Trauma Providers' Perceptions of Frailty Assessment: A Mixed-Methods Analysis of Knowledge, Attitudes, and Beliefs.

OBJECTIVES: Quality improvement in geriatric trauma depends on timely identification of frailty, yet little is known about providers' knowledge and beliefs about frailty assessment. This study sought to understand trauma providers' understanding, beliefs, and practices for frailty assessment. METHODS: We developed a 20-question survey using the Health Belief Model of health behavior and surveyed physicians, advanced practice providers, and trainees on the trauma services at a single institution that does not use formal frailty screening of all injured seniors. Results were analyzed via mixed methods. RESULTS: One hundred fifty-one providers completed the survey (response rate 92%). Respondents commonly included calendar age as an integral factor in their determinations of frailty but also included a variety of other factors, highlighting limited definitional consensus. Respondents perceived frailty as important to older adult patient outcomes, but assessment techniques were varied because only 24/151 respondents (16%) were familiar with current formal frailty assessment tools. Perceived barriers to performing a formal frailty screening on all injured older adults included the burdensome nature of assessment tools, insufficient training, and lack of time. When prompted for solutions, 20% of respondents recommended automation of the screening process by trained, dedicated team members. CONCLUSIONS: Providers seem to recognize the impact that a diagnosis of frailty has on outcomes, but most lack a working knowledge of how to assess for frailty syndrome. Some providers recommended screening by designated, formally trained personnel who could notify decision makers of a positive screen result.

Postfasciotomy Classification System for Acute Compartment Syndrome of the Leg.

OBJECTIVE: Acute compartment syndrome (ACS) is a true emergency. Even with urgent fasciotomy, there is often muscle damage and need for further surgery. Although ACS is not uncommon, no validated classification system exists to aid in efficient and clear communication. The aim of this study was to establish and validate a classification system for the consequences of ACS treated with fasciotomy. METHODS: Using a modified Delphi method, an international panel of ACS experts was assembled to establish a grading scheme for the disease and then validate the classification system. The goal was to articulate discrete grades of ACS related to fasciotomy findings and associated costs. A pilot analysis was used to determine questions that were clear to the respondents. Discussion of this analysis resulted in another round of cases used for 24 other raters. The 24 individuals implemented the classification system 2 separate times to compare outcomes for 32 clinical cases. The accuracy and reproducibility of the classification system were subsequently calculated based on the providers' responses. RESULTS: The Fleiss Kappa of all raters was at 0.711, showing a strong agreement between the 24 raters. Secondary validation was performed for paired 276 raters and correlation was tested using the Kendall coefficient. The median correlation coefficient was 0.855. All 276 pairs had statistically significant correlation. Correlation coefficient between the first and second rating sessions was strong with the median pair scoring at 0.867. All surgeons had statistically significant internal consistency. CONCLUSION: This new ACS classification system may be applied to better understand the impact of ACS on patient outcomes and economic costs for leg ACS.

American Board of Orthopaedic Surgery's Initiatives Toward Competency-Based Education.

The American Board of Orthopaedic Surgery (ABOS) is the national organization charged with defining education standards for graduate medical education in orthopaedic surgery. The purpose of this article is to describe initiatives taken by the ABOS to develop assessments of competency of residents to document their progress toward the independent practice of orthopaedic surgery and provide feedback for improved performance during training. These initiatives are called the ABOS Knowledge, Skills, and Behavior Program. Web-based assessment tools have been developed and validated to measure competence. These assessments guide resident progress through residency education and better define the competency level by the end of training. The background and rationale for these initiatives and how they serve as steps toward competency-based education in orthopaedic residency education in the United States will be reviewed with a vision of a hybrid of time and competency-based orthopaedic residency education that will remain 5 years in length, with residents assessed using standardized tools.

Non-union bone fractures.

The human skeleton has remarkable regenerative properties, being one of the few structures in the body that can heal by recreating its normal cellular composition, orientation and mechanical strength. When the healing process of a fractured bone fails owing to inadequate immobilization, failed surgical intervention, insufficient biological response or infection, the outcome after a prolonged period of no healing is defined as non-union. Non-union represents a chronic medical condition not only affecting function but also potentially impacting the individual's psychosocial and economic well-being. This Primer provides the reader with an in-depth understanding of our contemporary knowledge regarding the important features to be considered when faced with non-union. The normal mechanisms involved in bone healing and the factors that disrupt the normal signalling mechanisms are addressed. Epidemiological considerations and advances in the diagnosis and surgical therapy of non-union are highlighted and the need for greater efforts in basic, translational and clinical research are identified.

The American Board of Orthopaedic Surgery Response to COVID-19.

The COVID-19 pandemic has disrupted every aspect of society in a way never previously experienced by our nation's orthopaedic surgeons. In response to the challenges the American Board of Orthopaedic Surgery has taken steps to adapt our Board Certification and Continuous Certification processes. These changes were made to provide flexibility for as many Candidates and Diplomates as possible to participate while maintaining our high standards. The American Board of Orthopaedic Surgery is first and foremost committed to the safety and well-being of our patients, physicians, and families while striving to remain responsive to the changing circumstances affecting our Candidates and Diplomates.

Risk factors for femoral nonunion after femoral shaft fracture.

The purpose of this study was to evaluate risk factors for nonunion after femoral nailing of femoral shaft fractures. A case-control study with two to one matching was conducted. Forty-five patients with 46 femoral nonunions (cases) and 92 patients with healed femoral shaft fractures (controls) were identified from our orthopedic trauma registry. All cases and controls were initially managed with reamed, statically locked femoral nails. The characteristics that were significantly different between the two groups were open fracture, delay to weight bearing, and tobacco use. Fracture classification, gender, direction of nail insertion (antegrade vs. retrograde), and Injury Severity Score were not predictive of nonunion. We conclude that open fracture, tobacco use, and delayed weight bearing are risk factors for femoral nonunion after intramedullary nailing for diaphyseal femur fractures.

Fractures of the sustentaculum tali: injury characteristics and surgical technique for reduction.

BACKGROUND: The sustentaculum tali of the calcaneus is a vital load-bearing structure. Isolated sustentacular fractures are rare and may have implications for future hindfoot function. This retrospective cohort study describes sustentacular fracture patterns and characteristics, associated foot injuries, and a method of surgical treatment via a medial approach to the calcaneus. MATERIALS AND METHODS: During a 7-year period, 19 surgically-treated sustentacular fractures without calcaneal posterior facet involvement were identified from a prospectively-collected database at a single Level 1 regional trauma center. Of these, 15 underwent open reduction and internal fixation utilizing a medial approach to the calcaneus. Patient charts, plain radiographs, and CT scans were reviewed for injury characteristics/morphology and associated musculoskeletal injuries. RESULTS: Fourteen patients had associated ipsilateral foot/ankle injuries, and nine had other musculoskeletal injuries. Seven patients had intra-articular middle facet involvement, and seven had subtalar joint subluxation or dislocation. The medial approach to the calcaneus involves distal retraction of the neurovascular bundle and toe flexors. This allowed for an accurate indirect articular reduction using the extraarticular medial calcaneal cortex, as well as reduction of any associated subluxations. No complications were related to the surgical approach. Reduction was maintained through fracture healing. CONCLUSION: Fractures of the sustentaculum tali are rare injuries associated with high energy mechanisms, and associated ipsilateral foot injuries are common. Open reduction and internal fixation of these fractures was reliable and possible through a medial approach involving distal retraction of the digital flexors and neurovascular bundle, allowing for an anatomical extraarticular cortical reduction.

Femoral nonunion: risk factors and treatment options.

Despite advances in surgical technique, fracture fixation alternatives, and adjuncts to healing, femoral nonunion continues to be a significant clinical problem. Femoral fractures may fail to unite because of the severity of the injury, damage to the surrounding soft tissues, inadequate initial fixation, and demographic characteristics of the patient, including nicotine use, advanced age, and medical comorbidities. Femoral nonunion is a functional and economical challenge for the patient, as well as a treatment dilemma for the surgeon. Surgeons should understand the various treatment alternatives and their role in achieving the goals of deformity correction, infection management, and optimization of muscle strength and rehabilitation. Used appropriately, nail dynamization, exchange nailing, and plate osteosynthesis can help minimize pain and disability by promoting osseous union. A review of the potential risk factors and treatment alternatives should provide insight into the etiology and required treatment of femoral nonunion.

Frequency and fracture morphology of the posteromedial fragment in bicondylar tibial plateau fracture patterns.

OBJECTIVES: Bicondylar tibial plateau fracture management remains therapeutically challenging, partly because of multiplanar articular comminution. This study was performed to evaluate the frequency and morphologic characteristics of the posteromedial fragment in this injury pattern. DESIGN: Retrospective chart and radiographic review. SETTING: Urban Level 1 university trauma center. PATIENTS: Fifty-seven patients sustaining 57 Orthopedic Trauma Association (OTA) C-Type bicondylar tibial plateau fractures formed the study group. MAIN OUTCOME MEASURE: Between May 2000 and March 2003, 170 OTA C-Type bicondylar tibial plateau fractures were identified using an orthopaedic database. One hundred and forty-six fractures had computed tomographic (CT) scans performed prior to definitive fixation and were reviewed using the Picture Archiving and Communication System (PACS). Sixty-six (45.2%) injuries had fractures that involved the medial articular surface. Nine with suboptimal CTs were excluded, leaving 57 injuries for review. Forty-two patients demonstrated coronal plane posteromedial fragments. Morphologic evaluation of the posteromedial fragment included articular surface area, maximum posterior cortical height (PCH), and sagittal fracture angle (SFA). RESULTS: Forty-two of 57 injuries (74%) demonstrated a posteromedial fragment that comprised a mean of 58% of the articular surface of the medial tibial plateau (range, 19%-98%) and a mean of 23% of the entire tibial plateau articular surface (range, 8%-47%). Mean posteromedial fragment height was 42 mm (range, 16-59 mm), and mean sagittal fracture angle was 81 degrees (range, 33 degrees to 112 degrees). Six patients demonstrated fracture patterns not accurately identified by the AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association) fracture classification system. CONCLUSIONS: A posteromedial fragment was observed in nearly one third of the bicondylar plateau fractures evaluated. The morphologic features of this fragment may have clinical implications when using currently available laterally applied fixed-angle screw/plate implants to stabilize these injuries. Alternate or supplementary fixation methods may be required when managing this injury pattern.

Complications of cervical halo-vest orthoses in elderly patients.

Halo-vest orthoses have been associated with complications. Previous reports have suggested increased complications in elderly patients; however, data are limited. This study reviewed 75 patients =/>65 years with cervical spine fractures treated with halo-vest orthoses. Forty-one patients (55%) experienced at least 1 complication. Pin-site problems were the most frequent adverse outcome. Seventeen patients (23%) had significant pulmonary compromise. Pulmonary complications were associated with high morbidity. We found an 8% early mortality rate. Halo-vest orthoses are useful devises. However, adverse events experienced by elderly patients are common and may lead to significant morbidity and mortality.

Utility of Geriatric Assessment in the Projection of Early Mortality Following Hip Fracture in the Elderly Patients.

Hip fractures result in significant morbidity and mortality in elders. Indicators of frailty are associated with poor outcomes. Commonly used frailty tools rely on motor skills that cannot be performed by this population. We determined the association between the Charlson Comorbidity Score (CCS), intraoperative hypotension (IOH), and a geriatric medicine consult index (GCI) with short-term mortality in hip fracture patients. A retrospective cohort study was conducted at a single institution over a 2-year period. Patients aged 65 years and older who sustained a hip fracture following a low-energy mechanism were identified using billing records and our orthopedic fracture registry. Medical records were reviewed to collect demographic data, fracture classification and operative records, calculation of CCS, intraoperative details including hypotension, and assessments recorded in the geriatric consult notes. The GCI was calculated using 30 dichotomous variables contained within the geriatric consult note. The index, ranging from 0 to 1, included markers for physical and cognitive function, as well as medications. A higher GCI score indicated more markers for frailty. One hundred eight patients met inclusion criteria. Sixty-four (59%) were females and the average age was 77.3 years. Thirty-five (32%) patients sustained femoral neck fractures, and 73 (68%) patients sustained inter-/pertrochanteric hip fractures. The 30-day mortality was 6%; the 90-day mortality was 13%. The mean GCI was 0.30 in the 30-day survivor group as compared to 0.52 in those who died. The mean GCI was 0.28 in patients who were alive at 90 days as compared to 0.46 in those who died. In contrast, the CCS and IOH were not associated with 30- or 90-day mortality. In our older hip fracture patients, an index calculated from information routinely obtained in the geriatric consult evaluation was associated with 30- and 90-day mortality, whereas the CCS and measures of IOH were not.

Concomitant Upper Extremity Fracture Worsens Outcomes in Elderly Patients With Hip Fracture.

BACKGROUND: Elderly patients with low-energy hip fractures have high rates of morbidity and mortality, but it is not well known how often concurrent upper extremity fractures occur and how this impacts outcomes. We used the National Trauma Databank (NTDB), the largest aggregation of US trauma registry data available, to determine whether patients with concurrent upper extremity and hip fractures have worse outcomes than patients with hip fractures alone. METHODS: We accessed the NTDB to identify patients aged 65 to 100 who sustained a hip fracture. The cohort was then narrowed to include only patients who sustained their injury in a fall and had an injury severity score indicating hip fracture as the most severe injury. We then analyzed this group to assess the impact of a simultaneous upper extremity fracture on length of stay, in-hospital mortality, and discharge disposition. RESULTS: From 2007 to 2014, a total of 231,299 patients aged 65 to 100 were identified as having a hip fracture. The narrowed cohort with fall as the mechanism and hip fracture as the most severe injury included 193,862 patients. Of these, 12,618 patients sustained a concomitant upper extremity fracture (6.5%). Compared to isolated hip fractures, patients with a concomitant upper extremity fracture had higher odds of death in the hospital (odds ratio [OR] = 1.3; 95% confidence interval = 1.2-1.4), were less likely to be discharged to home as compared to a skilled facility (OR = 0.73; 95% confidence interval = 0.68-0.78), and had a significantly longer average length of stay (7.1 vs 6.4 days, P < .001). CONCLUSIONS: We found a 6.5% prevalence of concomitant upper extremity fractures in patients aged 65 to 100 with a hip fracture sustained after a fall where the hip fracture was the most severe injury. These patients had a higher risk of in-hospital mortality, were less likely to be discharged to home, and had longer average length of stay.

Open diaphyseal long bone fractures: a reduction method using devitalized or extruded osseous fragments.

Open diaphyseal and meta-diaphyseal fractures of the lower extremity remain therapeutically challenging. Currently accepted treatment methods consist of a thorough irrigation and debridement of nonviable tissue combined with locked intramedullary nailing. Although exact reduction parameters remain controversial, achievement of a satisfactory reduction becomes increasingly difficult with fracture comminution and overt bone loss. We describe the simple technique of using multiple associated devitalized tibial bone fragments to obtain an accurate reduction prior to intramedullary nailing. This technique can be extended to other long bone fractures.

Assessment of Osteoporosis in Injured Older Women Admitted to a Safety-Net Level One Trauma Center: A Unique Opportunity to Fulfill an Unmet Need.

BACKGROUND: Older trauma patients often undergo computed tomography (CT) as part of the initial work-up. CT imaging can also be used opportunistically to measure bone density and assess osteoporosis. METHODS: In this retrospective cohort study, osteoporosis was ascertained from admission CT scans in women aged ≥65 admitted to the ICU for traumatic injury during a 3-year period at a single, safety-net, level 1 trauma center. Osteoporosis was defined by established CT-based criteria of average L1 vertebral body Hounsfield units <110. Evidence of diagnosis and/or treatment of osteoporosis was the primary outcome. RESULTS: The study cohort consisted of 215 women over a 3-year study period, of which 101 (47%) had evidence of osteoporosis by CT scan criteria. There were no differences in injury severity score, hospital length of stay, cost, or discharge disposition between groups with and without evidence of osteoporosis. Only 55 (59%) of the 94 patients with osteoporosis who survived to discharge had a documented osteoporosis diagnosis and/or corresponding evaluation/treatment plan. CONCLUSION: Nearly half of older women admitted with traumatic injuries had underlying osteoporosis, but 41% had neither clinical recognition of this finding nor a treatment plan for osteoporosis. Admission for traumatic injury is an opportunity to assess osteoporosis, initiate appropriate intervention, and coordinate follow-up care. Trauma and acute care teams should consider assessment of osteoporosis in women who undergo CT imaging and provide a bridge to outpatient services.

Association of Radiologic Indicators of Frailty With 1-Year Mortality in Older Trauma Patients: Opportunistic Screening for Sarcopenia and Osteopenia.

Importance: Assessment of physical frailty in older trauma patients admitted to the intensive care unit is often not feasible using traditional frailty assessment instruments. The use of opportunistic computed tomography (CT) scans to assess sarcopenia and osteopenia as indicators of underlying frailty may provide complementary prognostic information on long-term outcomes. Objective: To determine whether sarcopenia and/or osteopenia are associated with 1-year mortality in an older trauma patient population. Design, Setting, and Participants: A retrospective cohort constructed from a state trauma registry was linked to the statewide death registry and Comprehensive Hospital Abstract Reporting System for readmission data analyses. Admission abdominopelvic CT scans from patients 65 years and older admitted to the intensive care unit of a single level I trauma center between January 2011 and May 2014 were analyzed to identify patients with sarcopenia and/or osteopenia. Patients with a head Injury Severity Score of 3 or greater, an out-of-state address, or inadequate CT imaging or who died within 24 hours of admission were excluded. Exposures: Sarcopenia and/or osteopenia, assessed via total cross-sectional muscle area and bone density at the L3 vertebral level, compared with a group with no sarcopenia or osteopenia. Main Outcomes and Measures: One-year all-cause mortality. Secondary outcomes included 30-day all-cause mortality, 30-day readmission, hospital length of stay, hospital cost, and discharge disposition. Results: Of the 450 patients included in the study, 269 (59.8%) were male and 394 (87.6%) were white. The cohort was split into 4 groups: 74 were retrospectively diagnosed with both sarcopenia and osteopenia, 167 with sarcopenia only, 48 with osteopenia only, and 161 with no radiologic indicators. Among the 408 who survived to discharge, sarcopenia and osteopenia were associated with higher risks of 1-year mortality alone and in combination. After adjustment, the hazard ratio was 9.4 (95% CI, 1.2-75.4; P = .03) for sarcopenia and osteopenia, 10.3 (95% CI, 1.3-78.8; P = .03) for sarcopenia, and 11.9 (95% CI, 1.3-107.4; P = .03) for osteopenia. Conclusions and Relevance: More than half of older trauma patients in this study had sarcopenia, osteopenia, or both. Each factor was independently associated with increased 1-year mortality. Given the prevalent use of abdominopelvic CT in trauma centers, opportunistic screening for radiologic indicators of frailty provides an additional tool for early identification of older trauma patients at high risk for poor outcomes, with the potential for targeted interventions.

Osteochondral fracture of the distal lateral femoral condyle: a report of two cases.

Osteochondral fractures of the lateral femoral condyle are uncommon injuries. These fractures often are misdiagnosed, and the majority of the cases reported have been managed with surgical excision. We present 2 cases of osteochondral fractures of the lateral femoral condyle. Both patients were treated with open reduction internal fixation of their fractures. A lateral approach to the posterolateral aspect of the distal femur is described.

Open clavicle fractures and associated injuries.

OBJECTIVES: To describe the associated injuries, demographic distribution, and management of patients sustaining open clavicle fractures. DESIGN: Retrospective case series. SETTING: A single level-1 trauma center. PATIENTS: Twenty patients with open clavicle fractures were identified from a prospectively collected orthopaedic trauma registry. INTERVENTION: All patients were managed with surgical irrigation and debridement with or without internal fixation. RESULTS: Thirteen patients (65%) had a closed head injury. Fifteen patients (75%) had a significant associated pulmonary injury. In that group, there were 10 patients who had a pneumothorax (7 bilateral). Additionally, 12 patients had rib fractures and 11 had documented pulmonary contusions or effusions. Seven patients (35%) had a cervical or thoracic spine fracture or dislocation. Eight patients (40%) had concomitant scapula fractures. Six patients (30%) had additional ipsilateral upper extremity injuries remote from the shoulder girdle. One patient had a scapulothoracic dissociation. Eleven patients (55%) sustained significant facial trauma including fractures (5 patients), lacerations, and hematomas. Fourteen patients (70%) were treated with open reduction internal fixation. Fifteen patients (75%) were followed to healing (mean: 111 wk, median: 56 wk, range: 13 to 333 wk). There were no other complications related to the operative fixations. There were no known infections or nonunions. CONCLUSIONS: Open clavicle fractures are a rare injury. Patients often have associated pulmonary and cranial injuries. Ipsilateral upper extremity and shoulder girdle injuries are common, whereas concomitant neurologic and vascular injuries are infrequent. The majority of patients have rapid and uneventful healing of their fractures after surgical treatment.

The olecranon osteotomy: a six-year experience in the treatment of intraarticular fractures of the distal humerus.

OBJECTIVES: The transolecranon exposure for distal humerus fractures is a suggested technique for improving articular visualization, allowing accurate reduction. Significant osteotomy complications such as nonunion and implant prominence have prompted recommendations for alternate exposures. The purposes of this study are to present the techniques and complications of the olecranon osteotomy for the management of distal humerus fractures, and to evaluate the adequacy of distal humeral and olecranon articular reductions. DESIGN: Retrospective review. SETTING: Urban level-1 University trauma center. PATIENTS: One hundred fourteen skeletally mature AO/OTA type 13-C distal humerus fractures were identified from the orthopedic trauma database and formed the study group. INTERVENTION: Seventy fractures (61%), including 42 open injuries, were managed using an intraarticular, chevron-shaped olecranon osteotomy. Osteotomy fixations were performed with an intramedullary screw and supplemental dorsal ulnar wiring, or plate stabilization. In the remaining 44 fractures (39%), soft-tissue mobilizing exposures were performed. MAIN OUTCOME MEASURE: Patient records and radiographs were reviewed to determine injury and operative characteristics, complications, and adequacy of articular reductions. Patient interviews were conducted by telephone to identify any subsequent surgical procedures. RESULTS: The proportion of osteotomies performed increased as fracture complexity increased (P<0.001). Sixty-seven of 70 patients had adequate follow-up to determine osteotomy union. All osteotomies united. There was 1 delayed union. Sixty-one of 70 patients had adequate follow-up to determine complications associated with ulnar fixations. Five of these patients (8%) underwent elective removal of symptomatic osteotomy fixations. An additional 13 patients had olecranon implants removed in conjunction with other surgical procedures (11 elbow contracture releases, 1 humeral nonunion repair, and 1 chronic draining sinus excision). Symptomatic ulnar fixations in this group could not be reliably ascertained, but may have been present. A total of 18 of 61 patients (29.5%), therefore, had proximal ulna fixations removed. All patients treated using an olecranon osteotomy exposure demonstrated satisfactory radiographic distal humeral articular reductions. Two osteotomies required early revision osteosynthesis secondary to loss of osteotomy reduction. CONCLUSIONS: In this study, no osteotomy nonunions were encountered in 67 patients, more than half of which were open injuries. Regardless of which type of fixation is used to secure the osteotomy, secure stabilization must be obtained. Isolated symptomatic olecranon fixation requiring removal occurred in approximately 8% of patients. Although not necessary for all fractures of the distal humerus, the olecranon osteotomy can be useful in the visualization of the complex articular injuries, allowing accurate articular reduction.

Salvage of an infected periprosthetic failed fracture fixation in a nonagenarian.

Infected nonunions resulting in segmental bone loss are a devastating complication for patients and a difficult problem for surgeons. Adequate soft tissue coverage, return of mobility, fracture stability, and long-term freedom from infection are all important goals of treatment. Although there are numerous published studies that provide some treatment guidelines, there are patients who require unique and individualized solutions. In this report, we present a case in which an antibiotic-impregnated cement spacer was used as a component of the definitive treatment in a geriatric patient with segmental bone loss of the femur secondary to severe infection as a salvage technique to avoid amputation.