Capsular distension in high-energy femoral shaft fractures is associated with occult femoral neck fracture: a preliminary retrospective comparative study.

OBJECTIVES: To determine the association between hip capsular distension, the computed tomography (CT) capsular sign, and lipohemarthrosis as they relate to occult femoral neck fracture (FNF) in the setting of ipsilateral femoral shaft fracture (FSF). DESIGN: Retrospective comparative study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Two hundred and forty-two patients with high-energy FSF and no evidence of FNF on preoperative radiographs and pelvis CT. All patients were stabilized with non-reconstruction style nails. INTERVENTION: Pelvis CT scans were examined for hip capsular distension irrespective of the other side, differing side-to-side measurements of capsular distension (i.e., the CT capsular sign), and lipohemarthrosis. MAIN OUTCOME MEASUREMENTS: FNF was observed for on postoperative radiographs. Relative risk (RR), number needed to treat (NNT), sensitivity (SN), and specificity (SP) were determined. RESULTS: Fifty-eight patients (24.0%) had capsular distension. Forty-two patients (17.4%) had differing capsular measurements (i.e., the CT capsular sign), and 16 (6.6%) had symmetrical distension from bilateral hip effusions. Eight patients (3.3%) had lipohemarthrosis. Four FNFs (1.7%) were identified. Three patients had capsular distension, 2 had CT capsular signs, and 1 had lipohemarthrosis. The last patient had no CT abnormalities. Only capsular distension (RR = 10, CI = 1.001-90, P = 0.049; SN = 75%, SP = 77%; NNT = 22) and lipohemarthrosis (RR = 23, CI = 1.6-335, P = 0.022; SN = 50%, SP = 96%; NNT = 8) were associated with occult FNF. CONCLUSIONS: Capsular distension is associated with FNF irrespective of the contralateral hip. Preemptive stabilization using a reconstruction nail could be considered in the setting of capsular distension or lipohemarthrosis to prevent displacement of an occult FNF. LEVEL OF EVIDENCE: Diagnostic Level III.

Single-staged treatment using a standardized protocol results in functional motion in the majority of patients with a terrible triad elbow injury.

BACKGROUND: Terrible triad injuries of the elbow, defined as elbow dislocation with associated fractures to the radial head and coronoid, are associated with stiffness, pain, and loss of motion. Studies to date have consisted of small sample sizes and used heterogeneous surgical techniques, which render comparisons difficult and unreliable. QUESTIONS/PURPOSES: In a group of patients treated under a standard surgical protocol, we sought to determine the early dislocation rate, the range of motion in those not undergoing secondary procedures, the frequency and types of secondary surgical interventions required, the difference in motion between those undergoing secondary surgery and those who did not, and the frequency of heterotopic ossification and patient-reported stiffness. METHODS: Patients underwent a surgical protocol that involved fixing the coronoid, fixing the radial head if possible, otherwise performing radial head arthroplasty, and repairing the lateral ligamentous structures. Patients were excluded if ipsilateral upper extremity fractures from the humerus to the distal forearm were present. Fifty-two patients had a minimum followup of 6 weeks and were included for the early dislocation rate, and 34 of these (65%) had a minimum of 6 months followup and were included for the rest of the data. Eighteen of the 52 (35%) were considered lost to followup because they were seen for less than 6 months postsurgically and were excluded from further analysis. Chart review was performed to determine the presence of early dislocation within the first 6 weeks after surgery, range of motion in patients not requiring a secondary procedure, the frequency and types of secondary procedures required, the range of motion before and after a secondary procedure if it was required, and postoperative stiffness. Postoperative radiographs were analyzed to determine the presence and severity of heterotopic ossification. RESULTS: One of 52 patients sustained a dislocation within the first weeks of surgery (1.9%). Those not undergoing a secondary procedure were able to achieve a flexion arc of 110° and a supination-pronation arc of 148°. Nine of 34 patients (26%) underwent a secondary surgical procedure with stiffness, heterotopic ossification, and ulnar neuropathy being the most common surgical indications. Before secondary surgical procedures, patients had a flexion arc of 57° and a supination-pronation arc of 55°, which was less than those only requiring primary surgery alone (p < 0.001). After secondary surgery, patients were able to achieve a flexion arc of 96° and a supination-pronation arc of 124°, which was not different from those who did not undergo reoperation (p = 0.09 and p = 0.08, respectively). Twenty-eight of 34 patients demonstrated evidence of heterotopic ossification on radiographs, whereas 20 patients, including all nine undergoing secondary procedures, reported stiffness at the elbow. CONCLUSIONS: Using a standardized surgical protocol, a low early dislocation rate was observed, although stiffness remains a challenge. Many patients who initially do not attain functional range of motion can usually attain this after secondary procedures aimed at removing the heterotopic ossification. LEVEL OF EVIDENCE: Level IV, therapeutic study. See guidelines for authors for a complete description of levels of evidence.

Implementing an Educational Module for Orthopaedic Residents Placing Skeletal Traction.

INTRODUCTION: Although placement of a distal femoral traction (DFT) pin is a relatively simple procedure used to stabilize femoral and pelvic fractures, it places patients at risk of iatrogenic vascular, muscular, or bony injury. We designed and implemented an educational module combining theory and practical experience to standardize and improve resident teaching on the placement of DFT pins. METHODS: We introduced a DFT pin teaching module into our second-year resident "boot camp," which is used to help prepare residents for taking primary call in the emergency department at our level I trauma center. Nine residents participated. The teaching module included a written pretest, an oral lecture, a video demonstration of the procedure, and a practice simulation on 3D printed models. After completing the teaching, each resident underwent a written examination and proctored live simulation involving 3D models using the same equipment available in our emergency department. Pre-teaching and post-teaching surveys were used to assess resident experience and confidence with placing traction in the emergency department. RESULTS: Before the teaching session, the rising postgraduate year 2 residents scored an average of 62.2% (range, 50% to 77.8%) on the DFT pin knowledge quiz. This improved to an average of 86.6% (range, 68.1% to 100%) (P = 0.0001) after the teaching session. After completing the educational module, they also demonstrated an improvement in confidence with the procedure, from 6.7 (range, 5 to 9) to 8.8 (range, 8 to 10) (P = 0.04). DISCUSSION: Despite reporting high levels of confidence in their ability to place traction pins before starting the postgraduate year 2 consult year, many residents also reported anxiety around the accurate placement of traction pins. Early results of our training program showed improved resident knowledge of safe placement of traction pins and improved confidence with the procedure.

Biomechanical analysis of the less invasive stabilization system for mechanically unstable fractures of the distal femur: comparison of titanium versus stainless steel and bicortical versus unicortical fixation.

BACKGROUND: The purpose of this study was to test the effect of (1) titanium versus stainless steel metal and (2) locked unicortical versus bicortical shaft fixation on stiffness of Less Invasive Stabilization System (LISS) constructs in a mechanically unstable nonosteoporotic distal femur fracture model. METHODS: An AO/OTA 33-A3 fracture was created in 24 sawbone femur specimens that simulated normal bone quality. Testing was performed on three groups: titanium unicortical LISS fixation, stainless steel unicortical LISS fixation, and bicortical stainless steel LISS fixation. Specimens were tested in axial, torsional, and cyclic axial loading in a materials testing machine. The outcome measurement was stiffness in axial and torsional loading, total deformation, and irreversible (plastic) deformation in cyclical axial loading. RESULTS: No difference was found in stiffness in axial loading or plastic and total deformation between all three groups. There was a small decrease in stiffness in torsional loading in the titanium group compared with the stainless steel groups (p < 0.0001) and a small increase in stiffness in torsional loading with bicortical versus unicortical proximal fixation (p = 0.04). CONCLUSIONS: Unstable distal femur fracture constructs, created in sawbone specimens, fixed with stainless steel and titanium LISS implants, with or without bicortical locking screws proximally, show similar biomechanical properties under loading. Although there are numerous considerations when selecting implants for these fractures, our results indicate that stiffness is not a significant factor in choosing between the constructs tested.

Minifragment plate fixation of high-energy navicular body fractures.

BACKGROUND: The purpose of this study was to assess the ability of miniplate fixation in navicular fractures to restore medial column stability, maintain reduction, and determine the impact this approach may have on the development of avascular collapse of the navicular. We hypothesized that comminuted fractures of the navicular can be safely reduced and maintained to union with minifragment plate fixation with a low incidence of avascular collapse. MATERIALS AND METHODS: A retrospective chart review was performed on 24 patients with navicular fractures treated with open reduction and internal fixation with minifragment plate fixation at a level one trauma center over a period of 6 years. RESULTS: All fractures united. No patient developed a deep infection. There was no loss of reduction. Isolated broken screws were evident in three patients (12.5%), with no plate breakage, and no implant failure by pullout. Four patients (17%) underwent plate removal for painful prominent hardware following fracture healing. Four patients (17%) developed radiographic arthrosis of the talonavicular joint. One patient (4%) had radiographic avascular collapse evident at 6 months and was treated with plate removal and an orthotic device. CONCLUSION: Minifragment fixation was a good alternative to independent lag screws for rigid stabilization of navicular body fractures.

Patient Outcomes After Transolecranon Fracture-Dislocation.

INTRODUCTION: There are few small case series that discuss patient outcomes after a transolecranon fracture-dislocation, and they suggest that patients have reasonable function after injury. The purpose of this study was to describe the injury pattern and clinical outcomes of transolecranon fracture-dislocations. METHODS: After Institutional Review Board approval, transolecranon fracture-dislocations treated at two academic level 1 trauma centers between 2005 and 2018 were retrospectively reviewed. Fracture characteristics and postsurgical complications were recorded. Radiographs were reviewed for arthrosis, and Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) scores were obtained at a minimum of 12 months after injury. RESULTS: Thirty-five patients with a mean follow-up of 28 months (range, 12 to 117 months) were included. Nine patients had associated radial head fracture, 23 patients had associated coronoid fracture, four patients had ligamentous injury, and two patients had capitellum fracture. Four patients (11%) developed infection and required irrigation and débridement with intravenous antibiotics. Thirteen patients (13 of 35, 37%) developed radiographic arthrosis with most (11 of 13) having grade 2 or three changes. Patients who had associated radial head fracture, coronoid fracture, capitellum fracture, and/or ligamentous injury had significant arthrosis (10 of 24, 42%) more commonly than patients with olecranon fracture alone (1 of 11, 9%) (P = 0.05). Twenty-eight patients completed patient outcomes instrument and achieved a mean QuickDASH score of 9 (range, 0 to 59). Patients with isolated transolecranon fracture had a significantly better QuickDASH score (0.93, 0 to 4) than patients with transolecranon fracture variant with associated coronoid fracture, radial head fracture, distal humeral fracture, or ligamentous injury (11.74, 0 to 59) (P = 0.04). DISCUSSION: Patients with transolecranon fracture-dislocation had excellent return to function based on the QuickDASH outcome assessment. Patients with transolecranon fracture with associated radial head fracture, coronoid fracture, humeral condyle fracture, and/or ligamentous injury tend to have worse functional outcome than patients with simple transolecranon fracture. LEVEL OF EVIDENCE: Level IV-case series.

Stabilization of the posteromedial fragment in bicondylar tibial plateau fractures: a mechanical comparison of locking and nonlocking single and dual plating methods.

BACKGROUND: The objective of this study is to compare locking and nonlocking single and dual plating constructs in maintaining posteromedial fragment reduction in a bicondylar tibial plateau fracture model. We hypothesized that posteromedial fragment fixation with medial and lateral nonlocked constructs would tolerate higher loads than with lateral locked constructs alone. METHODS: Thirty composite tibiae were fractured (AO 41-C1.3). Six constructs were tested: (1) lateral 3.5-mm conventional nonlocking proximal tibial plate (CP); (2) CP + posteromedial 3.5-mm limited contact dynamic compression plate; (3) CP + posteromedial 1/3 tubular plate (CP + 1/3 tubular); (4) 3.5-mm Zimmer Proximal Tibial Locking plate; (5) 3.5-mm Synthes Locking Compression plate; and (6) Less Invasive Stabilization System tibial plate. Specimens were cyclically loaded to failure or a maximum of 4000 N. RESULTS: Failure occurred at the posteromedial fragment first. The CP + 1/3 tubular had the highest average load to failure (3040 N). The CP + 1/3 tubular demonstrated higher load at failure compared with the 3.5-mm Synthes Locking Compression plate (p = 0.0060) and the Less Invasive Stabilization System (p = 0.0360). The CP + 1/3 tubular did not demonstrate a difference in load at failure when compared with the CP (p = 0.4225), the CP + posteromedial 3.5-mm limited contact dynamic compression plate (p = 0.4799), or the 3.5-mm Zimmer Proximal Tibial Locking plate (p = 0.1595). CONCLUSIONS: The posteromedial fragment tolerated higher loads with the CP + 1/3 tubular plate construct. The superiority of this construct may be caused by unreliable penetration of this fragment by the lateral locking screws.

The impact of open reduction internal fixation on acute pain management in unstable pelvic ring injuries.

BACKGROUND: The management of unstable pelvic ring injuries is complex. Displacement is a clear indication for surgical intervention. However, reduction of acute pain after stabilization may have substantial clinical benefits and affect management decisions. The purpose of this study was to determine the impact of operative fixation of unstable pelvic ring injuries in diminishing acute pain. METHODS: During a 33-month period, 70 patients with isolated pelvic ring injuries were managed at a Level-1 trauma center and retrospectively reviewed. On the basis of clinical and radiographic instability, 38 patients were managed surgically and formed the study group. Pain was assessed using visual analog scales and narcotic consumption during the index hospitalization. RESULTS: In the operative group, visual analog scale scores decreased 48% after fixation from 4.71 +/- 1.8 preoperatively to 2.85 +/- 0.8 postoperatively (p < 0.001). Concomitantly, narcotic requirements decreased 25% from 2.26 mg morphine per hour preoperatively to 1.71 mg morphine per hour postoperatively (p = 0.024). The mean total length of hospital stay was 5.6 days (SD, 1.2 days), and the postoperative length of hospital stay was 4.7 days (SD, 1.2 days). CONCLUSIONS: Operative reduction and fixation of unstable pelvic ring injuries significantly decreases acute pain. This has substantial physiologic benefits, particularly by improving mobilization, and should be an additional factor when determining surgical indication and timing.

Prolonged dislocation and delay to surgery are associated with higher rates of heterotopic ossification in operatively treated terrible triad injuries.

BACKGROUND: Heterotopic ossification (HO) formation after complex elbow injuries can significantly impact function. Prior studies have reported a 3%-45% incidence of HO following elbow trauma in a heterogeneous cohort of fracture patterns. The purpose of our study was to evaluate the prevalence of and identify risk factors for HO specifically in patients with terrible triad injuries. METHODS: A total of 61 patients (64 elbows) underwent operative treatment for terrible triad injuries with an average follow-up period of 19.8 months (range, 3-138 months). The medical records were reviewed for demographic data, duration of dislocation, number of reduction attempts, time to surgery, presence of radiographic HO, elbow motion at final follow-up, functional limitations, and need for secondary procedures. RESULTS: Radiographic HO developed in 77% of patients, and 63% had some level of functional restriction. Thirteen patients (26%) underwent a secondary procedure for HO excision. Patients with HO had a longer time to surgery (4.9 days vs. 2.8 days, P = .02), longer duration of dislocation (21 hours vs. 6 hours, P = .04), and reduced flexion-extension (94° vs. 112°, P = .04) and pronation-supination (109° vs. 163°, P = .002) arcs of motion compared with patients without HO. HO was also more likely to develop in patients who required closed reduction than in those with spontaneous reduction prior to presentation. CONCLUSION: The prevalence of radiographic and clinically relevant HO after terrible triad injuries was higher than previously reported. Persistent dislocation necessitating a closed reduction, a longer duration of dislocation, and a delay to surgery were associated with the development of HO. Providers should consider earlier surgical stabilization or urgent referral to a specialist for patients with unstable injuries.

Open diaphyseal long bone fractures: a reduction method using devitalized or extruded osseous fragments.

Open diaphyseal and meta-diaphyseal fractures of the lower extremity remain therapeutically challenging. Currently accepted treatment methods consist of a thorough irrigation and debridement of nonviable tissue combined with locked intramedullary nailing. Although exact reduction parameters remain controversial, achievement of a satisfactory reduction becomes increasingly difficult with fracture comminution and overt bone loss. We describe the simple technique of using multiple associated devitalized tibial bone fragments to obtain an accurate reduction prior to intramedullary nailing. This technique can be extended to other long bone fractures.

The effect of coronoid fractures on elbow kinematics and stability.

BACKGROUND: Coronoid fractures often occur in the setting of more complex elbow trauma. Little is known about the influence of coronoid fracture size on elbow kinematics, particularly in the setting of concomitant ligament injuries. The purpose of this study was to determine the effect of coronoid fractures on elbow kinematics and stability in ligamentously intact and medial collateral ligament deficient elbows and to determine the effect of forearm position on elbow stability in the setting of coronoid fracture. METHODS: Eight cadaveric arms were tested during simulated active dependent elbow motion and gravity-loaded passive elbow motion. Kinematic data were collected from an electromagnetic tracking system. The protocol was performed in ligament origin repaired and medial collateral ligament deficient elbows with radial head arthroplasty. Testing was carried out with the coronoid intact, and with 10% (Type I), 50% (Type II), and 90% (Type III) removed. Varus-valgus angulation of the ulna relative to the humerus and maximum varus-valgus laxity were measured. FINDINGS: With repaired ligament origins and medial collateral ligament deficiency, there was increased varus angulation and increased maximum varus-valgus laxity following simulation of a Type II and Type III coronoid fracture. There was less kinematic change with the forearm in supination than in pronation. INTERPRETATION: Elbow kinematics are altered with increasing coronoid fracture size. Repair of Type II and Type III coronoid fractures as well as lateral ligament repair is recommended where possible. Forearm supination may be considered during rehabilitation following coronoid repair. Valgus elbow positioning should be avoided if the medial collateral ligament is not repaired.

The effect of suture fixation of type I coronoid fractures on the kinematics and stability of the elbow with and without medial collateral ligament repair.

The objective of this study was to determine the effect of suture repair of type 1 coronoid fractures on elbow kinematics in ligamentously intact and medial collateral ligament (MCL)-deficient elbows. Cadaveric testing was performed in stable and MCL-deficient elbows with radial head arthroplasty and with the coronoid intact, with the coronoid fractured, and after suture repair. Ulna versus humerus angulation was measured during active motion. Varus and valgus motion pathways were measured during passive gravity-loaded flexion. With intact ligaments, there was a small increase in valgus angulation after a type 1 fracture that was not corrected with suture fixation. With MCL deficiency, there was no change in kinematics regardless of coronoid status. Type 1 coronoid fractures cause only small changes in elbow kinematics that are not corrected with suture repair. MCL repair, rather than type 1 coronoid fixation, should be considered if the elbow remains unstable after radial head repair or replacement and lateral ligament repair.

Radial Neck Dilatory Remodeling After Radial Head Arthroplasty With an Uncemented, Press Fit, Fully Chemically Etched Stem Design.

OBJECTIVES: To compare the radiographic outcomes of 2 widely used side loading, press fit, RHA implants used to reconstruct complex elbow trauma. DESIGN: Retrospective cohort study. SETTING: Level-1 Academic trauma center. PARTICIPANTS: Patients undergoing RHA. INTERVENTION: Cohort 1 received Synthes Radial Head Prosthesis. Cohort 2 received Biomet ExploR Radial Head Replacement. MAIN OUTCOME MEASUREMENTS: Radial neck dilatory remodeling. RESULTS: Eighty-two subjects were included in final analysis, 63 from the Biomet Cohort, and 19 from Synthes cohort. Demographic and injury characteristics were similar among cohorts. Radial neck dilatory remodeling as well as periprosthetic radiographic lucency were seen significantly more frequently and to a significantly greater degree in the Synthes cohort. The average percentage of dilatory remodeling of the Synthes cohort was 34.9% and that of the Biomet cohort was 2.7%. There were no differences in rates of revision surgery. CONCLUSIONS: Our study demonstrates significant radiographic differences between 2 frequently used RHA implants. Radial neck dilatory remodeling is a common, rapidly progressive, and dramatic finding frequently seen with the Synthes Radial Head Prosthesis. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of Appropriate Venous Thromboembolism Prophylaxis in Patients With Orthopaedic Trauma With Symptom-Driven Vascular and Radiographic Studies.

OBJECTIVE: To evaluate venous thromboembolism (VTE) prophylaxis adherence and effectiveness in orthopaedic trauma patients who had vascular or radiographic studies showing deep vein thromboses or pulmonary emboli. DESIGN: Retrospective review. SETTING: A level I trauma center that independently services a 5-state region. PATIENTS: Four hundred seventy-six patients with orthopaedic trauma who underwent operative treatments for orthopaedic injuries and had symptom-driven diagnostic VTE studies. INTERVENTION: The medical records of patients treated surgically between July 2010 and March 2013 were interrogated using a technical tool that electronically captures thrombotic event data from vascular and radiologic imaging studies by natural language processing. MAIN OUTCOME MEASUREMENTS: Patients were evaluated for hospital guideline-directed VTE prophylaxis adherence with mechanical or chemical prophylaxis. Patient demographics, associated injuries, mechanism of injury, and symptoms that led to imaging for a VTE were also assessed. RESULTS: Of the 476 orthopaedic patients who met inclusion criteria, 100 (mean age 52.3 median 52, SD 18.3, 70% men) had positive VTE studies. Three hundred seventy-six (age 47.3, SD 17.3, 69% men) had negative VTE studies. Of the 100 patients with VTE, 63 deep vein thromboses, and 49 pulmonary emboli were found. Eight-five percent of all patients met hospital guideline-VTE prophylaxis standards. CONCLUSION: The study population had better than previously reported VTE prophylaxis adherence, however, patients still developed VTEs. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Hyperextension Varus Bicondylar Tibial Plateau Fracture Pattern: Diagnosis and Treatment Strategies.

OBJECTIVES: The authors have identified a subset of bicondylar tibial plateau fractures with a hyperextension varus deformity (HEVBTP). The radiographic hallmarks of this pattern are (1) sagittal plane malalignment with loss of the normal posterior slope of the tibial plateau, (2) tension failure of the posterior cortex, (3) compression of the anterior cortex, and (4) varus deformity in the coronal plan. The purpose of this study was to describe this fracture pattern, to compare the associated injuries with non-HEVBTP fractures, and to suggest treatment strategies that may allow for improved reduction and stabilization. DESIGN: Retrospective Cohort Study. SETTING: Level 1 trauma center. PATIENTS: Preoperative radiographs and CT scans were reviewed in 208 patients who sustained 212 bicondylar tibial plateau fractures (OTA 41C). Twenty-five fractures in 23 patients fulfilled the radiographic criteria for HEVBTP fracture pattern. The remaining 187 bicondylar tibial plateau fractures were used as a control group. INTERVENTION: Initial spanning external fixation, followed by open reduction internal fixation and bone grafting with/without augmentation. MAIN OUTCOME MEASUREMENT: Associated injury rate compared with OTA 41C patients without HEVBTP pattern, nonunion rates, and loss of reduction rates. RESULTS: Thirty-two percent of the HEVBTP fractures demonstrated significant associated injuries compared with 16% in the control group. The incidence of popliteal artery disruption requiring repair was 12% in the HEVBTP group compared with 1% in the control group. Patients with HEVBTP had either partial or complete peroneal nerve injury in 16% of cases (8% in control group) and 12% of patients developed a leg compartment syndrome (10% in control group). CONCLUSIONS: The HEVBTP pattern is a unique fracture. The surgeon must recognize the possible associated injuries that accompany this injury. We suggest fixation strategies that address this injury's individual components which may help to avoid failure. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Preventing hospital-acquired venous thromboembolism: Improving patient safety with interdisciplinary teamwork, quality improvement analytics, and data transparency.

BACKGROUND: Hospital-acquired venous thromboembolism (HA-VTE) is a potentially preventable cause of morbidity and mortality. Despite high rates of venous thromboembolism (VTE) prophylaxis in accordance with an institutional guideline, VTE remains the most common hospital-acquired condition in our institution. OBJECTIVE: To improve the safety of all hospitalized patients, examine current VTE prevention practices, identify opportunities for improvement, and decrease rates of HA-VTE. DESIGN: Pre/post assessment. SETTING/PATIENTS: Urban academic tertiary referral center, level 1 trauma center, safety net hospital; all patients. INTERVENTION: We formed a multidisciplinary VTE task force to review all HA-VTE events, assess prevention practices relative to evidence-based institutional guidelines, and identify improvement opportunities. The task force developed an electronic tool to facilitate efficient VTE event review and designed decision-support and reporting tools, now integrated into the electronic health record, to bring optimal VTE prevention practices to the point of care. Performance is shared transparently across the institution. MEASUREMENTS: Harborview benchmarks process and outcome performance, including patient safety indicators and core measures, against hospitals nationally using Hospital Compare and Vizient data. RESULTS: Our program has resulted in >90% guideline-adherent VTE prevention and zero preventable HA-VTEs. Initiatives have resulted in a 15% decrease in HA-VTE and a 21% reduction in postoperative VTE. CONCLUSIONS: Keys to success include the multidisciplinary approach, clinical roles of task force members, senior leadership support, and use of quality improvement analytics for retrospective review, prospective reporting, and performance transparency. Ongoing task force collaboration with frontline providers is critical to sustained improvements. Journal of Hospital Medicine 2016;11:S38-S43. © 2016 Society of Hospital Medicine.

The effect of radial head fracture size on elbow kinematics and stability.

This study determined the effect of radial head fracture size and ligament injury on elbow kinematics. Eight cadaveric upper extremities were studied in an in vitro elbow simulator. Testing was performed with ligaments intact, with the medial collateral (MCL) or lateral collateral (LCL) ligament detached, and with both the MCL and LCL detached. Thirty degree wedges were sequentially removed from the anterolateral radial head up to 120 degrees . Valgus angulation and external rotation of the ulna relative to the humerus were determined for passive motion, active motion, and pivot shift testing with the arm in a vertical (dependent) orientation. Maximum varus-valgus laxity was calculated from measurements of varus and valgus angulation with the arm in horizontal gravity-loaded positions. No effect of increasing radial head fracture size was observed on valgus angulation during passive and active motion in the dependent position. In supination, external rotation increased with increasing fracture size during passive motion with LCL deficiency and both MCL and LCL deficiency. With intact ligaments, maximum varus-valgus laxity increased with increasing radial head fracture size. With ligament disruption, elbows were grossly unstable, and no effect of increasing radial head fracture size occurred. During pivot shift testing, performed with the ligaments intact, subtle instability was noted after resection of one-third of the radial head. In this in vitro biomechanical study, small subtle effects of radial head fracture size on elbow kinematics and stability were seen in both the ligament intact and ligament deficient elbows. These data suggest that fixation of displaced radial head fractures less than or equal to one-third of the articular diameter may have some biomechanical advantages; however, clinical correlation is required.

The effect of radial head excision and arthroplasty on elbow kinematics and stability.

BACKGROUND: Radial head fractures are common injuries. Comminuted radial head fractures often are treated with radial head excision with or without radial head arthroplasty. The purpose of the present study was to determine the effect of radial head excision and arthroplasty on the kinematics and stability of elbows with intact and disrupted ligaments. We hypothesized that elbow kinematics and stability would be (1) altered after radial head excision in elbows with intact and disrupted ligaments, (2) restored after radial head arthroplasty in elbows with intact ligaments, and (3) partially restored after radial head arthroplasty in elbows with disrupted ligaments. METHODS: Eight cadaveric upper extremities were studied in an in vitro elbow simulator that employed computer-controlled actuators to govern tendon-loading. Testing was performed in stable, medial collateral ligament-deficient, and lateral collateral ligament-deficient elbows with the radial head intact, with the radial head excised, and after radial head arthroplasty. Valgus angulation and rotational kinematics were determined during passive and simulated active motion with the arm dependent. Maximum varus-valgus laxity was measured with the arm in a gravity-loaded position. RESULTS: In specimens with intact ligaments, elbow kinematics were altered and varus-valgus laxity was increased after radial head excision and both were corrected after radial head arthroplasty. In specimens with disrupted ligaments, elbow kinematics were altered after radial head excision and were similar to those observed in specimens with a native radial head after radial head arthroplasty. Varus-valgus laxity was increased after ligament disruption and was further increased after radial head excision. Varus-valgus laxity was corrected after radial head arthroplasty and ligament repair; however, it was not corrected after radial head arthroplasty without ligament repair. CONCLUSIONS: Radial head excision causes altered elbow kinematics and increased laxity. The kinematics and laxity of stable elbows after radial head arthroplasty are similar to those of elbows with a native radial head. However, radial head arthroplasty alone may be insufficient for the treatment of complex fractures that are associated with damage to the collateral ligaments as arthroplasty alone does not restore stability to elbows with ligament injuries.

The effect of radial head fracture size on radiocapitellar joint stability.

OBJECTIVE: The purpose of this study was to determine the effect of radial head fracture size on radiocapitellar stability. DESIGN: Repeated measures using Instron materials testing machine. BACKGROUND: Radial head fractures are common injuries and controversy exists as to the optimal management of displaced wedge fractures. METHODS: Fractures were simulated in six fresh-frozen cadaveric radiocapitellar joints by removing sequential 20 degree wedges from the anterolateral aspect of each radial head until 140 degrees of the radial head was removed. Decreased shear load at the radial head during joint loading was used as an indicator of decreased stability at the radiocapitellar joint. Using a custom designed jig and employing a compressive joint load of 100 N, the maximum shear load at the radiocapitellar joint was measured at 30, 60, 90 and 120 degrees of elbow flexion. RESULTS: There was no difference in the shear load between the intact specimen and that with a 20 degree wedge removed at all flexion angles (P>0.05). Shear load decreased with each increase in wedge size between 20 and 120 degrees (P<0.05). After 120 degrees, one-third the diameter of the radial head, the shear load was always less than 0.8 N. CONCLUSIONS: This study demonstrated an inverse relationship between radiocapitellar joint stability and radial head fracture size. RELEVANCE: Small radial head fracture fragments are biomechanically significant. Therefore, the use of an arbitrary fragment size as an indication for surgery should be reconsidered, particularly if there is an associated ligamentous injury.