Subtrochanteric femur fractures: review of the complete pathologic spectrum with emphasis on distinguishing imaging features.

Subtrochanteric femur fractures result from a variety of mechanisms of injury and underlying pathologies. Radiologists can play a pivotal role by differentiating the etiology of a subtrochanteric femur fracture, which assists the orthopedic surgeon in choosing the correct method of treatment. To provide this valuable service, one must be familiar with the characteristic radiologic features of the numerous causative etiologies, ranging from Paget disease to underlying bone lesions to iatrogenic fractures.

ACR Appropriateness Criteria® Chronic Hip Pain: 2022 Update.

Chronic hip pain is a frequent chief complaint for adult patients who present for evaluation in a variety of clinical practice settings. Following a targeted history and physical examination, imaging plays a vital role in elucidating the etiologies of a patient's symptoms, as a wide spectrum of pathological entities may cause chronic hip pain. Radiography is usually the appropriate initial imaging test following a clinical examination. Depending on the clinical picture, advanced cross-sectional imaging may be subsequently performed for further evaluation. This documents provides best practice for the imaging workup of chronic hip pain in patients presenting with a variety of clinical scenarios. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Workplace Hazards in Orthopaedic Surgery Training: A Nationwide Resident Survey Involving Sharps-related Injuries.

INTRODUCTION: Surgical specialties are at an increased risk for occupational hazards, including sharps-related injuries. The objective of this study was to report the frequency of sharps injuries and evaluate which characteristics influence the number of injuries and reporting behaviors. METHODS: A web-based, anonymous survey was available for 10 weeks to 46 US orthopaedic surgery residency programs (1,207 potential residents) participating in an education research collaborative. The survey was divided into the following areas: demographics, training and attitudes concerning occupational hazards, and sharps injuries and reporting. Logistic regression was used to evaluate the association between the above variables on experiencing sharps injuries with significance threshold set at P < 0.05. RESULTS: In this study, 518 surveys were included yielding a response rate of 42.9% (518/1,207). Nearly 80% of the residents recalled some form of safety training during intern orientation and 62% of the respondents felt that they received adequate occupation safety training specifically related to orthopaedic surgery. Four hundred seventeen residents (80.5%) experienced a sharps injury (mean 2.8). Nearly 20% of the respondents experienced ≥5 sharps injuries. Needle sticks (38.8%) were responsible for the greatest percentage of injuries, followed by Kirschner wires (33.6%), scalpel (22.5%), and bone (17.3%). Only 42% of the residents consistently reported all injuries. Reasons included feelings of no risk (63.1%), too much hassle (58.9%), embarrassment (14.5%), other (8.7%), forgot (5.8%), and unclear what to do (3.3%). Inadequate safety training specific to orthopaedic surgery (odds ratio, 2.32 [95% confidence interval, 1.20 to 4.46]; P = 0.012) and greater training seniority (odds ratio, 2.04 [95% confidence interval, 1.64 to 2.52]; P < 0.0001) were associated with acquiring five or more sharps injuries. DISCUSSION: Sharps injuries are a prevalent and concerning reality for orthopaedic surgical trainees. Despite this common occurrence, only 42% of the residents always reported their injuries. Inadequate training specific to orthopaedic surgery and each subsequent year of postgraduate training are associated with increased sharps injuries. STUDY TYPE: Level III, retrospective observational survey.

Diagnosis and Prevention of Periprosthetic Joint Infections.

The Diagnosis and Prevention of Periprosthetic Joint Infections Clinical Practice Guideline is based on a systematic review of current scientific and clinical research. Through analysis of the current best evidence, this guideline seeks to evaluate strategies to mitigate the risk of periprosthetic joint infection (PJI) in hip and knee arthroplasty and identify best practices in the diagnostic evaluation for these infections. Twenty-five recommendations related to prevention and diagnosis of PJI are presented. In addition, the work group highlighted areas for needed additional research when evidence proved lacking on the topic and carefully reviewed the rationale behind the recommendations while also noting potential harms or risks associated with implementation.

Acute Workplace Hazards in Orthopedic Surgery: Resident Survey Regarding Splash and Workplace Violence Events.

INTRODUCTION: Orthopedic surgery residents are at risk for daily work-related hazards and exposures. Hazards related specific to this specialty includes radiation exposure, smoke inhalation (from electrocautery), and disease transmission through contact with surgical instruments or sharps during procedures. However, minimal research has been focused on other occupational hazard risks in orthopedic surgery including surgical splash events and workplace violence. This study focused on determining (1) whether or not use of protective eyewear in the workplace would be related to the availability of personal protective equipment (PPE); (2) resident education; and (3) the rate of workplace violence toward orthopedic surgery residents during their training. METHODS: An invitation to participate in a web-based, anonymous survey to 46 US allopathic orthopedic surgery residency programs (1207 potential resident respondents). The survey was conceptually divided into the following areas: (1) demographics; (2) training and attitudes concerning occupational hazards; (3) PPE provision and use; (4) sharps injuries and reporting; and (5) general safety knowledge and violence in the workplace. Those who answered yes to having a splatter event or receiving a threat at the hospital were compared to those who did not. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between these outcomes and selected independent variables of interest. p-Values of <0.05 were considered statistically significant. RESULTS: From January 18 to March 31, 2016, 518 surveys were received and included for analysis for a response rate of 42.9% (518/1207). One survey was excluded from analysis due to <50% completed response items. Self-reported program types were 64.5% (334/518) public university-affiliated, 23.2% (120/518) private university affiliated, 7.1% (37/518) community, and 5.2% (27/518) military. Residents were 83.0% = male and 17.0% = female. Overall, reported eye protection usage was 95% amongst all residents and 22% of residents reported experiencing a violent threat in the workplace. The risk of experiencing a splatter event was not statistically associated with residency type, gender, or geographic region. Senior residents were at an increased likelihood of experiencing a splatter event (OR 1.22, [95% CI 1.06-1.41], p = 0.006) when compared to PGY-1 residents. The risk of a violent experience at work was not statistically associated with residency type, year of residency training, or gender. Residents in the Northeast were more likely to have a violent experience (OR 2.78 [95% CI 1.41-5.49] p = 0.003). Overall, residents felt that they had adequate training to prevent occupational hazards (mean of 3.9/5 on Likert scale) and respond to hazards (mean of 3.7/5 Likert). CONCLUSIONS: Occupational hazards are not uncommon in orthopedic surgery training with high rates of improper eyewear PPE use and poor awareness of Occupational Safety and Health Administration and AAOS guidelines. Violence in the workplace impacts over one in 4 residents and training programs and hospitals should improve education and report efforts. Continual yearly PPE training and awareness of AAOS guidelines could be intertwined with duty hour and/or case logs in order to ensure residents are exposed to this material on a regular basis.

Accuracy of radiographic determination of the posterior femoral wall integrity in anterior cruciate ligament reconstruction.

OBJECTIVE: To evaluate the accuracy of radiographs in determining integrity of the posterior femoral cortex following ACL reconstruction. METHODS: Fifty adult volunteers undergoing primary arthroscopic transtibial ACL reconstructions were prospectively enrolled into this study. Plain radiographs and fine-cut CT of the operative knee were obtained post-operatively. Three blinded orthopaedic surgeons were asked to measure the distance from the femoral tunnel to the posterior cortex on lateral radiographs. Inter/intra-observer reliabilities were assessed with the interclass correlation coefficient. The true measurement of the posterior wall was determined on CT. For each, a measurement was made at the aperture, 5 mm, and 10 mm along the tunnel. Plain radiographic measurements were compared to the CT measurement of back wall using a paired t-test. RESULTS: All measurements made on the lateral radiograph were significantly different from those from the respective CT scans for each surgeon (p < 0.0001) at all points. When radiographic measurements were compared to CT at the level of the intra-articular aperture, 29 subjects showed violation of the posterior cortex, with only one being identified on plain films. At 5 mm, 7 subjects demonstrated posterior cortical violation, and none were identified on lateral radiographs. The posterior cortex remained intact in all cases at 10 mm. CONCLUSION: Lateral radiographs of the knee are insufficient for evaluation of the posterior cortical integrity following primary ACL reconstruction. Direct visualization of the femoral tunnel remains the gold standard for evaluation of the posterior wall and may be supplemented by CT scan if there remains concern over graft fixation.

What Leads to Lead: Results of a Nationwide Survey Exploring Attitudes and Practices of Orthopaedic Surgery Residents Regarding Radiation Safety.

BACKGROUND: Excessive radiation to health-care providers has been linked to risks of cancer and cataracts, but its negative effects can be substantially reduced by lead aprons, thyroid shields, and leaded glasses. Hospitals are required to provide education and proper personal protective equipment, yet discrepancies exist between recommendations and compliance. This article presents the results of a survey of U.S. orthopaedic surgery residents concerning attitudes toward radiation exposure and personal protective equipment behavior. METHODS: An invitation to participate in a web-based, anonymous survey was distributed to 46 U.S. allopathic orthopaedic surgery residency programs (1,207 potential resident respondents). The survey was conceptually divided into the following areas: demographic characteristics, training and attitudes concerning occupational hazards, personal protective equipment provision and use, and general safety knowledge. Prevalence ratios (PRs) and 95% confidence intervals (CIs) were calculated for the association between these characteristics and compliance with thyroid shield or lead gown wear. RESULTS: In this study, 518 surveys were received, with 1 survey excluded because of insufficient response, leaving 517 surveys for analysis (42.8% response rate). Ninety-eight percent of residents believed that personal protective equipment should be provided by the hospital or residency program. However, provision of personal protective equipment was not universal, with 33.8% reporting none and 54.2% reporting provision of a gown and thyroid shield. The prevalence of leaded glasses usage was 21%. Poor lead gown compliance and thyroid shield wear were associated with difficulty finding the corresponding equipment: PR, 2.51 (95% CI, 1.75 to 3.62; p < 0.001) for poor lead gown compliance and PR, 2.14 (95% CI, 1.46 to 3.16; p < 0.0001) for poor thyroid shield wear. Not being provided with personal protective equipment was also significantly associated with low compliance with both lead gowns (PR, 1.47 [95% CI, 1.04 to 2.08]; p = 0.03) and thyroid shields (PR, 1.69 [95% CI, 1.18 to 2.41]; p = 0.004). Respondents from the Southeast, West, or Midwest had lower compliance with lead gown usage. Forgetting was the number 1 reason to not wear a lead apron (42%). CONCLUSIONS: Radiation exposure is associated with increased risk of serious health problems. Our findings identified that the availability of lead personal protective equipment leads to increased compliance among residents surveyed. In addition to yearly occupational hazard training specific to orthopaedic surgery, greater efforts by residency programs and hospitals are needed to improve access to lead personal protective equipment and compliance for orthopaedic residents.

Occlusion training: pilot study for postoperative lower extremity rehabilitation following primary total knee arthroplasty.

With continued emphasis on the value of healthcare, factors such as quality of life and patient reported outcomes are critical in evaluating high-demand procedures such as knee replacement surgery. Equally important to the surgery itself is maximizing the effectiveness and efficiency of the treatment, both preoperatively and postoperatively, which can have a significant effect the final outcome. Technical outcomes of total knee replacement are generally considered excellent; however, many patients continue to have postoperative pain, functional limitations, and low treatment satisfaction. The recovery process can be difficult and is often prolonged in older patient populations. Blood flow restriction (BFR) training is a resistance exercise performed with a venous tourniquet that stimulates local changes in muscle at low resistance. Herein we report on 3 patients who participated in BFR exercises as an adjunct to their normal physical therapy following total knee arthroplasty.

Liposomal bupivacaine in total hip arthroplasty: Do the results justify the cost?

INTRODUCTION: Liposomal bupivacaine has a paucity of data regarding narcotic requirements and hospital length of stay in comparison to other peri-articular injections, specifically in the total hip arthroplasty (THA) population. METHODS: 69 patients who underwent THA by a single surgeon were divided into two cohorts over a 3 year period in this retrospective study comparing narcotic requirements, hospital length of stay and cost. The study group (n = 29) received liposomal bupivacaine whereas a matched control group (n = 40) received a pharmacy-mixed cocktail in peri-articular structures. Statistical and clinical differences were reported in this unfunded study. RESULTS: No difference was found in hospital length of stay [2.9 days in the study group (range 1-14) versus 3.1 days (range 1-11) in the control group, p = 0.101], however, the study group required less narcotics per day [22.6 mg (range 5-53.3) versus 29 mg (range 6.7-80.8) in the control group, p = 0.045]. The clinical difference between cohorts averaged less than one pill per day of hospitalization. The cost per patient of the local injection was more than 11 times greater in the liposomal bupivacaine group. CONCLUSION: Liposomal bupivacaine demonstrated a statistical improvement in narcotic requirements but not in hospital length of stay in comparison to a control group. The effects of liposomal bupivacaine on narcotic requirements and hospital length of stay may not justify its use in total hip arthroplasty patients given the substantial cost of these injections and the minimal clinical difference in outcomes compared to a more cost-effective injection.

Multimedia Campaign Enhances Orthopaedic Patient Perceptions of Health Care Quality: A Prospective Analysis of Effect at a Military Treatment Facility.

BACKGROUND: The importance of patient satisfaction as a measure of quality has grown with initiatives intended to enhance demand for services, refocus reimbursement paradigms, encourage health care efficiencies, and ultimately improve clinical outcomes. The purpose of our performance improvement project was to (1) characterize the effect of a two-pronged multimedia initiative on patient perceptions of health care quality and satisfaction as assessed by the Army Provider Level Satisfaction Survey (APLSS) and (2) assess for differences in APLSS scores between the surgeons that did and did not participate in the program. METHODS: Baseline APLSS data for our Department of Orthopaedic Surgery were collected and subsequently compared to APLSS results 3 months after the implementation of a department-wide multimedia campaign. The multimedia initiative consisted of two concurrently implemented interventions to the orthopaedic surgery outpatient clinics. One intervention involved placing large-framed posters about the orthopaedic clinic waiting areas on which were written, "We helped write the book," and included pictures of various orthopaedic textbooks of which attending surgeons and/or residents had contributed to as authors. The other intervention provided patients with surgeon "face sheets" upon arrival to their clinic appointments. These sheets included a picture of their attending surgeon, contact information for the surgeon's nurse care coordinator, and a brief biographical sketch of the surgeon's training, clinical interests and expertise, and other information at each surgeon's discretion. FINDINGS: Among APLSS survey results for the orthopaedic surgery clinic including all surgeons, significant increases were observed between baseline data and 3-month data for Top 1 and Top 2 responses to the questions, "How satisfied do you feel about your visit?" and "Did your surgeon listen to you carefully about your concerns and questions?" (p = 0.003 and p = 0.004, respectively). IMPACT: The implementation of a multimedia campaign resulted in significant improvements among indices of orthopaedic patient satisfaction. We believe this model could be used at other military or nonmilitary treatment facilities as a means to engender patients' familiarity with their surgeon and prompt an appreciation for his/her expertise and enhance overall patient perceptions of department-wide health care quality.

Dismounted Blast Injuries in Patients Treated at a Role 3 Military Hospital in Afghanistan: Patterns of Injury and Mortality.

BACKGROUND: The purposes of this study are to define the pattern of injuries sustained by dismounted troops exposed to improvised explosive devices blasts treated at a Role 3 combat support hospital and to assess injury patterns and mortality associated with the mechanism. Our hypothesis was that mortality is associated with pelvic fracture, massive transfusion, high Injury Severity Score (ISS), multiple limb amputations, and transfer from a Role 2 facility. STUDY DESIGN: Retrospective study of 457 patients. Analysis performed on trauma registry data and systematic review of radiographs. RESULTS: 99.9% were men with a median age of 23 years and median ISS 10. 141 patients (30.9%) required massive blood transfusion. Limb amputations were frequently observed injuries, 109 of 172 amputees (63.4%) had a double amputation. 34 subjects (7.4%) had pelvic fractures; majority of pelvic fractures (88%) were unstable (Tile B or C). Risk factors associated with the overall mortality rate of 1.8% were an ISS greater than 15 (odds ratio: 11.5; 95% confidence interval: 1.38, 533; p = 0.009), need for massive transfusion (p < 0.0001), and the presence of a pelvic fracture (odds ratio: 7.63; 95% confidence interval: 1.13, 41.3; p = 0.018). CONCLUSIONS: Dismounted improvised explosive devices blast injuries result in devastating multiple limb amputations and unstable pelvic fractures, which are associated with mortality after initial trauma resuscitation at a Role 3 hospital.

Implementation of TeamSTEPPS at a Level-1 Military Trauma Center: The San Antonio Military Medical Center Experience.

CONTEXT: When a health care system deals with complex trauma patients while simultaneously serving as an educational platform, teamwork and clear communication are imperative. While there are numerous tools and resources available to address the concerns surrounding patient safety, Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) emphasizes a team approach to improve communication among all caregivers and is specifically designed to improve patient safety through improved communication. This article reports the interim results of implementation of TeamSTEPPS in the operating room environment at the most complex and busiest tertiary military trauma center in the Department of Defense in the midst of the longest period of continuous combat operations in US history. METHODS: Data were collected from December 2013 through March 2014 on the number of total cases performed by month, number of debrief surveys submitted for those months, and associated percentage of surveys completed based on case category. RESULTS: The overall compliance rate for the TeamSTEPPS process (from the pre-op brief to the debrief survey completion) was 75.1%. Responses showed a decrease in concerns in all areas during the period of observation. Equipment-related complaints decreased by 48%; instrument-related issues decreased by 29.9%; supply issues decreased by 53.3%; personnel issues decreased by 90.5%; case scheduling issues decreased by 35.7%; and preference card issues decreased by 72.1%. CONCLUSIONS: Our results demonstrate that TeamSTEPPS can be successfully implemented in an integrated level-1 trauma center in the midst of combat casualty care with a greater than 75% overall compliance with TeamSTEPPS briefs. Further study on the sustainability of these results and the effect on operating room safety, productivity, and efficiency is necessary.

Infection Rate of Intramedullary Nailing in Closed Fractures of the Femoral Diaphysis After Temporizing External Fixation in an Austere Environment.

OBJECTIVES: To determine the infection rate of intramedullary (IM) nailing of closed diaphyseal femur fractures after temporary stabilization with external fixation in an austere combat environment. DESIGN: Retrospective case series. SETTING: Iraq and Afghanistan Theater and Military Medical Treatment Centers in the United States and Landstuhl, Germany. PATIENTS: Military personnel who underwent temporizing external fixation of a closed diaphyseal femur fracture (OTA 32) with later conversion to an IM nail between 2003 and 2012. INTERVENTION: Patients were identified from the Joint Theater Trauma Registry and Department of Defense electronic medical record, and a retrospective review was performed. MAIN OUTCOME MEASUREMENTS: Variables measured included age, gender, mechanism of injury, Injury Severity Score, associated injuries (to include thoracic and abdominal injuries), base deficit, history of massive transfusion, date of injury, date and place of external and IM fixations, time to conversion procedure, report of superficial or deep infection, report of fracture union, and date of last follow-up. RESULTS: One hundred twenty-two patients, mean age 25 (18-43) years, sustained 125 closed femoral diaphyseal fractures from May 2003 to July 2012. External fixation was performed at a mean of 0.2 days (median of the day of injury) and a range of 0-3 days. Mean time to IM nail conversion procedure was 6.9 (1-20) days. Infection rate was 2.5%, with a P of 0.188. Average follow-up was 41.4 (12-119) months. CONCLUSIONS: Acceptable low infection rates can be achieved after IM nailing of closed diaphyseal femur fractures treated with initial external fixation in an austere combat environment. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Trauma care at a multinational United Kingdom-led Role 3 combat hospital: resuscitation outcomes from a multidisciplinary approach.

UNLABELLED: Recent conflicts have led significant advancements in casualty care. Facilities serving combat wounded operate in challenging environments. Our purpose is to describe the multidisciplinary resuscitation algorithm utilized at a United Kingdom-led, Role 3 multinational treatment facility in Afghanistan focusing on injury severity and in-hospital mortality. METHODS: Data were extracted from our prospectively collected trauma registry on military members wounded in action. RESULTS: From November 1, 2009 to September 30, 2011, there were 3483 military trauma admissions. Common mechanisms of injury were improvised explosive devices (48%), followed by gunshot wounds (29%). Most patients (83.1%) had an Injury Severity Score (ISS) <15. For patients with complete ISS data, 8.4% had massive transfusion and 6.1% had an initial base deficit >5. Patients admitted with signs of life had a died of wounds rate of 1.8% with an average 1.2 day hospital stay. The mortality rate for patients undergoing massive transfusion was 4.8%, and for patients with a base deficit >5, mortality was 12.3%. Severely injured patients (ISS > 24) had a mortality rate of 16.5%. CONCLUSION: A systematic, multidisciplinary approach to trauma is associated with low in-hospital mortality. The outcomes in this study serve as a measure for future care in Role 3 facilities.