The Fragility of Statistical Findings in the Femoral Neck Fracture Literature: A Systematic Review of Randomized Controlled Trials.

OBJECTIVES: Randomized controlled trials (RCTs) in the femoral neck fracture literature frequently report P -values for outcomes, which have substantial implications in guiding surgical management. This study used the fragility index (FI), reverse fragility index (rFI), and fragility quotient (FQ) to assess the statistical stability of outcomes reported in RCTs evaluating the management and treatment of femoral neck fractures. DESIGN: PubMed, Embase, and MEDLINE were queried for RCTs (January 1, 2010 to February 28, 2023). SETTING: RCTs that evaluated surgical management or treatment of femoral neck fractures were included. STUDY SELECTION CRITERIA: RCTs with 2 treatment arms reporting categorical dichotomous outcomes were included. Non-RCT studies, RCTs with greater than 2 treatment arms, and RCTs without a femoral neck fracture cohort were excluded. OUTCOME MEASURES AND COMPARISONS: The FI and rFI were calculated as the number of outcome event reversals required to alter statistical significance for significant ( P < 0.05) and nonsignificant ( P ≥ 0.05) outcomes, respectively. The FQ was calculated by dividing the FI by the sample size for the study. RESULTS: Nine hundred eighty-five articles were screened, with 71 studies included for analysis. The median FI across a total of 197 outcomes was 4 [interquartile range (IQR) 2-5] with an associated FQ of 0.033 (IQR 0.017-0.060). Forty-seven outcomes were statistically significant with a median FI of 2 (IQR 1-4) and associated FQ of 0.02 (IQR 0.014-0.043). One hundred fifty outcomes were statistically nonsignificant with a median rFI of 4 (IQR 3-5) and associated FQ of 0.037 (IQR 0.019-0.065). CONCLUSIONS: Statistical findings in femoral neck fracture RCTs are fragile, with reversal of a median 4 outcomes altering significance of study findings. The authors thus recommend standardized reporting of P -values with FI and FQ metrics to aid in interpreting the robustness of outcomes in femoral neck fracture RCTs. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Racial/Ethnic and Gender Diversity of Orthopaedic Journal Editorial Boards.

BACKGROUND: In the current era of evidence-based medicine, scientific publications play a crucial role in guiding patient care. While the lack of diversity among orthopaedic surgeons has been well documented, little is known about the diversity of orthopaedic journal editorial boards. The purpose of this study was to assess the racial/ethnic and gender diversity of U.S. orthopaedic journal editorial boards. METHODS: The editorial boards of 13 orthopaedic journals were examined, including 10 subspecialty and 3 general orthopaedic journals. Race/ethnicity and gender were determined for each editorial board member. The representation observed on orthopaedic journal editorial boards was compared with representation at other phases of the orthopaedic pipeline, as well as within the various subspecialty fields of orthopaedics. Logistic regression and t tests were used to evaluate these comparisons. RESULTS: We identified 876 editorial board members of the 13 journals; 14.0% were Asian, 1.9% were Black, 1.9% were Hispanic, 2.4% were multiracial/other, and 79.7% were White. Racial/ethnic representation was similar across the subspecialty fields of orthopaedics (p > 0.05). The representation of women on orthopaedic editorial boards was 7.9%, with differences in gender diversity observed across subspecialty fields (p < 0.05). Among journals in the subspecialty fields of spine and trauma, female editorial board representation was lower than expected, even after taking into account the representation of women in these subspecialty fields (2.0% versus 9.0% [p = 0.002] and 3.8% versus 10.0% [p = 0.03], respectively). CONCLUSIONS: In this study of 13 subspecialty and general orthopaedic journals, the representation of racial/ethnic minorities and women on editorial boards was similar to their representation in academic orthopaedics. However, these values remain low in comparison with the population of patients treated by orthopaedic surgeons. Given the importance of scientific publications in the current era of evidence-based medicine, orthopaedic journals should continue working to diversify the membership of their editorial boards.

Distal Tibial Metaphyseal Malunion Treated with Clamshell Osteotomy: A Case Report.

CASE: Here, we describe a case of a 49-year-old female patient with a history of hypertension and polysubstance use disorder presenting with a distal tibial metaphyseal malunion treated with a clamshell osteotomy. Her follow-up was 2.5 years long. CONCLUSION: Malunions in the tibial diaphysis and distal metaphysis can cause significantly increased joint reaction forces and altered gait mechanics leading to cosmetic dissatisfaction and decreased quality of life for these patients. Correction of these deformities can improve patient satisfaction and quality of life, along with decrease the risk of early arthritis. The clamshell osteotomy, although initially described to treat diaphyseal long bone malunions, can safely be performed for treatment of complex periarticular metaphyseal malunions.

Orthogonal plating of distal femur fractures: A biomechanical comparison with plate-nail and parallel plating constructs.

Purpose: This study compared the biomechanical properties of orthogonal plating with plate-nail and parallel plating constructs for supracondylar distal femur fractures. Methods: A supracondylar distal femur fracture was simulated using 15 synthetic osteoporotic femurs. Constructs included: (1) plate-nail (lateral locked distal femoral plate + retrograde intramedullary nail); (2) parallel plating (lateral locked distal femoral plate + medial 4.0 mm compression plate); and (3) orthogonal plating (lateral locked distal femoral plate + posterior one-third tubular plate). Specimens underwent nondestructive loading, fatigue loading, and loading to failure. Gapping at the fracture was measured using a three-dimensional motion capture system. Baseline torsional and axial stiffness, stiffness and strain after fatigue loading, and load to failure were determined. A case example of orthogonal plating is also presented. Results: There was no difference in baseline torsional (p = 0.51) and axial stiffness (p = 0.53). Stiffness after fatigue loading was highest with parallel plating, with no difference between the plate-nail and orthogonal plating constructs (p = 0.84). Strain after fatigue loading was lowest in the parallel plating group (0.54 ± 0.19%), followed by the plate-nail (2.89 ± 0.83%) and orthogonal plating groups (3.04 ± 0.51%). Conclusion: Orthogonal plating demonstrated comparable baseline stiffness to plate-nail and parallel plating constructs, and similar biomechanical performance in fatigue loading to plate-nail constructs. All specimens had ≤3% strain after fatigue loading, suggesting sufficient stability for fracture healing. The benefits of enhanced stability from dual-implant fixation may be achieved through orthogonal plating while avoiding an additional medial surgical approach, and therefore warrants further investigation as a novel alternative for distal femur fracture fixation.

Conceptualizing Biological Aging and Frailty in Orthopaedics: A Framework for Clinical Practice.

➤: Biological aging can best be conceptualized clinically as a combination of 3 components: frailty, comorbidity, and disability. ➤: Despite advancements in the understanding of senescence, chronological age remains the best estimate of biological age. However, a useful exercise for practitioners is to look beyond chronological age in clinical and surgical decision-making. ➤: A chronologically aging person does not age biologically at the same rate. ➤: The best way to understand frailty is to consider it as a physical phenotype. ➤: Physical optimization should parallel medical optimization before elective surgery. ➤: The poorer the host (both in terms of bone quality and propensity for healing), the more robust the implant construct must be to minimize reliance on host biology.

Time to surgery and complications in hip fracture patients on novel oral anticoagulants: a systematic review.

BACKGROUND: Early surgery has been consistently demonstrated to reduce complications and mortality in hip fracture patients. There remains no general consensus, however, regarding the optimal time to surgery for hip fracture patients who are on novel oral anticoagulants (NOAC) on admission and its effect on clinical outcomes after surgery. The objective of this review was to assess the effect of preoperative NOAC therapy on time to surgery and postoperative complications in hip fracture patients. METHODS: We performed a systematic review of the literature using the PubMed, Embase, and Cochrane Library electronic databases. Relevant articles were identified and included if they: (i) included patients on NOAC therapy on admission who did not undergo reversal; (ii) included a control group of patients not on any anticoagulation; (iii) included time from admission to surgery; and (iv) included one of the following outcomes: blood transfusion, venous thromboembolism (VTE), stroke, readmission, and mortality. RESULTS: Nine studies were included with a total of 4,419 patients. There were 414 NOAC patients and 4,005 non-anticoagulated patients. Six of the nine studies found a significant increase in time to surgery for patients on NOAC therapy. Three of the seven studies that reported rates of blood transfusion found a significantly higher incidence of transfusion in patients on NOACs. None of the studies found a significant difference in VTE and stroke. One of the two studies that reported readmissions showed a higher risk of readmission for patients on NOACs. Eight of the nine included studies found no significant difference in postoperative mortality rates between the NOAC and control groups, with the remaining study finding a higher mortality rate only in patients on NOAC therapy who underwent fixation and not those who underwent arthroplasty. CONCLUSIONS: These mixed findings suggest that delay to surgery may not be warranted in the urgent surgical setting of patients on NOAC therapy who sustain hip fractures.

Anterior hip dislocation complicated by thrombus in the common femoral vein: A case report.

CASE: A 90-year-old male sustained a low energy anterior hip dislocation without fracture after a ground-level fall. Magnetic resonance imaging (MRI) detected femoral vessel compression and thrombosis. The patient underwent placement of an inferior vena cava (IVC) filter prior to successful closed reduction in the operating room. CONCLUSION: Anterior hip dislocations are rare events that require urgent intervention to reduce the risk of complications. One underreported complication is femoral vessel thrombosis from direct compression against the femoral head. Dedicated imaging should be considered to rule out a thrombus. An IVC filter can be placed prior to reduction attempts to avoid potential thrombotic emboli.

Early mortality after hip fracture surgery in COVID-19 patients: A systematic review and meta-analysis.

OBJECTIVE: The aim of this systematic review and meta-analysis was to assess the risk of early mortality in hip fracture patients with COVID-19 infection who undergo surgical intervention. DATA SOURCES: MEDLINE (PubMed) and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases. STUDY SELECTION: Studies were included in the systematic review if they reported postoperative mortality in patients with COVID-19 infection who underwent operative intervention for hip fracture. From this selection of studies, only investigations that reported postoperative mortality in a COVID-positive and a non-COVID group were included in the meta-analysis. DATA EXTRACTION: Data regarding patient demographics, age, and sex were recorded. Additional data that was extracted included study location, data collection period, length of follow-up, COVID testing methodology, COVID testing results, and number of patients who underwent operative versus nonoperative management. The primary outcome of interest was postoperative mortality. DATA SYNTHESIS: Random effects meta-analyses were performed to assess the pooled relative risk of postoperative mortality according to COVID status. Odds ratios and 95% confidence intervals (CI) were calculated. CONCLUSIONS: The overall pooled mortality rate in the early postoperative period for hip fracture patients with concomitant COVID-19 infection was 32.6%. The relative risk for postoperative mortality in COVID-positive patients compared to non-COVID patients was 5.66 (95% CI 4.01-7.98; p < 0.001). The currently available literature demonstrates that COVID-19 infection represents a substantial risk factor for early postoperative mortality in the already susceptible hip fracture population. Further investigations will be needed to assess longer-term morbidity and mortality in this patient population. LEVEL OF EVIDENCE: Therapeutic Level IV.

The effect of nail diameter on proximal femoral shortening after internal fixation of pertrochanteric hip fractures with short cephalomedullary nails.

OBJECTIVE: Investigate the effect of distal nail diameter on proximal femoral shortening (PFS) after cephalomedullary nailing of hip fractures. METHODS: A retrospective cohort study of 80 patients aged 50 years and older with pertrochanteric hip fractures treated with a 10 or 11 mm short cephalomedullary nail (CMN) was performed. We measured abductor lever arm shortening, femoral height shortening, and PFS. RESULTS: There was no difference in abductor lever arm shortening (p = 0.09), femoral height shortening (p = 0.86), and PFS (p = 0.34) between the 10 and 11 mm groups. CONCLUSIONS: Our results suggest that distal nail diameter does not affect PFS. LEVEL OF EVIDENCE: III.

Early outcomes after hip fracture surgery in COVID-19 patients in New York City.

INTRODUCTION: The COVID-19 pandemic has spread globally and placed healthcare systems under substantial strain. Hip fracture patients represent a high-risk population for severe COVID-19 symptoms, as they are generally older with multiple medical comorbidities. There has been limited information available on the presenting characteristics and outcomes of COVID-positive patients with hip fractures who undergo surgical treatment. METHODS: This was a retrospective study of 10 patients ≥60 years of age with a hip fracture and COVID-19 who underwent surgical treatment in New York City during the COVID-19 outbreak from March 1, 2020 to May 22, 2020. Clinical characteristics and early postoperative outcomes were reported. RESULTS: Eight out of the 10 COVID-positive hip fracture patients in our series were asymptomatic on admission with no clinical signs or symptoms of COVID-19 infection. Only 2 patients presented with hypoxia. All 10 patients underwent surgery within 2 days of admission. Five out of the 10 patients - including the patients who presented with hypoxia - subsequently required supplemental oxygen postoperatively. Two patients had persistently elevated oxygen demands requiring prolonged administration of supplemental oxygen therapy beyond postoperative day 3. None of the patients were put on mechanical ventilation. One patient had a presumed venous thromboembolism postoperatively and subsequently died on postoperative day 19, likely due to respiratory failure. There were no other deaths in the early postoperative period. The average length of inpatient stay was 7.8 days. CONCLUSIONS: Our findings suggest that hip fracture patients who present with asymptomatic or mild COVID-19 infection may have temporarily increased oxygen demands postoperatively, but they can safely undergo early surgical intervention after appropriate medical optimization.

Timing of proximal femoral shortening in the early postoperative period after cephalomedullary nailing of hip fractures.

OBJECTIVES: Examine the timing of proximal femoral shortening (PFS) after cephalomedullary nailing of hip fractures. METHODS: A retrospective cohort study of 21 patients ≥50 years old with pertrochanteric hip fractures treated with a short cephalomedullary nail (CMN) was performed. Abductor lever arm shortening, femoral height shortening, and PFS were measured. RESULTS: Mean PFS at 10-21 days postoperatively was 5.54 mm, compared to 11.31 mm at final follow-up. The percentage of total PFS that occurred within 10-21 days postoperatively was 53.9%. CONCLUSION: Approximately half of total PFS occurs within 1.5-3 weeks and is notable on radiographs by the first postoperative visit.

Utilization, effectiveness, and safety of tranexamic acid use in hip fracture surgery: A population-based study.

OBJECTIVE: To assess the effect of tranexamic acid (TXA) use in hip fracture surgery. METHODS: A retrospective cohort study was performed using the Premier Healthcare database. A propensity score matching approach was applied to assess associations between TXA use and blood transfusion, perioperative complications, length of stay (LOS), and hospitalization cost. RESULTS: In 153,169 patients, TXA use was associated with a 17% decrease in odds of blood transfusion, no increase in the risk of perioperative complications, 16% shorter LOS, and minimal effects on hospitalization cost. CONCLUSION: Our results are in support of a wider use of TXA in hip fracture surgery. LEVEL OF EVIDENCE: Level III.

Second physician review of radiographs after wrist and ankle reductions offers limited utility to clinical management.

PURPOSE: The purpose of this study is to determine the clinical utility of second-physician review of radiographs obtained after reduction of distal radius and ankle fractures. METHODS: Fifty consecutive ankle and distal radius fractures requiring reduction were reviewed. The time from post-reduction radiograph to second-physician interpretation was obtained. The second-physicians' interpretation was evaluated for clinically influential information. Patients requiring a repeat reduction were identified, and the timing of the repeat reduction radiograph was compared with the timing of the second-physician interpretation of the initial post-reduction radiograph. RESULTS: The mean time of second-physician interpretation for post reduction ankle radiographs was 6 h and 47 min (range 4 min to 43 h and 3 min). Eleven of 50 (22%) interpretations of post reduction ankle radiographs commented on acceptability of reduction. The mean time of second-physician interpretation for post reduction distal radius radiographs was 5 h and 34 min (range 8 min to 22 h and 59 min). Seven of 50 (14%) interpretations of post reduction distal radius radiographs commented on acceptability of reduction. Three distal radius (6%) and 8 ankle fractures (16%) required repeat reduction. Repeat reductions were completed in 10/11 cases (91%) before the second-physician review of the initial post reduction radiograph was obtained. In only 1 case of repeat reduction was the second-physician review of the post reduction radiograph available before repeat reduction was attempted. CONCLUSION: The timing and quality of second-physician review of post-reduction radiographs offers little utility to the clinical management of ankle and distal radius fractures.

The Influence of Incision Type on Patient Satisfaction After Plate Fixation of Clavicle Fractures.

BACKGROUND: Open reduction and internal fixation (ORIF) of the clavicle is a common procedure that has been shown to have improved outcomes over nonoperative treatment. Several incisions can be used to approach clavicle fractures, the decision of which is variable among surgeons. PURPOSE: To compare patient satisfaction and subjective outcomes between patients with a longitudinal incision versus those with a necklace incision for the treatment of diaphyseal clavicle fractures. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Thirty-six patients with a diaphyseal clavicle fracture (Orthopaedic Trauma Association type 15-B) were treated by 1 of 7 orthopaedic surgeons. The intervention was ORIF with anatomic contoured plates. Patients were divided into a necklace incision group and a longitudinal incision group depending on the surgical approach used. Medical records were reviewed, and participants completed an online survey with questions related to pain, numbness, scar appearance, and satisfaction. Function was assessed using the American Shoulder and Elbow Surgeons score. Statistical significance was determined with P < .05. RESULTS: There were 16 patients in the necklace incision group and 20 in the longitudinal incision group. Patients in the necklace incision group were significantly more satisfied with the appearance of their scars (P = .01), which correlated with overall satisfaction (P = .05). There were no differences in overall satisfaction, pain, numbness, or reoperation rates for hardware removal between the necklace (6%) and longitudinal groups (15%). CONCLUSION: Patients undergoing clavicle ORIF with a necklace incision are more satisfied with their scar appearance than those with a longitudinal incision. The overall satisfaction, rate of numbness, and plate removal were similar in both groups.

The effect of aortic stenosis on elderly hip fracture outcomes: A case control study.

INTRODUCTION: Aortic stenosis (AS) is an established predictor of perioperative complications following both cardiac and non-cardiac surgery. The purpose of this study was to evaluate the risk of mortality and perioperative complications among surgically treated hip fractures in elderly patients with moderate or severe AS compared to those without AS (negative controls). MATERIALS AND METHODS: A retrospective case-controlled review (1:2) of elderly (≥65 years) surgically treated hip fractures from 2011 to 2015 with moderate/severe AS (according to American Heart Association criteria) was conducted. Postoperative complication rates, 30 days and 1 year mortality were reviewed. RESULTS: Moderate/severe AS was identified in 65 hip fracture cases and compared to 129 negative controls. AS cases were significantly older with higher rates of coronary artery disease and atrial fibrillation (p<0.05). Rates of any 30-day perioperative complication (74% vs. 37%, p<0.001) and severe non-cardiac 30-day perioperative complication (52% vs. 26%, p=0.002) were significantly higher among AS cases compared to controls. Kaplan Meier estimates of 30-day mortality (14.7% vs. 4.2%, p<0.001) and 1-year mortality (46.8% vs. 14.1%, p<0.001) were significantly higher in AS cases compared to controls. Multivariate analysis of severe 30-day postoperative complications identified moderate/severe AS (OR 4.02, p=0.001), pulmonary disease (OR 7.36, p=0.002) and renal disease (OR 3.27, p=0.04) as independent predictors. Moderate/severe AS (OR 3.38, p=0.03), atrial fibrillation (OR 3.73, p=0.03) and renal disease (OR 4.44, p=0.02) were independent predictors of 30-day mortality. Moderate/severe AS (OR 5.79, p<0.001) and renal disease (OR 3.39, p=0.02) were independent predictors of 1-year mortality. CONCLUSION: Aortic stenosis is associated with a significantly increased risk of perioperative complications, 30-day mortality and 1-year mortality in elderly patients undergoing surgical treatment of hip fractures.

The financial impact of the loss of county indigent patient funding on a single orthopedic trauma surgery service.

BACKGROUND: We examined the financial ramifications on the orthopedic trauma service after loss of payment to our institution for care of indigent patients. Our institution is the only Level I trauma center located within the county. Before mid-2009, county insurance-eligible patients treated at our institution had their health care paid for by the county. After mid-2009, the county no longer reimbursed our institution for care provided. METHODS: A retrospective review was performed on 653 county patients treated by the four orthopedic trauma surgeons during a 4-year period including the 2 years before the loss of county payments as well as the 2-year period following the loss of payment. Data collected included demographics, admitting service, injuries treated, length of stay, surgeon billing, and reimbursement. We also classified the urgency of care that was rendered into one of three categories as follows: emergent, urgent, or elective. RESULTS: There was a higher frequency of emergent and urgent procedures and a lower frequency of elective cases performed in the noncontracted period versus the contracted period. During the contracted period, we billed and collected $1,161,036. After the loss of reimbursement from the county, we billed $870,590 and were paid $0. County reimbursements made up 33.5% of the total professional fees billed. There was a 20% net drop in total billing during the noncontracted period, of which the money not reimbursed by the county accounted for 31%. CONCLUSION: Despite the lack of county payment, our institution continues to provide care to the indigent population. This lack of payment may have significant long-term economic ramifications for the orthopedic trauma surgeons and for our institution. The financial burden preferentially falls on the "safety net" Level I trauma centers and the physicians who take care of patients with urgent and emergent injuries. This burden may be unsustainable in the future. LEVEL OF EVIDENCE: Economic and value-based evaluation, level V.

Evolving compartment syndrome detected by loss of somatosensory- and motor-evoked potential signals during cervical spine surgery.

Neurologic injury is a rare but devastating complication of spinal surgery that can result in mild sensory to severe motor deficits. Surgeons increasingly use electrophysiological spinal cord function monitoring, including somatosensory- and motor-evoked potentials, intraoperatively to provide information about spinal cord function, aid in surgical decision making, improve outcomes, and reduce complication rates. By providing real-time information about the dorsal and anterior motor column function, somatosensory- and motor-evoked potentials signals allow surgeons to reverse noticeable changes and avoid devastating neurologic injuries. Recognizing changes in baseline signals in the setting of known risk factors enables surgeons to correct these risks. This article describes a case in which somatosensory- and motor-evoked potentials monitoring were lost in the setting of an impending right forearm compartment syndrome during 2-level anterior cervical diskectomy and fusion. To the authors' knowledge, this is the first reported case of spinal cord monitoring detecting an evolving compartment syndrome during cervical spine surgery. The early changes in signal intensity enabled the surgeon to search for a cause and remedy the situation by removing the infiltrated intravenous line. Without the observed changes in somatosensory- and motor-evoked potentials, it is likely that the compartment syndrome may have progressed to the point of requiring fasciotomy to prevent lasting neuromuscular injury. This article describes a new cause of changes in electrophysiological monitoring and further displays the usefulness of somatosensory- and motor-evoked potentials monitoring during even routine spinal surgery.

Contemporary management of femoral neck fractures: the young and the old.

The optimal management strategy for femoral neck fractures remains highly debated. The femoral neck is intracapsular and the vascular supply is fragile. Furthermore, the curvature of the proximal femur results in high mechanical stresses through the femoral neck. Poor outcomes of nonunion and avascular necrosis (AVN) are common. This chapter reviews the current evidence with respect to the treatment principles of femoral neck fractures in two distinct patient populations: "young" and "old." Contemporary controversies including surgical timing, choice of implant, arthroplasty options, nonoperative management, capsulotomy, and associated complications will be discussed.

Elbow interposition arthroplasty.

End-stage elbow arthritis in young, active patients presents a challenging problem to the upper extremity surgeon. Total elbow arthroplasty is not a viable option in this population because of functional restrictions, limited implant survivorship, and the lack of an adequate salvage option. With the appropriate surgical indication, interposition arthroplasty can relieve severe pain, affording a functional elbow without severely proscribing permitted activities. In addition, bone stock is preserved, as are other reconstructive options for the future.