Effect of Computerized Tomography on Assessment and Surgical Planning for Olecranon Fractures.

OBJECTIVES: (1) Determine effects of computed tomography (CT) on reproducibility of olecranon fracture classification. (2) Determine effects of CT utilization on interobserver agreement regarding management of olecranon fractures. (3) Evaluate factors associated with articular impaction. METHODS: Seven surgeons retrospectively evaluated radiographs of 46 olecranon fractures. Each fracture was classified according to Colton, Mayo, Orthopaedic Trauma Association/AO Foundation (OTA/AO) systems. Observers determined whether articular impaction was present and provided treatment plans. This was repeated at minimum 6 weeks with addition of CT. Descriptive and comparative statistics were performed and intraclass correlation coefficients (ICCs) were calculated. RESULTS: Interrater agreement was near-perfect for all classifications using radiographs (ICC 0.91, 0.93, 0.89 for Colton, Mayo, OTA/AO) and did not substantially change with CT (ICC 0.91, 0.91, 0.93). Agreement was moderate regarding articular impaction using radiographs (ICC 0.44); this improved significantly with CT (ICC 0.82). Articular impaction was significantly associated with OTA/AO classification, with high prevalence of impaction in OTA/AO 2U1B1e ( P < 0.03). Agreement was substantial for chosen fixation construct using radiographs (ICC 0.71); this improved with CT (ICC 0.79). Utilization of CT changed fixation plans in 25% of cases. Agreement regarding need for void filler was fair using radiographs (ICC 0.37); this notably improved with CT (ICC 0.64). CONCLUSIONS: Utilization of CT for evaluating olecranon fractures led to significant improvements in interobserver agreement for presence of articular impaction. Impaction was significantly associated with fracture pattern, but not with patient-related factors. Addition of CT improved agreement regarding fixation construct and led to notable improvement in agreement regarding need for void filler.

In-Hospital Morbidity and Mortality With Delays in Femoral Shaft Fracture Fixation.

OBJECTIVES: To investigate trends in the timing of femur fracture fixation in trauma centers in the United States, identify predictors for delayed treatment, and analyze the association of timing of fixation with in-hospital morbidity and mortality using data from the National Trauma Data Bank. METHODS: Patients with femoral shaft fractures treated from 2007 to 2015 were identified from the National Trauma Data Bank and grouped by timing of femur fixation: <24, 24-48 hours, and >48 hours after hospital presentation. The primary outcome measure was in-hospital postoperative mortality rate. Secondary outcomes included complication rates, hospital length of stay (LOS), days spent in the intensive care unit LOS (ICU LOS), and days on a ventilator. RESULTS: Among the 108,825 unilateral femoral shaft fractures identified, 74.2% was fixed within 24 hours, 16.5% between 24 and 48 hours, and 9.4% >48 hours. The mortality rate was 1.6% overall for the group. When fixation was delayed >48 hours, patients were at risk of significantly higher mortality rate [odds ratio (OR) 3.60; 95% confidence interval (CI), 3.13-4.14], longer LOS (OR 2.14; CI 2.06-2.22), longer intensive care unit LOS (OR 3.92; CI 3.66-4.20), more days on a ventilator (OR 5.38; CI 4.89-5.91), and more postoperative complications (OR 2.05; CI 1.94-2.17; P < 0.0001). CONCLUSIONS: Our study confirms that delayed fixation of femoral shaft fractures is associated with increased patient morbidity and mortality. Patients who underwent fixation >48 hours after presentation were at the greatest risk of increased morbidity and mortality. Although some patients require optimization/resuscitation before fracture fixation, efforts should be made to expedite operative fixation. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The relationship between glenoid inclination and instability following primary reverse shoulder arthroplasty.

PURPOSE: Despite advances in implant design and surgical technique, instability remains the most common early complication and reason for early revision after reverse shoulder arthroplasty (RSA). The purpose of this study is to evaluate the glenoid implant inclination, as measured by the ß-angle, as an independent risk factor for instability after primary RSA. METHODS: A retrospective case-control study was conducted matching cases with instability after primary RSA using a single implant to controls without instability. Controls were matched to age, sex, body mass index, and baseplate type (1:3 ratio of cases to controls). The preoperative, postoperative, and the change in pre- to postoperative glenoid inclination (ß-angle) were compared between groups. RESULTS: Thirty-four cases (mean age, 66.2 years) were matched to 102 controls (mean age, 67.0 years). There was a wide range of postoperative (63° to 100°) and pre- to postoperative change (-16.5° to +30.5°) in ß-angles collectively. There was no significant difference in the postoperative ß-angle (mean, 80.8° vs. 82.7°, P = .19) or the change in ß-angle (mean, +1.7° vs. +3.4°, P = .35) between cases and controls, respectively. Regression analysis demonstrated no increased odds of instability with the postoperative ß-angle, odds ratio 0.965 (confidence interval [CI] = 0.916-1.02, P = .19). Likewise, for the preoperative to postoperative change in ß-angle, there was no significantly increased odds of instability, odds ratio 0.978 (CI = 0.934-1.03, P = .35). Finally, there was no difference in risk of instability in patients whose implant positioning resulted in a net superior increase in inclination, relative risk 0.85 (95% CI = 0.46-1.56, P = .28). CONCLUSIONS: Neither the final prosthetic glenoid inclination nor the change in glenoid inclination, as measured by the ß-angle, significantly influences the risk of prosthetic instability after primary RSA.