Successful Outcomes With Nonoperative Treatment and Immediate Weightbearing Despite Stress-Positive Radiographs in Isolated Distal Fibula (OTA/AO 44B) Fractures.

OBJECTIVES: To determine whether a nonoperative management protocol results in equivalent outcomes in isolated OTA/AO 44B (Weber B) fractures without initial medial clear space (MCS) widening regardless of stress radiography findings. DESIGN: Prospective cohort. SETTING: Level 1 academic trauma center. PATIENT SELECTION CRITERIA: Nonoperatively managed patients with isolated OTA/AO 44B fractures and MCS ≤4 mm on initial non-weightbearing injury radiographs between from January 2018 and January 2022 were included. All patients underwent emergency department gravity stress radiographs and those with widening were considered the widening cohort and those without the non-widening cohort. OUTCOME MEASURE AND COMPARISONS: MCS measurements on weightbearing radiographs were obtained at first follow-up, 6 weeks, 12 weeks, and 6 months postinjury, were considered indicative of instability if >4 mm and were compared between cohorts.; American Orthopaedic Foot and Ankle Society ankle-hindfoot scores were also compared between cohorts. RESULTS: Sixty-nine patients were studied. None of the 38 patients (55%) with widening on gravity stress radiographs demonstrated widening with weightbearing radiographs at any time point. Mean MCS measurement differences between the 2 cohorts were statistically significant for all time points ( P = 0.012); however, with a model adjusted mean MCS value of 2.7 mm for the nonwidening cohort and 2.9 mm for the widening cohort, these are not clinically significant. There was no statistically significant difference in overall final American Orthopaedic Foot and Ankle Society scores between the 2 groups ( P = 0.451). In addition, statistical equivalence using Schuirmann 2 one-sided tests was achieved between the 2 groups. Both cohorts had mean American Orthopaedic Foot and Ankle Society scores representing excellent outcomes at the final follow-up. CONCLUSIONS: Patients with isolated OTA/AO 44B fractures without MCS widening on initial injury radiographs did not demonstrate instability on subsequent weightbearing radiographs and had equivalent outcomes regardless of gravity stress radiography findings when treated nonoperatively. Weightbearing radiographs at the initial follow-up appear to be a reliable assessment of ankle stability in these injuries and are an appropriate alternative to painful and time-consuming stress radiography. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Orthopaedic Surgery First-Year Resident Surgical Skills Month Curriculum.

In 2012, a mandate came to formally teach surgical skills to orthopaedic surgery program year one residents. We describe our reasoning and the mechanics behind our 1-month surgical skills course that we developed for our first-year orthopaedic surgery residents. We include our rationale of design, our monthly and daily format, a discussion of cost, a description and samples of our feedback surveys and results, and thoughts moving forward. We think sharing our thought process and programs will help others refine or create their own orthopaedic first-year resident educational activities.

A Unique Mode of Failure in the Noncontact Bridging Periprosthetic Plating System.

Although lateral locking plates are often a preferred and successful fixation construct for the treatment of periprosthetic proximal and distal femur fractures, specific complications and modes of failure have been associated and well-described with their use. We present two cases of implant failure in the Non-Contact Bridge Periprosthetic Plating System (Zimmer Biomet) in which a nonlocked screw fretted through the annular seating of the plate. One case demonstrates failure in the setting of a proximal femur periprosthetic fracture, whereas the other demonstrates failure in the setting of a distal femur periprosthetic fracture. This unique mode of failure has not previously been reported in the literature.

Early Ambulation After Hip Fracture Surgery Is Associated With Decreased 30-Day Mortality.

INTRODUCTION: Hip fractures frequently present in complicated patients and are fraught with high morbidity and mortality rates. Postoperatively, delayed ambulation has been identified as a factor associated with increased mortality, although its magnitude has yet to be quantified. Therefore, this article aims to evaluate mortality after hip fracture surgery because it relates to early postoperative ambulation, taking into account preexisting comorbidity burden. METHODS: This is a retrospective review of patients older than age 65 years who underwent surgical fixation for hip fractures because of a low-energy mechanism. Ambulation during the first 3 postoperative days was recorded along with age and preexisting comorbidity burden (Modified 5-Factor Frailty Index), and 30-day and 1-year mortality statuses were examined. Multivariable logistic regression was used to analyze the association between postoperative ambulation and mortality. RESULTS: Of 485 patients initially identified, 218 met the inclusion criteria. Overall mortality rates were 6.4% at 30 days and 18.8% at 1 year. Two-thirds of patients ambulated in the first 3 postoperative days versus one-third who did not. Patients who did not ambulate had both significantly increased 30-day mortality (odds ratio [OR] 4.42, P = 0.010, 95% confidence intervals [CIs] 1.42 to 13.75) and 1-year mortality (OR 2.26, P = 0.022, 95% CI 1.12 to 4.53). After multivariable logistic regression accounting for age and comorbidity status, ambulation remained strongly associated with 30-day (OR 3.87, P = 0.024, 95% CI 1.20 to 12.50) but not 1-year mortality (OR 1.66, P = 0.176, 95% CI 0.80 to 3.48). Although neither were significant at 30 days, both increasing age (OR 1.05, P = 0.020, 95% CI 1.01 to 1.10) and Modified 5-Factor Frailty Index (OR 1.62, P = 0.005, 95% CI 1.16 to 2.26) correlated with increased mortality at 1 year. CONCLUSION: Early ambulation after hip fracture surgery bears a notable, almost four-fold, association with early postoperative mortality independent of age and medical comorbidities. Our results support a growing body of evidence that ambulation is a powerful tool that should continue to be emphasized to optimize mortality in hip fracture patients.

A Performance Improvement Project in Antibiotic Administration for Open Fractures.

INTRODUCTION: To evaluate the effects of a trauma performance improvement project involving standardized protocols for the administration of antibiotics in open fractures at a level one trauma center. This study specifically evaluated the protocol's efficacy for improving the timing of delivery and appropriate therapy administration and sought to identify factors that lead to the delay in antibiotic delivery. METHODS: Retrospective comparative cohort study comparing patients with open fractures treated at our hospital between January 2013 and September 2015 (group 1) and between April 2016 and June 2017 (group 2). Group 1 was treated before implementation of the performance improvement project and group 2 was treated after implementation. RESULTS: Group 1 consisted of 79 patients and group 2 consisted of 80 patients with open fractures. Each group was statistically similar in patient and injury factors. Group 1 received antibiotics at an average of 97 minutes after arrival to our hospital while group 2 patients received them at an average of 46 minutes (P < 0.0001). Average time from admission to initial evaluation improved from 10 to 3 minutes (P < 0.0001). Average time from evaluation to antibiotic order placement improved from 77 to 26 minutes (P < 0.0001). Average time from order entry to antibiotic administration showed no significant difference (12 versus 15 minutes, P = 0.25). Thirty-four percent (27/79) of group 1 patients and 84% (67/80) of group 2 patients received antibiotics within 1 hour of admission (P < 0.0001), while 91% and 99% received antibiotics within 3 hours, respectively (P = 0.03). DISCUSSION: The described multifaceted performance improvement protocol was highly effective for producing a more coordinated, efficient, and timely process for administration of antibiotics to patients with open fractures at our hospital. This protocol may be adopted and implemented at other facilities. LEVEL OF EVIDENCE: Therapeutic level III.

Immediate Weight-Bearing Protocol for the Determination of Ankle Stability in Patients With Isolated Distal Fibular Fractures.

OBJECTIVE: To evaluate an alternative protocol for allowing immediate weight-bearing (WB) as tolerated in a functional walking boot in patients with a medial clear space (MCS) of less than 4 mm on nonstressed initial radiographs with subsequent WB radiographs at 1-week follow-up to determine if this can differentiate stable from unstable distal fibular fractures. DESIGN: Retrospective case series. SETTING: Level 1 trauma center. PATIENTS: Seventy-nine patients who sustained an isolated distal fibular fracture with an MCS less than 4 mm on initial non-weight-bearing radiographs during a 6-year period. INTERVENTION: Patients with MCS less than 4 mm on 1-week radiographs were treated nonoperatively. Patients with MCS greater than or equal to 4 mm were treated operatively. MAIN OUTCOME MEASUREMENTS: Medial clear space measurements on WB ankle radiographs at the time of radiographic bony union. RESULTS: Two of the 79 (2.5%) patients had an MCS greater than 4 mm at 1-week follow-up with WB radiographs and underwent operative fixation. The remaining 77 patients were treated nonoperatively. All 77 patients had an MCS less than 4 mm on WB radiographs at the time of radiographic healing. CONCLUSION: These results suggest that our immediate weight-bearing protocol may be an effective method for determination of functional ankle stability only in the setting of an isolated distal fibula fracture with MCS less than 4 mm. However, it should be cautioned that careful evaluation of WB radiographs for joint asymmetry and/or MCS widening is mandatory to avoid poor outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

An Analysis of Research Quality and Productivity at Six Academic Orthopaedic Residencies.

OBJECTIVE: It remains largely unknown what factors impact the research productivity of residency programs. We hypothesized that dedicated resident research time would not affect the quantity and quality of a program's peer-reviewed publication within orthopedic residencies. These findings may help programs improve structure their residency programs to maximize core competencies. DESIGN: Three hundred fifty-nine residents and 240 staff from six different US orthopedic residency programs were analyzed. All publications published by residents and faculty at each program from January 2007 to December 2015 were recorded. SCImago Journal Rankings (SJR) were found for each journal. RESULTS: There were no significant differences in publications by residents at each program (p > 0.05). Faculty with 10+ years of on staff, had significantly more publications than those with less than 10 years (p < 0.01). Programs with increased resident research time did not consistently produce publications with higher SJR than those without dedicated research time. CONCLUSIONS: Increased dedicated resident research time did not increase resident publication rates or lead to publications with higher SJR.

Is It Safe to Prep the External Fixator In Situ During Second-Stage Pilon Surgical Treatment?

OBJECTIVE: To evaluate the infection rate of our protocol of prepping the external fixator in situ during definitive second-stage pilon fracture open reduction internal fixation. DESIGN: Retrospective clinical investigation. SETTING: Academic Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Out of 229 patients with distal tibia fractures presenting to our institution from 1999 to 2014, 100 were treated in a 2-stage fashion utilizing this protocol. INTERVENTION: Prepping the external fixator into the surgical field during the second-stage/definitive open reduction internal fixation procedure. MAIN OUTCOME MEASUREMENT: The rates of deep and superficial infections after definitive fixation. RESULTS: The deep infection rate was 13%, and the superficial infection rate was 11%. CONCLUSIONS: Infection rates using this protocol are comparable to previously reported infection rates for two-stage surgical treatment of pilon fractures. This protocol provides the treating surgeon information about an alternative method to streamline definitive fixation. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Suture Button Fixation Versus Syndesmotic Screws in Supination-External Rotation Type 4 Injuries: A Cost-Effectiveness Analysis.

BACKGROUND: In stress-positive, unstable supination-external rotation type 4 (SER IV) ankle fractures, implant selection for syndesmotic fixation is a debated topic. Among the available syndesmotic fixation methods, the metallic screw and the suture button have been routinely compared in the literature. In addition to strength of fixation and ability to anatomically restore the syndesmosis, costs associated with implant use have recently been called into question. PURPOSE: This study aimed to examine the cost-effectiveness of the suture button and determine whether suture button fixation is more cost-effective than two 3.5-mm syndesmotic screws not removed on a routine postoperative basis. STUDY DESIGN: Economic and decision analysis; Level of evidence, 2. METHODS: Studies with the highest evidence levels in the available literature were used to estimate the hardware removal and failure rates for syndesmotic screws and suture button fixation. Costs were determined by examining the average costs for patients who underwent surgery for unstable SER IV ankle fractures at a single level-1 trauma institution. A decision analysis model that allowed comparison of the 2 fixation methods was developed. RESULTS: Using a 20% screw hardware removal rate and a 4% suture button hardware removal rate, the total cost for 2 syndesmotic screws was US$20,836 and the total effectiveness was 5.846. This yielded a total cost of $3564 per quality-adjusted life-year (QALY) over an 8-year time period. The total cost for suture button fixation was $19,354 and the total effectiveness was 5.904, resulting in a total cost of $3294 per QALY over the same time period. A sensitivity analysis was then conducted to assess suture button fixation costs as well as screw and suture button hardware removal rates. Other possible treatment scenarios were also examined, including 1 screw and 2 suture buttons for operative fixation of the syndesmosis. To become more cost-effective, the screw hardware removal rate would have to be reduced to less than 10%. Furthermore, fixation with a single suture button continued to be the dominant treatment strategy compared with 2 suture buttons, 1 screw, and 2 screws for syndesmotic fixation. CONCLUSION: This cost-effectiveness analysis suggests that for unstable SER IV ankle fractures, suture button fixation is more cost-effective than syndesmotic screws not removed on a routine basis. Suture button fixation was a dominant treatment strategy, because patients spent on average $1482 less and had a higher quality of life by 0.058 QALYs compared with patients who received fixation with 2 syndesmotic screws. Assuming that functional outcomes and failure rates were equivalent, screw fixation only became more cost-effective when the screw hardware removal rate was reduced to less than 10% or when the suture button cost exceeded $2000. In addition, fixation with a single suture button device proved more cost-effective than fixation with either 1 or 2 syndesmotic screws.

Percutaneous retrograde posterior column acetabular fixation: is the sciatic nerve safe? A cadaveric study.

OBJECTIVES: The purpose of this cadaveric study was to determine the proximity of the neurologic structures to the path of the screw inserted percutaneously into the ischial tuberosity. DESIGN: Cadaver study. INTERVENTION: Ten screws were inserted in 10 limbs (5 cadavers) under fluoroscopic guidance. Dissection was then performed to expose the head of the screw and was extended laterally to expose the sciatic nerve, the posterior cutaneous nerve of the thigh, and its inferior cluneal branches. MAIN OUTCOME MEASURE: The distance from the screw head to the sciatic nerve, posterior cutaneous nerve of the thigh, and the inferior cluneal nerves. RESULTS: The distance from the center of the screw head to the sciatic nerve averaged 58 mm (range, 40-70 mm). The average distance between the screw head and the posterior cutaneous nerve of the thigh was 42 mm (range, 30-60 mm). The inferior cluneal branches were the closest to the path of the screw with an average distance of 3.5 mm in 6 specimens (range, 1-6 mm) and were injured by the screw in 3 and could not be located in another specimen. CONCLUSIONS: The sciatic nerve and the posterior cutaneous nerve of the thigh appear to be safe during retrograde percutaneous screw fixation of a posterior column acetabular fracture through a central entry point in the ischial tuberosity. However, the inferior cluneal nerves that are responsible for the cutaneous sensitivity of the lower half of the gluteal region are at risk of injury.

Distal humerus atrophic nonunion in a child with osteogenesis imperfecta.

UNLABELLED: Atrophic nonunion of the distal humerus in children with osteogenesis imperfecta is a vexing and disabling problem. Traditional treatments, including casting, intramedullary nailing, plating and bone grafting have not been universally successful. We report on a case of successful treatment of one atrophic nonunion of the distal humerus in ad 2 year 10 month old child with type III OI who had failed more traditional treatments. The treatment used a combination of telescoping intramedullary nails, locking plate fixation and bone morphogenic protein. LEVEL OF EVIDENCE: Level IV.

A paradigm shift in the surgical reconstruction of extra-articular distal humeral fractures: single-column plating.

OBJECTIVES: The study aimed (1) to examine if there are equivalent results in terms of union, alignment and elbow functionally comparing single- to dual-column plating of AO/OTA 13A2 and A3 distal humeral fractures and (2) if there are more implant-related complications in patients managed with bicolumnar plating compared to single-column plate fixation. DESIGN: This was a multi-centred retrospective comparative study. SETTING: The study was conducted at two academic level 1 trauma centres. PATIENTS/PARTICIPANTS: A total of 105 patients were identified to have surgical management of extra-articular distal humeral fractures Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 13A2 and AO/OTA 13A3). INTERVENTION: Patients were treated with traditional dual-column plating or a single-column posterolateral small-fragment pre-contoured locking plate used as a neutralisation device with at least five screws in the short distal segment. MAIN OUTCOME MEASUREMENTS: The patients' elbow functionality was assessed in terms of range of motion, union and alignment. In addition, the rate of complications between the groups including radial nerve palsy, implant-related complications (painful prominence and/or ulnar nerve neuritis) and elbow stiffness were compared. RESULTS: Patients treated with single-column plating had similar union rates and alignment. However, single-column plating resulted in a significantly better range of motion with less complications. CONCLUSIONS: The current study suggests that exposure/instrumentation of only the lateral column is a reliable and preferred technique. This technique allows for comparable union rates and alignment with increased elbow functionality and decreased number of complications.

Outcomes following distal humeral fracture fixation with an extensor mechanism-on approach.

BACKGROUND: Distal humeral fractures have traditionally been managed with surgical approaches that disrupt the extensor mechanism. We hypothesized that an extensor mechanism-on approach for operative fixation of distal humeral fractures with parallel or orthogonal plate constructs would allow excellent healing, a motion arc of the elbow exceeding 100°, and maintenance of extensor mechanism strength. METHODS: Distal humeral open reduction and internal fixation (ORIF) was performed with either orthogonal or parallel plate constructs in seventy-nine elbows. Thirty-seven elbows were fixed via an extensor mechanism-on surgical approach, and twenty-four of them were available for additional evaluation. Radiographs as well as MEPI (Mayo Elbow Performance Index), DASH (Disabilities of the Arm, Shoulder and Hand), and SF-36 (Short Form-36) scores were obtained. RESULTS: All thirty-seven fractures healed primarily. Three elbows underwent later release because of stiffness. The median arc of elbow motion was 126° (range, 60° to 141°). The mean MEPI was 91.5 points and the mean DASH score was 15.9 points, indicating excellent scores with mild impairment. The median percent loss of triceps strength was 10% (range, 0% to 49%) compared with the contralateral, normal elbow. CONCLUSIONS: Open treatment of distal humeral fractures with an extensor mechanism-on approach results in excellent healing, a mean elbow flexion-extension arc exceeding 100°, and maintenance of 90% of elbow extension strength compared with that of the contralateral, normal elbow.

Distal Humeral Fracture Fixation with an Extensor Mechanism-on Approach.

INTRODUCTION: Open treatment of extra-articular and intra-articular distal humeral fractures can be effectively accomplished through an extensor mechanism-on approach. STEP 1 PREOPERATIVE PLANNING: Assess all images for multiplane fracture lines involving the capitellum or trochlea. STEP 2 OPERATIVE SETUP: Verify with fluoroscopy that the patient and arm positions allow for adequate imaging of the distal part of the humerus. STEP 3 SURGICAL APPROACH: Perform medial and lateral arthrotomies posterior to the collateral ligament complexes and excise the intra-articular fat pad and posterior aspect of the capsule. STEP 4 FRACTURE REDUCTION AND PROVISIONAL FIXATION: Reduce the distal humeral fragments anatomically under direct visualization posteriorly and indirectly with fluoroscopy using the intact sigmoid notch as a template for reduction. STEP 5 DEFINITIVE FIXATION: Place multiple screws distally through the plates medially and laterally; each screw should be of maximal length and engage the opposite column. STEP 6 WOUND CLOSURE AND POSTOPERATIVE MANAGEMENT: Remove the dressing on postoperative day two and begin full active-assisted elbow range of motion and grip-strengthening therapy program. RESULTS: In our series of thirty-seven patients12, all fractures healed primarily with a median motion arc of 126° (range, 60° to 141°). The median triceps strength loss was 10% (range, 0% to 49%). WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

Evaluation of popliteal artery injury risk with locked lateral plating of the tibial plateau.

OBJECTIVES: This study was undertaken to determine if there is increased likelihood of popliteal artery injury as one places a fixed-angle lateral proximal tibia locking plate with posterior plate lift off and or anterior plate translation from the ideal position. METHODS: A Synthes (Synthes USA, West Chester, PA) 3.5-mm and 4.5-mm lateral proximal tibia locking plate was placed consecutively on each of six specimens in the straight lateral (SL) position. Screw position with respect to the medial cortex was recorded as well as the distance of the posterior most screw tip to the popliteal artery. Next a 3-mm shim was placed under the posterior edge of the same plate to mimic posterior plate lift off (LO) followed by placement of a 6-mm shim. The same experiment was repeated with the plate translated 5 mm anteriorly (AT). RESULTS: The popliteal artery was injured in zero of six specimens using the 3.5-mm plate. The popliteal artery was injured in six of six specimens using the 4.5-mm plate in the 5-mm AT 6-mm LO position, five of six with 5-mm AT and 3-mm LO, two of six with only 5-mm AT, four of six with SL and 6-mm LO, two of six with SL and 3-mm LO, and zero of six with SL. CONCLUSION: The Synthes 4.5-mm plate can put the popliteal artery at risk with as little as 3-mm posterior liftoff in the intended straight lateral position or with 5-mm anterior plate translation with no posterior liftoff. Therefore, placement of the 4.5-mm plate in the proper position and confirmation of its position with a true lateral radiograph is paramount to avoid injury to the popliteal artery.

Functional outcomes of Denis zone III sacral fractures treated nonoperatively.

OBJECTIVES: The purpose of this study is to report the outcomes of nonoperative treatment in patients with Denis Zone III sacral fractures at a minimum of 2 years follow up. DESIGN: Retrospective review of prospectively collected data of a consecutive series of patients. SETTING: Level I trauma center. PATIENTS: A consecutive series of 15 patients (15-47 years old) with Denis Zone III sacral fractures treated nonoperatively from 1997 to 2002 was studied. Eleven patients were available for follow-up questionnaires; nine participated in a physical examination. Time to final follow up averaged 43 months (range, 25-67 months). INTERVENTION: Demographic data; mechanism of injury; injury-specific assessment of bowel, bladder, and sexual function; physical examination; and fracture pattern were collected from a prospectively collected database. MAIN OUTCOME MEASUREMENTS: At a minimum of 2-year follow up, evaluation of SF-36 scores, Roland Morris back pain questionnaire, and Gibbons classification was conducted. RESULTS: All fractures healed. Six patients had a postinjury increase in kyphosis (range, 1 degrees -17 degrees ) without a correlation to final outcomes. Mean SF-36 scores were all uniformly lower than the normalized general population and were biased by frequent associated injuries. Final Roland-Morris scores averaged 3.3 +/- 3.3. Gibbons classification scores initially averaged 2 +/- 1.2 and decreased to 1.5 +/- 0.8, each within their standard deviations. Eight had residual bowel, bladder, and/or sexual dysfunction. CONCLUSIONS: Nonoperative treatment of Denis Zone III sacral fractures yields consistent healing. Despite improvement in initial neurologic deficits, residual complaints were common.

Distal tibia nonunions.

Although tibia metaphyseal nonunion is rare, its treatment is often complex. The merits of related management techniques are discussed. These techniques include: intramedullary nailing, fine wire fixation, and blade plate reconstruction, which is the method preferred by the authors.

The radiographic acromiohumeral interval is affected by arm and radiographic beam position.

OBJECTIVE: The objective was to determine whether arm and radiographic beam positional changes affect the acromiohumeral interval (AHI) in radiographs of healthy shoulders. MATERIALS AND METHODS: Controlling for participant's height and position as well as radiographic beam height and angle, from 30 right shoulders of right-handed males without shoulder problems four antero-posterior (AP) radiographic views each were obtained in defined positions. Three independent, blinded physicians measured the AHI to the nearest millimeter in 120 randomized radiographs. Mean differences between measurements were calculated, along with a 95% confidence interval. RESULTS: Controlling for observer effect, there was a significant difference between AHI measurements on different views (p< 0.01). All pair-wise differences were statistically significant after adjusting for multiple comparisons (all p values<0.01). CONCLUSIONS: Even in healthy shoulders, small changes in arm position and radiographic beam orientation affect the AHI in radiographs.

Anterior plate supplementation increases ankle arthrodesis construct rigidity.

BACKGROUND: The success of ankle arthrodesis for the treatment of post-traumatic ankle arthritis depends on achieving and maintaining rigid fixation of the prepared tibiotalar interface. The purpose of this study was to examine the biomechanical effect of anterior plate supplementation of a popular three-screw fusion construct. METHODS: Six fresh-frozen cadaver ankles were prepared and instrumented with three partially threaded screws compressing the tibiotalar interface. Testing was done with and without supplementary anterior plate fixation under three different decoupled loading conditions: plantarflexion/dorsiflexion, inversion/eversion, and rotation. Motion at the tibiotalar interface was recorded. RESULTS: Anterior plating increased construct stiffness by a factor of 3.5, 1.9, and 1.4 for the sagittal, coronal, and torsion modes, respectively. Less motion occurred at the tibiotalar interface in all to the three different loading conditions (p = 0.031) with plate supplementation. CONCLUSIONS: Compared to screws alone, anterior plate supplementation increases construct rigidity and decreases micromotion at the ankle fusion interface.

Interobserver and intraobserver reliability of two classification systems for intra-articular calcaneal fractures.

BACKGROUND: For a fracture classification to be useful it must provide prognostic significance, interobserver reliability, and intraobserver reproducibility. Most studies have found reliability and reproducibility to be poor for fracture classification schemes. The purpose of this study was to evaluate the interobserver and intraobserver reliability of the Sanders and Crosby-Fitzgibbons classification systems, two commonly used methods for classifying intra-articular calcaneal fractures. METHODS: Twenty-five CT scans of intra-articular calcaneal fractures occurring at one trauma center were reviewed. The CT images were presented to eight observers (two orthopaedic surgery chief residents, two foot and ankle fellows, two fellowship-trained orthopaedic trauma surgeons, and two fellowship-trained foot and ankle surgeons) on two separate occasions 8 weeks apart. On each viewing, observers were asked to classify the fractures according to both the Sanders and Crosby-Fitzgibbons systems. Interobserver reliability and intraobserver reproducibility were assessed with computer-generated kappa statistics (SAS software; SAS Institute Inc., Cary, North Carolina). RESULTS: Total unanimity (eight of eight observers assigned the same fracture classification) was achieved only 24% (six of 25) of the time with the Sanders system and 36% (nine of 25) of the time with the Crosby-Fitzgibbons scheme. Interobserver reliability for the Sanders classification method reached a moderate (kappa = 0.48, 0.50) level of agreement, when the subclasses were included. The agreement level increased but remained in the moderate (kappa = 0.55, 0.55) range when the subclasses were excluded. Interobserver agreement reached a substantial (kappa = 0.63, 0.63) level with the Crosby-Fitzgibbons system. Intraobserver reproducibility was better for both schemes. The Sanders system with subclasses included reached moderate (kappa = 0.57) agreement, while ignoring the subclasses brought agreement into the substantial (kappa = 0.77) range. The overall intraobserver agreement was substantial (kappa = 0.74) for the Crosby-Fitzgibbons system. CONCLUSIONS: Although intraobserver kappa values reached substantial levels and the Crosby-Fitzgibbons system generally showed greater agreement, we were unable to demonstrate excellent interobserver or intraobserver reliability with either classification scheme. While a system with perfect agreement would be impossible, our results indicate that these classifications lack the reproducibility to be considered ideal.