Injury Pattern Recognition and Surgical Technique of Pilon Fracture Reduction With Posterior Tibial Tendon Incarceration.

SUMMARY: Pilon fractures occur over a broad spectrum of injury severity and soft-tissue compromise. This article will review a distinct pilon injury variant characterized by posterior tibial tendon incarceration in posteromedial pilon fracture propagation. This injury pattern is vital to recognize preoperatively because failure to mobilize the entrapped posterior tibial tendon (PTT) will result in fracture malreduction and postoperative loss of PTT excursion. In addition, the authors' preferred surgical technique for PTT mobilization and anatomic fracture reduction is described.

Hands-free Femoral Traction Using the Bookwalter Retractor System During Anterior Approaches to the Acetabulum.

SUMMARY: Displaced acetabular fractures with medial and cranial displacement of the femoral head commonly require an anterior approach for reduction and stabilization. Restoration of the femoral head to its native position under the reduced acetabular dome is a primary goal of surgery. We present a surgical technique for applying traction to the proximal femur using the Bookwalter retractor system during the repair of acetabular fractures when using an anterior approach. By placing traction in line with the femoral neck, the femoral head is moved to a more anatomical position allowing acetabular fracture fragments to be reduced unimpeded and the femoral head may be used as a reconstructive template. We review a case series of 116 patients treated using this technique and report the short- and long-term radiographic and clinical results of treatment.

Statistical Literacy in the Orthopaedic Trauma Population.

OBJECTIVE: To evaluate the baseline level and demographic predictors of statistical literacy in orthopaedic patients who sustained traumatic injuries. DESIGN: Prospective observational. SETTING: Level 1 trauma center. PATIENTS: One hundred ninety-eight patients presenting to the orthopaedic trauma clinic. INTERVENTION: Berlin Numeracy Test (BNT) and General Health Numeracy Test-6 (GHNT-6). RESULTS: When assessed using the BNT, 67% of patients had results that placed them into the lowest quartile of objective numeracy skills. Only 3.5% of patients had results that scored in the top quartile. Our multivariate ordinal regression model demonstrated lower education level ( P = 0.01), and older age ( P = 0.03) were significant predictors of poor performance on the BNT. The mean score on the GHNT-6 was 36% (SD 30%). CONCLUSIONS: In a cohort of traumatically injured patients, poor statistical literacy was common, occurring in more than two-thirds of patient surveyed. Older age and lower levels of education were predictive of poor BNT performance and should be considered when discussing surgical options, associated risks, and likelihood of potential complications.

Extra-articular Unstable Iliac Fractures: Associated Injuries, Fixation Strategies, and Outcomes.

OBJECTIVE: To characterize the associated injuries, fixation constructs, and outcomes of extra-articular unstable iliac fractures. DESIGN: Retrospective cohort study. SETTING: Level I trauma center. PATIENTS: Thirty-three extra-articular unstable iliac fractures treated over a 20-year period. INTERVENTION: Percutaneous or open fixation of iliac fractures at the pelvic brim AND/OR iliac crest. MAIN OUTCOME MEASURES: Incidence of union, fixation failure, and angiography at the time of injury. RESULTS: Twenty-five patients were treated operatively with appropriate follow-up. Four patients had fixation failure with displacement, all in the group with only brim OR crest fixation (4/8 patients, 50% rate). In patients with both crest AND brim fixation (n = 17), there were no cases of implant failure or late displacement. In displaced fractures (n = 22), 4 patients (18%) required embolization by interventional radiology. In all 4 cases, the superior gluteal artery was embolized. In patients with both crest AND brim fixation, all went on to uneventful union with an average Visual Analog Scale (VAS) pain score of 0.9 (range, 0-5) at final follow-up. CONCLUSIONS: Extra-articular unstable iliac fractures are high-energy injuries that demonstrate a high rate of union when both pelvic brim AND iliac crest fixation is used. Approximately 1 in 5 patients with a displaced iliac fracture presented with a superior gluteal artery disruption requiring embolization. Pelvic brim OR iliac crest fixation used in isolation was associated with a fixation failure rate of 50%, supporting previous biomechanical work. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Association Between 6-Week Postdischarge Risk Classification and 12-Month Outcomes After Orthopedic Trauma.

Importance: Numerous studies have demonstrated that long-term outcomes after orthopedic trauma are associated with psychosocial and behavioral health factors evident early in the patient's recovery. Little is known about how to identify clinically actionable subgroups within this population. Objectives: To examine whether risk and protective factors measured at 6 weeks after injury could classify individuals into risk clusters and evaluate whether these clusters explain variations in 12-month outcomes. Design, Setting, and Participants: A prospective observational study was conducted between July 16, 2013, and January 15, 2016, among 352 patients with severe orthopedic injuries at 6 US level I trauma centers. Statistical analysis was conducted from October 9, 2017, to July 13, 2018. Main Outcomes and Measures: At 6 weeks after discharge, patients completed standardized measures for 5 risk factors (pain intensity, depression, posttraumatic stress disorder, alcohol abuse, and tobacco use) and 4 protective factors (resilience, social support, self-efficacy for return to usual activity, and self-efficacy for managing the financial demands of recovery). Latent class analysis was used to classify participants into clusters, which were evaluated against measures of function, depression, posttraumatic stress disorder, and self-rated health collected at 12 months. Results: Among the 352 patients (121 women and 231 men; mean [SD] age, 37.6 [12.5] years), latent class analysis identified 6 distinct patient clusters as the optimal solution. For clinical use, these clusters can be collapsed into 4 groups, sorted from low risk and high protection (best) to high risk and low protection (worst). All outcomes worsened across the 4 clinical groupings. Bayesian analysis shows that the mean Short Musculoskeletal Function Assessment dysfunction scores at 12 months differed by 7.8 points (95% CI, 3.0-12.6) between the best and second groups, by 10.3 points (95% CI, 1.6-20.2) between the second and third groups, and by 18.4 points (95% CI, 7.7-28.0) between the third and worst groups. Conclusions and Relevance: This study demonstrates that during early recovery, patients with orthopedic trauma can be classified into risk and protective clusters that account for a substantial amount of the variance in 12-month functional and health outcomes. Early screening and classification may allow a personalized approach to postsurgical care that conserves resources and targets appropriate levels of care to more patients.

Does Admission to Medicine or Orthopaedics Impact a Geriatric Hip Patient's Hospital Length of Stay?

OBJECTIVES: The aim of our study was to determine the association between admitting service, medicine or orthopaedics, and length of stay (LOS) for a geriatric hip fracture patient. DESIGN: Retrospective. SETTING: Urban level 1 trauma center. PATIENTS/PARTICIPANTS: Six hundred fourteen geriatric hip fracture patients from 2000 to 2009. INTERVENTIONS: Orthopaedic surgery for geriatric hip fracture. MAIN OUTCOME MEASUREMENTS: Patient demographics, medical comorbidities, hospitalization length, and admitting service. Negative binomial regression used to determine association between LOS and admitting service. RESULTS: Six hundred fourteen geriatric hip fracture patients were included in the analysis, of whom 49.2% of patients (n = 302) were admitted to the orthopaedic service and 50.8% (3 = 312) to the medicine service. The median LOS for patients admitted to orthopaedics was 4.5 days compared with 7 days for patients admitted to medicine (P < 0.0001). Readmission was also significantly higher for patients admitted to medicine (n = 92, 29.8%) than for those admitted to orthopaedics (n = 70, 23.1%). After controlling for important patient factors, it was determined that medicine patients are expected to stay about 1.5 times (incidence rate ratio: 1.48, P < 0.0001) longer in the hospital than orthopaedic patients. CONCLUSIONS: This is the largest study to demonstrate that admission to the medicine service compared with the orthopaedic service increases a geriatric hip fractures patient's expected LOS. Since LOS is a major driver of cost as well as a measure of quality care, it is important to understand the factors that lead to a longer hospital stay to better allocate hospital resources. Based on the results from our institution, orthopaedic surgeons should be aware that admission to medicine might increase a patient's expected LOS. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Acute Management of Traumatic Knee Dislocations for the Generalist.

Acute knee dislocations are an uncommon injury that can result in profound consequences if not recognized and managed appropriately on presentation. Patients presenting with knee pain in the setting of high- or low-energy trauma may have sustained a knee dislocation that spontaneously reduced. Prompt reduction of the dislocated knee and serial neurovascular examinations are paramount. Damage to the popliteal artery is a common associated injury that can be diagnosed on physical examination using ankle brachial indices (ABIs), CT angiography, or standard angiography. After reduction, patients with a normal pulse examination and an ABI ≥0.9 may be observed, with serial examination performed to document vascular status and monitor for compartment syndrome. Patients with asymmetric pulses or an ABI <0.9 in the presence of pulses may be treated urgently depending on the results of additional vascular imaging, and patients with absent pulses and clear signs of vascular compromise should be treated emergently. Some knee dislocations are not reducible and should be taken emergently to the operating room for an open reduction. Persistent joint subluxation or severe soft-tissue injuries after reduction require temporary external fixation before definitive repair or reconstruction of ligaments is performed.

Operative intervention for geriatric hip fracture: does type of surgery affect hospital length of stay?

Hip fractures are the most costly fall-related fractures. Differences in hospital length of stay (LOS) based on type of surgery could have major financial implications in a potential bundled payment system in which all hip fractures are reimbursed a standard amount. We conducted a study to analyze differences in hospital LOS and costs for total hip arthroplasty (THA), hemiarthroplasty (HA), cephalomedullary nailing, open reduction and internal fixation (ORIF), and closed reduction and percutaneous pinning (CRPP). Through retrospective chart review, 615 patients over age 60 years across a 9-year period at an urban level I trauma center were identified. Mean LOS and costs for hip fracture repair were 6.91 days and $30,011.25, respectively. HA/THA was associated with the longest mean LOS (7.43 days) and highest costs ($33,657.90). After several patient factors were adjusted for, ORIF was associated with 0.84 fewer in-patient days and $3805.20 less in hospitalization costs compared with HA/THA (P=.042). CRPP was associated with 1.63 fewer days and $7383.90 less in costs than HA/THA (P=.0076). Our results provide insight into the financial implications of hip fracture fixation and identify targets for quality improvement initiatives to improve efficiency of resource utilization.

Radiographs are not useful in detecting arthroscopically confirmed mild chondral damage.

UNLABELLED: Preoperatively predicting chondral damage is important. Weightbearing radiographs, including the standing anteroposterior and 45 degrees flexion posteroanterior views traditionally have been used for this purpose. We wanted to determine if one radiograph had superior sensitivity or specificity in detecting arthroscopically confirmed Grade II chondromalacia (mild arthritis). A standard prospective standing radiographic protocol was designed for all patients who presented to a sports medicine center with knee complaints. Patients who had subsequent arthroscopic surgery had their radiographs measured in a blinded manner for articular cartilage intervals in millimeters to detect joint-space narrowing. Intraarticular chondral damage was correlated with the radiographic findings. Three hundred forty-nine of a possible 411 (87%) patients during a 2-year period had both radiographs and subsequent arthroscopic grading of chondromalacia. This has been the largest study that correlated arthroscopic chondromalacia grades with two commonly preferred weightbearing radiograph projections. Despite specificities greater than 90%, the sensitivity was extremely low and neither standing radiograph was superior. Neither radiograph was useful in detecting Grade II chondral damage. LEVEL OF EVIDENCE: Diagnostic study, Level I-1 (testing of previously developed diagnostic criteria in series of consecutive patients--with universally applied reference "gold" standard). See the Guidelines for Authors for a complete description of levels of evidence.

Evaluation of neck pain, radiculopathy, and myelopathy: imaging, conservative treatment, and surgical indications.

Neck pain is a common complaint that typically represents a spectrum of disorders affecting the cervical spine. The clinical history and examination of patients with neck pain dictate the proper timing and selection of diagnostic studies such as plain radiography, MRI, and myelography with CT. Most neck pain is self-limiting and will resolve with appropriate conservative care. Nonsurgical treatment is the most appropriate first step in almost all cases of cervical radiculopathy. In contrast, the conservative care of cervical spondylotic myelopathy with measures such as physical therapy, spinal manipulation, medications, collars, and traction is limited.