Using Next-Generation Sequencing to Understand Infection Prevention in Surgical Treatment of Upper Extremity Fractures-A Prospective Cohort Study.

INTRODUCTION: Postoperative fracture site infection can lead to notable patient morbidity, increase cost of care, and further contribute to healthcare disparities globally. Dogma suggests surgical blades as a vehicle for introducing bacteria into the surgical site; however, there is a paucity of literature to support this claim. This study uses advanced DNA sequencing to detect bacterial DNA on surgical blades used in upper extremity fracture surgeries. METHODS: This was a prospective study, conducted at a high-volume level 1 trauma center. All acute, closed upper extremity fractures requiring surgical stabilization were consecutively enrolled in a prospective fashion. The primary end point was the presence of bacterial DNA on the surgical blade using next-generation sequencing (NGS). At the time of surgery, two blades were sterilely opened. One blade served as the control while the other was used for the initial skin incision. Two negative control blades were opened directly into a sterile container. Two positive control blades were used for skin incision through known infections. All samples were sent for NGS analysis. RESULTS: Forty patients were enrolled in this study. The median age was 33.5 years, and 30% were female; the median body mass index was 26.52. Humerus fractures were the most common injury (N = 17, 42.5%), followed by clavicle fractures (13, 32.5%) and radius/ulna fractures (10, 25.0%). NGS analysis revealed no contamination of test blades used for skin incision. Three control blades tested positive for bacterial DNA. Negative control blades tested negative for bacterial DNA (0/2); the positive control blades resulted positive for bacterial DNA contamination (2/2). CONCLUSION: Surgical blades used for skin incision in the upper extremity are not contaminated with bacterial DNA as analyzed by NGS. This finding challenges previous surgical dogma regarding surgical blade contamination and supports that the same surgical blade can safely be used for deeper dissection. LEVEL OF EVIDENCE: Level II study: IRB approval-IRB#848938.

Let's Take a Look at the Tape: The Impact of ERAS Video Prompts on Interview Offerings for Orthopaedic Surgery Residency Applicants: A Prospective Observational Study.

INTRODUCTION: Matching into an orthopaedic surgery residency consistently reinforces a competitive landscape, challenging the applicants and programs. A group of orthopaedic surgery residency programs implemented video prompts asking applicants to respond to a standardized question by video recording. Assessing the impact of this video on the decision to offer an interview can help guide programs and applicants through the interview process. METHODS: Twenty residency applications to one institution requiring video prompts were randomly selected and deidentified. Thirteen experienced faculty from various orthopaedic surgery programs served as applicant reviewers. The reviewers evaluated the electronic residency application service (ERAS) application and determined whether they would grant the applicant an interview ("no," "maybe," or "yes") before and after watching the video prompt. The reviewer also scored the impact of the applicant's dress, facial presentation, and video background distractions on their evaluation of the video. Multivariable logistic regressions were conducted using a group of applicants where interview status was not impacted by the video compared with the group of applicants where the interview status changed after video review. An alpha value of 0.05 was used to define significance. RESULTS: The video prompt impacted the decision to offer an interview 29.3% of the time; 15.8% were switched from "yes" or "maybe" to "no" and 13.5% were switched from "no" or "maybe" to "yes." For the positively impacted applicants, facial presentation score was significantly higher (P = 0.005). No recorded variables were associated with decreased chance of interview. DISCUSSION: Video prompts impacted the decision to offer interviews to orthopaedic surgery applicants approximately one-third of the time, with a similar number of applicants being positively and negatively impacted. Facial presentation score was associated with increased chance of interview, and no variables were associated with decreased chance of interview. Thus, the answer to the videos presumably negatively impacted applicants.

Fixation or Revision for Periprosthetic Fractures: Epidemiology, New Trends, and Projections in the United States.

BACKGROUND: Periprosthetic fractures can be devastating complications after total joint arthroplasty (TJA). The management of periprosthetic fractures is complex, spanning expertise in arthroplasty and trauma. The purpose of this study was to examine and project trends in the operative treatment of periprosthetic fractures in the United States. METHODS: A large, public and private payer database was queried to capture all International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes for periprosthetic femoral and tibial fractures. Statistical models were created to assess trends in treatment for periprosthetic fractures and to predict future surgical rates. An alpha value of 0.05 was used to assess significance. A Bonferroni correction was applied where applicable to account for multiple comparisons. RESULTS: In this study, from 2016 to 2021, 121,298 patients underwent surgical treatment for periprosthetic fractures. There was a significant increase in the total number of periprosthetic fractures. The incidence of periprosthetic hip fractures rose by 38% and that for periprosthetic knee fractures rose by 73%. The number of periprosthetic fractures is predicted to rise 212% from 2016 to 2032. There was a relative increase in open reduction and internal fixation (ORIF) compared with revision arthroplasty for both periprosthetic hip fractures and periprosthetic knee fractures. CONCLUSIONS: Periprosthetic fractures are anticipated to impose a substantial health-care burden in the coming decades. Periprosthetic knee fractures are predominantly treated with ORIF rather than revision total knee arthroplasty (TKA), whereas periprosthetic hip fractures are predominantly treated with revision total hip arthroplasty (THA) rather than ORIF. Both periprosthetic knee fractures and periprosthetic hip fractures demonstrated increasing trends in this study. The proportion of periprosthetic hip fractures treated with ORIF relative to revision THA has been increasing. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The hip fracture assessment tool: A scoring system to assess high risk geriatric hip fracture patients for post-operative critical care monitoring.

INTRODUCTION: Intensive care unit risk stratification models have been utilized in elective joint arthroplasty; however, hip fracture patients are fundamentally different in their clinical course. Having a critical care risk calculator utilizing pre-operative risk factors can improve resourcing for hip fracture patients in the peri­operative period. METHODS: A cohort of geriatric hip fracture patients at a single institution were reviewed over a three-year period. Non-operative patients, peri­implant fractures, additional procedures performed under the same anesthesia period, and patients admitted to the intensive care unit (ICU) prior to surgery were excluded. Pre-operative laboratory values, Revised Cardiac Risk Index (RCRI), and American Society of Anesthesiologists (ASA) scores were calculated. Pre-operative ambulatory status was determined. The primary outcome measure was ICU admission in the post-operative period. Outcomes were assessed with Fisher's exact test, Kruskal-Wallis test, logistic regression, and ROC curve. RESULTS: 315 patient charts were analyzed with 262 patients meeting inclusion criteria. Age ≥ 80 years, ASA ≥ 4, pre-operative hemoglobin < 10 g/dL, and a history of CVA/TIA were found to be significant factors and utilized within a "training" data set to create a 4-point scoring system after reverse stepwise elimination. The 4-point scoring system was then assessed within a separate "validation" data set to yield an ROC area under the curve (AUC) of 0.747. Score ≥ 3 was associated with 96.8 % specificity and 14.2 % sensitivity for predicting post-op ICU admission. Score ≥ 3 was associated with a 50 % positive predictive value and 83 % negative predictive value. CONCLUSION: A hip fracture risk stratification scoring system utilizing pre-operative patient specific values to stratify geriatric hip patients to the ICU post-operatively can improve the pre-operative decision-making of surgical and critical care teams. This has important implications for triaging vital hospital resources. LEVEL OF EVIDENCE: III (retrospective study).

Skin Antisepsis before Surgical Fixation of Extremity Fractures.

BACKGROUND: Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture). METHODS: In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications. RESULTS: A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups. CONCLUSIONS: Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).

Outcomes with spinal versus general anesthesia for patients with and without preoperative cognitive impairment: Secondary analysis of a randomized clinical trial.

INTRODUCTION: The effect of spinal versus general anesthesia on the risk of postoperative delirium or other outcomes for patients with or without cognitive impairment (including dementia) is unknown. METHODS: Post hoc secondary analysis of a multicenter pragmatic trial comparing spinal versus general anesthesia for adults aged 50 years or older undergoing hip fracture surgery. RESULTS: Among patients randomized to spinal versus general anesthesia, new or worsened delirium occurred in 100/295 (33.9%) versus 107/283 (37.8%; odds ratio [OR] 0.85; 95% confidence interval [CI] 0.60 to 1.19) among persons with cognitive impairment and 70/432 (16.2%) versus 71/445 (16.0%) among persons without cognitive impairment (OR 1.02; 95% CI 0.71 to 1.47, p = 0.46 for interaction). Delirium severity, in-hospital complications, and 60-day functional recovery did not differ by anesthesia type in patients with or without cognitive impairment. DISCUSSION: Anesthesia type is not associated with differences in delirium and functional outcomes among persons with or without cognitive impairment.

Local Infiltrative Analgesia of Murine Femur Fractures In Vivo Does Not Inhibit Fracture Healing.

The opioid epidemic in the United States has forced care providers to seek out alternatives to narcotic analgesics. Physicians involved in trauma care, including orthopaedic trauma surgeons, often have patients requiring significant amounts of these medications, especially in the perioperative period, given the acuity and severity of their injuries. Modalities such as local infiltration of fractures with anesthetic agents during operative treatment may provide some benefit to this population by decreasing postoperative pain and narcotic usage. However, prior data suggest that these agents are chondrotoxic, which may impede secondary fracture healing. The purpose of this study was to investigate the hypothesis that local anesthetics decrease secondary bone healing and callus formation in stabilized murine femur fractures through chondrocyte apoptosis. Male C57BL/6 mice underwent intramedullary stabilization and fracture of bilateral femurs followed by immediate infiltration of the fracture site with local anesthetic agents. Femurs were dissected at 10- and 20-days post-fracture and evaluated by [Formula: see text]CT and histological analysis. No significant differences were seen in callus size or mineralization between controls and fractures treated with a local anesthetic. When the callus was analyzed histologically, local anesthetic agents appeared to increase cartilage density. Therefore, infiltration of local anesthetics during operative treatment of fracture as part of a multimodal approach to pain control does not appear to significantly affect callus formation in a preclinical model, although subclinical molecular effects may be present. Local infiltrative analgesia with local anesthetics may be used as an adjunct for perioperative pain control during femur fracture surgery without a significant effect on secondary bone healing.

Objects in Mirror Are Closer Than They Appear: Symptoms of Depression and Suicidality in Orthopaedic Surgeons.

BACKGROUND: Suicide and depression among orthopaedic surgeons have recently emerged as rising concerns. Prior research has suggested that orthopaedic surgeons have the highest prevalence of suicide among surgical specialties. We sought to determine the factors associated with depression and suicidal ideation (SI) in orthopaedics, including subspecialty. METHODS: A survey including demographic questions, the Beck Depression Inventory, and the Columbia-Suicide Severity Rating Scale was administered electronically via a listserv to the orthopaedic subspecialties of trauma, adult reconstruction, hand and upper extremity, shoulder and elbow, foot and ankle, spine, pediatrics, sports medicine, and oncology. The responses were quantified according to previously published criteria. The associations of demographic factors, training, and current practice environment with depression and suicidality were assessed using Fisher exact tests. Reverse stepwise multivariable logistic regression models were developed to identify factors associated with depression and SI. RESULTS: The responses were obtained from 661 board-certified, practicing orthopaedic surgeons. In this study, 156 surgeons (23.6%) endorsed some level of active SI in their lifetime, 200 surgeons (30.3%) reported either active or passive SI in their lifetime, and 33 surgeons (5%) reported that, on at least 1 occasion in their lifetime, they had experienced active SI with a specific plan and intention to harm themselves. Gender, relationship status, having children, and residency and/or current practice region were significantly associated with depression and/or SI. Younger age, divorce, adult reconstruction and foot and ankle subspecialties, and attending residency in the Western U.S. were found on multivariable testing to be associated with symptoms of depression and SI (odds ratios, 1.03 [per 1-year decrease in age] to 8.28). CONCLUSIONS: Symptoms of depression and suicidality are not uncommon among orthopaedic surgeons, and variation by gender, relationship status, and geographic location are supported by prior research. Based on our results, depression and/or SI likely affect someone close to you or someone with whom you work. The normalization of discussions surrounding emotional well-being, depression, and SI is imperative.

Training Surgery Residents to be Leaders: Construction of a Resident Leadership Curriculum.

SUMMARY: Historically, the traditional pathways into plastic surgery required board eligibility in a surgical specialty such as general surgery, orthopedics, urology, neurosurgery, otolaryngology, or ophthalmology. This requirement resulted in plastic surgery residents who had served as chief residents before plastic surgery training. Their maturity emotionally and surgically allowed them to immediately concentrate on the new language and principles of plastic surgery. They had led others and were capable of leading themselves in a new surgical discipline. Today, medical students typically match into surgical specialties directly out of medical school and need to spend their time learning basic surgical skills and patient care because of the contracted time afforded to them. Formal leadership training has historically been limited in surgical training. The authors set out to delineate the creation, implementation, and perceptions of a leadership program within a surgical residency and provide guideposts for the development of engaged, conscious, and dedicated leaders within the residencies they lead.

Subspecialty Fellowship Training Is Not Associated With Better Outcomes in Fixation of Low-Energy Femoral Neck Fractures-An Analysis of the Fixation Using Alternative Implants for the Treatment of Hip Fractures Database.

OBJECTIVES: To compare risk of reoperation for femoral neck fracture patients undergoing fixation with cancellous screws (CSs) or sliding hip screws based on surgeon fellowship (trauma-fellowship-trained vs. non-trauma-fellowship-trained). DESIGN: Retrospective review of Fixation using Alternative Implants for the Treatment of Hip fractures data. SETTING: Eighty-one centers across 8 countries. PATIENTS/PARTICIPANTS: Eight hundred nineteen patients ≥50 years old with low-energy hip fractures requiring surgical fixation. INTERVENTION: Patients were randomized to CS or sliding hip screw group in the initial dataset. MAIN OUTCOME MEASUREMENTS: The primary outcome was risk of reoperation. Secondary outcomes included death, serious adverse events, radiographic healing, discharge disposition, and use of ambulatory devices postoperatively. RESULTS: There was no difference in risk of reoperation between the 2 surgeon groups (P > 0.05). Patients treated by orthopaedic trauma surgeons were more likely to be overweight/obese and have major medical comorbidities (P < 0.05). There was a higher risk of serious adverse events, higher likelihood of radiographic healing, and higher odds of discharge to a facility for patients treated by trauma-fellowship-trained surgeons (P < 0.05). CONCLUSIONS: Based on these data, risk of reoperation for low-energy femoral neck fracture fixation is equivalent regardless of fellowship training. The higher likelihood of radiographic healing noted in the trauma-trained group does not seem to have a major clinical implication because it did not affect risk of reoperation between the 2 groups. Patient-specific factors present preinjury, such as body habitus and medical comorbidities, may account for the lower odds of discharge to home and higher risk of postoperative medical complications for patients treated by orthopaedic trauma surgeons. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Who Did the Arthroplasty? Hip Fracture Surgery Reoperation Rates are Not Affected by Type of Training-An Analysis of the HEALTH Database.

OBJECTIVES: This study compares outcomes for patients with displaced femoral neck fractures undergoing hemiarthroplasty (HA) or total hip arthroplasty (THA) by surgeons of different fellowship training. DESIGN: Retrospective review of HEALTH trial data. SETTING: Eighty clinical sites across 10 countries. PATIENTS/PARTICIPANTS: One thousand four hundred forty-one patients ≥50 years with low-energy hip fractures requiring surgical intervention. INTERVENTION: Patients were randomized to either HA or THA groups in the initial data set. Surgeons' fellowship training was ascertained retrospectively, and outcomes were compared. MAIN OUTCOME MEASUREMENTS: The main outcome was an unplanned secondary procedure at 24 months. Secondary outcomes included death, serious adverse events, prosthetic joint infection (PJI), dislocation, discharge disposition, and use of ambulatory devices postoperatively. RESULTS: There was a significantly higher risk of PJI in patients treated by surgeons without fellowship training in arthroplasty (P = 0.01), surgeons with unknown fellowship training (P = 0.03), and surgeons with no fellowship training (P = 0.02) than those treated by an arthroplasty-trained surgeon. There were significantly higher odds of being discharged to a facility rather than home in patients who underwent surgery by a surgeon with no fellowship training compared with arthroplasty-fellowship-trained surgeons (P = 0.03). CONCLUSIONS: Arthroplasty for hip fracture can be performed by all orthopaedic surgeons with equivalent reoperation rates. Infection prevention strategies and use of "care pathways" by arthroplasty-fellowship-trained surgeons may account for the lower risk of PJI and higher rate of discharge to home. The authors advocate for the use of evidence-based infection prevention initiatives and standardized care pathways in this patient population. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Spatiotemporal Gait Parameters Following Operative Treatment of Trimalleolar Ankle Fractures vs Healthy Controls.

BACKGROUND: Controversy continues regarding appropriate indications for posterior malleolus fracture fixation in unstable rotational trimalleolar ankle injuries, with limited data comparing gait in operatively treated trimalleolar ankle fractures vs control populations. The purpose of this study was to evaluate the effect of trimalleolar ankle fracture fixation on gait parameters in the early postoperative period as compared to a healthy control population. METHODS: Adult patients having undergone operative treatment of isolated trimalleolar ankle fractures were eligible for inclusion. A total of 10 patients met the inclusion criteria and participated in the analysis. Patients were evaluated using standard parameters of human gait 6 months after their index procedures, with gait values compared to a population of 17 non-age-matched healthy control subjects in addition to literature values of healthy populations of younger and older subjects. RESULTS: Significant differences were noted between the spatiotemporal gait parameters of healthy control subjects and patients who had undergone operative treatment of trimalleolar ankle fractures. However, within the fracture group itself, no differences were found between patients with or without posterior malleolar fixation for any of the tested gait parameters. When patients were compared to literature values of younger and older healthy control populations, they were found to have gait patterns more similar to older rather than younger individuals. CONCLUSION: Operative fixation of trimalleolar ankle fracture does not restore normal gait function in the early postoperative period. Fixation of the posterior malleolus in particular also does not appear to improve gait characteristics. Patients who undergo surgery for these injuries demonstrate gait patterns similar to those of healthy older adults. LEVEL OF EVIDENCE: Level II, Therapeutic (prospective cohort study).

Periprosthetic Femur Fractures Around a Loose Femoral Stem.

A critical component in the evaluation of a patient with a periprosthetic hip fracture is determination of stem stability. Failure to critically evaluate preoperative radiographs and subsequently intraoperative stem position may result in an incorrect treatment algorithm and early catastrophic failure of the implant construct. In 2018, this is becoming a larger issue as demand for revision total hip arthroplasty increases. Several factors contribute to the type of implant used in these fractures and depend on age, activity level, comorbidities, and available bone stock. The purpose of this article is to review the evaluation of periprosthetic hip fractures around a loose stem and provide tips and tricks for their management to allow for a successful, long-lasting outcome.

Diagnosing Infection in Patients Undergoing Conversion of Prior Internal Fixation to Total Hip Arthroplasty.

BACKGROUND: Criteria for diagnosis of infected internal fixation implants at the time of conversion to total hip arthroplasty (THA) are not clear. The purpose of this study is to identify risk factors for infection in patients undergoing conversion to THA. METHODS: We retrospectively reviewed patients at a single institution who underwent conversion to THA from 2009 to 2014. Patients were diagnosed with infection preoperatively using Musculoskeletal Infection Society criteria or postoperatively if they were found to have positive cultures intraoperatively at the time of conversion surgery. Medical comorbidities and preoperative inflammatory markers were compared between infected and noninfected groups. Univariate and multivariate logistic regression analysis were performed to identify independent risk factors for infection. Receiver operating characteristic curves were generated to determine test performance of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). A post hoc power analysis was performed. RESULTS: Thirty-three patients were included in the study. Six patients (18%) were diagnosed with infection. We found no association between comorbidities and infection in this cohort. The mean ESR and CRP were higher in infected (ESR = 41.6 mm/h, CRP = 2.0 mg/dL) vs noninfected (ESR = 19.3 mm/h, CRP = 1.3 mg/dL) groups (both P < .01). ESR >30 mm/h (odds ratio 28.8, 95% confidence interval 2.6-315.4, P = .001) and CRP >1.0 mg/dL (odds ratio 11.5, 95% confidence interval 1.6-85.2, P = .01) were strongly associated with infection. Receiver operating characteristic curves for ESR (area under the curve [AUC] = 0.89) and CRP (AUC = 0.89) demonstrated good fit. CONCLUSION: We report a high incidence of infection in patients who underwent conversion to THA. Preoperative ESR and CRP are effective screening tools though occult infections may still be missed. Patients with borderline or elevated inflammatory markers should raise strong suspicion for infection.

Recent advances in the treatment of hip fractures in the elderly.

The treatment of hip fractures in the elderly represents a major public health priority and a source of ongoing debate among orthopaedic surgeons and anesthesiologists. Most of these injuries are treated with surgery in an expedient fashion. From the surgical perspective, there are certain special considerations in this population including osteoporosis, pre-existing arthritis, age, activity level, and overall health that contribute to the type of surgical fixation performed. Open reduction and internal fixation versus arthroplasty remain the two major categories of treatment. While the indications and treatment algorithms still remain controversial, the overall goal for these patients is early mobilization and prevention of morbidity and mortality. The use of preoperative, regional anesthesia has aided in this effort. The purpose of this review article is to examine the various treatment modalities for hip fractures in the elderly and discuss the most recent evidence in the face of a rapidly aging population.

Tibial Plateau Fractures in Elderly Patients.

Tibial plateau fractures are common in the elderly population following a low-energy mechanism. Initial evaluation includes an assessment of the soft tissues and surrounding ligaments. Most fractures involve articular depression leading to joint incongruity. Treatment of these fractures may be complicated by osteoporosis, osteoarthritis, and medical comorbidities. Optimal reconstruction should restore the mechanical axis, provide a stable construct for mobilization, and reestablish articular congruity. This is accomplished through a variety of internal or external fixation techniques or with acute arthroplasty. Regardless of the treatment modality, particular focus on preservation and maintenance of the soft tissue envelope is paramount.

Intertrochanteric Femur Fracture Stability: A Surrogate for General Health in Elderly Patients?

INTRODUCTION: Intertrochanteric (IT) femur fractures are common in elderly patients who are often in poor general health. Intertrochanteric fractures are classified as stable or unstable, taking into account fracture morphology and involvement of the posteromedial calcar. The purpose of this study is to determine whether IT fracture stability can be used as a marker for general health or as a predictor of postoperative medical complications in elderly patients. MATERIALS AND METHODS: We reviewed the records of all patients treated for IT fractures at our institution over the past 7 years. We excluded patients who were younger than 60 years, polytraumatized, involved in high-energy mechanisms of injury, managed nonoperatively, with hardware from previous surgery, or missing preoperative radiographs. Ninety-three patients were included in the present series. Three orthopedic surgeons independently reviewed all preoperative radiographs and classified each fracture as either stable or unstable. Interrater reliability was .77 (substantial) and consensus designation was assigned by majority. We reviewed charts for age, gender, time to surgery, length of hospital stay, type of surgery, estimated blood loss, American Society of Anesthesiologists (ASA) classification, and postoperative medical complications. Univariate and multivariate statistical analyses were conducted to determine the relationship of fracture stability on ASA class and medical complications. RESULTS: Intertrochanteric fracture stability had no detectable relationship with ASA class (P = .497). On univariate analysis, stability was not significantly related to medical complications (P = .421). Our multivariate analysis found that only ASA was related to medical complications (P = .004), and fracture stability was not related to complications (P = .538). CONCLUSION: Intertrochanteric fracture stability does not appear to be a marker for poor general health or to predict postoperative medical complications in elderly patients in this limited study. ASA class was predictive of medical complications. Interestingly, medical complications were 8% greater in patients with unstable fractures than in patients with stable fractures.

Global health and orthopaedic surgery-A call for international morbidity and mortality conferences.

INTRODUCTION: There is a large discrepancy between supply and demand of surgical services in developing countries. This inequality holds true in orthopaedic surgery and the delivery of musculoskeletal care. Intertwined amongst the decision to perform surgical procedures in the developing world are the ethics of doing so - just because one is capable of performing a procedure, should it be done? PRESENTATION OF CASE: A 31 year-old female with end-stage joint destruction underwent a left total hip replacement by a foreign orthopaedic team in Tanzania. She had a favorable outcome for 8 months, but is now diagnosed with tuberculosis and a deep space infection in her prosthetic left hip - an unsolvable problem in the developing world. DISCUSSION: This case demonstrates the ethical challenges that can be created from performing surgical procedures in the developing world without concomitant access to appropriate patient follow-up or resources for treating post-operative complications. While the current system is inadequate to manage the burden of disease, these inadequacies may be exacerbated at times by post-operative complications resulting from well-intentioned surgical missions. CONCLUSION: This case illustrates many difficulties in caring for individuals in the developing world, raising several questions: (1) How can complications be prevented in the future? (2) What are possible ways of managing complications with resources at hand once it occurs? (3) What resources are needed to minimize patient? Ideally an international forum can help provide descriptions of issues and problems that are encountered so as to increase awareness and identify potential solutions.

Intramedullary nailing of diaphyseal femur fractures secondary to gunshot wounds: predictors of postoperative malrotation.

OBJECTIVES: The purpose of this study was to determine significant factors that may impact the postoperative differences in femoral version (DFV) and differences in femoral length (DFL) between the fixed and uninjured sides after intramedullary nailing (IMN) secondary to gunshot wounds. DESIGN: Retrospective data registry study. SETTING: Academic level I trauma center. PATIENTS: Over a 10-year period, 417 patients underwent IMN of a diaphyseal femur fracture (OTA/AO 32A-C). Of these, 57 patients sustained fractures caused by gunshots and had a postoperative computed tomographic scanogram. MAIN OUTCOME MEASURES: DFV and DFL. The effect of the following variables on DFV and DFL were determined through univariate and stepwise multivariate regression analyses: age, sex, body mass index, trauma fellowship-trained versus nontrauma surgeon, daytime versus nighttime surgery, antegrade versus retrograde nail insertion, use of traction, type of operating table, and AO and Winquist classifications. RESULTS: The mean postoperative DFV for all patients was 8.62 degrees (±6.67 degrees). Postoperative DFV greater than 15 degrees was found in 12.3% of all patients. After IMN, no significant differences in DFV were found with increasing complexity of AO/OTA or Winquist fracture classification. None of the aforementioned independent variables were significantly predictive of postoperative DFV in univariate or multivariate analyses. The mean postoperative DFL for all patients was 5.25 mm (±4.36 mm). In a multivariate model, classification as Winquist type 3 or 4 was weakly (adjusted R = 0.075) but significantly predictive of less DFL than categorization as type 1 or 2 (P = 0.027). CONCLUSIONS: Although gunshot-associated femur fractures may present surgical challenges for treatment through IMN, acceptable femoral rotation and length are obtainable regardless of the fracture complexity or a variety of demographic and surgically-related variables. LEVEL OF EVIDENCE: Prognostic level II.