Risk Factors for Prolonged Hospital Stay After Femoral Neck Fracture.

The purpose of this study was to investigate the association between pre-operative anemia and prolonged hospital stay among geriatric patients with operative femoral neck fractures. This retrospective cohort study was performed at a level I trauma center and included geriatric patients with femoral neck fractures (OTA/AO 31) and operative treatment with Current Procedural Terminology code 27236. Exclusion criteria were admission to the intensive care unit, evacuation of subdural hematoma, and conditions requiring exploratory laparotomy. A total of 207 individuals, with data collected between January 2015 and August 2019 and age 65 years and older, were included in the analysis. Linear regression was used to evaluate the association between anemia and length of stay adjusting for potential confounders. Anemia was defined using preoperative hematocrit. The primary outcome was prolonged length of stay, defined as 5 or more days. The group was 65% women. The mean age was 80.2 years (range, 64-98 years). The majority (61%) of patients had anemia. American Society of Anesthesiologists classification was associated with preoperative anemia (P=.02). Patients with anemia had a 16% higher risk of prolonged length of stay compared with patients without anemia (81% vs 65%, P=.009). In the linear regression model, preoperative hematocrit was associated with length of stay (P=.032) when adjusted for sex, age, preoperative tranexamic acid, preoperative hemoglobin, postoperative hemoglobin, and postoperative hematocrit. Length of stay was approximately 1 week in this study, with anemia being a statistically significant risk factor for prolonged length of stay. Health care providers and administrators can consider anemia on admission when predicting length of stay. [Orthopedics. 2023;46(4):211-217.].

Isothermal Microcalorimetry Improves the Time to Diagnosis of Fracture-related Infection Compared With Conventional Tissue Cultures.

BACKGROUND: A consensus definition recently was formulated for fracture-related infection, which centered on confirmatory criteria including conventional cultures that take time to finalize and have a 10% to 20% false-negative rate. During this time, patients are often on broad-spectrum antibiotics and may remain hospitalized until cultures are finalized to adjust antibiotic regimens. QUESTIONS/PURPOSES: (1) What is the diagnostic accuracy of isothermal microcalorimetry, and how does its accuracy compare with that of conventional cultures? (2) Does isothermal microcalorimetry decrease time to detection (or diagnosis) of fracture-related infection compared with conventional cultures? (3) Does isothermal microcalorimetry have a diagnostic accuracy or time advantage over conventional cultures in patients on chronic suppressive antibiotics? METHODS: Between July 2020 and August 2021, we treated 310 patients with concerns for infection after prior fracture repair surgery. Of those, we considered all patients older than 18 years of age with fixation hardware in place at the time of presentation as potentially eligible. All included patients returned to the operating room with cultures obtained and assessed by both isothermal microcalorimetry and conventional cultures, and all were diagnosed using the consensus criteria for fracture-related infection. Based on that, 81% (250 of 310) of patients were eligible; a further 51% (157 of 310) were excluded because of the following reasons: the capacity of the isothermal microcalorimetry instrument limited the throughput on that day (34% [106 of 310]), they had only swab cultures obtained in surgery (15% [46 of 310]), or they had less than 3 months follow-up after surgery for infectious concerns (2% [5 of 310]), leaving 30% (93 of 310) of the originally identified patients for analysis. We obtained two to five cultures from each patient during surgery, which were sent to our clinical microbiology laboratory for standard processing (conventional cultures). This included homogenization of each tissue sample individually and culturing for aerobic, anaerobic, acid-fast bacilli, and fungal culturing. The remaining homogenate from each sample was then taken to our orthopaedic research laboratory, resuspended in growth media, and analyzed by isothermal microcalorimetry for a minimum of 24 hours. Aerobic and anaerobic cultures were maintained for 5 days and 14 days, respectively. Overall, there were 93 patients (59 males), with a mean age of 43 ± 14 years and a mean BMI of 28 ± 8 kg/m 2 , and 305 tissue samples (mean 3 ± 1 samples per patient) were obtained and assessed by conventional culturing and isothermal microcalorimetry. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of isothermal microcalorimetry to diagnose fracture-related infection were compared with conventional cultures using a McNemar test based on the consensus definition of fracture-related infection. This consensus criteria is comprised of two levels of certainty for the diagnostic variables. The first is confirmatory criteria, where infection is considered definitely present and includes the presence of fistula/sinus tract/wound breakdown, purulent drainage or the presence of pus, presence of microorganisms in deep tissue specimens on histopathologic examination, presence of more than five neutrophils/high-powered field by histopathologic examination (only for chronic/late onset cases), and identification of phenotypically indistinguishable pathogens by conventional culture from at least two separate deep tissue/implant specimens. The second is suggestive criteria in which further investigation is required to achieve confirmatory status. Fracture-related infection was diagnosed for this study to minimize subjectivity based on the presence of at least one of the confirmatory criteria as documented by the managing surgeon. When suggestive criteria were present without confirmatory criteria, patients were considered negative for fracture-related infection and followed further in clinic after surgical exploration (n = 25 patients). All 25 patients deemed not to have fracture-related infection were considered infection-free at latest follow-up (range 3 to 12 months). The time to detection or diagnosis was recorded and compared via the Mann-Whitney U test. RESULTS: Using the consensus criteria for fracture-related infection, there were no differences with the numbers available between isothermal microcalorimetry and conventional cultures in terms of sensitivity (87% [95% confidence interval 77% to 94%] versus 81% [95% CI 69% to 89%]), specificity (100% [95% CI 87% to 100%] versus 96% [95% CI 79% to 99%]), PPV (100% [95% CI 90% to 100%] versus 98% [95% CI 89% to 99%]), NPV (74% [95% CI 60% to 84%] versus 65% [95% CI 52% to 75%]), or accuracy (90% [95% CI 83% to 96%] versus 85% [95% CI 76% to 91%]; p = 0.13). The concordance by sample between conventional cultures and isothermal microcalorimetry was 85%. Isothermal microcalorimetry had a shorter median (range) time to detection or diagnosis compared with conventional cultures (2 hours [0.5 to 66] versus 51 hours [18 to 147], difference of medians 49 hours; p < 0.001). Additionally, 32 patients used antibiotics for a median (range) duration of 28 days (7 to 1095) before presentation. In these unique patients, there were no differences with the numbers available between isothermal microcalorimetry and conventional cultures in terms of sensitivity (89% [95% CI 71% to 98%] versus 74% [95% CI 53% to 88%]), specificity (100% [95% CI 48% to 100%] versus 83% [95% CI 36% to 99%]), PPV (100% [95% CI 85% to 100%] versus 95% [95% CI 77% to 99%]), NPV (63% [95% CI 37% to 83%] versus 42% [95% CI 26% to 60%]), or accuracy (91% [95% CI 75% to 98%] versus 78% [95% CI 57% to 89%]; p = 0.17). Isothermal microcalorimetry again had a shorter median (range) time to detection or diagnosis compared with conventional cultures (1.5 hours [0.5 to 48] versus 51.5 hours [18 to 125], difference of medians 50 hours; p < 0.001). CONCLUSION: Given that isothermal microcalorimetry considerably decreases the time to the diagnosis of a fracture-related infection without compromising the accuracy of the diagnosis, managing teams may eventually use isothermal microcalorimetry-pending developmental improvements and regulatory approval-to rapidly detect infection and begin antibiotic management while awaiting speciation and susceptibility testing to modify the antibiotic regimen. Given the unique thermograms generated, further studies are already underway focusing on speciation based on heat curves alone. Additionally, increased study sizes are necessary for both overall fracture-related infection diagnostic accuracy and test performance on patients using long-term antibiotics given the promising results with regard to time to detection for this groups as well. LEVEL OF EVIDENCE: Level II, diagnostic study.

Association Between COVID-19 and Mortality in Hip Fracture Surgery in the National COVID Cohort Collaborative (N3C): A Retrospective Cohort Study.

BACKGROUND: This study investigated the outcomes of coronavirus disease (COVID-19)-positive patients undergoing hip fracture surgery using a national database. METHODS: This is a retrospective cohort study comparing hip fracture surgery outcomes between COVID-19 positive and negative matched cohorts from 46 sites in the United States. Patients aged 65 and older with hip fracture surgery between March 15 and December 31, 2020, were included. The main outcomes were 30-day all-cause mortality and all-cause mortality. RESULTS: In this national study that included 3303 adults with hip fracture surgery, the 30-day mortality was 14.6% with COVID-19-positive versus 3.8% in COVID-19-negative, a notable difference. The all-cause mortality for hip fracture surgery was 27.0% in the COVID-19-positive group during the study period. DICUSSION: We found higher incidence of all-cause mortality in patients with versus without diagnosis of COVID-19 after undergoing hip fracture surgery. The mortality in hip fracture surgery in this national analysis was lower than other local and regional reports. The medical community can use this information to guide the management of hip fracture patients with a diagnosis of COVID-19.

Fracture and Patient Characteristics Associated With Early Conversion Total Hip Arthroplasty After Acetabular Fracture Fixation.

OBJECTIVES: To determine risk factors for early conversion total hip arthroplasty (THA) after operative treatment of acetabular fractures. DESIGN: Retrospective cohort. SETTING: Level I trauma center. PATIENTS AND INTERVENTION: We reviewed 685 operative acetabular fractures at our institution from 2011 to 2017, with a median follow-up of 12 months (range, 4-105 months). MAIN OUTCOME MEASURE: Multivariable regression analysis was performed after univariate analysis to identify independent risk factors for conversion THA. Sensitivity analysis was performed with minimum follow-up set at 6 and 12 months. RESULTS: One hundred eight patients (16%) underwent conversion THA, with 52% of conversions occurring within 1 year, an additional 27% within 2 years, and the remaining 21% within 6 years of the index acetabular open reduction internal fixation. The median time to conversion THA was 11.5 months (range, 0.5-72 months). The risk of conversion THA by fracture pattern was 53 of 196 (27%) for transverse posterior wall (TPW), 12 of 52 (23%) for T shaped, 10 of 68 (15%) for posterior column with posterior wall, and 25 of 207 (12%) for posterior wall. Independent risk factors for early conversion included the following: TPW fracture, protrusio, hip dislocation, increased body mass index, increased age, infection, and dislocation after open reduction internal fixation. Independent risk factors for early conversion THA specific to patients with TPW fractures include only increased age and body mass index. Sensitivity analysis showed no change in results using either 6 or 12-month minimum follow-up. CONCLUSION: Transverse posterior wall fractures have a high risk of early conversion THA compared with other acetabular fracture patterns, especially when in combination with other significant risk factors. Consideration for different and novel management options warrants further study in this subset of acetabular fracture patients. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intrawound Antibiotic Powder in Acetabular Fracture Open Reduction Internal Fixation Does Not Reduce Surgical Site Infections.

OBJECTIVES: To compare the risks of surgical site infection (SSI) and postoperative complications after acetabular fracture open reduction internal fixation (ORIF) in patients receiving topical intrawound antibiotic powder compared with those not receiving antibiotic powder (control group). DESIGN: Retrospective cohort. SETTING: Level I trauma center. PATIENTS AND INTERVENTION: We reviewed 789 acetabular fracture ORIF cases from 2010 to 2019 at our institution, with mean follow-up of 18 months (3-112 months). Overall, 326 patients comprised the control group and 463 received topical antibiotic powder (294 vancomycin and 169 vancomycin/tobramycin). MAIN OUTCOME MEASUREMENT: The study groups were compared for risk of SSI, seroma formation, wound dehiscence, acute kidney injury (AKI), and other postoperative complications. RESULTS: There were 63 total SSI (8.0%), 50 (6.3%) deep SSI and 13 suprafascial SSI (1.6%) cases. There was no difference in the risk of total SSI (8.3% vs. 7.8%, P = 0.80) or deep SSI (6.1% vs. 6.5%, P = 0.64). This was confirmed by multivariate analysis adjusting for covariates (odds ratio = 0.93; 95% confidence interval, 0.52-1.67; P = 0.80). Similar results were demonstrated when comparing the control group with the vancomycin and vancomycin/tobramycin subgroups. The control group and antibiotic powder groups had similar risks of all outcomes of interest, including seroma formation (1.8% vs. 1.7%, P = 1.00), wound dehiscence (1.2% vs. 2.2%, P = 0.42), total AKI (5.2% vs. 8.2%, P = 0.12), and RIFLE classification AKI (injury; 0.9% vs. 2.2%, P = 0.50). CONCLUSIONS: The addition of topical intrawound antibiotic powder, whether vancomycin alone or vancomycin/tobramycin before closure, does not reduce the risk of SSI after acetabular fracture ORIF compared with standard normal saline irrigation alone. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Civilian Ballistic Tibia Shaft Fractures Compared With Blunt Tibia Shaft Fractures: Open or Closed?

OBJECTIVES: To identify a group of ballistic tibia fractures, report the outcomes of these fractures, and compare them with both closed and open tibia fractures sustained by blunt mechanisms. We hypothesized that ballistic tibia fractures and blunt open fractures would have similar outcomes. DESIGN: Retrospective cohort study. SETTING: A single Level-1 trauma center. PATIENTS/PARTICIPANTS: Adult patients presenting with ballistic (44), blunt closed (179), or blunt open (179) tibia fractures. INTERVENTION: Intramedullary stabilization of tibia fracture. MAIN OUTCOMES: Unplanned reoperation, soft tissue reconstruction, nonunion, compartment syndrome, and fracture-related infection. RESULTS: Compared with the blunt closed group, the ballistic fracture group required more operations (P < 0.01), had a higher occurrence of soft tissue reconstruction (P < 0.01), and higher incidence of compartment syndrome (P = 0.02). Ballistic and blunt closed groups did not significantly differ in rates of unplanned reoperation (P = 0.67), nonunion (11.4% vs. 4.5%, P = 0.08), or deep infection (9.1% vs. 5.6%, P = 0.49). In comparison to the blunt open group, the ballistic group required a similar number of operations (P = 0.12), had similar rates of unplanned reoperation (P = 0.10), soft tissue reconstruction (P = 0.56), nonunion (11.4% vs. 17.9%, P = 0.49), and fracture-related infection (9.1% vs. 10.1%, P = 1.0) but a higher incidence of compartment syndrome (15.9% vs. 5.0%, P = 0.02). CONCLUSIONS: Ballistic tibia fractures require more surgeries and have higher rates of soft tissue reconstruction than blunt closed fractures and seem to have outcomes similar to lower severity open fractures. We found a significantly higher rate of compartment syndrome in ballistic tibia fractures than both open and closed blunt fractures. When treating ballistic tibia fractures, surgeons should maintain a high level of suspicion for the development of compartment syndrome and counsel patients that ballistic tibia fractures seem to behave like an intermediate category between closed and open fractures sustained through blunt mechanisms. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison Between the Direct Anterior and Posterior Approaches for Total Hip Arthroplasty Performed for Femoral Neck Fracture.

OBJECTIVES: To compare 90-day and 1-year outcomes, including mortality, of femoral neck fracture patients undergoing total hip arthroplasty (THA) by direct anterior approach (DAA) versus posterior approach (PA). DESIGN: Retrospective cohort. SETTING: Level I Trauma Center. PATIENTS: One hundred forty-three consecutive intracapsular femoral neck fractures treated with THA from 2010 to 2018. The minimum follow-up was 12 months, and the average follow-up was 14.6 months (12-72 months). MAIN OUTCOME MEASURES: Postoperative outcomes, including discharge ambulation, dislocation, periprosthetic joint infection, revision THA, and mortality at 90 days and 1 year after THA. RESULTS: Of the 143 THA included, 44 (30.7%) were performed by DAA while 99 (69.3%) were performed by PA. In-hospital outcomes were similar between the cohorts. Compared with DAA patients, PA patients were more likely to ambulate without assistance preinjury (88.9% vs. 72.7%, P = 0.025) and be nonambulatory at the time of discharge (27.3% vs. 11.4%, P = 0.049). There were no significant differences in 90-day and 1-year postoperative outcomes between the DAA and PA groups, including dislocation, periprosthetic joint infection, periprosthetic fracture, mechanical complications, and revision surgery. Although there was no difference in mortality rate at 90 days, at 1-year follow-up the mortality rate was lower in the DAA group (0% vs. 11.1%, P = 0.018). CONCLUSIONS: Performing THA by DAA provides similar benefits in regards to medical and surgical outcomes compared with the PA for displaced femoral neck fracture. However, the DAA may lead to decreased 1-year mortality rates, possibly, because of improved early ambulation capacity that is an important predictor of long-term mortality. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Early Orthopaedic Trauma Outcomes in COVID-19 Infected Patients: A Case Series.

Orthopaedic trauma presents a unique and complex challenge in the initial phase of the coronavirus 2019 (COVID-19) global crisis. Little is currently known about the surgical practices in orthopaedic emergencies in the early days of the COVID-19 outbreak (1). This is a retrospective case series of 10 orthopaedic trauma patients who underwent fracture fixation in March 2020. Of the 10 patients testing COVID-19 positive, there were a total of 16 long bone fractures, 5 pelvic ring fractures, and 1 lumbar burst fracture. There were 7 (70%) males in this cohort. Two (20%) of the COVID-positive patients did not develop fever, leukocytosis, respiratory insufficiency, or positive imaging findings and were younger (average age 25.5 years) with fewer comorbidities (average 0.5) compared with the 8 symptomatic COVID-19-positive patients (56.6 years with 1.88 comorbidities). Advancement of COVID-19 pathogenesis with lung opacities and prolonged intubation occurred in all 5 patients who remained on ventilation postoperatively (range 9 hours-11 days). At the time of most recent follow-up, all patients survived, 1 continues to require ventilation support, 1 remains admitted without ventilation support, and 8 (80%) were discharged to home. LEVEL OF EVIDENCE:: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Thrombin Hemostatic Matrix Reduces Heterotopic Ossification in Acetabular Fractures Fixed Through the Kocher-Langenbeck Approach.

OBJECTIVE: To determine whether an injectable thrombin product [thrombin hemostatic matrix (THM)] at closure of a Kocher-Langenbeck approach reduces the risk of heterotopic ossification (HO) formation after an acetabular fracture. DESIGN: Case control. SETTING: Two Level 1 trauma centers. PATIENTS: Patients with operatively treated acetabulum fractures fixed through Kocher-Langenbeck from 2013 to 2018. INTERVENTION: Records were reviewed for demographics, history of traumatic brain injury, HO medication or radiation prophylaxis, THM (Surgiflo, Ethicon, Bridgewater New Jersey) administration, and length of follow-up. Radiographs were reviewed for dislocation, fracture, Letournel and Orthopaedic Trauma Association classifications, HO, and Brooker grade if applicable. Patients receiving HO prophylaxis (eg, nonsteroidal anti-inflammatory drugs and radiation) were excluded. Remaining patients were divided into 2 groups: THM administration (intervention) and no THM. Continuous variables were compared using t-tests and categorical variables with chi-square or Fisher's exact tests. MAIN OUTCOME MEASUREMENTS: Risk ratios for the association between HO occurrence and THM administration. RESULTS: Three-hundred and twenty-eight acetabular fractures met inclusion criteria (126 intervention, 202 control) in patients with a mean age of 38.7 ± 15.9 years; 62.2% were male, and 42.1% were African American. Traumatic brain injury and posterior dislocation rates were equivalent between groups (P = 0.505, 0.754, respectively). HO rate in the control group was 42.6% compared with 21.4% in the THM group (P < 0.001). Booker grade 3/4 in control group was 17.3% versus 3.2% in the THM group (P < 0.001). Patients receiving THM had a 50% reduced risk of HO (95% confidence interval 0.35-0.73) compared to those who did not; adjustment for age, gender, ethnicity, and traumatic brain injury did not meaningfully change the association (risk ratio 0.46; 95% confidence interval 0.29-0.73; P < 0.001). CONCLUSION: The use of a surgiflo product at closure of a KO approach may reduce the risk of HO formation by 50% after an acetabular fracture. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Do Indomethacin or Radiation for Heterotopic Ossification Prophylaxis Increase the Rates of Infection or Wound Complications After Acetabular Fracture Surgery?

OBJECTIVES: To compare the rates of infection and wound complications in patients undergoing operative fixation (ORIF) of acetabular fractures receiving heterotopic ossification (HO) prophylaxis using indomethacin or external beam radiation therapy (XRT) versus no prophylaxis. DESIGN: Retrospective cohort. SETTING: Level I trauma center. PATIENTS: We reviewed 473 patients undergoing ORIF of acetabular fractures through posterior, combined, or extensile surgical approaches from 2012 to 2017, with a median follow-up of 13 months (0.5-77 months). MAIN OUTCOME MEASUREMENT: Rates of infection and wound complications were stratified according to their HO prophylaxis method into three groups as indomethacin, XRT, and no prophylaxis. RESULTS: Overall, 167 patients (35.3%) received indomethacin, 104 patients (22.0%) received postoperative XRT, and 202 patients (42.7%) received no prophylactic treatment. There was no difference between the 3 groups for the risk of surgical site infection (P = 0.280). The XRT group had a significantly increased risk of noninfectious wound complications (20.2%) compared with the indomethacin group (6.6%, P = 0.002) and the no prophylaxis group (5.0%, P < 0.0001). Multivariate analysis revealed XRT remained a significant risk factor for noninfectious wound complications compared with no prophylaxis (odds ratio 5.39; 95% confidence interval 2.37-12.22; P < 0.0001). CONCLUSIONS: Although there is no difference between XRT, indomethacin, and no HO prophylaxis for the risk of surgical site infection, the use of XRT results in more than 5 times increased risk of noninfectious wound complications compared with no prophylaxis. This increased risk should be considered when contemplating XRT for HO prophylaxis in acetabular fracture patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Value of Serological Screening Prior to Conversion Total Hip Arthroplasty.

BACKGROUND: This study sought (1) to assess the value of serological testing prior to conversion total hip arthroplasty (THA) in predicting infection and (2) to identify optimal serological values for routine diagnostic workup prior to conversion THA. METHODS: All patients at our tertiary referral center undergoing conversion THA after hip/acetabular fracture procedure from 2013 to 2018 were retrospectively reviewed. Inclusion criteria were patients previously undergoing hemiarthroplasty or open reduction and internal fixation of acetabular, intertrochanteric, and subtrochanteric fractures that progressed to conversion THA due to post-traumatic arthritis having erythrocyte sedimentation rate/C-reactive protein (CRP) prior to conversion. Infection was defined as positive intraoperative cultures not deemed contaminant in collaboration with infectious disease consult and/or development of PJI within 1 year postoperatively. RESULTS: Twelve of 87 (14%) patients undergoing conversion THA developed infection. The mean erythrocyte sedimentation rate (37.2 vs 24.4 mm/h, P = .2062) and CRP (22.4 vs 9.0 mg/L, P = .0026) in the infected cohort were elevated compared to the noninfected group. An optimal cutoff value for CRP of 12 mg/L (area under the curve = 0.77, 95% confidence interval 0.58-0.97) revealed 75% sensitivity, 84% specificity, 43% positive predictive value, and 95% negative predictive value (P < .0001) in the entire cohort. CONCLUSIONS: Even without clinical signs and symptoms, patients undergoing conversion THA from internal fixation of hip/acetabular fractures are still at high risk for developing periprosthetic joint infection. All patients undergoing conversion THA should have CRP measured preoperatively as a part of the diagnostic workup for underlying infection. Further research should be devoted to creating a preoperative diagnostic algorithm incorporating CRP, similar to Musculoskeletal Infection Society criteria, dedicated to patients undergoing conversion THA. LEVEL OF EVIDENCE: Level III, Diagnostic retrospective cohort study.

Modern Results of Functional Bracing of Humeral Shaft Fractures: A Multicenter Retrospective Analysis.

OBJECTIVES: To evaluate the rate of, and reasons for, conversion of closed treatment of humeral shaft fractures using a fracture brace, to surgical intervention. DESIGN: Multicenter, retrospective analysis. SETTING: Nine Level 1 trauma centers across the United States. PATIENTS: A total of 1182 patients with a closed humeral shaft fracture initially managed nonoperatively with a functional brace from 2005 to 2015 were reviewed retrospectively from 9 institutions. INTERVENTION: Functional brace. MAIN OUTCOME MEASUREMENTS: Conversion to surgery. RESULTS: A total of 344 fractures (29%) ultimately underwent surgical intervention. Reasons for conversion included nonunion (60%), malalignment beyond acceptable parameters (24%), inability to tolerate functional bracing (12%), and persistent signs of radial nerve palsy requiring exploration (3.7%). Univariate comparisons showed that females and whites were significantly (P < 0.05) more likely to be converted to surgery. The multivariate logistic regression identified females as being 1.7 times more likely and alcoholics to be 1.4 times more likely to be converted to surgery (P < 0.05). Proximal shaft as well as comminuted, segmental, and butterfly fractures were also linked to a higher rate of conversion. CONCLUSIONS: This large multicenter study identified a 29% surgical conversion rate, with nonunion as the most common reason for surgical intervention after the failure of functional brace. These results are markedly different than previously reported. These results may be helpful in the future when counseling patients on the choice between functional bracing and surgical intervention in managing humeral shaft fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Reamed Versus Unreamed Intertrochanteric Femur Fractures, Is It Time?

OBJECTIVES: This study compares the intraoperative and postoperative outcomes of the traditional technique of femoral canal reaming to placement of an unreamed 10-mm nail. DESIGN: Retrospective cohort study. SETTING: Academic Level I Trauma Center, Southeastern US. PATIENTS/PARTICIPANTS: Intertrochanteric femur fractures treated with a CMN (January 2016-December 2018) were retrospectively identified. Inclusion criteria were as follows: low-energy mechanism, at least 60 years of age, and long CMN. Exclusion criteria were as follows: short CMN, polytrauma, and subtrochanteric fractures. OUTCOME MEASUREMENTS: Records were reviewed for demographics, hematologic markers, transfusion rates, operative times, and postoperative complications. Variables were assessed with a χ or Student T-test. Significance was set at 0.05. RESULTS: Sixty-five patients were included (37 reamed and 28 unreamed), with a mean age of 76.2 years and mean body mass index of 25.1. Between the reamed and unreamed groups, respectively, mean nail size was 11.0 (SD 1.1) and 10.0 (SD 0.0), P < 0.001; mean blood loss was 209.1 mL (SD 177.5) and 195.7 mL (SD 151.5), P = 0.220; 55% (21/38), and 43% (12/28) were transfused, P = 0.319; operative time was 98.2 (SD 47.3) and 81.5 minutes (SD 40.7); P = 0.035. Changes in hemoglobin/hematocrit were not significant between the study groups. Two patients from the reamed group experienced implant failure due to femoral head screw cut out and returned to the operating room. Two patients from the unreamed group returned to operating room for proximal incision infection, without implant removal. One reamed patient and 2 unreamed patients died before 6-month follow-up. CONCLUSIONS: Unreamed CMNs for geriatric intertrochanteric femur fractures provide shorter operative times with no difference in perioperative complications. Both reamed and unreamed techniques are safe and effective measures for fixation of these fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Unique "Reverse" Crescent Fragment in an Anterior-Posterior Compression Fracture: A Case Report.

CASE: We describe a patient with an anterior-posterior compression type pelvic fracture sustained after a motorcycle crash, with pubic symphysis disruption and a "reverse" crescent fragment. The injury force ruptured the anterior sacroiliac ligaments and travelled posterior medially, creating a complete Denis zone 2 sacral fracture, rather than rupturing the posterior sacroiliac ligaments as would be expected. The patient underwent open reduction and internal fixation of the pubic symphysis and closed reduction and percutaneous pinning of the right sacroiliac joint. CONCLUSIONS: This case presents a unique "reverse" crescent fragment not previously described in the literature as an anterior-posterior compression type III variant.

Accurate Prediction of Antegrade and Retrograde Femoral Intramedullary Implant Length From Patient-Reported Height.

OBJECTIVE: To determine whether patient height correlates with implant length selection of antegrade or retrograde femoral intramedullary implants. DESIGN: Case-control Study. SETTING: A single level 1 trauma center. PATIENTS/PARTICIPANTS: All patients with operatively treated femoral shaft fractures from 2011 to 2017. INTERVENTION: All fractures were treated with an intramedullary nail. Retrograde or antegrade insertion was decided at the discretion of the surgeon and fracture location. MAIN OUTCOME MEASUREMENTS: Length of femoral implant and patient height. RESULTS: Five hundred sixty-seven operatively treated fractures were reviewed, 322 antegrade and 245 retrograde. The correlation between patient height and actual nail length was 0.55 for antegrade implants (P < 0.01) and 0.59 for retrograde implants (P < 0.01). Separate prediction equations for nail length based on patient height were estimated for antegrade and retrograde implants and found accurate prediction of length 86% and 88% of the time, respectively. CONCLUSIONS: Intramedullary nail length can be accurately predicted based on patient height and the technique using the equations below. This is the first study to establish a simple equation to serve as an adjunct for selecting the most appropriate length implant. This equation can be used in cases of bilateral femur fractures, templating to have appropriate sized implants in close proximity to the odds ratio, and in remote environments where surgical planning is critical for determining implant needs.

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.

Extreme Nailing: Is It Safe to Allow Immediate Weightbearing After Intramedullary Nail Fixation of Extra-articular Distal Tibial Fractures (OTA/AO 43-A)?

OBJECTIVES: To determine whether immediate weightbearing after intramedullary (IM) fixation of extra-articular distal tibial fractures (OTA/AO 43-A) results in a change in alignment before healing. DESIGN: Retrospective review. SETTING: Level 1 trauma center. INTERVENTION: IM nailing of distal tibial fractures. PATIENTS/PARTICIPANTS: Fifty-three patients with 54 fractures, all of whom could bear weight as tolerated postoperatively. Eighteen fractures were OTA/AO 43-A1, 20 OTA/AO 43-A2, and 16 OTA/AO 43-A3; 20 fractures were open. MAIN OUTCOME MEASUREMENTS: Change in fracture alignment or loss of position. RESULTS: Average change from initial angulation at final follow-up was 0.52 ± 1.49 degrees of valgus and 0.48 ± 3.14 degrees of extension. Final alignment was excellent in 14, acceptable in 28, and poor in 12; 2 fractures went from acceptable initial alignment to poor final alignment; and 2 fractures went from excellent to acceptable alignment. Seven fractures had an improvement in alignment over time. Two fractures required free-flap coverage and 4 required staged grafting because of bone loss. Ten fractures had an unplanned return to the operating room (5 for infected nonunion requiring implant exchange, 3 for infection requiring debridement without implant revision, and 2 for aseptic nonunion). No patient had revision for implant failure. CONCLUSIONS: Immediate weightbearing after IM fixation of extra-articular distal tibial fractures (OTA/AO 43-A) led to minimal change in alignment and seems to be safe for most patients. Complications were consistent with those reported in previous non-weightbearing cohorts. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Radiographic and Postoperative Outcomes of Plate Versus Screw Constructs in Open Reduction and Internal Fixation of Calcaneus Fractures via the Sinus Tarsi.

BACKGROUND: Intra-articular fractures of the calcaneus are a common injury to the hindfoot following high-energy trauma to the lower extremity. Treatment of these fractures has evolved. Due to the concern of wound complications associated with extensile open treatment, smaller incision techniques, such as the sinus tarsi approach, are increasing in popularity. A number of fixation strategies are utilized with this approach, and it is unknown which most accurately restores radiographic alignment. The purpose of this study was to compare the postoperative radiographic outcomes of a plate and screw construct versus a cannulated screw construct when using the sinus tarsi approach for open reduction and internal fixation (ORIF) of calcaneus fractures. METHODS: After institutional review board approval, records for all patients treated surgically at our institution for calcaneus fractures from 2012 to 2017 were reviewed. Inclusion criteria were intra-articular calcaneus fractures, patients aged 18 years or older, and use of the sinus tarsi approach. Exclusion criteria were open fractures and fractures with less than 6 weeks of postoperative weightbearing, which were excluded for radiographic outcomes. A total of 51 fractures underwent ORIF using cannulated screws alone (group 1), and 23 fractures underwent ORIF using a sinus tarsi plate (group 2). Sixty-one fractures (41 vs 20, respectively) met criteria for radiographic comparison. The primary outcomes of interest included pre- and postoperative Bohler and Gissane angles, wound complications, unplanned return to the operating room (OR), and cost comparison. RESULTS: There was no statistically significant difference between preoperative Bohler angles for group 1 (14.4 degrees) versus group 2 (12.2 degrees) (P = .44), nor was there a significant difference between postoperative Bohler angles for group 1 (30.1 degrees) versus group 2 (27.1 degrees) (P = .14). Similarly, preoperative Gissane angles for group 1 (130.5 degrees) and group 2 (133.4 degrees) (P = .54) and postoperative Gissane angles for group 1 (118.2 degrees) and group 2 (119.8 degrees) (P = .44) showed no statistically significant difference. There were a total of 3 wound complications in group 1 versus 2 wound complications in group 2 (P = .66). There was no statistically significant difference in operative duration (P = .97) or the number of unplanned returns to the OR between the 2 groups (P = .68). Based on the implants used at this institution, and depending on the number of screws used, the estimated cost range of a plate construct was $1070 to $1235, while the estimated cost range of a cannulated screw construct was $717 to $1264. CONCLUSION: When comparing the cannulated screw and plate and screw fixation techniques, there was no difference in restoration of the Bohler and Gissane angles. Furthermore, the amount of angular correction achieved by initial reduction showed no statistically significant difference between groups, and the amount of reduction lost between initial and final postoperative radiographs showed no statistically significant difference between groups. With regard to the 2 techniques, there was no statistically significant difference in rates of postoperative complications and return to the OR. Our data suggest that fixation using cannulated screws alone versus sinus tarsi plate provides similar radiographic outcomes and risk of complications. The 2 techniques were also similar in terms of implant costs. Our results indicate that either technique effectively improved radiographic parameters. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Evaluation of Orthopaedic Trauma Fellowship Web Sites and an Assessment of 21 Content Domains.

Background: A program's web site can attract or deter fellowship applications. It can also impact applicants' final rank lists. Web-based information may allow applicants to apply more selectively, decreasing interview costs for themselves and programs. The accessibility and content of program web sites for several orthopaedic subspecialties have been analyzed for inadequacies. The goal of this study was to perform an analysis for the web sites of orthopaedic trauma fellowships. Methods: A list of accredited orthopaedic trauma fellowships was obtained from the Orthopaedic Trauma Association (OTA) Fellowship Directory. Web site accessibility was determined by presence of a functional hyperlink in the directory and the web site's searchability using Google®. Web site content was evaluated based on 21 criteria. Results: 53 programs were identified, offering 84 positions. 27 had web sites accessible through the OTA fellowship directory via functioning links. 19 additional web sites were accessible using Google®. Seven programs lacked web sites entirely. Web site content varied between programs. Over half of the web sites lacked information for 13 of the 21 content criteria. A complete list of results can be located in Table 1. Conclusions: Inadequacies exist in the accessibility and content of OTA accredited Orthopaedic Trauma Fellowship web sites. We draw attention to 21 standard content areas pertinent to applicants that could be considered by the OTA and individual programs to include on their respective web sites. Standardization across web sites may allow for a more direct comparison between programs and improve the match process. Level of Evidence: Review Article.

OTA/AO Classification Is Highly Predictive of Acute Compartment Syndrome After Tibia Fracture: A Cohort of 2885 Fractures.

OBJECTIVE: To determine the correlation between the OTA/AO classification of tibia fractures and the development of acute compartment syndrome (ACS). DESIGN: Retrospective review of prospectively collected database. SETTING: Single Level 1 academic trauma center. PATIENTS: All patients with a tibia fracture from 2006 to 2016 were reviewed for this study. Three thousand six hundred six fractures were initially identified. Skeletally mature patients with plate or intramedullary fixation managed from initial injury through definitive fixation at our institution were included, leaving 2885 fractures in 2778 patients. METHODS: After database and chart review, univariate analyses were conducted using independent t tests for continuous data and χ tests of independence for categorical data. A simultaneous multivariate binary logistic regression was developed to identify variables significantly associated with ACS. RESULTS: ACS occurred in 136 limbs (4.7%). The average age was 36.2 years versus 43.3 years in those without (P < 0.001). Men were 1.7 times more likely to progress to ACS than women (P = 0.012). Patients who underwent external fixation were 1.9 times more likely to develop ACS (P = 0.003). OTA/AO 43 injuries were at least 4.0 times less likely to foster ACS versus OTA/AO 41 or 42 injuries (P < 0.007). OTA/AO 41-C injuries were 5.5 times more likely to advance to ACS compared with OTA/AO 41-A (P = 0.03). There was a significantly higher rate of ACS in OTA/AO 42-B (P = 0.005) and OTA/AO 42-C (P = 0.002) fractures when compared with OTA/AO 42-A fractures. In the distal segment, fracture type did not predict the risk of ACS (P > 0.15). Group 1 fractures had a lower rate of ACS compared with group 2 (P = 0.03) and group 3 (P = 0.003) fractures in the middle segment only. Bilateral tibia fractures had a 2.7 times lower rate of ACS (P = 0.04). Open injury, multiple segment injury, fixation type, and concurrent pelvic or femoral fractures did not predict ACS. CONCLUSIONS: In this large cohort of tibia fractures, we found that the age, sex, and OTA/AO classification were highly predictive for the development of ACS. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.