Current Management of Acute and Posttraumatic Critical Bone Defects.

SUMMARY: Limb reconstruction in patients with critical-sized bone defects remains a challenge due to the availability of various technically demanding treatment options and a lack of standardized decision algorithms. Although no consensus exists, it is apparent from the literature that the combination of patient, surgeon, and institutional collaborations is effective in providing the most efficient care pathway for these patients. Success relies on choosing a particular surgical approach that manages infection, soft tissue defects, stability, and alignment. Recent systematic reviews demonstrate high success rates with the following management options: Ilizarov bone transport, Masquelet (induced membrane) technique, cancellous bone grafting, and vascularized bone grafts.

Increased Duration and Frequency of Lateral C-Arm Draping Does Not Increase Contamination Rates.

This study sought to quantify the rate of culture-positive drape contamination with varying degrees of drape manipulation for intra-operative fluoroscopic imaging. In this prospective cohort study, 30 patients with operatively closed lower extremity fractures were evaluated. The clip-drape technique was employed to cover the emitter. Swab samples were collected for bacterial growth. A t-test was applied for statistical comparison. Three of 30 cases (10% of operations) showed evidence of contamination. There was no statistically significant difference between duration of drape use or the amount of drape manipulations. None of the 30 patients in this study developed surgical site infection 90-days post-surgery. The clip drape technique for lateral fluoroscopy appears to be effective in maintaining surgical field sterility. Moreover, the number of drape manipulations and length of time the drape was in use was not related to drape contamination. Level of Evidence: Therapeutic Level II. (Journal of Surgical Orthopaedic Advances 32(2):107-110, 2023).

How do surgeons decide when to treat proximal humerus fractures with operative versus nonoperative management?

PURPOSE: The objective of this study was to determine the underlying factors that drive the decision for surgeons to pursue operative versus nonoperative management for proximal humerus fractures (PHF) and if fellowship training had an impact on these decisions. METHODS: An electronic survey was distributed to members of the Orthopaedic Trauma Association and the American Shoulder and Elbow Surgeons Society to assess differences in patient selection for operative versus nonoperative management of PHF. Descriptive statistics were reported for all respondents. RESULTS: A total of 250 fellowship trained Orthopaedic Surgeons responded to the online survey. A greater proportion of trauma surgeons preferred nonoperative management for displaced PHF fractures in patients over the age of 70. Operative management was preferred for older patients with fracture dislocations (98%), limited humeral head bone subchondral bone (78%), and intraarticular head split (79%). Similar proportions of trauma surgeons and shoulder surgeons cited that acquiring a CT was crucial to distinguish between operative and nonoperative management. CONCLUSION: We found that surgeons base their decisions on when to operate primarily on patient's comorbidities, age, and the amount of fracture displacement when treating younger patients. Further, we found a greater proportion of trauma surgeons elected to proceed with nonoperative management in patients older than the age of 70 years old as compared to shoulder surgeons.

Racial and Sex Disparities in Resident Attrition in Orthopaedic Surgery.

Studies have suggested that female individuals and individuals from backgrounds under-represented in medicine (URiM) are at increased risk of attrition during residency. This likely exacerbates the lack of diversity in our field. The aims of this study were to (1) characterize demographic composition in orthopaedic residency from 2001 to 2018 and (2) determine the race/ethnicity and identify any disparities. Methods: Demographic and attrition data from 2001 to 2018 were obtained from the Association of American Medical Colleges. Attrition data comprised the following categories: withdrawals, dismissals, and transfers to another specialty. Analysis compared demographic composition and determined attrition rates with subgroup analysis by race/ethnicity and sex. Results: From 2001 to 2018, female orthopaedic residents increased from 8.77% to 15.54% and URiM residents from 9.49% to 11.32%. The overall and unintended attrition rates in orthopaedic surgery were 3.20% and 1.15%, respectively. Among female residents, the overall and unintended attrition rates were 5.96% and 2.09% compared with 2.79% and 1.01%, respectively, in male residents. URiM residents had overall and unintended attrition rates of 6.16% and 3.11% compared with 2.71% and 0.83%, respectively, for their White counterparts. Black/African American residents had an attrition rate of nearly 10%. Female residents averaged 12.9% of all residents but 24% of those leaving orthopaedics. URiM residents were 10.14% of all residents but 19.51% of those experiencing attrition. In logistic regression models, female residents had a relative risk (RR) of 2.20 (p < 0.001) for experiencing all-cause attrition and 2.09 (p < 0.001) for unintended attrition compared with male residents. Compared with their White male counterparts, URiM residents had a RR for overall and unintended attrition of 2.36 and 3.84 (p < 0.001), respectively; Black/African American residents had a RR for the same of 3.80 and 7.20 (p < 0.001), respectively. Conclusion: Although female resident percentage has increased, orthopaedics continues to train fewer female surgeons than all other fields. Female and URiM residents in orthopaedic surgery are disproportionately affected by attrition. While recruitment has been the primary focus of diversity, equity, and inclusion efforts, this study suggests that resident retention through appropriately supporting residents during training is equally critical.

Optimizing the Entry Point for Reconstruction Nailing of the Femur.

INTRODUCTION: Varus after antegrade medullary nailing of the proximal femur is associated with worse outcomes. Anecdotally, a more medialized "trochiformis" entry is beneficial to avoid varus with valgus-bend (greater trochanteric entry) femoral nails. However, the optimal entry point remains unknown. The purpose of this study was to define the optimal entry point for reconstruction nailing. METHODS: Using standing alignment radiographs from 51 patients, we templated the ideal entry point for straight and valgus-bend nails from three major manufacturers using TraumaCad software. We measured the distance from the tip of the trochanter to the ideal entry site for each nail. We compared piriformis (PF) with trochanteric (GT) entry for each company and across manufacturers. RESULTS: The mean greater trochanter offset from the femoral axis was 15.2 mm. The mean PF entry was 5.9 to 6.7 mm medial to the mean GT entry for each company's nail and was statistically distinct. No differences were observed in GT and PF entry points across manufacturers. Only 2 of 153 ideal GT entry points were lateral to the tip of the trochanter. An increased neck-shaft angle (NSA) and increased GT offset were correlated with a more medial ideal entry point. DISCUSSION: The ideal entry point for GT nails is similar across manufacturers and is medial to the tip of the greater trochanter; however, PF and GT entry sites remain distinct. During preoperative planning and when executing femoral nailing intraoperatively, it may also be important to consider the NSA and GT offset of a patient before committing to a certain entry point.

Racial and Sex Disparities in Resident Attrition Among Surgical Subspecialties.

Importance: Racial and sex disparities are prevalent in surgical trainees. Although retrospective studies on resident attrition have been conducted for individual specialties, this study analyzes racial and sex differences in resident attrition among all surgical subspecialties over an 18-year period. Objective: To evaluate the racial and sex differences in resident attrition among surgical specialties over an 18-year period. Design, Setting, and Participants: This was a large, cross-sectional, database study that analyzed program-reported resident censuses (program information, resident demographics, and attrition status) obtained by the Association of American Medical Colleges from 2001 to 2018 for trainees in surgical residency programs. Data were analyzed from March 20, 2021, to June 8, 2022. Main Outcomes and Measures: Demographic trends (including race and ethnicity and sex) for all surgical subspecialty training programs over an 18-year period. Resident attrition includes all-cause withdrawals, dismissals, and transfers to another specialty. Unintended attrition encompasses all withdrawals, dismissals, and transfers except for changing career plans. Results: This study included 407 461 program-reported resident years collected from 112 205 individual surgical residents (67 351 male individuals [60.0%]). The mean percentage of female trainees was 40.0% (44 835) and increased over the study period. Sex disparity remained greatest in orthopedic surgery. Residents who were underrepresented in medicine (URiM) comprised 14.9% (16 695) of all surgical trainees but demonstrated a 2.1% decrease over the study period. Overall attrition rate among all specialties was 6.9% (7759), with an unintended attrition rate of 2.3% (2556). Female residents had a significantly higher relative risk (RR) of attrition (RR, 1.16; 95% CI, 1.11-1.22; P < .001) and unintended attrition (RR, 1.17; 95% CI, 1.08-1.26; P < .001) compared with their male counterparts. URiM residents were at significantly higher RR for attrition (RR, 1.40; 95% CI, 1.32-1.48; P < .001) and unintended attrition (RR, 1.92; 95% CI, 1.75-2.11; P < .001) compared with non-URiM residents. The highest attrition (10.6% [746 of 7043]) and unintended attrition (5.2% [367 of 7043]) rates were in Black/African American residents. The lowest attrition and unintended attrition rates were seen in White residents at 6.2% (4300 of 69 323) and 1.8% (1234 of 69 323), respectively. Black/African American residents were at disproportionate risk for attrition (RR, 1.66; 95% CI, 1.53-1.80; P < .001) and unintended attrition (RR, 2.59; 95% CI, 2.31-2.90; P < .001) compared with all other residents. Orthopedic surgery had the highest attrition (RR, 3.80; 95% CI, 2.84-5.09; P < .001) and unintended attrition (RR, 7.20; 95% CI, 4.84-10.71; P < .001) for Black/African American residents. Conclusions and Relevance: Results of this cross-sectional study suggest that the percentage of female residents in surgical specialties has improved over the last 18 years, and the percentage of URiM residents has remained relatively unchanged. Risk for attrition and unintended attrition was significantly elevated for female and URiM residents, specifically Black/African Americans. These results highlight current racial and sex disparities in resident attrition and demonstrate the importance of developing strategies to recruit, retain, and support residents.

Characterizing Single-star Negative Online Reviews of Orthopaedic Trauma Association Members.

INTRODUCTION: The purpose of this study was to characterize factors that contribute to 1-star negative reviews regarding orthopaedic trauma surgeons. METHODS: A search was done for Orthopaedic Trauma Association members on Yelp.com , Healthgrade.com , and Vitals.com in New York, Boston, San Francisco, Los Angeles, Dallas, Phoenix, Seattle, Baltimore, Denver, Houston, Philadelphia, and Washington, DC. All single-star reviews (out of a possible 5 stars) were included in this study. Reviews were categorized as either clinical or nonclinical and then further subcategorized. Categorical variables were analyzed using a chi-square test. The rate ratio (the ratio of the rate for nonsurgical divided by surgical reviews) was determined for each category. RESULTS: Two hundred eighty-eight single-star reviews were included in the study, comprising 655 total complaints. Of all complaints, 274 (41.8%) were clinically related and 381 (58.2%) were nonclinical. Of the 288 single-star reviews, 96 (33.3%) were from surgically treated patients and 192 (66.7%) were from nonsurgical patients. Most complaints were in reference to nonclinical aspects of care such as physician bedside manner (173 reviews, 60%), not enough time spent with provider (58 reviews, 20%), and wait time (42 complaints, 15%). The most common clinical complaints were for complication (61 reviews, 21%), disagree with decision/plan (49 reviews, 17%), and uncontrolled pain (45 reviews, 16%). Surgical patients had a significantly higher rate of clinical complaints than nonsurgical patients (1.57 vs. 0.64 clinical complaints per review, P < 0.001). Nonsurgical patients had a significantly higher rate of nonclinical complaints than surgical patients (1.43 vs. 1.10 nonclinical complaints per review, P < 0.001). DISCUSSION: Most 1-star reviews referenced a nonclinical aspect of care with a physician's bedside manner being the most common complaint. Surgical patients were markedly more likely to reference a clinical aspect of care, such as complications or misdiagnosis compared with nonsurgical patients, who more commonly referenced nonclinical aspects of care.

Chronic Warfarin Anticoagulation in Hip Fracture Patients Delays Surgery and Is Associated With Increased Risk of Postoperative Complications: A Multicenter Propensity-Score-Matched Analysis.

OBJECTIVE: To evaluate the effect of warfarin on blood transfusion and postoperative complications in a low-energy hip fracture population compared with a non-anticoagulated comparison group. DESIGN: Multicenter Retrospective Cohort. SETTING: Three Urban Level I Academic Trauma Centers. PATIENTS: Acute, low-energy, native hip fractures in patients 55 years of age or older on chronic warfarin anticoagulation, propensity score matched 1:2 to non-anticoagulated hip fracture patients meeting all other inclusion criteria. MAIN OUTCOME MEASUREMENTS: Transfusion and postoperative complication rates. RESULTS: Two hundred ten anticoagulated hip fracture patients were matched to 420 nonanticoagulated patients. A higher proportion of patients required blood transfusion in the warfarin cohort (52.4% vs. 43.3%, P < 0.001), attributable mostly to the subgroup of patients undergoing arthroplasty. Warfarin patients had higher incidence of overall 90-day complications (47% vs. 38%, P = 0.039) and readmissions (31.4% vs. 8.9%, P < 0.001). Day of surgery international normalized ratio (INR) did not influence transfusions or complications among warfarin patients. Warfarin patients undergoing surgery within 24 hours had no difference in transfusions and had fewer complications compared with those undergoing surgery after 24 hours. On multivariable logistic regression analysis, warfarin use and day of surgery INR were not predictors of transfusion or complications. CONCLUSIONS: Patients on warfarin experienced longer time to surgery and higher incidence of overall transfusion and postoperative complications within 90 days of surgery. However, warfarin use and day of surgery INR was not independently associated with transfusions or complications. The reason for poorer outcomes in warfarin patients remains a topic of further investigation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Survey Analysis of Orthopedic Call Compensation.

We sought to determine the type, frequency, and compensation details of orthopedic call for orthopedic traumatologists. We administered a 24-question survey to all members of the Orthopaedic Trauma Association regarding the number and type of orthopedic surgeons within the call pool, frequency of call, number of hospitals covered, and compensation for weekday, weekend, holiday, and pediatric calls. A total of 105 orthopedic surgeons replied. The most common number of physicians in the call pool was 6 to 10 (42.9%), whereas the most common number of traumatologists was 0 to 5 (90.5%), with 71.4% taking call at 1 hospital. Further, 56.7% were paid separately for weekday trauma call, with the most common number of call days per week being 2. The most common compensation was $1001 to $1500 (31.6%). For weekend call, 49.5% of physicians were paid separately, with the most common number of weekends on call per year being 11 to 15 (34.3% of replies). For pediatric call, 54.3% of physicians took call, with 28.6% paid separately and 33.3% receiving $0 to $500. For holiday call, 40.2% of physicians were paid separately, with 30.8% receiving $1001 to $1500. We describe the characteristics of traumatology call. Approximately 50% of physicians (range, 28.6%-56.3%) are compensated separately for taking different forms of call (ie, weekday, weekend, holiday). [Orthopedics. 2022;45(5):293-296.].

Understanding postoperative rehabilitation preferences in operatively managed proximal humerus fractures: do trauma and shoulder surgeons differ?

BACKGROUND: Proximal humerus fractures (PHFs) are common, and their incidence is increasing as the population ages. Despite this, postoperative rehabilitation remains unstandardized and little is known about surgeon preferences. The aim of this study was to assess differences in postoperative rehabilitation preferences and patient education between orthopedic trauma and shoulder surgeons. METHODS: An electronic survey was distributed to members of the Orthopaedic Trauma Association and the American Shoulder and Elbow Surgeons to assess differences in postoperative rehabilitation preferences and patient counseling. Descriptive statistics were reported for all respondents, trauma surgeons, and shoulder surgeons. Chi-square and unpaired 2-sample t tests were used to compare responses. Multinomial regression was used to further elucidate the influence of fellowship training independent of confounding characteristics. RESULTS: A total of 293 surgeons completed the survey, including 172 shoulder and 78 trauma surgeons. A greater proportion of trauma surgeons preferred an immediate weightbearing status after arthroplasty compared to shoulder surgeons (45% vs. 19%, P = .003), but not after open reduction and internal fixation (ORIF) (62% vs. 75%, P = .412). A greater proportion of shoulder surgeons preferred home exercise therapy taught by the physician or using a handout following reverse shoulder arthroplasty (RSA) (21% vs. 2%, P = .009). A greater proportion of trauma surgeons began passive range of motion (ROM) <2 weeks after 2-part fractures (70% vs. 41%, P < .001). Conversely, a greater proportion of shoulder surgeons began passive ROM between 2 and 6 weeks for 2-part (57% vs. 24%, P < .001) and 4-part fractures (65% vs. 43%, P = .020). On multinomial regression analysis, fellowship training in shoulder surgery was associated with preference for a nonweightbearing duration of >12 weeks vs. 6-12 weeks after ORIF. Similarly, fellowship training in shoulder surgery was associated with increased odds of preferring a nonweightbearing duration of <6 weeks vs. no restrictions and >12 weeks vs. 6-12 weeks after arthroplasty. Training in shoulder surgery was associated with greater odds of preferring a nonweightbearing duration prior to beginning passive ROM of 2-6 weeks vs. <2 weeks or >6 weeks for 2-part fractures, but not 4-part fractures. CONCLUSION: Trauma surgeons have a more aggressive approach to rehabilitation following operative PHF repair compared to shoulder surgeons regarding time to weightbearing status and passive ROM. Given the increasing incidence of PHFs and substantial variations in reported treatment outcomes, differences in rehabilitation after PHF treatment should be further evaluated to determine the role it may play in the outcomes of treatment studies.

Factors influencing surgical management of proximal humerus fractures: do shoulder and trauma surgeons differ?

BACKGROUND: Proximal humerus fractures (PHFs) are managed with open reduction and internal fixation (ORIF), hemiarthroplasty (HA), reverse shoulder arthroplasty (RSA), or nonoperatively. Given the mixed results in the literature, the optimal treatment is unclear to surgeons. The purpose of this study was to survey orthopedic shoulder and trauma surgeons to identify the patient- and fracture-related characteristics that influence surgical decision-making. METHODS: We distributed a 23-question closed-response email survey to members of the American Shoulder and Elbow Surgeons and Orthopaedic Trauma Association. Questions posed to respondents included demographics, surgical planning, indications for ORIF and arthroplasty, and the use of surgical augmentation with ORIF. Numerical and multiple-choice responses were compared between shoulder and trauma surgeons using unpaired t-tests and χ2 tests, respectively. RESULTS: Respondents included 172 shoulder and 78 trauma surgeons. When surgery is indicated, most shoulder and trauma surgeons treat 2-part (69%) and 3-part (53%) PHFs with ORIF. Indications for managing PHFs with arthroplasty instead of ORIF include an intra-articular fracture (82%), bone quality (76%), age (72%), and previous rotator cuff dysfunction (70%). In patients older than 50 years, 90% of respondents cited a head-split fracture as an indication for arthroplasty. Both shoulder and trauma surgeons preferred RSA for treating PHFs presenting with a head-split fracture in an elderly patient (94%), pre-existing rotator cuff tear (84%), and pre-existing glenohumeral arthritis with an intact cuff (75%). Similarly, both groups preferred ORIF for PHFs in young patients with a fracture dislocation (94%). In contrast, although most trauma surgeons preferred to manage PHFs in low functioning patients with a significantly displaced fracture or nonreconstructable injury nonoperatively (84% and 86%, respectively), shoulder surgeons preferred either RSA (44% and 46%, respectively) or nonoperative treatment (54% and 49%, respectively) (P < .001). Similarly, although trauma surgeons preferred to manage PHFs in young patients with a head-split fracture or limited humeral head subchondral bone with ORIF (98% and 87%, respectively), shoulder surgeons preferred either ORIF (54% and 62%, respectively) or HA (43% and 34%, respectively) (P < .001). CONCLUSIONS: ORIF and HA are preferred for treating simple PHFs in young patients with good bone quality or fracture dislocations, whereas RSA and nonoperative management are preferred for complex fractures in elderly patients with poor bone quality, rotator cuff dysfunction, or osteoarthritis. The preferred management differed between shoulder and trauma surgeons for half of the common PHF presentations, highlighting the need for future research.

Delayed Surgery Does Not Reduce Transfusion Rates in Low-Energy Hip Fractures on Direct Oral Anticoagulants.

OBJECTIVES: To compare transfusion rates in patients on direct oral anticoagulants (DOACs) with nonanticoagulated patients undergoing hip fracture surgery and, secondarily, to determine whether time to surgery or complications differ between these groups. DESIGN: Multicenter retrospective cohort. SETTING: Three tertiary care, academic, Level I trauma centers. PATIENTS: Acute, operatively treated, low-energy hip fracture patients 55 years of age and older were included. Anticoagulated patients were matched in a 1:2 ratio to "control" nonanticoagulated hip fracture patients using propensity score matching. MAIN OUTCOME MEASUREMENTS: The primary outcome was incidence of perioperative transfusion. The secondary outcomes included time to surgery, length of stay, and 90-day complications, readmissions, reoperations, and mortality. RESULTS: One hundred thirty-two patients with hip fracture admitted on DOACs were identified (107 factor Xa inhibitors, 25 dabigatran) and were matched to 262 "control" nonanticoagulated patients. There was no difference in overall transfusion rates between anticoagulation and control groups (43.2%; n = 57 DOAC vs. 39.7%; n = 104 control; P = 0.517). The median time from admission to surgery was 41.7 hours in the DOAC group and 26.0 hours in the control group (P < 0.001). There were no differences in 90-day complication, readmission, reoperation, or mortality rates between DOAC and control groups. Comparing DOAC patients undergoing surgery within 24 hours and after 24 hours, there were no differences in transfusion rates (P = 0.558) or overall complication rates (P = 0.179). CONCLUSIONS: This study supports growing evidence that DOAC use should not be a determining factor in delaying surgery for patients with hip fracture who are otherwise medically optimized. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

COVID-19 Shelter-In-Place Orders Associated With Delayed Presentation and Deep Venous Thrombosis in Geriatric Hip Fractures.

Geriatric hip fractures benefit from timely surgery. At the onset of the corona-virus disease 2019 (COVID-19) pandemic, shelter-in-place (SIP) orders were mandated in high-risk cities. The authors hypothesized that geriatric patients with hip fractures were more likely to present to the hospital greater than 24 hours after injury during SIP orders. They retrospectively reviewed patients 65 years or older who presented with hip fractures between March 20, 2020, and May 24, 2020 (SIP group), and between March 20, 2019, and May 24, 2019 (historical group). Primary outcomes were incidence of presentation greater than 24 hours after injury and mean number of days between injury and presentation. Secondary outcomes were incidence of preoperative deep venous thrombosis (DVT) and 30- and 90-day mortality rates. Thirty-three patients comprised the SIP group, and 50 patients comprised the historical group. There were no significant differences in their demographics or medical comorbidities. The SIP group was more likely to present greater than 24 hours after injury (P=.05) and presented a greater number of days after injury (P=.02). There was a significant difference in the incidence of preoperative DVT (P=.03). There were no significant differences in 30- and 90-day mortality rates. Geriatric patients who sustained hip fractures during SIP restrictions for COVID-19 were more likely to present greater than 24 hours after injury, have a greater number of days between injury and presentation, and be diagnosed with a preoperative DVT. [Orthopedics. 2021;44(4):223-228.].

Characterization of Infraspinatus Tendon Anatomy: The Soft-Tissue Portion of Remplissage.

PURPOSE: To characterize the morphology of the infraspinatus (IS) tendon and evaluate the bony anatomy of the humeral head (HH) to determine if there is a correlation between HH measurements and the amount of available IS tendon. METHODS: The superior-inferior width as well as the medial-lateral (M-L) length of the inferior and superior portions of the IS tendon were measured in 15 human cadaveric shoulders. Three measurements were then obtained for each corresponding humeral head: (1) anterior to posterior (A-P) distance, (2) midcoronal humeral head distance (MCHH), and (3) M-L distance. Pearson correlation coefficients (R) of tendon measurements relative to HH measurements were determined. RESULTS: The mean ± SD HH measurements were 44.3 ± 3.3 mm for A-P, 49.3 ± 3.4 mm at the MCHH, and 52.2 ± 3.4 mm in the M-L plane. The mean M-L length of the superior portion of the IS tendon was significantly different from the inferior portion (42.4 vs 31.0 mm, P < .0001). The mean ± SD width of the IS tendon was 19.4 ± 3.0mm. There was a statistically significant correlation (R = 0.58) between the M-L length of the superior IS tendon relative to the M-L HH distance (P < .05) and the A-P HH distance (P < .05). CONCLUSIONS: The superior M-L IS tendon length was significantly greater than the inferior M-L length. The M-L HH and the AP HH distances were significantly correlated to the M-L length of the superior portion of the IS tendon. These relationships may provide an estimation of the length of available IS tendon to help guide the management of Hill-Sachs lesions (HSLs). CLINICAL RELEVANCE: Knowledge of the available IS length can help optimize the management of HSLs following anterior shoulder dislocation. If IS tendon M-L length is less than HSL M-L length, then remplissage may result in capsulomyodesis rather than tenodesis. Placement of the superior anchor in a position that is as superior as possible within the HSL defect will maximize the opportunity for IS tenodesis.

Patella Fractures: Approach to Treatment.

Patellar fracture morphology varies based on the mechanism of injury. Most fractures are either a result of direct impact or through an indirect eccentric extensor contraction injury. Each fracture pattern requires appropriate preoperative planning and individualization of the fixation method. Displaced fractures affect the extension apparatus, and often require surgical fixation. Surgical treatment is recommended in fractures with any of the following features: articular step-off > 2 mm, > 3 mm of fracture displacement, open fractures, and displaced fractures affecting the extensor mechanism. Meticulous handling of the soft-tissue envelope is of the utmost importance, given the patella's tenuous blood supply and limited soft-tissue envelope. Incongruent articular surface can result in detrimental long-term effects; therefore, surgical treatment is directed toward anatomic reduction and fixation. The evolution of patellar fracture fixation continues to maximize options to balance rigid fixation with low-profile fixation constructs. Improving functional outcomes, minimizing soft-tissue irritation, and limiting postoperative complications are possible by using the therapeutic principles of rigid anatomical fixation and meticulous soft-tissue handling.

Fascia Iliaca Regional Anesthesia in Hip Fracture Patients Revisited: Which Fractures and Surgical Procedures Benefit Most?

OBJECTIVES: Perioperative fascia iliaca regional anesthesia (FIRA) decreases pain in hip fracture patients. The purpose of this study is to determine which hip fracture types and surgical procedures benefit most. DESIGN: Prospective observational study compared with a retrospective historical control. PATIENTS/PARTICIPANTS: Patients older than 60 years who received perioperative FIRA were compared with a historical cohort not receiving FIRA. SETTING: This study was conducted at a Level 1 trauma center. MAIN OUTCOME MEASUREMENTS: The primary outcome was morphine milliequivalents (MME) consumed during the index hospitalization. Fracture pattern-specific preoperative and postoperative MME consumption and surgical procedure-specific postoperative MME consumption was compared between the FIRA and non-FIRA groups. RESULTS: A total of 949 patients were included in this study, with 194 (20.4%) patients in the prospective protocol group. There were no baseline differences between cohorts. Preoperatively, only femoral neck fracture patients receiving FIRA used fewer MME (P < 0.001). Postoperatively, femoral neck fracture patients receiving FIRA used fewer MME on postoperative day (POD) 1 (P = 0.027) and intertrochanteric fracture patients used fewer MME on POD1 and POD2 (P = 0.013; P = 0.002). Cephalomedullary nail patients receiving FIRA used fewer MME on POD1 and POD2 (P = 0.004; P = 0.003). Hip arthroplasty patients receiving FIRA used fewer MME on POD1 (P = 0.037). Percutaneous pinning and sliding hip screw patients had no significant MME reduction from FIRA. CONCLUSIONS: Preoperatively, patients with femoral neck fractures benefit most from FIRA. Postoperatively, both patients with femoral neck fractures and intertrochanteric fractures benefit from FIRA. Patients undergoing cephalomedullary nail fixation or hip arthroplasty benefit most from FIRA postoperatively. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Comparison in Outcomes of Preoperative Single-shot versus Continuous Catheter Fascia Iliaca Regional Anesthesia in Geriatric Hip Fracture Patients.

BACKGROUND: Fascia iliaca nerve blocks relieve pain in geriatric hip fracture patients and can be administered via a single-shot or continuous catheter. We compared perioperative opioid consumption and pain scores between these two blocks. METHODS: We performed a prospective, observational cohort study, including geriatric hip fracture patients who received a preoperative block. We compared morphine milligram equivalent (MME) consumption and visual analog scale (VAS) pain scores between single-shot and continuous fascia iliaca blocks at multiple time points: preoperative and on postoperative (POD) day 0, 1, and 2. We compared the change in preoperative total and hourly opioid consumption before and after block placement within and between groups. Secondary outcomes included opioid related adverse events, length of stay, and readmission rates. RESULTS: 107 patients were analyzed, 66 received a single-shot and 41 a continuous block. No significant differences were found between both blocks at any time point for median MME consumption or pain scores. MME [IQR]: preoperative 20.5 [6.0,48.8] vs. 24.0 [8.8,48.0], p=0.95; POD0 6.0 [0.0,18.6] vs. 10.0 [0.0,14.0], p=0.52; POD1 12.0 [0.0,30.0] vs. 18.0 [5.0,24.0], p=0.69; POD2 6.0 [0.0,21.2] vs. 12.0 [0.0,24.0], p=0.54. VAS [IQR]: preoperative 4.0 [2.2,5.3] vs. 4.6 [3.2,5.3], p=0.34; POD0 1.3 [0.0,3.7] vs. 2.5 [0.0,3.6], p=0.73; POD1 2.9 [1.7,4.4] vs. 3.7 [1.5,4.7], p=0.59; POD2 2.4 [1.0,4.4] vs. 3.3 [1.9,4.2], p=0.18. Preoperative MME/hr significantly decreased after the block for both groups: 1.05 [0.0,2.2] to 0.0 [0.0,0.0], p < 0.001; 1.4 [0.6,3.1] to 0.0 [0.0,0.1], p < 0.001. The reduction in MME/hr between groups was not significantly different: 0.9 [0.0,1.9] vs. 1.4 [0.6,3.1], p = 0.067. We found no significant differences in secondary outcomes between groups. CONCLUSIONS: We report no differences in opioid use and pain scores between single-shot and continuous catheter fascia iliaca nerve blocks. Both blocks similarly reduce preoperative opioid consumption.

A Comparison of 3 Fixation Strategies in the Treatment of Neer Type IIB Distal Clavicle Fractures.

OBJECTIVES: To compare the stability of NT2B clavicle fractures fixed with either a hook plating (HP), Superior Plating with Suture Augmentation (SPSA), or dual orthogonal plating (DP) with the hypothesis that DP would provide increased multiplanar stability across NT2B fractures. METHODS: NT2B distal clavicle fractures were created in cadaveric specimens and fixed using (1) HP, (2) SPSA, or (3) DP. Specimens were cyclically loaded in 3 different planes of motion: (1) anteroposterior (AP), (2) superior-inferior, and (3) axial rotation while displacement was continually recorded. Afterward, a superiorly directed load was applied to the clavicle. Load to failure, stiffness, and mode of failure were recorded. RESULTS: During AP loading, clavicles fixed with a DP had significantly lower mean posterior displacement compared to those fixed with SPSA at every 100-cycle interval of testing, P < 0.01. During inferior-superior loading, specimens fixed with a DP had less superior displacement than specimens fixed with an HP and SPSA, reaching significance at the 500-700 cycles of testing. There was no significant difference in axial rotation stability or load to failure between the 3 fixation techniques. CONCLUSIONS: Orthogonally placed minifragment plates provide improved stability against anterior displacement with no significant difference in superior stability, axial rotational stability, stiffness, or load to failure. Further clinical studies are needed to confirm the long-term stability of dual plating and determine the risks and benefits of this novel method of distal clavicle fixation.

Time to Block: Early Regional Anesthesia Improves Pain Control in Geriatric Hip Fractures.

BACKGROUND: Fascia iliaca nerve blocks (FIBs) anesthetize the thigh and provide opioid-sparing analgesia for geriatric patients with hip fracture awaiting a surgical procedure. FIBs are recommended for preoperative pain management; yet, block administration is often delayed for hours after admission, and delays in pain management lead to worse outcomes. Our objective was to determine whether opioid consumption and pain following a hip fracture are affected by the time to block (TTB). We also examined length of stay and opioid-related adverse events. METHODS: This prospective cohort study included patients who were ≥60 years of age, presented with a hip fracture, and received a preoperative FIB from March 2017 to December 2017. Individualized care timelines, including the date and time of admission, block placement, and surgical procedure, were created to evaluate the effect that TTB and time to surgery (TTS) had on outcomes. Patterns among TTB, TTS, and morphine milligram equivalents (MME) were investigated using the Spearman rho correlation. For descriptive purposes, we divided patients into 2 groups based on the median TTB. Multivariable regression for preoperative MME and length of stay was performed to assess the effect of TTB. RESULTS: There were 107 patients, with a mean age of 83.3 years, who received a preoperative FIB. The median TTB was 8.5 hours. Seventy-two percent of preoperative MME consumption occurred before block placement (pre-block MME). A longer TTB was most strongly correlated with pre-block MME (rho = 0.54; p < 0.001), and TTS was not correlated. Patients with a faster TTB consumed fewer opioids preoperatively (12.0 compared with 33.1 MME; p = 0.015), had lower visual analog scale scores for pain on postoperative day 1 (2.8 compared with 3.5 points; p = 0.046), and were discharged earlier (4.0 compared with 5.5 days; p = 0.039). There were no differences in preoperative pain scores, postoperative opioid consumption, delirium, or opioid-related adverse events. Multivariate regression showed that every hour of delay in TTB was associated with a 2.8% increase in preoperative MME and a 1.0% increase in the length of stay. CONCLUSIONS: Faster TTB in geriatric patients with hip fracture may reduce opioid use, pain, and length of stay. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.