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Background: Disruption of the medial patellofemoral ligament (MPFL) may lead to recurrent lateral patellar dislocation and patellofemoral chondral injury. Despite significant previous work investigating numerous performance parameters, the optimal graft choice for MPFL reconstruction for patellar instability remains unclear. Purpose: To compare functional outcomes scores, subjective recurrent instability, and revision rates between autograft and allograft in MPFL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent MPFL reconstruction with autograft between 2013 and 2018 were identified. A 2:1 comparison group of patients who underwent MPFL reconstruction with allograft was matched by sex, age (±3 years), and body mass index (BMI) (±3 kg/m2). Patient characteristics, preoperative radiograph measurements, and intraoperative data were compared between the groups, as were patient-reported outcome measures, including International Knee Documentation Committee (IKDC) score, Lysholm score, Single Assessment Numerical Evaluation (SANE), and visual analog scale (VAS) for pain. Subjective recurrent instability and revision rate were also compared between groups. Results: The autograft group was composed of 30 patients (13 male, 17 female) with a mean age of 24.4 years and mean BMI of 25.0 kg/m2, and the allograft group was composed of 60 matched patients (25 male, 35 female) with a mean age of 24.1 years and mean BMI of 25.1 kg/m2. The autograft and allograft groups reported similar IKDC scores (73.0 vs 73.7; P =.678), Lysholm scores (77.5 vs 80.7; P =.514), SANE (72.0 vs 75.8; P =.236), and VAS pain (30.7 vs 26.6; P =.482), as well as similar rates of postoperative patellar subluxations (20.0% vs 19.3%; P =.867) and dislocations (10.0% vs 15.0%; P =.805). Conclusion: Both allograft and autograft were found to be viable options for MPFL reconstruction. There were no significant group differences in failure rates, patient-reported outcomes, pain, or complications between autograft and allograft MPFL reconstruction in this series. [ABSTRACT FROM AUTHOR]

Background: Indications for removal of syndesmotic screws are not fully elucidated. This study aimed to determine factors related to elective syndesmotic screw removal. Methods: Patients who underwent fixation of ankle syndesmotic injuries were included. Screw removal was offered after a minimum of 12 weeks after surgery for pain, stiffness or patient desire to remove painful or broken hardware. Patient demographics, surgical data, distance of the syndesmotic screw from the joint, location of the screw at the physeal scar, and number of syndesmotic screws placed were collected for all patients. Bivariate and multivariate analyses were performed to determine the relationship between patient characteristics and screw removal and independent predictors of hardware removal. Results: Of 160 patients, 60 patients (38%) with an average age of 36.1 (range: 18-84) years underwent elective syndesmotic screw removal at a mean of 7 (range, 3-47) months after initial fixation. The most common reason for screw removal (50/60 patients) was ankle stiffness and pain (83%). Patients who underwent screw removal were more likely to be younger (36.1 years ± 13.0 vs 46.6 years ± 18.2, P < .001) and have a lower ASA score (2 ± 0.8 vs 2.1 ± 0.7, P = .003) by bivariate analysis. Of patients who underwent screw removal, 21.7% (13/60) had a broken screw at the time of removal. Whether the screw was placed at the physeal scar was not significantly associated with patient decision for hardware removal (P = .80). Conclusion: Younger and healthier patients were more likely to undergo elective removal of syndesmotic hardware. Screw distance from joint and screw placement at the physeal scar were not significantly associated with hardware removal. [ABSTRACT FROM AUTHOR]

Background: Studies to date comparing biceps tenodesis methods in the setting of concomitant rotator cuff repair (RCR) have demonstrated relatively equivalent pain and functional outcomes. Purpose: To compare biceps tenodesis constructs, locations, and techniques in patients who underwent RCR using a large multicenter database. Study Design: Cohort study; Level of evidence, 3. Methods: A global outcome database was queried for patients with medium- and large-sized tears who underwent biceps tenodesis with RCR between 2015 and 2021. Patients ≥18 years of age with a minimum follow-up of 1 year were included. The American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, visual analog scale for pain, and Veterans RAND 12-Item Health Survey (VR-12) scores were compared at 1 and 2 years of follow-up based on construct (anchor, screw, or suture), location (subpectoral, suprapectoral, or top of groove), and technique (inlay or onlay). Nonparametric hypothesis testing was used to compare continuous outcomes at each time point. The proportion of patients achieving the minimal clinically important difference (MCID) at the 1- and 2-year follow-ups were compared between groups using chi-square tests. Results: A total of 1903 unique shoulder entries were analyzed. Improvement in VR-12 Mental score favored anchor and suture fixations at 1 year of follow-up (P =.042) and the onlay tenodesis technique at 2 years of follow-up (P =.029). No additional tenodesis comparisons demonstrated statistical significance. The proportion of patients with improvement exceeding the MCID did not differ based on tenodesis methods for any outcome score assessed at the 1- or 2-year follow-up. Conclusion: Biceps tenodesis with concomitant RCR led to improved outcomes regardless of tenodesis fixation construct, location, or technique. A clear optimal tenodesis method with RCR remains to be determined. Surgeon preference and experience with various tenodesis methods as well as patient clinical presentation should continue to guide surgical decision-making. [ABSTRACT FROM AUTHOR]

Adjacent segment disease (ASD) in the lumbar spine is a possible consequence in segments adjacent to a fusion. As the number of lumbar fusions in the United States increases, the rates of ASD will continue to climb. There are several treatment options for ASD with open decompression and extension of the fusion being common. However, need for exposure and removal of existing instrumentation can lead to increased operative times resulting in increasing blood loss and infection risk. The purpose of this paper is to describe a case report for unilateral cortical trajectory screw instrumentation, allowing for posterior instrumentation without having to remove the existing pedicle screws in the setting of ASD. Our technique can be done with standard c-arm fluoroscopy without the need for navigation. [ABSTRACT FROM AUTHOR]

Background: Anterior vertebral body tethering (aVBT) has emerged as a novel treatment option for patients with idiopathic scoliosis. We present the results from the first U.S. Food and Drug Administration (FDA) Investigational Device Exemption (IDE) study on aVBT.Methods: In this prospective review of a retrospective data set, eligible patients underwent aVBT at a single center from August 2011 to July 2015. Inclusion criteria included skeletally immature patients with Lenke type-1A or 1B curves between 30° and 65°. Clinical and radiographic parameters were collected, with the latter measured by an independent reviewer.Results: Fifty-seven patients (49 girls and 8 boys), with a mean age (and standard deviation) of 12.4 ± 1.3 years (range, 10.1 to 15.0 years), were enrolled in the study. The patients had a mean of 7.5 ± 0.6 levels tethered, the mean operative time was 223 ± 79 minutes, and the mean estimated blood loss was 106 ± 86 mL. The patients were followed for an average of 55.2 ± 12.5 months and had a mean Risser grade of 4.2 ± 0.9 at the time of the latest follow-up. The main thoracic Cobb angle was a mean of 40.4° ± 6.8° preoperatively and was corrected to 18.7° ± 13.4° at the most recent follow-up. In the sagittal plane, T5-T12 kyphosis measured 15.5° ± 10.0° preoperatively, 17.0° ± 10.1° postoperatively, and 19.6° ± 12.7° at the most recent follow-up. Eighty percent of patients had curves of <30° at the most recent follow-up. The most recent Scoliosis Research Society (SRS) scores averaged 4.5 ± 0.4, and scores on the self-image questionnaire averaged 4.4 ± 0.7. No major neurologic or pulmonary complications occurred. Seven (12.3%) of 57 patients had a revision: 5 were done for overcorrection and 2, for adding-on.Conclusions: Anterior VBT is a promising technique that has emerged as a treatment option for patients with immature idiopathic scoliosis. We present the results from the first FDA-approved IDE study on aVBT, which formed the basis for the eventual Humanitarian Device Exemption approval. The findings affirm the safety and efficacy of this technique and suggest opportunities for improvement, particularly with respect to reoperation rates.Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background Context: Computer-assisted navigation (CAN) has emerged in spine surgery as an approach to improve patient outcomes. While there is substantial evidence demonstrating improved pedicle screw accuracy in CAN as compared to conventional spinal fusion (CONV), there is limited data regarding clinical outcomes and utilization trends in the United States.Purpose: The purpose of this study was to determine the utilization rates of CAN in the United States, identify patient and hospital trends associated with both techniques, and to compare their results.Study Design: Retrospective review of national database.Patient Sample: Nationwide Inpatient Sample (NIS), United States national database.Outcome Measures: CAN utilization, mortality, medical complications, neurologic complications, discharge destination, length of hospital stay, cost of hospital stay.Methods: The NIS database was queried to identify patients undergoing spinal fusion with CAN or CONV. CAN and CONV utilization were tracked by year and anatomic location (cervical, thoracic, lumbar/lumbosacral). Patient demographics, hospital characteristics, index length of stay (LOS), and cost of stay (COS) were compared between the cohorts. After multivariate adjustment, index hospitalization clinical outcomes were compared.Results: A total of 4,275,413 patients underwent spinal fusion surgery during the study period (2004 to 2014). CONV was performed in 98.4% (4,208,068) of cases and CAN was performed in 1.6% (67,345) of cases. The utilization rate of CAN increased from 0.04% in 2004 to 3.3% in 2014. Overall, CAN was performed most commonly in the lumbar/lumbosacral region (70.4%) compared to the cervical (20.4%) or thoracic (9.2%) regions. When normalized to region-specific rates of fusion with any technique, the proportional utilization of CAN was highest in the thoracic spine (2.7%), followed by the lumbar/lumbosacral (2.2%) and cervical (0.9%) regions. CAN utilization was positively correlated with patient factors including increasing age and number of medical comorbidities. Multivariate adjusted clinical outcomes demonstrated that compared to CONV, CAN was associated with a statistically significant decreased risk of mortality (0.28% vs 0.31%, OR=0.67, 95% CI: 0.46-0.97, p=.035) and increased risk of blood transfusions (9.1% vs 6.7%, OR=1.19, 95% CI: 1.02-1.39, p=.032). However, there was no difference in risk of neurologic complications. CAN patients had an increased average LOS (4.44 days vs. 3.97 days, p<.0001) and average COS ($34,669.49 vs $26,784.62, p<.0001) compared to CONV patients.Conclusions: CAN utilization increased in the United States from 2004-2014. Use of CAN was proportionately higher in the thoracic and lumbar/lumbosacral regions and in older patients with more comorbidities. Given the continued trend towards increased CAN utilization, large-scale studies are needed to determine the impact of this technology on long-term clinical outcomes. [ABSTRACT FROM AUTHOR]

Background Context: Pedicle screw placement is a demanding surgical skill as a spine surgeon can face challenges including variations in pedicle morphology and spinal deformities. Available CT simulators for spine pedicle placement can be very costly and hands-on cadaver courses are limited by specimen availability and are not readily accessible.Purpose: To conduct validation of a simulated training device for essential spine surgery skills.Design: Cross-sectional, empirical study of physician performance on a surgical simulator model.Sample: Spine attending physicians and residents from four different academic institutions across the United States.Outcome Measures: Performance metrics on two surgical simulator tasks.Methods: After IRB approval, an inexpensive ($30) simulator was developed to test two main psychomotor tasks (1) creation of the pedicle screw path with a standard gearshift probe without cortical breaks and (2) the ability to palpate for the presence or absence of cortical breaches as well as determine the location of wall defects. Orthopedic and neurosurgery residents (N=72) as well as spine attending surgeons (N=26) participated from four different institutions. To test construct validity, performance metrics were compared between participants of different training status through one-way analysis of variance and linear regression analysis, with significance set at p<.05.Results: Spine attending surgeons consistently scored higher than the residents, in the screw trajectory task with triangular base (p=.0027) and defect probing task (p=.0035). In defect probing, performance improved with linear trend by number of residency training years with approaching significance (p=.0721). In that task, independent of institutional affiliation, PGY-2 residents correctly identified an average of 1.25±0.43 fewer locations compared with attending physicians (p=.0049). More than 80% of the spine attendings reported they would use the simulator for training purposes.Conclusions: This low-cost fundamentals of spine surgery simulator detected differences in performances between spine attending surgeons and surgical residents. Programs should consider implementing a simulator such as fundamentals of spine surgery to assess and develop pedicle screw placement ability outside of the operating room. [ABSTRACT FROM AUTHOR]

Study Design: A retrospective case series., Objective: This study aims to assess the rates of lumbar interbody cage failures based on their material and manufacturer., Summary of Background Data: Perioperative lumbar interbody cage malfunctions are underreported events in the spine literature and may result in complications. Although the Food and Drug Administration ensures the safety of these devices under physiological conditions after implantation, these devices may experience nonphysiological conditions during implantation, which may be overlooked., Materials and Methods: The MAUDE database was examined for reports of lumbar cage device malfunctions from 2012 to 2021. Each report was categorized based on failure type and implant design. A market analysis was performed by dividing the total number of failures per year for each manufacturer by their approximate yearly revenue from spinal implants in the United States. Outlier analysis was performed to generate a threshold value above which failure rates were defined as greater than the normal index., Results: Overall, 1875 lumbar cage malfunctions were identified. Of these, 1230 (65.6%) were cage breakages, 257 (13.7%) were instrument malfunctions, 177 (9.4%) were cage migrations, 143 (7.6%) were assembly failures, 70 (4.5%) were screw-related failures, and 21 (1.1%) were cage collapses. Of the breakages, 923 (74.9%) occurred during insertion or impaction and 97 entries detailed a medical complication or a retained foreign body. Of the migrations, 155 (88.6%) were identified postoperatively, of which 73 (47.1%) detailed complications and 52 (33.5%) required a revision procedure. Market analysis demonstrated that Medtronic, Zimmer Biomet, Stryker, Seaspine, and K2M exceeded the calculated threshold., Conclusions: Lumbar cages with polyether ether ketone core material failed more frequently by breakage, whereas titanium surface cages failed more frequently by migration. Failure rates varied depending on the manufacturer. Most cage breakages identified in the present study occurred intraoperatively during implantation. These findings call for a more detailed Food and Drug Administration evaluation of these intraoperative malfunctions before commercial approval., Level of Evidence: Level 4., Competing Interests: O.R.R.: paid consultant: Aurora Spine and Pain Care, PainTEQ, Osteo Centric Technologies, Facet Dynamics, Olympus Terumo Biomaterials. D.G.K.: AO Foundation: Research Support; SI, Bone, Spineart: paid consultant, paid presenter or speaker; Spineart: IP Royalties. K.H.: Sparktek Medical Technology: Stock or stock options. J.Z.: paid consultant: Ivivi, Benvenue, Nocimed; Unpaid consultant: Spine 21; Stock options: Nocimed, Spine 21; Stock or stock options: Benvenue, Ivivi, Rio Grande, Spartek, Active Implants. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background Context: Surgeons have increasingly adopted robotic-assisted lumbar spinal fusion due to indications that robotic-assisted surgery can reduce pedicle screw misplacement. However, the impact of robotic-assisted spinal fusion on patient outcomes is less clear.Purpose: This study aimed to compare rates of perioperative complications between robotic-assisted and conventional lumbar spinal fusion.Study Design/setting: Retrospective cohort study.Patient Sample: A total of 520 patients undergoing lumbar fusion were analyzed. The average ages of patients in the robotic-assisted versus conventional groups were 60.33 and 60.31, respectively (p=.987). Patients with a diagnosis of fracture, traumatic spinal cord injury, spina bifida, neoplasia, or infection were excluded.Outcome Measures: This study compared the rates perioperative major and minor complications for elective lumbar fusion between each cohort.Methods: This study screened hospital discharges in the United States from 2010 to 2014 using the National Inpatient Sample and the Nationwide Inpatient Sample (NIS). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes were used to identify 209,073 patients who underwent conventional lumbar fusion (ICD 81.04-8) and 279 patients who underwent robotic-assisted lumbar fusion (ICD 81.04-8 and ICD 17.41, 17.49). Major and minor complications were identified using ICD-9-CM diagnosis codes. The robotic-assisted and conventional fusion groups were statistically matched on age, year, sex, indication, race, hospital type, and comorbidities. Univariate and multivariate logistic regression were used to compare risks of major and minor complications.Results: We matched 257 (92.11%) robotic-assisted patients with an equal number of patients undergoing conventional lumbar fusion. Minor complications occurred in 16.73% of cases in the conventional group and 31.91% of cases in the robotic-assisted group (p<.001). Major complications occurred in 6.61% of the conventional cases compared to 8.17% of robotic-assisted cases (p=.533). For robotic-assisted fusion, multivariate analysis revealed that there was no difference in the likelihood of major complications (OR=0.834, 95% CI=0.214-3.251) or minor complications (OR = 1.450, 95% CI=0.653-3.220).Conclusions: In a statistically matched cohort, patients who underwent robotic-assisted lumbar fusion had similar rates of major and minor complications compared to patients who underwent conventional lumbar fusion. [ABSTRACT FROM AUTHOR]

Background and Objective: Rapid design and production of patient-specific 3-dimensional-printed implants (3DPIs) present a novel opportunity to restore the biomechanically demanding integrity of the lumbopelvic junction. We present a unique case of a 61-year-old patient with severe neuropathic spinal arthropathy (Charcot spine) who initially underwent a T4-to-sacrum spinal fusion. Massive bone destruction led to dissociation of his upper body from his pelvis and legs. Reconstruction of the spinopelvic continuity was planned with the aid of a personalized lumbosacral 3DPI., Method: Using high-resolution computed tomography scans, the custom 3DPI was made using additive titanium manufacturing. The unique 3DPI consisted of (1) a sacral platform with iliac screws, (2) modular corpectomy device with rigid connection to the sacral platform, and (3) anterior plate connection with screws for proximal fixation. The procedures to obtain compassionate use Food and Drug Administration approval were followed. The patient underwent debridement of a chronically open wound before undertaking the 3-stage reconstructive procedure. The custom 3DPI and additional instrumentation were inserted as part of a salvage rebuilding procedure., Results: The chronology of the rapid implementation of the personalized sacral 3DPI from decision, design, manufacturing, Food and Drug Administration approval, and surgical execution lasted 28 days. The prosthesis was positioned in the defect according to the expected anatomic planes and secured using a screw-rod system and a vascularized fibular bone strut graft. The prosthesis provided an ideal repair of the lumbosacral junction and pelvic ring by merging spinal pelvic fixation, posterior pelvic ring fixation, and anterior spinal column fixation., Conclusion: To the best of our knowledge, this is the first case of a multilevel lumbar, sacral, and sacropelvic neuropathic (Charcot) spine reconstruction using a 3DPI sacral prosthesis. As the prevalence of severe spine deformities continues to increase, adoption of 3DPIs is becoming more relevant to offer personalized treatment for complex deformities., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Introduction: Removal of symptomatic implants is a common procedure performed by orthopaedic trauma surgeons. No guidance is available regarding which factors contribute to the likelihood of an implant becoming symptomatic. Our objective was to determine whether radiographic parameters associated with distal interlocks in retrograde femoral nails are associated with the rate of symptomatic screw removal.Patients and Methods: We conducted a retrospective review at a Level I trauma center. Study patients (n=442) had femoral fractures treated with retrograde intramedullary nails from 2007 to 2014 and at least 1year of follow-up. The main outcome measurement was symptomatic distal screw removal as predicted by radiographic parameters.Results: Symptomatic screw removal occurred in 12% of the patients. Increased distance between the most distal screw and the articular surface of the femur significantly reduced likelihood of symptomatic screw removal. A cutoff of 40mm from the articular block was predictive of removal (≥40mm, 0% removal; <40mm, 18% removal, p<0.0001). In patients with distal screws placed within 40mm of the articular surface of the femur, a ratio of screw length to distance between medial and lateral femoral cortices that was ≥1 was a strong predictor of symptomatic screw removal (area under Receiver Operating Characteristic curve, 0.75; p<0.0001).Conclusions: More distal screws and screws that radiographically extend to or beyond the medial cortex are more likely to cause pain and require removal in femoral fractures treated with retrograde intramedullary nails. We identified a specific distance from the joint (<40mm) and a ratio of screw length to bone width (≥1) that significantly increased the likelihood of symptomatic screw removal. Clinicians can use these data to inform patients of the likely risk of implant removal and perhaps to better guide placement and length of screws when the clinical scenario allows some flexibility in location and length of screws. [ABSTRACT FROM AUTHOR]

Introduction: Simultaneous ipsilateral clavicle and acromioclavicular (AC) joint injury have been infrequently reported in the literature at this time. The purpose of this study was to assess incidence as well as assess risk factors for this dual injury pattern.Methods: We performed a retrospective review of a prospectively collected database (Level III evidence), evaluating 383 adult patients without previous shoulder girdle injury or trauma with a minimum 1-year follow-up who sustained a displaced diaphyseal clavicle fracture. All patients in the study underwent either nonoperative management or surgical reduction and stabilization of a diaphyseal clavicle fracture with a plate and screw construct. Study subjects were followed with serial radiographs. Clavicle and shoulder radiographs, as well as chest radiographs and contralateral films in questionable cases, were used to assess for acromioclavicular joint injury in both operative and nonoperative groups. Additional data was collected on concurrent injuries, patient demographics, fracture characteristics, fixation techniques, surgical/post-operative data, and operative or nonoperative treatment.Results: We found that 13/183 (7.1%) of patients undergoing fixation of a diaphyseal clavicle fracture had an ipsilateral AC joint injury, while 13/200 (6.5%) of patients undergoing conservative management had an ipsilateral AC joint injury. Critical analysis of the data revealed that presence of ipsilateral scapular body fractures, and a likely incidental association with superior plating fixation, were associated with an increased rate of this injury pattern.Conclusions: Ipsilateral clavicle fracture and AC joint injury is much more common than traditionally believed, with an incidence of 6.8% overall. It is unknown how the presence of an associated AC injury influences outcome, as AC injury was not universally symptomatic. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to report the physical and functional outcomes after open reduction internal fixation of the olecranon in a large series of patients with region specific plating across multiple centres.Patients/methods: Between January 2007 and January 2014, 182 consecutive patients with a displaced olecranon fracture treated with open reduction internal fixation were included in this study. Retrospective review across four trauma centres collected elbow range of motion, DASH scores, hardware complications, and hardware removal. Postoperative visits in the outpatient clinic were at two, six, and twenty-four weeks. After 24 weeks, patients were eligible for hardware removal if symptomatic. All patients were contacted, at least 1 year following surgery, to determine if hardware was removed.Results: 182 patients (75 women, 105 men) average age 50 (16-89) with 162 closed and 19 open displaced olecranon fractures were treated with one region specific plate. Nineteen were lost to followup leaving 163 for analysis with all patients united. The most common deficiency was a lack of full extension with 39% lacking at least 10° of extension. Hardware was asymptomatic in 67%, painful upon leaning in 20%, and restricted activities in 11% resulting in a 15% rate of hardware removal. Hardware complaints were more common if a screw was placed in the corner of the plate (P=0.004). When symptomatic, the area of the plate that was bothersome encompassed the whole plate in 39%, was at the edge of the plate in 33%, and was a screw head in 28%. The DASH scores, collected at final follow-up of 24 weeks, was 10.1±16, indicating moderate disability was still present. Patients who lacked 10° of extension had a DASH of 12.3 as compared with 10.5 for those with near full extension, but this was not significant (P=0.5).Conclusion: Plating of the olecranon leads to predictable union. The most common complication was lack of full extension with 39% lacking more than 10°, although this did not have any effect on DASH scores. Overall results indicate that disability still exists after 6 months with an average DASH score of 10.Level Of Evidence: Therapeutic level III. [ABSTRACT FROM AUTHOR]

Background: Neck of femur fractures are associated with high mortality and have increased prevalence in dialysis patients. Delays in operating on dialysis patients can occur as a result of logistical or medical issues; it has previously been shown that delays on operating on neck of femur fractures in the general population results in increased mortality.Methods: Medical records of 27 dialysis patients admitted to a large district general hospital in the UK with a fractured neck of femur between January 2009 and January 2014 were analysed alongside records of 27 age and sex-matched non-dialysis patients. Fisher's exact test and the unpaired t test were applied to data to explore outcomes. Odds ratio was also used to compare mortality between the dialysis and non-dialysis groups.Results: Thirty-day mortality amongst dialysis patients was 22 %, compared to 7 % in the non-dialysis cohort. One-year mortality amongst dialysis patients was 70 %, compared to 15 % in the non-dialysis cohort (odds ratio 13.7 (3.56-52.4, 95 % confidence interval; p = 0.0001)). Average length of survival in dialysis patients overall was 311 days; average length of survival if the patient was operated on within 48 h of admission was 450 days (192-708 days, 95 % confidence interval) and was 224 days (45-402, 95 % confidence interval) if operated on after more than 48 h of admission (p = 0.16).Conclusions: Dialysis patients had higher post-operative mortality than the non-dialysis cohort. Odds ratio for death was significantly greater at one-year in the cohort of dialysis patients compared to the non-dialysis patients. Delay to operation amongst the dialysis patient cohort did not contribute significantly to mortality in this study. The higher rates of coronary artery disease, diabetes mellitus and malignancy may confound mortality amongst patients on dialysis who sustain a fractured neck of femur. Limitations of this study included small patient numbers, data from only one centre being used, and some missing data for certain patients. [ABSTRACT FROM AUTHOR]

Study Design: Multicenter prospective database review of patients with cerebral palsy (CP) and spinal deformity.Objective: To determine if the type of distal fixation is associated with improved correction of coronal deformity or pelvic obliquity (PO) at 2 years in long posterior fusions to the sacrum.Summary Of Background Data: Multiple techniques are utilized for distal fixation in patients with CP. Although there is emerging evidence that the augmentation of iliac screws with S1 screws may be beneficial, this remains controversial.Methods: A prospective, multicenter database was used to identify patients with CP who underwent long posterior fusions to the sacrum. Eighty-eight patients were included, 52 with iliac screws (I) and 36 with iliac and S1 screws (IS) for distal fixation. Preoperative, first erect, and 2-year follow-up radiographs and complications were analyzed. Statistical analysis was performed using ANOVA and repeated measures ANOVA with significance set at P < 0.05.Results: Scoliosis was the primary deformity in greater than 90% of patients in both groups (P=0.84). Preoperative coronal deformity was similar (I = 83°, IS = 87°, P = 0.49), but correction was better with the use of S1 screws on the first erect radiograph and at 2 years (I = 35°, IS = 22°, P = 0.001), reflecting correction of 58% and 74% for iliac and iliac-S1 screws, respectively (P < 0.001). Preoperative PO was similar (I = 29°, IS = 30°, P = 0.71) and was noted to improve more in the iliac-S1 group by 2 years (I = 11°, IS = 5°, P = 0.004), representing correction of 60% and 77% for the iliac and iliac-S1 groups, respectively (P = 0.018). There was no difference in the rate of major (P = 0.27) or minor (P = 0.65) complications in either group.Conclusion: Bilateral S1 and iliac screws are associated with improved spinal deformity and PO correction at 2 years in the CP population. Two points of distal fixation, S1, and ilium should be considered for this population.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

The study evaluated the incidence of and complications associated with the use of an intramedullary nail vs open reduction and internal fixation (ORIF) with a sliding compression hip screw and plate in treating intertrochanteric fractures. The authors hypothesized that the biomechanically stronger and less invasive intramedullary nail would have superior results and fewer complications compared with ORIF. Patients followed for up to 1 year postoperatively were identified from the 5% nationwide sample of Medicare administrative claims data (1998-2007) using the corresponding International Classification of Diseases, 9th revision, Clinical Modification, codes 820.21 and 820.31. There were 9157 patients treated with intramedullary nails and 27,687 treated with compression screw and plate fixation. Intertrochanteric hip fractures treated with an intramedullary nail during this period increased from 3.3% to 63.1% compared with ORIF. Patients treated with an intramedullary nail had a higher adjusted risk of pulmonary embolism at 90 days (P=.003) and a higher risk of mortality at 1 year (P<.001) compared with those treated with ORIF. Patients who underwent intramedullary nailing during 2006 to 2007 had a lower adjusted risk of conversion to total hip replacement at 1 year (P=.037) compared with those who had ORIF. Over the decade of the study, intramedullary nail usage increased 59.8% compared with ORIF. Increased use of intramedullary nails compared with ORIF has not shown improved outcomes or decreased complications in patients with intertrochanteric hip fractures. The increased use of intramedullary nails for intertrochanteric hip fractures appears to be multifactorial, including the less invasive nature of the surgery and increased experience with the closed surgical technique. [ABSTRACT FROM AUTHOR]

The article analyzes several patients who were treated, at six different institutions in the U.S., with bioabsorbable polymer plate and screws for anterior cervical discectomy and fusions (ACDF) surgery. According to the authors, radiographic fusion was achieved in 98.1% of the cases at six months. They found no clinical signs or symptoms of amreaction to the bioabsorbable material. They mentioned that ACDF surgery may be as effective as traditional titanium plating systems in single-level disease.

Introduction/Purpose: One of the most common injuries in the United States is the ankle sprain, accounting for 10-15% of sport injuries. Without proper treatment, about one-third of patients reinjure the same ankle and can progress to chronic lateral ankle instability. An ankle can be clinically evaluated by performing an inversion stress test and measuring the degree of varus tilt. The purpose of this retrospective chart review was to examine if a correlation exists between the degree of varus tilt on a stress x-ray and whether the patients were treated conservatively or surgically. Additionally, this chart review aims to confirm the validity of the guidelines of an abnormal talar tilt value, which is said to be a value greater than 10 degrees. Methods: A total of 584 patients between January 1st, 2016 and June 27th, 2019 were clinically diagnosed with lateral ankle instability and had an inversion stress x-ray. All 584 patients were seen and diagnosed by the same foot and ankle orthopedic surgeon in Columbus, Ohio. Of the 584 patients, 40 had bilateral lateral ankle instability and bilateral stress xrays, given a total of 624 ankles originally included in this chart review. Once the patient's charts were reviewed, 32 ankles were excluded because their ankle surgery did not involve correction of the lateral ankle instability. A total of 592 ankles (293 left and 299 right) were included in this review. The degree of varus tilt on all 592 ankles were determined by measuring the angle between the tibial plafond and the top of the talus. The angles were compared to the patients with surgical and conservative treatment. Results: The chart review showed that as the degree of varus tilt increases, the more likely the patient is to fail conservative treatment and need surgical correction. The types of conservative treatment that the patients failed were a combination of a brace, boot, physical therapy, orthotics, shoe changes, injection, and casting. The patients who had a varus tilt below 2.5 degrees were treated conservatively 60% of the time, where patients that had a varus tilt over 20.1 degrees were treated surgically 75% of the time. The review also showed a significant number of patients who were treated surgically with a varus tilt value less than 10 degrees (209 of 472 ankles), warranting further evaluation into what is considered an abnormal talar tilt. Conclusion: It is clear that patients with a higher degree of varus tilt have more ankle instability and are more likely to fail conservative treatment and require surgical correction. Additionally, this chart review showed that many patients needed surgical correction even with a low varus tilt value on stress x-ray. Further evaluation needs to be completed to determine what value is considered an abnormal varus tilt. One possible explanation of our findings is that the inversion stress test does not evaluate the subtalar joint, which can contribute to chronic lateral ankle instability. [ABSTRACT FROM AUTHOR]

This paper describes affordable equipment for testing bone screw torque, corresponding to ASTM standard F543-00 for testing metallic medical bone screws. Correct testing of thin and long bone screws is essential due to screw failures during insertion and removal of the screws. Furthermore, insertion torque is an important factor in predicting fixation strength, screw pull-out force and effects of surface treatment of screws. The capability of the custom-built tester was determined using polytetrafluoroethylene and wood disc samples and bone screws. Bovine cortical bones allowed testing to the failure limit, i.e. the torque increased in long screws to the fracture limit. For 2.7 and 3.5 mm thick self-tapping cortical bone screws, the failure torques were 30-50 per cent higher than the minimum values required by the standard (1.0 and 2.3 N m respectively). The equipment provided reproducible results and fulfilled the ASTM standard very well. Preliminary testing with amorphous diamond coated bone screws showed good durability of the coating and on average 10-15 per cent lower torque values compared with uncoated screws. The equipment can be used to measure insertion and removal torques as described in the standard. Furthermore, it also allows testing of normal screws and bolts. [ABSTRACT FROM AUTHOR]

Discusses the use of anterior Texas Scottish Rite Hospital (TSRH) instrumentation for the treatment of scoliosis. Analysis of the clinical outcomes of the patients; Introduction of TSRH bone screws onto the lateral surface of vertebral bodies.

Background: In this study, we aimed to compare a 4-mm lag screw and Kirschner wire technique versus a 4-mm lag screw and Kirschner wire (K-wire) technique with additional miniplate fixation for the treatment of medial malleolar fractures., Methods: A total of 23 patients who were diagnosed with isolated fractures of the medial malleolus and operated in our center were retrospectively analyzed. The patients were divided into two groups: Group A, medial malleolar fracture fixed with a 4-mm cannulated screw and a K-wire (n=11) and Group B, a 4-mm cannulated screw and K-wire used for fixation with miniplate fixation for extra stability (n=12). Clinical outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score at 2, 6, 12, and 24 months postoperatively. At 12-24 months, the presence of pain and tenderness in the medial malleolus with palpation was evaluated using the visual analog scale (VAS) pain scores., Results: The mean time to union was 2.23±0.56 (range, 1.8-2.9) months in Group A and 2.46±0.45 (range, 1.9-3.1) months in Group B, indicating no statistically significant difference between the two groups (p>0.05). The mean AOFAS score at 2 months postoperatively was 60.40±7.78 (range, 46-79) in Group A and 73.60±10.80 (range, 53-87) in Group B, indicating a statistically significant difference between the groups (p<0.01). However, there was no statistically significant difference in the mean AOFAS scores at 6 and 12 months between the groups (p>0.05). The mean VAS pain scores at 12-24 months postoperatively did not significantly differ between the groups (p>0.05)., Conclusion: Our study results suggest that the treatment of medial malleolar fractures with a cannulated screw and K-wire with additional stabilization using a miniplate ensures favorable early outcomes with early return to daily living activities. However, both techniques have similar outcomes in the mid-term.

Objectives: Although the body of literature on syndesmosis injuries is growing with regard to both the biomechanics and clinical outcomes for various fixation constructs, there is little consensus on the optimal treatment and return to sport strategy for these injuries. We endeavoured to assess the current approaches to managing syndesmotic injuries through a Research Electronic Data Capture survey., Methods: The survey consisted of 27 questions, including respondent demographics, indications for treatment of syndesmotic injuries, preferred treatment and technique, and postoperative management. Responses were generated through six different athlete scenarios: moderate impact, high impact, and very high impact athletes with/without complete deltoid injury. Frequencies and percentages were calculated for all categorical responses., Results: A total of 742 providers responded to the survey, including 457 American surgeons and 285 members of various international societies. Flexible devices were the preferred fixation construct (47.1%), followed by screws (29.6%), hybrid fixation (e.g. combination of flexible device and screw, 18%), and other (5.3%). Sixty-four percent of respondents noted that their rehabilitation protocols would not change for each athlete scenario. Considerable variability was present in anticipated return to full participation, largely dependent on the presence or absence of a deltoid ligament injury., Conclusion: The most common elements used as surgical indications were syndesmosis widening > 2 mm on x-ray, an anterior inferior talofibular ligament injury in combination with a posterior inferior talofinular ligament or deltoid ligament involvement on magnetic resonance imaging, and widening of the distal tibiofibular joint during arthroscopic evaluation. Overall, flexible fixation (e.g. suture button) was the preferred device choice for the repair of an injured syndesmosis. Most respondents did not alter their rehab protocol or anticipated return to play timeline based on the injury severity. However, there was considerable variability between respondents on the time to weight-bearing, running, and full participation. Further pragmatic outcomes data are necessary to guide safe return to play protocols for syndesmotic injuries., Level of Evidence: Level IV., Competing Interests: Declaration of competing interest K.J.H. reports other from Panther Orthopaedics, during the conduct of the study; In addition, he has a patent Puma issued. The other authors have no competing interests to declare., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: Intertrochanteric (IT) fractures are estimated to burden the healthcare system six billion dollars annually. Previous studies have documented a trend of early-career orthopaedic surgeons favoring intramedullary nails (IMNs) for these fractures, despite multiple randomized controlled trials demonstrating no evidence for improved patient outcomes when compared with sliding hip screws (SHSs). The purpose of this study was to report the trend of implant utilization for IT fracture fixation from 2007 to 2017., Methods: The American Board of Orthopaedic Surgery (ABOS) Part II (oral) database was used to identify IT fractures (International Classification of Diseases, 9th revision, code 820.21 or 820.31, and 10th revision, code S72.14) over a 10-year period (2007 to 2017). The cases were categorized by IMN or SHS fixation by surgeon-reported Current Procedural Terminology codes. Utilization of the devices was analyzed according to year, and the implants were compared for outcomes, complications, and cost., Results: As of 2017, 92.4% of IT fractures were being fixed through IMN, representing a 49.1% increase in the number of IMN devices used during the course of this study. SHS had significantly lower medical complication rate (21.3%) and readmittance rate (4.0%) compared with the IMN (medical complication: 26.9%; P < 0.01) (readmittance rate: 5.4%; P = 0.02). SHS also had significantly lower rates of anemia (5.2%) and patient expiration (4.8%) compared with IMN (anemia: 10.2%; P < 0.01) (patient expiration: 6.1%; P = 0.01). Overall surgical complication rates, reoperative rates, and anesthetic complications did not differ between constructs. A cost differential of $671,812 was found from the 2007-projected distribution, which rose to $3,911,211.00 across the entire 11-year duration of the study for the population., Discussion: Early-career orthopaedic surgeons continue to use a more expensive implant for IT fractures despite limited evidence for improved outcomes., Level of Evidence: Level III; Retrospective Cohort Study., (Copyright © 2021 by the American Academy of Orthopaedic Surgeons.)

Anterior vertebral body tether (AVBT) is a nonfusion surgical procedure for correction of scoliosis in skeletally immature individuals. With US Food and Drug Administration approval in 2019, AVBT technology is spreading and early to midterm reports are being published. Early clinical reports are promising while precise indications, outcomes, complication profiles, and best practices are being established. Patients who are skeletally immature and wish to avoid a fusion surgery may benefit from this procedure. This article highlights the translational science foundation, early to midterm clinical reports, and future directions for this growing technique in pediatric spinal deformity surgery., Competing Interests: Disclosure C.E. Baker has no disclosures. T.A. Milbrandt is a paid consultant to Medtronic, Orthopediatrics, and Zimmer, and holds stock in Viking Scientific. A.N. Larson has research supported by Globus Medical, Medtronic, Orthopediatrics, and Zimmer. There was no funding received for this work., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: To compare reports of implant fatigue failure submitted to the FDA of 2 commonly used cephalomedullary nails., Methods: In total, 2724 medical device reports from the FDA's MAUDE database from Jan 2015 to Oct 2019 were reviewed for the Trochanteric Femoral Nail-Advanced (TFNa) and Gamma 3 implants., Results: Data from 342 implant failures included in the MAUDE database were analyzed. TFNa and Gamma 3 had 183 and 159 reported fatigue failures, respectively. All failed implants fractured in the same location through the proximal screw aperture. Time from implantation to failure was on average 2 months shorter for TFNa implants that were reported fractured than for Gamma 3 implants reported, a difference that was statistically significant (P < 0.05). In total, 100 implants were reported to have failed within the first 4 months (53 and 47 for TFNa and Gamma 3, respectively). For Gamma 3 implants that failed in the first 4 months, almost all of the available manufacturers' inspection reports revealed implant notches at the point of failure from drilling. For TFNa implants that failed early, only one reported notch was noted in the available inspection reports., Conclusions: In contrast to other studies regarding fatigue failure, reported failures in both TFNa and Gamma 3 occurred earlier than can be attributed to delayed or nonunion. The reported failures of the TFNa in the MAUDE database occurred earlier than did those of the Gamma 3. Early failures of the Gamma 3 seemed to be the result of iatrogenic implant notching., Level of Evidence: Therapeutic Level III. See instructions for authors for a complete description of levels of evidence., Competing Interests: The author reports no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Total shoulder arthroplasty is an accepted treatment for glenohumeral osteoarthritis. The Arthrex Eclipse shoulder prosthesis is a stemless, canal-sparing humeral prosthesis with bone ingrowth capacity on the trunnion, as well as through the fenestrated hollow screw, that provides both diaphyseal and metaphyseal load sharing and fixation., Methods: Between 2013 and 2018, 16 sites in the United States enrolled 327 patients (Eclipse in 237 and Arthrex Univers II in 90). All patients had glenohumeral arthritis refractory to nonsurgical care. Strict exclusion criteria were applied to avoid confounding factors such as severe patient comorbidities, arthritis not consistent with osteoarthritis, and medical or prior surgical treatments that may have affected outcomes. Patients were randomized to the Eclipse or Univers II group via block randomization., Results: In total, 149 Eclipse and 76 Univers II patients reached 2-year follow-up (139 Eclipse patients [93.3%] and 68 Univers II patients [89.5%] had complete data). The success rate using the Composite Clinical Success score was 95% in the Eclipse group vs. 89.7% in the Univers II group. No patient exhibited radiographic evidence of substantial humeral radiolucency, humeral migration, or subsidence at any point. Reoperations were performed in 7 patients (3.2%) in the Eclipse group and 3 (3.8%) in the Univers II group., Conclusion: The Arthrex Eclipse shoulder prosthesis is a safe and effective humeral implant for patients with glenohumeral arthritis at 2-year follow-up, with no differences in outcomes compared with the Univers II shoulder prosthesis., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Early mobilization and weight-bearing have been proposed to improve hip fracture outcomes. This study aimed to compare early postoperative complications and outcomes of patients who underwent weight-bearing as tolerated (WBAT) on postoperative day one (POD1) with those that did not on: (1) 30-day mortality; (2) 30-day postoperative major and minor complications; (3) length of stay (LOS); and (4) discharge disposition after hip fracture management., Methods: The NSQIP database was used to identify 7947 hip fracture patients managed with a hemiarthroplasty and internal fixation, sliding hip screw, or cephalomedullary nail, for a total of 5845 patients were allowed to WBAT on POD1. They were compared to patients who were non-WBAT using adjusted multivariate regression models to evaluate the effect of WBAT status on the outcomes above., Results: Among the cephalomedullary nail patients, WBAT on POD1 was associated with a decreased likelihood of mortality. In the cephalomedullary nail and sliding hip screw treatment groups, patients were less likely to experience major and minor complications if they were WBAT on POD1. WBAT patients had shorter LOS in the sliding hip screw and cephalomedullary nail treatment groups. Patients were less likely to be discharged to a non-home facility when WBAT on POD1 regardless of treatment., Conclusion: Early weight-bearing after surgical care of hip fracture seems to decrease morbidity and mortality; however, this effect is treatment dependent. These findings further support the need for early mobilization and rapid recovery programs in the care of hip fracture patients., Level of Evidence: Level III.

Most minimally displaced scaphoid fractures and all displaced scaphoid fractures in elite athletes are treated with early fixation to maximally expedite the return to full function. Computed tomographic (CT) scans are recommended in all scaphoid fractures to facilitate a complete understanding of fracture anatomy and to allow for optimal screw placement. Screw placement is important to maximize healing capacity of the fracture and allow for return to sport. Postoperative CT scans can be helpful to evaluate the extent of healing and may allow patients to return to play sooner., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The number of screws used for sliding calcaneal osteotomy fixation has not been examined in the literature. The purpose of this paper is to examine this topic., Methods: Retrospective chart review was performed on 190 patients who met selection criteria. We compared complication risk for single versus double screw, headed versus headless screw, and short versus longitudinal incision cases., Results: The mean age was 48.4 (18-83) years and average follow up was 28 (12-150) weeks. All cases achieved radiographic union. Overall complication rate was 19.5% (37/190). Risk of complication did not differ significantly between single and double screw (RR: 1.170; 95% CI: 0.66-2.09; p=0.594) or short and extended incision groups (RR: 0.868; 95% CI: 0.42-1.80; p=0.704). Risk of complication differed significantly between headed and headless screw fixation (RR: 5.558; 95% CI: 2.69-11.50; p<0.0001)., Conclusions: Single screw fixation of sliding calcaneal osteotomy achieves similar outcomes as double screw fixation. Headless screws are advantageous for minimizing hardware pain and subsequent hardware removal., (Copyright © 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

The article discusses the future of robotics in spine surgery. Topics of discussion includes current role as guides to help position tools for accurate placement of pedicle screw, using them for providing "no-fly zones"around protected structures, helping a surgeon to burr away the lamina or perform an osteotomy without plunging into the spinal canal improved user interfaces such as gloves with motion sensors, to handle more complex soft tissues.

Objective: To determine whether percutaneous transiliac-transsacral screw fixation improves pain, ambulation, length of stay, and the rate of disposition to home in patients with sacral fragility fractures., Design: Retrospective cohort study., Setting: Single academic Level 1 trauma center., Patients/participants: Elderly patients who presented with an isolated sacral fragility fracture between August 2015 and August 2017. Of the 41 patients included in the study, 16 were treated operatively and 25 were treated nonoperatively., Intervention: Percutaneous transiliac-transsacral screw fixation., Main Outcome Measurements: Pain, ambulation, length of stay, complications, and disposition., Results: Patients treated operatively reported a greater improvement in pain as measured by the visual analog scale (3.9 vs. 0.6 points, P < 0.001). At the time of discharge, 100% of surgically treated patients were able to ambulate compared with 72% in the nonoperative group (P = 0.03). Average distance ambulating at the time of discharge was higher in the operative group (95 vs. 35 ft, P < 0.01). Length of stay was similar between the 2 groups (3.6 days in operative group vs. 4.2 days in nonoperative group, P = 0.5). Of the patients treated operatively, 75% were discharged to home compared with only 20% in the nonoperative group (P < 0.001). There were no complications related to surgery., Conclusions: Percutaneous transiliac-transsacral screw fixation of sacral fragility fractures lessens pain, improves ambulation, and increases the rate of disposition to home. Further investigation is needed to determine if surgical fixation provides benefit regarding medium- and long-term outcome variables., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: In the last 2 decades, surgical treatment of intertrochanteric (IT) femur fractures has shown a continuing trend towards the increased use of intramedullary nails (IMN) and decreased use of sliding hip screws (SHS). Recent trends in the United States regarding the use of these implants, including charges and reimbursement, have not been investigated., Methods: A national database of Medicare patients (PearlDiver, Inc.) was queried using Current Procedural Terminology (CPT) codes for patients with surgical dates from 2005-2011., Results: A total of 34,759 SHS or IMN procedures for intertrochanteric femur fractures were identified from 2005-2011. There was a significant increase in the percentage of IMN compared to SHS, from 46.9% IMN in 2005 to 79.1% in 2011. The average charges for IMN and SHS increased. Statistically higher rates of PE (p&lt;0.001), DVT (p&lt;0.001), MI (p&lt;0.001), respiratory failure (p&lt;0.001), UTI (p&lt;0.001), pneumonia (p&lt;0.001), CVA (p&lt;0.001) and blood transfusion (p&lt;0.001) were noted in the IMN group. The SHS group had higher 1 year (4.3% vs 3.8%, p = 0.012) and 2 year (5.8% vs 5.0%, p = 0.002) mortality rates., Conclusions: The previously recognised trend of increasing use of IMN for IT femur fractures has continued. The overall incidence of operative IT femur fractures is not increasing at this time. The cost of IMN remains higher than SHS.

Background: Femoral neck fractures in young adults (ages <60) are high-energy injuries that are associated with major fracture healing complications such as avascular necrosis, nonunion, and significant shortening. Historically, evidence from small trials has suggested multiple cannulated screws were the optimal implant; however, newer studies and implant designs warrant reevaluation of screws as the gold standard among surgeons. In addition, controversies surrounding reduction technique and urgency of surgical fixation have been previously identified. We aimed to survey surgeon treatment preferences for these challenging fractures., Methods: A 17-item survey was developed and tested for validity and reliability prior to administration. The questionnaire characterised surgeon demographics, treatment preferences for displaced and undisplaced fractures, and controversies for future clinical trials. The target population consisted of surgeons from the Canadian Orthopaedic Association, the Orthopaedic Trauma Association, and attendees at an international fracture course., Results: 540 surgeons completed the survey, exceeding our sample size requirement. There was a similar proportion of respondents from academic and community hospitals. Most surgeons (61%) treat 1-5 young adult femoral neck fractures per year. For undisplaced fractures, 78% of respondents prefer to use multiple cannulated screws. For displaced fractures, equal preference for multiple screws (46%) and the sliding hip screw (SHS, 49%) was reported. The majority of surgeons perform an open reduction in less than 25% of cases, and the time to fixation was typically between 8 and 24h., Conclusions: Multiple cannulated screws remain the preferred treatment for most surgeons treating undisplaced fractures; however, there is an equal divide in preference between multiple screws and the SHS for displaced fractures. This increased preference for the SHS contradicts previous survey and small trial data recommending multiple screws for all fracture patterns. The lack of surgeon consensus and the high rates of fracture complications associated with fixation of young femoral neck fractures supports the need for definitive clinical trials to optimise patient important outcomes., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Unstable ankle injuries with associated disruption of the distal-fibular syndesmosis are typically managed by adjunctive placement of temporary syndesmotic positioning screws. The widespread notion that positioning screws must be removed by default after healing of the syndesmosis remains a topic of debate which lacks scientific support. The present study was designed to test the hypothesis that syndesmotic positioning screws are safely retained per protocol in asymptomatic patients., Patients and Methods: A retrospective analysis of an institutional prospective database was performed during a 5-year time-window at an academic level 1 trauma centre in the United States. All ankle fractures requiring surgical fixation were included in the analysis. The primary outcome parameter consisted of the rate of elective hardware removal for syndesmotic positioning screws within 6 months after surgical fixation., Results: A total of 496 consecutive patients with 496 isolated ankle fractures managed by surgical fixation were included in this study. Of these, 140 injuries were managed by placement of syndesmotic positioning screws. Within 6 months follow-up, 17.1% of all syndesmotic screws were found to be radiographically broken, and 13.6% of syndesmotic screws revealed radiographic signs of loosening. Only 2 patients (1.4%) required the elective removal of symptomatic positioning screws within 6 months of surgical fracture fixation., Conclusion: Despite the high rate of radiographic complications related to breaking or loosening of syndesmotic screws in almost one third of all cases, more than 98% of all patients remain asymptomatic and do not require a scheduled hardware removal. The routine removal of syndesmotic positioning screws does not appear to be justified from a patient safety perspective., (Georg Thieme Verlag KG Stuttgart · New York.)

The article reports on the recall of Colorado 2-inch Spinal System Break-Off Nut, nonsterile, Rx, catalog number 8634111 by Warsaw Orthopedic Inc. According to the U.S. Food and Drug Administration (FDA), the product assembly may be compromised because two thread grooves are missing on the nut, which may cause damage to the bone screw and result in the need for the bone screw to be replaced. A letter was sent to customers to notify the product recall.

The article reports that Pioneer Surgical Technology Inc. has received 510(k) clearance from the U.S. Food and Drug Administration (FDA) in the marketing of its LowTop pedicle screw system. LowTop are bone screws implanted to the vertebral pedicle to treat spinal problems, trauma or deformity. The device will be released in the market in 2008.

Reports on the completion of a recall initiated by Plus Orthopedics USA Inc. to its Cancellous Bone Screw product in the U.S. Effect of the recall on the products' distribution; Details on the defect of the device; contact information.

Background: Medial malleolus fractures have traditionally been managed using partially threaded screws and/or Kirschner wire fixation. Using these conventional techniques, a non-union rate of as high as 20% has been reported. In addition too many patients complaining of prominent hardware as a source of pain post-fixation. This study was designed to assess the outcomes of medial malleolar fixation using a headless compression screw in terms of union rate, the need for hardware removal, and pain over the hardware site., Setting: Saint Louis University and Mercy Medical Center, Level 1 Trauma Centers, St. Louis, MO., Methods: After IRB approval, we used billing records to identify all patients with ankle fractures involving the medial malleolus. Medical records and radiographs were reviewed to identify patients with medial malleolar fractures treated with headless compression screw fixation. Our inclusion criteria included follow-up until full weight bearing and a healed fracture. Follow-up clinical records and radiographs were reviewed to determine union, complication rate and perception of pain over the site of medial malleolus fixation. Sixty-four ankles were fixed via headless compression screws and 44 had adequate follow-up for additional evaluation., Results: Seven patients had isolated medial malleolar fractures, 23 patients had bimalleolar fractures, and 14 patients had trimalleolar fractures. One patient (2%) required hardware removal due to cellulitis. One patient (2%) had a delayed union, which healed without additional intervention. Ten patients (23%) reported mild discomfort to palpation over the medial malleolus. The median follow-up was 35 weeks (range: 12-208 weeks). There were no screw removals for painful hardware and no cases of non-union., Conclusions: Headless compression screws provide effective compression of medial malleolus fractures and result in good clinical outcomes. The headless compression screw is a beneficial alternative to the conventional methods of medial malleolus fixation., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: In the United States there are more than 230,000 total hip replacements annually, and periprosthetic femoral fractures occur in 0.1-4.5% of those patients. The majority of these fractures occur at the tip of the stem (Vancouver type B1). The purpose of this study was to compare the biomechanically stability and strength of three fixation constructs and identify the most desirable construct., Methods: Fifteen medium adult synthetic femurs were implanted with a hip prosthesis and were osteotomized in an oblique plane at the level of the implant tip to simulate a Vancouver type B1 periprosthetic fracture. Fractures were fixed with a non-contact bridging periprosthetic proximal femur plate (Zimmer Inc., Warsaw, IN). Three proximal fixation methods were used: Group 1, bicortical screws; Group 2, unicortical screws and one cerclage cable; and Group 3, three cerclage cables. Distally, all groups had bicortical screws. Biomechanical testing was performed using an axial-torsional testing machine in three different loading modalities (axial compression, lateral bending, and torsional/sagittal bending), next in axial cyclic loading to 10,000 cycles, again in the three loading modalities, and finally to failure in torsional/sagittal bending., Results: Group 1 had significantly greater load to failure and was significantly stiffer in torsional/sagittal bending than Groups 2 and 3. After cyclic loading, Group 2 had significantly greater axial stiffness than Groups 1 and 3. There was no difference between the three groups in lateral bending stiffness. The average energy absorbed during cyclic loading was significantly lower in Group 2 than in Groups 1 and 3., Conclusions: Bicortical screw placement achieved the highest load to failure and the highest torsional/sagittal bending stiffness. Additional unicortical screws improved axial stiffness when using cable fixation. Lateral bending was not influenced by differences in proximal fixation., Clinical Relevance: To treat periprosthetic fractures, bicortical screw placement should be attempted to maximize load to failure and torsional/sagittal bending stiffness., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Objectives: This study was performed to determine (1) the incidence of humeral shaft fractures within the Medicare noncancer population, (2) the trends in utilization of humeral shaft fixation techniques by plate-and-screw devices and intramedullary nails, (3) differences in procedure times, and (4) the outcomes of individuals as measured by rate of secondary operations and 1-year mortality., Design/setting: Retrospective comparative cohort analysis. A cancer-free Medicare part B claims sample derived from a 5% sample from the years 1993 to 2007 was analyzed., Patients/intervention: Our cohorts were generated by diagnostic and procedural codes for humeral shaft fractures., Main Outcome Measurement: The incidence of humeral shaft fracture and trend in operative fixation were evaluated for all years of data. Surgical times were assessed by anesthesia Current Procedural Terminology codes. Outcomes and complications were assessed by Current Procedural Terminology codes. The proportion of individuals experiencing complications and 1-year mortality were compared by proportion hazards., Results: We identified 1385 claims for humeral shaft fractures over 15 years, with an adjusted rate of between 12.0 and 23.4 fractures per 100,000 beneficiaries. We identified 511 individuals who received surgical treatment for humeral shaft fractures, 451 of whom had complete 1-year follow-up data. Nail fixation was more prevalent than plate fixation most years and had shorter anesthesia time by 27.1 minutes (P < 0.0001). There were no significant differences in the complication rates between the 2 groups as measured by incidence of secondary operations and 1-year mortality., Conclusions: Intramedullary nails are used for the majority of operative humeral shaft fractures among Medicare beneficiaries. Nailing has a shorter mean operative time. The 2 surgical techniques had no significant differences in terms of risk of secondary procedures and 1-year mortality., Level of Evidence: : Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Unlabelled: The Food and Drug Administration has not cleared the following medical devices for the use described in this study. The following medical devices are being discussed for an off-label use: cervical lateral mass screws., Object: As an alternative for cases in which the anatomy and spatial relationship between C-2 and a vertebral artery precludes insertion of C-2 pedicle/pars or C1-2 transarticular screws, a technique that includes opposing laminar hooks (claw) at C-2 combined with C-1 lateral mass screws may be used. The biomechanical stability of this alternate technique was compared with that of a standard screw-rod technique in vitro., Methods: Flexibility tests were performed in 7 specimens (occiput to C-3) in the following 6 different conditions: 1) intact; 2) after creating instability and attaching a posterior cable/graft at C1-2; 3) after removing the graft and attaching a construct comprising C-1 lateral mass screws and C-2 laminar claws; 4) after reattaching the posterior cable-graft at C1-2 (posterior hardware still in place); 5) after removing the posterior cable-graft and laminar hooks and placing C-2 pedicle screws interconnected to C-1 lateral mass screws via rod; and 6) after reattaching the posterior cable-graft at C1-2 (screw-rod construct still in place)., Results: All types of stabilization significantly reduced the range of motion, lax zone, and stiff zone compared with the intact condition. There was no significant biomechanical difference in terms of range of motion or lax zone between the screw-rod construct and the screw-claw-rod construct in any direction of loading., Conclusions: The screw-claw-rod technique restricts motion much like the standard Harms technique, making it an acceptable alternative technique when aberrant arterial anatomy precludes the placement of C-2 pars/pedicle screws or C1-2 transarticular screws.

Background: Research on the relationship between orthopaedic volume and outcomes has focused almost exclusively on elective arthroplasty procedures. Geriatric patients who have sustained an intertrochanteric hip fracture are older and have a heavier comorbidity burden in comparison with patients undergoing elective arthroplasty; therefore, any advantage of provider volume in terms of mortality could be overwhelmed by the severity of the hip fracture condition itself. This study examined the association between surgeon and hospital volumes of procedures performed for the treatment of intertrochanteric hip fractures in Medicare beneficiaries and inpatient through ninety-day postoperative mortality., Methods: The Medicare 100% files of hospital and physician claims plus the beneficiary enrollment files for 2000 through 2002 identified beneficiaries who were sixty-five years of age or older and who underwent inpatient surgery for the treatment of an intertrochanteric hip fracture with internal fixation. Provider volumes of intertrochanteric hip fracture cases were calculated with use of unique surgeon and hospital provider numbers in the claims. Fixed effects regression analysis using generalized estimating equations was used to model the association between hospital and surgeon intertrochanteric hip fracture volume and inpatient through ninety-day mortality, controlling for age, sex, race, Charlson comorbidity score, subtrochanteric fracture, prefracture nursing home residence, Medicaid-administered assistance, surgical device, and year. The unadjusted inpatient, thirty, sixty, and ninety-day mortality rates and adjusted relative risks are reported., Results: Between March 1, 2000, and December 31, 2002, 192,365 claims met inclusion criteria and matched with provider information. The unadjusted inpatient, thirty-day, sixty-day, and ninety-day mortality rates were 2.91%, 7.92%, 12.34%, and 15.19%, respectively. Patients managed at lower-volume hospitals had significantly higher (10% to 20%) adjusted risks of inpatient mortality than those managed at the highest-volume hospitals. By sixty days postoperatively, the increased mortality risk persisted only among patients managed at the lowest-volume hospitals (six cases per year or fewer). Patients who were managed by surgeons who treated an average of two or three cases per year had the highest mortality risks when compared with patients managed by the highest-volume surgeons., Conclusions: Only the highest-volume hospitals showed an inpatient mortality benefit for Medicare patients with intertrochanteric hip fractures. Unlike the situation with elective arthroplasty procedures, our findings do not indicate a need to direct patients with routine hip fractures exclusively to high-volume centers, although the higher mortality rates found in the lowest-volume hospitals warrant further investigation.

Autogenous bone grafting of uncontained tibial bony defects was carried out in 18 patients during a cemented total knee arthroplasty. American Knee Society scores were used to compare the results of the grafted group with those of a control group of 132 total knee arthroplasty patients without a significant tibial bony defect. The patients were followed up for 10 years. There was a statistically significant difference in the mean knee scores of the 2 groups at the preoperative assessment. Postoperative results were comparable between the 2 groups, indicating a significant and similar improvement in the knee scores of the grafted and control groups. Autogenous bone grafting is an easy and reproducible method of dealing with uncontained tibial bony defects during a total knee arthroplasty.