Costs and Complications of Single-Stage Fixation Versus 2-Stage Treatment of Select Bicondylar Tibial Plateau Fractures.

OBJECTIVES: To determine the differences in costs and complications in patients with bicondylar tibial plateau (BTP) fractures treated with 1-stage definitive fixation compared with 2-stage fixation after initial spanning external fixation. DESIGN: Retrospective cohort study. SETTING: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Patients with OTA/AO 41-C (Schatzker 6) BTP fractures treated with open reduction internal fixation. INTERVENTION: Definitive treatment with open reduction internal fixation either acutely (1 stage) or delayed after initial spanning external fixation (2 stage). MAIN OUTCOME MEASURES: Wound healing complications, implant costs, hospital charges, Patient-Reported Outcomes Measurement Information System (PROMIS), reoperation, nonunion and infection. RESULTS: One hundred five patients were identified over a three-year period, of whom 52 met the inclusion criteria. There were 28 patients in the 1-stage group and 24 patients in the 2-stage group. Mean follow-up was 21.8 months, and 87% of patients had at least 12 months of follow-up. The mean number of days to definitive fixation was 1.2 in the 1-stage group and 7.8 in the 2-stage group. There were no differences between groups with respect to wound healing or any other surgery-related complications. Functional outcomes PROMIS were similar between groups. Mean implant cost in the 2-stage group was $10,821 greater than the 1-stage group, mostly because of the costs of external fixation. Median hospital inpatient charges in the 2-stage group exceeded the 1-stage group by more than $68,000 for all BTP fractures and by $61,000 for isolated BTP fractures. CONCLUSIONS: Early single-stage treatment of BTP fractures is cost-effective and is not associated with a higher complication rate than 2-stage treatment in appropriately selected patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Locking Plate Fixation in a Series of Bicondylar Tibial Plateau Fractures Raises Treatment Costs Without Clinical Benefit.

OBJECTIVES: To compare outcomes and costs between locking and nonlocking (NL) constructs in the treatment of bicondylar tibial plateau (BTP) fractures. DESIGN: Retrospective cohort study. SETTING: Level 1 academic trauma center. PATIENTS: All patients who presented with complete articular, BTP fractures OTA/AO 41-C and Schatzker VI between 2013 and 2015 were screened (n = 112). Patients treated with a mode of fixation other than plate-and-screw were excluded. Fifty-six patients with a minimum follow-up of 12 months were included in the analysis. INTERVENTION: Operative fixation of BTP fractures with locking (n = 29) or NL (n = 27) implants. MAIN OUTCOME MEASUREMENTS: Implant cost, patient-reported outcomes (PROMIS physical function and pain interference), clinical, and radiographic outcomes. RESULTS: There were no differences between the 2 groups with respect to demographics, injury characteristics, radiographic outcomes (change in alignment), or clinical outcomes (PROMIS, reoperation, nonunion, and infection). Implant costs were significantly greater in the locking group compared with the NL group (mean L, $4453; mean NL, $2569; P < 0.01). CONCLUSIONS: This study demonstrated improved value of treatment (less cost with no difference in clinical outcome) with NL implants for BTP fractures when dual-plate fixation strategies are performed. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Is Contralateral Templating Reliable for Establishing Rotational Alignment During Intramedullary Stabilization of Femoral Shaft Fractures? A Study of Individual Bilateral Differences in Femoral Version.

OBJECTIVES: To determine native individual bilateral differences (IBDs) in femoral version in a diverse population. METHODS: Computed tomography scans with complete imaging of uninjured bilateral femora were used to determine femoral version and IBDs in version. Age, sex, and ethnicity of each subject were also collected. Femoral version and IBDs in version were correlated with demographic variables using univariate and multivariate regression models. RESULTS: One hundred sixty-four subjects were included in the study. The average femoral version was 9.4 degrees (±9.4 degrees). The mean IBD in femoral version was 5.4 degrees (±4.4 degrees, P < 0.001). A total of 17.7% of subjects had a difference in version ≥10 degrees, and 4.3% had a difference in version ≥15 degrees. A femur with anteversion ≥20 degrees or retroversion was associated with a greater mean difference in version from the contralateral side compared with those with midrange anteversion. CONCLUSIONS: Bilateral differences in femoral version are common and can result in a difference from native anatomy that may be clinically significant if only the contralateral limb is used to establish rotational alignment during intramedullary stabilization of diaphyseal femur fractures. This is also an important consideration when considering malrotation of femur fractures because most studies define malrotation as a greater than 10-15-degree difference compared with the contralateral side. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgical anatomy of the lower trapezius tendon transfer.

BACKGROUND: The precise surgical anatomy of the lower trapezius tendon transfer has not been well described. A precise anatomic description of the different trapezius segments and the associated neurovascular structures is crucial for operative planning and execution. We aimed (1) to establish a reliable demarcation between the middle and lower trapezius, (2) to establish the precise relationship of the main neurovascular pedicle to the muscle belly, and (3) to evaluate the utility of the relationships established in (1) and (2) by using the results of this study to perform cadaveric lower trapezius tendon harvest. METHODS: In phase 1, a single surgeon performed all measurements using 10 cadavers. In phase 2, 10 cadaveric shoulders were used to harvest the tendon by using the relationships established in phase 1. RESULTS: We found anatomically distinct insertion sites for the lower and middle trapezius. The lower trapezius inserted at the scapular spine dorsum and the middle trapezius inserted broadly along the superior surface of the scapular spine. The distance from tip of tendon insertion to the nearest nerve at the most superior portion of the lower trapezius was 58 mm (standard deviation ± 18). By use of these relationships, there were no cases of neurovascular injury during our cadaveric tendon harvests. CONCLUSION: The lower trapezius can be reliably and consistently identified without violating fibers of the middle trapezius. Muscle splitting can be performed safely without encountering the spinal accessory nerve (approximately 2 cm medial to the medial scapular border).