Retrograde Intramedullary Nailing Versus Locked Plating for Extreme Distal Periprosthetic Femur Fractures: A Multicenter Retrospective Cohort Study.

OBJECTIVES: To compare clinical and radiographic outcomes after retrograde intramedullary nailing (rIMN) versus locked plating (LP) of "extreme distal" periprosthetic femur fractures, defined as those that contact or extend distal to the anterior flange. DESIGN: Retrospective review. SETTING: Eight academic level I trauma centers. PATIENT SELECTION CRITERIA: Adult patients with periprosthetic distal femur fractures at or distal to the anterior flange (OTA/AO 33B-C[VB1]) treated with rIMN or LP. OUTCOME MEASURES AND COMPARISONS: The primary outcome was reoperation to promote healing or to treat infection (reoperation for elective removal of symptomatic hardware was excluded from this analysis). Secondary outcomes included nonunion, delayed union, fixation failure, infection, overall reoperation rate, distal femoral alignment, and ambulatory status at final follow-up. Outcomes were compared between patients treated with rIMN or LP. RESULTS: Seventy-one patients treated with rIMN and 224 patients treated with LP were included. The rIMN group had fewer points of fixation in the distal segment (rIMN: 3.5 ± 1.1 vs. LP: 6.0 ± 1.1, P < 0.001) and more patients who were allowed to weight-bear as tolerated immediately postoperatively (rIMN: 45%; LP: 9%, P < 0.01). Reoperation to promote union and/or treat infection was 8% in the rIMN group and 16% in the LP group ( P = 0.122). There were no significant differences in nonunion ( P > 0.999), delayed union ( P = 0.079), fixation failure ( P > 0.999), infection ( P = 0.084), or overall reoperation rate ( P > 0.999). Significantly more patients in the rIMN group were ambulatory without assistive devices at final follow-up (rIMN: 35%, LP: 18%, P = 0.008). CONCLUSIONS: rIMN of extreme distal periprosthetic femur fractures has similar complication rates compared with LP, with a possible advantage of earlier return to weight-bearing. Surgeons can consider this treatment strategy in all fractures with stable implants and amenable prosthesis geometry, even extreme distal fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Long Bones Treated With Carbon-Fiber Nails for Oncologic Indications: International Multi-institutional Study.

BACKGROUND: Intramedullary nail fixation is commonly used for prophylactic stabilization of impending and fixation of complete pathological fractures of the long bones. However, metallic artifacts complicate imaging evaluation for bone healing or tumor progression and postoperative radiation planning. Carbon-fiber implants have gained popularity as an alternative, given their radiolucency and superior axial bending. This study evaluates incidences of mechanical and nonmechanical complications. METHODS: Adult patients (age 18 years and older) treated with carbon-fiber nails for impending/complete pathological long bone fractures secondary to metastases from 2013 to 2020 were analyzed for incidences and risk factors of mechanical and nonmechanical complications. Mechanical complications included aseptic screw loosening and structural failures of host bone and carbon-fiber implants. Deep infection and tumor progression were considered nonmechanical. Other complications/adverse events were also reported. RESULTS: A total of 239 patients were included; 47% were male, and 53% were female, with a median age of 68 (IQR, 59 to 75) years. Most common secondary metastases were related to breast cancer (19%), lung cancer (19%), multiple myeloma (18%), and sarcoma (13%). In total, 17 of 30 patients with metastatic sarcoma received palliative intramedullary nail fixation for impending/complete pathological fractures, and 13 of 30 received prophylactic nail stabilization of bone radiated preoperatively to manage juxta-osseous soft-tissue sarcomas, where partial resection of the periosteum or bone was necessary for negative margin resection. 33 (14%) patients had complications. Mechanical failures included 4 (1.7%) structural host bone failures, 7 (2.9%) implant structural failures, and 1 (0.4%) aseptic loosening of distal locking screws. Nonmechanical failures included 8 (3.3%) peri-implant infections and 15 (6.3%) tumor progressions with implant contamination. The 90-day and 1-year mortalities were 28% (61/239) and 53% (53/102), respectively. The literature reported comparable failure and mortality rates with conventional titanium treatment. CONCLUSIONS: Carbon-fiber implants might be an alternative for treating impending and sustained pathological fractures secondary to metastatic bone disease. The seemingly comparable complication profile warrants further cohort studies comparing carbon-fiber and titanium nail complications.

A PEEK into carbon fiber: A practical guide for high performance composite polymeric implants for orthopaedic oncology.

Introduction: The use of carbon fiber implants in orthopaedic oncology has increased within recent years. The most widely used type of polymer is carbon fiber polyether ether ketone (CF-PEEK). Its radiolucency enables targeted radiotherapy and artifact-free tumor surveillance, which provides major advantages over metallic hardware. We aim to summarize the unique benefits within orthopaedic oncology, clinical pitfalls, and recent advancements. Methods: Four representative patient cases from a single tertiary academic medical center were treated with carbon fiber implants (n = 2 nails, n = 2 plates) from 2021 to 2022. Results: There were no adverse events noted during intraoperative implantation or postoperative follow up. All patients reported improvements in pain and no difficulties in ambulation. There were no instances of catastrophic failure or implant loosening. Conclusion: CF implants offer a diverse array of advantages regarding its radiolucency, low scatter density, and bioinert profile. Nonetheless, further research is required to understand the long-term surgical outcomes and robustness of CF implants. Multi institutional trials could address important aspects of durability and stability over extended periods, feasibility and ease-of-use for different anatomical sites and bone quality, as well as cost-effectiveness in post-operative imaging, healthcare resource utilization, and revision rates. Providing orthopaedic surgeons with valuable insight will enable thorough clinically supported, informed decision making regarding optimal use of implants.

Outcomes of fixation of Vancouver B periprosthetic fractures around cemented versus uncemented stems.

BACKGROUND: The incidence of periprosthetic femur fracture (PPFF) in the setting of total hip arthroplasty (THA) is steadily increasing. We seek to address whether there is a difference in outcomes between Vancouver B fracture types managed with ORIF when the original stem was a press-fit stem versus a cemented stem. METHODS: In this retrospective cohort study at a level 1 trauma center, we identified 136 patients over 65 years-of-age with Vancouver B-type fractures sustained between 2005 and 2019. Patients were treated by ORIF and had either cemented or press-fit stems prior to their injury. Outcomes were subsidence of the femoral implant, time to full weight bearing, rate of the hip implant revision, estimated blood loss (EBL), postoperative complications, and the one-year mortality rate. RESULTS: A total of 103 (75.7%) press-fit and 33 (24.3%) cemented patients were reviewed. Patient baseline characteristics, Vancouver fracture sub-types, and implant characteristics were not found to be significantly different between groups. The difference in subsidence rates, postoperative complications, and time to weight bearing were not significantly different between groups. EBL and one-year mortality rate were significantly higher in the cemented group. CONCLUSIONS: In geriatric patients with Vancouver B type periprosthetic fractures managed with ORIF, patients with an originally press fit stem may have lower mortality, lower estimated blood loss, and similar subsidence and hospital length of stays when compared to those with a cemented stem.

Self-Reported Physical Function and Grit Are Not Correlated in Patients Who Undergo Open Reduction Internal Fixation for Distal Radius Fractures.

PURPOSE: "Grit" is defined as the perseverance and passion for long-term goals. Thus, grittier patients may have a better function after common hand procedures; however, this is not well-documented in the literature. Our purpose was to assess the correlation between grit and self-reported physical function among patients undergoing open reduction internal fixation (ORIF) for distal radius fractures (DRFs). METHODS: Between 2017 and 2020, patients undergoing ORIF for DRFs were identified. They were asked to complete the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire before surgery and at 6 weeks, 3 months, and 1 year after surgery. The first 100 patients with at least 1-year follow-up also completed the 8-question GRIT Scale, a validated measure of passion and perseverance for long-term goals measured on a scale of 0 (least grit) to 5 (most grit). The correlation between the QuickDASH and GRIT Scale scores was calculated using Spearman rho (ρ). RESULTS: The average GRIT Scale score was 4.0 (SD, 0.7), with a median of 4.1 (range, 1.6-5.0). The median QuickDASH scores at the preoperative, 6-week postoperative, 6-month postoperative, and 1-year postoperative time points were 80 (range, 7-100), 43 (range, 2-100), 20 (range, 0-100), and 5 (range, 0-89), respectively. No significant correlation was found between the GRIT Scale and QuickDASH scores at any time. CONCLUSIONS: We found no correlation between self-reported physical function and GRIT levels in patients undergoing ORIF for DRFs, suggesting no correlation between grit and patient-reported outcomes in this context. Future studies are needed to investigate the influence of individual differences in character traits other than grit on patient outcomes, which may help better align resources where needed and further the ability to deliver individualized, quality health care. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Complete tumor necrosis after neoadjuvant chemotherapy defines good responders in patients with Ewing sarcoma.

BACKGROUND: Survival in patients who have Ewing sarcoma is correlated with postchemotherapy response (tumor necrosis). This treatment response has been categorized as the response rate, similar to what has been used in osteosarcoma. There is controversy regarding whether this is appropriate or whether it should be a dichotomy of complete versus incomplete response, given how important a complete response is for in overall survival of patients with Ewing sarcoma. The purpose of this study was to evaluate the impact that the amount of chemotherapy-induced necrosis has on (1) overall survival, (2) local recurrence-free survival, (3) metastasis-free survival, and (4) event-free survival in patients with Ewing sarcoma. METHODS: In total, 427 patients who had Ewing sarcoma or tumors in the Ewing sarcoma family and received treatment with preoperative chemotherapy and surgery at 10 international institutions were included. Multivariate Cox proportional-hazards analyses were used to assess the associations between tumor necrosis and all four outcomes while controlling for clinical factors identified in bivariate analysis, including age, tumor volume, location, surgical margins, metastatic disease at presentation, and preoperative radiotherapy. RESULTS: Patients who had a complete (100%) tumor response to chemotherapy had increased overall survival (hazard ratio [HR], 0.26; 95% CI, 0.14-0.48; p < .01), recurrence-free survival (HR, 0.40; 95% CI, 0.20-0.82; p = .01), metastasis-free survival (HR, 0.27; 95% CI, 0.15-0.46; p ≤ .01), and event-free survival (HR, 0.26; 95% CI, 0.16-0.41; p ≤ .01) compared with patients who had a partial (0%-99%) response. CONCLUSIONS: Complete tumor necrosis should be the index parameter to grade response to treatment as satisfactory in patients with Ewing sarcoma. Any viable tumor in these patients after neoadjuvant treatment should be of oncologic concern. These findings can affect the design of new clinical trials and the risk-stratified application of conventional or novel treatments.

Lack of Surgeon Standardization on Implant Selection in Ankle Fracture Fixation May Increase Costs and Decrease Contribution Margin.

BACKGROUND: Surgical standardization has been shown to decrease costs without impacting quality; however, there is limited literature on this subject regarding ankle fracture fixation. Methods. Between October 5, 2015 and September 27, 2017, a total of 168 patients with isolated ankle fractures who underwent open reduction, internal fixation (ORIF) were analyzed. Financial data were analyzed across ankle fracture classification type, implant characteristics, and surgeons. Bivariate analyses were conducted. One-way analysis of variance was used to compare hardware costs across all 5 surgeons. Linear regression analysis was used to determine if hardware cost differed by surgeon when accounting for fracture type. RESULTS: The mean contribution margin was $4853 (SD $6446). There was a significant difference in implant costs by surgeon (range, lowest-cost surgeon: $471 [SD $283] to $1609 [SD $819]; P < .001). There was no difference in the use of a suture button or locking plate by fracture type (P = .13); however, the cost of the implant was significantly higher if a suture button or locking plate was used ($1014 [SD $666] vs $338 [SD $176]; P < .001). There was an association between surgeon 3 (ß = 200.32 [95% CI 6.18-394.47]; P = .043) and surgeon 4 (ß = 1131.07 [95% CI 906.84-1355.30]; P < .001) and higher hardware costs. CONCLUSIONS: Even for the same ankle fracture type, a wide variation in implant costs exists. The lack of standardization among surgeons accounted for a nearly 3.5-fold difference, on average, between the lowest- and highest-cost surgeons, negatively affecting contribution margin. LEVELS OF EVIDENCE: Level IV.

The Association Between Depression and Antidepressant Use and Outcomes After Operative Treatment of Distal Radius Fractures at 1 Year.

PURPOSE: Depression has been linked to inferior clinical outcomes among upper extremity patients. It often is challenging to distinguish the symptoms of depression, symptoms of injury, and the interaction between these 2 entities after a patient has been injured. We aimed to study the differences in clinical outcomes after surgical fixation of distal radius fractures between patients with and without a documented history and treatment for depression. METHODS: All subjects with an isolated, acute distal radius fracture undergoing operative fixation in a 10-year period at a level 1 academic trauma center were screened. Baseline demographic data were collected, and psychiatric history and antidepressant use were recorded and verified with a pharmacy database. Quick Disability of the Arm, Shoulder and Hand (QuickDASH), range of motion, and grip strength were assessed at 12 months after surgery. Multivariable linear regression analysis was used to assess the association of depression with QuickDASH scores at 1 year after surgery. RESULTS: A total of 211 patients were available for 1-year follow-up, 50 of whom were being treated actively for depression with medication at the time of injury and 161 were without a known diagnosis of, or treatment for, depression. Demographic and injury characteristics were similar between both groups. In a multivariable linear regression model controlling for age, sex, and a history of osteoporosis, active treatment for depression was associated with a slight mean increase in QuickDASH scores, 6.5 (1.3-11.8), 1 year after surgery. CONCLUSIONS: This study demonstrates a small increase in QuickDASH scores between subjects with a confirmed diagnoses of depression compared with all others after surgical fixation of distal radius fracture at 1-year follow-up. We suggest that a history of depression may portend worse clinical outcomes, although other factors, such as underreporting of depression may influence results. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Complications After Open Reduction and Internal Fixation for Distal Radius Fractures in Patients With and Without Rheumatoid Arthritis.

PURPOSE: Rheumatoid arthritis (RA) can have severe impact on patients' functional abilities and increase the risk of fragility fractures. Little is known about how patients with RA fare after operative management of distal radius fractures. The purpose of this study was to compare postoperative complications after surgical fixation in patients with RA and controls, hypothesizing that patients with RA would have higher levels of postoperative complications. METHODS: Patients were identified using Current Procedural Terminology and International Classification of Diseases, Ninth and Tenth Revision, codes for open treatment of distal radius fractures and RA at 3 level 1 trauma centers over a 5-year period (2015-2019). Chart abstraction provided details regarding injuries and treatment. Age- and sex-matched controls were identified in a 2:1 ratio. Postoperative complications were classified according to the Clavien-Dindo-Sink classification system and divided into early (less than 90 days) and late groups. RESULTS: Sixty-four patients (21 with RA and 43 controls) were included. The patients were predominantly women, with a mean age of 62 years and a mean Charlson comorbidity index of 2.1. The RA medications at the time of injury included conventional synthetic disease-modifying antirheumatic drugs (5/21), biologic disease-modifying antirheumatic drugs (5/21), or chronic oral prednisone (6/21). Rheumatoid medications, except hydroxychloroquine, were withheld for 2-3 weeks after surgery. Rheumatoid patients were significantly more likely to sustain a complication compared with the control group, although this was no longer significant on adjusted analysis. Class I complications were the most common. The incidence of early versus late complications was similar between the groups. A high rate of early return to surgery for fixation failure occurred in the RA group compared with none in the control group. CONCLUSIONS: Patients with RA undergoing operative management of distal radius fractures are at risk of postoperative complications, particularly fracture fixation failure, necessitating return to the operative room. High levels of pain, stiffness, and mechanical symptoms were noted in the RA group. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Comparison of carbon fibre and titanium intramedullary nails in orthopaedic oncology.

AIMS: Due to their radiolucency and favourable mechanical properties, carbon fibre nails may be a preferable alternative to titanium nails for oncology patients. We aim to compare the surgical characteristics and short-term results of patients who underwent intramedullary fixation with either a titanium or carbon fibre nail for pathological long-bone fracture. METHODS: This single tertiary-institutional, retrospectively matched case-control study included 72 patients who underwent prophylactic or therapeutic fixation for pathological fracture of the humerus, femur, or tibia with either a titanium (control group, n = 36) or carbon fibre (case group, n = 36) intramedullary nail between 2016 to 2020. Patients were excluded if intramedullary fixation was combined with any other surgical procedure/fixation method. Outcomes included operating time, blood loss, fluoroscopic time, and complications. Fisher's exact test and Mann-Whitney U test were used for categorical and continuous outcomes, respectively. RESULTS: Patients receiving carbon nails as compared to those receiving titanium nails had higher blood loss (median 150 ml (interquartile range (IQR) 100 to 250) vs 100 ml (IQR 50 to 150); p = 0.042) and longer fluoroscopic time (median 150 seconds (IQR 114 to 182) vs 94 seconds (IQR 58 to 124); p = 0.001). Implant complications occurred in seven patients (19%) in the titanium group versus one patient (3%) in the carbon fibre group (p = 0.055). There were no notable differences between groups with regard to operating time, surgical wound infection, or survival. CONCLUSION: This pilot study demonstrates a non-inferior surgical and short-term clinical profile supporting further consideration of carbon fibre nails for pathological fracture fixation in orthopaedic oncology patients. Given enhanced accommodation of imaging methods important for oncological surveillance and radiation therapy planning, as well as high tolerances to fatigue stress, carbon fibre implants possess important oncological advantages over titanium implants that merit further prospective investigation. Level of evidence: III, Retrospective study Cite this article: Bone Jt Open 2022;3(8):648-655.

Use of the PRECICE nail for distraction osteogenesis after tumor resection.

INTRODUCTION: Reconstructing long bone defects following intercalary tumor resection presents an exciting challenge with a greater range of surgical solutions than more typical situations requiring arthroplasty. Segmental bone transport (distraction osteogenesis) is the least utilized option for intercalary reconstruction; however, it arguably provides patients with the most desirable result. Distraction osteogenesis can be used in the management of multiple skeletal conditions including deformity (congenital or acquired), or in the presence of bone defects (by trauma or planned surgical excision). Lack of broader adoption of transport is likely due to the highly technical demands and common complications of utilizing fine-wire fixators via the Ilizarov method. More recently, internal lengthening nails such as the PRECICE nail have been employed to facilitate distraction osteogenesis without the added complexity of external fixation. AREAS COVERED: This review will examine the literature on the indications, design, and safety of the PRECICE nail (NuVasive) for intercalary reconstruction after tumor resection. EXPERT OPINION: Bone transport using the PRECICE nail represents a viable alternative to Ilizarov distraction and has the benefit of avoiding the complications of an external fixator. For large defects, the PRECICE nail can be supplemented with a locking plate for additional stability and maintenance of limb length.

Primary and Metastatic Bone Tumors of the Patella: Literature Review and Institutional Experience.

Background: Patellar tumors are rare but certainly must be considered in the differential diagnosis in patients with knee pain. Diagnosis can be challenging as often patellar neoplasms are confused with benign conditions and their clinical presentation is usually not specific. We performed an institutional and a literature review to determine what are the most common tumors affecting the patella and what is the best management. Methods: This is a case series from our institution including all patients with benign, malignant, and metastatic patellar neoplasms. Charts were reviewed for patient demographics, clinical presentation, pathology characteristics, radiographic classification, and oncologic and functional outcomes. Results: Twenty-four patients were identified; twelve patients had benign lesions, 10 metastatic and 2 primary malignant tumors. Chondroblastoma and Giant Cell Tumor were the most common tumors. Management of benign lesions with intralesional curettage and packing with bone graft or cement demonstrated excellent results with no local recurrence. In terms of malignant tumors, the spectrum of treatment is variable; it could range from medical management alone or in combination with surgical procedures to total patellectomy with reconstruction of the extensor mechanism. Conclusion: Patellar tumors should be part of the differential in patients with chronic knee pain that does not respond to initial conservative interventions. Recurrence rate with intralesional curettage and bone grafting or cement packing is very low and therefore should be the treatment of choice for benign intraosseous neoplasms. Resection with negative margins in malignant neoplasms or bone metastasis decreases local recurrence but only in the former group there is a potential impact in survival.

The Effect of an Electronic Prescribing Policy for Opioids on Physician Prescribing Patterns Following Common Upper Extremity Procedures.

Purpose: We evaluated physician prescribing patterns before and after the implementation of a state-mandated opioid electronic prescribing (ePrescribing) program after 4 common outpatient hand surgeries. Specifically, we aimed to answer the following: (1) is there a change in the number of opioids prescribed after the institution of ePrescribing for carpal tunnel release (CTR), ganglion excision, distal radius fracture (DRF) open reduction internal fixation (ORIF), and carpometacarpal (CMC) arthroplasty and (2) what factors are associated with an increased number of tablets or total morphine milligram equivalents (MMEs) prescribed. Methods: We retrospectively reviewed patients who underwent CTR, ganglion excision, DRF ORIF, or CMC arthroplasty and analyzed the number of tablets and MMEs prescribed before and after the policy implementation, as well as which factors were associated with an increased total number of opioid tablets and MMEs prescribed. Results: A total of 428 patients were included. After policy implementation, there was a significant decrease in MMEs prescribed for ganglion excision (68 [SD, 45] vs 50 [SD, 60], P = .03) and CMC arthroplasty (283 [SD, 147] vs 217 [SD, 92], P < .01). There was also a significant decrease in the total number of tablets prescribed for ganglion excision (11 [SD, 5.7] vs 6.8 [SD, 8.0], P < .01), CMC arthroplasty (36 [SD, 13] vs 29 [SD, 12], P < .01), and DRF ORIF (31 [SD, 8.6] vs 28 [SD, 8.5], P = .04). The number of patients receiving any opioid prescription also significantly decreased following CTR (30% vs 51%, P = .03) and ganglion excision (11% vs 53%, P < .01). Conclusions: The initiation of state-mandated ePrescribing was associated with a decreased number of opioids-both MMEs and tablets-prescribed after surgery by hand surgeons for a variety of common procedures. Furthermore, a greater percentage of patients received no opioid prescriptions after ePrescribing. These findings support the value of ePrescribing as a potential tool to further decrease excess opioid prescriptions. Type of study/level of evidence: Therapeutic III.

Factors Associated With Surgical Site Infections After Fasciotomy in Patients With Compartment Syndrome.

INTRODUCTION: Fasciotomy is the standard of care to treat acute compartment syndrome (ACS). Although fasciotomies often prevent serious complications, postoperative complications can be notable. Surgical site infection (SSI) in these patients is as high as 30%. The objective of this study was to determine factors that increase the risk of SSI in patients with ACS. METHODS: A retrospective review of 142 patients with compartment syndrome over 10 years was done. We collected basic demographics, mechanism of trauma, time to fasciotomy, incidence of SSI, use of prophylactic antibiotics, and type and time to wound closure. Statistical analysis of continuous variables was done using the Student t-test, ANOVA, multivariable regression model, and categorical variables were compared using the chi-square test. RESULTS: Twenty-five patients with ACS (17.6%) developed infection that required additional treatment. In the multivariate regression model, there were significant differences in median time to closure in patients with infection versus those without, odds ratio: 1.06 (Confidence Interval 95% [1.00 to 1.11]), P = 0.036. No differences were observed in infection based on the mechanism of injury, wound management modality, or the presence of associated diagnoses. CONCLUSION: In patients with ACS, the time to closure after fasciotomy is associated with the incidence of SSI. There seems to be a golden period for closure at 4 to 5 days after fasciotomy. The ability to close is often limited by multiple factors, but the correlation between time to closure and infection in this study suggests that it is worth exploring different closure methods if the wound cannot be closed primarily within the given timeframe.

Longitudinal Changes in Serum Markers of Bone Metabolism and Bone Material Strength in Premenopausal Women with Distal Radial Fracture.

BACKGROUND: Markers of bone metabolism (MBM) play an important role in fracture evaluation, and changes have been associated with increased fracture risk. The purpose of the present study was to describe changes in MBM in premenopausal women with distal radial fractures. METHODS: Premenopausal women with distal radial fractures (n = 34) and without fractures (controls) (n = 39) were recruited. Serum MBM in patients with distal radial fractures were obtained at the time of the initial presentation, 6 weeks, and 3, 6, and 12 months. MBM included 25(OH) vitamin D, PTH, osteocalcin, P1NP, BSAP, CTX, sclerostin, DKK1, periostin, and TRAP5b. Areal bone mineral density (aBMD) was assessed with dual x-ray absorptiometry, and the bone material strength index (BMSi) was assessed with microindentation. RESULTS: Most MBM reached peak levels at 6 weeks after the injury, including osteocalcin (+17.7%), sclerostin (+23.5%), and DKK1 (12.6%). Sclerostin was lower (-27.4%) and DKK1 was higher (+22.2%) at 1 year after the fracture. CTX declined below baseline levels at 6 and 12 months, whereas TRAP5b, BSAP, and periostin did not significantly change. At 12 months, sclerostin was lower (p = 0.003) and DKK1 was higher (p = 0.03) in the distal radial fracture group than in the control group. Greater fracture severity was associated with greater increases in P1NP and BSAP. aBMD and BMSi were not associated with fracture. CONCLUSIONS: Distal radial fractures caused increases in several MBM, which typically peaked at 6 weeks after injury and gradually decreased over 6 months. Sclerostin and DKK1 remained below and above baseline at 1 year, respectively. Increasing fracture severity resulted in larger changes in MBM. aBMD and BMSi did not discriminate between patients with distal radial fractures and controls. Continued efforts to identify markers of skeletal fragility in young women are warranted to mitigate future fracture risk. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Outcomes After Operative Fixation of Vancouver B2 and B3 Type Periprosthetic Fractures.

OBJECTIVES: The incidence of periprosthetic femur fracture in the setting of total hip arthroplasty is steadily increasing. Although the traditional dogma is that loose femoral components must be revised, we propose that in a frail geriatric population, anatomic reduction and fixation of Vancouver B2 and B3 periprosthetic fracture variants can restore stem stability and provide similar outcomes as revision arthroplasty. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center, tertiary academic medical center. PATIENTS/PARTICIPANTS: We identified 94 patients over 65 years of age with Vancouver B2 and B3 fractures sustained between 2005 and 2019. INTERVENTION: Patients were treated by either open reduction and internal fixation (ORIF) or revision arthroplasty (RA) with or without fixation. MAIN OUTCOME MEASUREMENTS: Outcomes were mortality, time to full weight-bearing after surgery, intraoperative estimated blood loss, perioperative complications, reoperation, subsidence rate, and Patient-Reported Outcomes Measurement Information System pain and physical function scores. RESULTS: A total of 75 (79.8%) ORIF and 19 (20.2%) RA patients were reviewed. One-year mortality for our cohort was 26.3%, and there was no significant difference between groups. Mean time to weight bear and surgical complication rates were similar between groups. The ORIF group had a significantly shorter time to surgery than the RA group. The RA group had greater incidence and amount of subsidence as well as estimated blood loss than the ORIF group. CONCLUSIONS: In geriatric patients with Vancouver B2 and B3 type periprosthetic fractures with known loose stems, ORIF may offer a similarly safe method of treatment than revision arthroplasty. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Radial Head Fractures Treated With the "Tripod Technique".

PURPOSE: For fractures requiring operative fixation, the "tripod technique" using headless compression screws has recently been described as a less invasive alternative to open reduction and internal fixation with plate and screws. The purpose of this study was to evaluate the clinical and radiographic outcomes of the tripod technique for the treatment of radial head and neck fractures. METHODS: We performed a retrospective chart review of all radial head and neck fractures treated with the tripod technique at our institution over a 10-year period. Patients with less than 6 months of follow-up were excluded. Outcomes were evaluated at the latest follow-up using range of motion measurements and the Quick Disabilities of the Arm, Shoulder and Hand questionnaire. RESULTS: We evaluated 13 patients with a mean age of 48 years and average follow-up of 72 months (range, 21-153 months). All the patients achieved union by 12 weeks after surgery. The average postoperative Quick Disabilities of the Arm, Shoulder and Hand score was 5.9 (range, 0-23). The mean flexion was 139°, and the mean extension was -8°. There were no major postoperative complications. Five patients had minor complications. No patients required a reoperation. CONCLUSIONS: The tripod technique is a useful alternative to the traditional method of plate and screw fixation for unstable radial head and neck fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Predictors of Management of Distal Radius Fractures in Patients Aged >65 Years.

BACKGROUND: Treatment of distal radius fractures (DRFs) in patients aged >65 years is controversial. The purpose of this study was to identify what patient and fracture characteristics may influence the decision to pursue surgical versus nonsurgical treatment in patients aged >65 years sustaining a DRF. METHODS: We queried our institutional DRF database for patients aged >65 years who presented to a single academic, tertiary center hand clinic over a 5-year period. In all, 164 patients treated operatively were identified, and 162 patients treated nonoperatively during the same time period were selected for comparison (total N = 326). Demographic variables and fracture-specific variables were recorded. Patient and fracture characteristics between the groups were compared to determine which variables were associated with each treatment modality (operative or nonoperative). RESULTS: The average age in our cohort was 72 (SD: 11) years, and 274 patients (67%) were women. The average Charlson Comorbidity Index (CCI) was 4.1 (SD: 2.1). The CCI is a validated tool that predicts 1-year mortality based on patient age and a list of 22 weighted comorbidities. Factors associated with operative treatment in our population were largely related to the severity of the injury and included increasing dorsal tilt (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.05-1.12; P < .001) and AO Classification type C fractures (OR, 5.42; 95% CI, 2.35-11.61; P < .001). Increasing CCI was the only factor independently associated with nonoperative management (OR, 0.84; 95% CI, 0.72-0.997; P = .046). CONCLUSION: Fracture severity is a strong driver in the decision to pursue operative management in patients aged >65 years, whereas increasing CCI predicts nonoperative treatment.

Revision Arthroplasty Versus Open Reduction and Internal Fixation of Vancouver Type-B2 and B3 Periprosthetic Femoral Fractures.

¼: Revision arthroplasty (RA) continues to be considered the gold standard in the surgical treatment of Vancouver type-B2 and B3 periprosthetic femoral fractures. However, open reduction and internal fixation (ORIF) has been associated with satisfactory outcomes. Thus, there is an ongoing discussion regarding the optimal surgical strategy for the treatment of these fractures. ¼: In this systematic review and meta-analysis, no significant differences in clinical and radiographic outcome were observed between ORIF and RA in the treatment of Vancouver type-B2 periprosthetic femoral fractures. ¼: ORIF of Vancouver type-B3 periprosthetic femoral fractures was associated with higher revision and reoperation rates than those after RA. ¼: Compared with RA, a significantly higher rate of subsidence was found in the ORIF group in Vancouver type-B2 periprosthetic femoral fractures whereas no significant difference in terms of loosening was observed. ¼: In the comparison of RA and ORIF for the treatment of Vancouver type-B2 and B3 fractures, the percentage of patients achieving full weight-bearing did not differ significantly. ¼: Mortality rates did not differ between RA and ORIF in the treatment of Vancouver type-B2 and B3 fractures. ¼: Overall complication rates did not differ between RA and ORIF in the treatment of Vancouver type-B2 and B3 fractures. ¼: We found a high heterogeneity in applied surgical and fixation techniques in the ORIF group.

What Is the Return on Investment of Spine Society Research Grants?

STUDY DESIGN: Retrospective, observational -study. OBJECTIVE: The objective of this study is to evaluate the return on investment (ROI) of the Cervical Spine Research Society (CSRS), Scoliosis Research Society (SRS), and North America Spine Society (NASS) grants as quantified by the number of publications generated and federal grants obtained (National Institute of Health [NIH], Department of Defense [DOD]). SUMMARY OF BACKGROUND DATA: The CSR, SRS, and NASS, have awarded numerous research grants over the past three decades. METHODS: Through publicly available data we identified grants awarded by the Spine Societies. We collected the type of grant awarded, the Principal Investigator information, dollar amount of the grant, number of publications in PubMed from each grant, number of citations, and the publication journal. The NIH and DOD website were queried to determine which grantees subsequently received either NIH or DoD funding. RESULTS: From 1989 to 2016: 81 (CSRS), 126 (SRS), and 93 (NASS) grants were awarded. From these grants 206 publications acknowledged receiving financial support from the spine societies. The SRS funded 100 papers, NASS 62 papers, and CSRS 44 papers. A total of 32 NIH grants and four DOD grants were subsequently awarded. The conversion rate to NIH grants was 15% (n = 12 CSRS), 7.9% (n = 10 SRS), and 11% (n = 10 NASS). The conversion rate to DOD grants was 3.7% (n = 3 CSRS), 0.8% (n = 1 SRS), and 0% (n = 0 NASS). ROI of spine society grant dollars per future NIH and DoD grants were the lowest for CSRS (Dollars Per NIH Grant: $207,434; Dollars Per DoD Grant: $829,734). Male investigators received 85% of CSRS grants, 75% of SRS grants, and 83% of NASS grants. CONCLUSION: CSRS grants appear to have the highest ROI of all spine society grants when evaluating subsequent NIH and DOD funding. However, the overall conversion rate to NIH and DOD grants remains low.Level of Evidence: 3.