What interventions add value in lateral compression type 1 fragility pelvis fractures? A retrospective cohort study.

Introduction: Fragility fractures are a large source of morbidity and mortality in the elderly. Orthopaedic surgeons are regularly the main point of contact in patients with lateral compression type 1 pelvis fractures, despite many of these being treated non-operatively. This study aims to identify risk factors for mortality and elucidate which follow-up visits have the potential to improve care for these patients. Methods and materials: In all, 211 patients have been identified with fragility lateral compression type 1 fractures at a level 1 trauma centre over a 5-year period. For all patients, we recorded patient demographics, imaging data, hospital readmissions, medical complications and death dates if applicable. Results: Of the 211 patients identified, 56.4% had at least one orthopaedic follow-up, of which no patient had a clinically meaningful medical intervention initiated. 30-day readmission rate was 19%, and 1-year mortality was 24%. Male sex, need for an assist device, higher Charlson Comorbidity Index and increased age were found to be statistically associated with increased risk of mortality. Patients who followed up with their primary care physician were found to have a statistically lower risk of mortality. Computed tomography scans were obtained in 70% of patients and never limited patient weight-bearing status or found any additional injury not already identified on the radiograph. Discussion/Conclusions: For patients with lateral compression type 1 type fragility fractures, orthopaedic surgeons did not offer additional clinically meaningful intervention after the time of initial diagnosis in this patient cohort. The rate of clinical follow-up with a primary care physician is relatively low despite high rates of medical comorbidity. Computed tomography scans were utilised frequently but did not change recommendations. The high rate of medical complications and lack of orthopaedic intervention suggest that we should re-evaluate the role of the orthopaedic surgeon versus the primary care physician as the primary point of medical contact for patients with these injuries.

Determination of the Inter- and Intra-rater Reliability of Fusion Assessment in First Tarsometatarsal Joint Arthrodesis Using CT Scan: An Observational Study.

Background: First tarsometatarsal joint arthrodesis is a common procedure performed by podiatrists and orthopedic surgeons. There remains debate on how useful CT scans are in assessing fusion status in the post-operative patient. The purpose of our study was to determine the reliability among both orthopedic surgeons and radiologists in reviewing both postoperative radiographs and CT in order to determine if fusion had occurred in patients undergoing 1st tarsometatarsal arthrodesis. A secondary purpose of this study was to determine if CT offered improved inter- and intra-rater reliability when compared to plain radiographs. Methods: Patients who underwent 1st tarsometatarsal arthrodesis were retrospectively reviewed and those who underwent CT post-operatively for persistent pain were identified. Orthopedic surgeons and radiologists then analyzed the radiographs and CT of these patients for union with a threshold for union being set at 50% of the joint being fused. Imaging was then re-evaluated by the same provider 6 months later. Results: 24 patients were identified meeting inclusion criteria. Inter-rater reliability and intra-rater reliability for assessment of 1st tarsometatarsal arthrodesis were better with CT compared to radiographs; however, this association was not deemed reliable. Both imaging modalities were not able to assess union status confidently and reliably across reviewers, although CT scan had better intra-rater reliability. Conclusions: While CT is frequently used to assess fusion in patients who have underwent 1st tarsometatarsal arthrodesis, it was not found to be better than radiographs. Practitioners should reconsider the use CT as the gold standard when assessing fusion in this population.

Which pediatric supracondylar humerus fractures are high risk for conversion to open reduction?

Supracondylar humerus fractures are common pediatric injuries encountered by orthopedic surgeons. Displaced fractures are treated operatively with closed reduction and percutaneous pinning or open reduction of injuries that cannot be adequately closed reduced. The purpose of this study is to identify preoperative injury characteristics associated with open reduction. Retrospective chart review was performed on all AO type 13A (Gartland type) supracondylar humerus fractures in patients 2-13 years old treated surgically at a single level 1 trauma center over 6 years. Preoperative demographics and radiographic parameters were obtained for all patients. Primary outcomes were closed reduction or conversion to open reduction of fractures prior to k-wire fixation. Initial bivariate analysis was done using Chi-square tests. Final multivariate analysis with Bonferonni correction was performed using a backward, stepwise regression model including potential predictor variables identified in the bivariate analysis. A total of 211 patients received surgical treatment and 18 of those patients (8.5%) failed closed reduction and underwent open reduction. Final multivariate analysis demonstrated that only flexion type [relative risk (RR), 10.2] and coronal displacement more than 7 mm (RR, 4.49) were significant preoperative factors for conversion to open reduction. Patients with significant coronal displacement and flexion-type injuries are markers of challenging reduction and are at high risk for conversion to open reduction.

"Nailable" Does Not Always Mean Reducible in Distal Femur Fractures: Arthroplasty Component and Nail Design Matter.

Distal femur fractures above a total knee arthroplasty (TKA) are challenging. These fractures can be fixed with a retrograde intramedullary nail (rIMN), but the design of the femoral component of the TKA influences the starting point for an rIMN. We performed a biomechanical study to evaluate how different TKA components influence the starting point for an rIMN and how that can lead to a deformity in the sagittal plane. We simulated a distal femur fracture with three different arthroplasty components. We used three different implants to simulate fracture reduction and measured the resultant sagittal plane deformity. Low and moderate femoral component ratio (FCR) design components were able to maintain fracture alignment within 5° of anatomic. High FCR component (more posterior starting point) sagittal plane deformities of up to 15° were observed with both the straight and medium Herzog bend nails, which was statistically significant (P<.001). Use of a high Herzog bend nail decreased the deformity by an average of 6°, which was statistically significant (P<.001). There is variability in how the TKA design affects the starting point and thus the sagittal plane alignment after fixation. This study helps quantify the effect of arthroplasty component design on fracture alignment. [Orthopedics. 2023;46(1):35-38.].

What Is the Rate of Displacement of Occult Posterior Malleolus Fractures in Nailed Tibial Shaft Fractures?

OBJECTIVE: To describe the radiographic consequences of posterior malleolus fractures (PMF) present with tibial shaft fractures fixed with intramedullary nails. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Seven hundred thirty-three patients with tibial shaft fractures. INTERVENTION: Intramedullary nail fixation and prophylactic articular fixation. MAIN OUTCOME MEASURE: Displacement of PMF with intramedullary nail insertion. RESULTS: Seven hundred thirty-three patients were identified with tibial shaft fractures treated with intramedullary nail fixation at a Level 1 trauma center without a uniform preoperative computed tomography protocol. One hundred thirty-three patients had an identifiable PMF appreciated on preoperative imaging. Of the 600 remaining patients without a known PMF, 29 had PMF identified after nail insertion: 24 patients with nondisplaced fractures that all healed radiographically at final follow-up, 3 patients had fractures <30% of the articular surface displaced 1-2 mm, and 2 patients had fractures >30% of the joint surface that displaced 1-2 mm. CONCLUSIONS: The incidence of radiographically observable PMF associated with tibial shaft fractures is high, even without a preoperative computed tomography screening protocol in place. In patients without an appreciable PMF on injury films, less than 1% (2/600) had displacement of a large, clinically significant PMF with nail placement. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Can Lateral X-Rays Reliably Determine Which Posterior Malleolus Ankle Fractures Need a CT?

BACKGROUND: For rotational ankle fractures with a posterior malleolus fracture (PMF), the decision to further evaluate the ankle injury with computed tomography (CT) is challenging. The objective of this study is to determine how well PMF fracture size on x-rays correlates with size on CT, and how well x-rays can predict which patients receive PMF fixation after CT review. METHODS: This is a retrospective study of adult ankle fractures with PMFs that had preoperative radiographs and CT imaging over a 5-year period. PMF x-ray and CT measurements were recorded, and relationships between x-ray measurements and final PMF fixation plan after CT review were evaluated. RESULTS: A total of 98 patients were identified with both x-rays and preoperative CT imaging. Pearson's rank correlation demonstrated a strong relation between PMF width percentage measured on x-ray and CT (r = 0.724). Of the 45 patients with a PMF size under 20% on x-ray, only one patient (with an apparent incarcerated fragment) underwent PMF fixation after review of the CT. CONCLUSIONS: PMF width on lateral x-ray correlates well with CT size and is sensitive for predicting the need for dedicated posterior malleolus based on one institutional practice pattern. Below 20% fracture width on lateral x-ray, a dedicated CT rarely leads to a decision to perform PMF fixation. Limiting pre-operative CT to those with PMF width >20% could reduce CT utilization by as much as 45% without negatively affecting patient care. LEVELS OF EVIDENCE: Level III: Diagnostic.

Is the Direct Anterior Approach to THA Cost-effective? A Markov Analysis.

BACKGROUND: The use of the direct anterior approach, a muscle-sparing technique for THA, has increased over the years; however, this approach is associated with longer procedure times and a more expensive direct cost. Furthermore, studies have shown a higher revision rate in the early stages of the learning curve. Whether the clinical advantages of the direct anterior compared with the posterior approach-such as less soft tissue damage, decreased short-term postoperative pain, a lower dislocation rate, decreased length of stay in the hospital, and higher likelihood of being discharged home-outweigh the higher cost is still debatable. Determining the cost-effectiveness of the approach may inform its utility and justify its use at various stages of the learning curve. QUESTIONS/PURPOSES: We used a Markov modeling approach to ask: (1) Is the direct anterior approach more likely to be a cost-effective approach than the posterior approach over the long-term for more experienced or higher volume hip surgeons? (2) How many procedures does a surgeon need to perform for the direct anterior approach to be a cost-effective choice? METHODS: A Markov model was created with three health states (well-functioning THA, revision THA, and death) to compare the cost-effectiveness of the direct anterior approach with that of the posterior approach in five scenarios: surgeons who performed one to 15, 16 to 30, 31 to 50, 51 to 100, and more than 100 direct anterior THAs during a 6-year span. Procedure costs (not charges), dislocation costs, and fracture costs were derived from published reports, and model was run using two different cost differentials between the direct anterior and posterior approaches (USD 219 and USD 1800, respectively). The lower cost was calculated as the total cost differential minus pharmaceutical and implant costs to account for differences in implant use and physician preference regarding postoperative pain management. The USD 1800 cost differential incorporated pharmaceutical and implant costs. Probabilities were derived from systematic review of the evidence as well as from the Australian Orthopaedic Association National Joint Replacement Registry. Utilities were estimated from best available literature and disutilities associated with dislocation and fracture were incorporated into the model. Quality of life was expressed in quality-adjusted life years (QALYs), which are calculated by multiplying the utility of a health state (ranging from 0 to 1) by the duration of time in that health state. The primary outcome measure was the incremental cost-effectiveness ratio, or the change in costs divided by the change in QALYs when the direct anterior approach was used for THA. USD 100,000 per quality-adjusted life years was used as a threshold for willingness to pay. One-way and probabilistic sensitivity analyses were performed for the scenario in which the direct anterior approach is cost-effective to further account for uncertainty in model inputs. RESULTS: At a cost differential of USD 219 (95% CI 175 to 263), the direct anterior approach was associated with lower cost and higher effectiveness compared with the posterior approach for surgeons with an experience level of more than 100 operations during a 6-year span. At a cost differential of USD 1800 (95% CI 1440 to 2160), the direct anterior approach remained a cost-effective strategy for surgeons who performed more than 100 operations. At both cost differentials, the direct anterior approach was not cost-effective for surgeons who performed fewer than 100 operations. One-way sensitivity analyses revealed the model to be the most sensitive to fluctuations in the utility of revision THA, probability of revision after the posterior approach THA, probability of dislocation after the posterior approach THA, fluctuations in the probability of dislocation after direct anterior THA, cost of direct anterior THA, and probability of intraoperative fracture with the direct anterior approach. At the cost differential of USD 219 and for surgeons with a surgical experience level of more than 100 direct anterior operations, the direct anterior approach was still the cost-effective strategy for the entire range of values. CONCLUSION: For high-volume hip surgeons, defined here as surgeons who perform more than 100 procedures during a 6-year span, the direct anterior approach may be a cost-effective strategy within the limitations imposed by our analysis. For lower volume hip surgeons, performing a more familiar approach appears to be more cost-effective.

Proximal humeral fracture-dislocations: which patterns can be reduced in the emergency department?

BACKGROUND: Shoulder fracture-dislocations can represent a challenging management scenario in the emergency department (ED) because of concern for the presence of occult fractures that may displace during a reduction attempt. The alternative, a closed reduction attempt in the operating room, has the benefit of full paralysis but requires additional resource utilization. There is limited guidance in the literature about the risks of an initial reduction attempt in the ED as a function of fracture pattern to help guide physicians with this decision. METHODS: This was a retrospective case review of adult patients with shoulder dislocations and fracture-dislocations seen in the ED at a level 1 trauma center over a 10-year period. Imaging and medical records were reviewed to evaluate whether the reduction attempt was successful, unsuccessful without worsening, or unsuccessful with worsening alignment of any fractures, as well as the ultimate clinical outcome. RESULTS: We identified 165 patients with fracture-dislocations and 484 patients with simple dislocations during the same period. Of the patients with fracture-dislocations, 103 had greater tuberosity fractures, 12 had nondisplaced surgical neck fractures, and 50 had displaced surgical neck fractures. None of the patients with simple dislocations had displacement during an ED reduction attempt, including 100 patients aged >65 years. Of the 103 patients with greater tuberosity fracture-dislocations, only 1 had displacement of a humeral shaft fracture during ED reduction. Displacement occurred in 6 of 8 patients with nondisplaced neck fractures who underwent an initial ED reduction attempt vs. 1 of 4 patients who underwent the initial reduction attempt in the operating room. ED reduction was attempted in 25 of the 50 displaced humeral neck fracture-dislocations and was successful in 10 of these (40%). CONCLUSIONS: For patients with greater tuberosity fracture-dislocations, there is a low rate of displacement with a reduction attempt in the ED, but an ED reduction attempt in nondisplaced neck fractures is not recommended because of the high rate of displacement. For displaced neck fractures, closed reduction can be successful in select patients. Finally, these data confirm prior reports that closed reduction of simple shoulder dislocations in patients aged >65 years is safe in the ED.

Nonoperative Treatment of Select Lateral Compression Type II Pelvic Ring Injuries (OTA/AO 61B2.2) Results in a Low Rate of Radiographic Displacement.

OBJECTIVES: To quantify radiographic outcomes and to identify predictors of late displacement in the nonoperative treatment of lateral compression type II (LC-2) pelvic ring injuries. DESIGN: Retrospective review. SETTING: Two Level 1 trauma centers. PATIENTS/PARTICIPANTS: Thirty eight patients 18 years of age or older with LC-2 pelvic ring injuries were included in the study. INTERVENTION: Nonoperative treatment. MAIN OUTCOME MEASUREMENTS: Crescent fracture displacement (CFD) was measured on initial axial computed tomography scan. Change in pelvic ring alignment was measured by the deformity index, simple ratio, and inlet and outlet ratios on successive plain radiographs. RESULTS: Patients in this study had minimally displaced LC-2 pelvic ring injuries, with median initial CFD of 2 mm and median initial deformity index of 2%. No patients had a change of more than or equal to 10 percentage points in deformity index over the treatment period, but small amounts of displacement were seen on the other ratios. No patients initially selected for nonoperative treatment converted to operative treatment. No radiographic predictors of late displacement were identified. Bilateral pubic rami fractures and the presence of a complete sacral fracture ipsilateral to the crescent fracture were not associated with late displacement. CONCLUSIONS: A spectrum of injury severity and stability exists in the LC-2 pattern. Nonoperative treatment of LC-2 injuries with low initial deformity and CFD results in minimal subsequent displacement. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

High variability in patient reported outcome utilization following hip fracture: a potential barrier to value-based care.

For patients with hip fractures, outcomes can be measured by giving surveys measuring "patient rated outcome measures" (PROMs), performance based measures (PBMS), and objective medical outcomes (e.g., mortality, living situation, resource utilization). This study reviewed articles on hip fracture published in top academic journals, and found that most studies are not reliably using a single set of outcome measures including PROMs, and no single PROM or outcome battery is being used commonly. PURPOSE/INTRODUCTION: Osteoporotic hip fractures are associated with high levels of morbidity, mortality, and cost, while gains in mortality over the past 30 years have been modest. To improve care beyond simple mortality metrics requires identifying and then consistently measuring outcomes that are meaningful to patients and families. The purpose of this study was to review the top-tier hip fracture literature published in the past 30 years to determine if there are consensus outcome measures being routinely used and if the rate of reporting clinically meaningful patient-rated outcome measures is improving over time. METHODS: This was a systematic review and meta-analysis on outcome measures reported in osteoporotic hip fractures. Articles were included if they had been published over the last 30 years and were from high impact factor journals. Inclusion criteria were elderly hip fractures, therapeutic or prognostic study, unique and identifiable patients, and included follow-up beyond initial hospitalization. We analyzed study type, inclusion criteria, outcomes reported, and journal specialty orientation. RESULTS: Three hundred eighty-four articles were included in the final analysis. Sixty-seven percent of the articles were therapeutic studies; 33% were prognostic studies. The average number of patients in each study was 435; the average age was 78 years. The most commonly reported outcome was mortality, and was present in 79% of studies. There was a high degree of heterogeneity in patient-reported outcome measures, with the most popular score (Harris Hip Score) reported only 14% of the time. Only 6% of articles had all components of essential core outcome sets previously defined in the literature. CONCLUSIONS: Despite the apparent advances that have been made in our ability to care for hip fractures, the overall rate of reporting outcomes beyond mortality rate remains low. This lack of consensus represents a major barrier to implementation of value-based care in this patient population.

A novel treatment for prevention of post-traumatic elbow stiffness using onaBotulinum toxin type A: a prospective placebo controlled randomized trial.

Approximately 30% of all upper extremity fractures are elbow fractures which may result elbow stiffness. This study aimed to investigate the efficacy of onaBotulinum Toxin type A injection to prevent post-traumatic pain and elbow-stiffness. All patients were included who presented to a single surgeon with supracondylar/ intraarticular distal humerus fractures, proximal ulna and radius fractures. The study was developed in a randomized placebo controlled study between 2003-2007. The Disabilities of the Arm, Shoulder, and Hand (DASH) score as well as the arc-of-motion (AOM) were assessed after three, six, twelve-months and final follow up for evaluation. Of the 31-patients included, 15-patients (48.4%) received Botox injections. In all patients no complication was observed when injecting a dosage 100-units for the brachialis and biceps brachii muscles. Furthermore, it was an effective method to prevent post-traumatic elbow stiffness, lasting six- months. Significant differences in DASH, VAS-score and ROM after three-months between the Botox and control group (DASH 21.6±11.0 vs. 55.3±11.0 ; VAS 1.2±5.2 vs. 5.7±21.9 ; ROM 103±7.6 vs. 73±6.3 ; p>0.05) were identified in the prospective group. Botulinum toxin is a safe, reliable and effective treatment to prevent post-traumatic elbow stiffness. Our study demonstrates improved early range-of- motion (p<0.05), better extension after 6 weeks and improved functional outcome including VAS and DASH score (p<0.05).

Modern treatment of tibial shaft fractures: Is there a role today for closed treatment?

PURPOSE: The decision to attempt closed treatment on tibial shaft fractures can be challenging. At our institution, we attempt treatment of nearly all closed, isolated tibial shaft fractures. The purpose of this study was to report the results of 10 years of experience to develop a tool to identify patients for whom non-operative treatment of tibial shaft fractures may be a viable option METHOD: This was a retrospective review of patients with tibial shaft fracture seen at a level 1 trauma center over 10 years. Patients with closed, isolated injuries underwent sedation, closed reduction, long-leg casting, and outpatient follow-up. Patients were converted to surgery for inability to obtain or maintain acceptable alignment or patient intolerance. Radiographic characteristics and patient demographics were extracted. Logistic regression analysis was used to develop a model to predict which patient and injury characteristics determined success of nonoperative treatment. RESULTS: 334 patients were identified with isolated, closed tibial shaft fractures, who were reduced and treated in a long leg cast. 234 patients (70%) converted to surgical treatment due to inability to maintain alignment, patient intolerance, and nonunion. In a regression model, coronal/sagittal translation, sagittal angulation, fracture morphology, and smoking status were shown to be significant predictors of success of nonoperative treatment (p < 0.05). We developed a Tibial Operative Outcome Likelihood (TOOL) score designed to help predict success or failure of closed treatment. The TOOL score can be used to identify a subsegment of patients with injuries amenable to closed treatment (38% of injuries) with a nonoperative success rate over 60%. CONCLUSION: Non-operative treatment of tibial shaft fractures is feasible, although there is a relatively high conversion rate to operative treatment. However, it is possible to use injury characteristics to identify a cohort of patients with a higher chance of success with closed treatment, which is potentially useful in a resource-constrained setting or for patients who wish to avoid surgery. LEVEL OF EVIDENCE: Prognostic Level 3.

Clinical Practice Guidelines on Ordering Echocardiography Before Hip Fracture Repair Perform Differently from One Another.

BACKGROUND: Osteoporotic hip fractures typically occur in frail elderly patients with multiple comorbidities, and repair of the fracture within 48 h is recommended. Pre-operative evaluation sometimes involves transthoracic echocardiography (TTE) to screen for heart disease that would alter peri-operative management, yet TTE can delay surgery and is resource intensive. Evidence suggests that the use of clinical practice guidelines (CPGs) can improve care. It is unclear which guidelines are most useful in hip fracture patients. QUESTIONS/PURPOSES: We sought to evaluate the performance of the five commonly used CPGs in determining which patients with acute fragility hip fracture require TTE and to identify common features among high-performing CPGs that could be incorporated into care pathways. PATIENTS AND METHODS: We performed a retrospective study of medical records taken from an institutional database of osteoporotic hip fracture patients to identify those who underwent pre-operative TTE. History and physical examination findings were recorded; listed indications for TTE were compared against those given in five commonly used CPGs: those from the American College of Cardiology/American Heart Association (ACC/AHA), the British Society of Echocardiography (BSE), the European Society of Cardiology and the European Society of Anaesthesiology(ESC/ESA), the Association of Anaesthetists of Great Britain and Ireland (AAGBI), and the Scottish Intercollegiate Guidelines Network (SIGN). We then calculated the performance (sensitivity and specificity) of the CPGs in identifying patients with TTE results that had the potential to change peri-operative management. RESULTS: We identified 100 patients who underwent pre-operative TTE. Among those, the patients met criteria for TTE 32 to 66% of the time, depending on the CPG used. In 14% of those receiving TTE, the test revealed new information with the potential to change management. The sensitivity of the CPGs ranged from 71% (ESC/ESA and AAGBI) to 100% (ACC/AHA and SIGN). The CPGs' specificity ranged from 37% (BSE) to 74% (ESC/ESA). The more sensitive guidelines focused on a change in clinical status in patients with known disease or clinical concern regarding new-onset disease. CONCLUSIONS: In patients requiring fixation of osteoporotic hip fractures, TTE can be useful for identifying pathologies that could directly change peri-operative management. Our data suggest that established CPGs can be safely used to identify which patients should undergo pre-operative TTE with low risk of missed pathology.

Compilation and Analysis of Web-Based Orthopedic Personalized Predictive Tools: A Scoping Review.

Web-based personalized predictive tools in orthopedic surgery are becoming more widely available. Despite rising numbers of these tools, many orthopedic surgeons may not know what tools are available, how these tools were developed, and how they can be utilized. The aim of this scoping review is to compile and synthesize the profile of existing web-based orthopedic tools. We conducted two separate PubMed searches-one a broad search and the second a more targeted one involving high impact journals-with the aim of comprehensively identifying all existing tools. These articles were then screened for functional tool URLs, methods regarding the tool's creation, and general inputs and outputs required for the tool to function. We identified 57 articles, which yielded 31 unique web-based tools. These tools involved various orthopedic conditions (e.g., fractures, osteoarthritis, musculoskeletal neoplasias); interventions (e.g., fracture fixation, total joint arthroplasty); outcomes (e.g., mortality, clinical outcomes). This scoping review highlights the availability and utility of a vast array of web-based personalized predictive tools for orthopedic surgeons. Increased awareness and access to these tools may allow for better decision support, surgical planning, post-operative expectation management, and improved shared decision-making.

Estimates of Direct and Indirect Costs of Ankle Fractures: A Prospective Analysis.

BACKGROUND: The quantification of the costs of ankle fractures and their associated treatments has garnered increased attention in orthopaedics through cost-effectiveness analysis. The purpose of this study was to prospectively assess the direct and indirect costs of ankle fractures in operatively and nonoperatively treated patients. METHODS: A prospective, observational, single-center study was performed. Adult patients presenting for an initial consult for an ankle fracture were enrolled and were followed until recurring indirect costs amounted to zero. Patients completed a cost form at every visit that assessed time away from work and the money spent in the last week on transportation, household chores, and self-care due to an ankle fracture. Direct cost data were obtained directly from the hospital billing department. RESULTS: Sixty patients were included in this study. With regard to patient characteristics, the mean patient age was 46.5 years, 55% of patients were female, 10% of patients had diabetes, and 17% of patients were active smokers. Weber A fractures composed 12% of fractures, Weber B fractures composed 72% of fractures, and Weber C fractures composed 18% of fractures. Operatively treated patients (n = 37) had significantly higher total costs and direct costs compared with nonoperatively treated patients (p < 0.01). In all patients, losses from missed work accounted for the largest portion of total and indirect costs, with a mean percentage of 35.8% of the total cost. The mean period preceding return to work of the 39 employed patients was 11.2 weeks. Longer periods of return to work were significantly associated with surgical fixation and having less than a college-level education (p < 0.05). The mean time for recurring observed costs to cease was 19.1 weeks. CONCLUSIONS: In patients treated operatively and nonoperatively, the largest discrete cost component was a specific indirect cost. Indirect costs accounted for a mean of 41.3% of the total cost. Although the majority of the direct costs of ankle fractures are accrued in the period immediately following the injury, indirect cost components will regularly be incurred for nearly 5 months and often longer. To capture the full economic impact of these injuries, future research should include detailed reporting on an intervention's impact on the indirect costs of ankle fractures. LEVEL OF EVIDENCE: Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

Can we predict failure of percutaneous fixation of femoral neck fractures?

PURPOSE: This study evaluated a series of geriatric femoral neck fracture treated with closed reduction percutaneous pinning (CRPP) at a single level-1 trauma center to determine if there are any simple, reliable, radiographic characteristics that can be used to predict increased risk of post-operative failure in nondisplaced and valgus impacted fracture patterns. METHODS: We conducted a retrospective cohort study of all patients with femoral neck fractures (AO/OTA 31B) who underwent CRPP over a 12-year period at a single Level 1 trauma center. Failure was defined as radiographic failure within the first year after the index operation requiring revision surgery. Common patterns identified on initial review were the presence of a visible medial transcervical line (MTL) felt to indicate a tension-sided failure, a straight inferior calcar (SIC) indicating severe valgus impaction, and quality of intra-operative screw positioning. X-rays of patients were then reviewed for these characteristics in a blinded manner by three different trauma-fellowship trained orthopedic surgeons. Inter-rater reliability was calculated using Fleiss' Kappa Coefficient. Comparisons of failure rates between groups were made using a Fisher's Exact test. RESULTS: 139 patients who underwent CRPP for a femoral neck fracture and follow-up for at least 90 days were identified and reviewed. There were a total of 19 failures (13.6%) within one year. The patients with a varus fracture had a failure rate of 9/24 (37.5%). Of the valgus/nondisplaced fractures, MTL was identified in 42/115 (36%) patients. Inter-rater agreement was high for the presence of an MTL (84%, Kappa 0.69). Patients with an MTL had a fourfold increase in risk of failure (7/42=17% with an MTL vs. 3/73=4% without, p  0.03). The presence of a SIC and quality of screw placement were not predictive of failure. CONCLUSION: Varus femoral neck fractures fixed with CRPP have a high rate of failure (37.5%). Nondisplaced or valgus impacted fractures with the presence of a visible medial transcervical line on pre-operative radiographic imaging resulted in a fourfold increase in the risk of failure after CRPP. Identification of the MTL will help treating surgeons better council patients when making pre-operative decisions between arthroplasty and CRPP.

"Found Down" Compartment Syndrome: Experience from the Front Lines of the Opioid Epidemic.

BACKGROUND: With the worsening of the opioid epidemic, there has been an increasing number of cases in which patients are "found down" following a drug overdose and develop a crush injury resulting in muscle necrosis, rhabdomyolysis, and elevated compartment pressures in a unique presentation of compartment syndrome. The purpose of the present study is to summarize our experience at a trauma center in a region with a high endemic rate of opiate abuse to provide guidance for the management of patients with "found down" compartment syndrome. METHODS: We performed a retrospective review of the records of patients who had been found unconscious as the result of overdose, with findings that were concerning for compartment syndrome, and had been managed with fasciotomy or observation at the discretion of the surgeon. The patients were divided into 3 groups based on presentation (partial deficits, complete deficits, or unexaminable), and the operative findings, hospital course, laboratory values, and functional status were compared between the groups. RESULTS: Over 12 years, we identified 30 "found down" patients who had an examination that was concerning for compartment syndrome. Twenty-five patients were managed with fasciotomy; this group required an average of 4.2 operations and had a 20% infection rate and a 12% amputation rate. Lactate, creatine phosphokinase, and creatinine levels typically were elevated but did not correspond with muscle viability or return of function. At the time of initial debridement, 56% of patients had muscle that appeared nonviable, although muscle function returned in 28% of the patients who had questionable viability. Four patients had no motor or neurological function on initial examination, and none had meaningful return of function at the time of the latest follow-up. Of the 10 patients who had partial neurological deficits at the time of presentation and underwent fasciotomy, over half (70%) had some improvement in ultimate function. CONCLUSIONS: Patients who are "found down" following an opiate overdose with crush injuries resulting in compartment syndrome have a high surgical complication rate and poor recovery of function. The limited data from the present study suggest that those with absent function at the time of presentation are unlikely to gain function after fasciotomy, and the risk-benefit ratio of fasciotomy in this patient population may be different from that for patients with traumatic compartment syndrome. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Orthopaedic Faculty and Resident Sex Diversity Are Associated with the Orthopaedic Residency Application Rate of Female Medical Students.

BACKGROUND: The representation of women in orthopaedics in the United States remains among the lowest in all fields of medicine, and prior research has suggested that this underrepresentation may stem from lower levels of interest among female medical students. Of the many proposed reasons for this lack of interest, the male-dominated nature of the field is one of the most commonly cited. The purpose of this study was to determine the degree to which the representation of women among orthopaedic faculty and residents influences female medical students at that institution to apply for a residency in orthopaedics. METHODS: Using data provided by the Association of American Medical Colleges, we identified all U.S. medical schools that were affiliated with an orthopaedic surgery department and an orthopaedic surgery residency program (n = 107). For each institution, data on the representation of women among the orthopaedic faculty and residents from 2014 through 2016 were collected, as well as data on the proportion of female medical school graduates who applied to an orthopaedic residency program from 2015 through 2017. The association between institutional factors and the female medical student orthopaedic application rate was assessed. RESULTS: Of 22,707 women who graduated from medical school during the 3-year study period, 449 (1.98%) applied to an orthopaedic surgery residency program. Women who attended medical school at institutions with high orthopaedic faculty sex diversity were more likely to apply for a residency in orthopaedics (odds ratio [OR], 1.30; 95% confidence interval [CI], 1.04 to 1.64; p = 0.023), as were women who attended medical school at institutions with high orthopaedic resident sex diversity (OR, 1.30; 95% CI, 1.05 to 1.61; p = 0.019). CONCLUSIONS: In this study, we found that increased sex diversity among orthopaedic faculty and residents was associated with a greater likelihood that female medical students at that institution would apply for an orthopaedic residency. These results suggest that at least some of the factors currently impeding female medical student interest in orthopaedics may be modifiable. These findings may have important implications for efforts to improve the sex diversity of the field of orthopaedics going forward.

Can the use of femoral notch view alone decrease measurement error of distal interlocking screws after retrograde femoral nailing.

OBJECTIVES: Determine if using different fluoroscopic views of the knee (Notch or Tangential) improves accuracy of screw lengths assessment compared to the standard posteroanterior (PA). PARTICIPANTS AND METHODS: Orthopaedic surgeons at three ACGME-accredited residency programs were asked via survey to assess screw lengths on PA, femoral notch, and tangential radiographic views. RESULTS: Responders correctly identified screw length using PA, femoral notch, and medial tangential views at rates of 46.75%, 52.27%, and 44.37% respectively. Respondents detected overall screw length discrepancies most accurately using the femoral notch view (Odds Ratio 1.26; 95% confidence interval: 1.07-1.47; P < 0.005). There was no statistical difference between the residents and faculty cohort in ability to detect screw length discrepancy. CONCLUSION: Differentiating distal interlocking screw lengths on traditional imaging (AP/Notch/Tangential) is poor. The femoral notch view significantly improves accuracy in radiographic determination of screw length. The femoral notch view should be used in conjunction with the traditional PA view to maximize sensitivity and specificity for detecting prominent screws.

Electronically augmented gait abnormality assessment following lower extremity trauma.

BACKGROUND: Objective evaluation of patient outcomes has become an essential component of patient management. Along with patient-reported outcomes, performance-based measures (PBMs) such as gait analysis are an important part of this evaluation. The purpose of this study was to evaluate the validity of utilizing a wearable inertial measurement unit (IMU) in an outpatient clinic setting to assess its ability to provide clinically relevant data in patients with altered gait resulting from lower extremity trauma. METHODS: Five orthopaedic trauma patients with varying degrees of gait pathologies were compared to 5 healthy control subjects. Kinematic data were simultaneously recorded by the IMU and a gold standard Vicon video motion analysis system (Vicon Motion Systems Ltd, Oxford, UK) during a modified 10-m walk test. Raw data captured by the IMU were directly compared to Vicon data. Additionally, 5 objective gait parameters were compared for controls and the 5 trauma patients. RESULTS: The IMU data streams strongly correlated with Vicon data for measured variables used in the subsequent gait analysis: vertical acceleration, vertical displacement, pitch angular velocity, and roll angular velocity (Pearson r-value > 0.9 for all correlations). Quantitative kinematic data in post-trauma patients significantly differed from control data and correlated with observed gait pathology. CONCLUSIONS: When compared to the gold standard motion capture reference system (Vicon), an IMU can reliably and accurately measure clinically relevant gait parameters and differentiate between normal and pathologic gait patterns. This technology is easily integrated into clinical settings, requires minimal time, and represents a performance-based method for quantifiably assessing gait outcomes. LEVEL OF EVIDENCE: Diagnostic Level 1.