External Fixator Usage and Delayed MRI Scans: A National Survey Study.

OBJECTIVE: To report the current state of institutional protocols regarding the use of MRI in patients with external fixation devices (EFDs) in the United States. DESIGN: National Survey Study. PARTICIPANTS: Practicing orthopaedic surgeons frequenting the Orthopaedic Trauma Association website were invited to participate in this study. RESULTS: Sixty-two eligible orthopaedic surgeons completed the survey. No respondents reported any known harmful complications of MRI use with an EFD. Eight respondents (13%) reported at least one early scan termination because of mild warmth or vibration without any lasting complications. Fifty-six respondents (90%) reported delays to care related to MRI-EFD compatibility labeling, and 27 respondents (48%) reported delayed MRI scans in every patient with an EFD who needed one. Twenty-six surgeons (42%) had modified their practice in some way in response to these barriers. Examples include delaying EFD placement until after MRI, relying on CT arthrograms over MRI for surgical planning, and taking patients to the operating room to remove EFDs temporarily and then replace them. Nineteen respondents (31%) had developed formal protocols to address this issue, but having a written protocol was not associated with any decrease in delays ( P = 0.119). Eighty-nine percent of respondents thought there was a need for a national consensus guideline on this issue. CONCLUSION: Despite no previous reports of harmful complications, MRI utilization is frequently delayed or prevented in patients with EFDs in place. This is a pervasive problem nationally, which persists despite the implementation of written institutional protocols. Additional research is needed, potentially at the national level, to address this common issue. LEVEL OF EVIDENCE: V.

Gait Analysis in Orthopaedic Surgery: History, Limitations, and Future Directions.

Gait analysis has expanding indications in orthopaedic surgery, both for clinical and research applications. Early work has been particularly helpful for understanding pathologic gait deviations in neuromuscular disorders and biomechanical imbalances that contribute to injury. Notable advances in image acquisition, health-related wearable devices, and computational capabilities for big data sets have led to a rapid expansion of gait analysis tools, enabling novel research in all orthopaedic subspecialties. Given the lower cost and increased accessibility, new gait analysis tools will surely affect the next generation of objective patient outcome data. This article reviews the basic principles of gait analysis, modern tools available to the common surgeon, and future directions in this space.

Indications for and Risks Associated With Implant Removal After Pediatric Trauma.

A wide range of implants are used in the treatment of pediatric fractures, including wires, plates, screws, flexible rods, rigid rods, and external fixation devices. Pediatric bones differ from adult bones both mechanically and biologically, including the potential for remodeling. Implants used in pediatric trauma patients present a unique set of circumstances regarding indications, risks, timing of implant removal, weight-bearing restrictions, and long-term sequelae. Indications for implant removal include wire/pin fixation, when substantial growth remains, and infection. When considering implant removal, the risks and benefits must be assessed. The primary risk of implant removal is refracture. The timing of implant removal varies widely from several weeks to a year or more with the option of retention depending on the fracture, type of implant, and skeletal maturity of the patient.

CT scans better assess lateral wall morphology of "stable appearing" intertrochanteric (IT) femur fractures and predict early failure of sliding hip screw (SHS) fixation.

To compare the efficacy of plain x-ray images and computed tomography (CT) to assess the morphology of the lateral wall (LW) component of intertrochanteric (IT) femur fractures and determine predictors of early fixation failure. DESIGN: Retrospective cohort study. SETTING: Level-one trauma center. PATIENTS/PARTICIPANTS: One hundred forty-two adult patients with IT fractures treated with either a sliding hip screw (SHS) or a cephalomedullary nail (CMN) who had both pre-op plain x-ray images and CT scans with at least 6 weeks of follow-up were reviewed. INTERVENTION: Preoperative CT scan and plain radiographs of the affected hip. MAIN OUTCOME MEASUREMENTS: Lateral wall assessment based on plain x-rays versus CT imaging in relation to implant failure. RESULTS: One hundred forty-two patients met inclusion criteria, 105 patients treated with a CMN, and 37 with a SHS. There was a poor correlation between the assessment of the LW on plain x-ray images and CT scans. Failures in the SHS group were significantly associated with all CT measurements (P < .05) but not with plain film LW assessment (P = .66). Fifteen patients had an early implant failure (6 CMN, 9 SHS). There were no statistically significant associations between any radiographic measurement (plain images and CT) and CMN failures. CONCLUSIONS: Plain film images are not accurate for assessing lateral wall morphology/integrity and are not predictive of SHS implant failures. Our novel CT measurements were effective at detecting lateral wall patterns at risk for treatment failure with SHS implants.Level of Evidence: Level III.

Clinical and Radiographic Predictors of Nonunion in Open Tibial Shaft Fractures.

Open fracture is a risk factor for nonunion of diaphyseal tibia fractures. Compared with closed injuries, there is a relative lack of scientific knowledge regarding the healing of open tibia fractures. The objective of this study was to investigate which patient, injury, and surgeon-related factors predict nonunion in open tibial shaft fractures. A cohort of 98 patients with 104 extra-articular open tibial shaft fractures (OTA/AO 41A2-3, 42A-C, and 43A) were treated surgically between 2007 and 2018 at a single level 1 trauma center and were retrospectively reviewed. Patients underwent irrigation and debridement followed by definitive intramedullary nailing or plate fixation. Patient, injury, and perioperative prognostic factors were analyzed as predictors of nonunion based on anteroposterior and lateral radiographs. The nonunion rate was 27.9% (n=29). There were 12 occurrences of deep infection (11.5%). The median follow-up was 14 months. High-energy mechanism of injury (hazard ratio [HR], 5.76), Gustilo-Anderson class IIIA injury (HR, 3.66), postoperative cortical continuity of 0% to 25% (HR, 2.90), early postoperative complication (HR, 4.20), and deep infection (HR, 2.25) were significant predictors of nonunion on univariable analysis (P<.05). On multivariable assessment, only high-energy mechanism of injury, Gustilo-Anderson class IIIA injury, and early postoperative complication reached significance as predictors of nonunion. These data also indicate that lack of cortical continuity is a significant univariable radiographic predictor of nonunion. This is potentially modifiable, may guide surgeons in selecting patients for early bone grafting procedures, and should be assessed carefully in this high-risk population. [Orthopedics. 2021;44(3):142-147.].

Incidence and Management of Articular Impaction in Geriatric Olecranon Fractures.

INTRODUCTION: Olecranon fractures are common in the elderly. Articular impaction is encountered occasionally, but the incidence and outcomes after treatment of this injury pattern have not been well characterized. METHODS: We evaluated a cohort of geriatric olecranon fractures to determine the incidence of articular impaction and describe a technique for open reduction and internal fixation. RESULTS: Of the 63 patients in our series, 31 had associated intraarticular impaction (49.2%). Patients with articular impaction did not have significantly different rates of postoperative complications (11/31, 35.5% versus 10/31, 32.3%; P = 1.00) or revision surgery (10/31, 32.3% versus 8/31, 25.8%; P = 0.780) compared with those without articular impaction. CONCLUSION: Articular impaction is a common feature of geriatric olecranon fractures. Surgeons must maintain a high index of suspicion and have a surgical plan in place for managing this component of the injury.

Medial Column Support in Pilon Fractures Using Percutaneous Intramedullary Large Fragment Fixation.

SUMMARY: Pilon fractures are complex injuries to the tibial plafond requiring stable fixation in the setting of effective soft tissue management, particularly in high-energy injuries, open fractures, or in geriatric individuals. Medial column support of the distal tibial metaphysis is often an essential component when applying balanced fixation. However, the biologic implications of multiple surgical approaches in the setting of damaged tissue, devitalized bone, or significant bone loss may contribute to increased complications. Percutaneous intramedullary large fragment screws offer both stability and a soft tissue-friendly approach for stabilizing the medial column. Here, we present our technique and indications for medial column support in pilon fractures using percutaneous large fragment fixation, along with our early clinical experience in a case series of 7 patients. At minimum 6-month follow-up, all patients healed their injuries with maintained alignment and without complications or further reoperation. Medial column support with percutaneous large fragment fixation in pilon fractures is a viable option to provide mechanical stability while effectively managing tenuous soft tissue envelopes.

A Comparison of Geriatric Hip Fracture Databases.

INTRODUCTION: The National Surgical Quality Improvement Project (NSQIP) and the Trauma Quality Improvement Project (TQIP) collect data on geriatric hip fractures (GHFs) that could be used to generate risk-adjusted metrics for care of these patients. We examined differences between GHFs reported by our own trauma center to the NSQIP and TQIP and those vetted through an internal GHF list. METHODS: We reviewed charts of GHFs treated between January 1 and December 31, 2015, and compared patients in an internal GHF database and/or reported to the NSQIP and/or TQIP and determined differences between databases. RESULTS: We identified 89 "true" GHFs, of which 96% were identified by our institutional database, 70% by NSQIP, and 9% by the TQIP. No differences were found in outcomes and total costs. The net revenue/patient in the NSQIP database was $24,373 more than those in the institutional database. CONCLUSION: Caution should be taken when using NSQIP/TQIP databases to evaluate the care of GHFs. LEVEL OF EVIDENCE: Level III.

Predictive Modeling for Geriatric Hip Fracture Patients: Early Surgery and Delirium Have the Largest Influence on Length of Stay.

BACKGROUND: Averaging length of stay (LOS) ignores patient complexity and is a poor metric for quality control in geriatric hip fracture programs. We developed a predictive model of LOS that compares patient complexity to the logistic effects of our institution's hip fracture care pathway. METHODS: A retrospective analysis was performed on patients enrolled into a hip fracture co-management pathway at an academic level I trauma center from 2014 to 2015. Patient complexity was approximated using the Charlson Comorbidity Index and ASA score. A predictive model of LOS was developed from patient-specific and system-specific variables using a multivariate linear regression analysis; it was tested against a sample of patients from 2016. RESULTS: LOS averaged 5.95 days. Avoidance of delirium and reduced time to surgery were found to be notable predictors of reduced LOS. The Charlson Comorbidity Index was not a strong predictor of LOS, but the ASA score was. Our predictive LOS model worked well for 63% of patients from the 2016 group; for those it did not work well for, 80% had postoperative complications. DISCUSSION: Predictive LOS modeling accounting for patient complexity was effective for identifying (1) reasons for outliers to the expected LOS and (2) effective measures to target for improving our hip fracture program. LEVEL OF EVIDENCE: III.

CT-measurement predicts shortening of stable intertrochanteric hip fractures.

PURPOSE: Intertrochanteric (IT) hip fractures can be treated with sliding hip screws (SHS) or cephalomedullary nails (CMN) based on the stability of the fracture. This stability is affected by the initial impaction of the fracture which can be difficult to assess. The aim of this paper is to develop specific pre-operative computed tomography (CT) measurements of IT fractures which are predictive of post-operative shortening. METHODS: A retrospective review was performed of 141 patients with AO/OTA 31A1 or 31A2 fracture patterns, who had pre-operative radiographs and CT scans, and who were treated with a SHS or a CMN. Pre-operative and post-operative imaging of IT fractures were analyzed for those fractures that shortened ≥15 mm post-fixation. RESULTS: 11 fractures shortened ≥15 mm with CMN being protective of shortening (6/36 SHS versus 5/105 CMN, p = 0.0268). A novel measurement made on the pre-operative CT scan called the cortical thin point (CTP) detected differences between patients with <15 mm and ≥15 mm of post-operative shortening for the SHS group (p = 0.0375). CTP was found to be a reliable predictor for post-operative shortening of ≥15 mm when a cutoff threshold of 9 mm was used in the SHS group (p = 0.0161). CONCLUSIONS: Measuring the CTP is predictive of post-operative shortening after fixation of an IT fracture with a SHS. CMN fixation may be protective of shortening. Patients with a CTP of ≤9 mm are at risk for fracture site shortening of more than 15 mm when treated with a SHS.

Bilateral lipoma arborescens -A proliferative case demonstrating progression in an adolescent male.

CASE: We describe a case of extensive symptomatic bilateral lipoma arborescens of the knee in a 19-year-old man who suffered from recurrent knee effusions for many years. This patient had MRI evidence of progression of disease prior to arthroscopic intervention. He was treated with bilateral complete arthroscopic synovectomies, demonstrating no evidence of cartilage wear. CONCLUSION: Lipoma arborescens is a progressive disease. Timely diagnosis and treatment may prevent disease evolution and sequela.

Pain and effusion and quadriceps activation and strength.

CONTEXT: Quadriceps dysfunction is a common consequence of knee joint injury and disease, yet its causes remain elusive. OBJECTIVE: To determine the effects of pain on quadriceps strength and activation and to learn if simultaneous pain and knee joint effusion affect the magnitude of quadriceps dysfunction. DESIGN: Crossover study. SETTING: University research laboratory. PATIENTS OR OTHER PARTICIPANTS: Fourteen (8 men, 6 women; age = 23.6 ± 4.8 years, height = 170.3 ± 9.16 cm, mass = 72.9 ± 11.84 kg) healthy volunteers. INTERVENTION(S): All participants were tested under 4 randomized conditions: normal knee, effused knee, painful knee, and effused and painful knee. MAIN OUTCOME MEASURE(S): Quadriceps strength (Nm/kg) and activation (central activation ratio) were assessed after each condition was induced. RESULTS: Quadriceps strength and activation were highest under the normal knee condition and differed from the 3 experimental knee conditions (P < .05). No differences were noted among the 3 experimental knee conditions for either variable (P > .05). CONCLUSIONS: Both pain and effusion led to quadriceps dysfunction, but the interaction of the 2 stimuli did not increase the magnitude of the strength or activation deficits. Therefore, pain and effusion can be considered equally potent in eliciting quadriceps inhibition. Given that pain and effusion accompany numerous knee conditions, the prevalence of quadriceps dysfunction is likely high.