Long-term outcome of persons with diabetic and non-diabetic neuro-osteoarthropathy after foot correction using external fixation.

AIM: Diabetic neuro-osteoarthropathy (Charcot foot) is a serious form of diabetic foot syndrome, often leading to severe deformity of the foot and subsequently to ulcers and osteomyelitis. The aim of this retrospective study was to determine the success rate and long-term outcomes for a Charcot foot operation using external fixation in 115 individuals who underwent surgery between July 2008 and December 2012. METHODS: Some 115 consecutive persons, 78 (68%) men and 37 (32%) women, were enrolled in this study. The eligibility criterion for this retrospective study was reconstructive foot surgery using a Hoffmann II external fixator in diabetic and non-diabetic neuro-osteoarthropathy. The main examination parameters in the follow-up were walking ability, amputation and mortality. Average follow-up was 5.7 (± 3.2) years. RESULTS: Ninety-seven per cent of people were able to walk after the operation with bespoke shoes or an orthosis. At follow-up, 77% were able to walk and 51% were fully mobile even outside the home. Subsequent amputations were performed in 29 individuals (26%), with 17 (15%) minor and 12 (11%) major amputations. Forty-seven individuals died before follow-up, the majority (53%) from cardiovascular events. Average survival time post surgery was 4.5 (± 2.9) years. CONCLUSION: Reconstruction surgery using external fixation is a very useful method for maintaining walking ability in the case of conservatively non-treatable diabetic and non-diabetic neuro-osteoarthropathy. Individuals with severe Charcot foot disease had a low rate of major amputations. Osteomyelitis was the main reason for major amputations.

Delay in Hip Fracture Repair in the Elderly: A Missed Opportunity Towards Achieving Better Outcomes.

BACKGROUND: Hip fractures are a major cause of morbidity and mortality in the elderly. The American Academy of Orthopedic Surgeons (AAOS) recommends surgical repair within 48 hours of admission, as this is associated with lower postoperative mortality and complications. This study demonstrates the association between patient demographics, level of care, and hospital region to delay in hip fracture repair in the elderly. METHODS: The National Trauma Data Bank (NTDB) was queried for elderly patients (age >65 years) who underwent proximal femoral fracture repair. Identified patients were subcategorized into two groups: hip fracture repair in <48 hours, and hip fracture repair > 48 hours after admission. Patient and hospital characteristics were collected. Outcome variables were timed from the day of admission to surgery and inpatient mortality. RESULTS: Out of 69,532 patients, 28,031 were included after inclusion criteria were applied. 23,470 (83.7%) patients underwent surgical repair within 48 hours. The overall median time to procedure was 21 (interquartile range [IQR] 7-38) hours. Females were less likely to undergo a delay in hip fracture repair (odds ratio [OR; 95% confidence interval {CI}]: 0.82 [0.76-0.88], P< 0.05), and patients with higher Injury Severity Score (ISS ≥25) had higher odds of delay in surgical repair (OR; 95% CI: 1.56 [1.07-2.29], P< 0.05). Patients treated at hospitals in the Western regions of the United States had lower odds of delay, and those treated in the Northeast and the South had higher odds of delay compared to the hospitals in the Midwest (taken as standard). There was no association between trauma level designation and odds of undergoing delay in hip fracture repair. CONCLUSION: Variables related to patient demographic and hospital characteristics are associated with delay in hip fracture repair in the elderly. This study delineates key determinants of delay in hip fracture repair in the elderly patients.

Incidence and treatment of adult femoral fractures with osteogenesis imperfecta: An analysis of a center of 72 patients in Taiwan.

Background: Osteogenesis imperfecta (OI) is a rare disease characterized by increased bone fragility and susceptibility for fractures. Only few studies have compared the management for femoral fractures in children with OI. Nevertheless, no cohort studies have described the treatment for femoral fractures in adults with OI in Taiwan. This study aimed to investigate and compare the incidence of union and non-union femoral fractures and the best treatment options to avoid non-union fractures. Methods: We enrolled 72 patients with OI who were older than 18 years at MacKay Memorial Hospital between January 2010 and December 2018. Femoral fracture incidence, non-union rate, and treatment modality were analyzed. Results: Of 72 patients with OI, 11 patients had femoral fractures and 4 patients of them had >1 femoral fracture. The incidence for all types of femoral fractures was 651 fractures per 100,000 person-years annually. In 15 total fractures, 4 fractures resulted in non-union, and patients with type 4 OI mostly had shaft fractures. The best outcomes for non-union shaft fracture is achieved by surgical treatment. Conclusion: Adults with OI tended to develop femoral fractures and non-unions. Adults with type 4 OI were particularly at high risk for non-unions in shaft fractures with conservative treatment.

Low-energy Gunshot-induced Tibia Fractures: What Proportion Develop Complications?

BACKGROUND: Gunshot injuries of the extremities are common in the United States, especially among people with nonfatal gunshot wounds. Controversy persists regarding the proper management for low-energy gunshot-induced fractures, likely stemming from varying reports on the likelihood of complications. There has yet to be published a study on a large cohort of patients with gunshot-induced tibia fractures on which to base our understanding of complications after this injury. QUESTIONS/PURPOSES: (1) What percentage of patients with low-energy gunshot-induced tibia fractures developed complications? (2) Was there an association between deep infection and fracture location, injury characteristics, debridement practices, or antibiotic use? METHODS: This was a multicenter retrospective study. Between January 2009 and December 2018, we saw 201 patients aged 16 years or older with a gunshot-induced fracture who underwent operative treatment; 2% (4 of 201) of those screened had inadequate clinical records, and 38% (76 of 201) of those screened had inadequate follow-up for inclusion. In all, 121 patients with more than 90 days of follow-up were included in the study. Nonunion was defined as a painful fracture with inadequate healing (fewer than three cortices of bridging bone) at 6 months after injury, resulting in revision surgery to achieve union. Deep infection was defined according to the confirmatory criteria of the Fracture-Related Infection Consensus Group. These results were assessed by a fellowship-trained orthopaedic trauma surgeon involved with the study. Complication proportions were tabulated. A Kaplan-Meier chart demonstrated presentations of deep infection by fracture location (proximal, shaft, or distal). Univariate statistics and multivariate Cox regression were used to examine the association between deep infection and fracture location, entry wound size, vascular injury, intravenous (IV) antibiotics in the emergency department (ED), deep and superficial debridement, the duration of postoperative IV antibiotics, and the use of topical antibiotics, while adjusting for age, race/ethnicity, smoking status, and BMI. A power analysis for the result of deep infection demonstrated that we would have had to observe a hazard ratio of 4.28 or greater for shaft versus proximal locations to detect statistically significant results at 80% power and alpha = 0.05. RESULTS: The overall complication proportion was 49% (59 of 121), with proportions of 14% (17 of 121) for infection, 27% (33 of 121) for wound complications, 20% (24 of 121) for nonunion, 9% (11 of 121) for hardware breakage, and 26% (31 of 121) for revision surgery. A positive association was present between deep infection and deep debridement (HR 5.51 [95% confidence interval 1.12 to 27.9]; p = 0.04). With the numbers available, we found no association between deep infection and fracture location, entry wound size, vascular injury, IV antibiotics in the ED, superficial debridement, the duration of postoperative IV antibiotics, and the use of topical antibiotics. CONCLUSION: In this multicenter study, we found a higher risk of complications in operative gunshot-induced tibia fractures than prior studies have reported. Infection, in particular, was much more common than expected based on prior studies. Consequently, surgeons might consider adopting the general management principles for nongunshot-induced open tibia fractures with gunshot-induced fractures, such as the use of IV antibiotics both initially and after surgery. Further research is needed to test and validate these approaches. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Hip fracture care during the 2020 COVID-19 first-wave: a review of the outcomes of hip fracture patients at a Scottish Major Trauma Centre.

BACKGROUND AND PURPOSE OF THE STUDY: This study reviewed whether the response to the Coronavirus (COVID-19) pandemic affected the care for hip fracture patients at a major trauma centre in Scotland during the first-wave lock-down period. METHODS: All patients referred to Orthopaedics with a hip fracture in a major trauma centre in Scotland were captured between 14 th March and 28 th May (11 weeks) in 2020 and 2019. Patients were identified using electronic patient records. The primary outcomes are time to theatre, length of admission and 30-day mortality. Secondary outcomes are COVID-19 prevalence, duration of surgery, proportion of patients to theatre within 36 hours and COVID-19 positive 30-day mortality from time of surgery. 225 patients were included: 108 from 2019 and 117 from 2020. THE MAIN FINDINGS: 30-day mortality was 3.7% (n=4) in 2019 and 8.5% (n=10) in 2020 (p=0.142). There was no statistical difference with time to theatre (p=0.150) nor duration of theatre (p=0.450). Duration of admission was reduced from 12 days to 6.5 days (p=<0.005). 4 patients tested positive for COVID-19 during admission, one 5 days after discharge, all underwent surgical management. 30-day mortality for COVID-19 positive patients during admission was 40%. COVID-19 prevalence of patients that were tested (n=89) was 5.62%. CONCLUSIONS: This study has shown the care of hip fracture patients has been maintained during the COVID-19 pandemic. There is no statistically significant change in mortality, time to theatre, and duration of surgery, however, the patient's admission duration was significantly less than the 2019 cohort.

Hip Fracture Following a Fall among Older Adults during the COVID-19 Pandemic.

BACKGROUND: Little is known regarding the impact of the coronavirus disease-2019 (COVID-19) pandemic on the incidence of hip fractures among older adults. OBJECTIVES: To compare the characteristics of patients with a hip fracture following a fall during the COVID-19 pandemic year and during the preceding year. METHODS: We conducted a retrospective cohort study of older patients who had undergone surgery for hip fracture repair in a major 495-bed hospital located in northern central Israel following a fall. Characteristics of patients who had been hospitalized in 2020 (pandemic year, n=136) and in 2019 (non-pandemic year, n=151) were compared. RESULTS: During the pandemic year, patients were less likely to have fallen in a nursing facility, to have had muscle or balance problems, and to have had a history of falls and fractures following a fall. Moreover, the average length of stay (LOS) in the hospital was shorter; however, the average time from the injury to hospitalization was longer. Patients were less likely to have acquired a postoperative infection or to have died. During the pandemic year, postoperative infection was only associated with prolonged LOS. CONCLUSIONS: The COVID-19 pandemic may have had a positive impact on the behavior of older adults as well as on the management of hip fracture patients. However, healthcare providers should be aware of the possible reluctance to seek care during a pandemic. Moreover, further research on the impact of the change in management during COVID-19 on hip fracture survival is warranted.

Prediction of Long Bone Fractures in Multiple Myeloma Patients in an Advanced Imaging World.

BACKGROUND: Multiple myeloma (MM) affects the long bones in 25% of patients. The advent of positron-emission tomography/computed tomography (PET/CT) scanners offers the possibility of both metabolic and radiographic information and may help determine fracture risk. To the best of our knowledge, no published study correlates these two factors with long bone fractures. OBJECTIVES: To evaluate the impact of PET/CT on fracture risk assessment in multiple myeloma patients. METHODS: We identified all bone marrow biopsy proven multiple myeloma patients from 1 January 2010 to 31 January 2015 at a single institution. We prospectively followed patients with long bone lesions using PET/CT scan images. RESULTS: We identified 119 patients (59 males/60 females) with 256 long bone lesions. Mean age at diagnosis was 58 years. The majority of lesions were in the femur (n=150, 59%) and humerus (n=84, 33%); 13 lesions in 10 patients (8%) required surgery for impending (n=4) or actual fracture (n=9). Higher median SUVmax was measured for those with cortical involvement (8.05, range 0-50.8) vs. no involvement (5.0, range 2.1-18.1). SUVmax was found to be a predictor of cortical involvement (odds ratio = 1.17, P = 0.026). No significant correlation was found between SUVmax and pain or fracture (P = 0.43). CONCLUSIONS: Improved medical treatment resulted improvement in 8% of patients with an actual or impending fracture. The orthopedic surgeons commonly use the Mirels classification for long bone fracture prediction. Adding PET/CT imaging to study in myeloma long bone lesions did not predict fracture risk directly but suggested it indirectly by cortical erosion.

Ex vivo comparison of standing and recumbent repair of incomplete parasagittal fractures of the first phalanx in horses.

OBJECTIVE: To assess suspensory ligament extensor branch location and fracture gap reduction with simulation of standing and recumbent cortical bone screw repair of experimental incomplete parasagittal proximal phalanx (P1) fractures. STUDY DESIGN: Controlled laboratory study. SAMPLE POPULATION: Twenty equine cadaver forelimbs. METHODS: Simulated fractures were repaired twice in random order. A proximal cortical bone screw was placed in lag fashion with the limb unloaded (simulated recumbent repair) and loaded to 38% of body weight (range, 375-568 kg; simulated standing repair). Changes in fracture gap width were assessed on computed tomography (CT) images and with intraplanar force-sensitive resistors measuring voltage ratios (V△ ) between loaded recumbent (R-1) and standing repair simulations (R-2). Extensor branch borders were determined relative to implant position and sagittal P1 width on transverse CT images. P ≤ .05 was considered significant. RESULTS: Standing repair simulation-associated fracture gaps were not wider than in R-1 while controlling for confounding factors (loading weight, implant position, or animal age; P > .7, repeated-measures analysis of variance). Voltage ratio data associated with R-2 were not smaller than with R-1 (mean difference, 0.002 ± 0.052; one-sided Wilcoxon signed-rank test, P = .27). More of P1 width was approachable palmar to extensor branches when limbs were loaded (0.804 ± 0.314 cm) vs unloaded (0.651 ± 0.31 cm; paired Student's t test, P < .001). CONCLUSION: Simulated standing repair was not associated with inferior fracture reduction compared with loaded simulations of recumbent repairs. Limb loading affected extensor branch location relevant to implant positioning. CLINICAL SIGNIFICANCE: Unloading during standing repair of incomplete parasagittal proximal P1 fractures may not be required to optimize fracture reduction.

Rate of venous thromboembolism after surgical treatment of proximal humerus fractures.

INTRODUCTION: The rate of venous thromboembolism following surgical treatment of proximal humerus fractures is not well established. METHODS: A retrospective review of all patients undergoing surgical treatment for proximal humerus fractures from September 2011 to May 2017 was performed. Included patients received only mechanoprophylaxis using sequential compression devises. All patients had at least 6 months follow-up. The primary outcome of interest was the rate of postoperative DVT and PE. RESULTS: 131 patients underwent 139 surgeries for proximal humerus fracture. After exclusion criteria were applied, 92 patients who underwent 92 surgeries were included. There were 47 females and 45 males. Five (5.4%) were taking Aspirin 81 mg preoperatively. There were 76 cases of open reduction and internal fixation (ORIF), 8 cases of reverse total shoulder arthroplasty, 4 cases of hemiarthroplasty, 3 cases of closed reduction percutaneous pinning (CRPP), 1 case of open reduction without fixation. 53.3% of patients had one or more risk factors for VTE. There were no cases of fatal PE or DVT. There were two cases of symptomatic PE (2.2%) following one ORIF and one CRPP. There was one additional case of asymptomatic PE found incidentally after ORIF. Overall VTE rate was 3.3%. Fisher's exact test yielded that there was no significant association between the presence of VTE risk factors and prevalence of VTE postoperatively (p = 0.245). CONCLUSIONS: The incidence of symptomatic VTE after surgery for proximal humerus fractures is low. Chemical VTE prophylaxis in patients after surgical fixation for proximal humerus fractures is not universally indicated. Selective prophylaxis for patients with systemic risk factors may be warranted.

The Effects of Cross-Border Transport on Patients With Tibia Fractures.

BACKGROUND: Tibia fractures are common after trauma. Prior studies have shown that delays in treatment are associated with poor outcomes. A subpopulation of our patients are transported from Mexico, adding barriers to prompt care. We hypothesized that patients with tibia fractures crossing from Mexico would have delays in treatment and subsequently worse outcomes. METHODS: The trauma registry of an American College of Surgeons-verified level 1 trauma center was retrospectively reviewed for all tibia fractures admitted from 2010 to 2015. Data collection included demographics, country of injury, characterization of injuries, interventions, complications, and outcomes. Patients were subdivided into those injured in the United States and in Mexico, and the two groups were compared. RESULTS: A total of 498 patients were identified, 440 from the United States and 58 from Mexico. Mexico patients were more severely injured overall, with higher injury severity scores and a higher percentage of patients with abbreviated injury scale scores ≥3 for both head and chest regions. Mexico patients had longer times from injury to admission, as well as increased times to both debridement of open fractures and operative fixation after admission. On subgroup analysis of patients with isolated tibia fractures (other system abbreviated injury scale < 3), times from arrival to treatment and injury severity score were no longer statistically different. CONCLUSIONS: Patients crossing the border from Mexico with tibia fractures have delays in time to admission and from admission to operative management, although this is primarily due to other severe injuries. Ongoing systems development is required to minimize delays in care and optimize outcomes.

Treatment of Facial Fractures at a Level 1 Trauma Center: Do Medicaid and Non-Medicaid Enrollees Receive the Same Care?

BACKGROUND: Timing of surgical treatment of facial fractures may vary with the patient age, injury type, and presence of polytrauma. Previous studies using national data sets have suggested that trauma patients with government insurance experience fewer operations, longer length of hospital stay (LOS), and worse outcomes compared with privately insured patients. The objective of this study is to compare treatment of facial fractures in patients with and without Medicaid insurance (excluding Medicare). METHODS: All adults with mandibular, orbital, and midface fractures at a Level 1 Trauma Center between 2009 and 2018 were included. Statistical analyses were performed to assess the differences in the frequency of surgery, time to surgery (TTS), LOS, and mortality based on insurance type. RESULTS: The sample included 1541 patients with facial fractures (mandible, midface, orbital), of whom 78.8% were male, and 13.1% (208) were enrolled in Medicaid. Mechanism of injury was predominantly assault for Medicaid enrollees and falls or motor vehicle accidents for non-Medicaid enrollees (P < 0.001). Patients with mandible and midface fractures underwent similar rates of surgical repair. Medicaid enrollees with orbital fractures underwent less frequent surgery for facial fractures (24.8% versus 34.7%, P = 0.0443) and had higher rates of alcohol and drug intoxication compared with non-Medicaid enrollees (42.8% versus 31.6%, P = 0.008). TTS, LOS, and mortality were similar in both groups with facial fractures. CONCLUSIONS: Overall, the treatment of facial fractures was similar regardless of the insurance type, but Medicaid enrollees with orbital fractures experienced less frequent surgery for facial fractures. Further studies are needed to identify specific socioeconomic and geographic factors contributing to these disparities in care.

Do Medicare Accountable Care Organizations Reduce Disparities After Spinal Fracture?

BACKGROUND: National changes in health care disparities within the setting of trauma care have not been examined within Accountable Care Organizations (ACOs) or non-ACOs. We sought to examine the impact of ACOs on post-treatment outcomes (in-hospital mortality, 90-day complications, and readmissions), as well as surgical intervention among whites and nonwhites treated for spinal fractures. MATERIALS AND METHODS: We identified all beneficiaries treated for spinal fractures between 2009 and 2014 using national Medicare fee for service claims data. Claims were used to identify sociodemographic and clinical criteria, receipt of surgery and in-hospital mortality, 90-day complications, and readmissions. Multivariable logistic regression analysis accounting for all confounders was used to determine the effect of race/ethnicity on outcomes. Nonwhites were compared with whites treated in non-ACOs between 2009 and 2011 as the referent. RESULTS: We identified 245,704 patients who were treated for spinal fractures. Two percent of the cohort received care in an ACO, whereas 7% were nonwhite. We found that disparities in the use of surgical fixation for spinal fractures were present in non-ACOs over the period 2009-2014 but did not exist in the context of care provided through ACOs (odds ratio [OR] 0.75; 95% confidence interval [CI] 0.44, 1.28). A disparity in the development of complications existed for nonwhites in non-ACOs (OR 1.09; 95% CI 1.01, 1.17) that was not encountered among nonwhites receiving care in ACOs (OR 1.32; 95% CI 0.90, 1.95). An existing disparity in readmission rates for nonwhites in ACOs over 2009-2011 (OR 1.34; 95% CI 1.01, 1.80) was eliminated in the period 2012-2014 (OR 0.85; 95% CI 0.65, 1.09). CONCLUSIONS: Our work reinforces the idea that ACOs could improve health care disparities among nonwhites. There is also the potential that as ACOs become more familiar with care integration and streamlined delivery of services, further improvements in disparities could be realized.

Knee Fracture Increases TKA Risk After Initial Fracture Treatment and Throughout Life.

BACKGROUND: Knee fractures may lead to post-traumatic knee osteoarthritis and subsequent TKA in some patients. However, absolute risk estimates and risk factors for TKA in patients with knee fractures compared with those of the general population remain largely unknown. Such knowledge would help establish the treatment burden and direct patient counseling after a knee fracture is sustained. QUESTIONS/PURPOSES: (1) What is the short-term risk of TKA after knee fracture? (2) What is the long-term risk of TKA after knee fracture? (3) What are the risk factors for TKA in patients with knee fractures? METHODS: A nationwide 20-year, matched-case comparison cohort study of prospectively collected data from the Danish National Patient Registry included all patients at least 15 years old with International Classification of Diseases, 10th revision codes DS724, DS820, or DS821 (knee fractures) on the date their knee fracture was registered. Each patient with a knee fracture was matched (by sex and age) to five people without knee fractures from the general Danish population on the date the knee fracture patient's knee fracture was registered (population controls). Patients with knee fractures and people in the population control group were followed from the date the knee fracture patient's knee fracture was registered to the date of TKA, amputation, knee fusion, emigration, death, or end of follow-up in April 2018. TKA risks for patients with knee fractures versus those for population controls and TKA risk factors in patients with knee fractures were estimated using hazard ratios (HRs) with 95% CIs. A total of 48,791 patients with knee fractures (median age 58 years [interquartile range 41-73]; 58% were female) were matched to 263,593 people in the population control group. RESULTS: The HR for TKA in patients with knee fractures compared with population controls was 3.74 (95% CI 3.44 to 4.07; p < 0.01) in the first 3 years after knee fracture. Among knee fracture patients, the risk of undergoing TKA was 2% (967 of 48,791) compared with 0.5% (1280 of 263,593) of people in the population control group. After the first 3 years, the HR was 1.59 (95% CI 1.46 to 1.71) and the number of patients with knee fractures with TKA events divided by the number at risk was 2% (849 of 36,272), compared with 1% (2395 of 180,418) of population controls. During the 20-year study period, 4% of patients with knee fractures underwent TKA compared with 1% of population controls. Risk factors for TKA in patients with knee fractures were: primary knee osteoarthritis (OA) versus no primary knee OA (HR 9.57 [95% CI 5.39 to 16.98]), surgical treatment with external fixation versus open reduction and internal fixation and reduction only (HR 1.92 [95 % CI 1.01 to 3.66]), proximal tibia fracture versus patellar fracture (HR 1.75 [95 % CI 1.30 to 2.36]), and distal femur fracture versus patellar fracture (HR 1.68 [95 % CI 1.08 to 2.64]). Surgical treatment of knee fractures was also a risk factor for TKA. The HRs for TKA in patients with knee fractures who were surgically treated versus those who were treated non-surgically were 2.05 (95% CI 1.83 to 2.30) in the first 5 years after knee fracture and 1.19 (95% CI 1.01 to 1.41) after 5 years. CONCLUSIONS: Patients with knee fractures have a 3.7 times greater risk of TKA in the first 3 years after knee fracture, and the risk remains 1.6 times greater after 3 years and throughout their lifetimes. Primary knee OA, surgical treatment of knee fractures, external fixation, proximal tibia fractures, and distal femur fractures are TKA risk factors. These risk estimates and risk factors highlight the treatment burden of knee fractures, building a foundation for future studies to further counsel patients on their risk of undergoing TKA based on patient-, fracture-, and treatment-specific factors. LEVEL OF EVIDENCE: Level III, prognostic study.

Medial Epicondyle Fractures: Current Practices and Preferences Between SLAOTI Members (Sociedad Latinoamericana de Ortopedia y Traumatología Infantil).

BACKGROUND: Medial epicondyle fractures represent up to 20% of elbow fractures in children and adolescents. There is a growing body of literature to support surgical fixation for displaced fractures. However, controversy regarding imaging modality for displacement measurement and surgical indications remain controversial. The purpose of this survey was to gauge Latin American surgeons' practices and preferences for the evaluation and treatment of medial epicondyle fractures. METHODS: A web-based survey containing 19 questions was distributed to active members of SLAOTI (Sociedad Latinoamericana de Ortopedia y Traumatología Infantil) in November 2018. The survey elicited information regarding surgeon demographics, evaluation methods, the factors involved in the decision to perform surgery, and their experience in cases of symptomatic nonunion. Categorical variables were summarized using frequencies and proportions. Analysis of associations between surgeon demographics and treatment preferences were carried out. RESULTS: A total of 193 out of 354 completed questionnaires were returned (54% response rate). In total, 74% of the participants (142/193) favored radiographs for the evaluation of the fracture displacement, and 25.4% (49/193) added a computed tomography scan for a more detailed evaluation. The majority of respondents (48.2%) would consider a 5 mm displacement as the cutoff for surgical treatment, 21.8% 2 mm, 20.7% 10 mm, and 9.3% 15 mm. There were no differences between the experience of the participants, academic versus private setting, or training regarding surgical/nonsurgical management. CONCLUSIONS: There are significant differences in opinions between SLAOTI members as to the optimal management of medial epicondyle fractures. Implications of disagreement in evaluation and treatment support the need for multicenter prospective studies to develop evidence-based guidelines for the management of this fracture. LEVEL OF EVIDENCE: Level V-expert opinion. Cross-sectional electronic survey.

Fewer patients undergo surgery when adding a comprehensive geriatric assessment in older patients with a hip fracture.

INTRODUCTION: Geriatricians have been increasingly involved in the pre-operative process in frail elderly patients with a hip fracture which can benefit re-hospitalization, post-operative functional performance, and mortality. The objective of this study was to compare the number of older patients with hip fractures who opted for non-surgical management after the addition of pre-operative comprehensive geriatric assessment (CGA) with shared decision making by a geriatrician to usual care. Secondary objectives were: reasons for non-surgical management, duration of life, and location of death. MATERIALS AND METHODS: A single-center, with a level 2 trauma center, retrospective study comparing care before and after introducing pre-operative CGA with shared decision making in September 2014. Patients ≥ 70 years with a hip fracture, admitted from January 2014 to September 2015, were included. The percentages of patients elected for non-surgical management and palliative care without or with CGA were compared. Differences in secondary objectives (age, sex, medical history, medication use, functional, and social status) were compared descriptively and qualitatively. RESULTS: With pre-operative CGA significantly more patients (or representatives) elected the non-surgical management option after hip fracture (respectively, 9.1% vs 2.7%, p = 0.008). Patient characteristics were comparable. Reported reasons not to undergo surgery include aversion to be more dependent on others, and severe dementia. CONCLUSION: The geriatrician can have an important role in decisions for non-surgical management by shared decision making in the pre-operative period in patients ≥ 70 years with a hip fracture in the emergency room.

Radiation exposure in the treatment of pediatric supracondylar humerus fractures.

PURPOSE: To determine the factors that influence radiation exposure during repair of supracondylar humerus fractures. METHODS: Medical records of almost 200 children with supracondylar fractures were retrospectively analyzed for variables correlated with fluoroscopy time and radiation dose as measures of radiation exposure. RESULTS: There was no statistically significant difference in fluoroscopy time (27 vs. 22 s p = 0.345) or direct radiation dose (0.394 vs. 0.318 mSv p = 0.290) between uniplanar and biplanar C-arm use. No statistically significant differences in fluoroscopy time or radiation dose were found for surgical technique, comorbid ipsilateral fractures, preoperative neurovascular compromise, or resident participation. There was a significant 8.3 s increase in fluoroscopy time (p = 0.022) and 0.249 mSv increase in radiation dose (p = 0.020) as the fracture type increased from II to III. An increase in one pin during CRPP resulted in a statistically significant 10.4 s increase in fluoroscopy time and a 0.205 mSv increase in radiation dose. There were significant differences between the physician with the lowest fluoroscopy time and radiation dose compared with the physicians with the two highest values for both fluoroscopy time and radiation dose (p < 0.01). CONCLUSIONS: We found no significant difference in direct radiation exposure or fluoroscopy time when comparing biplanar to uniplanar C-arm use, resident participation, preoperative neurovascular compromise, or for comorbid ipsilateral fractures. Both outcomes increased significantly as fracture type increased from II to III and as the number of pins used during CRPP increased. Both outcomes were significantly different between the surgeons performing CRPP.

Postoperative mortality after a hip fracture over a 15-year period in Denmark: a national register study.

Background and purpose - In Denmark, 44 per 10,000 persons over the age of 50 years suffered a hip fracture (HF) in 2011. We characterized the patients and identified risk factors associated with 30-day, 90-day, and 1-year postoperative mortality in Denmark from 2000 to 2014.Patients and methods - The study builds upon data from the Danish National Patients Register and the National Causes of Death Register including all acute hospitalized HF patients aged 18 years and above. Outcomes were 30-day, 90-day, and 1-year postoperative mortality. Mortality risk was analyzed with a univariable and multivariable Cox regression including predefined variables.Results - 113,721 acute hospitalized HF patients were admitted to Danish hospitals between 2000 and 2014. The 30-day mortality risk was 9.6%, 16% at 90 days, and 27% at 1 year after HF surgery. Mortality risk was similar from 2000 to 2014 while the median lengths of stay declined from 14 (IQR 8-25) to 8 (IQR 5-11) days. Male sex, increasing age, higher Charlson Comorbidity Index, per- and subtrochanteric fracture, and operation type other than total hip arthroplasty were independently associated with postoperative mortality.Interpretation - Short- and long-term mortality was high after hip fracture surgery and did not decline in Denmark from 2000 to 2014.

Incidence of distal ulna fractures in a Swedish county: 74/100,000 person-years, most of them treated non-operatively.

Background and purpose - Fractures of the distal ulna can occur in isolation or in conjunction with a distal radius fracture. They may result in incongruence and instability of the distal radioulnar joint. We investigated the incidence of distal ulna fractures, whether any fracture types were more common, and the methods of treatment used.Patients and methods - Data were collected from patients 18 years or older, treated for a fracture of the distal ulna in Östergötland, Sweden, during 2010-2012. Patients were identified in the patient registry. The fractures were classified according to the AO comprehensive classification of fractures.Results - The incidence of distal ulna fractures was 74/100,000 person-years. The most common fracture type was that of the ulnar styloid Q1 (79%), followed by the ulnar neck Q2 (11%). Rarest was ulna head fracture, type Q4 (1%). Incidental findings were a mean age of 63 years (SD 18), a concomitant distal radius fracture in 92% of the patients and that 79% were caused by falling from standing height. Internal fixation was performed in 30% of the Q2-Q6 fractures. This indicates that most were considered stable without internal fixation or stable after fixation of a concomitant radius fracture.Interpretation - Our results show that fractures of the distal ulna are not very common, and some fracture types are even rare. There seem to be no consensus on treatment.

Delayed surgery versus nonoperative treatment for hip fractures in post-COVID-19 arena: a retrospective study of 145 patients.

Background and purpose - Following the outbreak of COVID-19 in December 2019, in China, many hip fracture patients were unable to gain timely admission and surgery. We assessed whether delayed surgery improves hip joint function and reduces major complications better than nonoperative therapy. Patients and methods - In this retrospective observational study, we collected data from 24 different hospitals from January 1, 2020, to July 20, 2020. 145 patients with hip fractures aged 65 years or older were eligible. Clinical data was extracted from electronic medical records. The primary outcomes were visual analogue scale (VAS) score and Harris Hip Score. Major complications, including deep venous thrombosis (DVT) and pneumonia within 1 month and 3 months, were collected for further analysis. Results - Of the 145 hip fracture patients 108 (median age 72; 70 females) received delayed surgery and 37 (median age 74; 20 females) received nonoperative therapy. The median time from hip fracture injury to surgery was 33 days (IQR 24-48) in the delayed surgery group. Hypertension, in about half of the patients in both groups, and cerebral infarction, in around a quarter of patients in both groups, were the most common comorbidities. Both VAS score and Harris Hip Score were superior in the delayed surgery group. At the 3-month follow-up, the median VAS score was 1 in the delayed surgery group and 2.5 in the nonoperative group (p < 0.001). Also, the percentage of complications was higher in the nonoperative group (p = 0.004 for DVT, p < 0.001 for pulmonary infection). Interpretation - In hip fracture patients, delayed surgery compared with nonoperative therapy significantly improved hip function and reduced various major complications.

Do different surgical techniques in tibia pilon fractures change the results of the midterm?

Background/aim: Pilon fracture is difficult to treat fractures due to many complications that can develop after surgery. To achieve the best results, different surgical approaches are used.In our study, we aimed to compare the functional results and complication rates of our treatments in patients treated with 3 different surgical tecniques. Materials and methods: 89 pilon fractures of 87 patients treated for pilon fracture were evaluated. Patients were examined in 3 different groups (one step, two step surgery and Ilizarov). Functional results, postoperative complications and ankle AOFAS scores were evaluated. Results: The mean AOFAS score of the all patients was 77.67. There was no significant difference between 3 surgical techniques (P = 0,880). While skin complication was not seen in patients who underwent double-stage surgery and Ilizarov (0%); It was seen in 6 (15.7%) patients who underwent single-stage surgery. Treatment results were found to be better in type 1 and type 2 fractures, while in type 3 fractures (P = 0.004). Conclusion: Despite the different surgical approaches and implants applied, no difference was found between the midterm ankle functional results of the patients. Two-stage surgery and Ilizarov is a safe and effective treatment approach to reduce morbidity and early complications in pilon fractures.