Periprosthetic fractures are osteoporotic fractures: missed opportunities for osteoporosis diagnosis.

Joint replacement surgery is common in older adults, leading to increasing periprosthetic fracture (PPFx) occurrence. We reviewed all PPFx seen over a 4-year period at an academic hospital. Clinical osteoporosis could be diagnosed based on existing data in 104 (67%) at the time of PPFx. Periprosthetic fractures are generally osteoporosis-related. PURPOSE: Periprosthetic fractures (PPFx) cause morbidity, mortality, and cost. This study's purpose was to describe osteoporosis-related data available at the time of PPFx. METHODS: The electronic medical record (EMR) of PPFx patients seen over 4 years in a university orthopedic practice were reviewed. Demographic data and osteoporosis relevant parameters were collected. Prior DXA studies were reviewed, and L1 Hounsfield unit (HU) measurements were performed on CT scans obtained within 2 years before PPFx. Clinical osteoporosis was defined as prior diagnosis, prescribed osteoporosis treatment, T-score ≤ - 2.5, HU ≤ 100, or prior fracture. RESULTS: Records of 156 PPFx patients (115 F/41 M), mean (SD) age 75.4 (11.9), were reviewed. Almost all 153/156 (98%) of these fractures were femoral. Falls caused 139 (89%); 12 (8%) were spontaneous. Mean time post-arthroplasty was 7.9 (6.3) years. Prior fragility fracture(s) occurred in 72 (46%); 14 were PPFx. Osteoporosis was previously diagnosed in 45 (29%) and medications prescribed in 41 (26%). Prior to PPFx, DXA data were available in 62, mean (SD) lowest T-score was - 1.9 (0.9) and was ≤ - 2.5 in 19. CT data were available in 46; mean (SD) L1 HU was 79.0 (29.4) and was ≤ 100 in 35. Based on existing data, clinical osteoporosis could have been diagnosed in 104 (67%) at the time of PPFx. CONCLUSION: Periprosthetic fractures are osteoporosis-related. They occur in older adults, often female, and result from falls; BMD, when assessed, is low. Data available at the time of PPFx often allows osteoporosis diagnosis; this should prompt evaluation and pharmacologic treatment consideration.

Management of Femoral Defects Greater Than 5 cm Following Open Femur Fractures: A 12-Year Retrospective Review.

This study sought to evaluate the outcomes of patients with osseous defects exceeding 5 cm following open femur fractures. Size of the osseous defect, method of internal fixation (plate vs. intramedullary nail), patient demographics, medical comorbidities, and surgical complications were collected. Twenty-seven of the 832 open femur fracture patients had osseous defects exceeding 5 cm. Mean osseous defect size was 8 cm, and each patient had an average of four operations including initial debridement. Average time from injury to bone grafting was 123.7 days. The overall complication rate was 48.1% (n = 13). The most common complications were infection (26.0%, n = 7) and nonunion (41.0%, n = 11). Smoking, diabetes, ASA score, and defect size did not independently increase the risk of a complication. Management of open femur fractures with osseous defects greater than 5 cm is associated with high complication rate, driven primarily by infection and nonunion. (Journal of Surgical Orthopaedic Advances 27(3):203-208, 2018).

Damage Control Plating in Open Tibial Shaft Fractures: A Cheaper and Equally Effective Alternative to Spanning External Fixation.

The purpose of this study was to evaluate damage control plating (DCP) as an alternative to external fixation (EF) in the provisional stabilization of open tibial shaft fractures. Through retrospective analysis, the study found 445 patients who underwent operative fixation for tibial shaft fractures from 2008 to 2012. Twenty patients received DCP or EF before intramedullary nailing with a minimum follow-up of 3 months. Charts and radiographs were reviewed for postoperative complications. Hospital charges were reviewed for implant costs. Nine patients (45%) with DCP and 11 patients (55%) with EF were analyzed. There was no significant difference in the complication rates. The mean implant cost of DCP was $1028, whereas mean EF construct cost was $4204. Therefore, DCP resulted in significant cost savings with no difference in complication rates, making it a valuable alternative to EF for the provisional stabilization of open tibial shaft fractures.

Risk factors for adverse cardiac events in hip fracture patients: an analysis of NSQIP data.

PURPOSE: Cardiovascular complications constitute morbidity and mortality for hip fracture patients. Relatively little data exist exploring risk factors for post-operative complications. Using the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database, we identified significant risk factors associated with adverse cardiac events in hip fracture patients and provide recommendations for practising orthopaedists. METHODS: A cohort of 27,441 patients with hip fractures from 2006 to 2013 was identified using Current Procedural Terminology codes. Cardiac complications were defined as cardiac arrests or myocardial infarctions occurring within 30 days after surgery. Bivariate analysis was run on over 30 patient and surgical factors to determine significant associations with cardiac events. Multivariate logistical analysis was then performed to determine risk factors most predictive for cardiac events. RESULTS: Of the 27,441 hip fracture patients, 594 (2.2%) had cardiac complications within 30 days post-operatively. There was no significant association with respect to type of hip fracture surgery and adverse cardiac event rates (p = 0.545). After multivariate analysis, dialysis use (OR: 2.22, p = 0.026), and histories of peripheral vascular disease (OR: 2.11, p = 0.016), stroke (OR: 1.83, p = 0.009), COPD (OR: 1.69, p = 0.014), and cardiac disease (OR: 1.55, p = 0.017) were significantly predictive of post-operative cardiac events in all hip fracture patients. CONCLUSION: Orthopaedic trauma surgeons should be aware of cardiac disease history and atherosclerotic conditions (PVD, stroke) in risk stratifying patients to prevent cardiac complications. Our recommendations to reduce cardiac events include simple pre-operative lab-work to full-fledged cardiac work-up and referrals to specific medicine disciplines based on the specific risk factors present.

Regional anaesthesia for hip fracture surgery is associated with significantly more peri-operative complications compared with general anaesthesia.

INTRODUCTION: Although several studies have advocated the use of regional versus general anaesthesia as a means of reducing peri-operative complications from hip fracture surgery, the ideal method of anaesthesia remains controversial. Our purpose was to investigate the association between anaesthesia type and peri-operative complications in hip fracture surgery. METHODS: From the 2005-2011 ACS-NSQIP database, all patients with operatively treated hip fractures were identified using CPT codes, and fifteen peri-operative complications were recorded and categorized as either minor or major. Rates of minor, major, and total complications by anaesthesia type were compared using chi-square and Fischer's exact tests. A multivariate model was used to determine odds of minor, major, and total complications between anaesthesia types. Multivariate analysis was then repeated after combining patients who received regional nerve blocks or spinal anaesthesia. RESULTS: A total of 7,764 hip fracture patients were included in our analysis. Spinal anaesthesia had the highest total complication rate (19.6%), followed by general (17.9%) and regional nerve blocks (12.6%). Multivariate analysis demonstrated that spinal anaesthesia was associated with significantly greater odds of minor complications and total complications compared with general anaesthesia. After combining the regional nerve block and spinal anaesthesia groups, multivariate analysis again showed significantly greater odds of minor and total complications with regional versus general anaesthesia. CONCLUSIONS: Using a large multi-centre database, we demonstrate that regional anaesthesia was associated with significantly greater odds of minor and total peri-operative complications compared with general anaesthesia. Our results challenge the notion that regional anaesthesia is the preferred method of anaesthesia for hip fractures in the elderly.

What factors influence follow-up in orthopedic trauma surgery?

BACKGROUND: Among surgical patients, follow-up visits are essential for monitoring post-operative recovery and determining ongoing treatment plans. Non-adherence to clinic follow-up appointments has been associated with poorer outcomes in many different patient populations. We sought to identify factors associated with non-attendance at follow-up appointments for orthopedic trauma patients. MATERIALS AND METHODS: A retrospective chart review at a level I trauma center identified 2,165 patients who underwent orthopedic trauma surgery from 2008 to 2009. Demographic data including age, sex, race, tobacco use, American Society of Anesthesiologist (ASA) score, insurance status, distance from the hospital, and follow-up time were collected. Injury characteristics including fracture type, anatomic location of the operation, length of hospital stay, living situation and employment status were recorded. Attendance at the first scheduled follow-up visit was recorded. Multivariable log-binomial regression analyses were used with statistical significance maintained at p < 0.05. RESULTS: Of the 2,165 patients included in the analysis, 1,449 (66.9 %) attended their first scheduled post-operative clinic visit. 33.1 % (717) were not compliant with keeping their first clinic appointment after surgery. Patients who used tobacco, lived more than 100 miles from the clinic site, did not have private insurance, had an ASA score >2, or had a fracture of the hip or pelvis were significantly less likely to follow-up. Age, sex, and race were not significantly associated with failure to follow-up. DISCUSSION: Follow-up appointments are essential for preventing complications among orthopedic trauma patients. By identifying patients at risk of failure to follow-up, orthopedic surgeons can appropriately design and implement long-term treatment plans specifically targeted for high-risk patients.

Open fractures: evidence-based best practices.

Open fracture management is a common challenge to orthopaedic trauma surgeons and a burdensome condition to the patient, health care, and entire society. Fracture-related infection (FRI) is the leading morbid complication to avoid during open fracture management because it leads to sepsis, nonunion, limb loss, and overall very poor region-specific and general functional outcomes. This review, based on a symposium presented at the 2022 OTA International Trauma Care Forum, provides a practical and evidence-based summary on key strategies to prevent FRI in open fractures, which can be grouped as optimizing host factors, antimicrobial prophylaxis, surgical site management (skin preparation, debridement, and wound irrigation), provision of skeletal stability, and soft-tissue coverage. When it is applicable, strategies are differentiated between optimal resource and resource-limited settings.

Does Topical Vancomycin Powder Use in Fracture Surgery Change Bacteriology and Antibiotic Susceptibilities? An Analysis of the VANCO Trial.

OBJECTIVE: To determine whether intrawound vancomycin changes the bacteriology of surgical site infection pathogens and investigate the emergence of antibiotic-resistant pathogens. DESIGN: Secondary analysis of phase III, prospective, randomized clinical trial. SETTING: Thirty-six US trauma centers. PATIENT SELECTION CRITERIA: Patients who became infected after fixation of tibial plateau or pilon fracture. OUTCOME MEASURES AND COMPARISONS: Pathogen types and bacterial susceptibilities as determined from routine clinical culture in the operating room. RESULTS: Seventy-four patients were studied who were 67.5% male with a mean age of 48.6 years. A lower proportion of gram-positive cocci was observed in the vancomycin powder compared with the standard-of-care group (3.7% vs. 8.0%, P = 0.01). Methicillin-resistant Staphylococcus aureus infection incidence was comparable in both the vancomycin powder and the standard-of-care groups, but rates of methicillin-susceptible S. aureus infections were lower in the treatment group (1.4% vs. 4.8%, P = 0.01). The incidence of coagulase-negative Staphylococci and gram-negative rod infections were similar in both groups. There was no significant difference in susceptibilities between groups in rates of vancomycin-resistant enterococcus. CONCLUSIONS: Topical vancomycin powder decreases the likelihood of gram-positive infections consistent with the biologic activity of vancomycin. Fewer methicillin-susceptible S. aureus and coagulase-negative Staphylococci infections were observed in the group treated with vancomycin powder. An effect of vancomycin powder on methicillin-resistant S. aureus infection risk was not detected given the low incidence in both the intrawound vancomycin and the standard-of-care groups. There was no emergence of gram-negative rod infections or increased resistance patterns observed. Use of topical vancomycin powder does not seem to produce infections in these patients with greater antibiotic resistance than would have occurred without its use. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Republication of "A Novel Casting Technique for Tongue-Type Calcaneus Fractures With Soft Tissue Compromise".

Displaced calcaneal fractures encompass a spectrum of fracture patterns, many of which are associated with soft tissue complications. Displaced tongue-type calcaneal fractures often cause pressure on the posterior heel skin, particularly when treatment is delayed. Resultant partial- or full-thickness skin necrosis presents significant challenges to the treating surgeon. In this article, the authors report on a case of full-thickness skin necrosis associated with a displaced tongue-type calcaneus fracture. The authors describe the use of a specialized heel window casting technique, which eliminates posterior heel pressure and greatly facilitates soft tissue surveillance and local wound care. The article also reviews the literature on soft tissue complications associated with displaced calcaneus fractures.

Pelvic ring injuries: recent advances in diagnosis and treatment.

Pelvic ring injuries typically occur from high-energy trauma and are often associated with multisystem injuries. Prompt diagnosis of pelvic ring injuries is essential, and timely initial management is critical in the early resuscitation of polytraumatized patients. Definitive management of pelvic ring injuries continues to be a topic of much debate in the trauma community. Recent studies continue to inform our understanding of static and dynamic pelvic ring stability. Furthermore, literature investigating radiographic and clinical outcomes after nonoperative and operative management will help guide trauma surgeons select the most appropriate treatment of patients with these injuries.

Mortality Rates After Nonoperative Geriatric Hip Fracture Treatment: A Matched Cohort Analysis.

OBJECTIVE: To compare the mortality rate between geriatric patients with hip fracture treated nonoperatively and a matched cohort treated operatively. DESIGN: Retrospective Observational Matched Cohort Study. SETTING: Academic Level 1 Trauma Center. PATIENTS: Geriatric patients who sustained femoral neck and intertrochanteric/peritrochanteric fractures, excluding isolated greater trochanteric fractures. All patients older than 65 years with hip fractures over a 10-year period were identified. Operative patients were matched at a 2:1 ratio, when possible, to nonoperative patients based on Charlson Comorbidity Index and American Society of Anesthesiologists score. INTERVENTION: Nonoperative treatment or operative treatment (femoral neck fractures: cannulated screw fixation or hemiarthroplasty; intertrochanteric/peritrochanteric fractures: sliding hip screw or cephalomedullary nail fixation; or proximal femoral locking plate). MAIN OUTCOMES: Mortality calculated at 30 and 90 days, and 1-year after injury. Mortality was compared between groups using logistic regression while controlling for age, CVA/TIA, and dementia. RESULTS: Seven hundred seventy-two patients (171 nonoperative and 601 operative) were initially identified. After applying the matching algorithm, 128 nonoperative and 239 operative patients were included in the analysis. There were no significant differences in age, sex, Charlson Comorbidity Index, or American Society of Anesthesiologists score between the cohorts. Nonoperative patients had a significantly higher 1-year mortality rate than operative patients [46.1% vs. 18.0%, Odds Ratio (95% confidence interval): 3.85 (2.34-6.41), P < 0.001]. CONCLUSIONS: Geriatric patients with hip fracture treated nonoperatively had a 1-year mortality rate of 46.1%, more than double the rate among operative patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Factors Considered in Ranking Pediatric Orthopedic Fellowship Applicants: A Survey of Program Directors.

The field of orthopedic surgery continues to grow rapidly in popularity. Ninety percent of orthopedic residents pursue fellowship training after residency, representing the highest rate of subspecialty training among surgical specialties. The goal of this study was to determine the factors considered most important by pediatric orthopedic fellowship program directors (PDs) in evaluating applicants and determining a rank list. A web-based survey was sent to all 42 US pediatric orthopedic fellowship programs. The PDs were contacted through publicly accessible email addresses found on program websites or the Pediatric Orthopaedic Society of North America website. Respondents were asked to indicate the fellowship program size and the number of applicants interviewed and ranked each year. The PDs were then asked to rank a list of 12 factors to reflect the relative importance of these criteria in evaluating fellowship applicants. Three emails were sent: 1 at the initial survey release and 2 reminder emails at 2 and 4 weeks. Surveys were anonymous. The overall response rate was 69% (29 of 42). Of the responding PDs, 48% (14 of 29) indicated that the interview was the most important factor in ranking fellowship applicants, whereas 31% (9 of 29) considered the applicant's letters of recommendation most important. Personal connections to the applicant or letter writer and research experience were each considered most important by 10% of responding PDs. Nearly half (48%) of responding PDs considered in-person interviews the most important factor in ranking fellowship applicants. Our results provide useful information for medical students and orthopedic residents planning to pursue fellowship training in pediatric orthopedics. [Orthopedics. 2022;45(4):e207-210.].

International Orthopaedic Volunteer Opportunities in Low and Middle-Income Countries.

ABSTRACT: Globally, the burden of musculoskeletal conditions continues to rise, disproportionately affecting low and middle-income countries (LMICs). The ability to meet these orthopaedic surgical care demands remains a challenge. To help address these issues, many orthopaedic surgeons seek opportunities to provide humanitarian assistance to the populations in need. While many global orthopaedic initiatives are well-intentioned and can offer short-term benefits to the local communities, it is essential to emphasize training and the integration of local surgeon-leaders. The commitment to developing educational and investigative capacity, as well as fostering sustainable, mutually beneficial partnerships in low-resource settings, is critical. To this end, global health organizations, such as the Consortium of Orthopaedic Academic Traumatologists (COACT), work to promote and ensure the lasting sustainability of musculoskeletal trauma care worldwide. This article describes global orthopaedic efforts that can effectively address musculoskeletal care through an examination of 5 domains: clinical care, clinical research, surgical education, disaster response, and advocacy.

Is the timing of fixation associated with fracture-related infection among tibial plateau fracture patients with compartment syndrome? A multicenter retrospective cohort study of 729 patients.

BACKGROUND: Tibial plateau fractures with an ipsilateral compartment syndrome are a clinical challenge with limited guidance regarding the best time to perform open reduction and internal fixation (ORIF) relative to fasciotomy wound closure. This study aimed to determine if the risk of fracture-related infection (FRI) differs based on the timing of tibial plateau ORIF relative to closure of ipsilateral fasciotomy wounds. METHODS: A retrospective cohort study identified patients with tibial plateau fractures and an ipsilateral compartment syndrome treated with 4-compartment fasciotomy at 22 US trauma centers from 2009 to 2019. The primary outcome measure was FRI requiring operative debridement after ORIF. The ORIF timing relative to fasciotomy closure was categorized as ORIF before, at the same time as, or after fasciotomy closure. Bayesian hierarchical regression models with a neutral prior were used to determine the association between timing of ORIF and infection. The posterior probability of treatment benefit for ORIF was also determined for the three timings of ORIF relative to fasciotomy closure. RESULTS: Of the 729 patients who underwent ORIF of their tibial plateau fracture, 143 (19.6%) subsequently developed a FRI requiring operative treatment. Patients sustaining infections were: 21.0% of those with ORIF before (43 of 205), 15.9% at the same time as (37 of 232), and 21.6% after fasciotomy wound closure (63 of 292). ORIF at the same time as fasciotomy closure demonstrated a 91% probability of being superior to before closure (RR, 0.75; 95% CrI, 0.38 to 1.10). ORIF after fasciotomy closure had a lower likelihood (45%) of a superior outcome than before closure (RR, 1.02; 95% CrI; 0.64 to 1.39). CONCLUSION: Data from this multicenter cohort confirms previous reports of a high FRI risk in patients with a tibial plateau fracture and ipsilateral compartment syndrome. Our results suggest that ORIF at the time of fasciotomy closure has the highest probability of treatment benefit, but that infection was common with all three timings of ORIF in this difficult clinical situation.

Radiographic outcomes of femur fractures following SIGN Fin nailing in low- and middle-income countries.

OBJECTIVE: To measure the effectiveness of the Surgical Implant Generation Network (SIGN) Fin nail for achieving satisfactory postoperative radiographic alignment following femoral shaft fractures. METHODS: Femoral shaft fractures stabilized with the SIGN Fin nail were identified using the SIGN Online Surgical Database. A random number generator was used to identify 500 femur fractures fixed within 6 weeks of injury for which postoperative radiographs were available. Fractures were classified using OTA/AO and Winquist-Hansen classification systems. Deviation from anatomic alignment was measured on anterior-posterior and lateral radiographs using an on-screen protractor tool. Other clinical variables recorded in the SIGN Online Surgical Database were also analyzed. Simple logistic regression was used to assess for associations between subject and surgical characteristics and misalignment status. Intra- and inter-rater agreement was assessed with intraclass correlation coefficient (ICC). RESULTS: The overall rate of malalignment >5° was 9.4%. Factors associated with increased incidence of malalignment include older age, increased time to surgery, distal diaphyseal location, closed (vs open) reduction, degree of comminution, and fracture classification. Intra-rater ICC was 0.70 (0.52, 0.82) in the coronal plane and 0.55 (0.32, 0.72) in the sagittal plane. Inter-rater ICC was 0.37 (0.08, 0.60) and 0.32 (0.05, 0.54), respectively. CONCLUSION: The SIGN Fin nail is an effective implant for fixation of femoral shaft fractures in resource-limited regions, achieving rates of satisfactory postoperative alignment comparable to that of the standard SIGN nail as well as femoral shaft fractures treated in North American Trauma Centers. Further research is required to investigate rotational alignment and long-term clinical outcomes for the SIGN Fin nail. LEVEL OF EVIDENCE: IV.

Factors considered in ranking orthopedic shoulder and elbow fellowship applicants: a survey of program directors.

Background: Orthopedic fellowship positions continue to be increasingly competitive, with most orthopedic residency graduates pursuing fellowship after completion of residency. Shoulder and elbow fellowship training represents an increasingly competitive and relatively smaller cohort of applicants than other subspecialties; there are only 29 programs with a total of 40 offered positions. The purpose of this survey is to identify and rank factors considered most important by shoulder and elbow fellowship directors when identifying potential fellowship candidates. Methods: A web-based survey was emailed to all 29 orthopedic shoulder and elbow fellowship directors recognized by American Shoulder and Elbow Surgeons. Demographic information was collected regarding program size, total number of applicants interviewed, and total number of applicants subsequently ranked. The survey also included a list of twelve applicant characteristics which each program director was asked to rank in a sequential order (most important to least). The median score of each factor was calculated, and a weighted score was applied to the top five (of twelve) categories selected by each program. Five points were given to the top-ranked factor. Four points were given to factors ranked 2nd, three points to factors ranked 3rd, two points to factors ranked 4th, and one point to factors ranked 5th. The weighted scores were then used to determine the most highly desired applicant characteristics. Results: Twenty-two of 29 (76%) orthopedic shoulder and elbow fellowship programs responded to the survey. Fourteen of 22 (64%) programs interview 20 or fewer applicants each year. No programs ranked more than 25 applicants. Twelve of 22 (55%) of program directors rated the interview as the most important factor, whereas 6 of 22 (27%) selected letters of recommendation. Based on the weighted score calculation, interviews, letters of recommendation, and personal connections to the applicant/letter writers comprised the top three categories, respectively, and captured 193 of 330 (58%) of the total available points in the weighted score. Strength of shoulder/elbow experience in residency, ties to the geographical area, and comments made regarding technical competence scored among the lowest factors. Conclusion: Orthopedic shoulder and elbow fellowship directors consistently ranked interviews, letters of recommendation, and personal connection to applicant/letter writer higher than other factors when ranking applicants. This information provides both program directors as well as applicants with important information to consider when navigating the shoulder and elbow fellowship application process.

Factors Considered in Ranking Spine Surgery Fellowship Applicants: A Survey of Program Directors.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: To determine which factors spine surgery fellowship program directors (PDs) consider most important when ranking applicants. SUMMARY OF BACKGROUND DATA: Spine surgery is a popular orthopedic subspecialty. As such, the spine fellowship match process is highly competitive. Surveys of fellowship PDs in orthopedic sports medicine and hand surgery have demonstrated differing opinions regarding factors considered most important when ranking fellowship applicants. The factors considered important to spine surgery fellowship PDs have not been evaluated. METHODS: A web-based questionnaire was sent to the PDs of all spine surgery fellowships participating in the San Francisco (SF) Match Program. The questions were designed to identify criteria considered most important in ranking spine surgery fellowship applicants. A list of 12 criteria was presented and PDs were asked to rank these in order of importance. A weighted score for each criterion was calculated using the following scale: 5 points for each criterion ranked 1st, 4 points for 2nd, 3 points for 3rd, 2 points for 4th, and 1 point for 5th. RESULTS: Of the 73 PDs queried, 52 responded (71% response rate). The interview was the most important factor when ranking fellowship applicants. The other criteria deemed most important in order of weighted scoring were letters of recommendation and personal connections to the applicant and/or familiarity with the applicant's letter writer(s). CONCLUSION: Spine surgery fellowship PDs consider the interview, letters of recommendation, and personal connections with the applicant/letter writers to be the most important factors when ranking candidates. These results may be valuable to orthopedic residents and mentors of those pursuing fellowship training in spine surgery.Level of Evidence: 4.

Diagnosing Fractures of the Distal Tibial Articular Surface in Tibia Shaft Fractures: Is Computed Tomography Always Necessary?

OBJECTIVES: To identify the incidence of distal articular fractures in a series of distal third tibia shaft fractures and to report the utility of both computed tomography (CT) scans and Radiographic Investigation of the Distal Extension of Fractures into the Articular Surface of the Tibia (RIDEFAST) ratios for identification of articular involvement. DESIGN: Retrospective cohort. SETTING: Level 1 trauma center. PATIENTS: Four hundred seventeen patients with distal third tibia shaft fractures were included in the study. INTERVENTION: Intramedullary nail or plate fixation. MAIN OUTCOME MEASURES: Type of articular fracture, time of diagnosis, and RIDEFAST ratios. RESULTS: One hundred one of the 417 distal third fractures (24%) had a fracture of the distal tibia articular surface. Of these 101 fractures, 41 (41%) represented an extension of the primary fracture line and 60 (59%) were separate malleolar fractures. Of the 101 articular fractures, 95 (94%) were identified preoperatively and 6 (6%) were identified intraoperatively. Of the 95 fractures identified preoperatively, 87 (92%) were identified on plain radiographs and 8 (8%) by CT scan. Thirty-five preoperative CT scans were performed on distal third tibia shaft fractures in search of an intra-articular fracture. In 27 patients (77%), no articular fracture was present, representing an overall yield of 23% among CT scans performed to rule out an articular fracture in distal third tibia shaft fractures. RIDEFAST ratios for all 101 distal tibia shaft fractures with articular involvement and 100 fractures with no articular involvement were not significantly different (P > 0.05) using both coronal and sagittal plane measurements. CONCLUSIONS: CT scans performed on distal third tibia shaft fractures in search of articular fractures had a low yield (23%). Widespread use of CT scan to diagnose fractures of the distal tibia articular surface in the setting of distal tibia shaft fractures does not seem warranted. No statistically significant differences in RIDEFAST ratios were found between fractures with and without articular involvement, indicating that more work is necessary before RIDEFAST can be used to reliably rule out articular involvement in this setting. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Reduction techniques for intramedullary nailing of tibial shaft fractures: a comparative study.

OBJECTIVES: To assess the impact of various reduction techniques on postoperative alignment following intramedullary nail (IMN) fixation of tibial shaft fractures. DESIGN: Retrospective comparative study. SETTING: Level I trauma center. PATIENTS: Four hundred twenty-eight adult patients who underwent IMN fixation of a tibial shaft fracture between 2008 and 2017. INTERVENTION: IMN fixation with use of one or more of the following reduction techniques: manual reduction, traveling traction, percutaneous clamps, provisional plating, or blocking screws. MAIN OUTCOME MEASURES: Immediate postoperative coronal and sagittal plane alignment, measured as deviation from anatomic axis (DFAA); coronal and sagittal plane malalignment (defined as DFAA >5° in either plane). RESULTS: Four hundred twenty-eight patients met inclusion criteria. Manual reduction (MR) alone was used in 11% of fractures, and adjunctive reduction aids were used for the remaining 89%. After controlling for age, BMI, and fracture location, the use of traveling traction (TT) with or without percutaneous clamping (PC) resulted in significantly improved coronal plane alignment compared to MR alone (TT: 3.4°, TT+PC: 3.2°, MR: 4.5°, P = .007 and P = .01, respectively). Using TT+PC resulted in the lowest rate of coronal plane malalignment (13% vs 39% with MR alone, P = .01), and using any adjunctive reduction technique resulted in decreased malalignment rates compared to MR (24% vs 39%, P = .02). No difference was observed in sagittal plane alignment between reduction techniques. Intraclass correlation coefficient (ICC) results indicated excellent intraobserver reliability on both planes (both ICC>0.85), good inter-observer reliability in the coronal plane (ICC = 0.7), and poor inter-observer reliability in the sagittal plane (ICC = 0.05). CONCLUSIONS: The use of adjunctive reduction techniques during IMN fixation of tibia fractures is associated with a lower incidence of coronal plane malalignment when compared to manual reduction alone. LEVEL OF EVIDENCE: Therapeutic Level III.

Factors influencing management of bilateral femur fractures: A multicenter retrospective cohort of early versus delayed definitive Fixation.

INTRODUCTION: The purpose of our study was to evaluate the factors that influence the timing of definitive fixation in the management of bilateral femoral shaft fractures and the outcomes for patients with these injuries. METHODS: Patients with bilateral femur fractures treated between 1998 to 2019 at ten level-1 trauma centers were retrospectively reviewed. Patients were grouped into early or delayed fixation, which was defined as definitive fixation of both femurs within or greater than 24 hours from injury, respectively. Statistical analysis included reversed logistic odds regression to predict which variable(s) was most likely to determine timing to definitive fixation. The outcomes included age, sex, high-volume institution, ISS, GCS, admission lactate, and admission base deficit. RESULTS: Three hundred twenty-eight patients were included; 164 patients were included in the early fixation group and 164 patients in the delayed fixation group. Patients managed with delayed fixation had a higher Injury Severity Score (26.8 vs 22.4; p<0.01), higher admission lactate (4.4 and 3.0; p<0.01), and a lower Glasgow Coma Scale (10.7 vs 13; p<0.01). High-volume institution was the most reliable influencer for time to definitive fixation, successfully determining 78.6% of patients, followed by admission lactate, 64.4%. When all variables were evaluated in conjunction, high-volume institution remained the strongest contributor (X2 statistic: institution: 45.6, ISS: 8.83, lactate: 6.77, GCS: 0.94). CONCLUSION: In this study, high-volume institution was the strongest predictor of timing to definitive fixation in patients with bilateral femur fractures. This study demonstrates an opportunity to create a standardized care pathway for patients with these injuries. LEVEL OF EVIDENCE: Level III.