The performance of PROMIS computer adaptive testing for patient-reported outcomes in hip fracture surgery: a pilot study.

INTRODUCTION: Patient-reported outcome measures (PROMs) are essential to patient-centered care in orthopaedics. PROMIS measures have demonstrated reliability, validity, responsiveness, and minimal floor and ceiling effects in various populations of patients receiving orthopaedic care but have not yet been examined in hip fracture patients. This pilot study sought to evaluate the psychometric performance of the PROMIS Physical Function (PROMIS PF) and Pain Interference (PROMIS PI) computer adaptive tests and compare these instruments with legacy outcome measures in hip fracture patients. METHODS: This study included 67 patients who were 27-96 years old (median 76) and underwent osteosynthesis for a proximal femoral fracture. At 3, 6, and/or 12 months follow-up, patients completed both legacy (mHHS, SF-36-PCS, and VAS for pain) and PROMIS questionnaires (PROMIS PF and PROMIS PI). Respondent burden and floor/ceiling effects were calculated for each outcome measure. Correlation was calculated to determine concurrent validity between related constructs. RESULTS: A strong correlation was found between PROMIS PF and mHHS (rho = 0.715, p < 0.001) and moderately strong correlation between PROMIS PF and SF-36 PCS (rho = 0.697, p < 0.001). There was also a moderately strong correlation between the VAS and the PROMIS PI (rho = 0.641, p < 0.001). Patients who completed PROMIS PF were required to answer significantly fewer questions as compared with legacy PROMs (mHHS, SF-36). For the PROMIS measures, 1% of patients completing PROMIS PF achieved the highest allowable score while 34% of patients completing PROMIS PI achieved the lowest allowable score. Of the legacy outcome measures, 31% of patients completing the VAS for pain achieved the lowest allowable score and 7% of patients completing the mHHS achieved the highest allowable score. CONCLUSIONS: The results of this study support the validity of PROMIS CATs for use in hip fracture patients. The PROMIS PF was significantly correlated with SF-36 PCS and mHHS while requiring fewer question items per patient relative to the legacy outcome measures.

Atypical fracture with long-term bisphosphonate therapy is associated with altered cortical composition and reduced fracture resistance.

Bisphosphonates are the most widely prescribed pharmacologic treatment for osteoporosis and reduce fracture risk in postmenopausal women by up to 50%. However, in the past decade these drugs have been associated with atypical femoral fractures (AFFs), rare fractures with a transverse, brittle morphology. The unusual fracture morphology suggests that bisphosphonate treatment may impair toughening mechanisms in cortical bone. The objective of this study was to compare the compositional and mechanical properties of bone biopsies from bisphosphonate-treated patients with AFFs to those from patients with typical osteoporotic fractures with and without bisphosphonate treatment. Biopsies of proximal femoral cortical bone adjacent to the fracture site were obtained from postmenopausal women during fracture repair surgery (fracture groups, n = 33) or total hip arthroplasty (nonfracture groups, n = 17). Patients were allocated to five groups based on fracture morphology and history of bisphosphonate treatment [+BIS Atypical: n = 12, BIS duration: 8.2 (3.0) y; +BIS Typical: n = 10, 7.7 (5.0) y; +BIS Nonfx: n = 5, 6.4 (3.5) y; -BIS Typical: n = 11; -BIS Nonfx: n = 12]. Vibrational spectroscopy and nanoindentation showed that tissue from bisphosphonate-treated women with atypical fractures was harder and more mineralized than that from bisphosphonate-treated women with typical osteoporotic fractures. In addition, fracture mechanics measurements showed that tissue from patients treated with bisphosphonates had deficits in fracture toughness, with lower crack-initiation toughness and less crack deflection at osteonal boundaries than that of bisphosphonate-naïve patients. Together, these results suggest a deficit in intrinsic and extrinsic toughening mechanisms, which contribute to AFFs in patients treated with long-term bisphosphonates.

Sagittal ankle position does not affect axial CT measurements of the syndesmosis in a cadaveric model.

BACKGROUND: The purpose of this study was to evaluate the effect of ankle plantarflexion and the axial location of measurement on quantitative syndesmosis assessment. METHODS: Twelve fresh-frozen cadaveric specimens were secured in three positions of ankle plantarflexion (0°, 15°, and 30°) using an ankle-spanning external fixator and underwent CT scans at each position. Syndesmotic measurements were obtained on axial images using three previously described methods (six measurements) at the level of the tibial plafond and 1 cm proximal to the plafond. Method 1 evaluated the distance between the most anterior and posterior aspects of the fibula and tibia. Method 2 measured medial-lateral diastasis of the anterior and posterior aspects of the fibula, and fibular anterior-posterior translation. Method 3 evaluated axial rotation of the fibula. All measurements were performed by two independent observers. Inter-rater reliability of each measurement was evaluated using intra-class coefficients. Repeated measures analysis of variance (RM-ANOVA) was performed to evaluate within-specimen differences in measurements obtained at varying ankle positions. RESULTS: The anterior incisura component of method 1 demonstrated poor-to-moderate inter-rater reliability across all ankle positions and at both measurement locations. Inter-rater reliability was highest for method 2, especially when measured 1 cm proximal to the plafond. Method 3 demonstrated moderate reliability 1 cm proximal to the plafond. After correcting for multiple comparisons, RM-ANOVA and pairwise analysis revealed that none of the measurements changed significantly with varying ankle position. CONCLUSION: The inter-rater reliability of the most common method of syndesmotic evaluation (method 1) was found to be lower than in previous studies. The most reliable syndesmotic evaluation can be made by measuring diastasis and anteroposterior translation 1 cm proximal to the plafond (method 2). Ankle position from 0° to 30° of plantarflexion did not change the measurements obtained. LEVEL OF EVIDENCE: IV.

Clinical Outcomes of Hyperplantarflexion Variant Compared With Supination External Rotation Ankle Fractures: A Matched-Cohort Analysis.

Recent literature has reported an uncategorized hyperplantarflexion variant ankle fracture characterized by a posteromedial fragment separate from the posterior or medial malleolar fragments. The current study sought to determine whether the outcomes for surgically treated hyperplantarflexion variant fractures are similar to the more common supination external rotation (SER) IV fractures. A prospective registry of operatively treated ankle fractures was queried to create 2 age- and gender-matched cohorts: hyperplantarflexion variant and SER IV fractures. Each cohort had 23 patients (18 females), and matched pairs were within 2 years of age at the date of surgery. Patient demographics, comorbidities, and Foot and Ankle Outcomes Scores at minimum 12 months after the index surgery were compared. The cohorts were similar with respect to body mass index, the length of the clinical follow-up, medical comorbidities, dislocation rate, and postoperative articular incongruity (p > .05). Patient-reported outcomes demonstrated no statistically or clinically significant differences within any domain and were as follows: symptoms (70.8 versus 77.8, p = .11), pain (80.7 versus 85.0, p = .33), activities of daily living (83.7 versus 89.2, p = .23), sports (67.4 versus 73.4, p = .33), and quality of life (57.3 versus 63.9, p = .24) for the hyperplantarflexion and SER IV groups, respectively. No significant differences were found in the rang`e of motion for dorsiflexion (17.7° versus 18.1°, p = .52) or for plantarflexion (48.6° versus 47.1°, p = .71). Patients treated surgically for hyperplantarflexion variant ankle fractures have similar 1-year clinical outcomes when compared with the more common SER IV fracture patterns, provided that the injury is correctly identified preoperatively and treated appropriately.

Validating the Patient Reported Outcomes Measurement Information System (PROMIS) computerized adaptive tests for upper extremity fracture care.

BACKGROUND: Computerized adaptive testing (CAT) for patient-reported outcomes (PROs) is a developing area within orthopedic surgery. Our objective was to validate the Patient Reported Outcomes Measurement Information System (PROMIS) CATs for upper extremity fracture care. We sought to correlate PROMIS with legacy PROs and to investigate floor and ceiling effects. METHODS: Patients who underwent open reduction and internal fixation of upper extremity trauma were prospectively enrolled. Legacy PROs included the visual analog scale for pain, the Disabilities of the Arm, Shoulder and Hand questionnaire, the University of California-Los Angeles Shoulder Rating Scale, the Mayo Elbow Performance Score, and the 36-Item Short Form Health Survey. PROMIS CATs included Physical Function (PROMIS PF), PROMIS Pain Interference (PROMIS Pain), and PROMIS Upper Extremity (PROMIS UE). Correlations between the PROs were calculated as were the absolute and relative floor and ceiling effect. RESULTS: The study prospectively enrolled 174 patients with upper extremity trauma. There was moderate to high correlation between PROMIS UE CAT and legacy upper extremity-specific PROs (ρ = 0.42-0.79), and high correlation between the PROMIS PF CAT and the 36-Item Short Form Health Survey Physical Component Summary (ρ = 0.71, P < .001). The visual analog scale for pain, University of California-Los Angeles Shoulder Rating Scale, Constant Score, and Mayo Elbow Score demonstrated a significant absolute ceiling effect (20.5%-23.7%), whereas the PROMIS PF, PROMIS UE, and PROMIS Pain CATs demonstrated no absolute ceiling effect. CONCLUSION: PROMIS PF, Pain, and UE correlate well with legacy PROs in a upper extremity trauma population, with less absolute floor or ceiling effects. This study provides preliminary evidence for the utility of PROMIS CATs in upper extremity trauma patients.

Bone density correlates with clinical outcomes after ankle fracture fixation.

INTRODUCTION: Osteoporosis and decreased bone density are known to increase fracture incidence and severity. Although much is known regarding the effects of bone density on fracture risk and the treatment options for prevention of fragility fractures, whether bone quality alters clinical outcomes after fracture fixation is unknown. The purpose of this study was to determine whether bone quality correlates with clinical outcomes after fracture fixation. MATERIALS AND METHODS: A prospective database of all operatively treated ankle fractures by a single surgeon from 2003 to 2013 was used to identify patients. All patients included in the study had preoperative computed tomography (CT) imaging of the injured ankle and postoperative CT imaging of the contralateral ankle. Hounsfield unit (HU) measurement values were determined by placing an elliptical region of interest confined to the cancellous metaphyseal region of the distal tibia and fibula. The primary and secondary clinical outcomes included Foot and Ankle Outcome Scores (FAOS) and ankle range of motion (ROM). Included patients had at least 12 months of clinical outcome data. RESULTS: Sixty-four patients met the inclusion criteria. Comparison of HU values from the injured and contralateral side demonstrated almost perfect agreement (ICC(2,1) = 0.938), suggesting that HU values can be accurately measured in the setting of a fracture. Increased HU values of the injured distal tibia and fibula significantly correlated with improved outcomes in four of five FAOS domains, including pain, activities of daily living, sports, and quality of life (beta = 0.285-0.344; P ≤ 0.05 for all). Range of motion outcomes did not significantly correlate with HU values. CONCLUSIONS: Our results suggest that decreased bone quality, as measured using preoperative CT, significantly correlates with inferior short-term clinical outcomes. These results have significant implications for integrating bone quality into treatment algorithms for fracture patients.

The Use of Fibular Allograft in Complex Periarticular Fractures Around the Knee.

Although the use of fibular strut allografts in proximal humerus fractures has gained popularity, their use in other types of fractures is less well described. Fibular allografts have recently been used in the repair of complex periarticular fractures of the proximal tibia and distal femur. Fibular allografts can be inserted in a variety of manners to achieve goals specific to each individual fracture pattern. In the proximal tibia, insertion through a fracture line or cortical window facilitates joint surface elevation, prevents subsidence and enhances overall construct stability. In distal femoral fractures, including complex periarticular fractures, insertion through the fracture or cortical window permits indirect reduction of the medial cortex and provides necessary medial column support. An additional option in distal femur fractures includes fibula insertion as an intramedullary nail, allowing enhanced fixation in short distal fracture segments. In all cases, the use of a fibular allograft augments poor bone stock and provides improved screw purchase and construct stability when combined with conventional plating methods. Here we present a series of cases at our institution illustrating an array of novel techniques utilizing endosteal fibular allografts in the fixation of complex periarticular fractures about the knee.

An alternative technique for greater tuberosity fractures: use of the mesh plate.

INTRODUCTION: Isolated greater tuberosity (GT) fractures (AO 11-A1) tend to occur in the younger patient population and are poorly managed by most precontoured proximal humerus locking plates. The goal of this study was to identify and assess an alternative treatment strategy for greater tuberosity fractures. MATERIALS AND METHODS: A retrospective review of all cases of isolated greater tuberosity fractures treated with a 2.4/2.7 mesh plate (Synthes) between 2010 and 2015 was conducted. Patient demographics, operative reports, and clinical notes were reviewed. The time to radiographic union was assessed. Clinical outcomes were retrieved from patients at their follow-up visits or via mailed Disabilities of the Arm, Shoulder, Hand (DASH) questionnaires. RESULTS: Ten patients with isolated GT fractures treated with mesh plating were identified with an average age of 47.1 years. The average radiographic follow-up was 7.2 months and the average clinical follow-up was 8.0 months. The mean time to union was 8.5 weeks. Two patients underwent elective hardware removal. The mean DASH at final follow-up was 28.2 (±22.4), while the mean DASH work was 13.6 (±19.1). CONCLUSION: We have identified a viable alternative treatment option for the surgical management of isolated greater tuberosity fractures using a mesh plate that can be contoured to the patient's anatomy. Surgeons should be aware of this option for select patients.

Do clinical outcomes correlate with bone density after open reduction and internal fixation of tibial plateau fractures.

INTRODUCTION: The operative management of tibial plateau fractures in elderly patients has historically led to inconsistent results, and these clinical outcomes were thought to be associated with poor bone quality often in elderly patients. The goal of this study was to investigate the relationship between bone density and subjective clinical outcome scores after open reduction and internal fixation of tibial plateau fractures. MATERIALS AND METHODS: This is a retrospective cohort study from a single-surgeon conducted at an Academic, Level 1 Trauma Center. A preoperative computed tomography (CT) scan was obtained for all patients. Bone density of the distal femur was quantified with Hounsfield units (HU) as measured on axial CT scans. Inter-rater reliability of HU measurements was assessed using interclass correlation coefficients. Regression models controlling for age were used to identify relationships between bone density (HU) and the following variables: articular subsidence and 1-year subjective clinical outcomes scores [Knee Outcome Survey Activities of Daily Living Scale (KOS-ADLS), and Short-Form-36 (SF-36) physical and mental component scores (PCS, MCS)]. RESULTS: Sixty-one patients with a mean age of 59.3 years (range 27-85 years) and a minimum of 12 months of clinical follow-up were included in the study. The majority of the fractures (32 of 61) were classified as Schatzker II tibial plateau fractures, and there were 13 Schatzker V fractures, 11 Schatzker VI fractures, 2 Schatzker IV fractures and 1 Schatzker 1 fracture. HU measurements demonstrated an almost perfect inter-observer reliability (ICC = 0.97). Age was negatively correlated with HU measurements (r = -0.51, p < 0.001), and using a geriatric cut-off of 65 years of age, the geriatric group had a lower mean HU compared to the non-geriatric group (78.2 versus 114.8, p = 0.018). There was no significant relationship between bone quality, as assessed by distal femoral HU, and any subjective clinical outcome score. CONCLUSIONS: Inferior bone mineral density alone does not appear to affect clinical outcomes 1 year postoperatively when bone grafting is used to restore osseous voids. Poor bone quality should not be used as an indication for non-operative management of tibial plateau fractures.

Focal osteonecrosis in the femoral head following stable anatomic fixation of displaced femoral neck fractures.

INTRODUCTION: Femoral head (FH) osteonecrosis (ON) and subsequent segmental collapse is a major concern following displaced femoral neck fractures (FNF). We aimed to quantify residual perfusion to the FH following FNF and evaluate the viability of the FH overtime after surgical fixation. MATERIALS AND METHODS: Twenty-three patients with FNF underwent dynamic contrast-enhanced (DCE)-MRI to estimate bone perfusion in the FH, using the contralateral side as control. Following open anatomic reduction and a length/angle-stable fixation, a special MRI sequence evaluated the FH for ON changes over time at 3 and 12 months after surgery. RESULTS: We found significant compromise of both arterial inflow [83.1%-initial area under the curve (IAUC) and 73.8%-peak) and venous outflow (243.2%-elimination rate (K el)] in the FH of the fractured side. The supero-medial quadrant suffered the greatest decrease in arterial inflow with a significant decrease of 71.6% (IAUC) and 68.5% (peak). Post-operative MRI revealed a high rate (87%-20/23) of small ON segments within the FH, and all developed in the anterior aspect of the supero-medial quadrants. Fracture characteristics, including subcapital FNF, varus deformity, posterior roll-off ≥20° and Pauwel's angle of 30°-50° demonstrated a greater decrease in perfusion compared to contralateral controls. CONCLUSION: FNF significantly impaired the vascular supply to the FH, resulting in high incidence of small ON segments in the supero-medial quadrant of the FH. However, maintained perfusion, probably through the inferior retinacular system, coupled with urgent open anatomic reduction and stable fixation resulted in excellent clinical and radiographic outcomes despite a high rate of small ON segments noted on MRI. LEVEL OF EVIDENCE: Level I: Prognostic Investigation.

Comminuted olecranon fractures: biomechanical testing of locked versus minifragment non-locked plate fixation.

INTRODUCTION: Open reduction and internal fixation has long been accepted as optimal treatment for displaced olecranon fractures based on poor results seen with conservative management. With the presence of comminution, tension-band wiring constructs are contraindicated due to tendency to compress through fragments, thereby shortening the articular segment. Therefore, plate fixation is typically employed. Our hypothesis was that in a comminuted fracture model, 2.7 mm reconstruction plating without locking screws will perform equally to 3.5 mm locked plating in terms of fracture displacement and rotation (shear). MATERIALS AND METHODS: A three-part comminuted olecranon fracture pattern was created in nine matched pairs of cadaveric specimen using an oscillating saw in standardized, reproducible fashion. Each matched pair was then randomized to receive either 2.7 mm reconstruction plating or 3.5 mm proximal ulna locked plating. Random allocation software was used to assign the 2.7 mm plate construct to either the right or left side of each pair with the contralateral receiving the 3.5 mm plate construct. Specimens were cyclically loaded simulating passive range of motion exercises commonly performed during rehabilitation. Displacement and rotation in relation to the long axis of the ulna were measured through motion capture. Fragment gapping and rotation was quantified following 100 cycles at 10 N and again following 100 cycles at 500 N. RESULTS: No significant differences were detected between the 2.7 and 3.5 mm plates in fracture rotation or gapping following loads at 10 N (0.5° and 0.7°; 0.6 and 1.2 mm; respectively; p > 0.05) or 500 N (2.3° and 1.6°; 3.8 and 3.1 mm; respectively; p > 0.05) loading. Fragment rotation and gapping were positively correlated within each plate construct (R 2 > 0.445; p < 0.05). CONCLUSIONS: 2.7 mm plating is an alternative to 3.5 mm locked plating with decreased plate prominence without significantly sacrificing displacement and rotational control. This is beneficial in fracture patterns where the traditional dorsal plating does not offer optimal screw trajectory.

Surgical Exposure Trends and Controversies in Extremity Fracture Care.

Surgical exposures for the management of extremity fractures continue to evolve. Strategies to achieve satisfactory articular reconstitution require surgeons to have an appreciation and understanding of various conventional and contemporary surgical approaches. The recent literature has witnessed a surge in studies on surgical approaches for the fixation of extremity fractures. This increased interest in surgical exposures resulted from not only a desire to enhance outcomes and minimize complications but also a recognition of the inadequacies of traditionally accepted surgical exposures. Contemporary exposures may be modifications or combinations of existing exposures. All surgical exposures require proper surgical execution and familiarity with regional anatomic structures. Exposures, whether conventional or contemporary, must provide sufficient access for reduction and implant insertion. Proper exposure selection can greatly enhance a surgeon's ability to achieve acceptable reduction and adequate fixation. Unique characteristics of both the patient and his or her fracture pathoanatomy may dictate the surgical approach. Patient positioning, imaging access, and concomitant comorbidities (medical, systemic trauma, and regional extremity related) also must be considered. Minimally invasive methods of reduction and fixation are attractive and have merit; however, adherence to them while failing to achieve satisfactory reduction and fixation will not generate a desirable outcome. Surgeons should be aware of several site-specific anatomic regions in which evolving surgical exposures and strategies for extremity fracture management have had favorable outcomes.

Quantitative assessment of patellar vascularity following bone-patellar tendon-bone autograft harvest for ACL reconstruction.

PURPOSE: Recent anatomic studies have suggested that the dominant arterial supply of the patella enters through the inferior pole. Based upon these findings, we hypothesized that bone-patellar tendon-bone graft harvest can significantly diminish patellar vascularity. METHODS: Nine matched pair cadaveric knee specimens (mean age 47.4 years) were dissected and cannulated. A single knee was selected to undergo routine graft harvest, and the contralateral knee was left intact to serve as a control. Gadolinium was injected, and magnetic resonance imaging (MRI) signal enhancement was quantified to determine differences in uptake. Each matched pair was subsequently injected with a urethane polymer compound and dissected to correlate vessel disruption with MRI findings. RESULTS: We identified two predominating patterns of vessel entry. In one pattern, the vessel entered the inferomedial aspect (five o'clock/right, seven o'clock/left) of the patella and was disrupted by graft harvest in 2/9 (22.2 %) pairs. In the second pattern, the vessel entered further medial (four o'clock/right, eight o'clock/left) and was not disrupted (7/9, 78.8 %). The mean decrease in gadolinium uptake following disruption of the predominant vessel measured 56.2 % (range 42.6-69.5 %) compared to an average decrease of 18.3 % (range 7.1-29.1 %) when the dominant arterial supply to the inferior pole remained intact (p < 0.04). CONCLUSION: Medial entry of the predominant vessel precluded vessel disruption. Disruption of the dominant arterial supply can result in a significant decrease in patellar vascularity. Modification of graft harvest techniques and areas of surgical dissection should be explored to minimize vascular insult. Further correlation with clinical studies/outcomes is necessary to determine a potential association between vascular insult and anterior knee pain.

Perioperative vitamin D levels correlate with clinical outcomes after ankle fracture fixation.

INTRODUCTION: Hypovitaminosis D is common in patients undergoing orthopaedic trauma surgery. While previous studies have shown that vitamin D levels correlate with functional outcome after hip fracture surgery, the significance of vitamin D levels on outcomes after surgery in other orthopaedic trauma patients is unknown. The purpose of this study was to determine if vitamin D levels correlated with outcomes in ankle fracture patients. MATERIALS AND METHODS: We reviewed a prospective registry of patients who underwent operative treatment for ankle fractures from 2003 to 2012. Preoperative serum 25-hydroxyvitamin D (25[OH]D) levels were measured, and the primary and secondary outcomes included foot and ankle outcome scores (FAOS) and ankle range of motion. Data were also collected on patient comorbidities, articular malreductions, and wound complications. Included patients had at least 12 months of clinical outcome data. RESULTS: Ninety-eight patients operatively treated for ankle fractures met our inclusion criteria. Of these 98 patients, 36 (37%) were deficient in vitamin D (<20 ng/ml) and 31 (32%) had vitamin D insufficiency (<30 ng/ml, ≥20 mg/ml). Patients with vitamin D deficiency were similar with regard to age, gender, and comorbidities compared to patients with vitamin D levels ≥20. Univariate analysis revealed that patients with vitamin D deficiency had significantly worse FAOS with regard to symptoms (P = 0.017) and quality of life (P = 0.040) domains than patients with vitamin D levels ≥20. Multivariate regression analysis suggested that vitamin D deficiency was a factor in inferior FAOS with regard to symptoms, activities of daily living, and quality of life. CONCLUSIONS: In our group of patients with operative treated ankle fractures, preoperative vitamin D deficiency correlated with inferior clinical outcomes at a minimum of 1 year follow-up. Our study suggests that deficient vitamin D levels may result in worse outcomes in orthopaedic trauma patients recovering from fracture fixation.

The triceps-sparing posterior approach to plating humeral shaft fractures results in a high rate of union and low incidence of complications.

INTRODUCTION: The optimal treatment of humeral shaft fractures continues to be debated. In the current investigation, we sought to determine the clinical and radiographic outcomes following the plate fixation of humeral shaft fractures utilizing the triceps-sparing posterior approach. MATERIALS AND METHODS: A retrospective review identified a consecutive series of 66 humeral shaft fractures (OTA 12-A, 12-B, or 12-C) treated with dual plate fixation via a posterior, triceps-sparing approach between 2005 and 2014 by a single surgeon. Demographics, operative reports, clinical follow-up, and preoperative radiographs were reviewed. Postoperative radiographs were assessed for angular deformity and time to union. Range of motion and strength testing were also reviewed. RESULTS: A total of 66 humeral shaft fractures were reviewed with a mean clinical follow-up of 8.0 months. The mean time to union was 15.6 ± 11.1 weeks, and there was one case of delayed union. Seventeen of 66 (25.8 %) patients presented with a primary radial nerve palsy following injury, and 14 of the 17 (82 %) of the preoperative radial nerve palsies fully resolved at an average of 31 weeks following injury. Two additional patients developed radial nerve palsies postoperatively (3.0 %). CONCLUSION: This is a large consecutive series of humeral shaft fractures treated with plating through a posterior approach by a single surgeon. The triceps-sparing posterior approach to the humerus results in high union rates and a low incidence of secondary radial nerve palsy. LEVEL OF EVIDENCE: Level IV, Case Series.

Plate fixation and bone grafting of distal clavicle nonunions: radiologic and functional outcomes.

INTRODUCTION: The optimal treatment for distal clavicle nonunions remains unknown. Small series have reported outcomes following distal fragment excision and various fixation techniques. We present the clinical, radiographic and functional outcomes after superior plating or double (superior and anteroinferior) plating in combination with bone grafting as treatment for distal clavicle nonunions. METHODS: We collected demographic and radiographic data from a consecutive series of ten patients with symptomatic nonunion of the distal clavicle treated since 1998. Functional outcomes were assessed, as well as the visual analogue scale (VAS) score. RESULTS: The mean clinical follow-up was 41.4 months (range of 12-158 months). The mean radiological follow-up was 30.6 months (range of 3-158 months). All nonunions healed as demonstrated by subsidence of clinical symptoms and radiographic criteria. The average time to union was 3.7 months (range of 2-8 months). The mean The Disabilities of the Arm, Shoulder and Hand (DASH) score was 11.9 (range of 0-62.5) and mean VAS score was 0.9 at follow-up. CONCLUSION: This study illustrates good clinical, radiologic and functional outcomes in ten patients with distal clavicle nonunion treated with superior or double (superior and anteroinferior) plating in combination with bone grafting. Double-plating can be considered an alternative to superior plating offering better resistance against the pulling effect of the arm with the use of smaller fixation plates.

Dislocation is a risk factor for poor outcome after supination external rotation type ankle fractures.

INTRODUCTION: Ankle fractures are one of the most common fractures requiring surgical treatment. Ankle fracture-dislocations are significant injuries to the osseous and soft tissue envelope, but studies focused on the effect of dislocation on radiographic and functional outcomes are lacking. The objective of this study was to evaluate the effect of dislocations on postoperative outcomes in SER IV ankle fracture patients. MATERIALS AND METHODS: From 2004 through 2010, all operative SER IV ankle fractures treated by a single surgeon were enrolled in a prospective database. SER IV ankle fractures were separated into two groups based on clinical or radiographic evidence of dislocation. The primary and secondary functional outcomes measures were the Foot and Ankle Outcome Score (FAOS) and ankle and subtalar range of motion (ROM) with a minimum of 1-year follow-up, respectively. RESULTS: 108 patients with SER IV ankle fractures were identified, with 73 in the non-dislocation group (68%) and 35 patients in the dislocation group (32%). Patient demographics and co-morbidities were similar between the two groups. The incidence of open fractures and the application of an external fixator were significantly higher in the dislocation group (p = 0.037 and p = 0.003, respectively). The dislocation group showed a significant decrease in the accuracy of articular reduction (p = 0.003). At a mean follow-up of 21 months, ankle fracture-dislocation patients had increased pain (p = 0.005) and decreased activities of daily living (p = 0.014) on FAOS outcome measures and significantly worse ankle and subtalar ROM. CONCLUSIONS: The results of this study suggest that concurrent dislocation at time of ankle fracture is associated with worse radiographic and functional outcomes, but not an increase in superficial or deep infection. The results from this study may be helpful in counseling patients regarding expected clinical outcomes after ankle fracture-dislocation and in the surgical management of this complex injury.

Regional analysis of femoral head perfusion following displaced fractures of the femoral neck.

PURPOSE: To assess regional variations in the arterial and venous blood supply to the femoral head following displaced fracture of the femoral neck using dynamic contrast enhanced (DCE)-MRI quadrant analysis. MATERIALS AND METHODS: A total of 27 subjects with displaced femoral neck fractures were enrolled in the study. Quadrant specific DCE-MRI perfusion analysis was performed on a 1.5 Tesla MRI scanner. Simultaneous imaging of control and displaced fractured hips was done for comparison. RESULTS: Quadrant specific decreases were found in the arterial (A (0.52 versus 0.27; P = 5.7E-13), Akep (1.0/min(-1) versus 0.41/min(-1) ; P = 1.3E-9) and venous (kel (0.05/min(-1) versus -0.02/min(-1) ; P = 5.1E-5) supply to the femoral head between control and injured sides using a two-factor analysis of variance test. The fractional perfusion (initial area under the curve) in the supero/inferolateral quadrants was 49% min/54% min, in the supero/inferomedial quadrants was 43% min/46% min and for the total femoral head was 39% min on the fracture versus control sides. CONCLUSION: Quadrant specific decreases in arterial and venous perfusion on the fracture side were observed when compared with control.

Geriatric proximal humeral fracture patients show similar clinical outcomes to non-geriatric patients after osteosynthesis with endosteal fibular strut allograft augmentation.

BACKGROUND: Osteosynthesis of proximal humeral fractures is challenging in geriatric patients. The purpose of this investigation was to compare postoperative clinical outcomes between cohorts of geriatric (aged ≥65 years) and non-geriatric proximal humeral fracture patients treated via locked plating with endosteal fibular strut allograft augmentation. METHODS: From March 2007 to January 2013, 71 adult patients with 2-, 3-, and 4-part proximal humeral fractures according to the Neer classification underwent osteosynthesis with locked plating and fibular allograft augmentation and had at least 12 months of clinical follow-up. All patients followed the same postoperative rehabilitation protocol. We compared the following between geriatric and non-geriatric patients: Disabilities of the Arm, Shoulder and Hand scores; University of California, Los Angeles shoulder ratings; Constant-Murley scores; and range of motion; as well as injury characteristics and radiographic outcomes. RESULTS: Geriatric patients comprised 48% of the study cohort (34 of 71 patients). The mean age of the geriatric and non-geriatric cohorts was 74 years and 53 years, respectively. Geriatric patients showed significantly reduced forward flexion (147° vs 159°, P = .04) when compared with non-geriatric patients. There were no significant differences in functional scores, radiographic outcomes, or complication rates between the 2 cohorts, although in 1 geriatric patient, osteonecrosis developed and screw penetration through the collapsed head was present 3 years after surgery. CONCLUSIONS: Osteosynthesis of proximal humeral fractures via locked plating with fibular strut allograft augmentation results in similar clinical outcomes between geriatric and non-geriatric patients. We believe that enhanced stability provided by this fixation construct allows early intensive postoperative therapy and results in excellent outcomes despite patient age.

Elective removal of implants after open reduction and internal fixation of Tibial Plateau fractures improves clinical outcomes.

INTRODUCTION: Tibial plateau fractures are common injuries often treated with open reduction and internal fixation. We have noted improved patient satisfaction following implant removal for these patients. The purpose of this study was to assess the effect of removal of surgical implants after union on patient reported outcomes. MATERIALS AND METHODS: All patients at our Level 1 Trauma Center undergoing open reduction an internal fixation by the senior surgeon are offered enrollment into a prospective registry and have clinical outcomes recorded at follow-up [Knee Outcomes Survey (KOS), Lower Extremity Functional Scale (LEFS), Short Form-36 Physical and Mental Component Summary (SF-36 PCS, SF-36 MCS), and Visual analog pain scale (VAS)]. Routinely, removal of surgical implants is offered after fracture union resulting in two cohorts: those who had undergone elective removal of surgical implants and those who had not. Outcome scores were compared before and after implant removal as well as between the two study populations at final follow-up. RESULTS: Seventy-five patients were identified as having 12 month outcome scores: 36 (48%) had retained implants; 39 (52%) had implants removed. KOS and LEFS outcomes improved significantly after implant removal (p < 0.05). Clinical outcomes (KOS, SF-36 PCS) were also significantly better in patients who had implants removed compared to those that did not at final follow-up (p < 0.05). There was no statistical difference seen in VAS pain scores. CONCLUSIONS: The results of this study indicate that patients who have elective removal of their surgical implants after open reduction and internal fixation of a tibial plateau fracture have improved clinical outcomes after removal and also demonstrate significantly better outcomes than those who have retained implants at final follow-up. Patients who are unhappy with their clinical result should be counseled that removal of the implant may improve function, but may not improve pain.