Predictors of Episode-of-Care Costs for Ankle Fractures.

Ankle fractures are one of the most resource-consuming traumatic orthopedic injuries. Few studies have successfully evaluated the episode-of-care costs (EOCC) of common traumatic orthopedic injuries. The objective of this study was to determine the EOCC associated with the surgical management of ankle fractures. A retrospective cohort study of 105 consecutive patients who underwent open reduction internal fixation of an isolated ankle fracture at a Canadian Level-1 trauma center was conducted. Episode-of-care costs were generated using an activity-based costing framework. The median global episode-of-care cost for ankle fracture surgeries performed at the studied institution was $3,487 CAD [IQR 880] ($2,685 USD [IQR 616]). Patients aged 60 to 90 years had a significantly higher median EOCC than younger patients (p = .01). Supination-adduction injuries had a significantly higher median EOCC than other injury patterns (p = .01). The median EOCC for patients who underwent surgery within 10 days of their injury ($3,347 CAD [582], $2,577 USD [448]) was significantly lower than the cost for patients who had their surgery delayed 10 days or more after the injury ($3,634 CAD [776], $2,798 USD [598]) (p = .03). Patient sex, anesthesia type, ASA score and surgeon's fellowship training did not affect the EOCC. This study provides valuable data on predictors of EOCC in the surgical management of ankle fractures. Delaying simple ankle fracture cases due to operating time constraints can increase the total cost and burden of these fractures on the healthcare system. In addition, this study provides a framework for future episode-of-care cost analysis studies in orthopedic surgery.

Hospital episode-of-care costs for hip fractures: an activity-based costing analysis.

Background: Despite the large impact of hip fracture care on hospital budgets, accurate episode-of-care costs (EOCC) calculations for this injury remains a challenge. The objective of this article was to assess EOCC for geriatric patients with hip fractures using an activity-based costing methodology and identify intraoperative, perioperative, and patient-specific factors associated with higher EOCC. Material and Methods: This is a retrospective cohort study involving a total of 109 consecutive patients with hip fracture treated surgically at a Canadian level-1 trauma center from April 2018 to February 2019. Clinical and demographic data were extracted through the institution's centralized data warehouse. Data acquisition also included direct and indirect costs per episode of care, adverse events, and precise temporal data. Results: The median total EOCC was $13,113 (interquartile range 6658), excluding physician fees. Out of the total cost, 75% was attributed to direct costs, which represented a median expenditure of $9941. The median indirect cost of the EOCC was $3322. Based on the multivariate analysis, patients not operated within the 48 hours guidelines had an increased length of stay by 5.7 days (P = 0.003), representing an increase in EOCC of close to 5000$. Higher American Society of Anesthesiology (ASA) scores were associated with elevated EOCC. Conclusion: The cost of managing a patient with geriatric hip fracture from arrival in the emergency department to discharge from surgical ward represented $13,113. Main factors influencing the EOCC included adherence to the 48-hour benchmark surgical delay and ASA score. High-quality costing data are vital in assessing health care spending, conducting cost effectiveness analyses, and ultimately in guiding policy decisions. Level of Evidence: Level III (3), retrospective cohort study.

Is my wound infected? A study on the use of hyperspectral imaging to assess wound infection.

Introduction: Clinical signs and symptoms (CSS) of infection are a standard part of wound care, yet they can have low specificity and sensitivity, which can further vary due to clinician knowledge, experience, and education. Wound photography is becoming more widely adopted to support wound care. Thermography has been studied in the medical literature to assess signs of perfusion and inflammation for decades. Bacterial fluorescence has recently emerged as a valuable tool to detect a high bacterial load within wounds. Combining these modalities offers a potential objective screening tool for wound infection. Methods: A multi-center prospective study of 66 outpatient wound care patients used hyperspectral imaging to collect visible light, thermography, and bacterial fluorescence images. Wounds were assessed and screened using the International Wound Infection Institute (IWII) checklist for CSS of infection. Principal component analysis was performed on the images to identify wounds presenting as infected, inflamed, or non-infected. Results: The model could accurately predict all three wound classes (infected, inflamed, and non-infected) with an accuracy of 74%. They performed best on infected wounds (100% sensitivity and 91% specificity) compared to non-inflamed (sensitivity 94%, specificity 70%) and inflamed wounds (85% sensitivity, 77% specificity). Discussion: Combining multiple imaging modalities enables the application of models to improve wound assessment. Infection detection by CSS is vulnerable to subjective interpretation and variability based on clinicians' education and skills. Enabling clinicians to use point-of-care hyperspectral imaging may allow earlier infection detection and intervention, possibly preventing delays in wound healing and minimizing adverse events.

Local Insulin Improves Wound Healing: A Systematic Review and Bayesian Network Meta-Analysis.

BACKGROUND: Wounds are a significant health issue, and reliable and safe strategies to promote repair are needed. Clinical trials have demonstrated that local insulin promotes healing in acute and chronic wounds (ie, reductions of 7% to 40% versus placebo). However, the trials' sample sizes have prevented drawing solid conclusions. Furthermore, no analysis has focused on safety concerns (ie, hypoglycemia). Under the hypothesis that local insulin promotes healing through proangiogenic effects and cellular recruitment, the aim of this systematic review and network meta-analysis (NMA) was to assess its safety and relative effectiveness using a Bayesian approach. METHODS: Medline, CENTRAL, Embase, Scopus, LILACS, and gray literature sources were searched for human studies assessing the local use of insulin versus any comparator since inception to October of 2020. Data on glucose changes and adverse events, wound and treatment characteristics, and healing outcomes were extracted, and an NMA was conducted. RESULTS: A total of 949 reports were found, of which 23 ( n = 1240 patients) were included in the NMA. The studies evaluated six different therapies, and most comparisons were against placebo. NMA showed -1.8 mg/dL blood glucose level change with insulin and a lack of reported adverse events. Statistically significant clinical outcomes identified include reduction in wound size (-27%), increased healing rate (23 mm/day), reduction in Pressure Ulcer Scale for Healing scores (-2.7), -10 days to attain complete closure, and an odds ratio of 20 for complete wound closure with insulin use. Likewise, significantly increased neoangiogenesis (+30 vessels/mm 2 ) and granulation tissue (+25%) were also found. CONCLUSION: Local insulin promotes wound healing without significant adverse events.

Management of Patella Fracture Nonunion and Large Bone Defect After Bone-Patellar Tendon-Bone Autograft: A Case Report.

CASE: A 32-year-old patient was diagnosed with a vertical patella fracture nonunion after a bone-patellar tendon-bone (BTB) anterior cruciate ligament reconstruction. In addition, a 1 × 2 × 1 cm patellar bone defect was noticed at the graft harvesting site. The patient was treated surgically with open reduction and internal fixation and iliac crest bone autograft which resulted in fracture union. CONCLUSION: Many intraoperative and postoperative risk factors for iatrogenic patella fracture when harvesting BTB autograft were identified. Surgeons should be aware of technical skills needed to prevent this complication and should treat the fracture appropriately to avoid nonunion and optimize the outcome.

Cancellations and delays of emergent orthopedic operations at a Canadian level 1 trauma centre.

BACKGROUND: Day-of surgery cancellation (DOSC) is considered to be a very inefficient use of hospital resources and results in emotional stress for the patient. To examine opportunities to minimize the incidence of preventable cancellations - an indicator of quality of care - we assessed the incidence of and reasons for DOSCs over 3 months among inpatients and outpatients at a trauma orthopedic service. METHODS: This was a prospective study of 2 cohorts of patients, inpatients and outpatients, scheduled for emergent orthopedic surgery at a Canadian tertiary level 1 trauma centre from Jan. 1 to Mar. 31, 2020. Patient demographic characteristics, injury characteristics, delays until surgery and reasons for DOSCs were recorded. RESULTS: A total of 185 patients (100 males and 85 females with a mean age of 54 yr) were included in the study. There were 98 outpatients and 87 inpatients. Seventy-five (40%) of the scheduled procedures in the outpatient group and 34 (30%) of those in the inpatient group were cancelled. In both groups, more than 85% of the cancellations were because of prioritization of a more urgent orthopedic or nonorthopedic surgical case. The average operative delay for the outpatient group was 11.4 days, compared to 3.8 days for the inpatient group (p < 0.001). CONCLUSION: High DOSC rates were observed among both outpatients and inpatients. The main reason for delaying surgery was prioritization of a more urgent surgical case. Providing the orthopedic trauma service with a dedicated OR opened 6 days per week, along with extended hours of OR services to 1700 daily, might be effective at minimizing DOSCs.

Time-to-Incision for Hip Fractures in a Canadian Level-1 Trauma Centre: Are We Respecting the Guidelines?

Background: Surgical intervention within 48 hours is recommended for hip fractures in the elderly in order to reduce post-operative complications and lower mortality rates. The purpose of this retrospective study is to explore the causes of surgical delays for acute geriatric hip fractures. Methods: This is a retrospective cohort study involving a total of 109 consecutive geriatric patients who sustained proximal femur fractures ("hip fractures"), who subsequently underwent definitive fixation. Clinical, demographic, and direct costing data were extracted via a modern system and electronic medical records on a centralized data warehouse. Surgical delays and length of stay were analyzed according to clinical variables. Results: The established benchmark of a time-to-surgery of less than 48 hours was respected for 63 (57.8%) patients. Patients on oral anticoagulant (ACO) waited significantly longer, on average 58 hours compared to 44 for non-anticoagulated patients (p = .007). Patients with higher ASA scores waited significantly longer (p = .0018). More importantly, patients treated within 48 hours were discharged significantly earlier, on average after 10 days compared to 16 days for patients who waited more than 48 hours before receiving surgical treatment (p = .003), regardless of the pre-operative waiting time. Conclusion: Fewer than 60% of patients received surgery within the 48-hour benchmark after being admitted for an acute hip fracture in a Level-1 trauma centre. Patients with more comorbidities waited longer and stayed longer in the hospital after surgery. Implementing strategic, evidence-based changes should be done using this data to improve care of this vulnerable population.

Tarsal coalition: Systematic review of arthroscopic management.

INTRODUCTION: The standard of care in the treatment of symptomatic tarsal coalitions is open surgery. However, certain limitations exist with open surgery, which include limited visualization leading to an incomplete resection and possible recurrence of the tarsal coalition. Arthroscopic tarsal coalition resection (TCR) is an alternative that is gaining traction, primarily as the safety profile of posterior ankle and subtalar arthroscopy is more well understood. This study provides a systematic review of the outcomes of arthroscopic TCR. METHODS: PubMed and Embase were searched independently by 2 reviewers for relevant articles based on predetermined criteria. The subject heading "tarsal coalition" and its related key terms were used. RESULTS: A total of 416 studies were revealed by the initial search, out of which only 6 met our predetermined inclusion criteria. A total of 42 patients (average age: 17.6 years) were treated with arthroscopic TCR. Thirty-three (78.6%) and 9 (21.4%) patients had talocalcaneal and calcaneonavicular coalitions, respectively. The follow-up period ranged from 6 to 60 months (mean: 26 months), and no recurrence of the tarsal coalition was detected (0.0%). Complications occurred in two (4.8%) patients only, with one developing complex regional pain syndrome (CRPS), and another patient developing hyperesthesia on the medial aspect of the calcaneus. CONCLUSION: Arthroscopic TCR is a feasible and effective surgery for both CNC and TCC with minimal complications and no disease recurrence at an average of 26 months follow-up. Future high-level of evidence studies are needed to compare the outcomes of open versus arthroscopic TCR.

Isolated Arthroscopic-Assisted Subtalar Fusion: A Systematic Review.

BACKGROUND: The subtalar joint has a complex anatomic function that includes inversion and eversion of the hindfoot, assisting in walking on uneven surfaces. Arthritis is the most common pathological condition affecting this joint and can require fusion. The surgery can be performed open or with arthroscopic assistance. This systematic review assesses articles written on the safety and efficacy of isolated arthroscopic subtalar fusion. METHODS: Using MEDLINE and Embase, we systematically reviewed articles published before May 21, 2020. RESULTS: Of 395 articles, 17 on a total of 395 patients (409 operations) were included in the review. The average duration of follow-up was 40.0 months (range, 3 to 105 months). Radiographic evidence of union was reported for 95.8% of cases at an average of 11.9 weeks (range, 6 to 56 weeks) postoperatively. Delayed union was reported in 1.0% of patients and nonunion, in 4.3% of patients. In the articles reporting patient satisfaction, including pain relief, 95.4% of patients had positive outcomes. Postoperative complications were reported in 64 patients (16.2%), including 37 (9.4%) with symptomatic implants, 11 (2.8%) with dysesthesia or neuropathic pain, and 3 (0.8%) with postoperative infection. CONCLUSIONS: Arthroscopic subtalar fusion is a safe and effective alternative to open subtalar arthrodesis, with high patient satisfaction rates, high union rates at similar follow-up intervals, and low complication rates. The aim of future research should be to determine the ideal cases for this approach as well as the most efficient arthroscopic surgical technique and postoperative rehabilitation to optimize function and union as seen on radiographs. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Promise of Smartphone Applications in the Remote Monitoring of Postsurgical Wounds: A Literature Review.

OBJECTIVE: To review the clinical and scientific literature on remote monitoring and management of postsurgical wounds using smartphone applications (apps). DATA SOURCES: MEDLINE, PubMed, EMBASE, and Cochrane libraries were searched for relevant articles on patients who received surgery and were monitored postdischarge via an app. STUDY SELECTION: Articles were selected with the terms "mobile phones," "smartphones," "wounds," "monitor," and "patient preference." DATA EXTRACTION: The authors found 276 review articles related to telemedicine in wound care. Investigators reviewed the titles and abstracts of the search results and selected 83 articles that were relevant to the remote monitoring of wounds using smartphone apps. DATA SYNTHESIS: The topics explored in selected literature included smartphone app importance to telemedicine, benefits (medical and financial), app examples, and challenges in the context of wound monitoring and management. The authors identified several challenges and limitations that future studies in the field need to address. CONCLUSIONS: Remote monitoring and management of wounds using smartphone apps is a valuable technique to enhance the quality of and access to healthcare. However, although some patients may prefer this technology, some lack technological competence, limiting telemedicine's applicability. In addition, issues remain with the reliable interpretation of data collected through apps.

Intramedullary Versus Extramedullary Fixation for Unstable Intertrochanteric Fractures: A Prospective Randomized Controlled Trial.

BACKGROUND: The use of intramedullary devices for the management of intertrochanteric fractures has steadily increased without good evidence of their clinical efficacy. This prospective randomized multicenter study was designed to compare the clinical and radiographic outcomes of patients who had been treated with a traditional extramedullary hip screw for an unstable (AO/OTA 31-A2) intertrochanteric hip fracture with those of patients who had been treated with the newer intramedullary device for the same injury. METHODS: The Lower Extremity Measure (LEM) was used as the primary hip-specific outcome tool. The Functional Independence Measure (FIM), the timed "Up & Go" (TUG) test, as well as a timed two-minute walk test were used as secondary clinical outcome tools. Specific radiographic parameters were collected to assess for fracture movement, heterotopic ossification, and implant failure. RESULTS: No significant differences were noted between the intramedullary and extramedullary treatment arms with regard to either the primary or the secondary clinical outcome tools. The radiographic parameters favored the intramedullary treatment arm, which had less femoral neck shortening. CONCLUSIONS: While the use of the intramedullary devices led to better radiographic outcomes in this study, this did not translate to improved functional outcomes.

Attempting primary closure for all open fractures: the effectiveness of an institutional protocol.

BACKGROUND: Immediate primary closure of open fractures has been historically believed to increase the risk of wound infection and fracture nonunion. Recent literature has challenged this belief, but uncertainty remains as to whether primary closure can be used as routine practice. This study evaluates the impact of an institutional protocol mandating primary closure for all open fractures. METHODS: We retrospectively reviewed all open fractures treated in a single level 1 trauma centre in a 5-year period. Prior to the study, a protocol was adopted standardizing management of open fractures and advocating primary closure of all wounds as a necessary goal of operative treatment. Patient and fracture characteristics, type of wound closure and development of infectious and bone healing complications were evaluated from time of injury to completion of outpatient follow-up. RESULTS: A total of 297 open fractures were treated, 255 (85.8%) of them with immediate primary closure. Type III open injuries accounted for 24% of all injuries. Wounds that were immediately closed had a superficial infection rate of 11% and a deep infection rate of 4.7%. Both proportions are equivalent to or lower than historical controls for delayed closure. Fracture classification, velocity of trauma and time to wound closure did not correlate significantly with infection, delayed union or nonunion. CONCLUSION: Attempting primary closure for all open fractures is a safe and efficient practice that does not increase the postoperative risk of infection and delayed union or nonunion.

CONTEXTE: On a de tout temps cru que la fermeture primaire immédiate des fractures ouvertes accroissait le risque d'infection de la plaie et de non soudure osseuse. La littérature récente remet cette position en question, mais on ignore encore si la fermeture primaire peut être utilisée de routine. Cette étude évalue l'impact d'un protocole d'établissement imposant la fermeture primaire de toutes les fractures ouvertes. MÉTHODES: Nous avons passé en revue de manière rétrospective toutes les fractures ouvertes traitées dans un seul centre de traumatologie de Niveau 1 au cours d'une période de 5 ans. Avant l'étude, un protocole a été adopté pour standardiser la prise en charge des fractures ouvertes et promouvoir la fermeture primaire de toutes les plaies comme objectif imposé du traitement opératoire. Les caractéristiques des patients et des fractures, les types de fermeture de plaie et les complications infectieuses ou liées à la guérison osseuse ont été évalués à partir du moment de la blessure et jusqu'à la fin du suivi en clinique externe. RÉSULTATS: En tout, 297 fractures ouvertes ont été traitées, 255 d'entre elles (85,8 %), au moyen d'une fermeture primaire immédiate. Les traumatismes ouverts de Type III comptaient pour 24 % de toutes les blessures. Les plaies qui ont été refermées immédiatement ont présenté un taux d'infection superficielle de 11 % et un taux d'infection profonde de 4,7 %. Ces 2 proportions sont équivalentes ou inférieures à ce qui a été observé chez les témoins historiques chez qui la fermeture de plaie a été reportée. La classification des fractures, la vitesse de l'impact à l'origine des traumatismes et le temps écoulé avant la fermeture des plaies n'ont pas été en corrélation significative avec l'infection et le retard de soudure osseuse ou la non soudure osseuse. CONCLUSION: Tenter d'appliquer une fermeture primaire à toutes les fractures ouvertes est une pratique sécuritaire et efficace qui n'accroît pas le risque d'infection postopératoire, de retard de soudure osseuse ou de non soudure osseuse.

Circumferential Casting of Distal Radius Fractures.

OBJECTIVES: To determine the prevalence and predictive factors for the early cast alteration (splitting, trimming, and complete replacement) in patients with distal radius fractures (DRFs) treated in circumferential cast. To determine whether performing early cast alterations affects the fracture alignment. DESIGN: Retrospective Cohort Study. SETTING: Level 1 Trauma Center. PATIENTS: All adult patients who presented with a DRF to a tertiary care hospital over a 3-year period. INTERVENTION: All DRFs without immediate surgical indications are initially treated with circumferential casts at this center. OUTCOME MEASUREMENTS: The following variables were analyzed: patient demographics, polytrauma at the time of injury, physician subspecialty performing reduction, and type of cast alteration. Radiographs were used to assess initial fracture characteristics and secondary displacement of reduction over time. Analysis was performed primarily to identify predictive variables for the early cast alteration and secondarily to determine the effect of these alterations on fracture alignment. RESULTS: 296 patients were included in the study. One of every 4-5 patients had their cast altered within the first 10 days of treatment. One of 3 polytrauma patients had their cast altered. No type of cast alteration was found to be significantly predictive of loss of fracture alignment at 2 or 6 weeks. CONCLUSIONS: Cast alteration is commonplace after casting of DRFs but is not associated with the loss of alignment. Patients with polytrauma may benefit from immediate cast splitting. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Incorrect radiographic evaluation after vascularized bone grafting for scaphoid fracture or nonunion.

PURPOSE: The present study is a review of patients with scaphoid non-unions treated with a dorsal vascularized bone graft. The study highlights a subset of patients incorrectly diagnosed as graft failures. METHODS: A retrospective review of patients who received vascularized grafts for scaphoid nonunions was performed over a four-year period. The vascularized graft of choice for this group was the dorsal radial extensor compartment artery. RESULTS: Five patients from a scaphoid fracture group who were treated with vascularized grafts were diagnosed as being failures (average of five months). None of these patients had tenderness on palpation of the scaphoid, and they were scheduled for revised vascularized grafts. All patients at the time of surgery were found to have healed. These patients were treated with arthrolysis, resulting in healing and full range of motion. CONCLUSIONS: Scaphoid vascularized grafts may have a markedly delayed radiographic healing time. Reoperation to perform secondary vascularized procedures may result in unnecessary surgery. Early imaging following a scaphoid vascularized graft may be inaccurate and may demonstrate a continued nonunion.

Risk of axillary nerve injury during percutaneous proximal humerus locking plate insertion using an external aiming guide.

OBJECTIVES: The purpose of this study was to determine which screws could be safely inserted percutaneously into a proximal humerus locking plate using a new external aiming guide without injuring the axillary nerve. We also sought to evaluate that all the screws could be accurately inserted ina locked position with the external guide. METHODS: Eight cadaveric specimens were implanted with a proximal humerus locking plate using a minimally invasive direct-lateral deltoid splitting approach using an attached external aiming guide for screw insertion. The anatomic proximity of the axillary nerve to the guidewires and screws was measured following soft tissue dissection and inspection of the nerve. RESULTS: The two superior holes (C1 and C2) were proximal to the axillary nerve with an average distance of 15.1 mm. Screw F was on average 6.6 mm distal to the axillary nerve but within 2 mm of the nerve in two specimens. In all specimens, the locking screws were appropriately seated in a locked position using the external aiming guide. CONCLUSIONS: This study suggests that percutaneous fixation of a proximal humerus locking plate with an external aiming guide can be safely used for proximal humerus fractures. The limited number of screws that can be inserted into the proximal fragment using the current external guide arm may compromise fixation of more unstable fractures. Therefore, the indications for percutaneous locking plate fixation of the proximal humerus using an external aiming guide should be limited to stable fracture patterns that can be anatomically reduced.

Plating for distal radius fractures.

No area of fracture management has had such a recent explosion of new treatment modalities as distal radius plating. This explosion has largely been implant- and industry-driven, with little evidence-based research guiding the way. A perceived difficulty with commonly used modalities by the orthopedic community has been enough to drive an entire new set of options for distal radius fixation. A drift from dorsal to volar plating has occurred that has been unexamined by randomized research. Segment specific fixation has been a new mindset that has resulted in a novel plate line and has caused other manufacturers to redesign their product lines. Other novel approaches for proposed problems include locking plates, nail-plate combinations, and others. This article outlines some of these options with a literature opinion and a clarification from the authors. A treatment plan for common fractures of the distal radius is also outlined.

Dedicated orthopedic trauma theatres: effect on morbidity and mortality in a single trauma centre.

BACKGROUND: A general trend in orthopedic traumatology is the advent of daily, dedicated orthopedic trauma theatres. Availability of trauma theatres is believed to decrease morbidity and mortality, but this remains unproven. We performed a retrospective review comparing morbidity and mortality outcomes at a single institution before and after the establishment of a dedicated trauma room. The purpose was to determine whether a change in outcomes occurred for a single routine procedure with known outcome expectations (hemiarthroplasty of the hip after femoral neck fracture) with the implementation of a designated trauma theatre. METHODS: We examined a cohort of 457 elderly patients (245 before and 212 after trauma theatre implementation) who underwent hemiarthroplasty for displaced low-energy subcapital hip fractures. RESULTS: Patients in both groups were similar in terms of age, sex ratio and ASA classification. We found statistically significant differences favouring the dedicated trauma room system for postoperative morbidity. Despite this outcome, the average time to surgery for these patients significantly increased. We noted no difference in mortality between the 2 groups. CONCLUSION: The hip fracture population can be treated safely in the context of dedicated trauma room time; however, there needs to be prioritization of hip fractures in a tertiary care centre or other trauma cases will tend to take precedence.

Percutaneous humeral plating of fractures of the proximal humerus: results of a prospective multicenter clinical trial.

OBJECTIVES: To evaluate the safety and functional outcome of a recently described surgical technique of percutaneous plating for proximal humerus fractures. DESIGN: Prospective clinical trial. SETTING: : Two urban Level 1 university trauma centers. PATIENTS: From February 2002 to December 2003, 34 consecutive patients underwent surgery by 5 trauma surgeons from 2 teaching hospitals. Twenty-seven patients had 1-year follow-up. INTERVENTION: The technique involved 2 minimal incisions with a lateral deltoid split and a more distal shaft incision. A proximal humerus-specific locking plate was implemented. MAIN OUTCOME MEASUREMENTS: DASH (disabilities of the arm, shoulder, and hand) and Constant-Murley evaluation scores were used for functional evaluation. The presence of complications was noted. RESULTS: Specifically, there were no axillary nerve injury injuries and no loss of reduction. The average Constant score at 1 year was 82 and the DASH score was 26. CONCLUSION: This study demonstrated that the functional outcome results correspond to a normal age-adjusted score signifying an acceptable result.

Plating for distal radius fractures.

No area of fracture management has had such a recent explosion of new treatment modalities as distal radius plating. This explosion has largely been implant- and industry-driven, with little evidence-based research guiding the way. A perceived difficulty with commonly used modalities by the orthopedic community has been enough to drive an entire new set of options for distal radius fixation. A drift from dorsal to volar plating has occurred that has been unexamined by randomized research. Segment specific fixation has been a new mindset that has resulted in a novel plate line and has caused other manufacturers to redesign their product lines. Other novel approaches for proposed problems include locking plates, nail-plate combinations, and others. This article outlines some of these options with a literature opinion and a clarification from the authors. A treatment plan for common fractures of the distal radius is also outlined.

A new intramedullary nail device for the treatment of intertrochanteric hip fractures: Perioperative experience.

BACKGROUND: Traditional short nail fixation devices used for intertrochanteric (IT) fractures of the femur have several surgeon and patient benefits. However, these devices have had a high incidence of complications. A new intramedullary device designed to overcome these shortcomings has become commercially available. The goal of this study was to compare this intramedullary nail device with the traditional dynamic hip screw. METHOD: A prospective cohort study with 60 IT hip fractures was performed. Thirty patients treated with the trochanteric fixation nail (TFN) were compared with 30 patients treated with the dynamic hip screw (DHS) during the same time period. Implant selection was dictated by surgeon randomization. Primary outcomes planned for this study were immediate measures of operative blood loss, surgical time, and incidence of operative complications. Secondary outcome of return to preoperative ambulatory status was also recorded. Follow-up for secondary outcomes was conducted at an average of 6 months after surgery. Perioperative, functional, and radiologic outcome measures were collected. RESULT: No intra- or perioperative complications occurred with the new nail device. Operative time was 10 minutes shorter with TFN (50.7 minutes) compared with DHS (60.4 minutes). No Trendelenburg gait was noted in either group. No femur fractures or distal locking difficulties occurred in the TFN group. Twelve of 17 (71%) TFN patients returned to prefracture ambulation 6 months after surgery compared with only 6 of 18 (33%) DHS patients (p = 0.09). CONCLUSION: The rate of femoral fractures for short femoral nails was decreased compared with historical controls. Improved early mobilization was noted in TFN group.