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The current relative value units (RVU)-based system is built to reflect the varying presentation of ankle fractures (uni-malleolar vs bi-malleolar vs tri-malleolar) by assigning individual RVUs to different fracture complexities. However, no study has evaluated whether the current RVUs reflect an appropriate compensation per unit time following open reduction internal fixation for uni-malleolar versus bi-malleolar versus tri-malleolar ankle fractures. The 2012 to 2017 American College of Surgeons - National Surgical Quality Improvement Program files were queried using current Procedural Terminology (CPT) codes for patients undergoing open reduction internal fixation for uni-malleolar (CPT-27766,CPT-27769,CPT-27792), bi-malleolar (CPT-27814), and tri-malleolar (CPT-27822,CPT-27823) ankle fractures. A total of 7830 (37.2%) uni-malleolar, 7826 (37.2%) bi-malleolar and 5391 (25.6%) tri-malleolar ankle fractures were retrieved. Total RVUs, Mean RVU/minute and Reimbursement rate ($/min) and Mean Reimbursement/case for each fracture type were calculated and compared using Kruskal-Wallis tests. The mean total RVU for each fracture type was as follows: (1) Uni-malleolar: 9.99, (2) Bi-malleolar = 11.71 and 3) Tri-malleolar = 12.87 (p.001). A statistically significant difference was noted in mean operative time (uni-malleolar = 63.2 vs bi-malleolar = 78.6 vs tri-malleolar = 95.5; p.001) between the 3 groups. Reimbursement rates ($/min) decreased significantly as fracture complexity increased (uni-malleolar = $7.21/min vs bi-malleolar = $6.75/min vs tri-malleolar = $6.10; p.001). The average reimbursement/case was $358, $420, and $462 for uni-malleolar, bi-malleolar and tri-malleolar fractures respectively. Footankle surgeons are reimbursed at a higher rate ($/min) for treating a simple uni-malleolar fracture as compared to bi-malleolar and tri-malleolar fractures, despite the higher complexity and longer operative times seen in the latter. The study highlights the need of a change in the RVUs for bi-malleolar and tri-malleolar ankle fractures to ensure that surgeons are adequately reimbursed per unit time for treating a more complex fracture case.

Context Zoledronic acid (ZA) administered during the initial hospitalization for a fragility fracture improves the osteoporosis pharmacotherapy rate. Distinguishing the safety profile of inpatient ZA (IP-ZA) in this context is crucial if this approach is to be widely adopted. Objective To study the acute safety profile of IP-ZA. Design, Setting and Patients An observational study of patients admitted to the Massachusetts General Hospital with fragility fractures who were eligible to receive IP-ZA. Intervention Patients were treated with or without IP-ZA. Acetaminophen, either as a single pre-ZA dose or standing multiple-doses-per-day for 48 hours or longer after ZA infusion, was also administered along with protocolized vitamin D and calcium supplementation. Main outcome measures changes in body temperature, serum creatinine and serum calcium. Results 285 consecutive patients, meeting inclusion and exclusion criteria, are included in this analysis. 204 patients received IP-ZA. IP-ZA treatment was associated with a transient mean rise of body temperature of 0.31oC on the day following its administration. 15% of patients in the IP-ZA group and 4% in the non-treated group had temperatures above 38oC. Standing multiple-doses-per-day, but not a single pre-ZA dose of acetaminophen, effectively prevented this temperature increase. IP-ZA did not affect serum creatinine levels. Mean levels of serum total calcium and albumin-corrected calcium decreased by 0.54 mg/dl and 0.40 mg/dl, respectively, at their nadirs (Day 5). No patient experienced symptomatic hypocalcemia. Conclusions IP-ZA along with standing multiple-doses-per-day acetaminophen, administered to patients in the immediate post-fracture period, is not associated with significant acute adverse effects.

To compare the adverse event profile and patient comorbidity profile of lower extremity orthopedic trauma patients admitted via interfacility transfer (IT) to direct admission patients from home (DA).A total of 39,497 patients from 2012 to 2019 were identified in the ACS National Surgical Quality Improvement Program database. DA patients were compared to IT patients for differences in preoperative comorbidities, adverse events, length of stay (LOS), and readmissions in the 30-day postoperative period. Student-tests were used to assess continuous variables. Pearson's Chi-square and odds ratios were used for categorical variables.The interfacility transfer (IT) group comprised 7,167 patients, and the direct admission (DA) group 32,330 patients. IT patients were on average older (65.5 yo vs 58.8, p0.01), more likely to be American Society of Anesthesiologists Status2 (p0.01) and had a worse comorbidity profile for numerous preoperative risk factors. IT patients had significantly higher rates of mortality (3.3% vs. 1.4%, OR 2.29, 95%CI 1.96-2.77), major complications (10.2% vs 6.1%, OR 1.74, 95% CI 1.60-1.91), significantly higher readmission rates (5.8% vs 4.8%, p-value0.01, OR 1.22 95% CI 1.09-1.36) and more infectious complications (7% vs 4.7%, OR 1.54 95% CI 1.38-1.71) than DA patients. Transfer remained a significant factor predicting major adverse events in regression analysis controlling for patient characteristics and fracture type (p-value0.01, B 1.197, 95% CI 1.09-1.32).This study revealed IT patients undergoing operative management of pelvic, acetabular, and lower extremity fractures are at a significantly increased risk of major complications, readmission, and have a higher morbidity burden than direct admission patients. As healthcare transitions to value-based care and bundled payments, hospitals that accept a high volume of interfacility transfers will face exposure to added risk and financial penalties without adequate policy protections.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND: Critical access hospitals (CAHs) play an important role in providing access to care for many patients in rural communities. Prior studies have shown that these facilities are able to provide timely and quality care for patients who undergo various elective and emergency general surgical procedures. However, little is known about the quality and reimbursement of surgical care for patients undergoing surgery for hip fractures at CAHs compared with non-CAH facilities. QUESTIONS/PURPOSES: Are there any differences in 90-day complications, readmissions, mortality, and Medicare payments between patients undergoing surgery for hip fractures at CAHs and those undergoing surgery at non-CAHs? METHODS: The 2005 to 2014 Medicare 100% Standard Analytical Files were queried using ICD-9 procedure codes to identify Medicare-eligible beneficiaries undergoing open reduction and internal fixation (79.15, 79.35, and 78.55), hemiarthroplasty (81.52), and THA (81.51) for isolated closed hip fractures. This database was selected because the claims capture inpatient diagnoses, procedures, charged amounts and paid claims, as well as hospital-level information of the care, of Medicare patients across the nation. Patients with concurrent fixation of an upper extremity, lower extremity, and/or polytrauma were excluded from the study to ensure an isolated cohort of hip fractures was captured. The study cohort was divided into two groups based on where the surgery took place: CAHs and non-CAHs. A 1:1 propensity score match, adjusting for baseline demographics (age, gender, Census Bureau-designated region, and Elixhauser comorbidity index), clinical characteristics (fixation type and time to surgery), and hospital characteristics (whether the hospital was located in a rural ZIP code, the average annual procedure volume of the operating facility, hospital bed size, hospital ownership and teaching status), was used to control for the presence of baseline differences in patients presenting at CAHs and those presenting at non-CAHs. A total of 1,467,482 patients with hip fractures were included, 29,058 of whom underwent surgery in a CAH. After propensity score matching, each cohort (CAH and non-CAH) contained 29,058 patients. Multivariate logistic regression analyses were used to assess for differences in 90-day complications, readmissions, and mortality between the two matched cohorts. As funding policies of CAHs are regulated by Medicare, an evaluation of costs-of-care (by using Medicare payments as a proxy) was conducted. Generalized linear regression modeling was used to assess the 90-day Medicare payments among patients undergoing surgery in a CAH, while controlling for differences in baseline demographics and clinical characteristics. RESULTS: Patients undergoing surgery for hip fractures were less likely to experience many serious complications at a critical access hospital (CAH) than at a non-CAH. In particular, after controlling for patient demographics, hospital-level factors and procedural characteristics, patients treated at a CAH were less likely to experience: myocardial infarction (3% (916 of 29,058) versus 4% (1126 of 29,058); OR 0.80 [95% CI 0.74 to 0.88]; p < 0.001), sepsis (3% (765 of 29,058) versus 4% (1084 of 29,058); OR 0.69 [95% CI 0.63 to 0.78]; p < 0.001), acute renal failure (6% (1605 of 29,058) versus 8% (2353 of 29,058); OR 0.65 [95% CI 0.61 to 0.69]; p < 0.001), and Clostridium difficile infections (1% (367 of 29,058) versus 2% (473 of 29,058); OR 0.77 [95% CI 0.67 to 0.88]; p < 0.001) than undergoing surgery in a non-CAH. CAHs also had lower rates of all-cause 90-day readmissions (18% (5133 of 29,058) versus 20% (5931 of 29,058); OR 0.83 [95% CI 0.79 to 0.86]; p < 0.001) and 90-day mortality (4% (1273 of 29,058) versus 5% (1437 of 29,058); OR 0.88 [95% CI 0.82 to 0.95]; p = 0.001) than non-CAHs. Further, CAHs also had risk-adjusted lower 90-day Medicare payments than non-CAHs (USD 800, standard error 89; p < 0.001). CONCLUSION: Patients who received hip fracture surgical care at CAHs had a lower risk of major medical and surgical complications than those who had surgery at non-CAHs, even though Medicare reimbursements were lower as well. Although there may be some degree of patient selection at CAHs, these facilities appear to provide high-value care to rural communities. These findings provide evidence for policymakers evaluating the impact of the CAH program and allocating funding resources, as well as for community members seeking emergent care at local CAH facilities. LEVEL OF EVIDENCE: Level III, therapeutic study.

Despite increasing interest toward managing isolated ankle fractures in an outpatient setting, evidence of its safety remains largely limited. The 2007 to 2014 Humana Administrative Claims database was queried to identify patients undergoing open reduction internal fixation for unimalleolar, bimalleolar, or trimalleolar isolated closed ankle fractures. Two cohorts (outpatient versus inpatient) were then matched on the basis of age, sex, race, region, fracture type (uni-/bi-/trimalleolar) and Elixhauser Comorbidity Index to control for selection bias. Multivariate regression analyses were performed to report independent impact of outpatient-treated ankle fracture surgery on 90-day complications, readmission, and emergency department visit rates. Independent-samples t test was used to compare global 90-day costs between cohorts. A total of 5317 inpatient-treated and 6941 outpatient-treated closed ankle fractures were included in the final cohort. After matching and multivariate analyses, patients with outpatient ankle fractures, compared with patients with inpatient ankle fractures, had statistically lower rates of pneumonia (2.3% versus 4.0%; p.001), myocardial infarction (0.9% versus 1.8%; p = .005), acute renal failure (2.2% versus 5.3%; p.001), urinary tract infections (7.4% versus 12.3%; p.001), and pressure ulcers (0.9% versus 2.0%; p = .001). Outpatient ankle fractures also had lower rates of 90-day readmissions (9.7% versus 14.1%; p.001) and emergency department visits (13.8% versus 16.2%; p = .028). Last, overall 90-day costs for outpatient ankle fractures were nearly $9000 lower than costs for inpatient ankle fractures ($12,923 versus $21,866; p.001). Based on our findings, it appears that outpatient treatment of ankle fractures can be deemed safe and feasible in a select cohort of patients.

Background: The SARS-CoV-2 (COVID-19) pandemic has resulted in widespread cancellation of elective orthopaedic procedures. The guidance coming from multiple sources frequently has been difficult to assimilate as well as dynamic, with constantly changing standards. We seek to communicate the current guidelines published by each state, to discuss the impact of these guidelines on orthopaedic surgery, and to provide the general framework used to determine which procedures have been postponed at our institution. Methods: An internet search was used to identify published state guidelines regarding the cancellation of elective procedures, with a publication cutoff of March 24, 2020, 5:00 p.m. Eastern Daylight Time. Data collected included the number of states providing guidance to cancel elective procedures and which states provided specific guidance in determining which procedures should continue being performed as well as to orthopaedic-specific guidance. Results: Thirty states published guidance regarding the discontinuation of elective procedures, and 16 states provided a definition of “elective” procedures or specific guidance for determining which procedures should continue to be performed. Only 5 states provided guidelines specifically mentioning orthopaedic surgery; of those, 4 states explicitly allowed for trauma-related procedures and 4 states provided guidance against performing arthroplasty. Ten states provided guidelines allowing for the continuation of oncological procedures. Conclusions: Few states have published guidelines specific to orthopaedic surgery during the COVID-19 outbreak, leaving hospital systems and surgeons with the responsibility of balancing the benefits of surgery with the risks to public health.

Background: Type III open fractures are associated with an infection rate as high as 50%. The optimal antibiotic for open fracture prophylaxis remains unclear, and the literature comparing the safe...

As the current healthcare model transitions from fee-for-service to value-based payments, identifying cost-drivers of 90-day payments following surgical procedures will be a key factor in risk-adjusting prospective bundled payments and ensuring success of these alternative payment models. The 5% Medicare Standard Analytical Files data set for 2005-2014 was used to identify patients undergoing open reduction and internal fixation (ORIF) for isolated unimalleolar, bimalleolar, and trimalleolar ankle fractures. All acute care and post-acute care payments starting from day 0 of surgery to day 90 postoperatively were used to calculate 90-day costs. Patients with missing data were excluded. Multivariate linear regression modeling was used to derive marginal cost impact of patient-level (age, sex, and comorbidities), procedure-level (fracture type, morphology, location of surgery, concurrent ankle arthroscopy, and syndesmotic fixation), and state-level factors on 90-day costs after surgery. A total of 6499 patients were included in the study. The risk-adjusted 90-day cost for a female patient, aged 65 to 69 years, undergoing outpatient ORIF for a closed unimalleolar ankle fracture in Michigan was $6949 ± $1060. Individuals aged

Objectives To describe surgical technique for proper placement of the clavicle hook plate, determine whether there is subacromial impingement caused by hook plate fixation, and evaluate the mechanical strength of the clavicle hook plate construct. Methods Eight fresh-frozen cadaveric shoulders with a mean age of 48 years (range, 37-69) were used. Open reduction and internal fixation of simulated Rockwood type V AC joint dislocation was performed with the clavicle hook plate. Three-dimensional computed tomography studies and arthroscopic evaluation were performed with the glenohumeral joint in different orientations to assess the position of the hook plate relative to relevant joint structures. The clavicle was then superiorly loaded to mechanical failure. Results Computed tomography evaluations showed no contact between the humerus and the hook plate. Distance between the greater tuberosity and hook plate ranged from 14 to 31 mm with maximal shoulder forward flexion and 8.1-25.4 mm with maximal shoulder abduction. Arthroscopic evaluation of the subacromial space demonstrated that with maximal abduction/forward flexion, there was abutment of the rotator cuff with the hook plate in 6 of 8 specimens. In mechanical testing, mean failure load was determined to be 1011 N (range, 380-1563 N). Failure mechanisms included acromion fracture (4), slippage of the hook under acromion (3), and distal clavicle fracture (1). Conclusions This study demonstrates that the clavicle hook plate reduces AC joint dislocation or distal clavicle fractures anatomically, has supra-physiologic mechanical strength, does not cause bony impingement, and exhibits rotator cuff impingement only with maximal abduction/forward flexion of the shoulder.

Most of the current orthopaedic residents are considered Millennials (born between 1981 and 1996) and are often trained by attending surgeons who are from Generation X (born between 1965 and 1980) or the Baby Boomer generation (born between 1946 and 1964). The Generation X orthopaedic surgeons were largely trained by Baby Boomers who were very demanding of their trainees and expected excellence. The Baby Boomers had been inspired, mentored, and trained by the Greatest Generation (born between 1901 and 1927). Baby Boomers took nothing for granted and nothing was given to them on a silver platter. Generation X was trained under these premises and was expected to abide by similar values. Regarding the next generation of residents, current faculty hope to instill the same qualities that had been instilled in them during their training. This value transference sometimes presents a challenge because of the differences in attitudes and perspectives that may exist between Millennial residents and their predecessors regarding work-life balance, teaching styles, the regulation of duty hours, and feedback assessments. These differences require an evolution in the methods of surgical education to optimize the educational benefit and ensure good will and rapport between the generations. Trainees and faculty alike have a responsibility to understand each other's differences and come together to ensure that knowledge, experience, values, and skill sets are effectively passed on to a new generation of orthopaedic surgeons.

BACKGROUND: A significant proportion of patients undergoing hip fracture surgery are transferred from other locations. With no current orthopedic literature present, we sought to study the impact of transfer location on 30-day outcomes following geriatric hip fracture surgery. MATERIALS & METHODS: The 2015–2016 ACS-NSQIP database was queried using CPT codes to retrieve records of geriatric patients undergoing hip fracture surgery (total hip arthroplasty/THA, hemiarthroplasty/HA and open reduction internal fixation/ORIF). Transfer status was defined into four groups – 1) No transfer (admitted from home), 2) From acute care hospital, 3) From nursing home/chronic care facility and 4) From outside emergency department (ED). Patients with missing data were excluded. A total of 31,218 patients were included in the final cohort. RESULTS: Out of 31,218 patients - 23,659 (75.8%) were admitted from home, 1574 (5.0%) from acute care hospitals, 3299 (10.6%) from nursing home/chronic care facilities and 2686 (8.6%) from outside EDs. Following adjusted analysis, transfer from nursing home vs. home was associated with higher odds of 30-day mortality (OR 1.57 [95% 1.36–1.80]; p

Background: We compiled evidence from a large national surgical database to identify the incidence, risk factors and postoperative impact of Clostridium difficile infection (CDI) in patients undergoing hip fracture repair. Methods: We identified 17,474 patients who underwent hip fracture repairs in 2015 using the ACS-NSQIP database. Interventions studied were open reduction/Internal fixation, total hip arthroplasty or hemiarthroplasty being performed for traumatic hip fractures. Outcomes studied were incidence, preoperative and postoperative risk factors for occurrence of CDI were studied using descriptive and statistical analysis. Results: A total of 92 patients (0.53%) developed CDI within 30 days of the operation. Following adjustment using multi-variate logistic regression, preoperative and hospital-associated factors associated with development of CDI were smoking (OR 1.75 [95% CI 1.03–2.99]), hypertension (OR 1.70 [95% CI 1.01–2.85]), hyponatraemia (OR 1.65 [95% CI 1.04–2.63]), prior systemic inflammatory response syndrome (SIRS) (OR 2.18 [95% CI 1.32-3.59]) and a length of stay >7 days (OR 1.98 [95% CI 1.11–3.53]. Postoperative factors associated with occurrence of CDI were occurrence of a deep surgical site infection (SSI) (OR 5.89 [95% CI 1.31–26.6]), a stay in the hospital >30 days (OR 6.56 [95% CI 2.56–16.9]) and unplanned reoperations (OR 2.78 [95% CI 1.29–5.99]). Conclusion: As we move toward an era of bundled-payment models, identification of risk factors associated with the occurrence of postoperative complications, such as CDI, will help curb excess healthcare utilisation and costs associated with the management of this complication.

Introduction:Despite an increasing number of elderly individuals undergoing surgical fixation for ankle fractures, few studies have investigated peri-operative outcomes and safety of surgery in an octogenarian and nonagenarian population (age >80 years).Materials and Methods:The 2012-2017 American College of Surgeons database was queried for patients undergoing open reduction internal fixation for isolated uni-malleolar, bi-malleolar and tri-malleolar ankle fractures. The study cohort was divided into 3 comparison groups (age 80). Multi-variate regression analyzes were used to compare the independent effect of varying age groups on 30-day post-operative outcomes while controlling for baseline clinical characteristics and co-morbidity burdens.Results:A total of 19,585 patients were included: 5.3% were >80 years, 18.1% were 65-79 years, and 76.6% were 80 years were at a significantly Abstract: higher risk of 30-day wound complications (OR 1.84; p = 0.019), pulmonary complications (OR 3.88; p < 0.001), renal complications (OR 1.96; p = 0.015), septic complications (OR 3.72; p = 0.002), urinary tract infections (OR 2.24; p < 0.001), bleeding requiring transfusion (OR 1.90; p = 0.025), mortality (or 7.44; p < 0.001), readmissions (OR 1.65; p = 0.004) and non-home discharge (OR 13.91; p < 0.001).Discussion:Octogenarians undergoing ankle fracture fixation are a high-risk population in need of significant pre-operative surgical and medical optimization. With the majority of patients undergoing non-elective ORIF procedures, it is critical to anticipate potential complications and incorporate experienced geriatric providers early in the surgical management of these patients.Conclusions:Octogenarians and nonagenarians are fundamentally distinct and vulnerable age groups with a high risk of complications, readmissions, mortality and non-home discharges compared to other geriatric (65-79 years) and non-geriatric (

Background: Orthopaedic trauma etiologies are a common cause for amputation. Targeted muscle reinnervation (TMR) is a technique aimed at reducing or preventing pain and improving function. The purpose of this study was to examine postoperative phantom limb pain and residual limb pain following TMR in orthopaedic trauma amputees. In addition, postoperative rates of opioid and neuromodulator medication use were evaluated. Methods: Twenty-five patients (60% male) prospectively enrolled in a single-institution study and underwent TMR at the time of major limb amputation (48% nonmilitary trauma, 32% infection secondary to previous nonmilitary trauma, and 20% other, also secondary to trauma). Phantom limb pain and residual limb pain scores, pain temporality, prosthetic use, and unemployment status were assessed at the time of follow-up. The use of opioid and neuromodulator medications both preoperatively and postoperatively was also examined. Results: At a mean follow-up of 14.1 months, phantom limb pain and residual limb pain scores were low, with 92% of the patients reporting no pain or brief intermittent pain only. Pain scores were higher overall for male patients compared with female patients (p < 0.05) except for 1 subscore, and higher in patients who underwent amputation for infection (odds ratio, 9.75; p = 0.01). Sixteen percent of the patients reported opioid medication use at the time of the latest documented follow-up. Fifty percent of the patients who were taking opioids preoperatively discontinued use postoperatively, while 100% of the patients who were not taking opioids preoperatively discontinued postoperative use. None of the patients who were taking neuromodulator medication preoperatively discontinued use postoperatively (0 of 5). The median time to neuromodulator medication discontinuation was 14.6 months, with female patients taking longer than male patients (23 compared with 7 months; p = 0.02). At the time of the latest follow-up, the rate of reported prosthetic use was 85% for lower-extremity and 40% for upper-extremity amputees, with a rate of unemployment due to disability of 36%. Conclusions: The use of TMR in orthopaedic trauma amputees was associated with low overall pain scores at 2-year follow-up, decreased overall opioid and neuromodulator medication use, and an overall high rate of daily prosthetic use. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Introduction: We evaluated differences in reimbursement rates between native femoral shaft fractures treated with an intramedullary nail versus those undergoing repair of nonunion of femoral shaft fractures. Methods: The 2016 to 2017 American College of Surgeons—National Surgical Quality Improvement Program database was queried using International Classification of Diseases 10th Edition diagnosis codes and Current Procedural Terminology codes to identify patients undergoing surgery for native femoral shaft fractures and/or repair of nonunion of femoral shaft fracture with/without grafts. Results: The mean total relative value unit (RVU) and surgical time for each group were as follows: (1) native (RVU = 19.70, surgical time = 97.4 minutes), (2) nonunion w/out graft (RVU = 17.23, surgical time = 135.8 minutes), (3) nonunion w/graft (RVU = 18.88, surgical time = 164.5 minutes). Reimbursement rates decreased notably as complexity of case grew (native = $8.74/min versus nonunion w/graft = $6.07/min versus nonunion w/graft = $5.27/min; P < 0.001). The average reimbursement/case was $707 for native femoral shaft fracture, $618 for repair of nonunion w/out graft, and $678 for repair of nonunion with bone graft. Discussion: The study highlights the need for a change in the RVUs assigned to nonunions of the femoral shaft to ensure that the value of physician intensity is retained in future RVU evaluations.

Background: Discharge to an inpatient care facility (skilled-care or rehabilitation) has been shown to be associated with adverse outcomes following elective total joint arthroplasties. Current evidence with regard to hip fracture surgeries remains limited. Methods: The 2015–2016 ACS-NSQIP database was used to query for patients undergoing total hip arthroplasty, hemiarthroplasty and open reduction internal fixation for hip fractures. A total of 15,655 patients undergoing hip fracture surgery were retrieved from the database. Inpatient facility discharge included discharges to skilled-care facilities and inpatient rehabilitation units. Multi-variate regression analysis was used to assess for differences in 30-day post-discharge outcomes between home-discharge versus inpatient care facility discharge, while adjusting for baseline differences between the 2 study populations. Results: A total of 12,568 (80.3%) patients were discharged to an inpatient care facility. Discharge to an inpatient care facility was associated with higher odds of any complication (OR 2.03 [95% CI, 1.61–2.55]; p < 0.001), wound complications (OR 1.79 [95% CI, 1.10–2.91]; p = 0.019), cardiac complications (OR 4.49 [95% CI, 1.40–14.40]; p = 0.012), respiratory complication (OR 2.29 [95% CI, 1.39–3.77]; p = 0.001), stroke (OR 7.67 [95% CI, 1.05–56.29]; p = 0.045, urinary tract infections (OR 2.30 [95% CI, 1.52–3.48]; p < 0.001), unplanned re-operations (OR 1.37 [95% CI, 1.03–1.82]; p = 0.029) and readmissions (OR 1.38 [95% CI, 1.16–1.63]; p < 0.001) following discharge. Conclusion: Discharge to inpatient care facilities versus home following hip fracture surgery is associated with higher odds of post-discharge complications, re-operations and readmissions. These results stress the importance of careful patient selection prior to discharge to inpatient care facilities to minimise the risk of complications.

Background:. Orthopaedic trauma etiologies are a common cause for amputation. Targeted muscle reinnervation (TMR) is a technique aimed at reducing or preventing pain and improving function. The purpose of this study was to examine postoperative phantom limb pain and residual limb pain following TMR in orthopaedic trauma amputees. In addition, postoperative rates of opioid and neuromodulator medication use were evaluated. Methods:. Twenty-five patients (60% male) prospectively enrolled in a single-institution study and underwent TMR at the time of major limb amputation (48% nonmilitary trauma, 32% infection secondary to previous nonmilitary trauma, and 20% other, also secondary to trauma). Phantom limb pain and residual limb pain scores, pain temporality, prosthetic use, and unemployment status were assessed at the time of follow-up. The use of opioid and neuromodulator medications both preoperatively and postoperatively was also examined. Results:. At a mean follow-up of 14.1 months, phantom limb pain and residual limb pain scores were low, with 92% of the patients reporting no pain or brief intermittent pain only. Pain scores were higher overall for male patients compared with female patients (p < 0.05) except for 1 subscore, and higher in patients who underwent amputation for infection (odds ratio, 9.75; p = 0.01). Sixteen percent of the patients reported opioid medication use at the time of the latest documented follow-up. Fifty percent of the patients who were taking opioids preoperatively discontinued use postoperatively, while 100% of the patients who were not taking opioids preoperatively discontinued postoperative use. None of the patients who were taking neuromodulator medication preoperatively discontinued use postoperatively (0 of 5). The median time to neuromodulator medication discontinuation was 14.6 months, with female patients taking longer than male patients (23 compared with 7 months; p = 0.02). At the time of the latest follow-up, the rate of reported prosthetic use was 85% for lower-extremity and 40% for upper-extremity amputees, with a rate of unemployment due to disability of 36%. Conclusions:. The use of TMR in orthopaedic trauma amputees was associated with low overall pain scores at 2-year follow-up, decreased overall opioid and neuromodulator medication use, and an overall high rate of daily prosthetic use. Level of Evidence:. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Case A 20-year-old man with a history of right lower extremity fibular hemimelia previously treated with PRECICE femoral nail lengthening presented with a broken magnetic nail and a displaced fracture through an ununited distraction osteogenesis site. Using a combination of techniques, we removed the broken implant while maintaining the achieved limb length and preserving the native biology without bone grafting. Conclusion The unique challenges associated with the removal of a broken PRECICE femoral nail are described, with a technique for implant removal that preserves the achieved length, the innate biology of the distraction osteogenesis site, and promoting union without bone grafting.

Past literature has reported metabolic syndrome (MetS) to complicate postoperative care in patients undergoing various surgical procedures. We sought to analyze the impact of MetS on 30-day outcomes following hip fracture surgeries in the geriatric population. The 2015–2016 ACS-NSQIP database was queried for patients undergoing hip fracture repair using CPT codes for total hip arthroplasty (27130), hemiarthroplasty (27125) and open reduction internal fixation (27236, 27244, 27245). Only patients ≥ 65 years of age undergoing surgery due to a traumatic hip fracture were included in the study. MetS was defined using preset criteria used by other NSQIP studies as the presence of—(1) diabetes mellitus AND (2) hypertension requiring medication AND (3) BMI ≥ 30 kg/m2. Out of 31,621 patients, a total of 1388 (4.4%) geriatric patients with MetS underwent hip fracture surgery. Following adjusted analysis, the presence of MetS was associated with higher odds of a prolonged length of stay > 5 days (OR 1.14 [95% CI 1.01–1.29]; p = 0.031), deep SSI (OR 2.48 [95% CI 1.20–5.14]; p = 0.014), progressive renal insufficiency (OR 3.27 [95% CI 1.98–5.42]; p

Background We sought to determine how frequently pubic root fracture is incorrectly identified as anterior column fracture by radiologists and describe differences in characteristics and outcomes between injury patterns. Methods We identified 155 patients who sustained pelvic or acetabular fractures at a single, level 1 trauma academic institution. Pelvis computed tomography (CT) scans were evaluated to determine whether patients sustained an anterior column fracture or pubic root fracture. Demographic and clinical factors such as mortality, ambulatory status, type of treatment (nonoperative/surgery), and mechanism of energy were assessed. Results There were a total of 83 patients in the anterior column group and 72 patients in the pubic root cohort. Eighty-five percent of pubic root fractures were read as anterior column fractures by radiologists. A total of 77.8% of pubic root fractures had posterior ring involvement. Patients with true anterior column acetabular fracture were more likely to need surgery (63.86% vs 41.70%, P = 0.01) and be discharged to skilled nursing or inpatient rehabilitation (59.04% vs 40.27%, P = 0.02) compared to patients with pubic root fracture. Conclusion Pubic root fractures are frequently misread as anterior column fractures in radiology reports. Correctly diagnosing pubic root fractures and differentiating them from anterior column acetabular fractures can have significant impact on patients. Level of Evidence III, Therapeutic.

Trimalleolar ankle fractures are unstable injuries with possible syndesmotic disruption. Recent data have described inherent morbidity associated with screw fixation of the syndesmosis, including the potential for malreduction, hardware irritation, and post-traumatic arthritis. The posterior malleolus is an important soft tissue attachment for the posterior inferior syndesmosis ligament. We hypothesized that fixation of a sizable posterior malleolar (PM) fracture in supination external rotation type IV (SER IV) ankle fractures would act to stabilize the syndesmosis and minimize or eliminate the need for trans-syndesmotic fixation. A retrospective review of trimalleolar ankle fractures surgically treated from October 2006 to April of 2011 was performed. A total of 143 trimalleolar ankle fractures were identified, and 97 were classified as SER IV. Of the 97 patients, 74 (76.3%) had a sizable PM fragment. Syndesmotic fixation was required in 7 of 34 (20%) and 27 of 40 (68%), respectively, when the PM was fixed versus not fixed (p = .0002). When the PM was indirectly reduced using an anterior to posterior screw, 7 of 15 patients (46.7%) required syndesmotic fixation compared with none of 19 patients when the PM fragment was fixated with direct posterior lateral plate fixation (p = .0012). Fixation of the PM fracture in SER IV ankle fractures can restore syndesmotic stability and, thus, lower the rate of syndesmotic fixation. We found that fixation of a sizable PM fragment in SER IV or equivalent injuries through posterolateral plating can eliminate the need for syndesmotic screw fixation.

INTRODUCTION: Pre-operative urinary tract infection (UTI) may be associated with a high rate of complications following surgeries. Few studies have investigated the clinical impact of a pre-operative UTI on post-operative outcomes following surgeries for hip-fracture in geriatric patients. METHODS: The 2015–2016 ACS-NSQIP database was queried for patients undergoing hip fracture surgery using CPT-Codes for Total Hip Arthroplasty (27130), Hemiarthroplasty (27125) and Open Reduction/Internal Fixation (ORIF) (27236, 27244, 27245). Only patients ≥65 years of age undergoing surgery due to a traumatic hip fracture were included in the study. RESULTS: Out of 31,621 patients undergoing surgical treatment for a hip fracture, 410 (1.3%) had UTI at the time of the surgery. Following adjusted logistic regression analysis, UTI present at the time of surgery was associated with a longer length of stay>5 days (OR 5.46 [95% CI 2.27–13.1]; p = 0.008), any complication (OR 1.33 [95% CI 1.49–1.63]; p = 0.007), infectious complications (OR 1.71 [95% CI 1.19–2.47]; p = 0.004), non-infectious complications (OR 1.28 [95% CI 1.04–1.58]; p = 0.021), 30-day unplanned re-operations (OR 1.96 [95% CI 1.25–3.06]; p = 0.003) and 30-day readmissions (OR 2.04 [95% CI 1.57–2.66]; p

Category: Trauma Introduction/Purpose: Current literature revolving around understanding cost-determinants of 90-day payments following ankle fractures is limited to single-institution studies. As the current healthcare model transitions from fee-for-service to value- based payments, risk-adjustment of 90-day payments will be a key factor driving success of these bundled payment models. The current study, utilizes a national Medicare database, to understand patient-level, procedure-level and state-level variation in 90-day payments following open reduction internal fixation (ORIF) of isolated ankle fractures. Methods: The 2005-2014 5% Medicare SAF (Standard Analytical Files) database was queries using Current Procedural Terminology codes to identify patients undergoing open reduction internal fixation (ORIF) for uni-malleolar (27766, 27769, 27792), bi-malleolar (27814) and tri-malleolar (27822, 27823) ankle fractures. Patients with polytrauma or those undergoing a concurrent surgical fixation of the upper extremity, hip, femur, knee or tibia were removed from the study to capture a relevant cohort of isolated ankle fracture patients. All payments starting from day 0 of surgery up to day 90 post-operatively were used to calculate 90-day costs. Patients with missing data were excluded. Multi-variate linear regression modeling was used to derive marginal cost-impact of patient-level (age, gender, co-morbidities), procedure-level (fracture type, morphology, location of surgery, concurrent ankle arthroscopy and syndesmotic fixation) and state-level factors on 90-day costs following surgery. Results: Following application of inclusion/exclusion criteria, a total of 6,499 patients were included in the study. The risk- adjusted 90-day price of a non-geriatric (ageConclusion: Using a national administrative claims database, the study identifies numerous patient-level, procedure-level and state-level factors that significantly contribute to the cost-variation seen in 90-day payments following ORIF for ankle fracture. Risk adjustment of 90-day costs will become a necessity as bundled-payment models begin to take over the current fee-for-service model in fracture patients.

Category: Ankle, Trauma Introduction/Purpose: Tri-malleolar fractures, as compared to simple uni-malleolar fractures, are technically more challenging cases, have longer operative times and require a higher effort. The current RVU-based system is built to reflect the varying presentation of ankle fractures (uni-malleolar vs. bi-malleolar vs. tri-malleolar) by assigning individual RVUs to different fracture complexities. However, no study has evaluated whether the current RVUs reflect an appropriate compensation per unit time following open reduction internal fixation (ORIF) for uni-malleolar vs. bi-malleolar vs. tri-malleolar ankle fractures. Methods: The 2012-2017 American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP) files were queried using CPT codes for patients undergoing open reduction internal fixation (ORIF) for uni-malleolar (CPT-27766, CPT- 27769, CPT-27792), bi-malleolar (CPT-27814) and tri-malleolar (CPT-27822, CPT-27823) ankle fractures. A total of 7,830 (37.2%) uni-malleolar, 7,826 (37.2%) bi-malleolar and 5,391 (25.6%) tri-malleolar ankle fractures were retrieved. Total RVUs were calculated for each case. Mean RVU/minute was derived by dividing the total RVU of each case by the total operative time. Reimbursement rate ($/min) was calculated by multiplying the mean RVU/min of each procedure by a preset CMS-defined rate of $35.8887/RVU. Mean Reimbursement/case was calculated by multiplying the reimbursement rate by the operative time of each procedure. Kruskal-Wallis tests were used to compare RVUs, operative time and reimbursements between the three fracture groups. Results: The mean total RVU for each fracture type was as follows:- 1) Uni-malleolar: 9.99, 2) Bi-malleolar=11.71 and 3) Tri- malleolar=12.87 (pConclusion: Orthopaedic surgeons are reimbursed at a higher rate ($/min) for treating a simple uni-malleolar fracture as compared to bi-malleolar and tri-malleolar fractures, despite the higher complexity and longer operative times seen in the latter. The study highlights the need of a change in the RVUs for bi-malleolar and tri-malleolar ankle fractures to ensure that surgeons are adequately reimbursed per unit time for treating a more complex fracture case.

Category: Ankle, Trauma Introduction/Purpose: Metabolic syndrome (MetS) has been shown to be associated with significant post-operative morbidity. Despite an increasing prevalence of MetS in the US population, it’s impact on post-operative outcomes following ankle fractures remains limited. Methods: The 2012-2016 ACS-NSQIP database was used to query for patients undergoing ORIF for ankle fractures using Current Procedural Terminology (CPT) codes – 27766, 27769, 27792, 27814, 27822 and 27823. Patient undergoing surgery for polytrauma were excluded from the analysis. Records were further filtered to remove patients with missing data. The study cohort was divided into two groups – MetS vs. No MetS. MetS was identified using a pre-defined criteria, used previously in other studies, as the co-existence of 1) Diabetes Mellitus, 2) Hypertension and 3) BMI =30 kg/m2. Results: A total of 1,013 (6.7%) MetS underwent ORIF for ankle fractures. Following adjustment for differences in baseline demographic, co-morbidities, pre-operative and operative data, MetS was an independent predictor of experiencing any 30-day complication (OR 1.35 [95% CI 1.05 -1.74]; p=0.020), wound complications (OR 1.67 [95% CI 1.07-2.60]; p=0.024), renal complications (OR 3.54 [95% CI 1.20-10.48]; p=0.022), 30-day readmissions (OR 1.66 [95% CI 1.24-2.22]; p=0.001), 30-day unplanned re-operations (OR 1.69 [95% CI 1.14-2.51]; p=0.009). MetS was significantly associated with decreased odds of home discharge (OR 0.66 [95% CI 0.54-0.79]; pConclusion: Patients with MetS undergoing ORIF for ankle fractures are at an increased risk of experiencing adverse complications, re-admissions and re-operations within 30-days of the surgery. Providers should understand the need of appropriate post-operative surveillance in this high-risk group to minimize the risk of poor outcomes.

Introduction: While the benefits of early mobility for prevention of complications such as pneumonia, thromboembolic events, and improved mortality have been well studied in postsurgical patients, it is unclear which patients may struggle to achieve full weight-bearing on the first postoperative day. Materials and Methods: The 2016 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Hip Fracture Database was queried regarding the ability to achieve weight-bearing on first postoperative day for older adults. Cases that occurred secondary to malignancy were excluded or for which weight-bearing was unachievable on the first postoperative day due to medical reasons were excluded. Results: A total of 6404 patients met inclusion and exclusion criteria for the study, with 1640 (25.6%) patients unable to bear weight on the first postoperative day. Following adjusted analysis, nonmodifiable patient factors such as dependent (partial or total) functional health status, dyspnea with moderate exertion (odds ratio [OR]: 1.31 [95% confidence interval, CI: 1.04-1.65]), ventilator dependency, and preoperative dementia on presentation to hospital were associated with lack of achievement of weight-bearing on the first postoperative day. Modifiable patient factors such as presence of systemic inflammatory response syndrome (OR: 1.35 [95% CI: 1.11-1.64]), delirium, and low preoperative hematocrit and modifiable system factors including delayed time to surgery, total postoperative time >90 minutes, and transfer from an outside emergency department were also associated with inability to achieve weight-bearing on the first postoperative day. Discussion: Medical teams can utilize the results from this study to better identify patients preoperatively who may be at risk of not achieving early mobilization and proactively employ implement strategies to encourage mobility as soon as possible for hip fracture patients.

INTRODUCTION: Pelvic/acetabular fractures are associated with significant morbidity, mortality and cost to the society. We sought to utilize a national surgical database to assess the incidence and factors associated with prolonged length of stay (LOS), non-home discharge destination, 30-day adverse events and readmissions following surgical fixation of pelvic/acetabular fractures. MATERIALS & METHODS: The 2011–2016 ACS-NSQIP database files were queried using CPT codes (27215, 27217, 27218, 27226, 27227, 27228) for patients undergoing open reduction/internal fixation (ORIF) for pelvic/acetabular fractures. Patients undergoing additional procedures for associated fractures (vertebral fractures, distal radius/ulna fractures or femoral neck/hip fractures) were excluded from the analysis to ensure that a relevant population of patients with isolated pelvic/acetabular injuries were included in the analysis. A total of 572 patients were included in the final cohort. Severe adverse events (SAE) were defined as: death, ventilator use >48 h, unplanned intubation, stroke, deep venous thrombosis, pulmonary embolism, cardiac arrest, myocardial infarction, acute renal failure, sepsis, septic shock, re-operation, deep SSI and organ/space SSI. Minor adverse events (MAE) included – wound dehiscence, superficial SSI, urinary tract infection (UTI) and progressive renal insufficiency. An extended LOS was defined as >75th centile (>9days). RESULTS: Factors associated with AAE were partially dependent functional health status pre-operatively (p = 0.020), transfusion ≥1 unit of packed RBCs (p = 0.001), and ASA > II (p 140 min (p = 0.034) and Hct II (p = 0.007). Patients with an ASA > II (p = 0.001), total operative time>140 min (p 9 days. Male gender (p = 0.026), prior history of CHF (p = 0.024), LOS >9 days (p = 0.030) and >10% bodyweight loss in last 6 months before the procedure (p = 0.002) were predictors of 30-day mortality. CONCLUSION: Patients with ASA grade > II, greater co-morbidity burden and prolonged operative times were likely to experience adverse events and have a longer length of stay. Surgeons can utilize this data to risk stratify patients so that appropriate pre-operative and post-operative medical optimization can take place.

Introduction Despite abundant literature present on complications following hip fracture surgery, few studies have focused on the timing of these complications. Materials and methods The 2015–2016 American College of Surgeons – National Surgical Quality Improvement Program database was queried for patients ≥65 years of age undergoing hip fracture surgery, due to trauma, using CPT-Codes for total hip arthroplasty (27130), Hemiarthroplasty (27125) and Open Reduction/Internal Fixation (ORIF) (27236, 27244, 27245). For each complication being studied, the median time to diagnosis was determined along with the interquartile range (IQR). Cox-regression analyses were used to assess complication timings between various surgeries. Results A total of 31,738 were included in the final cohort. The median time of occurrence (days) for myocardial infarction was 2 [IQR 1–6], pneumonia 4 [IQR 2–12], stroke/CVA 3 [IQR 1–10], pulmonary embolism 5 [IQR 2–14], urinary tract infection (UTI) 8 [IQR 2–15], deep venous thrombosis (DVT) 9 [IQR 4–17], sepsis 11 [IQR 5–19], death 12 [IQR 6–20], superficial surgical site infection (SSI) 16 [IQR 12–22], deep SSI 23 [IQR 15–24] and organ/space SSI 19 [IQR 15–23]. Undergoing a THA vs. ORIF for hip fracture was associated a relatively early occurrence of pneumonia (day 3 [IQR 1–5.25]; p = 0.029) and urinary tract infection (day 4 [IQR 1–13]; p = 0.035) and a later occurrence of organ/space SSI (day 23.5 [IQR 19.5–26.75]; p = 0.002). Conclusion Orthopaedic trauma surgeons can utilize this data to optimize care strategies during the time-periods of highest risk to prevent complications from occurring early on in the course of post-operative care.

Subcutaneous internal plate fixation for anterior pelvic ring injuries has become more common, but implants require removal, usually by 12 weeks. The purpose of this article is to report a novel, minimally invasive, endoscopic-assisted technique for the removal of subcutaneous anterior pelvic plates safely and atraumatically without violating the underlying fascia.

Delirium is one of the most common acute psychiatric disturbances taking place in patients, particularly elderly, following hip fractures. Using a validated national surgical database, we sought to define the incidence, risk factors and clinical impact associated with the occurrence of delirium following open reduction and internal fixation (ORIF) for hip fracture.The 2016 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) Hip Fracture Targeted Procedure file-was retrieved and merged with the ACS-NSQIP 2016 file. A total of 7859 patients were finally included in the study.A total of 2177 (27.7%) patients experienced an episode of delirium following the procedure. Adjusted analysis showed an increasing age ≥ 65 years (p 0.001), partially dependent functional health status prior to surgery (p = 0.001), bleeding disorder (p = 0.012), preoperative dementia (p 0.001), preoperative delirium (p 0.001), being bed-ridden postoperatively (p 0.001), no weight bearing as tolerated on first postoperative day (p 0.001), an ASA grade II (p 0.001), non-emergency case (p = 0.010) and a prolonged length of stay 3 days (p 0.001). In addition, Black or African-American ethnicity had a lower odds of developing postoperative delirium (p = 0.020) as compared to Whites. Moreover, postoperative delirium was significantly associated with non-home discharge disposition (p 0.001), higher odds of 30-day readmissions (p 0.001) and 30-day mortality (p 0.001).This study identifies several risk factors associated with the occurrence of postoperative delirium in patients undergoing ORIF for hip fracture. Surgeons can utilize these data to risk stratify and consequently tailor an appropriate preoperative and postoperative care protocol to prevent the occurrence of delirium.

Objectives To compare radiographic and clinical midterm outcomes of posterior malleolar fractures treated with posterior buttress plating versus anterior to posterior lag screw fixation. Design Retrospective case series. Setting Level I trauma center. Patients/participants Between January 2002 and December 2010, patients with posterior malleolar fractures were identified by Current Procedural Terminology code and their charts reviewed for eligibility. Intervention Posterior malleolar fixation using either anterior to posterior (AP) lag screws or posterior buttress plating. Main outcome measurements Demographic data, length of follow-up, range of motion, and postoperative Short Musculoskeletal Function Assessment (SMFA) scores were the main outcome measurements. Immediate postoperative radiographs for residual gap/step-off and final follow-up radiographs for the degree of arthritis that developed were evaluated. Results Thirty-seven patients were eligible for the study, and 27 chose to participate. Sixteen patients underwent posterior buttress plating, and 11 underwent AP screw fixation with mean follow-up times of 54.9 and 32 months, respectively. Demographic data were similar between groups. The posterolateral plating group demonstrated superior postoperative SMFA scores compared with the AP screw group with statistically significant differences in the SMFA bother index (26.7 vs. 9.2, P = 0.03) and trends toward improvement in the mobility (28.3 vs. 12.9, P = 0.08) and functional indices (20.2 vs. 9.4, P = 0.08). There were no significant differences in the range of motion or the development of ankle arthritis over time. Conclusions Patients with trimalleolar ankle fractures in whom the posterior malleolus was treated with posterolateral buttress plating had superior clinical outcomes at follow-up compared with those treated with AP screws. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

© 2017 Elsevier Ltd Background Reoperation rates are high after surgery for hip fractures. We investigated the effect of a sliding hip screw versus cancellous screws on the risk of reoperation and other key outcomes. Methods For this international, multicentre, allocation concealed randomised controlled trial, we enrolled patients aged 50 years or older with a low-energy hip fracture requiring fracture fixation from 81 clinical centres in eight countries. Patients were assigned by minimisation with a centralised computer system to receive a single large-diameter screw with a side-plate (sliding hip screw) or the present standard of care, multiple small-diameter cancellous screws. Surgeons and patients were not blinded but the data analyst, while doing the analyses, remained blinded to treatment groups. The primary outcome was hip reoperation within 24 months after initial surgery to promote fracture healing, relieve pain, treat infection, or improve function. Analyses followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT00761813. Findings Between March 3, 2008, and March 31, 2014, we randomly assigned 1108 patients to receive a sliding hip screw (n=557) or cancellous screws (n=551). Reoperations within 24 months did not differ by type of surgical fixation in those included in the primary analysis: 107 (20%) of 542 patients in the sliding hip screw group versus 117 (22%) of 537 patients in the cancellous screws group (hazard ratio [HR] 0·83, 95% CI 0·63–1·09; p=0·18). Avascular necrosis was more common in the sliding hip screw group than in the cancellous screws group (50 patients [9%] vs 28 patients [5%]; HR 1·91, 1·06–3·44; p=0·0319). However, no significant difference was found between the number of medically related adverse events between groups (p=0·82; appendix); these events included pulmonary embolism (two patients [

The Letournel and Judet classification system is commonly used for classifying acetabular fractures. However, for orthopaedic surgeons with less experience with these fractures, correct classification can be more difficult. A stepwise approach has been suggested to enhance the inexperienced observer's ability to properly classify acetabular fractures, but it is unclear whether this actually improves one's ability.We asked (1) whether the use of a step-by-step algorithm improves residents' ability to classify acetabular fractures, (2) whether resident experience influenced ability to correctly classify acetabular fractures, and (3) which acetabular fractures were the most difficult to classify?Forty-six residents reviewed 15 sets of plain radiographs of 10 acetabular fracture patterns. Residents used the Letournel and Judet classification with only a diagram for reference. Three weeks later they were asked to classify the fractures a second time with the use of the algorithm. We then compared the number of correct responses from the two sessions and determined whether resident experience and use of the algorithm influenced correct classification.We found an improvement in the number of correctly classified fractures between the first (348/690 [50%]) and second (409/690 [59%]) sessions. Thirty-two of 46 participants improved their score with the use of the algorithm. There was a tendency for participants with more residency training to correctly classify the fractures.The algorithm provided modest improvement to the residents' ability to classify acetabular fractures. This or other such algorithms could provide residents with a basic tool to better evaluate standard radiographs and classify acetabular fractures.

Background: Lower-extremity injury severity scoring systems were developed to assist surgeons in decision-making regarding whether to amputate or perform limb salvage after high-energy trauma to the lower extremity. These scoring systems have been shown to not be good predictors of limb amputation or salvage. This study was performed to evaluate the clinical utility of the five commonly used lower-extremity injury severity scoring systems as predictors of final functional outcome. Methods: We analyzed data from a cohort of patients who participated in a multicenter prospective study of clinical and functional outcomes after high-energy lower-extremity trauma. Injury severity was assessed with use of the Mangled Extremity Severity Score; the Limb Salvage Index; the Predictive Salvage Index; the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score; and the Hannover Fracture Scale-98. Functional outcomes were measured with use of the physical and psychosocial domains of the Sickness Impact Profile at both six months and two years following hospital discharge. Four hundred and seven subjects for whom the reconstruction regimen was considered successful at six months were included in the analysis. We used partial correlation statistics and multiple linear regression models to quantify the association between injury severity scores and Sickness Impact Profile outcomes with the subjects' ages held constant. Results: The mean age of the patients was thirty-six years (interquartile range, twenty-six to forty-four years); 75.2% were male and 24.8% were female. The median Sickness Impact Profile scores were 15.2 and 6.0 points at six and twenty-four months, respectively. The analysis showed that none of the scoring systems were predictive of the Sickness Impact Profile outcomes at six or twenty-four months to any reasonable degree. Likewise, none were predictive of patient recovery between six and twenty-four months postoperatively as measured by a change in the scores in either the physical or the psychosocial domain of the Sickness Impact Profile. Conclusions: Currently available injury severity scores are not predictive of the functional recovery of patients who undergo successful limb reconstruction. Level of Evidence: Prognostic Level I. See Instructions to Authors for a complete description of levels of evidence.

Femoral neck fractures in young adults are uncommon and often the result of high-energy trauma. They are associated with higher incidences of femoral head osteonecrosis and nonunion. Multiple factors can play a significant role in preventing these devastating complications and contribute to a good outcome. While achieving an anatomic reduction and stable internal fixation are imperative, other treatment variables, such as time to surgery, the role of capsulotomy and the fixation methods remain debatable. Open reduction and internal fixation through a Watson-Jones exposure is the recommended approach. Definitive fixation can be accomplished with three cannulated or noncannulated cancellous screws. Capsulotomy in femoral neck fractures remains a controversial issue and the practice varies by trauma program, region and country. Until there is conclusive data (i.e. prospective and controlled) we recommend performing a capsulotomy. The data available is inconclusive on whether this fracture should be operated emergently, urgently or can wait until the next day. Until there is conclusive data available, we recommend that surgery should be done on an urgent basis. The key factors in treating femoral neck fractures should include early diagnosis, early surgery, anatomic reduction, capsular decompression and stable internal fixation.

Background: While the anatomy of the medial part of the knee has been described qualitatively, quantitative descriptions of the attachment sites of the main medial knee structures have not been reported. The purpose of the present study was to verify the qualitative anatomy of medial knee structures and to perform a quantitative evaluation of their anatomic attachment sites as well as their relationships to pertinent osseous landmarks. Methods: Dissections were performed and measurements were made for eight nonpaired fresh-frozen cadaveric knees with use of an electromagnetic three-dimensional tracking sensor system. Results: In addition to the medial epicondyle and the adductor tubercle, a third osseous prominence, the gastrocnemius tubercle, which corresponded to the attachment site of the medial gastrocnemius tendon, was identified. The average length of the superficial medial (tibial) collateral ligament was 94.8 mm. The superficial medial collateral ligament femoral attachment was 3.2 mm proximal and 4.8 mm posterior to the medial epicondyle. The superficial medial collateral ligament had two separate attachments on the tibia. The distal attachment of the superficial medial collateral ligament on the tibia was 61.2 mm distal to the knee joint. The deep medial collateral ligament consisted of meniscofemoral and meniscotibial portions. The posterior oblique ligament femoral attachment was 7.7 mm distal and 6.4 mm posterior to the adductor tubercle and 1.4 mm distal and 2.9 mm anterior to the gastrocnemius tubercle. The medial patellofemoral ligament attachment on the femur was 1.9 mm anterior and 3.8 mm distal to the adductor tubercle. Conclusions: The medial knee ligament structures have a consistent attachment pattern. Clinical Relevance: Identification of the gastrocnemius tubercle and the quantitative relationships presented here will be useful in the study of anatomic repairs and reconstructions of complex ligamentous injuries that involve the medial knee structures.

Item does not contain fulltext BACKGROUND: The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) has been extensively evaluated in groups of patients with osteoarthritis, yet not in patients with a femoral neck fracture. This study aimed to determine the reliability, construct validity, and responsiveness of the WOMAC compared with the Short Form-12 (SF-12) and the EuroQol 5D (EQ-5D) questionnaires for the assessment of elderly patients with a femoral neck fracture. METHODS: Reliability was tested by assessing the Cronbach alpha. Construct validity was determined with the Pearson correlation coefficient. Change scores were calculated from ten weeks to twelve months of follow-up. Standardized response means and floor and ceiling effects were determined. Analyses were performed to compare the results for patients less than eighty years old with those for patients eighty years of age or older. RESULTS: The mean WOMAC total score was 89 points before the fracture in the younger patients and increased from 70 points at ten weeks to 81 points at two years postoperatively. In the older age group, these scores were 86, 75, and 78 points. The mean WOMAC pain scores before the fracture and at ten weeks and two years postoperatively were 92, 76, and 87 points, respectively, in the younger age group and 92, 84, and 93 points in the older age group. Function scores were 89, 68, and 79 points for the younger age group and 84, 71, and 73 points for the older age group. The Cronbach alpha for pain, stiffness, function, and the total scale ranged from 0.83 to 0.98 for the younger age group and from 0.79 to 0.97 for the older age group. Construct validity was good, with 82% and 79% of predefined hypotheses confirmed in the younger and older age groups, respectively. Responsiveness was moderate. No floor effects were found. Moderate to large ceiling effects were found for pain and stiffness scales at ten weeks and twelve months in younger patients (18% to 36%) and in the older age group (38% to 53%). CONCLUSIONS: The WOMAC showed good reliability, construct validity, and responsiveness in both age groups of elderly patients with a femoral neck fracture who had been physically and mentally fit before the fracture. The instrument is suitable for use in future clinical studies in these populations. CLINICAL RELEVANCE: The results are based on two clinical trials. The questionnaires used concern pure, clinically relevant issues (ability to walk, climb stairs, etc.). Moreover, the results can be used for future research comparing clinical outcomes (or treatments) for populations with a femoral neck fracture.

Objective This study examines the relationship between self-recorded resident work hours and Orthopedic In-training Examination (OITE) scores, resident clinical performance, and American Board of Orthopedic Surgery pass rates. The hypothesis of this study is that increasing duty hours would have a positive correlation with clinical and OITE performance. Design Total duty hours and recorded operating room hours from a single orthopedic residency program were extracted from 2006 to 2012. During the same time span, OITE scores, resident clinical scores from the E-Valuation system, and American Board of Orthopedic Surgery pass rates were collected. The correlation between the variables was assessed using the Pearson correlation coefficient's precision statistic. Setting A large public tertiary academic center in the upper Midwestern United States. Participants A total of 82 orthopedic surgery residents over 7 years. Results A total of 82 residents were matriculated between 2006 and 2012. The average weekly recorded duty hours were as follows: postgraduate year 2 (PGY2) = 60 hours/week (Standard Deviation (SD) ± 4), PGY3=59 hours/week (SD ± 5), PGY4=51 hours/week (SD ± 4), PGY5=49 hours/week (SD ± 3). There was significant variability in the average number of hours worked among residents (range: 2128-3753h/y) for the full academic year. The OITE scores and the work hours were found to be independent of each other ( ρ = 0.017, p=0.825), and no correlation was found between OITE scores and the resident E-value scores ( ρ = 0.071, p=0.34). Residents spent 36% to 48% of their time in the operating room. Second year residents logging more hours scored higher on faculty evaluation of overall competency ( ρ = 0.31, p=0.035). Faculty assessment of technical skills had a positive correlation with operating room duty hours for PGY5 class ( ρ = 0.346, p=0.025). Conclusions A large variation in duty hours exists between resident-logged duty hours. No correlation exists between in-training scores and duty hours. There is a positive correlation between senior resident operating room hours and technical skill scores.