High- Versus Low-Energy Intertrochanteric Hip Fractures in Young Patients: Injury Characteristics and Factors Associated With Complications.

OBJECTIVE: To compare fracture patterns and associated injuries for young patients with high- versus low-energy intertrochanteric hip fractures and to report on factors associated with complications after surgical fixation of high-energy fractures. DESIGN: Retrospective comparative study. SETTING: Academic Level 1 Trauma Center. PATIENTS: A total of 103 patients 50 years of age or younger were included: 80 high-energy fractures and 23 low-energy fractures. INTERVENTION: Cephalomedullary nailing (N = 92) or a sliding hip screw (N = 11). MAIN OUTCOME MEASURES: Radiographic characteristics of fracture morphology, implant position, and reduction quality and postoperative complications were the main outcome measures. RESULTS: Compared with young patients with low-energy fractures, those with high-energy fractures had more fracture comminution ( P = 0.013) and higher ISS scores ( P < 0.003) and were more likely to require open reduction ( P < 0.001). Patients with low-energy fractures from a ground-level fall had higher rates of alcohol abuse (0.032), cirrhosis (0.010), and chronic steroid use (0.048). Overall reoperation rate for high-energy fractures was 7%, including 2 IT fracture nonunions (5%) and 1 deep infection (2%). For high-energy fractures, ASA class ( P = 0.026), anterior lag screw position ( P = 0.001), and varus malreduction ( P < 0.001) were associated with malunion. Four-part fracture (OTA/AO 31A2.3/Jensen 5) ( P = 0.028) and residual calcar gap >3 mm ( P = 0.03) were associated with reoperation. CONCLUSIONS: Surgical treatment of high-energy IT fractures in young patients is technically demanding with potential untoward outcomes. Injury characteristics and severity are significantly different for young patients with high-energy IT fractures compared with low-energy fractures. For young patients with a high-energy IT fracture, surgeons can anticipate a high rate of associated injuries and complex fracture patterns requiring open reduction. For young patients with a low-energy IT fracture, comanagement with a hospitalist or a geriatrician should be considered because they may be physiologically older. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes After Acute Versus Staged Fixation of Complete Articular Tibial Plafond Fractures.

OBJECTIVE: To determine the outcomes after acute versus staged fixation of complete articular tibial plafond fractures. DESIGN: Retrospective cohort study. SETTING: Single Level 1 Trauma center. PARTICIPANTS: 98 skeletally mature patients with OTA/AO 43C type fractures who underwent definitive fixation with plate and screw constructs and had a minimum 6 months of follow-up. INTERVENTION: Acute open reduction internal fixation (aORIF) versus staged (sORIF) definitive fixation. MAIN OUTCOME MEASUREMENT: Rates of wound dehiscence/necrosis and deep infection. RESULTS: Acute (N = 40) versus staged (N = 58) ORIF groups had comparable rates of vascular disease, renal disease, and substance/nicotine use, but aORIF patients had higher rates of diabetes mellitus (10% vs. 0%, P < 0.001), which correlated with higher American Society of Anaesthesiologist scores (>American Society of Anaesthesiologist 3: 37.5% vs. 13.8%, P = 0.02). Both groups achieved anatomic/good reductions, as determined by postoperative CT scans, at rates greater than 90%; however, the sORIF group required modestly longer operative times to achieve this outcome (aORIF vs. sORIF: 121 vs. 146 minutes, P = 0.02). Postoperatively, both groups had similar rates of wound dehiscence (2.5% vs. 6.9%, P = 0.65), superficial infections (10% vs. 17.2%, P = 0.39), and deep infections (10% vs. 8.6%, P = 0.99). While the injury pattern itself required free flap coverage in 1 patient in each group, unplanned free flap coverage occurred in 10.0% and 10.3% of aORIF and sORIF groups, respectively. Overall, rates of unplanned reoperations, excluding ankle arthrodesis, did not differ between groups (aORIF vs. sORIF:12.5% vs. 25.9%, P = 0.13). CONCLUSIONS: In select patients managed by fellowship-trained orthopaedic traumatologists, acute definitive pilon fixation can produce acceptable outcomes. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Immediate Weight Bearing as Tolerated Is Safe Following Intramedullary Fixation of Extra-articular Metaphyseal Proximal Tibia Fractures (OTA/AO 41-A).

OBJECTIVES: To determine whether immediate weight bearing after intramedullary fixation of extra-articular proximal tibia fractures (OTA/AO 41A) results in change of alignment before union. DESIGN: Retrospective Review. SETTING: Level I and Level II Trauma Center. PATIENTS/PARTICIPANTS: Thirty-seven patients with 37 proximal tibial fractures, all whom could bear weight as tolerated postoperatively. Eighteen fractures were OTA/AO 41-A2, and 19 were OTA/AO 41-A3. INTERVENTION: Intramedullary nailing of extra-articular proximal tibia fractures. MAIN OUTCOME MEASUREMENTS: Change in fracture alignment or loss of reduction. RESULTS: The average change in coronal alignment at the final follow-up was 1.22 ± 1.28 degrees of valgus and 1.03 ± 1.05 degrees of extension in the sagittal plane. Twenty-five patients demonstrated excellent initial alignment, 10 patients demonstrated acceptable initial alignment, and 2 patients demonstrated poor initial alignment. Five patients demonstrated a change in alignment from excellent to acceptable at the final follow-up. No patient went from excellent or acceptable initial alignment to poor final alignment. Five patients required unplanned secondary surgical procedures. Two patients required return to the operating room for soft-tissue coverage procedures, 2 patients required surgical debridement of a postoperative infection, and 1 patient underwent debridement and exchange nailing of an infected nonunion. No patient underwent revision for implant failure or loss of reduction. CONCLUSION: Immediate weight bearing after intramedullary fixation of extra-articular proximal tibia fractures (OTA/AO 41A) led to minimal change in alignment at final postoperative radiographs. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Does a Reduced Secondary Operation Rate Offset Higher Implant Charges when Utilizing Suture Button Fixation for Syndesmotic Injuries?

OBJECTIVE: To determine whether a reduced secondary operation rate offsets higher implant charges when using suture button fixation for syndesmotic injuries. DESIGN: Retrospective cohort study. SETTING: Single, urban, Level 1 trauma center. PARTICIPANTS: Three-hundred twenty-seven (N = 327) skeletally mature patients with rotational ankle fractures (OTA/AO type 44) necessitating concurrent syndesmotic fixation. INTERVENTION: Suture button or solid 3.5-mm screw syndesmotic fixation. MAIN OUTCOME MEASUREMENTS: To compare implant charges with secondary operation charges based on differential implant removal rates between screws and suture buttons. RESULTS: Patients undergoing screw fixation were older (48.8 vs. 39.6 years, P < 0.01), had more ground-level fall mechanisms (59.3% vs. 51.1%, P = 0.026), and sustained fewer 44C type injuries (34.7% vs. 56.8%, P = 0.01). Implant removal occurred at a higher rate in the screw fixation group (17.6% vs. 5.7%, P = 0.005). Binomial logistic regression identified nonsmoker status (B = 1.03, P = 0.04) and implant type (B = 1.41, P = 0.008) as factors associated with implant removal. Adjusting for age, the NNT with a suture button construct to prevent one implant removal operation was 9, with mean resulting additional implant charges of $9747 ($1083/case). Backward calculations using data from previous large studies estimated secondary operation charges at approximately $14220, suggesting a potential 31.5% cost savings for suture buttons when considering reduced secondary operation rates. CONCLUSIONS: A reduced secondary operation rate may offset increased implant charges for suture button syndesmotic fixation when considering institutional implant removal rates for operations occurring in tertiary care settings. Given these offsetting charges, surgeons should use the syndesmotic fixation strategy they deem most appropriate in their practice setting. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Various Antibiotic Cement-Coated Intramedullary Implants on the Treatment of Long Bone Septic Nonunion.

OBJECTIVE: To determine the effectiveness of various types of antibiotic-coated intramedullary implants in the treatment of septic long bone nonunion. DESIGN: Retrospective chart review. SETTING: Level 1 trauma center. PARTICIPANTS: Forty-one patients with septic long bone nonunion treated with an antibiotic cement-coated intramedullary implant. INTERVENTION: Surgical debridement and placement of a type of antibiotic-coated intramedullary implant. MAIN OUTCOME MEASUREMENTS: Union and need for reoperation. RESULTS: At an average 27-month follow-up (6-104), 27 patients (66%) had a modified radiographic union score of the tibia of 11.5 or greater, 12 patients (29%) a score lower than 11.5, and 2 patients (5%) underwent subsequent amputation. Six patients underwent no further surgical procedures after the index operation. Patients treated with a rigid, locked antibiotic nail achieved earlier weight-bearing (P = 0.001), less frequently required autograft (P = 0.005), and underwent fewer subsequent procedures (average 0.38 vs. 3.60, P = 0.004) than those treated with flexible core antibiotic rods. CONCLUSIONS: Antibiotic-coated intramedullary implants are successful in the treatment of septic nonunions in long bones. In our cohort, rigid, statically locked nails allowed faster rehabilitation, decreased the need for autograft, and decreased the number of additional surgical procedures. Further study is needed to confirm these findings. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

"Unstable" Pediatric Femoral Shaft Fractures Treated With Flexible Elastic Nails Have Few Complications.

OBJECTIVES: To determine our complication rate in pediatric femoral shaft fractures treated with flexible elastic nailing and to determine fracture characteristics that may predict complications. DESIGN: Retrospective cohort study. SETTING: One Level 1 and One Level 2 academic trauma centers. PATIENTS/PARTICIPANTS: One hundred one pediatric femoral shaft fractures treated from 2006 to 2018. MAIN OUTCOME MEASUREMENT: Major and minor complications. RESULTS: One hundred one femurs met inclusion criteria. The average age was 7 years (range 3-12 years). The average weight was 29.0 kg (range 16-55 kg). The average follow-up was 11 months (6-36 months). Ninety-three patients underwent elective implant removal at our institution. Fifty-one of the 101 (50%) fractures were "unstable" patterns. Ninety-three percent had implants that filled >80% of the canal (69 titanium and 32 stainless steel). Seventeen percent (18) had cast immobilization. All fractures went on to union. No patient required revision surgery for malunion as follows: 6 had coronal/sagittal malalignment >10 degrees, 3 had malrotation >15 degrees, and none had a leg length inequality >1 cm. Three patients had an unplanned surgery as follows: 2 for prominent implants and 1 for refracture after a second injury. There were no patient, fracture, or treatment characteristics that were predictive of complications or unplanned surgery, including "unstable" fractures (P = 0.78). CONCLUSION: Our study demonstrates that flexible elastic nailing can be safely used in most pediatric femoral shaft fractures, including those previously described as "unstable." LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Iatrogenic Nerve Palsy Occurs With Anterior and Posterior Approaches for Humeral Shaft Fixation.

OBJECTIVE: To determine if surgical approach impacts the rate of nerve palsy after plate fixation of humerus shaft fractures and whether or not iatrogenic nerve palsy recovers in similar ways to preoperative palsy. DESIGN: Retrospective. SETTING: Two trauma centers. PATIENTS: Patients 18+ years of age with nonpathologic, extra-articular humerus shaft fractures (OTA/AO 12A/B/C and 13A2-3) treated with plate fixation. INTERVENTION: Plate fixation of humerus shaft fractures, from 2008 to 2016. MAIN OUTCOME MEASUREMENT: Rate of iatrogenic nerve palsy by a surgical approach and injury characteristics. RESULTS: Two hundred sixty-one humeral shaft fractures were included. The rate of preoperative palsy was 19%. Radial nerve palsy (RNP) was present in 18%. Iatrogenic RNP occurred in 12.2% and iatrogenic ulnar palsy in 1.2%. Iatrogenic palsy occurred in 15.6% of middle and 15% of distal fractures, with fracture location significantly different in those developing RNP (P = 0.009). Iatrogenic RNP occurred in 7.1% of anterolateral, 11.7% of posterior triceps-splitting, and 17.9% of posterior triceps-sparing approaches (P = 0.11). Follow-up data were available for 139 patients at an average of 12 months. Preoperative RNP resolved less often than iatrogenic RNP, in 74% versus 95% (P = 0.06). Time to resolution was longer for preoperative RNP, at 5.5 versus 4.1 months (P = 0.91). Twenty-two percent with preoperative RNP underwent tendon transfer or wrist fusion, versus 0% after iatrogenic RNP (P = 0.006). CONCLUSION: Iatrogenic RNP is not uncommon with humeral fracture fixation and occurs at similar rates in anterior and posterior approaches and with midshaft and distal fractures. Iatrogenic RNP had a high rate of recovery. Preoperative RNP more often requires surgery for unresolved palsy. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effect of Nail Size, Insertion, and Δ Canal-Nail on the Development of a Nonunion After Intramedullary Nailing of Femoral Shaft Fractures.

OBJECTIVE: To determine whether intramedullary nail (IMN) diameter, antegrade versus retrograde insertion, or the difference between the canal and IMN diameter affect femoral shaft fracture healing. DESIGN: Retrospective analysis of a prospective database. SETTING: Level One Regional Trauma Center. PATIENTS/PARTICIPANTS: Seven hundred thirty-three femoral shaft fractures (OTA/AO 32) treated with an IMN between 1999 and 2017. After exclusion criteria, 484 fractures remained in the final analysis. INTERVENTION: Closed section, cannulated, interlocked, titanium alloy IMN using a reamed insertion technique. MAIN OUTCOME MEASUREMENTS: Nonunion, IMN size (10, 11.5, and 13 mm), antegrade versus retrograde insertion, Δ canal-nail diameter (ΔD) after reaming (<1, 1-2, or >2 mm). RESULTS: IMN diameters used were as follows: 314/10 mm (64%), 137/11.5 mm (28%), and 33/13 mm (8%). Forty-five percent were placed in antegrade versus 55% retrograde. Four hundred fifty-six fractures (94.2%) healed uneventfully. There were no IMN failures. 10/484 IMNs (2%) had broken interlocking screws; only 4 were associated with a NU. Average time to union was 23 weeks (12-119). Twenty-eight (5.8%) developed NU. There was no statistical correlation between (1) the NU rate and IMN diameter: 10 mm, 6.3%; 11.5 mm, 5.1%; 13 mm, 3% (P = 0.8, power = 0.85), (2) the NU rate and ΔD: 7.1% <1 mm, 5.6% 1-2 mm, 20% >2 mm (P = 0.36), (3) the NU rate and fracture location: Prox = 11%, Mid = 5%, Dist = 3% (P = 0.13), or (4) the NU rate and antegrade (7.2%) versus retrograde (4.2%) insertion (P = 0.24). CONCLUSION: Similar healing rates occurred regardless of IMN diameter, Δ canal-nail diameter after reaming, or insertion site. This indicates that a closed section, cannulated, interlocked, titanium alloy IMN with a diameter of 10 mm can be considered the standard diameter for the treatment of acute femoral shaft fractures, regardless of entry point. This should be associated with less reaming and therefore shorter operative times, and possibly less hospital implant inventories as well. Larger diameter IMN should be reserved for revision surgery. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Symptomatic Iliosacral Screw Removal After Pelvic Trauma-Incidence and Clinical Impact.

OBJECTIVE: To calculate the incidence of symptomatic iliosacral (SI) screw removal following pelvic trauma and to determine the clinical impact of the secondary intervention. DESIGN: Retrospective chart review. SETTING: Level 1 and Level 2 trauma centers. PATIENTS: Four hundred seventy-one consecutive patients undergoing percutaneous posterior pelvic fixation over 10 years, with 7 excluded for spinopelvic fixation,and 7 excluded due to age <16 year old. INTERVENTION: Implant removal. MAIN OUTCOME MEASUREMENT: Secondary intervention. RESULTS: A total of 25/457 patients underwent screw removal (5.4%). Two patients were lost to follow-up, leaving 23 for analysis. There were 13 male patients and 10 female patients. There were 13 SI and 10 trans-sacral screws removed. Four screws were loose before removal (17%). Average time to screw removal was 10.7 months (4-26 minutes). Fifteen (83.3%) patients had subjective improvement, and 3 (16.7%) had no notable improvement. CONCLUSION: The incidence of symptomatic SI screws necessitating removal is low (5.4%). When removed, there is a high likelihood (83%) that the secondary intervention will result in subjective symptomatic improvement. Routine screw removal is unnecessary because most patients tolerate the implants without symptoms necessitating subsequent surgery. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Orthopaedic Watercraft Injuries: Characterization of Mechanisms, Fractures, and Complications in 216 Injuries.

OBJECTIVE: To review the orthopaedic injuries from watercraft treated surgically at our institution and report the mechanisms, fractures, and complications encountered. DESIGN: Retrospective case series. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: There were 216 fractures from watercraft in 146 patients. Average age was 33 years (range 4-78 years), there were 68% males (99/146), and 16% of the injuries occurred in children. INTERVENTION: Operative fracture fixation. MAIN OUTCOME MEASUREMENTS: After IRB approval, data were collected from January 1, 1998, to December 31, 2015, for patients including demographics, watercraft type, mechanism of injury, fracture pattern, infection, organisms, union, and amputation. Descriptive statistics were used. RESULTS: There were 130 closed fractures (60%) and 86 open fractures (40%). There were 146 (67%) lower extremity injuries, 49 (23%) upper extremity injuries, and 21 (10%) pelvic injuries. The overall postoperative infection rate was 9% (20/216) and was commonly polymicrobial in nature. The postoperative infection rate in closed fractures was 4% (5/130) and the postoperative infection rate in open fractures was 17% (15/86). Open fractures also had a high proportion of nonunion (8%) and amputation (16%). CONCLUSIONS: This is the largest reported series of orthopaedic injuries from watercraft. These injuries can be devastating in nature and difficult to manage, particularly when they are open (40%). There is a high rate of postoperative infection (17%), nonunion (8%), and amputation (16%) associated with open orthopaedic watercraft fractures. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Cephalomedullary Nail Fixation of Intertrochanteric Femur Fractures: Are Two Proximal Screws Better Than One?

OBJECTIVES: To analyze radiographic changes in intertrochanteric (IT) fracture alignment after treatment with either a single sliding lag screw or an integrated compressed and locked, dual screw, cephalomedullary nail construct. DESIGN: Retrospective comparative study. SETTING: Level 1 regional trauma center. PATIENTS: 1004 OTA/AO 31A, 31B2.1 fractures treated with either a single screw cephalomedullary nail (Gamma 3) or an integrated dual screw cephalomedullary nail (InterTAN) between February 1, 2005, and June 30, 2013. Four hundred thirteen remained after exclusion criteria; 130 were treated with a single screw device (79 stable and 51 unstable), and 283 with an integrated dual screw device (155 stable and 128 unstable). INTERVENTION: Cephalomedullary nail insertion. OUTCOME MEASURES: Radiographic analysis included fracture pattern, fracture reduction, neck-shaft angle (NSA), and femoral neck shortening (FNS) differences at 3, 6, and 12 months. Measurements were normalized using known lag screw dimensions, digitally corrected for magnification. Rotation between x-rays was controlled using a ratio of known to measured dimensions. The Mann-Whitney U test was used for statistical analysis. RESULTS: The single screw device resulted in 2.5 times more varus collapse (NSA) and 2 times more FNS over 1 year, as compared to the locked, integrated dual screw device, regardless of stability (P < 0.001). NSA and FNS changes were greater for both devices in unstable fracture patterns, but significantly less movement occurred with the dual screw device (P < 0.001). CONCLUSIONS: A cephalomedullary nail with 2 integrated proximal screws that can be compressed and then locked seems to maintain initial IT fracture reduction and subsequent position over time, with less varus collapse and less shortening than a single screw device. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.