The performance of PROMIS computer adaptive testing for patient-reported outcomes in hip fracture surgery: a pilot study.

INTRODUCTION: Patient-reported outcome measures (PROMs) are essential to patient-centered care in orthopaedics. PROMIS measures have demonstrated reliability, validity, responsiveness, and minimal floor and ceiling effects in various populations of patients receiving orthopaedic care but have not yet been examined in hip fracture patients. This pilot study sought to evaluate the psychometric performance of the PROMIS Physical Function (PROMIS PF) and Pain Interference (PROMIS PI) computer adaptive tests and compare these instruments with legacy outcome measures in hip fracture patients. METHODS: This study included 67 patients who were 27-96 years old (median 76) and underwent osteosynthesis for a proximal femoral fracture. At 3, 6, and/or 12 months follow-up, patients completed both legacy (mHHS, SF-36-PCS, and VAS for pain) and PROMIS questionnaires (PROMIS PF and PROMIS PI). Respondent burden and floor/ceiling effects were calculated for each outcome measure. Correlation was calculated to determine concurrent validity between related constructs. RESULTS: A strong correlation was found between PROMIS PF and mHHS (rho = 0.715, p < 0.001) and moderately strong correlation between PROMIS PF and SF-36 PCS (rho = 0.697, p < 0.001). There was also a moderately strong correlation between the VAS and the PROMIS PI (rho = 0.641, p < 0.001). Patients who completed PROMIS PF were required to answer significantly fewer questions as compared with legacy PROMs (mHHS, SF-36). For the PROMIS measures, 1% of patients completing PROMIS PF achieved the highest allowable score while 34% of patients completing PROMIS PI achieved the lowest allowable score. Of the legacy outcome measures, 31% of patients completing the VAS for pain achieved the lowest allowable score and 7% of patients completing the mHHS achieved the highest allowable score. CONCLUSIONS: The results of this study support the validity of PROMIS CATs for use in hip fracture patients. The PROMIS PF was significantly correlated with SF-36 PCS and mHHS while requiring fewer question items per patient relative to the legacy outcome measures.

The effects of locking inserts and overtorque on the mechanical properties of a large fragment locking compression plate.

PURPOSE: The study was to determine the effect of locking hole inserts and their insertion torque on the fatigue life of a large fragment Locking Compression Plate (LCP) under bending forces. METHODS: Fatigue strength of the LCP was examined using cyclic three-point bend testing at 80% yield strength of the construct. Locking hole inserts were used in 2, 4, and 6-hole of a 12-hole plate to simulate three different working lengths. Within each working length, plates were tested without locking inserts serving as the control group. In the experimental groups, inserts were tightened to manufacturer recommendations (4 Nm) and using overtorque (8 Nm). RESULTS: Significantly fewer cycles to failure were observed in control groups versus the locking hole insert groups for all working lengths (2-hole: 4 Nm p = 0.003, 8 Nm p = 0.003; 4-hole: 4 Nm p = 0.02, 8 Nm p < 0.001; 6-hole: 4 Nm p = 0.004, 8 Nm p < 0.001). There was a statistically significant increase in fatigue strength when using overtorque in the 4-hole (p = 0.04) and 6-hole (p = 0.01) defect groups. This was not shown in the 2-hole defect group (p = 0.99). CONCLUSIONS: By placing locking inserts in the empty locking regions of Combi holes along the working length, the number of cycles to failure was increased. Tightening inserts to twice the recommended insertion torque further increased cycles to failure in longer working length models. A longer fatigue life has the potential to decease the incidence of plate failure especially in the setting of delayed union due to poor intrinsic healing capacity, fractures in the geriatric population, osteoporosis and periprosthetic fractures.

Arthroscopic-Assisted Removal of Proximal Humerus Locking Plates With Capsular Release Significantly Improves Range of Motion and Function.

PURPOSE: To investigate the clinical outcomes following the arthroscopic removal of proximal humerus locking plates for symptomatic hardware after open reduction and internal fixation (ORIF) of proximal humerus fractures. METHODS: Patients who underwent arthroscopic removal of hardware (ROH) with capsular release due to pain and/or immobility after receiving locking plates to treat proximal humerus fractures from 2009 to 2016 were identified. Operative and clinic records were reviewed to obtain demographic information, concomitant procedures during ROH, and pre- and postoperative active shoulder range of motion. Postoperative patient-reported outcomes included the QuickDASH, PROMIS Pain Intensity, Constant, and University of California, Los Angeles shoulder rating scale. RESULTS: In total, 88 patients were included. Patients were evaluated at a minimum of 6 weeks postoperatively after ROH. Patients with pre- and postoperative active range of motion values demonstrated significant improvements in mean forward elevation (n = 69; 78.4%; 115.1° to 152.1°, P < .001), abduction (n = 29; 33.0%; 70.9° to 138.7°, P < .001), external rotation (n = 49; 55.7%; 43.7° to 58.6°, P = .012), and internal rotation (n = 45; 51.1%; 25.7° to 61.9°, P < .001). Patients also reported positive patient-reported scores, including the QuickDASH (4.1 ± 7.8), PROMIS Pain Intensity (3.5 ± 0.9), Constant (84.6 ± 10.7), and University of California, Los Angeles shoulder rating scale (33 ± 2.9), which were measured 70.6 ± 26.6 months postoperatively. There were no surgical complications, no arthroscopic cases were converted to open, but 2 reported refractures (2.3%). CONCLUSIONS: Arthroscopic-assisted removal of proximal humerus locking plates significantly improves motion and function while allowing for management of concomitant shoulder pathology and potentially avoiding open surgery complications. Given that patients undergoing this procedure frequently have multiple comorbidities, arthroscopic-assisted removal with smaller incisions may minimize risks while restoring shoulder mobility. Therefore, arthroscopic ROH for patients experiencing symptomatic hardware after ORIF is recommended. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Posterior Malleolus Fracture Displacement Is Associated with Rotational Ankle Fracture Stability in Patients Without Medial Malleolar Fractures.

BACKGROUND: The optimal method for the determination of ankle stability remains controversial in rotational ankle fractures without medial bony injury. QUESTIONS/PURPOSES: The purposes of this study were to (1) evaluate whether posterior malleolar (PM) fracture displacement is associated with deltoid ligament injury in supination-external rotation (SER) ankle fractures and (2) compare the diagnostic accuracy of PM displacement and magnetic resonance imaging (MRI) evaluation of the deep deltoid ligament in identifying fractures with deltoid ligament incompetence. METHODS: Patients with rotational bimalleolar injuries containing lateral malleolar and PM fractures without bony medial injury were included. After operative lateral and PM fixation, an external rotation stress test was performed to evaluate deltoid ligament stability. Operative dictations were reviewed to confirm injury pattern, stability on stress test, and visual inspection of the deltoid ligament. Maximum PM displacement was assessed on lateral X-ray. Pre-operative MRI of the ankle was performed following closed reduction and splinting. RESULTS: The final cohort consisted of 13 trimalleolar equivalent fractures (torn deltoid ligament) and 20 bimalleolar fractures (medial malleolus and deltoid ligament intact). Average PM displacement was significantly higher for SER trimalleolar equivalent patterns when measured on lateral X-ray. The sensitivity of detecting trimalleolar equivalent fracture was higher on all reported X-ray findings than the sensitivity obtained by the reported MRI findings of deltoid ligament injury. CONCLUSION: PM displacement on X-ray is a useful adjuvant along with external rotation stress radiography and MRI evaluation of deep deltoid integrity to distinguish between stable and unstable fracture patterns and thus helps facilitate treatment decisions.

Endosteal Vasculature Dominates Along the Tibial Cortical Diaphysis: A Quantitative Magnetic Resonance Imaging Analysis.

OBJECTIVE: Disrupted blood supply has been proposed as an underlying cause for delayed union in tibial shaft fractures (OTA/AO 42). Although tibial blood supply has been qualitatively evaluated, quantitative studies are lacking. The purpose of this project was to quantify the relative contribution of the endosteal supply to the tibial diaphysis. METHODS: The superficial femoral artery of 8 fresh frozen cadaveric matched pair lower extremities was cannulated. The nutrient artery was ligated at its proximal branch point in experimental limbs. Pregadolinium and postgadolinium enhanced magnetic resonance imaging was performed with high resolution fat-suppressed ultrashort echo time magnetic resonance imaging sequences. Perfusion was assessed in 3 zones (outer, central, and inner cortex) for the proximal, middle, and distal diaphysis, respectively, using custom software to quantify and compare signal intensity between experimental and control limbs. RESULTS: On average, the endosteal system supplied 91.4% (±3.9%) of the cortex and was the predominant blood supply for the inner, central, and outer thirds. The dominance of the endosteal contribution was most pronounced in the inner two-third of the cortex, with more than 97% loss of perfusion. Disruption of the nutrient artery also resulted in 76.3% (±11.2%) loss of perfusion of the outer one-third of the cortex. CONCLUSION: This quantitative study revealed a predominance of endosteal blood supply to all areas (inner, middle, and outer thirds) of the tibial diaphyseal cortex. To prevent delayed bone healing, surgeons should take care to preserve the remaining periosteal vascular network in fracture patterns in which the nutrient artery has likely been disrupted.

Sagittal ankle position does not affect axial CT measurements of the syndesmosis in a cadaveric model.

BACKGROUND: The purpose of this study was to evaluate the effect of ankle plantarflexion and the axial location of measurement on quantitative syndesmosis assessment. METHODS: Twelve fresh-frozen cadaveric specimens were secured in three positions of ankle plantarflexion (0°, 15°, and 30°) using an ankle-spanning external fixator and underwent CT scans at each position. Syndesmotic measurements were obtained on axial images using three previously described methods (six measurements) at the level of the tibial plafond and 1 cm proximal to the plafond. Method 1 evaluated the distance between the most anterior and posterior aspects of the fibula and tibia. Method 2 measured medial-lateral diastasis of the anterior and posterior aspects of the fibula, and fibular anterior-posterior translation. Method 3 evaluated axial rotation of the fibula. All measurements were performed by two independent observers. Inter-rater reliability of each measurement was evaluated using intra-class coefficients. Repeated measures analysis of variance (RM-ANOVA) was performed to evaluate within-specimen differences in measurements obtained at varying ankle positions. RESULTS: The anterior incisura component of method 1 demonstrated poor-to-moderate inter-rater reliability across all ankle positions and at both measurement locations. Inter-rater reliability was highest for method 2, especially when measured 1 cm proximal to the plafond. Method 3 demonstrated moderate reliability 1 cm proximal to the plafond. After correcting for multiple comparisons, RM-ANOVA and pairwise analysis revealed that none of the measurements changed significantly with varying ankle position. CONCLUSION: The inter-rater reliability of the most common method of syndesmotic evaluation (method 1) was found to be lower than in previous studies. The most reliable syndesmotic evaluation can be made by measuring diastasis and anteroposterior translation 1 cm proximal to the plafond (method 2). Ankle position from 0° to 30° of plantarflexion did not change the measurements obtained. LEVEL OF EVIDENCE: IV.

The Diagnostic Accuracy of Radiographs and Magnetic Resonance Imaging in Predicting Deltoid Ligament Ruptures in Ankle Fractures.

BACKGROUND: Operative indications for supination-external rotation (SER) ankle fractures depend on the integrity of the medial structures. Despite the importance of assessing deep deltoid ligament injuries, the accuracy of common diagnostic tests has not been established. QUESTIONS/PURPOSES: The objective of this study was to compare the ability of injury (non-stress) and stress radiographs and magnetic resonance imaging (MRI) to diagnose deep deltoid ligament ruptures in operative SER ankle fractures. METHODS: Patients were included who underwent surgical fixation of SER ankle fractures and had appropriate injury and manual stress test radiographs, pre-operative ankle MRI, and intra-operative assessment of deep deltoid integrity by direct visualization. The medial clear space (MCS) was considered positive for all values over 5 mm on the injury or stress mortise radiographs. MRI analysis of the deep deltoid ligament injury was performed by blinded fellowship-trained musculoskeletal radiologists. Intra-operative direct visualization and assessment of the deltoid was performed using a direct medial ankle approach at the time of operative fracture fixation. RESULTS: Using intra-operative visualization as the gold standard, MCS measurements and MRI had differing abilities to diagnose a deep deltoid rupture. In cases where the MCS was less than 5 mm on injury radiographs and stress tests were performed, MCS measurements were much less accurate than MRI in predicting deltoid ruptures (46% versus 79%, respectively) with a high false positive rate (80%). In contrast, an MCS measurement of greater than 5 mm on injury radiographs was a strong predictor of deep deltoid rupture (accuracy of 95%). CONCLUSION: Compared with direct visualization of the deltoid ligament intra-operatively, these data support proceeding with surgery when the MCS on injury radiographs is greater than 5 mm without any additional stress tests or advanced imaging. When the MCS is less than 5 mm, we recommend MRI analysis because of its increased accuracy and decreased false positive rate. Improving our ability to diagnose deltoid ruptures will contribute to more effective management of patients with SER ankle fractures.

Femoral Head Vascularity: Implications Following Trauma and Surgery About the Hip.

Traumatic injury and surgical intervention about the hip joint place the arterial supply to the femoral head (FH) at risk. Compromised perfusion may lead to FH ischemia, cell death, and osteonecrosis. Progression to FH collapse may lead to pain, functional impairment, and decreased quality of life, especially in younger patients. This review describes the arterial supply to the FH, analyzes the impact of femoral neck fractures on FH vascularity, and explores the vascular implications of various surgical interventions about the hip, offering specific techniques to minimize iatrogenic damage to the vessels supplying the FH. [Orthopedics. 2019; 42(5):250-257.].

Clinical Outcomes of Hyperplantarflexion Variant Compared With Supination External Rotation Ankle Fractures: A Matched-Cohort Analysis.

Recent literature has reported an uncategorized hyperplantarflexion variant ankle fracture characterized by a posteromedial fragment separate from the posterior or medial malleolar fragments. The current study sought to determine whether the outcomes for surgically treated hyperplantarflexion variant fractures are similar to the more common supination external rotation (SER) IV fractures. A prospective registry of operatively treated ankle fractures was queried to create 2 age- and gender-matched cohorts: hyperplantarflexion variant and SER IV fractures. Each cohort had 23 patients (18 females), and matched pairs were within 2 years of age at the date of surgery. Patient demographics, comorbidities, and Foot and Ankle Outcomes Scores at minimum 12 months after the index surgery were compared. The cohorts were similar with respect to body mass index, the length of the clinical follow-up, medical comorbidities, dislocation rate, and postoperative articular incongruity (p > .05). Patient-reported outcomes demonstrated no statistically or clinically significant differences within any domain and were as follows: symptoms (70.8 versus 77.8, p = .11), pain (80.7 versus 85.0, p = .33), activities of daily living (83.7 versus 89.2, p = .23), sports (67.4 versus 73.4, p = .33), and quality of life (57.3 versus 63.9, p = .24) for the hyperplantarflexion and SER IV groups, respectively. No significant differences were found in the rang`e of motion for dorsiflexion (17.7° versus 18.1°, p = .52) or for plantarflexion (48.6° versus 47.1°, p = .71). Patients treated surgically for hyperplantarflexion variant ankle fractures have similar 1-year clinical outcomes when compared with the more common SER IV fracture patterns, provided that the injury is correctly identified preoperatively and treated appropriately.

Predictors of In-Hospital Ambulatory Status Following Low-Energy Hip Fracture Surgery.

Introduction: Twenty-five percent to seventy-five percent of independent patients do not walk independently after hip fracture (HF), and many patients experience functional loss. Early rehabilitation of functional status is associated with better long-term outcomes; however, predictors of early ambulation after HF have not been well described. Purposes: To assess the impact of perioperative and patient-specific variables on in-hospital ambulatory status following low-energy HF surgery. Methods: This is a retrospective analysis of 463 geriatric patients who required HF surgery at a metropolitan level-1 trauma center. The outcomes were time to transfer (out of bed to chair) and time to walk. Results: Three hundred ninety-two (84.7%) patients were able to transfer after surgery with a median time of 43.8 hours (quartile range: 24.7-53.69 hours), while 244 (52.7%) patients were able to walk with a median time of 50.86 hours (quartile range: 40.72-74.56 hours). Preinjury ambulators with aids (hazard ratio [HR]: 0.70, confidence interval [CI]: 0.50-0.99), age >80 years (HR: 0.66, CI: 0.52-0.84), peptic ulcer disease (HR: 0.57, CI: 0.57-0.82), depression (HR: 0.66, CI: 0.49- 0.89), time to surgery >24 hours (HR: 0.77, CI: 0.61-0.98), and surgery on Friday (HR: 0.73, CI: 0.56-0.95) were associated with delayed time to transfer. Delayed time to walk was observed in patients over 80 years old (HR: 0.74, CI: 0.56-0.98), females (HR: 0.67, CI: 0.48-0.94), peptic ulcer disease (HR: 0.23, CI: 0.84-0.66), and depression (HR: 0.51, CI: 0.33-0.77). Conclusions: Operative predictors of delayed time to transfer were surgery on Friday and time to surgery >24 hours after admission. Depression is associated with delayed time to transfer and time to walk. These data suggest that is important to perform surgeries within 24 hours of admission identify deficiencies in care during the weekends, and create rehabilitation programs specific for patient with depression. Improving functional rehabilitation after surgery may facilitate faster patient discharge, decrease inpatient care costs, and better long-term functional outcomes.

Novel Treatment Options for the Surgical Management of Young Femoral Neck Fractures.

In physiologically young patients with displaced femoral neck fractures, surgical treatment is aimed at achieving fracture union while preserving native hip anatomy and biomechanics. The intracapsular environment, tenuous vascular supply, and unfavorable hip biomechanics contribute to the high complication rates seen after osteosynthesis of these fractures. Conventional fixation methods for osteosynthesis of femoral neck fractures include multiple cancellous screws, fixed-angle dynamic implants, and fixed-angle length-stable constructs. Despite several biomechanical and clinical studies evaluating various surgical options, the optimal fixation construct to allow healing and prevent nonunion of displaced femoral neck fractures is not known. This article will review the clinical data regarding conventional fixation constructs and describe the technique and rationale behind 2 novel alternative treatment options for these challenging fractures. The surgical technique and clinical examples for constructs involving multiple cannulated screws/Pauwels screw augmented with a fibular strut graft, as well as a novel fixed-angle locking plate with controlled dynamic compression, are presented.

Supination External Rotational Ankle Fracture Injury Pattern Correlation With Regional Bone Density.

BACKGROUND:: Rotational ankle fractures can present with an array of possible osseous and ligamentous injury combinations in reliable anatomic locations. What accounts for these different injury patterns and whether specific patient and injury factors underlie the different injury patterns is unclear. The purpose of this study was to determine whether causative factors exist that could account for the various injury patterns seen with rotational ankle fractures. METHODS:: A registry of operatively treated supination external rotation stage IV (SER IV) ankle fractures was used to identify patients. Computed tomography imaging was used to calculate regional bone density by using average Hounsfield unit measurements on axial images from the distal tibia and fibula. Patients were grouped into those with no posterior or medial malleolar fracture (equivalent group), those with either a posterior or medial malleolus fracture (bimalleolar group), and those with both posterior and medial malleolar fractures (trimalleolar group). Sixty-seven patients met inclusion criteria. RESULTS:: Regional bone density at the ankle, as measured with Hounsfield units, was significantly higher in the equivalent group (371) than in the bimalleolar group (271, P < .0001) and trimalleolar group (228, P < .0001). Logistic regression analyses identified regional bone density as a significant predictor of a medial malleolus fracture ( P = .002) and of a posterior malleolus fracture ( P = .005). CONCLUSION:: In our cohort of SER IV ankle fractures, regional bone density at the ankle significantly correlated with the presence and number of malleolar fractures compared with ligamentous ruptures. Treating surgeons can use this information to anticipate bone quality during operative fixation based on ankle fracture injury pattern. In addition, the presence of a trimalleolar ankle fracture was a significant indicator of poor bone quality and may represent the first clinical sign of abnormal bone metabolism in many patients. LEVEL OF EVIDENCE:: Level III, prognostic retrospective cohort study.

Radiographic and Clinical Outcomes of Periprosthetic Distal Femur Fractures Treated With Open Reduction Internal Fixation.

OBJECTIVES: To report outcomes and complications of periprosthetic distal femur fractures (PPDFF) treated with open reduction internal fixation (ORIF) using a plate construct, with or without endosteal augmentation. DESIGN: Retrospective Case Series. SETTING: One Level I trauma center and one tertiary care hospital. PATIENTS/PARTICIPANTS: Forty patients with PPDFFs, treated by 3 surgeons, were identified using an institutional trauma registry. Thirty-two patients with 12 months of clinical and radiographic follow-up were included, and 8 patients were lost to follow-up before 12 months. INTERVENTION: All patients underwent ORIF of the PPDFF with lateral locked plating, and 11 received additional endosteal augmentation using allograft fibula. RESULTS: Thirty-two patients were available for the final follow-up. Ninety-four percent of patients achieved union at an average of 6.5 months postoperatively. Twenty-one percent of patients underwent subsequent surgery, with more than half of those being for removal of implants. Anatomic limb alignment was achieved in all cases (no malunions). Almost half of the patients required assistive devices for ambulation in the long term. CONCLUSIONS: ORIF of PPDFF with direct visualization using periarticular locking plates ± endosteal strut allograft resulted in a 94% union rate and no deep infections. There was no difference in outcomes between groups treated with or without additional endosteal fibular allograft. However, these are catastrophic injuries in frail patients, and 20% of patients either died or were lost to follow-up, and almost half required an assistive device for ambulation after surgery despite restoration of limb alignment. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clamshell Osteotomy for Acute Fractures in the Malunion Setting: A Technical Note.

Surgical management of lower extremity malunions and acute fractures in the setting of lower extremity deformities presents a unique challenge for orthopaedic surgeons. The objective of this study was to evaluate the outcomes of using the clamshell osteotomy in patients with acute fractures involving a malunion or deformity. A retrospective review of the cases performed by various orthopaedic traumatologists at 4 different trauma centers was performed to identify cases using the clamshell osteotomy from January 2012 to January 2016. Nine clamshell osteotomy cases were identified, 4 presenting fractures in the setting of previous malunions. All osteotomies healed within 15 months (average 6.8 ± 4.4 SD). In this multicenter case series, we demonstrate that using clamshell osteotomies can result in excellent outcomes for permitting intramedullary nailing of acute fractures in patients with lower extremity deformity.

Gait Analysis After Intertrochanteric Hip Fracture: Does Shortening Result in Gait Impairment?

OBJECTIVE: To determine the association between fracture collapse with altered gait after intertrochanteric (IT) fracture using the trochanteric fixation nail (TFN) and helical blade. DESIGN: Prospective cohort study. SETTING: Academic Level I trauma center. PATIENTS: Seventy-two patients with IT hip fractures (OTA/AO 31) treated between 2012 and 2016. The average age was 79.7 years (range, 51-94 years); there were 59 women and 13 men. INTERVENTION: All patients were treated with cephalomedullary nailing using the TFN (DePuy-Synthes, West Chester, PA) with a helical blade. MAIN OUTCOME MEASURES: At follow-up appointments, temporospatial gait parameters were measured and recorded. Radiographs were analyzed at the time of surgery and at each follow-up visit. Amount of radiographic femoral neck shortening was measured radiographically. Patients completed the Harris Hip Score, visual analog scale for pain, Short Form-36 Physical Component Score, and Short Form-36 Mental Component Score. RESULTS: The mean length of follow-up between the surgery and the gait analysis was 8.6 months (±0.7 months). The mean amount of shortening was 4.7 mm (±0.6 mm). Out of the 72 patients analyzed, there were 15 patients (20.8%) who shortened more than 8 mm, 7 patients (9.7%) who shortened 10 mm or more, and 2 patients (2.8%) who shortened more than 20 mm. Mean shortening was 3.0 mm for stable OTA/AO 31-A1 fractures, whereas the unstable patterns (OTA/AO 31-A2, 31-A3) demonstrated a mean shortening of 5.9 mm (P = 0.02). There was significant correlation between increased shortening and decreased cadence (P = 0.008), increased double support time (P < 0.001), decreased step length (P = 0.001), and increased single support asymmetry (P = 0.04) during gait analysis. The threshold of 8 mm of shortening predicted decreased cadence (P = 0.008), increased double support time (P < 0.001), and decreased step length (P = 0.006). Analysis of patient-reported outcome scores, including the Harris Hip Score, visual analog scale, SF-36 Physical Component Score, and SF-36 Mental Component Score, revealed no significant association with shortening. CONCLUSIONS: Results from this study indicate that shortening after cephallomedullary nailing of IT hip fractures using the TFN with a helical blade is associated with altered gait, specifically decreased cadence, increased double support time, decreased step length, and increased single support time asymmetry. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Bone density correlates with clinical outcomes after ankle fracture fixation.

INTRODUCTION: Osteoporosis and decreased bone density are known to increase fracture incidence and severity. Although much is known regarding the effects of bone density on fracture risk and the treatment options for prevention of fragility fractures, whether bone quality alters clinical outcomes after fracture fixation is unknown. The purpose of this study was to determine whether bone quality correlates with clinical outcomes after fracture fixation. MATERIALS AND METHODS: A prospective database of all operatively treated ankle fractures by a single surgeon from 2003 to 2013 was used to identify patients. All patients included in the study had preoperative computed tomography (CT) imaging of the injured ankle and postoperative CT imaging of the contralateral ankle. Hounsfield unit (HU) measurement values were determined by placing an elliptical region of interest confined to the cancellous metaphyseal region of the distal tibia and fibula. The primary and secondary clinical outcomes included Foot and Ankle Outcome Scores (FAOS) and ankle range of motion (ROM). Included patients had at least 12 months of clinical outcome data. RESULTS: Sixty-four patients met the inclusion criteria. Comparison of HU values from the injured and contralateral side demonstrated almost perfect agreement (ICC(2,1) = 0.938), suggesting that HU values can be accurately measured in the setting of a fracture. Increased HU values of the injured distal tibia and fibula significantly correlated with improved outcomes in four of five FAOS domains, including pain, activities of daily living, sports, and quality of life (beta = 0.285-0.344; P ≤ 0.05 for all). Range of motion outcomes did not significantly correlate with HU values. CONCLUSIONS: Our results suggest that decreased bone quality, as measured using preoperative CT, significantly correlates with inferior short-term clinical outcomes. These results have significant implications for integrating bone quality into treatment algorithms for fracture patients.

Computerized Adaptive Testing for Patient Reported Outcomes in Ankle Fracture Surgery.

BACKGROUND: Advantages of using computerized adaptive testing (CAT) include decreased survey-burden, diminished floor and ceiling effect, and improved ability to detect the minimal clinical significant difference (MCID) among patients. The goal of this study was to compare the legacy patient-reported outcome measures (PROMs) to the Patient-Reported Outcomes Measurement Information System (PROMIS) scores in terms of ability to detect clinically significant changes in patients who have undergone surgery for ankle fractures. METHODS: Patients who underwent osteosynthesis for an unstable ankle fracture between 2013-2016 and completed legacy outcome scores (Foot and Ankle Outcome Score [FAOS], Olerud and Molander Ankle Score [OMAS], and Weber Score) along with the PROMIS Physical Function (PF) and PROMIS Lower Extremity (LE) CATs postoperatively were included. Correlation between the scores at 3-month, 6-month, and 1-year intervals, as well as floor and ceiling effects, in addition to MCIDs were calculated for each instrument. A total of 132 patients were included in the study. RESULTS: There was no observed floor or ceiling effect in either the PROMIS PF or the PROMIS LE scores. Clinically significant changes in the PROMIS LE score were detected in patients between 6-month and 12-month postoperative visits ( P = .0006), whereas the reported OMAS score and Weber scores did not identify a clinically significant difference between patients at their 6-month and 12-month visit. CONCLUSION: The results of this study indicate that the PROMIS LE was superior for evaluating patients following ankle fracture surgery in terms of lower floor and ceiling effects and greater ability to distinguish clinically significant changes in patients between time points following surgery. LEVEL OF EVIDENCE: Level III, comparative study.

Osseous Vascularity of the Medial Elbow After Ulnar Collateral Ligament Reconstruction: A Comparison of the Docking and Modified Jobe Techniques.

BACKGROUND: Although vascularity plays a critical role in healing after ulnar collateral ligament (UCL) reconstruction, intraosseous blood flow to the medial epicondyle (ME) and sublime tubercle remains undefined. PURPOSE: To quantify vascular disruption caused by tunnel drilling with the modified Jobe and docking techniques for UCL reconstruction. STUDY DESIGN: Controlled laboratory study. METHODS: Eight matched pairs (16 specimens) of fresh-frozen cadaveric upper extremities were randomized to 1 of 2 study groups: docking technique or modified Jobe technique. One elbow in each pair underwent tunnel drilling by the assigned technique, while the contralateral elbow served as a control. Pregadolinium and postgadolinium magnetic resonance imaging were performed to quantify intraosseous vascularity within the ME, trochlea, and proximal ulna. Three-dimensional computed tomography (CT) and gross dissection were performed to assess terminal vessel integrity. RESULTS: Ulnar tunnel drilling had minimal impact on vascularity of the proximal ulna, with maintenance of >95% blood flow for each technique. Perfusion in the ME was reduced 14% (to 86% of baseline) for the docking technique and 60% (to 40% of baseline) for the modified Jobe technique (mean difference, 46%; P = .029). Three-dimensional CT and gross dissection revealed increased disruption of small perforating vessels of the posterior aspect of the ME for the modified Jobe technique. CONCLUSION: Although tunnel drilling in the sublime tubercle appears to have a minimal effect on intraosseous vascularity of the proximal ulna, both the docking and modified Jobe techniques reduce flow in the ME. This reduction was 4 times greater for the modified Jobe technique, and these findings have important implications for UCL reconstruction surgery. CLINICAL RELEVANCE: As the rate of revision UCL reconstructions continues to rise, investigation into causes for failure of primary surgery is needed. One potential cause is poor tendon-to-bone healing due to inadequate vascularity. This study quantifies the amount of vascular insult that is incurred in the ME during UCL reconstruction. While vascular insult is only one of many factors that affects the surgical success rate, surgeons performing this procedure should be mindful of this potential for vascular disruption.

Dual Radial Styloid and Volar Plating for Unstable Fractures of the Distal Radius.

As the operative management of displaced distal radius fractures evolves, intraoperative techniques and fixation strategies evolve as well. Achieving and maintaining an acceptable reduction is paramount but can be difficult with particular fracture patterns. In this article, we describe the use of a radial column plate as a reduction tool in the management of unstable distal radius fractures, along with clinical and radiographic clinical outcomes. This technique can be useful in situations where multiplanar instability exists, or simply when intraoperative assistance is limited. Surgeons can expect acceptable radiographic and clinical outcomes when using this technique, although effects on scar formation and wrist range of motion are currently not known.

Validating the Patient Reported Outcomes Measurement Information System (PROMIS) computerized adaptive tests for upper extremity fracture care.

BACKGROUND: Computerized adaptive testing (CAT) for patient-reported outcomes (PROs) is a developing area within orthopedic surgery. Our objective was to validate the Patient Reported Outcomes Measurement Information System (PROMIS) CATs for upper extremity fracture care. We sought to correlate PROMIS with legacy PROs and to investigate floor and ceiling effects. METHODS: Patients who underwent open reduction and internal fixation of upper extremity trauma were prospectively enrolled. Legacy PROs included the visual analog scale for pain, the Disabilities of the Arm, Shoulder and Hand questionnaire, the University of California-Los Angeles Shoulder Rating Scale, the Mayo Elbow Performance Score, and the 36-Item Short Form Health Survey. PROMIS CATs included Physical Function (PROMIS PF), PROMIS Pain Interference (PROMIS Pain), and PROMIS Upper Extremity (PROMIS UE). Correlations between the PROs were calculated as were the absolute and relative floor and ceiling effect. RESULTS: The study prospectively enrolled 174 patients with upper extremity trauma. There was moderate to high correlation between PROMIS UE CAT and legacy upper extremity-specific PROs (ρ = 0.42-0.79), and high correlation between the PROMIS PF CAT and the 36-Item Short Form Health Survey Physical Component Summary (ρ = 0.71, P < .001). The visual analog scale for pain, University of California-Los Angeles Shoulder Rating Scale, Constant Score, and Mayo Elbow Score demonstrated a significant absolute ceiling effect (20.5%-23.7%), whereas the PROMIS PF, PROMIS UE, and PROMIS Pain CATs demonstrated no absolute ceiling effect. CONCLUSION: PROMIS PF, Pain, and UE correlate well with legacy PROs in a upper extremity trauma population, with less absolute floor or ceiling effects. This study provides preliminary evidence for the utility of PROMIS CATs in upper extremity trauma patients.