Periprosthetic Tibial Fractures After Total Knee Arthroplasty: Early and Long-Term Clinical Outcomes.

BACKGROUND: Although periprosthetic fractures are increasing in prevalence, evidence-based guidelines for the optimal treatment of periprosthetic tibial fractures (PTx) are lacking. Thus, the purpose of this study is to assess the clinical outcomes in PTx after a total knee arthroplasty (TKA) which were treated with different treatment options. METHODS: A retrospective review was performed on a consecutive series of 34 nontumor patients treated at 2 academic institutions who experienced a PTx after TKA (2008-2016). Felix classification was used to classify fractures (Felix = I-II-III; subgroup = A-B-C) which were treated by closed reduction, open reduction/internal fixation, revision TKA, or proximal tibial replacement. Patient demographics and surgical characteristics were collected. Failure of treatment was defined as any revision or reoperation. Independent t-tests, one-way analysis of variance, chi-squared analyses, and Fisher's exact tests were conducted. RESULTS: Patients with Felix I had more nonsurgical complications when compared to Felix III patients (P = .006). Felix I group developed more postoperative anemia requiring transfusion than Felix III group (P = .009). All fracture types had >30% revision and >50% readmission rate with infection being the most common cause. These did not differ between Felix fracture types. Patients who underwent proximal tibial replacement had higher rate of postoperative infection (P = .030), revision surgery (P = .046), and required more flap reconstructions (P = .005). CONCLUSION: PTx after a TKA is associated with high revision and readmission rates. Patients with Felix type I fractures are at higher risk of postoperative nonsurgical complications and anemia requiring transfusion. Fractures treated with proximal tibial replacement are more likely to develop postoperative infections and undergo revision surgery.

Fungal osteomyelitis and septic arthritis.

Management of fungal osteomyelitis and fungal septic arthritis is challenging, especially in the setting of immunodeficiency and conditions that require immunosuppression. Because fungal osteomyelitis and fungal septic arthritis are rare conditions, study of their pathophysiology and treatment has been limited. In the literature, evidence-based treatment is lacking and, historically, outcomes have been poor. The most common offending organisms are Candida and Aspergillus, which are widely distributed in humans and soil. However, some fungal pathogens, such as Histoplasma, Blastomyces, Coccidioides, Cryptococcus, and Sporothrix, have more focal areas of endemicity. Fungal bone and joint infections result from direct inoculation, contiguous infection spread, or hematogenous seeding of organisms. These infections may be difficult to diagnose and eradicate, especially in the setting of total joint arthroplasty. Although there is no clear consensus on treatment, guidelines are available for management of many of these pathogens.

Characterization and bioactive properties of zirconia based polymeric hybrid for orthopedic applications.

Zirconia is a transition metal oxide with current applications to orthopedic implants. It has been shown to up-regulate specific genes involved in bio-integration and injury repair. This study examines the effects of zirconia and polydimethylsiloxane (PDMS) hybrids on the proliferation and viability of human primary osteoblast and fibroblast cells. In this study, zirconia-PDMS hybrid coatings were synthesized using a modified sol gel process. The hybrid material was characterized using optical microscopy, scanning electron microscopy, X-ray photoelectron spectroscopy, and contact angle analysis. This study demonstrates that Zr-PMDS surface materials display hydrophobic surface properties coupled with a preferential deposition of polymer near the surface. Primary osteoblast and fibroblast proliferation and viability on hybrid coated surfaces were evaluated via a rapid screening methodology using WST-1 and calcein AM assays. The cells were seed at 5,000 cells per well in 96-well plates coated with various composition of Zr-PDMS hybrids. The results showed increasing cell proliferation with increasing zirconia concentration, which peaked at 90 % v/v zirconia. Proliferation of osteoblasts and fibroblasts displayed similar trends on the hybrid material, although osteoblasts displayed a bi-phasic dose response by the calcein AM assay. The results of this current study show that Zr-PDMS may be used to influence tissue-implant integration, supporting the use of the hybrid as a promising coating for orthopedic trauma implants.

Initial management of ankle fractures in the overweight and obese: the providence pinch.

BACKGROUND: Obese and overweight people have higher rates of ankle injury, particularly operative ankle fractures. The initial management of unstable ankle fractures includes closed reduction and splinting to limit soft tissue injury and articular cartilage damage until definitive operative fixation can be performed. Adequate reduction can be more difficult in the obese patient due to the weight and additional padding provided by the larger soft tissue envelope. DISCUSSION: A novel technique, described herein by the authors, may be useful in obtaining a suitable reduction of the ankle in the initial management of unstable ankle fractures in the overweight and obese. CONCLUSIONS: Obese patients have unique musculoskeletal injury profiles and special considerations in their management. The authors have found this technique useful in the management of their ankle fractures.

Distal Fibular Metastasis of Colorectal Carcinoma: A Case Report.

Case: A 62-year-old woman presenting with ankle pain was initially treated for a non-displaced fracture. Persistent pain despite months of conservative management for her presumed injury prompted repeat radiographs which demonstrated the progression of a lytic lesion and led to an orthopedic oncology referral. Following a complete work-up, including biopsy and staging, she was diagnosed with colorectal carcinoma metastatic to the distal fibula. Conclusion: Secondary tumors of the fibula are uncommon but an important diagnosis to consider for intractable lower extremity pain especially in patients with history of malignancy or lack of age-appropriate cancer screening.

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.

Implant Charge Differences Between Distal Radius Fixation Constructs (CPT 25607, 25608, and 25609).

BACKGROUND: Implants are a significant contributor to health care costs. We hypothesized that extra-articular fracture patterns would have a lower implant charge than intra-articular fractures and aimed to determine risk factors for increased cost. METHODS: In total, 163 patients undergoing outpatient distal radius fracture fixation at 2 hospitals were retrospectively reviewed stratified by Current Procedural Terminology codes. Implants and associated charges were noted, as were sex, age, insurance status, surgeon specialty, and location. Bivariate and multivariable regression were used to determine associations. RESULTS: Total implant charges were significantly lower for 25607 (extraarticular, $3,348) than 25608 (2-part intraarticular, $3,859) and 25609 (3+ part intraarticular, $3,991). In addition, intra-articular fractures had higher charges for distal screws/pegs and bone graft. Charge was lower when surgery was performed at a trauma center. There was no charge difference associated with insurance status, age, sex, hand surgery specialty, or fellow status. Substantial intersurgeon variation existed in all fracture types. CONCLUSION: Distal radius fractures may represent a good model for examining implant costs. Extra-articular fractures had lower implant charges than intra-articular fractures. These data may be used to help construct pricing for distal radius fracture bundles and potential cost savings.

Defining Incidence of Acute Compartment Syndrome in the Research Setting: A Proposed Method From the PACS Study.

OBJECTIVE: To compare the retrospective decision of an expert panel who assessed likelihood of acute compartment syndrome (ACS) in a patient with a high-risk tibia fracture with decision to perform fasciotomy. DESIGN: Prospective observational study. SETTING: Seven Level 1 trauma centers. PATIENTS/PARTICIPANTS: One hundred eighty-two adults with severe tibia fractures. MAIN OUTCOME MEASUREMENTS: Diagnostic performance (sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and receiver-operator curve) of an expert panel's assessment of likelihood ACS compared with fasciotomy as the reference diagnostic standard. SECONDARY OUTCOMES: The interrater reliability of the expert panel as measured by the Krippendorff alpha. Expert panel consensus was determined using the percent of panelists in the majority group of low (expert panel likelihood of ≤0.3), uncertain (0.3-0.7), or high (>0.7) likelihood of ACS. RESULTS: Comparing fasciotomy (the diagnostic standard) and the expert panel's assessment as the diagnostic classification (test), the expert panel's determination of uncertain or high likelihood of ACS (threshold >0.3) had a sensitivity of 0.90 (0.70, 0.99), specificity of 0.95 (0.90, 0.98), PPV of 0.70 (0.50, 0.86), and NPV of 0.99 (0.95, 1.00). When a threshold of >0.7 was set as a positive diagnosis, the expert panel assessment had a sensitivity of 0.67 (0.43, 0.85), specificity of 0.98 (0.95, 1.00), PPV of 0.82 (0.57, 0.96), and NPV of 0.96 (0.91, 0.98). CONCLUSION: In our study, the retrospective assessment of an expert panel of the likelihood of ACS has good specificity and excellent NPV for fasciotomy, but only low-to-moderate sensitivity and PPV. The discordance between the expert panel-assessed likelihood of ACS and the decision to perform fasciotomy suggests that concern regarding potential diagnostic bias in studies of ACS is warranted. LEVEL OF EVIDENCE: Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Partnered disaster preparedness: lessons learned from international events.

Military, governmental, and civilian agencies routinely respond to disasters around the world, including large-scale mass casualty events such as the earthquake in Pakistan in 2005, Hurricane Katrina in the United States in 2005, and the earthquake in Haiti in 2010. Potential exists for improved coordination of medical response between civilian and military sectors and for the creation of a planned and practiced interface. Disaster preparedness could be enhanced with more robust disaster education for civilian responders; creation of a database of precredentialed, precertified medical specialists; implementation of a communication bridge; and the establishment of agreements between military and civilian medical/surgical groups in advance of major catastrophic events.

Essentials of disaster management: the role of the orthopaedic surgeon.

Disaster preparedness and management education is essential for allowing orthopaedic surgeons to play a valuable, constructive role in responding to disasters. The National Incident Management System, as part of the National Response Framework, provides coordination between all levels of government and uses the Incident Command System as its unified command structure. An "all-hazards" approach to disasters, whether natural, man-made, intentional, or unintentional, is fundamental to disaster planning. To respond to any disaster, command and control must be established, and emergency management must be integrated with public health and medical care. In the face of increasing acts of terrorism, an understanding of blast injury pathophysiology allows for improved diagnostic and treatment strategies. A practical understanding of potential biologic, chemical, and nuclear agents and their attendant clinical symptoms is also prerequisite. Credentialing and coordination between designated organizations and the federal government are essential to allow civilian orthopaedic surgeons to access systems capable of disaster response.

A Simple Initiative to Decrease Time to Antibiotic Prophylaxis for Open Fractures Is Durable After 2 Years.

INTRODUCTION: A simple antibiotic prophylaxis initiative can effectively decrease the time to antibiotic administration for patients with open fractures. We aim to determine whether adherence to the protocol decreased over time without active input from the orthopaedic trauma team. PATIENTS AND METHODS: This retrospective cohort study included adult patients with open fractures (excluding hand) presenting directly to the emergency department at one Level I trauma center. Three separate 50-patient groups were included: a preimplementation cohort, immediately postimplementation cohort, and a retention cohort 2 years later. The primary outcome was time from emergency department presentation to antibiotic administration, and secondary outcomes were the percentage of patients receiving antibiotics within 60 minutes and incidence of infection requiring revision surgery within 90 days. The χ2 and Student t-tests evaluated between-group differences, and multivariable linear or logistic regression evaluated risk factors. RESULTS: After implementation, the time from presentation to antibiotic administration decreased markedly from 123.1 to 35.7 minutes and remained durable (50.0 minutes) at retention. The proportion of patients receiving antibiotics within 60 minutes increased markedly from 46% preimplementation to 82% postintervention and remained similar at retention (80%). The postintervention and retention groups were markedly more likely to receive antibiotics within 60 minutes than the preintervention group (odds ratio [OR], 8.4 and 4.7, respectively), as were patients with a higher Gustilo-Anderson type (OR, 2.4/unit increase), lower extremity injury (OR, 2.8), and male sex (OR, 3.1); mechanism, age, and Injury Severity Score were not associated. No difference was observed in infection. CONCLUSIONS: Our educational initiative showed durable results in reducing the time from presentation to antibiotic administration after 2 years. LEVEL OF EVIDENCE: Therapeutic Level III.

Partial Delaminated Quadriceps Tendon Rupture: A Case Report.

CASE: We present a case of a 41-year-old male bodybuilder with a partial delaminated quadriceps tendon rupture after a traumatic injury. Partial quadriceps tendon tears are rare overall and usually are treated nonoperatively with conservative management depending on the patient's limitations. He was found to have an intact superficial quadriceps tendon with a partial thickness tear of the vastus intermedius and delamination of the undersurface quadriceps tendon precluding active knee extension. CONCLUSION: To our knowledge, there has never been a reported partial quadriceps tendon tear with delamination of the undersurface, causing a complete extensor mechanism failure necessitating operative repair.

Pain, Depression, and Posttraumatic Stress Disorder Following Major Extremity Trauma Among United States Military Serving in Iraq and Afghanistan: Results From the Military Extremity Trauma and Amputation/Limb Salvage Study.

OBJECTIVES: Assess the burden and co-occurrence of pain, depression, and posttraumatic stress disorder (PTSD) among service members who sustained a major limb injury, and examine whether these conditions are associated with functional outcomes. DESIGN: A retrospective cohort study. SETTING: Four U.S. military treatment facilities: Walter Reed Army Medical Center, National Naval Medical Center, Brooke Army Medical Center, and Naval Medical Center San Diego. PATIENTS/PARTICIPANTS: Four hundred twenty-nine United States service members who sustained a major limb injury while serving in Afghanistan or Iraq met eligibility criteria upon review of their medical records. INTERVENTION: Not applicable. MAIN OUTCOME MEASUREMENTS: Outcomes assessed were: function using the short musculoskeletal functional assessment; PTSD using the PTSD Checklist and diagnostic and statistical manual criteria; pain using the chronic pain grade scale. RESULTS: Military extremity trauma and amputation/limb salvage patients without pain, depression, or PTSD, were, on average, about one minimally clinically important difference (MCID) from age- and gender-adjusted population norms. In contrast, patients with low levels of pain and no depression or PTSD were, on average, one to 2 MCIDs from population norms. Military extremity trauma and amputation/limb salvage patients with either greater levels of pain, and who experience PTSD, depression, or both, were 4 to 6 MCIDs from population norms. Regression analyses adjusting for injury type (upper or lower limb, salvage or amputation, and unilateral or bilateral), age, time to interview, military rank, presence of a major upper limb injury, social support, presence of mild traumatic brain injury/concussion, and combat experiences showed that higher levels of pain, depression, and PTSD were associated with lower one-year functional outcomes. CONCLUSIONS: Major limb trauma sustained in the military results in significant long-term pain and PTSD. Overall, the results are consistent with the hypothesis that pain, depression, and PTSD are associated with disability in this population. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Fluorescent-conjugated antibodies as rapid ex vivo markers for bacterial presence on orthopedic surgical explants and synovium: A pilot study.

Surgical infection is one of the most pressing problems in the field of orthopedic surgery; however, current detection methods are plagued by high costs and long wait times. This study seeks to demonstrate the ability of a novel assay using fluorescently conjugated antibodies and confocal laser scanning microscopy (CLSM) to accurately detect bacterial presence on orthopedic surgical explants, tissue, and synovial fluid in 30 min. Explanted hardware, tissue, and synovial fluid samples suspected to be infected were collected from human subjects with institutional review board consent. Samples were prepared using a 30-min protocol, consisting of rinsing, nonspecific blocking and staining steps, and imaged using CLSM. Images were analyzed using ImageJ (National Institute of Health) to determine the percent area of Gram positive and Gram negative bacteria. Results of the assay were compared to the hospital's microbiological laboratory and Gram staining results. Ninety three samples were collected and tested using the 30-min testing protocol; 75 samples were synovial fluid and 18 were tissue and explants. Seventy four of 75 (98.6%) synovial fluid samples correlated with the hospital laboratory's microbiological findings. Of the 18 explant and tissue samples, our assay found bacterial presence in 14 of 18 samples, while the hospital microbiology laboratory found bacterial presence in 13 of 18 samples. This assay reliably stained and rapidly identified the presence of Gram negative and Gram positive bacteria on surgical explants, tissue and synovial fluid in 30 min. This methodology may serve as a point of service tool for the determination of bacterial presence during surgical procedures.

Adding a Fibular Strut Allograft to Intramedullary Nail and Cancellous Autograft During Stage II of the Masquelet Technique for Segmental Femur Defects: A Technique Tip.

Reconstruction of segmental diaphyseal bone defects has been a major challenge in limb salvage surgery. Staged reconstruction as first described by Masquelet is a common strategy to deal with this problem in limb salvage surgery. One consequence of this technique is a time period of prolonged limited weightbearing while the segmental defect heals. The purpose of this study was to describe an adjunctive technique for stage II of the Masquelet procedure and retrospectively analyze the outcome and weight bearing progression of 3 patients who sustained femur fractures with significant bone loss and underwent this technique. A retrospective chart review was performed. The patients (2 males, 1 female with an average age of 36.6 years) all sustained segmental femur fractures which resulted in significant bone loss. Induced membrane technique with adjunct use of a fibular strut allograft was performed after initial stabilization and PMMA spacer placement. All three patients went on to union and full weight bearing after being treated by the described technique. All the patients were allowed toe-touch weight bearing immediately after surgery and all progressed to weight bearing as tolerated at an average of 3.6 months. Using a fibular strut allograft as an adjunct to the induced membrane technique serves as a biologic and mechanical scaffold and may allow earlier weightbearing.

Opioid-Limiting Legislation Associated With Reduced Postoperative Prescribing After Surgery for Traumatic Orthopaedic Injuries.

OBJECTIVES: To evaluate opioid-prescribing patterns after surgery for orthopaedic trauma before and after implementation of opioid-limiting mandates in one state. DESIGN: Retrospective review. SETTING: Level-1 trauma center. PATIENTS/PARTICIPANTS: Seven hundred fifty-three patients (297 pre-law and 456 post-law) undergoing isolated fixation for 6 common fracture patterns during specified pre-law (January 1, 2016-June 28, 2016) and post-law (June 01, 2017-December 31, 2017) study periods. Polytrauma patients were excluded. INTERVENTION: Implementation of statewide legislation establishing strict limits on initial opioid prescriptions [150 total morphine milligram equivalents (MMEs), 30 MMEs per day, or 20 total doses]. MAIN OUTCOME MEASUREMENTS: Initial opioid prescription dose, cumulative MMEs filled by 30 and 90 days postoperatively. RESULTS: Pre-law and post-law patient groups did not differ in terms of age, sex, opioid tolerance, recent benzodiazepine use, or open versus closed fracture pattern (P > 0.05). The post-law cohort received significantly less opioids (363.4 vs. 173.6 MMEs, P < 0.001) in the first postoperative prescription. Furthermore, the post-law group received significantly less cumulative MMEs in the first 30 postoperative days (677.4 vs. 481.7 MMEs, P < 0.001); This included both opioid-naïve (633.7 vs. 478.1 MMEs, P < 0.001) and opioid-tolerant patients (1659.2 vs. 880.0 MMEs, P = 0.048). No significant difference in opioid utilization between pre- and post-law groups was noted after postoperative day 30. Independent risk factors for prolonged (>30 days) postoperative opioid use included male gender (odds ratio 2.0, 95% confidence interval 1.4-2.9, P < 0.001) and preoperative opioid use (odds ratio 5.1, 95% confidence interval 2.4-10.5, P < 0.001). CONCLUSIONS: Opioid-limiting legislation is associated with a statistically and clinically significant reduction in initial and 30-day opioid prescriptions after surgery for orthopaedic trauma. Preoperative opioid use and male gender are independently associated with prolonged postoperative opioid use in this population. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Perfusion Pressure Lacks Diagnostic Specificity for the Diagnosis of Acute Compartment Syndrome.

OBJECTIVE: To evaluate the diagnostic performance of perfusion pressure (PP) thresholds for fasciotomy. DESIGN: Prospective observational study. SETTING: Seven Level-1 trauma centers. PATIENTS/PARTICIPANTS: One hundred fifty adults with severe leg injuries and ≥2 hours of continuous PP data who had been enrolled in a multicenter observational trial designed to develop a clinical prediction rule for acute compartment syndrome (ACS). MAIN OUTCOME MEASUREMENTS: For each patient, a given PP criterion was positive if it was below the specified threshold for at least 2 consecutive hours. The diagnostic performance of PP thresholds between 10 and 30 mm Hg was determined using 2 reference standards for comparison: (1) the likelihood of ACS as determined by an expert panel who reviewed each patient's data portfolio or (2) whether the patient underwent fasciotomy. RESULTS: Using the likelihood of ACS as the diagnostic standard (ACS considered present if median likelihood ≥70%, absent if <30%), a PP threshold of 30 mm Hg had diagnostic sensitivity 0.83, specificity 0.53, positive predictive value 0.07, and negative predictive value 0.99. Results were insensitive to more strict likelihood categorizations and were similar for other PP thresholds between 10- and 25-mm Hg. Using fasciotomy as the reference standard, the same PP threshold had diagnostic sensitivity 0.50, specificity 0.50, positive predictive value 0.04, negative predictive value 0.96. CONCLUSION: No value of PP from 10 to 30 mm Hg had acceptable diagnostic performance, regardless of which reference diagnostic standard was used. These data question current practice of diagnosing ACS based on PP and suggest the need for further research. LEVEL OF EVIDENCE: Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

The Military Extremity Trauma Amputation/Limb Salvage (METALS) Study: Outcomes of Amputation Compared with Limb Salvage Following Major Upper-Extremity Trauma.

BACKGROUND: Severe upper-extremity injuries account for almost one-half of all extremity trauma in recent conflicts in the Global War on Terror. Few long-term outcomes studies address severe combat-related upper-extremity injuries. This study's objective was to describe long-term functional outcomes of amputation compared with those of limb salvage in Global War on Terror veterans who sustained severe upper-extremity injuries. Limb salvage was hypothesized to result in better arm and hand function scores, overall functional status, and quality of life, with similar pain interference. METHODS: This retrospective cohort study utilized data from the Military Extremity Trauma Amputation/Limb Salvage (METALS) study for a subset of 155 individuals who sustained major upper-extremity injuries treated with amputation or limb salvage. Participants were interviewed by telephone 40 months after injury, assessing social support, personal habits, and patient-reported outcome instruments for function, activity, depression, pain, and posttraumatic stress. Outcomes were evaluated for participants with severe upper-extremity injuries and were compared with participants with concomitant severe, lower-extremity injury. The analysis of outcomes comparing limb salvage with amputation was restricted to the 137 participants with a unilateral upper-extremity injury because of the small number of patients with bilateral upper-extremity injuries (n = 18). RESULTS: Overall, participants with upper-extremity injuries reported moderate to high levels of physical and psychosocial disability. Short Musculoskeletal Function Assessment (SMFA) scores were high across domains; 19.4% screened positive for posttraumatic stress disorder (PTSD), and 12.3% were positive for depression. Nonetheless, 63.6% of participants were working, were on active duty, or were attending school, and 38.7% of participants were involved in vigorous recreational activities. No significant differences in outcomes were observed between patients who underwent limb salvage and those who underwent amputation. CONCLUSIONS: Severe, combat-related upper-extremity injuries result in diminished self-reported function and psychosocial health. Our results suggest that long-term outcomes are equivalent for those treated with amputation or limb salvage. Addressing or preventing PTSD, depression, chronic pain, and associated health habits may result in less disability burden in this population. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

External Fixation in the Emergency Department for Pilon and Unstable Ankle Fractures.

INTRODUCTION: Pilon and unstable ankle fractures are often treated initially with an external fixator (ex-fix). Ex-fix application in the emergency department (ED) has been described but not compared with that placed in the operating room (OR). METHODS: Retrospective, case-cohort study was performed at a level-1 trauma center. Using CPT codes, we identified patients who had surgical fixation of pilon or ankle fractures with an initial ex-fix application (in the ED or the OR). Postoperative outcomes and hospital logistical data were compared between the two groups. RESULTS: Ninety-six patients met the inclusion criteria. The average age of patients was 47 years, and 54 (56%) of the patients were men. Thirty-three patients had the ex-fix placed in the OR, whereas 63 patients had the ex-fix placed in the ED. Postsurgical complications (prominent implant, nonunion, deep infection, deep vein thrombosis, loss of reduction) were seen in 6 of 33 patients in the ED ex-fix group and in 8 of 63 patients in the OR ex-fix group (P = 0.51). Deep infections occurred in 2 of 33 patients in the OR ex-fix group and in 5 of 63 patients in the ED ex-fix group (P = 0.71). Revision ex-fix for loss of reduction was performed in 4 of 33 patients in the OR ex-fix group and in 10 of 63 patients in the ED ex-fix group (P = 0.59). Mean length of stay was 14 days for the OR ex-fix group and 13 days for the ED ex-fix group (P = 0.35). CONCLUSION: No statistically significant differences were found in postsurgical complications (surgical or infectious) or ex-fix revision rates for the ED ex-fix group and the OR ex-fix group. Results indicate that uniplanar ex-fix may be safely applied in the ED. LEVEL OF EVIDENCE: Level III, therapeutic.

Treatment of femoral neck fractures in patients 45-64 years of age.

INTRODUCTION: Young patients with femoral neck fractures are optimally treated with reduction and stable fixation, while patients over the age of sixty-five are often treated with arthroplasty. This study analyzes in-hospital outcomes associated with total hip arthroplasty, hip hemiarthroplasty and internal fixation for treatment of femoral neck fractures in patients aged 45-64. METHODS: Records of patients between the ages of 45-64, from 2002 to 2014, sustaining femoral neck fractures and treated with internal fixation, hip hemiarthroplasty or total hip arthroplasty were obtained from the Nationwide Inpatient Sample (NIS). Examined variables were age, sex and Charlson Comorbidity Index (CCI). Outcome measures included hospital length of stay (LOS), complications, and inpatient hospitalization charge. RESULTS: From 2002-2014 74,678 femoral neck fractures were available for analysis. THA use increased from 5.3% of operatively managed fractures in 2002 to 22.3% of operatively managed fractures in 2014 (p < 0.0001). Patients undergoing THA had higher hospital cost, higher in hospital complication rates and longer length of stay than patients undergoing internal fixation (p < 0.0001). The in-hospital mortality for patients undergoing a hip hemiarthroplasty was higher (1.2%) than either total hip arthroplasty (0.2%) or internal fixation (0.5%) (P = 0.007). CONCLUSION: This study demonstrates that the use of total hip arthroplasty in treatment of femoral neck fractures in patients from the age of 45-64 increased 4.2-fold over the study period. This treatment is associated with increased hospital cost, length of stay and complications. Additionally, as age increased in our study population, there was a stepwise increase in the use of arthroplasty, and it appears that hemiarthroplasty is being used with a different patient population.