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To investigate the diagnostic performance of preoperative MRI in evaluating posterolateral corner (PLC) structures after acute knee dislocation (KD) and determine the correlation of MRI with operative findings for grading structure integrity.Acute knee (femorotibial) dislocations between 2005 and 2020 with preoperative MRI and surgical posterolateral corner repair were identified from a single academic institution. From MRI, integrity was evaluated for PLC structures: lateral collateral ligament (LCL), popliteus tendon (PT), biceps femoris tendon (BFT), and ligamento-capsular complex (LCC). Frequency of injury to each structure and number of PLC structures torn in each case were tabulated. Diagnostic performance of MRI was determined using surgery as the reference standard. Correlation between MRI and surgery for each PLC structure was determined using kappa.Thirty-nine KD cases (19 right) in 39 patients (28 male) were included, with mean age of 33 years. Mechanism of injury was as follows: high energy 52%, low energy 38%, ultra-low energy 10%. LCL was most frequently torn, in 95% (37/39) of cases. Most commonly, three of four PLC structures were torn in 54% (21/39) of cases. Diagnostic accuracy of MRI was high for LCL 95%, BFT 87%, PT 82%, and LCC 92%. Correlation between MRI and surgical findings was variable: substantial for BFT, moderate for LCL and PT, and fair for LCC.MRI has high accuracy for detecting tears of posterolateral corner stabilizers in the setting of acute KD. However, for grading structure integrity, the correlation of MRI with surgical findings is variable, ranging from fair to substantial.• In acute knee dislocation, MRI has high diagnostic accuracy for detecting tears of posterolateral corner (PLC) structures. • Preoperative MRI should be considered by orthopedic surgeons when there is clinical concern for posterolateral corner instability following acute knee dislocation. • Although MRI is valuable in the preoperative investigation of knee dislocation, clinical assessment and intraoperative exploration may still be required for definitive diagnosis.

Cephalomedullary (CMN) implants are commonly used to address elderly intertrochanteric hip fractures. Multiple CMN implant systems exist with subtle variation between manufacturers. Multiple modes of CMN failure have been described in the literature. The present study assessed the local modes and rates of construct failure (nail fracture, cut-out and non-union) of two such implants, after a change in implant supply provided the opportunity for retrospective comparison. Additional investigation was undertaken to assess whether any predictors of failure could be identified based on common radiographic measurement parameters.Based on local implant records, all consecutive patients who suffered an intertrochanteric fracture, treated at a tertiary care hospital with a cephalomedullary nail from January 2014 to January 2018 were included. Patients were excluded if they received a CMN for pathologic fracture. Within the collection period all patients received either a Synthes Trochanteric Fixation Nail (TFN) or Zimmer Natural Nail (ZNN). Patients were retrospectively assessed for fracture reduction and implant technique parameters at the time of initial surgery. Radiographic data were assessed at minimum two years post-operatively to assess for union. Patient demographic data was followed to assess rate and mode of failure.Six hundred and sixty-two patients were included in the study, from which a propensity matched cohort was derived. Comparing across equivalent cohorts, no differences in the rate or mode of construct failure were identified between the TFN and ZNN. When assessing the entire cohort we observed 39 construct failures (5.9%), which included 31 instances of nail cutout (4.7%), 4 episodes of nail fracture (0.6%) and 4 failures related to non-union (0.6%). Tip to apex distance, sagittal malalignment and Cleveland zone were identified as significant predictors of nail failure.No difference in rates or modes of failure were identified between the TFN and ZNN constructs. Similar to previous reports we again identified the impact of tip to apex distance on construct failure and further identified Cleveland zone and sagittal malalignment as significant risks for failure.

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

Fragility fractures (FFs) are low-energy trauma fractures that occur at or below standing height. Among FFs, hip fractures are associated with the greatest morbidity, mortality and cost to Canadian health care systems. This review highlights the current state of medical care for hip fractures in Canada, with specific focus on the role of the multidisciplinary team. Gaps in care exist, as FFs represent a unique challenge requiring both acute and chronic management. Furthermore, there is a lack of ownership of FFs by a medical specialty. These gaps can be addressed through the use of multidisciplinary teams, which have been shown to be efficacious and cost-effective. This model of care also addresses numerous patient-identified barriers to treatment, including inadequate patient counselling. However, there is still room for improvement in both the identification of patients at risk for hip fracture and patient adherence to therapy.Les fractures de fragilisation (FF) sont des fractures qui surviennent lors d’un traumatisme léger se produisant depuis la position debout ou d’une hauteur moindre. Les fractures de la hanche sont les FF associées aux plus grands taux de morbidité et de mortalité et aux plus grands coûts pour les systèmes de santé au Canada. La présente revue s’intéresse à l’état actuel des soins médicaux pour une fracture de la hanche au pays et porte une attention spéciale au rôle de l’équipe multidisciplinaire. Des lacunes dans les soins existent et sont mises en évidence par les FF, qui posent un défi bien particulier en nécessitant une prise en charge à la fois aiguë et chronique. De plus, cette prise en charge ne relève d’aucune spécialité médicale. La correction de ces lacunes peut passer par le recours aux équipes multidisciplinaires, dont l’efficacité et la rentabilité ont été démontrées. Ce modèle de soins élimine également de nombreux obstacles au traitement signalés par les patients, y compris le counseling inadéquat. Des améliorations sont néanmoins encore nécessaires dans l’identification des patients à risque de fracture de la hanche et dans l’observance du traitement.

The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported.To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia.Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505).46 U.S. and Canadian hospitals.Patients aged 50 years or older undergoing hip fracture surgery.Spinal or general anesthesia.Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care.A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups.Missing outcome data and multiple outcomes assessed.Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia.Patient-Centered Outcomes Research Institute

Background: Guidelines for urinary catheterization in patients with hip fracture recommend limiting catheter use and using intermittent catheterization preferentially to avoid complications such as urinary tract infection (UTI) and postoperative urinary retention (POUR). We aimed to compare current practices to clinical guidelines, describe the incidence of POUR and UTI, and determine factors that increase the risk of these complications. Methods: We retrospectively reviewed the charts of patients with hip fracture who presented to a single large tertiary care centre in southeastern Ontario between November 2015 and October 2017. Data collected included comorbidities, catheter use and length of stay. We compared catheter use to guidelines, and investigated the incidence of and risk factors for POUR and UTI. Results: We reviewed the charts of 583 patients, of whom 450 (77.2%) were treated with a catheter, primarily indwelling (416 [92.4%]). Postoperative urinary retention developed in 98 patients (16.8%); however, it did not affect length of stay (p = 0.2). Patients with indwelling catheters for more than 24 hours after surgery had a higher incidence of POUR than those who had their catheter removed before 24 hours (65/330 [19.7%] v. 10/98 [10.2%]) (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.06–4.38). A UTI developed postoperatively in 62 patients (10.6%). Catheter use was associated with a 6.6-fold increased risk of UTI (OR 6.6, 95% CI 2.03–21.4). Patients with indwelling catheters did not have a significantly higher incidence of UTI than those with intermittent catheterization (57/416 [13.7%] v. 2/34 [5.9%]) (p = 0.2). Patients who developed a UTI had significantly longer catheter use than patients who did not (p < 0.002). Conclusion: Indwelling catheters were used frequently, which suggests low compliance with clinical guidelines. Longer duration of catheter use led to higher rates of UTI and POUR. Further investigation of the reasons for the common use of indwelling rather than intermittent catheterization is needed.

Summary Engaging patients—defined broadly as individuals with lived experience of a given condition, family members, caregivers, and the organisations that represent them—as partners in research is a priority for policymakers, funders, and the public. Nonetheless, formal efforts to engage patients are absent from most studies, and models to support meaningful patient engagement in clinical anaesthesia research have not been previously described. Here, we review our experience in developing and implementing a multifaceted patient engagement strategy within the Regional Versus General Anesthesia for Promoting Independence After Hip Fracture (REGAIN) surgery trial, an ongoing randomised trial comparing spinal vs general anaesthesia for hip fracture surgery in 1600 older adults across 45 hospitals in the USA and Canada. This strategy engaged patients and their representatives at both the level of overall trial oversight and at the level of individual recruiting sites. Activities spanned a continuum ranging from events designed to elicit patients' input on key decisions to longitudinal collaborations that empowered patients to actively participate in decision-making related to trial design and management. Engagement activities were highly acceptable to participants and led to concrete changes in the design and conduct of the REGAIN trial. The REGAIN experience offers a model for future efforts to engage patients as partners in clinical anaesthesia research, and highlights potential opportunities for investigators to increase the relevance of anaesthesia studies by incorporating patient voices and perspectives into the research process.

OBJECTIVE To determine if geriatric intertrochanteric hip fracture patients achieve equivalent postoperative functional status after management with either a short (180-200 mm) or a long (260-460 mm) InterTAN intramedullary device. DESIGN Retrospective review of a prospective randomized control trial. SETTING Four Level I Trauma Centers. PATIENTS/PARTICIPANTS One hundred eight patients with OTA/AO classification 31A-1 and 31A-2 intertrochanteric hip fractures were included in the study. INTERVENTION Internal fixation using an IT device. MAIN OUTCOMES MEASURES Primary outcomes included Functional Independence Measure and Timed Up and Go. Secondary outcomes included blood loss, surgical time, length of stay, adverse events, and mortality. RESULTS Seventy-one short and 37 long IT patients met study inclusion criteria. Demographics were similar between groups. There was no difference in Functional Independence Measure or Timed Up and Go scores between the 2 IT groups at any of the time points collected. Mean operative time was lower in the short IT group than in the long IT group (60 vs. 73 minutes; P = 0.021). A higher proportion of long IT patients had reamed constructs (95% vs. 48% short IT, P < 0.001). Postoperative blood loss was significantly higher in the long IT group without a significant influence on the number of patients requiring transfusion (P = 0.582) or average units transfused (P = 0.982). There was no significant difference in the proportion of postoperative adverse events between the 2 cohorts despite a higher number of peri-implant femur fractures in the short IT group than in the long IT group (5 vs. 1, P = 0.350). CONCLUSIONS Postoperative functional status was not influenced by the length of IT device in the management of geriatric intertrochanteric hip fractures. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

To assess the accuracy of a new radiographic measurement of the distal tibia and fibula on the lateral view of the ankle in normal adults: the anteroposterior tibiofibular (APTF) ratio.Thirty adults without history of trauma or disease of the ankle were included. Bilateral ankles were x-rayed with a true lateral view of the ankle. A line from the anterior tibial physis scar to the posterior tibial cortex, passing by the intersection of the physis and the fibula anterior cortex, was drawn. The APTF ratio was calculated as the ratio of the anterior segment to the posterior segment. The measurements were done by 3 independent evaluators. Intra- and interobserver reliability was obtained using intraclass correlation.The APTF ratio was 0.94 ± 0.13 with a range of 0.63-1.31. Sex and age had no effect on the results. Inter- and intraobserver reliability was good to very good with an intraclass correlation between 0.6 and 0.8. A strong correlation between the left and the right APTF ratio was observed (r = 0.501 and P = 0.001).The distal tibiofibular joint anatomy in the sagittal plane can be accurately assessed with a new reliable radiographic measurement, the APTF ratio. The reduction of this joint during surgery can be confirmed with a true lateral view of the ankle. The anterior fibula cortex crosses the tibial physeal scar at the center of the line crossing this point and the anterior cortex of the tibia at the level of the physeal scar in the normal ankle.

There have been no studies assessing the optimal biomechanical tension of suture button constructs. The purpose of this study was to assess optimal tensioning of suture button fixation and its ability to maintain reduction under loaded conditions using a stress computed tomography (CT) model.Ten cadaveric lower limbs disarticulated at the knee were used. The limbs were placed in a modified ankle load frame that allowed for the application of sustained torsional axial or combined torsional/axial loads. The syndesmosis and the deep deltoid ligaments complex were sectioned and the limbs were randomized to receive a suture button construct tightened at 4, 8, or 12 kg. The specimens were loaded under the 3 loading scenarios with CT scans performed after each and at the conclusion of testing. Multiple measurements of translation and rotation were compared with baseline CT scan taken before sectioning.Significant lateral (maximum 5.26 mm) and posterior translation (maximum 6.42 mm) and external rotation (maximum 11.71 degrees) was noted with the 4 kg repair. Significant translation was also seen with both the 8 and the 12 kg repairs; however, the incidence was less than with the 4 kg repair. Significant overcompression (ML = 1.69 mm, B = 2.69 mm) was noted with the 12 kg repair and also with the 8 kg repair (B = 2.01 mm).Suture button constructs must be appropriately tensioned to maintain reduction and re-approximate the degree of physiological motion at the distal tibiofibular joint. These constructs also demonstrate overcompression of the syndesmosis; however, the clinical effect of this remains to be determined.

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. Objectives: To compare outcomes in elderly patients with intertrochanteric hip fractures treated with either the sliding hip screw (SHS) or InterTAN intramedullary device (IT). Design: Prospective, randomized, multicenter clinical trial. Setting: Five level 1 trauma centers. Patients: Two hundred forty-nine patients 55 years of age or older with AO/OTA 31A1 (43) and OA/OTA 31A2 (206) fractures were prospectively enrolled and followed for 12 months. Intervention: Computer generated randomization to either IT (n = 123) or SHS (n = 126). Main Outcome Measurements: The Functional Independence Measure (FIM) and the Timed Up and Go test (TUG) were used to measure function and motor performance. Secondary outcome measures included femoral shortening, complications, and mortality. Results: Demographics, comorbidities, preinjury FIM scores and TUG scores were similar between groups. Patients (17.2%) who received an IT had limb shortening greater than 2 cm compared with 42.9% who received an SHS (P < 0.001). To determine the importance of preinjury function and fracture stability, we analyzed the subgroup of patients with the ability to walk 150 m independently preinjury and an OA/OTA 31A-2 fracture (n = 70). In this subgroup, patients treated with SHS had greater shortening and demonstrated poorer FIM and TUG scores compared with patients treated with an IT. Conclusions: Overall, most patients with intertrochanteric femur fractures can expect similar functional results whether treated with an intramedullary or extramedullary device. However, active, functional patients have an improved outcome when the InterTAN is used to treat their unstable intertrochanteric fracture. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Acetabular fracture patterns in the elderly, with increased involvement of the anterior column, quadrilateral plate comminution, medialization of the femoral head, and marginal impaction, differ from those noted among a younger cohort. Poor prognostic factors for open reduction and internal fixation (ORIF) are posterior wall comminution, marginal impaction of the acetabulum, a femoral head impaction fracture, a so-called gull sign, and hip dislocation. The rate of conversion to total hip arthroplasty following formal ORIF has been reported to be 22% at a mean of twenty-nine months. Total hip replacement after an acetabular fracture generally yields good clinical results; however, in the acute setting, it must be combined with proper stable fracture fixation.