Search

Background: Ankle fractures associated with syndesmotic injury have a poorer prognosis than those without such an injury. Anatomic reduction of the distal tibiofibular joint restores joint congruency and minimizes contact pressures, yet operative fixation of syndesmotic ankle injuries is frequently complicated by malreduction of the syndesmosis. Current methods of assessing reduction have been shown to be inadequate. As such, additional methods to judge the accuracy of syndesmotic reduction are required.Questions/purposes: The purposes of our study were (1) to determine the anatomic axis of the syndesmosis, or the trans-syndesmotic angle (TSA), and (2) to describe the intraoperative fluoroscopic appearance of syndesmotic clamp reduction oriented along the anatomic syndesmotic angle.Methods: Computed tomography (CT) scans of 45 uninjured adult ankles were analyzed to measure the TSA, defined as the angle between the plane of a lateral ankle radiograph and a line drawn perpendicular to the fibular incisura. Three-dimensional reconstructions of CT scans were then used to demonstrate clamp placement collinear with the TSA as would be seen on an intraoperative lateral ankle radiograph.Results: The average TSA measured 21±5° anterior to the plane of a lateral radiograph. When a simulated reduction clamp tine was placed on the fibular ridge and the clamp oriented along the TSA, the medial tine, as seen on a lateral radiograph, was within the anterior one-third of the tibia 93% of the time. It was, on average, 23±7% of the distance from the anterior to the posterior tibial cortex, with tine placement occurring in this range in 73% of ankles. The medial tine rested 53±17% of the distance between the anterior cortices of the tibia and fibula, with 71% of tines placed in this range.Conclusions: Reduction clamp placement oriented along the TSA has a predictable appearance on lateral ankle imaging and can guide clamp positioning during syndesmotic reduction. With one tine placed on the fibular ridge, placing the medial clamp tine in the anterior third of the tibia, or halfway between the anterior cortices of the tibia and fibula is the most accurate position for reduction in line with the TSA.Level Of Evidence: 2 (Retrospective diagnostic). [ABSTRACT FROM AUTHOR]

Introduction: Post-operative knee pain is common following intramedullary nailing of the tibia, regardless of surgical approach, though the exact source is controversial. Historically, the most common surgical approaches position the knee in hyperflexion, including patellar tendon splitting (PTS) and medial parapatellar (MPP). A novel technique, the semi-extended lateral parapatellar approach simplifies patient positioning, fracture reduction, fluoroscopic assessment, and implant insertion. It also avoids violation of the knee joint capsule. However, this approach has not yet been directly compared against the historical standards. We hypothesised that in a comparison of patient outcomes, the semi-extended approach would be associated with decreased knee pain and better function relative to knee hyperflexion approaches.Methods: A trauma patient database from a Level I centre was queried for patients who underwent intramedullary nailing of the tibia between 2009 and 2013. Patients were surveyed for knee pain severity (NRS scale 1 to 10) and location, and completion of the Lysholm Knee Scale (LKS). Data was compared between the semi-extended lateral parapatellar, medial parapatellar, and tendon splitting groups regarding knee pain severity, location, total LKS, and individual knee function scores from the Lysholm questionnaire. Pre-hoc power analysis determined the necessary sample size (n=34). Post-hoc analysis utilised two-way ANOVA analysis with a significance threshold of p<0.05.Results: Comparison of knee pain severity between the groups found no significant difference (p=0.69), with average ratings of: semi-extended (3.26), PTS (3.59), and MPP (3.63). Analysis found no significant differences in total LKS score (p=0.33), with average sums of: semi-extended (75.97), MPP (77.53), and PTS (81.68). Individual knee function scores from the LKS were similar between the groups, except for limping, with MPP being significantly worse (p=0.04). There was no significant difference in knee pain location (p=0.45).Conclusion: In this adequately-powered study, at minimum 1 year follow-up there were no significant differences between the 3 approaches in knee pain severity, location, or overall function. The three were significantly different in post-operative limping, with medial parapatellar having the lowest score. The semi-extended lateral parapatellar approach vastly simplifies many technical aspects of nailing compared to knee hyperflexion approaches, and does not violate the knee joint. [ABSTRACT FROM AUTHOR]

Objective: To report the current state of institutional protocols regarding the use of MRI in patients with external fixation devices (EFDs) in the United States., Design: National Survey Study., Participants: Practicing orthopaedic surgeons frequenting the Orthopaedic Trauma Association website were invited to participate in this study., Results: Sixty-two eligible orthopaedic surgeons completed the survey. No respondents reported any known harmful complications of MRI use with an EFD. Eight respondents (13%) reported at least one early scan termination because of mild warmth or vibration without any lasting complications. Fifty-six respondents (90%) reported delays to care related to MRI-EFD compatibility labeling, and 27 respondents (48%) reported delayed MRI scans in every patient with an EFD who needed one. Twenty-six surgeons (42%) had modified their practice in some way in response to these barriers. Examples include delaying EFD placement until after MRI, relying on CT arthrograms over MRI for surgical planning, and taking patients to the operating room to remove EFDs temporarily and then replace them. Nineteen respondents (31%) had developed formal protocols to address this issue, but having a written protocol was not associated with any decrease in delays ( P = 0.119). Eighty-nine percent of respondents thought there was a need for a national consensus guideline on this issue., Conclusion: Despite no previous reports of harmful complications, MRI utilization is frequently delayed or prevented in patients with EFDs in place. This is a pervasive problem nationally, which persists despite the implementation of written institutional protocols. Additional research is needed, potentially at the national level, to address this common issue., Level of Evidence: V., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Importance: Longer time to surgery (TTS) for hip fractures has been associated with higher rates of postoperative complications and mortality. Given that more than 300 000 adults are hospitalized for hip fractures in the United States each year, various improvement programs have been implemented to reduce TTS with variable results, attributed to contextual patient- and system-level factors., Objective: To catalog TTS improvement programs, identify their results, and categorize program strategies according to Expert Recommendations for Implementing Change (ERIC), highlighting components of successful improvement programs within their associated contexts and seeking to guide health care systems in implementing programs designed to reduce TTS., Evidence Review: A systematic review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Three databases (MEDLINE/PubMed, EMBASE, and Cochrane Trials) were searched for studies published between 2000 and 2021 that reported on improvement programs for hip fracture TTS. Observational studies in high-income country settings, including patients with surgical, low-impact, nonpathological hip fractures aged 50 years or older, were considered for review. Improvement programs were assessed for their association with decreased TTS, and ERIC strategies were matched to improvement program components., Findings: Preliminary literature searches yielded 1683 articles, of which 69 articles were included for final analysis. Among the 69 improvement programs, 49 were associated with significantly decreased TTS, and 20 programs did not report significant decreases in TTS. Among 49 successful improvement programs, the 5 most common ERIC strategies were (1) assess for readiness and identify barriers and facilitators, (2) develop a formal implementation blueprint, (3) identify and prepare champions, (4) promote network weaving, and (5) develop resource-sharing agreements., Conclusions and Relevance: In this systematic review, certain components (eg, identifying barriers and facilitators to program implementation, developing a formal implementation blueprint, preparing intervention champions) are common among improvement programs that were associated with reducing TTS and may inform the approach of hospital systems developing similar programs. Other strategies had mixed results, suggesting local contextual factors (eg, operating room availability) may affect their success. To contextualize the success of a given improvement program across different clinical settings, subsequent investigation must elucidate the association between interventional success and facility-level factors influencing TTS, such as hospital census and type, teaching status, annual surgical volume, and other factors.

Purpose: This study examined the outcomes and complications after treatment of unstable distal clavicle fractures with hook or locking plate fixation., Methods: A retrospective search was performed of all acute distal clavicle fractures treated with open reduction and internal fixation from 2009 to 2019 at a Level I trauma center. Patients were separated into hook and locking plate fixation groups. Rates of union, complications, and reoperation, were extracted. QuickDASH (Disabilities of Arm, Shoulder, and Hand) scores were determined., Results: Thirty-one patients met the inclusion criteria and were included in the study. Of these, 12 patients were treated with hook plates and 19 were treated with locking plates. All fractures healed without loss of reduction, regardless of implant selection. There were no immediate or long-term complications in either group. 83% of hook plate patients underwent planned implant removal, while 37% of locking plate patients requested implant removal secondary to irritation. QuickDASH scores were comparable and excellent in both groups., Conclusions: Hook and locking plate fixation for Neer type-II and type-V distal clavicle fractures have comparably high rates of union. Hook plates were removed routinely per protocol, while locking plates were removed only if symptomatic and occurred significantly less often.

Introduction: Increased overlap in the scope of practice between orthopaedic surgeons and podiatrists has led to increased podiatric treatment of foot and ankle injuries. However, a paucity of studies exists in the literature comparing orthopaedic and podiatric outcomes following ankle fracture fixation., Methods: Using an insurance claims database, 11,745 patients who underwent ankle fracture fixation between 2007 and 2015 were retrospectively evaluated. Patient data were analyzed based on the provider type. Complications were identified by the International Classification of Diseases, Ninth Revision, codes, and revision surgeries were identified by the Current Procedural Terminology codes. Complications analyzed included malunion/nonunion, infection, deep vein thrombosis, and rates of irrigation and débridement. Risk factors for complications were compared using the Charlson Comorbidity Index., Results: Overall, 11,115 patients were treated by orthopaedic surgeons and 630 patients were treated by podiatrists. From 2007 to 2015, the percentage of ankle fractures surgically treated by podiatrists had increased, whereas that treated by orthopaedic surgeons had decreased. Surgical treatment by podiatrists was associated with higher malunion/nonunion rates among all types of ankle fractures. No differences in complications were observed in patients with unimalleolar fractures. In patients with bimalleolar or trimalleolar fractures, treatment by a podiatrist was associated with higher malunion/nonunion rates. Patients treated by orthopaedic surgeons versus podiatrists had similar comorbidity profiles., Discussion: Surgical treatment of ankle fractures by orthopaedic surgeons was associated with lower rates of malunion/nonunion when compared with that by podiatrists. The reasons for these differences are likely multifactorial but warrants further investigation. Our findings have important implications in patients who must choose a surgeon to surgically manage their ankle fracture, as well as policymakers who determine the scope of practice., Level of Evidence: Level III-retrospective cohort study.

Objective: To determine how the utilization of open versus percutaneous treatment of posterior pelvic ring injuries in early-career orthopaedic surgeons has changed over time., Methods: Case log data from surgeons testing in the trauma subspecialty for part II of the American Board of Orthopaedic Surgery examination from 2003 to 2015 were evaluated. Current procedural terminology codes for percutaneous fixation (27216) and open fixation (27218) of the posterior pelvic ring were evaluated using a regression analysis., Results: A total of 377 candidates performed 2095 posterior ring stabilization procedures (1626 percutaneous, 469 open). Total case volume was stable over time [β = -1.7 (1.1), P = 0.14]. There was no significant change in the number of posterior pelvic ring fracture surgery cases performed per candidate per test year [β = 0.1 (0.1), P = 0.50]. The proportion of posterior pelvic ring cases performed percutaneously increased significantly from 49% in 2003 to 79% in 2015 [β = 1.0 (0.4), P = 0.03]. There was a significant decrease in the number of open cases reported per candidate [β = -0.07 (0.03), P = 0.008]., Discussion and Conclusion: Early-career orthopaedic surgeons are performing more percutaneous fixation of the posterior pelvic ring and less open surgery. The impact of this change in volume on surgeon proficiency is unknown and warrants additional research.

Objectives: Open wounds occur with calcaneus fracture from direct application of force and from tearing along the medial side of the fracture as the tuberosity displaces laterally. Secondary soft tissue injury can also occur from pressure of the displaced fracture fragments. Tongue-type fractures of the calcaneus lead to variable amounts of displacement of the posterior tuberosity. This displacement may threaten the posterior soft tissue envelope. Because many calcaneus fractures are splinted initially and immobilized for several weeks until swelling resolves, failure to acutely recognize the potential for posterior skin breakdown may lead to severe soft tissue morbidity. The purpose of this study was to determine the incidence of posterior skin involvement in tongue-type calcaneus fractures and to determine the patient and fracture characteristics that lead to high-risk situations., Setting: University level I trauma center., Patients/participants: All tongue-type calcaneus fractures treated at 1 institution between 2002 and 2007 were identified from a trauma registry. Of 954 patients with calcaneal fractures, 139 tongue-type calcaneus fractures in 127 patients formed the study group., Intervention: Patient demographics, comorbidities, injury mechanism, fracture displacement, and time to presentation were evaluated. Those injuries that were associated with posterior, secondary soft tissue breakdown were identified and compared to those without breakdown., Main Outcome Measurements: Univariate analysis and stepwise multinomial logistic regressions were used to identify significant predictors of posterior soft tissue compromise., Results: Twenty-nine fractures (21%) had some degree of posterior skin compromise at presentation, including 12 with threatened skin, 10 with partial thickness breakdown, and 7 with full thickness breakdown. Six soft tissue coverage procedures and one amputation resulted. Patients with posterior skin compromise were less likely to have a fall mechanism (P = 0.001), had significantly greater fracture displacement (P = 0.007), were more likely to smoke (P = 0.039), and were more frequently referred on a delayed basis (P = 0.007). Those with threatened posterior skin who were treated emergently with percutaneous reduction did not progress to soft tissue compromise., Conclusion: A high incidence (21%) of posterior skin compromise occurs in tongue-type calcaneus fractures. These should be treated with immediate reduction, plantarflexion splinting, and close monitoring. Although mechanism, displacement, and time to presentation were significantly correlated with posterior skin involvement, the surgeon should be aware of this potential complicating factor in all tongue-type fractures.

Background: Osteoporosis is a common disease characterized by decreased bone mass and increased fracture risk in postmenopausal women and the elderly. Hip fractures are among the most common consequences of osteoporosis and unfortunately usually occur late in the course of the disease. When a patient is admitted to the hospital with a fragility hip fracture, a unique opportunity for diagnosis and treatment presents itself. Fortunately, several medications have proven to be effective in lowering the risk of future fractures. The purposes of the present study were to test the hypothesis that most fragility hip fractures go untreated and to determine whether educational efforts to raise physician awareness have led to an improvement in osteoporosis treatment rates., Methods: A retrospective cohort study was performed with use of the patient databases at two university medical centers and one university-affiliated community hospital. The charts of 300 randomly selected patients were sorted with use of ICD-9 (International Classification of Diseases, Ninth Revision) codes for femoral neck fractures. There were 100 patients from each center, with twenty-five patients from each year between 1997 and 2000. The admitting diagnosis, mechanism of injury, admission medications, procedures performed during hospitalization, and discharge medications were then extracted and analyzed. During this period, the National Osteoporosis Foundation established guiding principles for the treatment of fragility fractures., Results: Of the seventy-five patients from all centers for each year from 1997 to 2000, 11%, 13%, 24%, and 29%, respectively, were discharged with a prescription for some medication targeting osteopenia, either supplemental calcium or an antiosteoporotic medication (estrogen, calcitonin, a bisphosphonate, or raloxifene). A trended chi-square analysis of this increase revealed a p value of <0.001, indicating that this improvement in treatment was unlikely due to chance alone. Fifty-eight (19.3%) of the 300 patients in the study received a prescription at the time of discharge. However, forty of these patients (13.3% of the overall group) received calcium and only eighteen (6.0% of the overall group) received a medication to actively prevent bone resorption and treat osteoporosis. In addition, no patient underwent a bone density scan while in the hospital., Conclusions: Elderly patients and postmenopausal women who are admitted to the hospital and diagnosed with a low-energy femoral neck fracture have been undertreated for osteoporosis. However, over the four years of the present study, there was a significant increase in the rate of treatment. It is hoped that treatment rates will continue to increase in the future with continued educational efforts.