Arthroplasty Versus Internal Fixation for the Treatment of Undisplaced Femoral Neck Fractures: A Retrospective Cohort Study.

OBJECTIVE: To compare the 24-month risk of mortality between arthroplasty and internal fixation for undisplaced femoral neck fractures (FNFs). DESIGN: Retrospective cohort study. SETTING: Secondary data analysis of 2 multinational randomized controlled trials. PARTICIPANTS: Patients aged 50 years or older with a FNF. INTERVENTION: Arthroplasty (n = 1441), including total hip arthroplasty and hemiarthroplasty, performed for a displaced FNF versus internal fixation (n = 734), including sliding hip screw or multiple cancellous screws, performed for an undisplaced FNF. MAIN OUTCOME MEASUREMENT: The primary outcome was mortality within 24 months of injury. Secondary outcomes included reoperation and health-related quality of life. RESULTS: The 24-month mortality rate was 15.0% (n = 327). Arthroplasty was associated with a significant reduction in the odds of mortality [adjusted odds ratio (aOR): 0.56, 95% confidence interval (CI): 0.44-0.72, P < 0.01] compared with treatment with internal fixation. 11.4% (n = 248) of the study patients required reoperation within 24 months of injury. The odds of reoperation were 59% lower with arthroplasty treatment than with internal fixation (aOR: 0.41, 95% CI: 0.32-0.55, P < 0.01). The 24-month SF-12 physical component scores were 2.7 points higher in arthroplasty patients compared with internal fixation patients (95% CI: 1.6-3.8, P < 0.01). CONCLUSIONS: Our findings suggest arthroplasty for a FNF may reduce the risk of mortality and reoperation compared with internal fixation of undisplaced fractures. This finding is counter to many current surgical practices but consistent with a mounting body of evidence. Before widespread adoption of arthroplasty for undisplaced fractures, these results should be confirmed in a definitive comparative trial. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Valuing the Recovery Priorities of Orthopaedic Trauma Patients After Injury: Evidence From a Discrete Choice Experiment Within 6 Weeks of Injury.

OBJECTIVES: To determine the recovery priorities of extremity fracture patients during the subacute phase and the patient factors associated with variation in recovery priorities. DESIGN: Discrete choice experiment. SETTING: Academic trauma center. PATIENTS: One hundred ninety-eight patients with a fracture to the appendicular skeleton. Patients with severe traumatic brain injuries, spinal cord injuries, and non-English-speaking patients were excluded. MAIN OUTCOME MEASUREMENT: The relative importance of clinical recovery, work-related recovery, and obtaining disability benefits after injury. RESULTS: In the subacute period, clinical recovery was the main priority for fracture patients (mean: 62%, SD: 5.3). Work-related recovery (mean: 27%, SD: 3.9) and the receipt of other disability benefits (mean: 11%, SD: 6.4) were each of significantly less importance. Heterogeneity was observed across these estimates based on the physical demands of preinjury employment, preinjury physical health, preinjury work status, health insurance type, and the severity of the fracture. CONCLUSION: Clinical recovery was of paramount importance for fracture patients during the subacute recovery phase. However, patients also valued resuming work and access to disability benefits. Understanding a patient's recovery priorities early in the clinical care pathway will enable the development of multidisciplinary care plans that are responsive to these priorities and, hence, deliver value-based health care. LEVEL OF EVIDENCE: Level V. See Instructions for Authors for a complete description of levels of evidence.

Does an Implant Usage Report Card Impact Orthopaedic Trauma Implant Stewardship?

OBJECTIVES: As hospitals seek to control variable expenses, orthopaedic surgeons have come under scrutiny because of relatively high implant costs. We aimed to determine whether feedback to surgeons regarding implant costs results in changes in implant selection. METHODS: This study was undertaken at a statewide trauma referral center and included 6 fellowship-trained orthopaedic trauma surgeons. A previously implemented implant stewardship program at our institution using a "red-yellow-green" (RYG) implant selection tool classifies 7 commonly used trauma implant constructs based on cost and categorizes each implant as red (used for patient-specific requirements, most expensive), yellow (midrange), and green (preferred vendor, least expensive). The constructs included were femoral intramedullary nail, tibial intramedullary nail, long and short cephalomedullary nails, distal femoral plate, proximal tibial plate, and lower-limb external fixator. Baseline implant usage from the previous year was obtained and provided to each surgeon. Each surgeon received a monthly feedback report containing individual implant utilization and overall ranking. RESULTS: The overall RYG score increased from 68.7 to 79.1 of 100 (P < 0.001). Three of the 7 implants (tibial and femoral nails and lower-limb external fixation) had significant increases in their RYG scores; implant selections for the other 4 implants were not significantly altered. A decrease of 1.8% (95% confidence interval, 0.4-3.2, P = 0.01) was noted in overall implant costs over the study period. CONCLUSION: Our intervention resulted in changes in surgeons' implant selections and cost savings. However, surgeons were unwilling to change certain implants despite their being more expensive.

Femoral Neck Shortening After Hip Fracture Fixation Is Associated With Inferior Hip Function: Results From the FAITH Trial.

OBJECTIVE: To describe the distribution of femoral neck shortening after internal fixation and to determine whether shortening is associated with inferior hip function at 24 months after a hip fracture in patients 50 years of age or older. DESIGN: Retrospective cohort study. SETTING: A secondary analysis of data from 81 clinical centers included in the Fixation using Alternative Implants for the Treatment of Hip Fractures (FAITH) trial. PARTICIPANTS: Three hundred fifty patients, 50 years of age or older, who had an isolated femoral neck fracture and underwent timely operative fixation of the fracture. INTERVENTION: Femoral neck shortening was measured as a categorical variable and classified into one of the following groups, as determined by the Central Adjudication Committee: no shortening, mild shortening (≤5 mm), moderate shortening (6-10 mm), or severe shortening (>10 mm). MAIN OUTCOME MEASUREMENT: The primary outcome for the current analysis was hip function, as measured by the Western Ontario & McMaster Universities Osteoarthritis Index questionnaire, at 24 months after injury. RESULTS: Two-thirds of patients had no or mild shortening (≤5 mm), whereas one-third of patients had moderate or severe shortening (>5 mm). After adjusting for surgical treatment, a greater amount of femoral neck shortening was found to be associated with poorer hip function (P < 0.01). CONCLUSIONS: We found that increasing femoral neck shortening was associated with inferior hip function. Although internal fixation often results in successful union, patients who heal in a shortened position report poorer functional outcomes. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Incidence of Knee Pain Beyond 1 Year: Suprapatellar Versus Infrapatellar Approach for Intramedullary Nailing of the Tibia.

OBJECTIVE: To compare the magnitude of knee pain between the suprapatellar (SP) and infrapatellar (IP) approach for tibial nailing in patients who are more than 1 year after injury. DESIGN: Retrospective cohort study. SETTING: Academic Level I trauma center. PATIENTS/PARTICIPANTS: All tibia fracture patients 18-80 years of age treated with an intramedullary tibial nail during a 5-year period were retrospectively reviewed for inclusion. The surgical approach was determined by surgeon preference, with 3 of the 9 surgeons routinely using the SP approach. The primary outcome was knee pain during kneeling, with secondary assessments comparing knee pain during resting, walking, and the past 24 hours. INTERVENTION: Intramedullary nailing of a tibia fracture with either the SP or IP approach. MAIN OUTCOME MEASUREMENTS: Knee pain assessed with the Numeric Rating Scale between 0 and 10. A difference of >1.0 was considered to be clinically meaningful. RESULTS: The study group consisted of 262 patients (SP, n = 91; IP, n = 171) with a mean age of 41.4 years (SD = 16.6). The median follow-up was 3.8 years (range: 1.5-7.0). No difference in knee pain during kneeling was detected between the surgical approaches (IP: 3.9, SP 3.8; P = 0.90; mean difference: -0.06, 95% confidence interval, -1 to 0.9). Similarly, no differences were detected in average knee pain scores at rest (IP: 2.0, SP: 2.0; P = 1.00), walking (IP: 2.7, SP 3.0; P = 0.51), or the last 24 hours (IP: 2.6, SP 2.9; P = 0.45). CONCLUSIONS: In contrast to a study conducted by Sun et al, in which there was a statistical difference in knee pain between the SP and IP surgical approaches, we did not detect any statistical or clinical differences in knee pain between the SP and IP surgical approaches among patients with greater than 12 months of follow-up. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Variations in the Organisms Causing Deep Surgical Site Infections in Fracture Patients at a Level I Trauma Center (2006-2015).

OBJECTIVES: To quantify the current bacteriology of deep surgical site infections (SSIs) after fracture surgery at 1 institution and to compare those data with historical controls at the same institution, assessing variations in infecting organisms over the past decade. DESIGN: Retrospective review. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Two hundred forty-three patients requiring surgical intervention for deep SSI between January 2011 and December 2015 were compared with 211 patients requiring surgical intervention for deep SSI between December 2006 and December 2010. INTERVENTION: None. MAIN OUTCOME MEASUREMENTS: Bacteria were categorized as Staphylococcus aureus, coagulase-negative staphylococci (CoNS), Streptococcus, Enterococcus, gram-negative rods (GNR), gram-positive rods, anaerobes, or negative cultures. The proportion of each bacterial type was determined and compared with previously published data from the same trauma center (December 2006 to December 2010). RESULTS: Patients most commonly had S. aureus infections (48%), followed by GNR (40%) and CoNS (19%). The proportion of CoNS species (26% vs. 12%, P < 0.01) in infected patients was significantly higher during the current study period compared with historical controls. The proportion of S. aureus species in infected patients was significantly less during the current study period (39% vs. 56%, P < 0.01). The reduction in the proportion of S. aureus species in infected patients was driven by a decrease in the proportion of methicillin-resistant S. aureus (MRSA) in the overall sample. CONCLUSIONS: Bacteriology of deep SSI of fractures has changed substantially over the past decade at our center, specifically the proportions of GNR, CoNS, and MRSA. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Practical Guide to Delivering Surgical Skills Courses in a Low-Income Country: Knowledge Gained From a Surgical Education Partnership in Haiti.

Routine surgical skills training is known to advance a surgeon's technical proficiency. However, orthopaedic providers in low-income countries have limited access to skills training programs. International academic partnerships can augment locally available orthopaedic education, improving the quality of and capacity to deliver orthopaedic care in low-income countries. The objective of this study is to provide a practical guide to delivering an orthopaedic skills training course in a low-resource setting. The information provided is based on the experiences of the authors, along with specific feedback from previous course participants in Haiti.

Role of North-South Partnership in Trauma Management: Uganda Sustainable Trauma Orthopaedic Program.

Uganda, as do many low-middle income countries, has an overwhelming volume of orthopaedic trauma injuries. The Uganda Sustainable Trauma Orthopaedic Program (USTOP) is a partnership between the University of British Columbia, McMaster University and Makerere University that was initiated in 2007. The goal of the project is to reduce the disabilities that occur secondary to musculoskeletal trauma in Uganda. USTOP works with local collaborators to build orthopaedic trauma capacity through teaching, innovation, and research. USTOP has maintained a multidisciplinary approach to training, involving colleagues in anesthesia, nursing, rehabilitation, and sterile reprocessing. The project was initiated at the invitation of the Department of Orthopaedics at Makerere University and Mulago Hospital in Kampala. The project is a collaboration between Canadian and Ugandan orthopaedic surgeons and is driven by the needs identified by the Ugandan surgeons. The program has also worked with collaborators to develop several technologies aimed at reducing the cost of providing orthopaedic care without compromising quality. As orthopaedic trauma capacity in Uganda advances, USTOP strives to continually evolve and provide relevant support to colleagues in Uganda to ensure that changes result in sustainable improvements in patient care.

Risk Factors for Knee Stiffness Surgery After Tibial Plateau Fracture Fixation.

OBJECTIVE: To determine the risk factors for knee stiffness surgery after tibial plateau fixation. DESIGN: Retrospective observational cohort study. SETTING: Academic Level I trauma center. PATIENTS/PARTICIPANTS: A study group of 110 patients who underwent knee stiffness surgery (manipulation while under anesthesia, arthroscopic lysis of adhesion, or quadricepsplasty) at a time remote from open reduction and internal fixation of tibial plateau fractures and a control group of 319 patients with tibial plateau fractures treated with open reduction and internal fixation who did not undergo knee stiffness surgery and who had either a minimum of 1 year of follow-up or clearly documented range of motion ≥110 degrees with a minimum of 90 days of follow-up. INTERVENTION: Each case was assessed from the time of index admission through study event, end of minimum follow-up, or achievement of ≥110 degrees range of motion. MAIN OUTCOME MEASUREMENTS: Knee stiffness surgery. RESULTS: Total number of weeks in an external fixator (odds ratio, 1.5 per week; 95% confidence interval, 1.3-1.7; P < 0.001) and the presence of bilateral tibial plateau fractures (odds ratio, 3.3; 95% confidence interval, 1.2-9.1; P = 0.02) were significant predictors of knee stiffness intervention. CONCLUSION: Clinicians should be aware that the time spent in external fixation and the presence of bilateral tibial plateau injuries are strong risk factors for requiring subsequent surgery to treat knee stiffness. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Orthopaedic Trauma Association Annual Meeting Program Committee: Analysis of Impact of Committee Size and Review Process on Abstract Acceptance.

OBJECTIVE: To evaluate whether scientific abstracts selected for podium presentation at the Orthopaedic Trauma Association (OTA) Annual Meeting differ based on the program committee size and/or the proportion of abstracts each committee member evaluates. METHODS: Abstract scores from the Orthopaedic Trauma Association program committee from 2010 through 2016 were obtained. All members (range, 8-9) reviewed each clinical abstract (range, 506-778) each year in a blinded fashion. The 90 top-scoring abstracts were considered "accepted" for this study. To determine the effect of reducing the committee size, all possible combinations of reviewers for each possible committee size were modeled. To determine the effect of reducing the number of abstracts each member reviewed, we used Monte Carlo simulation with 100 cycles to generate possible combinations of 1-9 reviewers for each abstract. Mean percent agreement with the actual selection was the primary outcome. RESULTS: The mean percent agreement progressively declined from 90.2% with 1 less committee member to 56.7% with only a single reviewer. For each reduction in the number of committee members, 4.4% agreement was lost. If all committee members were retained but the number of reviewers per abstract was reduced from 8 to 1, the mean percent agreement declined from 88.8% to 43.0%. Each reduction in reviewers per abstract reduced the mean percent agreement 6.3%. CONCLUSION: The findings inform program committees striving to balance the trade-off between an acceptable reduction in agreement, given a reduction in the program committee size or the proportion of abstracts each committee member evaluates.

Is Lateral Femoral Nailing Associated With Increased Intensive Care Unit Days? A Propensity-Matched Analysis of 848 Cases.

OBJECTIVE: The purpose of this study is to determine if lateral patient position during femoral nailing is associated with increases in intensive care unit (ICU) length of stay (LOS) or ventilator days when compared with femoral nailing in a supine position. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Patients with femoral shaft fractures treated with intramedullary fixation were identified. Propensity matching was performed to minimize selection bias using factors thought to be associated with surgeon selection of supine nailing at our institution (Injury Severity Score, Abbreviated Injury Score brain, and bilateral fractures). After matching, 848 patients were included in the analysis. INTERVENTION: Femoral nailing in the lateral position compared with the supine position. MAIN OUTCOME MEASUREMENTS: Our primary outcome measure was ICU LOS. Ventilator days were the secondary outcome. RESULTS: Treating patients with femoral nailing in the lateral position was associated with a 1.88 days (95% confidence interval, 0.73-3.02; P = 0.001) reduction in ICU LOS in our adjusted model. Intramedullary nailing in the lateral position was associated with a 1.29 days (95% confidence interval, -0.12 to 2.69) decrease in postoperative time on a ventilator. However, this finding was not statistically significant (P = 0.07). CONCLUSION: Lateral femoral nailing was associated with decreased ICU LOS (P = 0.001) even after accounting for selection bias using propensity score matching. Our data indicate that lateral femoral nailing is likely not associated with the increased risk of pulmonary complication. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Prevalence of Depression and Posttraumatic Stress Disorder After Acute Orthopaedic Trauma: A Systematic Review and Meta-Analysis.

OBJECTIVES: This study aims to systematically assess the existing literature and to derive a pooled estimate of the prevalence of depression and posttraumatic stress disorder (PTSD) in adult patients after acute orthopaedic trauma. DATA SOURCES: A comprehensive search of databases, including MEDLINE, Embase, PsycINFO, and Cochrane Central Register of Controlled Trials databases was conducted through June 2015. STUDY SELECTION: We included studies that assessed the prevalence of depression or PTSD in patients who experienced acute orthopaedic trauma to the appendicular skeleton or pelvis. Studies with a sample size of ≤10 were excluded. DATA EXTRACTION: Two authors independently extracted data from the selected studies and the data collected were compared with verify agreement. DATA SYNTHESIS: Twenty-seven studies and 7109 subjects were included in the analysis. Using a random-effects model, the weighted pooled prevalence of depression was 32.6% (95% CI, 25.0%-41.2%) and the weighted pooled prevalence of PTSD was 26.6% (95% CI, 19.0%-35.9%). Six studies evaluated the prevalence of both depression and PTSD in patients with acute orthopaedic injuries. The weighted pooled prevalence of both depression and PTSD for those patients was 16.8% (95% CI, 9.0%-29.4%). CONCLUSIONS: Nearly one-third of patients suffer from depression and more than one-quarter of patients suffer from PTSD after an acute orthopaedic injury suggesting that strategies to address both the mental and physical rehabilitation after an orthopaedic injury should be considered to optimize patient recovery. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Developing Orthopaedic Trauma Capacity in Uganda: Considerations From the Uganda Sustainable Trauma Orthopaedic Program.

Uganda, like many low-income countries, has a tremendous volume of orthopaedic trauma injuries. The Uganda Sustainable Trauma Orthopaedic Program (USTOP) is a partnership between the University of British Columbia and Makerere University that was initiated in 2007 to reduce the consequences of neglected orthopaedic trauma in Uganda. USTOP works with local collaborators to build orthopaedic trauma capacity through clinical training, skills workshops, system support, technology development, and research. USTOP has maintained a multidisciplinary approach to training, involving colleagues in anaesthesia, nursing, rehabilitation, and sterile reprocessing. Since the program's inception, the number of trained orthopaedic surgeons practicing in Uganda has more than doubled. Many of these newly trained surgeons provide clinical care in the previously underserved regional hospitals. The program has also worked with collaborators to develop several technologies aimed at reducing the cost of providing orthopaedic care without compromising quality. As orthopaedic trauma capacity in Uganda advances, USTOP strives to continually evolve and provide relevant support to colleagues in Uganda.

Making Safe Surgery Affordable: Design of a Surgical Drill Cover System for Scale.

Many surgeons in low-resource settings do not have access to safe, affordable, or reliable surgical drilling tools. Surgeons often resort to nonsterile hardware drills because they are affordable, robust, and efficient, but they are impossible to sterilize using steam. A promising alternative is to use a Drill Cover system (a sterilizable fabric bag plus surgical chuck adapter) so that a nonsterile hardware drill can be used safely for surgical bone drilling. Our objective was to design a safe, effective, affordable Drill Cover system for scale in low-resource settings. We designed our device based on feedback from users at Mulago Hospital (Kampala, Uganda) and focused on 3 main aspects. First, the design included a sealed barrier between the surgical field and hardware drill that withstands pressurized fluid. Second, the selected hardware drill had a maximum speed of 1050 rpm to match common surgical drills and reduce risk of necrosis. Third, the fabric cover was optimized for ease of assembly while maintaining a sterile technique. Furthermore, with the Drill Cover approach, multiple Drill Covers can be provided with a single battery-powered drill in a "kit," so that the drill can be used in back-to-back surgeries without requiring immediate sterilization. The Drill Cover design presented here provides a proof-of-concept for a product that can be commercialized, produced at scale, and used in low-resource settings globally to improve access to safe surgery.