Hip external rotation and extension angles for exposure and preparation of the proximal femur in direct anterior total hip arthroplasty: A cadaveric study.

INTRODUCTION: The direct anterior approach (DAA) to total hip arthroplasty (THA) has a known learning curve, largely due to difficulty achieving exposure and visualization of the acetabulum and proximal femur for joint preparation. There is paucity of information on limb positioning and the degree of angulation at which the limb is positioned for adequate visualization. This study aimed to identify the mean angles of limb positioning necessary for adequate exposure when using two Mueller retractors for femoral preparation using traditional table. MATERIALS & METHODS: A surgeon performed a DAA THA on 11 cadaveric hemipelves, exposing the femoral canal with two simple, robust Mueller retractors. The degree of external rotation and extension of the hip was measured. RESULTS: Of the 11, the mean age was 77.6 years and mean BMI was 27.95. The mean external rotation angle was 56.5 ±â€¯13.5°. The mean extension angle was 19.9 ±â€¯6.6°. DISCUSSION & CONCLUSION: The key technical step in this study incorporated a second robust Mueller retractor on the posterior aspect of the greater trochanter, providing maximum leverage to deliver the femur and achieve visibility while reducing angles of limb positioning thereby reducing complications, and ultimately lessening the learning curve.

Anatomical structures at risk in the arthroscopic Broström-Gould procedure: A cadaver study.

BACKGROUND: The Broström Gould procedure is the gold standard for repair of lateral ankle ligament injury and ankle instability. This procedure has demonstrated excellent short- and long-term outcomes in the orthopedic literature. Arthroscopic Broström Gould techniques have become increasingly popular among some foot and ankle orthopedic surgeons. Typically, this technique requires standard anteromedial and anterolateral portals along with an accessory lateral working portal. The exact location of this portal is variable within the available described surgical techniques. The objective of this cadaveric study is to establish a standard entry point for and to assess the safety of the accessory lateral portal with respect to nearby anatomical structures. METHODS: Ten fresh-frozen below-knee cadaver specimens were used. The location of the accessory lateral portal was created 1.5 cm anterior to the distal tip of the fibula. A small vertical incision was made at this point, followed by insertion of a Kirschner wire into the joint. The wire was then gently impacted into the fibula. Superficial dissection was subsequently carried out around the entry point to identify the peroneal tendons, superficial peroneal nerve branches, and sural nerve branches. Structures were marked with colored push pins, and distance was measured between the nearest edge of the Kirschner wire and each of the three anatomic structures listed. Any instances of structural contact or damage were documented. RESULTS: The average distance from the Kirschner wire to the peroneal tendon was 16.1 (±4.41) mm. The average distance from the wire to the superficial peroneal nerve and sural nerve was 13.11 (±6.79) mm and 12.33 (±4.08) mm, respectively. There were no instances of injury to any of the studied structures. However, there was a notable amount of variability in the proximity of structures in question for each cadaver. A branch of the superficial peroneal nerve was measured as close as 2 mm and as far as 24 mm in separate cadaver specimens. CONCLUSION: Arthroscopic Broström Gould procedures are a safe and effective method for lateral ankle ligamentous repair but are not without risk. Accessory lateral portal placement is relatively safe but should be meticulously executed to avoid damage to nearby anatomical structures.

Anterior acetabular retractors and the femoral neurovascular bundle in anterior total hip arthroplasty: a cadaveric study.

PURPOSE: The direct anterior approach for primary total hip arthroplasty (THA) has become increasingly popular in recent years. Nerve compression or traction with a retractor is a common cause of nerve injury in this approach. The purpose of this cadaveric study was to evaluate the anatomic relationship of the femoral neurovascular bundle to the anterior acetabular retractor during direct anterior approach THA. METHODS: Eleven fresh-frozen cadavers underwent a standard direct anterior THA, with placement of an anterior acetabular retractor in the usual fashion between the iliopsoas and acetabulum for visualization during acetabular preparation. Careful dissection of the femoral triangle was performed, and the distances from the anterior retractor tip to the femoral nerve, artery, and vein were recorded and analyzed as mean distance ± standard deviation. RESULTS: In all 11 cadavers, the retractor tip was medial to the femoral nerve. The mean distance from retractor tip to femoral artery and vein was 5.9 mm (SD = 5.5, range 0-20) and 12.6 mm (SD 0.7, range 0-35), respectively. CONCLUSIONS: Surgeons should be aware of the proximity of the neurovascular structures in relation to the anterior acetabular retractor in the direct anterior approach, taking care to avoid perforating the iliopsoas muscle during retractor insertion and limit excessive traction to prevent nerve injury.

Do Geographic Region, Medicaid Status, and Academic Affiliation Affect Access to Care Among Medicaid and Privately Insured Total Hip Arthroplasty Patients?

BACKGROUND: Medicaid provides health coverage to those beneath the federal poverty line. The literature shows that patients with Medicaid experience barriers to scheduling initial and follow-up visits, although this has not been studied in patients undergoing total hip arthroplasty (THA). The purpose of this study is to assess whether insurance type, geographic location, Medicaid expansion, or academic affiliation affect access to evaluation for THA. METHODS: The American Academy of Orthopedic Surgeons directory was used to call a total of 100 practices. Five random private and 5 random academic medical facilities were called from each of 5 Medicaid-expanded and 5 non-expanded states representing different US geographic regions. Calls were made by an investigator requesting the earliest available appointment for their fictitious parent to be evaluated for a THA. Half of the calls were made with the investigator reporting private insurance of Blue Cross Blue Shield (BCBS), and half reporting Medicaid. Appointment success rate and average time to appointment were compared. Further comparisons were drawn among Medicaid-expanded vs non-expanded states, geographic regions, and private vs academic affiliation. RESULTS: Appointments were successful for 99 of 100 (99%) calls made with BCBS, and 72 of 100 (72%) with Medicaid (P < .001). Success rates were significantly higher for BCBS, regardless of academic vs private affiliation. In all geographic regions, appointment success rate was significantly lower with Medicaid than with BCBS (P ≤ .01). Average time to appointment was also significantly longer for Medicaid (26 days) than private (13 days) insurance (P = .020). In the Medicaid group, appointment success rate was significantly greater for academically affiliated practices compared to private practices (84.0% vs 60.0%, respectively; P = .008). CONCLUSION: Patients with Medicaid seeking consultation for THA experience limits in access to evaluation for THA when compared to patients with private insurance, regardless of geographic region or affiliation of the practice.

Outcomes of Inpatient Versus Outpatient Elective Foot and Ankle Surgery.

Background Complications following orthopedic surgeries are undesirable and costly. A potential method to reduce these costs is to perform traditionally inpatient surgical procedures in the outpatient setting. The purpose of this study is to compare outcomes between inpatient and outpatient settings for elective foot and ankle surgeries using the National Surgical Quality Improvement Program (NSQIP) database. Methods Patients with Current Procedural Terminology (CPT) codes specific to orthopedic foot and ankle surgery were identified from the 2011-2015 American College of Surgeons NSQIP database. Demographics, comorbidities, and complications were compared between patients undergoing inpatient and outpatient procedures. Results Patients receiving inpatient surgery were significantly older and more frequently male. Black patients were significantly more likely to undergo inpatient surgery than outpatient surgery while white patients were significantly more likely to undergo outpatient surgery. Outpatients had a significantly higher mean body mass index (BMI) than inpatients. Smokers were at a significantly greater risk of undergoing inpatient surgery than outpatient surgery. Outpatients had significantly longer operative times, were more likely to receive general anesthesia, had a lower American Society of Anesthesiologists (ASA) class, were more likely to be functionally independent, and were less likely to expire postoperatively. Patients who received surgery as an inpatient were significantly more likely to have comorbidities as compared to outpatients. The overall risk of surgical complications was significant between groups with 8.6% in the inpatient group and 2.0% in the outpatient group. The overall risk of medical complications was 16.9% in the inpatient group and 1.7% in the outpatient group. Similar to the surgical complications, inpatients were significantly more likely to sustain each of the individual medical complications except for stroke/CVA and venous thromboembolism. Conclusions Outpatient management is associated with decreased postoperative complications in select patients. Performing more operations in the outpatient setting in select patients may be beneficial for cost reduction and patient satisfaction.

A systematic review and meta-analysis of complications in conversion arthroplasty methods for failed intertrochanteric fracture fixation.

BACKGROUND: Conversion arthroplasty for failed primary fixation of intertrochanteric fractures can be achieved using various methods, including cemented total hip arthroplasty, uncemented total hip arthroplasty, hybrid total hip arthroplasty, and hemiarthroplasty. Complication rates vary between each conversion method. The purpose of this paper is to examine the effect of conversion method on total conversion complication rates. METHODS: We performed a meta-analysis of five studies with sufficient data for analysis. We created a null hypothesis stating that the expected distribution of complications across conversion methods would reflect the distribution of conversion method used for failed primary fixation. Using a z test, we compared proportions of the expected distribution of complications to the observed distribution of complications. RESULTS: A total of 138 cases of conversion arthroplasty with 49 complications were available for analysis. The mean age was 73 (range, 32-96) years. 19 males and 48 females were included, with one study not including patient gender. The mean time from primary fixation failure to conversion was 11 months, and the mean duration of conversion surgery was 132 min. Expected and observed complication rate distributions were as follows: cemented total hip arthroplasty, 6.5% versus 4.1% (p = 0.79); uncemented total hip arthroplasty, 77.5% versus 81.6% (p = 0.69); hybrid total hip arthroplasty, 2.9% versus 2.0% (p = 1); and hemiarthroplasty, 13% versus 12.2% (p = 1). CONCLUSIONS: Our findings suggest that the method of conversion arthroplasty following failed primary intertrochanteric femur fracture fixation does not influence complication rate.

Marijuana use and mortality following orthopedic surgical procedures.

Background: The association between marijuana use and surgical procedures is a matter of increasing societal relevance that has not been well studied in the literature. The primary aim of this study is to evaluate the relationship between marijuana use and in-hospital mortality, as well as to assess associated comorbidities in patients undergoing commonly billed orthopedic surgeries. Methods: The National Inpatient Sample (NIS) database from 2010 to 2014 was used to determine the odds ratios for the associations between marijuana use and in-hospital mortality, heart failure (HF), stroke, and cardiac disease (CD) in patients undergoing 5 common orthopedic procedures: total hip (THA), total knee (TKA), and total shoulder (TSA) arthroplasties, spinal fusion, and traumatic femur fracture fixation. Results: Of 9,561,963 patients who underwent one of the 5 selected procedures in the 4-year period, 26,416 (0.28%) were identified with a diagnosis of marijuana use disorder. In hip and knee arthroplasty patients, marijuana use was associated with decreased odds of mortality compared with no marijuana use (P < .0001) and increased odds of HF (P = .018), stroke (P = .0068), and CD (P = .0123). Traumatic femur fixation patients had the highest prevalence of marijuana use (0.70%), which was associated with decreased odds of mortality (P = .0483), HF (P = .0076), and CD (P = .0003). For spinal fusions, marijuana use was associated with increased odds of stroke (P < .0001) and CD (P < .0001). Marijuana use in patients undergoing total shoulder arthroplasty was associated with decreased odds of mortality (P < .001) and stroke (P < .001). Conclusions: In this study, marijuana use was associated with decreased mortality in patients undergoing THA, TKA, TSA, and traumatic femur fixation, although the significance of these findings remains unclear. More research is needed to provide insight into these associations in a growing surgical population.

A case example and literature review of catastrophic wear before catastrophic failure: identification of trunnionosis and metallosis in metal-on-polyethylene hip arthroplasty prior to frank failure or fracture.

Though rare, there are documented failures of femoral prosthesis due to corrosion of the head-neck interface in total hip arthroplasty (THA), a phenomenon known as trunnionosis. This wear can result in metallosis, whereby metal debris scatters the surrounding soft tissues. We present on a 58-year-old female who presented with increase in hip and back pain 10 years following right THA using a metal-on-polyethylene construct with a large femoral head (44 mm). Aspiration withdrew metallic fluid, and intraoperative findings showed corrosion of the head-neck taper with surrounding metallosis and pseudocapsule formation. Despite advances in THA design, corrosion and wear between components still exists and may be cause for failure. We present on both the subtle clinical findings and the recommended workup when suspicion is high for trunnionosis, metallosis, or wear, ideally with identification prior to catastrophic failure such as component dislocation or fracture as previously reported.

Impact of time to surgery from injury on postoperative infection and deep vein thrombosis in periprosthetic knee fractures.

PURPOSE: Periprosthetic fracture (PPF) is a serious complication that occurs in 0.3%-2.5% of all total knee arthroplasties used to treat end-stage arthritis. To our knowledge, there are no studies in the literature that evaluate the association between time to surgery after PPF and early postoperative infections or deep vein thrombosis (DVT). This study tests our hypothesis that delayed time to surgery increases rates of postoperative infection and DVT after PPF surgery. METHODS: Our study cohort included patients undergoing PPF surgery in the American College of Surgeons National Surgical Quality Improvement Program database (2006-2015). The patients were dichotomized based on time to surgery: group 1 with time ≤2 days and group 2 with time >2 days. A 2-by-2 contingency table and Fisher's exact test were used to evaluate the association between complications and time to surgery groups, and multivariate logistic regression was used to adjust for demographics and known risk factors. RESULTS: A total of 263 patients (80% females) with a mean age of 73.9 ± 12.0 years were identified receiving PPF surgery, among which 216 patients were in group 1 and 47 patients in group 2. Complications in group 1 included 3 (1.4%) superficial infections (SI), 1 (0.5%) organ space infection (OSI), 1 (0.5%) wound dehiscence (WD), and 4 (1.9%) deep vein thrombosis (DVT); while complications in group 2 included 1 (2.1%) SI, 1 (2.1%) OSI, 1 (2.1%) DVT, and no WD. No significant difference was detected in postoperative complications between the two groups. However, patients in group 2 were more likely (p = 0.0013) to receive blood transfusions (57.5%) than those in group 1 (32.4%). CONCLUSION: Our study indicates patients with delayed time to surgery have higher chance to receive blood transfusions, but no significant difference in postoperative complications (SI, OSI, WD, or DVT) between the two groups.

Correlation of Appointment Times and Subspecialty With the No-Show Rates in an Orthopedic Ambulatory Clinic.

EXECUTIVE SUMMARY: Unexpectedly missed appointments ("no-shows") cause clinic inefficiency, lost time and revenue, wasted healthcare resources, and provider dissatisfaction. No-shows can be associated with miscommunication, transportation difficulties, employment status, age, race, and socioeconomic status. This study investigates the association between no-show rates and patient, appointment time, and provider characteristics. Data for all scheduled appointments in a single orthopedic multispecialty institution during calendar year 2016 were obtained. Data points included patient age, gender, and race; hour; month; and subspecialty. Chi-square testing was used to compare no-show and kept appointments with respect to patient and appointment characteristics. Logistic regression was used to calculate differences in no-show rates between orthopedic subspecialties. The overall no-show rate was 11.5%. Race, age, and subspecialties were all found to be associated with higher no-show rates. No significant differences were observed for gender, appointment time, or month of appointment. The authors suggest that patients at higher risk of not showing up for scheduled appointments may need extra effort from providers to accommodate the patients' schedules when making appointments, to confirm their appointments a few days before, and/or to incentivize patients to minimize no-shows.

Risk Factors for Readmission Following Revision Total Hip Arthroplasty in Patients Undergoing Surgery for Noninfective Causes.

Introduction Readmission following revision orthopedic surgery imposes tremendous costs due to the increased length of stay, procedure complexity, and revision surgery. Following revision total hip arthroplasty, as many as one in five patients are readmitted postoperatively. Readmissions cost the federal government $17.4 billion annually. The purpose of this study was to identify risk factors for unplanned readmission following revision total hip arthroplasty. Methods This was a retrospective case series review of randomized revision total hip arthroplasties (THA) patients between 2008 and 2018. Exclusions were as follows: outside hospital revisions, staged revisions, revisions for infection, and bilateral revisions. Data were collected by manual chart review. Readmissions were tracked from discharge until the final follow-up. Results A total of 61 patients and 85 revision THAs were analyzed. Nineteen patients (31.1%) were readmitted; 31.6% of the readmitted patients had a coronary artery disease compared to 6.5% of non-readmitted patients. Readmission was also associated with obesity, former smokers, and hypertension. Also, the mean duration of follow-up was 26.5 months for readmitted patients as compared to 8.96 for non-readmitted patients. Conclusion Obesity, former tobacco use, younger age, coronary artery disease (CAD), and hypertension were associated with readmission. The medical optimization of patients with these risk factors prior to surgery could significantly lower costs relative to revision THA.

A Case Report of Revision Total Knee Arthroplasty After 17 Years: All Grown Up, What Happens When Implants Mature?

The number of total knee arthroplasties (TKAs) being performed annually is steadily rising. Recommendations for clinical follow-up guidelines following these arthroplasties is controversial, with no strict guidelines for long-term follow up. Although a few case series exist which identify a minority of patients who require revision TKA for aseptic loosening or pain more than 15 years after index surgery, no published studies have yet described these patients or the pathology present at the time of surgery in detail. We present the case of a patient who underwent revision TKA for pain and instability that developed 17 years after index surgery. Postoperative pathology revealed foreign body giant cell reaction of the tissue surrounding the previous implant. This case of revision after more than 17 years attempts to improve our understanding of long-term reactions to implants and highlights the necessity of long-term follow up in patients with TKA. It is one of the longest follow-ups of TKA reporting long-term anatomic changes at the bone cement interphase and around the implant.

Total hip arthroplasty for posttraumatic osteoarthritis following acetabular fracture: A systematic review of characteristics, outcomes, and complications.

PURPOSE: Posttraumatic arthritis (PTA) may develop years after acetabular fracture, hindering joint function and causing significant chronic musculoskeletal pain. Given the delayed onset of PTA, few studies have assessed outcomes of delayed total hip arthroplasty (THA) in acetabular fracture patients. This study systematically reviewed the literature for outcomes of THA in patients with PTA and prior acetabular fracture. METHODS: Pubmed, EMBASE, SCOPUS, and Cochrane library were searched for articles containing the keywords "acetabular", "fracture", "arthroplasty", and "post traumatic arthritis" published between 1995 and August 2017. Studies with less than 10 patients, less than 2 years of follow-up, conference abstracts, and non-English language articles were excluded. Data on patient demographics, surgical characteristics, and outcomes of delayed THA, including implant survival, complications, need for revision, and functional scores, was collected from eligible studies. RESULTS: With 1830 studies were screened and data from 10 studies with 448 patients were included in this review. The median patient age on date of THA was 51.5 years, ranging from 19 to 90 years. The median time from fracture to THA was 37 months, with a range of 27-74 months. Mean follow-up times ranged from 4 to 20 years. The mean Harris hip scores (HHS) improved from 41.5 pre-operatively, to 87.6 post-operatively. The most prevalent postoperative complications were heterotopic ossification (28%-63%), implant loosening (1%-24%), and infection (0%-16%). The minimum 5-year survival of implants ranged from 70% to 100%. Revision rates ranged from 2% to 32%. CONCLUSION: Despite the difficulties associated with performing THA in patients with PTA from previous acetabular fracture (including soft tissue scarring, existing hardware, and acetabular bone loss) and the relatively high complication rates, THA in patients with PTA following prior acetabular fracture leads to significant improvement in pain and function at 10-year follow-up. Further high quality randomized controlled studies are needed to confirm the outcomes after delayed THA in these patients.

Gastrocnemius recession for recalcitrant plantar fasciitis in overweight and obese patients.

BACKGROUND: Plantar fasciitis is a common foot pathology that is typically treated non-operatively. However, a minority of patients fail non-operative management, develop chronic symptoms, and request a surgical option. Gastrocnemius recession has recently been shown to be effective for the treatment of chronic plantar fasciitis. The purpose of this paper is to present evidence that gastrocnemius recession is safe and effective in the subset of chronic plantar fasciitis patients who are overweight and obese. METHODS: We retrospectively reviewed 18 cases (17 patients) of chronic plantar fasciitis in overweight or obese patients who underwent gastrocnemius recession (mean age=46years, mean body mass index=34.7kg/m2, mean follow-up=20months). Data was gathered regarding pre-operative and post-operative pain (visual analog scale, 0-10), Foot Function Index score, and complications. RESULTS: Mean Foot Function Index score improved from 66.4 (range, 32.3-97.7) preoperatively to 26.5 (range, 0-89.4) postoperatively (p<0.01). Mean pain score improved from 8.3 (range, 5-10) preoperatively to 2.4 (range, 0-7) at final follow-up (p<0.01). CONCLUSIONS: Gastrocnemius recession improved foot function and pain symptoms in overweight and obese patients with chronic plantar fasciitis.

Readmission Following Revision Total Knee Arthroplasty: An Institutional Cohort.

PURPOSE: Total knee arthroplasty (TKA) is the most common joint replacement surgery performed in the United States. Given the aging and increasingly comorbid patient populations undergoing these procedures, complication rates and the need for subsequent hospital readmission are only expected to rise. It is, therefore, crucial to investigate the risk factors leading to readmission in order to improve patient outcomes. The purpose of this study is to identify significant risk factors for readmission following revision TKA procedures. METHODS: Patients undergoing revision TKA were identified at our institution from 2006-2017. The primary outcome was hospital readmission after revision TKA. Patient demographics, comorbidities, and postoperative complications were recorded and compared between readmitted and non-readmitted patients. RESULTS: Forty-five (26.2%) of the 171 cases were readmitted following revision TKA. The leading diagnoses at readmission varied from arthrofibrosis in 28.9% of patients, implant infection in 22.2% of patients, and implant failure in 20.0% of patients. Male gender was found to be a significant independent variable for readmission. This study also found that 51.1% of all readmitted patients continued to have complaints that required additional hospital readmissions. The average number of total readmissions was 2.1 per readmitted patient. CONCLUSION: This study was successful in identifying variables associated with readmission following revision TKA, as well as presenting information regarding the diagnoses associated with readmission. Our data also showed that if a patient was readmitted after revision TKA, it was likely that they would be admitted again. Due to the increasing prevalence and cost of these procedures, further studies are needed to better understand the risk factors and comorbidities leading to readmission in order to improve the perioperative care of these patients.

Tibiotalocalcaneal Arthrodesis With Intramedullary Fibular Strut Graft With Adjuvant Hardware Fixation.

Tibiotalocalcaneal arthrodesis (TTCA) is a well-established operative procedure for different severe pathologic conditions of the ankle and hindfoot joints. We present our results with a modified technique of TTCA using an intramedullary fibular strut graft in a series of complex cases of patients treated for multiple etiologies shown to have improved union rates. The technique involves inserting the fibular strut graft intramedullary after joint preparation and the use of either a Taylor spatial frame or plate and screws for definitive fixation. We reviewed the records of 16 patients who had undergone TTCA with this technique at our hospital from September 2013 to April 2015. Sixteen patients (10 males [62.5%] and 6 females [37.5%]) were included in the present study. These patients had complex cases and multiple risk factors, including diabetes, smoking, poor bone stock, and a history of previous surgeries. The mean follow-up time was 9.1 (range 9 to 18) months. Thirteen patients (81.2%) subsequently achieved union. The mean visual analog scale scores at the final follow-up examination had improved from 6.9 to 1.2. We suggest that our technique of TTCA with intramedullary fibular strut graft with fixation is a reasonable option to salvage complex cases with risk factors for operative complications.

Gunshot-associated Fractures in Children and Adolescents Treated at Two Level 1 Pediatric Trauma Centers.

INTRODUCTION: Gunshot injuries are a potentially significant cause of morbidity and mortality in the pediatric population. The objective of this study was to evaluate the epidemiology, fracture locations, associated injuries, types of treatment, and complications of gunshot-associated fractures in children and adolescents treated at two level 1 trauma centers. METHODS: The clinical and radiographic records of all children and adolescents who had a gunshot-associated fracture treated at 1 of 2 level 1 pediatric trauma centers between January, 2005, and April, 2013, were reviewed. The following characteristics were recorded: patient age and sex, type of weapon, fracture location, presence of neurovascular injury or other associated injuries, antibiotic treatment, method of stabilization, duration of hospital stay, complications, and need for subsequent procedures. RESULTS: Forty-nine patients with 58 fractures were identified; 9 patients had multiple fractures. The 41 males and 8 females had an average age of 12.2 years (range, 1 to 18 y). The tibia and femur were the most common sites of fracture (19% each), followed by the small bones of foot (4%) and the fibula (4%). Most of the fractures (71%) were treated nonoperatively. Nearly half (47%) of the patients had additional injuries, including abdominal or genitourinary injuries, neuropraxia or nerve injuries, and vascular injuries. Two patients (4%) developed infections (1 superficial and 1 deep) that required multiple irrigation and debridement procedures. Three patients developed compartment syndrome, and 4 patients had vascular injuries requiring repair. Nearly a third of patients (35%) had fractures or complications that required additional operative procedures. CONCLUSIONS: This large retrospective study highlights the significant morbidity of fractures caused by gunshots. Although the overall infection rate was low and most of these fractures were successfully treated nonoperatively, many of the patients required an additional operative procedure and nearly half had additional nonorthopaedic injuries. This emphasizes the necessity of coordination among emergency, general surgeons, intensivist, and orthopaedic surgical teams. LEVEL OF EVIDENCE: Level IV­retrospective case series.

Epidemiology of Pediatric Fractures Presenting to Emergency Departments in the United States.

BACKGROUND: Fractures in children are an important public health issue and a frequent cause of emergency room visits. The purpose of this descriptive epidemiological study was to identify the most frequent pediatric fractures per 1000 population at risk in the United States using the 2010 National Electronic Injury Surveillance System (NEISS) database and 2010 US Census information. METHODS: The NEISS database was queried for all fractures in 2010 in children between the ages of 0 and 19 years. The NEISS national estimates were compared with the 2010 US Census data to extrapolate national occurrence rates. RESULTS: The annual occurrence of fractures increased from ages 0 to 14, peaking in the 10 to 14 age range (15.23 per 1000 children). The annual occurrence rate for the entire pediatric population (0 to 19 y) was 9.47 per 1000 children. Fractures of the lower arm (forearm) were the most common among the entire study population, accounting for 17.8% of all fractures, whereas finger and wrist fractures were the second and third most common, respectively. Finger and hand fractures were most common for age groups 10 to 14 and 15 to 19 years, respectively. The overall risk of a fracture occurring throughout childhood and adolescence was 180 per 1000 children, or just under 1 in every 5 children. CONCLUSIONS: Pediatric fractures represent a significant proportion of pediatric emergency department visits in the United States. Children between 10 and 14 years of age have the highest risk of having fractures. Overall, forearm fractures were the most common pediatric fractures. Most pediatric fractures can be treated on outpatient basis, with only 1 of 18 fractures requiring hospitalization or observation. LEVEL OF EVIDENCE: Level III-Retrospective comparative study.

Changes in the Treatment of Pediatric Femoral Fractures: 15-Year Trends From United States Kids' Inpatient Database (KID) 1997 to 2012.

BACKGROUND: The options for treating femoral fractures in children and adolescents have evolved over the last 2 decades to include a variety of nonoperative and operative methods. The purpose of this study was to identify changes in the types of treatment for pediatric femoral fractures in the United States from 1997 to 2012. METHODS: From discharge estimates for 1997, 2000, 2003, 2006, 2009, and 2012 in the Kids' Inpatient Database, data were extracted using the International Classification of Diseases, 9th revision, and Clinical Modification for pediatric femoral fracture treatments. Patients included were 0 to 17 years old and were categorized into 5 age groups: younger than 1, 1 to 4, 5 to 9, 10 to 14, and 15 to 17 years. RESULTS: A total of 74,483 estimated discharges were recorded for pediatric patients with femoral fractures in the database for years 1997, 2000, 2003, 2006, 2009, and 2012. A total of 12,986 pediatric femoral fractures were estimated for 1997 and 9813 for 2012, which was statistically different (P<0.0001). Significantly fewer fractures were treated with closed reduction alone in 2012 than in 1997 in age groups 5 to 9, 10 to 14, and 15 to 17 years. Children aged 5 to 9 had more frequent open reduction and internal fixation in 2012 than in 1997, whereas adolescents aged 15 to 17 had less frequent open reduction and internal fixation in 2012 than in 1997. CONCLUSIONS: Although the number of femoral shaft fractures overall has decreased, the frequency of operative treatment has increased significantly in patients 5 to 9 years of age. Knowledge of these trends can guide educational efforts and resource allocation, but further study is necessary to determine procedure-specific (eg, nailing, plating, external fixation) trends and their clinical and economic impacts. LEVEL OF EVIDENCE: Level III-case series.