Compartment Syndrome in Association with Tibial Plateau Fracture: Standardized Protocols Ensure Optimal Outcomes.

The purpose of this study was to report on the treatment, results, and longer-term outcomes of patients who sustained a tibial plateau fracture with an associated leg compartment syndrome (CS). A total of 766 patients who sustained 766 tibial plateau fractures met inclusion criteria. Fourteen patients (1.8%) were diagnosed with CS in association with a tibial plateau fracture during their initial hospitalization, 13 at the time of presentation and 1 delayed. The treatment protocol consisted of initial external fixation and fasciotomy, followed by irrigation and debridement, and eventual closure. Fasciotomy cases included 2/14 (14.3%) single incision approaches and 12/14 (85.7%) dual incision approaches. Operative treatment of the tibial plateau fracture was performed at the time of final closure or once soft tissues were permitted. One case of CS that developed following definitive fixation was treated with fasciotomy and delayed primary closure after initial stabilization. Ten (71.4%) were available at 1-year follow-up. We compared these 10 cases to the patients with operative tibial plateau fractures without CS to assess for surgical, radiographic, clinical, and functional outcomes. We used a propensity match based on age, body mass index, sex, Charleson comorbidity index, and fracture type to reduce the presence of confounding biases. Standard statistical methods were employed. Those in the CS cohort were younger males (p < 0.05). At latest follow-up, function did not differ between those in the CS group compared with the non-CS cohort (p > 0.05). Clinically, knee flexion (130.7 vs. 126; p = 0.548), residual depression (0.5 vs. 0.2; p = 0.365), knee alignment (87.7 vs. 88.3; p = 0.470), and visual analog scale pain scores (3.0 vs. 2.4; p = 0.763) did not differ between the cohorts. Although infection was higher in the CS cohort, the overall complication rates did not differ between the CS patients and non-CS cohort (p > 0.05). Early identification and standardized treatment protocols for the management of CS that develops in association with a tibial plateau fracture lead to outcome scores that were not significantly different from patients who did not develop CS.

A 65-Year-Old Female with Missed Open Clavicle Fracture and Subsequent Fracture-Related Infection, Treated with Distal Clavicle Resection.

Introduction: Open clavicle fractures are rare, and there are no current reported cases in the literature of a missed open clavicle with resultant fracture-related infection and osteomyelitis. Case Report: We present a 65-year-old female with no reported medical history, who presented to our institution with left clavicular pain and wound drainage 8 days after she was struck by a motor vehicle in her home country of Guyana. She was found to have a missed open clavicle fracture with an associated severe infection. She was subsequently treated with irrigation, debridement, and distal clavicle excision. Conclusion: We present this unique case with a potential procedure which could prove beneficial in cases of infection, trauma, or oncologic lesions in which the distal clavicle is deemed unsalvageable.

Effect of patient age on fifth metatarsal fracture pattern, management, and outcomes.

Patients with 5th metatarsal (MT) fractures encompass a broad age distribution. This study evaluated the impact of age on the differences in clinical outcomes and management of these fractures. This was a retrospective cohort study of patients presenting to a single large, urban, academic hospital system with a 5th MT fracture over a 10-year period. Patients were stratified into groups of younger than 65 years old and equal to or greater than 65 years old. Initial and successive radiographs were reviewed, and fractures were categorized as Zone 1, Zone 2, Zone 3, Shaft, Neck, or Head fractures. 2,461 patients with 5th MT fractures were evaluated. Patients who did not follow up after initial evaluation in the emergency department or urgent care were excluded. Among 2,020 patients with mean follow-up of 1.03 years who met inclusion criteria, 76.2% were younger than 65 years and 23.8% were greater than or equal to 65 years. There was a significant difference in fracture type between groups as older patients were more likely to sustain metatarsal neck fractures but less likely to sustain Zone 1 base fractures (p < 0.05). There was no difference in time to clinical healing (p = 0.108) or time to radiographic union (p = 0.367) for all fractures between age groups. In conclusion, older patients sustain different 5th metatarsal fracture patterns compared to younger patients. However, despite the differences in age, there was no evidence for any difference in clinical and radiographic outcomes between groups.

Chronic Preinjury Anemia Is Associated With Increased Risk of 1-Year Mortality in Geriatric Hip Fracture Patients.

INTRODUCTION: To assess whether a diagnosis of preexisting anemia impacts outcomes of geriatric hip fractures. METHODS: This is a retrospective comparative study conducted at a single, urban hospital system consisting of an orthopaedic specialty hospital, two level 1 trauma centers, and one university-based tertiary care hospital. Data of patients aged 55 years or older with a femoral neck, intertrochanteric, or subtrochanteric hip fracture (AO/OA 31A, 31B, and 32A-C) at a single hospital center treated from October 2014 to October 2023 were retrieved from an institutional review board-approved database. Patients were included if they had a hemoglobin measurement recorded between 6 and 12 months before hospitalization for their hip fracture. Patients were cohorted based on whether their hemoglobin values recorded anemic or not. Comparative analysis was conducted to analyze 1-year mortality, 30-day mortality, 30-day readmission, 90-day readmission, and inpatient major complications. RESULTS: Four hundred ninety-eight patients had hemoglobin values recorded at 6 to 12 months before their surgery in the electronic medical record. Two hundred seventy-three patients (54.8%) were considered anemic at that time, whereas 225 patients (45.2%) were not. Cohorts were markedly different regarding sex, Charlson Comorbidity Index, preinjury ambulatory status, and Score for Trauma Triage in Geriatric and Middle-Aged Patients (STTGMA) score (P < 0.05 for all). Multivariable analysis revealed that chronic preinjury anemia patients had a higher likelihood of 1-year mortality and a higher risk of major inpatient complication and 30- and 90-day readmission (P < 0.05 for all). CONCLUSION: Chronic preinjury anemia within 6 to 12 months before a hip fracture is associated with an increased risk of 1-year mortality, inpatient major complications, and 30- and 90-day readmission after hip fracture fixation. LEVEL OF EVIDENCE: Level III.

Evaluating the Severity Spectrum: A Hierarchical Analysis of Complications during Hip Fracture Admission Associated with Mortality.

OBJECTIVES: To determine which in-hospital complications following the operative treatment of hip fractures are associated with increased inpatient, 30-day and 1 year mortality. METHODS: Design: Retrospective study. SETTING: A single academic medical center and a Level 1 Trauma Center. PATIENT SELECTION CRITERIA: All patients who were operatively treated for hip fractures (OTA/AO 31A, 31B and Vancouver A,B, and C periprosthetic fractures) at a single center between October, 2014 and June, 2023. OUTCOME MEASURES AND COMPARISONS: Occurrence of an in-hospital complication was recorded. Cohorts were based upon mortality time points (during admission, 30-days and 1-year) and compared to patients who were alive at those time points to determine which in- hospital complications were most associated with mortality. Correlation analysis was performed between patients who died and those who were alive at each time point. RESULTS: A total of 3,134 patients (average age of 79.6 years, range 18-104 years and 66.6% female) met inclusion for this study. The overall mortality rate during admission, 30 days and 1 year were found to be 1.6%, 3.9% and 11.1%, respectively. Sepsis was the complication most associated with increased in-hospital mortality (OR: 7.79, 95% CI 3.22 - 18.82, p<0.001) compared to other in-hospital complications. Compared to other in-hospital complications, stroke was the complication most associated with 30-day mortality (OR: 7.95, 95% CI 1.82 - 34.68, p<0.001). Myocardial infarction was the complication most associated with 1-year mortality (OR: 2.86, 95% CI 1.21 - 6.77, p=0.017) compared to other in-hospital complications. CONCLUSIONS: Post-operative sepsis, stroke and myocardial infraction were the three complications most associated with mortality during admission, 30-day mortality and 1-year mortality, respectively, during the operative treatment of hip fractures. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Management of zone 2 fifth metatarsal fractures varies based on treating specialty.

Aims: This study evaluated the effect of treating clinician speciality on management of zone 2 fifth metatarsal fractures. Methods: This was a retrospective cohort study of patients with acute zone 2 fifth metatarsal fractures who presented to a single large, urban, academic medical centre between December 2012 and April 2022. Zone 2 was the region of the fifth metatarsal base bordered by the fourth and fifth metatarsal articulation on the oblique radiograph. The proportion of patients allowed to bear weight as tolerated immediately after injury was compared between patients treated by orthopaedic surgeons and podiatrists. The effects of unrestricted weightbearing and foot and/or ankle immobilization on clinical healing were assessed. A total of 487 patients with zone 2 fractures were included (mean age 53.5 years (SD 16.9), mean BMI 27.2 kg/m2 (SD 6.0)) with a mean follow-up duration of 2.57 years (SD 2.64). Results: Overall, 281 patients (57.7%) were treated by orthopaedic surgeons, and 206 patients (42.3%) by podiatrists. When controlling for age, sex, and time between symptom onset and presentation, the likelihood of undergoing operative treatment was significantly greater when treated by a podiatrist (odds ratio (OR) 2.9 (95% CI 1.2 to 8.2); p = 0.029). A greater proportion of patients treated by orthopaedic surgeons were allowed to immediately bear weight on the injured foot (70.9% (178/251) vs 47.3% (71/150); p < 0.001). Patients treated by podiatrists were immobilized for significantly longer (mean 8.4 weeks (SD 5.7) vs 6.8 weeks (SD 4.3); p = 0.002) and experienced a significantly longer mean time to clinical healing (12.1 (SD 10.6) vs 9.0 weeks (SD 7.3), p = 0.003). Conclusion: Although there was considerable heterogeneity among zone 2 fracture management, orthopaedic surgeons were less likely to treat patients operatively and more likely to allow early full weightbearing compared to podiatrists.

Under pressure: symptomatic pulmonary hypertension is a predictor of poor outcome following hip fracture.

INTRODUCTION: Pulmonary hypertension (PHTN) is associated with increased morbidity and mortality in noncardiac surgery and elective surgery. This population of patients has a low physiological reserve and is prone to cardiac arrest as a result. This study aims to identify the impact that PHTN has on outcomes among geriatric hip fracture patients. METHODS: A 3:1 propensity-score-matched retrospective case (PHTN)-control (no PHTN [N]) study of hip fracture patients from 2014 to 2022 was performed. Patients were matched utilizing propensity score matching of a validated geriatric trauma risk assessment tool (STTGMA). All patients were reviewed for hospital quality measures and outcomes. Comparative univariable and multivariable analyses were conducted between the two matched cohorts. A sub-analysis compared patients across PHTN severity levels (mild, moderate, severe) based on pulmonary artery systolic pressures (PASP) as measured by transthoracic echocardiogram. RESULTS: PHTN patients (n = 67) experienced a higher rate of inpatient, 30-day, and 1-year mortality, major complications, and 90-day readmissions as compared to the N cohort (n = 201). PHTN patients with a PASP > 60 experienced a significantly higher rate of major complications, need for ICU, longer admission length, and worse 1-year functional outcomes. Pulmonary hypertension was found to be independently associated with a 3.5 × higher rate of 30-day mortality (p = 0.016), 2.7 × higher rate of 1-year mortality (p = 0.008), 2.5 × higher rate of a major inpatient complication (p = 0.028), and 1.2 × higher rate of 90-day readmission (p = 0.044). CONCLUSION: Patients who had a prior diagnosis of pulmonary hypertension before sustaining their hip fracture experienced significantly worse inpatient and post-discharge outcomes. Those with a PASP > 60 mmHg had worse outcomes within the PHTN cohort. Providers must recognize these at-risk patients at the time of arrival to adjust care planning accordingly. LEVEL OF EVIDENCE: III.

Lateral Tibial Plateau Reconstruction Using Tricortical Iliac Crest Autograft as the Weight-Bearing Surface.

VIDEO AVAILABLE AT: https://ota.org/education/ota-online-resources/video-library-procedures-techniques/lateral-tibial-plateau.

Regional anesthesia is safe for use in intramedullary nailing of low-energy tibial shaft fractures.

PURPOSE: The purpose was to compare perioperative outcomes of patients who underwent general or regional anesthesia for intramedullary (IM) nailing of tibial shaft fractures (TSFs). METHODS: Retrospective chart review was performed on a consecutive series of low-energy TSF patients who presented to a single academic medical center and a level 1 trauma center who underwent operative repair with a reamed IM nail. Collected information included demographics, injury information, anesthesia type (general or regional i.e. peripheral nerve block), intra-operative opiate consumption (converted to morphine milliequivalents [MME], and post-operative pain visual-analog scale [VAS] pain scores. Patients were divided into 3 groups based on the type of anesthesia received and univariate analysis was performed to compare the 3 groups. RESULTS: Seventy-six patients were included, with an average age of 44.47±16.0 years. There were 38 (50 %) who were administered general anesthesia and 38 (50 %) who were administered regional anesthesia in the form of a peripheral nerve block. There were no differences between the groups with respect to demographics, medical co-morbidities, rate of open fractures or AO/OTA fracture classification. Regional anesthesia patients received less intra-operative MME than general anesthesia patients (17.57±10.6, 28.96±13.8, p < 0.001). Patients who received regional anesthesia also spent less time in the operating room, received less MME on post-operative day 1, and ambulated further on post-operative day 1, however none of these differences were statistically significant. There were no cases of missed post-operative compartment syndrome or complications related to the administration of the peripheral nerve block. CONCLUSIONS: Regional anesthesia in TSF surgery received less intra-operative opioid requirements, without any untoward effects. LEVEL OF EVIDENCE: Therapeutic Level III.

Osteonecrosis of the Humeral Head 3 Years Following Fracture Fixation of a 4-Part Proximal Humerus Fracture: A Case Report.

Introduction: Osteonecrosis (ON) of the humeral head is defined as "avascular" when the death of bone is due to a disrupted blood supply. It is a known complication following proximal humeral fractures and can lead to poor long-term outcomes and even additional revision surgeries. Case Report: Patient AP developed symptomatic ON, 3 years following repair of a 4-part valgus impacted proximal humerus fracture. The point of interest in this case is the length of time from injury at which she developed symptomatic ON. Following surgical repair, she was seen at standard intervals, 6 weeks, 3-, 6-, and 12- month follow-ups and demonstrated an excellent recovery. By the 1 year follow-up appointment, she had obtained a range of motion in her left shoulder of 170° forward elevation and 60° in external rotation. At this point, she was able to discontinue physical therapy and was radiographically and clinically healed. However, 2 years after, she began experiencing sudden onset of pain with shoulder ROM and progressive limitation. She was diagnosed with an ON of her proximal humerus. The patient was prescribed a 3-month course of corticosteroid, 3 months following her operation for a gynecological-related issue. However, with strong progress being made 9 months after this prescription, and problems occurring over 2 years after taking the medication, it is unclear whether the ON was related to her fracture pattern or developed as a result of the corticosteroid usage or a combination of the 2 due to a "double hit." Conclusion: This case review points out the potential need for continued monitoring even after radiographic and clinical healing is achieved in these injuries.

Classification of open tibia fractures: the rationale for a new classification system.

Open tibial shaft fractures are one of the most common long bone injuries encountered. Current existing classifications are designed to characterize the nature of the injury and guide clinical decision making. However, despite these advancements, there are areas in our current classification system that can be improved to not only make reliability more producible but also create prognostic factors that can help guide treatment.

Subtrochanteric Femur Fractures: The Association Between Obesity and Perioperative, Clinical, and Radiographic Outcomes.

OBJECTIVES: To evaluate the association between obesity and treatment approaches, perioperative factors, and clinical and radiographic outcomes following subtrochanteric fracture fixation. DESIGN: Retrospective Cohort. SETTING: Academic Medical Center. PATIENT SELECTION CRITERIA: Patients operatively treated for an AO/OTA 32Axa, 32Bxa, or 32Cxa subtrochanteric femur fracture. OUTCOME MEASURES AND COMPARISONS: Injury characteristics, perioperative parameters, fixation information, postoperative complications, and clinical and radiographic outcomes. Univariate analyses were conducted between the obese (BMI ≥30 kg/m2) and the nonobese (BMI <30 kg/m2) cohorts. Regression analyses were performed to assess BMI as a continuous variable. RESULTS: Of 230 operatively treated subtrochanteric fracture patients identified, 49 (21%) were obese and 181 (79%) were nonobese. The average age of the obese cohort was 69.6 ± 17.2 years, with 16 (33%) male and 33 (77%) female. The average age of the nonobese cohort was 71.8 ± 19.2 years, with 60 (33%) male and 121 (77%) female. Aside from BMI, there were no significant differences in demographics between the obese and nonobese (age [P = 0.465], sex [P = 0.948], American Society of Anesthesiology Score [P = 0.739]). Both cohorts demonstrated similar injury characteristics including mechanism of injury, atypical fracture type, and AO/OTA fracture pattern (32A, 32B, 32C). Obese patients underwent more open reduction procedures (59% open obese, 11% open nonobese, P < 0.001), a finding further quantified by a 24% increased likelihood of open reduction for every 1 unit increase in BMI (OR: 1.2, 95% CI, 1.2-1.3, P < 0.001). There was no difference in average nail diameter, 1 versus 2-screw nail design, or number of locking screws placed. The obese cohort was operated more frequently on a fracture table (P < 0.001) when compared with the nonobese cohort that was operated more frequently on a flat table (P < 0.001). There were no significant differences (P > 0.050) in postoperative complications, mortality/readmission rates, hospital quality measures, fixation failure, or time to bone healing. CONCLUSIONS: The treatment of subtrochanteric fractures in obese patients is associated with a higher likelihood of surgeons opting for open fracture reduction and the use of different operating room table types, but no difference was observed in postoperative complications, mortality or readmission rates, or healing timeline when compared with nonobese patients. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for delayed return to work following tibial shaft fracture surgery.

PURPOSE: To determine when patients return to work following operative repair of tibial shaft fractures (TSF) and what risk factors are associated with a delayed return to work (RTW), defined as greater than 180 days after operative repair. METHODS: Retrospective chart review was performed on a consecutive series of TSF patients who underwent operative repair. Time to RTW was based on documented work-clearance communications from the operating surgeon. Patients were divided into 3 groups based on when they returned to work: early (≤ 90 days), average (91-80 days), and late (≥ 180 days). Univariate analysis was performed, and significant variables were included in multinomial logistic regression. RESULTS: There were 168 patients identified. Eighteen were excluded (retired, unemployed, or never returned to work) leaving 150 patients. The average time to RTW for the overall study population was 4.17 ± 2.06 months. There were 39 (26.0%) patients in the early RTW group, 85 (56.7%) in the average RTW group, and 26 (17.3%) in the late RTW group. Patient with high-energy injuries (p = 0.024), open fractures (p = 0.001), initial external-fixation (p = 0.036), labor-intensive job (p = 0.018) and post-operative non-weight bearing status (p = 0.023) all had significantly longer RTW. Multinomial logistic regression including these parameters found a closed fracture was associated with a 1.9 decreased risk of delayed RTW (p = 0.004, 95% CI 0.039-0.533). CONCLUSIONS: Open fractures, initial external-fixation, restricted post-operative weight-bearing and labor-intensive jobs are associated with a delayed RTW following operative repair of TSFs. LEVEL OF EVIDENCE: Therapeutic Level III.

Psychiatric Diagnosis Does Not Influence Management or Resolution of Confirmed Fracture-Related Infection.

BACKGROUND: The purpose of this study was to determine if the presence of a standing Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, psychiatric diagnosis is associated with worse outcomes for patients who develop a confirmed fracture-related infection (FRI). MATERIALS AND METHODS: Included patients had open or closed fractures managed with internal fixation and had confirmed FRIs. Baseline demographics, injury information, and outcomes were collected via chart review. All patients who had a diagnosis of psychiatric illness, which included depression, bipolar disorder, anxiety disorder, and schizophrenia, were identified. Patients with and without a psychiatric diagnosis were statistically compared. RESULTS: Two hundred eleven patients were diagnosed with a confirmed FRI. Fifty-seven (27.0%) patients had a diagnosis of a psychiatric illness at the time of FRI diagnosis. Patients with a psychiatric diagnosis had a higher rate of smoking (56% vs 40%, P=.039) and drug use (39% vs 19%, P=.004) and a higher American Society of Anesthesiologists (ASA) classification (2.35±1.33 vs 1.96±1.22, P=.038); however, there were no other demographic differences. Clinical outcomes also did not differ between the groups, as patients with an FRI and a psychiatric diagnosis had a similar time to FRI diagnosis, similar confirmatory FRI characteristics, and a similar rate of reoperation. Furthermore, there was no difference between patients with FRI with and without a psychiatric diagnosis regarding rate of infection resolution (89% vs 88%, P=.718) or time to final follow-up (20.13±24.93 vs 18.11±21.81 months, P=.270). CONCLUSION: The presence of a psychiatric diagnosis does not affect clinical outcomes in the patient population with FRI. This is the first study exploring the impact of psychiatric illness on patient outcomes after a confirmed FRI diagnosis. [Orthopedics. 2024;47(4):198-204.].

"Off-Hour" Surgical Start Times Do Not Influence Surgical Precision and Outcomes in Middle-aged Patients and Patients 65 Years and Older With Hip Fractures.

BACKGROUND: Previous studies show the "off-hour" effect impacts outcomes after surgery in non-orthopedic settings. This study assessed if the off-hour effect impacts surgical precision and outcomes in middle-aged patients and patients 65 years and older with hip fractures. MATERIALS AND METHODS: All operative patients in an academic medical center's institutional review board-approved hip fracture registry were reviewed for demographics, hospital quality measures, operative details, radiographic parameters, and outcomes. Patients were grouped into standard (7 am to 4:59 pm) and off-hour (5 pm to 6:59 am) cohorts depending on surgical start time and comparative analyses were conducted. Two subanalyses were conducted: one comparing the quality of reduction for patients with intertrochanteric hip fractures and another comparing the rates of inpatient transfusion and postoperative dislocation for patients treated with arthroplasty. RESULTS: A total of 2334 patients underwent operative treatment. The off-hour cohort had hospital quality measures and outcomes similar to the standard cohort, including length of stay, rates of inpatient complication, mortality, and readmission. Sub-analysis of 814 intertrochanteric hip fractures demonstrated similar tip-apex distance, residual calcar step-off, and post-fixation neck-shaft angle, while subanalysis of 713 patients undergoing arthroplasty showed similar rates of transfusion and dislocation between cohorts. CONCLUSION: The time of day patients undergo hip fracture repair does not affect surgical outcomes or hospital quality measures. These results highlight the need for standardized hip protocols and treatment pathways to provide equitable care at all hours of the day. [Orthopedics. 2024;47(3):185-191.].

Clinical and Radiographic Healing of Nonoperative and Operative Treatment of Jones Fractures.

BACKGROUND: Significant heterogeneity in the classification and treatment of zone 3 proximal fifth metatarsal base fractures ("true Jones fractures") exists. This study compared time to clinical and radiographic healing between patients treated operatively and nonoperatively. We hypothesized that patients treated nonoperatively may demonstrate a greater time to clinical healing. METHODS: This was a retrospective cohort study of patients presenting to a large, urban, academic medical center with "Jones" fractures between December 2012 and April 2022. Jones fractures were defined as fifth metatarsal base fractures occurring in the proximal metadiaphyseal region, distal to the articulation of the fourth and fifth metatarsals on the oblique radiographic view. Clinical healing was the time point at which the patient had returned to their baseline ambulatory status with no tenderness to palpation. Radiographic healing was the presence of bridging callus across at least 3 cortices. RESULTS: A total of 2450 patients presented with fifth metatarsal fractures, and 166 fractures (6.8%) were true Jones fractures. Among patients with Jones fractures, 120 patients with 121 Jones fractures followed up at our institution and were included in the analysis (mean age 46.5 ± 18.5 years). Ninety-nine fractures (81.8%) were treated nonoperatively and 22 fractures (18.2%) operatively. There were no differences between nonoperative and operative groups in time to clinical healing (12.7 ± 7.1 vs 12.8 ± 4.8 weeks, P = .931) or radiographic healing (13.2 ± 8.1 vs 11.7 ± 5.9 weeks, P = .331). Overall healing rate was 96% for the nonoperative group compared with 96.2% for the operative group. CONCLUSION: In this study, nonoperative and operative treatment of true Jones fractures were associated with equivalent clinical and radiographic healing. The rate of delayed union in true Jones fractures was lower than previously described, and there was no difference in delayed union rate between nonoperative and operative management. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Periprosthetic fracture following arthroplasty for femoral neck fracture: is a cemented stem protective?

BACKGROUND: Periprosthetic femoral fractures (PFF) carry significant morbidity following arthroplasty for femoral neck fracture (FNF). This study assessed fracture complications following arthroplasty for FNF and the effect of cement fixation of the femoral component on intraoperative and post-operative PFF. METHODS: Between February 2014 and September 2021, 740 patients with a FNF who underwent arthroplasty were analyzed for demographics, surgical management, use of cement for fixation of the femoral component, and subsequent PFF. Variables were compared with Mann-Whitney or Chi-square as appropriate. Multivariate logistic regression was used to assess independent risk factors associated with intraoperative or post-operative PFF. RESULTS: There were 163 THAs (41% cemented) and 577 HAs (95% cemented). There were 28 PFFs (3.8%): 18 post-operative and 10 intraoperative. Fewer post-operative PFFs occurred with cemented stems (1.63% vs. 6.30%, p = 0.002). Mean time from surgery to presentation with post-operative PFF was 14 months (0-45 months). Mean follow-up time was 10.3 months (range: 0-75.7 months). In multivariate regression, use of cement and THA was independently associated with decreased post-operative PFF (cement: OR 0.112, 95% CI 0.036-0.352, p < 0.001 and THA: OR 0.249, 95% CI 0.064-0.961, p = 0.044). More intraoperative fractures occurred during THA (3.68% vs. 0.69%, p = 0.004) and non-cemented procedures (5.51% vs. 0.49%, p < 0.001). In multivariate regression, use of cement was protective against intraoperative fracture (OR 0.100, CI 0.017-0.571, p = 0.010). CONCLUSIONS: In patients with a FNF treated with arthroplasty, cementing the femoral component is associated with a lower risk of intraoperative and post-operative PFF. Choice of procedure may be based on patient factors and surgeon preference.

No difference in clinical and hospital quality outcomes in treatment of reverse obliquity intertrochanteric Hip fractures (AO/OTA 31.A3) based on Cephalomedullary nail length.

INTRODUCTION: The purpose of this study was to evaluate outcomes following reverse obliquity (RO) intertrochanteric hip fractures based on the use of short cephalomedullary nails (CMNs) compared to long CMNs for fixation. METHODS: An IRB-approved prospectively collected hip fracture registry at an urban academic medical center was queried for all AO/OTA 31A3.1-3 reverse obliquity intertrochanteric (RO) fractures. One hundred and seventy patients with age > 55 years old and minimum 6-month follow-up were identified for analysis. Data was collected for patient demographics, injury details, intraoperative radiographic parameters, perioperative physiologic parameters, hospital quality measures, and outcomes including radiographic time to healing, need for reoperation, nonunion, and mortality. Comparative analyses were conducted between cohorts. Additional multivariable binary logistic and linear regression analyses were performed to evaluate for factors independently associated with short and long nail usage. RESULTS: The mean age of the entire cohort was 80.91±10.09 years: 103 patients had a long CMN implanted, and 67 patients had a short CMN implanted. There were no demographic differences or differences in radiographic time to healing, rates of mortality, readmission, nonunion, and need for reoperation. Univariable analysis revealed that short CMN had lower intraoperative blood loss (111.19±83.97 mL vs 176.72±161.45 mL, p = 0.002), decreased need for transfusion (37% vs. 55 %, p = 0.022), and shorter procedures (118.67±57.87 min vs. 148.95±77.83 min, p = 0.002. Multivariable analysis revealed that short nail usage was associated with decreased intraoperative blood loss, decreased need for transfusion, and shorter operative times. CONCLUSION: Nail length does not affect healing or hospital quality outcomes in the treatment of RO hip fractures. The use of short CMNs for these fractures did correlate with lower intraoperative blood loss, operative time, and need for blood transfusion, with non-inferior outcomes and similar hospital quality measures when compared to long CMNs.

Pneumothorax After Superior Plating of Clavicle Fractures: Are the Concerns Warranted?

PURPOSE: The primary goal of this study was to determine the anatomic relationship between the clavicle and the apical lung segment. The secondary goal was to determine the incidence of pneumothorax (PTX) in patients who underwent clavicle ORIF to analyze the utility of postoperative chest radiographs. METHODS: Six hundred thirty-one patients with a midshaft clavicle fracture who underwent superior plating at a single institution were identified. Forty-two patients had a CT scan of the chest. Three points on the uninjured clavicle were defined: 2 cm from the medial end of the clavicle, the mid-point of the clavicle, and 2 cm from the lateral end of the clavicle. At each point, the distance from both the inferior cortex and the superior cortex of the clavicle to the apical lung segment was measured. All 631 patients who underwent Open Reduction and Internal Fixation had a postoperative chest radiograph to evaluate implant placement, restoration of clavicular length, and presence of PTX. RESULTS: From the lateral end of the clavicle, the mean distance of the lung was 60.0 ± 14.9 mm (20.1 to 96.1 mm) from the inferior cortex of the clavicle. At the mid-point, the mean distance of the lung was 32.3 ± 7.2 mm (20.4 to 45.5 mm) from the inferior cortex of the clavicle. At the medial end, the mean distance of the lung was 18.0 ± 5.5 mm (8.1 to 28.9 mm) from the inferior cortex of the clavicle. A review of postoperative radiographs for all 631 patients revealed none (0%) with a postoperative iatrogenic PTX. CONCLUSION: The risk of injury is minimal in all three zones. Postoperative chest radiographs after clavicle fracture repair to rule out PTX are unnecessary.

External fixation about the elbow: Indications and long-term outcomes.

Background: Operative management is often required for fractures of the elbow, with treatment goals aiming to restore stability, reduction, and early range of motion. The purpose of this study was to determine risk factors for necessitating the application of an external fixator, and to compare range of motion and functional outcomes between patients who required an elbow external fixator to those who did not. Hypothesis: We hypothesize that patients who require an external fixator will have worse elbow range of motion and functional outcomes when compared to those who did not. Patients and methods: This is a retrospective study of 391 patients who presented at a Level-I trauma center between March 2011 and January 2021 for operative management of a fracture/fracture-dislocation of the distal humerus (AO/OTA 13A-C) and/or proximal ulna and/or radius (AO/OTA 21A-C). A primary analysis was performed to determine risk factors for necessitating the application of an external fixator. A secondary analysis was performed comparing elbow range-of-motion and functional outcomes between cases and controls. Results: 391 patients were identified; 26 required external fixation (cases) and 365 did not (controls). Significant risk factors for necessitating placement of an external fixator included large BMI (OR = 1.087, 95 % CI = 1.007-1.173, p = 0.033), elbow dislocation (OR = 7.549, 95 % CI = 2.387-23.870, p = 0.001), open wound status (OR = 9.584, 95 % CI = 2.794-32.878, p < 0.001), and additional non-contiguous orthopaedic injury (OR = 9.225, 95 % CI = 2.219-38.360, p = 0.002). Elbow ROM was poorer in the external fixator group with regards to extension (-15°), flexion (+19.4°), and pronation (+14.3°) (p < 0.05). In addition, those who did not need external fixation had better functional scores (+20.4 points MEPI) (p < 0.05). Discussion: The use of external fixation about the elbow is associated with significantly worse initial injuries and results in poorer outcomes. These results can be used to inform the surgeon-patient discussion regarding treatment options and expected functional outcomes. Level of evidence: III.