Salvage of Failed Lisfranc/Midfoot Injuries.

Salvage of Lisfranc, or tarsometatarsal injuries, may be necessary because of a variety of clinical scenarios. Although rare, these injuries represent a broad spectrum of injury to the midfoot ranging from low-energy ligamentous injuries to high-energy injuries with significant displacement and associated fractures. Poor outcomes and complications may occur including posttraumatic arthritis, instability, pain, infection, and loss of function. Strategies and technical considerations for salvage of these complex injuries are provided.

Use of a Mandatory Clinical Decision Unit Reduces Readmission Rates following Total Joint Arthroplasty.

Readmission penalties have encouraged the implementation of protocols to reduce readmission rates. We hypothesized that by keeping postoperative patients, who return to the emergency department (ED) in a clinical decision unit (CDU) until being evaluated by the orthopaedic team, there would be a reduction in the readmission rate after total joint arthroplasty (TJA) at our institution. Our institution mandated the use of the CDU for all potential orthopaedic TJA readmissions. A retrospective review of prospectively collected data was performed on 365 patients who presented to the ED after either total hip arthroplasty (THA) or total knee arthroplasty (TKA). Patients presenting in the year prior to the implementation of the CDU program were compared with patients presenting in the year after implementation. Demographics, length of stay, comorbidities, and 30-day readmission rates were recorded. Additionally, a financial analysis was performed. Overall, for THA and TKA, there were a combined 141 ED visits prior to the implementation of the CDU program and 224 afterward; of these, 40 were readmitted before the CDU program and only 13 were readmitted afterward (p < 0.01). The financial analysis found that the overall 90-day cost for patients in the postoperative period was nearly $800 lower on average (p = 0.027) post-CDU implementation.During the first year of the CDU project at our institution, we significantly reduced the readmission rates following TJA and demonstrated significant cost saving. This is a Level III, prognostic study.

Early Results of a Modern Uncemented Total Knee Arthroplasty System.

Historically, cementless total knees were associated with early failure, which made cemented total knee arthroplasty the gold standard. Manufacturers have introduced newer uncemented technologies that provide good initial stability and use highly porous substrates for bony in-growth. The authors hypothesized that the implants would have equivalent 90-day clinical and economic outcomes. Prospectively collected data on 252 uncemented knees in the Michigan Arthroplasty Registry Collaborative Quality Initiative database were reviewed. Ninety-day outcomes, demographics, length of stay, complications, emergency department visits, readmissions, and financial data were compared with those of an age-matched group of cemented knees. Uncemented knees had shorter length of stay (1.58 vs 1.87 days; P<.01), were more frequently discharged home (90.48% vs 68.75%; P<.0001), and used less home care (6.35% vs 19.14%; P<.0001) or extended care facilities (2.78% vs 11.72%; P=.0001). More uncemented knees had "no complications." Moreover, there were no re-operations in uncemented knees, compared with 19 reoperations in cemented knees. Uncemented knees were better than age-matched counterparts for Knee injury and Osteoarthritis Outcome Score (63.69 vs 47.10, n=85 and n=43, P<.0001) and Patient-Reported Outcomes Measurement Information System (PROMIS) T-Physical and T-Mental scores (44.12 vs 39.45, P<.0001; 51.84 vs 47.82, P=.0018). Cemented cases were more expensive overall, and surgical ($6806.43 vs $5710.78; P<.01) and total hospital ($8347.65 vs $7016.11; P<.01) costs were higher. The 90-day readmission and hospital outpatient costs were not significantly different between designs. Uncemented total knee arthroplasty, when using modern technologies, is successful and economically viable for an at-risk bundle. The results of this study should alleviate fears of increased cost, early failure, complications, or poor outcomes with the use of a modern uncemented total knee arthroplasty. [Orthopedics. 2019; 42(6):355-360.].

Remodeling of the Calcaneocuboid Joint in the Acquired Flatfoot.

There has been debate recently as to whether the lateral column is actually short in the acquired flatfoot. Doubters argue that it is not possible for the lateral column to change in length and actually shorten, especially in the acquired type. In this series of 21 consecutive patients operated on for an acquired flatfoot, the calcaneocuboid joint (CC) had remodeled in all, resulting in the calcaneal side being short, facing laterally and dorsally. These findings give evidence to the rationale for performing a lateral column lengthening (LCL) proximal to the CC joint to treat the acquired flatfoot. When performing a LCL, one should attempt to restore length to the calcaneal side of the joint and to redirect it medially and plantarward. (Journal of Surgical Orthopaedic Advances 27(3):237-245, 2018).

Unreported Sharps Exposures in Orthopedic Surgery Residents A Silent Majority.

Sharps-related injuries represent a significant occupational hazard to orthopedic surgeons. Despite increased attention and targeted interventions, evidence suggests that the majority of incidents continue to go unreported. The purpose of this study was to examine the incidence, attitudes, and factors that affect the reporting of sharps injuries among orthopedic surgery residents at a large academic teaching hospital in an effort to increase reporting rates and design effective interventions. This study administered an anonymous cross-sectional survey regarding intraoperative sharps exposures to current orthopedic house staff, with an 87% (54/62) response rate. Overall, 76% of surveyed residents (41/54) had at least one sharps exposure during residency. The majority of these incidents (55%) were never reported. The most common reason cited for not reporting was a "perception of low risk." Residents whose exposures were witnessed by others on the surgical team were more likely to report the incident (57% vs. 23%, p = 0.043), suggesting that peer pressure acts to improve reporting rates. While the implementation of a "needlestick hotline" and increased education has led to improved reporting rates at our institution, further improvements aimed at reducing unwitnessed incidents, and therefore unreported incidents, could comprise an increased emphasis on surgical team vigilance, positive peer pressure, the incorporation of sharps-specific surgical debriefing statements and anonymous tip lines.

Posterior Fibula of Pes Cavus: Real or Artifact? Answer Based on Cross-Sectional Imaging.

Cavus foot deformity is an often overlooked source of pathology. In the cavus foot, the fibula is often noted to be posterior on lateral radiographs. The objective of the study was to determine with three-dimensional imaging if the fibula is truly posterior or just artifact. Using physical examination, patients with cavus were selected and compared to controls. An established technique to determine fibular position on computed tomography and magnetic resonance imaging was used to compare the study group to controls. Thirty-six cavus feet were compared to 36 controls. The average cavus fibula was noted to be 72% more posterior than the fibula of control patients and the difference in axial malleolar index was significant between the groups. This study shows that the cavus fibula is truly more posterior in patients with high arches. (Journal of Surgical Orthopaedic Advances 27(4):255-260, 2018).

Short-Term Outcomes Following Hip Fractures in Patients at Least 100 Years Old.

BACKGROUND: The number of hip fractures is rising as life expectancy increases. As such, the number of centenarians sustaining these fractures is also increasing. The purpose of this study was to determine whether patients who are ≥100 years old and sustain a hip fracture fare worse in the hospital than those who are younger. METHODS: Using a large database, the New York Statewide Planning and Research Cooperative System (SPARCS), we identified patients who were ≥65 years old and had been treated for a hip fracture over a 12-year period. Data on demographics, comorbidities, and treatment were collected. Three cohorts were established: patients who were 65 to 80 years old, 81 to 99 years old, and ≥100 years old (centenarians). Outcome measures included hospital length of stay, estimated total costs, and in-hospital mortality rates. RESULTS: A total of 168,087 patients with a hip fracture were identified, and 1,150 (0.7%) of them had sustained the fracture when they were ≥100 years old. Centenarians incurred costs and had lengths of stay that were similar to those of younger patients. Despite the similarities, centenarians were found to have a significantly higher in-hospital mortality rate than the younger populations (7.4% compared with 4.4% for those 81 to 99 years old and 2.6% for those 65 to 80 years old; p < 0.01). Male sex and an increasing number of medical comorbidities were found to predict in-hospital mortality for centenarians sustaining extracapsular hip fractures. No significant predictors of in-hospital mortality were identified for centenarians who sustained femoral neck fractures. An increased time to surgery did not influence the odds of in-hospital mortality. CONCLUSIONS: Centenarians had increased in-hospital mortality, but the remaining short-term outcomes were comparable with those for the younger cohorts with similar fracture patterns. For this extremely elderly population, time to surgery does not appear to affect short-term mortality rates, suggesting a potential benefit to preoperative optimization. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Hip Fracture Treatment at Orthopaedic Teaching Hospitals: Better Care at a Lower Cost.

OBJECTIVE: To compare the cost and outcomes of patients treated at orthopaedic teaching hospitals (OTHs) with those treated at nonteaching hospitals (NTHs). DESIGN: Retrospective study. SETTING: The Statewide Planning and Research Cooperative Systems (SPARCS) database, which includes all admissions to New York State hospitals from 2000-2011. PATIENTS/PARTICIPANTS: A total of 165,679 patients with isolated closed hip fracture 65 years of age and older met inclusion criteria. Of them, 57,279 were treated at OTH and 108,400 were treated at NTH. INTERVENTION: Admission for the management of a hip fracture. MAIN OUTCOME MEASURE: Cost, length of stay (LOS), and inpatient mortality. RESULTS: Univariate analysis shows that mean total hospital costs were higher at OTH ($16,576 ± $17,514) versus NTH ($13,358 ± $11,366) (P < 0.001); LOS was equivalent at OTH (8.0 ± 9.0 days) versus NTH (8.0 ± 7.6 days) (P = 0.904); and mortality was lower in OTH (3.4%) versus NTH (4.0%) (P < 0.001). In the multivariate total cost analysis, in addition to demographic differences, we identified total hospital beds and total ICU beds as significant confounding variables. Interestingly, when controlling for these patient and hospital factors, OTH designation was not a significant predictor of cost. In addition, multivariate analysis found that OTH status decreased LOS by 0.743 days (95% confidence interval: 0.632-0.854, P < 0.001) and mortality by 21% (odds ratio 0.794, 95% confidence interval: 0.733-0.859, P < 0.001), confirming the univariate trends. CONCLUSIONS: While OTH may seem to have higher hospital costs for operative hip fractures on cursory analysis, controlling for patient and hospital factors including hospital bed number negates this effect such that OTH has no additional cost compared with NTH. In addition, OTH status is associated with shorter LOS and lower in-hospital mortality. With the results of this study, health care systems and patients should feel confident that the quality of care at teaching hospitals is no less and potentially better than that at NTH with no added cost. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Tibial Eminence Involvement With Tibial Plateau Fracture Predicts Slower Recovery and Worse Postoperative Range of Knee Motion.

OBJECTIVES: To examine 1-year functional and clinical outcomes in patients with tibial plateau fractures with tibial eminence involvement. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Academic Medical Center. PATIENTS/PARTICIPANTS: All patients who presented with a tibial plateau fracture (Orthopaedic Trauma Association (OTA) 41-B and 41-C). INTERVENTION: Patients were divided into fractures with a tibial eminence component (+TE) and those without (-TE) cohorts. All patients underwent similar surgical approaches and fixation techniques for fractures. No tibial eminence fractures received fixation specifically. MAIN OUTCOME MEASUREMENTS: Short musculoskeletal functional assessment (SMFA), pain (Visual Analogue Scale), and knee range-of-motion (ROM) were evaluated at 3, 6, and 12 months postoperatively and compared between cohorts. RESULTS: Two hundred ninety-three patients were included for review. Patients with OTA 41-C fractures were more likely to have an associated TE compared with 41-B fractures (63% vs. 28%, P < 0.01). At 3 months postoperatively, the +TE cohort was noted to have worse knee ROM (75.16 ± 51 vs. 86.82 ± 53 degree, P = 0.06). At 6 months, total SMFA and knee ROM was significantly worse in the +TE cohort (29 ± 17 vs. 21 ± 18, P ≤ 0.01; 115.6 ± 20 vs. 124.1 ± 15, P = 0.01). By 12 months postoperatively, only knee ROM remained significantly worse in the +TE cohort (118.7 ± 15 vs. 126.9 ± 13, P < 0.01). Multivariate analysis revealed that tibial eminence involvement was a significant predictor of ROM at 6 and 12 months and SFMA at 6 months. Body mass index was found to be a significant predictor of ROM and age was a significant predictor of total SMFA at all time points. CONCLUSION: Knee ROM remains worse throughout the postoperative period in the +TE cohort. Functional outcome improves less rapidly in the +TE cohort but achieves similar results by 1 year. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Presence of Failed Fracture Implants in Association With Lower Extremity Long Bone Nonunion Does Not Portend Worse Outcome After Nonunion Repair.

OBJECTIVE: The purpose of this study was to determine whether the finding of failed fracture implants in association with lower extremity long bone fracture nonunion portends worse clinical or functional outcome after surgical nonunion repair. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Academic Medical Center. PATIENTS: One hundred eighty-one patients who presented to our institution over a 10-year period and underwent surgical repair of a lower extremity fracture nonunion. INTERVENTION: Surgical repair of lower extremity fracture nonunion. MAIN OUTCOME MEASUREMENTS: Time to union, postoperative complications, visual analog scale pain scores, and Short Musculoskeletal Function Assessment scores after lower extremity nonunion repair. Data were analyzed to assess for differences in postoperative outcomes based on the integrity of fracture implants at the time of nonunion diagnosis. Implant integrity was defined using 3 groups: broken implants (BI), implants intact (II), and no implants (NI). RESULTS: There was no significant difference in time to union after surgery between the BI, II, or NI groups (mean 8.1 months vs. 7.6 months vs. 6.2 months, respectively). Fourteen patients (7.7%) failed to heal, including 5 BI patients, 7 II patients, and 2 NI patients. One tibial nonunion patient in each of the 3 groups underwent amputation for persistent nonunion after multiple failed revision attempts at a mean of 4.8 years after initial injury. There was no difference in postoperative pain scores, the rate of postoperative complications, or functional outcome scores identified between the 3 groups. CONCLUSIONS: The finding of failed fracture implants at the time of lower extremity long bone nonunion diagnosis does not portend worse clinical or functional outcome after surgical nonunion repair. Patients who present with failed fracture implants at the time of nonunion diagnosis can anticipate similar time to union, complication rates, and functional outcomes when compared with patients who present with intact implants or those with history of nonoperative management. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Spinal Anesthesia Improves Early Pain Levels After Surgical Treatment of Tibial Plateau Fractures.

OBJECTIVES: To determine the effect of spinal anesthesia (SA) on short-term outcomes when compared with general anesthesia in operatively managed tibial plateau fractures. DESIGN: This is an institutional review board-approved retrospective review of prospectively collected data. SETTING: Two level-1 trauma centers. PARTICIPANTS: One hundred twelve patients with a surgically managed tibial plateau fracture were identified within a registry of patients. INTERVENTION: Of these, 29 (25.9%) received SA and 83 (74.1%) received general anesthesia in a nonrandomized fashion. MAIN OUTCOME MEASURES: Short Musculoskeletal Functional Assessment scores, pain levels, knee range of motion, complications, and reoperations. RESULTS: SA was found to be a predictor of lower pain scores at 3 months (odds ratio, 0.32; 95% confidence interval, 0.12-0.95; P = 0.039) but not at 6 months (P = 0.266) or the latest follow-up (P = 0.056). In the multivariate Short Musculoskeletal Functional Assessment model, although anesthesia type was not found to be a statistically significant predictor, other predictors were identified. Anesthesia type was not a predictor of complications or reoperations. In the univariate analysis, SA was associated with an increased knee range of motion at 3 months (121 vs. 111 degrees; P = 0.048) but not at 6 months (P = 0.31) or the latest follow-up (P = 0.053). CONCLUSION: In patients who undergo surgical management of a tibial plateau fracture, the use of SA is associated with decreased pain levels in the early postoperative period; however, there was no effect on functional assessment scores. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Development of a Middle-Age and Geriatric Trauma Mortality Risk Score A Tool to Guide Palliative Care Consultations.

INTRODUCTION: This study aimed to develop a tool to quantify risk of inpatient mortality among geriatric and middleaged trauma patients. This study sought to demonstrate the ability of the novel risk score in the early identification of high risk trauma patients for resource-sparing interventions, including referral to palliative medicine. MATERIALS AND METHODS: This retrospective cohort study utilized data from a single level 1 trauma center. Regression analysis was used to create a novel risk of inpatient mortality score. A total of 2,387 low energy and 1,201 high-energy middle-aged (range: 55 to 64 years of age) and geriatric (65 years of age or odler) trauma patients comprised the study cohort. Model validation was performed using 37,474 lowenergy and 97,034 high-energy patients from the National Trauma Databank (NTDB). Potential hospital cost reduction was calculated for early referral of high risk trauma patients to palliative medicine services in comparison to no palliative medicine referral. RESULTS: Factors predictive of inpatient mortality among the study and validation patient cohorts included; age, Glasgow Coma Scale, and Abbreviated Injury Scale for the head and neck and chest. Within the validation cohort, the novel mortality risk score demonstrated greater predictive capacity than existing trauma scores [STTGMALE-AUROC: 0.83 vs. TRISS 0.80, (p < 0.01), STTGMAHE-AUROC: 0.86 vs. TRISS 0.85, (p < 0.01)]. Our model demonstrated early palliative medicine evaluation could produce $1,083,082 in net hospital savings per year. CONCLUSION: This novel risk score for older trauma patients has shown fidelity in prediction of inpatient mortality; in the study and validation cohorts. This tool may be used for early intervention in the care of patients at high risk of mortality and resource expenditure.

Surgical Fracture Repair in Chronic Renal Failure Patients on Hemodialysis An Analysis of Complications and Hospital Quality Measures.

In end stage renal disease (ESRD) patients on hemodialysis (HD), it is known that renal bone disease has a negative impact on postoperative complication rate of fracture repair compared to non-ESRD patients. Previous studies have examined complications following surgical hip fracture repair in ESRD patients on HD. However, there is paucity of information outside of hip fracture repair. This study was undertaken to investigate complications associated with surgical fracture repair in ESRD patients on hemodialysis and to compare quality measures with a control group for various fracture types. Data of all consecutive ESRD patients on HD was collected prospectively starting in 2013. Charts of 2,558 ESRD patients on HD from 2010 to 2013 were also reviewed. Thirty-four patients who underwent surgical fracture repair were included in the study. Additionally, 1,000 patients without ESRD who underwent fracture repair were also identified, and a random sample of 267 patients was selected for inclusion as a control group. Primary outcomes were major complications as defined by the Clavien-Dindo complication rating system for orthopaedic surgery. Secondary outcomes were minor complications, defined by the same method. Demographic information and hospital quality measures, such as hospital length of stay (LOS) and discharge disposition, were also collected. There were no differences between the two groups in terms of BMI, ethnicity, or gender distribution. The ESRD patients were older than control patients (62.6 versus 46.8 years; p > 0.01). Overall, the complication rate in the ESRD group was 14.7% compared to 3% in the control group (p < 0.05) while the rate of major complications was similar (5.8% versus 2.2%, p = 0.2). The rate of minor complications was higher in the ESRD group though this did not reach statistical significance (8.8% versus 1%, p = 0.07). Median LOS was significantly higher in the ESRD group (15.9 versus 6.4 days; p < 0.01), and patients in the ESRD group were less likely to be discharged to home (29.4% versus 78%; p < 0.01). Surgical fracture repair in ESRD patients can be performed with similar major complication rate as a control group. However, the higher rate of minor complications and poorer hospital quality measures in the ESRD group must be taken into account as we move toward "pay for performance" and bundled payment initiatives for orthopaedic trauma patients.

Outcomes Over a Decade After Surgery for Unstable Ankle Fracture: Functional Recovery Seen 1 Year Postoperatively Does Not Decay With Time.

OBJECTIVES: To evaluate long-term clinical and radiographic outcomes after surgical fixation of unstable ankle fractures. DESIGN: Prospective follow-up study. SETTING: Academic medical center with 2 Level-I trauma centers and a tertiary care center. PATIENTS: One hundred forty-one patients who underwent surgical repair of an unstable ankle fracture. INTERVENTION: Open reduction internal fixation of an unstable ankle fracture. MAIN OUTCOME MEASUREMENTS: Short Musculoskeletal Function Assessment (SMFA) scores and radiographic outcomes based on the van Dijk criteria at a mean of 11.6 years follow-up. RESULTS: Of the 281 patients meeting the inclusion criteria for this study, follow-up data were obtained from 141 patients (50%), at a mean of 11.6 years after surgery. Overall, mean long-term SMFA scores were improved when compared with scores at 1 year. The American Society of Anesthesiologists class 1 or 2 was found to be a significant predictor of recovery based on SMFA scores. Sixty-three percent of follow-up radiographs demonstrated evidence of radiographic arthritis, including 31% with mild osteoarthritis, 22% with moderate osteoarthritis, and 10% with severe osteoarthritis. Fracture dislocation at injury was found to be a significant predictor of radiographic posttraumatic osteoarthritis at latest follow-up. One patient (0.7%) underwent a tibiotalar fusion secondary to symptomatic posttraumatic arthrosis. One patient (0.7%) underwent total ankle replacement due to severe osteoarthritis. CONCLUSIONS: Our data indicate that over a decade after ankle fracture fixation, most of the patients are doing well. Despite the presence of radiographic arthritis in 63% of patients, few experience pain or have restrictions in function, and mean long-term functional outcome scores are improved when compared with scores at 1 year. Patients undergoing operative fixation of unstable ankle fractures can anticipate functional outcomes that are maintained over time. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Impact of Diabetes Mellitus on Surgical Quality Measures After Ankle Fracture Surgery: Implications for "Value-Based" Compensation and "Pay for Performance".

OBJECTIVES: To evaluate the impact of diabetes mellitus (DM) and associated complications on cost, length of stay, and inpatient mortality after open reduction internal fixation (ORIF) of an ankle fracture, and the implications of these variables during a time of health care payment reform. DESIGN: Retrospective study. SETTING: The Statewide Planning and Research Cooperative System database, which includes all admissions to New York State hospitals from 2000 to 2011. PATIENTS/PARTICIPANTS: A total of 58,748 patients were identified as having undergone the primary procedure of ORIF of the ankle (ICD-9-CM procedure code 79.36). INTERVENTION: ORIF of the ankle. MAIN OUTCOME MEASURE: Cost, length of stay, and inpatient mortality. RESULTS: Of the 58,748 patients evaluated, 7501 (12.8%) had DM. Mean length of stay and total hospital charges were significantly greater for the DM cohort compared to the without DM cohort (P < 0.01). Patients with DM had greater Charlson Comorbidity Index scores and greater in-hospital mortality than patients without DM (both P < 0.01). Of the patients with diabetes, 1098/7501 had complicated diabetes mellitus (C-DM). Patients with C-DM stayed 2.4 days longer and were $6895 more costly than those with diabetes alone (both P < 0.01). Patients with C-DM also had a significantly higher in-hospital mortality rate than those with diabetes alone. CONCLUSIONS: Patients with diabetes admitted to the hospital for ankle ORIF have more expensive hospital stays and higher in-hospital mortality rates than patients without diabetes. The presence of diabetic complications further increases these risks. These data will help provide risk-adjustment for future health care payment reform initiatives. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Continuous Popliteal Sciatic Nerve Block Versus Single Injection Nerve Block for Ankle Fracture Surgery: A Prospective Randomized Comparative Trial.

OBJECTIVES: To compare rebound pain and the need for narcotic analgesia after ankle fracture surgery for patients receiving perioperative analgesia through either a continuous infusion or a single injection nerve block. DESIGN: Prospective randomized controlled trial. SETTINGS: Surgeries were performed at 2 hospitals affiliated with a large urban academic medical center. PATIENTS/PARTICIPANTS: Fifty patients undergoing operative fixation of an ankle fracture (AO/OTA type 44). INTERVENTION: Participants were randomized to receive either a popliteal sciatic nerve block as a single shot (SSB group) or a continuous infusion through an On Q continuous infusion pump (On Q group). MAIN OUTCOME MEASUREMENTS: Visual analog scale and numeric rating scale (0-10) pain levels and amount of pain medication taken. RESULTS: For all time points after discharge, mean postoperative pain scores and number of pain pills taken were lower in the On Q group versus the SSB group. Pain scores were significantly lower in the On Q group at the 12 hours postoperative time point (P = 0.002) and at 2 weeks postoperatively. The number of pain pills taken in the first 72 hours was lower in the On Q group (14.9 vs. 20.0; P = 0.036). Overall, 7/23 patients in the On Q group had their pump malfunction and 1 patient accidently removed the catheter. CONCLUSIONS: Use of continuously infused regional anesthetic for pain control in ankle fracture surgery significantly reduces "rebound pain" and the need for oral opioid analgesia compared with single-shot regional anesthetic. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Development of Compartment Syndrome Negatively Impacts Length of Stay and Cost After Tibia Fracture.

OBJECTIVES: To quantify the impact of compartment syndrome in the setting of tibial shaft fracture on hospital length of stay (LOS) and total hospital charges. DESIGN: Retrospective case-control study. SETTING: All New York State hospital admissions from 2001 to 2011, as recorded by the New York Statewide Planning and Research Cooperative System database. PATIENTS: Thirty three thousand six hundred twenty-nine inpatients with isolated open or closed fractures of the tibia and/or fibula (AO/OTA 41-43). Six hundred ninety-two patients developed a compartment syndrome in the setting of tibia fracture. All patients were filtered to ensure none had other complications or medical comorbidities that would increase LOS or total hospital charges. INTERVENTION: Fasciotomy and delayed closure in patients who developed a compartment syndrome. MAIN OUTCOME MEASURE: Hospital LOS (days) and total inflation-adjusted hospital charges. RESULTS: A total of 33,629 patients with tibial shaft fracture were included in the study. There were 32,937 patients who did not develop a compartment syndrome. For this group, the mean LOS was 6 days, and the mean inflation-adjusted hospital charges were $34,000. Patients who developed compartment syndrome remained in-house for an average of 14 days with average charges totaling $79,000. These differences were highly significant for both lengths of stay and hospital charges (P < 0.001). CONCLUSIONS: Besides the obvious physical detriment experienced by patients with compartment syndrome, there is also a significant economic impact to the healthcare system. Compartment syndrome after a tibial fracture more than doubles LOS and total hospital charges. These findings highlight the need for a standardized care algorithm aimed toward efficiently and adequately treating acute compartment syndrome. Such an algorithm would optimize cost of care and presumably decrease LOS. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Longitudinal Lisfranc injury.

Most Lisfranc or tarsometatarsal (TMT) joint injuries result from a horizontally directed force in which the metatarsals are displaced relative to the midfoot. The injury pattern that is described in this article is one of a longitudinal force through the first ray and cuneiform. A reliable measure to recognize the longitudinal Lisfranc variant injury has been the height difference between the distal articular surfaces of the first and second cuneiform bones in an anteroposterior (AP) weight-bearing radiograph. This measure helps identify subtle injuries in which there is a proximal and medial subluxation of the first cuneiform-metatarsal complex. Delayed diagnosis and treatment have been associated with poorer results and significant functional consequences. This article describes a simple radiographic measurement to recognize the longitudinal injury pattern and to aid in determining whether operative intervention is required.