

Arthroscopy versus arthrotomy for the treatment of septic knee arthritis.

PURPOSE: To compare complications following arthroscopy and arthrotomy for treatment of septic knee arthritis. METHODS: Patients undergoing arthroscopy and arthrotomy for a diagnosis of septic knee arthritis were identified in National Surgical Quality Improvement Program and placed in a multivariate analysis to determine if type of surgery contributed to postoperative complications. RESULTS: Knee arthrotomy was associated with an increased risk for increased operative time [Parameter estimate 4.555 (95% CI:3.023-6.085); p < 0.0001], minor morbid events [OR 2.064 (95% CI: 1.447-2.943); p < 0.0001], and any morbidity [OR 2.285 (95% CI:1.527-3.419); p < 0.0001]. CONCLUSIONS: Knee arthrotomy was associated with a higher risk of complications.

Do Hospital Rankings Mislead Patients? Variability Among National Rating Systems for Orthopaedic Surgery.

INTRODUCTION: A growing number of online hospital rating systems for orthopaedic surgery are found. Although the accuracy and consistency of these systems have been questioned in other fields of medicine, no formal analysis of these systems in orthopaedics has been found. METHODS: Five hospital rating systems (US News, HealthGrades, CareChex, Women's Choice, and Hospital Compare) were examined which designate "high-performing" and "low-performing" hospitals for orthopaedic surgery. Descriptive analysis was conducted for all hospitals defined as high- or low-performing in any of the five rating systems, and assessment for agreement/disagreement between ratings was done. A subsample of hospitals ranked by all systems was then created, and agreement between rating systems was investigated using a Cohen's kappa. Each hospital was included in a multinomial logistic regression model investigating which hospital characteristics increased the odds of being favorably/unfavorably rated by each system. RESULTS: One thousand six hundred forty hospitals were evaluated by every rating system. Six hundred thirty-eight unique hospitals were identified as high-performing by at least 1 rating system; however, no hospital was ranked as high-performing by all five rating systems. Four hundred fifty-two unique hospitals were identified as low-performing; however, no hospital was ranked as low-performing by all the three rating systems which define low-performing hospitals. Within the study subsample of hospitals evaluated by each system, little agreement between any combination of rating systems (κ < 0.10) regarding top-tier or bottom-tier performance was found. It was more likely for a hospital to be considered high-performing by one system and low-performing by another (10.66%) than for the majority of the five rating systems to consider a hospital high-performing (3.76%). CONCLUSION: Little agreement between hospital quality rating systems for orthopaedic surgery is found. Publicly available hospital ratings for performance in orthopaedic surgery offer conflicting results and provide little guidance to patients, providers, or payers when selecting a hospital for orthopaedic surgery. LEVEL OF EVIDENCE: Level 1 economic study.

Novel Treatment for Recurrent Posttraumatic Hip Instability: A Case Report.

CASE: A 26-year-old woman sustained a traumatic right hip dislocation with posterior wall component in a motor vehicle collision. Initial treatment consisted of open reduction internal fixation of her posterior wall fracture. Six years later, she developed low-energy recurrent hip instability. Imaging demonstrated posterior capsular insufficiency and femoral retrotorsion. The patient underwent intertrochanteric femoral rotational osteotomy. Nine years postoperatively, the patient has returned to activity without restriction or subsequent dislocations. CONCLUSIONS: Recurrent posttraumatic hip instability requires careful identification of the etiology of instability. This case provides long-term follow-up after successful treatment with intertrochanteric femoral rotational osteotomy.

The Experiential Benefit of an Orthopedic Trauma Fellowship: An Analysis of ACGME Case Log Data From 2006 to 2017.

OBJECTIVE: The Accreditation Council for Graduate Medical Education (ACGME) has published orthopedic case log data since the 2006/2007 academic year. Here, we use this data to analyze the variability in orthopedic trauma case experience reported by orthopedic trainees and to better understand the impact of an orthopedic trauma fellowship on orthopedic surgical training. DESIGN, SETTING, AND PARTICIPANTS: Data were gathered from ACGME case log reports for orthopedic residents (reporting the cumulative case experience of graduating residents) and orthopedic trauma fellows (reporting the case experience of their fellowship year only) for all available years. RESULTS: The average orthopedic trauma fellow reported significantly more trauma cases in multiple body regions ("Pelvis/Hip", "Femur/Knee", and "Foot/Toes") and "Open Complex" reductions (as defined by the ACGME) in their 1 year of fellowship than the average resident reported in their 5 years of residency. CONCLUSION: On average, orthopedic trauma fellowships substantially increase the trauma case volumes of orthopedic trainees, especially with respect to lower extremity trauma.