Ankle fractures: High implant cost is not associated with better patient reported outcomes

IntroductionAnkle fractures comprise 9% of all fractures and are among the most common fractures requiring operative management. Open reduction and internal fixation (ORIF) with plates and screws is the gold standard for the treatment of unstable, displaced ankle fractures. While performing ORIF, orthopaedic surgeons may choose from several fixation methods including locking versus nonlocking plating and whether to use screws or suture buttons for syndesmotic injuries.Nearly all orthopaedic surgeons treat ankle fractures but most are unfamiliar with implant costs. No study to date has correlated the cost of ankle fracture fixation with health status as perceived by patients through patient reported outcomes (PROs). The purpose of this study was to determine whether there is a relationship between increasing implant cost and PROs after a rotational ankle fracture.MethodsAll ankle fractures treated with open reduction internal fixation (ORIF) at a level I academic trauma center from January 2018 to December 2022 were identified. Inclusion criteria included all rotational ankle fractures with a minimum 6-month follow-up and completed 6-month PRO. Patients were excluded for age <18, polytrauma and open fracture. Variables assessed included demographics, fracture classifications, Foot and Ankle Ability Measure-Activities of Daily Living (FAAM-ADL) score, implant type, and implant cost.ResultsThere was a statistically significant difference in cost between fracture types (p < 0.0001) with trimalleolar fractures being the most expensive. The mean FAAM-ADL score was lowest for trimalleolar fractures at 78.9, 95% CI [75.5, 82.3]. A diagnosis of osteoporosis/osteopenia was associated with a decrease in cost of $233.3, 95% CI [−411.8, −54.8]. There was no relationship between syndesmotic fixation and implant cost, $102.6, 95% CI [−74.9, 280.0]. There was no correlation between implant cost and FAAM-ADL score at 6 months (p = 0.48).ConclusionsThe utilization of higher cost ankle fixation does not correlate with better FAAM-ADL scores. Orthopaedic surgeons may choose less expensive implants to improve the value of ankle fixation without impacting patient reported outcomes.     

Humeral shaft fractures: national trends in management

Background

The incidence of humeral shaft fractures has been increasing over time. This represents a growing public health concern in a climate of cost containment. The purpose of this study is to analyze national trends in surgical management of humeral shaft fractures and determine factors predictive of surgical intervention.

Materials and methods

Humeral shaft fractures were identified by the International Classification of Diseases, Ninth Revision, Clinical Modification codes 812.21 and 812.31 in the United States Nationwide Inpatient Sample from 2002 to 2011. Open reduction and internal fixation (ORIF) was identified by code 79.31 (ORIF, humerus). Other case codes analyzed were 79.01 (closed reduction without internal fixation), 79.11 (closed reduction with internal fixation), and 79.21 (open reduction without internal fixation). Multivariate regression analysis was utilized to determine predictive factors for utilization of ORIF.

Results

27,908 humeral shaft fractures were identified. Utilization of ORIF increased from 47.2% of humeral shaft fractures in 2002 to 60.3% in 2011. Demographically, patients who underwent ORIF were younger (51.5 versus 59.7 years, p < 0.001; odds ratio 0.87 per decade of age). There were modest increases in ORIF usage with private insurance, open fracture, and hospital size, which persisted with multivariate regression analysis. Surprisingly, there was a tendency to shift from a slight increase in ORIF for males with the bivariate case to a slight preference for females in the multivariate case.

Conclusion

Utilization of ORIF for humeral shaft fractures has been steadily increasing with time. Surgical intervention was more common with younger patients, female gender, private insurance, and larger hospital size. The increasing incidence of surgical management for humeral shaft fractures may represent a public health burden given the historical success of non-operative management.

Level of evidence

IV.

     

早期切开复位与闭合复位治疗移位的儿童股骨颈骨折的疗效比较

目的:比较早期切开复位与闭合复位内固定治疗移位的儿童股骨颈骨折的临床疗效。方法:2006年3月至2010年5月对收治的34例移位股骨颈骨折患儿进行回顾性分析,采用早期切开复位空心钉固定治疗19例(A组),男11例,女8例,年龄(8.1±1.3)岁;早期闭合复位内固定组15例(B组),男9例,女6例,年龄(7.9±1.5)岁。根据Ratliff评定标准比较两者术后疗效及并发症的差异。结果:所有患者获得随访,时间1～3年,平均1.2年。骨折均愈合,2组间的术后疗效差异有统计学意义(Z=2.389,P=0.017),2组术后并发症的发生差异也有统计学差异(P=0.046)。结论:早期切开复位内固定治疗移位的DelbetⅡ、Ⅲ型儿童股骨颈骨折比早期闭合复位内固定有较好的临床效果,并发症较少,早期切开复位内固定治疗移位的DelbetⅡ、Ⅲ型儿童股骨颈骨折是值得考虑的方法。     

经皮微创钢板内固定与切开复位内固定治疗成人胫骨远端骨折的Meta分析

目的:对经皮微创钢板内固定术(MIPPO)与切开复位内固定术(ORIF)治疗成人胫骨远端骨折的疗效进行Meta分析。方法:通过计算机检索Pubmed(1968年至2014年3月),Cochrane图书馆、中国知网数据库(1998年至2014年3月),手工检索相关的中英文骨科杂志。收集MIPPO与ORIF治疗成人胫骨远端骨折的病例对照研究,选择术后感染率、手术时间、术中出血量、骨折不愈合率、骨折延迟愈合、骨折畸形愈合率作为Meta分析的评价指标,按Cochrane协作网推荐的方法进行系统评价。结果:共纳入5项研究366例患者。Meta分析结果显示:MIPPO组感染率低于ORIF组[OR=0.23,95%CI(0.06,0.92),P=0.04];MIPPO组骨折不愈合率低于ORIF组[OR=0.16,95%CI(0.03,0.76),P=0.02];ORIF组骨折畸形愈合率低于MIPPO组[OR=7.46,95%CI(1.68,33.10),P=0.008];MIPPO组手术时间短于ORIF组[MD=-14.42,95%CI(-27.79,-1.05),P <0.05];MIPPO组术中出血量少于ORIF组[MD=-87.17,95%CI(-99.20,-75.15),P <0.05];两组骨折延迟愈合率比较差异无统计学意义。结论:对于成人胫骨远端骨折,与切开复位内固定治疗相比,经皮微创钢板内固定治疗手术时间短、出血量较少、术后感染率和骨折不愈合率低,但骨折畸形愈合率高。总体来看MIPPO较ORIF治疗成人胫骨远端骨折更有优势,但最佳治疗方案的选择应结合患者的病情进行综合考虑。     

Open versus closed pilon fractures: Comparison of management,outcomes, and complications

BackgroundDespite the low incidence of pilon fractures amongst lower limb injuries, their high impact nature presents difficulties in surgical management and recovery. The high complication rate and long recovery times presents a challenge for surgeons and patients. Current literature is varied, with no universal treatment algorithm. We aim to highlight differences in outcomes and complications between open and closed pilon fractures, and between patients treated by open reduction internal fixation (ORIF) or fine wire fixator (FWF) for open and closed fracture subgroups.MethodsThis retrospective study was conducted at a major trauma centre including 135 patients over a 6-year period. Primary outcome was AOFAS score at 3, 6, and 12-months post-injury. Secondary outcomes included time to partial weight-bear (PWB) and full weight-bear (FWB), bone union time, and complications during the follow-up time. AO/OTA classification was used (43A: n = 23, 43B: n = 30, 43C: n = 82). Interobserver agreement was high for bone union time (kappa=0.882) and AO/OTA class (kappa=0.807).ResultsHigher AOFAS scores were seen in ORIF groups of both open and closed fractures, compared to FWF groups. The difference was not statistically significant apart from 12-month AOFAS score of 43C open fractures (p = 0.003) and in 43B closed fractures 3 and 6 months post-injury (p<0.001 and p<0.001, respectively). The majority of ORIF subgroups, open and closed fractures, also had shorter time to PWB, FWB, time to union, and follow-up. Statistically significant differences were seen in the following cases: ORIF-treated 43B closed fracture subgroup had shorter time to PWB and FWB (p<0.001 and p = 0.017, respectively), ORIF-treated 43C closed fractures had shorter time to union (p = 0.005). Common complications for open fractures were non-union (24%), post-traumatic arthritis (16%); for closed fractures they were post-traumatic arthritis (24%), superficial infection (21%). All occurred more frequently in FWF-treated patients.ConclusionMost ORIF-treated subgroups in either open or closed pilon fractures showed better primary and secondary outcomes than FWF-treated subgroups, yet few were statistically significant. Overall, our use of a two-staged approach involving temporary external fixation, followed with ORIF or FWF achieved low complication rates and good functional recovery.     

Operatively Treated Talus Fractures: Complications and Survivorship in a Large Patient Sample

Talus fractures are relatively uncommon; however, the sequelae of talus fractures can cause significant morbidity. Although avascular necrosis has been a consistently reported complication, the reported rates of subsequent arthrodesis have varied widely. The purpose of the present study was to report the complications in a large patient sample of operatively treated talus fractures and to describe the survivorship of open reduction internal fixation (ORIF) of the talus. Patients undergoing talus ORIF for closed or open fractures from 2007 to 2011 were identified in the United Healthcare System database by International Classification of Diseases, 9th revision, code 825.21 and Current Procedural Terminology codes 28445, 28436, and 28430. Patients with a nonoperative talus fracture or isolated osteochondral defect were excluded, leaving 1527 patients in the final analysis. We also identified patients who had required subsequent subtalar, pantalar, and tibiotalocalcaneal arthrodeses using Current Procedural Terminology codes 28725, 28705, and 28715, respectively. Complications and demographic data were recorded. Of the 1527 patients, 29 (1.9%) had undergone subsequent arthrodesis within 4 years; 64 patients (4.2%) developed wound complications that did not require surgical intervention, 11 patients (0.7%) were readmitted, 204 (13.3%) presented to the emergency department (ED), and 96 (6.3%) underwent operative irrigation and debridement (I&D). The overall complication rate was 19.5%. Patients aged >34 years had a significantly greater rate of ED visits (54.7%, p?=?.015) and overall complications (56.8%, p?<?.001). In conclusion, ORIF of talus fractures has good survivorship when considering the failure of initial surgery or the requirement for secondary arthrodesis. Medical complications and hospital readmission were relatively rare; however, ED visits and infection requiring I&D were relatively common after ORIF of talus fractures.     

What is the value of 3D virtual reality in understanding acetabular fractures?

Background

Acetabular fractures are difficult to classify owing to the complex three-dimensional (3D) anatomy of the pelvis. 3D printing helps to understand and reliably classify acetabular fracture types. 3D-virtual reality (VR) may have comparable benefits. Our hypothesis is that 3D-VR is equivalent to 3D printing in understanding acetabular fracture patterns.

Methods

A total of 27 observers of various experience levels from several hospitals were requested to classify twenty 3D printed and VR models according to the Judet–Letournel classification. Additionally, surgeons were asked to state their preferred surgical approach and patient positioning. Time to classify each fracture type was recorded. The cases were randomized to rule out a learning curve. Inter-observer agreement was analyzed using Fleiss’ kappa statistics (κ).

Results

Inter-observer agreements varied by observer group and type of model used to classify the fracture: medical students: 3D print (κ = 0.61), VR (κ = 0.41); junior surgical residents: 3D print (0.51) VR (0.54); senior surgical residents: 3D print (0.66) VR (0.52); junior surgeons: 3D print (0.56), VR (0.43); senior surgeons: 3D print (κ = 0.59), VR (κ = 0.42).

Using 3D printed models, there was more agreement on the surgical approach (junior surgeons κ = 0.23, senior surgeons κ = 0.31) when compared with VR (junior surgeons κ = 0.17, senior surgeons 0.25). No difference was found in time used to classify these fractures between 3D printing and VR for all groups (P = 1.000).

Conclusions

The Judet–Letournel acetabular classification stays difficult to interpret; only moderate kappa agreements were found. We found 3D-VR inferior to 3D printing in classifying acetabular fractures. Furthermore, the current 3D-VR technology is still not practical for intra-operative use.

     

Therapeutic Effect of Resection,Prosthetic Replacement and Open Reduction and Internal Fixation for the Treatment of Mason Type III Radial Head Fracture

Abstract

Aim of the Study: Mason type III radial head fractures are a source of concern due to the severe injury and poor recovery. At present, radial head resection, open reduction and internal fixation (ORIF), and prosthetic replacement are three common treatment methods for these fractures. The clinical efficacy and postoperative complications are controversial, which makes it difficult for physicians to determine the most appropriate regimen. Herein, this present prospective, non-randomized, parallel-controlled study was conducted to compare the therapeutic effects and identify the most effective treatment method for Mason type III radial head fracture. Materials and Methods: We assessed patients with Mason type III radial head fracture treated with resection, prosthetic replacement, and ORIF to compare preoperative and postoperative pain condition, elbow joint function, curative effect, and complication rate. A visual analog scale was used to score pain. The elbow joint function was observed using the Broberg–Morrey elbow joint score. Results: No significant differences were found in patient demographics among the resection, prosthetic replacement, and ORIF groups. The prosthetic replacement and ORIF procedures were more complex and had higher technical requirements. Prosthetic replacement and ORIF enabled higher elbow joint scores and lower pain scores than resection. Excellent and good ratings were highest and complication rates were lowest in the prosthetic replacement group, followed by the ORIF group. Conclusion: Our results showed that prosthetic replacement is more effective than ORIF and radial head resection in relieving pain, functional recovery and reducing complications in the treatment of Mason type III radial head fractures.     

Clinical outcome of conversion from external fixation to definitive internal fixation for open fracture of the lower limb

IntroductionFew reports have examined the outcomes and complications of temporary bridging external fixation (EF) in open fracture of the lower limb followed by conversion to open reduction internal fixation (ORIF). The purpose of this study was to evaluate healing rates and complications in patients treated with conversion from external fixation to definitive internal fixation for open fracture of the lower limb.MethodPatients who underwent temporary bridging EF and subsequent conversion to internal fixation (IF) for open fracture of the lower limb, with follow-up period ≥12 months were included in this study. Demographic data, Gustilo-Anderson classification, fracture type, duration to definitive surgery, surgical procedure, perioperative complications, and additional procedures for cases with complications were obtained.ResultsIn total, 58 patients (43 males, 15 females), 63 fractures were included in this study. Four fractures (6.3%) were Gustilo grade I, 11 fractures (17.5%) were grade II, 34 fractures (54.0%) were grade IIIa, 12 fractures (19.0%) were grade IIIb, and two fractures (3.2%) were grade IIIc. Mean duration of the application of EF was 12.4 days (range, 3–45 days) until conversion to definitive IF. Rates of deep infection and nonunion were both 9.5%, with two cases showing concomitant infection and nonunion. Rates of infection were 8.8% (3/34) in grade IIIa and 25% (3/12) in grade IIIb. Rates of nonunion were 9.1% (1/11) in grade II, 2.9% (1/34) in grade IIIa and 33% (4/12) in grade IIIb.ConclusionTemporary EF for open fracture of the lower limb followed by conversion to IF, as early as soft tissue and general condition permit, may be a safe and effective procedure for patients with lower-limb open fracture of Gustilo grade IIIa or less.Level of evidenceLevel IV, Case series.     

Complications after talus fractures: A trauma centre experience

BackgroundTalus fractures are anatomically complex, high-energy injuries that can be associated with poor outcomes and high complication rates. Complications include non-union, avascular necrosis (AVN) and post-traumatic osteoarthritis (OA). The aim of this study was to analyse the outcomes of these injuries in a large series.MethodsWe retrospectively collected data on 100 consecutive patients presenting to a single high volume major trauma centre with a talus fracture between March 2012 and March 2020. All patients were over the age of 18 with a minimum of 12 months follow up post injury. Retrospective review of case notes and imaging was conducted to collate demographic data and to classify fracture morphology. Whether patients were managed non-operatively or operatively was noted and where used, the type of operative fixation, outcomes and complications were recorded.ResultsThe mean age was 35 years (range: 18–76 years). Open injuries accounted for 22% of patients. An isolated talar body fracture was the most frequent fracture (47%), followed by neck fractures (20%). The overall non-union rate was 2% with both cases occurring in patients with open fractures. The AVN rate was 6%, with the highest prevalence in talar neck fractures. Overall rates of post-traumatic OA of the tibio-talar, sub-talar and talo-navicular joints were 12%, 8%, and 6%, respectively. These were higher after a joint dislocation, and higher in neck or head fractures. The postoperative infection rate was 6%. The overall secondary surgery rate was 9%. There were 2% of patients who subsequently underwent a joint arthrodesis.ConclusionOur study found that talar body fractures are more common than previously reported; however, talar neck fractures cause the highest rates of AVN and post-traumatic arthritis. Open fractures also carry a greater risk of complications. This information is useful during consenting and preoperatively when planning these cases to ensure adverse outcomes may be anticipated.     

Standardised virtual fracture clinic management of radiographically stable Weber B ankle fractures is safe,cost effective and reproducible

BackgroundVirtual clinics have been shown to be safe and cost-effective in many specialties, yet barriers exist to their implementation in orthopaedics. Ankle fractures are common and therefore represent a significant clinical workload. The aim of this study was to evaluate the management of radiographically stable Weber B ankle fractures using a standardised treatment protocol in a virtual fracture clinic setting, to assess clinical outcomes, any complications and its cost effectiveness.MethodsAll patients referred to the VFC with an actual or suspected stable Weber B ankle fracture between September 2013 and September 2015 were identified. The primary outcome measure was successful fracture union. Any complications were noted and a cost analysis comparing the VFC and traditional fracture clinic models was undertaken.Results314 patients referred with a radiographically stable Weber B ankle fracture were identified. Follow up was complete for 98.4% (309/314) of patients. The union rate was 99.4% (307/309) in patients where follow up was completed. 3.5% (11/309) of patients were underwent acute surgical intervention. Of these patients, 6 were identified as having an unstable injury on weight bearing radiographs at 2 weeks and underwent ORIF, 4 were identified as having an unstable injury on EUA and underwent ORIF and 1 had an EUA with no fixation. 2 patients required ORIF for radiographically confirmed non-union. A cost saving analysis comparing the traditional fracture clinic model and VFC model revealed a saving of £237 per patient (32% reduction) with a VFC model. This represents an estimated saving of almost £40,000 per year for the management of this injury alone in our institution.ConclusionOur study supports the use of a virtual fracture clinic model that is standardised, initiated in ED, and is both safe and cost-effective in the management of radiographically stable Weber B ankle fractures.Level of evidenceLevel III–Retrospective Cohort Study.     

Extended intralesional curettage preferred over resection–arthrodesis for giant cell tumour of the distal radius

Background

Distal radius giant cell tumour (GCT) is known to be associated with distinct management difficulties, including high rates of local recurrence and lung metastases compared to other anatomic locations. Multiple treatment options exist, each with different outcomes and complications.

Questions/purposes

To compare oncological and functional outcomes and complications following treatment of patients with distal radius GCT by extended intralesional curettage (EIC) or resection–arthrodesis.

Methods

Patients operated on for distal radius GCT were identified from prospectively collected databases at four Canadian musculoskeletal oncology specialty centres. There were 57 patients with a mean age of 35.4 years (range 17–57). Thirteen tumours were Campanacci grade 2, and 40 were Grade 3 (4 unknown). Twenty patients presented with an associated pathologic fracture. There were 34 patients treated by EIC and 23 by en bloc resection and wrist arthrodesis. All resections were performed for grade 3 tumours. The mean follow-up was 86 months (range 1–280).

Results

There were a total of 11 (19%) local recurrences: 10 of 34 (29%) in the EIC group compared to only 1 of 23 (4%) in the resection–arthrodesis group (p = 0.028). For the 10 patients with local recurrence following initial treatment by EIC, 7 underwent repeat EIC, while 3 required resection–arthrodesis. The one local recurrence following initial resection was managed with repeat resection–arthrodesis. Six of the 11 local recurrences followed treatment of Campanacci grade 3 tumours, while 4 were in grade 2 lesions and in one case of recurrence the grade was unknown. There were no post-operative complications after EIC, whereas 7 patients (30%) had post-operative complications following resection–arthrodesis including 4 infections, one malunion, one non-union and one fracture (p = 0.001). The mean post-operative Musculoskeletal Tumor Society score was 33.5 in the curettage group compared to 27 in the resection group (p = 0.001). The mean Toronto Extremity Salvage Score was 98.3% following curettage compared to 91.5% after resection (p = 0.006). No patients experienced lung metastasis or death.

Conclusions

EIC is an effective alternative to wide resection–arthrodesis following treatment of distal radius GCT, with the advantage of preserving the distal radius and wrist joint function, but with a higher risk of local recurrence. Most local recurrences following initial treatment by EIC could be managed with iterative curettage and joint preservation. Wide excision and arthrodesis were associated with a significantly lower risk of tumour recurrence but was technically challenging and associated with more frequent post-operative complications. EIC was associated with better functional scores. Resection should be reserved for the most severe grade 3 tumours and recurrent and complex cases not amenable to treatment with EIC and joint salvage.

Level of evidence

III, retrospective comparative trial.

     

Open fractures of the upper limb – do the BOAST guidelines need an update?

AimsThis scoping review aims to explore the published literature on the current management strategies and outcomes of open upper limb injuries using the BOAST 4 guidelines as a structure.Materials and methodsA comprehensive search of the MEDLINE, EMBASE, Cochrane and OrthoSearch computerised literature databases (from January 2012 through April 2022) was performed. The medical subject headings used were “open fracture”/ “Gustilo Anderson” and “forearm” or “radius” or “ulna” or “elbow” or “humerus” or “clavicle” or “shoulder” or “scapula”. Abstract titles were reviewed for relevance. If the article was deemed eligible, the article was retrieved and reviewed in full.ResultsThe literature reveals lower rates of infection for upper limb injuries compared to their lower limb counterparts. Early antibiotic administration remains a key component of their management. Those without significant soft tissue injury (Gustilo Anderson 1) can often be treated as per their closed counterparts and timing to definitive fixation can be safely delayed in selected cases.DiscussionThere is limited high quality evidence available on the management of open upper limb injuries with guidelines built on borrowed principles from the more studied open tibia fractures. What the available evidence does show is that with lower infection rates and a more forgiving soft tissue envelope it may be safe to diverge from the current BOAST guidelines in certain cases. This has relevance in complex fracture patterns requiring specialist input where it is not possible to achieve definitive fixation in 72 h and when there are other life threatening injuries to manage. Despite this early antibiotic administration and debridement within 24 h remains a key component of the early management.     

Plate fixation through the lateral extensile approach versus cannulated screw fixation through the sinus tarsi approach for calcaneal fracture: a multicenter,propensity score-matched TRON study

Purpose

For calcaneal fracture, plate fixation through lateral extensive approach (LEP) is the most common procedure performed to achieve anatomic reduction. However, wound complications sometimes occur after LEP. To reduce complications, minimally invasive operative methods with cannulated screw fixation through sinus tarsi approach (STS) were developed. The aim of this multicenter propensity-matched study was to compare the clinical and radiographic outcomes of LEP to those of STS for calcaneal fracture and to evaluate the incidence of postoperative complications including surgical site infection (SSI).

Methods

We extracted 271 patients with calcaneal fracture undergoing surgery between January 2014 and March 2019 from our multicenter TRON database. We assessed the American Orthopedic Foot and Ankle Society (AOFAS) score at the final follow-up as the clinical outcome. We obtained the Bohler and Preis angles as radiographic parameters and also recorded the complications. We divided the subjects into two groups: LEP group and STS group. To adjust for baseline differences between the groups, a propensity score matching algorithm was used in a 1:1 ratio.

Results

After matching, there were 32 fractures in each group. There was no significant difference between the LEP versus STS group in AOFAS score at final follow-up (90 vs 90 points, p = 0.98) and in the Bohler and Pries angles (19.2 vs. 18.0 degrees, p = 0.74 and 16.0 vs. 17.5 degrees, p = 0.47). The rate of SSI in the LEP group was higher than that in the STS group (21.9% vs. 0.0%, p = 0.01).

Conclusion

For calcaneal fracture, STS provides similar fixation effectiveness and functional outcomes as LEP while reducing the likelihood of infection.

     

Tibial periprosthetic fractures in Total Knee Arthroplasty – A scoping review

BackgroundPeriprosthetic tibial fractures in Total Knee Arthroplasty are much less commonly seen than femoral fractures, and there is a paucity of available literature and management recommendation for these fractures. We aimed to identify the relevant and up-to-date literature on this subject to analyse the incidence, risk factors, and management recommendations.MethodsA literature search was done on the databases of PubMed and SCOPUS using appropriate keywords. All the published literature in the English language was included for this review.ResultsWe included 21 studies comprising 260 tibial periprosthetic fractures (91 intra-operative (35%) and 169 (65%) post-operative or delayed fractures). Only 5.9% of these fractures were managed conservatively. Whereas 98 cases (58%) were managed with open reduction and internal fixation (ORIF) with plating, 19 (11.2%) were managed with revision TKA. Seventeen cases (10%) were managed with minimally invasive percutaneous plate osteosynthesis (MIPPO), and 8 (4.7%) were managed with intramedullary nailing. Less than 6% of cases were managed with other means, viz. megaprosthesis (n = 4), arthrodesis (n = 5), amputation (n = 1), and external fixator (n = 1).ConclusionIntraoperative fractures accounted for one-third of the fractures in our review. A majority of the delayed periprosthetic fractures were treated with surgical intervention. The most preferred surgical treatment method was ORIF of fractures using locking plates (either open or MIPPO). Revision TKA or megaprosthesis was used in cases with the loosened implants in association with the fracture.Level of evidenceIV     

The role of arthroscopy in the management of fractures about the ankle

Anatomic restoration of the joint is the goal of management in fractures about the ankle. Open reduction and internal fixation (ORIF) is the standard of care for unstable ankle fractures; however, arthroscopic management has been proposed. The use of arthroscopic reduction and internal fixation (ARIF) is surgeon-dependent. Reported indications for ARIF include transchondral talar dome fracture, talar fracture, low-grade fracture of the distal tibia, syndesmotic disruption, malleolar fracture, and chronic pain following definitive management of fracture about the ankle. Among the potential benefits are less extensive exposure, preservation of blood supply, and improved visualization of the pathology. Although arthroscopy is increasingly used in the setting of trauma, the effectiveness of ARIF compared with ORIF for management of fractures of the distal tibia, malleolus, displaced talar neck, and talar body has yet to be determined. Most of these fractures are effectively managed with open procedures.     

Obesity is associated with increased postoperative complications after operative management of tibial shaft fractures

ObjectivesTo assess the association of obesity and postoperative complications after operative management of tibial shaft fractures.MethodsPatients who underwent operative management of a tibial shaft fracture were identified in a national database by Current Procedural Terminology (CPT) codes for: (1) open reduction and internal fixation (ORIF) and (2) intramedullary nailing (IMN) procedures in the setting of International Classification of Diseases, Ninth Revision (ICD-9) codes for tibial shaft fracture. These groups were then divided into non-obese, obese, and morbidly obese cohorts using ICD-9 codes. Each cohort was then assessed for grouped complications within 90 days, removal of implants within 6 months, and nonunion within 9 months postoperatively. Odds ratios and 95% confidence intervals were calculated.ResultsFrom 2005 to 2012, 14,638 patients who underwent operative management of tibial shaft fractures were identified, including 4425 (30.2%) ORIF and 10,213 (69.8%) IMN. Overall, 1091 patients (7.4%) were coded as obese and 820 (5.6%) morbidly obese. In each operative group, obesity and morbid obesity was associated with a substantial increase in the rate of major and minor medical complications, venous thromboembolism, infection, procedures for implant removal, and nonunion.ConclusionsIn patients who undergo either ORIF or IMN for tibial shaft fractures, obesity and its related medical comorbidities are associated with significantly increased rates of postoperative medical complications, infection, nonunion, and implant removal compared to non-obese patients.     

Outcomes of Total Hip Arthroplasty After Acetabular Open Reduction and Internal Fixation in the Elderly—Acute vs Delayed Total Hip Arthroplasty

BackgroundOptimum management for the elderly acetabular fracture remains undefined. Open reduction and internal fixation (ORIF) in this population does not allow early weight-bearing and has an increased risk of failure. This study aimed to define outcomes of total hip arthroplasty (THA) in the setting of an acetabular fracture and compared delayed THA after acetabular ORIF (ORIF delayed THA) and acute fixation and THA (ORIF acute THA).MethodsAll acetabular fractures in patients older than 60 years who underwent ORIF between 2007 and 2018 were reviewed (n = 85). Of those, 14 underwent ORIF only initially and required subsequent THA (ORIF delayed THA). Twelve underwent an acute THA at the time of the ORIF (ORIF acute THA). The ORIF acute THA group was older (81 ± 7 vs 76 ± 8; P < .01) but had no other demographic- or injury-related differences compared with the ORIF delayed THA group. Outcome measures included operative time, length of stay, complications, radiographic assessments (component orientation, leg-length discrepancy, heterotopic ossification), and functional outcomes using the Oxford Hip Score (OHS).ResultsOperative time (P = .1) and length of stay (P = .5) for the initial surgical procedure (ORIF only or ORIF THA) were not different between groups. Four patients had a complication and required further surgeries; no difference was seen between groups. Radiographic assessments were similar between groups. The ORIF acute THA group had a significantly better OHS (40.1 ± 3.9) than the ORIF delayed THA group (33.6 ± 8.5) (P = .03).ConclusionIn elderly acetabulum fractures, ORIF acute THA compared favorably (a better OHS, single operation/hospital visit, equivalent complications) with ORIF delayed THA. We would thus recommend that in patients with risk factors for failure requiring delayed THA (eg, dome or roof impaction) that ORIF acute THA be strongly considered.     

Complications and timing of soft tissue coverage after complete articular,open tibial plateau fractures

PurposeComplete articular tibial plateau fractures are typically high-energy injuries associated with significant soft tissue trauma. The primary aim of this study was to evaluate the incidence of wound complications and need for soft tissue coverage after open, complete articular tibial plateau fractures. The secondary aim was to study the effect of timing of fixation and timing of flap coverage on deep infection rates in these injuries.MethodsThis was a retrospective cohort study of consecutive patients > 18 years undergoing ORIF of a Bicondylar Tibial Plateau (BTP) fracture between 2001 and 2018. Surgical data were recorded for open fractures including number of debridements, timing of definitive ORIF and soft tissue coverage relative to injury. Primary outcomes included rates of deep infection and unplanned reoperation.Results508 AO/OTA 41C BTP fractures were identified, with 51 open fractures included in 50 patients with a mean (SD) age 45.7 (12.3) years and a mean (SD) follow up of 4.3 (3.8) years. There were 20 cases of deep infection, unplanned reoperation occurred in 26 cases. The majority of cases (28 fractures) had initial external fixation placed, while 24 had ORIF at the initial debridement. Twelve patients had a planned flap for definitive closure on average of 6.4 days (SD 3.9) after injury, 14 required a flap for wound complications. Among patients with IIB and C injuries, rates of deep infection (5/6 vs 1/6, p = 0.02) and reoperation (5/7 vs 2/6, p = 0.08) were higher in patients treated with flap coverage >7 days from injury compared to early flap coverage. There were no differences in complication rates between early (<24hrs) and delayed fixation.ConclusionsComplete articular, open tibial plateau fractures are associated with high rates of complications. Time to flap coverage of seven days or more was a significant predictor of deep infection and unplanned reoperation in this cohort. Patients should be counseled about the high rate of unplanned reoperation and definitive soft tissue coverage should be accomplished within a week of injury whenever possible.     

Closed reduction in the treatment of tibial tubercle fractures

IntroductionOpen reduction and internal fixation (ORIF) is considered the standard care for displaced tibial tubercle fractures, but closed reduction and internal fixation (CRIF) can also be successful. Our aim was to compare outcomes between ORIF and CRIF for tibial tubercle fractures.Materials and methodsChildren younger than 18 years presenting for a tibial tubercle fracture at a single institution. The main outcomes were operative details (blood loss, tourniquet time, operative time) and complications. Follow-up of at least one month was required.Results98 fractures from 95 patients were included. Follow-up averaged 8.7 months. 49% of the fractures had intraarticular involvement (type III). The most common associated injuries were patellar tendon tears and compartment syndrome, occurring in 10.2% and 3.1% of patients, respectively. No meniscal or ligamentous injuries were encountered.ORIF was performed for 81 fractures and CRIF for 17. Both groups were similar regarding sex, age, weight, and follow-up duration (P>0.4). No tourniquet was used for CRIF, while the majority of ORIF cases utilized a tourniquet for an average of 50.6 minutes. Operative blood loss was 31mL less in CRIF (P<0.0001), and the procedure of CRIF was 23.3 minutes shorter than ORIF (P=0.0003).All cases, except 1 fracture treated with ORIF, achieved union. The complication rate was similar in both groups (P=0.79). At final follow-up, patients from both groups had favorable outcomes, with normal knee range of motion and angulation, gait, and quadriceps strength on exam.DiscussionCRIF is often overlooked in the surgical treatment of displaced tibial tubercle fractures. It is a less invasive treatment option for such fractures and has advantages such as less bleeding, avoiding a tourniquet, and shorter operative duration. Patients treated with either ORIF and CRIF healed with similar rates of complications and had a satisfactory outcome. Given the rarity of associated meniscal or ligamentous injuries, open reduction to visualize the joint surface might not be needed for most patients. The two most common associated injuries, patellar tendon tears and compartment syndrome, can be preliminarily diagnosed pre-operatively.ConclusionClosed reduction could be initially attempted for tibial tubercle fractures, even ones with intraarticular extension.