Acute versus staged fixation of bicondylar tibial plateau fractures: a dual centre international study.

BACKGROUND: Bicondylar tibial plateau fractures pose many treatment challenges due to their complex fracture patterns and associated soft tissue compromise. We aim to evaluate outcomes of acute ORIF (aORIF) versus staged ORIF (sORIF) of high energy bicondylar tibial plateau fractures. METHODS: We retrospectively reviewed 186 patients at two high-volume Level I trauma centers. One hundred one patients underwent aORIF and 85 underwent sORIF between 2011 and 2019. Clinical outcomes of interest included operative time, wound dehiscence, superficial and deep infection, nonunion, flap coverage, arthrodesis, and early conversion to arthroplasty. RESULTS: Patients had a median follow up of 12 months (6-98 months). The sORIF group had a higher ISS (p = 0.02) and a higher rate of open fractures (24.7% vs 11.9%, p = 0.03). The groups were statistically similar in other demographics and co-morbidities. Operative time was significantly shorter in the aORIF group (157 vs 213 min., p < 0.001). There was no statistical difference in wound dehiscence, deep infection, flap coverage, nonunion, unplanned reoperation, or post-traumatic arthritis between groups. However, aORIF was associated with a significantly lower rate of superficial infection (p = 0.01), arthroplasty (p = 0.003) and unplanned reoperation (p = 0.005). Subgroup analysis of only the 41C3 fractures showed a lower rate of superficial infections in the aORIF group (p = 0.04). No difference in complications was found between the fracture subgroups. CONCLUSION: We found no increased risk of complications with aORIF compared to sORIF for bicondylar tibial plateau fractures. While not all injuries may be appropriate for aORIF, our results demonstrate the safety of aORIF when patients are properly selected by experienced fracture surgeons. LEVEL OF EVIDENCE: Level III.

Is ChatGPT a trusted source of information for total hip and knee arthroplasty patients?

Aims: While internet search engines have been the primary information source for patients' questions, artificial intelligence large language models like ChatGPT are trending towards becoming the new primary source. The purpose of this study was to determine if ChatGPT can answer patient questions about total hip (THA) and knee arthroplasty (TKA) with consistent accuracy, comprehensiveness, and easy readability. Methods: We posed the 20 most Google-searched questions about THA and TKA, plus ten additional postoperative questions, to ChatGPT. Each question was asked twice to evaluate for consistency in quality. Following each response, we responded with, "Please explain so it is easier to understand," to evaluate ChatGPT's ability to reduce response reading grade level, measured as Flesch-Kincaid Grade Level (FKGL). Five resident physicians rated the 120 responses on 1 to 5 accuracy and comprehensiveness scales. Additionally, they answered a "yes" or "no" question regarding acceptability. Mean scores were calculated for each question, and responses were deemed acceptable if ≥ four raters answered "yes." Results: The mean accuracy and comprehensiveness scores were 4.26 (95% confidence interval (CI) 4.19 to 4.33) and 3.79 (95% CI 3.69 to 3.89), respectively. Out of all the responses, 59.2% (71/120; 95% CI 50.0% to 67.7%) were acceptable. ChatGPT was consistent when asked the same question twice, giving no significant difference in accuracy (t = 0.821; p = 0.415), comprehensiveness (t = 1.387; p = 0.171), acceptability (χ2 = 1.832; p = 0.176), and FKGL (t = 0.264; p = 0.793). There was a significantly lower FKGL (t = 2.204; p = 0.029) for easier responses (11.14; 95% CI 10.57 to 11.71) than original responses (12.15; 95% CI 11.45 to 12.85). Conclusion: ChatGPT answered THA and TKA patient questions with accuracy comparable to previous reports of websites, with adequate comprehensiveness, but with limited acceptability as the sole information source. ChatGPT has potential for answering patient questions about THA and TKA, but needs improvement.

Open Reduction And Internal Fixation of Tarsometatarsal (Lisfranc) Fracture Dislocations-Is Arthrodesis Necessary?

INTRODUCTION: Controversy remains regarding the optimal management of tarsometatarsal (Lisfranc) fracture dislocations. Open reduction and internal fixation (ORIF) and ORIF with primary arthrodesis (PA) have been described in the treatment of these injuries, although adverse sequelae remain problematic. Previous work has yielded small cohorts with heterogenous results. We aimed to describe the outcomes of Lisfranc fracture dislocations managed with ORIF and/or PA to identify risk factors for complications, such as nonunion and revision surgery. METHODS: A retrospective review of 206 consecutive tarsometatarsal fracture dislocations that underwent surgical repair between 2015 and 2021 was performed. Time to radiographic union was noted. Complications were recorded, including revision surgery, infection, symptomatic implant removal, posttraumatic arthritis, secondary arthrodesis, and nonunion. A comparative subgroup analysis of outcomes by treatment modality (ie, PA versus ORIF) and by injury severity (isolated injury versus concomitant lower extremity fracture) were performed. Logistic regression analysis was performed to assess factors associated with revision surgery. RESULTS: 104 patients met the inclusion criteria with a mean 13-month follow-up. Ninety-three (n = 93) patients underwent ORIF, and 11 patients underwent PA. Radiographic union was achieved in 94.2% of cases (98/104) at an average 106 days. Complications included superficial infection (3.8%), deep infection (7.7%), symptomatic implant removal (19.2%), posttraumatic arthritis (12.5%), secondary arthrodesis (4.8%), and nonunion (2.9%). No difference existed in the complication rates between those who underwent ORIF and those who underwent PA ( P = 0.50). Revision surgery rates were similar between patients who sustained isolated injuries and those with concomitant lower extremity fractures ( P = 0.31). Risk factors for revision surgery included open fractures (OR 4.01, P = 0.042) and previous psychiatric illness (OR 5.77, P = 0.016). DISCUSSION: The vast spectrum of injury in Lisfranc fracture dislocations makes uniform treatment challenging. In this large consecutive series, few failed to achieve union or required secondary arthrodesis. Open fractures and previous psychiatric illness portended worse clinical outcomes. ORIF without PA remains a viable treatment in these injuries. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Do Long-Segment Blocking Screws Increase the Stability of Intramedullary Nail Fixation in Proximal Tibia Fractures, Eliminating the "Bell-Clapper Effect?"

OBJECTIVES: To determine change in stiffness and horizontal translation of a geriatric extra-articular proximal tibia fracture model after intramedullary nailing with distal (long)-segment blocking screws versus proximal (short)-segment blocking screws. METHODS: Unstable extra-articular proximal tibia fractures (OTA/AO 41-A3) were created in 12 geriatric cadaveric tibias. Intramedullary nails were locked with a standard construct (4 proximal screws and 2 distal screws). Specimens were then divided into 2 groups (6 matched pairs per group). Group 1 had a blocking screw placed lateral to the nail in the proximal segment (short segment). Group 2 had a blocking screw placed 1 cm distal to the fracture and medial to the nail (long segment). Specimens were then axially loaded and cycled to failure or cycle completion (50,000 cycles). RESULTS: Long-segment blocking screws significantly decreased the amount of horizontal translation at the fracture site compared with short-segment screws (0.77 vs. 2.0 mm, P = 0.039). They also resulted in a greater trend towards greater baseline stiffness, (807.32 ± 216.95 N/mm vs. 583.12 ± 130.1 N/mm, P = 0.072). There was no difference in stiffness after cyclic loading or survival through 50,000 cycles between the long-segment and short-segment groups. CONCLUSION: Long-segment blocking screws added to an intramedullary nail construct resulted in decreased horizontal translation at the fracture site compared with short-segment screws in this model of a geriatric proximal tibia fracture. CLINICAL RELEVANCE: Blocking screws are commonly used to aid in fracture alignment during intramedullary nailing of proximal tibia fractures. Even when not required to attain or maintain alignment, the addition of a blocking screw in either the proximal or the distal (long) segment may help mitigate the "Bell-Clapper Effect" in geriatric patients.

The Effect of Topical Antibiotic Powder Application in the Emergency Department on Deep Fracture-Related Infection in Type III Open Lower Extremity Fractures.

OBJECTIVE: Despite advances in management, open fractures are at an elevated risk for deep fracture-related infection (FRI). Time to systemic antibiotic (ABX) administration and intraoperative topical administration of ABX powder have been used to decrease FRI risk. The purpose of this study was to determine whether topical application of antibiotic powder to type III open lower extremity fractures immediately on presentation to the emergency department (ED) reduces the rate of FRI. DESIGN: Prospective cohort compared with retrospective historical control. SETTING: Level I trauma center. INTERVENTION: Application of 1 g of vancomycin and 1.2 g of tobramycin powder directly to open fracture wounds on presentation to the ED. PATIENT SELECTION CRITERIA: Patients with type III open lower extremity fractures treated from July 1, 2019, to September 17, 2022, who received topical ABX powder in the ED were compared with patients from a 4-year historical cohort from July 1, 2015, to June 30, 2019, who were treated without topical ABX powder. OUTCOME MEASURES AND COMPARISONS: Development of a FRI within 6 months of follow-up. Patient demographics, injury characteristics, and postoperative data were analyzed as risk factors for FRI. RESULTS: Sixty-six patients received topical ABX powder in the ED and were compared with 129 patients who were treated without topical ABX powder. The rate of FRI in the trial group was 6/66 (9.09%) versus 22/129 (17.05%) in the control cohort ( P = 0.133). Multivariate analysis demonstrated higher body mass index as a risk factor for development of FRI ( P = 0.036). CONCLUSION: No statistically significant difference in rates of FRI in open lower extremity fractures treated with immediate topical ABX administration in the ED versus standard-of-care treatment without topical ABX was found. These findings may have been limited by insufficient power. Further large-scale study is warranted to determine the significance of topical antibiotic powder application in the ED. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pelvic ring injuries: recent advances in diagnosis and treatment.

Pelvic ring injuries typically occur from high-energy trauma and are often associated with multisystem injuries. Prompt diagnosis of pelvic ring injuries is essential, and timely initial management is critical in the early resuscitation of polytraumatized patients. Definitive management of pelvic ring injuries continues to be a topic of much debate in the trauma community. Recent studies continue to inform our understanding of static and dynamic pelvic ring stability. Furthermore, literature investigating radiographic and clinical outcomes after nonoperative and operative management will help guide trauma surgeons select the most appropriate treatment of patients with these injuries.

Surgeon Learning Curve for the Sinus Tarsi Approach to Intra-articular Calcaneus Fractures - Improvement with Experience.

OBJECTIVE: To analyze the relationship between surgeon experience with the sinus tarsi approach (STA) and outcomes in the treatment of displaced intra-articular calcaneus fractures (DIACF). SETTING: Single level 1 trauma center. DESIGN: Retrospective.Patients/Participants: 103 consecutive DIACF (OTA/AO 82C; Sanders II-IV) treated operatively using STA from 2015 to 2021. INTERVENTION: Open management using the STA performed by two fellowship-trained orthopaedic traumatologists. MAIN OUTCOME MEASUREMENT: Quality of anatomic reduction based on postoperative CT scans and standard radiographs. RESULTS: Sixty-six patients met inclusion criteria. Patients were primarily men (75.8%) with mean age 41 years (range 20-71 years), including 14 smokers (21.2%), 9 diabetics (13.6%), and 10 open fractures (15.2%). Sanders III fractures were most common (68.2% vs 28.5% and 6.1% Sanders II/IV respectively). Reduction quality was predominantly Good (59.1%, n=39) or Excellent (25.8%, n=17). Complications included wound necrosis (1), superficial infection (1), deep infection (1), and symptomatic posttraumatic arthritis requiring arthrodesis (3). There was a 29.3% reduction in likelihood of surgical complication with each year in surgeon experience with the STA and an 8.9% reduction per case (p<0.001). The likelihood of achieving a Good or Excellent reduction was 1.8 and 2.3 times greater than achieving a Fair reduction, respectively, for each year increase in surgeon experience with the STA (p=0.012 and 0.007, respectively). For each successive case, there was a 1.2 times greater likelihood of achieving a Good reduction (p=0.03). CONCLUSION: Surgeon experience plays a critical role in outcomes. We found that outcomes (reduction, complications) improve with each cumulative case and year of experience with the STA to treat DIACF. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

High Nonunion and Amputations Rates With Either Early Intramedullary Nail Removal or Retention for Tibial Shaft Fracture-Related Infections.

OBJECTIVES: To compare debridement, antibiotics, and implant retention (DAIR) and intramedullary nail (IMN) removal with subsequent strategy for fracture stabilization in the treatment of tibia fracture-related infections (FRIs) occurring within 90 days of initial IMN placement. DESIGN: Retrospective case-control. SETTING: Four academic, Level 1 trauma centers. PATIENTS: Sixty-six patients who subsequently received unplanned operative treatment for FRI diagnosed within 90 days of initial tibia IMN. INTERVENTION: DAIR versus IMN removal pathways. MAIN OUTCOME MEASUREMENTS: Fracture union. RESULTS: Twenty-eight patients (42.4%) were treated with DAIR and 38 (57.6%) via IMN removal with subsequent strategy for fracture stabilization. Mean follow-up was 16.3 months. At final follow-up, ultimate bone healing was achieved in 75.8% (47/62), whereas 24.2% (15/62) had persistent nonunion or amputation. No significant difference was observed in ultimate bone healing ( P = 0.216) comparing DAIR and IMN removal. Factors associated with persistent nonunion or amputation were time from injury to initial IMN ( P < 0.001), McPherson systemic host grade B ( P = 0.046), and increasing open-fracture grade, with Gustilo-Anderson IIIB/IIIC fractures being the worst ( P = 0.009). Fewer surgeries after initial FRI treatment were positively associated with ultimate bone healing ( P = 0.029). CONCLUSIONS: Treatment of FRI within 90 days of tibial IMN with DAIR or IMN removal with subsequent strategy for fracture stabilization results in a high rate, nearly 1 in 4, of persistent nonunion or amputation, with neither appearing superior for improving bone healing outcomes. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Academic productivity metrics correlate positively with industry funding amongst orthopedic shoulder and elbow surgeons.

Background: Research efforts can produce practice-changing results with widespread implications for patient care. While critical to the advancement of the field, such efforts do not often provide direct compensation. However, a researcher's academic productivity may facilitate industry relationships, either as the impetus for the affiliation or a result of collaboration. Methods: Queries of the Centers for Medicaid and Medicare Services publicly available Open Payments System allowed for extraction of industry compensation data for orthopedic surgeons in 7 categories, including royalties and licensing fees, consulting fees, gifts, honoria, and 3 unique speaking fees delineations. This system identifies physicians by taxonomy identifications; however, Centers for Medicaid and Medicare Services does not have a unique code for shoulder and elbow surgeons. Therefore, identification of shoulder and elbow surgeons proceeded utilizing the American Shoulder and Elbow Surgeons (ASES) society 2019 membership directory. Cross-referencing this membership list with extracted Open Payments data provided industry funding information for all ASES members. Physicians then underwent an academic productivity assessment. Queries of Web of Science, Scopus, and Google Scholar User Profile databases provided the Hirsch index (h-index) and m-index for each surgeon. Bivariate and multivariate analyses produced statistical results. Results: From 2016 to 2020, 631,130, 158, and 72 ASES members earned mean annual industry compensation <$1000, between $1001 and $10,000, between $10,001 and $100,000, and >$100,000, respectively. Royalties (91.5%) predominated in the top earning group, compared with consulting fees (58.0%, 55.0%) in the 2 middle-tier groups. H-index and m-index correlated positively with total compensation (h-index: r = 0.18, P < .001; m-index: r = 0.10, P < .001). The highest income group (>$100,000) had higher h-index and m-index scores than either intermediate ($1001-$10,000, $10,001-$100,000) or lowest (<$1000) compensation groups (From lowest to highest income bracket-h-index: 14.8 vs. 16.4 vs. 19.4 vs. 32, P < .001; m-index: 0.79 vs. 0.85 vs. 0.91 vs. 1.18, P = .003). Multivariable analysis of factors associated with increased industry compensation identified only h-index (B = 8046, P < .001) as having a significant association with physician compensation, with each single unit increase in h-index associated with an 18% increase in industry funding. Conclusion: Among a group of academic shoulder and elbow surgeons, industry compensation correlates positively with academic productivity metrics, with an associated $8046/yr increase in industry funding for each single-unit increase in h-index over 9. Future studies may focus on more clearly defining the causal directionality of these results.

Needle Arthroscopy as a Reduction Aid for Lower Extremity Peri-Articular Fractures: Case Series and Technical Tricks.

Background: Intra-articular fractures represent a challenging group of injuries that can occur in many different locations. In addition to restoring the mechanical alignment and stability of the extremity, accurate reduction of the articular surface is a primary goal for the treatment of peri-articular fractures. A variety of methods have been deployed to assist in the visualization and subsequent reduction of the articular surface, each with a unique set of pros and cons. The ability to visualize the articular reduction must be balanced against the soft tissue trauma required for extensile exposures. Arthroscopic assisted reduction has gained popularity for the treatment of a variety of articular injuries. Recently, needle based arthroscopy has been developed, predominantly as an outpatient tool for the diagnosis of intra-articular pathology. We present an initial experience with and technical tricks for the use of a needle based arthroscopic camera in the treatment of lower extremity peri-articular fractures. Methods: A retrospective review of all cases where needle arthroscopy was used as a reduction adjunct in lower extremity peri-articular fractures at a single, academic, level one trauma center was performed. Results: Five patients with six injuries were treated with open reduction internal fixation with adjunctive needle based arthroscopy. Early experience and tips and tricks for successful utilization of this technique are presented. Conclusion: Needle based arthroscopy may represent a valuable adjunct in the treatment of peri-articular fractures and warrants further investigation. Level of Evidence: IV.

Comparative Analysis of Supplemental Medial Buttress Plate Fixation for High-Energy Displaced Femoral Neck Fractures in Young Adults.

OBJECTIVES: To evaluate whether augmenting traditional fixation with a femoral neck buttress plate (FNBP) improves clinical outcomes in young adults with high-energy displaced femoral neck fractures. DESIGN: Multicenter retrospective matched cohort comparative clinical study. SETTING: Twenty-seven North American Level 1 trauma centers. PATIENTS: Adult patients younger than 55 years who sustained a high-energy (nonpathologic) displaced femoral neck fracture. INTERVENTION: Operative reduction and stabilization of a displaced femoral neck fracture with (group 1) and without (group 2) an FNBP. MAIN OUTCOME MEASUREMENTS: Complications including failed fixation, nonunion, osteonecrosis, malunion, and need for subsequent major reconstructive surgery (early revision of reduction and/or fixation), proximal femoral osteotomy, or arthroplasty. RESULTS: Of 478 patients younger than 55 years treated operatively for a displaced femoral neck fracture, 11% (n = 51) had the definitive fixation augmented with an FNBP. One or more forms of treatment failure occurred in 29% (n = 15/51) for group 1 and 49% (209/427) for group 2 ( P < 0.01). When FNBP fixation was used, mini-fragment (2.4/2.7 mm) fixation failed significantly more often than small-fragment (3.5 mm) fixation (42% vs. 5%, P < 0.01). Irrespective of plate size, anterior and anteromedial plates failed significantly more often than direct medial plates (75% and 33% vs. 9%, P < 0.001). CONCLUSIONS: The use of a femoral neck buttress plate to augment traditional fixation in displaced femoral neck fractures is associated with improved clinical outcomes, including lower rates of failed fixation, nonunion, osteonecrosis, and need for secondary reconstructive surgery. The benefits of this technique are optimized when a small-fragment (3.5 mm) plate is applied directly to the medial aspect of the femoral neck, avoiding more anterior positioning . LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effects of Technical Errors on the Outcomes of Operatively Managed Femoral Neck Fractures in Adults Less than 50 Years of Age.

OBJECTIVE: To evaluate the effect of technical errors (TEs) on the outcomes after repair of femoral neck fractures in young adults. DESIGN: Multicenter retrospective clinical study. SETTING: 26 North American Level 1 Trauma Centers. PATIENTS: Skeletally mature patients younger than 50 years of age with 492 femoral neck fractures treated between 2005 and 2017. INTERVENTION: Operative repair of femoral neck fracture. MAIN OUTCOME MEASUREMENTS: The association between TE (malreduction and deviation from optimal technique) and treatment failure (fixation failure, nonunion, malunion, osteonecrosis, malunion, and revision surgery) were examined using logistic regression analysis. RESULTS: Overall, a TE was observed in 50% (n = 245/492) of operatively managed femoral neck fractures in young patients. Two or more TEs were observed in 10% of displaced fractures. Treatment failure in displaced fractures occurred in 27% of cases without a TE, 56% of cases with 1 TE, and 86% of cases with 2 or more TEs. TEs were encountered less frequently in treatment of nondisplaced fractures compared with displaced fractures (39% vs. 53%, P < 0.001). Although TE(s) in nondisplaced fractures increased the risk of treatment failure and/or major reconstructive surgery (22% vs. 9%, P < 0.001), they were less frequently associated with treatment failure when compared with displaced fractures with a TE (22% vs. 69% P < 0.001). CONCLUSIONS: TEs were found in half of all femoral neck fractures in young adults undergoing operative repair. Both the occurrence and number of TEs were associated with an increased risk for failure of treatment. Preoperative planning for thoughtful and well-executed reduction and fixation techniques should lead to improved outcomes for young patients with femoral neck fractures. This study should also highlight the need for educational forums to address this subject. LEVEL OF EVIDENCE: Therapeutic 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.

Academic Productivity in Orthopaedic Traumatology Correlates Positively With Industry Compensation.

OBJECTIVE: To determine the association between academic productivity and industry compensation among Orthopaedic Traumatologists. DESIGN: Retrospective cohort study. SETTING: Review of the Centers for Medicaid and Medicare Services Open Payments program from 2016 to 2020. PARTICIPANTS: 1120 Orthopaedic Traumatologists. MAIN OUTCOME MEASUREMENTS: To determine if an Orthopaedic Traumatologist's h-index and m-index, as generated from Web of Science, Scopus, and Google Scholar User Profile databases, correlate with total payments from medical industry in 7 categories, including Royalties and Licensing Fees, Consulting Fees, Gifts, Honoraria, and 3 unique Speaking Fee delineations. RESULTS: Of 30,343 Orthopaedic Surgeons in the Open Payments program, 1120 self-identified with the Orthopaedic Trauma taxonomy. From 2016 to 2020, 499 surgeons (44.6%) received compensation in one of the eligible categories, most commonly from Consulting Fees (67.3%), though payments from Royalties provided the greatest gross income (70.4%). Overall, for all 1120 surgeons, h-index (r = 0.253, P < 0.001) and m-index (r = 0.136, P < 0.01) correlated positively with mean annual total industry compensation. The highest annual compensation group had higher h-index ($0 vs. $1-$1k vs. $1k-$10k vs. >$10k: 5.0 vs. 6.6 vs. 9.6 vs. 16.8, P < 0.001) and m-index ($0 vs. $1-$1k vs. $1k-$10k vs. >$10k: 0.48 vs. 0.60 vs. 0.65 vs. 0.89, P < 0.001) scores than either the intermediate or the no compensation groups. Multivariable analysis of factors associated with increased industry compensation, including H-index and years active, identified both as having significant associations with physician payments [H-index (B = 0.073, P < 0.001); years active (B = 0.059, P < 0.001)]. Subgroup analysis of the highest annual earner group (>$250k/year) also demonstrated the highest overall h-index (27.6, P < 0.001) and m-index (1.23, P = 0.047) scores, even when compared with other high-earners ($10k-$50k, $50k-$250k). Overall, each increase in h-index above an h-index of 3 was associated with an additional $1722 (95% CI: $1298-2146) of annual industry compensation. CONCLUSIONS: Academic productivity metrics have a positive association with industry compensation for Orthopaedic Traumatologists. This may highlight a potential ancillary benefit to scholarly efforts.

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.

The Association Between Orthopaedic Surgeon Academic Productivity Metrics and Compensation from Medical Industry.

INTRODUCTION: Academic research has value well beyond personal financial gain. However, these endeavors do require a notable amount of time and opportunity cost. Academic productivity may raise a researcher's profile within the field, increasing the likelihood for interactions with the medical industry and possibly cultivating relationships with future monetary significance. METHODS: Queries of the Centers for Medicaid and Medicare Services publicly available Open Payments System allowed for extraction of industry compensation data for orthopaedic surgeons. Aggregate data produce three compensation groups (mean annual income) for individual physicians: none; 1 to $100,000; and >$100,000. Physicians in the highest income category were matched 1:1 with physicians in each of the other two compensation groups. Selected physicians then underwent an academic productivity assessment. Queries of Web of Science, Scopus, and Google Scholar User Profile databases provided the h-index and m-index for each surgeon. Bivariate and multivariate analyses produced statistical results. In addition to the analysis of the tiered income groups, analysis of compensation as a continuous variable also occurred. RESULTS: From 2016 to 2020, 636, 7,617, and 22,091 US orthopaedic surgeons earned mean annual industry compensation >$100,000; between $1 and $100,000; and $0, respectively. Royalties (80.8%) predominated in the top earning group, compared with Consulting Fees (46.5%) in the second-tier group. The highest income group had higher h-index ($0 versus $1 to 100,000 versus >$100,000 = 3.6 versus 7.5 versus 20.0, P < 0.001) and m-index ($0 versus $1 to 100,000 versus >$100,000 = 0.26 versus 0.44 versus 0.80, P < 0.001) scores than either the intermediate or no compensation groups. In addition, h-index and m-index correlated positively with total compensation (h-index: r = 0.32, P < 0.001; m-index: r = 0.20, P < 0.001). Multivariable analysis of factors associated with increased industry compensation identified h-index (B = 0.034, P < 0.001) and years active (B = 0.042, P < 0.001) as having significant associations with physician compensation. Physician subspecialty also correlated with industry compensation. DISCUSSION: Academic research can provide invaluable contributions to the improvement of patient care. These efforts often require notable personal sacrifice with minimal direct remuneration. However, academic productivity metrics correlate positively with industry compensation, highlighting a possible supplementary benefit to scholarly efforts. LEVEL OF EVIDENCE: Level III.

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.

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.

A Prospective Randomized Controlled Trial Comparing Enoxaparin & Rivaroxaban for Venous Thromboembolism Prophylaxis in Orthopaedic Trauma.

OBJECTIVES: To determine whether there is a difference in orthopaedic trauma patient medication satisfaction and adherence using an oral versus subcutaneous injectable anticoagulant for venous thromboembolism chemoprophylaxis. DESIGN: Randomized controlled trial. SETTING: Single academic Level 1 trauma center. PARTICIPANTS: One hundred twenty adult orthopaedic trauma patients with operative pelvic or lower extremity fractures were randomized and completed the study. INTERVENTION: Three weeks of either the service standard 40 mg once daily enoxaparin versus trial medication 10 mg once daily rivaroxaban postoperatively. MAIN OUTCOME MEASURES: Patient satisfaction as measured by the Treatment Satisfaction Questionnaire for Medication (TSQM-9). Medication adherence as measured by the Morisky Medication Adherence Scale (MMAS-8). RESULTS: Medication adherence was similar in both groups. Medication satisfaction was significantly higher in the oral rivaroxaban group based on the TSQM-9 and patient-reported data. Secondary outcomes found no significant difference in the incidence of bleeding events or clinically relevant venous thromboembolism. The enoxaparin group experienced more adverse medication-related events. The rivaroxaban medication regimen costs 7.5-10× less out of pocket for uninsured patients. CONCLUSION: The results of this randomized controlled trial demonstrate that patients with surgical orthopaedic trauma prefer an oral anticoagulant for postoperative venous thromboembolism chemoprophylaxis and suggest that rivaroxaban may be a viable option. Furthermore, large-scale studies are needed to confirm safety and efficacy for rivaroxaban in this population as a potential alternative to enoxaparin and aspirin. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.