Which Pre-Operative, Modifiable Risk Factors are Most Predictive of Complications in orthopedic Upper Extremity Surgery?

Objectives: Identification of modifiable comorbid conditions in the preoperative period is important in optimizing outcomes. We evaluate the association between such risk factors and postoperative outcomes after upper extremity surgery using a national database. Methods: The National Surgical Quality Improvement Program (NSQIP) 2006-2016 database was used to identify patients undergoing an upper extremity principle surgical procedure using CPT codes. Modifiable risk factors were defined as smoking status, use of alcohol, obesity, recent loss of >10% body weight, malnutrition, and anemia. Outcomes included discharge destination, major complications, bleeding complications, unplanned re-operation, sepsis, and prolonged length of stay. Chi square and multivariable logistic regressions were used to identify significant predictors of outcomes. Significance was defined as P<0.01. Results: After applying exclusion criteria, 53,780 patients were included in the final analysis. Preoperative malnutrition was significantly associated with non-routine discharge (OR=4.75), major complications (OR=7.27), bleeding complications (OR=7.43), unplanned re-operation (OR=2.44), sepsis (OR=10.22), and prolonged length of stay (OR=5.27). Anemia was associated with non-routine discharge (OR=2.67), bleeding complications (OR=13.27), and prolonged length of stay (OR=3.26). In patients who had a weight loss of greater than 10%, there was an increase of non-routine discharge (OR=2.77), major complications (OR=2.93), and sepsis (OR=3.7). Smoking, alcohol use, and obesity were not associated with these complications. Conclusion: Behavioral risk factors (smoking, alcohol use, and obesity) were not associated with increased complication rates. Malnutrition, weight loss, and anemia were associated with an increase in postoperative complication rates in patients undergoing upper limb orthopaedic procedures and should be addressed prior to surgery, suggesting nutrition labs should be part of the initial blood work.

Cephalomedullary Nailing has a Higher Reoperation Rate Compared to Sliding Hip Screw Fixation in the Treatment of Intertrochanteric Femur Fractures: A Systematic Literature Review and Meta-analysis.

Objectives: Intertrochanteric hip fractures are a common orthopaedic injury in the United States. Complications of surgical treatment include nonunion, lag screw cutout, implant failure, post-operative pain, risk of refracture or reoperation, and infection. The purpose of this study was to compare the rate of complications of sliding hip screw fixation (SHS) compared to cephalomedullary nailing (CMN) for the treatment of closed intertrochanteric femur fractures in adult patients. Methods: PubMed, CINAHL, and Cochrane Library databases were searched for studies comparing SHS to CMN in the treatment of closed intertrochanteric femur fractures in adults. Data were compiled to observe the rate of nonunion, cutout failure, infection, refracture, perioperative blood loss, reoperation, postoperative pain, pulmonary embolism/deep venous thrombosis (DVT), length of hospital stay, and mortality. Results: Seventeen studies were included comprising 1,500 patients treated with SHS and 1,890 patients treated with CMN. Treatment of intertrochanteric femur fractures with SHS demonstrated significantly fewer refractures and reoperations. There was no significant difference in other variables between SHS and CMN treated groups. Conclusion: This meta-analysis shows that the only notable difference in outcomes is patients treated with CMN have a higher rate of refracture and reoperation. With new advances in the development of both CMNs and SHS, further studies will be required to see if these differences persist in the coming years.

Comparison of Treatment Options for Chronic Scapholunate Interosseous Ligament (SLIL): A Systematic Literature Review and Meta-Analysis.

Background: The scapholunate interosseous ligament (SLIL) is an important contributor to wrist stability and functionality. SLIL injury is debilitating and therefore many surgical techniques have been proposed, but the optimal treatment modality remains debated.This meta-analysis reviews the available literature comparing surgical techniques used in the treatment of chronic SLIL to determine the best approach. Methods: An electronic search of the literature was conducted to identify all randomized controlled trials and cohort studies published before January 2019 that evaluated clinical outcomes of capsulodesis reconstruction, the modified Brunelli technique, and the reduction and association of the scaphoid and lunate (RASL) procedure for treatment of chronic SLIL. A chi-square analysis was performed to identify possible differences between each technique for several outcome measures. Results: A total 20 studies encompassing 409 patients met inclusion criteria. Average age among patients was 36.7 years, and 68.2% of patients were male. Reductions in visual analog scale pain scale; Disabilities of Arm, Shoulder, and Hand (DASH) scores; and increases in grip strength and range of motion were observed for all techniques. Capsulodesis was superior to the modified Brunelli technique regarding preserved range of motion. Conclusions: No significant differences were observed among any of the techniques for pain, DASH score, and grip strength outcomes. Capsulodesis, modified Brunelli, and RASL surgical techniques for the treatment of chronic SLIL injuries may all be seen as reliable methods of treatment of chronic SLIL injuries. While future trials directly comparing these methods are needed, this study suggests there is no superiority of one technique over another.

Intraoperative Nerve Conduction Studies During Open Carpal Tunnel Release: A Pilot Study.

Background: Operative management of carpal tunnel syndrome (CTS) involves release of the transverse carpal ligament (TCL) and often the volar antebrachial fascia (VAF). Evidence of a difference between TCL and TCL+VAF release is limited. We conducted a pilot study to measure changes of intraoperative nerve conduction velocity (NCV) after CTS surgery and compared outcomes of variable degrees of decompression. Methods: Patients aged 18 to 65 years diagnosed with idiopathic CTS that failed to respond to conservative management were included in this study. Patients were excluded if they had prior surgical release, diabetes, acute CTS, trauma, or cervical spine radiculopathy. Outcomes included motor and sensory amplitude and latency. Electrodes were placed on the skin intraoperatively along the abductor pollicis brevis, index finger, and forearm. Outcome data were recorded at baseline, after TCL release, and after TCL+VAF release. Data were compared using a single-tail t test. Results: A total of 10 patients were included in this study. There were no significant changes in mean motor or sensory amplitude and latency from baseline to TCL release, TCL to VAF release, or from baseline to TCL+VAF release measured intraoperatively. Conclusions: This pilot study shows there is no immediate detectable difference in NCV following release of TCL or TCL+VAF. This suggests that NCV may not be useful for assessing intraoperative improvement. We highlight the need for future research in the form of case-control studies to determine the utility of intraoperative NCV. These studies should be conducted with larger numbers of patients and involve multiple hand specialists.

Is Insurance Status Associated With Likelihood of Operative ACL Injury Treatment Compared With Nonoperative Treatment?

Background: While many factors inform the choice of operative versus nonoperative treatment of injuries to the anterior cruciate ligament (ACL) of the knee, socioeconomic status influences this decision, as has been reported with other procedures. Purpose: To identify any associations between insurance status and likelihood of operative treatment of ACL injuries. Study Design: Cross-sectional study; Level of evidence, 3. Methods: The Nationwide Inpatient Sample database was queried using International Classification of Diseases, 9th Revision codes for ACL injuries and reconstruction from 2001 to 2013. Chi-square analysis was performed to determine significant predictors of operative intervention. Binary logistic regression was used to account for demographic and significant predictor variables. Results were recorded as odds ratios (ORs) and 95% CIs. Significance was defined as P < .05. Results: A total of 32,541 patients with ACL injuries were included in the final analysis. Overall incidence of surgical reconstruction was 85.4% (n = 27,805). Multivariable regression revealed that nonprivate insurance types were associated with lower likelihoods of operative reconstruction compared with private insurance: the lowest likelihood of operation was seen in uninsured patients (OR, 0.31; P < .01), followed by Medicare (OR, 0.33; P < .01) and Medicaid (OR, 0.51; P < .01) patients. There was also a decreased likelihood of surgery for elderly (OR, 0.0 [for age ≥75 years]; P < .01) and Black patients (OR, 0.65; P < .01). An increased likelihood of surgery was seen with female patients (OR, 1.14; P < .01). Patients in the highest median household income quartile were more likely to undergo surgery than those in the lowest (OR, 1.36; P < .01). Conclusion: Compared with privately insured patients, patients with nonprivate insurance had lower likelihood of surgery. Furthermore, patients in higher income quartiles were more likely to undergo operative fixation. These findings may suggest a need for more precise treatment guidelines and studies that investigate causes of such differences.

Association of Bacterial Etiology With Rates of Reoperation in Patients With Septic Tenosynovitis of the Hand.

Background: The anatomy of the hand makes it uniquely sensitive to complications after bacterial infection. The causative organism has been implicated as a predictor of complications after surgery. We hypothesize that bacterial etiology is associated with different operation and reoperation rates in patients with flexor tenosynovitis. Methods: The Nationwide Inpatient Sample 2001-2013 database was queried for cases of tenosynovitis by using International Classification of Diseases, 9th Revision (ICD-9) diagnostic codes 727.04 and 727.05. The pathogen cultured was also identified with ICD-9 codes, and surgical intervention was determined using ICD-9 procedural codes. χ2 analysis and logistic regression were used to determine predictors of outcomes. Outcomes included initial surgery and the need for additional surgery, which was defined as records having ICD-9 procedural codes repeated for the same patient. Results: A total of 17,476 cases were included. The most common bacterial etiology was methicillin-sensitive Staphylococcus aureus followed by Streptococcus species. Infections with gram-positive organisms, including methicillin-sensitive and methicillin-resistant S aureus, unspecified Staphylococcus, and Streptococcus species were significantly associated with higher rates of initial surgery for tenosynovitis. Patients receiving Medicaid and Hispanic patients had a statistically significant lower likelihood of surgery. Higher rates of reoperation were reported in patients aged 30 to 50 years, 51 to 60 years, 61 to 79 years, and ≥80 years; other factors associated with higher reoperation rates were Streptococcus and Staphylococcus infections and use of Medicare. Conclusions: The data show that cultures of Streptococcus and certain species of Staphylococcus in patients with septic tenosynovitis are predictive of operation and reoperation rates. Patients with these infectious etiologies may have more severe presentations that warrant operative intervention. This data may allow for more informed decision-making in the preoperative period.

A simplified preoperative risk assessment tool as a predictor of complications in the surgical management of forearm fractures.

PURPOSE: Frailty is a well-known predictor of adverse postoperative outcomes and is often considered in the preoperative planning stage of surgery. In recent years, the modified frailty index (mFI), a novel metric used to quantify frailty, has become increasingly used in the orthopedic literature as a risk assessment tool. In this study, we analyze the utility of the mFI in predicting unplanned repeat operations and morbidity in the surgical treatment forearm fractures. METHODS: We used the American College of Surgeons National Surgical Quality Improvement Program 2006-2014 dataset to identify patients undergoing open fixation of forearm fractures. The mFI was calculated based on 5 possible comorbid conditions. Demographic and predictor variables were analyzed for associations with each outcome. In order to assess frailty in both the general and elderly population, two analyses were completed: one for the entire population and one for a population of age 65 or older. The primary outcome of interest was unplanned repeat operation. Secondary outcomes included discharge destination and major post-operative complications. Chi square and logistic regression analyses were used to identify associations. RESULTS: A total of 4641 patients were included in our final analysis. There was a higher prevalence of females and patients between the ages of 61 and 80 compared to other age groups. An mFI score ≥2 was a positively associated with unplanned repeat operation in the general population. An mFI score ≥2 was also positively associated with a discharge destination other than home and major post-operative complications. In the elderly population, mFI ≥2 was similarly associated with a discharge destination other than the patient's home. CONCLUSIONS: Patients undergoing open treatment of forearm fractures were at an increased likelihood of having an unplanned repeat operation and having major complications as frailty score increased, demonstrating that the mFI may be clinically applicable risk assessment tool for these patients.

Differences in the Predictive value of Elixhauser Comorbidity Index and the Charlson Comorbidity indices in patients with hand infections.

PURPOSE: Hand infections are a common source of potentially debilitating morbidity, particularly in patients with comorbid disease. We hypothesize that there is a difference in predictive value between two commonly used comorbidity indices for the prognosis of hand infections, which may have clinical implications in the management of these conditions. METHODS: The Nationwide Inpatient Sample 2001-2013 database was queried for hand infections using International Classification of Diseases, Ninth Revision codes. The Elixhauser (ECI) and Charlson (CCI) comorbidity scores were calculated based on validated sets of ICD-9 codes. Primary outcomes included mortality, prolonged length of stay (LOS, defined as >95 percentile), discharge destination, and postoperative complications. Indices were compared using receiver operating characteristic (ROC) curves and the areas under the curve (AUC). If confidence intervals overlapped, significance was determined using the DeLong method for correlated ROC curves. This is a validated, non-parametric comparison used for the calculation of the difference between two AUCs. RESULTS: A weighted total of 1,511,057 patients were included in this study. The majority were Caucasian (57.1%) males (61.4%). Complication rates included 0.9% mortality, 5.3% prolonged length of stay, 25.3% discharges to non-home destinations, and 5.3% post-operative complications. The ECI and CCI each demonstrated good predictive value for mortality, but poor predictive value for non-routine discharge, prolonged LOS, and post-operative complications. There was a significantly increased likelihood of each complication with increasing comorbidity score for both indices, with the greatest odds ratio in the ECI ≥4 cohort. CONCLUSIONS: The CCI was superior in predicting mortality while the ECI was superior in predicting non-routine discharge, prolonged length of stay, and postoperative complications, but these indices may not be clinically relevant. While both represent good predictive models, a score specifically designed for patients with hand infections may have superior prognostic value. LEVEL OF EVIDENCE: Level IV.

Epidemiology of orthopaedic fractures due to firearms.

The majority of firearm injuries involve the extremities and have concomitant orthopaedic injuries. National data on the epidemiology of wounds caused by firearms may better inform physicians and identify areas of public health intervention. We conducted an analysis of a national database to describe the epidemiology of orthopaedic firearm injuries in the United States. The Nationwide Inpatient Sample 2001-2013 database was queried for adult patients with fractures excluding those of the skull using injury billing codes. Characterization of injury was determined using External Cause of Injury billing codes. Sociodemographic and geographic variables were reported. Chi square and multinomial logistic regression analyses were performed to identify predictors of type of firearm implicated in injury. 334,212 firearm injuries were reported in the database and about half had concomitant orthopaedic fractures. Most patients were between the ages 19 and 29, were African American, and were male. The most frequent circumstance of injury was assault/homicide, the most common firearm used was a handgun, and the most common fracture site was the femur. Patients without insurance and patients of lower income were most commonly afflicted. Knowing this distribution of the burden of this class of injury provides the opportunity to identify and intervene on behalf of at-risk populations, potentially reducing injuries by promoting firearm safety to these groups and advocating sensible practices to reduce inequitable outcomes caused by these injuries.

Clavicle fractures: Associated trauma and morbidity.

BACKGROUND: Clavicle fractures are frequently associated with trauma to regions beyond the immediate zone of injury. In order to provide surgeons with information on injury prevalence to prevent delays in diagnosis and management, we describe the epidemiology of concomitant injuries in patients with clavicle fractures and identify differences between those with open and closed fractures. Methods:The Nationwide Inpatient Sample (NIS) 2001-2013 database was queried for adult patients discharged with a diagnosis of a clavicle fracture using ICD-9 codes. A "common" injury was defined as prevalence ≥4.0% in our study population. We analyzed data for injury locations associated with open vs. closed clavicle fractures with chi square and independent samples t-tests. RESULTS: A total of 41,1612 patients were included in our study population. The majority of patients had closed clavicle fractures (98.2%). The most common concomitant fracture was that of the rib, followed by the spine. The most common non-vascular, non-nervous injury was a hemo/pneumothorax followed by a lung, bronchus, or diaphragm injury. Fractures of the humerus, rib, scapula, pelvis, tibia or fibula, and facial bones as well as concussion, pneumo/hemothorax, other pulmonary, and splenic injuries were more common in patients with open clavicle fractures. Patients with open clavicle fractures were, on average, 11.8 years younger than those with closed fractures. CONCLUSION: There is a significant association between clavicle fractures and concussion, splenic, and thoracic injuries, as well as increased rate of complications with open fractures. Clinicians may use this information to perform risk assessments prevent delays in diagnosis.

Union of Radiocarpal Fusion With and Without Proximal Row Carpectomy: A Systematic Review.

PURPOSE: Wrist fusion provides a solution to the painful, arthritic wrist, and can be concomitantly performed with or without a proximal row carpectomy (PRC). The benefits of combining a PRC with fusion include a large amount of local bone graft for fusion and a lower number of joints needed to fuse. We hypothesized that wrist fusion combined with PRC will have a higher fusion rate than wrist fusion performed without PRC. METHODS: A systematic review was performed to identify all papers involving wrist arthrodesis using the following databases: PubMed, Ovid, Scopus, Web of Science, and COCHRANE. A literature search was performed using the phrases "wrist" OR "radiocarpal" and "fusion" OR "arthrodesis". Inclusion criteria included complete radiocarpal fusion performed for rheumatoid, posttraumatic, or primary arthritis; union rates available; English-language study. Studies were excluded if case reports; diagnoses other than the ones listed previously; inability to abstract the data. Data collected included wrist fusions with PRC or without PRC, union rate, patient age, underlying diagnosis, and method of fixation. RESULTS: A total of 50 studies were included in the analysis. There were 41 studies with no PRC, 8 studies with PRC, and 1 study with and without PRC. There were 347 patients with a PRC and 339 patients had a successfully fused wrist (97.7%). There were 1,355 patients who had a wrist fusion with no PRC, and1,303 patients had successful wrist fusion (96.2%). The difference in fusion rate between the 2 groups, 97.7% versus 96.2%, was not statistically significant. CONCLUSIONS: There is no statistically significant difference with regards to union rate in wrist fusion with a PRC versus wrist fusion without a PRC. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Epidemiology and survival of liposarcoma and its subtypes: A dual database analysis.

PURPOSE: Liposarcoma (LPS) is a one of the most commonly diagnosed soft tissue sarcomas. Little is known about the epidemiology and prognosis of each subtype. We present an analysis of epidemiology and survival of the subtypes of LPS using a national database. METHODS: We queried the Survival Epidemiology, and End Results (SEER) and the Canadian Institute for Clinical Evaluative Sciences (ICES) databases for data on 7 types of LPS. Pearson's chi square was used to determine associations between variables and subtypes. Kaplan-Meier and Cox Regression analyses were performed for two tests: one using SEER data and the other using variables common to both SEER and ICES. RESULTS: The well-differentiated subtype was the most common subtype identified. Metastatic disease was associated with decreased survival across all subtypes and age >35 was associated with decreased survival in well-differentiated and myxoid subtypes. Tumor grade was associated with decreased survival in the well-differentiated, myxoid, mixed, and round cell subtypes. In the secondary analysis, age >35 was associated with decreased survival in the myxoid subtype. CONCLUSIONS: The prognosis of liposarcoma differs greatly by subtype. Clinicians should account for patient factors at the time of diagnosis to best navigate treatment of their patients.

Patient frailty as a risk assessment tool in surgical management of long bone fractures.

BACKGROUND: Frailty is an important predictor of surgical outcomes and has been quantified by several models. The modified frailty index (mFI) has recently been adapted from an 11-item index to a 5-item index and has promise to be a valuable risk assessment tool in orthopedic trauma patients. We perform a retrospective analysis of the 5-item mFI and evaluate its effectiveness in predicting outcomes in patients with long bone fractures. METHODS: The National Surgery Quality Improvement Program (NSQIP) 2006-2016 database was queried for surgical procedures in the treatment of long bone fractures by current procedural terminology (CPT) codes, excluding those performed on metacarpals and metatarsals. Cases were excluded if they were missing demographic, frailty, and variable data. The 5-item frailty index was calculated based on the sum of presence of 5 conditions: COPD/pneumonia, congestive heart failure, diabetes, hypertension, and impaired functional status. Chi square was used to determine variables significantly associated with each outcome. The significant variables were included in multivariate logistic regression along with the mFI. Significance was defined as p < 0.05. RESULTS: Of the 140,249 fixation procedures performed on long bone fractures in NSQIP, 109,423 cases remained after exclusion criteria were applied. The majority of patients were between the ages of 61 and 80 (34.0%), were female (65.6%) and Caucasian (86.3%). Multivariate analysis revealed that mFI scores ≥3 were predictive of unplanned reoperation (OR = 1.57), wound disruption (OR = 2.83), unplanned readmission (OR = 2.12), surgical site infection (OR = 1.90), major complications (OR = 3.04), and discharge destination (OR = 3.06). CONCLUSIONS: Our study analyzed the relationship of frailty and postoperative complications in patients with long bone fractures. Patients had increased likelihood of morbidity, independent of other comorbidities and demographic factors. The mFI may have a role as a simple, easy to use risk assessment tool in cases of orthopedic trauma.

A new role for orthopaedic surgeons: ongoing changes, lessons learned, and perspectives from a level I trauma center during the COVID-19 pandemic.

The COVID-19 pandemic has redefined global health care. With almost 13 million confirmed cases worldwide, medical professionals have been forced to modify their practice to take care of an expanded, critically ill population. Institutions have been challenged to implement innovative ways to maximize the utility and the safety of residents and personnel. Guided by lessons learned from prior mass causalities, wars, and previous pandemics, adjustments have been made in order to provide optimal care for all patients while still protecting limited resources and the lives of health care workers. Specialists who are trained in the management of lethal aspects of this disease continue to have a high demand and obvious role. Orthopedic surgeons, with ill-defined roles, have been redeployed to manage complex medical problems. Still, the need to manage trauma, fractures, infections, tumors, and dislocations remains a necessity. Various innovative measures have been taken to maximize the utility and safety of residents in the inpatient and outpatient setting. Commonalities to most measures and distinct changes in practice philosophy can be identified and applied to both current and future pandemic responses.

Risk factors of venous thromboembolism in patients with benign and malignant musculoskeletal tumors: a dual database analysis.

PURPOSE: Venous thromboembolism (VTE) is a potentially life-threatening condition associated with both orthopaedic surgery and tumour growth. In this study, we identify risk factors associated with VTE in patients with musculoskeletal tumours using two national datasets. METHODS: The ACS-NSQIP and NIS databases were queried for patients undergoing surgery with a diagnosis of benign or malignant musculoskeletal tumours. Chi-square and binary logistic regression analyses were used to determine risk factors for VTE. RESULTS: The incidence of VTE was 2% in both databases. Patients with malignant tumours, those with tumours of the pelvis, sacrum, or coccyx, obesity, arrhythmias, paralysis, metastatic disease, coagulopathy, and recent weight loss were at increased risk for VTE. In patients with benign tumours, those who were African American, those with tumours of the pelvis, sacrum, or coccyx, diabetes, anaemia, and coagulopathy were at increased risk of VTE. CONCLUSIONS: Patients with malignant or benign lesion are at greater risk of VTE if they are age 30 and over, of the African American population, or with tumors of the pelvis/sacrum/coccyx, or any of the following comorbidities: pulmonary disease, paralysis, other neurological disorders, or coagulopathy.

The Use of Nitinol Compression Staple Fixation and Bone Graft for Scaphoid Waist Fractures and Nonunion: A Surgical Technique.

In the management of scaphoid fractures, nonunion is an important complication that can lead to carpal instability and early-onset arthritis. Various techniques have been described to treat scaphoid nonunions, yet a clear consensus on the superiority of one method is not yet established. The use of compression staple fixation has been described in the literature and may be a viable alternative to other fixation techniques. Volar Nitinol staple fixation avoids damage to the trapezium during retrograde fixation with a screw. It also avoids damage to the proximal dorsal cartilage, which occurs during anterograde screw fixation. Because of its shape and position on the volar aspect of the scaphoid, staple fixation provides compression, prevents graft extrusion, and avoids taking up space in the medullary canal of the scaphoid. Moreover, it may be technically easier than screw fixation. Despite these advantages, this technique has not been widely adopted. We describe the technique for utilizing Nitinol compression staples and bone grafting in the treatment of scaphoid nonunion.

Increased risk of complications in patients with hypoalbuminemia undergoing revision total hip arthroplasty.

OBJECTIVE: The relationship between hypoalbuminemia and complications after revision total hip arthroplasty (THA) has not been established. We hypothesize that hypoalbuminemia is associated with complications in patients undergoing revision THA. METHODS: The ACS-NSQIP database was queried for patients undergoing revision THA. Chi square and regression analyses were used to assess the relationship between hypoalbuminemia, demographics, other comorbidities, and complications. RESULTS: Hypoalbuminemia is associated with an increased risk of reoperation, bleeding complications, surgical site infections, non-routine discharge, medical complications, and surgical complications. CONCLUSIONS: Albumin levels should be considered in the preoperative planning of patients undergoing revision THA for possible nutritional optimization.

Survival and Prognosis of Chondrosarcoma Subtypes: SEER Database Analysis.

Chondrosarcomas are rare tumors and, historically, investigation of these tumors has been limited to small series and single-institution studies. There have been no studies that evaluated the identification or comparison of differences in prognostic factors between the five known non-conventional chondrosarcoma subtypes (myxoid, juxtacortical, clear-cell, mesenchymal, and dedifferentiated). The purpose of this paper was to determine the demographic, clinical, incidence, and tumor characteristics of all five known non-conventional chondrosarcoma subtypes, determine the 1-, 5-year, and median survival differences between these subtypes, and to determine the demographic and clinical variables that are significant prognostic indicators for each chondrosarcoma subtypes. We retrospectively reviewed the SEER database for all patients with non-conventional chondrosarcoma. χ2 testing was used for correlations between clinical variables. Kaplan-Meier and Cox proportional hazard analysis were used to compare survival of the subtypes, and to assess the prognostic value of age group, race, sex, grade, anatomic location, and metastatic involvement. Several demographic characteristics including gender, race, age, and grade varied between chondrosarcoma subtypes. The tumor characteristics showed marked differences in presence of metastasis on presentation between the subtypes with increasing order of rate of metastasis with juxtacortical (2.1%), clear cell (5.7%), myxoid (7.6%), mesenchymal (10.6%), and the highest in dedifferentiated (19.8%). One-, 5-year, and median survival differed significantly between chondrosarcomas subtypes. The highest median survival was found in the juxtacortical subtype (97 months), followed by clear cell (79 months), myxoid (60 months), mesenchymal (33.5 months), and lowest in dedifferentiated (11 months). The only prognostic variable that was shown to significantly impact the survival of each non-conventional chondrosarcoma subtype was a metastatic disease at diagnosis (p = 0.03 to p < 0.001). Subtyping classification of chondrosarcoma should be made whenever possible, given differences in survival and prognostic factors between chondrosarcoma subtypes. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:311-319, 2020.

Operative Versus Nonoperative Outcomes of Middle-Third Clavicle Fractures: A Systematic Review and Meta-Analysis.

OBJECTIVES: Middle third clavicle fractures have long been managed conservatively with immobilization. Some patients, especially those with completely displaced or shortened clavicle fractures are now thought to have increased risk of nonunion or symptomatic malunion. The authors performed a meta-analysis to study the incidence of nonunion and symptomatic malunion and test the hypothesis that surgical fixation of these fractures significantly lowers the risk of these complications. METHODS: A search was performed in the PubMed, Embase, and Cochrane Library databases for randomized clinical trials and quasi-experimental trials that compare outcomes of operative and nonoperative management for clavicle fractures that are fully (100%) displaced or have greater than 2 cm of shortening. Pooled patient data were used to construct forest plots for the meta-analysis. RESULTS: Eleven studies including 497 patients who were treated and 457 patients treated conservatively were analyzed. Patients managed operatively had significantly lower relative risk of developing nonunion [0.17 (95% confidence interval 0.08-0.33)] and symptomatic malunion [0.13 (95% confidence interval 0.05-0.37)]. Plate fixation significantly reduced the risk of nonunion, but intramedullary nail fixation did not. There was no difference in Constant-Murley or DASH scores between the 2 treatment groups or in the rate of secondary operative procedures. CONCLUSIONS: Patients who undergo operative fixation of displaced middle-third clavicle fractures have a lower incidence of nonunion and symptomatic malunion. The clinical significance of this effect is uncertain, as functional scores were similar in both groups. Further research into the risk factors for nonunion and symptomatic malunion will be necessary to determine which patients benefit from operative fixation. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

What Is the Normal Ulnar Bow in Adult Patients?

BACKGROUND: Rotation of the forearm is a result of the complex interaction among the radius, ulna, and interosseous membrane. Although the radius is recognized as curved, the ulna is generally thought of as a "straight bone." To better describe normal anatomy, which may lead to more successful anatomic fixation of forearm fractures, we aimed to apply a method of measuring the normal ulnar bow and determine the mean ulnar bow in adults. QUESTIONS/PURPOSES: (1) To what degree is the ulna bowed in the coronal and sagittal planes in normal adult forearms? (2) To what degree is the radius bowed in the coronal plane in normal adult forearms? METHODS: Radiographs of the forearms of adults taken during a 1-year period were initially obtained retrospectively. These radiographs were performed for various reasons, including forearm pain and routine radiographic follow-up. Radiographs were excluded if evidence of a fracture or post-fracture fixation was found, if a patient had missing AP or lateral images, or if a suboptimal technique was used. The coronal and sagittal bow of the ulna was measured with a method adapted from previous studies that assessed radial bow using AP and lateral radiographs, respectively. Similar measurements were made in the coronal plane for the radius. All measurements were performed independently by the four authors. There was excellent interobserver reliability for ulnar bow in the coronal and sagittal planes (interclass correlation coefficient = 0.96 and 0.97, respectively) and for radial bow in the coronal plane (interclass correlation coefficient = 0.90). RESULTS: The mean maximal coronal ulnar bow was 7 ± 2 mm and was located at 75% of the ulnar length, measured proximally to distally. The location of coronal bow was consistently distal to the radial bow location. The mean maximal sagittal ulnar bow was 6 ± 3 mm and was located at 39% of the ulnar length. The mean maximal coronal bow of the radius was 14 ± 2.0 mm and was 59% of the total length of the radius from proximal to distal. CONCLUSIONS: The ulna is not a "straight bone," as is commonly thought, but rather has a bow in both the coronal and sagittal planes. CLINICAL RELEVANCE: Knowledge of the standard ulnar bow may be pivotal to prevent malunion of the ulna during surgery. Future research using these data in preoperative planning may lead to changes in plate contouring and clinical outcomes in forearm fracture management.