Clinical Practice Guidelines in Action: Differences in Femoral Neck Fracture Management by Trauma and Arthroplasty Training.

INTRODUCTION: The purpose of this study was to survey trauma and arthroplasty surgeons to investigate associations between subspecialty training and management of geriatric femoral neck fractures and to compare treatments with the American Academy of Orthopaedic Surgeons clinical practice guidelines. METHODS: Five hundred fifty-six surgeons completed the online survey consisting of two sections: (1) surgeon demographics and (2) two geriatric hip fracture cases with questions regarding treatment decisions. RESULTS: In both clinical scenarios, arthroplasty surgeons were more likely than trauma surgeons to recommend total hip arthroplasty (THA) (case 1: 96% versus 84%; case 2: 29% versus 10%; P ≤ 0.02) and spinal anesthesia (case 1: 70% versus 40%; case 2: 62% versus 38%; P < 0.01). Surgeons who have made changes based on clinical practice guidelines (n = 96; 21% of surveyed) cited more use of THA (n = 56; 58% of respondents) and cemented stems (n = 28; 29% of respondents). CONCLUSION: Arthroplasty surgeons are more likely to recommend THA over hemiarthroplasty and have a higher expectation for spinal anesthesia for the management of geriatric femoral neck fractures.

A Novel Indirect Reduction Technique in Ankle Syndesmotic Injuries: A Cadaveric Study.

OBJECTIVE: To describe a novel technique using preoperative computed tomography (CT) to plan clamp tine placement along the trans-syndesmotic axis (TSA). We hypothesized that preoperative CT imaging provides a reliable template on which to plan optimal clamp tine positioning along the TSA, reducing malreduction rates compared with other described techniques. METHODS: CT images of 48 cadaveric through-knee specimens were obtained, and the TSA was measured as well as the optimal position of the medial clamp tine. The syndesmosis was then fully destabilized. Indirect clamp reductions were performed with the medial clamp tine placed at positions 10 degrees anterior to the TSA, along the TSA, and at both 10 and 20 degrees posterior to the TSA. The specimens were then separately reduced using manual digital pressure and palpation alone. CT was performed after each clamp and manual reduction. RESULTS: On average, reduction clamp tines were within 3 ± 2 degrees of the desired angle and within 5% ± 4% of the templated location along the tibial line for all clamp reduction attempts. Palpation and direct visualization produced the overall lowest malreduction rates in all measurements: 4.9% and 3.0%, respectively. Off-axis clamping 10 degrees anterior or 20 degrees posterior to the patient-specific TSA demonstrated an increased overall malreduction rate: 15.8% and 11.3%, respectively. Significantly more over-compression occurred when a reduction clamp was used versus manual digital reduction alone (8.6% vs. 0%). CONCLUSIONS: Reduction clamp placement directly along an optimal clamping vector can be facilitated by preoperative CT measurements of the uninjured ankle. However, even in this setting, the use of reduction clamps increases the risk for syndesmotic malreduction and over-compression compared with manual digital reduction or direct visualization.

Functional Outcomes of Syndesmotic Injuries Based on Objective Reduction Accuracy at a Minimum 1-Year Follow-Up.

OBJECTIVE: To evaluate whether objective syndesmosis reduction predicts functional outcomes and pain scores in patients with operatively treated syndesmotic injuries at a minimum 1-year follow-up. DESIGN: Prospective Cohort. SETTING: Urban Level I Trauma Center. PATIENTS: Sixty-nine patients with operatively treated syndesmotic injuries were initially identified and consented for inclusion in the study. Nine patients were excluded perioperatively. Twelve patients were lost to follow-up. Forty-eight patients with operatively treated unilateral syndesmotic injuries were available and participated at the final follow-up. INTERVENTION: Trans-syndesmotic stabilization with either 1 or 2 quadricortical position screws. Postoperatively, bilateral ankle computed tomography scans were obtained to objectively assess syndesmosis reduction accuracy. MAIN OUTCOME MEASUREMENTS: Olerud-Molander Ankle Score, Short Musculoskeletal Function Assessment Dysfunction Index and Bother Index, and Numeric Pain Rating Scales at a minimum 1-year postoperative follow-up. RESULTS: At 1-year follow-up, there was no significant difference in functional outcomes between reduced and malreduced groups at the 1.5-, 2-, and 3-mm thresholds for linear measurements. Similarly, there was no functional difference between the reduced and malreduced groups for rotational malreductions at a 10 or 15 degrees threshold. Patients with state-sponsored insurance (Medicaid) had significantly worse functional scores and pain scores when compared with the groups with private insurance, Medicare, or no insurance. CONCLUSIONS: At 1-year follow-up, functional outcomes were not related to objective measures of syndesmosis reduction. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Incisura Morphology as a Risk Factor for Syndesmotic Malreduction.

BACKGROUND: The goal of this study was to objectively assess if rotational or translational syndesmotic malreduction is associated with certain syndesmotic morphologies. Prior studies based on subjective assessment of syndesmotic morphology and reduction have not shown any difference between groups. METHODS: Thirty-five prospectively recruited patients with operatively treated syndesmotic injuries were recruited at an Urban Level I Trauma Center. Patients underwent postoperative bilateral computed tomographic (CT) scans of the ankle to assess incisura depth and syndesmotic reduction. The uninjured extremity was used as a control. Side-to-side differences of syndesmotic reduction were measured at several anatomic points and compared to the incisura depth. RESULTS: There was a significant correlation between more shallow syndesmoses and increased anterior translation of the fibula in the incisura (r = -0.63, P ≤ .001). Six of 8 patients with "shallow" (≤2.5 mm) incisura were anteriorly malreduced greater than or equal to 1.5 mm compared to the contralateral ankle. The anterior malreduction rate in those with a shallow incisura was significantly greater than in the "non-shallow" patients (P < .001). There were 9 patients with incisurae greater than or equal to 4.5 mm deep. Five of the "deep" patients had posterior malreductions greater than or equal to 1.5 mm. The posterior malreduction rate in the "deep" group was significantly greater than the "non-deep" patients (P = .02). There was a significant correlation between increasing syndesmotic depth and increased malrotation (r = .46, P = .01). CONCLUSION: Syndesmotic morphology was found to be associated with specific malreduction patterns. Shallow syndesmoses were correlated with anterior fibular malreduction, and were less likely to be malrotated. Conversely, deep syndesmoses predisposed to posterior sagittal plane and rotational malalignment. Preoperative CT scans that assess the syndesmosis morphology may allow surgeons to alter reduction strategies to avoid syndesmotic malreduction. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

In Vivo Syndesmotic Overcompression After Fixation of Ankle Fractures With a Syndesmotic Injury.

OBJECTIVES: The goals of this study were to assess syndesmotic reductions using computerized tomography and to determine whether malreductions are associated with certain injury types or reduction forceps. DESIGN: Prospective cohort. SETTING: Urban level 1 trauma center. PATIENTS: Twenty-seven patients with operatively treated syndesmotic injuries were recruited prospectively. INTERVENTION: Patients underwent postoperative bilateral computerized tomography of the ankle and hindfoot to assess syndesmotic reduction. The uninjured extremity was used as a control. MAIN OUTCOME MEASUREMENT: Side-to-side differences of the fibular position within the tibial incisura were measured at several anatomic points and analyzed based on injury type, the presence of posterior malleolar injury, level of fracture, and type of reduction forceps used. RESULTS: On average, operatively treated syndesmotic injuries were overcompressed (fibular medialization) by 1 mm (P < 0.001) and externally rotated by 5° (P = 0.002) when compared with the uninjured extremity. The absence of a posterior malleolar injury and Weber B (OTA 44-B) fractures seemed to have a protective effect against malrotation, but not against overcompression. There was no difference in malreduction based on the type of the clamp used. CONCLUSIONS: It is possible, and highly likely based on these data, to overcompress the syndesmosis when using reduction forceps. Care should be taken to avoid overcompression, as this may affect the ankle motion and functional outcomes. To our knowledge, this is the first in vivo series of syndesmotic overcompression. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.