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Objectives To describe the trajectory of recovery following fixation of pilon fractures from baseline to 5 years follow-up. Design Prospective cohort study. Setting Level 1 trauma centre. Patients/participants Patients with pilon fractures (OTA/AO 43.C) treated with open reduction and internal fixation (ORIF). Intervention None. Main outcomes measurements Patient reported outcome measures (PROMs) were measured at baseline, 6 months, 1 year and 5 years using the Short-Form 36 Health Survey Physical and Mental Component Scores (SF-36; PCS, MCS), Short Musculoskeletal Functional Assessment (SMFA), and the Foot and Ankle Outcome Score (FAOS). Results 102 patients were enrolled: mean age was 42.6 years; 69% were males; 88% had an injury severity score (ISS) of 9; 74 patients (73%) completed 1 year follow-up; 40 patients (39%) completed 5 years follow-up. Trajectory of recovery of physical function showed a significant decline between baseline and 6 months, with significant improvement between 6 months and 1 year, and then ongoing but slower improvement between 1 year and 5 years. 64% of patients returned to baseline SF-36 PCS at 5 years. Pain was a persistent issue and remained significantly worse at 5 years when compared to baseline. Psychological wellbeing (SF-36 MCS) did not significantly change from baseline at 5 years. Conclusion Functional recovery following ORIF for pilon fractures was characterized by an initial decrease in function from baseline, followed by an increase between 6 months and 1 year, and then slower but continued increases from 1 year to 5 years. Function did not return to baseline levels, pain was a persistent issue, and mental wellbeing showed no change from baseline at 5 years. This information may be useful when counselling patients.Level of Evidence:Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES To determine the prevalence of ulnar head subluxation/dislocation in distal radius fracture and to discuss management, surgical outcomes, and relevant anatomy. DESIGN Retrospective review of prospectively collected data. SETTING Urban tertiary care hospitalPatients/Participants: 271 patients with displaced distal radius fractures undergoing surgical management were reviewed to determine the incidence of ulnar head subluxation or dislocation using the criteria defined by Mino et al. MAIN OUTCOMES Post-operative CT and radiographs were assessed for sigmoid notch and DRUJ reduction and fracture healing. Range of motion, functional limitation, and pain were documented at final outcome. RESULTS Of the 271 cases, there were 8 cases of pre-reduction DRUJ subluxation/dislocation, including two frank dislocations and six subluxations (2.95%). All were treated with open reduction and internal fixation of the distal radius (ORIF) with a volar locked plate. Additionally, one patient underwent ORIF of an associated distal ulnar shaft fracture and another, who had a Grade 1 open fracture over the distal ulna, underwent open TFCC repair. The remaining six patients had closed reduction of the DRUJ without further stabilizing procedures. All had stable DRUJ joints following ORIF, both intra-operatively and at final follow-up. All ulnar heads were located within the DRUJ on post-op CT; using the more sensitive radioulnar ratio there was residual ulnar head subluxation in 5/8 patients. Range of motion and functional outcome were excellent at an average of 133 weeks post-operatively. The DRUJ was stable at long-term follow-up in all patients. CONCLUSIONS Ulnar head subluxation/dislocation is an uncommon injury in the setting of distal radius fracture. When present, it can usually be treated effectively with operative stabilization of the distal radius fracture without further stabilizing procedures. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES To investigate patient demographics, injury characteristics, radiographic outcomes, and identify risk factors for developing post-traumatic arthritis in high energy transsyndesmotic ankle fracture dislocations, or "Logsplitter" injuries. DESIGN Retrospective cohort study. SETTING Academic level one trauma center. PATIENTS/PARTICIPANTS Twenty-seven adult patients with logsplitter injuries. INTERVENTION All patients were treated with open reduction internal fixation, with possible addition of syndesmosis screw(s) and deltoid repair. MAIN OUTCOME MEASUREMENTS Rate of post-traumatic arthritis at one year along with rate and reasons for reoperation. RESULTS Twenty-seven patients were included with mean follow up of 14.5+/-12.5 months. At one year postoperative, 14/20 patients (70%) demonstrated posttraumatic arthritis. Two patients (7.4%) went onto fusion. Reoperation rate was 51.9%. There was no significant difference in arthritis rate with the number of syndesmosis screws used, quality of reduction, or the addition of deltoid repair. CONCLUSIONS The logsplitter injury is one with devastating outcomes and high rates of arthritis; it should be considered separately from conventional ankle fractures. The role of deltoid repair remains unclear. Further study of this injury pattern is required. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES Assess outcomes of acetabular open-reduction and internal fixation (ORIF) in the elderly; 2) Investigate factors influencing outcome; 3) Compare outcomes following low and high energy mechanisms of injury. DESIGN Retrospective case series. SETTING Level 1 trauma center. PATIENTS Seventy-eight patients over 60 (age:70.1±7.4; 73.1% males). INTERVENTION ORIF for acetabular fractures. MAIN OUTCOME MEASUREMENTS Complications, re-operation rates, and Oxford Hip Score (OHS), joint preservation and development of symptomatic OA. Cases with OA and OHS

Objectives To determine the effect of intramedullary screw-based fixation on early postoperative complications after olecranon fractures. We hypothesized that intramedullary screw-based fixation results in decreased need for reoperation compared to plate and screw and tension band-based fixation. Design: Retrospective cohort. Setting 2 academic level-1 trauma centers.Patients / Participants: 556 patients treated with a tension band, plate and screw, or intramedullary-based construct for an olecranon fracture over a 10-year period. Intervention: Open reduction and internal fixation. Main outcome measurement Unplanned reoperation. Demographic, injury type and severity, supplemental fixation, and length of follow up data were viewed as potential confounders and analyzed as such. Results We identified 556 relevant patients. 199 patients were treated with an intramedullary screw-based construct, 229 with a plate and screw-based construct, and 128 with a tension band-based construct. We observed significant differences in the age, fracture type, percentage of open fractures, use of supplemental fixation, and treating institution between the treatment groups. 95 patients (17.1%) had an unplanned reoperation. When we adjusted for confounders, intramedullary screw-based fixation reduced the odds of an unplanned reoperation by 54% compared to plate and screw-based treatment. In the adjusted analysis, we did not observe a difference between plate and screw-based treatment and tension band-based fixation. Conclusions Intramedullary screw-based fixation of olecranon fractures results in decreased need for early reoperation compared with more common olecranon fixation strategies. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES: Laser-assisted Indocyanine Green Angiography (LA-ICGA) is a novel method for objectively quantifying soft tissue perfusion. The primary aim of this study was to determine whether skin perfusion surrounding tibial plateau and pilon fractures is associated with the Tscherne classification for severity of soft tissue injury. The secondary aim was to determine if soft tissue perfusion improves from the time of injury to the time of definitive fracture fixation in fractures treated using a staged protocol. DESIGN: Prospective cohort study SETTING: Academic trauma centre PATIENTS: Eight pilon fracture patients and 19 tibial plateau fracture patients that underwent open reduction internal fixation MAIN OUTCOME MEASUREMENTS: Skin perfusion (fluorescence units) as measured by LA-ICGA RESULTS: Six patients were classified as Tscherne grade 0, nine as grade 1, ten as grade 2, and two as grade 3. Perfusion decreased by 14 fu (95% CI: −21, −6, p

SUMMARY Intra-articular fractures of the distal humerus present challenges to treating physician and patient alike. The olecranon osteotomy is accepted as the standard exposure for intra-articular distal humerus fractures; nevertheless, complications such as nonunion and implant prominence are common. In this article, we describe the clinical outcomes and anatomic features of the triceps tenotomy as an alternative method of exposure for internal fixation of intra-articular distal humerus fractures. The olecranon osteotomy approach affords greater exposure of the distal humerus articular surface; however, there was no difference in quality of fracture reduction, progression to fracture union, posttraumatic arthrosis, or implant failure between approaches in our series. The osteotomy approach resulted in a greater need for reoperation (15% vs. 46%, respectively); largely as a result of olecranon implant-related complications. In summary, the triceps tenotomy offers an alternative exposure for intra-articular distal humerus fracture fixation with comparable clinical outcomes to the olecranon osteotomy technique.

Objective To determine the rate of acute compartment syndrome (ACS) in a series of patients with Gustilo-Anderson type IIIB open tibial shaft fractures that were treated using a specific two-stage orthoplastic protocol. Design Consecutive cohort study.Patients/Participants: Ninety-three (n =93) consecutive patients with a type IIIB open tibial shaft fracture (OTA/AO-42) treated utilizing a two-stage orthoplastic approach, between August 2015 and January 2018. Following exclusions, eighty-three (n=83) were eligible for analysis. Intervention Colloid resuscitation and two-stage orthoplastic reconstruction of type IIIB open tibial shaft fracture. Stage one consists of "three-vessel view" early debridement and temporary internal fixation, with stage two consisting of a single-stage fix and flap. Main outcome measurements Rate of ACS. Secondary outcomes included early/late sequelae of missed ACS, deep infection, arterial injury, nonunion and flap failure. Results Eighty-three (n = 83) patients were included for analysis. Median age was 45.4 years (Interquartile range (IQR) 35) with a median follow up of 1.6 years (IQR 0.8). Median number of operations was 2.0 (IQR 4). For the primary outcome, there were a total of zero (0/83) patients who required fasciotomy or developed early/late clinical sequelae of missed ACS. Six (6/83, 7.2%) patients developed deep infection, eighteen patients (18/83, 21.7%) experienced non-ischaemic arterial injury, five patients (5/83, 6.0%) experienced nonunion, with four patients (4/83, 4.8%) experiencing flap failure. Diabetes was the only variable associated with deep infection (p=0.025) and nonunion (p Conclusions Patients with type IIIB open tibial shaft fractures treated with colloid resuscitation and a two-stage orthoplastic protocol, which includes early "three-vessel view" exposure and debridement, do not appear to develop ACS. Furthermore, no sequelae of missed compartment syndrome was observed at final follow up. Level of evidence Therapeutic level III. See Instructions for Authors for a complete description of levels of evidence.

Titanium plats are the gold-standard for fracture fixation. Titanium is considered biocompatible, corrosion resistant with an elasticity-modulus closest to bone. Nonetheless, titanium plates are not always as inherent as hoped. The authors investigated morbidity associated with titanium plates in mandibular fractures. A retrospective study of mandibular fractures treated between 2000 and 2018 using internal-fixation was conducted. Data included age, gender, complications, and location. Predictor-variable was location. Outcome-variable was plate removal. A total of 571 patients were included, 107 resulted in plate removal (18.7%). Body was the most prevalent location of fracture (29.3%). Symphysis/para-symphysis showed the highest removal rate (24.1%), followed by body and angle (21.3/19.8%). A total of 23.4% of double-plating cases resulted in plate removal, upper-border in 15% and lower-border in 8.8%, all reconstruction-plates. Exposure was the most frequent complication leading to removal. Although titanium plates are the gold standard, almost every fifth patient returns for plate removal. Age-distribution emphasizing 41 to 50 with decrease towards extremities may imply better healing in the young and soft-tissue elasticity and less complaints in the elderly. Significantly more complications in double-plating compared to lower border suggests proximity to the oral-cavity as a risk-factor for removal. Complication rates and patterns are not negligible and perhaps should encourage clinicians to consider using biodegradable-systems for upper-border plates.

Background Progressive spinal deformity following laminectomy and resection surgery of spinal tumor has been well-documented. However, the postlaminectomy deformity in adolescent patients often bring challenge to clinical treatment, which may be subjected to rapid progression of kyphosis during the growth spurt. The aim of this study is to investigate the clinical outcome of long fusion correction surgery for thoracic or thoracolumbar kyphotic deformity secondary to laminectomy and tumor resection in adolescent patients. Methods Records of 12 cases underwent correction surgery of postlaminectomy thoracic (n=6) or thoracolumbar (n=6) kyphotic deformity were reviewed. The Cobb angle of sagittal and coronal curve before surgery, immediately after surgery, and at the final follow-up were measured to evaluate the correction of deformity and loss of correction. Neurological function was evaluated using the Frankel grading system. Back pain was assessed by using the visual analog score (VAS). Disability status was evaluated by the Oswestry Disability Index (ODI). Patients' satisfaction to surgery was assessed by the patient satisfactory index. Results The mean kyphosis angle reduced from 76±20 degrees before surgery to 34±18 degrees immediately after surgery and remained at 39±17 degrees at the final follow-up with the average correction rate of 58.6% and 51.0%, respectively. For 7 patients with concomitant scoliosis, the Cobb angle of major curve reduced from 52±21 degrees before surgery to 16±9 degrees immediately after surgery and 20±9 degrees at the final follow-up. The average corrective rate was 69.5% and 62.4%, respectively. The mean ODI score improved from 19.9±7.5 to 10.8±8.0, whereas the mean VAS score improved from 5.3±2.0 to 1.5±1.4. The sagittal and coronal balance of the spine, Frankel grading, ODI, and VAS were improved, and the patient satisfactory index was 100%. One patient had inferior paraplegia recovered to Frankel grade E after treatment. Conclusions Satisfactory clinical outcomes can be achieved after long fusion surgery for thoracic or thoracolumbar kyphotic deformity secondary to laminectomy for spinal tumor. Due to the high risk of secondary kyphotic deformity in adolescent patients, internal fixation should be performed simultaneously with the resection of spinal tumor, especially for the cases in the thoracic or thoracolumbar region. Level of evidence Level III.

OBJECTIVE To compare immediate quality of open reduction of femoral neck fractures by alternative surgical approaches. DESIGN Retrospective cohort study. SETTING Twelve Level 1 North American trauma centers. PATIENTS Eighty adults 18-65 years of age with isolated, displaced, OTA/AO type 31-B2 or -B3 femoral neck fractures treated with internal fixation. INTERVENTION Thirty-two modified Smith-Petersen anterior approaches versus 48 Watson-Jones anterolateral approaches for open reduction performed by fellowship-trained orthopaedic trauma surgeons. MAIN OUTCOME Reduction quality as assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs. RESULTS No difference was observed in the rate of acceptable reduction by modified Smith-Petersen (81%) versus Watson-Jones (81%) approach (risk difference null, 95% confidence interval -17.4% to 17.4%, P = 1.00) with 90.4% panel agreement (Fleiss' weighted κ = 0.63, P < 0.01). Stratified analyses did not identify a significant difference in the rate of acceptable reduction between approaches when stratified by Pauwels angle, basicervical or transcervical fracture location, or posterior comminution. The Smith-Petersen approach afforded a better reduction when preoperative skeletal traction was not applied (RR = 1.67 [95% CI 1.10-2.52] vs. RR = 0.87 [95% CI 0.70-1.08], P = 0.006). CONCLUSIONS No difference was observed in the quality of open reduction of displaced femoral neck fractures in young adults when a Watson-Jones anterolateral approach versus a modified Smith-Petersen anterior approach was performed by orthopaedic trauma surgeons. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives To evaluate a large series of open fractures of the forearm following gunshot wounds in order to determine complication rates and factors that may lead to infection, nonunion, or compartment syndrome. Design Multi-center retrospective review. Setting Nine Level 1 Trauma CentersPatients/Participants: 168 patients had 198 radius and ulna fractures due to firearm injuries. All patients were adults, had a fracture due to a firearm injury and at least one year clinical follow-up or follow-up until union. Average follow-up was 831 days. Intervention Most patients (91%) received antibiotics. Formal irrigation and debridement in the operating room was performed in 75% of cases along with either internal fixation (75%), external fixation (6%), or I&D without fixation (19%). Main outcome measures Complications including neurovascular injuries, compartment syndrome, infection and nonunion. Results Twenty-one percent of patients had arterial injuries and 40% had nerve injuries. Nine patients (5%) developed compartment syndrome. Seventeen patients (10%) developed infections, all in comminuted or segmental fractures. Antibiotics were not associated with a decreased risk of infection. Infections in the ulna were more common in fractures with retained bullet fragments and bone loss. Twenty patients (12%) developed a nonunion. Nonunions were associated with high velocity firearms and bone defect size. Conclusions Open fractures of the forearm from gunshot wounds are serious injuries that carry high rates of nonunion and infection. Fractures with significant bone defects are at increased risk of nonunion and should be treated with stable fixation and proper soft tissue handling. Ulna fractures are at particularly high risk for deep infection and septic nonunion and should be treated aggressively. Forearm fractures from gunshot wounds should be followed until union to identify long term complications. Level of evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

INTRODUCTION Overprescribing contributes to the misuse and overuse of narcotics. We hypothesized that implementation of postoperative prescribing guidelines would consistently reduce the amount of opioids prescribed after ambulatory hand surgery. METHODS A divisional protocol was instituted in November 2018. A retrospective cohort study was designed to examine the policy's effects on postoperative prescribing. Postoperative opioid prescriptions for patients undergoing ambulatory hand surgery were evaluated 1 year before and 1 year after policy initiation. All prescriptions were converted into the total oral morphine equivalent (OME) prescribed. RESULTS A total of 1,672 surgeries were included. Six hundred sixty-one cases were in preimplementation group, and 1,011 cases were in the postimplementation group. The median of total OME decreased significantly after distribution of prescribing guidelines from 75 in the preimplementation group to 45 in the postimplementation group (p < .001) with significant reductions seen for carpal tunnel release (p < .001), trigger finger release (p < .001), distal radius open reduction internal fixation (p < .001), and finger closed reduction and pinning (p < .001). When categorized by procedure type, the median of total OME decreased from 75 to 30 for soft tissue procedures (p < .001) and from 120 to 100 for bony procedures (p < .001). CONCLUSION Divisional prescribing guidelines lead to consistent short-term to mid-term reductions in the amount of opioid medication prescribed postoperatively.

Background Medial clavicle fractures are uncommon, occurring in older and multiply injured patients. The management of these fractures and the factors that predispose toward poor outcomes are controversial. Furthermore, the functional outcomes of treatment are not well characterized or correlated with fracture patterns. Questions/purposes (1) To determine minimum 1-year functional outcomes using QuickDASH scores and pain scores after medial clavicle fractures and (2) to identify factors associated with these outcome variables. Methods In an institutional review board-approved, retrospective study, we identified adult patients with medial clavicle fractures at two tertiary care referral centers in a single metropolitan area in the United States from January 2010 to March 2019. Our initial query identified 1950 patients with clavicle fractures, from which 74 adult patients with medial clavicle fractures and at least 1 year of follow-up were identified. We attempted to contact these eligible patients by telephone for functional outcomes and pain scores. Twenty-six patients were deceased according to the most recent Social Security Death Index data and public obituaries, three declined participation, and 14 could not be reached, leaving 42% of the total (31 of 74) and 65% (31 of 48) of living patients included in the analysis. Demographic characteristics, fracture characteristics, and clinical and radiographic union as assessed by plain radiography and CT were collected through record review. Twenty-nine patients were treated nonoperatively and two patients underwent open reduction internal fixation. Sixty-eight percent (21 of 31) of the included patients also had radiographic follow-up at least 6 weeks postoperatively; two patients had persistent nonunion at a mean of 5 ± 3 years after injury. Our primary response variable was the QuickDASH score at a minimum of 1 year (median [range] 5 years [2 to 10]). Our secondary response variable was the pain score on a 10-point Likert scale. A bivariate analysis was performed to identify factors associated with these response variables. The following explanatory variables were studied: age, gender, race, dominant hand injury, employment status, manual labor occupation, primary health insurance, social deprivation, BMI, diabetes mellitus, smoking status, American Society of Anesthesiologists physical status classification, Charlson Comorbidity Index, nonisolated injury, high-energy mechanism of injury, nondisplaced fracture, fracture comminution, superior-inferior fracture displacement, medial-lateral fracture shortening, and surgical treatment of the medial clavicle fracture. Results The mean QuickDASH score was 12 ± 15, and the mean pain score was 1 ± 1 at a mean of 5 ± 3 years after injury. The mortality rate of the cohort was 15% (11 of 74) at 1 year, 22% (16 of 74) at 3 years, and 34% (25 of 74) at 5 years after injury. With the numbers available, no factors were associated with the QuickDASH score or pain score, but it is likely we were underpowered to detect potentially important differences. Conclusion Medial clavicle fractures have favorable functional outcomes and pain relief at minimum 1-year follow-up among those patients who survive the trauma, but a high proportion will die within 3 years of the injury. This likely reflects both the frailty of a predominantly older patient population and the fact that these often are high-energy injuries. The outcome measures in our cohort were not associated with fracture displacement, shortening, or comminution; however, our sample size was underpowered on these points, and so these findings should be considered preliminary. Further studies are needed to determine the subset of patients with this injury who would benefit from surgical intervention. Level of evidence Level IV, therapeutic study.

The predominant method for transconjunctival orbital fat transposition is by conducting 1 or several temporary externalized sutures. A new method that could internally and more securely fixate the fat to the periosteum remains desirable. This manuscript introduces a technique that utilizes a titanium ring to guide transconjunctival orbital fat fixation for lower blepharoplasty. With 8 to 10 mm transconjunctival incisions, the orbicularis retaining ligaments were released. An intraoperatively made ring guided the sutures that was made transcutaneously and anchored on the periosteum to exit the preseptal space through the transconjunctival incision. The orbital fat graft was then fixated internally by this suture. From October 2017 to November 2019, 51 patients were included in this study. The mean patient age was 35.7 years (ranged 28-42 years). The mean operative time for the surgical procedure was 52 minutes. No major complications were noticed in any patients. There was 1 case in which the eye bag relapses at fifth week postoperatively, but was corrected by the same approach. At the average follow-up period of 12.1 months, all patients presented significant improvement of the lower eyelid cosmesis. Forty-four patients rated the aesthetic outcomes as "Very Satisfied," the other 7 rated "Satisfied" in a self-assessment questionnaire.Global Aesthetic Improvement Scale echoed similar outcomes. This guided internal fixation technique is technically practical when properly executed. It offers a new method for facilitating orbital fat transposition in lower blepharoplasty.

OBJECTIVE To assess the direct costs of distal radius fracture volar plate (VP) fixation and to create a model to examine the effect of these cost drivers. MATERIALS AND METHODS Retrospectively, 744 distal radius fractures treated with open reduction and internal fixation (ORIF) were identified. The outcomes assessed included (1) the direct costs related to distal radius ORIF and (2) if a VP alone was amenable. Costs were represented as a cost ratio relative to the average cost of distal radius ORIF, where the average value is set as 1.0. Simulation models were run with all cost drivers (sex, age, open fracture, intra-articular fracture, and ancillary fixation) and with only ancillary fixation as a cost driver. RESULTS The cost ratio ranged from 0.61 to 1.81 and ancillary fixation was associated with increased implant costs in multivariable analysis. In the simulations, the cost ratio ranged from 0.96 to 1.23 when all cost drivers were included and from 0.99 to 1.20 if only ancillary fixation was included as a cost driver, a reduction of the range by 22.2%. Older patients, females, closed fractures, and extra-articular fractures were more amenable to VP fixation alone. CONCLUSIONS Eighty-three percent of the surgically treated distal radius fractures were treated with VP fixation alone. A disposable kit could help limit cost variance per case by roughly 22%, as only ancillary fixation varies these costs. Closed fractures and extra-articular fractures in older patients or female patients are more amenable to VP fixation alone. LEVEL OF EVIDENCE Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES To compare and stratify the healing rates after our index nonunion surgery using contemporary methods of fixation, report the prevalence of recalcitrant non-union, and identify specific demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion. DESIGN Retrospective analysis of a prospectively collected database. SETTING Academic Level 1 Trauma Center. PATIENTS/PARTICIPANTS Two hundred twenty-two tibial nonunions treated with internal fixation by a single surgeon. INTERVENTION Bivariate and multivariate regression analysis were performed to compare healing rates by the type of fixation and graft augmentation and to identify specific demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion. RESULTS Of the 222 patients, 162 (73%) healed as intended and 51 (23%) required 1 or more subsequent interventions to achieve union (96%). Nine fractures (4%) failed to unite. The 60 fractures (27%) that required a subsequent intervention(s) or failed to consolidate were defined as recalcitrant nonunions. There were no statistically significant differences in the recalcitrant rate when we compared plates versus nails or types of bone graft. Risk factors for developing a recalcitrant nonunion were multifactorial and included grade III open fractures, compartment syndrome, deep infection, and 2 or more prior surgical procedures. CONCLUSIONS Internal fixation remains a successful method of treatment for most tibial nonunions. However, 27% of patients required a subsequent intervention because of failure to heal our index nonunion procedure. Factors that are associated with recalcitrant nonunions were a grade III open fracture, compartment syndrome, deep infection, and 2 or more or more prior surgical procedures. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background Subcondylar fractures represent 25 to 35 percent of all mandibular fractures, yet the treatment paradigm has remained controversial. Closed treatment relies on the plasticity of the condyle head during recovery, whereas open treatment is challenging and risks facial nerve injury. Perioperative, functional, and patient-reported outcomes were measured to compare methods of open versus closed treatment of subcondylar fractures. Methods Selected displaced subcondylar fracture cases with open (open reduction and internal fixation of subcondylar fracture with maxillomandibular fixation) versus closed (maxillomandibular fixation) treatment were compared (n = 60). Demographics, perioperative data, complications, persistent symptoms, chin deviation, malocclusion, change in mouth opening, functional scores, and FACE-Q patient satisfaction were recorded. Results Open versus closed groups had similar demographics and perioperative data, except the open group had longer operating room time (76.39 minutes versus 56.15 minutes). In long-term follow-up, open-treated patients had fewer symptoms (9 percent versus 67 percent), less chin deviation (0 percent versus 40 percent), a less restricted mouth opening (3mm versus 5mm), and better functional scores (1.92 versus 0.861). Transient facial nerve weakness was seen in 6 percent of open cases. Conclusion For selected subcondylar fracture patients, open treatment with endoscopic assistance, nerve monitoring, and specialized plates provides superior long-term results compared to closed treatment when considering symptoms and functional parameters. Clinical question/level of evidence Therapeutic, II.

BACKGROUND Health-care expenditures in the U.S. are continually rising, prompting providers, patients, and payers to search for solutions to reduce costs while maintaining quality. The present study seeks to define the out-of-pocket price that patients undergoing hand surgery are willing to pay, and also queries the potential cost-cutting measures that patients are most and least comfortable with. We hypothesized that respondents would be less accepting of higher out-of-pocket costs. METHODS A survey was developed and distributed to paid, anonymous respondents through Amazon Mechanical Turk. The survey introduced 3 procedures: carpal tunnel release, cubital tunnel release, and open reduction and internal fixation of a distal radial fracture. Respondents were randomized to 1 of 5 out-of-pocket price options for each procedure and asked if they would pay that price. Respondents were then presented with various cost-saving methods and asked to select the options that made them most uncomfortable, even if those would save them out-of-pocket costs. RESULTS There were 1,408 respondents with a mean age of 37 years (range, 18 to 74 years). Nearly 80% of respondents were willing to pay for all 3 of the procedures regardless of which price they were presented. Carpal tunnel release was the most price-sensitive, with rejection rates of 17% at the highest price ($3,000) and 6% at the lowest ($250). Open reduction and internal fixation was the least price-sensitive, with rejection rates of 11% and 6% at the highest and lowest price, respectively. The use of older-generation implants was the least acceptable cost-cutting measure, at 50% of respondents. CONCLUSIONS The present study showed that most patients are willing to pay a considerable amount of money out of pocket for hand surgery after the condition, treatment, and outcomes are explained to them. Furthermore, respondents are hesitant to sacrifice advanced technology despite increased costs.

STUDY DESIGN Retrospective descriptive study. OBJECTIVE To create topographical maps of occipital bone thickness and venous sinus (VS) presence to assess the risks of screw insertion in four commercially available occipital plates. SUMMARY OF BACKGROUND DATA Craniocervical junction instability and deformity are serious pathological conditions that require posterior fixation of the occipital bone to the cervical vertebrae. Insertion of occipital bone screws requires evaluation of both occipital bone thickness for effective internal fixation and intracranial venous sinus presence for vascular injury prevention. Despite the surgical risks, there is a paucity of research on safe screw placement. METHODS We created a matrix of 231 standardized measurement points to analyze the occipital bone thickness and venous sinus presence in cervical spine CT angiograms. These measurements were used to create topographical maps of occipital bone thickness and likelihood of venous sinus presence, which we then compared to the screw hole configurations of four occipital plates. RESULTS 100 patients were assessed. Maximum occipital bone thickness of 13.9 ± 3.3 mm was midline in the occipital bone, 45 mm from the foramen magnum, around the external occipital protuberance (EOP). Regions with thicknesses >8 mm were 2 cm lateral to the EOP at the level of the superior nuchal line and 2.5 cm inferior to the EOP. The area with the highest VS presence rate was around the EOP and the superior nuchal line. The right transverse VS was more prominent in both sexes. CONCLUSION There is a limited area of the occipital bone with thicknesses for enough screw purchase. Previous studies have shown 8 mm as the minimum screw length to reduce the risk of implant failure. In our analysis, only "T"-shaped plates had configurations with thicknesses >8 mm for each screw hole. For every screw hole in the analyzed occipital plates, there was a possibility of venous sinus presence ranging from 8-33%.Level of Evidence: 5.

Buried Kirschner's wires (K-wires) following internal fixation of paediatric Lateral condyle fracture of humerus allow them to hold the bone until radiological consolidation but requires another surgical procedure for implant removal. Exposed wires need meticulous pin tract care, earlier implant removal and may carry a higher risk of infection. The objective of this study was to compare the outcomes of buried versus exposed K-wires for these fractures. This prospective comparative(nonrandomised) study was conducted from July 2016 to April 2020 at a tertiary care level I trauma centre on 80 children

OBJECTIVES To determine if inclusion of an olecranon osteotomy to the posterior paratricipital approach for operative fixation of distal humerus fractures significantly affects surgical complication rates (OTA/AO 13). DESIGN Retrospective comparative cohort study. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS Three hundred four patients underwent open reduction internal fixation of a distal humerus fracture between 2007 and 2017. Of those, 134 met inclusion criteria (≥15 years, OTA/AO fracture type 13A, B, or C, and posterior surgical approach) for the study (n = 64 with olecranon osteotomy; n = 70 without olecranon osteotomy). INTERVENTION Open reduction internal fixation of distal humerus fractures performed using a posterior paratricipital approach with or without olecranon osteotomy. MAIN OUTCOME MEASURE Ulnar neuropathy (UN), fracture site bony nonunion, and surgical site infection (SSI). RESULTS Thirty-one (33.3%) who underwent the paratricipital approach without olecranon osteotomy, and 15 patients (26.8%) who underwent olecranon osteotomy reported postoperative UN with no significant difference between approaches (P = 0.438). There was no significant difference in rates of SSI (P = 0.418) or fracture site nonunion (P = 0.263) when comparing the approaches. Subjects with Charlson comorbidity index ≥2 were more likely to not undergo an olecranon osteotomy (P = 0.01), whereas subjects with more complex fractures by OTA/AO classification were more likely to have an olecranon osteotomy approach (P = 0.001). CONCLUSIONS Addition of an olecranon osteotomy with the paratricipital approach for fixation of distal humerus fractures does not result in higher rates of UN, fracture site nonunion, or SSI. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES To evaluate trends and variations in hospital charges and payments relative to surgeon charges and payments for surgical treatment of hip fractures in the US Medicare population. METHODS Hospital and surgeon charges and payments after treatment of hip fractures by closed reduction and percutaneous pinning (CRPP), open reduction internal fixation (ORIF), or intramedullary nail (IMN), along with corresponding patient demographics, 90-day and 1-year mortality, Charlson Comorbidity Index (CCI), and length of stay (LOS) from 2005 to 2014 were captured from the 5% Medicare Standard Analytic Files. The ratio of hospital to surgeon charges (CM: Charge Multiplier) and the ratio of hospital to surgeon payments (PM: Payment Multiplier) were calculated for each year and region of the United States and trended over time. Correlations between the CM and PM and LOS were evaluated using a Pearson correlation coefficient (r). RESULTS Three thousand twenty-eight patients who underwent CRPP and 25,341 patients who underwent ORIF/IMN were included. The CM for CRPP increased from 10.1 to 15.6, P < 0.0001. The CM for ORIF/IMN increased from 11.9 to 17.2, P < 0.0001. The PM for CRPP increased from 15.1 to 19.2, P < 0.0001. The PM for ORIF/IMN increased from 11.5 to 17.4, P < 0.0001. CONCLUSIONS Hospital charges and payments have continually increased relative to surgeon charges and payments for treatment of hip fractures despite decreasing LOS.

OBJECTIVES To assess both clinical and radiological long-term outcomes after hook plate osteosynthesis for Neer type II lateral clavicle fractures. DESIGN Retrospective case series. SETTING Level-1 trauma center. PATIENTS/PARTICIPANTS Patients who underwent open reduction internal fixation with a hook plate for displaced fractures of the lateral third of the clavicle (Neer type II) at a single trauma hospital were identified. INTERVENTION Lateral clavicle open reduction internal fixation with a hook plate. MAIN OUTCOME MEASURES At the first of 2 long-term follow-up appointments, bilateral magnetic resonance imaging (MRI) scans and strength measurements were performed, Constant-Murley score, subjective shoulder value (SSV), and Oxford shoulder score (OSS) of both shoulders were obtained. At the second follow-up, specific acromioclavicular (AC) score, SSV, and OSS were obtained. RESULTS Twenty-one patients (mean age, 29.5 ± 9.7 years) could be included who were available for at least 1 of 2 follow-ups after 7.4 years (±2.3) and 13.9 years (±2.2). Bony union was achieved in all patients (100%) at an average of 3.4 months (±1.4). The hook plate was removed at an average of 5.5 months (±3.3) after initial surgery in all patients. No significant side-to-side differences were found in OSS, Constant-Murley score, SSV, and specific AC score and for strength testing and MRI scans. CONCLUSIONS Long-term outcome after hook plate fixation of Neer type II lateral clavicle fractures demonstrated good clinical results and shoulder strength without higher radiographic rates of AC joint osteoarthritis, subacromial impingement, or rotator cuff lesions. That may be related to a standardized early plate removal after bony fracture union. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objectives To compare the relative frequencies of intra-articular extension of supracondylar distal femur fractures in blunt versus ballistic trauma, as well as the diagnostic accuracy of conventional radiography in identifying intra-articular extension in these fractures. Design Retrospective review. Setting Urban academic trauma center. Study group Thirty-eight patients were included for analysis, with 19 blunt and 19 ballistic mechanism distal femur fractures. Intervention Fleiss' kappa score was calculated in determining interobserver reliability of OTA/AO classification. Radiographic specificity and sensitivity were compared using Fischer's exact testing. Quantitative data were compared using two-tailed t-testing for continuous variables and chi-square tests for proportions. Main outcome measurements Rate of intra-articular extension of ballistic versus blunt supra-condylar femur fractures. Results 17 out of 19 patients (89.5%) with blunt trauma had intra-articular involvement compared to 5 out of 19 patients (26.3%) with ballistic trauma (p=0.001). For blunt fractures, pre-operative radiographs were 94% sensitive for the detection of intra articular extension compared to 100% sensitive for ballistic fractures (p=1.000). We identified one case, in the blunt cohort, where the operative plan changed from intramedullary nail to open reduction and internal fixation as a result of the additional coronal plane fracture pattern identified on CT. There were no such occurrences in the ballistic cohort. Conclusions The rate of intra-articular extension for ballistic supracondylar femur fractures is lower than blunt distal femur fracture. There were low rates of missed intra-articular fractures and changes in operative plans after reviewing CT imaging for both blunt and ballistic distal femur fractures. Level of evidence Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Distal radius fractures (DRFs) are one of the most common major fractures. Despite their frequency, the tradeoffs in different outcomes after casting or surgery for closed extraarticular DRFs in older adults are unknown. Questions/purposes (1) For adults older than 60 years with closed extraarticular DRFs, what are the tradeoffs in outcomes for choosing casting versus surgery? (2) In what settings would surgery be preferred over casting? Method This is a secondary analysis of data from the Wrist and Radius Injury Surgical Trial (WRIST), a randomized, multicenter clinical trial that enrolled patients from April 10, 2012 to December 31, 2016. For WRIST, researchers recruited patients older than 60 years who sustained closed extraarticular distal radius fractures from 24 sites in the United States, Canada, and Singapore. We conducted a secondary analysis using data from WRIST, which had longitudinal data from a robust collection of covariates for patients who underwent surgery and casting. Among the 296 patients recruited in the WRIST study, 59% (174) of patients (mean age 71 ± 9 years) with complete sociodemographic data and 12-month follow-up for each primary outcome were included in the main analysis. More patients underwent surgery than casting (72% [126 of 174] versus 28% [48 of 174]). Most sociodemographic variables were similar between the surgery and casting groups, except for age and volar tilt. The surgical cohort was composed of patients randomized to external fixation, closed reduction percutaneous pinning, or volar locking plate internal fixation. The casting cohort consisted of patients who elected to be treated with closed reduction and casting. A tree-based reinforcement statistical learning method was used to determine the best treatment, either surgery or casting, to maximize functional and esthetic outcomes while minimizing pain. Tree-based reinforcement learning is a statistical learning method to build an unsupervised decision tree within a causal inference framework that will identify useful variables and their cutoff values to tailor treatment assignment accordingly to achieve the best health outcome desired. The primary outcome was minimization of pain (12-month Michigan Hand Outcomes Questionnaire pain subdomain score), maximization of grip strength, total ROM (supination and wrist arc of motion), and esthetics (12-month Michigan Hand Outcomes Questionnaire esthetics subdomain score). Results Casting was the best treatment to reduce pain and maximize esthetics, whereas surgery maximized grip strength and ROM. When the patient favored gaining ROM over pain reduction (more than 80:20), surgery was the preferred treatment. When the patient prioritized the importance of grip strength over pain reduction (more than 70:30), surgery was also the preferred treatment. Conclusion There are tradeoffs in outcomes after treating patients older than 60 years with closed extraarticular distal radius fractures with casting or surgery. When patients are attempting to balance minimizing pain and improving functional outcomes, unless they desire maximal functional recovery, casting may be the better treatment. Surgery may be beneficial if patients want to regain as much grip strength and ROM as possible, even with the possibility of having residual pain. These findings can be referenced for more concrete preoperative counseling and patient expectation management before treatment selection. Level of evidence Level III, therapeutic study.

Objectives We studied the safety of immediate weight bearing as tolerated (IWBAT) and immediate range of motion (IROM) following open reduction internal fixation (ORIF) of selected malleolar ankle fractures (defined as involving bony or ligamentous disruption of two or more of the malleoli or syndesmosis without articular comminution), and attempted to identify risk factors for complications. Design Retrospective case-control study SETTING:: Level 1 Urban Trauma Center and multiple community hospitals, orthopedic specialty hospitals, and outpatient surgicenters within one metropolitan area PATIENTS/PARTICIPANTS:: Out of 268 patients at our level 1 trauma center who underwent primary ORIF of a selected malleolar fracture from 2013-18, we identified 133 (49.6%) who were selected for IWBAT and IROM. We used propensity-score matching to identify 172 controls who were non-weight bearing (NWB) and no range of motion for 6 weeks post-operatively. The groups did not differ significantly in age, BMI, Charleston Comorbidity Index, smoking status, diabetes status, malleoli involved, percentages undergoing medial malleolus (60.9% IWBAT vs. 51.7% NWB), posterior malleolus (24.1% IWBAT, 26.7% NWB), or syndesmosis fixation (41.4% IWBAT, 42.4% NWB, p=0.85). Intervention IWBAT and IROM after ankle ORIF vs. non-weight bearing for 6 weeksMain Outcome Measurements: post-operative complications, including delayed wound healing, superficial or deep infection, and loss of reduction RESULTS:: There was no significant difference in total complications (p=0.41), nonoperative complications (p=0.53), or operative complications, including loss of reduction (p=0.89). We did not identify any factors associated with increased complication risk, including posterior malleolus or syndesmosis fixation, diabetes, age, or pre-injury assisted ambulation. Conclusions We failed to demonstrate a difference in complications in general and loss of reduction in particular when allowing immediate weight bearing/ROM in selected cases of operatively treated malleolar fractures, suggesting this may be safe. Future prospective randomized studies are necessary to determine if immediate weight bearing/ROM is safe and whether it offers any benefits to patients with operatively treated malleolar fractures. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES To compare the deep infection rates after immediate versus staged open reduction internal fixation (ORIF) for pilon fractures. DESIGN Retrospective cohort study. SETTING Three academic Level I trauma centers. PATIENTS Four hundred one patients with closed OTA/AO type 43C distal tibia fractures treated with ORIF. Sixty-six percent were men, and the mean age was 45.6 years. The median (interquartile range) follow-up was 1.7 (1.0-3.7) years. INTERVENTION Acute, primary ( 24 hours). MAIN OUTCOME MEASUREMENT Deep infection or wound complication as defined by return to operating room for surgical irrigation and debridement. RESULTS Patients were grouped by time from presentation to surgery: acute ORIF (n = 99) and delayed ORIF (n = 302). Acute ORIF was more frequent in patients with OTA/AO type 43C1 fractures, low-energy mechanisms (ie, fall from standing), younger and female patients. Patients who demonstrated severe swelling (242, 80%), swelling and fracture blisters (26, 9%), swelling and ecchymosis precluding planned surgical approach (4, 1%), polytrauma requiring resuscitation (20, 6%), who were transferred from an outside facility with external fixator in place (6, 2%), who had evolving compartment syndrome (2, 1%), and who required medical clearance (2, 1%) underwent staged, delayed fixation. There were significantly more 43C1 fractures in the acute fixation group (31% vs. 7%, P < 0.001) and significantly more 43C3 fractures in the delayed group (63% vs. 37%, P < 0.001). The overall deep infection rate was 17%. Early surgery was not associated with an increased risk of postoperative wound complication (early 12% vs. delayed 18%, P = 0.235). Multivariate analysis adjusted for timing of surgery found high-energy trauma [odds ratio (OR) 4.0, 95% confidence interval (CI) 1.1-13.8], smoking (OR 2.4, CI 1.3-4.6), male sex (OR 2.1, CI 1.0-4.1), and increasing age (OR 1.02, CI 1.00-1.04, P = 0.040) to be independent predictors of deep infection. Diabetes demonstrated a nonstatistically significant increased risk (OR 2.6, 95% CI 0.9-7.3, P = 0.063). CONCLUSIONS This study confirms the high risk of infection after the fixation of tibial plafond fractures. If early definitive fixation is considered, extreme care should be taken to carefully evaluate the soft tissue envelope and assess for other risk factors (such as age, male sex, smokers, diabetics, and those with higher-energy fracture patterns) that may predispose the patient to a postoperative soft tissue infection. Our study has shown that the judicious use of early definitive fixation in closed pilon fractures, in the appropriate patient, and with careful evaluation of the soft tissue envelope, is likely safe and does not seem to increase the risk of wound complications and deep infection in the hands of experienced fracture surgeons. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND There is interest in hallux valgus deformity correction using internal fixation with the minimally invasive chevron and Akin osteotomies (MICA) technique. The objective of this study was to assess the correction measured on postoperative radiographs and clinical outcomes, using validated outcome measures, at 2 years following third-generation MICA. METHODS This is a prospective single-surgeon case series of 333 consecutive feet that underwent MICA surgery between July 2014 and April 2018. The primary clinical outcome measures included the Manchester-Oxford Foot Questionnaire (MOXFQ), EuroQol-5 Dimensions-5 Level (EQ-5D-5L) Index, EuroQol-visual analogue scale (EQ-VAS), and a VAS for pain (VAS-pain). Secondary outcome measures included radiographic parameters and complication rates. RESULTS Preoperative and 2-year postoperative patient-reported outcome measures (PROMs) were collected for 292 feet (87.7%). At a minimum 2-year follow-up, the MOXFQ scores (mean ± standard deviation [SD]) had improved in each domain-i.e., reduced from 44.5 ± 21.0 preoperatively to 9.4 ± 15.8 postoperatively for pain (p < 0.001), from 38.7 ± 23.4 to 6.5 ± 14.6 for walking and standing (p < 0.001), and from 48.0 ± 22.3 to 6.6 ± 13.5 for social interaction (p < 0.001). The VAS-pain score improved from 31.4 ± 22.7 preoperatively to 8.4 ± 16.4 at the 2-year follow-up (p < 0.001), the 1-2 intermetatarsal angle was reduced from 15.3° ± 3.6° preoperatively to 5.7° ± 3.2° at the 2-year follow-up (p < 0.001), and the hallux valgus angle was reduced from 32.9° ± 10.2° to 8.7° ± 5.2° (p < 0.001). CONCLUSIONS The third-generation MICA provided significant improvement in clinical outcome measures at the 2-year follow-up and can be successfully used for correction of a range of hallux valgus deformities with a low rate of symptomatic recurrence. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objective A meta-analysis and systematic review was performed to compare outcomes of open reduction and internal fixation (ORIF), hemiarthroplasty (HA), and reverse total shoulder arthroplasty (rTSA) for complex proximal humerus fractures. Data sources: MEDLINE, Embase, and Cochrane Library databases were screened. Search terms included reverse total shoulder arthroplasty, open reduction internal fixation, hemiarthroplasty, and proximal humerus fracture. Study selection English-language studies published within the past 15 years evaluating outcomes of ORIF, rTSA, or HA for complex proximal humerus fractures with minimum of 1-year follow-up were included, resulting in 51 studies with 3064 total patients. Review articles, basic science studies, biomechanical studies, and cadaveric studies were excluded. Data extraction The methodological quality of evidence was assessed using the Jadad scale and methodological index for nonrandomized studies. Data synthesis Demographic data were compared using the χ2 test. Mean data were weighted by study size and used to calculate composite mean values and confidence intervals. Continuous data were compared using the Metan module with fixed effects. Count data were compared using the Kruskal-Wallis test. Alpha was set at 0.05 for all tests. Conclusions Patients undergoing rTSA had lower risks of complication (relative risk 0.41) and reoperation (relative risk 0.28) than HA patients. rTSA resulted in higher Constant scores (standard mean difference 0.63) and improved active forward flexion when compared with HA (standard mean difference 0.76). Pooled mean data demonstrated better outcome scores and active forward flexion of ORIF versus HA and rTSA, although the patients were younger and had more simple fracture patterns. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND The use of electric scooters (e-scooters) has dramatically increased as they become an attractive alternative for public transportation in busy metropolitan areas worldwide. Despite their benefits, e-scooters challenge the health-care system with poorly understood forms of injuries, mainly orthopaedic fractures. To our knowledge, this study is the first to investigate e-scooter-related orthopaedic fracture patterns, mechanisms of injury, and management. METHODS Data on 3,331 e-scooter-related admissions were retrospectively collected between May 2017 and February 2020 in a level-I trauma center. These admissions were analyzed for demographic variables, orthopaedic fracture diagnosis (using the AO/OTA classification), associated injuries, and surgical treatment. RESULTS During the study period, a total of 716 fractures were diagnosed in 563 patients, with 46.4% of the patients requiring hospitalization. Of 492 upper-limb fractures, 89.2% occurred in a rider fall mechanism; and of 210 lower-limb fractures, 15.7% occurred in rider-vehicle collisions. Fifty-nine percent of long bone fractures were complex fragmentary and/or intra-articular fractures. Orthopaedic surgeons recommended that 225 fractures undergo surgical treatment. The most common upper-limb fracture was AO/OTA class 2R1A, with open reduction and internal fixation of the distal part of the radius being the most common upper-limb procedure (n = 58). The most common lower-limb fracture was AO/OTA class 41C, with open reduction and internal fixation of the proximal part of the tibia being the most common procedure (n = 28). A total of 22 patients (3.9%) required reoperation within 1 year. CONCLUSIONS This investigation provides unique information on demographic characteristics, patterns, and treatment of orthopaedic fractures secondary to the high-energy mechanism of e-scooter injuries. These new in-depth data are important, first, for health-care system preparedness with regard to management and resource allocation to treat these challenging injuries and, second, for legislators promoting safety and injury prevention strategies.

Introduction The purpose of this study was to evaluate nationwide trends and regional variability in opioid prescriptions after common orthopaedic procedures. Methods A retrospective analysis of privately insured subjects from the MarketScan database between 2015 and 2016 was conducted. Median oral morphine equivalents and interquartile ranges were analyzed by region for the initial post-op prescriptions and 90-day total prescriptions for opioid-naive patients undergoing the following: carpal tunnel release; anterior cruciate ligament reconstruction; arthroscopic meniscectomy; bimalleolar ankle fracture open reduction and internal fixation; distal radius fracture open reduction and internal fixation; arthroscopic rotator cuff repair; single-level anterior cervical discectomy and fusion; and total shoulder, hip, and knee arthroplasties. We hypothesized that notable regional variability exists with postoperative narcotic prescribing habits. Results Seventy three thousand nine hundred twenty-one opioid-naive patients were identified. A notable regional variability was observed across the United States in the prescriptions given for all procedures, except total joint arthroplasty. Furthermore, although patients undergoing soft-tissue-only procedures required the fewest refills, patients undergoing total joint arthroplasty required the most. Discussion Notable regional variability exisits in opioid prescribing patterns for many common orthopaedic procedures. Furthermore, prescriptions were smallest in the region most affected by the opioid epidemic. This information can be used to re-evaluate recommendations, serve as a benchmark for surgeons, and develop institutional and quality improvement guidelines to reduce excess postoperative opioid prescriptions. Level of evidence Level III observational cohort study.

» Multiple studies comparing nonoperative and operative treatment for displaced proximal humeral fractures in the geriatric population have demonstrated minimal differences in functional outcomes. Factors such as surgeon experience as well as the quality and maintenance of the reduction may influence operative outcomes, and their impact on these findings merits further investigation. » In the treatment of 2 and 3-part fractures involving the surgical neck, intramedullary nailing has demonstrated functional outcomes that are comparable with those of open reduction and internal fixation (ORIF). » In the geriatric population, reverse total shoulder arthroplasty has demonstrated improved functional outcomes, with a decreased rate of reoperation, compared with hemiarthroplasty. Tuberosity repair has been shown to improve functional outcomes and range of motion after both procedures and should be performed at the time of arthroplasty. » Several authors have demonstrated the negative effect of osteopenia on outcomes after ORIF of proximal humeral fractures. Augmentative procedures, including cortical strut augmentation, are being investigated to address this issue; their role in the treatment of these fractures is unclear at this time.

Proximal humerus fractures are common, particularly in elderly patients and those with osteopenia or osteoporosis. Although nonsurgical management results in satisfactory outcomes for most patients, surgical treatment is indicated in select cases. Despite an increasing trend toward arthroplasty, open reduction and internal fixation of proximal humerus fractures can still provide excellent clinical outcomes. Proper technique for internal fixation of the proximal humerus requires an understanding of osseous and neurovascular anatomy. In particular, understanding reliable regions of biomechanically superior bone can help prevent failure of fixation. Biomechanical studies have shown that locked plating of proximal humerus fractures provides stable fixation. Cadaveric and finite element models underscore the importance of screw placement in the posteromedial metaphysis. When medial column support is challenging to obtain, or when bone quality is poor, augmentation with bone autograft, allograft, and/or synthetic composites can improve the biomechanics of internal fixation constructs. The purpose of this review is to outline the anatomic, biologic, and biomechanical principles of plate fixation for proximal humerus fractures to provide evidence-based recommendations for optimizing fixation and preventing fixation failure.

Background Metaphyseal fracture healing in the distal femur requires a stable biomechanical environment. The presence of arthritis-induced coronal-plane knee deformities can cause deviation of the mechanical axis, which results in asymmetric loading and increased bending forces in fractures of the distal femur metaphysis. This predisposes patients to nonunions or loss of fixation. Concurrent TKA during revision osteosynthesis might facilitate fracture healing, owing to its ability to correct coronal alignment, thereby restoring normal loading patterns at the fracture site, but to our knowledge, this has not been studied. Questions/purposes (1) Does TKA with concurrent revision internal fixation achieve fracture union in patients with coronal-plane deformity from knee arthritis and nonunion or loss of fixation in distal metaphyseal femoral fractures? (2) What is the survivorship and what are the short-term functional outcomes after these reconstructions? (3) What complications occur after these reconstructions? Methods Between 2015 and 2018, one surgeon treated 16 patients with a distal metaphyseal femur fracture nonunion and/or loss of fixation using concurrent TKA plus revision internal fixation. Autologous iliac crest bone grafting was performed in five patients with evident gaps at the fracture site. The indications for the procedure included patients older than 55 years of age presenting with a nonunion and/or loss of fixation of a distal metaphyseal femur fracture in the setting of painful Ahlback Grade III to V knee arthritis with an associated coronal-plane deformity. All patients meeting these indications were treated with this approach during the study period. Fracture union assessed by radiological bridging of at least three cortices, TKA survival free from revision due to any reason, coronal-plane correction using tibiofemoral angle, and patient mobility status assessed presurgery and at follow-up using the Parker mobility score (scored 0-9 points, with 9 indicating best mobility) were assessed by two surgeons who were not involved in the care of the study patients. Immediate and delayed complications were recorded. Patients were followed for a minimum of 24 months. The median (range) follow-up was 38 months (27 to 52 months). Results All fractures united after concurrent TKA plus revision internal fixation. In all, 14 of 16 fractures healed before 5 months, while the remaining two fractures united by 6 months. Survivorship analysis revealed a TKA component survival of 94% (95% CI 63% to 99%) at 52 months. The median (range) preoperative Parker mobility score of 5 points (3 to 8) improved to 7 points (2 to 9) at 12 months postoperatively and was maintained at last follow-up (p = 0.001). Four patients experienced complications; these were (1) prolonged surgical wound drainage resulting in debridement and polyethylene liner exchange, (2) deep knee infection needing a staged revision, (3) popliteal vein thrombosis, and (4) prolonged graft site pain. Conclusion Concurrent TKA plus revision internal fixation is effective for achieving union in patients with distal metaphyseal femur nonunion and loss of fixation in the setting of coronal-plane deformity induced by knee arthritis. Short-term TKA survival and improvement in patient mobility are excellent, although 4 of 16 patients in this report experienced complications, as one might expect with a procedure of this magnitude. Based on our results, correction of arthritis-induced coronal-plane knee malalignment can be considered part of the surgical strategy when treating such distal metaphyseal femur nonunions. Better preoperative evaluation of the deformity and control-based comparative studies can further validate the utility of this technique. Level of evidence Level II, therapeutic study.

OBJECTIVES To evaluate the efficacy of intraoperative tobramycin powder in preventing surgical site infection (SSI) and implant colonization with Enterobacter cloacae in a rabbit fixation model. Gram-negative rods, particularly Enterobacter species, comprise an increasing percentage of SSI at our institution. METHODS Eighteen New Zealand White rabbits underwent surgical fixation of the left tibia with implantation of a plate and screws. The surgical site and implant were inoculated with 1 × 107 CFUs E. cloacae. The selected E. cloacae isolate was resistant to tobramycin and capable of forming biofilms. Nine rabbits received 125 mg tobramycin powder directly into the surgical site, overlying the implant. The control group was untreated. Fourteen days postinfection, the tibiae and implants were explanted. Radiographs were taken with and without the implants in place. One tibia from each group was examined after hematoxylin and eosin staining. The remaining tibiae and implants were morselized or sonicated, respectively, and plated on agar to determine infection burden. Data were analyzed with Fisher exact tests and Mann-Whitney U tests. RESULTS No bone infection or implant colonization occurred in the tobramycin-treated group. In the control group, 7 of 8 rabbits developed bone infections (P = 0.001), and 4 of 8 implants were colonized (P = 0.07). No gross disruption of the normal bone architecture was observed in either group. CONCLUSIONS Intraoperative tobramycin powder applied at the time of contamination prevented bone infection with E. cloacae in this rabbit fixation model. The results are encouraging because the E. cloacae isolate was tobramycin-resistant, demonstrating the utility of intraoperative powdered antibiotics.

Objectives To determine if overlap of definitive plate fixation with external fixator pin sites is a risk factor for infection in pilon fractures. Design Retrospective Cohort SETTING:: Level 1 trauma center PATIENTS:: One-hundred and forty-six patients with pilon fractures treated between 2012 and 2018. Intervention Staged treatment with ankle-spanning external fixation followed by delayed open reduction and internal fixation. Main outcome measures Demographic, radiographic, and operative data were reviewed and the distance between the temporary external fixator pin sites and the definitive plate was measured. The primary outcome measure was the development of a deep post-operative infection. Results Overall, 22 (15%) of patients developed deep wound infections. Overlap of definitive plate and external fixation pin-site occurred in 58 (40%) of ankles. Of these, 7 (12%) developed deep wound infection compared to 15 (17%) of patients without overlap (p=0.484). There was no significant difference in amount of overlap (p=0.636) or distance from plate to pin site (p=0.607) in patients with and without deep infection. Of the patients with deep infection, 11 (50%) occurred in patients with open fractures. Conclusion Overlap of definitive plate fixation with primary spanning external fixator pin sites is not a risk factor for development of deep infection in a staged treatment of high energy pilon fractures. Level of evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Distal humerus fractures pose the most challenging task in treatment, which can lead to poor functional outcomes. Anatomic reduction and internal fixation, along with early mobilization, are predicted to improve the functional outcomes. To evaluate the functional outcome, rate of malunion, and intercondylar fixation of distal humerus fractures treated with anatomically precontoured locking plates. Methods: Thirty patients of either sex admitted with type 13 C2 distal humerus fractures, were included in this prospective study. All patients underwent open reduction and internal fixation with anatomically precontoured locking plates and screws using the modified triceps tongue flap approach. Postoperatively, patients were followed up for 6 months. During follow-up, they were evaluated clinically, radiologically, and functionally by mayo elbow performance score (MEPS). The results were analyzed using Chi-square test. Results: A majority of the injuries were seen in males (66.7% vs. 33.3%). The mean age was 36.9 ± 14.7 years. The common mode of injury was through road traffic accident (66.7%). The right upper limb (76.7%) was the most common side involved. The overall excellent/good scores, according to the MEPS, were observed in 80% of the patients. The average time taken for the radiological union at the fracture site was 10.2 ± 2.1 weeks. The mean arc of extension-flexion at 6th weeks was 32.1°–104.1° and at 6th months was 11.5°–124.2°. The complications were early superficial infection (3.3%), ulnar neuropraxia (3.3%), delayed union (3.3%), malunion (3.3%), and chronic osteomyelitis (3.3%). Conclusion: Distal humerus fractures treated with anatomically precontoured locking plates was effective in preserving the functional outcome of the elbow.

Objectives To determine if the use of intrawound vancomycin powder reduces surgical-site infection after open reduction and internal fixation of bicondylar tibial plateau, tibial pilon, and calcaneus fractures. Design Retrospective analysis. Setting Level I trauma center. Patients All fractures operatively treated from January 2011 to February 2015 were reviewed; 583 high-risk fractures were included, of which 35 received topical vancomycin powder. A previously published prospectively collected cohort of 235 similar high-risk fractures treated at our center from 2007 through 2010 served as a second comparison group. Intervention Topical vancomycin powder at wound closure. Main outcome measurements Deep surgical-site infection. Analyses used both univariate comparison of all patients and 1:2 matching analysis using both nearest neighbor and propensity-based matching. Results Compared with a control group of fractures treated during the same time period without vancomycin powder, the infection rate with vancomycin powder was significantly lower [0% (0/35) vs. 10.6% (58/548), P = 0.04]. Compared with our previously published historical infection rate of 13% for these injuries, vancomycin powder was also associated with significantly decreased deep surgical-site infection (0% vs. 13%, P = 0.02). These results agreed with the matched analyses, which also showed lower infection in the vancomycin powder group (0% vs. 11%-16%, P ≤ 0.05). Conclusions Vancomycin powder may play a role in lowering surgical-site infection rates after fracture fixation. A larger randomized controlled trial is needed to validate our findings. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objective To evaluate the clinical and patient-reported outcomes of patients with femoral head fractures treated at a single level I trauma center with a minimum 10-year follow-up. Design Retrospective review SETTING:: Academic Level-1 Trauma Center PATIENTS/PARTICIPANTS:: One hundred and one consecutive femoral head fractures were identified for this study. The final study group consisted of 28 patients with a minimum of 10-years of clinical follow-up. Intervention All patients were treated with one or in combination with the following treatments: nonoperative management, open reduction and internal fixation, fragment excision, or total hip arthroplasty. Main outcome measures Oxford Hip Score at final follow-up along with clinical and radiological complications; infection, avascular necrosis, post-traumatic osteoarthritis, heterotopic ossification, and conversion to total hip arthroplasty. Results Twenty-eight patients with greater than 10 years of follow-up were included in this evaluation. The average follow-up was 14 years and the average age was 39.2 years. Surgical management occurred in 86% of patients, and the mean time to definitive treatment was 3.7 days. Overall, 21 patients (75%) experienced a complication. Seven patients (30%) were later converted to a total hip arthroplasty (THA) at an average of 6.4 years from initial injury. Three of the seven late THA conversions (43%) required later revision. Oxford hip scores (OHS) were obtained in all 28 patients at final follow-up. The average OHS was 36.6. The mean OHS of the native hips was 37 at an average follow-up of 13.6 years. The mean OHS of primary THA was 41 and the mean OHS of secondary THA at final follow-up was 31.4, but this was not statistically significant (p = .134). Conclusions Patients should be counseled that the long-term results of open reduction and internal fixation may be satisfactory but unfortunately are not predictable. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives To characterize the fracture pattern and pattern of fragmentation for displaced, midshaft clavicle fractures undergoing operative management. Design Prospective observational study. Setting Two institutions. Level 1 and Level 2 Trauma Centers. Patients/participants Fifty-three patients who underwent operative repair of midshaft clavicle fracture. Intervention All clavicles were treated by operative open reduction internal fixation. Main outcome measurements All clavicles were categorized by the Robinson classification based on injury plain film bilateral upright clavicle radiographs. In addition, intraoperative fracture characteristics of fragment length and location were measured and recorded to evaluate the fracture pattern. All fractures were analyzed to determine the frequency of segmental comminution versus length-stable patterns, analyze characteristics of butterfly fragment size, number and location as well as the location of the cortical read for those length-stable fractures. Results Analysis revealed 55% were Robinson 2B2 based on preoperative radiographs. Length-stable, anatomic reduction was achievable in 83%. For those in which an anatomic cortical read was achievable, 97.7% had a read present in the posterior-superior aspect of the clavicle. Conclusions Midshaft clavicle fractures that meet conventional criteria for operative repair occur in a predictable manner with butterfly fragments generated from anterior-inferior compression and simple fracture line generated from tension along the posterior-superior aspect of the clavicle. Understanding this pattern can assist in the in surgical planning.

OBJECTIVE This study aimed to assess whether ramus height is restored in children with extracapsular condylar fractures treated by conservative or surgery procedures. METHODS The sample consisted of 35 children (collected consecutively) less than 12 years old who presented with extracapsular condylar fractures and treated within an 8-year period (June 2011 to April 2019). Data on the age, gender, date of injury, mechanism of trauma, location and pattern of mandibular condylar fracture, associated injuries and treatment methods were recorded and analyzed. Ramus height restoration is the main evaluation indicator during the follow-up period. RESULTS Within the 8-year record retrieval, the 35 children sustained 41 extracapsular condylar fractures. For the sample size, 10 (24.4%) and 31 (75.6%) had condylar neck and base fractures, respectively. Deviation and green-stick fracture were the predominant types in condylar neck and base fractures, accounting for more than 3 quarters (31, 75.6%). The majority (33, 80.5%) of patients were treated with nonsurgical treatment, and 8 (19.5%) were treated by open reduction and internal fixation (ORIF). During the follow-up period (1-1419 days, average time of 110.6 days), only 1 patient (with bilateral extracapsular condylar fractures) had their ramus height restored (follow-up period, 256 days). Most members of the ORIF group (5 of 8, 62.5%) postoperatively showed bended ramus (deviated angularly/fragment angulation). CONCLUSION Conservative treatment could hardly restore the ramus height of children with extracapsular condylar fractures. Anatomically or totally restoring the ramus height is difficult even with the surgical treatment of ORIF; however, surgical treatment of ORIF can substantially restore the ramus height for dislocated fractures or seriously displaced fractures.

Navicular stress fractures are multifactorial injuries due to chronic overload on the navicular, particularly in young athletes. The navicular is subject to unique stresses and has a complex blood supply, making it susceptible to stress fractures and potentially delayed union or nonunion. Expeditious diagnosis is critical to prevent a delay in treatment and a poor outcome. Advanced imaging is essential in making the diagnosis and monitoring healing. Both nonsurgical and surgical treatments have demonstrated good results. Nonsurgical management consists of a period of immobilization and nonweight bearing, and surgical management typically involves open reduction and internal fixation. Patients need to be appropriately counseled regarding expectations for these challenging injuries.

Metastatic disease is the most common pathologic cause of bone destruction, and the upper extremity is frequently involved. This location presents many surgical challenges, but there have been several recent implant and technique-related advances that have improved outcomes. Patients can be treated nonsurgically, with radiation or with surgery, depending on patient characteristics, signs/symptoms, primary diagnosis, location, and extent of bone destruction. Most locations in the upper extremity besides the humerus can be treated nonsurgically or with radiation. This is also true of the humerus, but when surgery is indicated, plate fixation is acceptable when adequate proximal and distal cortical bone is present for screw purchase. Intramedullary nailing is used frequently in metastatic humeral disease as well, especially in the diaphysis. When extensive destruction or disease progression precludes internal fixation, a resection with endoprosthetic reconstruction can be considered. Oncologic hemiarthroplasty endoprosthetics still have a role, but reverse shoulder designs are beginning to show improved function. Humeral prosthesis designs are continuing to improve, and are becoming more modular, with custom implants still playing a role in certain challenging scenarios.

Nondisplaced (Garden I and II) femoral neck (FN) fractures are commonly encountered by the practicing orthopaedic surgeon. Although these fractures are primarily classified based on the AP radiograph, the lateral radiograph should be closely scrutinized as well because posterior tilt has emerged as a consistent predictor of fixation failure. Internal fixation has for many years been the standard of care, with both cannulated screws and the sliding hip screw representing acceptable options. However, the outcomes after fixation of Garden I and II FN fractures have not been uniformly positive, with the rates of revision surgery ranging from 8% to 27%. Complications after fixation of nondisplaced FN fractures include nonunion, fixation failure, osteonecrosis, and femoral shortening causing inferior hip function. For these reasons, arthroplasty is increasingly considered a viable option in the treatment of these fractures, especially in the presence of factors that predispose to failure after fixation. Novel devices for FN fixation have recently been developed, although clinical data supporting their use are sparse at the present time.

Study design A morphometric measurement study. Objective To measure the length and angle parameters of the screw paths of pedicle screws (PS), lateral mass screws (LMS), and paravertebral foramen screws (PVFS) of subaxial cervical spine in Chinese population. Summary of background data Aramomi proposed a novel internal fixation technology, named PVFS, as an alternative to LMS and PS for subaxial cervical vertebrae (C3-C7). Methods This study measured the length and medial angles of screw paths on the three-dimensional reconstruction model of cervical computerized tomography data of 50 patients (25 men and 25 women) in our hospital from January 2018 to June 2018. Results In general, the optimum length and medial angle of the PVFS in Chinese population were 10.65 mm and 21.12° at C3; 10.12 mm, 22.62° at C4; 9.82 mm, 23.66° at C5; 9.19 mm, 24.13° at C6; and 9.10 mm, 27.54° at C7. The optimum axial length and medial angle of PS in Chinese population were 30.94 mm, 33.92° at C3; 30.50 mm, 34.95° at C4; 31.92 mm, 33.42° at C5; 30.50 mm, 31.94° at C6; and 29.87 mm, 31.01° at C7. The optimum lengths of LMS paths in Chinese population were C3, 14.84 mm; C4, 15.33 mm; C5, 15.44 mm; C6, 14.74 mm; and C7, 14.06 mm. Conclusion Although the length of PVFS is limited, it still can be used as an effective substitute for LMS and PS. The PVFS does not have the risk of directly injuring the vertebral artery, its safety angle of insertion is larger than that in PS, and it has higher surgical safety.Level of Evidence: 3.

Study design A 2-year follow-up review of 62 patients with severe rigid scoliosis (>120°). Objective To evaluate the effectiveness and safety of halo-pelvic traction (HPT) for treating severe rigid scoliosis (>120°). Summary of background data Severe rigid scoliosis (>120°) is still a challenge for spine surgeons. A combination of presurgical HPT traction, osteotomy, and internal fixation could be a safe and effective solution for these cases. Methods We reviewed the records of all the patients with severe rigid scoliosis (>120°) treated with presurgical HPT from 2013 through 2017. Radiographic measurements were performed. The period of traction, estimated blood loss, operation time, complications, and bed rest period were recorded. Results A total of 62 patients who had 2-year radiological follow-up were included in the study. In 30 patients, vertebral column resection (VCR) was performed aiming to achieve a better correction rate. In patients who received a VCR, the average preoperative Cobb angle was 133.6°, and the average correction rate at 2 years after surgery was 65.4%. Compared with the average height before treatment, at 2 years after surgery the average height was 12.5 cm greater. In patients who did NOT received VCR, the average preoperative Cobb angle was 131.5°, and the average correction rate at 2 years after surgery was 64.1%. Compared with the average height before treatment, at 2 years after surgery the average height was 14.0 cm greater. Common complications during HPT included infected pelvic pins, brachial plexus palsy, and weakness of the lower extremities. No patients experienced permanent neurological deficits or death. Conclusion For severe rigid scoliosis with a Cobb angle greater than 120°, a combination of short-term presurgical HPT and posterior surgery is an effective and safe solution. After 4 to 6 weeks of presurgical HPT the Cobb angle can be decreased by approximately 50%, providing a favorable condition for spine corrective surgery.Level of Evidence: 3.

Background Mandibular body fractures can cause severe and long-term morbidity in the pediatric population. Nonetheless, there is insufficient data on the treatment and management of this specific fracture type in children. This study aimed to investigate the etiology, treatment, and outcomes of pediatric mandibular body fractures by analyzing our institution's experience managing these uncommon injuries. Methods This was a 30-year retrospective, longitudinal cohort study of pediatric patients presenting to a single institution with isolated, unilateral, mandibular body fractures. Patient data was extracted from electronic medical records, while subgroup analysis was completed by dentition stage. Results A total of 14 patients met inclusion criteria, of whom 8 (57.1%) had deciduous, 3 (21.4%) had mixed, and 3 (21.4%) had permanent dentition. Deciduous dentition patients with displaced, mobile or comminuted fractures underwent open reduction and internal fixation (ORIF), while those with nondisplaced and/or nonmobile fractures received soft diet or closed treatment with maxillomandibular fixation. For the mixed dentition cohort, all patients (100%) received closed treatment with maxillomandibular fixation. Among permanent dentition patients, most patients (66.6%) underwent ORIF regardless of fracture severity. The post-ORIF complication rate was 20% (dental maleruption). Conclusions Isolated, unilateral mandible body fractures are relatively uncommon in the pediatric population, and management differs by dentition stage and injury pattern. While isolated body fractures had considerable associated morbidity, this fracture pattern did not result in major growth restrictions or malformations.