Preoperative measurement of the thickness of the center of the humeral head predicts screw cutout after locked plating of proximal humeral fractures.

HYPOTHESIS AND BACKGROUND: Preoperative computed tomography (CT) scans can be used to measure the thickness of the center of the humeral head to identify patients at a higher risk of screw cutout after open reduction-internal fixation. METHODS: At an academic medical center, we performed a retrospective review of all patients aged ≥ 18 years who had sustained a proximal humeral fracture that was treated with open reduction-internal fixation between January 1, 2005, and December 31, 2014, and who underwent preoperative shoulder CT. Ninety-four patients were included. Patient charts were reviewed to obtain demographic data, and radiographs were reviewed to assess screw cutout. A standardized method was devised to measure the thickness of the center of the humeral head. RESULTS: Screw cutout developed in 17 patients (17.7%). The mean humeral head thickness was significantly smaller on the axial (18 mm vs. 21 mm, P = .0031), coronal (18 mm vs. 21 mm, P = .0084), and sagittal (18 mm vs. 21 mm, P = .0033) sections in the patients who experienced screw cutout. When the smallest of the 3 measurements for each patient was analyzed, the risk of cutout was markedly greater when the humeral head thickness was <20 mm (25% vs. 6%). In addition, when the humeral head thickness was >25 mm, the risk of cutout was reduced to 0%. A low-energy injury was associated with a lower risk of cutout whereas age, sex, and fracture classification were not independent predictors of cutout on multivariate logistic regression. CONCLUSIONS: In a patient with a proximal humeral fracture in whom a preoperative CT scan is available, calculating the thickness of the center of the humeral head may provide valuable information to both the surgeon and the patient for preoperative planning and counseling. A smaller thickness of the center of the humeral head on preoperative CT is predictive of screw cutout following locked plating of proximal humeral fractures. A measurement of >25 mm in any one plane is highly protective against cutout; however, extreme caution and consideration of supplemental fixation methods should be taken when the measurements in all planes are <15 mm. This information may be helpful in counseling patients regarding the possibility of postoperative screw cutout.

Detection of Femoral Neck Fractures in Pediatric Patients With Femoral Shaft Fractures.

BACKGROUND: Ipsilateral femoral neck fractures occur in 1% to 9% of adult trauma patients with femoral shaft fractures making dedicated imaging important. This is not as clear in children. Our purpose is to establish the incidence of ipsilateral femoral neck fractures in children with femoral shaft fractures and to provide recommendations regarding diagnostic imaging protocols. METHODS: A retrospective analysis of medical records was performed for pediatric patients (below 18 y) with femoral shaft fractures seen at our trauma center over a 10-year period. Mechanism of injury, associated injuries, procedures, and follow-up data were collected, and all radiographs reviewed. Exclusion criteria included peri-implant fractures or evidence of pathologic fracture. A similar retrospective analysis was performed in a cohort of adult patients. RESULTS: Of 267 pediatric patients with femoral shaft fractures, 2 patients (0.7%) had ipsilateral femoral neck fractures. One femoral neck fracture was detected on initial plain radiographs and the other on a pelvic computed tomography (CT) scan. Both of these fractures resulted from high-energy trauma, which accounted for 92 (42%) of pediatric femoral shaft fractures. The cohort of 100 adults aged 18 to 89 years with femoral shaft fractures revealed 6 adult patients (6%) with ipsilateral femoral neck fractures, all from high-energy trauma. High-energy trauma accounted for 85% of the adult femoral shaft fractures, and was more common than in the pediatric population (P<0.005). The difference in incidence of ipsilateral femoral neck fracture between the pediatric (0.7%) and the adult group (6%) was significant (P=0.007). No missed or delayed diagnoses were identified. CONCLUSIONS: The incidence of associated ipsilateral femoral neck fracture in pediatric patients with femoral shaft fracture is very low (0.7%). Most (58%) pediatric femur fractures are caused by low-energy trauma. We were unable to demonstrate a need for routine CT scanning of the femoral neck in children with femoral shaft fractures. Given the increased risks of radiation exposure with younger and smaller patients, it does not appear that routine CT scanning low-energy pediatric femoral shaft fractures to evaluate for femoral neck fractures is justified unless there is a high level of clinical suspicion. LEVEL OF EVIDENCE: Level II.

Risk factors for loss of reduction following locked plate fixation of proximal humerus fractures in older adults.

PURPOSE: To identify characteristics associated with loss of reduction following open reduction and locked plate fixation (ORIF) of proximal humerus fractures in older adults and determine if loss of reduction affects patient reported outcomes (PROs), range of motion (ROM), and complication rates during the first postoperative year. METHODS: Patients >55 years old who underwent proximal humerus ORIF were reviewed. Patient and fracture characteristics were recorded. Fixation characteristics were measured on the initial postoperative AP radiograph including humeral head height (HHH) relative to the greater tuberosity (GT), head shaft angle (HSA), screw-calcar distance, and screw tip-joint surface distance. Loss of reduction was defined as GT displacement >5 mm or HSA displacement >10° on final follow up radiographs. Patient, fracture, and fixation characteristics were tested for association with loss of reduction. Outcomes including ROM, visual analog scale pain and PROMIS scores, and complication/reoperation rates during the first postoperative year were compared between those with or without loss of reduction. RESULTS: A total of 79 patients were identified, 23 (29.1%) of which had a loss of reduction. Calcar comminution (relative risk [RR]=2.5, 95% Confidence Interval [CI]=1.3-5.0, p<0.01), HHH <5 mm above GT (RR=2.0, CI=1.0-3.9, p = 0.048), and screw-calcar distance ≥12 mm (RR=2.1, CI=1.1-4.1, p = 0.03) were risk factors for loss of reduction. Upon multivariate analysis, calcar comminution was determined to be an independent risk factor for loss of reduction (RR=2.4, CI=1.2-4.7, p = 0.01). Loss of reduction led to higher complication (44% vs 13%, p<0.01) and reoperation rates (30% vs 7%, p<0.01), and decreased achievement of satisfactory ROM (>90° active forward flexion, 57% vs 82%, p = 0.02) compared to maintained reduction, but similar PROs. CONCLUSIONS: Calcar comminution, decreased HHH, and increased screw-calcar distance are risk factors for loss of reduction following ORIF of proximal humerus fractures. These morphologic and technical factors are important considerations for prolonged reduction maintenance.

Early Outcomes of Proximal Humerus Fractures in Adults Treated With Locked Plate Fixation Compared with Nonoperative Treatment: An Age-, Comorbidity-, and Fracture Morphology-Matched Analysis.

OBJECTIVES: To compare patient-reported outcomes (PROs), range of motion (ROM), and complication rates for proximal humerus fractures managed nonoperatively or with open reduction internal fixation (ORIF). DESIGN: Retrospective cohort. SETTING: Academic level 1 trauma center. PATIENTS/PARTICIPANTS: Four hundred thirty-one patients older than 55 years were identified retrospectively. 122 patients were excluded. 309 patients with proximal humerus fractures met inclusion criteria (234 nonoperative and 75 ORIF). After matching, 192 patients (121 nonoperative and 71 ORIF) were included in the analysis. INTERVENTION: Nonoperative versus ORIF (locked plate) treatment of proximal humerus fracture. MAIN OUTCOME MEASUREMENTS: Early Visual Analog Score (VAS), ROM, PROs, complications, and reoperation rates between groups. RESULTS: At 2 weeks, ORIF showed lower VAS scores, better passive ROM, and patient-reported outcomes measurement information system (PROMIS) scores ( P < 0.05) compared with nonoperative treatment. At 6 weeks, open reduction internal fixation (ORIF) had lower VAS scores, better passive ROM, and PROMIS scores ( P < 0.05) compared with nonoperative treatment. At 3 months, ORIF showed similar PROMIS scores ( P > 0.05) but lower VAS scores and better passive ROM ( P < 0.05) compared with nonoperative treatment. At 6 months, ORIF showed similar VAS scores, ROM, and PROMIS scores ( P > 0.05) compared with nonoperative treatment. There was no difference in secondary operation rates between groups ( P > 0.05). ORIF patients trended toward a higher secondary reoperation rate (15.5% vs. 5.0%) than nonoperative patients ( P = 0.053). CONCLUSIONS: In an age-, comorbidity-, and fracture morphology-matched analysis of proximal humerus fractures, ORIF led to decreased pain and improved passive ROM early in recovery curve compared with nonoperative treatment that normalized after 6 months between groups. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Superior Outcomes With Reverse Shoulder Arthroplasty versus Nonoperative Management for Proximal Humerus Fractures: A Matched Cohort Analysis.

OBJECTIVE: To evaluate early outcomes (within 1 year) for geriatric proximal humerus fractures managed nonoperatively or with reverse shoulder arthroplasty (RSA). DESIGN: Retrospective cohort. SETTING: Academic level 1 trauma center, level 2 trauma/geriatric fracture center. PATIENTS/INTERVENTION: Seventy-one patients with proximal humerus fractures that underwent nonoperative management or RSA, matched by age, comorbidity burden, and fracture morphology. MAIN OUTCOME MEASUREMENTS: Patient-reported outcomes, range of motion, and complications rates within 1 year of treatment. RESULTS: RSA patients demonstrated greater active forward flexion (aFF) and external rotation compared with nonoperative patients throughout the first 6 months after treatment ( P < 0.05 for all). RSA patients achieved satisfactory ROM (>90 degrees aFF) at higher rates than nonoperative patients (96.2% vs. 62.2%, P < 0.01). RSA led to significantly lower shoulder pain and PROMIS pain interference scores throughout the first year post-treatment ( P < 0.05). PROMIS physical function scores were also higher in the RSA group at 3 months, 6 months, and 1 year compared with the nonoperative group ( P < 0.05 for all). Similar complication rates were experienced in both groups (nonoperative = 8.9%, RSA = 7.7%; P = 0.36). CONCLUSIONS: In an age, comorbidity and fracture morphology matched analysis, treatment of proximal humerus fractures with RSA is associated with greater shoulder ROM throughout the first 6 months of treatment, decreased pain, and improved physical function compared with nonoperative management, without significant differences in short-term complications. These results suggest that RSA may be superior to nonoperative management during the early recovery period for proximal humerus fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes for type C proximal humerus fractures in the adult population: comparison of nonoperative treatment, locked plate fixation, and reverse shoulder arthroplasty.

Background: This study compares patient-reported outcomes and range of motion (ROM) between adults with an AO Foundation/Orthopaedic Trauma Association type C proximal humerus fracture managed nonoperatively, with open reduction and internal fixation (ORIF), and with reverse shoulder arthroplasty (RSA). Methods: This is a retrospective cohort study of patients >60 years of age treated with nonoperative management, ORIF, or RSA for AO Foundation/Orthopaedic Trauma Association type 11C proximal humerus fractures from 2015 to 2018. Visual analog scale pain scores, Patient-Reported Outcomes Measurement Information System (PROMIS) scores, ROM values, and complication and reoperation rates were compared using analysis of variance for continuous variables and chi square analysis for categorical variables. Results: A total of 88 patients were included: 41 nonoperative, 23 ORIF, and 24 RSA. At the 2-week follow-up, ORIF and RSA had lower visual analog scale scores and lower PROMIS pain interference scores (P < .05) than nonoperative treatment. At the 6-week follow-up, ORIF and RSA had lower visual analog scale, PROMIS pain interference, and PF scores and better ROM (P < .05) than nonoperative treatment. At the 3-month follow-up, ORIF and RSA had better ROM and PROMIS pain interference and PF scores (P < .05) than nonoperative treatment. At the 6-month follow-up, ORIF and RSA had better ROM and PROMIS PF scores (P < .05) than nonoperative treatment. There was a significantly higher complication rate in the ORIF group than in the non-operative and RSA groups (P < .05). Conclusion: The management of AO Foundation/Orthopaedic Trauma Association type 11C proximal humerus fractures in older adults with RSA or ORIF led to early decreased pain and improved physical function and ROM compared to nonoperative management at the expense of a higher complication rate in the ORIF group.

Review of treatment and diagnosis of acute compartment syndrome of the calf: current evidence and best practices.

Compartment syndrome of the calf has received a great deal of attention in the literature. A MEDLINE search was conducted to identify English-language publications pertaining to compartment syndrome of the leg and calf so that principles, recent evidence, and best practices for the diagnosis and treatment of this syndrome could be reviewed. Clinical series that reported outcomes and diagnostic criteria were reviewed and summarized. The currently available evidence is limited to level IV and V studies. Early diagnosis and treatment of compartment syndromes is associated with better results; however, many patients have chronic symptoms after treatment, even when the diagnosis is made promptly and fasciotomy is performed early. Although compartment syndrome of the leg and calf often has been described in the literature, prospective clinical series are lacking, and meaningful outcomes data are scarce. There is a need for further study on functional outcomes of acute compartment syndrome of the calf, with particular attention to diagnosis and treatment.

Diagnosis and treatment of less common compartment syndromes of the upper and lower extremities: current evidence and best practices.

Compartment syndromes of the forearm, gluteal region, thigh, and foot have not been extensively studied. To provide best-practice recommendations, the available evidence from four systematic reviews of English-language reports with two or more patients with compartment syndromes of the forearm, gluteal region, thigh, and foot were reviewed and compared. For each case of compartment syndrome, the cause, method of diagnosis, treatment options, and outcomes were determined. Most compartment syndromes were caused by trauma, with the exception of gluteal compartment syndrome, which usually resulted from prolonged immobilization and postarthroplasty analgesia. The diagnosis was often based on clinical findings, with compartment pressure measurements performed in approximately 50% of the patients. Compartment pressure measurements of the foot were more commonly obtained (in 64% of the patients). Compartment syndrome of the forearm and thigh were treated surgically in 73% and 100% of patients, respectively. Complications occurred with all four compartment syndromes, with nerve deficits and stiffness being the most common problems. Reports on functional outcomes lacked uniformity and did not allow for meaningful comparisons. Management principles for the less common compartment syndromes are the same as those used in treating compartment syndrome of the calf. Gluteal compartment syndrome usually has a nontraumatic etiology and is less likely to be surgically treated, probably because of major systemic complications and late presentation. Complications are common after these four types of compartment syndrome, but outcomes data are lacking.

Increasing the Educational Value of the Orthopaedic Subinternship: The Design and Implementation of a Fourth-Year Medical Student Curriculum.

INTRODUCTION: Most orthopaedic subinternships function as month-long interviews. These rotations remain relatively unstructured and lack standardization, and their overall educational value has been called into question. The goals of this educational initiative were to create a structured subinternship curriculum for orthopaedic applicants and to shift the focus of the subinternship from a month-long interview to an organized educational experience. METHODS: After review of knowledge and skills expected for early orthopaedic residency under the structure of the Accreditation Council for Graduate Medical Education Milestones, a curriculum dedicated to orthopaedic subinternships was created. Students who completed the curriculum filled out anonymous Likert scale evaluations (rating their comfort/knowledge from 0 to 10 before and after their rotation) and answered open-ended qualitative questions. RESULTS: Forty-six subinterns participated in the program over 3 years. Four weekly learning modules were designed and taught by orthopaedic residents, with faculty oversight of content and structure. Each monthly rotation began with an orthopaedic surgical skills laboratory and concluded with a case-based oral presentation. Weeks two and three covered different milestone-based topics and included didactic and skills development. Data analysis revealed that students reported notable improvement in knowledge and familiarity with each of the topics. The greatest improvements were in tibia intramedullary nailing and applying a tension band to an olecranon fracture. When asked which surgical skills station was the most helpful, 70% chose lag screw insertion and basic plating techniques. All students felt that creating their case presentation was productive. CONCLUSION: This educational initiative resulted in the successful design and implementation of a milestone-based orthopaedic surgery subinternship curriculum. The program was well received by students, contributed to learning and competency, and provided teaching opportunities for residents. The format and content of this subinternship curriculum can easily be adapted to regional and national teaching programs.

The aging road warrior: national trend toward older riders impacts outcome after motorcycle injury.

Industry statistics suggest that motorcycle owners in the United States are getting older. Our objective was to analyze the effect of this demographic shift on injuries and outcomes after a motorcycle crash. Injured motorcyclists aged 17 to 89 years in the National Trauma Databank were reviewed from 1996 to 2005. Age trends and injury patterns were assessed over time. Injury Severity Score (ISS), length of stay (LOS), intensive care unit (ICU) use, comorbidities, complications, mortality, injury patterns, helmet use, and alcohol use were compared for subjects 40 and older versus those younger than 40-years-old. There were 61,689 subjects included. Over the study period, the mean age increased from 33.9 to 39.1 years (P < 0.01), and the proportion of subjects 40 years of age or older increased from 27.9 to 48.3 per cent. ISS, LOS, ICU LOS, and mortality were higher in the 40 years of age or older group (P < or = 0.01). The rates of admission to the ICU (32.3 vs. 27.3%), pre-existing comorbidities (20 vs. 9.7%), and complications (7.6 vs. 5.5%) were all higher in the 40 years of age and older group (P < 0.01). The average age of the injured motorcyclist is increasing. Older riders' injuries appear more serious, and their hospital course is more likely to be challenged by comorbidities and complications contributing to poorer outcomes. Motorcycle safety education and training initiatives should be expanded to specifically target older motorcyclists.

The Current Status of Medical School Clerkship Grades in Residency Applicants.

BACKGROUND: Two criteria that have been investigated for evaluating orthopedic surgery residency candidates are achieving an "honors" grade during a surgery clerkship and the total number of honors grades received in all clerkships. Unfortunately, the rate of honors grades given and the criteria for earning an honors grade differ between medical schools, making comparison of applicants from different medical schools difficult. OBJECTIVE: We measured the rate of honors grades in clerkships at different medical schools in the United States to examine the utility of clerkship grades in evaluating orthopedic surgery residency applicants. METHODS: Adequate data via the Electronic Residency Application Service were available for 86 of 142 Association of American Medical Colleges medical schools from the 2017 Match cycle. Descriptive statistics and Wilcoxon rank sum tests were performed to identify differences in grade distributions within each clerkship and in school ranking for research by U.S. News & World Report. RESULTS: For the surgery clerkship, the median rate of honors grades given was 32.5% (range 5%-67%). There was a high rate of interinstitutional variability in all clerkships. We were unable to demonstrate a statistically significant relationship between research ranking and percentage honors grades given for individual clerkships. CONCLUSIONS: A standardized method for grading medical students during clinical clerkships does not exist, resulting in a high degree of interinstitutional variability. Surgery clerkship grades are an unreliable measure for comparing orthopedic surgery residency applicants from different medical schools. Standardized measures of applicant evaluation might be helpful in the future.

Rethinking strategies for blood transfusion in hip fracture patients.

OBJECTIVES: Most patients can tolerate a hemoglobin (Hgb) > 8 g per deciliter. In some cases, however, transfusion will delay physical therapy and hospital discharge. This study aims to review Hgb and transfusion data for a large volume of recent hip fracture patients in order to identify new opportunities for decreasing the length of hospital stay. Our hypotheses are that in some cases, earlier transfusion of more blood will be associated with shorter hospital stays, and that Hgb levels consistently decrease for more than 3 days postoperatively. DESIGN: Retrospective chart review. SETTING: Two academic medical centers with Geriatric Fracture Programs. PATIENTS: Data was collected from patients 50 years and older with hip fractures April 2015 and October 2017. INTERVENTION: Operative stabilization of the hip fractures according to standard of care for the fracture type and patient characteristics. Transfusion according to established standards. MAIN OUTCOME MEASUREMENTS: Electronic records were retrospectively reviewed for demographic information, Hgb levels, and transfusion events. RESULTS: One thousand fifteen patients with femoral neck or intertrochanteric hip fractures were identified. Eight hundred sixty met the inclusion criteria. The average length of hospital stay was 6.7 days. The mean patient age was 82 years. The average American Society of Anesthesiologists score was 2.9. The average Hgb level consistently decreased for 5 days postoperatively before beginning to increase on day 6. There was poor consistency between intraoperative Hgb levels and preoperative or postoperative Hgb levels. Three hundred sixty-eight (42.8%) patients were transfused an average of 1.9 (range 1-6) units. One hundred five patients required a transfusion on postoperative day (POD) 1: 72 received only 1 unit of blood: 36 (50%) of the 72 required a second transfusion in the following days, compared to 9 of 33 (27%) who received 2 units on POD 1 (χ2 = 3.8898; P < .05). Patients who received transfusions on POD 3 or later had an average length of stay >2.5 days longer than those who received a transfusion earlier (P = 0.005). CONCLUSIONS: Our findings do not support earlier transfusion of more blood. Although in some cases, there is an association between earlier transfusion of more blood and shorter hospital stay, routine transfusion of more blood would incur higher transfusion risks in some patients who would not otherwise meet criteria for transfusion. After hip fracture surgery, the Hgb usually decreases for 5 days and does not begin to increase until POD 6. This information will provide utility in the population health management of hip fracture patients. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Study.

Immediate Improvement in Physical Function After Symptomatic Syndesmotic Screw Removal.

OBJECTIVE: To investigate the immediate impact of removing symptomatic syndesmotic screws on PROMIS outcomes and ankle range of motion (ROM) in patients who had previously undergone ankle fracture open reduction and internal fixation (ORIF) and syndesmotic fixation and later experienced functional limitations. DESIGN: Prospective cohort study. SETTING: Level 1-trauma center. PATIENTS/PARTICIPANTS: Fifty-eight patients with ankle fractures with syndesmotic instability that required ORIF with syndesmotic fixation who underwent syndesmotic screw removal (SSR) and 71 patients who underwent ankle ORIF with syndesmotic fixation, but without screw removal during the same study period. INTERVENTION: Symptomatic SSR for patients with functional limitations and decreased ankle ROM. MAIN OUTCOME MEASUREMENTS: PROMIS physical function (PF) and pain interference T-scores and ankle ROM before and after screw removal. RESULTS: Patients who underwent SSR had a statistically significant improvement in the PF T-score to 44.5 (P < 0.01) in the early postoperative period (mean 48 days) after screw removal. The screw removal occurred an average of 184 days after initial ORIF. This PF T-score change also met the minimally clinically important difference. There was a trend toward a significant improvement in PF T-scores for the SSR group as compared to the cohort group (44.5 vs. 41.6; P = 0.06) after screw removal. Removal of symptomatic implants resulted in an early mean improvement of total arc ankle ROM by 17 degrees (P < 0.01). CONCLUSIONS: Patients experienced an immediate and significant improvement in PF outcomes and ankle ROM after symptomatic SSR for ankle fracture ORIF with syndesmotic fixation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Orthopedic Surgery and the Geriatric Patient.

As more patients live longer, it is probable that an increasing number of geriatric patients will require surgery. An organized, systematic, coordinated, multidisciplinary approach to the perioperative management of these patients will result in fewer complications, improved outcomes, and reduced cost of care. Details are herein provided on the preoperative diagnostic evaluation and assessment as well as perioperative care provided to optimize outcomes. The diagnosis, workup, and treatment of osteoporosis and fragility fractures are presented. The article concludes with a review of the care of the geriatric orthopedic patient in the posthospital time period.

Surgical management of U/H type sacral fractures: outcomes following iliosacral and lumbopelvic fixation.

BACKGROUND: U and H-type sacral fractures are under diagnosed injuries resulting from significant axial loading that are often associated with neurological deficits. No studies to date have compared two common methods of surgical fixation, iliosacral screw fixation (ISF) and lumbopelvic fixation (LPF). METHODS: Patients with sacral fractures from 2009-2015 at one level 1 trauma center were identified by current procedural terminology (CPT) code and imaging reviewed for U/H type sacral fractures. RESULTS: Four hundred and fifty-three sacral fractures were identified during the study period, of which sixteen patients met inclusion criteria for the study. Six patients had the presence of a documented neurological injury at the time of presentation, 9 patients had concurrent spine fractures and 10 patients had concurrent pelvic fractures. Eight patients underwent ISF and 8 patients underwent LPF. There was no significant difference between the two groups in regards to age, intensive care unit (ICU) requirement, length of stay, or estimated blood loss. There was a significant increase in surgical time in the LPF group (P=0.002). In addition, there was a significant difference between those patients that underwent ISF that were discharged to a rehab facility compared to those treated with LPF (P=0.04). CONCLUSIONS: Patients with U/H type sacral fractures can be treated with ISF or LPF without an expected increase in hospital length of stay (LOS) or need for ICU. Treatment with LPF may increase operative time however; the patient is more likely to be discharged to home instead of a rehab facility.

Routine removal of external fixators without anesthesia.

OBJECTIVE: To examine the degree of discomfort experienced by patients with routine removal of all external fixators without anesthesia. DESIGN: Retrospective review. SETTING: Outpatient clinic and hospital. PATIENTS: A total of 106 consecutive patients for whom removal of external fixators was indicated. INTERVENTION: External fixators were removed without anesthesia. MAIN OUTCOME MEASUREMENTS: Visual Analog Pain Scale (VAS) following external fixator removal and patients' reported willingness to repeat the procedure without anesthesia. RESULTS: Patients with pin site inflammation had a significantly higher VAS (4.82 vs. 2.92, P < 0.0001). The chi test revealed that pin site inflammation was less common with wrist spanning fixators than with lower extremity and pelvic fixators. No correlation existed between age, site of fixator, closed head injury, use of olive wires, or the duration of fixation and VAS. In all, 95 of 106 patients (89.6%) responded yes when asked if they would undergo removal of their fixator again without anesthesia. Despite the association between inflamed pin sites and a higher VAS, in 84% (37/44) of the cases with inflamed pin sites, the patient would choose to undergo fixator removal without anesthesia again. CONCLUSIONS: Removal of external fixators without anesthesia is well tolerated by the great majority of patients. Inflammation at pin sites is associated with a higher degree of discomfort during external fixator removal. Despite the higher pain score, most patients with pin-site inflammation report that they would repeat the procedure without anesthesia.

Radiographic Risk Factors For Interprosthetic Femur Fractures.

PURPOSE: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are among the most common orthopaedic procedures performed in the United States annually. As the number of patients undergoing these procedures increases so too does the incidence of periprosthetic femur fractures. A number of these periprosthetic fractures occur between two ipsilateral implants, so-called interprosthetic fractures. Recent biomechanical data has challenged the importance of these interprosthetic distances, relating that cortical width and osteoporotic bone are more closely correlated with fracture than interprosthetic distance. The purpose of the current study is to further define the presence of osteoporosis, cortical width (CW) and medullary diameter (MD) as potential predictive factors for interprosthetic femur fractures. METHODS: Current Procedural Terminology (CPT) codes were used to identify a cohort of patients undergoing operative treatment for periprosthetic femur fractures. A review of the medical records identified 23 patients (5 male / 18 female) with a femur fracture between two intramedullary implants. CPT codes were also used to identify a second cohort of 25 patients (8 male / 17 female) having undergone ipsilateral THA and TKA. The intact femoral isthmus was identified radiographically and the MD and CW (mm) were measured. A ratio of MD to CW was also determined. Chart review was undertaken and any diagnosis of osteoporosis was recorded. An independent sample T-test was performed comparing the mean MD, CW, and the ratio of MD:CW for these groups. Significance was set at p.

Risk Factors Associated With Cephalomedullary Nail Cutout in the Treatment of Trochanteric Hip Fractures.

OBJECTIVES: To evaluate the association of cephalomedullary nail cutout in trochanteric femur fractures with the presence of the following radiographic variables: lateral wall fracture, posteromedial fragment, angular malreduction, residual basicervical fracture gapping, screw placement, and tip-apex distance. DESIGN: Retrospective review. SETTING: Academic medical center. PATIENTS: A total of 362 patients were included in the study. The average age was 83 years and the majority was female. All sustained low-energy trochanteric femur fractures treated operatively with cephalomedullary nails. Minimum radiographic follow-up was 3 months, with an average of 11 (range 3-88) months. INTERVENTION: Cephalomedullary nailing with either a lag screw or helical blade. MAIN OUTCOME MEASURES: Cutout of the lag screw or helical blade. RESULTS: A total of 22 (6%) cutouts occurred. Univariate analysis showed significantly (P ≤ 0.01) more frequent cutout with fracture of the lateral wall, posteromedial fragment, residual gapping (>3 mm) at basicervical component, neck-shaft malreduction >5 degrees varus or 15 degrees valgus, and tip-apex distance >25 mm, and superior screw/blade positioning. There was no difference with unstable fracture pattern (P = 0.58) or fellowship training (P = 0.21). Multivariate regression analysis demonstrates that lateral wall fracture (Odds ratios [OR] = 8.0, 95% confidence interval [CI], 2.4-27.1), neck-shaft malreduction (OR = 4.3, CI, 1.3-14.7), and residual basicervical gapping (OR = 3.6, CI, 1.0-13.0) were associated with fixation cutout. CONCLUSIONS: Risk factors for cutout of trochanteric fractures in our study can be viewed as modifiable or nonmodifiable factors. Statistically significant factors included lateral wall fracture (nonmodifiable) as well as basicervical gapping and malreduction (modifiable). LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Radiographic Review of Helical Blade Versus Lag Screw Fixation for Cephalomedullary Nailing of Low-Energy Peritrochanteric Femur Fractures: There is a Difference in Cutout.

OBJECTIVES: To compare the rate of cutout of helical blades and lag screws in low-energy peritrochanteric femur fractures treated with a cephalomedullary nail (CMN). DESIGN: Retrospective review. SETTING: Academic medical center. PATIENTS: Overall, this study included 362 patients with an average age of 83 year old, a majority of whom were women, and had sustained a low-energy peritrochanteric femur fracture treated with a CMN. All patients had at least 3 months of clinical and radiographic follow, with an average follow-up of 11 months and a range of 3-88 months follow-up. INTERVENTION: Cephalomedullary nailing with the use of a helical blade or single lag screw for proximal fixation. MAIN OUTCOME MEASUREMENTS: Cutout of the helical blade or lag screw. RESULTS: Twenty-two cutouts occurred, 14 (15.1%) of 93 patients with helical blades and 8 (3.0%) of 269 patients with lag screws. Cutout with the helical blade was significantly more frequent than with the lag screw (P = 0.0001). The average tip-apex distance (TAD) was significantly greater for those patients who experienced cutout both for the helical blades (23.5 vs. 19.7 mm; P = 0.0194) and lag screws (24.5 vs. 20.0 mm; P = 0.0197). An absolute TAD predictive of cutout could not be determined. CONCLUSIONS: When the helical blade was used, implant cutout occurred at a significantly higher rate compared with lag screw fixation. There was not a threshold TAD that was predictive of cutout for either implant. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The impact of residual angulation on patient reported functional outcome scores after non-operative treatment for humeral shaft fractures.

PURPOSE: To determine if residual angular deformity following non-operative treatment of humeral diaphyseal fractures correlates with patient reported outcomes. METHODS: Skeletally mature patients treated by one of three orthopaedic trauma surgeons at a level 1 trauma centre with humeral shaft fractures treated without surgery were retrospectively identified over a 7 year period. After inclusion and exclusion criteria, 42 patients were eligible for the study. Disabilities of the Arm, Shoulder, and Hand (DASH); Simple Shoulder Test (SST); General health questionnaire SF-12 physical component summary (SF-12 PCS) and mental component summary (SF-12 MCS) were obtained from study participants. Healed angular deformity was obtained from patient charts. RESULTS: Thirty two subjects were successfully recruited (32/42 or 76%). Average age was 45 ± 22 with average study follow up being 47 ± 29 months. Average outcome scores were DASH 12 ± 16, SST 10 ± 2.7, SF-12 PCS 50 ± 7.9, and SF-12 MCS 54 ± 8.8. Healed sagittal plane deformity averaged 8 ± 5.7° [range 0-18], and 15 ± 7.9° [range 2-27] in the coronal plane. There was no correlation between residual sagittal or coronal plane deformity and outcome scores (DASH and SST for both p>0.05). Patients with at least 20° (n=7; 22%) of healed coronal deformity had similar outcomes to those with <20° ([DASH (13.2 ± 18.7 vs 11.7 ± 16.1; p=0.83]; [SST (10.3 ± 2 vs 10.0 ± 2.9; p=0.81]). Higher SF-12 PCS and MCS scores correlated with better DASH and SST scores (p<0.05 for all). CONCLUSION: Residual angular deformity ranging from 0 to 18° in the sagittal plane and from 2 to 27° in the coronal plane after non-operative treatment for humeral shaft fractures had no correlation with patient reported DASH scores, SST scores, or patient satisfaction. Instead, overall physical and mental health status as measured by the SF-12 significantly correlated with patient reported outcomes.