Does Flipping From Prone to Supine for Medial Malleolar Fixation of Trimalleolar Ankle Fractures Improve Results?

There has been a paradigm shift towards fixing the posterior malleolus in trimalleolar ankle fractures. This study evaluated whether a surgeon's preference to intraoperatively flip or not flip patients from prone to supine for medial malleolar fixation following repair of fibular and posterior malleoli impacted surgical outcomes. A retrospective patient cohort treated at a large urban academic center and level 1 trauma center was reviewed to identify all operative trimalleolar ankle fractures initially positioned prone. One hundred and forty-seven patients with mean 12-month follow-up were included and divided based on positioning for medial malleolar fixation, prone or supine (following closure, flip and re-prep, and drape). Data was collected on patient demographics, injury mechanism, perioperative variables, and complication rates. Postoperative reduction films were reviewed by orthopedic traumatologists to grade the accuracy of anatomic fracture reduction. Overall, 74 (50.3%) had the medial malleolus fixed prone, while 73 (49.7%) were flipped and fixed supine. No differences in demographics, injury details, and fracture type existed between the groups. The supine group had a higher rate of initial external fixation (p = .047), longer operative time in minutes (p < .001), and a higher use of plate and screw constructs for medial malleolar fixation (p = .019). There were no differences in clinical and radiographic outcomes and complication rates. This study demonstrated that intraoperative change in positioning for improved medial malleolar visualization in trimalleolar ankle fractures results in longer operative times but similar radiographic and clinical results. The decision of operative position should be based on surgeon comfort.

Surgical repair of large segmental bone loss with the induced membrane technique: patient reported outcomes are comparable to nonunions without bone loss.

OBJECTIVE: To compare the outcomes of patients with segmental bone loss who underwent repair with the induced membrane technique (IMT) with a matched cohort of nonunion fractures without bone loss. DESIGN: Retrospective analysis on prospectively collected data. SETTING: Academic medical center. PATIENTS: Two cohorts of patients, those with upper and lower extremity diaphyseal large segmental bone loss and those with ununited fractures, were enrolled prospectively between 2013 and 2020. Sixteen patients who underwent repair of 17 extremities with segmental diaphyseal or meta-diaphyseal bone defects treated with the induced membrane technique were identified, and matched with 17 patients who were treated for 17 fracture nonunions treated without an induced membrane. Sixteen of the bone defects treated with the induced membrane technique were due to acute bone loss, and the other was a chronic aseptic nonunion. MAIN OUTCOME MEASUREMENTS: Healing rate, time to union, functional outcome scores using the Short Musculoskeletal Functional Assessment (SMFA) and pain assessed by the Visual Analog Scale (VAS). RESULTS: The initial average defect size for patients treated with the induced membrane technique was 8.85 cm. Mean follow-up times were similar with 17.06 ± 10.13 months for patients treated with the IMT, and 20.35 ± 16.68. months for patients treated without the technique. Complete union was achieved in 15/17 (88.2%) of segmental bone loss cases treated with the IMT and 17/17 (100%) of cases repaired without the technique at the latest follow up visit. The average time to union for patients treated with the induced membrane technique was 13.0 ± 8.4 months and 9.64 ± 4.7 months for the matched cohort. There were no significant differences in reported outcomes measured by the SMFA or VAS. Patients treated with the induced membrane technique required more revision surgeries than those not treated with an induced membrane. CONCLUSION: Outcomes following treatment of acute bone loss from the diaphysis of long bones with the induced membrane technique produces clinical and radiographic outcomes similar to those of long bone fracture nonunions without bone loss that go on to heal. LEVEL OF EVIDENCE: III.

Fracture related infection (FRI) of the upper extremity correlates with poor bone and soft tissue healing.

PURPOSE: The purpose of this study was to evaluate the specific course and complication profile following the development of FRI in the upper extremity. METHODS: An IRB-approved retrospective review was conducted on a consecutive series of operatively managed patients within an academic medical center between 1/2010 and 6/2022. Included patients met the following criteria: (1) upper extremity fracture definitively treated with internal fixation (2) development of criteria for suggestive or confirmatory FRI (as per the FRI Consensus Group) and (3) age ≥ 18 years. Baseline demographics, medical history, injury information, infection characteristics, hospital quality measures, and outcomes were recorded. A 3:1 propensity-matched control cohort of patients without FRI was obtained using the same dataset. Univariable analysis was performed to compare the outcomes (rate of nonunion, time to bone healing, need for soft tissue coverage, patient reported joint stiffness at final follow-up) of the FRI vs Non-FRI cohorts. RESULTS: Of 2827 patients treated operatively for an upper extremity fracture, 43 (1.53%) met criteria for suggestive of confirmatory FRI. The successful propensity match (43 FRI, 129 Non-FRI) revealed no differences in demographics, baseline health status, or fracture location. FRI patients underwent more reoperations (p < 0.001), experienced an increased rate of removal of hardware (p < 0.001), and were admitted more frequently following index operation (p < 0.001). The FRI cohort had higher rates of fracture nonunion (p = 0.003), and a prolonged mean time to bone healing in months (8.37 ± 7.29 FRI vs. 4.14 ± 5.75 Non-FRI, p < 0.001). Additionally, the FRI cohort had a greater need for soft tissue coverage throughout their post-operative fracture treatment (p = 0.014). While there was no difference in eventual bone healing (p = 0.250), FRI patients experienced a higher incidence of affected joint stiffness at final follow-up (p < 0.001). CONCLUSION: Patients who develop an FRI of the upper extremity undergo more procedures and experience increased complications throughout their treatment, specifically increased joint stiffness. Despite this, ultimate outcome profiles are similar between patients who experience FRI and those who do not following operative repair of an upper extremity fracture. LEVEL OF EVIDENCE: III.

Under pressure: symptomatic pulmonary hypertension is a predictor of poor outcome following hip fracture.

INTRODUCTION: Pulmonary hypertension (PHTN) is associated with increased morbidity and mortality in noncardiac surgery and elective surgery. This population of patients has a low physiological reserve and is prone to cardiac arrest as a result. This study aims to identify the impact that PHTN has on outcomes among geriatric hip fracture patients. METHODS: A 3:1 propensity-score-matched retrospective case (PHTN)-control (no PHTN [N]) study of hip fracture patients from 2014 to 2022 was performed. Patients were matched utilizing propensity score matching of a validated geriatric trauma risk assessment tool (STTGMA). All patients were reviewed for hospital quality measures and outcomes. Comparative univariable and multivariable analyses were conducted between the two matched cohorts. A sub-analysis compared patients across PHTN severity levels (mild, moderate, severe) based on pulmonary artery systolic pressures (PASP) as measured by transthoracic echocardiogram. RESULTS: PHTN patients (n = 67) experienced a higher rate of inpatient, 30-day, and 1-year mortality, major complications, and 90-day readmissions as compared to the N cohort (n = 201). PHTN patients with a PASP > 60 experienced a significantly higher rate of major complications, need for ICU, longer admission length, and worse 1-year functional outcomes. Pulmonary hypertension was found to be independently associated with a 3.5 × higher rate of 30-day mortality (p = 0.016), 2.7 × higher rate of 1-year mortality (p = 0.008), 2.5 × higher rate of a major inpatient complication (p = 0.028), and 1.2 × higher rate of 90-day readmission (p = 0.044). CONCLUSION: Patients who had a prior diagnosis of pulmonary hypertension before sustaining their hip fracture experienced significantly worse inpatient and post-discharge outcomes. Those with a PASP > 60 mmHg had worse outcomes within the PHTN cohort. Providers must recognize these at-risk patients at the time of arrival to adjust care planning accordingly. LEVEL OF EVIDENCE: III.

Periprosthetic fracture following arthroplasty for femoral neck fracture: is a cemented stem protective?

BACKGROUND: Periprosthetic femoral fractures (PFF) carry significant morbidity following arthroplasty for femoral neck fracture (FNF). This study assessed fracture complications following arthroplasty for FNF and the effect of cement fixation of the femoral component on intraoperative and post-operative PFF. METHODS: Between February 2014 and September 2021, 740 patients with a FNF who underwent arthroplasty were analyzed for demographics, surgical management, use of cement for fixation of the femoral component, and subsequent PFF. Variables were compared with Mann-Whitney or Chi-square as appropriate. Multivariate logistic regression was used to assess independent risk factors associated with intraoperative or post-operative PFF. RESULTS: There were 163 THAs (41% cemented) and 577 HAs (95% cemented). There were 28 PFFs (3.8%): 18 post-operative and 10 intraoperative. Fewer post-operative PFFs occurred with cemented stems (1.63% vs. 6.30%, p = 0.002). Mean time from surgery to presentation with post-operative PFF was 14 months (0-45 months). Mean follow-up time was 10.3 months (range: 0-75.7 months). In multivariate regression, use of cement and THA was independently associated with decreased post-operative PFF (cement: OR 0.112, 95% CI 0.036-0.352, p < 0.001 and THA: OR 0.249, 95% CI 0.064-0.961, p = 0.044). More intraoperative fractures occurred during THA (3.68% vs. 0.69%, p = 0.004) and non-cemented procedures (5.51% vs. 0.49%, p < 0.001). In multivariate regression, use of cement was protective against intraoperative fracture (OR 0.100, CI 0.017-0.571, p = 0.010). CONCLUSIONS: In patients with a FNF treated with arthroplasty, cementing the femoral component is associated with a lower risk of intraoperative and post-operative PFF. Choice of procedure may be based on patient factors and surgeon preference.

No Differences Between White and Non-White Patients in Terms of Care Quality Metrics, Complications, and Death After Hip Fracture Surgery When Standardized Care Pathways Are Used.

BACKGROUND: Many initiatives by medical and public health communities at the national, state, and institutional level have been centered around understanding and analyzing critical determinants of population health with the goal of equitable and nondisparate care. In orthopaedic traumatology, several studies have demonstrated that race and socioeconomic status are associated with differences in care delivery and outcomes of patients with hip fractures. However, studies assessing the effectiveness of methods to address disparities in care delivery, quality metrics, and complications after hip fracture surgery are lacking. QUESTIONS/PURPOSES: (1) Are hospital quality measures (such as delay to surgery, major inpatient complications, intensive care unit admission, and discharge disposition) and outcomes (such as mortality during inpatient stay, within 30 days or within 1 year) similar between White and non-White patients at a single institution in the setting of a standardized hip fracture pathway? (2) What factors correlate with aforementioned hospital quality measures and outcomes under the standardized care pathway? METHODS: In this retrospective, comparative study, we evaluated the records of 1824 patients 55 years of age or older with hip fractures from a low-energy mechanism who were treated at one of four hospitals in our urban academic healthcare system, which includes an orthopaedic tertiary care hospital, from the initiation of a standardized care pathway in October 2014 to March 2020. The standardized 4-day hip fracture pathway is comprised of medicine comanagement of all patients and delineated tasks for doctors, nursing, social work, care managers, and physical and occupational therapy from admission to expected discharge on postoperative day 4. Of the 1824 patients, 98% (1787 of 1824) of patients who had their race recorded in the electronic medical record chart (either by communicating it to a medical provider or by selecting their race from options including White, Black, Hispanic, and Asian in a patient portal of the electronic medical record) were potentially eligible. A total of 14% (249 of 1787) of patients were excluded because they did not have an in-state address. Of the included patients, 5% (70 of 1538) were lost to follow-up at 30 days and 22% (336 of 1538) were lost to follow-up at 1 year. Two groups were established by including all patients selecting White as primary race into the White cohort and all other patients in the non-White cohort. There were 1111 White patients who were 72% (801) female with mean age 82 ± 10 years and 427 non-White patients who were 64% (271) female with mean age 80 ± 11 years. Univariate chi-square and Mann-Whitney U tests of demographics were used to compare White and non-White patients and find factors to control for potentially relevant confounding variables. Multivariable regression analyses were used to control for important baseline between-group differences to (1) determine the correlation of White and non-White race on mortality, inpatient complications, intensive care unit (ICU) admissions, and discharge disposition and (2) assess the correlation of gender, socioeconomic status, insurance payor, and the Score for Trauma Triage in the Geriatric and Middle Aged (STTGMA) trauma risk score with these quality measures and outcomes. RESULTS: After controlling for gender, insurer, socioeconomic status and STTGMA trauma risk score, we found that non-White patients had similar or improved care in terms of mortality and rates of delayed surgery, ICU admission, major complications, and discharge location in the setting of the standardized care pathway. Non-White race was not associated with inpatient (odds ratio 1.1 [95% CI 0.40 to 2.73]; p > 0.99), 30-day (OR 1.0 [95% CI 0.48 to 1.83]; p > 0.99) or 1-year mortality (OR 0.9 [95% CI 0.57 to 1.33]; p > 0.99). Non-White race was not associated with delay to surgery beyond 2 days (OR = 1.1 [95% CI 0.79 to 1.38]; p > 0.99). Non-White race was associated with less frequent ICU admissions (OR 0.6 [95% CI 0.42 to 0.85]; p = 0.03) and fewer major complications (OR 0.5 [95% CI 0.35 to 0.83]; p = 0.047). Non-White race was not associated with discharge to skilled nursing facility (OR 1.0 [95% CI 0.78 to 1.30]; p > 0.99), acute rehabilitation facility (OR 1.0 [95% CI 0.66 to 1.41]; p > 0.99), or home (OR 0.9 [95% CI 0.68 to 1.29]; p > 0.99). Controlled factors other than White versus non-White race were associated with mortality, discharge location, ICU admission, and major complication rate. Notably, the STTGMA trauma risk score was correlated with all endpoints. CONCLUSION: In the context of a hip fracture care pathway that reduces variability from time of presentation through discharge, no differences in mortality, time to surgery, complications, and discharge disposition rates were observed beween White and non-White patients after controlling for baseline differences including trauma risk score. The pathway detailed in this study is one iteration that the authors encourage surgeons to customize and trial at their institutions, with the goal of providing equitable care to patients with hip fractures and reducing healthcare disparities. Future investigations should aim to elucidate the impact of standardized trauma care pathways through the use of the STTGMA trauma risk score as a controlled confounder or randomized trials in comparing standardized to individualized, surgeon-specific care. LEVEL OF EVIDENCE: Level III, therapeutic study.

Subtrochanteric Femur Fractures: Pearls and Pitfalls.

Management of subtrochanteric femur fractures is challenging because of the multiple planes of fracture deformity. Specific techniques starting with patient positioning and appropriate operating room table selection can improve the efficiency of the surgery. Sequential reduction techniques starting with closed methods, percutaneous techniques, and finally open clamping can be performed to obtain anatomic reduction of the fracture. The gold standard implant for definitive fixation is a locked intramedullary nail and overall outcomes are excellent if anatomic alignment and stable fixation is achieved.

Skilled Nursing Facility Following Hip Fracture Arthroplasty Diminishes Care "Value".

BACKGROUND: Value is defined as outcome/cost. The purpose of this study was to analyze differences in the lengths of care, outcomes, and costs between skilled nursing facilities (SNFs) and home with health services (HHS) for patients treated with arthroplasty for femoral neck fracture (FNF). METHODS: Between October 2018 and September 2020, 192 patients eligible for the Comprehensive Care for Joint Replacement bundle program treated for a displaced FNF with total hip arthroplasty (THA) or hemiarthroplasty (HA) and discharged to SNF or HHS were analyzed for demographics, comorbidities, postoperative outcomes, costs of care, and discharge rehabilitation details. Variables were compared using chi-squared or t-tests as appropriate. There were 60 (31%) patients discharged to HHS (37% THA and 63% HA) and 132 (69%) patients discharged to SNF (14% THA and 86% HA). Patients discharged to SNF were older (P < .01), had lower Risk Assessment and Prediction Tool scores (P < .01), had higher comorbidity scores (P = .011), and had longer posthospitalization care (P < .01). RESULTS: There were no differences in rates of inpatient minor complications (P = .520), inpatient major complications (P = .119), Intensive Care Unit admissions (P = .193), or readmissions within 30 (P = .690) and 90 days (P = .176). Costs of care at a SNF were higher than HHS (P < .01). In multivariate regressions, a lower Risk Assessment and Prediction Tool score was associated with discharge to SNF (odds ratio 0.69, 95% confidence interval 0.58-0.83, P < .001). CONCLUSION: Among Comprehensive Care for Joint Replacement bundle patients treated for a displaced FNF with arthroplasty, discharge with HHS may be a more cost-effective option than discharge to a SNF that does not increase risk of readmission in medically appropriate patients.

Microbiome of infected fracture nonunion: Does it affect outcomes?

BACKGROUND: Infected fracture nonunions often require prolonged treatment and recovery courses. It is unclear whether the bacterial microbiome influences the time to healing as well as the eradication of infection. The goals of this study are (1) to assess the bacterial microbiome affecting infected nonunions and (2) to evaluate the effects of bacterial speciation on associated outcomes. METHODS: Between 2006 and 2022, data from 551 adult patients from a single academic institution who presented with a fracture nonunion were analyzed retrospectively for infection. All patients underwent revision surgery with three sets of cultures obtained intra-operatively. Patients with significant intra-operative cultures were grouped into gram-positive and gram-negative culture cohorts. These patients were managed with a standardized protocol involving surgical debridement, nonunion site fixation, and culture-directed antibiotic treatment. Primary outcome was time to fracture union. Secondary outcomes included number of re-operations and eventual amputation or reconstructive surgery. RESULTS: 56 nonunion patients (10 %) were diagnosed with an infected nonunion (44 g-positive, 12 g-negative). Of these, 3 g-positive patients received an amputation or arthroplasty procedure prior to fracture union, and seven were lost to follow-up. There were no significant differences in age, gender, or nonunion site between cohorts. Most nonunions occurred in the lower extremity. The most common bacteria were staph species (54.3 %). 36 g-positive and 10 g-negative patients achieved fracture union. Time to union was on average 158.4 days longer in the gram-negative cohort-but did not reach statistical significance (446.8 days gram-positive, 662.3 days gram-negative, p = 0.69). There was no difference in re-operation rates (1.9 % gram-positive, 2.2 % gram-negative, p = 0.84). CONCLUSIONS: Patients with infected nonunions had wide-ranging bacterial contamination that were treated successfully using a standardized protocol. However, patients with any gram-negative culture trended toward a delay in time to union.

Nonunion of conservatively treated humeral shaft fractures is not associated with anatomic location and fracture pattern.

INTRODUCTION: Humeral shaft fractures make up 1-3% of all fractures and are most often treated nonoperatively; rates of union have been suggested to be greater than 85%. It has been postulated that proximal third fractures are more susceptible to nonunion development; however, current evidence is conflicting and presented in small cohorts. It is our hypothesis that anatomic site of fracture and fracture pattern are not associated with development of nonunion. MATERIALS AND METHODS: In a retrospective cohort study, 147 consecutive patients treated nonoperatively for a humeral shaft fracture were assessed for development of nonunion during their treatment course. Their charts were reviewed for demographic and radiographic parameters such as age, sex, current tobacco use, diabetic comorbidity, fracture location, fracture pattern, AO/OTA classification, and need for intervention for nonunion. RESULTS: One hundred and forty-seven patients with 147 nonoperatively treated humeral shaft fractures were eligible for this study and included: 39 distal, 65 middle, and 43 proximal third fractures. One hundred and twenty-six patients healed their fractures by a mean 16 ± 6.4 weeks. Of the 21 patients who developed a nonunion, two were of the distal third, 10 of the middle third, and nine were of the proximal third. In a binomial logistic regression analysis, there were no differences in age, sex, tobacco use, diabetic comorbidity, fracture pattern, anatomic location, and OTA fracture classification between patients in the union and nonunion cohorts. CONCLUSIONS: Fracture pattern and anatomic location of nonoperatively treated humeral shaft fractures were not related to development of fracture nonunion.

The standardized exploration of the radial nerve during humeral shaft fixation reduces the incidence of iatrogenic palsy.

BACKGROUND: The purpose of this study is to determine if a standardized protocol for radial nerve handling during humeral shaft repair reduces the incidence of iatrogenic nerve palsy post operatively. METHODS: Seventy-three patients were identified who underwent acute or reconstructive humeral shaft repair with radial nerve exploration as part of the primary procedure for either humeral shaft fracture or nonunion. All patients exhibited intact radial nerve function pre-operatively. A retrospective chart review and analysis identified patients who developed a secondary radial nerve palsy post-operatively. In each case, the radial nerve was identified and mobilized for protection, regardless of whether the implant necessitated the extensile exposure. RESULTS: Fractures were classified according to AO/OTA guidelines and included 23 Type 12A, 11 Type 12B, and 3 Type 12C. Eight patients had periprosthetic fractures and 28 fractures could not be classified. All patients in the cohort were fixed with locking plates. Surgery was indicated for 36 patients with humeral nonunions and 37 patients with acute humeral shaft fractures. Of the 73 patients, 2 (2.7%) developed radial nerve palsy following surgery, one from the posterior approach and one from the anterolateral approach. Both patients exhibited complete recovery of radial nerve function by 6-month follow-up. No significant differences (p > 0.05) were found in any demographic or surgical details between those with and without radial nerve injury. CONCLUSIONS: Nerve exploration identification and protection leads to a low incidence of transient radial nerve palsy compared to the rate reported in the current literature (2.7% compared to 6-24%). Thus, radial nerve exploration and mobilization should be considered when approaching the humeral shaft for acute fracture and nonunion repairs. LEVEL OF EVIDENCE: Level III.

Screws Alone for Acute Lisfranc Injuries Fixed Without Arthrodesis: A Better "Value" Than Plating in the Short Term.

This study compares outcomes of patients with Lisfranc injuries treated with screw only fixation constructs to those treated with dorsal plate and screw constructs. Seventy patients who underwent surgical treatment for acute Lisfranc injury without arthrodesis and minimum 6-month (mean >1-year) follow-up were identified. Demographics, surgical information, and radiographic imaging were reviewed. Cost data were compared. The primary outcome measure was the American Orthopedic Foot and Ankle Surgery (AOFAS) midfoot score. Univariate analysis through independent sample t tests, Mann-Whitney U, and chi-squared compared the populations. Twenty-three (33%) patients were treated with plate constructs and 47 (67%) with screw only fixation. The plate group was older (49 ± 18 vs 40 ± 16 years, p = .029). More screw constructs treated isolated medial column injuries compared to plate constructs (92% vs 65%, p = .006). At latest follow-up (mean 14 ± 13 months), all tarsometatarsal joints were aligned. There was no difference in AOFAS midfoot scores. Plate patients experienced longer operations (131 ± 70 vs 75 ± 31 minutes, p < .001) and tourniquet time (101 ± 41 vs 69 ± 25 minutes, p = .001). Plate constructs were more expensive than screw ($2.3X ± $2.3X vs $X ± $0.4X, p < .001) ($X is the mean cost of screws alone). Plate patients had a higher incidence of wound complications (13% vs 0%, p = .012). Treatment of Lisfranc fracture dislocation injuries with screws only demonstrated a higher value procedure as similar outcomes were found amidst lower implant costs. Screw only fixation required a shorter operative and tourniquet time with less frequent wound complications. Screw only fixations proved mechanically sound enough to achieve goals of repair without inferior outcomes.

Fixed-angle plate fixation and autogenous iliac crest graft for repair of distal metaphyseal femoral nonunion.

PURPOSE: To analyze clinical, radiographic and patient-reported outcomes of distal metaphyseal femoral nonunions treated with fixed-angle plates and screws. METHODS: All patients presenting with a distal metaphyseal femoral fracture nonunion repaired with fixed-angle plating from one urban level 1 trauma center and an orthopedic specialty hospital were identified. Baseline demographic, injury information, and outcomes (healing rates, Short Musculoskeletal Function Assessment, range of motion, and post-operative pain levels) at 12 months following nonunion repair were collected. Outcomes were evaluated between patients fixed with a blade plate and with a locking plate. RESULTS: Of these 31 patients, 27 (87.1%) healed after their index nonunion surgery, 2 (6.5%) healed after one reoperation, 1 (3.2%) healed after 2 reoperations, and 1 (3.2%) had a persistent nonunion but did not want further treatment. At one-year follow-up, the group demonstrated a significant improvement in functional recovery with a mean difference of 14.5 points (p = 0.007) when compared to status before fixed-angle fixation of the nonunion. There was also a significant change in patient-reported pain levels using the VAS scale with a mean difference of 2.0 points (p = 0.009). At one-year follow-up, 11 (39.3%) had full knee range of motion (0-130), 11 (39.3%) had flexion greater than 90 and less than 120°, and 6 (21.4%) had range of motion less than 90°. CONCLUSION: Patients who undergo fixed angle plating and autogenous bone grafting for distal femoral metapyseal nonunions demonstrate improved functional outcomes and VAS pain score at one year follow up.

Can we predict size, Haraguchi type and preoperative displacement of posterior malleolar fractures in association with tibial shaft fractures?

PURPOSE: To (1) determine if any injury characteristics or radiographic parameters of tibial shaft fractures (TSFs) could predict posterior malleolar fracture (PMF) size, and (2) identify characteristics of PMFs that were fixed versus those that were not in a cohort of ipsilateral TSFs that underwent intramedullary nailing. METHODS: A cross-sectional radiographic study was performed at a single academic institution. Demographic and radiographic parameters of TSFs were recorded, including fracture obliquity angle (FOA) and distance from distal extent of fracture to plafond (DFP). Using CT, the PMFs were evaluated for Haraguchi classification, size measurements, and preoperative displacement. Multivariate regression analysis was used to identify independent predictors of PMF Harachuchi classification, size parameters, and preoperative displacement. Univariate differences between PMF that were fixed and not fixed were identified. RESULTS: 47 (50%) PMF underwent surgical fixation with 47 treated conservatively. There were no demographic differences between groups. Multivariate linear regression demonstrated increasing DFP and high energy injury mechanism as independent variables correlated with plafond surface area involvement, PMF height and width on sagittal CT cuts. Increasing DFP alone was correlated with PMF width on axial CT cuts and extent > 50% into incisura. Haraguchi type II fractures were associated with high energy injury mechanism (OR = 4.2 [95% CI = 1.3-14.5]; p = 0.02). Odds of Haraguchi type 3 fractures increased 9% per increased year of age (OR = 1.09 [95% CI = 1.04-1.16]; p = 0.006) and decreased 13% per 1% increase in relative DFP (OR = 0.87 [95% CI = 0.75-0.98]; p = 0.04). CONCLUSIONS: An increasing DFP of TSFs and high energy injury mechanism were independent predictors of PMF size, and high energy injury mechanism was also correlated with Haraguchi type II fracture patterns. Increasing age and decreasing DFP of TSFs predict Haraguchi type III PMF patterns. These radiographic parameters should prompt surgeons to plan for fixation in scenarios in which CT scan is not available. LEVEL OF EVIDENCE: Diagnostic Level III.

Fracture obliquity angle and distance from plafond: novel radiographic predictors of posterior malleolar involvement in tibial shaft fractures.

BACKGROUND: The purpose of this study was to identify specific radiographic parameters that are predictive of associated PM fractures in TSFs. METHODS: All TSFs presenting over a 6-year period were identified. A review of plain radiographs and CT scans included: identification of an isolated PM fracture, AO/OTA classification, measurements of the fracture obliquity angle (FOA), absolute and relative distance from distal extent of fracture to plafond (DFP and DFP%), and presence and level of associated fibular fractures. Patients with and without PM fractures were compared. Multivariate logistic regression determined independent correlates of PM fractures and cutoff values for FOA and DFP%. RESULTS: A total of 405 TSFs in 397 patients were identified, and 94 TSFs (23.2%) had an associated PM fracture. The majority (85.1%) of TSFs with PM fractures were AO/OTA type 42-A1, 42-B1 or 42-C1 (p < 0.001). The mean FOA was 60.9 ± 12.1° in the PM group versus 40.8 ± 18.9° in the non-PM group (p < 0.001). The mean DFP was 5.9 ± 2.7 cm in the PM group versus 11.9 ± 7.9 cm in the non-PM group (p < 0.001). Multivariate regression demonstrated that AO/OTA classification type 42-A1, 42-B1 or 42-C1 (OR 4.7 [95% CI 2.4-9.8]; p < 0.001), FOA greater than 45° (OR 4.4 [95% CI 1.9-10.9]; p = 0.001) and fracture extension to the distal third of the tibia (DFP% < 33%; OR 18.3 [95% CI 3.8-330.4]; p = 0.005) were independent correlates of PMs fractures regardless of mechanism of injury or fibula fracture presence or location (AUROC 0.83 [95% CI 0.80-0.87]). Separate multivariate regression showed for every 1° increase in FOA, PM fracture odds increase 6% per degree and for every 1 cm increase in DFP odds of PM fracture decreased by 15%. CONCLUSIONS: Spiral fractures (simple, wedge or complex), fracture angles greater than 45° and extension into the distal 1/3 of the tibial shaft are independent predictors of PM fractures in TSFs regardless of mechanism of injury.

Does a hip fracture mean we should we operate on a concomitant proximal humerus fracture?

BACKGROUND: Concomitant upper extremity and hip fractures present a challenge in postoperative mobilization in the geriatric population. Operative fixation of proximal humerus fractures allows for upper extremity weight bearing. This retrospective study compared outcomes between operative and non-operative proximal humerus fracture patients with concomitant hip fractures. METHODS: A trauma database of 13,396 patients age > 55 years old was queried for concomitant hip and proximal humerus fracture patients between 2014-2021. Medical records were reviewed for demographics, hospital quality measures, Neer classification, morphine milligram equivalents (MME), and outcomes. All hip fractures were treated operatively. Patients were grouped based on operative vs. non-operative treatment of their proximal humerus fracture. Primary outcomes included comparing postoperative ambulatory status, pain, length of stay (LOS), intensive care unit (ICU) need, discharge disposition, and readmission rates. RESULTS: Forty-eight patients (0.4%) met inclusion criteria. Twelve patients (25%) underwent operative treatment for their proximal humerus fracture and 36 (75%) received non-operative treatment. Patients with operative fixations were younger (p < 0.01), had more complex Neer classifications (p = 0.031), more likely to be community ambulators (p < 0.01), and required more inpatient MMEs (p < 0.01). There were no differences in LOS (p = 0.415), need for ICU (p = 0.718), discharge location (p = 0.497), 30-day readmission (p = 0.228), or 90-day readmission (p = 0.135) between cohorts. At 6 months postoperatively, among community or household ambulators, a higher percentage of operative patients returned to their baseline ambulatory functional status, however, this was not significant (70% vs. 52%, p = 0.342). There were three deaths in the non-operative cohort and no deaths in the operative cohort. CONCLUSION: Patients with hip fractures and concomitant proximal humerus fractures treated operatively required more inpatient MMEs and trended toward maintaining baseline ambulatory function. There were no differences in inpatient LOS, ICU need, discharge location, or readmissions. Future larger, multicenter studies are needed to further delineate if operative repair of concomitant proximal humerus fractures provides a benefit in the geriatric population.

Decreasing Postoperative Opioid Prescriptions After Orthopedic Trauma Surgery: The "Lopioid" Protocol.

OBJECTIVE: To assess the effectiveness of a multimodal analgesic regimen containing "safer" opioid and non-narcotic pain medications in decreasing opioid prescriptions after surgical fixation in orthopedic trauma. DESIGN: Retrospective cohort study. SETTING: One urban, academic medical center. SUBJECTS: Patients with traumatic fracture from 2018 (n=848) and 2019 (n=931). METHODS: In 2019, our orthopedic trauma division began a standardized protocol of postoperative pain medications that included 50 mg of tramadol four times daily, 15 mg of meloxicam once daily, 200 mg gabapentin twice daily, and 1 g of acetaminophen every 6 hours as needed. This multimodal regimen was dubbed the "Lopioid" protocol. We compared patients who received this protocol with all patients from the prior year who had followed a standard protocol that included Schedule II narcotics. RESULTS: Greater mean morphine milligram equivalents were prescribed at discharge from fracture surgery under the standard protocol than under the Lopioid protocol (252.3 vs 150.0; P < 0.001), and there was a difference in the type of opioid medication prescribed (P < 0.001). There was a difference in the number of refills filled for patients discharged with opioids after surgical treatment between the standard and Lopioid cohorts (0.31 vs 0.21; P = 0.002). There were no differences in the types of medication-related complications (P = 0.710) or the need for formal pain management consults (P = 0.199), but patients in the Lopioid cohort had lower pain scores at discharge (2.2 vs 2.7; P = 0.001). CONCLUSIONS: The Lopioid protocol was effective in decreasing the amount of Schedule II narcotics prescribed at discharge and the number of opioid refills after orthopedic surgery for fractures.

Hip-preserving surgery for nonunion about the hip.

INTRODUCTION: Nonunions about the hip occur as a result of femoral neck, intertrochanteric, and certain subtrochanteric fractures. Treatment of a hip fracture nonunion allows for the choice between hip preservation or arthroplasty. The goal of this study was to examine outcomes of hip-preservation nonunion surgery METHODS: Patients who underwent hip preservation for a fracture nonunion of the femoral neck, intertrochanteric and subtrochanteric region to 1 cm below the lesser trochanter over a 10-year period were identified in our nonunion registry. Patients were followed for a minimum of 1 year. Functional outcomes were recorded at follow-up visits. For comparison regarding surgical and hospital outcomes, a group of 23 patients who underwent conversion total hip arthroplasties (cTHA) at the same academic medical center was reviewed. Quality measures such as length of stay, reoperation, and complications were collected. All statistics analysis utilized IBM SPSS 25 (Armonk, NY) RESULTS: Thirty patients who underwent 30 hip-preserving nonunion surgeries were analyzed and compared with 23 cTHA patients. Twenty-nine nonunions went on to heal (average time to union 6.3 months). There was improvement in functional outcome scores for the hip preservation group between baseline and latest follow-up (p < 0.001). Reoperation was required in five patients (17%), including four failed to heal and required a second repair to gain union and one failure that was converted to THA rather than attempt a second nonunion repair. Hip preservation failures were older than those that healed with the index treatment (p = 0.11). There was no significant difference in hospital length of stay, complication rate, or need for reoperation when compared to cTHA group. CONCLUSION: Hip-preserving surgery is an option that should be considered for patients with nonunion of fractures about the hip. The rates of complications (20.3 vs 17.3%) and reoperation (16.7 vs 17.3%) were equivalent to conversion THA. Excellent outcomes can be achieved in terms of radiographic union and function with hip preservation.

Autogenous iliac crest bone grafting for tibial nonunions revisited: does approach matter?

BACKGROUND: Tibial nonunion remains a considerable burden for patients and the surgeons who treat them. In recent years, alternatives to autogenous grafts for the treatment of tibial nonunions have been sought. The purpose of this study was to evaluate the efficacy of autogenous iliac crest bone graft (ICBG) in the treatment of tibial shaft nonunions. MATERIAL AND METHODS: Sixty-nine patients were identified who underwent ICBG for repair of atrophic or oligotrophic tibial nonunion and had complete data with at least one year of follow-up (mean 27.9 months). Surgical treatments consisted of revision/supplemental fixation ± ICBG. Surgical approaches for graft placement were either posterolateral (PL), anterolateral (AL), or direct medial (DM). Healing status, time to union, postoperative pain, and functional outcomes were assessed. RESULTS: Bony union was achieved by 97.1% (67/69) of patients at a mean time of 7.8 ± 3.2 months postoperatively. There was no significant difference in mean time to union between the three surgical approach groups: (PL (44.9%) = 7.3 months, AL (20.3%) = 9.2 months, DM (34.8%) = 7.6 months; p = 0.22). Intraoperative cultures obtained at the time of nonunion surgery were positive in 27.5% of patients (19/69). Positive cultures were associated with need for secondary surgery as 8/19 patients (42.1%) with positive cultures required re-operation. Two out of four patients that developed iliac donor site hematomas/infections requiring washout had positive intraoperative cultures as well. There was no difference in final SMFA among the three surgical approach groups. CONCLUSIONS: Autogenous ICBG remains the gold standard in the management of persistent tibial nonunions regardless of surgical approach. There is a small risk for complication at the iliac crest donor site. Given the high union rate, autogenous iliac crest bone grafting for tibial nonunion remains the gold standard for this difficult condition. LEVEL OF EVIDENCE: Level III.

Nail plate combination in the upper extremity: surgical technique and clinical application.

Nail plate constructs (NPC) have shown promising results in complex lower extremity peri-articular fractures as well as in peri-prosthetic fractures. The combination of both implants allows for improved mechanical stability and immediate weight bearing. The use of NPC has not been described in the upper extremity in the literature. We herein describe potential indications and surgical technique for NPC usage for complex upper extremity trauma and reconstruction.