Mini-Blade Plate to Obtain Length Across Lateral Malleolus Fractures: Surgical Technique and Biomechanical Evaluation.

Background: Restoration of fibular length is the main determinant in preventing mal-union and early ankle arthritis in lateral malleolus fractures. A 1/3 tubular plate fashioned into a mini-blade plate can be used to distract the distal fragment and achieve length in a controlled fashion over time. The purpose of this study was to describe the surgical technique and perform a biomechanical comparison of the blade plate to a locking plate. Methods: A 1/3 tubular plate is fashioned into a 135° blade plate. Blades are seated into the lateral malleolus and a distally directed force is applied on the plate to obtain length.A lateral malleolus fracture was created in 20 cadaveric ankles. The distal fragment was fixed with either a blade plate (BP, n = 10) or a locking plate (LP, n = 10). A distally directed force was applied by an Instron machine and fracture distraction, maximal load and construct stiffness were measured and compared. Results: The average maximal load was 262.06 N compared to 255.52 N for the BP and LP groups, respectively. The maximal distraction was 3.57 mm compared to 4.57 mm for the BP and LP groups, respectively. The loading pattern of the blade plate over time differed from that of a locking plate as the blades seat into bone. Conclusion: A 1/3 tubular mini-blade plate demonstrates biomechanical similarities in terms of load and distraction to the more expensive locking plate. We recommend using this technique for fractures with late presentation or with significant shortening. Level of Evidence: Level V-Mechanism-based reasoning.

Safe Zones for Cerclage Wiring of the Humeral Diaphysis.

Cerclage wiring of the humeral diaphysis entails particular danger to the radial nerve and the deep brachial artery. We sought to delineate safe zones for minimally invasive cerclage wiring of the humeral diaphysis, specifically in relation to the radial nerve and accompanying vasculature. Cerclage wires were percutaneously inserted into three groups of fresh-frozen cadaveric humeri. Group 1-proximal midshaft humerus at 30% of humeral height (n = 4); Group 2-midshaft spiral groove at 45% of humeral height (n = 4); and Group 3-distal midshaft humerus at 60% of humeral height (n = 4). Subsequently, an extensive surgical exploration of the arteries and nerves around the humerus was performed, noting any disturbance to the vessels or nerves and measuring the distance from the cerclage wire to the radial nerve. Neurovascular structures were injured in 75% of specimens when the cerclage wire was inserted at the level of the spiral groove. Both posterior structures, e.g. the radial nerve and the deep brachial artery, and medial structures, e.g., the median nerve and brachial artery, were incarcerated. Application of the cerclage at 30% or 60% of humeral height did not cause neurovascular injury. Minimally invasive application of the cerclage wire at the spiral groove, which is at 45% of humeral height, is likely to cause injury to neurovascular structures. Application of the cerclage at the proximal or distal midshaft humeral areas is associated with less risk of such injury. Clin. Anat. 33:552-557, 2020. © 2019 Wiley Periodicals, Inc.

Discriminative Ability for Adverse Outcomes After Surgical Management of Hip Fractures: A Comparison of the Charlson Comorbidity Index, Elixhauser Comorbidity Measure, and Modified Frailty Index.

OBJECTIVES: The Charlson comorbidity index (CCI), Elixhauser comorbidity measure (ECM), and modified frailty index (mFI) have been associated with mortality after hip fracture. The present study compares the clinically informative discriminative ability of CCI, ECM, and mFI, as well as demographic characteristics for predicting in-hospital adverse outcomes after surgical management of hip fractures. METHODS: Patients undergoing hip fracture surgery were selected from the 2013 National Inpatient Sample. The discriminative ability of CCI, ECM, and mFI, as well as demographic factors for adverse outcomes were assessed using the area under the curve analysis from receiver operating characteristic curves. Outcomes included the occurrence of any adverse event, death, severe adverse events, minor adverse events, and extended hospital stay. RESULTS: In total, 49,738 patients were included (mean age: 82 years). In comparison with CCI and mFI, ECM had the significantly largest discriminative ability for the occurrence of all outcomes. Among demographic factors, age had the sole or shared the significantly largest discriminative ability for all adverse outcomes except extended hospital stay. The best performing comorbidity index (ECM) outperformed the best performing demographic factor (age) for all outcomes. CONCLUSION: Among both comorbidity indices and demographic factors, the ECM had the best overall discriminative ability for adverse outcomes after surgical management of hip fractures. The use of this index in correctly identifying patients at risk for postoperative complications may help set appropriate patient expectations, assist in optimizing prophylaxis regimens for medical management, and adjust reimbursements. More widespread use of this measure for hip fracture studies may be appropriately considered. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Diabetes confers little to no increased risk of postoperative complications after hip fracture surgery in geriatric patients.

BACKGROUND: Diabetes and hip fractures in geriatric patients are common, and many elderly patients have a history of diabetes. However, the influence of diabetes on surgical complications may vary based on which particular type of diabetes a patient has. To our knowledge, no prior study has stratified patients with diabetes to compare patients with noninsulin-dependent and insulin-dependent diabetes regarding rates of postoperative adverse events, length of hospitalization, and readmission rate after surgical stabilization of hip fractures in geriatric patients. QUESTIONS/PURPOSES: We asked whether patients with noninsulin-dependent or insulin-dependent diabetes are at increased risk (1) of sustaining an aggregated serious adverse event, aggregated minor adverse event, extended length of stay, or hospital readmission within 30 days of hip fracture surgery; (2) of experiencing any individual serious adverse event within 30 days of hip fracture surgery; and (3) of experiencing any individual minor adverse event within 30 days of hip fracture surgery. METHODS: Patients older than 65 years undergoing surgery for hip fracture between 2005 and 2012 were identified (n = 9938) from the American College of Surgeons National Surgical Quality Improvement Program(®) database. This database reports events within 30 days of the surgery. Demographics were compared between three groups of patients: patients with noninsulin-dependent diabetes, patients with insulin-dependent diabetes, and patients without diabetes. Patients without diabetes served as the reference group, and the relative risks for aggregated serious adverse events, aggregated minor adverse events, length of stay greater than 9 days, and readmission within 30 days were calculated for patients with noninsulin-dependent and with insulin-dependent diabetes. We then calculated relative risks for each specific serious adverse event and minor adverse event using multivariate analyses. RESULTS: Patients with noninsulin-dependent and insulin-dependent diabetes were at no greater risk of sustaining an aggregated serious adverse event, aggregated minor adverse event, extended postoperative length of stay, or readmission. Among individual serious adverse events, only postoperative myocardial infarction was found to be increased in the diabetic groups (relative risk [RR] = 1.9 for noninsulin-dependent diabetes, 95% CI, 1.3-2.8; RR = 1.5 for insulin-dependent diabetes, CI, 0.9-2.6; p = 0.003). Patients with noninsulin-dependent and insulin-dependent diabetes were at no greater risk of sustaining any individual minor adverse event. CONCLUSIONS: Despite previously reported and perceived risks associated with diabetes, we found little difference in terms of perioperative risk among geriatric patients with hip fracture with noninsulin-dependent or insulin-dependent diabetes relative to patients without diabetes. Clinically, the implications of these findings will help to improve, specify, and increase the efficiency of the preoperative workup and counseling of patients with diabetes who need hip fracture surgery. LEVEL OF EVIDENCE: Level III, case-control study. See Instructions for Authors for a complete description of levels of evidence.

Postoperative length of stay and 30-day readmission after geriatric hip fracture: an analysis of 8434 patients.

OBJECTIVES: To identify factors associated with increased postoperative length of stay (LOS) and readmission after surgical repair of geriatric hip fractures. METHODS: Patients aged 70 years and older who underwent hip fracture surgery from January 2011 through December 2012 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patient characteristics were tested for association with postoperative LOS and readmission using bivariate and multivariate analyses. RESULTS: For the 8434 patients with hip fracture identified, the average age was 83.8 ± 5.9 years (mean ± SD), and 26.9% were male. Average postoperative LOS was 5.6 ± 6.0 days. Ten percent were readmitted within the first 30 postoperative days. Increased postoperative LOS of at least 1 full day was associated with increased time from admission to surgery, non-general anesthesia, and procedure type on multivariate analysis. Readmission was associated with increased age, male sex, body mass index ≥35 kg/m, American Society of Anesthesiologists class ≥3, pulmonary disease, hypertension, steroid use, dependent functional status, and discharge to a facility on multivariate analysis. CONCLUSIONS: Ten percent of patients were readmitted after hip fracture repair in this national sample. Preoperative time to surgery, anesthesia type, and implant selection are 3 risk factors for increased LOS that can potentially be modified. A clinically significant risk factor for readmission was body mass index ≥35 kg/m, which was not associated with increased postoperative LOS. The identified risk factors illuminate opportunities for optimizing care for hip fracture patients aged 70 and older. LEVEL OF EVIDENCE: Prognostic level II. See Instructions for Authors for a complete description of levels of evidence.

Haptic biofeedback for improving compliance with lower-extremity partial weight bearing.

After lower-extremity orthopedic trauma and surgery, patients are often advised to restrict weight bearing on the affected limb. Conventional training methods are not effective at enabling patients to comply with recommendations for partial weight bearing. The current study assessed a novel method of using real-time haptic (vibratory/vibrotactile) biofeedback to improve compliance with instructions for partial weight bearing. Thirty healthy, asymptomatic participants were randomized into 1 of 3 groups: verbal instruction, bathroom scale training, and haptic biofeedback. Participants were instructed to restrict lower-extremity weight bearing in a walking boot with crutches to 25 lb, with an acceptable range of 15 to 35 lb. A custom weight bearing sensor and biofeedback system was attached to all participants, but only those in the haptic biofeedback group were given a vibrotactile signal if they exceeded the acceptable range. Weight bearing in all groups was measured with a separate validated commercial system. The verbal instruction group bore an average of 60.3±30.5 lb (mean±standard deviation). The bathroom scale group averaged 43.8±17.2 lb, whereas the haptic biofeedback group averaged 22.4±9.1 lb (P<.05). As a percentage of body weight, the verbal instruction group averaged 40.2±19.3%, the bathroom scale group averaged 32.5±16.9%, and the haptic biofeedback group averaged 14.5±6.3% (P<.05). In this initial evaluation of the use of haptic biofeedback to improve compliance with lower-extremity partial weight bearing, haptic biofeedback was superior to conventional physical therapy methods. Further studies in patients with clinical orthopedic trauma are warranted.

Extramedullary compared with intramedullary implants for intertrochanteric hip fractures: thirty-day outcomes of 4432 procedures from the ACS NSQIP database.

BACKGROUND: For more than thirty-five years, the sliding hip screw, an extramedullary implant, has been the standard treatment for the stabilization of intertrochanteric fractures. Over the last decade, intramedullary implants have replaced extramedullary implants as the most commonly used type of implant in the United States for the treatment of this condition, without strong evidence of superior outcomes. METHODS: We conducted a retrospective cohort study with use of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Patients seventy years of age or older who had sustained an intertrochanteric fracture treated with extramedullary or intramedullary implant during 2009 to 2012 were identified. General surgical outcomes were compared between implant types, with adjustment for demographic data and comorbidities. RESULTS: A total of 4432 patients were identified; 1612 (36.4%) were treated with an extramedullary implant, and 2820 (63.6%) with an intramedullary implant. The rates of the composite outcomes "serious adverse events" and "any adverse events" did not differ by implant type. The mean postoperative length of stay was shorter for patients treated with an intramedullary implant compared with those treated with an extramedullary implant (5.4 compared with 6.5 days; p < 0.001). Operation time, operating room time, and the rate of hospital readmission did not differ by implant type. CONCLUSIONS: These results reinforce the results of previous randomized trials, demonstrating little difference in rates of general surgical adverse events between implant types. The present study presents an important departure from previous trials in its finding that patients treated with intramedullary implants have, on average, a shorter postoperative length of stay (by 1.1 days). The finding may negate the perceived excess cost associated with intramedullary treatment. Limitations regarding the ACS NSQIP database include a lack of detail regarding fracture subtype, outcomes beyond thirty days, and orthopaedic-specific outcomes.

Patient compliance with postoperative lower extremity touch-down weight-bearing orders at a level I academic trauma center.

After lower extremity fracture or surgery, physicians often prescribe limited weight bearing. The current study was performed to evaluate teaching and compliance of touch-down weight bearing (defined as 25 lb) at a level I academic trauma center. A survey was distributed to physical therapists (PTs) from the orthopedic ward to gauge their training methods and their confidence in patients' ability to comply. Patients with recommended touch-down weight bearing were then evaluated on the day of discharge and again at their first follow-up appointment using the SmartStep weight-bearing measurement device (Andante Medical Devices, Inc, White Plains, New York). Fifteen PTs completed the survey (average of 14 years in practice). Inconsistency was observed in weight-bearing teaching methods: verbal cues were used 87% of the time, tactile methods were used 41%, demonstration was used 23%, and a scale was used only 1%. Limited confidence was found in the instruction efficacy by those surveyed. Twenty-one patients were seen the day of discharge and 18 of those were seen at first follow-up. At discharge, average minimum and maximum weight bearing were 3.2 and 30.2 lb, respectively. Only 31% of steps were within an acceptable range of 15 to 35 lb. At first follow-up, average minimum and maximum weight bearing were 12.2 and 50.8 lb, respectively. Only 27% of steps were within the acceptable range. The majority of steps were less than the prescribed weight at discharge, whereas the majority of steps were greater than the prescribed weight at first follow-up. These data suggest that more uniform and effective teaching methods for prescribed weight-bearing orders are warranted assuming compliance is an important clinical objective.

Nationwide Inpatient Sample and National Surgical Quality Improvement Program give different results in hip fracture studies.

BACKGROUND: National databases are being used with increasing frequency to conduct orthopaedic research. However, there are important differences in these databases, which could result in different answers to similar questions; this important potential limitation pertaining to database research in orthopaedic surgery has not been adequately explored. QUESTIONS/PURPOSES: The purpose of this study was to explore the interdatabase reliability of two commonly used national databases, the Nationwide Inpatient Sample (NIS) and the National Surgical Quality Improvement Program (NSQIP), in terms of (1) demographics; (2) comorbidities; and (3) adverse events. In addition, using the NSQIP database, we identified (4) adverse events that had a higher prevalence after rather than before discharge, which has important implications for interpretation of studies conducted in the NIS. METHODS: A retrospective cohort study of patients undergoing operative stabilization of transcervical and intertrochanteric hip fractures during 2009 to 2011 was performed in the NIS and NSQIP. Totals of 122,712 and 5021 patients were included from the NIS and NSQIP, respectively. Age, sex, fracture type, and lengths of stay were compared. Comorbidities common to both databases were compared in terms of more or less than twofold difference between the two databases. Similar comparisons were made for adverse events. Finally, adverse events that had a greater postdischarge prevalence were identified from the NSQIP database. Tests for statistical difference were thought to be of little value given the large sample size and the resulting fact that statistical differences would have been identified even for small, clinically inconsequential differences resulting from the associated high power. Because it is of greater clinical importance to focus on the magnitude of differences, the databases were compared by absolute differences. RESULTS: Demographics and hospital lengths of stay were not different between the two databases. In terms of comorbidities, the prevalences of nonmorbid obesity, coagulopathy, and anemia in found in the NSQIP were more than twice those in the NIS; the prevalence of peripheral vascular disease in the NIS was more than twice that in the NSQIP. Four other comorbidities had prevalences that were not different between the two databases. In terms of inpatient adverse events, the frequencies of acute kidney injury and urinary tract infection in the NIS were more than twice those in the NSQIP. Ten other inpatient adverse events had frequencies that were not different between the two databases. Because it does not collect data after patient discharge, it can be implied from the NSQIP data that the NIS does not capture more than ½ of the deaths and surgical site infections occurring during the first 30 postoperative days. CONCLUSIONS: This study shows that two databases commonly used in orthopaedic research can identify similar populations of operative patients but may generate very different results for specific commonly studied comorbidities and adverse events. The NSQIP identified higher rates of morbid obesity, coagulopathy, and anemia. The NIS identified higher rates of peripheral vascular disease, acute kidney injury, and urinary tract infection. LEVEL OF EVIDENCE: Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Osteoporotic pelvic ring injuries.

As with most fractures associated with osteoporosis, the incidence of pelvic ring injuries in this population of patients is rising rapidly. Osteoporotic pelvic ring injuries are exceedingly different in their etiology, natural history, and treatment from the more recognizable patterns in young patients with high-energy pelvic ring injuries. Recognition of a potentially unstable fracture pattern, careful evaluation of the ambulatory and functional status of each patient before injury, and the potential pitfalls and benefits of operative versus nonoperative care are critical to the effective treatment.

Lower-extremity weight-bearing compliance is maintained over time after biofeedback training.

Previous studies have shown immediate compliance with weight-bearing instructions to be better after biofeedback training than after verbal or scale training. This study assessed retention of biofeedback training to determine potential clinical applicability. Twelve participants were enrolled in a prospective clinical study at an academic orthopedic center. Participants were trained with a biofeedback device to comply with touch-down weight-bearing instructions (25 lb). Immediately following the training session, weight bearing was assessed for each participant. The retention of this training was then reassessed at 2 to 4, 6 to 8, and 22 to 24 hours. Two control participants were given no biofeedback training (verbal instructions only) and were followed similarly. Following initial biofeedback training at 25 lb, participants bore an average of 20.4±2.12 lb. Retention tests during the 24-hour period showed no significant difference from the original testing, with 2- to 4-hour retention of 19.98±4.75 lb, 6- to 8-hour retention of 25.07±6.60 lb, and 22- to 24-hour retention of 21.75±4.58 lb. Participants who only received verbal instructions consistently bore several-fold greater weight than instructed. Biofeedback training has previously been shown to have a strong immediate effect on partial weight-bearing compliance. This study demonstrated that this effect lasts up to 24 hours. This maintained weight-bearing compliance after biofeedback training suggests that this method may be an effective way to train patients to comply with given instructions for limited weight bearing.

Effect of age on partial weight-bearing training.

Biofeedback devices are increasingly used to train orthopedic patients to comply with partial weight-bearing instructions for an injured or postoperative extremity. In a previous study, the authors showed that biofeedback was effective in training young participants. However, because many partial weight-bearing orthopedic patients are of advanced age, the current study was designed to test the effect of age on partial weight-bearing training. Fifty asymptomatic participants aged between 20 and 78 years completed 3 interventions: (1) verbal instructions on weight bearing, (2) training with a bathroom scale, and (3) training with a biofeedback device. Participants given only verbal touchdown weight-bearing instructions (25 lb) initially bore an average of 61.25±4.80 lb. This was reduced to 51.50±4.47 lb after training with a bathroom scale and further reduced to 30.01±2.33 lb after biofeedback training. Likewise, participants given verbal partial weight-bearing instructions (75 lb) initially bore an average of 89.06±5.58 lb. No improvement was observed with the use of a bathroom scale (average, 88.47±4.75 lb). After training with the biofeedback device, weight bearing improved to an average of 68.11±2.46 lb. Mixed-model analysis revealed that age was not a significant predictor of compliance. However, a higher body mass index and male sex were predictive of worse compliance and heavier weight bearing. Biofeedback training leads to superior compliance to weight-bearing instructions compared with verbal instructions or training with a bathroom scale. Because partial weight-bearing instructions are commonly given to orthopedic patients, biofeedback training may be appropriately considered in any age group with similar effect.

Current advances in training orthopaedic patients to comply with partial weight-bearing instructions.

Partial weight-bearing instructions are commonly given to orthopaedic patients and are an important part of post-injury and/or post-operative care. However, the ability of patients to comply with these instructions is poorly defined. Training methods for instructing these patients vary widely among institutions. Traditional methods of training include verbal instruction and use of a bathroom scale. Recent technological advances have created biofeedback devices capable of offering feedback to partial weight-bearing patients. Biofeedback devices have shown great promise in training patients to better comply with partial weight-bearing instructions. This review examines the background and significance of partial weight bearing and offers insights into current advances in training methods for partial weight-bearing patients.

Is it possible to train patients to limit weight bearing on a lower extremity?

Orthopedic patients are often instructed on how much weight to bear on an injured or postoperative extremity. Although specific weight-bearing instructions are given to a majority of lower-extremity orthopedic patients, the ability of patients to comply with these instructions is questioned in the medical literature. This study compared the effectiveness of new forms of clinical interventions designed to train patients on weight bearing, focusing on the use of biofeedback devices designed to offer real-time feedback to partial weight-bearing patients. Twenty healthy patients aged 20 to 30 years completed 3 interventions: (1) verbal instructions on weight bearing, (2) training with a bathroom scale, and (3) training with a biofeedback device.Patients given touchdown weight-bearing instructions (25 lb) initially bore an average of 63.57±6.24 lb when given verbal instructions. This was reduced to 44.75±5.69 lb after training with a bathroom scale (P<.001), and was further reduced to 26.2±1.57 lb with biofeedback training (P=.011). Likewise, patients given partial weight-bearing instructions (75 lb) initially bore an average of 92.28±7.85 lb. No improvement occurred with the use of a bathroom scale (at 75 lb), which showed an average of 90.82±7.19 lb (P=1.000). Training with a biofeedback device improved the average weight bearing to 69.67±3.18 lb (P=.014).Biofeedback training led to superior compliance with touchdown and partial weight-bearing instructions. Because partial weight-bearing instructions are commonly given to orthopedic patients, training with such a device may be appropriately considered.

Direct cellular vs. indirect pager communication during orthopaedic surgical procedures: a prospective study.

BACKGROUND: Cellular phone use within the hospital setting has increased as physicians, nurses, and ancillary staff incorporate wireless technologies in improving efficiencies, cost, and maintaining patient safety and high quality healthcare [11]. Through the use of wireless, cellular communication, an overall improvement in communication accuracy and efficiency between intraoperative orthopaedic surgeons and floor nurses may be achieved. METHODS: Both communication types occurred while the surgeon was scrubbed in the operating room (OR). Indirect communication occurred when the pager call was answered by the OR circulating nurse with communication between the surgeon, circulating nurse, and floor nurse. Direct communication consisted of cell phone and Jabra Bluetooth BT200 wireless ear piece used by the surgeon. The surgeon answered the floor nurse's cellular call by phone ring-activated automatic answering. The study was conducted during scheduled orthopaedic procedures. An independent observer measured time variables with a stop-watch while orthopaedic nurses randomly called via pager or cell phone. The nurses asked for patient caregiver confirmation and answers to 30 different patient-care questions. RESULTS: Sixty trials were performed with 30 cell and 30 page communications. Direct cellular communication showed a better response rate than indirect page (Cell 100%, Page 73%). Indirect page communication allowed a 27% and 33% error rate with patient problem and surgeon solution communications, respectively. There were no reported communication errors while using direct wireless, cellular communication. When compared to page communications, cellular communications showed statistically significant improvements in mean time intervals in response time (Cell = 11s, Page = 211s), correct patient identification (Cell = 5s, Page = 172s), patient problem and solution time (Cell = 13s, Page = 189s), and total communication time (Cell = 32s, Page = 250s) (s = seconds, all P < 0.001). Floor nurse satisfaction ratings (dependent on communication times and/or difficulties) were improved with direct cellular communication (Cell = 29 excellent, Page = 11 excellent). Intraoperative case interruptions (defined as delaying surgical progress) were more frequent with indirect page communication (10 page v. 0 cell). CONCLUSION AND SIGNIFICANCE: Our study demonstrates that direct wireless communication may be used to improve intraoperative communication and enhance patient safety. Direct wireless, cellular intraoperative communication improves communication times, communication accuracy, communication satisfaction, and minimizes intraoperative case interruption. As a result of this study, we hope to maintain our transition to direct wireless, cellular intraoperative orthopaedic communication to reduce medical errors, improve patient care, and enhance both orthopaedic surgeon and nursing efficiencies.

Technical tips in fracture care: fractures of the hip.

Hip fracture is an increasingly common and clinically significant injury with substantial economic impact. Associated risk factors are age, gender, race, bone density, activity level, and medical disorders. Prevention efforts include treatment of osteoporosis and programs to reduce the risks of a fall. Nondisplaced or impacted fractures of the femoral neck can be treated with screw fixation. Displaced femoral neck fractures in younger, more active patients may be treated with reduction and fixation. In physiologically older patients, joint arthroplasty is indicated for displaced fractures. In patients with systemic arthritis or preexisting hip disease, total hip arthroplasty may be an appropriate treatment choice. Intertrochanteric fractures are treated with reduction and fixation using either a sliding hip screw and side plate or intramedullary nail with cephalic interlock. Key technical points for successful outcomes include proper patient positioning, using a correct starting point for the nail, achieving acceptable reduction before fixation, and the use of various reduction techniques and aids.

Fractures of the calcaneus: a review with emphasis on CT.

The calcaneus is the most commonly fractured tarsal bone and accounts for about 2% of all fractures. Advances in cross-sectional imaging, particularly in computed tomography (CT), have given this modality an important role in identifying and characterizing calcaneal fractures. Fracture characterization is essential to guide the management of these injuries. Calcaneal fractures have characteristic appearances based on the mechanism of injury and are divided into two major groups, intraarticular and extraarticular. Most calcaneal fractures (70%-75%) are intraarticular and result from axial loading that produces shear and compression fracture lines. Of the two major systems for classifying intraarticular fractures-Hannover and Sanders-the latter is used most often and is helpful in treatment planning and determining prognosis. Extraarticular fractures account for about 25%-30% of calcaneal fractures and include all fractures that do not involve the posterior facet. The article describes in detail calcaneal anatomy, mechanism of calcaneal injuries and their associated fracture patterns, CT features of intra- and extraarticular fractures, and management implications. Familiarity with calcaneal anatomy and fracture patterns is essential for radiologists to guide the treating physicians.

Reducing complications in the surgical treatment of intertrochanteric fractures.

The increasing number of hip fractures in the elderly constitutes a health care burden. The subset of unstable intertrochanteric hip fractures is important because the treatment of these fractures continues to be hampered by a moderate complication rate. Osteoporosis, fracture geometry, and the success of surgical treatment are strong predictors of outcome. The surgeon is in control of fracture reduction, implant selection, and implant placement, all of which must be optimized to ensure the success of surgical intervention.

Unstable intertrochanteric hip fractures in the elderly.

Unstable intertrochanteric hip fractures account for approximately one quarter of all hip fractures in the elderly and are increasing in frequency. Treatment goals include immediate mobilization while limiting complications. Preoperatively, medical comorbidities should be identified and managed. For stable intertrochanteric hip fractures, consistently good results have been achieved with compression hip screw fixation. However, with more unstable fracture patterns, problems with compression hip screw fixation, such as excessive fracture collapse and implant cutout, increase. For these fractures, adding a trochanteric stabilizing plate or using an axial compression hip screw or intramedullary hip screw is warranted. Surgical care should maximize the patient's chance of a successful outcome by realigning the fracture with minimal additional surgical insult, selecting the appropriate implant, and positioning it properly.

Coronal fractures of the femoral condyle: a brief report of five cases.

Coronal fractures of the femoral condyle (Hoffa fractures) are uncommon injuries that have a better outcome when treated surgically. We report a series of five Hoffa fractures (including one nonunion) treated at a Level 1 trauma center by one surgeon employing a protocol of open reduction and internal fixation with lag screws through a formal parapatellar approach. Postoperatively, all patients began immediate unrestricted range of motion. Initial weight bearing was limited, but all patients were permitted full weight bearing by 10 weeks. All fractures healed within 12 weeks without complications. The final range of motion for the patients with acute fractures was at least 0 degrees to 115 degrees. The patient with a nonunion had a preoperative flexion contracture of 20 degrees and a final range of motion of 20 degrees to 125 degrees. Long-term follow-up (average 37 months, range 18-57 months) was available for 3 of the 5 patients, and Knee Society scores were calculated for these patients (average 173 of 200 points, range 160-180 points). The literature regarding the management of Hoffa fractures is reviewed.