Dual Mini-Fragment Plate Fixation of Midshaft Clavicle Fractures Reduces Risk of Reoperation Compared With Single-Plate Fixation Techniques.

BACKGROUND: Recent studies have highlighted dual plating as a method of reducing high rates of postoperative complication after operative management of displaced midshaft clavicular fractures. However, few studies have reliably characterized reoperation rates and magnitude of risk reduction achieved when using dual versus anterior and superior single-plate techniques. HYPOTHESIS: There would be lower rates of reoperation among patients who underwent open reduction and internal fixation (ORIF) of displaced midshaft clavicular fractures via dual plating. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This was a retrospective analysis of patients who underwent ORIF for a displaced midshaft clavicular fracture between 2010 and 2021 at a level 1 trauma center with a minimum 12-month follow-up. Patients were separated into 3 cohorts based on fixation type: (1) orthogonal dual mini-fragment plate fixation, (2) superior plate fixation, and (3) anterior plate fixation. Data on patient characteristics, fracture pattern, and reoperations were documented. All-cause reoperation rates and hazard ratio (HR) estimates of dual, superior, and anterior plating were calculated using a multivariate multilevel mixed-effects parametric survival model. Significant confounders including high-risk fracture morphology and smoking status were controlled for in the final model. RESULTS: A final cohort of 256 patients was identified with mean follow-up of 4.9 ± 3.8 years. In total, 101 patients underwent superior plating, 92 underwent anterior plating, and 63 underwent dual plating. Overall, 31 reoperations took place (18 in superior, 12 in anterior, 1 in dual plating) among 22 patients. Major contributors to reoperation included symptomatic hardware (n = 11), nonunion (n = 8), deep infection (n = 7), and wound dehiscence (n = 2). Superior plating revealed the highest reoperation rate of 0.031 per person-years, followed by anterior plating with 0.026 per person-years and dual plating with 0.005 per person-years. Overall, single plating (either anterior or superior placement) had a nearly 8-fold greater risk of reoperation than dual plating (HR, 7.62; 95% CI, 1.02-56.82; P = .048). Further broken down by technique, superior plating had an 8-fold greater risk of reoperation than dual plating (HR, 8.36; 95% CI, 1.10-63.86; P = .041), but anterior plating did not demonstrate a statistically significant difference compared with dual plating (HR, 6.79; 95% CI, 0.87-52.90; P = .068). CONCLUSION: Dual-plate fixation represents an excellent treatment for displaced midshaft clavicular fractures, with low rates of nonunion and reoperation. When compared with single locked superior or anterior plate fixation, dual mini-fragment plate fixation has a nearly 8-fold lower risk of reoperation.

Technical Trick: Supplemental Medial Column Screw Fixation of Distal Femur Fractures Treated With a Laterally Based Locked Plate.

SUMMARY: Given known failure rates after lateral plating of distal femur fractures, there is an increasing interest in augmenting fixation to improve outcomes. The addition of medial plates or intramedullary nails have been described with promising results, decreasing nonunion and varus collapse rates. However, the use of dual implants increases implant costs, adds surgical complexity, and requires a second surgical approach that may increase morbidity. A supplemental, percutaneously placed, medial column screw may provide a less invasive means of improving stability and achieving fracture union compared with lateral plating alone.

Early initiation of physical therapy after geriatric hip fracture surgery is associated with shorter hospital length of stay and decreased thirty-day mortality.

INTRODUCTION: While the importance of timely surgery and early mobilization are understood in geriatric fracture populations, the relationship between timing of initiation of physical therapy (PT) postoperatively on length of stay (LOS) and mortality has not been well delineated. The purpose of this investigation was to determine the effect of PT initiated on postoperative day zero (POD0) on LOS and mortality in geriatric hip fracture patients. MATERIALS AND METHODS: Patients aged 60 and over who underwent hip fracture surgery, including arthroplasty or internal fixation, between January 2017 and December 2019 at three affiliated academic hospitals were identified. Retrospective chart review and review of hospital charges were used to determine patient demographics, Charlson Comorbidity Index (CCI), surgery performed, timing of postoperative PT visits, LOS, and mortality. RESULTS: Of 1,551 patients identified that met inclusion criteria, 83 (5.3%) received PT on POD0. Most patients (76.3%) received PT on postoperative day 1 (POD1), and 18.4% received first PT on postoperative day 2 or later (POD2+). Time from admission to surgery, CCI, sex, and BMI did not differ significantly between groups. The age difference between patients in the POD0 and the POD1/POD2+ groups was statistically significant with the mean age in the POD1/2+ group being 2.3 years older than the POD0 group (p=0.045). There was no difference in postoperative length of stay (PLOS) based on type of fixation. The average PLOS was 3.4 days in the POD0 PT group compared to 5.2 days in the POD1 group (p<0.0001) and 8.2 days in the POD2+ group (p<0.0001). The POD0/1 group had significantly lower mortality than the POD2+ group [3.7% vs. 9.8%, OR 0.354 (95% CI 0.217-0.575), p<0.0001]. CONCLUSION: Earlier initiation of PT postoperatively is associated with significantly shorter total and postoperative LOS and initiation of PT before POD2 is associated with decreased 30-day mortality. Each day that initiation of PT is delayed is associated with a two- to three-day increase in LOS.

Postoperative radial nerve palsy in humeral shaft nonunion reconstruction: Can the lateral paratricipital approach prevent this common complication?

BACKGROUND: Postoperative radial nerve palsy (RNP) is a well-known complication of nonunion reconstruction of the humerus. The purpose of the current study is to determine if the surgical approach for nonunion reconstruction of the humerus influences the rate of postoperative radial nerve palsy. METHODS: A retrospective case-control study of all humeral shaft and extraarticular distal humerus nonunion reconstructions performed between January 1, 2004, and August 31, 2021, was conducted. Patients included were over 18 years of age, had a non-pathologic humerus fracture nonunion and had intact radial nerve function prior to nonunion reconstruction. Exclusion criteria consisted of nonunions involving the proximal humerus, intraarticular fractures, and reconstructive treatment procedures with either intramedullary nail or external fixation methods. Perioperative variables were recorded and analyzed in regard to the development of postoperative RNP. A subgroup analysis was performed to assess the interaction of significant variables on the development of postoperative RNP. RESULTS: The overall rate of postoperative RNP in this series was 6/53 (11%). However, no cases of postoperative radial nerve palsy were observed in patients who underwent nonunion reconstruction with a lateral paratricipital approach. A new RNP was seen in 4/9 (44%) of those patients who underwent a triceps splitting approach, which was significantly higher than those utilizing either an anterolateral approach (2/28, 7%) or a lateral paratricipital approach (0/16, 0%, p = 0.007). DISCUSSION AND CONCLUSION: Our data suggests that the lateral paratricipital exposure decreases the risk of radial nerve injury with nonunion reconstruction of the humerus. The lateral paratricipital exposure offers the benefit of radial nerve exploration, decompression, neurolysis and protection prior to fracture manipulation and instrumentation. This study shows conventional approaches may predispose patients to a high rate of postoperative RNP, similar to that in the literature.

Subcuticular Barbed Suture and Skin Glue Wound Closure Decreases Reoperation and Length of Stay in Geriatric Hip Fractures When Compared With Staples.

INTRODUCTION: Patients with geriatric hip fracture are notoriously frail and at risk for complications. Persistent postoperative wound drainage can lead to prolonged hospital stay, increased risk for infection, and need for revision surgery. The purpose of this study was to determine the effect of wound closure technique, barbed monofilament subcuticular suture and skin glue versus staples on rates of intervention for wound drainage and length of hospital stay after geriatric hip fracture fixation. METHODS: A retrospective review of isolated hip fractures in patients older than 60 years at a single institution over a 3-year period was done. Hip fractures included femoral neck, intertrochanteric, and subtrochanteric femur fractures treated with internal fixation or arthroplasty. Skin closure technique, at the discretion of the operating surgeon, included either barbed subcuticular monofilament suture and skin glue or staples. Charts and radiographs were reviewed to determine patient characteristics, Charlson Comorbidity Index, type of wound closure, length of stay, and interventions for persistent wound drainage. RESULTS: There were 175 patients in the barbed suture and skin glue group and 211 patients in the staples group. The barbed suture group had an average postsurgical length of stay of 5.0 days which was significantly lower than the staples group (7.0 days, P < 0.00001). In the staples group, 17 patients (8%) required incisional negative pressure wound therapy due to wound drainage with five patients (2.4%) returning to the operating room secondary to persistent wound drainage. No patients were observed in the barbed suture group that required intervention for wound drainage. DISCUSSION: Barbed suture and skin glue closure is associated with markedly shorter hospital stay and fewer interventions for wound drainage when compared with staples after surgical treatment of geriatric hip fractures.

Increased Medial Displacement of the Humeral Shaft of at Least 40% Correlates With an Increased Incidence of Nerve Injury in Proximal Humerus Fractures.

BACKGROUND: Peripheral nerve and infraclavicular brachial plexus injury following proximal humerus fractures are commonplace, but diagnosing a concomitant nerve injury in the acute setting is challenging. Fracture displacement has been identified as a qualitative risk factor for nerve injury, and additional attention should be paid to the neurologic exams of patients with proximal humerus fractures with significant medial shaft displacement. However, a quantitative relationship between the risk of nerve injury and medialization of the humeral shaft has not been shown, and additional risk factors for this complication have not been assessed. The aim of this study was to identify the risk factors for a neurologic deficit following a proximal humerus fracture, with particular interest in the utility of the magnitude of medial shaft displacement as a predictor of neurologic dysfunction. METHODS: A retrospective chart review was performed on all proximal humerus fractures in a 3-year period (2012-2015) at a level one trauma center. Isolated greater tuberosity fractures (OTA 11-A1) were excluded. Fracture displacement was measured on initial injury AP shoulder radiograph and expressed as a percentage of humeral diaphyseal width. All orthopedic inpatient documentation was assessed to identify clinical neurologic deficits. RESULTS: We identified 139 patients for inclusion. There were 22 patients (16%) with new neurologic deficits at presentation (8 axillary nerve, 2 radial nerve, 12 infraclavicular brachial plexus or multiple nerve injuries). The average shaft medial displacement in patients with neurologic injuries was 59% vs. 21% without nerve deficits (p=0.03). Using a 40% medial displacement threshold, the odds ratio for a nerve injury was 5.24 (95% CI 1.54 - 17.77, p=.008). CONCLUSION: Increased medial displacement of the humeral shaft following proximal humerus fracture is associated with an increased incidence of nerve injury at the time of initial presentation. This finding is not meant to be a surrogate for a high-quality neurologic exam in all patients with proximal humerus fractures. However, improved knowledge of the specific risk factors for an occult neurologic injury will improve the clinician's ability to accurately diagnose and properly treat proximal humerus fractures and their sequelae.Level of Evidence: III.

Distal locking of short cephalomedullary nails decreases varus collapse in unstable intertrochanteric fractures - a biomechanical analysis.

INTRODUCTION: Peritrochanteric fractures are a growing problem and complications relating to operative fixation of these fracture, including varus collapse and screw cutout, are common in elderly osteoporotic patients. We hypothesize that unlocked nails will demonstrate increased varus collapse and inferior construct stiffness in specimens with increased diaphyseal medullary diameter. MATERIALS AND METHODS: Sixteen non-cadaveric osteoporotic biomechanical femur specimens were utilized in this study, with eight specimens having an artificially large femoral canal to represent Dorr C femurs. All femurs were instrumented with a short cephalomedullary nail with and without distal cross-lock screw fixation and had an unstable intertrochanteric fracture created in a repeatable pattern. Specimens underwent cyclic compression to a maximal load of 1000N with segmental motion quantified through the use of visual tracking markers. Statistical comparisons were performed using one-way ANOVA with Tukey post-hoc analysis to determine differences between specific groups. Significance was defined as p<0.05. RESULTS: Unlocked short cephalomedullary nails showed increased varus collapse due to motion of the nail within the femoral canal in capacious femoral canals compared with narrow femoral canals and distally cross-locked nails. The coronal deformation of the wide canal unlocked group (17.9 o±2.6o) was significantly greater in the varus direction than any other fixation under compressive load of 1000N. There was no significant difference in varus angulation between the wide canal or narrow canal locked groups (11.1o±8.7o vs. 8.2o±1.7o respectively, p=0.267). The narrow canal unlocked group (13.7o±2.4o) showed significantly greater varus angulation than the narrow canal locked (p=0.015). The wide canal unlocked group showed significantly greater varus angulation than the wide canal locked group (p=0.003). Motion between the femoral shaft and the cephalomedullary nail (toggling of the nail within the shaft) was significantly greater in narrow or wide canal unlocked specimens, 7.94o±2.13o and 10.2o±1.7o respectively, than in the narrow or wide canal locked specimens, 2.4o±0.2o and 4.2o±0.5o respectively (p<0.05) CONCLUSION: Unlocked short intramedullary fixation for unstable peritrochanteric fractures results in increased varus collapse under axial compression. This study supports the use of distal cross-locking of short intramedullary fixation for unstable peritrochanteric fractures in patients with capacious femoral canals secondary to osteoporosis who might otherwise be as risk for varus collapse, device failure, and malunion.

Temporizing External Fixation vs Splinting Following Ankle Fracture Dislocation.

BACKGROUND: Closed reduction and splinting followed by outpatient management is standard of care for temporizing most ankle fractures. However, ankle fracture-dislocation potentially warrants a different approach based on the propensity for loss of reduction. The purpose of this study was to determine the rate of complications associated with closed reduction and splinting of unstable ankle fracture-dislocations. Further, we sought to determine the efficacy of immediate external fixation as an alternative to splinting in cases too swollen for acute operation. METHODS: This retrospective chart review analyzed all ankle-fracture dislocations that came through a large health care system from 2008 to 2018. Patients managed with acute open reduction internal fixation (ORIF) and open fractures were excluded. In patients managed late, the cohorts were divided into those temporized with closed reduction/splinting vs external fixation. Reduction quality and splint technique were additionally assessed in splinted patients. A total of 354 closed ankle fracture-dislocations were identified: 298 patients (84%) underwent ORIF within 48 hours and were excluded; 28 (15 female/13 male, average age 46.8 years) were placed in an external fixator and 28 (22 female/6 male, average age 57.2 years) were reduced, splinted, and discharged. RESULTS: At follow-up, 14 of the patients (50%) in the splint group developed loss of reduction and 5 of these patients (17.6%) developed anteromedial skin necrosis from skin tenting. None of the patients in the ex-fix group developed loss of reduction or skin necrosis. The rate of redislocation and the rate of development of skin necrosis was statistically higher in cases temporized with a splint versus an external fixator (P < .01 and P = .05, respectively). CONCLUSION: We found that in ankle fracture-dislocations not treated with acute ORIF, splint immobilization was associated with an increased risk of complications, including redislocation and skin necrosis, when compared to a temporizing external fixator. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Opioid use patterns and risk characteristics among injured patients.

Background: Injured patients are at risk for prolonged opioid use after discharge from care. Limited evidence exists regarding how continued opioid use may be related to opioid medication misuse and opioid use disorder (OUD) following injury. This pilot study characterized opioid consumption patterns, health characteristics, and substance use among patients with active prescriptions for opioid medications following injury care. Methods: This study was a cross-sectional screening survey combined with medical record review from February 2017 to March 2018 conducted among outpatient trauma and orthopedic surgery clinic patients. Eligible patients were 18-64 years of age, admitted/discharged for an injury or trauma-related orthopedic surgery, returning for clinic follow-up ≤6 months post hospital discharge after the index injury, prescribed opioid pain medication at discharge, and currently taking an opioid medication (from discharge or a separate prescription post discharge). Data collected included demographic, substance use, mental health, and physical health information. Descriptive and univariate statistics were calculated to characterize the population and opioid-related risks. Results: Seventy-one participants completed the survey (92% response). Most individuals (≥75%) who screened positive for misuse or OUD reported no nonmedical/illicit opioid use in the year before the index injury. A positive depression screen was associated with a 3.88 times increased likelihood for misuse or OUD (95% confidence interval [CI] = 1.1-13.5). Nonopioid illicit drug use (odds ratio [OR] = 1.89, 95% CI = 1.1-3.4) and opioid craving (OR = 1.29, 95% CI = 1.1-1.5) were also associated with increased likelihood for misuse or OUD. Number of emergency department visits in the 3 years previous to the index injury was associated with a 22% likelihood of being misuse or OUD positive (95% CI = 1.0-1.5). Conclusions: Patients with behavioral health concerns and greater emergency department utilization may have heightened risk for experiencing adverse opioid-related outcomes. Future research must further establish these findings and possibly develop protocols to identify patients at risk prior to pain management planning.

Assessing Postoperative Reduction After Acetabular Fracture Surgery: A Standardized Digital Computed Tomography-Based Method.

Quality of reduction after acetabular fracture surgery is an important predictor of clinical outcome. Computed tomography (CT) is likely superior to plain pelvic radiography for assessment of postoperative reduction, but interobserver reliability may be limited in the absence of a widely adopted technique. We describe a standardized digital CT-based method for measuring residual (gap and step) displacement on CT after acetabular fracture surgery. In a selection of patients, we determined the interobserver reliability for measuring displacement and grading the quality of reduction on postoperative pelvic radiography and CT, with and without the use of this novel technique.

Equivalent mortality and complication rates following periprosthetic distal femur fractures managed with either lateral locked plating or a distal femoral replacement.

INTRODUCTION: Management of distal femur fractures above total knee arthroplasty (TKA) remains challenging. Two common surgical options are locked lateral plating (LLP) and distal femoral arthroplasty (DFR). Unfortunately, approximately 30-50% of patients may die within one year of injury, require further surgery, or not regain prior mobility performance. We compared 87 LLP to 53 DFR patients - to our knowledge the largest comparative study - focusing on 90- and 365-day mortality, mobility maintenance, and further surgery. METHODS: We performed a retrospective review of patients at least 55 years old who sustained femur fractures near a primary TKA (essentially OTA-33 or Su types 1, 2, or 3) from 2000 to 2015 assigning cohort based on treatment: LLP or DFR. We excluded patients having prior care for the injury, whose surgery was not for fracture (e.g. loosening), or having other surgical intervention (e.g. intramedullary nail). RESULTS: Results Cohorts were similar based on body mass index and age adjusted Charlson Comorbidity Index (aaCCI). LLP was more common than DFR for fractures above and at the level of the implant, but similar for fractures within the implant for patients with aaCCI ≥ 5. LLP and DFR had similar mortality at 90 days (9% vs 4%) and 365 days (22% vs 10%), need for additional surgery (9% vs 3%), and survivors maintaining ambulation (77% vs 81%). Patients whose surgery occurred 3 or more days after presentation had similar mortality risk to those whose surgery was before 3days. The mean age of one year survivors was 77 whereas for patients who died it was 85. Neither surgical choice nor aaCCI was associated with increased risk in time to surgery. CONCLUSIONS: Fracture location, remaining bone stock, and patient's prior mobility and current comorbidities must guide treatment. Our study suggests that 90- and 365-day mortality, final mobility, and re-operation rate are not statistically different with LLP vs DFR management.

Geriatric distal femur fracture: Are we underestimating the rate of local and systemic complications?

BACKGROUND: Low energy distal femur fractures often occur in a fragile elderly population that is prone to local and systemic complications following operative treatment of extremity fractures. The nonunion rate and early complication rate following laterally based locked plating in this specific fracture are not well described. METHODS: We conducted a retrospective cohort study conducted at three affiliated tertiary care hospitals to evaluate nonunion, early post operative complications, discharge disposition, length of stay, and mortality in patients over 60 years old undergoing laterally based locked plating of a low energy distal femur fracture. RESULTS: Forty-four out of 176 patients were deceased at one year (25%). Predictors of one year mortality included older age, higher Charlson Comorbidity Index (CCI), and delay to surgery greater than 2days (p<0.001). Of 99 patients alive and with follow up at one year, 24 (24%) developed a nonunion and 21 of 24 required nonunion surgery. Development of a surgical site infection was statistically significantly correlated with development of nonunion. Age and CCI did not predict development of nonunion. Average length of stay was 10days and 82% of patients were discharged to a skilled nursing facility. Thirty eight percent of patients experienced at least one postoperative systemic complication. CONCLUSIONS: Laterally based locked plating of the low energy geriatric distal femur fracture is most often followed by a tumultuous post-operative course with a high rate of local and systemic complications including death, nonunion, and extended hospital stays. LEVEL OF EVIDENCE: Level III prognostic.

Proximal Periprosthetic Femur Fractures: Strategies for Internal Fixation.

As the number of patients living with total hip arthroplasty continues to rise, there will be an increase in periprosthetic fractures requiring surgical treatment. Treatment of periprosthetic femur fractures below a well-fixed hip arthroplasty stem presents a unique set of challenges. A review of the existing literature on surgical technique, including plate selection and configuration, proximal fixation options, and use of allograft, can serve to guide treatment of these challenging injuries. While not conclusive, the literature supports using soft tissue preserving techniques, bicortical proximal fixation, and fixation spanning the length of the femur.

Treatment of periprosthetic femur fractures around a well-fixed hip arthroplasty implant: span the whole bone.

INTRODUCTION: Periprosthetic femur fractures are a growing problem in the geriatric population. This study examines Vancouver B1 periprosthetic femur fractures treated with open reduction internal fixation using a laterally based plate. Outcomes using plates which spanned the length of the femur to the level of the femoral condyles were compared to those which did not. The hypothesis was that spanning internal fixation would result in a decreased rate of refracture and subsequent reoperation. MATERIALS AND METHODS: Patients admitted to three affiliated academic hospitals treated with open reduction internal fixation for a periprosthetic femur fracture in the setting of a preexisting total hip arthroplasty or hemiarthroplasty stem were identified. Patient data were reviewed for age, gender, fracture classification, operative intervention, time to union, as well as complications related to treatment and need for further surgery. RESULTS: Over a 5-year period, 58 patients were treated with open reduction internal fixation using a laterally based plate for Vancouver B1 femur fractures. Twenty-one patients were treated with plates that extended to the level of the femoral condyles. In that group there were no nonunions or subsequent periprosthetic fractures reported. Of 36 patients treated with short plates, 3 went on to nonunion resulting in plate failure and refracture and 2 sustained a subsequent fracture distal to the existing fixation. CONCLUSIONS: In this series, fixation for periprosthetic femur fractures around a well-fixed arthroplasty stem which spans the length of the femur to the level of the femoral condyles is associated with a decreased rate of nonunion and refracture. By decreasing the rate of refracture and nonunion, spanning fixation decreases the morbidity and mortality associated with additional surgery in a fragile geriatric population.