Hip Fracture Repair by the Post-Call Surgeon: A Multicenter Retrospective Review.

INTRODUCTION: The purpose of this study was to evaluate surgeons' ability to perform or supervise a standard operation with agreed-upon radiologic parameters after being on call. METHODS: We reviewed a consecutive series of patients with intertrochanteric hip fractures treated with a fixed angle device at 9 centers and compared corrected tip-apex distance and reduction quality for post-call surgeons versus those who were not. Subgroup analyses included surgeons who operated the night before versus not and attending-only versus resident involved cases. Secondary outcomes included union and perioperative complications. RESULTS: One thousand seven hundred fourteen patients were of average age 77 years. Post-call surgeons treated 823 patients and control surgeons treated 891. Surgical corrected tip-apex distance did not differ between groups: on-call 18 mm versus control 18 mm (P = 0.59). The Garden indices were 160° on the AP and 179° on the lateral in both groups. In 66 cases performed by surgeons who operated the night before, the TAD was 17 mm. No difference was noted in corrected tip-apex distance with and without resident involvement (P = 0.101). No difference was observed in pooled fracture-related complications (P = 0.23). CONCLUSION: Post-call surgeons demonstrated no difference in quality and no increase in complications when performing hip fracture repair the next day compared with surgeons who were not on call.

Adequate bone healing after supplementary fixation of periprosthetic total knee arthroplasty fractures using Luque cerclage wiring: a retrospective case series.

PURPOSE: Cerclage wiring is a well-known supplemental fixation technique that can be used in many types of fractures. With the tendency toward minimally invasive approaches in the management of periprosthetic total knee arthroplasty (TKA) fractures, and with absence of a dedicated study that reports the results of cerclage wiring in TKA fractures in particular, the aim of this retrospective study is to report the outcomes of supplementary cerclage wiring using simple Luque wires in fractures of distal femur associated with TKA. METHOD: Eighteen cases, with a mean age of 77.2 years had complete follow-up data and had their radiographs and clinical data assessed for this study. Patients received cerclage wiring along with plates, retrograde nailing or around cracked femoral shaft overlying revision TKA femoral stem during the surgical management of periprosthetic TKA distal femur fractures. RESULTS: Fracture healing with adequate callus formation occurred in all 18 cases at a mean of 11.4 weeks postoperatively. None of the cases had any vascular injury, and after a mean clinical follow-up of 51 weeks, none of the cases had nonunion or hardware complications. One case had postoperative periprosthetic infection that developed 8 months after full fracture healing and had a two-stage revision using revision stemmed TKA and protective cerclage wiring with successful eradication of infection. CONCLUSION: Supplementary cerclage wiring in distal femur TKA fractures can aid in enhanced bone healing with minimal complications, provided that adequate reduction and rigid fixation were achieved. This study reflects the level of evidence IV.

How do we PI? Results of an EAST quality, patient safety, and outcomes survey.

Background: Quality improvement is a cornerstone for any verified trauma center. Conducting effective quality and performance improvement, however, remains a challenge. In this study, we sought to better explore the landscape and challenges facing the members of the Eastern Association for the Surgery of Trauma (EAST) through a survey. Methods: A survey was designed by the EAST Quality Patient Safety and Outcomes Committee. It was reviewed by the EAST Research and Scholarship Committee and then distributed to 2511 EAST members. The questions were designed to understand the frequency, content, and perceptions surrounding quality improvement processes. Results: There were 151 respondents of the 2511 surveys sent (6.0%). The majority were trauma faculty (55%) or trauma medical directors (TMDs) (37%) at American College of Surgeons level I (62%) or II (17%) trauma centers. We found a wide variety of resources being used across hospitals with the majority of cases being identified by a TMD or attending (81%) for a multidisciplinary peer review (70.2%). There was a statistically significant difference in the perception of the effectiveness of the quality improvement process with TMDs being more likely to describe their process as moderately or very effective compared with their peers (77.5% vs. 57.7%, p=0.026). The 'Just Culture' model appeared to have a positive effect on the process improvement environment, with providers less likely to report a non-conducive environment (10.9% vs. 27.6%, p=0.012) and less feelings of assigning blame (3.1% vs. 13.8%, p=0.026). Conclusion: Case review remains an essential but challenging process. Our survey reveals a need to continue to advocate for appropriate time and resources to conduct strong quality improvement processes. Level of evidence: Epidemiological study, level III.

Warm Saline Irrigation Protocol Decreases Cement Curing Time in Hip Arthroplasty.

Cementation in hip arthroplasty is a common and reliable technique for achieving a stable bone-component interface. However, there are significant costs to the patient, surgeon, and hospital related to the use of cement. It has been previously demonstrated that increasing ambient room temperature and femoral component temperature decreases cement curing time. A protocol utilizing warmed saline irrigation within the surgical field and a warm saline bath for the femoral component was developed. We performed a comparative cohort study to investigate if this protocol reduced time to cement curing in an in vivo setting. Ten patients were enrolled in the experimental group and 11 patients in the control group. Time to cement curing was significantly lower in the experimental group (7.5 minutes vs. 11.1 minutes, p < 0.0001). The use of a simple and inexpensive warmed saline irrigation protocol during cemented hip arthroplasty decreases time to cement curing.

Successful Primary Treatment of Ankle Fractures in Diabetic Patients with Peripheral Neuropathy Using a Tibiotalocalcaneal Nail: A Case Series.

Background: Among diabetics, patients with peripheral neuropathy are at increased risk of developing complications following an ankle fracture. While the outcomes in these patients treated nonoperatively have been poor, the outcomes in those undergoing open reduction and internal fixation are at the best modest. We hypothesize that closed reduction and internal fixation with tibiotalocalcaneal nail is an effective primary procedure in this complication prone patient group. Methods: A retrospective review of diabetic patients with peripheral neuropathy who underwent acute treatment of an ankle fracture with closed reduction and internal fixation with a tibiotalocalcaneal nail at two Level 1 trauma centers was performed. 30 patients were identified and divided into 2 groups with respect to their postoperative weight bearing protocol: 20 patients in the early weight bearing (EWB) group and 10 patients in the touch-down weight bearing (TDWB). The primary outcome was the rate of return to baseline function and the secondary outcomes included the incidence of wound dehiscence, wound infection, implant failure, loss of fixation, loss of reduction and amputation. Results: In the EWB group, 15/20 patients returned to their baseline function, 5/20 had wound dehiscence and infection, 2/20 had implant failure, 5/20 had loss of fixation, 4/20 had loss of reduction, and 4/20 underwent amputation. In the TDWB group, 9/10 patients returned to their baseline function, 1/10 had implant failure, 1/10 had loss of fixation. No patients from this group had loss of reduction or underwent amputation. Conclusion: Treatment with tibiotalocalcaneal nail is an effective primary procedure in this complication prone group of patients, assuming that weight bearing is delayed for six weeks to protect soft tissues and surgical incisions. Level of Evidence: Level IV, retrospective case series.

An analysis of cost and complications for patients sustaining a second, contralateral hip fracture within 1 year.

INTRODUCTION: Hip fractures are an increasingly common occurrence among the aging population. With increased life expectancy and advancements in medicine, patients sustaining a hip fracture are at an increasing risk of sustaining a contralateral hip fracture. Efforts are being made to better understand the environment of these hip fractures so that secondary prevention clinics and guidelines can be made to help prevent recurrent osteoporotic hip fractures. The estimated incidence of a contralateral hip fracture varies from 2 to 10% and is reportedly associated with a higher incidence of complications. Previous studies evaluating contralateral hip fractures compared a single cohort of patients sustaining a second hip fracture with patients who sustained only one hip fracture. We aimed to investigate the overall complications and associated costs as it relates to a patients first hip fracture and contrast this to the same patient's contralateral, second hip fractures. METHODS: We performed a retrospective review of all patients in our health systems electronic database who were found to have surgically treated hip fractures between January 2004 and July 2019. Patients with surgically treated hip fractures (CPT Codes: 27235, 27236, 27245, 27244), who sustained a second contralateral hip fracture were included. Medical complications within 30 days of either procedure (such as pneumonia, UTI, altered mental status and others), length of stay, orthopedic complications (such as wound complications, infection, hardware failure, nonunion), type of implants, costs, comorbidities, and ASA Class as well as Mortality were reviewed. RESULTS: A total of 4,870 hip fractures were identified during the study period where 137 (2.8%) patients sustained a second hip fracture, and 47 (0.9%) of which were sustained within the first year after their index hip fracture. There was no statistical difference in length of stay (p = 0.68), medical (p>0.99) or orthopedic complications (p>0.99) between patients first and second hip fractures. There was an increased incidence of cognitive impairment with the second hip fracture (P = 0.0002). For patients that underwent operative treatment of a second hip fracture, the total cost of care was higher for the second surgery (mean difference 757. 38 USD) however the difference wasn't statistically significant (p = 0.31). The overall 1-year mortality rate was 14.9 percent. CONCLUSIONS: Our study demonstrates there is no statistical difference between the first and second surgery regarding length of stay, medical or orthopedic complications and cost.

The Utility of Routine Follow-up Radiographs in the Nonoperative Management of Proximal Humerus Fractures in Patients 65 Years and Older.

Whereas prior studies have aimed to define the utility of routine radiographs for the closed treatment of upper extremity fractures, it remains uncertain whether routine radiographs influence management decisions for nonoperative treatment of proximal humerus fractures (PHFs). The purpose of this investigation was to assess the utility of routine radiographic monitoring of closed PHFs in elderly patients initially indicated for nonoperative treatment. We identified all patients 65 years and older who had a PHF from 2016 to 2019. We excluded cases of pathologic fractures or peri-prosthetic fractures, nonunion, malunion, cases with insufficient follow-up, and cases for which surgery was indicated either in the emergency department or at the first orthopedic visit. After applying these exclusion criteria, 402 cases remained. We recorded baseline demographics and fracture descriptions and noted any conversion to operative treatment after the initial office visit. Two-part fractures were most common (56%). Of the 402 fractures indicated for nonoperative treatment, 21 (5%) were converted to operative management during the follow-up period. Nine fractures (2%) were converted to operative management within 30 days of the first office visit. Eight cases (2%) were converted to operative treatment more than 120 days after the initial office visit: 6 due to nonunion and 2 due to posttraumatic arthritis. For patients 65 years and older who undergo initial nonoperative treatment of a PHF, routine follow-up radiographs do not appear to alter management decisions. Given the risk and cost associated with routine radiographs, surgeons should consider forgoing these images in the absence of clinical concern. [Orthopedics. 2023;46(4):e244-e248.].

An Analysis of Formal Patient Complaints, Risk, and Malpractice Events Involving Orthopedic Trauma Surgeons During a 10-Year Period.

Formal patient complaints and malpractice events involving orthopedic trauma surgeons (OTSs) can have substantial career implications. Our purpose was to analyze formal patient complaints, risk events, and malpractice events against OTSs during a 10-year period. We reviewed all formal patient complaints within our institution's patient advocacy database involving 9 fellowship-trained OTSs throughout a decade. Complaints were categorized using the Patient Complaint Analysis System. Potential risk and malpractice events involving the OTSs were recorded. A control group of all patients seen by the surgeons during the study period was created. Demographics between patients with complaints and the control group were analyzed, as were malpractice, risk, and complaint rates between the surgeons. Of 33,770 patients, 136 filed a formal complaint (0.40%). There were 29 malpractice claims and 2 malpractice lawsuits. The care and treatment domain accounted for the highest percentage of complaints (36%), followed by the access and availability domain (26%). Results of the logistic regression analysis indicated that private insurance (odds ratio, 1.58) and operative treatment (odds ratio, 3.65) were significantly associated with complaints. Despite statistically significant differences in the rates of complaint and risk events between surgeons, malpractice events did not differ. The rate of patient complaints within a large orthopedic trauma practice during a 10-year period was 0.40%. Patients with private insurance and those treated operatively were more likely to file a complaint. Whereas complaint rates among surgeons varied, there was no significant difference in the rate of malpractice events. Understanding patient complaint rates and categorizations may allow surgeons to target areas for improvement. [Orthopedics. 2023;46(2):121-127.].

Open lower extremity fractures in the geriatric population.

INTRODUCTION: Open fractures in the elderly are distinct compared to younger populations. The purpose of this study is to follow a series of open fractures of the lower extremity in the geriatric population to better prognosticate outcomes. METHODS: We performed a retrospective chart review of patients over the age of 65 years old who were treated for an open, lower extremity fracture across two level I trauma medical systems. Patients were included if they had documented wound healing problems in the postoperative period, or 6 months of follow-up, or if they had a definitive radiographic outcome. Sixty-four patients were included of an average age of 76.23, of whom 73.4% were female. RESULTS: The fracture types were midshaft femur in 3, distal femur in 9, patella in 2, proximal tibia in 3, proximal fibula in 1, midshaft tibia in 14, distil tibia in 8, ankle in 23, and talar neck/calcaneus in 1. Forty-two fractures were the result of low energy mechanism and 22 fractures were from high energy mechanism. Fourteen fractures were type 1, 32 were type 2, 11 were type 3A, 6 were type 3B, and 1 was type 3C. At final follow-up, 13 wounds were well healed, 39 wounds were healed following a delay of more than 6 weeks to achieve healing, 3 were infected, 3 had been treated with amputation, 2 had chronic ulceration, 2 with active draining, and 2 had draining sinuses. DISCUSSION: Open lower extremity fractures are serious injuries with high rates of morbidity. Such risks are even higher in the geriatric population, particularly with regard to wound healing. This study provides important prognostic information in counseling geriatric patient with an open lower extremity fracture, as well as informs treatment in terms of wound surveillance and care in the postoperative period.

Modified Masquelet Technique and Primary Tibial Metaphyseal Shortening for the Management of Proximal Tibial-infected Non-union in a Patient with Alcohol-induced Neuropathy: A Case Study.

Aim: To highlight the role of the Masquelet technique as a limb salvage procedure for a neuropathic patient presenting with infected non-union of proximal tibia. Background: The management of an infected non-union in neuropathic patients is most challenging; with various treatment options available, the prognosis is often guarded. Case description: A 37-year-old male with chronic polyneuropathy, also possessing a contralateral midfoot Charcot arthropathy secondary to a history of alcohol abuse, developed infection after a proximal tibial osteotomy for a preceding mal-non-union of a proximal tibia fracture. The management included hardware removal, excision of necrotic bone, interim insertion of antibiotic-loaded bone cement followed by an acute shortening and revision of the internal fixation utilising a second surgical incision. Successful bone union and eradication of infection was achieved and maintained after 13 months follow-up. Conclusion: A successful outcome was achieved for an infected non-union of a long bone in a neuropathic patient using the Masquelet technique which was then followed with a second-stage removal of the spacer and shortening. By performing the revision ORIF surgery utilising a different skin incision in the setting of complicated previous surgical scars proved to be a viable technique towards reducing risk of recurrence of infection and a good outcome. Clinical significance: Utilisation of the Masquelet technique and limb shortening in a staged manner for the management of long bone infections in neuropathic patients has not been reported before and may be valuable in such demanding clinical situations. How to cite this article: Mahmoud AN, Watson JT, Horwitz DS. Modified Masquelet Technique and Primary Tibial Metaphyseal Shortening for the Management of Proximal Tibial-infected Non-union in a Patient with Alcohol-induced Neuropathy: A Case Study. Strategies Trauma Limb Reconstr 2023;18(3):181-185.

Bicondylar Tibial Plateau Fractures: What Predicts Infection?

OBJECTIVES: The purpose of this study was to identify the patient, injury, and treatment factors associated with infection of bicondylar plateau fractures and to evaluate whether center variation exists. DESIGN: Retrospective review. SETTING: Eighteen academic trauma centers. PATIENTS/PARTICIPANTS: A total of 1,287 patients with 1,297 OTA type 41-C bicondylar tibia plateau fractures who underwent open reduction and internal fixation were included. Exclusion criteria were follow-up less than 120 days, insufficient documentation, and definitive treatment only with external fixation. INTERVENTION: Open reduction and internal fixation. MAIN OUTCOME MEASUREMENTS: Superficial and deep infection. RESULTS: One hundred one patients (7.8%) developed an infection. In multivariate regression analysis, diabetes (DM) (OR [odds ratio] 3.24; P ≤ 0.001), alcohol abuse (EtOH) (OR 1.8; P = 0.040), dual plating (OR 1.8; P ≤ 0.001), and temporary external fixation (OR 2.07; P = 0.013) were associated with infection. In a risk-adjusted model, we found center variation in infection rates (P = 0.030). DISCUSSION: In a large series of patients undergoing open reduction and internal fixation of bicondylar plateau fractures, the infection rate was 7.8%. Infection was associated with DM, EtOH, combined dual plating, and temporary external fixation. Center expertise may also play a role because one center had a statistically lower rate and two trended toward higher rates after adjusting for confounders. LEVEL OF EVIDENCE: Level IV-Therapeutic retrospective cohort study.

Open Ankle Fractures: What Predicts Infection? A Multicenter Study.

OBJECTIVE: To identify the patient, injury, and treatment factors associated with an acute infection during the treatment of open ankle fractures in a large multicenter retrospective review. To evaluate the effect of infectious complications on the rates of nonunion, malunion, and loss of reduction. DESIGN: Multicenter retrospective review. SETTING: Sixteen trauma centers. PATIENTS: One thousand and 3 consecutive skeletally mature patients (514 men and 489 women) with open ankle fractures. MAIN OUTCOME MEASURES: Fracture-related infection (FRI) in open ankle fractures. RESULTS: The charts of 1003 consecutive patients were reviewed, and 712 patients (357 women and 355 men) had at least 12 weeks of clinical follow-up. Their average age was 50 years (range 16-96), and average BMI was 31; they sustained OTA/AO types 44A (12%), 44B (58%), and 44C (30%) open ankle fractures. The rate FRI rate was 15%. A multivariable regression analysis identified male sex, diabetes, smoking, immunosuppressant use, time to wound closure, and wound location as independent risk factors for infection. There were 77 cases of malunion, nonunion, loss of reduction, and/or implant failure; FRI was associated with higher rates of these complications (P = 0.01). CONCLUSIONS: Several patient, injury, and surgical factors were associated with FRI in the treatment of open ankle fractures. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Proximal tibia fracture dislocations: Management and outcomes of a severe and under-recognized injury.

INTRODUCTION: Proximal tibia fracture dislocations (PTFDs) are a subset of plateau fractures with little in the literature since description by Hohl (1967) and classification by Moore (1981). We sought to evaluate reliability in diagnosis of fracture-dislocations by traumatologists and to compare their outcomes with bicondylar tibial plateau fractures (BTPFs). METHODS: This was a retrospective cohort study at 14 level 1 trauma centers throughout North America. In all, 4771 proximal tibia fractures were reviewed by all sites and 278 possible PTFDs were identified using the Moore classification. These were reviewed by an adjudication board of three traumatologists to obtain consensus. Outcomes included inter-rater reliability of PTFD diagnosis, wound complications, malunion, range of motion (ROM), and knee pain limiting function. These were compared to BTPF data from a previous study. RESULTS: Of 278 submitted cases, 187 were deemed PTFDs representing 4% of all proximal tibia fractures reviewed and 67% of those submitted. Inter-rater agreement by the adjudication board was good (83%). Sixty-one PTFDs (33%) were unicondylar. Eleven (6%) had ligamentous repair and 72 (39%) had meniscal repair. Two required vascular repair. Infection was more common among PTFDs than BTPFs (14% vs 9%, p = 0.038). Malunion occurred in 25% of PTFDs. ROM was worse among PTFDs, although likely not clinically significant. Knee pain limited function at final follow-up in 24% of both cohorts. CONCLUSIONS: PTFDs represent 4% of proximal tibia fractures. They are often unicondylar and may go unrecognized. Malunion is common, and PTFD outcomes may be worse than bicondylar fractures.

Potential Benefits of Limited Clinical and Radiographic Follow-up After Surgical Treatment of Ankle Fractures.

INTRODUCTION: Ankle fractures are one of the most prevalent musculoskeletal injuries, with a significant number requiring surgical treatment. Postoperative complications requiring additional interventions frequently occur during the early postoperative period. We hypothesize that there is a limited need for routine clinical and radiographic follow-up once the fracture is deemed healed. METHODS: IRB approval was obtained at four academic trauma centers. A retrospective chart review was done to identify adults with healed unimalleolar and bimalleolar ankle fractures treated surgically with at least 12 months of follow-up. Based on postoperative radiographs, changes in fracture alignment and implant position from radiographic union to final follow-up were documented. The average reimbursement for a final follow-up clinic visit and a set of ankle radiographs were estimated. RESULTS: A total of 140 patients met inclusion criteria. The mean age at injury was 49.5 years, and 67.9% of patients were female. The mean time to healing was 82.2 days (±33.5 days). After radiographic healing, one patient had radiographic changes but was asymptomatic and full weight bearing at their final follow-up. On average, our institution was reimbursed $46 to $49 for a follow-up clinic visit and $364 to $497 for a set of ankle radiographs. CONCLUSION: Given the average time to healing, there is limited utility in routine radiographic and clinical follow-up beyond 16 weeks in asymptomatic patients. In our series, this would result in a savings of $950 to $1,200 per patient. However, after ankle fractures were deemed healed, 0.7% patients had radiographic evidence of a change in implant position. Documenting this change did not modify the immediate course of fracture treatment. Surgeons will need to balance the need for routine follow-up with the potential economic benefits in reducing costs to the healthcare system.

What is the Real Rate of Radial Nerve Injury After Humeral Nonunion Surgery?

OBJECTIVES: To determine the radial nerve palsy (RNP) rate and predictors of injury after humeral nonunion repair in a large multicenter sample. DESIGN: Consecutive retrospective cohort review. SETTING: Eighteen academic orthopedic trauma centers. PATIENTS/PARTICIPANTS: Three hundred seventy-nine adult patients who underwent humeral shaft nonunion repair. Exclusion criteria were pathologic fracture and complete motor RNP before nonunion surgery. INTERVENTION: Humeral shaft nonunion repair and assessment of postoperative radial nerve function. MAIN OUTCOME: Measurements: Demographics, nonunion characteristics, preoperative and postoperative radial nerve function and recovery. RESULTS: Twenty-six (6.9%) of 379 patients (151 M, 228 F, ages 18-93 years) had worse radial nerve function after nonunion repair. This did not differ by surgical approach. Only location in the middle third of the humerus correlated with RNP (P = 0.02). A total of 15.8% of patients with iatrogenic nerve injury followed for a minimum of 12 months did not resolve. For those who recovered, resolution averaged 5.4 months. On average, partial/complete palsies resolved at 2.6 and 6.5 months, respectively. Sixty-one percent (20/33) of patients who presented with nerve injury before their nonunion surgery resolved. CONCLUSION: In a large series of patients treated operatively for humeral shaft nonunion, the RNP rate was 6.9%. Among patients with postoperative iatrogenic RNP, the rate of persistent RNP was 15.8%. This finding is more generalizable than previous reports. Midshaft fractures were associated with palsy, while surgical approach was not. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Traumatic Orthopaedic Injuries in the Prison Population.

The United States has the highest population of inmates in the world (per capita and total). Musculoskeletal disorders are included within the 10 most frequent medical reports of prisoners; however, the literature about them is limited. The purpose of this study is to describe the epidemiology and complications of traumatic musculoskeletal injuries. To our knowledge, this is the first report of musculoskeletal trauma and complications in the prison population. Methods: A list of all traumatic orthopaedic injuries and complications, except for spine, was sent to the billing contractor of the Pennsylvania state prison system based on the Current Procedure Terminology, and it was queried over a 3-year period. Results: Five hundred seventy-six patients met the criteria. The hand and wrist was the most commonly injured region (65%), followed by foot and ankle (20%). Metacarpal fracture represented 22% of all injuries. A low complication rate was noted among all surgical procedures. Infection was seen in 1.15% of hand surgeries and in 2% of ankle surgeries. In addition, a low incidence of nonunion was recorded (1.5%). Nonsurgical management was the chosen method of treatment in 64% of all injuries. Conclusion: In this prison population with musculoskeletal injuries, upper extremity injuries and nonsurgical treatment are more prevalent and low energy injuries are more common. Contrary to popular belief, there is a trend toward low infection and complication rates after orthopaedic treatment. Further studies are necessary to best identify the patterns of injuries and the best way to treat inmates with orthopaedic injuries.

Long-term outcomes comparing metabolic surgery to no surgery in patients with type 2 diabetes and body mass index 30-35.

BACKGROUND: We previously conducted a randomized study comparing metabolic surgery with medical weight management in patients with type 2 diabetes (T2D) and body mass index (BMI) 30 to 35 kg/m2. At 3-year follow-up, surgery was very effective in T2D remission; furthermore, in the surgical group, those with a higher baseline soluble receptor for advanced glycation end products had a lower postoperative BMI. OBJECTIVES: To provide long-term follow-up of this initial patient cohort. SETTING: University Hospital. METHODS: Retrospective chart review was performed of the initial patient cohort. Patients lost to follow-up were systematically contacted to return to clinic for a follow-up visit. Data were compared using 2-sample t test, Fisher's exact test, or analysis of variance when applicable. RESULTS: Originally, 57 patients with T2D and BMI 30 to 35 kg/m2 were randomized to metabolic surgery (n = 29) or medical weight management (n = 28). Ten patients in the medical weight management group crossed over to surgery. Five-year follow-up data were available in 43 of 57 (75%) patients. Baseline mean BMI and glycated hemoglobin were 32.6 kg/m2 and 7.8%, respectively. Median follow-up was 79 and 88 months in the surgical group and nonsurgical group, respectively. Compared with the nonsurgical group, the surgical patients had significantly lower rate of T2D (62% versus 100%; P = .008), lower insulin use (10% versus 50%; P = .0072), lower glycated hemoglobin (6.93% versus 8.26%; P = .012), lower BMI (25.8 versus 28.6 kg/m2; P = .007), and higher percent weight loss (21.4% versus 10.3%; P = .025). Baseline soluble receptor for advanced glycation end products was not associated with long-term outcomes. CONCLUSIONS: Metabolic surgery in T2D patients with BMI 30 to 35 kg/m2 remains effective long term. Baseline soluble receptor for advanced glycation end products are most likely predictive of early outcomes only.

Modern Results of Functional Bracing of Humeral Shaft Fractures: A Multicenter Retrospective Analysis.

OBJECTIVES: To evaluate the rate of, and reasons for, conversion of closed treatment of humeral shaft fractures using a fracture brace, to surgical intervention. DESIGN: Multicenter, retrospective analysis. SETTING: Nine Level 1 trauma centers across the United States. PATIENTS: A total of 1182 patients with a closed humeral shaft fracture initially managed nonoperatively with a functional brace from 2005 to 2015 were reviewed retrospectively from 9 institutions. INTERVENTION: Functional brace. MAIN OUTCOME MEASUREMENTS: Conversion to surgery. RESULTS: A total of 344 fractures (29%) ultimately underwent surgical intervention. Reasons for conversion included nonunion (60%), malalignment beyond acceptable parameters (24%), inability to tolerate functional bracing (12%), and persistent signs of radial nerve palsy requiring exploration (3.7%). Univariate comparisons showed that females and whites were significantly (P < 0.05) more likely to be converted to surgery. The multivariate logistic regression identified females as being 1.7 times more likely and alcoholics to be 1.4 times more likely to be converted to surgery (P < 0.05). Proximal shaft as well as comminuted, segmental, and butterfly fractures were also linked to a higher rate of conversion. CONCLUSIONS: This large multicenter study identified a 29% surgical conversion rate, with nonunion as the most common reason for surgical intervention after the failure of functional brace. These results are markedly different than previously reported. These results may be helpful in the future when counseling patients on the choice between functional bracing and surgical intervention in managing humeral shaft fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.