Costs and Complications of Single-Stage Fixation Versus 2-Stage Treatment of Select Bicondylar Tibial Plateau Fractures.

OBJECTIVES: To determine the differences in costs and complications in patients with bicondylar tibial plateau (BTP) fractures treated with 1-stage definitive fixation compared with 2-stage fixation after initial spanning external fixation. DESIGN: Retrospective cohort study. SETTING: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Patients with OTA/AO 41-C (Schatzker 6) BTP fractures treated with open reduction internal fixation. INTERVENTION: Definitive treatment with open reduction internal fixation either acutely (1 stage) or delayed after initial spanning external fixation (2 stage). MAIN OUTCOME MEASURES: Wound healing complications, implant costs, hospital charges, Patient-Reported Outcomes Measurement Information System (PROMIS), reoperation, nonunion and infection. RESULTS: One hundred five patients were identified over a three-year period, of whom 52 met the inclusion criteria. There were 28 patients in the 1-stage group and 24 patients in the 2-stage group. Mean follow-up was 21.8 months, and 87% of patients had at least 12 months of follow-up. The mean number of days to definitive fixation was 1.2 in the 1-stage group and 7.8 in the 2-stage group. There were no differences between groups with respect to wound healing or any other surgery-related complications. Functional outcomes PROMIS were similar between groups. Mean implant cost in the 2-stage group was $10,821 greater than the 1-stage group, mostly because of the costs of external fixation. Median hospital inpatient charges in the 2-stage group exceeded the 1-stage group by more than $68,000 for all BTP fractures and by $61,000 for isolated BTP fractures. CONCLUSIONS: Early single-stage treatment of BTP fractures is cost-effective and is not associated with a higher complication rate than 2-stage treatment in appropriately selected patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical anatomy of the lower trapezius tendon transfer.

BACKGROUND: The precise surgical anatomy of the lower trapezius tendon transfer has not been well described. A precise anatomic description of the different trapezius segments and the associated neurovascular structures is crucial for operative planning and execution. We aimed (1) to establish a reliable demarcation between the middle and lower trapezius, (2) to establish the precise relationship of the main neurovascular pedicle to the muscle belly, and (3) to evaluate the utility of the relationships established in (1) and (2) by using the results of this study to perform cadaveric lower trapezius tendon harvest. METHODS: In phase 1, a single surgeon performed all measurements using 10 cadavers. In phase 2, 10 cadaveric shoulders were used to harvest the tendon by using the relationships established in phase 1. RESULTS: We found anatomically distinct insertion sites for the lower and middle trapezius. The lower trapezius inserted at the scapular spine dorsum and the middle trapezius inserted broadly along the superior surface of the scapular spine. The distance from tip of tendon insertion to the nearest nerve at the most superior portion of the lower trapezius was 58 mm (standard deviation ± 18). By use of these relationships, there were no cases of neurovascular injury during our cadaveric tendon harvests. CONCLUSION: The lower trapezius can be reliably and consistently identified without violating fibers of the middle trapezius. Muscle splitting can be performed safely without encountering the spinal accessory nerve (approximately 2 cm medial to the medial scapular border).