Total Elbow Arthroplasty Historical and Current Concepts.

The evolution of total elbow arthroplasty (TEA) has laid the groundwork for modern day TEA and has contributed to our understanding of elbow biomechanics. Trends in the usage of TEA have also varied significantly over time. This article aims to review the history and evolution of the TEA implant with a focus on modern day implant biomechanics and the trends in TEA indications. Additionally, this review discusses various complications that can occur with modern day TEA and looks toward the future to identify innovation and future trends.

Bone Health Evaluations and Secondary Fragility Fractures in Hip Fracture Patients.

Purpose: This study sought to examine the utilization of bone health evaluations in geriatric hip fracture patients and identify risk factors for the development of future fragility fractures. Materials and Methods: A consecutive series of patients ≥55 years who underwent surgical management of a hip fracture between September 2015 and July 2019 were identified. Chart review was performed to evaluate post-injury follow-up, performance of a bone health evaluation, and use of osteoporosis-related diagnostic and pharmacologic treatment. Results: A total of 832 patients were included. The mean age of the patients was 81.2±9.9 years. Approximately 21% of patients underwent a comprehensive bone health evaluation. Of this cohort, 64.7% were started on pharmacologic therapy, and 73 patients underwent bone mineral density testing. Following discharge from the hospital, 70.3% of the patients followed-up on an outpatient basis with 95.7% seeing orthopedic surgery for post-fracture care. Overall, 102 patients (12.3%) sustained additional fragility fractures within two years, and 31 of these patients (3.7%) sustained a second hip fracture. There was no difference in the rate of second hip fractures or other additional fragility fractures based on the use of osteoporosis medications. Conclusion: Management of osteoporosis in geriatric hip fracture patients could be improved. Outpatient follow-up post-hip fracture is almost 70%, yet a minority of patients were started on osteoporosis medications and many sustained additional fragility fractures. The findings of this study indicate that orthopedic surgeons have an opportunity to lead the charge in treatment of osteoporosis in the post-fracture setting.

Damage-control orthopedics or early total care: What you need to know.

ABSTRACT: Patients with multisystem injuries are defined as multiply injured patients and may need multiple surgical procedures from more than one specialty. The importance of evaluating and understanding the resuscitation status of a multiple-injury patient is critical. Orthopedic strategies when caring for these patients include temporary stabilization or definitive early fixation of fractures while preventing further insult to other organ systems. This article will define multiple injuries and discuss specific markers used in assessing patients' hemodynamic and resuscitation status. The decision to use damage-control orthopedics or early total care for treatment of the patient are based on these factors, and an algorithm is presented to guide treatment. We will also discuss principles of external fixation and the management of pelvic trauma in a multiple-injury patient.

A Good Tip-Apex Distance Does Not Make Up For a Poor Reduction in Intertrochanteric Hip Fractures Treated with an Cephalomedullary Nail: The Utility of the Neck-Shaft Angle in Preventing Fixation Failure.

PURPOSE: Determine if any fracture characteristics or radiographic parameters were predictive of fixation failure [FF] within 1 year following cephalomedullary nailing for intertrochanteric fractures. METHODS: A consecutive series of intertrochanteric hip fracture patients (AO/OTA 31A) treated with a cephalomedullary nail were reviewed. Pre-fixation (neck-shaft angle [NSA], distance from ischial tuberosities to greater and lesser trochanters, integrity of lesser trochanter, and fracture angulation) and post-fixation (post-fixation NSA, posteromedial cortex continuity, lag screw position, tip to apex distance [TAD], and post-fixation angulation and translation) radiographic parameters were measured by blinded independent reviewers. The FF and non-FF groups were statistically compared. Logistic regression was performed to determine radiographic parameter correlates of FF. RESULTS: Of 1249 patients, 23 (1.8%) developed FF within 1 year. The FF patients were younger than their non-FF counterparts (77.2 years vs 81.0 years, p=0.048), however there were no other demographic differences. The FF cohort did not differ in frequency of TAD over 25 mm (4.3% vs 9.6%, p=0.624) and had decreased mean TAD (13.6mm vs 16.3mm, p=0.021) relative to the non-FF cohort. The FF cohort had a higher rate of a post-fixation coronal plane NSA more than 10° different from the contralateral side (delta NSA>10°, 34.8% vs 13.7%, p=0.011) with the majority fixed in relative varus. For every 1° increase in varus compared to the contralateral side the odds of FF increased 7% (OR=1.065, 95%CI[1.005-1.130], p=0.034) on univariate analysis. On univariate logistic regression, patients with an absolute post-fixation NSA of 10° or more of varus compared to contralateral were significantly more likely to have a FF (OR=3.139, 95%CI[1.067-8.332], p=0.026). CONCLUSION: Despite an acceptable TAD, post-fixation NSA in relative varus as compared to the contralateral side was significantly associated with failure in intertrochanteric hip fractures fixed with a cephalomedullary nail. LEVEL OF EVIDENCE: Prognostic Level III.

Early Weight-bearing Following Surgical Treatment of Ankle Fractures Without Trans-syndesmotic Fixation Is Safe and Improves Short-term Outcomes.

OBJECTIVES: The objective of this study was to ascertain outcome differences after fixation of unstable rotational ankle fractures allowed to weight-bear 2 weeks postoperatively compared with 6 weeks. DESIGN: Prospective case-control study. SETTING: Academic medical center; Level 1 trauma center. PATIENT SELECTION CRITERIA: Patients with unstable ankle fractures (OTA/AO:44A-C) undergoing open reduction internal fixation (ORIF) were enrolled. Patients requiring trans-syndesmotic fixation were excluded. Two surgeons allowed weight-bearing at 2 weeks postoperatively (early weight-bearing [EWB] cohort). Two other surgeons instructed standard non-weight-bearing until 6 weeks postoperatively (non-weight-bearing cohort). OUTCOME MEASURES AND COMPARISONS: The main outcome measures included the Olerud-Molander questionnaire, the SF-36 questionnaire, and visual analog scale at 6 weeks, 3 months, 6 months, and 12 months postoperatively and complications, return to work, range of ankle motion, and reoperations at 12 months were compared between the 2 cohorts. RESULTS: One hundred seven patients were included. The 2 cohorts did not differ in demographics or preinjury scores ( P > 0.05). Six weeks postoperatively, EWB patients had improved functional outcomes as measured by the Olerud-Molander and SF-36 questionnaires. Early weight-bearing patients also had better visual analog scale scores (standardized mean difference -0.98, 95% confidence interval [CI] -1.27 to -0.70, P < 0.05) and a greater proportion returning to full capacity work at 6 weeks (odds ratio = 3.42, 95% CI, 1.08-13.07, P < 0.05). One year postoperatively, EWB patients had improved pain measured by SF-36 (standardized mean difference 6.25, 95% CI, 5.59-6.92, P < 0.01) and visual analog scale scores (standardized mean difference -0.05, 95% CI, -0.32 to 0.23, P < 0.01). There were no differences in complications or reoperation at 12 months ( P > 0.05). CONCLUSIONS: EWB patients had improved early function, final pain scores, and earlier return to work, without an increased complication rate compared with those kept non-weight-bearing for 6 weeks. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

The Effect of Underrepresented Minority Mentorship on Orthopaedic Spine Surgery Recruitment and Diversity: A 20-Year Analysis at a Single Institution.

INTRODUCTION: Despite national efforts to increase diversity and inclusion, underrepresented minority (URM) representation among orthopaedic spine surgery faculty remains low. Research has shown that URM trainees are more likely to pursue surgical careers when they have access to URM mentors. The purpose of this study was to explore the influence of URM representation among spine faculty on the rate of URM orthopaedic residents pursuing spine surgery fellowships. METHODS: From 2004 to 2023, data were collected from each residency class at our academic institution: residency year, number of residents per class (total and URM), and number of residents applying to spine surgery fellowships. These ethnicities were considered URM: Black or African American, Hispanic or Latino, and Native American. In 2018, two African American spine faculty were hired. Data were compared between Before and After their arrival. A subanalysis was done to include a period of increasing URM recruitment (2012 to 2018). Binary logistic regression analysis evaluated associations between appointment of URM faculty and fellowship choice of URM residents. RESULTS: Two hundred fifty-six residents were included. Thirty-one total URM residents were in the program during the study period (12.1%). Overall, URM representation in the program increased over time [OR: 1.1, 95% CI: 1.1 to 1.2], whereas residents applying to spine surgery fellowships did not change [OR: 1.0, 95% CI: 1.0 to 1.1]. Comparing Before-2012 and 2012 to 2018 groups with the After-2018 group demonstrated a significant difference in the proportion of URM residents applying to spine surgery fellowships after the hiring of URM spine faculty (0.0% versus 23.1% versus 74.1%; P = 0.001). CONCLUSION: This retrospective study provides empirical evidence of the importance of URM representation among orthopaedic spine surgery faculty and the potential effect on URMs pursuing orthopaedic fellowships. Institutions should consider prioritizing the representation of URM faculty in spine surgery to address the lack of current and future diversity in the field. LEVEL OF EVIDENCE: III.

Does Flipping From Prone to Supine for Medial Malleolar Fixation of Trimalleolar Ankle Fractures Improve Results?

There has been a paradigm shift towards fixing the posterior malleolus in trimalleolar ankle fractures. This study evaluated whether a surgeon's preference to intraoperatively flip or not flip patients from prone to supine for medial malleolar fixation following repair of fibular and posterior malleoli impacted surgical outcomes. A retrospective patient cohort treated at a large urban academic center and level 1 trauma center was reviewed to identify all operative trimalleolar ankle fractures initially positioned prone. One hundred and forty-seven patients with mean 12-month follow-up were included and divided based on positioning for medial malleolar fixation, prone or supine (following closure, flip and re-prep, and drape). Data was collected on patient demographics, injury mechanism, perioperative variables, and complication rates. Postoperative reduction films were reviewed by orthopedic traumatologists to grade the accuracy of anatomic fracture reduction. Overall, 74 (50.3%) had the medial malleolus fixed prone, while 73 (49.7%) were flipped and fixed supine. No differences in demographics, injury details, and fracture type existed between the groups. The supine group had a higher rate of initial external fixation (p = .047), longer operative time in minutes (p < .001), and a higher use of plate and screw constructs for medial malleolar fixation (p = .019). There were no differences in clinical and radiographic outcomes and complication rates. This study demonstrated that intraoperative change in positioning for improved medial malleolar visualization in trimalleolar ankle fractures results in longer operative times but similar radiographic and clinical results. The decision of operative position should be based on surgeon comfort.

Updates on Residual Limb Management in Lower Extremity Amputation From Nerve to Bone.

Traumatic extremity amputation can be devastating for patients' functional and psychological health. Challenges of initial management and considerations for limb salvage versus amputation for mangled lower extremities are well documented. However, literature geared toward orthopedic surgeons highlighting management considerations for the residual limb of an amputation is scarce. This article reviews recent literature on management of the residual limb in the perioperative and rehabilitation phases of treatment.

Eponyms for the Description and Classification of Calcaneus Fractures.

There are several eponyms used in the assessment and management of calcaneus fractures. However, the origin of these eponyms is no longer widely known. Named for orthopaedic surgeons who made substantial contributions to the management of calcaneus fractures as well as the field of orthopaedic surgery, understanding the context of how these descriptors were derived helps give context to their use in the present day. The purpose of this review is to provide a historical perspective and comprehensive collection of the most common eponyms related to calcaneus fractures.

Implications of COVID-19 on hip fracture care discharge locations during the early stages of the pandemic.

Objectives: To document discharge locations for geriatric patients treated for a hip fracture before and during the COVID pandemic and subsequent changes in outcomes seen between each cohort. Design: Retrospective cohort study. Setting: Academic medical center. Patients/Participants: Two matched cohorts of 100 patients with hip fracture treated pre-COVID (February-May 2019) and during COVID (February-May 2020). Intervention: Discharge location and COVID status on admission. Discharge locations were home (home independently or home with health services) versus facility [subacute nursing facility (SNF) or acute rehabilitation facility]. Main Outcome Measurements: Readmissions, inpatient and 1-year mortality, and 1-year functional outcomes (EQ5D-3L). Results: In COVID+ patients, 93% (13/14) were discharged to a facility, 62% (8/13) of whom passed away within 1 year of discharge. Of COVID+ patients discharged to an SNF, 80% (8/10) died within 1 year. Patients discharged to an SNF in 2020 were 1.8x more likely to die within 1 year compared with 2019 (P = 0.029). COVID- patients discharged to an SNF in 2020 had a 3x increased 30-day mortality rate and 1.5x increased 1-year mortality rate compared with 2019. Patients discharged to an acute rehabilitation facility in 2020 had higher rates of 90-day readmission. There was no difference in functional outcomes. Conclusions: All patients, including COVID- patients, discharged to all discharge locations during the onset of the pandemic experienced a higher mortality rate as compared with prepandemic. This was most pronounced in patients discharged to a skilled nursing facility in 2020 during the early stages of the pandemic. If this trend continues, it suggests that during COVID waves, discharge planning should be conducted with the understanding that no options eliminate the increased risks associated with the pandemic. Level of Evidence: III.

Home discharge location is safest following fracture of the hip.

PURPOSE: To determine the factors associated with discharge location in patients with hip fractures and whether home discharge was associated with a lower readmission and complication rate. METHODS: Hip fracture patients who presented to our academic medical center for operative management of a hip fracture were enrolled into an IRB-approved hip fracture database. Radiographs, demographics, and injury details were recorded at the time of presentation. Patients were grouped based upon discharge disposition: home (with or without home services), acute rehabilitation facility (ARF), or sub-acute rehabilitation facility (SAR). RESULTS: The cohorts differed in marital status, with a greater proportion of patients discharged to home being married (51.7% vs. 43.8% vs. 34.1%) (P < 0.05). Patients discharged to home were less likely to require an assistive device (P < 0.05). Patients discharged to home experienced fewer post-operative complications (P < 0.05) and had lower readmission rates (P < 0.05). Being married was associated with an increased likelihood of discharge to home (OR = 1.679, CI = 1.391-2.028, P < 0.001). Being enrolled in Medicare/Medicaid was associated with decreased odds of discharge to home (OR = 0.563, CI = 0.457-0.693, P < 0.001). Use of an assistive device was associated with decreased odds of discharge to home (OR = 0.398, CI = 0.326-0.468, P < 0.001). Increases in CCI (OR = 0.903, CI = 0.846-0.964, P = 0.002) and number of inpatient complications (OR = 0.708, CI = 0.532-0.943, P = 0.018) were associated with decreased odds of home discharge. CONCLUSION: Hip fracture patients discharged to home were healthier and more functional at baseline, and also less likely to have had a complicated hospital course. Those discharged to home also had lower rates of readmission and post-operative complications. LEVEL OF EVIDENCE: III.

One year later: How outcomes of hip fractures treated during the "first wave" of the COVID-19 pandemic were affected.

The purpose of this study was to assess the impact of COVID-19 on long-term outcomes in the geriatric hip fracture population. We hypothesize that COVID + geriatric hip fracture patients had worse outcomes at 1-year follow-up. Between February and June 2020, 224 patients > 55 years old treated for a hip fracture were analyzed for demographics, COVID status on admission, hospital quality measures, 30- and 90-day readmission rates, 1-year functional outcomes (as measured by the EuroQol- 5 Dimension [EQ5D-3L] questionnaire), and inpatient, 30-day, and 1-year mortality rates with time to death. Comparative analyses were conducted between COVID + and COVID- patients. Twenty-four patients (11%) were COVID + on admission. No demographic differences were seen between cohorts. COVID + patients experienced a longer length of stay (8.58 ± 6.51 vs. 5.33 ± 3.09, p < 0.01) and higher rates of inpatient (20.83% vs. 1.00%, p < 0.01), 30-day (25.00% vs. 5.00%, p < 0.01), and 1-year mortality (58.33% vs. 18.50%, p < 0.01). There were no differences seen in 30- or 90-day readmission rates, or 1-year functional outcomes. While not significant, COVID + patients had a shorter average time to death post-hospital discharge (56.14 ± 54.31 vs 100.68 ± 62.12, p = 0.171). Pre-vaccine, COVID + geriatric hip fracture patients experienced significantly higher rates of mortality within 1 year post-hospital discharge. However, COVID + patients who did not die experienced a similar return of function by 1-year as the COVID- cohort.

Does a Modified Frailty Index Predict 30-day Complications After Long-Bone Nonunion or Malunion Surgery?

OBJECTIVE: To assess the ability of a modified frailty index (mFI-5) score, which includes the presence of congestive heart failure, hypertension, chronic obstructive pulmonary disease, diabetes, and nonindependent functional status, and to identify patients at increased risk of complications after surgical treatment of long-bone nonunions/malunions. DESIGN: Retrospective. SETTING: Hospitals participating in the 2005-2018 American College of Surgeons National Surgical Quality Improvement Program. PATIENTS/PARTICIPANTS: Patients in the American College of Surgeons National Surgical Quality Improvement Program database with upper extremity and lower extremity fractures were enrolled. INTERVENTION: Surgical repair of nonunions/malunions of upper and lower extremity long bones. MAIN OUTCOME MEASURE: Postoperative complications after long-bone nonunion/malunion surgery. RESULTS: Respective univariate analysis of the 2964 UE [1786 (60.3%) with mFI-5 of 0 and 386 (13.0%) with mFI-5 ≥2] and 3305 LE [1837 (55.6%) with mFI-5 of 0 and 498 (15.1%) with mFI-5 ≥2] showed that increasing mFI-5 score was associated with medical complications, extended longer length of stay, adverse discharge, and readmission. Binomial logistic regression showed that UE patients with mFI-5 ≥2 had increased risk of wound complications [odds ratio (OR) 2.512, 95% (confidence interval) CI: 1.037-6.086, P = 0.041), adverse discharge (OR 1.735, 95% CI: 1.204-2.499, P = 0.003), and unplanned readmission (OR 2.102, 95% CI: 1.038-4.255, P = 0.039), while LE patients with mFI-5 ≥2 had an increased risk of medical complications (OR 1.847, 95% CI: 1.307-2.610, P = 0.001), cumulative morbidity (OR 1.835, 95% CI: 1.342-2.510, P < 0.001), extended longer length of stay (OR 1.809, 95% CI: 1.233-2.654, P = 0.002), and adverse discharge (OR 1.841, 95% CI: 1.394-2.432, P < 0.001). CONCLUSIONS: mFI-5 score ≥2 is associated with significant increase in postoperative complications after surgical repair of long-bone nonunions/malunions. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Role of External Fixation in the Management of Upper Extremity Fractures.

External fixation is a powerful tool in the armamentarium of the active orthopaedic surgeon. The upper extremity, however, poses unique challenges in the techniques of external fixation because of the smaller soft-tissue envelope and the proximity of neurovascular structures, which may be entrapped in fracture fragments or traversing in line with pin trajectories. This review article summarizes the indications, techniques, clinical outcomes, and complications of external fixation of the upper extremity in the setting of proximal humerus, humeral shaft, distal humerus, elbow, forearm, and distal radius fractures.

The 2-Window Posterolateral vs Single-Window Approach for Ankle Fracture Fixation.

BACKGROUND: The posterolateral approach to the ankle allows for reduction and fixation of the posterior and lateral malleoli through the same surgical incision. This can be accomplished via 1 or 2 surgical "windows." The purpose of this study is to compare outcomes including wound complications following direct fixation of unstable rotational ankle fracture through the posterolateral approach using either 1 or 2 surgical windows. METHODS: One hundred sixty-four patients with bi- or trimalleolar ankle fractures treated using the single-window posterolateral approach (between the peroneal tendons and the flexor hallucis longus [FHL]) or the 2-window technique (between the peroneal tendons and the FHL for posterior malleolus fixation; lateral to the peroneal tendons for fibula fixation) were reviewed for demographics, radiographic details, and clinical outcomes. We were able to review these 164 at the 3-month follow-up and a subset of 104 at a minimum of 12-month follow-up. RESULTS: One hundred eight ankles had the single-window approach; 56 had the 2-window approach. These 2 cohorts did not differ in demographic or injury characteristics. Ankles in the 2-window group experienced a greater number of early (3 months postsurgery) wound complications (32% vs 12%, P < .01). Two-window patients had more wound complications among ankles treated later than 1 week after injury (44% vs 16%, P < .01). There was no difference in surgical site infection, with low rates in both cohorts. Single-window patients had greater plantarflexion (35 ± 10 vs 30 ± 11 degrees, P = .025) and dorsiflexion after 12 months (21 ± 10 vs 16 ± 11 degrees, P = .021). We did not find a significant difference in nerve complications for these 2 cohorts. CONCLUSION: In our study, we found the single-window posterolateral approach to be associated with fewer wound complications and better postoperative range of ankle motion when compared to the 2-window approach. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Screws Alone for Acute Lisfranc Injuries Fixed Without Arthrodesis: A Better "Value" Than Plating in the Short Term.

This study compares outcomes of patients with Lisfranc injuries treated with screw only fixation constructs to those treated with dorsal plate and screw constructs. Seventy patients who underwent surgical treatment for acute Lisfranc injury without arthrodesis and minimum 6-month (mean >1-year) follow-up were identified. Demographics, surgical information, and radiographic imaging were reviewed. Cost data were compared. The primary outcome measure was the American Orthopedic Foot and Ankle Surgery (AOFAS) midfoot score. Univariate analysis through independent sample t tests, Mann-Whitney U, and chi-squared compared the populations. Twenty-three (33%) patients were treated with plate constructs and 47 (67%) with screw only fixation. The plate group was older (49 ± 18 vs 40 ± 16 years, p = .029). More screw constructs treated isolated medial column injuries compared to plate constructs (92% vs 65%, p = .006). At latest follow-up (mean 14 ± 13 months), all tarsometatarsal joints were aligned. There was no difference in AOFAS midfoot scores. Plate patients experienced longer operations (131 ± 70 vs 75 ± 31 minutes, p < .001) and tourniquet time (101 ± 41 vs 69 ± 25 minutes, p = .001). Plate constructs were more expensive than screw ($2.3X ± $2.3X vs $X ± $0.4X, p < .001) ($X is the mean cost of screws alone). Plate patients had a higher incidence of wound complications (13% vs 0%, p = .012). Treatment of Lisfranc fracture dislocation injuries with screws only demonstrated a higher value procedure as similar outcomes were found amidst lower implant costs. Screw only fixation required a shorter operative and tourniquet time with less frequent wound complications. Screw only fixations proved mechanically sound enough to achieve goals of repair without inferior outcomes.

The Lateral Femoral Cutaneous and Over the Hip (LOH) Block for the Surgical Management of Hip Fractures: A Safe and Effective Anesthetic Strategy.

OBJECTIVES: To examine the efficacy of regional anesthesia with sedation only for a variety of hip fractures using the newly described lateral femoral cutaneous with over the hip (LOH) block. DESIGN: Retrospective. SETTING: Orthopedic specialty hospital. PATIENTS/PARTICIPANTS: 40 patients who presented between November 2021 and February 2022 for fixation of OTA/AO 31.A1-3 and 31.B1-3 fractures. Matched cohorts of 40 patients who received general anesthesia and 40 patients who received spinal anesthesia for hip fracture fixation were also used. INTERVENTION: Operative fixation under LOH block and sedation only. The LOH block is a regional hip analgesic that targets the lateral femoral cutaneous nerve, articular branches of femoral nerve, and accessory obturator nerve. MAIN OUTCOME MEASUREMENTS: Demographics, intraoperative characteristics, anesthesia-related complications, hospital quality metrics, and short-term mortality and reoperation rates. RESULTS: A total of 120 patients (40 each: general, spinal, and LOH block) were compared. The cohorts were similar in age, race, body mass index, sex, Charlson comorbidity index, trauma risk score, ambulatory status at baseline, fracture type, and surgical fixation technique performed. Physiologic parameters during surgery were more stable in the LOH block cohort ( P < 0.05). Total OR time and anesthesia time were the shortest for the LOH block cohort ( P < 0.05). Patients in the LOH block cohort also had lower postoperative pain scores ( P < 0.05). Length of hospital stay was the shortest for patients in the LOH block cohort ( P < 0.05), and during discharge, patients in the LOH block cohort ambulated the furthest ( P < 0.05). No differences were found for anesthesia-related complications, palliative care consults, major and minor hospital complications, discharge disposition, reoperation and readmission rates, and mortality rates. CONCLUSIONS: The LOH block is safe and effective anesthesia for the treatment of all types of hip fractures in the elderly patients requiring surgery. In addition, this block may decrease postoperative pain and length of hospital stay, and allow for greater ambulation in the early postoperative period for patients with hip fracture. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Observational prospective unblinded case-control study to evaluate the effect of the Gamma3® distal targeting system for long nails on radiation exposure and time for distal screw placement.

PURPOSE: To determine if the DTS decreases radiation exposure (primary outcome measure), fluoroscopy time (secondary outcome measure), and time to distal screw placement (secondary outcome measure) compared to the freehand "perfect circles" method when used for locking of cephalomedullary nails in the treatment of femur fractures METHODS: Fifty-eight patients with hip or femoral shaft fractures that were treated with a long cephalomedullary nail were enrolled in this study. Cohorts were determined based on the method of distal interlocking screw placement into either the "Perfect Circles" or "Distal Targeting" cohort. Time from cephalad screw placement to placement of final distal interlocking screw (seconds), radiation exposure (mGy), and fluoroscopy time (seconds) were compared between groups. Hospital quality measures were compared between cohorts. RESULTS: Use of the DTS resulted in 77% (4.3x) lower radiation exposure (p < 0.001), 64% (2.7x) lower fluoroscopy time (p < 0.001), and 60% (1.7x) lower intraoperative time from end of cephalad screw placement to end of distal interlocking screw placement (p < 0.001) compared to the freehand "perfect circles" method. There was no difference in 30-day or 90-day complication rates between cohorts. CONCLUSION: The Stryker Gamma3® Distal Targeting System is a safe, effective and efficient alternative to the freehand "perfect circles" method.

Clinical and Radiographic Comparison of Splinting Constructs for Distal Radius Fractures: An Effort to Free the Elbow.

OBJECTIVES: To compare short-term functional outcomes, reduction loss, and rates of surgery for distal radius fractures initially immobilized with a traditional sugar-tong splint versus clamshell splint freeing the elbow. DESIGN: Prospective randomized trial. SETTING: Level 1 trauma center. PATIENTS: Eighty-nine consecutive patients sustaining distal radius fractures were enrolled between 2018 and 2020. Short-term first follow-up (1-2 weeks) radiographic parameters and 6 weeks for functional questionnaires were established to assess initial outcomes. MAIN OUTCOME MEASURES: The main outcome measures were reduction loss based on radiographic criteria, rate of surgery, and short-term patient functional outcome using the Disabilities of the Arm, Shoulder, and Hand (DASH) score. RESULTS: There were no differences noted in DASH scores ( P -value = 0.8) or loss of reduction ( P -value = 0.69), and splint type was not correlated with likelihood to have surgery ( P = 0.22). A binomial regression model demonstrated splint type was not a significant predictor variable of loss of fracture reduction in the regression model. CONCLUSIONS: These results suggest both sugar-tong splint and clamshell splint construct are acceptable options in the acute management of distal radius fractures. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.