The MCID of the PROMIS physical function instrument for operatively treated tibial plateau fractures.

INTRODUCTION: Understanding minimal clinically important differences (MCID) in patient reported outcome measurement are important in improving patient care. The purpose of this study was to determine the MCID of Patient-Reported Outcome Measurement System (PROMIS) Physical Function (PF) domain for patients who underwent operative fixation of a tibial plateau fracture. METHODS: All patients with tibial plateau fractures that underwent operative fixation at a single level 1 trauma center were identified by Current Procedural Terminology codes. Patients without PROMIS PF scores or an anchor question at two-time points postoperatively were excluded. Anchor-based and distribution-based MCIDs were calculated. RESULTS: The MCID for PROMIS PF scores was 4.85 in the distribution-based method and 3.93 (SD 14.01) in the anchor-based method. There was significantly more improvement in the score from the first postoperative score (<7 weeks) to the second postoperative time (<78 weeks) in the improvement group 10.95 (SD 9.95) compared to the no improvement group 7.02 (SD 9.87) in the anchor-based method (P < 0.001). The percentage of patients achieving MCID at 7 weeks, 3 months, 6 months, and 1 year were 37-42 %, 57-62 %, 80-84 %, and 95-87 %, respectively. DISCUSSION: This study identified MCID values for PROMIS PF scores in the tibial plateau fracture population. Both MCID scores were similar, resulting in a reliable value for future studies and clinical decision-making. An MCID of 3.93 to 4.85 can be used as a clinical and investigative standard for patients with operative tibial plateau fractures.

Bladder Repair With Irrigation and Debridement and Open Reduction Internal Fixation of the Anterior Pelvic Ring Is Safe and Decreases Risk of Infection in Pelvic Ring Injuries With Extraperitoneal Bladder Ruptures.

OBJECTIVES: To determine the incidence of infection in nonoperative versus operative management of extraperitoneal bladder ruptures in patients with pelvic ring injuries. DESIGN: A retrospective cohort study of 2 prospectively collected trauma registries. SETTING: Two Level 1 trauma centers. PATIENT SELECTION CRITERIA: Patients with operative pelvic ring injuries, 68 (6%) had extraperitoneal bladder ruptures. OUTCOME MEASURES AND COMPARISONS: The primary outcome was the incidence and associated risk factors of deep pelvic infection requiring return to OR for surgical debridement. Secondary outcomes included quality of reduction, other complications, and radiographic union. Comparisons were made based on the status of any associated bladder injury. RESULTS: Of 1127 patients with operative pelvic ring injuries, 68 patients had extraperitoneal bladder ruptures, 55 had bladder repair and 13 did not. Of those 13 without repair, none had ORIF of the anterior pelvic ring. Patients without bladder repair had an increased odds of infection 17-fold compared to patients who did have a repair performed (OR 16.9, 95% CI 1.75 - 164, P = 0.01). Other associated factors for deep pelvic infection included use of suprapubic catheter ( p < 0.02) and a closed reduction of the anterior ring ( p < 0.01). Patients undergoing anterior ring ORIF and bladder repair had improved reductions and no increased infection risk. CONCLUSIONS: Operative repair of extraperitoneal bladder ruptures decreases risk of infection in patients with pelvic ring injuries. Additionally, ORIF of the anterior pelvic ring does not increase the risk of infection and results in better reductions compared to closed reduction. Treatment algorithms for these combined injuries should consider recommending early bladder repair and anterior pelvic ORIF. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Percutaneous sacral screw fixation alone sufficient for mildly displaced U-type sacral fractures with preserved osseous fixation pathways.

PURPOSE: To describe U-type sacral fracture characteristics amenable to percutaneous sacral screw fixation. METHODS: U-type sacral fractures were identified from a trauma registry at a level 1 trauma center from 2014 to 2020. Patient demographics, injury mechanism, fracture characteristics, and fixation construct were retrospectively retrieved. Associations between fracture pattern and surgical fixation were identified. RESULTS: 82 U-type sacral fractures were reviewed. Six treated with lumbopelvic fixation (LPF) and 76 were treated with percutaneous sacral screws (PSS) alone. Patients receiving LBF had greater sacral fracture displacement in coronal, sagittal, and axial planes compared to patients receiving PSS alone (P < 0.05), negating osseous fixation pathways. All patients went onto sacral union and there were no implant failures or unplanned reoperations for either group. CONCLUSION: If osseous fixation pathways are present, U-type sacral fractures can be successfully treated with percutaneous sacral screws. LPF may be indicated in more displaced fractures with loss of spinopelvic alignment. Both techniques for U-type sacral fractures result in reliable fixation and healing without reoperations.

Transfusion after harvesting bone graft with RIA: Practice changes reduced transfusion rate by more than half.

INTRODUCTION: The Reamer Irrigator Aspirator (RIA) is frequently used as a tool for bone graft harvesting procedures. The initial use of this instrument for bone grafting was met with significant blood loss and high transfusion rates. However, the RIA remains an excellent tool to obtain large volumes of viable autologous graft. The aim of this study was to investigate how changes in the technical use of the RIA may affect blood loss. MATERIALS AND METHODS: We conducted a retrospective chart review of all patients who underwent RIA bone graft harvest over a 12-year study period. The patients were divided into two cohorts based upon changes in the technique used to obtain autograft harvest with the RIA. The traditional cohort (2008-2012) connected the RIA to dilation and curettage suction and selected reamer size based on radiographic parameters. The modified cohort (2012-2020) connected the RIA to wall suction, used improved techniques for reamer head sizing, and more diligence was paid toward the time the RIA was suctioning in the canal. Demographic information, surgical details, pre- and post-operative hematocrit (HCT), transfusion rate, intra-operative blood loss, reported volume of graft harvested, and iatrogenic fracture were recorded. RESULTS: 201 patients were included in the study with 61 patients in the traditional and 140 patients in the modified cohorts respectively. The average age was 51 years (range: 18-97) with 107 (53%) males. There was no difference in the demographic data between the two cohorts. No difference was noted between the traditional and modified cohorts in terms of the amount of average graft harvested (54cc vs 51cc; p = 0.34) or major complications (1 vs 2; p = 0.91). However, when comparing the traditional versus modified cohorts the traditional group demonstrated a larger average blood loss (675cc vs 500cc; p=<0.01) and HCT drop (13.7 vs 9.5; p=<0.01) with a higher transfusion rate (44% vs 19%; p = 0.001). CONCLUSION: This series demonstrated a significant improvement in blood loss and transfusion with modified techniques used to obtain autologous bone graft with the RIA. Importantly, these techniques do not appear to limit bone graft harvest yield and can therefore be efficiently implemented without limiting the utility of the RIA.

Assessment of sacral osseous fixation pathways for same-level dual transiliac-transsacral screw insertion.

INTRODUCTION: The purpose of this study is to (1) describe a pre-operative planning technique using non-reformatted CT images for insertion of multiple transiliac-transsacral (TI-TS) screws at a single sacral level, (2) define the parameters of a sacral osseous fixation pathway (OFP) that will allow for insertion of two TI-TS screws at a single level, and (3) identify the incidence of sacral OFPs large enough for dual-screw insertion in a representative patient population. METHODS: Retrospective review at a level-1 academic trauma center of a cohort of patients with unstable pelvic injuries treated with two TI-TS screws in the same sacral OFP, and a control cohort of patients without pelvic injuries who had CT scans for other reasons. RESULTS: Thirty-nine patients had two TI-TS screws at S1. Eleven patients, all with dysmorphic osteology, had two TI-TS screws at S2. The average pathway size in the sagittal plane at the level the screws were placed was 17.2 mm in S1 vs 14.4 mm in S2 (p = 0.02). Twenty-one patients (42%) had screws that were intraosseous and 29 (58%) had part of a screw that was juxtaforaminal. No screws were extraosseous. The average OFP size of intraosseous screws was 18.1 mm vs. 15.5 mm for juxtaforaminal screws (p = 0.02). Fourteen millimeters was used as a guide for the lower limit of the OFP for safe dual-screw fixation. Overall, 30% of S1 or S2 pathways were ≥ 14 mm in the control group, with 58% of control patients having at least one of the S1 or S2 pathways ≥ 14 mm. CONCLUSIONS: OFPs ≥ 7.5 mm in the axial plane and 14 mm in the sagittal plane on non-reformatted CT images are large enough for dual-screw fixation at a single sacral level. Overall, 30% of S1 and S2 pathways were ≥ 14 mm and 58% of control patients had an available OFP in at least one sacral level.

Minimal Clinically Important Differences of Patient-Reported Outcomes Measurement Information System Physical Function in Patients With Tibial Shaft Fracture.

OBJECTIVE: To calculate the minimal clinically important differences (MCIDs) of patient-reported outcomes measurement information system physical function (PROMIS PF) scores for patients with operatively treated tibial shaft fractures. DESIGN: Retrospective Cohort Study. SETTING: A Level 1 trauma center. PATIENTS: All operatively treated tibial shaft fractures identified by Current Procedural Terminology codes. INTERVENTION: Enrolled patients treated acutely with operative fixation of their tibia. MAIN OUTCOME MEASUREMENTS: MCIDs were calculated by distribution-based and anchor-based methods, calculated from PROMIS PF scores completed at least at two-time points postoperatively. MCIDs were calculated at different time points including overall, 7-12 weeks, 3-6 months, and 6-24 months. MCIDs were calculated for different subgroups including open fractures, closed fractures, any complications, and no complications. RESULTS: MCID for PROMIS PF scores was 5.7 in the distribution-based method and 7.84 (SD 18.65) in the anchor-based method. At 6-24 postoperatively, the months the distribution-based MCID was 5.95 from a postoperative baseline 27.83 (8.74) to 42.85 (9.61), P < 0.001. At 6-24 months, the anchor-based MCID was 10.62 with a score difference between the improvement group of 16.03 (10.73) and the no improvement group of 5.41 (15.75), P < 0.001. Patients with open fractures (distribution-based 6.22 and anchor-based 8.05) and any complications (distribution-based 5.71 and anchor-based 9.29) had similar or higher MCIDs depending on the methodology used than the overall cohort MCIDs. CONCLUSION: This study identified distribution-based MCID of 5.7 and anchor-based MCID of 7.84 calculated from PROMIS PF scores in operative tibial shaft fractures. Distribution-based methods yielded smaller MCIDs than anchor-based methods. These MCID scores provide a standard to compare clinical and investigational outcomes.

Recovery Curve for Patients With Pilon Fractures Using Patient-Reported Outcome Measurement Information System.

BACKGROUND: The time frame in which patients can expect functional improvement after open reduction internal fixation (ORIF) of pilon fractures is unclear. The purpose of this study was to determine the trajectory and rate at which patients' physical function improves up to 2 years postinjury. METHODS: The patients studied sustained a unilateral, isolated pilon fractures (AO/OTA 43B/C) and followed at a level 1 trauma center over a 5-year period (2015-2020). Patient-Reported Outcomes Measurement Information Systems (PROMIS) Physical Function (PF) scores from these patients at defined follow-up times of immediately, 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery defined the cohorts and were retrospectively studied. RESULTS: There were 160 patients with PROMIS scores immediately postoperatively, 143 patients at 6 weeks, 146 patients at 12 weeks, 97 at 24 weeks, 84 at 1 year, and 45 at 2 years postoperatively. The average PROMIS PF score was 28 immediately postoperatively, 30 at 6 weeks, 36 at 3 months, 40 at 6 months, 41 at 1 year, and 39 at 2 years. There was a significant difference between PROMIS PF scores between 6 weeks and 3 months (P < .001), and between 3 and 6 months (P < .001). Otherwise, no significant differences were detected between consecutive time points. CONCLUSION: Patients with isolated pilon fractures demonstrate the majority of their improvement in terms of physical function between 6 weeks and 6 months postoperatively. No significant difference was detected in PF scores after 6 months postoperatively up to 2 years. Furthermore, the mean PROMIS PF score of patients 2 years after recovery was approximately 1 SD below the population average. This information is helpful in counseling patients and setting expectations for recovery after pilon fractures. LEVEL OF EVIDENCE: Level III, prognostic.

Comparing Emergency Department Stress of Lateral Compression Type 1 Pelvis Fractures With a Validated Instability Scoring System.

INTRODUCTION: Lateral compression type 1 (LC1) pelvic ring injuries represent a heterogeneous group of fractures with controversial surgical indications. Recently, multiple institutions have suggested the safety and reliability of an emergency department (ED) stress to evaluate for occult instability. The purpose of this study was to correlate ED stress examination of LC1 pelvis fractures against a validated fracture instability scoring system. METHODS: This was a retrospective review of a consecutive series of 70 patients presenting with minimally displaced LC1 fractures at a level 1 academic trauma center. All patients were stressed in the ED radiology suite, and displacement was measured by comparing calibrated stress radiographs with static radiographs (>10 mm displacement defined positivity). ED stress results were compared with radiographic scores assigned according to the validated Beckmann scoring system (score <7: stable-nonsurgical recommendation; score 7 to 9: indeterminant recommendation; and score >9: unstable-surgical recommendation). RESULTS: Thirteen patients had a positive ED stress examination, and 57 patients stressed negative. The mean displacement was significantly different between the three groups (Beckmann 5 to 6: 3.31 mm, SD = 2.4; Beckmann 7 to 9: 4.23 mm, SD = 3.2; Beckmann 10+: 12.1 mm, SD = 8.6; P < 0.001). Zero of 18 patients in the stable group stressed positive, and only 3 of 38 patients in the indeterminant group stressed positive (7.9%). Finally, 10 of 14 patients in the unstable group stressed positive (71.4%; P < 0.001) . Sacral displacement ( P = 0.001), superior ramus location ( P < 0.02), and sacral columns ( P < 0.001) significantly predicted ED stress positivity in multivariate analysis. CONCLUSIONS: Comparison of a validated instability scoring system with ED stress examination of minimally displaced LC1 fractures in awake and hemodynamically stable patients showed excellent correlation. This suggests that the ED stress examination is a useful diagnostic adjunct. LC1 fracture characteristics should be analyzed to determine which pelvic fracture characteristics determine occult instability before stress examination. LEVEL OF EVIDENCE: Level III diagnostic.

Distractor Application and Dry Arthroscopy to Improve Articular Visualization During Scapula Fracture Surgery Via a Posterior Approach.

SUMMARY: Intra-articular glenoid displacement is an indication for open reduction and internal fixation of scapular fractures. However, direct visualization of the glenoid is limited, and articular reductions are typically performed and assessed using extra-articular cortical reduction reads and fluoroscopic imaging. In this technique, we describe the application of a distractor for direct visualization of the glenoid articular surface. In this way, anatomic reduction of the glenoid articular surface can be assessed and achieved. In addition, we discuss the use of a portable, dry arthroscopy when needed. This technique has resulted in good-to-excellent articular reductions by adjusting extra-articular reads that seemed adequate before intra-articular visualization. This technique is safe, requires minimal extra set-up or instruments, and results in good-to-excellent articular reductions.

Venous thromboembolism in patients with surgically treated ankle fractures.

OBJECTIVES: In patients with rotational ankle fracture, we compare the rate of venous thromboembolism development between patients who received chemoprophylaxis vs those patients that received none. DESIGN: Retrospective cohort study. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Between 2014 and 2018, we identified 483 patients with rotational ankle fracture that had no VTE risk factors, were under 70 years of age, and had an isolated injury. INTERVENTION: Chemoprophylaxis vs no chemoprophylaxis after open reduction internal fixation of a rotational ankle fracture. MAIN OUTCOME MEASUREMENTS: Development of VTE was the primary outcome. Secondary outcomes included wound problems, infection, hematoma, or non-union. RESULTS: There were 313 patients that received no prophylaxis and 170 patients that received chemoprophylaxis after operative fixation of an isolated ankle fracture. Demographics including age, gender, body mass index, and ASA class were similar between groups. The rate of DVT/PE was 3.5% in those without DVT prophylaxis, and 4.1% in those on DVT prophylaxis with no significant differences found (p = 0.8). There was no significant difference in wound complication (no VTE prophylaxis-3.7% vs VTE prophylaxis-2.5%, p = 0.7) or infection rates (no VTE prophylaxis-3.8% vs VTE prophylaxis 4.1%, p = 1.0) between groups. CONCLUSIONS: No difference was detected in the rate of symptomatic DVT or PE in patients based on chemoprophylaxis. Our results support the conclusion that the use of chemoprophylaxis may remain surgeon preference and based on patient risk factors for VTE development. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Periarticular multimodal analgesia in decreasing perioperative pain in tibial plateau fractures: A double blind randomized controlled pilot study.

INTRODUCTION: The use of periarticular multimodal analgesia injections is increasing and has become commonplace in some surgeries. However, there is no data on the effectiveness of local periarticular multimodal analgesia for tibial plateau fractures. We hypothesized that closed tibial plateau fracture patients receiving the local multimodal analgesic medications would experience a decrease in VAS pain scores. METHODS: Patients aged between 18 and 79 with an isolated closed tibial plateau fracture (AO 41-B and C) were prospectively enrolled and randomized in a 1:1 double blinded fashion to either a placebo or active medication treatment arm. After ORIF, gel-foam sponges soaked in either multimodal analgesic solution or normal saline. Patients were followed for 24 h post-operatively with Visual Analog pain Scores (VAS). Patients were monitored post-operatively for complications including compartment syndrome, infection, and non-union. RESULTS: The planned study was terminated prior to completion due to higher than anticipated rates of infection (18%), distributed equally among active (3) and placebo (2) groups, raising concerns that this may have been due to the presence of the delivery device. Twenty-eight patients were enrolled, 15 in the active group and 13 in the placebo group. Patients in the active medication group had significantly decreased pain scores at hours 4 (p = 0.005, 4.2 vs 6.9), 8 (p = 0.05, 5 vs 7), and 12 (p = 0.02, 3.8 vs 6.2). Pain scores at hours 16 (p = 0.10, 4.5 vs 6.5), 20 (p = 0.08, 4.6 vs 6.4), and 24 (p = 0.10, 4.8 vs 6.5) were also decreased but did not reach significance. DISCUSSION: The use of local multimodal periarticular analgesic for closed tibial plateau fractures appears to be beneficial for short-term pain control post-operatively. Concerns regarding an implantable delivery vehicle leading to infection has warranted a change in method of drug administration. Completion of the full study will permit us to validate or refute these findings. LEVEL OF EVIDENCE: Therapeutic Level 1.

Minimal Clinically Important Differences of PROMIS PF in Ankle Fracture Patients.

BACKGROUND: Evaluating the minimal clinically important differences (MCIDs) in patient-reported outcome scores is essential for use of clinical outcomes data. The purpose of the current study was to calculate MCID of Patient Reported Outcome Information System Physical Function (PROMIS PF) scores for ankle fracture patients. METHODS: All patients who underwent operative fixation for ankle fractures at a single level 1 trauma center were identified by Current Procedural Terminology code. PROMIS PF scores were collected. Patients had to complete an anchor question at 2 time points postoperatively to be included in this study. Anchor-based and distribution-based MCIDs were calculated. RESULTS: A total of 331 patients were included in the distribution-based analysis, and 195 patients were included in the anchor-based analysis. Mean age was 45.3 years (SD 17.5), and 59.4% of participants were female. MCID for PROMIS PF scores was 5.05 in the distribution-based method and 5.43 in the anchor-based method. CONCLUSION: This study identified MCID values based on 2 time points postoperatively for PROMIS PF scores in the ankle fracture population. Both methods of MCID calculation resulted in equivalent MCIDs. This can be used to identify patients outside the normal preoperative and postoperative norms and may help to make clinically relevant practice decisions. LEVEL OF EVIDENCE: Level I, diagnostic study, testing of previously developed diagnostic measure on consecutive patients with reference standard applied.

Reformatting of Computed Tomography Scans Parallel to the S1 End Plate Increases Visualization of Trans Sacral Pathway in the First Sacral Segment, Especially With Dysmorphism.

OBJECTIVE: To determine whether reformatted computed tomography (CT) scans would increase surgeons' confidence in placing a trans sacral (TS) screw in the first sacral segment. SETTING: Level 1 trauma center. DESIGN: A retrospective cohort study. PATIENTS/PARTICIPANTS: There were 50 patients with uninjured pelvises who were reviewed by 9 orthopaedic trauma fellowship-trained surgeons and 5 orthopaedic residents. MAIN OUTCOME MEASUREMENTS: The overall percentage of surgeons who believe it was safe to place a TS screw in the first sacral segment with standard (axial cuts perpendicular to the scanner gantry) versus reformatted (parallel to the S1 end plate) CT scans. RESULTS: Overall, 58% of patients were believed to have a safe corridor in traditional cut axial CT scans, whereas 68% were believed to have a safe corridor on reformatted CT scans ( P < 0.001). When grouped by dysplasia, those without sacral dysplasia (n = 28) had a safe corridor 93% of the time on traditional scans and 93% of the time with reformatted CT scans ( P = 0.87). However, of those who had dysplasia (n = 22), only 12% were believed to have a safe corridor on original scans compared with 35% on reformatted scans ( P < 0.001). CONCLUSIONS: CT scan reformatting parallel to the S1 superior end plate increases the likelihood of identifying a safe corridor for a TS screw, especially in patients with evidence of sacral dysplasia. The authors would recommend the routine use of reformatting CT scans in this manner to provide a better understanding of the upper sacral segment osseous fixation pathways.

Neocortex Formation in a Tapered Wedge Stem is Not Indicative of Complications or Worse Outcomes.

BACKGROUND: The formation of sclerotic bone, a neocortex, distally surrounding total hip arthroplasty (THA) stems may commonly be seen on radiographs around proximally porous coated stems but can be confused with loosening. The goal of this study was to determine the prevalence of the neocortex finding and whether it associated with worse outcomes after THA. METHODS: A retrospective review of 825 patients with a single tapered wedge stem was performed. Radiographs at 1-year, as well as final follow-up were reviewed for evidence of sclerotic bone (neocortex) surrounding the stem in all 14 Gruen zones. The final attending radiology read of lucency was also recorded. Patients were grouped by the presence of the neocortex. PROMIS Physical Function scores and complications were compared between neocortex groups. RESULTS: The neocortex group had 558 (68%) patients compared to 267 (32%) in the no neocortex group. The most common Gruen zones for evidence of neocortex were 10 (55%), 11 (52%), and 12 (51%). Seven percent of patients had a finding of lucency on radiology read. There was no difference between groups in terms of dislocations (P = .61), infection (P = .79), fracture rates (P = .54), revision surgery (P = .73), and reoperation for any cause (P = .62). PROMIS PF scores were significantly higher in the neocortex group (P < .0001). CONCLUSION: The presence of a distal neocortex is a common finding on radiographs after THA with this proximally porous-coated tapered wedge stem and does not portend worse outcomes, nor is it a sign of aseptic loosening, increased revision rates, infection, dislocation, or periprosthetic fracture risk.

Femoral neck shaft angle is not correlated with femoral version: A retrospective study of computed tomography scans.

BACKGROUND: An understanding of femoral anteversion and neck-shaft angle (NSA) is essential to deliver optimal orthopaedic surgical care. Despite the importance, there is little research examining the relationship between femoral anteversion and the NSA in an adult population. This study sought to determine if there is a correlation between femoral neck shaft angle and version in skeletally mature adults using computed tomography (CT) scanograms. METHODS: Between January 2010 and June 2017, all skeletally mature patients who had received a CT scanogram of the lower extremity were reviewed. Exclusion criteria included: (1) radiographic evidence of osteoarthritis, (2) history of hip, femur, or knee surgery or trauma, (3) and anatomic abnormalities of the proximal femur including prior slipped capital femoral epiphysis or Legg-Calvé-Perthes disease. Both femoral version and NSA were measured by a musculoskeletal fellowship trained radiologist using CT scanograms. Correlation between femoral version and NSA was determined using coefficient of determination (R2) and Pearson correlation coefficient (r) for the group as a whole and for each sex. RESULTS: There was no statistical correlation between femoral version and NSA for either the entire cohort or for each sex. For the entire cohort, R2 = 0.0016 and r was 0.04 (p=0.45), for females, R2 = 0.0005 and r was 0.0224 (p=0.72), and for males, R2 = 0.0342 and r was 0.185 (p=0.07). CONCLUSION: There was no correlation between femoral version and NSA. This finding is beneficial for surgeons to understand the proximal femoral anatomy. Patients with an increased femoral NSA should not be assumed to have increased femoral anteversion. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Study.

Evaluation of Risk Factors for Loss of Acceptable Alignment for Distal Radius Fractures That Are Nondisplaced or Minimally Displaced on Initial Presentation.

PURPOSE: Numerous studies have evaluated risk factors for loss of acceptable radiographic alignment, as described by the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines (CPG), following closed reduction of distal radius fractures (DRFs). Less is known about DRFs that are well aligned on initial presentation and do not require closed reduction. We evaluated the rate of and risk factors for displacement of DRFs that are nondisplaced or minimally displaced on initial presentation. METHODS: This retrospective cohort study identified patients with nondisplaced or minimally displaced DRFs seen at a single academic tertiary center between 2015 and 2019. DRFs that required a reduction or initial surgical treatment based on the American Academy of Orthopaedic Surgeons CPG and those with a volar shear pattern were excluded. We recorded standard radiographic measurements on presentation and wrist radiographs after 6 weeks. Univariate and binary multivariable logistic regression analyses evaluated associations between sex, age, the presence of dorsal comminution, intra-articular involvement, associated ulnar fractures, and minimal displacement (vs nondisplacement on initial radiographs) with loss of acceptable alignment. RESULTS: Of the 110 included patients, 72% were female and the mean age was 52 years (SD, 17 years). Overall, 33 (30%) had displacement beyond the AAOS CPG criteria at 6 weeks. A multivariable analysis demonstrated that the presence of dorsal comminution (odds ratio, 37.8) and age >60 years (odds ratio, 3.6) were significantly associated with loss of acceptable alignment, whereas sex, intra-articular involvement, associated ulnar styloid/neck fractures, and minimal displacement were not associated. CONCLUSIONS: For DRFs that were initially nondisplaced or minimally displaced, the overall rate of unacceptable radiographic displacement at 6 weeks was 30%. Dorsal comminution and age >60 years were both independently associated with displacement, suggesting that patients with these risk factors may warrant closer follow-up than those without risk factors. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Emergency Department Stress Radiographs of Lateral Compression Type-1 Pelvic Ring Injuries Are Safe, Effective, and Reliable.

BACKGROUND: Occult instability of lateral compression type-1 (LC1) pelvic ring injuries may be determined with a fluoroscopic stress examination under anesthesia (EUA) performed in the operating room. We hypothesized that LC1 injuries, similar to some fractures of the extremities, could be radiographically stressed for stability in the emergency department (ED). Our primary objective was to determine if stress examination of LC1 fractures could be safely and accurately performed in the ED and could be tolerated by patients. METHODS: A prospective, consecutive series of 70 patients with minimally displaced LC1 pelvic injuries (<10-mm displacement on presentation) underwent stress examinations performed by the on-call orthopaedic resident in the ED radiology suite. The stress examination series included static 40° inlet, internal rotation stress inlet, and external rotation stress inlet views. Pelvic fractures that had positive stress results (≥10 mm of overlap of the rami) were indicated for a surgical procedure. These fractures also underwent EUA in order for the 2 techniques to be compared. RESULTS: All patients tolerated the ED stress examination without general anesthetic or hemodynamic instability. Fifty-seven patients (81%) had negative stress results and were allowed to bear weight. All patients with negative stress results who had 3-month follow-up went on to radiographic union without substantial displacement. For the patients with a positive stress result in the ED, the mean displacement was 15.15 mm (95% confidence interval [CI], 10.8 to 19.4 mm) for the ED stress test and 15.60 mm (95% CI, 11.7 to 19.4 mm) for the EUA (p = 0.86). Two patients with a negative ED stress test did not mobilize during their hospitalization and underwent EUA and conversion to a surgical procedure. Thus, a total of 11 patients underwent both stress testing in the ED and EUA; no patient had a positive result on one test but a negative result on the other. CONCLUSIONS: ED stress examination of LC1 injuries is a safe and reliable method to determine pelvic ring stability. The displacement measured in the ED stress examination is similar to the displacement measured under general anesthesia. Furthermore, a negative ED stress examination predicts successful nonoperative treatment. Given the results of this study, we encourage the use of stress examination in the ED for LC1-type injuries involving complete sacral fractures only. Widescale adoption of this streamlined protocol may substantially diminish cost, anesthetic risk, and potential operations for patients. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Determining your implant: Templating a nail for the distal tibia fracture.

The goal of this article is to aid the orthopedic surgeon in determining whether an intra-medullary (IM) device for fixation of a distal tibia fracture is feasible. Using Computed Tomography (CT) scans of the fracture, this review demonstrates a simple way to determine whether two or even three distal interlocking screws are achievable in stable bone. Additionally, this paper offers a summary chart of commonly used tibial nails which can be used for planning purposes. Finally, a clinical summary of very distal tibial shaft fractures treated with IM fixation is provided.

True antiglide fixation of Danis-Weber B fibula fractures has lower rates of removal of hardware.

INTRODUCTION: Plating of unstable OTA/AO 44-B2 equivalent lateral malleolus (Danis-Weber B) fractures has been associated with pain, peroneal irritation, and the need for subsequent hardware removal (ROH). The purpose of this study is to retrospectively compare the rates of ROH in unstable Weber B fractures fixed with a posterior, true antiglide plate with no screws in the distal segment versus those that were fixed with a similarly placed posterior, neutralization construct that included screws in the distal fragment. Thus, evaluating the role of the distal screws in rates of ROH. METHODS: Skeletally mature patients that were treated for an unstable, isolated Weber B fracture at a single level-1 trauma center over a ten-year period were reviewed. Fractures treated with a single posterior plate with at least six months of follow-up were included and those fixed with a direct lateral plate were excluded. The primary outcome of this study was hardware removal defined as entire plate removal; isolated syndesmotic screw removal was not included. RESULTS: Ninety-six patients were included in the study with average age of 46 years (range 17-83) and mean length of follow-up of 24.5 months (range 6.1-140.3). There were 33 patients in the antiglide group (mean follow-up 25.5 months) and 63 in the neutralization plate group (mean follow-up 24 months, p=0.81). Fractures fixed with or without distal screws had equivalent excellent results related to bony union and alignment. However, there was a statistically significant decrease in ROH rates in the antiglide group (antiglide ROH rate 15.2%; neutralization ROH rate 38.1%; p=0.02). Relative risk of ROH with antiglide plate was 0.4 (95% CI 0.17 - 0.95; p=0.04). CONCLUSIONS: Antiglide plating shows a significant risk reduction in the rate of ROH when compared to posterior based neutralization plating. A true antiglide plating construct should be considered as a safe and effective way of managing Weber B fractures with a lower relative risk of a second operation for hardware removal. LEVEL OF EVIDENCE: Therapeutic level III. See Instructions for Authors for a complete description of levels of evidence.

Complications of Hardware Removal.

BACKGROUND: While hardware removal may improve patient function, the procedure carries risks of unexpected outcomes. Despite being among the most commonly performed orthopaedic procedures, scant attention has been given to its complication profile. METHODS: We queried the American Board of Orthopaedic Surgery (ABOS) de-identified database of Part II surgical case lists from 2013 through 2019 for American Medical Association Current Procedural Terminology (CPT) implant-removal codes (20680, 20670, 22850, 22852, 22855, 26320). Hardware removal procedures that were performed without any other concurrent procedure ("HR-only procedures") were examined for associated complications. RESULTS: In the 7 years analyzed, 13,089 HR-only procedures were performed, representing 2.1% (95% confidence interval [CI], 2.1% to 2.2%) of the total of 609,150 surgical procedures during that period. A complication was reported to have occurred in association with 1,256 procedures (9.6% [95% CI, 9.1% to 10.1%]), with surgical complications reported in association with 1,151 procedures (8.8% [95% CI, 8.3% to 9.3%]) and medical/anesthetic complications reported in association with 196 procedures (1.5% [95% CI, 1.3% to 1.7%]). Wound-healing delay/failure (2.1% [95% CI, 1.8% to 2.3%]) and infection (1.6% [95% CI, 1.4% to 1.8%]) were among the most commonly reported complications after HR-only procedures, but other serious events were reported as well, including unexpected reoperations (2.5% [95% CI, 2.2% to 2.7%]), unexpected readmissions (1.6% [95% CI, 1.4% to 1.8%]), continuing pain (95% CI, 1.2% [1.0% to 1.4%]), nerve injury (0.6% [95% CI, 0.4% to 0.7%]), bone fracture (0.5% [95% CI, 0.4% to 0.6%]), and life-threatening complications (0.4% [95% CI, 0.3% to 0.5%]). CONCLUSIONS: Hardware removal is one of the most commonly performed orthopaedic procedures and was associated with an overall complication rate of 9.6% (95% CI, 9.1% to 10.1%) in a cohort of recently trained orthopaedic surgeons in the United States. Although specific complications such as infection, refractures, and nerve damage were reported to have relatively low rates of occurrence, and associated life-threatening complications occurred rarely, surgeons and patients should be aware that hardware removal carries a definite risk. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.