Postoperative pain score does not correlate with injury severity in isolated tibial plateau fractures.

PURPOSE: Appropriate management of acute postoperative pain is critical for patient care and practice management. The purpose of this study was to determine whether postoperative pain score correlates with injury severity in tibial plateau fractures. METHODS: A retrospective review of prospectively collected data was completed at a single academic level one trauma center. All adult patients treated operatively for tibial plateau fractures who did not have concomitant injuries, previous injury to the ipsilateral tibia or knee joint, compartment syndrome, inadequate follow-up, or perioperative regional anesthesia were included (n = 88). The patients were split into groups based on the AO/OTA fracture classification (B-type vs C-type), energy mechanism, number of surgical approaches, need for temporizing external fixation, and operative time as a proxy for injury severity. The primary outcome measure was the visual analog scale (VAS) pain score (average in the first 24 h, highest in the first 24 h, two- and six-week postoperative appointments). Psychosocial and comorbid factors that may affect pain were studied and controlled for (history of diabetes, neuropathy, anxiety, depression, PTSD, and previous opioid prescription). Additionally, opioid use in the postoperative period was studied and controlled for (morphine milligram equivalents (MME) administered in the first 24 h, discharge MME/day, total discharge MME, and opioid refills). RESULTS: VAS scores were similar between groups at each time point except the two-week postoperative time point. At the two-week postoperative time point, the absolute difference between the groups was 1.3. The groups were significantly different in several injury and surgical variables as expected, but were similar in all demographic, comorbid, and postoperative opioid factors. CONCLUSIONS: There was no clinical difference in postoperative pain between AO/OTA 41B and 41C tibial plateau fractures. This supports the idea of providers uncoupling nociception and pain in postoperative patients. Providers should consider minimizing extended opioid use, even in more severe injuries.

Dysphagia is associated with increased mortality risk after hip fracture surgery.

PURPOSE: This study aims to explore the prevalence of dysphagia, as well as mortality associated with dysphagia in the elderly population receiving surgical treatment for a hip fracture. METHODS: A retrospective cohort study was completed at an academic level 1 tertiary care center. Patients older than or equal to 65 admitted with a hip fracture diagnosis from January 2015 to December 2020 (n = 617) were included. The main outcome was the prevalence of dysphagia and association with mortality. Secondary analysis included timing of dysphagia and contributions to mortality. RESULTS: Fifty-six percent of patients had dysphagia, and the mortality rates were higher in patients with dysphagia (8.9%) versus those without dysphagia (2.6%), chi-square p = 0.001, and odds ratio 3.69 (CI 1.6-8.5). Mortality rates in patients with acute dysphagia were also higher (12.4%) than those with chronic dysphagia (5%) and chi-squared p = 0.02. Mortality rates in patients with a perioperative dysphagic event (13.9%) were higher than those with non-perioperative dysphagia (4%) and chi-squared p = 0.001. Mortality rates in patients who had acute perioperative dysphagia (21.2%) were higher than those with chronic dysphagia that presented perioperatively (6.8%) and chi-squared p = 0.006. CONCLUSIONS: This study demonstrates high rates of dysphagia in the elderly hip fracture population and a significant association between dysphagia and mortality. Timing and chronicity of dysphagia were relevant, as patients with acute perioperative dysphagia had the highest mortality rate. Unlike other identified risk factors, dysphagia may be at least partially modifiable. More research is needed to determine whether formal evaluation and treatment of dysphagia lowers mortality risk.

Traumatic brain injury is common and undertreated in the orthopaedic trauma population.

INTRODUCTION: Traumatic brain injuries (TBIs) can be difficult to diagnose and are often marginalized when compared to more obvious physical injuries. Despite this, recognition and early treatment can lead to improved outcomes. Even mild TBIs have the potential to cause significant long-term consequences for patients, which may affect their physical recovery from orthopaedic injuries. The objective of this study was to examine the incidence and treatment of TBI within the orthopaedic trauma population. METHODS: Inclusion criteria were all patients presenting after an acute trauma with an orthopaedic surgery consult over a continuous 3 month timeframe (n = 187). A retrospective review was completed at an academic tertiary referral trauma center. The primary outcome was the rate of TBI. Secondary outcomes included rate of TBI listed as a discharge diagnosis and rate of follow up plan. Several secondary variables were noted and their associations with TBI evaluated. RESULTS: 27 % of the 187 patients had an acute TBI. 61 % of TBI patients had the diagnosis listed in their discharge summary. 6 % had a follow up plan. The positive TBI group was associated with more high energy injuries (p = 0.032), average limbs involved (p = 0.007), upper extremity injury (p < 0.001), bilateral lower extremity injury (p = 0.004), and Injury Severity Score (p < 0.001). 82 % of patients with an acute TBI had an occupational therapy consult and 39 % had a neurosurgery consult. 24 % of patients with a TBI were admitted to the orthopaedic primary service. CONCLUSIONS: Patients presenting after an acute trauma with orthopaedic injuries have high rates of TBI, but low rates of diagnosis and treatment. This lack of diagnosis and treatment can negatively impact recovery from orthopaedic injuries. Orthopaedic providers should be aware of the diagnostic criteria and initial treatment steps for TBI to ensure prompt and effective treatment, which has been shown to improve outcomes.

Evaluation of a 30-day-mortality risk calculator for patients undergoing surgical fixation of fragility hip fractures.

INTRODUCTION: Hip fractures often occur in medically complex patients and can be associated with high perioperative mortality. Mortality risk assessment tools that are specific to hip fracture patients have not been extensively studied. The objective of this study is to evaluate a recently published 30-day mortality risk calculator (Hip Fracture Estimator of Mortality Amsterdam [HEMA]) in a group of patients treated at a university health system. MATERIALS & METHODS: 625 patients treated surgically for hip fractures between 2015 and 2020 at our institution were retrospectively reviewed. Patients younger than age 65, periprosthetic fractures, revision procedures, and fractures treated non-operatively were excluded. Univariate and multivariate analyses were used to determine significant relationships between variables and 30-day mortality after surgery. Additional patient-specific risk factors not included in the original risk calculator were also evaluated. RESULTS: The observed 30-day mortality was 5.6%. HEMA score was significantly associated with 30-mortality, though our cohort had significantly lower mortality rates in high-risk patients than expected based on the HEMA tool. In analyzing patient characteristics not included in HEMA score, history of dementia and elevated troponin were significantly associated with 30-day mortality. DISCUSSION: The HEMA score reliably stratifies risk for 30-day mortality after hip fracture, though overestimates mortality in high-risk patients treated at a tertiary care center with a multidisciplinary team. The HEMA score may be enhanced by considering additional variables, including troponin level and history of dementia. LEVEL OF EVIDENCE: IV.

"Bring Your Own Device"-A New Approach to Wearable Outcome Assessment in Trauma.

Background and Objectives: Outcome data from wearable devices are increasingly used in both research and clinics. Traditionally, a dedicated device is chosen for a given study or clinical application to collect outcome data as soon as the patient is included in a study or undergoes a procedure. The current study introduces a new measurement strategy, whereby patients' own devices are utilized, allowing for both a pre-injury baseline measure and ability to show achievable results. Materials and Methods: Patients with a pre-existing musculoskeletal injury of the upper and lower extremity were included in this exploratory, proof-of-concept study. They were followed up for a minimum of 6 weeks after injury, and their wearable outcome data (from a smartphone and/or a body-worn sensor) were continuously acquired during this period. A descriptive analysis of the screening characteristics and the observed and achievable outcome patterns was performed. Results: A total of 432 patients was continuously screened for the study, and their screening was analyzed. The highest success rate for successful inclusion was in younger patients. Forty-eight patients were included in the analysis. The most prevalent outcome was step count. Three distinctive activity data patterns were observed: patients recovering, patients with slow or no recovery, and patients needing additional measures to determine treatment outcomes. Conclusions: Measuring outcomes in trauma patients with the Bring Your Own Device (BYOD) strategy is feasible. With this approach, patients were able to provide continuous activity data without any dedicated equipment given to them. The measurement technique is especially suited to particular patient groups. Our study's screening log and inclusion characteristics can help inform future studies wishing to employ the BYOD design.

Regional anesthesia provides limited decreases in opioid use following distal tibia and ankle fracture surgery.

PURPOSE: Regional anesthesia (RA) is used for pain control, but its impacts on the orthopedic trauma population are not well known. This study evaluated the impact of peripheral nerve blocks after distal tibia and ankle fracture repair on opioid use and pain scores and quantified the magnitude and duration of any changes. METHODS: This retrospective cohort study included patients treated operatively for distal tibia and ankle fractures over a 5-year period, both with and without peripheral nerve blocks. Total inpatient 5 mg oxycodone equivalents (OEs) used in the post-operative period, from 0-24, 24-48, to 48-72 h and maximum visual analog scale (VAS) pain ratings from 0-24, 24-48, to 48-72 h were recorded. RESULTS: 540 non-polytrauma patients and 183 polytrauma patients were included. Patients in the non-polytrauma group who received nerve blocks required fewer opioids on post-operative day (POD) 1 compared to the non-nerve block group (4.8 [95% CI 4.2-5.4] vs. 10.5 [95% CI: 9.2-11.8]; p < 0.001) and had lower VAS scores on POD1 (5.0 [95% CI 4.6-5.4] vs. 7.7 [95% CI: 7.3-8.1]; p < 0.001). However, there were no differences between these groups on POD2 or POD3 and no differences at any timepoints in the polytrauma group. CONCLUSION: Patients with isolated distal tibia and ankle fractures who receive peripheral nerve blocks demonstrate modest reductions in inpatient opioids and pain scores on POD1. However, there are no clear benefits beyond this point. Furthermore, polytrauma patients do not experience any reductions in opioid consumption or pain scores.

Serology and Comorbidities in Patients With Fracture Nonunion: A Multicenter Evaluation of 640 Patients.

INTRODUCTION: This multicenter cohort study investigated the association of serology and comorbid conditions with septic and aseptic nonunion. METHODS: From January 1, 2011, to December 31, 2017, consecutive individuals surgically treated for nonunion were identified from seven centers. Nonunion-type, comorbid conditions and serology were assessed. RESULTS: A total of 640 individuals were included. 57% were male with a mean age of 49 years. Nonunion sites included tibia (35.2%), femur (25.6%), humerus (20.3%), and other less frequent bones (18.9%). The type of nonunion included septic (17.7%) and aseptic (82.3%). Within aseptic, nonvascular (86.5%) and vascular (13.5%) nonunion were seen. Rates of smoking, alcohol abuse, and diabetes mellitus were higher in our nonunion cohort compared with population norms. Coronary artery disease and tobacco use were associated with septic nonunion (P < 0.05). Diphosphonates were associated with vascular nonunion (P < 0.05). Serologically, increased erythrocyte sedimentation rate, C-reactive protein, parathyroid hormone, red cell distribution width, mean platelet volume (MPV), and platelets and decreased absolute lymphocyte count, hemoglobin, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, and albumin were associated with septic nonunion while lower calcium was associated with nonvascular nonunion (P < 0.05). The presence of four or more of increased erythrocyte sedimentation rate, C-reactive protein, or red cell distribution width; decreased albumin; and age younger than 65 years carried an 89% positive predictive value for infection. Hypovitaminosis D was seen less frequently than reported in the general population, whereas anemia was more common. However, aside from hematologic and inflammatory indices, no other serology was abnormal more than 25% of the time. DISCUSSION: Abnormal serology and comorbid conditions, including smoking, alcohol abuse, and diabetes mellitus, are seen in nonunion; however, serologic abnormalities may be less common than previously thought. Septic nonunion is associated with inflammation, younger age, and malnourishment. Based on the observed frequency of abnormality, routine laboratory work is not recommended for nonunion assessment; however, specific focused serology may help determine the presence of septic nonunion.

Risk Factors for Infection and Revision Surgery following Patellar Tendon and Quadriceps Tendon Repairs: An Analysis of 3,442 Patients.

Disruption of the extensor mechanism is debilitating with surgical repair being the accepted treatment. The incidence of infection and reoperation after extensor mechanism repair are not well reported in the literature. Thus, the objective of the current study was to (1) determine the incidence of surgical site infection and reoperation within 1 year of primary extensor mechanism repair and (2) identify independent risk factors for infection and reoperation following patellar and quadriceps tendon repair. A retrospective review of the 100% Medicare Standard Analytic files from 2005 to 2014 was performed to identify patients undergoing isolated patellar tendon repair and quadriceps tendon repair. Diagnosis of infection within 1 year of operative intervention and revision repair were assessed. Extensor mechanism injuries in the setting of total knee arthroplasty and polytrauma were excluded. Multivariate logistic regression analysis was performed to evaluate risk factors for postoperative infection and reoperation within 1 year. Infection occurred in 6.3% of patients undergoing patellar tendon repair and 2.6% of patients undergoing quadriceps tendon repair. Diabetes mellitus (odds ratio [OR] = 1.89, p = 0.005) was found to be an independent risk factor for infection following patellar tendon repair. Reoperation within 1 year occurred in 1.3 and 3.9% following patellar tendon and quadriceps tendon repair, respectively. Age less than 65 years (OR = 2.77, p = 0.024) and obesity (OR = 3.66, p = 0.046) were significant risk factors for reoperation after patellar tendon repair. Hypertension (OR = 2.13, p = 0.034), hypothyroidism (OR = 2.01, p = 0.010), and depression (OR = 2.41, p = 0.005) were significant risk factors for reoperation after quadriceps tendon repair. Diabetes mellitus was identified as a risk factor for infection after patellar tendon repair. Age less than 65 years, peripheral vascular disease, and congestive heart failure were risk factors for infection after quadriceps tendon repair. The current findings can be utilized to counsel patients regarding preoperative risk factors for postoperative complications prior to surgical intervention for extensor mechanism injuries.

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.

Intramedullary nailing of extra-articular distal tibial fractures.

AIMS: The aim of this study was to determine the immediate post-fixation stability of a distal tibial fracture fixed with an intramedullary nail using a biomechanical model. This was used as a surrogate for immediate weight-bearing postoperatively. The goal was to help inform postoperative protocols. METHODS: A biomechanical model of distal metaphyseal tibial fractures was created using a fourth-generation composite bone model. Three fracture patterns were tested: spiral, oblique, and multifragmented. Each fracture extended to within 4 cm to 5 cm of the plafond. The models were nearly-anatomically reduced and stabilized with an intramedullary nail and three distal locking screws. Cyclic loading was performed to simulate normal gait. Loading was completed in compression at 3,000 N at 1 Hz for a total of 70,000 cycles. Displacement (shortening, coronal and sagittal angulation) was measured at regular intervals. RESULTS: The spiral and oblique fracture patterns withstood simulated weight-bearing with minimal displacement. The multifragmented model had early implant failure with breaking of the distal locking screws. The spiral fracture model shortened by a mean of 0.3 mm (SD 0.2), and developed a mean coronal angulation of 2.0° (SD 1.9°) and a mean sagittal angulation of 1.2° (SD 1.1°). On average, 88% of the shortening, 74% of the change in coronal alignment, and 75% of the change in sagittal alignment occurred in the first 2,500 cycles. No late acceleration of displacement was noted. The oblique fracture model shortened by a mean of 0.2 mm (SD 0.1) and developed a mean coronal angulation of 2.4° (SD 1.6°) and a mean sagittal angulation of 2.6° (SD 1.4°). On average, 44% of the shortening, 39% of the change in coronal alignment, and 79% of the change in sagittal alignment occurred in the first 2,500 cycles. No late acceleration of displacement was noted. CONCLUSION: For spiral and oblique fracture patterns, simulated weight-bearing resulted in a clinically acceptable degree of displacement. Most displacement occurred early in the test period, and the rate of displacement decreased over time. Based on this model, we offer evidence that early weight-bearing appears safe for well reduced oblique and spiral fractures, but not in multifragmented patterns that have poor bone contact. Cite this article: Bone Joint J 2021;103-B(2):294-298.

Use of Standardized Language for C-arm Fluoroscopy Improves Intraoperative Communication and Efficiency.

INTRODUCTION: Intraoperative fluoroscopy is a ubiquitous tool in orthopaedic surgery. However, many orthopaedic surgeons and radiology technologists are not taught standard terminology to communicate with one another. Breakdown of communication leads to inefficiencies. Simulation studies have demonstrated that a common language for C-arm movements may reduce time to capture the desired images and number of radiographs required. Our objective was to investigate the effect of a standardized language protocol for intraoperative C-arm fluoroscopy on communication as perceived by the surgeon and radiology technologists. METHODS: Our study intervention was the implementation of a common C-arm fluoroscopy terminology education protocol. To evaluate the efficacy of this protocol, a survey was administered to orthopaedic surgeons and radiology technologists after procedures involving the use of intraoperative fluoroscopy. Study end points were measured using a 5-point Likert scale and included effectiveness of communication, need for obtaining repeat radiographs, need to correct the C-arm position, and confusion noted during surgery. This survey was administered before and after the study intervention. RESULTS: The study intervention resulted in a statistically significant improvement in the mean perceived quality of intraoperative communication between the surgeon and the radiology technologist (0.398 [0.072, 0.725], P = 0.017). There was also a reported decrease in confusion in the operating room (-0.572 [-0.880, -0.263], P < 0.001), movement correction of the C-arm fluoroscope (-0.592 [-0.936, -0.248], P = 0.001), and need for repeat radiographs (-0.782 [-1.158, -0.406], P < 0.001) after the implementation of a standardized fluoroscopy language. CONCLUSION: A standardized fluoroscopy language protocol improves intraoperative communication between orthopaedic surgeons and radiology technologists.

Harris Heel View is Inadequate to Visualize Screw Prominence of the Medial Calcaneus: A Case Report and Cadaveric Evaluation.

CASE: A 58-year-old man sustained multiple right foot injuries during a motor vehicle accident that included a calcaneus fracture requiring open reduction and internal fixation (ORIF). The procedure was complicated by a prominent implant inferior to the sustentaculum, which necessitated a return to the operating room. Commonly used fluoroscopic views do not adequately image this area. A cadaveric study was undertaken to identify the optimal 2-dimensional fluoroscopic view that evaluates prominent implants at the medial calcaneus. CONCLUSION: The sustentaculum tunnel view gives a reliable image of prominent medial implants, and use of this technique may limit complications after calcaneus ORIF.

Treatment Algorithm for Surgical Site Infections Following Extensor Mechanism Repair.

¼: Despite general agreement regarding techniques for extensor mechanism repair, there is very limited guidance in the literature for the management of surgical site infections (SSIs) that may occur after these procedures. ¼: Early or mild superficial SSIs, such as cellulitis, can be managed on an outpatient basis while monitoring for improvement, with escalated intervention if the symptoms do not resolve within 1 week. ¼: Deep SSIs should be managed more aggressively with surgical irrigation and debridement (I&D), including the knee joint, depending on the results of the aspiration, removal of all braided nonabsorbable suture (if necessary) with immediate or delayed exchange with monofilament suture, and the administration of parenteral antibiotics based on culture results and an infectious disease consult. ¼: Arthrocentesis should be performed early to monitor for the spread of infection to the joint space, and diagnosis of a septic knee joint should be immediately followed by arthroscopic or open I&D. ¼: For refractory cases (i.e., wound coverage issues or persistent infections despite multiple attempts at debridement), a consult with a plastic surgeon for consideration of a gastrocnemius flap is recommended, and surgeons should remain suspicious of the possibility of the contiguous spread of osteomyelitis.

Simultaneous Use of Kocher-Langenbeck and Lateral Window Approaches for Transverse Acetabular Fracture Open Reduction and Internal Fixation: A Case Report.

CASE: An otherwise healthy 39-year-old man presented after a fall from 30 feet with a right transverse, transtectal acetabular fracture. The fracture was not reducible with an isolated anterior or posterior approach. A simultaneous combined approach was used in the lateral decubitus position. The fracture was appropriately reduced and stabilized. CONCLUSIONS: This combined approach with the patient in the lateral decubitus position was effective without requiring repositioning of the patient during surgery. This technique may be helpful for reduction of challenging transverse acetabular fractures.

A Locked Sacroiliac Joint Dislocation Requiring Open Reduction: A Case Report.

CASE: Vertically unstable pelvic ring injuries are often associated with sacroiliac (SI) joint subluxations or dislocations. The following report describes an irreducible SI joint dislocation where the ilium was locked in a position superior to the sacrum. This injury was refractory to initial closed reduction techniques and ultimately required an open reduction. CONCLUSIONS: This report demonstrates the limitations of closed manipulation for some vertically unstable pelvic ring injuries. It is critical to have a strong understanding of the anatomy and typical manipulations to succeed in both closed and open SI joint reduction attempts.

Understanding and Perception of Overlapping Surgery in an Orthopaedic Trauma Population: A Survey Study.

INTRODUCTION: Recently, overlapping surgery has received attention on the national scale. This study quantifies orthopaedic trauma patients' familiarity and concern with overlapping surgery as it relates to their care. METHODS: A 15-question survey was voluntarily completed by 200 orthopaedic trauma patients in the outpatient setting of a level I trauma center. Three domains were evaluated in the survey: demographic data, familiarity with overlapping surgery, and the degree of concern with overlapping surgery. Patients read a position statement explaining the practice of overlapping surgery, and their changes in level of concern were evaluated. Descriptive statistics were used to evaluate the data. RESULTS: A total of 200 patients completed the survey, of which 98 (49%) were male. The age range was broadly distributed. After surgery, 124 patients (62%) were seen for follow up. The remaining 76 patients (38%) did not undergo surgery. Regarding the practice of overlapping surgery, 116 respondents (58%) had no knowledge. There were 127 patients (63%) who reported their concern level as a 1 on an ordinal scale from 1 to 5, corresponding to the lowest possible level. Overall, 182 patients (91%) reported a level of concern of 3 (the median) or less with an average score of 1.7, indicating a low average level of concern. Six patients (3%) reported the maximum level of concern. On the whole, 160 patients (80%) reported either a decreased level of concern or no change after reading our department's position statement on overlapping surgery. Of the 124 patients, 81 (65%) postoperatively reported that they perceived no effect by overlapping surgery. The most common factors cited as areas of concern by patients were the absence of attending physician in the operating room (26%), risk of error by the resident (34%), and risk of a missed step in the surgical procedure (31%). CONCLUSION: These data indicate that most respondents had no previous knowledge of overlapping surgery and had a generally low level of concern with its use as practiced at our institution. Disclosing the use of overlapping surgery and its purpose to patients is an important component of preoperative counseling. LEVEL OF EVIDENCE: Level V.

The Effect of Time During the Academic Year or Resident Training Level on Complication Rates After Lower-Extremity Orthopaedic Trauma Procedures.

BACKGROUND: Few studies have evaluated the effect of resident participation on morbidity and mortality after orthopaedic trauma surgery. The goal of this study was to evaluate whether complications after orthopaedic trauma procedures involving residents correlate with the level of resident training and the timing in the academic year. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent operative fixation of proximal femoral fractures, femoral shaft fractures, and tibial shaft fractures from 2005 to 2012. A total of 1,851 cases with resident involvement were identified, and complication rates were calculated and analyzed with respect to resident level of training (postgraduate year [PGY] 1 through 6) and the academic quarter in which the procedure took place. RESULTS: The composite complication rates in the first academic quarter for serious adverse events (10.96%), any adverse events (18.57%), and surgical complications (9.62%) did not significantly differ from those during the remainder of the year (11.40%, 17.81%, and 7.19%, respectively). The rates of any adverse event were significantly higher for senior-level residents (quarter 1, 20.58%; quarter 2, 20.05%) than for junior residents (quarter 1, 11.76%; quarter 2, 12.44%) during the first half of the academic year (quarter 1, p = 0.044; quarter 2, p = 0.024). CONCLUSIONS: This evaluation of the composite complication rates found no "July effect" in lower-extremity orthopaedic trauma surgery. There was evidence for a July effect for superficial surgical site infections, in that there was a significantly higher rate in the first academic quarter. Senior residents may benefit from more oversight or instruction during the first portion of the academic year.

Lateral Distal Femur Plate for Periprosthetic Fracture.

In this case, a lateral locking plate is used for fixation of a periprosthetic distal femur fracture in a 68-year-old woman. Modern implants with locking screw options and soft-tissue-sparing surgical techniques have improved the care of periprosthetic distal femur fractures. Although much debate about the working length and technical variables of plating exists, it is generally accepted that longer (>10 hole) plates with adequate working length and careful soft-tissue handling are preferred. This case outlines a stepwise approach to distal femur fractures to achieve appropriate plate position and restoration of alignment while avoiding excessive surgical exposure or soft-tissue dissection. In this case, retrograde intramedullary nail was not considered because of the distal nature of the fracture, but this option may be favorable for cruciate-retaining total knee arthroplasty or open box designs that will accommodate nail insertion. Although weight bearing was protected for 6 weeks, plate fixation allows early rehabilitation and knee range of motion. This patient went on to successful union and excellent clinical outcome with return to baseline function.

Evaluation of Orthopedic Trauma Surgery Follow-up and Impact of a Routine Callback Program.

A high rate of patients lost to follow-up is a common problem in orthopedic trauma surgery. This adversely affects the ability to produce accurate clinical outcomes research. The purpose of this project was to (1) evaluate the rate of loss to follow-up at an academic level I trauma center; (2) identify the patient-reported reasons for loss to follow-up; and (3) evaluate the efficacy of a routine patient callback program. All patients who underwent surgery in the orthopedic trauma division of the University of Virginia Medical Center from April 1, 2014, to September 30, 2014, and did not complete their postoperative clinic follow-up were analyzed. The characteristics of these patients were evaluated, and the primary reason for not completing the recommended follow-up was identified. All patients were then offered additional orthopedic follow-up at the time of contact. Of the 480 patients who met the inclusion criteria, 41 (8.5%) failed to complete the recommended postoperative follow-up course. The most common reason for being lost to follow-up was feeling well and not having the need to be seen (46.3%). Only 6 (14.6%) of the 41 patients requested follow-up care at the time of contact. The lost to follow-up rate in this study, 8.5%, was considerably lower than that previously reported, but patient characteristics were consistent with those of prior studies on this subject. The low lost to follow-up rate may reflect a difference in geographic location or patient population. The patient callback program had a low yield of patients requesting additional follow-up after being contacted. [Orthopedics. 2017; 40(2):e312-e316.].