Discharge to a Skilled Nursing Facility After Hip Fracture Results in Higher Rates of Periprosthetic Joint Infection

BACKGROUND

Femoral neck fractures (FNFs) in elderly patients are associated with major morbidity and mortality. The influence of postoperative discharge location on recovery and outcomes after arthroplasty for hip fractures is not well understood.

METHODS

A multisite retrospective cohort from 9 academic centers identified patients who had FNF treated with hemiarthroplasty or total hip arthroplasty between 2010 and 2019. Patients who had diagnoses of dementia, stroke, age > 80 years, or high energy fracture were excluded. Discharge location was identified, including home-based health services (HHS), inpatient rehabilitation (IPR), or a skilled nursing facility (SNF). Rates of reoperation, periprosthetic joint infection (PJI), and mortality were compared between cohorts. Multivariate logistic regressions were performed, adjusting for age, American Society of Anesthesiologists (ASA) score, body mass index, sex, and tobacco use. Statistical significance was defined as P < .05.

RESULTS

A total of 672 patients (315 HHS, 144 IPR, and 213 SNF) were included in this study. The average follow-up was 30 months. The SNF cohort was significantly older (P < .0001) with higher ASA scores (P < .0001) than the HHS cohort. In a logistic regression model adjusting for age, ASA score, and body mass index, the SNF cohort had higher mortality rates than the HHS cohort (P = .0296) and were more likely to have PJI within 90 days (odds ratio = 4.55, 95% confidence interval = 1.40, 4.74) and within 1 year (odds ratio = 3.08, 95% confidence interval = 1.08, 8.78). Time to PJI was significantly shorter in the SNF cohort (SNF 38 versus HHS 231 days, P = .0155). No differences were seen in dislocation or reoperation rates between the SNF and HHS cohorts. No differences were seen in complication rates between the IPR and HHS cohorts.

CONCLUSIONS

Discharge to a SNF after arthroplasty for FNF is associated with increased mortality and higher rates of PJI. Hip fracture care pathways that uniformly discharge patients to SNFs may need to be re-evaluated, and surgeons should consider discharge to home with HHS when possible.

Risk of reverse golf club deformity with medial plating of distal femur fracture

INTRODUCTION

This study described a deformity induced by medial plating of supracondylar distal femur fractures using plates that are precontoured for other anatomic locations.

MATERIALS AND METHODS

OTA/AO 33A fractures were created in 12 sawbone femurs and fixed with either a proximal humerus locking plate (PH), an ipsilateral lateral tibial plateau plate (LTP), or an ipsilateral medial distal tibial plate (MDT). A motion capture system measured changes in length and rotation of the distal femur as the plate was applied. Each plate underwent four trials and the mean and standard deviation (SD) for each measurement was reported. An analysis of variance with post hoc Tukey test compared malreduction measures between plate types.

RESULTS

All plates consistently created a varus deformity. There was lateral lengthening with a compensatory medial shortening and an increase in the lateral distal femoral angle. The distal fracture fragment was laterally translated, and internally rotated. The PH plate had significantly greater lateral length (27.39 mm SD 4.78, p = 0.007), shorter medial length (13.57 mm SD 4.99, p = 0.028), greater lateral translation (28.82 mm SD 5.70, p = 0.010) and greater widening of the lateral distal femoral angle (28.54° SD 4.98, p < 0.001) than the LTP and MDT plates. The MDT plate had significantly greater angulation anteriorly (8.40° SD 1.07, p < 0.001) and laterally (7.63° SD 3.10, p = 0.002) than the PH and LTP plates. There was no significant difference between plates in internal rotation (PH: 3.07° SD 2.79; LTP: 2.05° SD 1.05; MDT 3.81° SD 3.56; p = 0.659).

CONCLUSION

When dual plating supracondylar distal femur fractures, poor plate positioning and a mismatch between plate contour and the slope of the medial distal femur can lead to varus angulation, internal rotation, and lateral translation or a "reverse golf club deformity". After comparing three types of precontoured plates, the authors recommend initial evaluation of the ipsilateral proximal tibial plate when placing a plate along the medial distal femur.

LEVEL OF EVIDENCE

IV.

The EMS stress view: occult pelvic instability revealed by pre-hospital pelvic binder placement

PURPOSE

To describe and evaluate the serendipitous pelvic binder stress radiographs of lateral compression type (LC) pelvic ring injuries.

METHODS

This was a retrospective case series performed at a single, level I academic trauma center from 2016 to 2018. All patients presenting with a minimally displaced LC pelvic ring injury were reviewed (< 10 cm displacement on static pelvic radiographs). Patients with X-rays (XR) in a pelvic binder (EMS stress) and with the pelvic binder removed were included. Pelvic ring stability was determined by attending surgeon evaluation of EMS stress radiographs versus static XR of the pelvis. Patients were treated non-operatively and allowed to weight bear or taken to the operating room for exam under anesthesia (EUA) and potential operative fixation. Clinical success of treatment was determined by evaluation of further displacement at the completion of their most recent follow-up.

RESULTS

Thirty-seven patients of the initial 398 reviewed met inclusion criteria. Fourteen of 37 patients (38%) were categorized as stable with no significant pelvis displacement seen on EMS stress and were treated non-operatively without further sequelae (4.6 months mean follow-up). The remaining 23/37 (62%) were treated operatively. Occult instability was identified on EMS stress in 14 (61%) of those 23 patients and the remainder were determined to be unstable based upon fracture pattern or EUA. All patients went on to successful treatment without significant pelvic deformity (7.8 months mean follow-up).

CONCLUSION

The EMS stress XR is a valuable, opportunistic evaluation in LC pelvic ring injuries. This evaluation is a useful diagnostic adjunct to alert the provider that additional stress imaging may be indicated to evaluate for occult pelvic ring instability.

Validation of a novel large animal intra-articular tibial plafond fracture model

BACKGROUND

Large animal fracture models that allow for anatomic fracture fixation are currently lacking. It was hypothesized that a compressed air impaction system can generate a reproducible tibial plafond fracture and be adjustable to create fractures consistent with high and low energy fractures seen in humans.

METHODS

Pilot testing of the impaction system was done by impacting polyurethane foam blocks at varying compressed air pressures. A guillotine impaction test was performed on the same foam blocks to create an energy conversion. A total of 12 porcine hindlimb hindlimbs were subjected to low-energy (42.2 J) and high-energy (73.9 J) impact to create tibial plafond fractures.

FINDINGS

Guillotine impaction test demonstrated strong correlations between potential energy and foam block impaction depth (R² = 0.99). Compressed air impaction system test strongly correlated with foam block impaction depth (R² = 0.99). All six porcine hindlimbs in the low-energy group developed simple coronal split tibial plafond fractures. All six porcine hindlimbs in the high-energy group developed complex, multi-fragmentary tibial plafond fractures.

INTERPRETATION

This porcine fracture model created tibial plafond fracture patterns with similar fracture morphology as human patients without violation of the soft tissue structures or adjacent joints. This model would allow for anatomic fixation, the study of post-traumatic osteoarthritis, or the delivery of locally targeted therapeutics to the ankle joint.

Dual Approach to Talar Dome Increases Access for Fracture Care Without Osteotomy

BACKGROUND

There is no consensus surgical treatment algorithm for talar body fractures, with authors recommending both soft tissue-only and osteotomy-based approaches. This study evaluates talar dome access via dual approaches to the talar dome through anterolateral transligamentous (ATL) and modified posteromedial (mPM) approaches.

METHODS

Ten cadaveric legs (5 matched pairs) were included. An mPM approach, between flexor hallucis longus and Achilles tendon, and an ATL approach, utilizing the anterolateral interval with transection of anterior talofibular ligament and calcaneofibular ligament, were performed on each specimen. Order of approach was alternated within each pair. Accessible dome surface area (DSA) was outlined by drilling with a 1.6-mm Kirschner wire at the visualized talar dome margin both with and without 4 mm of tibiotalar distraction using an external fixator. Specimens were analyzed by computed tomography (CT). Primary outcome was accessible DSA. Student t tests compared DSA accessed by different exposure methods.

RESULTS

An initial mPM approach exposed 25.6% and 33.6% of DSA without and with distraction (P = .002). An initial ATL approach accessed 47.0% and 58.1% of DSA without and with distraction, respectively (P = .003). Accessibility via dual approaches was 71.7% and 93% of DSA without and with distraction with an initial ATL approach and 71.3% and 87.5% of DSA without and with distraction with an initial mPM approach (P = .96 and .37, respectively). The central talar dome was inaccessible in an almond-shaped area, tapered at the medial and lateral ends. Anterior, lateral, and posterior articular margins were able to be fully exposed, often with overlapping exposure between posterior and anterior approaches, with distraction reliably improving lateral visualization.

CONCLUSION

Dual approaches provided access to greater than 70% and 85% of talar DSA without and with distraction, respectively. Order of approach did not significantly affect exposure and thus should be determined by surgeon discretion. These results may promote soft tissue-only treatment strategies in talar body fracture care with an extensile exposure of the talar dome surface. Careful preoperative planning optimizes the advantages of this approach.

LEVEL OF EVIDENCE

Level IV, case series.

Dual Approach to Talar Body Fractures Increases Talar Dome Access for Fracture Care without Osteotomy

Category:

Trauma; Ankle; Hindfoot

Introduction/Purpose:

No consensus surgical treatment algorithm exists for talar body fractures, with authors recommending both soft-tissue and osteotomy-based approaches. This study evaluated the utility of dual approaches to the talar dome through anterolateral transligamentous (ATL) and modified posteromedial (mPM) approaches, both with and without distraction.

Methods:

Ten cadaveric legs (5 matched pairs) were included. A mPM approach, between FHL and Achilles tendon, and an ATL approach, utilizing an anterolateral incision with transection of the ATFL and CFL fibular insertions, were performed on each specimen. Order of approach was alternated within each pair. Accessible dome surface area (DSA) was outlined by drilling with a 1.6-mm Kirschner wire at the visualized talar dome margin both with and without 4mm of tibiotalar distraction. Specimens were analyzed by micro-computed tomography. Primary outcome was total accessible DSA. Student's t-tests compared DSA accessed by different exposure methods.

Results:

An initial mPM approach allowed access to 25.6% and 33.6% of DSA without and with distraction (p=0.002). An initial ATL approach provided access to 47.0% and 58.1% of DSA without and with distraction, respectively (p=0.003). No significant difference in DSA accessibility were observed for either approach when they were performed second. Accessibility via dual approaches was 71.7% and 93% of DSA without and with distraction with an initial ATL approach and 71.3% and 87.5% of DSA without and with distraction with an initial mPM approach (p=0.96 and 0.37, respectively). (Figure 1)

Conclusion:

Dual approaches provided access to greater than 70% and 85% of DSA without and with distraction. Order of approach did not change access. These results may promote soft-tissue only treatment strategies in talar body fracture care.

Increased Complications and Cost Associated With Hip Arthroplasty for Femoral Neck Fracture: Evaluation of 576,119 Medicare Patients Treated With Hip Arthroplasty

BACKGROUND

The benefit of total hip arthroplasty (THA) for treatment of osteoarthritis (OA) and femoral neck fractures (FNFs) in the geriatric population is well established. We compare perioperative complications and cost of THA for treatment of OA to hemiarthroplasty (HA) and THA for treatment of FNF.

METHODS

Data from the Centers for Medicare & Medicaid Services were used to identify all patients 65 years and older undergoing primary hip arthroplasty between 2013 and 2017. Patients were divided into 3 cohorts: THA for OA (n = 326,313), HA for FNF (n = 223,811), and THA for FNF (n = 25,995). Generalized regressions were used to compare group mortality, 90-day readmission, thromboembolic events, and 90-day episode costs, controlling for age, gender, race, and comorbidities.

RESULTS

Compared to patients treated for OA, FNF patients were older and had significantly more comorbidities (all P < .001). Even among the youngest age group (65-69 years) without comorbidities, FNF was associated with a greater risk of mortality at 90 days (THA-FNF odds ratio [OR] 9.3, HA-FNF OR 27.0, P < .001), 1 year (THA-FNF OR 7.8, HA-FNF OR 19.0, P < .001) and 5 years (THA-FNF hazard ratio 4.5, HA-FNF hazard ratio 10.0, P < .001). The average 90-day direct cost was $12,479 and $14,036 greater among THA and HA for FNF respectively compared to THA for OA (all P < .001).

CONCLUSION

Among Centers for Medicare & Medicaid Services hip arthroplasty patients, those with an FNF had significantly higher rates of mortality, thromboembolic events, readmission, and greater direct cost. Reimbursement models for arthroplasty should account for the distinctly different perioperative complication and resource utilization for FNF patients.

True antiglide fixation of Danis-Weber B fibula fractures has lower rates of removal of hardware

INTRODUCTION

Plating of unstable OTA/AO 44-B2 equivalent lateral malleolus (Danis-Weber B) fractures has been associated with pain, peroneal irritation, and the need for subsequent hardware removal (ROH). The purpose of this study is to retrospectively compare the rates of ROH in unstable Weber B fractures fixed with a posterior, true antiglide plate with no screws in the distal segment versus those that were fixed with a similarly placed posterior, neutralization construct that included screws in the distal fragment. Thus, evaluating the role of the distal screws in rates of ROH.

METHODS

Skeletally mature patients that were treated for an unstable, isolated Weber B fracture at a single level-1 trauma center over a ten-year period were reviewed. Fractures treated with a single posterior plate with at least six months of follow-up were included and those fixed with a direct lateral plate were excluded. The primary outcome of this study was hardware removal defined as entire plate removal; isolated syndesmotic screw removal was not included.

RESULTS

Ninety-six patients were included in the study with average age of 46 years (range 17-83) and mean length of follow-up of 24.5 months (range 6.1-140.3). There were 33 patients in the antiglide group (mean follow-up 25.5 months) and 63 in the neutralization plate group (mean follow-up 24 months, p=0.81). Fractures fixed with or without distal screws had equivalent excellent results related to bony union and alignment. However, there was a statistically significant decrease in ROH rates in the antiglide group (antiglide ROH rate 15.2%; neutralization ROH rate 38.1%; p=0.02). Relative risk of ROH with antiglide plate was 0.4 (95% CI 0.17 - 0.95; p=0.04).

CONCLUSIONS

Antiglide plating shows a significant risk reduction in the rate of ROH when compared to posterior based neutralization plating. A true antiglide plating construct should be considered as a safe and effective way of managing Weber B fractures with a lower relative risk of a second operation for hardware removal.

LEVEL OF EVIDENCE

Therapeutic level III. See Instructions for Authors for a complete description of levels of evidence.

Emergency Department Stress Radiographs of Lateral Compression Type-1 Pelvic Ring Injuries Are Safe, Effective, and Reliable

BACKGROUND

Occult instability of lateral compression type-1 (LC1) pelvic ring injuries may be determined with a fluoroscopic stress examination under anesthesia (EUA) performed in the operating room. We hypothesized that LC1 injuries, similar to some fractures of the extremities, could be radiographically stressed for stability in the emergency department (ED). Our primary objective was to determine if stress examination of LC1 fractures could be safely and accurately performed in the ED and could be tolerated by patients.

METHODS

A prospective, consecutive series of 70 patients with minimally displaced LC1 pelvic injuries (<10-mm displacement on presentation) underwent stress examinations performed by the on-call orthopaedic resident in the ED radiology suite. The stress examination series included static 40° inlet, internal rotation stress inlet, and external rotation stress inlet views. Pelvic fractures that had positive stress results (≥10 mm of overlap of the rami) were indicated for a surgical procedure. These fractures also underwent EUA in order for the 2 techniques to be compared.

RESULTS

All patients tolerated the ED stress examination without general anesthetic or hemodynamic instability. Fifty-seven patients (81%) had negative stress results and were allowed to bear weight. All patients with negative stress results who had 3-month follow-up went on to radiographic union without substantial displacement. For the patients with a positive stress result in the ED, the mean displacement was 15.15 mm (95% confidence interval [CI], 10.8 to 19.4 mm) for the ED stress test and 15.60 mm (95% CI, 11.7 to 19.4 mm) for the EUA (p = 0.86). Two patients with a negative ED stress test did not mobilize during their hospitalization and underwent EUA and conversion to a surgical procedure. Thus, a total of 11 patients underwent both stress testing in the ED and EUA; no patient had a positive result on one test but a negative result on the other.

CONCLUSIONS

ED stress examination of LC1 injuries is a safe and reliable method to determine pelvic ring stability. The displacement measured in the ED stress examination is similar to the displacement measured under general anesthesia. Furthermore, a negative ED stress examination predicts successful nonoperative treatment. Given the results of this study, we encourage the use of stress examination in the ED for LC1-type injuries involving complete sacral fractures only. Widescale adoption of this streamlined protocol may substantially diminish cost, anesthetic risk, and potential operations for patients.

LEVEL OF EVIDENCE

Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Treatment of Recalcitrant Femoral Shaft Nonunion With Medial Femoral Condyle Pedicled Autograft: Technical Trick

SUMMARY

Nonunited fractures of the femoral shaft and distal femur are usually successfully addressed with stabilization with or without autogenous bone grafting. For the small subset of these problems that prove recalcitrant to front-line treatment, a pedicled medial femoral condyle (MFC) bone flap can provide a source of vascularized autograft with minimal donor site morbidity. The MFC has gained recent widespread adoption as a free vascularized bone transfer, and here, we present a surgical technique and retrospective analysis of patients treated with a pedicled MFC technique. This serves as a useful treatment option for these difficult problems and may be especially helpful in low resource environments or where microsurgical anastomosis is not feasible.

Talar Dome Access Through Posteromedial Surgical Intervals for Fracture Care

BACKGROUND

Posterior talar body fractures are rare injuries without a consensus surgical approach. This study evaluates the accessible area of the talar dome through 2 posteromedial approach intervals (posteromedial [PM] and modified posteromedial [mPM]) both with and without distraction.

METHODS

Ten male cadaveric legs (5 matched pairs) were included. A PM approach, between flexor hallucis longus (FHL) and the tibial neurovascular bundle, and an mPM approach, between FHL and Achilles tendon, was performed on each pair. In total, 4 mm of distraction across the tibiotalar joint was applied with the foot held in neutral position. Accessible dome surface area (DSA) was outlined by drilling with a 1.6-mm Kirschner wire with and without distraction. Specimens were explanted and analyzed by micro-computed tomography with 3-dimensional reconstruction. Primary outcomes were total accessible DSA and sagittal plane access at predetermined intervals.

RESULTS

The PM approach allowed access to 19.1% of the talar DSA without distraction and 33.1% of the talar dome with distraction (P < .001). The mPM approach provided access to 20.4% and 35.6% of the talar DSA without and with distraction (P < .001). Both approaches demonstrated similar sagittal plane access at all intervals except the lateral border of the talus, where the mPM approach provided greater access both without distraction (20.5% vs 4.38%, P = .002) and with distraction (34.3% vs 17.8%, P = .02).

CONCLUSION

The mPM approach, using an interval between FHL and Achilles tendon, provides similar access to the posterior surface of talar dome and better sagittal plane access to the most lateral portion of the dome. The mPM interval provides the advantage of avoiding direct dissection of the tibial nerve or posterior tibial artery. Using an external fixator for distraction can improve talar dome visualization substantially.

LEVEL OF EVIDENCE

Level V, Cadaveric Study.

Mapping of Posterior Talar Dome Access Through Posteromedial Versus Posterolateral Approaches

OBJECTIVE

To evaluate the accessible area of the talar dome through 2 standard posterior approaches [posteromedial (PM) and posterolateral (PL)] with and without distraction.

METHODS

A standard PM or PL approach was performed with and without external fixator distraction on 12 through-knee cadaveric legs (6 matched pairs). The accessible area of the talar dome was outlined and imaged in a microcomputed tomography scanner to achieve 3D reconstructions of the accessible surface area. The study outcomes were accessible surface area of the talar dome in (1) total surface area and (2) sagittal plane distance of the talar dome at predetermined intervals.

RESULTS

The PM approach provided significantly more access to the talar dome than did the PL approach both with and without distraction (P < 0.001). The PM approach allowed access to 15.8% (SD = 4.7) of the talar dome without distraction and 26.4% (SD = 8.0, P < 0.001) of the talar dome with distraction. The PL approach provided access to 6.69% (SD = 2.69, P = 0.006 compared with PM) and 14.6% (SD = 6.24, P = 0.006 compared with PM) of the talar dome surface area without and with distraction. At the difficult to access posterocentral region (L50) of the talus, the PM approach without and with distraction allowed 26.7% (SD = 4.1) and 38.6% (SD = 5.6, P < 0.001) sagittal plane access compared with 18.7% (SD = 5.61, P = 0.03) and 27.5% (SD = 7.11, P = 0.003) through a PL approach.

CONCLUSION

The PM approach provides greater access to the posterocentral and PM talus. Using an external fixator for distraction can improve intraoperative visualization by at least 40%. This study provides a roadmap that can help guide talar dome surgical access for treatment of posterior talus fractures and help determine when an approach that includes an osteotomy can be avoided.

Are We Being Fooled by Fluoroscopy? Distortion May Affect Limb-Length Measurements in Direct Anterior Total Hip Arthroplasty

BACKGROUND

Distortion is an intrinsic phenomenon associated with image-intensified fluoroscopy that is both poorly understood and infrequently appreciated by orthopedic surgeons. Little information exists regarding its potential influence on intraoperative parameters during orthopedic surgery, let alone during direct anterior (DA) total hip arthroplasty (THA). The purpose of this study was to quantify the amount of potential error caused by fluoroscopic distortion during DA THA.

METHODS

Intra-operative fluoroscopic pelvic images from 74 DA THAs were reviewed by two independent readers. All images were obtained using the same fluoroscopic C-arm unit with a radiopaque grid attached to the image intensifier. The vertical distortion from a straight central horizontal line at the peripheries of images were measured and summed to yield the combined vertical distortion similar to how a surgeon calculates a side to side comparison of limb lengths. Simple linear regression was used to evaluate associations between total distortion and patient demographics, operating theaters, and various operative parameters.

RESULTS

The average combined distortion was 10.0mm (range 2.0-20.0mm). There was a significant difference in the average distortion observed in different theaters (P < .001). There was no association between distortion and patient demographics or fluoroscopic time (all, P > .05).

CONCLUSION

Fluoroscopic distortion is unpredictable and can cause a substantial amount of error when comparing limb lengths during DA THA. This is a critical finding as this amount of inaccuracy could lead to unintended implant positioning and limb-length discrepancies if unaccounted for.

Socioeconomic Status May Not Be a Risk Factor for Periprosthetic Joint Infection

BACKGROUND

Periprosthetic joint infection (PJI) is a devastating complication after total joint arthroplasty, carrying significant economic and personal burden. The goal of this study is to use an established database to analyze socioeconomic variables and assess their relationship to PJI. Additionally, we sought to evaluate whether socioeconomic factors, along with other known risk factors of PJI, when controlled for in a statistical model affected the familial risk of PJI.

METHODS

With approval from our Institutional Review Board we performed a population-based retrospective cohort study on all primary total joint arthroplasty cases of the hip or knee (n = 85,332), within a statewide database, between January 1996 and December 2013. We excluded 9854 patients due to age <18 years, missing data, history of PJI prior to index procedure, and no evidence of 2-year follow-up (excluding those with PJI). Cases that developed PJI following the index procedure (n = 2282) were compared to those that did not (n = 73,196).

RESULTS

After adjusting for covariates, patients with Medicaid as a primary payer were at greater risk for experiencing PJI (relative risk 1.40, 95% confidence interval [CI] 1.08-1.82, P = .01). There was no difference in risk between the groups associated with education level or median household income (all, P > .05). First-degree relatives of patients who develop PJI (hazard ratio 1.66, 95% CI 1.23-2.24, P = .001) and first-degree and second-degree relatives combined (hazard ratio 1.39, 95% CI 1.09-1.77, P = .007) were at greater risk despite controlling for the above socioeconomic factors.

CONCLUSION

Our study provides further support that genetic factors may underlie PJI as we did observe significant familial risk even after accounting for socioeconomic factors and payer status. We did not find a correlation between education level or household income and PJI; however, Medicaid payees were at increased risk. Continued study is needed to define a possible heritable disposition to PJI in an effort to optimize treatment and possibly prevent this complication.

Locked Plating and Advanced Augmentation Techniques in Osteoporotic Fractures

"The incidence of osteoporotic fracture is increasing with the aging US population. Because osteoporosis leads to a decrease in bone mineral density with a decrease in both trabecular and cortical bones, osteoporotic fracture presents fixation challenges with standard plate and screw constructs. Locked plating has been developed to create a fixed-angle plate-screw construct that is more resistant to failure in osteoporotic bone. Endosteal replacement, additional plates, and cement augmentation have all been demonstrated to further supplement osteoporotic fracture fixation. Technologies on the horizon to treat osteoporotic fracture include SMV screws, hydroxyapatite-coated implants, and far cortical locking screws."