Complications of Hip Hemiarthroplasty.

Hip hemiarthroplasty is a commonly performed orthopedic surgery, used to treat proximal femur fractures in the elderly population. Although hip hemiarthroplasty is frequently successful in addressing these injuries, complications can occur. Commonly seen complications include dislocation, periprosthetic fracture, acetabular erosion, and leg-length inequality. Less frequently seen complications include neurovascular injury and capsular interposition. This article presents a comprehensive review of the complications associated with the management of hip hemiarthroplasty. [Orthopedics. 2023;46(4):e199-e209.].

Varus displacement of intertrochanteric femur fractures on injury radiographs is associated with screw cutout.

INTRODUCTION: The purpose of this study was to determine if varus displacement of intertrochanteric femur fractures on injury radiographs is associated with screw cutout after fixation. METHODS: A retrospective review performed at two urban level 1 trauma centers identified 334 patients with intertrochanteric femur fractures treated with either a cephalomedullary nail (CMN) or a sliding hip screw (SHS). Median patient age was 75 years, 69% were female and 46% had unstable fractures. Varus fracture displacement on injury radiographs, defined as the most proximal aspect of the femoral head being at or below the most proximal aspect of the greater trochanter, was present in 38% of patients. Screw cutout was recorded. RESULTS: Varus displacement was associated with unstable fracture patterns (62% vs. 37%, difference (D) 25%, 95% confidence interval (CI) 15-35%), female gender (77% vs. 64%, D 13%, CI 3-22%) and poor/adequate reductions (54% vs. 41%, D 13%, CI 2-23%). Cutout occurred in 9 (3%) patients, 8 of which had varus displacement. There was no detectable difference, with wide confidence intervals, between patients that did and did not experience cutout in terms of age, gender, unstable fractures, implants, tip-apex distance (TAD) or poor/adequate reductions. On univariate and multivariate analysis, varus displacement was the only variable associated with cutout. Patients with and without varus displacement had a cutout incidence of 6 and 0.5% (Odds ratio 13, CI 1.6-108). CONCLUSION: Intertrochanteric fractures presenting with varus displacement were more likely to experience cutout. This potential risk factor for cutout warrants further study. LEVEL OF EVIDENCE: Level 3, retrospective cohort.

Screws are at a safe distance from critical structures after superior plate fixation of clavicle fractures.

INTRODUCTION: Injuries to the critical structures underlying the clavicle are possible during open reduction and internal fixation (ORIF) and afterward secondary to prominent screws. The purpose of this study was to identify patients who received chest computerized tomography (CT) scans after clavicle ORIF to evaluate the distance between the screws and the subclavian vessels. METHODS: A retrospective review was performed at a single level-one trauma center. Nineteen patients with chest CT scans after superior plate fixation were included. Coronal CT reconstructions were analyzed to determine distances between the subclavian vessels and screw tips along with the prominence of the screws. Vessels within 15 mm of the screw were considered at risk. RESULTS: None of the screws (0/142) were within 15 mm of the subclavian vessels. Average screw prominence was 1.3 ± 1 mm (range, 0-3.6 mm). One of the 19 patients had a complication, a re-fracture requiring revision ORIF. The remaining 18 patients had no complications, including neurovascular or pulmonary, at the last follow-up. CONCLUSIONS: None of the screws were excessively prominent or within 15 mm of the subclavian vessels. Attentive superior plate fixation of the clavicle with screws is a safe technique. LEVEL OF EVIDENCE: Level IV, case series.

Needlestick and sharps injuries in orthopedic surgery residents and fellows.

OBJECTIVE: Needlestick and sharps injury (NSSI) is a common occupational hazard of orthopedic surgery training. The purpose of this study was to examine the incidence and surrounding circumstances of intraoperative NSSI in orthopedic surgery residents and fellows and to examine postexposure reporting. DESIGN: A 35-question cross-sectional survey. SETTING: The study was conducted by orthopedic surgery residents and faculty at a nonprofit regional hospital. PARTICIPANTS: The questionnaire was distributed to US allopathic orthopedic surgery residency and fellowship programs; 300 orthopedic surgery trainees participated in the survey. RESULTS: Of 223 trainees who had completed at least 1 year of residency, 172 (77.1%) sustained an NSSI during residency, and 57 of 63 trainees (90.5%) who had completed at least 4 years sustained an NSSI during residency. The most common causes of NSSI were solid needles, followed by solid pins or wires. The surgical activity most associated with NSSI was wound closure, followed by fracture fixation. The type of surgery most frequently associated with NSSI was orthopedic trauma, followed by hip and knee arthroplasty. Of 177 trainees who had sustained a prior NSSI, 99 (55.9%) failed to report all events to their institution's occupational health department. CONCLUSIONS: The incidence of NSSI during residency training is high, with >90% of trainees in their fifth year or later of training having received an injury during their training, with a mean of >4 separate events. Most trainees with an NSSI did not report all of their events, which implies that changes are needed in the incident reporting process universally.

Autograft, Allograft, and Bone Graft Substitutes: Clinical Evidence and Indications for Use in the Setting of Orthopaedic Trauma Surgery.

Bone grafts are the second most common tissue transplanted in the United States, and they are an essential treatment tool in the field of acute and reconstructive traumatic orthopaedic surgery. Available in cancellous, cortical, or bone marrow aspirate form, autogenous bone graft is regarded as the gold standard in the treatment of posttraumatic conditions such as fracture, delayed union, and nonunion. However, drawbacks including donor-site morbidity and limited quantity of graft available for harvest make autograft a less-than-ideal option for certain patient populations. Advancements in allograft and bone graft substitutes in the past decade have created viable alternatives that circumvent some of the weak points of autografts. Allograft is a favorable alternative for its convenience, abundance, and lack of procurement-related patient morbidity. Options include structural, particulate, and demineralized bone matrix form. Commonly used bone graft substitutes include calcium phosphate and calcium sulfate synthetics-these grafts provide their own benefits in structural support and availability. In addition, different growth factors including bone morphogenic proteins can augment the healing process of bony defects treated with grafts. Autograft, allograft, and bone graft substitutes all possess their own varying degrees of osteogenic, osteoconductive, and osteoinductive properties that make them better suited for different procedures. It is the purpose of this review to characterize these properties and present clinical evidence supporting their indications for use in the hopes of better elucidating treatment options for patients requiring bone grafting in an orthopaedic trauma setting.

Increased risk for complications following removal of hardware in patients with liver disease, pilon or pelvic fractures: A regression analysis.

PURPOSE: Indications for removing orthopedic hardware on an elective basis varies widely. Although viewed as a relatively benign procedure, there is a lack of data regarding overall complication rates after fracture fixation. The purpose of this study is to determine the overall short-term complication rate for elective removal of orthopedic hardware after fracture fixation and to identify associated risk factors. MATERIALS AND METHODS: Adult patients indicated for elective hardware removal after fracture fixation between July 2012 and July 2016 were screened for inclusion. Inclusion criteria included patients with hardware related pain and/or impaired cosmesis with complete medical and radiographic records and at least 3-month follow-up. Exclusion criteria were those patients indicated for hardware removal for a diagnosis of malunion, non-union, and/or infection. Data collected included patient age, gender, anatomic location of hardware removed, body mass index, ASA score, and comorbidities. Overall complications, as well as complications requiring revision surgery were recorded. Statistical analysis was performed with SPSS 20.0, and included univariate and multivariate regression analysis. RESULTS: 391 patients (418 procedures) were included for analysis. Overall complication rates were 8.4%, with a 3.6% revision surgery rate. Univariate regression analysis revealed that patients who had liver disease were at significant risk for complication (p=0.001) and revision surgery (p=0.036). Multivariate regression analysis showed that: 1) patients who had liver disease were at significant risk of overall complication (p=0.001) and revision surgery (p=0.039); 2) Removal of hardware following fixation for a pilon had significantly increased risk for complication (p=0.012), but not revision surgery (p=0.43); and 3) Removal of hardware for pelvic fixation had a significantly increased risk for revision surgery (p=0.017). CONCLUSIONS: Removal of hardware following fracture fixation is not a risk-free procedure. Patients with liver disease are at increased risk for complications, including increased risk for needing revision surgery following hardware removal. Patients having hardware removed following fixation for pilon fractures also are at increased risk for complication, although they may not require a return trip to the operating room. Finally, removal of pelvic hardware is associated with a higher return to the operating room.

Muscle Viability Revisited: Are We Removing Normal Muscle? A Critical Evaluation of Dogmatic Debridement.

PURPOSE: Determination of muscle viability during debridement is a subjective process with significant consequences. Evaluating muscle color, consistency, contractility, and capacity to bleed (the 4 Cs) was established by a study performed half a century ago. This work reinvestigates the utility of the 4 Cs using current histopathologic techniques. METHODS: After institutional review board approval, 36 biopsies were prospectively collected at a level-1 trauma center from 20 patients undergoing a debridement for open fracture (81%), compartment syndrome (11%), infection (5%), or crush injury (3%). Surgeons graded the biopsies using the 4 Cs, and provided their overall impression as healthy, borderline, or dead. Blinded pathological analysis was performed on each specimen. A correlation between the 4 Cs and surgeon impression with histopathological diagnosis was sought through a univariate statistical analysis. RESULTS: The surgeon's impression was dead muscle in 25 specimens, borderline in 10, and healthy in 1. Pathological analysis of the 35 specimens considered as dead or borderline muscle by the surgeon demonstrated normal muscle or mild interstitial inflammation in 21 specimens (60%). Color (P = 0.07), consistency (P = 0.12), contractility (P = 0.51), capacity to bleed (P = 0.07), and surgeon impression (P = 0.50) were unable to predict histologic appearance. CONCLUSIONS: Neither the 4 Cs nor the surgeon's impression correlate with histological findings regarding muscle viability. In 72% of specimens, the treating surgeon's gross assessment differed from the histopathologic appearance. Although the fate of the debrided muscle remains unclear if left in situ, these results raise questions regarding current practices, including the possibility that surgeons are debriding potentially viable muscle. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Analysis of Failure with the Use of Locked Plates for Stabilization of Proximal Humerus Fractures.

OBJECTIVE: To evaluate factors associated with complications in a series of patients with proximal humerus fractures treated with locked plating. DESIGN: Retrospective chart review. SETTING: Level 1 Trauma Center. PATIENTS AND METHODS: A retrospective review was performed on patients older than 18 years of age treated with a locked plate for a proximal humerus fracture between June 2007 and December 2011 in order to identify any factors associated with failure. Patients had a minimum of 6 months of clinical follow-up. RESULTS: 78 proximal humerus fractures in 78 patients were stabilized using a locked plate. Twenty-four patients were lost to follow-up, while 54 patients were available for 6-month minimum follow-up and comprised the study group. A healing complication occurred in 20 patients (37%) and consisted of loss of reduction (16), varus malunion (16), avascular necrosis (6) or implant penetration (1). Eleven of 54 patients (20%) required secondary surgery. Factors associated with a healing complication were number of fracture parts (p < 0.029), one or more comorbidities (p <0.016), three or more comorbidities (p < 0.038), and varus malreduction (p < 0.001). CONCLUSION: An overall complication rate of 37% was found in patients stabilized using a locked plate after sustaining a proximal humerus fracture. Factors associated with healing complications included increased number of fracture parts, increasing number of comorbidities, and initial varus malreduction. Patient selection for locked plating after proximal humerus fracture should incorporate many factors with meticulous attention to surgical technique.

Manipulation Under Anesthesia: A Safe and Effective Treatment for Posttraumatic Arthrofibrosis of the Knee.

OBJECTIVES: This study investigates the results of closed manipulations performed under anesthesia (MUA) to evaluate whether it is an effective means to treat posttraumatic knee arthrofibrosis. DESIGN: Retrospective review. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Twenty-two patients with a mean age of 40 underwent closed MUA for posttraumatic knee arthrofibrosis. Injuries included fractures of the femur, tibia, and patella as well as ligamentous injuries and traumatic arthrotomies. The mean time from treatment to manipulation was 90 days. Mean follow-up after manipulation was 7 months. INTERVENTION: Closed knee MUA. OUTCOME MEASUREMENTS: Improvement of knee range of motion (ROM) arc was the primary outcome. Patient demographics were correlated with manipulation success using a 2-sample t test. A delay in manipulation of 90 days or greater was also evaluated in this fashion with regard to its role in predicting the benefit of MUA. RESULTS: The mean premanipulation ROM arc was 59 ± 25 degrees. The mean intraoperative arc of motion, achieved at the time of the manipulation was 123 ± 14 degrees. No complications occurred during the MUA procedure. At the most recent follow-up, the mean ROM arc was 110 ± 19 degrees. Tobacco use, associated injuries, elevated body mass index, open fracture, and advanced age did not impact manipulation efficacy. Additionally, manipulations performed 90 days or more after surgical treatment provided a benefit equaling those performed more acutely (P = 0.12). DISCUSSION: MUA is a safe and effective method to increase knee ROM in the setting of posttraumatic arthrofibrosis. Improvement in ROM was noted in all patients. A 90-day window between fracture fixation and manipulation did not impact ROM at final follow-up and may prevent fracture displacement during the MUA. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Hip fracture evaluation with alternatives of total hip arthroplasty versus hemiarthroplasty (HEALTH): protocol for a multicentre randomised trial.

INTRODUCTION: Hip fractures are a leading cause of mortality and disability worldwide, and the number of hip fractures is expected to rise to over 6 million per year by 2050. The optimal approach for the surgical management of displaced femoral neck fractures remains unknown. Current evidence suggests the use of arthroplasty; however, there is lack of evidence regarding whether patients with displaced femoral neck fractures experience better outcomes with total hip arthroplasty (THA) or hemiarthroplasty (HA). The HEALTH trial compares outcomes following THA versus HA in patients 50 years of age or older with displaced femoral neck fractures. METHODS AND ANALYSIS: HEALTH is a multicentre, randomised controlled trial where 1434 patients, 50 years of age or older, with displaced femoral neck fractures from international sites are randomised to receive either THA or HA. Exclusion criteria include associated major injuries of the lower extremity, hip infection(s) and a history of frank dementia. The primary outcome is unplanned secondary procedures and the secondary outcomes include functional outcomes, patient quality of life, mortality and hip-related complications-both within 2 years of the initial surgery. We are using minimisation to ensure balance between intervention groups for the following factors: age, prefracture living, prefracture functional status, American Society for Anesthesiologists (ASA) Class and centre number. Data analysts and the HEALTH Steering Committee are blinded to the surgical allocation throughout the trial. Outcome analysis will be performed using a χ(2) test (or Fisher's exact test) and Cox proportional hazards modelling estimate. All results will be presented with 95% CIs. ETHICS AND DISSEMINATION: The HEALTH trial has received local and McMaster University Research Ethics Board (REB) approval (REB#: 06-151). RESULTS: Outcomes from the primary manuscript will be disseminated through publications in academic journals and presentations at relevant orthopaedic conferences. We will communicate trial results to all participating sites. Participating sites will communicate results with patients who have indicated an interest in knowing the results. TRIAL REGISTRATION NUMBER: The HEALTH trial is registered with clinicaltrials.gov (NCT00556842).

Intramedullary nailing of subtrochanteric fractures--does malreduction matter?

INTRODUCTION: Subtrochanteric femur fractures remain challenging injuries to treat. Historically, varus malreduction has been linked to the development of nonunion; however, there is a paucity of literature evaluating the impact of sagittal plane malreduction. The purpose of this study was to evaluate the influence of coronal and sagittal plane malreductions on time to union of subtrochanteric femur fractures treated with an intramedullary device. METHODS: A retrospective study was performed of all sub-trochanteric fractures (AO/OTA type 32) treated at a single institution. Inclusion criteria consisted of: 1. 18 or more years of age, and 2. fracture stabilization using an intramedullary device. All patients included were followed to union or revision surgery. Radiographic evidence of healing was defined as bridging callus on three of four cortices on AP and lateral views. Delayed union was defined as lack of radiographic healing by 4 months postoperatively and nonunion as lack of healing by 6 months. The definition of malreduction was coronal or sagittal plane deformity greater than 10° at the fracture site. RESULTS: Thirty-five patients met inclusion criteria; 20 men and 15 women with an average age of 55 years (range 19 to 100 years). Mean clinical follow up was 7 months (range 3 to 18 months). Thirty-four of 35 fractures (97%) healed without need for additional surgery. Twenty-one of the 35 fractures (60%) healed within 4 months of surgery. Thirteen fractures (37%) had delayed union, and 1 (2.9%) developed nonunion requiring reoperation. Seven of 35 fractures (20.0%) had a malreduction of greater than 10°, defined as varus (2 fractures), flexion (4 fractures), or both (1 fracture). Of the seven fractures with a malreduction, all (100%) developed a delayed (6) or nonunion (1). Of the 28 fractures without malreduction, 21 (75%) healed within 4 months, 7 (25%) had a delayed union, and none had a nonunion. The presence of a malreduction greater than 10° in any plane resulted in a significantly higher rate of delayed or nonunion (p = 0.0005). CONCLUSION: For patients with subtrochanteric fractures treated with an intramedullary device, malreduction in any plane of greater than 10° resulted in a significantly increased rate of delayed or nonunion or both.

Minimally displaced clavicle fracture after high-energy injury: are they likely to displace?

BACKGROUND: Nondisplaced or minimally displaced clavicle fractures are often considered to be benign injuries. These fractures in the trauma patient population, however, may deserve closer follow-up than their low-energy counterparts. We sought to determine the initial assessment performed on these patients and the rate of subsequent fracture displacement in patients sustaining high-energy trauma when a supine chest radiograph on initial trauma survey revealed a well-aligned clavicle fracture. METHODS: We retrospectively reviewed the cases of trauma alert patients who sustained a midshaft clavicle fracture (AO/OTA type 15-B) with less than 100% displacement treated at a single level 1 trauma centre between 2005 and 2010. We compared fracture displacement on initial supine chest radiographs and follow-up radiographs. Orthopedic consultation and the type of imaging studies obtained were also recorded. RESULTS: Ninety-five patients with clavicle fractures met the inclusion criteria. On follow-up, 57 (60.0%) had displacement of 100% or more of the shaft width. Most patients (63.2%) in our study had an orthopedic consultation during their hospital admission, and 27.4% had clavicle radiographs taken on the day of admission. CONCLUSION: Clavicle fractures in patients with a high-energy mechanism of injury are prone to fracture displacement, even when initial supine chest radiographs show nondisplacement. We recommend clavicle films as part of the initial evaluation for all patients with clavicle fractures and early follow-up within the first 2 weeks of injury.

CONTEXTE: Les fractures de la clavicule accompagnées d'un déplacement minime voire nul sont souvent considérées comme des blessures mineures. Toutefois, ces fractures méritent probablement un suivi plus étroit chez le patient polytraumatisé que chez le patient dont la blessure résulte d'un impact à faible énergie. Nous avons voulu analyser l'évaluation initiale de ces patients et le degré de déplacement subséquent des fractures chez les victimes d'un traumatisme à forte énergie dont la première radiographie du thorax en position couchée a initialement révélé une fracture de la clavicule présentant un bon alignement. MÉTHODES: Nous avons passé en revue de façon rétrospective les dossiers de patients polytraumatisés ayant fait l'objet d'une alerte, atteints d'une fracture de la clavicule (type 15-B selon la classification AO/OTA) accompagnée d'un déplacement inférieur à 100 % et traités dans un seul centre de traumatologie de niveau 1 entre 2005 et 2010. Nous avons comparé le déplacement des fractures entre les radiographies thoraciques initiales en position couchée et les radiographies de suivi. Les consultations en orthopédie et les types d'épreuves d'imagerie ont aussi été consignés. RÉSULTATS: Quatre-vingt-quinze patients atteints d'une fracture de la clavicule répondaient aux critères d'inclusion. Au moment du suivi, 57 (60 %) présentaient un déplacement de 100 % ou plus du corps de la clavicule. La plupart des patients (63 %) de notre étude ont eu une consultation en orthopédie au cours de leur hospitalisation et 27 % avaient subi une radiographie de la clavicule le jour de leur admission. CONCLUSION: Les fractures de la clavicule chez des patients victimes d'un traumatisme à forte énergie sont sujettes au déplacement, et ce, même si les radiographies thoraciques initiales en position couchée ne montrent aucun déplacement. Nous recommandons la prise de clichés de la clavicule dans le cadre de l'évaluation initiale de tous les patients victimes d'une fracture de la clavicule et un suivi rapproché dans les 2 premières semaines suivant la fracture.

Efficacy and safety of recombinant human bone morphogenetic protein-2/calcium phosphate matrix for closed tibial diaphyseal fracture: a double-blind, randomized, controlled phase-II/III trial.

BACKGROUND: Recombinant human bone morphogenetic protein-2 (rhBMP-2) applied on an absorbable collagen sponge improves open tibial fracture-healing as an adjunct to unreamed intramedullary nail fixation. We evaluated rhBMP-2 and a new, injectable calcium phosphate matrix (CPM) formulation in acute closed tibial diaphyseal fractures treated with reamed intramedullary nail fixation. METHODS: Patients were randomized (1:2:2:1) to receive standard of care, which consisted of definitive fracture fixation within seventy-two hours of injury with a locked intramedullary nail after reaming; standard of care and injection with 1.0 mg/mL of rhBMP-2/CPM; standard of care and injection with 2.0 mg/mL of rhBMP-2/CPM; or standard of care and injection with buffer/CPM, to evaluate the activity of the CPM delivery matrix and provide for sponsor and investigator blinding. The co-primary end points of the study were the effects of rhBMP-2/CPM on the time to fracture union (based on blinded assessment of radiographs) and the time to return to normal function (based on blinded assessment of the time to full weight-bearing without pain at the fracture site) compared with standard of care alone. RESULTS: Three hundred and sixty-nine patients were randomized and included in the intent-to-treat population. This study was terminated after an interim analysis (180 patients with six months of follow-up) revealed no shortening in the time to fracture union in the active treatment arms compared with the standard of care control (the SOC group). In the final primary analysis, the median time to radiographic fracture union was not significantly different for the SOC (13.1 weeks), 1.0-mg/mL rhBMP-2/CPM (13.0 weeks), 2.0-mg/mL rhBMP-2/CPM (15.9 weeks), or buffer/CPM (15.4 weeks) treatment groups. The median time to pain-free full weight-bearing was also not significantly different among the SOC (13.4 weeks), 1.0-mg/mL rhBMP-2/CPM (13.4 weeks), 2.0-mg/mL rhBMP-2/CPM (14.3 weeks), and buffer/CPM (16.4 weeks) treatment groups. CONCLUSIONS: In patients with closed tibial fractures treated with reamed intramedullary nailing, the time to fracture union and pain-free full weight-bearing were not significantly reduced by rhBMP-2/CPM compared with standard of care alone. 24306696

Is reconstruction nailing of all femoral shaft fractures cost effective? A decision analysis.

OBJECTIVES: Femoral shaft fractures are usually treated with anterograde or retrograde nails that typically do not provide femoral neck fixation. Ipsilateral femoral neck fractures occur with 2.5%-10% of femoral shaft fractures; 19%-55% of associated femoral neck fractures are missed with plain films and 5%-22% with computed tomography (CT). This study was performed to determine if routine reconstruction nailing of all femoral shaft fractures with or without occult femoral neck fractures is cost effective. METHODS: A decision tree model examined the cost effectiveness of reconstruction nailing over standard intramedullary nailing for all femoral shaft fractures in which an associated femoral neck fracture was not identified on plain radiographs. As a base model, we assumed that 5% of shaft fractures had an ipsilateral femoral neck fracture, and 37% were missed and required further surgery. We assigned a small morbidity and additional cost ($680) for the use of a reconstruction nail and 2 screws. Model inputs including costs, clinical outcome probabilities, and health utilities were derived from the literature, estimated from institutional data, or assumed by the authors. Sensitivity analyses evaluated the effect of the rate of associated femoral neck fracture, the rate of missed femoral neck fracture, the complication rate of reconstruction screws, the cost of the extra reconstruction screws, and the utilities of each outcome on the incremental cost effectiveness (ICER) of both strategies. Current practice in cost-effectiveness analysis uses a threshold of $100,000 per quality-adjusted life year gained as cost effective. A secondary analysis of the use CT scans to reduce missed femoral neck fractures was also performed. RESULTS: The base model showed that the placement of reconstruction nails in all isolated femur fractures was not cost effective. Sensitivity analysis demonstrated that the ICER was most sensitive to the cost of the reconstruction nail, hemiarthroplasty, and a missed femoral neck fracture. The ICER was affected by the rate of femoral neck fracture and the rate of missed femoral neck fracture. If the rate of missed femoral neck fractures was >38%, then reconstruction nailing was a cost-effective strategy. If the probability of an ipsilateral femoral neck fracture was >7%, then reconstruction nailing was cost effective. Protocolized CT scans had an ICER >$100,000. If the additional cost of the reconstruction nails was <$650, then it was cost effective to perform reconstruction nailing for all femoral shaft fractures. CONCLUSIONS: Reconstruction nailing of femoral shaft fractures can be a cost-effective method to reduce the risks and morbidity of missed femoral neck fractures if the incremental implant costs are <$650. Routine reconstruction nailing is cost effective if the rate of associated femoral neck fracture is >7% or the rate of missed femoral neck fracture is >38%. CT scans are not a cost-effective strategy to reduce the risk and morbidity of missed femoral neck fractures if the cost is >$243. Weaknesses of this study include the reliance on low-powered studies and on estimations of some utilities and costs. To prevent the morbidity of missed or occult femoral neck fractures, the use of reconstruction nails for femoral shaft fractures is cost effective when the incremental costs of implants are <$650. LEVEL OF EVIDENCE: Economic Level II. See Instructions for Authors for a complete description of levels of evidence.

Are recent graduates of orthopaedic training programs performing less fracture care? American Board of Orthopedic Surgeons part II: a quality improvement initiative.

OBJECTIVES: The purpose of this study was to evaluate whether there has been a change in the amount of fracture care performed by recent graduates of orthopaedic residency programs over time. DESIGN: Retrospective review. SETTING: American Board of Orthopaedic Surgery (ABOS) Part II database. PARTICIPANTS: Candidates applying for Part II of the second part of the Orthopaedic (ABOS) certification. INTERVENTION: The ABOS Part II database was searched from years 1999 to 2008 for Current Procedural Terminology codes indicating 1) "simpler fractures" that any candidate surgeon should be able to perform; 2) "complex fractures" that are often referred to surgeons with specialty training; and 3) "emergent cases" that should be done emergently by a physician. MAIN OUTCOME MEASURE: Logistic regression and chi-square tests were used to evaluate whether there has been a change in the amount of fracture care among recent graduates of orthopaedic residency programs over time. RESULTS: Over the 10-year period (1999-2008), a total of 95,922 cases were in the simpler fractures category; 16,523 were classified as complex fractures and 17,789 were classified as emergent cases. The overall number of cases by fracture type increased from 1999 to 2008 as did the average number of surgery cases performed by surgeons in each category over the 6-month collection period. Simpler fracture cases increased 18% (8304-9784 cases) with the average number surgically treated by surgeons performing at least one simple fracture case also increasing 18% (14.1-16.6 cases per surgeon). Complex fracture cases increased 51% (1266-1916 cases) with the average number of these cases per surgeon operating at least one complex fracture case increasing 52% (3.3-5.0 cases per surgeon). Emergent fracture cases increased 92% (1178-2264 cases) with the average number of these cases per surgeon operating at least one emergent fracture case increasing 49% (4.5-6.7 cases per surgeon). CONCLUSION: From the data presented here, candidate orthopaedic surgeons are treating fractures as least as often as young surgeons were 10 years ago.

The effect of hospital setting and teaching status on outcomes after hip fracture.

This study used the National Inpatient Sample database for 1998 through 2003 to identify patients who were aged 65 years or older and had undergone surgical treatment for an isolated femoral neck or intertrochanteric hip fracture. Hospital setting (urban vs rural) and teaching status (teaching vs nonteaching) were the primary independent variables studied. The final cohort consisted of 226,239 patients. Overall in-hospital mortality was 2.6%. Higher in-hospital mortality risk was associated with increased number of in-hospital complications, increased number of comorbidities, male sex, longer surgical delay, and age 85 years or older. The overall surgical complication rate was 10.1%; there was little effect for any of the studied factors on risk for in-hospital complication. Contrary to expectation, hospital setting and teaching status were generally not as relevant to in-hospital outcomes as other factors were.

Does surgeon volume for total hip arthroplasty affect outcomes after hemiarthroplasty for femoral neck fracture?

We conducted a study to compare complication rates in patients treated with hemiarthroplasty for femoral neck fracture by surgeons with variable experience in primary total hip arthroplasty (THA) and revision THA. A cohort of Medicare beneficiaries (N = 115,352) was identified from Medicare part A claims from 1994 and 1995. All patients had undergone hemiarthroplasty for femoral neck fracture. Patients were grouped according to surgeon procedure volume (how many primary and revision THAs surgeon performed per year): 0 (no volume), 1-5 (low volume), 6-24 (mid volume), and 25+ (high volume). Claims were evaluated up to 5 years after surgery to identify patient encounters for complications, such as mortality, dislocation, and infection. Compared with patients treated by no-volume surgeons, patients treated by high-volume surgeons had significantly lower rates of mortality, prosthetic dislocation, and superficial infection. The difference was significant for mortality at 30 days (5.6% vs 6.5%), 90 days (10.8% vs 12.8%), and 1 year (22.3% vs 23.8%); for prosthetic dislocation at 1 year (1.2% vs 1.7%); and for superficial infection at 90 days (1.1% vs 1.6%), 1 year (1.4% vs 1.9%), and 5 years (1.5% vs 2.0%). Revision surgery rates, however, were statistically higher for the high-volume group than for the no-volume group at 90 days (0.9% vs 0.7%), 1 year (3.3% vs 2.9%), and 5 years (8.4% vs 7.7%). There were no differences in rates of venous thromboembolism or deep infection between the groups. Surgical experience in primary and revision THA has a significant effect on patient outcomes after hemiarthroplasty for femoral neck fracture.

Is surgery for displaced, midshaft clavicle fractures in adults cost-effective? Results based on a multicenter randomized, controlled trial.

OBJECTIVES: To determine the cost-effectiveness of open reduction internal fixation (ORIF) of displaced, midshaft clavicle fractures in adults. DESIGN: Formal cost-effectiveness analysis based on a prospective, randomized, controlled trial. SETTING: Eight hospitals in Canada (seven university-affiliated and one community hospital). PATIENTS/PARTICIPANTS: One hundred thirty-two adults with acute, completely displaced, midshaft clavicle fractures. INTERVENTION: Clavicle ORIF versus nonoperative treatment. MAIN OUTCOME MEASUREMENTS: Utilities derived from SF-6D. RESULTS: The base case cost per quality-adjusted life-year (QALY) gained for ORIF was $65,000. Cost-effectiveness improved to $28,150/QALY gained when the functional benefit from ORIF was assumed to be permanent with cost per QALY gained falling below $50,000 when the functional advantage persisted for 9.3 years or more. In other sensitivity analyses, the cost per QALY gained for ORIF fell below $50,000 when ORIF cost less than $10,465 (base case cost $13,668) or the long-term utility difference between nonoperative treatment and ORIF was greater than 0.034 (base case difference 0.014). Short-term disutility associated with fracture healing also affected cost-effectiveness with the cost per QALY gained for ORIF falling below $50,000 when the utility of a fracture treated nonoperatively before union was less than 0.617 (base case utility 0.706) or when nonoperative treatment increased the time to union by 20 weeks (base case difference 12 weeks). CONCLUSIONS: The cost-effectiveness of ORIF after acute clavicle fracture depended on the durability of functional advantage for ORIF compared with nonoperative treatment. When functional benefits persisted for more than 9 years, ORIF had a favorable value compared with many accepted health interventions.

Is prophylactic fixation a cost-effective method to prevent a future contralateral fragility hip fracture?

OBJECTIVE: : A previous hip fracture more than doubles the risk of a contralateral hip fracture. Pharmacologic and environmental interventions to prevent hip fracture have documented poor compliance. The purpose of this study was to examine the cost-effectiveness of prophylactic fixation of the uninjured hip to prevent contralateral hip fracture. METHODS: : A Markov state-transition model was used to evaluate the cost and quality-adjusted life-years (QALYs) for unilateral fixation of hip fracture alone (including internal fixation or arthroplasty) compared with unilateral fixation and contralateral prophylactic hip fixation performed at the time of hip fracture or unilateral fixation and bilateral hip pad protection. Prophylactic fixation involved placement of a cephalomedullary nail in the uninjured hip and was initially assumed to have a relative risk of a contralateral fracture of 1%. Health states included good health, surgery-related complications requiring a second operation (infection, osteonecrosis, nonunion, and malunion), fracture of the uninjured hip, and death. The primary outcome measure was the incremental cost-effectiveness ratio estimated as cost per QALY gained in 2006 US dollars with incremental cost-effectiveness ratios below $50,000 per QALY gained considered cost-effective. Sensitivity analyses evaluated the impact of patient age, annual mortality and complication rates, intervention effectiveness, utilities, and costs on the value of prophylactic fixation. RESULTS: : In the baseline analysis, in a 79-year-old woman, prophylactic fixation was not found to be cost-effective (incremental cost-effectiveness ratio = $142,795/QALY). However, prophylactic fixation was found to be a cost-effective method to prevent contralateral hip fracture in: 1) women 71 to 75 years old who had 30% greater relative risk for a contralateral fracture; and 2) women younger than age 70 years. Cost-effectiveness was greater when the additional costs of prophylaxis were less than $6000. However, for most analyses, the success of prophylactic fixation was highly sensitive to the effectiveness and the relative morbidity and mortality of the additional procedure. CONCLUSION: : Prophylactic fixation with a cephalomedullary nail was not found to be cost-effective for the average older woman who sustained a hip fracture. However, it may be appropriate for select patient populations. The study supports the need for basic science and clinical trials investigating the effectiveness of prophylactic fixation for patient populations at higher lifetime risk for contralateral hip fracture.

Is early internal fixation preferred to cast treatment for well-reduced unstable distal radial fractures?

BACKGROUND: In the treatment of distal radial fractures, physicians often advocate internal fixation over cast treatment for potentially unstable fracture patterns, citing the difficulties of successful nonoperative treatment and a decrease in patient tolerance for functional deficiencies. This study was performed to evaluate whether early internal fixation or nonoperative treatment would be preferred for displaced, potentially unstable distal radial fractures that initially had an adequate reduction. METHODS: A decision analytic model was created to compare early internal fixation with use of a volar plate and nonoperative management of a displaced, potentially unstable distal radial fracture with an acceptable closed reduction. To identify the optimal treatment, quality-adjusted life expectancy was estimated for each management approach. Data from the literature were used to estimate rates of treatment complications (e.g., fracture redisplacement with nonoperative treatment) and of treatment outcomes. Mean health-state utilities for treatment outcomes of painless malunion, functional deficit, and painful malunion were derived by surveying fifty-one adult volunteers with use of the time trade-off method. Sensitivity analysis was used to determine which model parameters would change the treatment decision over a plausible range of values. RESULTS: Early internal fixation with volar plating was the preferred strategy in most scenarios over the ranges of parameters available, but the margins were small. The older patient (mean age, 57.8 years) who sustains a distal radial fracture can expect 0.08 more quality-adjusted life years (29.2 days) with internal fixation compared with nonoperative treatment. Sensitivity analysis revealed no single factor that changed the preferred option within the reported ranges in the base case. However, the group of patients sixty-five years or older, who had lower disutility for painful malunion, derived a very small benefit from operative treatment (0.01 quality-adjusted life year or 3.7 days) and would prefer cast treatment in some scenarios. CONCLUSIONS: Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature. This long-term gain in quality-adjusted life years outweighed the short-term risks of surgical complications, making early internal fixation the preferred treatment in most cases. However, the difference was quite small. Patients, especially those over sixty-four years old, who have lower disutility for the malunion and painful malunion outcome states may prefer nonoperative treatment.