The Rates of Nonunion and Malunion in Lower Extremity Fractures: Experience in South Carolina over 17 years.

Our purpose was to determine the rates of lower extremity nonunion and malunion over 17 years in South Carolina. Our hypothesis was that malunions and nonunions decreased over time due to improved access to trauma centers and improved orthopaedic surgical training. The South Carolina Department of Budget and Control Hospital Discharge Database was queried between 1998-2014 and yielded a total of 4,994 malunions and 16,454 nonunions. Malunions increased from 1.2% (1998) to 1.8% (2010); nonunions increased from 4.0% (1999) to 5.8% (2011). Older age and gender were predictive of malunion and nonunion. This study identified females as having a higher odds ratio for malunion or nonunion; higher nonunion rates in worker's compensation or government payer status; and older age as incurring greater risks for sustaining fractures or developing a malunion or nonunion. There was increased prevalence of nonunion and malunion despite improved access to trauma centers and trained orthopaedic trauma surgeons. (Journal of Surgical Orthopaedic Advances 29(3):129-134, 2020).

Surgical Complications Associated With Atypical Femur Fractures Attributed to Bisphosphonate Use.

Complications of atypical femur fractures (AFFs) are common. AFFs often receive the same treatment as other femoral fractures; however, there appears to be a higher rate of adverse outcomes. Nine patients sustained a total of 13 AFFs, had documented bisphosphonate use before fracture, and had surgery between 2006 and 2012. Complications included continued pain, surgical revision, nonunion, malunion, deformity, or heterotopic ossification. The overall complication rate was 33.3%, with four of the 12 surgeries performed at this institution resulting in one nonunion and three minor complications. None of the primary fixations required revision. There was a higher complication rate for AFFs when compared with non-bisphosphonate-related intramedullary nail femur fracture fixations. This cohort demonstrated a lower rate of major complications compared to the literature. Using a reamed, statically locked nail, halting bisphosphonate medication, and allowing early weight bearing is a safe and efficacious method to treat atypical femur fractures. (Journal of Surgical Orthopaedic Advances 27(1):14-20, 2018).

Tibiotalocalcaneal fusion using the hindfoot arthrodesis nail: a multicenter study.

BACKGROUND: Tibiotalocalcaneal arthrodesis is a salvage option for severe ankle and hindfoot deformities, arthritis of the ankle and subtalar joints, avascular necrosis of the talus, failed total ankle arthroplasty, and Charcot arthropathy. This multicenter study reports clinical experience with the hindfoot arthrodesis nail (HAN) in the treatment of patients with severe ankle and foot abnormalities. METHODS: Seven participating clinics from Europe and North America recruited 38 patients who underwent ankle/subtalar arthrodesis using retrograde nailing with the HAN. Information was collected regarding technical details, complications, and functional and quality of life outcomes (Short Form-36 [SF-36], American Academy of Orthopaedic Surgeons-Foot and Ankle Outcomes [AAOS-FAO], and numeric rating scale [NRS] for pain) after an average of 2 years of follow-up. RESULTS: The rate of superficial wound infection was 2.4%. No deep soft tissue or bone infections were reported. The overall union rate was 84%. At the time of follow-up, low pain levels were reported, with a mean NRS of 2.2; the mean AAOS-FAO score was 38; and the SF-36 mean physical and mental health component scores were 41.2 and 52.5, respectively. All 13 patients who were unable to work prior to surgery were able to fully return to work. CONCLUSIONS: The HAN offered a safe and reliable salvage option for tibiotalocalcaneal arthrodesis in patients with severe ankle and hindfoot disease. It achieved acceptable functional outcome and low complication rates despite the challenging patient cohort. A considerable socioeconomic benefit appeared to result based on the high proportion of patients who were able to return to work postoperatively. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Middle-third clavicle fracture with associated type IV acromioclavicular separation: case report and literature review.

Review of available English literature suggests that combined injuries involving a clavicle shaft fracture and an acromioclavicular (AC) separation are rare. The force dissipation after the occurrence of either a midshaft clavicle fracture or an AC separation typically renders the injuries mutually exclusive. This article presents a review of literature on this combined injury pattern. A variety of treatment approaches have been put forth, including nonoperative, operative, and hybrid management of the two distinct injuries. The most appropriate treatment rendered depends on the degree of AC joint instability. This case report involves a midshaft clavicle fracture associated with a type IV AC separation in a patient ejected during a high-speed motor vehicle collision. Internal fixation of each injury was chosen and the patient had a successful final result. Other reported treatment options and recommendations are reviewed.

Intradepartmental orthopaedic fragility fracture liaison improves osteoporosis follow-up and treatment.

OBJECTIVE: Over 2 million people in the United States sustain fractures related to osteoporosis annually, but only 20% of these patients receive treatment for their osteoporosis. The purpose of this study was to evaluate the effects of a fragility fracture liaison within the orthopedic department on treatment and follow up for osteoporosis. DESIGN: Retrospective cohort study SETTING: University Level I Trauma center PARTICIPANTS: 112 patients treated under the aegis of an interdepartmental fracture liaison and 208 patients treated following the introduction of an orthopedic fragility fracture liaison at a single institution. INTERVENTION: Transition from referral to interdepartmental fracture liaison to intradepartmental orthopedic fragility fracture liaison for fragility fractures. MAIN OUTCOME MEASURES: Outcomes evaluated included demographics, fracture type, DEXA scan results, follow up and treatment plan, and subsequent fracture. RESULTS: The mean age at time of fracture was 75 years, and the mean BMI was 27. The most common fracture types were femoral neck fractures (29%), pertrochanteric fractures (30%) and femur fractures (8%). There was a statistically significant increase in adherence to follow up and treatment after the introduction of an orthopaedic fragility fracture liaison. CONCLUSIONS: The introduction of an intradepartmental fragility fracture liaison significantly increases osteoporosis follow-up and introduces the ability to combine both osteoporosis treatment and postoperative orthopaedic care. The results of this study highlight the utility of incorporating a fragility fracture liaison within the orthopaedic department given the economic burden of fragility fractures and the morbidity associated with these fractures. LEVEL OF EVIDENCE: III cohort study.

Ankle arthrodesis using anatomically contoured anterior plate.

BACKGROUND: More than 40 fusion techniques for the ankle joint have been reported. The purpose of this retrospective study was to review our preliminary clinical and radiographic results using an anatomically contoured anterior plate for ankle arthrodesis. MATERIALS AND METHODS: Ten ankle arthrodeses with an anatomically contoured anterior plate performed by a single surgeon were reviewed with an average of 14 months followup. One underwent revision surgery due to screw loosening by reapplying the same plate. Plain radiographs were taken to help determine the stability of fixation and time of fusion. The AOFAS clinical rating system was applied to evaluate patients preoperatively and postoperatively. RESULTS: Nine of ten patients achieved solid fusion radiographically and clinically at an average of 15 (range, 12 to 22) weeks. Bony healing was achieved after an additional 12 weeks for the patient who underwent revision fusion. There were no postoperative wound problems or infections. All patients reported an improvement in their pain level following successful fusion. CONCLUSION: The application of an anatomically contoured plate provides many advantages, including less soft tissue disruption by using a single anterior incision, ease of deformity correction, early rehabilitation, and high rate of union.

Conventional plate fixation of periarticular fractures.

Over the last few years, locking plates have become increasingly popular for the treatment of a variety of periarticular fractures. Despite the popularity of these new implants, older implants have a long track record of success and are still appropriate for a variety of periarticular fractures. This article reviews some of the current literature on locking plates and compares results for general fracture types to conventional plate fixation. The question of whether a locking plate or conventional plate is best for the patient, easier for the surgeon to use, and cost-effective is discussed.

National Athletic Trainers' Association Position Statement: Immediate Management of Appendicular Joint Dislocations.

OBJECTIVE: To provide certified athletic trainers (ATs) with recommendations and guidelines for the immediate management of patients with joint dislocations. BACKGROUND: One of the primary responsibilities of ATs is to provide immediate injury care for active individuals. Although ATs are confronted with managing patients who have many kinds of injuries, the onsite management of a joint dislocation presents challenges in evaluation and immediate treatment. The critical concern in managing a dislocation is deciding when a joint can be reduced onsite and when the patient should be splinted and transported for reduction to be performed in the hospital or medical setting. Factors that influence the decision-making process include the following: whether the AT possesses a documented protocol that is supported by his or her supervising physician(s), employer documents, and respective state regulations; the AT's qualifications and experience; the dislocated joint; whether the dislocation is first time or recurrent; the patient's age and general health; and whether associated injuries are present. RECOMMENDATIONS: These guidelines are intended to provide considerations for the initial care of specific joint dislocations. They are not intended to represent the standard of care and should not be interpreted as a standard of care for therapeutic or legal discussion.

Heterotopic Ossification in Trauma.

Better understanding of the biology of heterotopic ossification (HO) formation will lead to treatment and prevention modalities that can be directed specifically at the cellular level. Early identification of HO precursor cells and target genes may provide prognostic value that guides individualized prophylactic treatment. Better understanding of molecular signaling and proteomics variability will allow surgeons to individualize preemptive treatment to suppress inflammation and formation of HO. Careful surgical technique to avoid muscle damage is important. Damaged muscle should be debrided as a prophylactic measure. Hemostasis and avoidance of a postoperative hematoma may decrease the chance of formation of HO.

A comparison of ProOsteon, DBX, and collagraft in a rabbit model.

Many bone graft substitutes (BGSs) have been developed and are commercially available. These products differ in the tailoring of their properties, including size, form, osteoconductivity, osteoinductivity, and resorption kinetics. Differential enhancement of these properties may optimize the performance of these materials for varying applications. BGSs offer an opportunity to lessen morbidity of harvesting and use of autogenous and/or allograft bone. The purpose of this study is to quantitatively compare the magnitude of bony ingrowth and biodegradation of different commercially available BGS materials in a rabbit femoral defect model. BGSs from each of three classes (ceramic (ProOsteon), demineralized bone matrix (DBX), and composite (Collagraft)) were implanted in cylindrical defects in bilateral femoral condyles of 12 adult New Zealand White rabbits. Each of the three BGS materials and the empty controls were compared. The specimens were harvested at 3 months postimplantation for radiographic and histologic evaluation. Histomorphometry yielded resorption of graft material remaining in the index defect. Magnitude of bony ingrowth was assessed based on an 8-bit 256 densitometry model. Histomorphometric analysis of the data demonstrated statistical differences in the resorption and magnitude of bony ingrowth of the three BGS materials. The three BGS were significantly different for ingrowth (p = 0.046) when using the Wilcoxon Test. The ceramic graft material averaged 47% bony ingrowth. Rabbit-based DBX material showed extensive osseous ingrowth (35%) and the composite graft material demonstrated significant bony ingrowth (56%). The control, as anticipated, showed the least amount of bony ingrowth (29%). Fisher's Exact Test yielded statistical differences (p = 0.0003) when comparisons for resorption were conducted. An ideal BGS material should be biocompatible, be able to withstand the local load environment for a given application, degrade in concert with bony replacement, and be both osteoinductive and osteoconductive. This in-vivo, head-to-head comparison of three commercially available BGS materials in an animal model compares these characteristics and demonstrates differences between them, which may act as a guide in the use of these products in human applications.

The impact of race on the development of severe heterotopic ossification following acetabular fracture surgery.

OBJECTIVES: To determine the association between race on severe heterotopic ossification (HO) following acetabular fracture surgery. DESIGN: Retrospective case control study. SETTING: Level I university trauma centre. METHODS: Two hundred and fifty-three patients who were surgically treated for acetabular fractures were retrospectively evaluated. Postoperative radiographs were evaluated for HO by a blinded musculoskeletal radiologist, and classified based on a modified Brooker classification. RESULTS: Of the 253 patients that met inclusion and exclusion criteria, 175 (69%) were male and 78 (31%) were female. One hundred and fifty-four (61%) patients were Caucasian, and 99 (39%) were African American (AA). Fifty-five (21%) patients developed severe HO. Of those who developed severe HO, 25 were Caucasian (45%), 30 were African American (55%). Forty-one patients (75%) with severe HO were male, and 14 (25%) were female. No statistical differences (p>0.05) were found between groups in terms of age, days to surgery, GCS at presentation, surgical approach, perioperative HO prophylaxis, or AO/OTA fracture classification. The patient population was then stratified by race, gender, and race/gender. AA were more likely than Caucasians to develop severe HO (odds ratio [OR], 2.24; confidence interval [CI], 1.22-4.11). When gender was considered independent of race, no statistical differences (p>0.05) were observed (OR, 1.40; CI, 0.71-2.75). AA males were much more likely to develop severe HO when compared to Caucasian females (OR, 4.4; CI, 1.38-14.06). CONCLUSION: Race is associated with different rates of severe HO formation following acetabular fracture surgery. AA patients are significantly more likely to develop severe HO following acetabular fracture surgery when compared to Caucasian patients.

Compartment syndrome after low-energy tibia fractures sustained during athletic competition.

OBJECTIVE: The purpose of this study was to determine whether patients who sustain tibia fractures during athletic competition are at an increased risk of developing acute compartment syndrome (ACS). DESIGN: Retrospective review. SETTING: University Level I trauma center. PARTICIPANTS/PATIENTS: Acute tibia fractures in 626 patients between July 2006 and June 2009. METHODS: A retrospective review of 626 consecutive tibia fractures treated by our department between July 2006 and June 2009 was performed. We recorded the mechanism and type of fracture as well as whether or not ACS developed. Soccer and football injuries were analyzed as specific groups. Chi square was used to analyze our results. MAIN OUTCOME MEASUREMENTS: The rate of ACS in patients injured during sporting events versus that of all patients with a tibia fracture. RESULTS: Thirty-four patients (5.4%) developed ACS, which is consistent with the published literature. Nine patients sustained the injury while playing soccer (1.4% of patients), whereas 11 patients (1.7%) were injured playing football. Five of the nine soccer players (55%; P < 0.001) and three of the football players (27%; P < 0.001) developed ACS. Collectively, tibia fractures sustained in football and soccer led to 25% of ACS cases despite accounting for only 3.1% of all tibia fractures. CONCLUSIONS: Tibia fractures sustained during soccer and football had a statistically significant association with development of ACS in our patient population during this time period. Such patients should be monitored closely and followed with high clinical suspicion for ACS.

Randomized prospective clinical trial comparing reamer irrigator aspirator (RIA) to standard reaming (SR) in both minimally injured and multiply injured patients with closed femoral shaft fractures treated with reamed intramedullary nailing (IMN).

PURPOSE: To investigate whether inflammatory markers are improved among patients with traumatic femur fractures who undergo RIA reamed intramedullary nailing (IMN) prior to fixation when compared to patients treated with standard reamed (SR) IMN. METHODS: A prospective, randomized, single-blind trial was conducted on patients who had a closed femoral shaft fracture amenable to reamed IMN. Patients were randomized to undergo IMN with standard reaming or IMN with the RIA in a 1:1 ratio. Patients were stratified by Injury Severity Score (ISS) and by presence or absence of chest injury with AIS > 3. Patients had blood samples and bronchioalveolar lavage samples taken at specified time points pre- and postoperatively. Specimens from SR and RIA cohorts were compared for the presence of IL-2, IL-6, IL-8, TNF, and IL-10 in plasma and IL-1b and IL-8 in bronchioalveolar lavage (BAL) samples to determine the relationship between inflammatory markers and intramedullary reaming. RESULTS: Nineteen consecutive patients participated in the study with 9 assigned in the RIA group and 10 in SR group. Significant differences existed for ISS between SR and RIA groups (p=0.04). Bronchial lavage data showed no statistical significant differences when RIA and standard reamers were compared and when ISS >16 and <16 were compared, however there were differences for the bronchial IL-8 change when those with chest injury were compared to those without chest injury. Plasma samples showed a trend towards increased IL-6 and IL-10 levels after reaming consistent with the second hit impact. A trend towards higher levels for IL-6 in the SR group was noted at 24 hours post-operatively whereas the IL-10 levels at the post-reaming time point were higher in the RIA group. CONCLUSIONS: This prospective study of reamer type indicates that RIA may be protective of systemic inflammation. This is supported by data showing decreased levels of IL-8 in the bronchial washings and increased level of IL-10 in the serum. Reaming and intramedullary fixation may cause an increase in IL-6 levels regardless of reamer type. Further investigations with a larger cohort of patients are desirable.

When life is on the line: orthopaedic trauma care in South Carolina.

There are approximately 300 orthopaedic surgeons in South Carolina, a state with a population of approximately four million. There is one orthopaedic surgeon per approximately 13,000 people, which should be adequate to meet the demand for orthopaedic care. The problem is not the quantity of orthopaedic surgeons. The problem is staffing our trauma centers with orthopaedic surgeons who are enthusiastic, have an interest in trauma care, and maintain high levels of CME and technical expertise. They need to be supported with appropriate medical liability reform, such as has been adopted in other states, and methods should be put into place to compensate surgeons for expensive, time consuming, and potentially risky procedures performed on uninsured and under insured patients. The number of patients with extremity trauma in South Carolina increased 25.6 percent during a five-year time period and is expected to continue to increase. It is estimated that 40 percent of all surgical charges generated for orthopaedic surgeons staffing trauma centers are for self-pay patients. Given the higher liability cost and lower reimbursement from other payer sources for elective procedures, it will soon become impossible for orthopaedic surgeons to continue to provide services at trauma centers without support from hospitals or government agencies.