Adult Reconstruction Studies Presented at AAOS and AAHKS 2011-2015 Annual Meetings. Is There a Difference in Future Publication?

BACKGROUND: The purpose of this study was to compare adult reconstruction abstracts presented at the American Academy of Orthopaedic Surgeons (AAOS) and the American Association of Hip and Knee Surgeons (AAHKS) annual meetings. METHODS: A total of 1355 podium and 1731 poster presentations from the adult reconstruction sections of the AAOS and AAHKS meetings from 2011 to 2015 were reviewed for publication in peer-reviewed literature. Authors who were added or removed from the original abstract and the final manuscript were recorded. The corresponding journals were assigned the most recent impact factor. The publication rates for each annual meeting, the mean changes in authorship and journal's impact factors were compared. RESULTS: There were 2129 abstracts presented at AAOS and 957 abstracts presented at AAHKS. The overall publication rate was different between AAOS and AAHKS (56% vs 60%, P = .030). Compared with AAOS, there were more AAHKS abstracts published in 2011 (57% vs 77%, P = .0008) and 2012 (57% vs 76%, P = .0001); however, there were no significant differences in 2013, 2014, or 2015. The mean overall change in authors was lower for AAOS compared with AAHKS abstracts (0.78 vs 1.06, P < .0001). The mean journal's impact factors for AAOS and AAHKS publications were also similar (2.86 vs 2.85, P = .874). CONCLUSION: AAOS and AAHKS abstracts presented in the adult reconstruction subspecialty had a similar overall rate of publication, change in authorship, and impact factor. It would be beneficial if further studies subdivided these into basic and clinical science and review articles.

A Single-Center Experience With a Titanium Modular Neck Total Hip Arthroplasty.

BACKGROUND: Added modular junction has been associated with implant-related failures. We report our experience with a titanium-titanium modular neck-stem interface to assess complications, possible clinical factors influencing use of neck modularity, and whether modularity reduced the incidence of dislocation. METHODS: A total of 809 total hip arthroplasties completed between 2005 and 2012 from a prospectively collected database were reviewed. The mean follow-up interval was 5.7 years (3.3-10.3 years). Forty-five percent were male (360 of 809), and 55% were female (449 of 809). All stems were uncemented PROFEMUR TL (titanium, flat-tapered, wedge) or PROFEMUR Z (titanium, rectangular, dual-tapered) with a titanium neck. RESULTS: Increased modularity (anteverted/retroverted and anteverted/retroverted varus/valgus (anteverted/retroverted + anteverted/retroverted varus/valgus) was used in 39.4% (135 of 343) of cases using the posterior approach compared with 6.8% (20 of 293) of anterior and 23.7% (41 of 173) of lateral approaches. Four males sustained neck fractures at a mean of 95.5 months (69.3-115.6 months) after primary surgery. Overall dislocation rate was 1.1% (9 of 809). The posterior approach had both the highest utilization of increased modularity and the highest dislocation rate (2.3%), of which the most were recurrent. The anterior (0.3%) and lateral (0%) approaches had lower dislocation rates with no recurrences. CONCLUSION: At a mean 5.7 years, our experience demonstrates a low neck fracture (0.5%) and a low dislocation rate (1.1%). Use of increased modularity may not improve dislocation risk for the posterior approach. Continued surveillance of this group will be necessary to determine long term survivorship of this modular titanium implant.

Hip fusion takedown to a total hip arthroplasty-is it worth it? A systematic review.

INTRODUCTION: Patients with surgically or spontaneously fused hips are often dissatisfied with their overall function and the debilitating effect on adjacent joints. Therefore, in properly selected patients, hip fusion-takedown and conversion to total hip arthroplasty (THA) can result in improved function and decreased pain. We aimed to (1) evaluate the indications for conversion, (2) evaluate the clinical outcomes, (3) analyze the overall complications, and (4) identify the overall satisfaction following the procedure. METHODS: A systematic and comprehensive literature search was performed to analyze studies evaluating conversion of hip fusion to THA. After reviewing 3,882 studies, 27 total studies (1,104 hips) met our inclusion/exclusion criteria and were included in our final analysis. A weighted mean of rates was determined for each complication, including infection, instability, loosening, nerve-related, abductor-related, venous thrombotic event, and revision. RESULTS: The study population consisted of 53.2% male and 46.8% female subjects. The mean age at time of conversion was 52 years (range 36-65 years), the mean time until follow-up was 9.2 years (range 2.5-17.3), and the mean duration of arthrodesis was 27.7 years (range 11-40.2). As measured by Harris Hip Score, overall clinical outcomes improved from 58.1 points (range 42.4-70 points) pre-operatively to 80.0 (range 62-93.5) post-operatively. The specific complication rates were 5.3% (range 0-43.6%) for infection, 2.6% (range 0-15.4%) for instability, 6.2% (range 0-17.2%) for loosening, 4.7% (range 0-13%) for nerve-related complications, 13.1% (range 0-87%) for abductor-related complications, and 1.2% (range 0-13%) for venous thrombotic events. The revision rate was 12.0% (range 0-43.6%). CONCLUSION: Takedown of a fused-hip can be a challenging procedure. Although patients can benefit functionally, both patients and surgeons need to be aware of the complications and increased risk of further revision procedures, which should be an important part of the pre-operative discussion.

Management of Ankle Fractures With Syndesmotic Disruption: A Survey of Orthopaedic Surgeons.

INTRODUCTION: With no current "gold standard" fixation strategy for syndesmotic injuries and differences in preferred preoperative and intraoperative diagnostic techniques and criteria, methods of reduction, fixation constructs, and postoperative management, the goals of this study were to determine how orthopaedic surgeons currently manage ankle fractures with concomitant syndesmotic disruption, as well as to identify surgeon demographics predictive of syndesmotic management techniques. METHODS: This study was conducted as a web-based survey of foot and ankle fellowship-trained surgeons, Orthopaedic Trauma Association (OTA) members, and Canadian Orthopaedic Association (COA) members. The survey, sent and completed via the HIPAA-compliant Research Electronic Data Capture (REDCap) system, consisted of 18 questions: 6 surgeon demographic questions and 12 specific syndesmotic management questions regarding perioperative protocols and syndesmotic fixation construct techniques. RESULTS: One hundred and ten orthopaedic surgeons completed our survey. Years of practice and type of fellowship were found to be the variables that influenced perioperative syndesmotic management strategies the most, while a number of fractures operated on per year, country of practice, and practice setting also influenced management decisions. Additionally, 59% (65/110) surgeons indicated that the way they have managed syndesmotic injuries has changed at some point in their career, while 33% (36/110) specified that they could foresee themselves changing their management of these injuries in the future. CONCLUSIONS: There was significant variability among responders in preoperative and intraoperative assessment technique, fixation construct, screw removal protocol, and postoperative weightbearing protocol. This study raises awareness of differences in and factors predictive of management strategies and should be used for further discussion when determining a potential gold standard for the management of these complex injuries.

Length of stay and 30-day readmissions after isolated humeral shaft fracture open reduction and internal fixation compared to intramedullary nailing.

INTRODUCTION: Open reduction with internal fixation (ORIF) and intramedullary nailing (IMN) have similar union rates for treating humerus shaft fractures, but IMN leads to increased incidence of shoulder impingement and reoperation. The difference in 30-day readmission rate and length of stay (LOS) between these procedures is unknown. The objective of the study was to compare 30-day unplanned readmissions and length of stay between humeral shaft fractures fixed with either ORIF or IMN. METHODS: The nationwide readmissions database (NRD) was queried for patients with humeral shaft fractures treated with ORIF or IMN between 2015-2016. IMN cases were propensity matched to ORIF cases based on demographic and co-morbid variables. Multivariable logistic regression determined if treatment modality was an independent risk factor for 30-day readmission or length of stay >3 days. RESULTS: There were 406 patients treated with IMN matched to 406 patients treated with ORIF. The 30-day readmission rate was 6.4% for IMN and 4.9% for ORIF (p = 0.45), and the median LOS was 3 days for each group (p = 0.45). Congestive heart failure (CHF)(OR=2.7, p = 0.04), depression (OR=3.3, p = 0.0008), and electrolyte abnormality (OR=3.6, p = 0.0003) were independent risk factors for readmission. Older age (OR=1.02, p = 0.03), CHF (OR=2.4, p = 0.03), electrolyte abnormality (OR=2.6, p = 0.0001), obesity (OR=2.8, p<0.0001), Medicaid (OR=2.1, p = 0.04), discharge to a facility (OR = 5.2, p<0.0001), discharge with home health services (OR=2.4, p = 0.0003), and open fracture (OR=2.3, p = 0.01) were independent risk factors for LOS >3 days. Procedure (ORIF vs. IMN) was not a predictor of 30-day readmission or LOS >3 days. CONCLUSION: Comorbid conditions are risk factors for 30-day readmission and increased LOS. Comorbidity, discharge disposition, and open fractures are risk factors for increased LOS. Treating humeral shaft fractures with either ORIF or IMN did not affect readmission or length of stay.

Radial Nerve Sensory Branch Anatomical Variant: A Case Report and Literature Review.

CASE: Two patients sustained comminuted extra-articular distal humerus fractures. One patient was neurovascularly intact preoperatively. The other patient had a complete radial motor palsy with preserved sensation. Intraoperatively, both exhibited anatomic variants of the radial sensory nerve of the arm that pierced the triceps rather than branching from the distal third of the radial nerve proper, as is traditionally reported. CONCLUSIONS: Although rare, variations in the radial nerve may exist about the distal humerus. Surgeons should be aware of these variations to avoid iatrogenic injury.

Current Concepts in Talar Neck Fracture Management.

PURPOSE OF THE REVIEW: Talar neck fractures are a rare but potentially devastating injury, which require a comprehensive understanding of the unique osteology, vasculature, and surrounding anatomy to recognize pathology and treat correctly. The purpose of this article is to describe both classic and current literature to better understand the evolution of talar neck fracture management. RECENT FINDINGS: Urgent reduction of displaced fractures and dislocations remains the standard of care to protect the soft tissue envelope and neurovascular structures. Delayed definitive fixation has proven to be safe. CT is the imaging modality of choice to fully identify the fracture pattern and associated injuries. Anatomic reduction and restoration of the peritalar articular surfaces are the pillars of talar neck fracture treatment. Dual incision approach with plate and screw fixation has become the modern surgical strategy of choice to accomplish these goals. Although complications such as osteonecrosis (ON) and posttraumatic arthritis (PTA) can still occur at high rates, treatment should be dictated by patient symptoms. Talar neck fractures pose treatment challenges with both initial injury and potential sequelae. Future research will determine whether modern treatment algorithms will decrease complication rate and improve patient outcome.

Guiding Device for the Patellar Cut in Total Knee Arthroplasty: Design and Validation.

An incorrect cut of the patella (kneecap) during total knee arthroplasty, affects the thickness in different quadrants of the patella, leading to pain and poor function. Because of the disadvantages of existing devices, many surgeons choose to perform the cut freehand. Given this mistrust of existing devices, a quick, but accurate, method is needed that guides the cut, without constraining the surgeon. A novel device is described that allows the surgeon to mark a line at the desired cutting plane parallel to the front (anterior) surface using a cautery tool, remove the device, and then align the saw guide, reamer, or freehand saw with the marked line to cut the patella. The device was tested on 36 artificial patellae, custom-molded from two shapes considered easier and harder to resect accurately, and eight paired cadaveric specimens, each in comparison to the conventional saw guide technique. The mediolateral angle, superoinferior angle, difference from intended thickness, and time were comparable or better for the new device. Addressing the remaining outliers should be possible through additional design changes. Use of this guidance device has the potential to improve patellar resection accuracy, as well as provide training to residents and a double-check and feedback tool for expert surgeons.

Comparison of outcomes after triceps split versus sparing surgery for extra-articular distal humerus fractures.

OBJECTIVES: To compare elbow range of motion (ROM), triceps extension strength, and functional outcome of AO/OTA type A distal humerus fractures treated with a triceps-split or -sparing approach. DESIGN: Retrospective review. SETTING: Two level one trauma centres. PATIENTS: Sixty adult distal humerus fractures (AO/OTA 13A2, 13A3) presenting between 2008 and 2012 were reviewed. Exclusion criteria removed 18 total patients from analysis and three patients died before final follow-up. INTERVENTION: Patients were divided into two surgical approach groups chosen by the treating surgeon: triceps split (16 patients) or triceps sparing (23 patients). MAIN OUTCOME MEASUREMENTS: Elbow ROM and triceps extension strength testing were completed in patients after fractures had healed. All patients were also given the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. RESULTS: Compared to the triceps-split cohort, the triceps-sparing cohort had greater elbow flexion (sparing 143 ± 7° compared to split 130 ± 12°, p=0.03) and less extension contracture (sparing 6 ± 8° compared to split 23 ± 4°, p<0.0001). Triceps strength compared to the uninjured arm also favoured the triceps-sparing cohort (sparing 88.9 ± 28.3% compared to split 49.4 ± 17.0%, p=0.007). DASH scores were not statistically significant between the two cohorts (sparing 14.5 ± 12.2 compared to split 23.6 ± 22.3, p=0.333). CONCLUSIONS: A triceps-sparing approach for surgical treatment of extra-articular distal humerus fractures can result in better elbow ROM and triceps strength than a triceps-splitting approach. Both approaches, however, result in reliable union and similar functional outcome. LEVEL OF EVIDENCE: Level III.