How to Avoid Failures in Tibial Plafond Fractures.

Tibial plafond fractures include a wide spectrum of injuries that show their complexity. Soft-tissue injury in tibial plafond fractures is much more important than bony injury. Commonly, a staged treatment, that is, temporary external fixation followed by definitive surgery when the soft tissue is ready, is performed. Knowledge of multiple surgical approaches is a prerequisite for open reduction and internal fixation of tibial plafond fractures because of the large variation of fracture patterns.

Retrograde intramedullary nailing below a hip arthroplasty prosthesis: a viable fixation option for periprosthetic and interprosthetic femur fractures.

BACKGROUND: Periprosthetic femur fractures (PPFF) distal to a femoral stem are traditionally treated with open reduction and internal fixation (ORIF) with plate and screws. To our knowledge, no studies exist comparing outcomes following ORIF vs retrograde intramedullary nails (RIMN) for this injury. METHODS: This is a retrospective comparison of PPFFs distal to a femoral stem treated by ORIF (n = 17) vs RIMN (n = 13). The primary outcome was unplanned re-operation. RESULTS: There was no difference in unplanned re-operation (17.6 vs 23.1%, p > 0.99), infection, nonunion, refracture, and alignment between groups. The RIMN group had shorter surgical time (89 vs 157 min, p < 0.01), less blood loss (137 vs 291 ml, p = 0.03), and greater obesity. CONCLUSION: RIMN is a potential option for operative fixation of PPFF distal to a femoral stem worthy of additional study.

Frequent complications and severe bone loss associated with the repiphysis expandable distal femoral prosthesis.

BACKGROUND: The treatment of choice for distal femur malignancies in skeletally immature patients remains controversial. An expandable endoprosthesis device (Repiphysis Limb Salvage System; Wright Medical Technology, Arlington, TN, USA) allows for limb preservation and noninvasive lengthening but has been associated with significant complications; however, the extent and implications of bone loss associated with this implant have not been reported. QUESTIONS/PURPOSES: Our goals were to report (1) the 2-year minimum clinical outcomes after placement of the Repiphysis expandable prosthesis for pediatric distal femur malignancies; (2) the complications associated with this prosthesis; (3) the failure rate of this prosthesis; and (4) the revision alternatives available for salvage procedures. METHODS: Between 2002 and 2010, one surgeon (SG) treated all skeletally immature patients (mean age, 10.1 years; range, 4.7-13.6 years) with distal femoral osteosarcoma using a Repiphysis expandable prosthesis. Of the 12 patients who met these criteria, two were excluded for death from disease before 2 years, and mean followup for the remaining 10 was 72 months (range, 26-119 months). Medical records were retrospectively reviewed for complications and clinical outcomes, as assessed by the Musculoskeletal Tumor Society (MSTS) scoring system. Radiographs at final followup were reviewed for bone loss and analyzed by the two senior authors (SG, WWV) to determine reconstruction options available for future revisions. RESULTS: MSTS scores averaged 67%, and we observed 37 implant-related complications requiring a total of 15 reoperations. Six patients underwent implant revisions with aseptic loosening being the predominant mode of failure; ultimately, four of these were converted to adult modular oncology prostheses, and two underwent total femoral replacements. Bone loss in this series was severe in terms of femoral length, cortical thinning, and metadiaphyseal compromise, and most patients will not have sufficient bone stock to permit future revision using standard stem fixation. CONCLUSIONS: The bone loss around the stem of this prosthesis limits subsequent revision options, often resulting in a total femoral prosthesis. Although the decision to use the Repiphysis device must be made on an individual basis, surgeons should recognize the potential for significant bone compromise limiting revision options and consider other options. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Is intralesional treatment of giant cell tumor of the distal radius comparable to resection with respect to local control and functional outcome?

BACKGROUND: A giant cell tumor is a benign locally aggressive tumor commonly seen in the distal radius with reported recurrence rates higher than tumors at other sites. The dilemma for the treating surgeon is deciding whether intralesional treatment is adequate compared with resection of the primary tumor for oncologic and functional outcomes. More information would be helpful to guide shared decision-making. QUESTIONS/PURPOSES: We asked: (1) How will validated functional scores, ROM, and strength differ between resection versus intralesional excision for a giant cell tumor of the distal radius? (2) How will recurrence rate and reoperation differ between these types of treatments? (3) What are the complications resulting in reoperation after intralesional excision and resection procedures? (4) Is there a difference in functional outcome in treating a primary versus recurrent giant cell tumor with a resection arthrodesis? METHODS: Between 1985 and 2008, 39 patients (39 wrists) were treated for primary giant cell tumor of the distal radius at two academic centers. Twenty patients underwent primary intralesional excision, typically in cases where bony architecture and cortical thickness were preserved, 15 underwent resection with radiocarpal arthrodesis, and four had resection with osteoarticular allograft. Resection regardless of reconstruction type was favored in cases with marked cortical expansion. A specific evaluation for purposes of the study with radiographs, ROM, grip strength, and pain and functional scores was performed at a minimum of 1 year for 21 patients (54%) and an additional 11 patients (28%) were available only by phone. We also assessed reoperations for recurrence and other complications via chart review. RESULTS: With the numbers available, there were no differences in pain or functional scores or grip strength between groups; however, there was greater supination in the intralesional excision group (p=0.037). Tumors recurred in six of 17 wrists after intralesional excision and none of the 15 after en bloc resection (p=0.030). There was no relationship between tumor grade and recurrence. There were 12 reoperations in eight of 17 patients in the intralesional excision group but only one of 11 patients (p=0.049) who underwent resection arthrodesis with distal radius allograft had a reoperation. There were no differences in functional scores whether resection arthrodesis was performed as the primary procedure or to treat recurrence after intralesional excision. CONCLUSIONS: Resection for giant cell tumor of the distal radius with distal radius allograft arthrodesis showed a lower recurrence rate, lower reoperation rate, and no apparent differences in functional outcome compared with joint salvage with intralesional excision. Because an arthrodesis for recurrence after intralesional procedures seems to function well, we believe that intralesional excision is reasonable to consider for initial treatment, but the patient should be informed about the relative benefits and risks of both options during the shared decision-making process. Because arthrodesis after recurrence functions similar to the initial resection and arthrodesis, an initial treatment with curettage remains a viable, and likely the standard, mode of treatment for most giant cell tumors of the distal radius unless there is extensive bone loss. LEVEL OF EVIDENCE: Level III, therapeutic study.

Work Productivity Loss After Minimally Displaced Complete Lateral Compression Pelvis Fractures.

OBJECTIVE: To quantify work impairment and economic losses due to lost employment, lost work time (absenteeism), and lost productivity while working (presenteeism) after a lateral compression pelvic ring fracture. Secondarily, productivity loss of patients treated with surgical fixation versus nonoperative management was compared. DESIGN: Secondary analysis of a prospective, multicenter trial. SETTING: Two level I academic trauma centers. PATIENT SELECTION CRITERIA: Adult patients with a lateral compression pelvic fracture (OTA/AO 61-B1/B2) with a complete posterior pelvic ring fracture and less than 10 mm of initial displacement. Excluded were patients who were not working or non-ambulatory before their pelvis fracture or who had a concomitant spinal cord injury. OUTCOME MEASURES AND COMPARISONS: Work impairment, including hours lost to unemployment, absenteeism, and presenteeism, measured by Work Productivity and Activity Impairment assessments in the year after injury. Results after non-operative and operative treatment were compared. RESULTS: Of the 64 included patients, forty-seven percent (30/64) were treated with surgical fixation, and 53% (30/64) with nonoperative management. 63% returned to work within 1 year of injury. Workers lost an average of 67% of a 2080-hour average work year, corresponding with $56,276 in lost economic productivity. Of the 1395 total hours lost, 87% was due to unemployment, 3% to absenteeism, and 10% to presenteeism. Surgical fixation was associated with 27% fewer lost hours (1155 vs. 1583, P = 0.005) and prevented $17,266 in average lost economic productivity per patient compared with nonoperative management. CONCLUSIONS: Lateral compression pelvic fractures are associated with a substantial economic impact on patients and society. Surgical fixation reduces work impairment and the corresponding economic burden. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Predictors of Improved Early Clinical Outcomes After Elective Implant Removal.

OBJECTIVES: To determine preoperative factors predictive of improvement in pain and function after elective implant removal. We hypothesized that patients undergoing orthopaedic implant removal to relieve pain would have significant improvements in both pain and function. DESIGN: Prospective cohort study. SETTING: Level I Trauma Center. PATIENTS/PARTICIPANTS: One hundred eighty-nine patients were enrolled after consenting for orthopaedic implant removal to address residual pain. One hundred sixty-three were available for 3-month follow-up. MAIN OUTCOME MEASUREMENT: Preoperative and postoperative outcome measures including Patient Reported Outcomes Measurement Information System (PROMIS) scores were compared. Preoperative scores, surgeon prediction of pain improvement, and palpable implants were analyzed as predictors of outcomes. RESULTS: Median PROMIS physical function and pain interference scores and visual analogue scale significantly improved by 6, 8, and 2 points, respectively (P < 0.001 for all). Worse preinjury scores predicted improvement in respective postoperative outcomes (P < 0.001 for all). Surgeon prediction of improvement was associated with improved PROMIS pain interference (P = 0.005), patient subjective assessment of pain improvement (P = 0.03), and subjective percent of pain remaining at 3 months (P = 0.02). Implant superficial palpability was not predictive for any postoperative outcomes. CONCLUSIONS: Although the primary indication for implant removal in this population was pain relief, many patients also had a clinically relevant improvement in physical function. In addition, patients who start with worse global indices of pain and function are more likely to improve after implant removal. This suggests that implant-related pain directly contributes to global dysfunction. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Is Immediate Weight-Bearing Safe After Single Implant Fixation of Elderly Distal Femur Fractures?

OBJECTIVES: To compare early complications in elderly patients with extra-articular distal femur fractures (DFFs) allowed to weight-bear as tolerated (WBAT) immediately versus patients prescribed initial touchdown weight-bearing (TDWB). DESIGN: Retrospective cohort study. SETTING: Level 1 academic trauma center. PATIENTS: One hundred thirty-five patients 60 years or older who underwent surgical fixation of an extra-articular DFF, including the OTA/AO fracture classification of 33-A1-3, and periprosthetic fractures with a stable knee prosthesis (Lewis and Rorabeck type I or II) with at least 6 months follow-up. INTERVENTION: Immediate WBAT or TDWB after surgical fixation of an extra-articular DFF with either an intramedullary nail or locked plate. MAIN OUTCOME MEASUREMENTS: The primary outcome was a major adverse event within the first 6 months, defined as (1) early fixation failure or change in alignment leading to reoperation, (2) nonunion, or (3) deep infection. Secondary outcomes included postoperative inpatient length of stay, discharge disposition (secondary facility vs. home), malunion, mortality, and patient-reported outcomes. RESULTS: The rate of early adverse events requiring reoperation was similar between the WBAT group (6, 10.7%) and the TDWB group (15, 19.0%; P = 0.23). There was no difference between groups with respect to length of stay, discharge disposition, malunion, and patient-reported outcomes. CONCLUSIONS: This study supports allowing carefully selected elderly patients, based on surgeon preference, to immediately weight-bear after operative fixation of an extra-articular DFF regardless of implant choice. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Prospective Clinical Trial Comparing Surgical Fixation Versus Nonoperative Management of Minimally Displaced Complete Lateral Compression Pelvis Fractures.

OBJECTIVE: To compare the early pain and functional outcomes of operative fixation versus nonoperative management for minimally displaced complete lateral compression (LC; OTA/AO 61-B1/B2) pelvic fractures. DESIGN: Prospective clinical trial. SETTING: Two academic trauma centers. PATIENTS: Forty-eight adult patients with LC pelvic ring injuries with <10 mm of displacement were treated nonoperatively and 47 with surgical fixation. Sixty percent of participants were randomized. Seventy-three percent of the fractures were displaced <5 mm, and 71% were LC-1 patterns. INTERVENTION: Operative fixation versus nonoperative management. MAIN OUTCOME MEASUREMENTS: The primary outcome was patient-reported pain using the 10-point Brief Pain Inventory. Functional outcome was measured using the Majeed pelvic score. Outcomes were analyzed using hierarchical Bayesian models to compare the average treatment effect from injury to 12 and 52 weeks postinjury. The probability of the mean treatment benefit exceeding a clinically important difference was determined. RESULTS: The 3-month average treatment effect of surgery compared with nonoperative management was a 1.2-point reduction in pain [95% credible interval (CrI): 0.4-1.9] and an 8% absolute improvement in the Majeed score (95% CrI: 3%-14%). Similar results persisted to 1 year. Patients with initial fracture displacement ≥5 mm experienced a larger reduction in pain (2.2, 95% CrI: 0.9-3.5) compared with those patients with less initial displacement (0.9, 95% CrI: 0.1-1.8). CONCLUSION: On average, surgical fixation likely provides a small improvement in pain and functional outcome for up to 12 months. Patients with ≥5 mm of posterior pelvic ring displacement are more likely to experience clinically important improvements in pain. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Effect of Intrawound Vancomycin Powder in Operatively Treated High-risk Tibia Fractures: A Randomized Clinical Trial.

Importance: Despite the widespread use of systemic antibiotics to prevent infections in surgically treated patients with fracture, high rates of surgical site infection persist. Objective: To examine the effect of intrawound vancomycin powder in reducing deep surgical site infections. Design, Setting, and Participants: This open-label randomized clinical trial enrolled adult patients with an operatively treated tibial plateau or pilon fracture who met the criteria for a high risk of infection from January 1, 2015, through June 30, 2017, with 12 months of follow-up (final follow-up assessments completed in April 2018) at 36 US trauma centers. Interventions: A standard infection prevention protocol with (n = 481) or without (n = 499) 1000 mg of intrawound vancomycin powder. Main Outcomes and Measures: The primary outcome was a deep surgical site infection within 182 days of definitive fracture fixation. A post hoc comparison assessed the treatment effect on gram-positive and gram-negative-only infections. Other secondary outcomes included superficial surgical site infection, nonunion, and wound dehiscence. Results: The analysis included 980 patients (mean [SD] age, 45.7 [13.7] years; 617 [63.0%] male) with 91% of the expected person-time of follow-up for the primary outcome. Within 182 days, deep surgical site infection was observed in 29 of 481 patients in the treatment group and 46 of 499 patients in the control group. The time-to-event estimated probability of deep infection by 182 days was 6.4% in the treatment group and 9.8% in the control group (risk difference, -3.4%; 95% CI, -6.9% to 0.1%; P = .06). A post hoc analysis of the effect of treatment on gram-positive (risk difference, -3.7%; 95% CI, -6.7% to -0.8%; P = .02) and gram-negative-only (risk difference, 0.3%; 95% CI, -1.6% to 2.1%; P = .78) infections found that the effect of vancomycin powder was a result of its reduction in gram-positive infections. Conclusions and Relevance: Among patients with operatively treated tibial articular fractures at a high risk of infection, intrawound vancomycin powder at the time of definitive fracture fixation reduced the risk of a gram-positive deep surgical site infection, consistent with the activity of vancomycin. Trial Registration: ClinicalTrials.gov Identifier: NCT02227446.

Intercalary allograft reconstructions using a compressible intramedullary nail: a preliminary report.

BACKGROUND: Although intercalary allograft reconstructions are commonly performed using intramedullary devices, they cannot generate compression across host-allograft junctions. Therefore, they sometimes are associated with gap formation and suboptimal healing conditions. QUESTIONS/PURPOSES: We describe a new technique and present preliminary results for intercalary allograft reconstructions for tumors using a compressible intramedullary nail. PATIENTS AND METHODS: We retrospectively reviewed 10 patients (19 host-allograft junctions) who underwent intercalary allograft reconstruction using the compression nailing technique. Two patients were excluded as they had additional vascularized fibular autografts, leaving 15 junctions in eight patients for analysis. Three of the intercalary reconstructions had supplemental plate fixation at one junction. All patients received host bone reamings and cancellous allograft and one had bone marrow aspirate and demineralized bone matrix in addition to the cancellous allograft. The minimum followup was 3 months (mean, 18 months; range, 3-39 months). RESULTS: Thirteen of 15 junctions healed without additional surgery. Two diaphyseal-diaphyseal junctions did not unite after allograft arthrodeses. One patient underwent revision for nonunion 8 months after the initial procedure, with subsequent healing. The second patient had no evidence of union at 6 months, after which he was lost to followup. There were no allograft fractures or infections in any reconstruction. One patient died of metastatic renal cell carcinoma, and one patient had multicentric local soft tissue recurrences of a periosteal osteosarcoma requiring resection. CONCLUSIONS: Our early observations indicate newer compressible intramedullary nails reliably address junctional gap formation, providing for a high rate of union while retaining the long-term benefits of intramedullary stabilization. LEVEL OF EVIDENCE: Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Significant Improvement in the Value of Surgical Treatment of Tibial Plateau Fractures Through Surgeon Practice Standardization.

INTRODUCTION: It is unclear whether cost-based decisions to improve the value of surgical care (quality:cost ratio) affect patient outcomes. Our hypothesis was that surgeon-directed reductions in surgical costs for tibial plateau fracture fixation would result in similar patient outcomes, thus improving treatment value. METHODS: This was a prospective observational study with retrospective control data. Surgically treated tibial plateau fractures from 2013 to October 2014 served as a control (group 1). Material costs for each case were calculated. Practices were modified to remove allegedly unnecessary costs. Next, cost data were collected on similar patients from November 2014 through 2015 (group 2). Costs were compared between groups, analyzing partial articular and complete articular fractures separately. Minimum follow-up (f/u) was 1-year. Outcomes data collected include Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference domains, Western Ontario and McMaster Universities Osteoarthritis Index, visual analog pain scale, infection, nonunion, unplanned return to surgery, demographics, injury characteristics, and comorbidities. RESULTS: Group 1 included 57 partial articular fractures and 57 complete articular fractures. Group 2 included 37 partial articular fractures and 32 complete articular fractures. Median cost of partial articular fractures decreased from $1,706 to $1,447 (P = 0.025), and median cost of complete articular fractures decreased from $2,681 to $2,220 (P = 0.003). Group 1 had 55 patients who consented to clinical f/u, and group 2 had 39. Median PROMIS PF score was 40 for group 1 and was 43 for group 2 (P = 0.23). There were no significant differences between the groups for any clinical outcomes, demographics, injury characteristics, or comorbidities. Median f/u in group 1 was 31 months compared with 15 months in group 2 (P < 0.0001). DISCUSSION: We have demonstrated that surgeons can improve value of surgical care by reducing surgical costs while maintaining clinical outcomes.

Intramedullary nailing of proximal and distal one-third tibial shaft fractures with intraoperative two-pin external fixation.

BACKGROUND: Fractures of the proximal and distal one thirds of the tibial shaft have historically higher malunion rates than those of the midshaft. This retrospective case series evaluates the postoperative radiographic outcome of intramedullary nailing of proximal and distal one-third tibial shaft fractures using intraoperative two-pin external fixation, often referred to as traveling traction. MATERIALS AND METHODS: Between 2000 and 2005, 15 consecutive patients with proximal third and 27 consecutive patients with distal third displaced extra-articular fractures of the tibia were treated with statically locked intramedullary nailing and supplementary intraoperative two-pin rectangular frame external fixation. The external fixation was removed once the proximal and distal locking screws were in place. The alignment of the fractures was determined using standard postoperative anteroposterior and lateral radiographs. RESULTS: Postoperatively, 14 of 15 patients with proximal fractures and 25 of 27 patients with distal fractures had less than 5 degrees of angular deformity in both the coronal and sagittal planes and less than 1 cm shortening. CONCLUSIONS: Statically locked intramedullary nailing with simultaneous intraoperative traveling traction external fixation as treatment for proximal and distal one-third extra-articular tibial shaft fractures is successful in achieving a high rate of acceptable postoperative alignment.

Locking plates for extremity fractures.

Thirty-three peer-reviewed studies met the inclusion criteria for the Overview. Criteria were framed by three key questions regarding indications for the use of locking plates, their effectiveness in comparison with traditional nonlocking plates, and their cost-effectiveness. The studies were divided into seven applications: distal radius, proximal humerus, distal femur, periprosthetic femur, tibial plateau (AO/OTA type C), proximal tibia (AO/OTA type A or C), and distal tibia. Patient enrollment criteria were recorded to determine indications for use of locking plates, but the published studies do not consistently report the same enrollment criteria. Regarding effectiveness, there were no statistically significant differences between locking plates and nonlocking plates for patient-oriented outcomes, adverse events, or complications. The literature search did not identify any peer-reviewed studies that address the cost-effectiveness or cost-utility of locking plates.

Association Between 6-Week Postdischarge Risk Classification and 12-Month Outcomes After Orthopedic Trauma.

Importance: Numerous studies have demonstrated that long-term outcomes after orthopedic trauma are associated with psychosocial and behavioral health factors evident early in the patient's recovery. Little is known about how to identify clinically actionable subgroups within this population. Objectives: To examine whether risk and protective factors measured at 6 weeks after injury could classify individuals into risk clusters and evaluate whether these clusters explain variations in 12-month outcomes. Design, Setting, and Participants: A prospective observational study was conducted between July 16, 2013, and January 15, 2016, among 352 patients with severe orthopedic injuries at 6 US level I trauma centers. Statistical analysis was conducted from October 9, 2017, to July 13, 2018. Main Outcomes and Measures: At 6 weeks after discharge, patients completed standardized measures for 5 risk factors (pain intensity, depression, posttraumatic stress disorder, alcohol abuse, and tobacco use) and 4 protective factors (resilience, social support, self-efficacy for return to usual activity, and self-efficacy for managing the financial demands of recovery). Latent class analysis was used to classify participants into clusters, which were evaluated against measures of function, depression, posttraumatic stress disorder, and self-rated health collected at 12 months. Results: Among the 352 patients (121 women and 231 men; mean [SD] age, 37.6 [12.5] years), latent class analysis identified 6 distinct patient clusters as the optimal solution. For clinical use, these clusters can be collapsed into 4 groups, sorted from low risk and high protection (best) to high risk and low protection (worst). All outcomes worsened across the 4 clinical groupings. Bayesian analysis shows that the mean Short Musculoskeletal Function Assessment dysfunction scores at 12 months differed by 7.8 points (95% CI, 3.0-12.6) between the best and second groups, by 10.3 points (95% CI, 1.6-20.2) between the second and third groups, and by 18.4 points (95% CI, 7.7-28.0) between the third and worst groups. Conclusions and Relevance: This study demonstrates that during early recovery, patients with orthopedic trauma can be classified into risk and protective clusters that account for a substantial amount of the variance in 12-month functional and health outcomes. Early screening and classification may allow a personalized approach to postsurgical care that conserves resources and targets appropriate levels of care to more patients.

Arthroscopically assisted minimally invasive intraarticular bullet extraction: technique, indications, and results.

BACKGROUND: We describe a new arthroscopically assisted, minimally invasive approach to intraarticular bullet extraction limited in its surgical dissection to the bullet tract itself. This procedure accomplishes intraarticular irrigation and removal of the retained missile without the need for a formal open approach. Additionally, we report on a novel extension of this technique to include bullet removal from the sacroiliac joint. METHODS: During a 5-year period (April 2001 to April 2006), 11 patients with retained intraarticular missiles as a result of low-velocity gunshot wounds were treated at our institution with attempted arthroscopically assisted minimally invasive bullet extraction. All patients were male with a mean age of 22.3 years (range, 17-45). Anatomic location of the retained bullets included the knee (6), hip (4), and sacroiliac joint (1). RESULTS: We report a 90.9% success rate of arthroscopically assisted intraarticular bullet extraction from the hip, knee, and sacroiliac joint. One case involving the knee required conversion to an open approach to avoid iatrogenic osseous damage to the posterior aspect of the femoral condyle. CONCLUSIONS: Surgical extraction of retained intraarticular missiles from low-velocity handguns should be performed to minimize the risk of mechanical arthritis, synovitis, and lead toxicity. Arthroscopically assisted bullet extraction using the bullet tract with a minimally invasive approach should be considered when it can be safely accomplished without iatrogenic damage associated.

The use of locking plates in orthopedic oncology reconstructions.

Locking-plate systems are believed to provide better purchase in poor quality bone and equivalent purchase with fewer screws, and also to limit screw pullout by functioning as fixed-angle devices. This retrospective study examined 25 oncologic reconstructions involving locking plates. There were 8 cases of open reduction and internal fixation for pathologic fracture or nonunion and 17 limb-salvage reconstructions. Mean follow-up was 18.2 months with 92% of constructs intact (there were 2 implant-related failures). Locking plates offer advantages that can be useful in orthopedic oncology reconstructions. The long-term performance and mechanisms of failure of these implants remains to be defined.

Intramedullary Nailing of Periarticular Fractures.

Plate fixation has historically been the preferred surgical treatment method for periarticular fractures of the lower extremity. This trend has stemmed from difficulties with fracture reduction and concerns of inadequate fixation with intramedullary implants. However, the body of literature on management of periarticular fractures of the lower extremities has expanded in recent years, indicating that intramedullary nailing of distal femur, proximal tibia, and distal tibia fractures may be the preferred method of treatment in some cases. Intramedullary nailing reliably leads to excellent outcomes when performed for appropriate indications and when potential difficulties are recognized and addressed.

Costs and Complications of Single-Stage Fixation Versus 2-Stage Treatment of Select Bicondylar Tibial Plateau Fractures.

OBJECTIVES: To determine the differences in costs and complications in patients with bicondylar tibial plateau (BTP) fractures treated with 1-stage definitive fixation compared with 2-stage fixation after initial spanning external fixation. DESIGN: Retrospective cohort study. SETTING: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Patients with OTA/AO 41-C (Schatzker 6) BTP fractures treated with open reduction internal fixation. INTERVENTION: Definitive treatment with open reduction internal fixation either acutely (1 stage) or delayed after initial spanning external fixation (2 stage). MAIN OUTCOME MEASURES: Wound healing complications, implant costs, hospital charges, Patient-Reported Outcomes Measurement Information System (PROMIS), reoperation, nonunion and infection. RESULTS: One hundred five patients were identified over a three-year period, of whom 52 met the inclusion criteria. There were 28 patients in the 1-stage group and 24 patients in the 2-stage group. Mean follow-up was 21.8 months, and 87% of patients had at least 12 months of follow-up. The mean number of days to definitive fixation was 1.2 in the 1-stage group and 7.8 in the 2-stage group. There were no differences between groups with respect to wound healing or any other surgery-related complications. Functional outcomes PROMIS were similar between groups. Mean implant cost in the 2-stage group was $10,821 greater than the 1-stage group, mostly because of the costs of external fixation. Median hospital inpatient charges in the 2-stage group exceeded the 1-stage group by more than $68,000 for all BTP fractures and by $61,000 for isolated BTP fractures. CONCLUSIONS: Early single-stage treatment of BTP fractures is cost-effective and is not associated with a higher complication rate than 2-stage treatment in appropriately selected patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Locking Plate Fixation in a Series of Bicondylar Tibial Plateau Fractures Raises Treatment Costs Without Clinical Benefit.

OBJECTIVES: To compare outcomes and costs between locking and nonlocking (NL) constructs in the treatment of bicondylar tibial plateau (BTP) fractures. DESIGN: Retrospective cohort study. SETTING: Level 1 academic trauma center. PATIENTS: All patients who presented with complete articular, BTP fractures OTA/AO 41-C and Schatzker VI between 2013 and 2015 were screened (n = 112). Patients treated with a mode of fixation other than plate-and-screw were excluded. Fifty-six patients with a minimum follow-up of 12 months were included in the analysis. INTERVENTION: Operative fixation of BTP fractures with locking (n = 29) or NL (n = 27) implants. MAIN OUTCOME MEASUREMENTS: Implant cost, patient-reported outcomes (PROMIS physical function and pain interference), clinical, and radiographic outcomes. RESULTS: There were no differences between the 2 groups with respect to demographics, injury characteristics, radiographic outcomes (change in alignment), or clinical outcomes (PROMIS, reoperation, nonunion, and infection). Implant costs were significantly greater in the locking group compared with the NL group (mean L, $4453; mean NL, $2569; P < 0.01). CONCLUSIONS: This study demonstrated improved value of treatment (less cost with no difference in clinical outcome) with NL implants for BTP fractures when dual-plate fixation strategies are performed. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Costs and Radiographic Outcomes of Rotational Ankle Fractures Treated by Orthopaedic Surgeons With or Without Trauma Fellowship Training.

INTRODUCTION: We evaluated the radiographic outcomes and surgical costs of surgically treated rotational ankle fractures in our health system between providers who had completed a trauma fellowship and those who had not. METHODS: We grouped patients into those treated by trauma-trained orthopaedic surgeons (TTOS) and non-trauma-trained orthopaedic surgeons (NTTOS). We graded the quality of fracture reductions and calculated implant-related costs of treatment. RESULTS: A total of 208 fractures met the inclusion criteria, with 119 in the TTOS group and 89 in the NTTOS group. Five patients lost reduction during the follow-up period. The adequacy of fracture reduction at final follow-up did not differ (P = 0.29). The median surgical cost was $2,940 for the NTTOS group and $1,233 for the TTOS group (P < 0.001). DISCUSSION: We found no notable differences in radiographic outcomes between the TTOS and NTTOS groups. Cost analysis demonstrated markedly higher implant-related costs for the NTTOS group, with the median surgical cost being more than twice that for the TTOS group. LEVEL OF EVIDENCE: Level III.