Cost analysis and clinical outcomes of anatomic pre-contoured locking versus conventional plates for distal fibula ankle fractures.

PURPOSE: To analyze differences in union, complication rates and cost from surgical fixation of distal fibula fractures with fibular plating implants. METHODS: In total, 380 adult patients from 2012 to 2015 treated with 12 fibular plates from 4 different manufacturers utilized by 9 surgeons were retrospectively reviewed. They were stratified into a conventional one-third tubular fibular plate group, pre-contoured anatomic locking plate group, or a heterogeneous group including 3.5-mm reconstruction, one-third tubular locking, composite, and limited compression plates. The outcomes included failure of fixation, deep infection requiring debridement, time to union, anatomic reduction, superficial infection, hardware removal, and post-traumatic arthritis. Plate and screw costs were calculated from hospital billing records. RESULTS: Pre-contoured locking plates were used in older, female patients with a greater number of comorbidities. Open injuries and OTA 44B fractures were more likely to be an indication for pre-contoured plates. There was no difference noted in time to union between the different plating groups. Risk factors for deep infection requiring debridement included a history of tobacco use, open fractures, and pre-contoured locking plates relative to the conventional plating group. The pre-contoured plating group was on average $586 more expensive compared to the conventional group. CONCLUSION: Pre-contoured locking plates achieved similar radiographic outcomes compared to conventional plates with an increased risk of complications and higher cost. Surgeons should consider their choice of implant based on the patient's fracture pattern, underlying comorbidities, and risk for infection.

Refracture after plate removal of midshaft clavicle fractures after bone union-incidence, risk factors, management and outcomes.

INTRODUCTION: There is a great debate on the routine use of open reduction and internal fixation (ORIF) for midshaft clavicle fractures, and one concern is the adverse events after ORIF, such as implant removal after bone union. In this retrospective study, we assessed the incidence, risk factors, management and outcomes of refracture after plate removal of midshaft clavicle fractures after bone union. MATERIALS AND METHODS: Three hundred fifty-two patients diagnosed with acute midshaft clavicle fractures who had complete medical records from primary fractures to refracture were recruited. Details of imaging materials and clinical characteristics were carefully reviewed and analysed. RESULTS: The incidence rate of refracture was 6.5% (23/352), and the average interval from implant removal to refracture was 25.6 days. Multivariate analysis showed that the risk factors were Robinson type-2B2 and fair/poor reduction. Females were 2.4 times more likely to have refracture, although it was not significant in multivariate analysis (p = 0.134). Postmenopausal females with a short interval (≤ 12 months) from primary surgery to implant removal had a significant risk for refracture. Tobacco use and alcohol use during bone healing were potential risk factors for male patients, although they were not significant in multivariate analysis. Ten patients received reoperation with or without bone graft, and they had a higher rate of bone union than 13 patients who refused reoperation. CONCLUSION: The incidence of refracture following implant removal after bone union is underestimated, and severe comminute fractures and unsatisfactory reduction during primary surgery are risk factors. Implant removal for postmenopausal female patients is not recommended due to a high rate of refracture.

Effects of Economic Well-Being on Outcomes at One Year after Volar Plate Fixation of Distal Radius Fractures.

Background: The objective of this study was to determine whether economic well-being is associated with patient-reported functional outcomes and range of motion 1 year following volar plate fixation of distal radius fracture. Methods: A retrospective study was performed on 200 patients with distal radius fractures treated with volar plate fixation at two Level 1 trauma centres from 2006 to 2017 with 1-year clinical follow-up using a previously published cohort. The economic well-being of patients was assessed using the Distressed Communities Index (DCI). Our outcome variables were patient-reported functional outcomes assessed by QuickDASH score and wrist and forearm range of motion 1 year after surgery. The analysis of variance (ANOVA) test was used to compare outcome variables across pre-established tiers of economic well-being. Results: The mean QuickDASH score at 1 year following distal radius fracture volar plate fixation was 10.8 and ranged from 7.3 to 12.2 across tiers of economic well-being. QuickDASH score and wrist range of motion were not significantly different across all tiers of economic well-being. However, wrist flexion-extension arc at 1 year following surgery was significantly decreased in the economically at-risk group compared with the remaining cohort. Conclusions: Patient-reported functional outcomes 1 year after volar plate fixation of distal radius fracture are similar across tiers of economic well-being. Economically disadvantaged patients are at risk for poorer wrist motion following distal radius fracture surgery, though it is not clear if this difference is clinically significant. Level of Evidence: Level II (Prognostic).

Biomechanical assessment of screw safety between far cortical locking and locked plating constructs.

With the emerging concerns for more flexible and less stiff bridge constructs in the interest of stimulating bone healing, the technique of far cortical locking has been designed to reduce the stiffness of locked plating (LP) constructs while retaining construct strength. This study utilized simulation with diaphyseal bridge plating biomechanical models to investigate whether far cortical locking causes larger screw fracture risk than LP during rehabilitation. The fracture risk of the screws in the far cortical locking constructs increases in the non-osteoporotic and osteoporotic diaphysis compared with the screws in the LP constructs.

The ideal implant for Mayo 2A olecranon fractures? An economic evaluation.

BACKGROUND: The ideal implant for stable, noncomminuted olecranon fractures is controversial. Tension band wiring (TBW) is associated with lower cost but higher implant removal rates.On the other hand, plate fixation (PF) is purported to be biomechanically superior, with lower failure and implant removal rates, although associated with higher cost. The primary aim of this study is to look at the clinical outcomes for all Mayo 2A olecranon between PF and TBW. The secondary aim is to perform an economic evaluation of PF vs. TBW. MATERIALS AND METHODS: This is a retrospective study of all surgically treated Mayo 2A olecranon fractures in a tertiary hospital from 2005-2016. Demographic data, medical history, range of motion, and complications were collected. All inpatient and outpatient costs in a 1-year period postsurgery including the index surgical procedure were collected via the hospital administrative cost database (normalized to 2014). RESULTS: A total of 147 cases were identified (94 TBW, 53 PF). PF was associated with higher mean age (P < .01), higher American Society of Anesthesiologists score (P < .01), and higher proportion of hypertensives (P = .04). There was no difference in the range of motion achieved at 1 year for both groups. In terms of complications, TBW was associated with more symptomatic hardware (21.6% vs. 13.7%, P = .24) and implant failures (16.5% vs. none, P < .01), whereas the plate group had a higher wound complication (5.9% vs. none, P = .02) and infection rate (9.8% vs. 3.1%, P = .09). TBW had a higher implant removal rate of 30.9% compared with 22.7% for PF (P = .36). PF had a higher cost at all time points, from the index surgery ($10,313.64 vs. $5896.36, P < .01), 1-year cost excluding index surgery ($5069.61 vs. $3850.46, P = .46), and outpatient cost ($1667.80 vs. $1613.49, P = .27). DISCUSSION AND CONCLUSION: Based on our study results, we have demonstrated that TBW is the ideal implant for Mayo 2A olecranon fractures from both a clinical and economic standpoint, with comparable clinical results, potentially similar implant removal rates as PF's, and a lower cost over a 1-year period. In choosing the ideal implant, the surgeon must take into account, first, the local TBW and PF removal rate, which can vary significantly because of the patient's profile and beliefs, and second, the PF implant cost.

Comparison of Locking Versus Nonlocking Plates for Distal Fibula Fractures.

Locking plates might offer a biomechanical fixation advantage for distal fibula fractures with comminution or osteoporotic bone. In January 2011, our unit introduced a bone-specific locking plate for the distal fibula. The aim of the present study was to compare it against more conventional plating system implants for lateral malleolar fixation in terms of outcomes, crude costs, and complications. We retrospectively reviewed a consecutive cohort of patients with closed ankle fractures who presented within a 24-month period. The clinical and radiographic outcomes were compared among conventional plating using a one-third semitubular plate, a 3.5-mm limited-contact dynamic compression plate, and a 2.7-mm/3.5-mm locking compression distal fibula plate. A total of 145 patients with ankle fractures underwent surgical fixation: 87 (60.0%) with the semitubular plate, 22 (15.2%) with the limited-contact dynamic compression plate, and 36 (24.8%) with the locking compression distal fibula plate. A greater proportion of patients with established osteoporosis or osteoporosis risk factors were in the locking compression distal fibula plate group (27.8% versus 2.3% and 0%). Four patients (2.8%) required washout for infection. No significant differences were found between the sex distribution within the 3 groups (p = .432). No significant difference was found in the complication rate (p = .914) or the reoperation rate (p = .291) among the 3 groups. Although costing >6 times more than a standard fibula fixation construct (implant cost), bone-specific locking compression distal fibula plates add to the portfolio of implants available, especially for unstable fractures with poor bone quality.

Outcomes of Surgical Management of Supracondylar Periprosthetic Femur Fractures.

BACKGROUND: Fracture location is an important consideration in managing supracondylar periprosthetic femur fractures. The outcomes of locked plating and intramedullary (IM) nail fixation were therefore compared based on fracture location, being above or at/below the total knee arthroplasty (TKA) flange. METHODS: Fifty-seven patients were identified from surgical records as being treated for supracondylar periprosthetic femur fracture with either a locking plate (n = 38) or IM nail (n = 19). Based on fracture location, either above or at/below the TKA flange, both groups were assessed for time to full weight bearing, time to radiographic union, number of postoperative complications, subsequent surgery, transfusion requirements, as well as range of motion, pain, and instability at most recent follow-up. Radiographs were reviewed to assess fracture alignment with comparisons made immediately postoperative to most recent. RESULTS: Mean follow-up for IM nail and locking plate fixation was 13.9 and 15.6 months, respectively. There was no statistical difference between groups in the mean time to fully weight bear, the incidence of postoperative pain, range of motion, use of gait aids, time to full radiographic union, or the overall radiographic alignment of a healed fracture (P > .05). Comparison based on fracture location yielded similar outcomes. Nonunion was only demonstrated in the IM nail cohort, particularly for fractures below the TKA flange (n = 2). CONCLUSION: The use of either IM nail or locking plate fixation for supracondylar periprosthetic fractures provides comparable clinical outcomes. Caution is recommended in using IM nails for fractures below the flange where limited fixation may increase the risk of nonunion.

Ultrasonographic Assessment of the Flexor Pollicis Longus Tendon After Plate Fixation.

Rupture of the flexor pollicis longus tendon is a major complication after volar locking plate fixation of distal radius fracture. This study used ultrasonography to assess the flexor pollicis longus tendon and intermediate tissue. The study assessed 27 patients (28 wrists) who underwent removal of the volar locking plate. Before plate removal, radiography and ultrasonography were performed to assess the relation between the flexor pollicis longus tendon and the volar locking plate. Intraoperatively, the authors evaluated the intermediate tissues between the flexor pollicis longus tendon and the distal volar margin of the plate. Preoperative and intraoperative findings were compared. Intraoperative findings were strongly related to the distance between the flexor pollicis longus tendon and the volar locking plate on ultrasonography. The sensitivity of ultrasonography in detecting thin, membrane-like intermediate tissue through which the plate was visible was 95%, and the specificity was 89% if the distance between the flexor pollicis longus tendon and the plate was less than 0.7 mm. Compression of the flexor pollicis longus tendon was seen in 11 cases (39.3%), and this finding suggested the presence of thin, membrane-like intermediate tissue. The study results showed that ultrasonography could be used to identify the type of intermediate tissue between the flexor pollicis longus tendon and the volar locking plate. [Orthopedics. 2017; 40(1):e104-e108.].

Complication Risk After Treatment of Intertrochanteric Hip Fractures in the Medicare Population.

The study evaluated the incidence of and complications associated with the use of an intramedullary nail vs open reduction and internal fixation (ORIF) with a sliding compression hip screw and plate in treating intertrochanteric fractures. The authors hypothesized that the biomechanically stronger and less invasive intramedullary nail would have superior results and fewer complications compared with ORIF. Patients followed for up to 1 year postoperatively were identified from the 5% nationwide sample of Medicare administrative claims data (1998-2007) using the corresponding International Classification of Diseases, 9th revision, Clinical Modification, codes 820.21 and 820.31. There were 9157 patients treated with intramedullary nails and 27,687 treated with compression screw and plate fixation. Intertrochanteric hip fractures treated with an intramedullary nail during this period increased from 3.3% to 63.1% compared with ORIF. Patients treated with an intramedullary nail had a higher adjusted risk of pulmonary embolism at 90 days (P=.003) and a higher risk of mortality at 1 year (P<.001) compared with those treated with ORIF. Patients who underwent intramedullary nailing during 2006 to 2007 had a lower adjusted risk of conversion to total hip replacement at 1 year (P=.037) compared with those who had ORIF. Over the decade of the study, intramedullary nail usage increased 59.8% compared with ORIF. Increased use of intramedullary nails compared with ORIF has not shown improved outcomes or decreased complications in patients with intertrochanteric hip fractures. The increased use of intramedullary nails for intertrochanteric hip fractures appears to be multifactorial, including the less invasive nature of the surgery and increased experience with the closed surgical technique.

The efficacy and complications of 2-hole 3.5 mm reconstruction plates and 4 mm noncanulated cancellous screws for temporary hemiepiphysiodesis around the knee.

BACKGROUND: Persistent angular deformities around the knee can lead to growth-plate damage in childhood and osteoarthritis in adulthood. The treatment options include osteotomy and hemiepiphysiodesis. Tension-band plate hemiepiphysiodesis with 8-plate is an effective way to correct these deformities. However, its high cost makes it less available in many countries. In the present series, we have used 3.5 mm reconstruction plates for tension-band temporary hemiepiphysiodesis. METHODS: Twenty-one patients with bilateral angular deformities of the knee (42 extremities) underwent temporary hemiepiphysiodesis with 3.5 mm reconstruction plates. The diagnosis, BMI, weight, amount of correction of the deformity age, and device failure were analyzed. The mean follow-up period after plate removal was 17 months (ranging from 8 to 24 mo). RESULTS: The mean age of the patients was 10 years and 3 months (± 2 y and 10 mo). Complete correction of the deformities was achieved in 86% of patients. Of the 58 plate and screw constructs, 10% had screw breakage. Patients with genu valgum had 2 screw failures (6.25%), but in the genu varum group there were 4 screw failures (40%). Of the 3 patients who did not have complete correction of the deformities, 2 had mucopolysaccharidosis and 1 was nearing skeletal maturity (16 y old). The age of the patient, body weight, BMI, and degrees of angulation did not have any statistically significant correlation with the screw failure. Screw failures in female patients were more common than in male patients. All implant failures occurred in idiopathic patients. CONCLUSIONS: The efficacy of 3.5 mm reconstruction plates for temporary hemiepiphysiodesis around the knee is similar to that of 8-plates. However, the reconstruction plates have a lower cost and are easily available. Noncanulated 3.5 or 4.5 mm cortical screws seem to be superior to 4 mm noncanulated cancellous screws. LEVEL OF EVIDENCE: Level 3.

Subacromial morphometric assessment of the clavicle hook plate.

BACKGROUND: Clavicle hook plates are an effective plate fixation alternative for distal clavicle fractures and severe acromioclavicular joint dislocations. However, post-operative complications associated with the subacromial portion of the hook include acromial osteolysis and subacromial impingement. We examine and quantify the three-dimensional position of the subacromial portion of the hook plate relative to surrounding acromial and subacromial structures in a series of cadaveric shoulders to determine if hook positioning predisposes the shoulder to these noted post-operative complications. MATERIALS AND METHODS: Fifteen cadaveric shoulders (seven males, eight females) were implanted with 15- or 18-mm hook plates. Dimensions of the acromion and hook plate were digitised and reconstructed into a three-dimensional model to measure acromion dimensions and distances of the subacromial hook relative to surrounding acromial and subacromial structures. RESULTS: Inter-specimen dimensions of the acromion were highly variable. Mean acromion width and thickness were greater in males than in females (p=0.01). The posterior orientation of the subacromial hook varied widely (mean posterior implantation angle=32.5+/-20 degrees, range 0-67 degrees). The hook pierced the subacromial bursa in 13/15 specimens, made contact with the belly of the supraspinatus muscle in 9/15 specimens, and had focal contact at the hook tip with the undersurface of the acromion in 9/15 specimens. CONCLUSIONS: The wide range of acromial dimensions leads to a high degree of variability in the positioning of the subacromial hook. The observed frequency of hook contact with surrounding subacromial structures in a static shoulder confirms that the position of the hook portion of the implant can predispose anatomic structures to the post-operative complications of subacromial impingement and bony erosion.

Clinical outcomes and costs among patients with Staphylococcus aureus bacteremia and orthopedic device infections.

We evaluated costs and outcomes of patients with S. aureus bacteremia and orthopedic device infections (ODI). Patients with ODI had higher relapse of S. aureus infection, compared to bacteremic patients without ODI. Costs and outcomes were similar among ODI patients undergoing device removal and those treated with debridement and retention.

Complications of anterior cervical discectomy and fusion using recombinant human bone morphogenetic protein-2.

The use of bone morphogenetic protein-2 (rhBMP-2) in spinal fusion has increased dramatically since an FDA approval for its use in anterior lumbar fusion with the LT cage. There are several reports of its use in transforaminal lumbar interbody fusion, posterolateral fusion, and anterior cervical fusion. Reports on adverse effects of rhBMP-2 when used in spinal fusion are scarce in literature. An Institutional Review Board approved retrospective study was conducted in patients undergoing anterior spinal fusion and instrumentation following diskectomy at a single center. Forty-six consecutive patients were included. Twenty-two patients treated with rhBMP-2 and PEEK cages were compared to 24 in whom allograft spacers and demineralized bone matrix was used. Patients filled out Cervical Oswestry Scores, VAS for arm pain, neck pain, and had radiographs preoperatively as well at every follow up visit. Radiographic examination following surgery revealed end plate resorption in all patients in whom rhBMP-2 was used. This was followed by a period of new bone formation commencing at 6 weeks. In contrast, allograft patients showed a progressive blurring of end plate-allograft junction. Dysphagia was a common complication and it was significantly more frequent and more severe in patients in whom rhBMP-2 was used. Post operative swelling anterior to the vertebral body on lateral cervical spine X-ray was significantly larger in the rhBMP-2 group when measured from 1 to 6 weeks after which it was similar. These effects are possibly due to an early inflammatory response to rhBMP-2 and were observed to be dose related. With the parameters we used, there was no significant difference in the clinical outcome of patients in the two groups at 2 years. The cost of implants in patients treated with rhBMP-2 and PEEK spacers was more than three times the cost of allograft spacers and demineralized bone matrix in 1, 2, and 3-level cases. Despite providing consistently good fusion rates, we have abandoned using rhBMP-2 and PEEK cages for anterior cervical fusion, due to the side effects, high cost, and the availability of a suitable alternative.

Cranial plate and screw fixation in infancy: an assessment of risk.

Sixty-seven surgeons, members of the International Craniofacial Surgery Society, responded to a questionnaire focused on assessing the incidence and risk of cranial plate and screw translocation intracranially in infants undergoing cranial surgery. Despite screws, plates, and wires being evident intracranially in individual cases, no apparent increase in seizure frequency or susceptibility to head trauma was noted in this preliminary study.

A comparative study of miniplates used in the treatment of mandibular fractures.

The purposes of this study were to investigate the differences in mechanical properties of major miniplating systems used for noncompression miniplate osteosynthesis of mandibular fractures and to determine whether these properties influence treatment outcome. The study was conducted in two parts. First, six of the major miniplate systems currently used at the Royal Adelaide Hospital were subjected to bending tests at the University of Adelaide Engineering Department to quantify the relative stiffness of each plate. Second, a prospective sample of patients presenting with mandibular fractures was analyzed. These patients were treated with a variety of the miniplating systems. The results of treatment as a whole were compared to identify any direct benefit consequent on the miniplate selected. While significant differences in stiffness were identified between the plating systems, no significant differences in treatment outcome were identified, between the noncompression plates employed. Since no observable benefits have been identified by choice of miniplate, selection should be based on surgical preference, biocompatibility, CT compatibility and unit cost. Because of the variations in materials, design, properties, CT compatibility, and unit cost, it is important not to regard all miniplates as equal and interchangeable.

Mandible fracture repair: specific indications for newer techniques.

Mandible fracture repair is commonly undertaken by otolaryngologists. Although the essential principles of reduction and immobilization are undisputed, the approach used to obtain these goals varies considerably. We performed a critical evaluation of all mandible fractures treated at the Santa Clara Valley Medical Center by the otolaryngology service between January 1988 and February 1992, with the purpose of better defining the indications for plate fixation and for the use of more traditional techniques. One hundred eighty-three fractures in 112 patients were evaluable. Thirty-six (32.1%) of these patients had at least one plate placed (group A); 39 (34.8%) underwent an open procedure, with interosseous wire fixation (group B); and 37 (33.0%) were treated with closed techniques (group C). The severity of fracture (indexed by comminution, presence of infection, teeth in the fracture line, interval to repair, and whether the fracture was open or closed) was similar in plated and nonplated mandibles. Mean (+/- standard deviation) operative times for the three groups were 3.2 +/- 1.6 hours for group A, 3.0 +/- 0.9 hours for group B, and 1.4 +/- 0.5 hours for group C. The number of follow-up visits required was not statistically different (group A, 5.6 +/- 3.8 visits; group B, 5.2 +/- 2.5 visits; and group C, 5.3 +/- 2.0 visits). The overall incidence of major complications was 14.3% (16 of 112), including 11 of 36 (30.6%) in group A, 4 of 39 (10.3%) in group B, and 1 of 37 (2.7%) in group C.(ABSTRACT TRUNCATED AT 250 WORDS)

Costs and complications in mandibular reconstruction.

Because of increasing concerns about the high cost of complex medical care, we compared the combined cost of ablation and reconstruction incurred using five different management strategies for patients undergoing mandibular resection. We also compared the rates of complication and failure for the methods used. The records of 69 patients undergoing segmental or total mandibulectomy between January 1, 1986, and June 30, 1990, were reviewed. Of these, 15 had reconstruction with soft tissue only (average cost, $36,137; complication rate, 33%), whereas 20 had immediate reconstruction with vascularized bone (average cost, $46,894; complication rate, 50%), and 15 had reconstruction with only a metal plate (average cost, $47,678; complication rate, 73%). Nine patients had plate reconstructions initially but subsequently underwent reconstructions with bone (average cost, $54,346; complication rate, 78%), whereas 10 patients had no initial reconstruction but subsequently underwent delayed reconstruction with bone (average cost, $52,486; complication rate, 70%). If reconstruction was performed with bone, immediate reconstruction was more cost effective than delayed reconstruction and had a lower complication rate as well.

Sliding-screw plate fixation of proximal femoral fractures: radiographic assessment.

The sliding compression screw-sideplate combination is currently the most widely employed device for internal fixation of stable and unstable intertrochanteric fractures of the femur. The normal and abnormal radiographic appearances of this device in the immediate post-operative period are discussed. Potential long-term complications including mal- or non-union, intra-articular penetration, metal failure, rotation of the proximal fracture fragment, disengagement, trochanteric bursitis, leg length discrepancy, delayed cervical stress fracture, and ischemic necrosis are reviewed.

[Diagnostic value of osteoscintigraphy and osteoscintimetry for assessment of post-traumatic osteomyelitis and of its complications (author's transl)]. / Die Wertigkeit der Osteoszintigraphie und Osteoszintimetrie für die Beurteilung der posttraumatischen Osteomyelitis und ihrer Komplikationen.

The importance of osteoscintigraphy and osteoscintimetry for diagnosis and case control in post-traumatic osteomyelitis and its complications is discussed by means of 182 bone scintigraphs. Scintigraphy as a functional examination enables clear statements on the probable future course of development of an infection of the bone, of a sequestrum, on the vitality of bone fragments, and on the probable course of infected psuedarthroses and spongiosa transplants.