Together is better - RibScore and SCARF in the prediction of pulmonary complications and association with SSRF

BACKGROUND

Optimal treatment of patients with rib fractures requires identification of those patients at risk of pulmonary complications. It is also important to determine which patients would benefit from Surgical Stabilisation of Rib Fractures (SSRF). This study aims to validate two scoring systems (RibScore and SCARF score) in predicting complications and association with SSRF in an Australian trauma population. Clinical observation suggests that complications and criteria for SSRF is associated with anatomical and physiological factors. Therefore it is hypothesized that utilisation of an anatomical (RibScore) and physiological (SCARF) in conjunction will have improved predictive ability.

METHOD

Retrospective cohort study of rib fracture patients admitted to an Australian Level I trauma centre from Jan 2017 to Jan 2021. RibScore and SCARF score were calculated. Multivariate logistic regression was performed to determine risk factors associated with complications and SSRF, as well the scoring systems' ability via ROC AUC.

RESULTS

1157 patients were included. Higher median RibScore (1vs0; p < 0.001) and SCARF score (3vs1, p < 0.001) was associated with development of complications. Similarly for SSRF, RibScore (3vs0; p < 0.001), SCARF score (3vs1; p < 0.001) were higher. On multivariate analysis, increasing RibScore and SCARF score were associated with an increased risk of respiratory failure, pneumonia, death, and SSRF. The sensitivity for a patient with a high risk score in either RibScore or SCARF increased to 96.3 % in identifying pulmonary complications (from 66.7 % in RibScore and 88 % in SCARF, when used individually) and 91.9 % in identifying association with SSRF (from 86.5 % in RibScore and 70.3 % in SCARF).

CONCLUSION

RibScore and SCARF score demonstrate predictive ability for complications and SSRF in an Australian trauma rib fracture population. Combining a radiological score with a clinical scoring system demonstrates improved sensitivity over each score individually for identifying patients at risk of complications from rib fractures, those who may require SSRF, and those who are low risk.

STUDY TYPE

Retrospective Cohort Study LEVEL OF EVIDENCE: Level III.

Proximal humerus fractures: Postoperative protocols and factors affecting treatment decisions among shoulder and elbow and orthopedic trauma surgeons

Background

Proximal humerus fractures (PHFs) can lead to functional decline in geriatric and polytraumatized patients. Treatment of PHFs is an area of much debate and much variability between practitioners.

Objectives

We surveyed orthopedic trauma (OT) and shoulder and elbow (SE) surgeons to evaluate differences in postoperative protocols when treating acute PHFs with open reduction internal fixation (ORIF), intramedullary nailing (IMN), or hemi or reverse shoulder arthroplasty (rTSA).

Materials and methods

We distributed a web-based survey to three OT and SE associations between August 2018-April 2019. Questions included practice characteristics, standard postoperative protocols for weight-bearing, lifting, and range of motion (ROM) by treatment modality, and factors affecting modality and postoperative protocol decisions. We compared the subspecialties.

Results

239 surgeons [100 (42.2 %) OT, 118 (49.8 %) SE] completed the survey. OT were more likely to allow immediate ROM, lifting, and weight bearing following intramedullary nailing (IMN), open reduction internal fixation with a locking plate (ORIF), or arthroplasty (all p < 0.025), and to allow earlier unrestricted use of the extremity following IMN and arthroplasty (p = 0.001, p = 0.021 respectively). OT were more likely to consider operating on a PHF if there was contralateral upper extremity injury or need of the injured arm for work or activities of daily living (all p < 0.026). The subspecialties did not differ significantly on factors affecting their postoperative protocols. OT preferred IMN and SE surgeons preferred rTSA for allowing immediate unrestricted postoperative weight bearing, ROM, or lifting (all p < 0.001).

Conclusion

There are significant differences in postoperative protocols between trauma and SE surgeons when treating PHFs. Postoperative protocols should be further studied to balance surgical outcomes and the risks of functional decline when treating patients with PHFs.

Trends in the surgical management of proximal humerus fractures in Ireland from 2009 to 2022: An increasing usage of reverse shoulder arthroplasty

BACKGROUND

Proximal humeral fractures are a common injury accounting for a significant workload across orthopaedic departments. Though often managed non-operatively, surgical management is indicated for a proportion of patients.

AIMS

The aim of this study is to examine the trends in the management of proximal humeral fractures within Ireland over the past 13 years.

METHODS

A retrospective review of Irish Hospital In-Patient Enquiry (HIPE) data was performed between January 2009 and December 2022. Information regarding demographics including age and gender, along with procedure type were collated after patients with proximal humerus fractures, were identified using relevant ICD 10 codes.

RESULTS

Demographic details remained stable with females and those within the 55-69 year age bracket accounting for the highest proportion of patients. The mean annual number of procedures performed across the study period was 365 (273-508), with an increase from 288 cases in 2009 to 441 in 2022. Open reduction and internal fixation were the most common procedures accounting for 76.4% of cases. There has been a rising usage of total shoulder arthroplasty for fixation with an increase from < 5 cases in 2016 to 84 in 2022. A decrease in the usage of hemiarthroplasty and closed reduction internal fixation was also observed.

CONCLUSIONS

There has been an increasing volume of operatively managed proximal humeral fractures in Ireland, which sustained despite the 2015 publication of the highly publicised PROPHER trial. The increasing utilisation of total shoulder arthroplasty in acute trauma management is notable and necessitates appropriate training for trauma theatre personnel.

Radiological outcomes following open versus percutaneous fixation versus arthroscopically assisted percutaneous fixation of calcaneal fractures: a ten-year retrospective observational study

BACKGROUND

Calcaneal fractures are often major injuries associated with considerable morbidity. The optimal surgical management of displaced calcaneal fractures remains contentious with open, percutaneous and arthroscopically assisted percutaneous approaches all offering potential benefits for patients. The aim of this study was to assess which of these three separate surgical approaches to the management of displaced calcaneal fractures provides the best radiographic deformity correction.

METHODS

This is a retrospective observational study of all calcaneal fractures undergoing operative fixation at a single major trauma centre in the UK. The primary outcome was pre- and post-operative assessment of the deformity correction using radiographic parameters (angle of Gissane and Bohler's angle). Secondary outcomes included fracture configuration, complications and re-operation rate.

RESULTS

Between 01/01/2009 and 31/12/2019, 152 calcaneal fractures in 134 patients underwent operative management via either an open or percutaneous approach. One-way ANOVA testing of the pre- and post-operative radiographic parameters demonstrated that an open approach offered superior post-operative correction of Bohler's angle when compared to percutaneous alone (p < 0.05); however, there was no difference in post-operative angle of Gissane (p > 0.05). The mean follow-up for complication and re-operation data was 3.5 years (range 0.1-12.4). Overall complication rate following all surgical fixation was 7.2% with a further 32.2% requiring further long-term surgical intervention for subtalar arthritis or removal of metalwork.

CONCLUSION

Arthroscopically assisted percutaneous fixation does not offer superior radiographic deformity correction compared to percutaneous technique alone. Open fixation yielded improved correction of Bohler's angle when compared to percutaneous alone; however, there was no difference in post-operative angle of Gissane.

LEVEL OF EVIDENCE

III.

The effectiveness ORIF for neglected periprosthetic femoral fractures after hemiarthroplasty: A case report

INTRODUCTION AND IMPORTANCE

Periprosthetic fractures are a growing concern due to the increasing frequency of primary joint replacement surgery, with total hip arthroplasty being the most common. The incidence of periprosthetic fractures after revision surgery ranges from 4 to 11 %, with up to 30 % reported after knee revision surgery. This case report aims to describe the treatment of an 81-year-old woman suffering from neglected periprosthetic femoral fracture post hemiarthroplasty.

CASE PRESENTATION

An 81-year-old woman with a history of hemiarthroplasty surgery and hypertension was admitted to the ER with pain in her right thigh. She had a middle shaft femoral fracture and was scheduled for open reduction and internal fixation. Despite being fully conscious and having an average pulse rate and blood pressure, she had cardiomegaly and congestive pulmonum. Unfortunately, this patient did not receive appropriate medical treatment after it occurred for 1 month. After surgery, we evaluated the implant, and the implant stabilized the fracture. After 1-3 months after surgery, the LEFS (The Lower Extremity Functional Scale) score was found that the score increase significantly after surgery.

CLINICAL DISCUSSION

The Vancouver classification system manages periprosthetic fractures by assessing location, stability, and bone quality. Type A fractures involve the trochanter, while type B fractures are diaphyseal and can extend distally. ORIF is used for subtype B1 fractures, but newer techniques offer shorter operating times and fewer complications.

CONCLUSION

From this study, we can conclude that even though neglected cases procedure with ORIF promises a good outcome based on clinical evaluation.

Comparative efficacy and safety of medical treatments for proximal humerus fractures: a systematic review and network meta-analysis

BACKGROUND

Various surgical techniques and conservative therapies are useful tools for treating proximal humerus fractures (PHFs), but it is important to understand how to properly utilize them. Therefore, we performed a systematic review and network meta-analysis to compare and rank the efficacy and safety of medical treatments for PHF.

METHODS

PubMed, Embase, the Cochrane Library, and the ClinicalTrials.gov databases were systematically searched for eligible randomized controlled trials (RCTs) from inception until June 2022. Conservative therapy-controlled or head-to-head RCTs of open reduction internal fixation (ORIF), intramedullary nailing (IMN), hemiarthroplasty (HA), and reverse total shoulder arthroplasty (RTSA) used for the treatment of adult patients with PHF were included. The surface under the cumulative ranking (SUCRA) probabilities were applied to compare and rank the effects of medical treatments for PHF.

RESULTS

Eighteen RCTs involving 1,182 patients with PHF were selected for the final analysis. Mostly baseline characteristics among groups were well balanced, and the imbalanced factors only included age, injury type, medial comminution, blood loss, and cognitive function in single trial. The SUCRA probabilities found that RTSA provided the best effect on the Constant-Murley score (SUCRA: 100.0%), and the disabilities of the arm, shoulder and hand (DASH) score (SUCRA: 99.0%). Moreover, HA (SUCRA: 85.5%) and RTSA (SUCRA: 68.0%) had a relatively better effect on health-related quality of life than the other treatment modalities. Furthermore, conservative therapy (SUCRA: 84.3%) and RTSA (SUCRA: 80.7%) were associated with a lower risk of secondary surgery. Finally, the best effects on the risk of complications are varied, including infection was observed with conservative therapy (SUCRA: 94.2%); avascular necrosis was observed in HA (SUCRA: 78.1%), nonunion was observed in RTSA (SUCRA: 69.6%), and osteoarthritis was observed in HA (SUCRA: 93.9%).

CONCLUSIONS

This study found that RTSA was associated with better functional outcomes, while the comparative outcomes of secondary surgery and complications varied. Optimal treatment for PHF should consider patient-specific factors.

Minimally Invasive Percutaneous Leverage Reduction in the Treatment of Pediatric Salter-Harris IV and V Distal Femoral Physeal Fractures

OBJECTIVE

Distal femoral physeal fractures (DFPF) are rare but severe injuries in children, and there is no consensus on treatments for Salter-Harris (S-H) IV and V type of DFPF yet. This study aimed to introduce a minimally invasive technique using percutaneous leverage reduction combined with Kirschner wires fixation in treating pediatric DFPF with S-H IV and V type of injury and evaluate the clinical results.

METHODS

From July 2008 to June 2018, the authors' institute (Union Hospital, Tongji Medical College) retrospectively reviewed all patients diagnosed with pediatric DFPF. They were divided into two groups according to received treatment: children in the minimally invasive technique group were treated with a minimally invasive percutaneous leverage reduction technique, and the traditional technique group included the other children who received the conventional open reduction with internal fixation (ORIF). The surgical and clinical results of the two groups were collected and analyzed. The independent sample t-test analysis and the chi-square test were applied to compare continuous and categorical variables.

RESULTS

A total of 14 pediatric patients were recruited, including five females and nine males with DFEF. All eight patients in the minimally invasive technique group and four of the six patients in the ORIF group were treated successfully. One patient in the minimally invasive technique group opted for conservative treatment due to his good functional recovery, while the other two patients in the ORIF group needed further surgery because of the limb length discrepancy. There was a difference in surgery duration (p < 0.001), intraoperative fluoroscopy numbers (p = 0.006), intraoperative blood loss (p < 0.001), radiological union time (p = 0.003) and knee flexion angle (p < 0.001) between two groups. Patients in the minimally invasive technique group all received total knee society (KSS) scores, while the average scores in the ORIF group were lower (100.00 vs. 97.67).

CONCLUSION

The minimally invasive technique is better than conventional ORIF in terms of surgery duration, intraoperative blood loss, radiological union time, knee flexion angle and average KSS score. This percutaneous leverage reduction technique might be a good alternative for treating S-H IV and V DFPF in children.

Quality of life, functional and radiological outcomes of treatment of three-part and four-part proximal humerus fractures with locking plates and comparison in young versus older than 70 years: a retrospective cohort study

PURPOSE

Verify if the use of locking plates in displaced three- and four-part proximal humerus fractures has meant an improvement even in patients over 70 years of age.

MATERIAL AND METHODS

We performed surgery with locking plate fixation in 56 consecutive patients with three- and four-part proximal humerus fractures according to Neer's classification between 1/1/15 and 12/31/20 at our Hospital. Patient satisfaction, quality of life, functionality and radiological variables, as well as the comparison between patients older and younger than 70 years were the main outcomes. Likewise, factors and complications that may have influenced these variables were analyzed as secondary outcomes. The analysis of all these variables was performed after a minimum follow-up time of 24 months after surgery.

RESULTS

51 patients (92%) ended up satisfied or very satisfied according to the SF-36 test and with no disability or mild disability according to the DASH Score questionnaire. 46 patients (82%) obtained a satisfactory or excellent result according to the Neer scale modified by Cofield and 38 (68%) a good or excellent function according to the Constant Murley questionnaire. In 47 cases (84%) good radiological alignment was observed. Complications occurred in 20 patients (36%). The complications and the results of the SF-36, DASH Score, Neer scale modified by Cofield and Constant Murley tests depended on the radiological alignment (p = 0.009, p = 0.006, p = 0.025, p = 0.0008 and p = 0.0004). There were 37 patients younger than 70 years and 19 older than 70 years with no statistically significant differences when comparing the two groups.

CONCLUSIONS

This study demonstrates that satisfactory results can be obtained with osteosynthesis with locking plates in displaced proximal humerus fractures even in patients older than 70 years of age.

LEVEL OF EVIDENCE III

Retrospective Cohort, Treatment Study.

The Pitfalls of Difficult Distal Radius Fractures and Provisional Reduction

Distal radius fractures are some of the most common injuries encountered in orthopedics and require careful consideration when determining the appropriate treatment options. These fractures can be difficult injuries to treat surgically based on a large variability of fracture patterns, bone quality, and anatomy. It is important to understand the potential pitfalls associated with the treatment of difficult distal radius fractures to prevent avoidable complications. Some of these pitfalls include but are not limited to appropriate surgical exposure and soft tissue handling, provisional reduction, fixation type, and augmentation of fracture fixation.

Outcomes after ORIF are similar in young and elderly patients with tibial plateau fractures: A minimum 2-year follow-up study

BACKGROUND

This study aimed to compare the outcomes of open reduction internal fixation in young and elderly patients with tibial plateau fractures.

METHODS

A total of 224 patients with tibial plateau fractures treated with open reduction internal fixation at a level I trauma center from 2014 to 2019 were reviewed. The patients with a minimum follow-up of 2 years were divided into two groups, with those aged 60 years and older divided into the elderly group and those under 60 years divided into the young group. The mean follow-up time was 55 months (range: 24-80), and the primary outcomes were quality of reduction and function. The secondary outcomes included complications, fracture healing time, and conversion to total knee arthroplasty.

RESULTS

The elderly group had a higher proportion of women than the young group (61.1% vs. 23.9%, p < 0.001). Diabetes was more prevalent in the elderly cohort than in the young cohort (18.9% vs. 9.0%, p = 0.030). The rate of bone grafts was higher in the elderly group (57.8% vs. 41.8%, p = 0.019), but no significant differences were found between the groups regarding fracture characteristics, the operative time or intraoperative blood loss. The reduction quality, knee function, postoperative complications, healing time, and total knee arthroplasty conversion rate were not significantly different (p > 0.05) between the groups.

CONCLUSIONS

Open reduction internal fixation remains a satisfactory technique to treat tibial plateau fractures in the elderly. Although the rate of bone grafts is higher in elderly patients, they had comparable outcomes compared with their younger counterparts.

How good is good enough? Lessons learned from review of outcomes of 50 patients following extraoral open reduction and internal fixation of condylar neck and base fractures at a regional major trauma centre

The management of mandibular fractures is routine owing to their frequency, particularly those of the mandibular condyle, which are invariably common. Notwithstanding disparities in the literature, the international consensus towards which fractures of the mandibular condyle benefit from open surgical intervention is almost universally accepted. Closed reduction or non-operative management may be utilised in certain circumstances. Whilst outcome research has addressed complications with respect to operative side effects, outcomes related to the quality of bone repair and the setting in which this is delivered have not been universally addressed. The aim of this study was to determine the predictability of translating an indicated operative treatment plan into an acceptable functional result. We evaluated the outcomes of 59 extracapsular condylar fractures in 50 patients who were treated by extraoral open reduction and internal fixation (ORIF) between March 2021 and August 2022. We reviewed demographic data, surgical approach, and plating strategy, and critically evaluated the clinical and radiological outcomes. Whilst we found that the quality of reduction was not universally perfect, the majority were within tolerance, which we set according to the Strasbourg Osteosynthesis Research Group (SORG) definition for minimal displacement (<2 mm overlap and 10° angulation). The cohort had good functional occlusion and minimal long-term postoperative complications. Two patients required re-operation for non-union, and we discuss causality in these cases. In conclusion, we found that ORIF of condylar neck and base fractures is predictable in real-time surgical practice with respect to functional outcome. However, if imperfectly reduced, there is a small risk of non-union.

Indications, complications, and clinical outcomes of fixation and acute total hip arthroplasty for the treatment of acetabular fractures: A systematic review

PURPOSE

Acetabular fracture fixation can be challenging, especially in the elderly. Open reduction and internal fixation (ORIF) alone may not allow for early weight bearing and is associated with a high rate of secondary osteoarthritis; therefore, a combined hip procedure (CHP) or ORIF with acute total hip arthroplasty, may be beneficial in this population. The objective of this study was to perform a systematic review of all reported cases of CHP.

METHODS

PubMed, Embase, Scopus, and Cochrane databases were searched for studies analyzing acetabular fractures in the elderly managed with a combined hip procedure (CHP). The research was performed following the PRISMA guidelines. The included studies' methodological quality was evaluated using the MINORS score. The present study was registered on PROSPERO.

RESULTS

Eleven clinical studies were included in the final analysis. The mean age was 74.4 (63.2-78) years. Low-energy trauma was the most common mechanism of injury (64%). The most prevalent fracture pattern was the anterior column and posterior hemitransverse (ACPHT) (30.6%). The Kocher-Langenbeck approach was preferred for ORIF of posterior fractures and hip arthroplasty. The ilioinguinal approach and modified Stoppa were generally used for anterior fractures. The overall complication rate was 12.2%, and hip dislocation was the most frequent cause of reoperation (4.4%). The average Harris Hip Score reported postoperatively was 81.6 points, which was considered "good."

CONCLUSIONS

CHP is a safe treatment for elderly acetabular fractures with an acceptable complication and reoperation rate that results in good clinical outcomes.

LEVEL OF EVIDENCE

Level of evidence IV.

Aspartate Aminotransferase-to-Platelet Ratio Index Suggestive of Liver Dysfunction Predicts Early Complications After Open Reduction Internal Fixation of Distal Radius Fractures

Purpose

Aspartate aminotransferase-to-platelet ratio index (APRI) is a cost-effective and noninvasive measure of liver function, an alternative to the gold standard liver biopsy, which is resource-intensive and invasive. The purpose of this study was to investigate the association between preoperative APRI and 30-day postoperative complications after isolated open reduction internal fixation (ORIF) of distal radius fractures (DRFs).

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent isolated ORIF of DRFs between 2015 and 2021. The study population was divided into two groups on the basis of preoperative APRI: normal/reference (APRI, <0.5) and liver dysfunction (APRI, ≥0.5). Information on patient demographics, comorbidities, and 30-day postoperative complications after isolated ORIF of DRFs was collected. Multivariate logistic regression analysis was performed to investigate the relationship between preoperative APRI and postoperative complications.

Results

Compared to patients with normal APRI, patients with preoperative APRI associated with liver dysfunction were significant for male sex (P < .001), younger age (P < .001), American Society of Anesthesiologists classification grade ≥3 (P < .001), being smokers (P < .001), and having comorbid diabetes (P = .002) and bleeding disorders (P < .001). Preoperative APRI associated with liver dysfunction was independently associated with a greater likelihood of any complications (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.19-1.87; P < .001), nonhome discharge (OR, 1.62; 95% CI, 1.15-2.27; P = .005), and a length of stay of >2 days (OR, 1.70; 95% CI, 1.32-2.20; P < .001).

Conclusions

Aspartate aminotransferase-to-platelet ratio index values associated with liver dysfunction were associated with an increased rate of early postoperative complications after DRF ORIF.

Clinical relevance

This study suggests APRI's utility as a cost-effective, noninvasive measure of liver function that physicians can use before surgery to better identify surgical candidates with DRFs and suspicion of liver dysfunction.

Type of study/level of evidence

Prognostic III.

The Saint-Joseph Acetabular score: a reproducible and accurate prediction of the outcome of open reduction and internal fixation of acetabular fractures

PURPOSE

Acetabular fractures are associated to an increased risk of subsequent hip osteoarthritis. The only available score for post-operative reduction assessment in acetabular fractures (Matta's score) is x-ray based. CT-scan was shown superior to X-rays in post-operative reduction assessment. We aim to describe a CT-scan-based post-operative reduction score in acetabular fractures and evaluate its accuracy and reproducibility.

METHODS

This is a retrospective study that includes 138 patients who underwent surgery for an acetabular fracture in our tertiary referral centre with a mean follow-up of 104.39±42.2 months. The post-operative CT-scan was reviewed and residual displacement (maximum gap and step) measured by three independent observers. The association between the occurrence of THA and the CT-scan measurements was evaluated. This led to a new prognostic score. The interobserver reliability and accuracy of this score were calculated.

RESULTS

Interobserver reproducibility for the residual maximal gap was 0.82 (95% CI [0.70-0.89]) and 0.61 (95% CI [0.52-0.70]) for the residual maximal step displacement measurements. We created a score from a logistic regression model, attributing 1 point for every 1 mm of residual maximal step displacement and 1 point for every 2 mm of residual maximal gap displacement. The interobserver reproducibility of this score was 0.78 (95% CI [0.71-0.84]), and its AUC was 0.79 (95% CI [0.69-0.88]).

CONCLUSION

This is the first CT-scan-based score for the assessment of residual displacement of a surgically treated acetabular fracture. It shows good interobserver reproducibility and accuracy in predicting the risk for secondary THA. It should be regularly used per-operatively (if per-operative 3D imaging is available) and post-operatively to predict the prognosis.

Management of Bennett's fracture: A systematic review and meta-analysis

Background

First described in 1882, Bennett's fracture is an intra-articular fracture of the first metacarpal associated with a dislocation of the carpometacarpal joint. Usually, open reduction internal fixation is used to manage such fractures. However, closed reduction has shown good outcomes recently. This meta-analysis compares closed reduction to open reduction internal fixation in the management of Bennett's fracture.

Methods

PubMed, Cochrane, and Google Scholar (pages 1-20) were searched until August 2023. The clinical outcomes consisted of post-traumatic arthritis, grip and pinch strengths, range of motion, functional scores, and mean adduction deformity.

Results

Six retrospective studies were included in this meta-analysis. Our results show higher grip and pinch strengths, better extension and flexion of the thumb, and lower mean adduction deformity in the open reduction internal fixation group.

Conclusion

Higher grip and pinch strengths, better extension and flexion of the carpometacarpal joint, and a smaller mean adduction deformity of the thumb in the open reduction internal fixation group. No differences were seen in the remaining outcomes. However, a higher rate of complications is associated with open reduction internal fixation. Nevertheless, more randomized controlled studies are needed to confirm such results.

Level of evidence

III.

A rare rotated, medially displaced fracture-dislocation of the medial clavicle - Case report and review of the literature

Clavicle fractures combined with sternoclavicular joint dislocations are very rare injuries that need to be addressed quickly and treated effectively due to the altered biomechanics of the shoulder girdle as well as to the potential damages to the surrounding "noble" anatomical structures. A diagnostic and therapeutic algorithm for such injuries has not yet been established. Computer Tomography with 3D reconstruction should be the diagnostic gold standard. In case of a highly displaced fracture and/or dislocation in an active patient, surgical treatment is advised in order to obtain proper bone and joint healing with satisfactory functional outcomes as well as to protect the surrounding anatomical structures from potential damages. We present the case of an 18-year-old male, skeletally mature patient, who had a fall while snowboarding. Subsequently he was diagnosed with a very uncommon combination of a displaced medial clavicle fracture and complete posterior Sterno-Clavicular dislocation with 111° rotation of the sternoclavicular fragment. We opted for surgery, decided to use "off-label" a 2.5 V-plate Ulna plate long (Medartis®) and to associate this procedure with a Sterno-Clavicular arthrodesis with tape-augmentation to stabilize the SC joint; this treatment strategy resulted in a good clinical outcome without any remaining instability and satisfactory ROM. We collected this case to describe this seldom combination, to show our treatment strategy and to advocate the creation of a standardized diagnostic and therapeutic algorithm. X-rays, Computer Tomography images and intraoperative photos are presented.

Coverage of Palmar Mini Plates with Flexor Pulleys in the Treatment of Dorsal Fracture-Subluxation of the Proximal Interphalangeal Joint

Introduction: Dorsal fracture dislocations (DFD) of the proximal interphalangeal joint (PIPJ) are challenging fractures. A palmar surgical approach and plate fixation has a high complication rate, including flexor contractions, reduction of range of motion (ROM) and secondary need for plate removal. Methods: We use the flexor tendon pulleys to cover the mini plate with the assumption that it may reduce the adhesion between the mini plates and the tendons and reduce postoperative complications. We present the outcomes of using this technique in eight patients. Results: All patients had an excellent outcome at a mean follow-up of 17 months, and none required removal of the implants. Conclusions: This study presents a surgical technique that may potentially reduce the high complication rate found after ORIF for treatment of DFD of the PIPJ. Therefore, improving the clinical outcomes after this type of surgery. Level of Evidence: Level IV (Therapeutic).

What is the best method of fixation for minimally displaced subcapital neck of femur fractures? A systematic review

BACKGROUND

Femoral neck fractures are a common cause of morbidity and mortality in the community. Minimally displaced subcapital necks of femoral fractures are usually managed with internal fixation, although there is debate as to which method is superior. This systematic review aimed to compare the outcomes of different fixation methods in the management of this common fracture.

METHODS

This systematic review was conducted in accordance with PRISMA statement guidelines. The databases searched were MEDLINE (Ovid), Cochrane Central Register of Controlled Trials, and EMBASE (Ovid). The study quality and risk of bias were assessed using the Newcastle-Ottawa Quality Assessment Scale, and relevant data were extracted and synthesised.

RESULTS

Nine articles met the inclusion criteria. A total of 819 patients were included in this study. Eight of the nine studies were case series, and one was a randomised control trial. The mean risk of bias was 7.4/9 for non-randomised articles. The fixation methods used in the included studies were dynamic hip screw (DHS), cannulated screws, Smith-Peterson nail, hooknail, Moore's pins, and Knowle's pins. DHS was found to be a superior method of fixation and was supported by a clinical trial. It has high rates of union (99 %), low rates of avascular necrosis (<1 %), and low rates of fixation failure (<1 %).

CONCLUSIONS

Based on the available data, DHS appears to be the superior method of fixation for the minimally displaced subcapital neck of femoral fractures. Given the general low level of evidence currently available, additional clinical trials are needed in this area.

Venous thromboembolism following surgical management of proximal humerus fractures: a systematic review

Background

Currently, there is limited information on the incidence of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE) after surgical treatment of proximal humerus fractures (PHFs). Therefore, the purpose of this systematic review is to evaluate the incidence of VTE, DVT, and PE following surgery for PHFs.

Methods

A comprehensive search of several databases was performed from inception to May 27, 2022. Studies were screened and evaluated by 2 reviewers independently utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Only original, English studies that evaluated the incidences of VTE following surgical management of PHFs were included. Surgical procedures consisted of shoulder arthroplasty (SA) including both hemiarthroplasty (Hemi) and reverse shoulder arthroplasty (RSA) in addition to open reduction and internal fixation (ORIF). A pooled incidence for postoperative DVT, PE, and overall VTE was reported.

Results

Twelve studies met the inclusion and exclusion criteria, encompassing a total of 18,238 patients. The overall DVT, PE, and VTE rates were 0.14%, 0.59%, and 0.7%, respectively. VTE was more frequently reported after SA than ORIF, (1.27% vs. 0.53%, respectively). Among SA patients, a higher rate of DVT was seen with RSA (1.2%) with the lowest DVT rate was observed for ORIF with 0.03%.

Conclusions

Symptomatic VTEs following surgical treatment of PHFs, are rare, yet still relevant as a worrisome postoperative complication. Among the various procedures, VTE was the most frequently reported after SA when compared to ORIF, with RSA having the highest VTE rate.

Chronic Steroid Use, Complications, and Readmission Following Open Reduction Internal Fixation of Distal Radius Fracture

Purpose

The increasing incidence of both distal radius fractures (DRFs) and chronic conditions that necessitate long-term steroid use has resulted in a growing intersection between the patient populations of the two. Chronic steroid use is known to increase bone frailty and the likelihood of fractures but may also contribute to poorer outcomes following the repair of DRF. The purpose of this study was to investigate the association between preoperative chronic steroid use, postoperative complications, and readmission after open reduction internal fixation (ORIF) of DRF.

Methods

The American College of Surgeons National Surgical Quality Improvement database was queried for all patients who underwent DRF ORIF between 2015 and 2021. However, 30-day postoperative complications after DRF ORIF were collected. Multivariate logistic regression analysis was conducted to investigate the relationship among preoperative chronic steroid use, postoperative complications, and patient factors associated with readmission.

Results

The postoperative complications associated with the steroid cohort were categorized as major, minor, and overall complications. Additionally, pneumonia, stroke, myocardial infarction, bleeding transfusions, deep vein thrombosis, pulmonary embolism, readmission, non-home discharge, and mortality were recorded. Chronic steroid use was found to be independently associated with major , minor, and overall complications, deep vein thrombosis, and readmission. Further investigation of readmission showed that male sex and comorbid chronic obstructive pulmonary disease were the only two patient factors independently associated with a greater likelihood of readmission after DRF ORIF.

Conclusions

Preoperative chronic steroid use was associated with an increasing rate of postoperative complications after DRF ORIF. Male sex and comorbid chronic obstructive pulmonary disease were characteristics of chronic steroid-use patients independently associated with increased risk of readmission after DRF ORIF. A better understanding of preoperative chronic steroid use as a risk factor for postoperative complications may allow surgeons to improve preoperative risk stratification and patient counseling in the management of DRF.

Type of study/level of evidence

Prognostic III.

Preoperative Anemia as a Risk Factor for Postoperative Complications After Open Reduction Internal Fixation of Distal Radius Fractures

Purpose

The incidence of distal radius fractures (DRFs) in the United States is more than 640,000 cases per year and is projected to increase. The overall prevalence of anemia in the United States increased from 5.71% in 2005 to 6.86% in 2018. Therefore, preoperative anemia may be an important risk factor to consider before surgical fixation of a distal radius fracture. The purpose of this study was to investigate preoperative anemia and its association with short-term complications after surgical treatment of DRFs.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent open reduction internal fixation (ORIF) of DRFs between 2015 and 2020. The initial pool of patients was divided into cohorts based on preoperative hematocrit. Multivariate logistic regression, adjusted for all significantly associated patient demographics and comorbidities, was used to identify associations between preoperative anemia and postoperative complications after ORIF of DRFs.

Results

A total of 22,923 patients who underwent ORIF of DRFs were identified in National Surgical Quality Improvement Program from 2015 to 2020. Of the 12,068 patients remaining after exclusion criteria, 9,616 (79.7%) patients were included in the normal cohort, 2,238 (18.5%) patients were included in the mild anemia cohort, and 214 (1.8%) patients were included in the severe anemia cohort. Compared with the reference cohort, patients with any anemia were independently associated with higher rates of reintubation (odds ratio [OR], 6.51; 95% confidence interval [CI], 1.29-32.80; P = .023), blood transfusion (OR, 11.83; 95% CI, 3.95-35.45; P < .001), septic shock (OR, 10.76; 95% CI, 1.19-97.02; P = .034), readmission (OR, 2.10; 95% CI, 1.60-2.76; P < .001), nonhome discharge (OR, 2.22; 95% CI, 1.84-2.68; P < .001), and mortality (OR, 2.70; 1.03-7.07; P = .043).

Conclusions

Preoperative anemia, both mild and severe, were clinically significant predictors for postoperative complications within 30-day after ORIF of DRFs. Severe anemia was associated with higher rates of blood transfusion, nonhome discharge, and mortality compared with mild anemia.

Type of study/level of evidence

Prognostic III.

Predictors for post-traumatic hip osteoarthritis in patients with transverse acetabular fractures following open reduction internal fixation: a minimum of 2 years' follow-up multicenter study

BACKGROUND

The predictors of post-traumatic osteoarthritis (PTOA) in patients with transverse acetabular fractures (TAFs) following open reduction internal fixation (ORIF) remain unclear. This study aimed to investigate the risk factors for PTOA in TAFs after ORIF.

METHODS

Data of TAF patients receiving ORIF were collected from January 2012 and February 2021. Patients suffered PTOA were classified as the osteoarthritis group (OG), while those without PTOA were classified as the non- osteoarthritis group (NG) with a minimum follow-up of 2 years. PTOA was diagnosed according to Tönnis OA classification during the period of follow-up. Univariate analysis, logistic regression analysis, and receiver operating characteristic (ROC) curve analyses were used to evaluate demographics, injury-related characteristics, perioperative and post-discharge information.

RESULTS

Three hundred and eleven TAF patients were analyzed in this study, including 261 males and 50 females, with a mean age of 40.4 years (range 18 to 64 years). The incidence of PTOA was 29.6% (92 of 311) during the mean follow-up of 36.8 months (range 24 to 70 months). Several factors of PTOA were found using univariate analysis, including transverse fracture associated with posterior wall acetabular fracture (TPW-AF, p = 0.002), acetabular roof fracture (ARF, p = 0.001), femoral head lesion (FHL, p = 0.016), longer time from injury to surgery (TIS, p＜0.001) and physical work after surgery (PWAS, p＜0.001). Logistic regression analysis showed that TPW-AF (p = 0.007, OR = 2.610, 95%CI: 1.302-5.232), ARF (p = 0.001, OR = 2.887, 95%CI: 1.512-5.512), FHL (p = 0.005, OR = 2.302, 95%CI: 1.283-4.131), TIS (p<0.0001, OR = 1.294, 95%CI: 1.192-1.405) and PWAS (p<0.0001, 3.198, 95%CI: 1.765-5.797) were independent risk factors of PTOA. Furthermore, ROC curve analysis indicated 11.5 days as the cut-off values to predict PTOA.

CONCLUSIONS

Our findings identified that TPW-AF, ARF, FHL, TIS and PWAS were independent risk factors for PTOA in patients with TAFs following ORIF. It can help orthopedic surgeons to take early individualized interventions to reduce its incidence.

A network meta-analysis of multiple modalities for the treatment of complex proximal humeral fractures in older adults

OBJECTIVE

Four principal treatment modalities are applied to treat complex proximal humeral fractures in older adults: conservative treatment, open reduction internal fixation, hemiarthroplasty, and reverse shoulder arthroplasty. However, among these, the optimal treatment modality has yet to be determined. Therefore, a network meta-analysis was carried out to compare treatment modalities and assess their effectiveness.

METHODS

The databases PUBMED, EM-BASE, the Cochrane Central Register of Controlled Trials, Web of Science, and CNKI were searched for randomised controlled trials on complex proximal humeral fractures in older people, ranging from inception of each database to May 2023.

RESULTS

This meta-analysis included 14 randomised controlled trials, containing 791 patients aged over 60 years who were treated for complex proximal humeral fractures. Reverse shoulder arthroplasty and hemiarthroplasty yielded the highest Constant shoulder scores, whilst conservative treatment performed poorly. Hemiarthroplasty and open reduction internal fixation yielded the best performances on the visual analogue pain scale, whilst conservative treatment performed poorly. Reverse shoulder arthroplasty and open reduction internal fixation allowed for maximum forward flexion and outreach of range of motion, whilst hemiarthroplasty allowed for the least. Open reduction internal fixation and reverse shoulder arthroplasty allowed for maximum internal rotation of the range of motion, whilst conservative treatment allowed for the least. Hemiarthroplasty and conservative treatment allowed for maximum external rotation of the range of motion, whilst open reduction internal fixation allowed for the least.

CONCLUSION

Compared with open reduction internal fixation, reverse shoulder arthroplasty yields better Constant shoulder scores and allows for greater forward flexion and outreach of range of motion of the shoulder joint in complex proximal humerus fractures in older patients. Meanwhile, hemiarthroplasty yields the best visual analogue scale scores and allows for maximum external rotation of the range of motion. However, open reduction with internal fixation remains the preferred clinical treatment for complex proximal humeral fractures in older patients.

Comparison of a minimally invasive osteosynthesis technique with conventional open surgery for transverse patellar fractures

PURPOSE

The study aims to compare the efficacy and safety of a new minimally invasive osteosynthesis technique with those of conventional open surgery for transverse patellar fractures.

METHODS

It was a retrospective study. Adult patients with closed transverse patellar fracture were included, and with open comminuted patellar fracture were excluded. These patients were divided into minimally invasive osteosynthesis technique (MIOT) group and open reduction and internal fixation (ORIF) group. Surgical time, frequency of intraoperative fluoroscopy, visual analogue scale score, flexion, extension, Lysholm knee score, infection, malreduction, implant migration and implant irritation in two groups were recorded and compared. Statistical analysis was performed by the SPSS software package (version 19). A p < 0.05 indicated statistical significance.

RESULTS

A total of 55 patients with transverse patellar fractures enrolled in this study, the minimally invasive technique was performed in 27 cases, and open reduction was performed in 28 cases. The surgical time in the ORIF group was shorter than that in the MIOT group (p = 0.033). The visual analogue scale scores in the MIOT group were significantly lower than those in the ORIF group only in the first month after surgery (p = 0.015). Flexion was restored faster in the MIOT group than that in the ORIF group at one month (p = 0.001) and three months (p = 0.015). Extension was recovered faster in the MIOT group than that in the ORIF group at one month (p = 0.031) and three months (p = 0.023). The recorded Lysholm knee scores in the MIOT group were always greater than those in the ORIF group. Complications, such as infection, malreduction, implant migration, and implant irritation, occurred more frequently in the ORIF group.

CONCLUSION

Compared with the ORIF group, the MIOT group reduced postoperative pain and had less complications and better exercise rehabilitation. Although it requires a long operation time, MIOT may be a wise choice for transverse patellar fractures.

Rising incidence of acute total hip arthroplasty for primary and adjunctive treatment of acetabular fracture in older and middle-aged adults

BACKGROUND

Acute total hip arthroplasty (THA) may be an alternative or an adjuvant to internal fixation for surgical treatment of acetabular fractures. We investigate recent trends in the operative management of acetabular fractures. We hypothesize that the incidence of acute THA for acetabular fractures has increased over time.

METHODS

4569 middle-aged (45-64 years) and older adults (≥ 65 years) who received acute operative management of an acetabular fracture within 3 weeks of admission between 2010 and 2020 were identified from the United States Nationwide Inpatient Sample database. Treatment was classified as open reduction internal fixation (ORIF), THA, or combined ORIF and THA (ORIF + THA). Patients were stratified by age ≥ 65 years old. Associations between demographic factors and the incidence of each procedure over the study period were modeled using linear regression.

RESULTS

The relative incidence of treatments was 80.9% ORIF, 12.1% THA, and 7.0% ORIF + THA. Among patients aged 45-64 years old, THA increased 4.8% [R² = 0.62; β₁ = 0.6% (95% Confidence Interval (CI) 0.2-0.9%)] and ORIF + THA increased 2.6% [R² = 0.73; β₁ = 0.3% (95% CI 0.2-0.4%)], while the use of ORIF decreased 7.4% [R² = 0.75; β₁ = -0.9% (95% CI -1.2 to -0.5%)]. Among patients ≥ 65 years old, THA increased 16.5% [R² = 0.87; β₁ = 1.7% (95% CI 1.2-2.2%)] and ORIF + THA increased 5.0% [R² = 0.38, β₁ = 0.6% (95% CI 0.0-1.3%)], while ORIF decreased 21.5% [R² = 0.75; β₁ = -2.4% (95% CI -3.45 to -1.3%)].

CONCLUSION

The treatment of acetabular fractures with acute THA has increased in the last decade, particularly among older adults.

Rehabilitation progress following reverse total shoulder replacement and internal fixation for geriatric three and four-part proximal humerus fractures - a propensity score matched comparison

BACKGROUND

Proximal humerus fracture is one of the most common fractures in the elderly population. However, in patients with complex fracture patterns, there is still no general consensus in the best treatment method. This study aims to evaluate the outcomes between those treated with reverse total shoulder arthroplasty (rTSA) and open reduction internal fixation (ORIF).

METHODS

All geriatric patients (> 60 years of age) with proximal humerus fractures undergoing surgical treatment were analysed. There were 25 patients treated with rTSA and 75 with ORIF. Propensity score matching was used to select 25 matching patients from the ORIF group according to age and gender. All patients underwent surgical intervention within 7 days (mean 3.8 days). All patients followed a protocol-driven rehabilitation programme with outcome assessment at 3, 6, 12 and 24 months. Constant score, qDASH, range of motion, rate of complications and revision surgery were recorded and compared.

RESULTS

Twenty-five rTSA were age and gender matched with 25 ORIF patients. The average age of patients in rTSA and ORIF groups were 77.0 years and 75.2 years respectively. At 3 months, mean Constant score was 37.7 (rTSA) vs 45.5 (ORIF) (p = 0.099). Mean qDASH score was 50.6 (rTSA) vs 29.4 (ORIF) (p = 0.003). Mean forward flexion range was 72.9° (rTSA) vs 94.4° (ORIF) (p = 0.007). Mean abduction range was 64.0° (rTSA) vs 88.6° (ORIF) (p = 0.001). At 2 years, mean Constant score was 72.8 (rTSA) vs 70.8 (ORIF) (p = 0.472). Mean qDASH score was 4.50 (rTSA) vs 11.0 (ORIF) (p = 0.025). Mean forward flexion range was 143° (rTSA) vs 109° (ORIF) (p < 0.001). Mean abduction range was 135° (rTSA) vs 110° (ORIF) (p = 0.025). There was a higher number of complications observed for ORIF (3) than rTSA (1) (p = 0.297) and a higher number of re-operations for ORIF (3) than rTSA (1) (p = 0.297), which was not statistically significant.

CONCLUSION

rTSA appears to yield a slower recovery at 3 months but a better outcome at 2 years. It is a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome.

Arthroscopy for Traumatic Ankle Injuries

Using ankle arthroscopy in conjunction to open reduction internal fixation of traumatic ankle injuries can play an important role in the management of these injuries by way of treating intra-articular pathologies, leading to improved patient outcomes. While a majority of these injuries are not treated with concurrent arthroscopy, its addition may lead to more prognostic information to dictate the patient's course. This article has illustrated its use in managing malleolar fractures, syndesmotic injuries, pilon fractures and pediatric ankle fractures. While additional studies may be needed to further support AORIF, it may prove to play a vital role in the future.

Acetabular fracture and central hip dislocation in osteogenesis imperfecta child treated surgically with bone grafts augmented by recombinant human bone morphogenetic protein-2: A rare case report

INTRODUCTION AND IMPORTANCE

Rare congenital disorder osteogenesis imperfecta (OI) can make treating complex acetabular fractures-dislocations challenging. Open reduction and internal fixation (ORIF) with locking plates and screws may not produce satisfactory results. We present the outcome of ORIF with reconstruction locking plate and screw augmented by bone grafts with recombinant bone morphogenetic protein-2 (rhBMP-2) for OI type I child with Judet-Letournel both column type acetabular fracture associated with central hip dislocation.

CASE PRESENTATION

We present a case of a 13-year-old female OI type I patient with right hip pain after falling while biking. Both eyes had blue sclera and OI family history. Intraoperatively, the Stoppa approach was used. Proximal femoral skeletal traction was used to reduce the femoral head and aid bone graft reconstruction of the acetabular wall. Intraosseous injection of rhBMP-2 was added. Fractures were fixed with a curved reconstruction locking plate and screws. Bones and soft tissues were gently manipulated to prevent blood loss. Radiographic and functional results were remarkable.

CLINICAL DISCUSSION

Fractures and blood loss are more likely to occur in OI type I patients due to collagen type I deficiency. Proximal femur skeletal traction is crucial for ORIF plating in acetabular fractures with central hip dislocation. This minimizes bone and soft tissue manipulation. RhBMP-2-injected bone grafts have structural support and osteoinductive properties that enhance bone healing. Despite its exceptional results in this case, further research is needed.

CONCLUSION

The combination of our technique and rhBMP-2 effectively accelerates bone healing in OI patient treated with ORIF.

What Is the Effect of Resident Involvement on Short-Term Outcomes after Distal Radius Fracture Surgery?

Background: The objective of this study was to assess whether resident involvement in distal radius fracture open reduction internal fixation (ORIF) affect 30-day postoperative complication, hospital readmission, reoperation and operative time. Methods: A retrospective study was performed using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database by querying the Current Procedural Terminology (CPT) codes for distal radius fracture ORIF from 1 January 2011 to 31 December 2014. A final cohort of 5,693 adult patients who underwent distal radius fracture ORIF during the study period were included. Baseline patient demographics and comorbidities, intraoperative factors, including operative time and 30-day postoperative outcomes, including complications, readmission and reoperations, were collected. Bivariate statistical analyses were performed to identify variable associated with complication, readmission, reoperation and operative time. The significance level was adjusted using a Bonferroni correction as multiple comparisons were performed. Results: In this study of 5,693 patients who underwent distal radius fracture ORIF, 66 patients had a complication, 85 patients were readmitted and 61 patients underwent reoperation within 30 days of surgery. Resident involvement in the surgery was not associated with 30-day postoperative complication, readmission or reoperation, but was associated with longer operative time. Moreover, 30-day postoperative complication was associated with older age, American Society of Anesthesiologists (ASA) classification, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypertension and bleeding disorder. Thirty-day readmission was associated with older age, ASA classification, diabetes mellitus, COPD, hypertension, bleeding disorder and functional status. Thirty-day reoperation was associated with higher body mass index (BMI). Longer operative time was associated with younger age, male sex and the absence of bleeding disorder. Conclusions: Resident involvement in distal radius fracture ORIF is associated with longer operative time, but no difference in rates of episode-of-care adverse events. Patients may be reassured that resident involvement in distal radius fracture ORIF does not negatively impact short-term outcomes. Level of Evidence: Level IV (Therapeutic).

Proximal humerus fracture management and outcomes are distinctly different for individuals 60 years of age or younger: a systematic review

Background

Proximal humerus fractures (PHFs) occur most commonly in an elderly and osteoporotic population, but a considerable proportion of these injuries occur in relatively younger individuals. Differences in treatment principles and outcomes in this younger population remain poorly understood. The purpose of this review was to characterize the treatment algorithms and outcomes for patients less than or equal to 60 years of age with PHFs.

Methods

A comprehensive search of the Medline, Pubmed, Embase, and Cochrane databases for articles published between January 2005 and December 2020 was performed in January 2021. Levels of evidence I-IV analyzing outcomes (patient reported outcomes and/or complications) following PHFs in adult patients less than or equal to 60 years of age were included. The search was carried out in accordance with the preferred reported items for systematic reviews and meta-analyses guidelines. The risk of bias 2 tool and methodological index for nonrandomized studies score were utilized to evaluate included studies.

Results

Fourteen studies met the inclusion criteria (open reduction internal fixation: 5, intramedullary nail: 4, hemiarthroplasty: 2, nonoperative: 1, and reverse total shoulder arthroplasty (RTSA): 1). Seven studies reported differences in outcomes between younger and older patient populations, with three studies noting separate management algorithms for those 60 years of age or younger. There were no studies comparing different treatments modalities in those less than 60 years of age, and the lone study on RTSA did not include patient-reported outcomes.

Conclusion

Treatment algorithms and outcomes following PHFs in patients less than or equal to 60 years of age are distinctly different from that of a more elderly population. However, evidence-based treatment recommendations for this younger population are limited by the lack of studies comparing treatment modalities and the absence of patient-reported outcomes for individuals undergoing RTSA.

Routine postoperative computed tomography (CT) scans following acetabulum open reduction internal fixation (ORIF): A survey of orthopaedic traumatologists

OBJECTIVE

The purpose of this study was to assess the practices related to obtaining postoperative pelvic CT scans following acetabular ORIF and revision surgery rates.

DESIGN

A 20-question survey published on the Orthopaedic Trauma Association (OTA) website assessed each surgeon's preference and rationale for or against the routine use of postoperative CT scans for acetabular fractures.

PARTICIPANTS

Fellowship-trained orthopaedic traumatologists.

MAIN OUTCOME MEASUREMENTS

We examined the percentage of surgeons ordering routine postoperative CT scans, surgeon demographics, and revision surgery rates based on these routine CT scan results.

RESULTS

Responses were received from 57 surgeons. Practices varied regarding postoperative CT scans, with 16 surgeons (28%, Group A) routinely ordering them and 41 surgeons (72%, Group B) not ordering them on all patients. No significant difference in surgeon demographics were found between the groups. Majority of Group A report a revision surgery rate of <1% based on the results of the postoperative CT. Group A report routine postoperative scans were obtained to assess reduction, hardware placement, identify intra-articular fragments, and for educational purposes. Group B did not obtain routine postoperative CTs due to the following: unlikely to change postoperative treatment, adequate reduction and instrumentation placement assessed intraoperatively and by postoperative radiographs, and increased radiation exposure and cost to patients. Group B did report obtaining postop CT scans on select patients, with inadequate intraoperative imaging and postoperative neurological changes being the most common indications.

CONCLUSION

The routine use of postoperative CTs following open reduction internal fixation of acetabular fractures is a controversial topic. While we recognize the role for postoperative CT scans in select patients, our study questions the clinical utility of these scans in all patients and in conclusion do not recommend this protocol.

Arthroscopically assisted versus open reduction internal fixation for ankle fractures: a systematic review and meta-analysis

BACKGROUND

Open reduction and internal fixation were routinely used to treat patients with unstable ankle fractures (ORIF). However, some patients may experience persistent ankle pain and disability following ORIF due to untreated intra-articular lesions. Moreover, ankle fractures may be treated with arthroscopically assisted reduction and internal fixation (ARIF). This study aimed to compare the feasibility and benefits of ARIF versus ORIF for ankle fractures.

METHODS

We performed this meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A systematic search was conducted for comparative studies comparing ARIF and ORIF for ankle fractures. Nine studies were included in the analysis of clinical and secondary outcomes. In summary, we calculated the mean difference (MD), risk ratio (RR), confidence interval, and p value.

RESULTS

This meta-analysis demonstrated that the ARIF group achieved a higher Olerud-Molander Ankle (OMA) score (MD: 6.6; 95% CI 0.20 to 13.0; p = 0.04) and lower visual analog scale (VAS) score (MD: - 0.36; 95% CI - 0.64 to - 0.10; p = 0.01) at the final follow-up. Nevertheless, the smallest treatment effect of OMA score and VAS score did not exceed the minimum clinically important difference (MCID). There were longer surgery time (MD: 15.0; 95% CI 10.7 to 19.3; p < 0.01) and lower complication rates (RR: 0.53; 95% CI 0.31 to 0.89; p = 0.02) in ARIF compared with ORIF. The random-effect model suggested no significant difference in the arthritis change rate between the two groups.

CONCLUSION

In summary, the results of this meta-analysis indicated that ARIF and ORIF are comparable in terms of providing pain relief and improving function for patients with ankle fractures. Therefore, the choice between the two techniques should be based on the patient's individual factors and the surgeon's personal preference.

Short-term clinical and radiographic outcomes in patients treated with a modern intramedullary nailing system for 2-part proximal humerus fractures

OBJECTIVES

The optimal surgical treatment of displaced proximal humerus fractures (PHFs) remains controversial. There are advocates for both open reduction and internal fixation with plate and screws (ORIF) and intramedullary nailing (IMN). The purpose this study was to evaluate the early-term clinical and radiographic outcomes of IMN for isolated, displaced 2-part surgical neck PHFs using a modern, straight nail system and to determine the effect of preoperative patient and fracture characteristics on outcome.

METHODS

This was a case series of 23 patients with displaced 2-part surgical neck PHFs who were treated with ORIF using a straight IMN with minimum follow-up of 1 year (mean 2.5 years [range, 1.1-4.6]). Patients were identified retrospectively and contacted for measurement of active range of motion (AROM) and patient reported outcome measures (PROMs) including the American Shoulder and Elbow Surgeons (ASES) score, Oxford Shoulder Score (OSS), and Single Assessment Numeric Evaluation (SANE), EuroQol-5D (EQ-5D), and Visual Analog Scale Pain score (VAS Pain). Plain radiographs were evaluated to assess the quality of the reduction and failure of fixation. Complications and reoperations were identified.

RESULTS

Reduction was anatomic in 12 (52%) patients, acceptable in 9 (39%), and 2 (9%) were malreduced. There were no differences in reduction quality based on sex (p = 0.37), age at surgery (p = 0.68), calcar comminution (p = 0.68), number of screws in the head (p = 0.99), or medial hinge disruption (p = 0.06). At final follow-up, the mean ASES score was 92 ± 10, OSS was 45 ± 4, SANE was 93 ± 7, EQ-5D of 0.85 ± 0.17, and VAS Pain was 0 ± 1. The mean active forward flexion was 143° ± 16°, active external rotation was 68° ± 20°, and internal rotation was T11 ± 4 vertebrae. Two (9%) patients underwent reoperation and 2 (9%) patients experienced clinical failure not requiring reoperation.

CONCLUSIONS

Straight IMN is a reliable treatment for displaced 2-part surgical neck PHFs with excellent radiographic and clinical outcomes in early follow-up. The implant facilitated anatomic or acceptable alignment of the fracture in the vast majority of patients.

Functional results and unfavorable events after treatment of proximal humerus fractures using a new locking plate system

BACKGROUND

Proximal humerus fractures are often treated with a fixed-angle titanium plate osteosynthesis. Recently, plates made of alternative materials such as carbon fibre-reinforced polyetheretherketone (CFR-PEEK) have been introduced. This study presents the postoperative results of patients treated with a CFR-PEEK plate.

METHODS

Patients with proximal humerus fractures treated with a CFR-PEEK plate (PEEKPower™ Humeral Fracture Plate (HFP)) were included. In follow-up examination, age and gender adjusted Constant-Murley Score (ACS), Subjective Shoulder Value (SSV), Quick Disabilities of the Arm, Shoulder and Hand Score (QDASH) and pain score (Visual Analog Scale (VAS)) were analyzed. General condition at follow-up was measured by European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L). Range of motion was recorded. In addition, radiographs at follow-up, unfavorable events and revision rate were analyzed.

RESULTS

In total, 98 patients (66.0 ± 13.2 years, 74 females, 24 males) were reexamined. Mean follow-up was 27.6 ± 13.2 months. There were 15 2-part, 28 3-part and 55 4-part fractures. The functional scores showed good results: SSV 83.3 ± 15.6%, QDASH 13.1 ± 17.0 and ACS 80.4 ± 16.0. A 4-part-fracture, head split component, nonanatomic head shaft reposition and preoperative radiological signs of osteoarthritis were significant negative predictors for poorer clinical scores. Unfavourable events were observed in 27 patients (27.6%). Revision surgery was performed in 8 (8.2%) patients. Risk factors for an unfavourable event were female gender, age of 50 years and older, diabetes, affected dominant hand, 4-part fracture, head split and preoperative radiological signs of osteoarthritis.

CONCLUSION

There are several advantages of the CFR-PEEK plate (PEEKPower™ Humeral Fracture Plate (HFP)) such as the polyaxial screw placement and higher stability of locking screws. In summary, the CFR-PEEK plate osteosynthesis is a good alternative with comparable clinical results and some biomechanical advantages. Proximal humerus fractures show good clinical results after treatment with a CFR-PEEK plate. The revision rate and the risk of unfavorable events are not increased compared to conventional titanium plate osteosynthesis.

LEVEL OF EVIDENCE

IV.

Surgical timing for torsional ankle fractures is not associated with post-operative complications in patients with type II diabetes mellitus

INTRODUCTION

Surgical stabilization of ankle fractures is one of the most commonly performed procedures in orthopedics, but these injuries can prove difficult to manage in patients with type II diabetes mellitus (DMII). The goal of this study is to determine if a correlation exists between surgical timing and complication rates among diabetic patients with ankle fractures.

METHODS

This is a retrospective case-control study spanning from 2012 to 2019 including patients with DMII undergoing operative fixation for ankle fractures. The primary independent variable was surgical timing and the primary dependent variable was the rate of post-operative complications.

RESULTS

The overall complication rate was 25.5% with 60% of these patients requiring repeat surgical intervention. The most common complication was superficial surgical-site infection. There was no significant difference in surgical timing between patients experiencing post-operative complication compared to those who did not.

CONCLUSION

Among patients with DMII, we failed to show a correlation between surgical timing and post-operative complication.

Treatment patterns of ABOS part II candidates: A decline of operative management among geriatric proximal humerus fractures over the decade (2010-2020)

BACKGROUND

The purpose of this study was to assess trends in ABOS part II candidate's operative management of geriatric (≥65 years) proximal humerus fractures over the 2010-2020 decade.

METHODS

This retrospective database cohort study utilized the American Board of Orthopaedic Surgery (ABOS) database for candidates taking Part II of their boards. Surgical coding was reviewed and the ICD10 data was correlated to the CPT code for shoulder arthroplasty or open reduction internal fixation. We investigated the number of proximal humerus fracture operative cases per year, the percent arthroplasty used per year, the stratification of percent arthroplasty per orthopaedic fellowship subspecialty and geographic region.

RESULTS

A total of 2,409 operative cases for proximal humerus fractures in patients 65 years of age and older were submitted by 1,420 ABOS candidates. There was a 37% reduction in operatively managed proximal humerus fractures among ABOS part II candidates between the first half of the decade (2010-2015, 263.2 +/- 13.4) and the second half of the decade (2016-2020, 166 +/- 31.2; p<.05). There also was a downward trend with a 53% reduction in percent treated with arthroplasty as compared to ORIF during those same windows (2010-2015, 34.4 +/-11.7) and (2016-2020, 16.2 +/- 6.4; p<.5). Partitioned by single fellowship training, Shoulder and Elbow (S&E) surgeons performed the highest percent arthroplasty at 25.2%, followed by Sports at 23.1% and the lowest percent arthroplasty was Trauma at 11.7%. The Southeast United States had the lowest percentage arthroplasty at 15.8% as compared to the Midwest (23.8%) and Northeast (25.8%).

CONCLUSION

Despite the rapid growth of both the elderly population and related geriatric proximal humerus fractures, ABOS candidates are treating less with surgery. There has been approximately a 37% decrease in the total number of operatively treated proximal humerus fractures between the first and second half 2010-2020 decade. When operative treatment is performed, there is a trend towards ORIF over an arthroplasty. Trauma fellowship trained surgeons are less likely to perform an arthroplasty as compared to other subspecialties. The Southeast region is least likely to perform an arthroplasty as compared to the Midwest or Northeast.

Treatment of displaced intra-articular calcaneal fractures: A single-center experience study with 20 years follow-up

INTRODUCTION

This study was conducted to identify the patient characteristics, classification, treatment, complications, and functional outcomes of operatively treated displaced intra-articular calcaneal fractures (DIACFs) in a level-I trauma center over a 20-year period.

METHODS

Patients with a DIACF classified as Sanders ≥2 and operatively treated with percutaneous reduction and screw fixation (PSF) or open reduction and internal fixation (ORIF) between 1998 and 2017 were identified. Pre- and postoperative radiological assessments were performed. Functional outcomes were evaluated using the American Orthopaedic Foot & Ankle Society (AOFAS) score and the Maryland Foot Score (MFS). General health and patient satisfaction were assessed using the Short Form-36 Health Survey (SF-36) and the visual analog scale (VAS).

RESULTS

In total, 120 patients with a DIACF that were operatively treated with PSF or ORIF. Of these patients, 72 with a total of 80 DIACFs completed the questionnaires (60%). The average follow-up was 130 months. Mean scores for PSF and ORIF were 74 and 75 for AOFAS, 78 and 78 for MFS, 68 and 61 for SF-36, and 7.7 and 7.5 for VAS, respectively. An infection was the most common complication associated with ORIF (31%), and hardware removal (58%) was the most common complication in patients treated with PSF. Overall, 36 patients (68%) were able to return to work after a median time 6 months (IQR, 3-7) and 6 months (IQR, 3,25-6,75) for PSF and ORIF treated, respectively CONCLUSION: This long-term follow-up study reviews ORIF using ELA and PSF in the treatment of DIACFs. This study shows that both treatments are capable of restoring the Böhler angle and yield relatively good long-term functional outcomes. Differences in complication rates were apparent, infectious problems are inherent to ORIF using ELA, and hardware removal is associated with PSF.

Fragility of statistically significant findings from randomized clinical trials of surgical treatment of humeral shaft fractures: A systematic review

BACKGROUND

Despite recent meta-analyses of randomized controlled trials (RCTs), there remains no consensus regarding the preferred surgical treatment for humeral shaft fractures. The fragility index (FI) is an emerging tool used to evaluate the robustness of RCTs by quantifying the number of participants in a study group that would need to switch outcomes in order to reverse the study conclusions.

AIM

To investigate the fragility index of randomized control trials assessing outcomes of operative fixation in proximal humerus fractures.

METHODS

We completed a systematic review of RCTs evaluating the surgical treatment of humeral shaft fractures. Inclusion criteria included: articles published in English; patients randomized and allotted in 1:1 ratio to 2 parallel arms; and dichotomous outcome variables. The FI was calculated for total complications, each complication individually, and secondary surgeries using the Fisher exact test, as previously published.

RESULTS

Fifteen RCTs were included in the analysis comparing open reduction plate osteosynthesis with dynamic compression plate or locking compression plate, intramedullary nail, and minimally invasive plate osteosynthesis. The median FI was 0 for all parameters analyzed. Regarding individual outcomes, the FI was 0 for 81/91 (89%) of outcomes. The FI exceeded the number lost to follow up in only 2/91 (2%) outcomes.

CONCLUSION

The FI shows that data from RCTs regarding operative treatment of humeral shaft fractures are fragile and does not demonstrate superiority of any particular surgical technique.

Treatment of tibial plateau fractures: A comparison of two different operation strategies with medium-term follow up

Background

The objective of this study was to compare the clinical and radiological outcomes of two surgical methods for tibial plateau fractures (TPFs): minimally invasive surgery (MIS) using a double reverse traction repositor and traditional open reduction internal fixation (ORIF).

Methods

From our prospectively collated database, 187 consecutive adult patients with 189 operatively treated TPFs in our level I trauma center were included from January 2015 to March 2018 who had a minimum of three years’ follow-up. All cases were performed by the senior surgeon using either MIS (group 1, 84 patients with 84 TPFs) or ORIF (group 2, 103 patients with 105 TPFs). Details of the demographics, injury mechanism, pre- and postoperative follow-up imaging, operative procedures and complications were collected. The final results from the 36-Item Short-Form Health Survey (SF-36), Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) and Hospital for Special Surgery (HSS) were obtained at the final follow-up.

Results

Clinically, significant differences were observed in the WOMAC (pain, P ​= ​0.001; stiffness, P ​< ​0.001), HSS (P ​= ​0.003) and SF-36 (P ​= ​0.001). Radiologically, significant intergroup differences were observed in the loss of immediate postoperative reduction rates, secondary loss of reduction rates and signs of osteoarthritis (Kellgren–Lawrence). Two and ten superficial infections in group 1 (2.4%) and group 2 (9.5%), respectively, and 6 lateral popliteal nerve palsy cases occurred (0 MIS, 6 ORIF), with significant intergroup differences.

Conclusion

Our study shows that the MIS using a double reverse traction repositor is promising and safe technique for the TPFs when used for the correct indications.

The translational potential of this article

The current status of using a minimally invasive surgery for the treatment of TPFs have been analyzed and a new method of using a double reverse traction repositor for the treatment of TPFs have been proposed in this study, which updated treatment concept of TPFs.

Is fixation of the medial malleolus necessary in unstable ankle fractures?

INTRODUCTION

It is unclear whether the medial malleolus in unstable bi- and tri- malleolar ankle fractures without medial talar displacement should be addressed surgically. This study reviews a fixation protocol for the medial malleolar component of unstable bi- or tri- malleolar ankle fractures.

MATERIALS AND METHODS

Two hundred fifty-seven patients who sustained bi- (AO/OTA 44-B2) or tri- (AO/OTA 44-B3) malleolar ankle fractures between January 2005 and August 2019 at two Level 1 trauma centers were retrospectively identified. Medial malleolar fractures were defined as anterior, supra or intercollicular fractures based on the exit of the posterior fracture line. Fixation of the medial malleolar component was performed based on surgical algorithm. Only large or significantly displaced medial malleolar fractures were fixed if the soft tissues were amenable. Primary outcome measure was the presence of medial-sided ankle pain after operative or non-operative treatment of the medial malleolar fracture after a minimum follow up of 6 months. Presence of pain was defined by a pain score of 3 or higher on a 10-point VAS pain score at the site of the medial malleolar fracture.

RESULTS

Significantly more patients in the supracollicular group reported the presence of pain when this type was not fixed versus fixed (28 vs 14%, p = 0.0094). Significantly more patients in the anterior collicular subgroup reported the presence of pain when this type was fixed versus not fixed (40 vs 10%, p = 0.0438). There was no difference in the number of patients reporting pain in the intercollicular group when comparing those who were fixed versus not fixed, (21 vs 22%, p = 1.000).

CONCLUSIONS

When examining post-operative pain, not all medial malleolar fractures require fixation when appropriately selected based on fracture pattern. Only 10% of patients with anterior collicular fractures reported pain after non operative management. Unsurprisingly, more patients in the supracollicular fractures reported pain without surgery compared to with surgery. Fracture pattern should be considered in the treatment algorithm for the medial malleolar component in bi- and tri- malleolar fractures.

Outcome of Two-Stage Revision Total Hip and Knee Arthroplasty as a Salvage Procedure for Deep Infection of Peri-Articular Fracture Fixation: Propensity Score-Matched Study

BACKGROUND

Failed open reduction internal fixation (ORIF) of peri-articular fractures due to deep infection is associated with decreased functional outcomes and increased mortality rates. Two-stage revision total joint arthroplasty (TJA) is often needed as a salvage procedure. The aim of this study was to evaluate the outcome of two-stage revision total hip and knee arthroplasty as a salvage procedure for the treatment of deep infection of peri-articular fracture fixation.

METHODS

Using propensity score-matching, a total of 120 patients was evaluated: 1) 40 consecutive patients were treated with planned salvage two-stage revision for the treatment of deep peri-articular infection, and 2) a control group of 80 patients who underwent two-stage revision for periprosthetic joint infection (PJI) after non-IF TJA. An infection occurred after a fracture of the acetabulum (27.5%), femoral neck (22.5%), intertrochanteric femur (15.0%), subtrochanteric femur (5.0%), femoral shaft (7.5%), distal femur (5.0%), and tibia (15.0%).

RESULTS

At an average follow up of 4.5 years (range, 1.0-25.8), the overall failure rate was 42.5% for the IF group compared to 21.3% for the non-ORIF group (P=0.03). There was a significantly higher reinfection rate for the IF group compared to the non-IF group (35.0% vs. 11.3%, p=0.005). Tissue cultures for the IF patients demonstrated significantly higher polymicrobial growth (30.0% vs. 11.3%, P=0.01) and methicillin-resistant Staphylococcus aureus (20.0% vs. 7.5%, P=0.04).

CONCLUSION

Salvage two-stage revision arthroplasty for infected IF of peri-articular fractures was associated with poor outcome. The overall post-operative complications after salvage two-stage revision for infected IF of peri-articular fractures was high with 35% reinfection rates associated with the presence of mixed and resistant pathogens.

Revision Strategies for the Aseptic, Malaligned, Surgically Treated Ankle Fracture

Although surgical fixation can take many forms depending on ankle fracture morphology, the goals of open reduction internal fixation are to restore fracture alignment, re-establish ankle stability, and achieve an anatomic mortise. A subset of patients may present postoperatively with evidence of suboptimal open reduction internal fixation. Increased contact pressures across the tibiotalar joint, increased talar shift, and pathologic joint loading leading to the development of post-traumatic arthritis are common sequela of the malaligned mortise. Treatment necessitates a comprehensive approach. This article describes our preferred systematic approach for diagnosis and treatment of the aseptic, malaligned, surgically treated ankle fracture.

Comparison of 30-day complications between reverse shoulder arthroplasty and open reduction internal fixation for the treatment of proximal humerus fractures

PURPOSE

While the use of open reduction internal fixation (ORIF) has remained stable over the last decade, there has been a significant increase in the use of reverse total shoulder arthroplasty (RTSA) for proximal humerus fractures (PHFs). This study sought to compare the complication profiles of RTSA to ORIF in a large, validated, retrospective cohort.

METHODS

Patients who underwent surgical treatment for PHFs with RTSA or ORIF were identified in a national database (NSQIP) using CPT and ICD codes. Demographics and comorbidities were identified for each cohort of patients. Thirty-day complications were analyzed with univariate and multivariate analyses using Chi-square, Fischer's exact and analysis of variance testing.

RESULTS

The total number of patients included in this study was 2157.522 (24.2%) underwent RTSA and 1635 (75.8%) underwent ORIF. Patients undergoing RTSA were older with an average age of 73.52 years compared with 63.84 years in those undergoing ORIF (p < 0.001). Patients with RTSA were more likely to experience any complications (p < 0.001), pulmonary complications (p = 0.029), extended length of stay > 3 days (p < 0.001), and perioperative transfusion requirement (p < 0.001) after univariate analysis. After controlling for demographic differences, the only statistically significant complication was perioperative transfusion requirement (OR 1.383).

CONCLUSION

After controlling for demographic variables and comorbidities, RTSA placed patients at increased risk for perioperative blood transfusion. Patients undergoing RTSA should be counseled prior to surgery regarding the risk for transfusion and potentially optimized medically through multidisciplinary care if the surgeon elects to proceed with RTSA versus ORIF for the treatment of PHFs.

Trigger thumb preceding flexor pollicis longus tendon rupture after distal radius volar plate fixation: A case report

INTRODUCTION

Flexor pollicis longus (FPL) tendon rupture is a known complication after a distal radius (DR) fracture and subsequent fixation with a volar plate. A commonly accepted theory is the attrition of the flexor tendon by the prominent volar plate or theoretical injury to the tendon during the initial injury. An increasingly rare complication of distal radius open reduction internal fixation (ORIF) with volar plate fixation is stenosing tenosynovitis, more commonly known as trigger finger.

PRESENTATION OF CASE

We present a case of FPL rupture 7 years after volar plate fixation for DR fracture with thumb triggering in an elderly patient. To treat her trigger thumb, a corticosteroid injection was administered for symptomatic relief. Without resolution of her symptoms, she was scheduled for hardware removal and A1 pulley release. At her preoperative visit, she was found to have a rupture of her FPL tendon.

DISCUSSION/CONCLUSION

This case report provides insight into an atypical presentation of delayed-onset FPL rupture and preceding trigger thumb. Especially in individuals with no inciting events, the patient's trigger thumb after volar plate distal radius ORIF may have been a warning sign for impending FPL rupture. This underscores the importance in considering potential tendon attrition as part of a differential diagnosis in a patient presenting with trigger thumb after distal radius ORIF with a volar plate. In assessing for FPL tendon rupture, diagnostic imaging modalities such as ultrasound may be utilized in evaluating this condition to prevent potential loss of function.

Treatment trends in distal humerus fractures between ABOS part II candidates

PURPOSE

The purpose of this study was to determine how fellowship training influences the treatment of distal humerus fractures with either total elbow arthroplasty (TEA) or open reduction internal fixation (ORIF).

METHODS

The American Board of Orthopaedic Surgery (ABOS) Part II Examination Database was queried for all orthopaedic surgeons who sat for the Part II examination between the years 2003-2019. Inclusion criteria were ORIF or TEA cases, selected by individual CPT codes for each procedure, and patients of at least age 65 years who sustained acute distal humerus fractures. Analysis was performed for each type of fellowship training completed, total number of procedures performed, the type of procedure performed, patient demographics, and any complications.

RESULTS

There were 149 TEAs and 1306 ORIFs performed for distal humerus fractures between the exam years of 2003-2019. The proportion of TEA to ORIF increased from 7.6% to 11.0%. Partitioned by fellowship training, Hand and Upper Extremity surgeons performed 69 (17.4%) TEAs and 328 (82.6%) ORIFs, Shoulder and Elbow surgeons performed 34 (29.6%) TEAs and 81 (70.4%) ORIFs, Sports Medicine surgeons performed 14 (5.1%) TEAs and 263 (94.6%) ORIFs, and Trauma surgeons performed 16 (4.2%) TEAs and 366 (95.8%) ORIFs. Hand and Upper Extremity surgeons treated the most distal humerus fractures (397, 27.3%), followed by Trauma surgeons (382, 26.3%).

CONCLUSION

Our data suggests that fellowship training does influence the surgical decision-making process for treating distal humerus fractures in elderly populations. Hand and Upper Extremity surgeons performed the greatest number of TEA for acute distal humerus fractures, followed by Shoulder and Elbow surgeons. Conversely, trauma surgeons performed the lowest proportion of TEA to ORIF.

LEVEL OF EVIDENCE

III.

What's New in Geriatric Acetabular Fractures

The incidence of acetabular fractures in the geriatric population is growing, yet the optimal treatment algorithm remains a controversial topic among orthopaedic surgeons. This review highlights key studies published over the past 5 years on the outcomes of various treatment options for geriatric acetabular fractures. Topics include surgical timing, mortality and risk factors, nonoperative treatment, open reduction internal fixation, and acute total hip arthroplasty.

Factors associated with return to duty and need for subsequent procedures after calcaneus open reduction internal fixation in the military

INTRODUCTION

Calcaneus fractures can be devastating injuries, and operative treatment is fraught with complications. We are unaware of any studies evaluating all calcaneus fractures, both open and closed, treated operatively in the military. The purpose of this study is to evaluate all calcaneus fractures that required open reduction internal fixation to determine soldiers' ability to return to work and the need for additional surgeries.

METHODS

All active-duty patients undergoing open reduction internal fixation of calcaneus fractures from 2010-2016 were identified utilizing the Military Health System Management Analysis and Reporting Tool (M2). Armed Forces Health Longitudinal Technology Application (AHLTA) was utilized to determine comorbid medical conditions, subsequent procedures, surgical outcomes, and duty status within the military.

RESULTS

Three hundred seventy-five active-duty service members who met our inclusion/exclusion criteria were identified. One hundred fifty-one patients (55.1%) sustained their calcaneus fracture as a result of a blast injury. One hundred sixty (59.3%) patients required separation from the military as a result of their injury. Among patients who required a subsequent procedure, thirty-four patients (9.1%) required a subtalar arthrodesis, and thirty-two patients (8.5%) eventually required a below knee amputation. Blast as mechanism of injury was the single most predictive variable for patients requiring separation from the military (Odds Ratio 16.2, p< .001), requiring a subsequent procedure (Odds Ratio 8.4, p < .001), and for requiring a below knee amputation (Odds Ratio 47.3, p < .001).

CONCLUSION

Calcaneus fractures treated operatively in the military are often caused by blast injuries, and have a high rate of requiring subsequent procedures, amputation, and separation from the military.

Evaluation of patient outcomes after operative treatment of intra-articular calcaneus fractures

BACKGROUND

Percutaneous reduction with fixation and open reduction internal fixation are often used to treat intra-articular calcaneus fractures with no consensus on the preferred method. Open techniques have been associated with an increased risk of wound complications, while percutaneous techniques may result in inferior reduction capabilities. These injuries pose a challenge to patients as they often result in poor patient outcomes. We retrospectively analyzed patient outcomes of a single surgeon's experience in treating these injuries at a busy urban Level 1 trauma center.

METHODS

Patients with intra-articular calcaneus fractures managed operatively over 10 years with a minimum six-month follow-up were included. Patients were divided into two cohorts based on operative technique: closed reduction and percutaneous fixation (CRPF) or open reduction internal fixation (ORIF). Descriptive analysis of each cohort included postoperative infection, the need for repeat operations, development of post-traumatic subtalar arthritis, and reduction capabilities as assessed by Bohler's angle.

RESULTS

Sixty-two patients were included in this study, with 33 patients in the CRPF group and 29 patients in the ORIF group. Infection requiring a return to the operating room occurred in 1 (3%) CRPF and 7 (24%) ORIF patients. Instrumentation was removed in 23 (70%) CRPF and 9 (31%) ORIF patients. Clinical subtalar arthritis developed in 10 (30%) CRPF and 7 (24%) ORIF patients, requiring arthrodesis in 2 (6%) and 5 (17%) patients, respectively. Both techniques had acceptable restoration of Bohler's angle immediately postoperatively and at final follow-up.

CONCLUSIONS

Percutaneous reduction with fixation and open reduction internal fixation may both be considered for the surgical treatment of intra-articular calcaneal fractures. Indications for each technique may vary between surgeons, and each has its own set of risk factors and complications, however, both have been shown to result in an acceptable reduction.

LEVEL OF EVIDENCE

Level IV.