Acetabular fractures in elderly patients: a comparative study of low-energy versus high-energy injuries.

PURPOSE: The goal of this study is to compare the characteristics, clinical course, and mortality rates of acetabular fractures in the elderly population with respect to two types of injury. METHODS: We reviewed 183 consecutive patients with acetabular fractures aged 60 years old and older. One hundred eighty-three patients (129 men and 54 women) were included in the study with an average age of 70.2 years. There were 186 fractures, which included three cases of bilateral fractures. Patients were divided into two groups: low-energy injuries (group I), 56, and high-energy injuries (group II), 130. Patient characteristics and fracture pattern, as well as in-hospital mortality rates were compared between the low-energy and high-energy groups. RESULTS: Patient demographics and comorbidities were significantly different between the groups. In group I, the average age was 74.9 years, versus 68.2 years in group II (p < 0.001). The percent of females in each group was 39.3 % and 24.6 %, respectively (p = 0.043), and the average body mass index (BMI) was 25.6 and 28.4, respectively (p = 0.001). The Charlson comorbidity index was higher in group I (1.98 vs 0.95 in group II, p < 0.001). However, the American Society of Anesthesiologists physical status (ASA) was similar between groups (2.56 vs 2.53, respectively, p = 0.808). The proportion of surgical treatment was 44.6 % in group I and 61.6 % in group II (p = 0.019). Group II had a longer hospital stay (10.4 days vs 14.5 days, p = 0.025), but in-hospital death was not significantly different (5.3 % vs 7.9 %, respectively, p = 0.567). CONCLUSION: Patients with acetabular fractures resulting from low-energy injuries were older and had lower BMI with more comorbidities. This study may highlight characteristics of fragility fractures of the acetabulum.

An alternative technique for transosseous calcaneal pinning in external fixation.

The authors describe a technique in which two 5.5-mm pins are inserted from the posterior aspect of the calcaneus and advanced anteriorly on a slightly convergent vector. The 2 points of fixation, with a 5/8 ring, provide a "steering wheel" effect allowing for leverage and control of the hindfoot and ankle. The construct also allows for offloading of the posterior calcaneus.

Routine Postoperative Computed Tomography Scans Following Posterior Pelvic Fixation of Pelvic Ring Fractures: A Survey of (OTA) Orthopaedic Traumatologists.

OBJECTIVE: To assess practices related to ordering computed tomography (CT) scans routinely after posterior pelvic ring fixation and revision surgery rates. DESIGN: A 20-question cross-sectional survey. PARTICIPANTS: Fellowship-trained orthopaedic traumatologists. MAIN OUTCOME MEASUREMENTS: (1) Percentage of surgeons ordering a routing postoperative CT after posterior pelvic ring fixation, (2) Revision surgery rates based on routine CT scan results. RESULTS: Responses were received from 57 surgeons. Practices varied regarding postoperative CT scans, with 20 surgeons (35%, group A) routinely ordering them and 37 surgeons (65%, group B) not ordering them on all patients. Group A were younger and with less years of experience than those in Group B. Most group A surgeons report a revision surgery rate of <1% based on results of the postoperative CT. Group A report routine postoperative scans were obtained to assess reduction, instrumentation placement, and for educational purposes. Group B did not obtain routine postoperative CTs because of the following: unlikely to change postoperative treatment course, adequate reduction and instrumentation placement assessed intraoperatively and by postoperative radiographs, and increased radiation exposure and cost to patients. Group B did report obtaining postop CT scans on select patients, with postoperative neurological deficit being the most common indication. CONCLUSIONS: The routine use of postoperative CTs following posterior fixation of pelvic ring fractures is a controversial topic. Although we recognize the role for postoperative CT scans in select patients, our study questions the clinical utility of these scans in all patients and in conclusion do not recommend this protocol.

Proposal of a new shared payment model for healthcare financing in the United States: a hypothesis.

The healthcare repayment system in America is highly flawed due to several factors such as uncontrolled costs, unequal access, varied reimbursement systems, and complex patient interfaces. In fact, it is rated the worst among the eleven developed nations analyzed in the Commonwealth Fund's evaluation conducted every three years. We propose a novel three-tiered model for healthcare repayment designed to fulfill the needs of the patients, the providers, the payers and the nation as a whole. We hypothesized that our new plan may spread cost between multiple entities and offer better coverage and access to care. Our model uses a shared-cost approach wherein the total risk expenditure becomes the responsibility of various stakeholders including the government, insurance industry, hospitals, patients, providers as well as the nation's economy. While there is no perfect solution to healthcare in America, we believe our three-tiered model can create an economically balanced solution to break deadlock between party lines and result in better outcomes and patient care.

Hidden burdens of orthopedic injury care: the lost providers.

BACKGROUND: There are no previously known studies on the effects of orthopedic trauma on informal caregivers despite rich literature in other areas of caregiving. In this prospective study, we characterize personal and socioeconomic impact on orthopedic trauma caregivers. METHODS: Ninety-nine subjects were given the Caregiver Burden Scale and an original survey measuring emotional, employment, and socioeconomic burden. Demographic, patient injury, and treatment data were also collected. RESULTS: Seventy percent of caregivers were female family members of the patient. Fifty-four percent experienced substantial disruption to social life and emotional stress. Fifty-one percent spent more than 21 hrs/wk caregiving postinjury. Before/after injury time spent caring for the patient was statistically significant (p < 0.01). Many caregivers experienced employment stress; 8% quit their jobs. Before/after injury employment stress was statistically significant (p < 0.01). Caregivers also expressed considerable financial stress. CONCLUSIONS: Socioeconomic impacts related to caregiving experiences extend beyond the clinical care of the patient with caregivers facing extensive stress, financial drain, and employment difficulties. Understanding the complex nature of caring for orthopedic patients may assist in connecting patients and caregivers to the appropriate services and further improve patient outcomes.

Economic value of orthopaedic trauma: the (second to) bottom line.

OBJECTIVES: We evaluated the economic aspects of an orthopaedic trauma section at a regional Level I, semi-academic community hospital. This study analyzes the economics of a dedicated hospital-based orthopaedic trauma program. METHODS: Institutional financial reports were analyzed for 2 time periods. In the pre-program (PRE) period (2 years), we estimated the amount of forsaken revenue resulting from cases transferred to other institutions. In the post-program (POST) period (2 years), we analyzed financial reports to evaluate fiscal solvency. Health Care Cost and Utilization Project National Inpatient Sample (HCUP-NIS) data, International Classification of Diseases, 9th Revision (ICD-90 codes, and Eclipsys software were used. Standard accounting definitions for gross revenue, net revenue, direct costs, contribution margin, indirect costs, and net profit/loss were used. RESULTS: In the PRE-program period 88 patients were transferred; forsaken charges were about $1.25 million/year. Based on historic collection rates, there was about $450,000/year of actual lost revenue. In the POST-program period net revenue was about $7 million with a $1.5 million contribution margin, which increased 9%-11% in year 2. With inclusion of indirect costs, there was a net loss of nearly $5 million/year, but the financial software uses the direct cost expense as a major determinant of indirect costs. Based on the definition of indirect costs (overhead for lights, maintenance, etc) and with such expenses being used prior to the program, we felt that indirect cost was not an accurate variable and contribution margin is the better measure of economic value. CONCLUSION: We found that orthopaedic trauma is a financially viable program. Understanding the determination and interpretation of financial data is essential for any such analysis.

Locking plates: tips and tricks.

Locking plates are fracture fixation devices that allow the insertion of fixed-angle/angular-stable screws or pegs and do not require friction between the plate and bone. The clinical care impetus for the development of these plates has been a combination of factors, including the increasing survival of patients with high-energy injuries, aging Western European and North American populations with an increasing rate of fragility fractures, and dissatisfaction of patients and surgeons with the outcomes of treatment of specific periarticular fractures. Nonclinical factors likely include a push by industry for new technology and new markets as well as the general interest of the public in "minimally invasive" surgery.

External fixation: how to make it work.

The external fixator has been in use for more than a century. Wutzer (1789-1863) used pins and an interconnecting rod-and-clamp system. Parkhill (1897) and Lambotte (1900) used devices that were unilateral with four pins and a bar-clamp system. By 1960, Vidal and Hoffmann had popularized the use of an external fixator to treat open fractures and infected pseudarthroses. The complications associated with the use of external fixation in the late 20th century were predominantly caused by a lack of understanding of the principles of application, the principles of fracture healing with external fixation, and old technology. Its use was reserved for the most severe injuries and for cases complicated by infection. Thus, pin problems, nonunions, and malunions were common. Better technology and understanding have since allowed for greater versatility and better outcomes. Simultaneous with developments in the Western world, Ilizarov developed the principles of external fixation with use of ring and wire fixation. It was not until the late 1980s and early 1990s, when more interaction and exchange between the West and East (Russia) became possible, and with the help of Italians who embraced the philosophy of external fixation, that the use of external fixation was proven to be successful. Several variations of external fixation have been developed, and its use is now widespread. However, in the United States, all but a minority of surgeons still have substantial apprehension about the use of external fixation.

Technical tips in fracture care: fractures of the hip.

Hip fracture is an increasingly common and clinically significant injury with substantial economic impact. Associated risk factors are age, gender, race, bone density, activity level, and medical disorders. Prevention efforts include treatment of osteoporosis and programs to reduce the risks of a fall. Nondisplaced or impacted fractures of the femoral neck can be treated with screw fixation. Displaced femoral neck fractures in younger, more active patients may be treated with reduction and fixation. In physiologically older patients, joint arthroplasty is indicated for displaced fractures. In patients with systemic arthritis or preexisting hip disease, total hip arthroplasty may be an appropriate treatment choice. Intertrochanteric fractures are treated with reduction and fixation using either a sliding hip screw and side plate or intramedullary nail with cephalic interlock. Key technical points for successful outcomes include proper patient positioning, using a correct starting point for the nail, achieving acceptable reduction before fixation, and the use of various reduction techniques and aids.

Efficacy of composite allograft and demineralized bone matrix graft in treating tibial plateau fractures with bone loss.

Tibial plateau fractures with bone loss or significant comminution require grafting and stable fixation. We hypothesized a standardized protocol of internal fixation augmented with a mixture of demineralized bone matrix and corticocancellous allograft chips would result in high healing rates with minimal subsidence. Union was achieved in all 36 patients available for follow-up by a mean of 4.4 months. Mean range of motion was 2 degrees to 120 degrees. One patient developed osteomyelitis. Subsidence ranging from 2.5 to 5.7 mm occurred in 4 patients (11%). This treatment method provides sufficient structural integrity with a high union rate and a low complication rate.

Radiographic Evaluation of Acetabular Fractures: Review and Update on Methodology.

Despite increased availability of modern imaging techniques, plain radiographs remain the initial step in the classification of acetabular fractures. The ability to interpret the injury configuration allows the surgeon to develop a thorough preoperative plan and to evaluate the quality of reduction and fixation intraoperatively. Proficiency in the mental conversion of a two-dimensional radiograph into a three-dimensional conceptual image is imperative. The widely used radiographic classification scheme developed by Judet and Letournel in the 1960s is both practical and simple. However, understanding the subtleties of the fracture pattern can be a challenge even for experienced surgeons. Current evaluation methods include CT and three-dimensional reconstructions in addition to plain radiographs. Our diagnostic algorithm uses three plain radiographs to classify the fracture into one of the 10 fracture patterns described by Judet and Letournel.

Early Comparative Outcomes of Carbon Fiber-Reinforced Polymer Plate in the Fixation of Distal Femur Fractures.

OBJECTIVE: To evaluate the early clinical results of distal femur fractures treated with carbon fiber-reinforced polyetheretherketone (CFR-PEEK) plates compared with stainless steel (SS) lateral locking plates. DESIGN: Retrospective comparative cohort study. SETTING: ACS Level I trauma center. PATIENTS/PARTICIPANTS: Twenty-two patients (11 SS, 11 CFR-PEEK) with closed distal femur fractures treated by a single surgeon over a 6-year period. MAIN OUTCOME MEASUREMENTS: Nonunion, hardware failure, reoperation, time to full weight-bearing, and time union were assessed. RESULTS: The CFR-PEEK cohort was on average older (71 vs. 57 years, P = 0.03) and more likely to have diabetes (P = 0.02). Nonunion was diagnosed in 4/11 (36%) patients in the SS group and 1/11 (9%) patients in the CFR-PEEK group (P = 0.12). Hardware failure occurred in 2 SS patients (18%) compared with none in the CFR-PEEK group (P = 0.14). Time to full weight-bearing was similar between groups, occurring at 9.9 and 12.4 weeks in the CFR-PEEK and SS groups, respectively (P = 0.23). Time to radiographic union averaged 12.4 weeks in the SS group and 18.7 weeks in the CFR-PEEK group (P = 0.26). There were 4 reoperations in the SS group and 1 in the CFR-PEEK group (P = 0.12). CONCLUSIONS: CFR-PEEK plates show encouraging short-term results in the treatment of distal femur fractures with a comparable nonunion, reoperation, and hardware failure rates to those treated with SS plates. This data suggest that CFR-PEEK plates may be a viable alternative to SS plates in fixation of these fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

CT-guided stabilization for chronic sacroiliac pain: a preliminary report.

BACKGROUND: We evaluated a percutaneous, computed tomographic, stabilization from S1 to S2, for chronic painful sacroiliac disease. Our hypothesis was that this technique carries low morbidity, and may provide substantial relief of recalcitrant sacroiliac pain. METHODS: 17 patients had CT guided injection with local anesthesia and steroid to confirm the diagnosis. If symptoms recurred, they had a CT guided stabilization using only local anesthesia and conscious sedation. Outcome was evaluated with a visual analog scale. Univariate analysis and Spearman correlations used for analysis. RESULTS: Pain improved from a mean of 8.3 pre-injection to 3.5 post-injection and remained at 3.3 at final follow up. Four patients had complete relief, 11 patients had significant pain relief, and two patients experienced little to no pain relief. There was a statistically significant difference between pre-injection and post injection pain scores (p < 0.0001), final and pre injection pain scores (p < 0.0001), but not between the post injection and final pain scores (p = 0.8906). A statistically significant correlation (p < 0.02) was found between final pain score and the difference between pre and post injection scores. There were no infections, hardware or technical complications. CONCLUSIONS: This technique appeared effective in relieving the majority of confirmed sacroiliac pain and appeared to be lasting with few complications. While we did not confirm nor deny an arthrodesis with this technique, it appears that stabilization of the sacroiliac joint may have resulted in enough stability (e.g. alkalosis, mechanical restriction) that it relieved symptoms.

Use of calcium-based demineralized bone matrix/allograft for nonunions and posttraumatic reconstruction of the appendicular skeleton: preliminary results and complications.

BACKGROUND: There are numerous autograft alternatives promoted. Although most have laboratory or animal data, few have evaluations of clinical performance. We performed an evaluation of a new calcium sulfate-demineralized bone matrix/Allomatrix in the treatment of nonunions. METHODS: A consecutive series of patients requiring bone grafting for atrophic/avascular nonunions were retrospectively studied. Patients were monitored for healing and adverse effects, which included local or systemic reactions, wound problems, infection, and any secondary surgery caused by graft complications. RESULTS: Over half of the patients (51%) developed postoperative drainage. Of the 41 patients, 13 (32%) had drainage that required surgical intervention and 14 (34%) developed a deep infection. Eleven patients with deep infections also required surgical treatment of drainage. Also, 19 (46%) patients did not heal and required secondary surgical intervention. Using chi it was found that there were correlations between infection and a history of previously treated infection (p < 0.007), as well as wound drainage (p < 0.001). Failure of treatment correlated to the presence of a postoperative infection (p < 0.001). Other analyses were not performed because of the small sample size, which was because of early termination of the study. CONCLUSIONS: The use of Allomatrix/demineralized bone matrix as an alternative for autogenous bone graft in the treatment of nonunions resulted in an unacceptably high rate of complications. Although we recommend further study, we do not recommend the use of Allomatrix for the treatment of nonunions, especially if there is a large volumetric defect or a history of any prior contamination of the tissue bed.

Osseous healing with a composite of allograft and demineralized bone matrix: adverse effects of smoking.

We report on our use of a composite graft of lyophilized cancellous allogenic chips and demineralized bone matrix (DBM; Grafton; Osteotech, Eatontown, NJ) to manage traumatic osseous defects and nonunions. Data were prospectively collected from all patients who received this composite bone graft between 1996 and 2000. Only acute fractures with bone loss resulting in a uncontained defect and atrophic non-unions were included in the present study. Demographic data and complications related to composite use, tobacco use, and other comorbidities that could affect healing were evaluated. One hundred seven patients (112 bone graft sites) were followed up for a mean of 32 months (range, 12-60 months). Graft sites included the forearm, femur and tibia. Of the 112 patients, there were 56 smokers (25 non-unions and 31 fractures) and 56 non-smokers (28 fractures and 28 non-unions). Healing occured in 38/56 smokers compared with 49/56 non-smokers. In failed cases, smoking was characteristic in 7/9 non-unions and 11/16 fractures. There were 26 acute uncontained injuries, 29 acute contained defects, and 67 nonunions. Grafting sites were radius/ulna (13 cases), humerus (17), femur (31), and tibia/fibula (51). Significant comorbidities were diabetes mellitus (4 cases), fungal osteomyelitis (1), and pulmonary alveolar proteinosis (1). Eight (73%) of the 11 patients with graft failure had a significant smoking history. This composite graft is an option for managing osseous defects and nonunions traditionally treated with autologous bone grafting but should be used with caution when treating patients who are smokers.

Clinical evaluation of a true percutaneous technique for antegrade femoral nailing.

From July 1997 to March 2001, 209 consecutive patients with 215 femoral shaft fractures amenable to antegrade femoral nailing were enrolled. A true percutaneous insertion technique was performed using a stab wound incision. One hundred ninety-seven (92%) fractures achieved primary union with anatomic or near anatomic alignment. Eighteen (8%) healing problems and two deep infections (1%) responded to repeat interventions. There was one iatrogenic complication related to an anterior starting point. External blood loss was minimal (generally <100 cc). Incisions averaged 16 mm and healed uneventfully. At one-year follow-up only 10% of patients had hip abductor pain. The percutaneous technique appears to be a safe and effective alternative to the standard technique. Hip pain at one year appears decreased compared to reports using a traditional approach.

Similar hematologic effects of long-term linezolid and vancomycin therapy in a prospective observational study of patients with orthopedic infections.

Linezolid is an alternative to vancomycin for the long-term treatment of gram-positive bacterial orthopedic infections because of its antibacterial spectrum and oral bioavailability, but duration-related myelosuppression could offset its advantages. To evaluate the hematologic effects of these agents, we prospectively studied 65 consecutive adults with gram-positive bacterial orthopedic infections requiring > or =2 weeks of vancomycin therapy (n=52) or linezolid therapy (n=20). Trends suggesting higher incidence of hematologic effects among the patients receiving vancomycin were not significant, regardless of whether the end point was lowest cell count during therapy or change from baseline. The only difference was a higher incidence of thrombocytopenia (<150x10(9) platelets/L) in the subset of the linezolid recipients who had received vancomycin within 2 weeks before starting linezolid therapy than in the linezolid recipients who had not received vancomycin (5 [71%] of 7 patients vs. 2 [15%] of 13; P=.02). All hematologic effects were reversible. In conclusion, hematologic effects were detectable through weekly monitoring and were reversible; therefore, concern about myelosuppression need not preclude linezolid use for orthopedic infections requiring long-term therapy.

Use of a vertical transarticular pin for stabilization of severe ankle fractures.

Transarticular pin fixation has been used successfully to stabilize severe ankle fractures. This technique is most commonly used as provisional fixation until internal fixation is appropriate. In addition, transarticular pin fixation can be a supplement in cases involving persistent tibiotalar instability after internal fixation and can provide sole definitive fixation of arthritic and osteoporotic ankles. In this article, we describe the surgical technique, report results, and review when transarticular pin fixation may be appropriate. We believe that all orthopedic surgeons should know this technique--especially those treating cases of complex orthopedic trauma.

Preventing eccentric reaming of the trochanter during trochanteric nailing.

The lateralizing vector of a flexible guide wire can result in eccentric lateral reaming of the proximal femur during intramedullary nailing procedures. This effect is especially true with peritrochanteric fractures that have a fracture line exit near the entry point, and in obese patients. We present one method of maintaining a co-axial position of the guide wire and reamer assembly to help direct the portal of reaming in a more anatomic position. Use of a concave shaped retractor such as an Appendiceal or Richardson helps to "capture" the reamer shaft and control where proximal reaming occurs. We have found this method to be easy to use and effective when indicated.

Interlocking screws placed with freehand technique and uni-planar image intensification: the "dip-stick" technique.

OBJECTIVE: To report our experience with a novel alternative method of freehand interlocking of intramedullary nails. This method requires the use of only anterior-posterior image intensification and an intramedullary guide wire to verify screw placement. Our results are compared with historical results in the literature. METHODS: A total of 815 patients were treated using this technique from January 2008 to December 2012; 603 patients had fractures of the tibia and 212 had fractures of the femur. RESULTS: The mean duration of surgery for tibial shaft fractures was 55.6 minutes (range 42-60 minutes) and that for fractures of the femur was 78 minutes (range 50-90 minutes). The mean time for each distal locking was 3.8 minutes (2.5-5.1 minutes), with 7.65 seconds of exposure to radiation during each block. CONCLUSIONS: The surgical technique is simple, easy and reproducible. Mean time of surgery and radiation exposure was less than that in the literature. A comparative study should be performed.