Chiropractic Manipulation Causing Anterior-Posterior Compression Type Pelvic Ring Injury: A Case Report.

CASE: We present a case of an anteroposterior compression (APC) type pelvic ring injury that occurred after chiropractic manipulation in a patient with a history of quadriplegia. Emergent surgical stabilization was undertaken, and he had an excellent outcome with no complications at 3.5-year follow-up. CONCLUSION: APC type pelvic ring injuries usually occur to high-energy mechanisms. We describe a case of a patient with quadriplegia and osteopenia that suffered a pelvic ring injury because of a unique mechanism. Practitioners performing pelvic manipulation should be aware of this type of injury in at-risk patients.

Effectiveness of Flat-Panel Fluoroscopy in Direct Anterior Total Hip Arthroplasty: A Comparison to Image Intensifier Fluoroscopy With Radiopaque Grid.

Introduction: The use of traditional, image intensifier fluoroscopy with a radiopaque grid during direct anterior total hip arthroplasty (DA THA) has demonstrated reduced variability in component positioning and operative time compared to fluoroscopy without a grid. A disadvantage of image intensifier fluoroscopy is spatial distortion, particularly compared to flat-panel fluoroscopy systems. The purpose of this study is to determine whether flat-panel fluoroscopy decreases variability in component positioning during DA THA compared to the use of traditional grid fluoroscopy. Methods: We retrospectively reviewed 70 consecutive DA THAs between February 2020 and February 2021: 36 using flat-panel fluoroscopy, and 34 using traditional fluoroscopy with a grid. Radiographs were independently reviewed by 2 authors to identify components exceeding goal parameters: cup abduction of 40 ± 10 degrees, as well as offset and limb lengths within 10 mm of the contralateral side. Binary values for goal parameter achievement were assigned for each THA. Results: No significant difference was observed in the number of hips that met goals for cup abduction (100% vs 97%, P = 1.00), hip offset (88% vs 88%, P = 1.00), limb length (91% vs 94% [ ±10 mm], P = .669, 65% vs 72% [±5 mm], P = .498), or for the number of hips that met all 3 component goals (79% vs 80%, P = 1.00). No significant difference in operative time was noted between the 2 groups (110.2 minutes vs 100.9, P = .76). Conclusions: We demonstrated no significant difference in component positioning in DA THAs utilizing flat-panel fluoroscopy as compared to using traditional fluoroscopy with a grid.

The direct anterior approach for conversion to total hip arthroplasty after acetabular fixation is safe and effective.

INTRODUCTION: Total Hip Arthroplasty (THA) after prior acetabular fracture repair is known to be demanding as studies have shown inferior implant survival rates and higher infection rates for these procedures. The direct anterior (DA) approach might help mitigate some of these risks by utilizing a new surgical tissue plane. However, potential criticisms of the DA approach for these surgeries include the inability to access previous acetabular implants or heterotopic ossification (HO) if they were to inhibit implant placement. The goals of this study are to analyze the efficacy of the DA approach for conversion to hip arthroplasty surgery after previous acetabular fixation. METHODS: After reviewing all records at our institution using current procedural terminology codes, we isolated patients with previous acetabular repair who underwent conversion to THA through the DA approach. Patient records were reviewed, and patients were contacted to obtain Harris Hip Scores. RESULTS: 23 patients (16 males and 7 females) were found with a mean follow-up time of 46 months (range 16-156 months). The mean age was 50 (range 28 - 83) and mean BMI was 28.5 (range 15.2 - 39.2). The average blood loss was 400 ml (range 200 - 900). The average operative time was 140 min (range 85-200 min). In 7 cases (32%) implants were encountered during acetabular reaming but the implants were either removed entirely or removed partially with a burr so that the acetabular cup could be positioned within acceptable parameters. In 2 cases pre-operative HO was encountered and was resected. The average Harris Hip Score at final follow-up was 92 (range 75 - 100). There were no deep infections and no neurovascular injuries encountered. 2 patients (9%) underwent revision surgery for aseptic femoral stem loosening. There was 1 anterior dislocation (4.5%) at 3 days post-operatively that was successfully treated with closed reduction and maintenance of hip precautions. Otherwise, the remaining 19 (86%) patients went on to uncomplicated recovery. CONCLUSION: This is the largest known cohort analyzing the DA approach for conversion to hip arthroplasty after previous acetabular fixation. Overall, we demonstrate that the DAA is safe for conversion THA after acetabular fixation.

Positive Correlation Between Social Media Utilization by Orthopaedic Journals and Impact Factor.

INTRODUCTION: Social media use has exploded in popularity over the past decade with over 1.5 billion users on Facebook and 320 million users on Twitter. The aim of this study was to analyze the use of social media by orthopaedic journals and determine whether a relationship exists between social media followers and journal impact factor. METHODS: The Clarivate Analytics Impact Factor tool was used to identify all orthopaedic journals with a 2022 impact factor of greater than 1.5. We then conducted a query on Instagram, Twitter, LinkedIn, and Facebook to determine which programs had pages on each platform. RESULTS: Seventeen journals were included across all orthopaedic subspecialties. Of the 17 journals, 14 (82.4%) had a Facebook page, eight (47%) had an Instagram page, 15 (88.2%) had a Twitter account, and 8 (47%) had a LinkedIn profile. When compiling the number of followers by social media platform, Twitter had the most (177,543), followed by Facebook (149,388), Instagram (81,739), and LinkedIn (77,459). We found a significant correlation between the number of social media followers and journal impact factor (Pearson correlation coefficient [PCC] = 0.67; P = 0.003). When analyzing each social media platform independently, we found a significant correlation between the number of Facebook and Twitter followers and journal impact factor (PCC = 0.54; P = 0.02 and PCC = 0.80; P < 0.001, respectively). DISCUSSION: We have shown a notable association between the number of social media followers and a journal's impact factor. With the increasing shift toward online distribution, orthopaedic journals may use our data when evaluating their social media strategy to maintain and potentially increase their exposure and potentially their impact factor.

Fellowship-Trained Orthopaedic Trauma Surgeons Achieve Better Postoperative Radiographic Parameters After Intramedullary Nailing of Intertrochanteric Femur Fractures when Compared With Non-trauma-Trained Surgeons.

INTRODUCTION: Intertrochanteric femoral fractures are common orthopaedic injuries accounting for nearly 30% of all fracture-related hospitalizations. Because many factors predictive of failure are related to technical aspects of the surgery, the purpose of this study was to compare radiographic parameters after fixation, comparing fellowship-trained orthopaedic trauma surgeons with surgeons who did not complete an orthopaedic trauma fellowship. METHODS: We initiated a search for CPT code 27245 across our hospital network to identify 100 consecutive patients treated by five fellowship-trained orthopaedic traumatologists and 100 consecutive patients treated by community surgeons. Patients were then stratified based on their surgeon's subspecialty training (trauma vs community). Primary outcome variables were neck-shaft angle (NSA), a comparison of the repaired NSA with the uninjured side, tip-apex distance, and reduction quality. RESULTS: One hundred patients were included in each group. The mean age in the community group was 77 years compared with 79 years in the trauma group. The mean tip-apex distance for the trauma group was 10 mm compared with 21 mm for the community group ( P < 0.001). The mean postoperative NSA for the trauma group was 133° compared with 127° for the community group ( P < 0.001). The mean difference of the NSA of the repaired side compared with the uninjured side was 2.5° of valgus in the trauma group compared with 5° of varus for the community group ( P < 0.001). There were 93 good reductions in the trauma group compared with 19 in the community group ( P < 0.001). There were 0 poor reductions in the trauma group and 49 in the community group ( P < 0.001). DISCUSSION: Overall, we have shown that fellowship-trained orthopaedic trauma surgeons achieve better reductions when treating intertrochanteric femur fractures with intramedullary nails. Orthopaedic residency training should emphasize teaching proper techniques and acceptable parameters for reduction and implant placement when treating geriatric intertrochanteric femur fractures.

The Evolution of the Musculoskeletal Trauma Section of the Orthopaedic In-Training Examination.

INTRODUCTION: In 1963, the American Academy of Orthopaedic Surgeons administered the Orthopaedic In-Training Examination (OITE), the first and longest running yearly medical specialty examination. There have been no recent studies to evaluate the content of the musculoskeletal trauma section of the OITE. METHODS: We analyzed all questions that were classified by the American Academy of Orthopaedic Surgeons as musculoskeletal trauma from 2012 to 2019. We recorded the number of musculoskeletal trauma questions in each examination, the topics and imaging modalities tested, the references cited, and the taxonomy classification of each question. We extrapolated from a similar musculoskeletal trauma study published in 2011 to create the previous examination cohort for comparison. RESULTS: For the current cohort, the average number of musculoskeletal trauma questions was 43.5 questions per examination (18.4%). The most frequently tested topics were proximal tibia fractures, pediatric trauma, hip fractures, and diaphyseal femur fractures, respectively. In previous examinations, questions from T1 and 2 were tested significantly more frequently compared with the current examinations (P < 0.001 and P = 0.02, respectively). In the current cohort, T3 questions were tested significantly more frequently than previous examinations (P = 0.001). Previous examinations had significantly more questions without an image (36 questions per year versus 25 questions per year, P < 0.001). In current versions of the examination, radiographs are tested significantly more frequently than other imaging modalities (P < 0.001). DISCUSSION: The musculoskeletal trauma section of the OITE has evolved. To improve and focus study efforts, residents may use this study as a guide when preparing for the examination.

Treatment of Diaphyseal Tibial Fractures Distal to a Total Knee Arthroplasty by Intramedullary Nailing Is Safe and Effective.

OBJECTIVES: To report the clinical result of a series of patients who underwent intramedullary nailing (IMN) of tibial shaft fractures distal to a total knee arthroplasty (TKA). DESIGN: Retrospective case series. SETTING: Level-1 trauma center. PATIENTS/PARTICIPANTS: Patients who sustained a tibial shaft fracture distal to a TKA treated with an IMN. INTERVENTION: IMN of tibial shaft fractures distal to a TKA. MAIN OUTCOME MEASUREMENTS: Postoperative weight-bearing status, readmissions, and complications or failure of treatment within 90 days; Knee Injury and Osteoarthritis Outcome Scores at the final follow-up; failure of treatment; and revision surgery. RESULTS: Nine patients were included. The average age was 71.4 years (range 55-87 years). All TKAs were cemented. The average distance between the tibial keel and the cortical density of the tibial tubercle was 24.1 mm (range 19.5-26.7 mm). Six nails were inserted using an infrapatellar portal, 2 were inserted using a suprapatellar portal, and 1 was inserted using a lateral parapatellar approach. The median nail diameter was 10 mm (range 9-12 mm). All fractures were healed at the final follow-up. There were no infections or arthroplasty-related complications. Knee Injury and Osteoarthritis Outcome Scores ranged from 100% to 74% (median 82%). CONCLUSION: Overall, we report on the largest cohort in the literature undergoing IMN of a tibial shaft fracture distal to a TKA. We demonstrate that IMN of diaphyseal tibial fractures distal to a TKA can be performed safely. We additionally demonstrate that this treatment is highly effective in achieving fracture union with no arthroplasty-related complications. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Retrograde intramedullary nailing of comminuted intra-articular distal femur fractures results in high union rate.

PURPOSE: Retrograde intramedullary nailing of intra-articular distal femur fractures with metaphyseal and/or epiphyseal comminution is controversial and considered a contraindication to nailing. The purpose of this study was to report union rate, complications, and secondary procedures after open reduction and retrograde intramedullary nailing of comminuted, intra-articular, distal femur fractures. MATERIALS AND METHODS: A retrospective review performed at an urban level one trauma center identified 16 patients AO/Orthopedic Trauma Association (OTA) 33-C2 and 33-C3 femur fractures treated with open reduction, lag screws, and retrograde intramedullary nail fixation. Radiographic union, complications, secondary operations were reviewed. RESULTS: At the 3-month follow-up 12 (86%) of the 14 patients with radiographs had healed. At last follow-up, all 16 femur fractures achieved radiographic union after the index procedure. No patient required a revision procedure for delayed union or nonunion. Complications occurred in 6 (38%) patients, including failed distal interlocking screws (n = 2), knee arthrofibrosis (n = 3), superficial wound infection (n = 1), and wound dehiscence (n = 1). Three (19%) patients required secondary procedures, which included knee manipulation under anesthesia (n = 3), distal interlocking screw removal (n = 2), and closure of a wound dehiscence (n = 1). CONCLUSIONS: Comminuted intra-articular distal femur fractures that can be successfully treated with retrograde IMN fixation will reliably go on to union with a complication rate that is favorable to that reported for plate fixation. LEVEL OF EVIDENCE: Level IV, retrospective case-series.

Membrane-Inducing "Masquelet" Technique for Massive Traumatic Diaphyseal Femur Bone Loss in a Pediatric Patient: A Case Report.

CASE: A 14-year-old boy sustained 22 cm of femur bone loss after a motor vehicle accident. The patient underwent treatment with the membrane-inducing "Masquelet" technique for management of the injury. The grafts incorporated to form new bone and fill-in the void. CONCLUSION: Although the Masquelet technique is thoroughly described in adult orthopaedic trauma and oncology literature, there are minimal reports to support its use in pediatric patients. Five-year follow-up data on this patient concluded that utilization of this technique for significant bone defects proves to be a safe and effective alternative for the management of pediatric trauma patients.

Theme Park Water Slides: A New Mechanism of Causing 61B2.3 Pelvic Ring Injuries: A Case Series.

CASE: We present a series of 3 pelvic ring injuries that occurred on 1 high-speed water slide at a theme park in Orlando, FL. This is the first time this injury has been reported at a water park in the United States. All patients underwent surgical management and had an excellent outcome. CONCLUSION: Pelvic ring injuries usually occur because of high-energy mechanisms, but unique mechanisms of injuries are possible. We aim to draw attention to this unique mechanism of injury because serious injury may occur to riders. Water parks should use the information presented in this study to develop and refine safety requirements for patrons.

Long-Term Patient-Reported Knee Outcomes After Suprapatellar Intramedullary Tibial Nailing.

BACKGROUND: Suprapatellar nailing of tibial fractures has not been shown to affect short-term knee outcomes, however long-term outcomes are unknown. The purpose of this study was to report long-term patient-reported knee outcomes after suprapatellar nailing. METHODS: Thirty-five adult patients with 37 tibial shaft fractures treated with suprapatellar nailing completed the Tegner-Lysholm Knee Score (TLKS) at an average of 5 years (range, 4-9 years) follow-up. RESULTS: The median TLKS was 98 (interquartile range, 85-100): Scores were considered excellent in 24 (68%), good in 3 (9%), fair in 3 (9%), and poor in 5 (14%). Based on patient responses, 28 (80%) patients did not have a limp, 32 (91%) ambulated without assistance, 22 (63%) were pain free, 29 (83%) had no knee instability, 30 (86%) endorsed no catching or locking, 27 (77%) could climb stairs with no issue, and 24 (69%) had no problems with squatting. Patients with poor/fair outcomes on the TLKS were more likely to have had a complication [3 (38%) vs. 1 (4%), difference 34%, 95% confidence interval 1-65%] and had no detectable difference in age, gender, open fracture, fracture classification, or worker's compensation. CONCLUSION: At long-term follow-up a majority of patients undergoing suprapatellar nailing had good/excellent knee outcomes. Poor/fair knee outcomes were associated with the development of complications. LEVEL OF EVIDENCE: III, Retrospective cohort study.

Comparison of standard versus reconstruction proximal interlocking screw configurations for antegrade intramedullary nail fixation of femoral shaft fractures.

BACKGROUND: The standard proximal interlocking screw (SS) configuration for antegrade intramedullary nail (IMN) fixation of femoral shaft fractures is lateral to medial or from the greater to less trochanter. Some authors argue for the routine use of the reconstruction screw (RS) configuration (oriented up the femoral neck) instead to prevent femoral neck complications. The purpose of this study was to compare a matched cohort of patients receiving these screw configurations and subsequent complications. METHODS: A retrospective review of two urban level-one trauma centers identified adults with isolated femoral shaft fractures undergoing antegrade IMN. Patients with RS and SS configurations were matched 1:1 by age, sex, fracture location, and AO classification in order to compare complications. RESULTS: 130 patients with femoral shaft fractures were identified. SS and RS configurations were used in 83 (64%) and 47 (36%) patients. 30 patients from each group were able to be matched for analysis. The RS and SS group did not differ in age, fracture location, AO classification, operative time, or number of distal interlocking screws. The RS group had fewer open fractures and were more likely to have two proximal screws. There were 7 complications, including 5 nonunions and 2 delayed unions, with no detectable difference between RS vs. SS groups (10% vs 13%, Proportional difference -3%, 95% confidence interval (CI) -30 to 14%, p = 0.1). There were no femoral neck complications in the entire cohort of 130 patients. On multivariate analysis none of the variables analyzed were independently associated with the development of complications. CONCLUSIONS: In this matched cohort of patients with femoral shaft fractures undergoing antegrade IMN fixation, RS and SS configurations were associated with a similar number of complications and no femoral neck complications. The SS configuration remains the standard for antegrade IMN femoral shaft fixation. LEVEL OF EVIDENCE: Level III, Retrospective cohort study.

Lower Extremity Fractures: Tips and Tricks for Nails and Plates.

Lower extremity fractures, ranging from the proximal femur to the distal tibia, come in a variety of patterns and complexity. Treatment modalities typically consist of using plates and intramedullary nails; however, each has its advantages and disadvantages in each anatomic region. In this instructional course, salient points and nuances in setup and implant choice are reviewed. Furthermore, the essential tips and tricks to avoid pitfalls and achieve a desired clinical result are discussed.

Variables Associated With Lag Screw Sliding After Single-Screw Cephalomedullary Nail Fixation of Intertrochanteric Fractures.

OBJECTIVES: To evaluate variables associated with lag screw sliding after single-screw cephalomedullary nail (CMN) fixation of intertrochanteric femur fractures. DESIGN: Retrospective cohort study. SETTING: Level-one trauma center. PATIENTS/PARTICIPANTS: One hundred fifty-eight intertrochanteric fractures in patients older than 65 years with an average follow-up of 22 months. INTERVENTION: Single-screw CMN fixation. MAIN OUTCOME MEASUREMENTS: Lag screw sliding and revision surgeries. RESULTS: The average amount of lag screw sliding was 5 ± 5 mm (range, 0-21 mm). Lag screw sliding was greater with unstable fracture patterns (mean difference 2 mm, 95% confidence interval 0.4-3.5 mm, P = 0.01) and calcar gapping >4 mm (mean difference 3.7 mm, 95% confidence interval 2-5 mm, P < 0.01). No association was found between lag screw sliding and age, female gender, implants, long versus short nails, distal interlock screw use, postoperative neck-shaft angle, or tip-apex distance (P > 0.05). Revision surgeries were performed in 6 (4%) patients. Indications included symptomatic lag screw removal (n = 2), avascular necrosis (n = 1), cutout (n = 1), loss of reduction (n = 1), and perimplant fracture (n = 1). CONCLUSIONS: Unstable fracture patterns are unavoidable; however, careful attention to calcar reduction and selection of dual-screw CMN implants may minimize lag screw sliding and its detrimental effects on outcomes. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Early Operative Treatment of Acetabular Fractures Does Not Increase Blood Loss: A Retrospective Review.

OBJECTIVES: To compare cell salvage (CS) volume, intraoperative blood loss, intraoperative blood transfusions, and operative time for acetabular fractures undergoing early (≤48 hours from admission) versus delayed fixation (>48 hours from admission). DESIGN: Retrospective. SETTING: Level one trauma center. PATIENTS: One hundred thirty-one patients with unilateral acetabular fractures involving at least one column. INTERVENTION: Open reduction and internal fixation performed through the anterior intrapelvic approach or posterior approach. MAIN OUTCOME MEASUREMENTS: CS volume, estimated blood loss (EBL), intravenous fluids (IVFs), intraoperative packed red blood cells (PRBCs), and operative time. RESULTS: Early versus delayed fixation through the posterior approach was associated with shorter operative times and less intraoperative PRBCs (140 vs. 301 mL, MD -161 mL, 95% confidence interval -25 to -296 mL) with no differences in CS, EBL, or IVF. Early versus delayed fixation through an anterior intrapelvic approach was more common in less severe fracture patterns with no differences in PRBCs, CS, EBL, or IVF. CS, through either approach, was successful in returning blood to 77% of patients for an average of 267 ± 168 mL (range, 105-900 mL). CONCLUSIONS: Fixation of acetabular fractures within 48 hours of admission did not increase blood loss or intraoperative transfusions. CS was successful in returning an average of one unit of blood to a majority of patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Screws are at a safe distance from critical structures after superior plate fixation of clavicle fractures.

INTRODUCTION: Injuries to the critical structures underlying the clavicle are possible during open reduction and internal fixation (ORIF) and afterward secondary to prominent screws. The purpose of this study was to identify patients who received chest computerized tomography (CT) scans after clavicle ORIF to evaluate the distance between the screws and the subclavian vessels. METHODS: A retrospective review was performed at a single level-one trauma center. Nineteen patients with chest CT scans after superior plate fixation were included. Coronal CT reconstructions were analyzed to determine distances between the subclavian vessels and screw tips along with the prominence of the screws. Vessels within 15 mm of the screw were considered at risk. RESULTS: None of the screws (0/142) were within 15 mm of the subclavian vessels. Average screw prominence was 1.3 ± 1 mm (range, 0-3.6 mm). One of the 19 patients had a complication, a re-fracture requiring revision ORIF. The remaining 18 patients had no complications, including neurovascular or pulmonary, at the last follow-up. CONCLUSIONS: None of the screws were excessively prominent or within 15 mm of the subclavian vessels. Attentive superior plate fixation of the clavicle with screws is a safe technique. LEVEL OF EVIDENCE: Level IV, case series.

Caregivers of hip fracture patients: The forgotten victims?

INTRODUCTION: The burden that family and friends assume when caring for hip fracture patients can negatively impact the caregiver's quality of life, relationships, and the decision to place the patient in a care facility. The purpose of this study was to evaluate the burden of caregiving for intertrochanteric hip fractures to better counsel patients and caregivers in order to prevent delayed admission to a care facility. METHODS: A retrospective analysis of a prospectively gathered elderly hip fracture database identified 29 patients and their caregivers with complete 6 month follow-up. Caregiver burden and depression scales were administered to the primary caregiver in the immediate perioperative period (baseline), at 3 month follow-up, and at 6 month follow-up. At each time point caregivers reported the effects of caregiving on their finances, work hours, relationships, and their willingness to admit the patient to a long-term care facility. RESULTS: At 6 month follow-up, <30% of caregivers reported negative effects on their finances, relationships, work hours, or intent to place the patient in care facility, while 77% endorsed cherishing their time spent as a caregiver. The number of caregivers with a high caregiver burden remained stable at 20% over the 6 month follow-up; these caregivers were more likely to have a depressed mood (p < 0.01), to consider placement of the patient into a long-term care facility (p < 0.01), and to have negatively affected finances (p = 0.03) and relationships (p < 0.01). CONCLUSIONS: High degrees of burden were experienced by 20% of caregivers of hip fracture patients. Caregivers with high caregiver burdens were more likely to consider placement of the patient into a long-term care facility. Risk factors for high caregiver burdens should be identified to optimize the quality of caregiving after discharge and to prevent delayed admission to a long-term care facility. LEVEL OF EVIDENCE: Level IV, case series.

Needlestick and sharps injuries in orthopedic surgery residents and fellows.

OBJECTIVE: Needlestick and sharps injury (NSSI) is a common occupational hazard of orthopedic surgery training. The purpose of this study was to examine the incidence and surrounding circumstances of intraoperative NSSI in orthopedic surgery residents and fellows and to examine postexposure reporting. DESIGN: A 35-question cross-sectional survey. SETTING: The study was conducted by orthopedic surgery residents and faculty at a nonprofit regional hospital. PARTICIPANTS: The questionnaire was distributed to US allopathic orthopedic surgery residency and fellowship programs; 300 orthopedic surgery trainees participated in the survey. RESULTS: Of 223 trainees who had completed at least 1 year of residency, 172 (77.1%) sustained an NSSI during residency, and 57 of 63 trainees (90.5%) who had completed at least 4 years sustained an NSSI during residency. The most common causes of NSSI were solid needles, followed by solid pins or wires. The surgical activity most associated with NSSI was wound closure, followed by fracture fixation. The type of surgery most frequently associated with NSSI was orthopedic trauma, followed by hip and knee arthroplasty. Of 177 trainees who had sustained a prior NSSI, 99 (55.9%) failed to report all events to their institution's occupational health department. CONCLUSIONS: The incidence of NSSI during residency training is high, with >90% of trainees in their fifth year or later of training having received an injury during their training, with a mean of >4 separate events. Most trainees with an NSSI did not report all of their events, which implies that changes are needed in the incident reporting process universally.

Increased risk for complications following removal of hardware in patients with liver disease, pilon or pelvic fractures: A regression analysis.

PURPOSE: Indications for removing orthopedic hardware on an elective basis varies widely. Although viewed as a relatively benign procedure, there is a lack of data regarding overall complication rates after fracture fixation. The purpose of this study is to determine the overall short-term complication rate for elective removal of orthopedic hardware after fracture fixation and to identify associated risk factors. MATERIALS AND METHODS: Adult patients indicated for elective hardware removal after fracture fixation between July 2012 and July 2016 were screened for inclusion. Inclusion criteria included patients with hardware related pain and/or impaired cosmesis with complete medical and radiographic records and at least 3-month follow-up. Exclusion criteria were those patients indicated for hardware removal for a diagnosis of malunion, non-union, and/or infection. Data collected included patient age, gender, anatomic location of hardware removed, body mass index, ASA score, and comorbidities. Overall complications, as well as complications requiring revision surgery were recorded. Statistical analysis was performed with SPSS 20.0, and included univariate and multivariate regression analysis. RESULTS: 391 patients (418 procedures) were included for analysis. Overall complication rates were 8.4%, with a 3.6% revision surgery rate. Univariate regression analysis revealed that patients who had liver disease were at significant risk for complication (p=0.001) and revision surgery (p=0.036). Multivariate regression analysis showed that: 1) patients who had liver disease were at significant risk of overall complication (p=0.001) and revision surgery (p=0.039); 2) Removal of hardware following fixation for a pilon had significantly increased risk for complication (p=0.012), but not revision surgery (p=0.43); and 3) Removal of hardware for pelvic fixation had a significantly increased risk for revision surgery (p=0.017). CONCLUSIONS: Removal of hardware following fracture fixation is not a risk-free procedure. Patients with liver disease are at increased risk for complications, including increased risk for needing revision surgery following hardware removal. Patients having hardware removed following fixation for pilon fractures also are at increased risk for complication, although they may not require a return trip to the operating room. Finally, removal of pelvic hardware is associated with a higher return to the operating room.

Femoral neck fractures: current management.

Femoral neck fractures are a commonly encountered injury in orthopaedic practice and result in significant morbidity and mortality. It is essential that surgeons are able to recognize specific fracture patterns and patient characteristics that indicate the use of particular implants and methods to effectively manage these injuries. Use of the Garden and Pauwels classification systems has remained the practical mainstay of femoral neck fracture characterization that help dictate appropriate treatment. Operative options include in situ fixation, closed or open reduction and internal fixation, hemiarthroplasty, and total hip arthroplasty. Recent reports demonstrate diversity among orthopaedic surgeons in regard to the optimal treatment of femoral neck fractures and changing trends in management. The present discussion focuses on the current indications and methods for femoral neck fracture management to provide direction with respect to appropriate and effective care of these injuries.