Hip Fracture Repair by the Post-Call Surgeon: A Multicenter Retrospective Review.

INTRODUCTION: The purpose of this study was to evaluate surgeons' ability to perform or supervise a standard operation with agreed-upon radiologic parameters after being on call. METHODS: We reviewed a consecutive series of patients with intertrochanteric hip fractures treated with a fixed angle device at 9 centers and compared corrected tip-apex distance and reduction quality for post-call surgeons versus those who were not. Subgroup analyses included surgeons who operated the night before versus not and attending-only versus resident involved cases. Secondary outcomes included union and perioperative complications. RESULTS: One thousand seven hundred fourteen patients were of average age 77 years. Post-call surgeons treated 823 patients and control surgeons treated 891. Surgical corrected tip-apex distance did not differ between groups: on-call 18 mm versus control 18 mm (P = 0.59). The Garden indices were 160° on the AP and 179° on the lateral in both groups. In 66 cases performed by surgeons who operated the night before, the TAD was 17 mm. No difference was noted in corrected tip-apex distance with and without resident involvement (P = 0.101). No difference was observed in pooled fracture-related complications (P = 0.23). CONCLUSION: Post-call surgeons demonstrated no difference in quality and no increase in complications when performing hip fracture repair the next day compared with surgeons who were not on call.

Bicondylar Tibial Plateau Fractures: What Predicts Infection?

OBJECTIVES: The purpose of this study was to identify the patient, injury, and treatment factors associated with infection of bicondylar plateau fractures and to evaluate whether center variation exists. DESIGN: Retrospective review. SETTING: Eighteen academic trauma centers. PATIENTS/PARTICIPANTS: A total of 1,287 patients with 1,297 OTA type 41-C bicondylar tibia plateau fractures who underwent open reduction and internal fixation were included. Exclusion criteria were follow-up less than 120 days, insufficient documentation, and definitive treatment only with external fixation. INTERVENTION: Open reduction and internal fixation. MAIN OUTCOME MEASUREMENTS: Superficial and deep infection. RESULTS: One hundred one patients (7.8%) developed an infection. In multivariate regression analysis, diabetes (DM) (OR [odds ratio] 3.24; P ≤ 0.001), alcohol abuse (EtOH) (OR 1.8; P = 0.040), dual plating (OR 1.8; P ≤ 0.001), and temporary external fixation (OR 2.07; P = 0.013) were associated with infection. In a risk-adjusted model, we found center variation in infection rates (P = 0.030). DISCUSSION: In a large series of patients undergoing open reduction and internal fixation of bicondylar plateau fractures, the infection rate was 7.8%. Infection was associated with DM, EtOH, combined dual plating, and temporary external fixation. Center expertise may also play a role because one center had a statistically lower rate and two trended toward higher rates after adjusting for confounders. LEVEL OF EVIDENCE: Level IV-Therapeutic retrospective cohort study.

Fat embolism syndrome in patients with bilateral femur fractures: a systematic review and case comparison.

Objectives: Fat embolism and fat embolism syndrome (FES) remain common complications following long bone fractures. Incidence is highest after bilateral femur fractures. We performed a systematic review of FES after bilateral femur fractures and present two cases. Data sources: Systematic literature search of the Cochrane, EMBASE, MEDLINE, Scopus, and, Web of Science Library databases was performed in August 2021. Terms used including plural and alternate spellings: "fat embolism,""fat embolism syndrome,""fat embolus," and "bilateral femur fracture." Articles in German and English were considered. No time frame was applied. Study selection: Original studies, case series and case reports on fat embolism after bilateral femur fracture were included. Insufficient documentation or patients with relevant previous heath conditions were excluded. Data extraction: Abstracts were organized using EndNote X9 by Carivate. Three authors independently screened the abstracts; cross check of the extracted data was performed by the senior author. Data synthesis: Scarcity of articles only allowed for a qualitative synthesis. Data was compared with our cases and situated within the scientific background. Results: Ten articles were included for qualitative synthesis (n = 144 patients). The symptoms were inhomogeneous with neurological deficits being most prominent. Degree of displacement was high, when reported. Although the modes and timing of surgery varied, this appeared unrelated with outcome. Conclusions: FES remains a relevant complication after bilateral femur fractures, despite damage control strategies and improved reaming techniques. Fracture displacement and reduction maneuvers might play a more substantial role in the formation than previously accredited. Level of evidence: 4.

Proximal tibia fracture dislocations: Management and outcomes of a severe and under-recognized injury.

INTRODUCTION: Proximal tibia fracture dislocations (PTFDs) are a subset of plateau fractures with little in the literature since description by Hohl (1967) and classification by Moore (1981). We sought to evaluate reliability in diagnosis of fracture-dislocations by traumatologists and to compare their outcomes with bicondylar tibial plateau fractures (BTPFs). METHODS: This was a retrospective cohort study at 14 level 1 trauma centers throughout North America. In all, 4771 proximal tibia fractures were reviewed by all sites and 278 possible PTFDs were identified using the Moore classification. These were reviewed by an adjudication board of three traumatologists to obtain consensus. Outcomes included inter-rater reliability of PTFD diagnosis, wound complications, malunion, range of motion (ROM), and knee pain limiting function. These were compared to BTPF data from a previous study. RESULTS: Of 278 submitted cases, 187 were deemed PTFDs representing 4% of all proximal tibia fractures reviewed and 67% of those submitted. Inter-rater agreement by the adjudication board was good (83%). Sixty-one PTFDs (33%) were unicondylar. Eleven (6%) had ligamentous repair and 72 (39%) had meniscal repair. Two required vascular repair. Infection was more common among PTFDs than BTPFs (14% vs 9%, p = 0.038). Malunion occurred in 25% of PTFDs. ROM was worse among PTFDs, although likely not clinically significant. Knee pain limited function at final follow-up in 24% of both cohorts. CONCLUSIONS: PTFDs represent 4% of proximal tibia fractures. They are often unicondylar and may go unrecognized. Malunion is common, and PTFD outcomes may be worse than bicondylar fractures.

Peri-implant fractures of the upper and lower extremities: a case series of 61 fractures.

PURPOSE: To assess outcomes for patients who sustained peri-implant fractures (PIFs). METHODS: Medical records of patients who sustained a PIF were reviewed for demographic, injury, outcome, and radiographic data. PIFs were classified using a reproducible system and stratified into cohorts based on fracture location. Clinical outcomes were evaluated for each cohort. RESULTS: Fifty-six patients with 61 PIFs with at least 6 months of follow-up were included. The mean age of the cohort was 60.4 ± 19.5 years. Twenty-two (36.1%) PIFs occurred in males, while 39 (63.9%) occurred in females. Fifty-two (85.2%) PIFs were sustained from a low-energy injury mechanism. PIFs were most often treated with plate/screw constructs (50.8%). Complications included: 6 (9.8%) nonunions, 5 of which were successfully treated to healing, 5 (8.2%) fracture related infections (FRI), and 1 (1.6%) hardware failure. Sixty (98.4%) PIFs ultimately demonstrated radiographic healing. CONCLUSION: PIFs are usually treated surgically and have a relatively high incidence of complications, with nonunion in femoral PIFs being the greatest. Despite this, the rate of ultimate healing is quite high.

Timing of Flap Coverage With Respect to Definitive Fixation in Open Tibia Fractures.

OBJECTIVES: We conducted a large, U.S wide, observational study of type III tibial fractures, with the hypothesis that delays between definitive fixation and flap coverage might be a substantial modifiable risk factor associated with nosocomial wound infection. DESIGN: A retrospective analysis of a multicenter database of open tibial fractures requiring flap coverage. SETTING: Fourteen level-1 trauma centers across the United States. PATIENTS: Two hundred ninety-six (n = 296) consecutive patients with Gustilo III open tibial fractures requiring flap coverage at 14 trauma centers were retrospectively analyzed from a large orthopaedic trauma registry. We collected demographics and the details of surgical care. We investigated the patient, and treatment factors leading to infection, including the time from various points in care to the time of soft-tissue coverage. INTERVENTION: Delay definitive fixation and flap coverage in tibial type III fractures. MAIN OUTCOME MEASUREMENTS: (1) Results of multivariate regression with time from injury to coverage, debridement to coverage, and definitive fixation to coverage in the model, to determine which delay measurement was most associated with infection. (2) A second multivariate model, including other factors in addition to measures of flap delay, to provide the estimate between delay and infection after adjustment for confounding. RESULTS: Of 296 adults (227 M: 69 F) with open Gustilo type III tibial fractures requiring flap coverage, 96 (32.4%) became infected. In the multivariate regression, the time from definitive fixation to flap coverage was most predictive of subsequent wound infection (odds ratio 1.04, 95% confidence interval 1.01 to 1.08, n = 260, P = 0.02) among the time measurements. Temporary internal fixation was not associated with an increased risk of infection in both univariate (P = 0.59) or multivariate analyses (P = 0.60). Flap failure was associated with the highest odds of infection (odds ratio 6.83, 95% confidence interval 3.26 to 14.27, P < 0.001). CONCLUSION: Orthoplastic teams that are dedicated to severe musculoskeletal trauma, that facilitate coordination of definitive fixation and flap coverage, will reduce the infection rates in Gustilo type III tibial fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Operative vs. Nonoperative Treatment of Isolated Humeral Shaft Fractures: A Prospective Cohort Study.

The purpose was to compare plate and screw fixation (open reduction internal fixation [ORIF]) and functional bracing (FB) of isolated humeral shaft fractures with treatment and patient-based outcomes. We performed a prospective trial of ORIF v. FB at 12 centers. Surgeons counseled patients on treatment options and a patient centered decision was made. We enrolled 179 patients, of which 6-month data was analyzed for 102 (39 female; 63 male). Forty-five were treated with ORIF and 57 with FB. We found no difference in the disability of the arm, shoulder and hand (DASH) score, visual analogue score (VAS) or elbow range of motion (ROM) at 6 months. However, 11% of the FB group developed nonunion. Complications in the ORIF group included a 2% infection and nonunion rate and 13% iatrogenic radial nerve dysfunction (RND). ORIF can be expected to result in higher union rates with the inherent risks of infection and RND. Finally, at 6 months, both groups demonstrated higher DASH scores than population norms, indicating a lack of full recovery. (Journal of Surgical Orthopaedic Advances 30(2):067-072, 2021).

Is There a Critical Radiographic Angle That Portends Poor Functional Outcome Scores in Nonoperative Treatment of Isolated Humeral Shaft Fractures?

Our purpose was to evaluate radiographic alignment of nonoperatively treated humerus fractures and determine if there is a critical angle associated with worse outcomes. All patients with humeral shaft fractures that were prospectively followed as part of a larger multicenter trial were reviewed. These patients were selected for nonoperative management based on shared decision making. There were 80 patients that healed with adequate data. The receiver operating characteristic (ROC) had best fit with a sagittal radiographic angle of 10° (AUC: 0.731) and coronal angle of 15° (AUC: 0.580) at 1-year follow-up. We found increased or worse disabilities of the arm, shoulder and hand (DASH) scores with > 10° sagittal alignment or > 15° of coronal alignment. Poor DASH scores were observed at angles lower than previously accepted for nonoperative treatment. These findings are useful in decision making and patient guidance. (Journal of Surgical Orthopaedic Advances 30(2):073-077, 2021).

Potential Benefits of Limited Clinical and Radiographic Follow-up After Surgical Treatment of Ankle Fractures.

INTRODUCTION: Ankle fractures are one of the most prevalent musculoskeletal injuries, with a significant number requiring surgical treatment. Postoperative complications requiring additional interventions frequently occur during the early postoperative period. We hypothesize that there is a limited need for routine clinical and radiographic follow-up once the fracture is deemed healed. METHODS: IRB approval was obtained at four academic trauma centers. A retrospective chart review was done to identify adults with healed unimalleolar and bimalleolar ankle fractures treated surgically with at least 12 months of follow-up. Based on postoperative radiographs, changes in fracture alignment and implant position from radiographic union to final follow-up were documented. The average reimbursement for a final follow-up clinic visit and a set of ankle radiographs were estimated. RESULTS: A total of 140 patients met inclusion criteria. The mean age at injury was 49.5 years, and 67.9% of patients were female. The mean time to healing was 82.2 days (±33.5 days). After radiographic healing, one patient had radiographic changes but was asymptomatic and full weight bearing at their final follow-up. On average, our institution was reimbursed $46 to $49 for a follow-up clinic visit and $364 to $497 for a set of ankle radiographs. CONCLUSION: Given the average time to healing, there is limited utility in routine radiographic and clinical follow-up beyond 16 weeks in asymptomatic patients. In our series, this would result in a savings of $950 to $1,200 per patient. However, after ankle fractures were deemed healed, 0.7% patients had radiographic evidence of a change in implant position. Documenting this change did not modify the immediate course of fracture treatment. Surgeons will need to balance the need for routine follow-up with the potential economic benefits in reducing costs to the healthcare system.

Combined Orthopaedic and Vascular Injuries With Ischemia: A Multicenter Analysis.

OBJECTIVES: To review a large, multicenter experience to identify the current salvage and amputation rates of these combined injuries and, where possible, the variables that predict amputation. DESIGN: Retrospective. SETTING: Nine trauma centers. PATIENTS: This study involved 199 patients presenting to 9 trauma centers with orthopaedic and vascular injuries resulting in ischemic limbs for whom the orthopaedic service was involved with the decision for salvage versus amputation. RESULTS: We reviewed 199 patients, 17-85 years of age. One hundred seventy-two of the injuries were open. Thirty-eight patients (19%) were treated with amputation upon admission as they were deemed to be unsalvageable. Of the remaining 161 patients who had attempted salvage, 36 (30%) required late amputation. Closed injuries were successfully salvaged in 25 of 27 cases (93%). The highest rate of amputation was in tibia fractures with a combined amputation rate of 62%. In those attempted to be salvaged, 21 of 48 (44%) required amputation. The ischemia time for successful salvage was significantly less, P = 0.03. One hundred twenty-four patients had their definitive vascular repair before the bony reconstruction. There were 15 vascular complications, of which 13 (86%) had the definitive vascular repair performed before the definitive osseous repair, although this was not statistically significant. CONCLUSIONS: In this series of combined orthopaedic and vascular injuries, we found a high rate of acute and late amputations. It is possible that other protocols, such as shunting and stabilizing the osseous injury, before vascular repair may benefit limb salvage, although this needs more study. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

External Fixation Devices Within the Magnetic Resonance Imaging Bore: A Safety and Radiologic Analysis.

OBJECTIVES: To (1) report the thermal changes encountered at the pin/skin interface in a cadaver with a knee-spanning external fixator inside the magnetic resonance imaging (MRI) bore and (2) report on the quality of the MRI sequences collected. METHODS: Three commonly used external fixation systems were placed on cadaveric lower extremities to simulate knee external fixation. Fiber optic thermal probes were placed at the pin/skin interface of a femoral and tibial pin. A control probe was embedded in the soft tissues of the thigh. Full knee MRI scans were performed using a 1.5-Tesla magnet. Real-time thermal data were collected. A clinically significant increase in temperature compared with the control was defined as 2°C. Two blinded radiologists evaluated the images for image quality and overall diagnostic utility using a standardized 5-point grading scale. RESULTS: There were statistically significant differences in the temperature changes between the femoral/tibial pin sites and the control probe sites during each phase of the MRI scan. However, there was only one clinically significant difference in temperature change during a single sequence of one MRI scan of one of the external fixator devices. Overall image quality was graded as a 4 for each image set with 100% interobserver agreement (k = 1.0). CONCLUSIONS: Despite significant differences in temperature changes between the pin sites and controls over multiple MRI sequences in commonly used external fixator devices, the differences in temperature change are likely not clinically relevant. Overall image quality and interpretability of the images were excellent.

Postoperative Complications of Hip Fractures Patients on Chronic Coumadin: A Comparison Based on Operative International Normalized Ratio.

In current clinical practice, orthopedic surgeons often delay the surgery intervention on geriatric hip fracture patients to optimize the international normalized ratio (INR), in order to decrease the risk of postoperative hematological complications. However, some evidence suggests that full reversal protocols may not be necessary, especially for patients with prior thromboembolic history. Our study aims to compare the surgical outcomes of patients with normal versus elevated INR values. We conducted a retrospective chart review on 217 patients who underwent surgeries on hip fractures at two academic trauma centers. We found that in our group (n = 124) of patients with an INR value of 1.5-3.0, there was only one reoperation for a hematoma, but there was a trend for more blood transfusions. There was no statistically significant difference in the odds of reoperation or overall complications. Nevertheless, there were significantly more events of postoperative anemia in this high INR patient group.

What is the Real Rate of Radial Nerve Injury After Humeral Nonunion Surgery?

OBJECTIVES: To determine the radial nerve palsy (RNP) rate and predictors of injury after humeral nonunion repair in a large multicenter sample. DESIGN: Consecutive retrospective cohort review. SETTING: Eighteen academic orthopedic trauma centers. PATIENTS/PARTICIPANTS: Three hundred seventy-nine adult patients who underwent humeral shaft nonunion repair. Exclusion criteria were pathologic fracture and complete motor RNP before nonunion surgery. INTERVENTION: Humeral shaft nonunion repair and assessment of postoperative radial nerve function. MAIN OUTCOME: Measurements: Demographics, nonunion characteristics, preoperative and postoperative radial nerve function and recovery. RESULTS: Twenty-six (6.9%) of 379 patients (151 M, 228 F, ages 18-93 years) had worse radial nerve function after nonunion repair. This did not differ by surgical approach. Only location in the middle third of the humerus correlated with RNP (P = 0.02). A total of 15.8% of patients with iatrogenic nerve injury followed for a minimum of 12 months did not resolve. For those who recovered, resolution averaged 5.4 months. On average, partial/complete palsies resolved at 2.6 and 6.5 months, respectively. Sixty-one percent (20/33) of patients who presented with nerve injury before their nonunion surgery resolved. CONCLUSION: In a large series of patients treated operatively for humeral shaft nonunion, the RNP rate was 6.9%. Among patients with postoperative iatrogenic RNP, the rate of persistent RNP was 15.8%. This finding is more generalizable than previous reports. Midshaft fractures were associated with palsy, while surgical approach was not. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Standardized, Patient-specific, Postoperative Opioid Prescribing After Inpatient Orthopaedic Surgery.

BACKGROUND: Opioid-related mortality has increased over the past 2 decades, leading to the recognition of a nationwide opioid epidemic and prompting physicians to reexamine their opioid prescribing practices. At our institutions, we had no protocol for prescribing opioids upon discharge after inpatient orthopaedic surgery, resulting in inconsistent and potentially excessive prescribing. Here, we report the results of the implementation of a patient-specific protocol using an opioid taper calculator to standardize opioid prescribing at discharge after inpatient orthopaedic surgery. METHODS: The opioid taper calculator is a tool that creates a patient-specific opioid taper based on each patient's 24-hour predischarge opioid utilization. We implemented this taper for patients discharged after inpatient orthopaedic surgery at our two institutions (Boston Medical Center and Lahey Hospital and Medical Center-Burlington Campus). We compared discharge opioid quantities between orthopaedic patients postimplementation and quantities prescribed preimplementation. We also compared discharge opioid quantities between orthopaedic and nonorthopaedic surgical services over the same time period. RESULTS: Nine-months postimplementation, a patient-specific taper was used in 74% of eligible discharges, resulting in a 24% reduction in opioids prescribed at discharge, along with a 35% reduction in variance. Over the same time frame, a smaller reduction (9%) was seen in the opioids prescribed at discharge by nonorthopaedic services. The most notable reductions were seen after total joint arthroplasty and spinal fusions. Despite this reduction, most patients (65%) reported receiving sufficient opioids, and no substantial change was observed in 30-day postdischarge opioid prescription refills after versus before protocol implementation (1.58 versus 1.71 fills per discharge). DISCUSSION: Using the opioid taper calculator, a patient-specific taper can be successfully used to standardize opioid prescribing at discharge after inpatient orthopaedic surgery without a substantial risk of underprescription. LEVEL OF EVIDENCE: Level II.

Henry Versus Thompson Approach for Fixation of Proximal Third Radial Shaft Fractures: A Multicenter Study.

OBJECTIVE: To compare the volar Henry and dorsal Thompson approaches with respect to outcomes and complications for proximal third radial shaft fractures. DESIGN: Multicenter retrospective cohort study. PATIENTS/PARTICIPANTS: Patients with proximal third radial shaft fractures ± associated ulna fractures (OTA/AO 2R1 ± 2U1) treated operatively at 11 trauma centers were included. INTERVENTION: Patient demographics and injury, fracture, and surgical data were recorded. Final range of motion and complications of infection, neurologic injury, compartment syndrome, and malunion/nonunion were compared for volar versus dorsal approaches. MAIN OUTCOME: The main outcome was difference in complications between patients treated with volar versus dorsal approach. RESULTS: At an average follow-up of 292 days, 202 patients (range, 18-84 years) with proximal third radial shaft fractures were followed through union or nonunion. One hundred fifty-five patients were fixed via volar and 47 via dorsal approach. Patients treated via dorsal approach had fractures that were on average 16 mm more proximal than those approached volarly, which did not translate to more screw fixation proximal to the fracture. Complications occurred in 11% of volar and 21% of dorsal approaches with no statistical difference. CONCLUSIONS: There was no statistical difference in complication rates between volar and dorsal approaches. Specifically, fixation to the level of the tuberosity is safely accomplished via the volar approach. This series demonstrates the safety of the volar Henry approach for proximal third radial shaft fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Previous Implant Fractures: A New Descriptive Classification System.

OBJECTIVES: To propose a previous implant fractures (PIFs) classification system with good interobserver reliability. DESIGN: Retrospective classification. SETTING: Four academic medical centers. PATIENTS/PARTICIPANTS: A retrospective review of PIFs treated at 4 academic medical centers over 10 years was performed. Data collected included initial implant and PIF radiographs. There were 103 PIFs in 96 patients during the study period. Seventy-three (70.9%) were about plate/screw (PS) constructs and 30 (29.1%) were about intramedullary (IM) devices. INTERVENTION: Assignment of PIF classification. MAIN OUTCOME MEASUREMENTS: PIFs were classified based on initial implant (PS or IM) and fracture location with respect to the initial implant (proximal or distal to the implant, at the tip of the construct, or within the construct). Reliability of this scheme was assessed among 5 observers using Fleiss' kappa tests. RESULTS: Of PIFs about plate/screw constructs, 26.0% were proximal/distal to the implant (classification: PS1), 57.5% involved bone between the most proximal/distal screw and the same end of the plate (classification: PS2), and 16.4% involved only bone between the most proximal and distal screws (classification: PS3). Of PIFs about IM, 43.3% were distal to the device (classification: IM1), 46.7% involved bone between the most proximal/distal locking bolt and the same end of the device (classification: IM2), and 10.0% involved only bone between locking bolts (classification: IM3). Interobserver reliability for the classification system was excellent between observers, κ = 0.839, P < 0.0005. CONCLUSIONS: The proposed system offers a simple method to classify and describe fractures that occur about a previously implanted fracture device. Development of a classification system will allow for comparison of treatment modalities between injury types.

Garden 1 and 2 Femoral Neck Fractures Collapse More Than Expected After Closed Reduction and Percutaneous Pinning.

OBJECTIVES: To report on the final displacement after in situ percutaneous pinning for Garden type 1 and 2 fractures in height, femoral neck fracture collapse, and loss of offset. DESIGN: Retrospectively reviewed case series. SETTING: Three Academic Medical Centers. Boston University Medical Center (Level 1 Trauma Center), Lahey Hospital and Medical Center (Level 2 Trauma Center), and Geisinger Medical Center (level 2 Trauma Center). PATIENTS/PARTICIPANTS: One hundred thirty skeletally mature patients with 130 fractures (78 garden 1 and 52 garden 2) who were treated between January 2000 and January 2014 at participating hospitals with percutaneous pinning with a cannulated screw system to successful union after sustaining an intracapsular femoral neck fracture without complete displacement. INTERVENTION: In situ percutaneous pinning with 3 cannulated, partially threaded screws in an inverted triangle orientation. MAIN OUTCOME MEASUREMENTS: Femoral neck fracture collapse (mm), femoral height shortening (mm), and femoral offset shortening (mm). RESULTS: A total of 130 patients (81F, 49M), average age 72 years, sustained 78 Garden 1 and 52 Garden 2 femoral neck fractures. Maximal collapse occurred in the plane of the femoral neck. Thirty-three of 78 (42%) Garden 1 fractures and 33/52 (63%) Garden 2 fractures demonstrated >10 mm fracture collapse. The range of displacements was 0-39 mm as measured along the plane of the femoral neck. CONCLUSIONS: Garden 1 fractures collapse less frequently than Garden 2 fractures, but both have high rates of fracture collapse when treated to union with in situ percutaneous pin fixation. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

THE EFFECTS OF HYPONATREMIA ON BONE DENSITY AND FRACTURES: A SYSTEMATIC REVIEW AND META-ANALYSIS.

Objective: Hyponatremia decreases bone mineral density and is a major risk factor for fragility fractures. Objectives of our systematic review and meta-analysis were to analyze the overall effects of hyponatremia on bone fractures, osteoporosis, and mortality. Methods: We extracted data from Medline, Cochrane Central, and EMBASE 1960-2017 and conference abstracts from 2007-2017. We included studies with data on serum sodium, fractures, bone density, or diagnoses of osteoporosis. Studies were independently reviewed by two authors and assessed for bias using the Newcastle-Ottawa scale. Random effect models meta-analysis was used when at least three studies reported the same outcome measures. We reported summary odds ratios (ORs) and 95% confidence intervals (CIs). Results: We included 26 studies for qualitative analysis. Fifteen studies were included in the meta-analysis to evaluate the effects of hyponatremia on fractures, four studies for bone mineral density changes, and six for mortality. Hyponatremia increased the odds of fractures at all sites (summary OR, 2.34 [95% CI, 1.86, 2.96]. There was an increase in the odds of osteoporosis (summary OR, 2.67 [95% CI, 2.07, 3.43]). Mortality risk among the included studies remained high (summary OR, 1.31 [95% CI, 1.16, 1.47]). Conclusion: Our meta-analysis confirms a statistically significant association of hyponatremia with bone fractures and osteoporosis along with higher mortality. Long-term prospective studies evaluating the impact of correcting hyponatremia on bone health, fractures, and mortality are required. Abbreviations: AVP = arginine vasopressin; CI = confidence interval; CKD = chronic kidney disease; OR = odds ratio; SIADH = syndrome of inappropriate antidiuretic hormone.

Endoscopic Management of a Trauma-Induced Urethral Pseudoaneurysm.

Background: Urethrorrhagia is a rare urologic event with urethral pseudoaneurysm a potential cause. All previous reports of urethral pseudoaneurysm have been managed with angioembolization. Case Report: A 25-year-old man experienced delayed presentation of urethrorrhagia secondary to urethral pseudoaneurysm formation after significant pelvic trauma. Urethral pseudoaneurysm was definitively managed with endoscopic transurethral external compression. Endoscopic thrombosis of pseudoaneurysm was confirmed by postprocedure angiography. Conclusion: Endoscopic transurethral management of a urethral pseudoaneurysm is an alternative form of treatment for urethral pseudoaneurysm, with potentially fewer downstream effects on voiding and erectile function.

Correlation Between 24-Hour Predischarge Opioid Use and Amount of Opioids Prescribed at Hospital Discharge.

Importance: The United States is experiencing an opioid abuse epidemic. Opioid overprescription by physicians may contribute to this epidemic. Objectives: To determine if there was a correlation between a postoperative patient's 24-hour predischarge opioid use and the amount of opioids prescribed at hospital discharge and to determine the number of patients who used no opioids prior to discharge but were still prescribed opioids after hospital discharge. Design, Setting, and Participants: This cross-sectional study performed a retrospective record review of 18 343 postoperative patients at Boston Medical Center and Lahey Hospital and Medical Center-Burlington Campus who were discharged home after a postoperative inpatient admission of at least 24 hours. Data collection spanned from May 22, 2014, to June 30, 2016, in the Boston Medical Center data set and from March 23, 2015, to September 7, 2016, in the Lahey Hospital and Medical Center-Burlington Campus data set. Exposures: Surgery requiring a postoperative inpatient hospital stay longer than 24 hours. Main Outcomes and Measures: The main outcome measures were the patient's 24-hour predischarge opioid use and the total quantity of opioids prescribed at hospital discharge. Potential overprescription was defined as the number of patients who used no opioids in the 24 hours prior to hospital discharge but were still prescribed opioids after hospital discharge. Results: Among the 18 343 patients (10 069 women and 8274 men; mean age, 52.2 years) who underwent 21 452 surgical procedures, there was wide variation in the amount of opioids prescribed at hospital discharge given a postoperative patient's 24-hour predischarge opioid use. A total of 6548 patients (35.7%) used no opioids in the 24 hours prior to hospital discharge; however, 2988 of these patients (45.6%) were prescribed opioids at hospital discharge, suggesting potential overprescription. Services that had the highest rates of potential overprescription (obstetrics [adjusted odds ratio (AOR), 3.146; 95% CI, 2.094-4.765] and gynecology [AOR, 2.355; 95% CI, 1.663-3.390], orthopedics [AOR, 0.943; 95% CI, 0.719-1.242], and plastic surgery [AOR, 0.733; 95% CI, 0.334-1.682]) generally had the highest rates of patients still using opioids at hospital discharge. Pediatric surgery was the only service that did not have any cases of potential overprescription (AOR, 2.09 × 10-7; 95% CI, 0.000-0.016). Conclusions and Relevance: Opioids are not regularly prescribed in a patient-specific manner to postoperative patients. Potential opioid overprescription occurs regularly after surgery among almost all surgical specialties.