Chiropractic Manipulation Causing Anterior-Posterior Compression Type Pelvic Ring Injury: A Case Report.

CASE: We present a case of an anteroposterior compression (APC) type pelvic ring injury that occurred after chiropractic manipulation in a patient with a history of quadriplegia. Emergent surgical stabilization was undertaken, and he had an excellent outcome with no complications at 3.5-year follow-up. CONCLUSION: APC type pelvic ring injuries usually occur to high-energy mechanisms. We describe a case of a patient with quadriplegia and osteopenia that suffered a pelvic ring injury because of a unique mechanism. Practitioners performing pelvic manipulation should be aware of this type of injury in at-risk patients.

Effectiveness of Flat-Panel Fluoroscopy in Direct Anterior Total Hip Arthroplasty: A Comparison to Image Intensifier Fluoroscopy With Radiopaque Grid.

Introduction: The use of traditional, image intensifier fluoroscopy with a radiopaque grid during direct anterior total hip arthroplasty (DA THA) has demonstrated reduced variability in component positioning and operative time compared to fluoroscopy without a grid. A disadvantage of image intensifier fluoroscopy is spatial distortion, particularly compared to flat-panel fluoroscopy systems. The purpose of this study is to determine whether flat-panel fluoroscopy decreases variability in component positioning during DA THA compared to the use of traditional grid fluoroscopy. Methods: We retrospectively reviewed 70 consecutive DA THAs between February 2020 and February 2021: 36 using flat-panel fluoroscopy, and 34 using traditional fluoroscopy with a grid. Radiographs were independently reviewed by 2 authors to identify components exceeding goal parameters: cup abduction of 40 ± 10 degrees, as well as offset and limb lengths within 10 mm of the contralateral side. Binary values for goal parameter achievement were assigned for each THA. Results: No significant difference was observed in the number of hips that met goals for cup abduction (100% vs 97%, P = 1.00), hip offset (88% vs 88%, P = 1.00), limb length (91% vs 94% [ ±10 mm], P = .669, 65% vs 72% [±5 mm], P = .498), or for the number of hips that met all 3 component goals (79% vs 80%, P = 1.00). No significant difference in operative time was noted between the 2 groups (110.2 minutes vs 100.9, P = .76). Conclusions: We demonstrated no significant difference in component positioning in DA THAs utilizing flat-panel fluoroscopy as compared to using traditional fluoroscopy with a grid.

The direct anterior approach for conversion to total hip arthroplasty after acetabular fixation is safe and effective.

INTRODUCTION: Total Hip Arthroplasty (THA) after prior acetabular fracture repair is known to be demanding as studies have shown inferior implant survival rates and higher infection rates for these procedures. The direct anterior (DA) approach might help mitigate some of these risks by utilizing a new surgical tissue plane. However, potential criticisms of the DA approach for these surgeries include the inability to access previous acetabular implants or heterotopic ossification (HO) if they were to inhibit implant placement. The goals of this study are to analyze the efficacy of the DA approach for conversion to hip arthroplasty surgery after previous acetabular fixation. METHODS: After reviewing all records at our institution using current procedural terminology codes, we isolated patients with previous acetabular repair who underwent conversion to THA through the DA approach. Patient records were reviewed, and patients were contacted to obtain Harris Hip Scores. RESULTS: 23 patients (16 males and 7 females) were found with a mean follow-up time of 46 months (range 16-156 months). The mean age was 50 (range 28 - 83) and mean BMI was 28.5 (range 15.2 - 39.2). The average blood loss was 400 ml (range 200 - 900). The average operative time was 140 min (range 85-200 min). In 7 cases (32%) implants were encountered during acetabular reaming but the implants were either removed entirely or removed partially with a burr so that the acetabular cup could be positioned within acceptable parameters. In 2 cases pre-operative HO was encountered and was resected. The average Harris Hip Score at final follow-up was 92 (range 75 - 100). There were no deep infections and no neurovascular injuries encountered. 2 patients (9%) underwent revision surgery for aseptic femoral stem loosening. There was 1 anterior dislocation (4.5%) at 3 days post-operatively that was successfully treated with closed reduction and maintenance of hip precautions. Otherwise, the remaining 19 (86%) patients went on to uncomplicated recovery. CONCLUSION: This is the largest known cohort analyzing the DA approach for conversion to hip arthroplasty after previous acetabular fixation. Overall, we demonstrate that the DAA is safe for conversion THA after acetabular fixation.

Positive Correlation Between Social Media Utilization by Orthopaedic Journals and Impact Factor.

INTRODUCTION: Social media use has exploded in popularity over the past decade with over 1.5 billion users on Facebook and 320 million users on Twitter. The aim of this study was to analyze the use of social media by orthopaedic journals and determine whether a relationship exists between social media followers and journal impact factor. METHODS: The Clarivate Analytics Impact Factor tool was used to identify all orthopaedic journals with a 2022 impact factor of greater than 1.5. We then conducted a query on Instagram, Twitter, LinkedIn, and Facebook to determine which programs had pages on each platform. RESULTS: Seventeen journals were included across all orthopaedic subspecialties. Of the 17 journals, 14 (82.4%) had a Facebook page, eight (47%) had an Instagram page, 15 (88.2%) had a Twitter account, and 8 (47%) had a LinkedIn profile. When compiling the number of followers by social media platform, Twitter had the most (177,543), followed by Facebook (149,388), Instagram (81,739), and LinkedIn (77,459). We found a significant correlation between the number of social media followers and journal impact factor (Pearson correlation coefficient [PCC] = 0.67; P = 0.003). When analyzing each social media platform independently, we found a significant correlation between the number of Facebook and Twitter followers and journal impact factor (PCC = 0.54; P = 0.02 and PCC = 0.80; P < 0.001, respectively). DISCUSSION: We have shown a notable association between the number of social media followers and a journal's impact factor. With the increasing shift toward online distribution, orthopaedic journals may use our data when evaluating their social media strategy to maintain and potentially increase their exposure and potentially their impact factor.

Fellowship-Trained Orthopaedic Trauma Surgeons Achieve Better Postoperative Radiographic Parameters After Intramedullary Nailing of Intertrochanteric Femur Fractures when Compared With Non-trauma-Trained Surgeons.

INTRODUCTION: Intertrochanteric femoral fractures are common orthopaedic injuries accounting for nearly 30% of all fracture-related hospitalizations. Because many factors predictive of failure are related to technical aspects of the surgery, the purpose of this study was to compare radiographic parameters after fixation, comparing fellowship-trained orthopaedic trauma surgeons with surgeons who did not complete an orthopaedic trauma fellowship. METHODS: We initiated a search for CPT code 27245 across our hospital network to identify 100 consecutive patients treated by five fellowship-trained orthopaedic traumatologists and 100 consecutive patients treated by community surgeons. Patients were then stratified based on their surgeon's subspecialty training (trauma vs community). Primary outcome variables were neck-shaft angle (NSA), a comparison of the repaired NSA with the uninjured side, tip-apex distance, and reduction quality. RESULTS: One hundred patients were included in each group. The mean age in the community group was 77 years compared with 79 years in the trauma group. The mean tip-apex distance for the trauma group was 10 mm compared with 21 mm for the community group ( P < 0.001). The mean postoperative NSA for the trauma group was 133° compared with 127° for the community group ( P < 0.001). The mean difference of the NSA of the repaired side compared with the uninjured side was 2.5° of valgus in the trauma group compared with 5° of varus for the community group ( P < 0.001). There were 93 good reductions in the trauma group compared with 19 in the community group ( P < 0.001). There were 0 poor reductions in the trauma group and 49 in the community group ( P < 0.001). DISCUSSION: Overall, we have shown that fellowship-trained orthopaedic trauma surgeons achieve better reductions when treating intertrochanteric femur fractures with intramedullary nails. Orthopaedic residency training should emphasize teaching proper techniques and acceptable parameters for reduction and implant placement when treating geriatric intertrochanteric femur fractures.

The Evolution of the Musculoskeletal Trauma Section of the Orthopaedic In-Training Examination.

INTRODUCTION: In 1963, the American Academy of Orthopaedic Surgeons administered the Orthopaedic In-Training Examination (OITE), the first and longest running yearly medical specialty examination. There have been no recent studies to evaluate the content of the musculoskeletal trauma section of the OITE. METHODS: We analyzed all questions that were classified by the American Academy of Orthopaedic Surgeons as musculoskeletal trauma from 2012 to 2019. We recorded the number of musculoskeletal trauma questions in each examination, the topics and imaging modalities tested, the references cited, and the taxonomy classification of each question. We extrapolated from a similar musculoskeletal trauma study published in 2011 to create the previous examination cohort for comparison. RESULTS: For the current cohort, the average number of musculoskeletal trauma questions was 43.5 questions per examination (18.4%). The most frequently tested topics were proximal tibia fractures, pediatric trauma, hip fractures, and diaphyseal femur fractures, respectively. In previous examinations, questions from T1 and 2 were tested significantly more frequently compared with the current examinations (P < 0.001 and P = 0.02, respectively). In the current cohort, T3 questions were tested significantly more frequently than previous examinations (P = 0.001). Previous examinations had significantly more questions without an image (36 questions per year versus 25 questions per year, P < 0.001). In current versions of the examination, radiographs are tested significantly more frequently than other imaging modalities (P < 0.001). DISCUSSION: The musculoskeletal trauma section of the OITE has evolved. To improve and focus study efforts, residents may use this study as a guide when preparing for the examination.

Retrograde Nailing for Extremely Proximal Fractures of the Femoral Shaft.

OBJECTIVES: To report the results of retrograde intramedullary nailing (RIMN) for the treatment of extremely proximal femur fractures. DESIGN: Retrospective cohort study. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: 63 patients with femoral shaft fractures involving the anatomic region within 10 centimeters of the inferior border of the lesser trochanter, which were treated with retrograde intramedullary nailing. INTERVENTION: Retrograde intramedullary femoral nail. MAIN OUTCOME MEASUREMENTS: Time to union, nonunion, malunion, and unplanned reoperation. RESULTS: Between 2009 and 2020, 63 fractures were followed up to fracture union, reoperation, or a minimum of 1 year clinically. The mean follow-up was 32 months, and 48 (76%) of the patients were followed up beyond 1 year clinically. The mean patient age was 34 years (range 18-84 years), and the mean BMI was 27 (range 14-45) kg/m 2 . Forty (64%) patients were polytraumatized. Clinical and radiographic union was achieved in 59 (94%) fractures after index operation at a mean time to union of 22 weeks (range 9-51 weeks). Delayed union requiring nail dynamization occurred in 1 (2%) instance. Malreduction was noted in 1 (2%) patient with a 12-degree flexion deformity that resulted in nonunion. In total, there were 3 (5%) nonunions requiring revision surgery, 1 treated with retrograde exchange nailing and 2 revised to cephalomedullary nails; all were united after revision. CONCLUSIONS: Retrograde intramedullary nailing can be an effective treatment strategy for extremely proximal femur fractures when necessary. Our series demonstrated a high rate of union and a low rate of malalignment and complications. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Treatment of Diaphyseal Tibial Fractures Distal to a Total Knee Arthroplasty by Intramedullary Nailing Is Safe and Effective.

OBJECTIVES: To report the clinical result of a series of patients who underwent intramedullary nailing (IMN) of tibial shaft fractures distal to a total knee arthroplasty (TKA). DESIGN: Retrospective case series. SETTING: Level-1 trauma center. PATIENTS/PARTICIPANTS: Patients who sustained a tibial shaft fracture distal to a TKA treated with an IMN. INTERVENTION: IMN of tibial shaft fractures distal to a TKA. MAIN OUTCOME MEASUREMENTS: Postoperative weight-bearing status, readmissions, and complications or failure of treatment within 90 days; Knee Injury and Osteoarthritis Outcome Scores at the final follow-up; failure of treatment; and revision surgery. RESULTS: Nine patients were included. The average age was 71.4 years (range 55-87 years). All TKAs were cemented. The average distance between the tibial keel and the cortical density of the tibial tubercle was 24.1 mm (range 19.5-26.7 mm). Six nails were inserted using an infrapatellar portal, 2 were inserted using a suprapatellar portal, and 1 was inserted using a lateral parapatellar approach. The median nail diameter was 10 mm (range 9-12 mm). All fractures were healed at the final follow-up. There were no infections or arthroplasty-related complications. Knee Injury and Osteoarthritis Outcome Scores ranged from 100% to 74% (median 82%). CONCLUSION: Overall, we report on the largest cohort in the literature undergoing IMN of a tibial shaft fracture distal to a TKA. We demonstrate that IMN of diaphyseal tibial fractures distal to a TKA can be performed safely. We additionally demonstrate that this treatment is highly effective in achieving fracture union with no arthroplasty-related complications. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Retrograde intramedullary nailing of comminuted intra-articular distal femur fractures results in high union rate.

PURPOSE: Retrograde intramedullary nailing of intra-articular distal femur fractures with metaphyseal and/or epiphyseal comminution is controversial and considered a contraindication to nailing. The purpose of this study was to report union rate, complications, and secondary procedures after open reduction and retrograde intramedullary nailing of comminuted, intra-articular, distal femur fractures. MATERIALS AND METHODS: A retrospective review performed at an urban level one trauma center identified 16 patients AO/Orthopedic Trauma Association (OTA) 33-C2 and 33-C3 femur fractures treated with open reduction, lag screws, and retrograde intramedullary nail fixation. Radiographic union, complications, secondary operations were reviewed. RESULTS: At the 3-month follow-up 12 (86%) of the 14 patients with radiographs had healed. At last follow-up, all 16 femur fractures achieved radiographic union after the index procedure. No patient required a revision procedure for delayed union or nonunion. Complications occurred in 6 (38%) patients, including failed distal interlocking screws (n = 2), knee arthrofibrosis (n = 3), superficial wound infection (n = 1), and wound dehiscence (n = 1). Three (19%) patients required secondary procedures, which included knee manipulation under anesthesia (n = 3), distal interlocking screw removal (n = 2), and closure of a wound dehiscence (n = 1). CONCLUSIONS: Comminuted intra-articular distal femur fractures that can be successfully treated with retrograde IMN fixation will reliably go on to union with a complication rate that is favorable to that reported for plate fixation. LEVEL OF EVIDENCE: Level IV, retrospective case-series.

Membrane-Inducing "Masquelet" Technique for Massive Traumatic Diaphyseal Femur Bone Loss in a Pediatric Patient: A Case Report.

CASE: A 14-year-old boy sustained 22 cm of femur bone loss after a motor vehicle accident. The patient underwent treatment with the membrane-inducing "Masquelet" technique for management of the injury. The grafts incorporated to form new bone and fill-in the void. CONCLUSION: Although the Masquelet technique is thoroughly described in adult orthopaedic trauma and oncology literature, there are minimal reports to support its use in pediatric patients. Five-year follow-up data on this patient concluded that utilization of this technique for significant bone defects proves to be a safe and effective alternative for the management of pediatric trauma patients.

Theme Park Water Slides: A New Mechanism of Causing 61B2.3 Pelvic Ring Injuries: A Case Series.

CASE: We present a series of 3 pelvic ring injuries that occurred on 1 high-speed water slide at a theme park in Orlando, FL. This is the first time this injury has been reported at a water park in the United States. All patients underwent surgical management and had an excellent outcome. CONCLUSION: Pelvic ring injuries usually occur because of high-energy mechanisms, but unique mechanisms of injuries are possible. We aim to draw attention to this unique mechanism of injury because serious injury may occur to riders. Water parks should use the information presented in this study to develop and refine safety requirements for patrons.

Long-Term Patient-Reported Knee Outcomes After Suprapatellar Intramedullary Tibial Nailing.

BACKGROUND: Suprapatellar nailing of tibial fractures has not been shown to affect short-term knee outcomes, however long-term outcomes are unknown. The purpose of this study was to report long-term patient-reported knee outcomes after suprapatellar nailing. METHODS: Thirty-five adult patients with 37 tibial shaft fractures treated with suprapatellar nailing completed the Tegner-Lysholm Knee Score (TLKS) at an average of 5 years (range, 4-9 years) follow-up. RESULTS: The median TLKS was 98 (interquartile range, 85-100): Scores were considered excellent in 24 (68%), good in 3 (9%), fair in 3 (9%), and poor in 5 (14%). Based on patient responses, 28 (80%) patients did not have a limp, 32 (91%) ambulated without assistance, 22 (63%) were pain free, 29 (83%) had no knee instability, 30 (86%) endorsed no catching or locking, 27 (77%) could climb stairs with no issue, and 24 (69%) had no problems with squatting. Patients with poor/fair outcomes on the TLKS were more likely to have had a complication [3 (38%) vs. 1 (4%), difference 34%, 95% confidence interval 1-65%] and had no detectable difference in age, gender, open fracture, fracture classification, or worker's compensation. CONCLUSION: At long-term follow-up a majority of patients undergoing suprapatellar nailing had good/excellent knee outcomes. Poor/fair knee outcomes were associated with the development of complications. LEVEL OF EVIDENCE: III, Retrospective cohort study.

Complications after fibula intramedullary nail fixation of pilon versus ankle fractures.

BACKGROUND: Intramedullary nail (IMN) fixation of the fibula in malleolar ankle fractures has been shown to result in less wound complications then plate fixation. Therefore, IMN fibula fixation may also be associated with lower rates of wound complications when used for higher-risk pilon fractures. The purpose of this study was to compare complications of fibula IMN fixation in pilon versus malleolar ankle fractures. METHODS: A retrospective cohort comparison was performed at an urban level one trauma center involving fibula fractures in 47 patients with AO/Orthopaedic Trauma Association (OTA) type 43 fractures and 48 patients with AO/OTA type 44 fractures being treated with fibula IMN fixation. Complications, fibula-specific complications, revision surgeries, and implant removals were reviewed. RESULTS: There was no detectable difference in complications (27% vs. 23%, 95% confidence interval of the odds ratio (CIOR) 0.5 to 3.2), fibular-specific complications (6% vs. 10%, CIOR 0.1 to 3.5), revision surgeries (4% vs. 4%, CIOR 0.1 to 7.5), or symptomatic fibula implant removals (13% vs. 21%, CIOR 0.1 to 1.6) between pilon and ankle fracture groups, respectively. There was one (2%) fibular nonunion and one wound complication (2%) in each of the fracture groups. CONCLUSION: Fibula IMN fixation of pilon versus ankle fractures resulted in a similar number of complications. Comparative studies of fibula IMN and plate fixation are necessary to determine if the benefits of fibula IMN in ankle fractures extends to pilon fractures. LEVEL OF EVIDENCE: Level III, retrospective cohort.

Comparison of standard versus reconstruction proximal interlocking screw configurations for antegrade intramedullary nail fixation of femoral shaft fractures.

BACKGROUND: The standard proximal interlocking screw (SS) configuration for antegrade intramedullary nail (IMN) fixation of femoral shaft fractures is lateral to medial or from the greater to less trochanter. Some authors argue for the routine use of the reconstruction screw (RS) configuration (oriented up the femoral neck) instead to prevent femoral neck complications. The purpose of this study was to compare a matched cohort of patients receiving these screw configurations and subsequent complications. METHODS: A retrospective review of two urban level-one trauma centers identified adults with isolated femoral shaft fractures undergoing antegrade IMN. Patients with RS and SS configurations were matched 1:1 by age, sex, fracture location, and AO classification in order to compare complications. RESULTS: 130 patients with femoral shaft fractures were identified. SS and RS configurations were used in 83 (64%) and 47 (36%) patients. 30 patients from each group were able to be matched for analysis. The RS and SS group did not differ in age, fracture location, AO classification, operative time, or number of distal interlocking screws. The RS group had fewer open fractures and were more likely to have two proximal screws. There were 7 complications, including 5 nonunions and 2 delayed unions, with no detectable difference between RS vs. SS groups (10% vs 13%, Proportional difference -3%, 95% confidence interval (CI) -30 to 14%, p = 0.1). There were no femoral neck complications in the entire cohort of 130 patients. On multivariate analysis none of the variables analyzed were independently associated with the development of complications. CONCLUSIONS: In this matched cohort of patients with femoral shaft fractures undergoing antegrade IMN fixation, RS and SS configurations were associated with a similar number of complications and no femoral neck complications. The SS configuration remains the standard for antegrade IMN femoral shaft fixation. LEVEL OF EVIDENCE: Level III, Retrospective cohort study.

Varus displacement of intertrochanteric femur fractures on injury radiographs is associated with screw cutout.

INTRODUCTION: The purpose of this study was to determine if varus displacement of intertrochanteric femur fractures on injury radiographs is associated with screw cutout after fixation. METHODS: A retrospective review performed at two urban level 1 trauma centers identified 334 patients with intertrochanteric femur fractures treated with either a cephalomedullary nail (CMN) or a sliding hip screw (SHS). Median patient age was 75 years, 69% were female and 46% had unstable fractures. Varus fracture displacement on injury radiographs, defined as the most proximal aspect of the femoral head being at or below the most proximal aspect of the greater trochanter, was present in 38% of patients. Screw cutout was recorded. RESULTS: Varus displacement was associated with unstable fracture patterns (62% vs. 37%, difference (D) 25%, 95% confidence interval (CI) 15-35%), female gender (77% vs. 64%, D 13%, CI 3-22%) and poor/adequate reductions (54% vs. 41%, D 13%, CI 2-23%). Cutout occurred in 9 (3%) patients, 8 of which had varus displacement. There was no detectable difference, with wide confidence intervals, between patients that did and did not experience cutout in terms of age, gender, unstable fractures, implants, tip-apex distance (TAD) or poor/adequate reductions. On univariate and multivariate analysis, varus displacement was the only variable associated with cutout. Patients with and without varus displacement had a cutout incidence of 6 and 0.5% (Odds ratio 13, CI 1.6-108). CONCLUSION: Intertrochanteric fractures presenting with varus displacement were more likely to experience cutout. This potential risk factor for cutout warrants further study. LEVEL OF EVIDENCE: Level 3, retrospective cohort.

An international survey of pelvic trauma surgeons on the management of pelvic ring injuries.

INTRODUCTION: There exists substantial variability in the management of pelvic ring injuries among pelvic trauma surgeons. The objective of this study was to perform a comprehensive survey on the management of pelvic ring injuries among an international group of pelvic trauma surgeons to determine areas of agreement and disagreement. METHODS: A 45-item questionnaire was developed using an online survey platform and distributed to 30 international pelvic trauma surgeons. The survey consisted of general questions on the acute management of pelvic ring injuries and questions regarding 5 cases: Lateral compression (LC) type 1 injury, LC-3, Anterior-posterior compression (APC) type 3 injury, a combined vertical shear (VS) injury through the sacrum, and VS injury through sacroiliac joint. Respondents were shown blinded anteroposterior pelvis radiographs and axial computed tomography (CT) images for each case and asked if the injury needed fixation, the type of fixation, the order of fixation, and postoperative weight-bearing status. The Kappa statistic was calculated to assess agreement between respondents for each question. RESULTS: Nineteen out of 30 pelvic trauma surgeons completed the survey. Respondents practiced in Brazil (n = 1), Germany (n = 1), India (n = 1), Italy (n = 1) United Kingdom (n = 1), and the United States (n = 14). Of the 45 questions in this survey, 38 (84%) had minimal to no agreement among the respondents. There was moderate agreement, for performing lumbopelvic fixation when indicated, for anterior and posterior fixation of the LC-3 injury, and on forgoing EUA or stress X-rays for the APC-3 injury. There was strong agreement for open reduction and internal fixation of the anterior pelvic ring in the APC-3 injury and the VS injury through the SI joint. In contrast, LC-1 injury and combined VS pelvic ring injury through the sacrum had no areas of moderate to strong agreement. DISCUSSION: This study identified specific areas of pelvic ring injury management with minimal to no agreement among pelvic trauma surgeons. Future research should target these areas with a lack of agreement to decrease practice variability and improve patient outcomes.

Medically Necessary Orthopaedic Surgery During the COVID-19 Pandemic: Safe Surgical Practices and a Classification to Guide Treatment.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has rapidly evolved as a viral pandemic. Countries worldwide have been affected by the recent outbreak caused by the SARS (severe acute respiratory syndrome)-CoV-2 virus. As with prior viral pandemics, health-care workers are at increased risk. Orthopaedic surgical procedures are common in health-care systems, ranging from emergency to elective procedures. Many orthopaedic surgical procedures are life or limb-saving and cannot be postponed during the COVID-19 pandemic because of potential patient harm. Our goal is to analyze how orthopaedic surgeons can perform medically necessary procedures during the pandemic and to help guide decision-making perioperatively. METHODS: We performed a review of the existing literature regarding COVID-19 and prior viral outbreaks to help guide clinical practice in terms of how to safely perform medically necessary orthopaedic procedures during the pandemic for both asymptomatic patients and high-risk (e.g., COVID-19-positive) patients. We created a classification system based on COVID-19 positivity, patient health status, and COVID-19 prevalence to help guide perioperative decision-making. RESULTS: We advocate that only urgent and emergency surgical procedures be performed. By following recommendations from the American College of Surgeons, the Centers for Disease Control and Prevention, and the recent literature, safe orthopaedic surgery and perioperative care can be performed. Screening measures are needed for patients and perioperative teams. Surgeons and perioperative teams at risk for contracting COVID-19 should use appropriate personal protective equipment (PPE), including N95 respirators or powered air-purifying respirators (PAPRs), when risk of viral spread is high. When preparing for medically necessary orthopaedic procedures during the pandemic, our classification system will help to guide decision-making. A multidisciplinary care plan is needed to ensure patient safety with medically necessary orthopaedic procedures during the COVID-19 pandemic. CONCLUSIONS: Orthopaedic surgery during the COVID-19 pandemic can be performed safely when medically necessary but should be rare for COVID-19-positive or high-risk patients. Appropriate screening, PPE use, and multidisciplinary care will allow for safe medically necessary orthopaedic surgery to continue during the COVID-19 pandemic. LEVEL OF EVIDENCE: Prognostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Lower Extremity Fractures: Tips and Tricks for Nails and Plates.

Lower extremity fractures, ranging from the proximal femur to the distal tibia, come in a variety of patterns and complexity. Treatment modalities typically consist of using plates and intramedullary nails; however, each has its advantages and disadvantages in each anatomic region. In this instructional course, salient points and nuances in setup and implant choice are reviewed. Furthermore, the essential tips and tricks to avoid pitfalls and achieve a desired clinical result are discussed.

Variables Associated With Lag Screw Sliding After Single-Screw Cephalomedullary Nail Fixation of Intertrochanteric Fractures.

OBJECTIVES: To evaluate variables associated with lag screw sliding after single-screw cephalomedullary nail (CMN) fixation of intertrochanteric femur fractures. DESIGN: Retrospective cohort study. SETTING: Level-one trauma center. PATIENTS/PARTICIPANTS: One hundred fifty-eight intertrochanteric fractures in patients older than 65 years with an average follow-up of 22 months. INTERVENTION: Single-screw CMN fixation. MAIN OUTCOME MEASUREMENTS: Lag screw sliding and revision surgeries. RESULTS: The average amount of lag screw sliding was 5 ± 5 mm (range, 0-21 mm). Lag screw sliding was greater with unstable fracture patterns (mean difference 2 mm, 95% confidence interval 0.4-3.5 mm, P = 0.01) and calcar gapping >4 mm (mean difference 3.7 mm, 95% confidence interval 2-5 mm, P < 0.01). No association was found between lag screw sliding and age, female gender, implants, long versus short nails, distal interlock screw use, postoperative neck-shaft angle, or tip-apex distance (P > 0.05). Revision surgeries were performed in 6 (4%) patients. Indications included symptomatic lag screw removal (n = 2), avascular necrosis (n = 1), cutout (n = 1), loss of reduction (n = 1), and perimplant fracture (n = 1). CONCLUSIONS: Unstable fracture patterns are unavoidable; however, careful attention to calcar reduction and selection of dual-screw CMN implants may minimize lag screw sliding and its detrimental effects on outcomes. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.