Complications of Morbid Obesity in the Treatment of Acetabular Fractures: Re-evaluating Outcomes a Decade Later.

OBJECTIVES: To determine the rate of perioperative complications between morbidly obese (body mass index greater than 40 kg/m2) and nonmorbidly obese patients undergoing operative treatment of acetabular fractures across 2 periods (2000-2005 and 2012-2019). DESIGN: Retrospective, case-control study. SETTING: Level I academic trauma center. PATIENTS: Four hundred thirty-five consecutive patients from 2000 to 2005 and 216 consecutive patients from 2012 to 2019 with acetabular fractures treated by a single surgeon. INTERVENTION: Operative fixation of acetabular fracture. MAIN OUTCOME MEASUREMENTS: Outcome variables include positioning time, operative time, estimated blood loss, hospital stay, wound complications, and perioperative complications. RESULTS: Twenty-eight morbidly obese and 188 nonmorbidly obese patients from 2012 to 2019, as well as 41 morbidly obese patients and 394 nonmorbidly obese patients from 2000 to 2005 were included in the study. The relative risk (RR) of wound complications between 2012 and 2019 groups was significantly higher for morbidly obese patients (RR = 5.31, P = 0.009) but has decreased significantly for morbidly obese patients between 2000-2005 and 2012-2019 (RR = 0.31, P = 0.017). The rate of total perioperative complications was similar between morbidly obese and nonmorbidly obese groups from 2012 to 2019 (21% vs. 8%, P = 0.230). For morbidly obese patients, the rate of total perioperative complications decreased significantly between 2000-2005 and 2012-2019 (63% vs. 21% P = 0.010). CONCLUSION: Acetabular fracture surgery can be safely performed in morbidly obese patients. Although obesity remains a significant risk factor for wound complications, the risk for morbidly obese patients has decreased significantly since our initial investigation because of adaptations to surgical techniques and surgeon's experience. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Tibial Shaft and Pilon Fractures With Associated Syndesmotic Injury: A Matched Cohort Assessment.

OBJECTIVE: To determine the outcomes of pilon and tibial shaft fractures with syndesmotic injuries compared with similar fractures without syndesmotic injury. DESIGN: Retrospective case-control study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: All patients over a 5-year period (2012-2017) with tibial shaft or pilon fractures with a concomitant syndesmotic injury and a control group without a syndesmotic injury matched for age, OTA/AO fracture classification, and Gustilo-Anderson open fracture classification. INTERVENTION: Preoperative or intraoperative diagnosis of syndesmotic injury with reduction and fixation of both fracture and syndesmosis. MAIN OUTCOME MEASUREMENT: Rates of deep infection, nonunion, unplanned reoperation, and amputation in patients with a combined syndesmotic injury and tibial shaft or pilon fracture versus those without a syndesmotic injury. RESULTS: A total of 30 patients, including 15 tibial shaft and 15 pilon fractures, were found to have associated syndesmotic injuries. The matched control group comprised 60 patients. The incidence of syndesmotic injury in all tibial shaft fractures was 2.3% and in all pilon fractures was 3.4%. The syndesmotic injury group had more neurologic injuries (23.3% vs. 8.3% P = 0.02), more vascular injuries not requiring repair (30% vs. 15%, P = 0.13), and a higher rate compartment syndrome (6.7% vs. 0%, P = 0.063). Segmental fibula fracture was significantly more common in patients with a syndesmotic injury (36.7% vs. 13.3%, P = 0.04). Fifty percent of the syndesmotic injury group underwent an unplanned reoperation with significantly more unplanned reoperations (50% vs. 27.5%, P = 0.04). The syndesmotic group had a significantly higher deep infection rate (26.7% vs. 8.3% P = 0.047) and higher rate of amputation (26.7% vs. 3.3% P = 0.002) while the nonunion rate was similar (17.4% vs. 16.7% P = 0.85). CONCLUSIONS: Although syndesmotic injuries with tibial shaft or pilon fractures are rare, they are a marker of a potentially limb-threatening injury. Limbs with this combined injury are at increased risk of deep infection, unplanned reoperation, and amputation. The presence of a segmental fibula fracture should raise clinical suspicion to evaluate for syndesmotic injury. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Clamshell Osteotomy for Diaphyseal Malunion in Deformity Correction and Fracture Surgery.

Diaphyseal malunion poses a great challenge for the orthopedic surgeon, and an inundation of morbidity for the patient. Diaphyseal malunion can cause altered gait, adjacent joint osteoarthritis and body dissatisfaction. This problem is fraught with complications without surgical intervention. There is a myriad of options for the management of a diaphyseal malunion. The clamshell osteotomy was engendered to ameliorate the difficulty in managing this issue. This technique is a viable option to correct diaphyseal malunion about the femur and tibia. Recently, the indications of a clamshell osteotomy have been expanded to function as a derotational or shortening osteotomy.

Geriatric Acetabular Fractures and Femoral Head Protrusio: Methods of Fixation and the Option of Total Hip Arthroplasty.

SUMMARY: Currently, the literature is unclear regarding the optimal treatment algorithm for geriatric acetabular fractures. In a recent epidemiological study, 70% of all acetabular fractures in patients older than 65 years were classified as either associated both column or anterior column/posterior hemitransverse. Within the subset of these fractures, variants with significant femoral head protrusio, which is defined as the displacement of the femoral head medial to the ilioischial line, present with unique challenges. Goals of treatment in these cases should include surgical techniques that minimize the physiologic insult for the patient yet restore hip congruity and stability. "Fix and replace" is becoming an increasingly popular approach in the acute setting; however, its indications are not yet well-established. At our institution, we often favor open reduction and internal fixation alone as an effective and efficient way to treat the protrusio variant, even at the expense of protected weight-bearing. In the following article, we present a systematic approach for the management of geriatric acetabular fracture femoral head protrusio along with specific case examples.

Treatment of Distal Femur Fractures With the DePuy-Synthes Variable Angle Locking Compression Plate.

OBJECTIVES: To determine the failure rate of the DePuy-Synthes variable angle locking compression curved condylar plate (VA-LCP) and quantify failure modes. DESIGN: Retrospective review. SETTING: Level I Trauma Center. PATIENTS/PARTICIPANTS: One hundred thirteen patients with 118 OTA/AO classification 33A and 33C distal femoral fractures were included in the study. INTERVENTION: Internal fixation using only the DePuy-Synthes VA-LCP plate. MAIN OUTCOME MEASUREMENTS: Primary outcomes included mechanical failure rate of the DePuy-Synthes VA-LCP plate in open and closed fractures. Secondary outcomes included overall failure rate of treatment, risk factors for mechanical failure, and the specific location of failure: loss of fixation in the proximal segment, implant failure over the working length, or failure of locking screw fixation distally. RESULTS: There were 11 total failures (9.3%) in 118 fractures. Failure rates for the closed and open fracture groups were 5.4% and 15.9%, respectively. Twenty patients (16.9%) required reoperation to promote union. Open fractures (P = 0.00475), the presence of medial metaphyseal comminution (P = 0.037), the length of the zone of comminution (P = 0.037), and plate length (P = 0.0096) were significantly higher in those with implant failure. Most failures (63.6%) were in the working length of the implant. CONCLUSIONS: The use of the Synthes VA-LCP is a viable option in distal femoral fractures and has an acceptable failure rate and reoperation to promote union rate. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Delay in Hip Fracture Surgery Prolongs Postoperative Hospital Length of Stay but Does Not Adversely Affect Outcomes at 30 Days.

OBJECTIVES: To evaluate the association between the timing of hip fracture surgery with postoperative length of stay and outcomes. DESIGN: Retrospective review using the American College of Surgeons National Surgical Quality Improvement Program database. SETTING: National inquiry database incorporating 140 academic and private medical centers. PATIENTS: Seventeen thousand four hundred fifty-nine patients who underwent surgery for a hip fracture between 2006 and 2013 were identified from the National Surgical Quality Improvement Program database. INTERVENTION: Surgical management of hip fractures was performed at the discretion of participating surgeons. OUTCOME MEASURE: Thirty-day outcomes including postoperative length of stay, readmission rates, reoperation rates, complications, and mortality rates. RESULTS: Of the 17,459 patients, 4107 (23.5%) were operated on within 24 hours, 8740 (50.1%) within 24-48 hours, and 4612 (26.4%) more than 48 hours after hospital admission. Increased time to surgery was associated with longer postoperative hospital length of stay. Prolonged time to surgery did not adversely affect postoperative outcomes. CONCLUSIONS: Although a delay in the management of hip fractures is associated with an increase in postoperative hospital length of stay, 30-day postoperative outcomes are not adversely affected in patients undergoing hip fracture fixation. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors for Kidney Dysfunction With the Use of Gentamicin in Open Fracture Antibiotic Treatment.

OBJECTIVES: To evaluate all patients who received gentamicin for open fracture treatment and determine the incidence of, and risk factors for, kidney injury in this population. DESIGN: Retrospective, case control. SETTING: Single institution; Level 1 trauma center. PATIENTS/PARTICIPANTS: A retrospective chart review identified patients who received gentamicin for open fracture antibiotic treatment from January 2008 to December 2012. Overall, 371 patients met the inclusion criteria and were categorized into 2 groups using risk, injury, failure, loss of kidney function, and end-stage kidney disease criteria: normal kidney function (74.9%) versus abnormal kidney function (25.1%). INTERVENTION: Use of gentamicin in open fracture antibiotic treatment. MAIN OUTCOME MEASUREMENTS: Kidney function; injury and treatment characteristics (eg, mechanism of injury; Gustilo-Anderson classification; number of surgical debridements, timing of definitive wound coverage, and type of wound coverage); and patient information (eg, age, height, weight, and body mass index, tobacco use, diabetes mellitus, human immunodeficiency virus, hepatitis, and current chemotherapy treatment). RESULTS: Those with abnormal kidney function had lower baseline creatinine (P < 0.001) and higher injury severity scores (16.5 vs. 11.8, P < 0.001) and were more likely to require intensive care unit admission (P < 0.001) than the normal group. Female sex (P = 0.015), and higher weight (P = 0.004), ICU admission (P < 0.001), and use of CT contrasted imaging (P < 0.001) were independently associated with abnormal kidney function. Abnormal kidney function incidence also sharply increased with age. CONCLUSIONS: Females and heavier individuals are at-risk of kidney injury while receiving gentamicin. ICU admission and concurent CT contrasted imaging are strongly associated with kidney injury in patients receiving gentamicin for open fracture treatment, and gentamicin should be avoided in those >60 years of age. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Obesity in the Polytrauma Patient.

The rates of obesity continue to increase in the United States and the overall impact of obesity on health care spending and patient outcomes after trauma is considerable. The unique physiology of the obese places them at higher risk for complications, including infection, failure of fixation, nonunion, multiorgan failure, and death. These physiologic differences and overall patient size can make orthopedic care in obese patients with trauma more difficult, but appropriate initial resuscitation, careful preoperative planning, meticulous surgical technique, diligent postoperative medical management, and specialized rehabilitation give these patients their best opportunity for a good outcome.

Management of Pelvic and Acetabular Fractures in the Obese Patient.

Acetabular and pelvic ring injuries in obese patients are difficult to treat. Obese patients require great attention to detail during the trauma evaluation to prevent medical and anesthetic complications in the perioperative period. Radiographic evaluation is often compromised by modalities available and loss of resolution with plain film imaging. Patient positioning must be meticulous to ensure stability on the bed while allowing access to the operative site, preventing pressure necrosis, and minimizing ventilation pressure. Complications after surgical treatment are common and often due to infection and loss of fixation. Careful technique can mitigate but not prevent these complications.

Increasing Severity of Malnutrition Is Associated With Poorer 30-Day Outcomes in Patients Undergoing Hip Fracture Surgery.

OBJECTIVES: Low serum albumin levels (hypoalbuminemia) have classically been used to identify malnutrition. The effect of increasing severity of malnutrition on postoperative outcomes in patients undergoing hip fracture surgery has not been well delineated on a large scale. DESIGN: Retrospective. SETTING: Multicenter. PATIENT/PARTICIPANTS: A total of 12,373 patients undergoing hip fracture surgery from 2006 to 2013 National Surgery Quality Improvement Project data were identified. INTERVENTION: Patient demographic, comorbidity, and preoperative laboratory data and complication, reoperation, and readmission data were collected. MAIN OUTCOME MEASUREMENTS: Multivariate logistic regression was used to determine the effect of increasing severity of malnutrition on rates of 30-day postoperative complications, readmissions, and reoperations. RESULTS: A total of 12,373 hip fractures met inclusion criteria. A total of 6506 (52.6%) patients had normal albumin levels (albumin ≥3.5 g/dL), 3205 (25.9%) patients were mildly malnourished (albumin 3.1-3.49 g/dL), 2265 (18.3%) were moderately malnourished (albumin 2.4-3.1 g/dL), and 397 (3.2%) patients were severely malnourished (albumin <2.4 g/dL). Mean age was similar between the 4 cohorts (P < 0.001). Severe malnutrition was associated with a 2-fold increase in the odds of postoperative complications and mortality when compared with mild malnutrition (P < 0.001). Increasing severity of malnutrition was associated with significantly longer lengths of stay and higher odds of experiencing a related readmission (P < 0.001). CONCLUSIONS: Increasing severity of hypoalbuminemia is independently associated with poorer outcomes in the 30 days after hip fracture surgery. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objective Methodology to Assess Meaningful Research Productivity by Orthopaedic Residency Departments: Validation Against Widely Distributed Ranking Metrics and Published Surrogates.

The mission of any academic orthopaedic training program can be divided into 3 general areas of focus: clinical care, academic performance, and research. Clinical care is evaluated on clinical volume, patient outcomes, patient satisfaction, and becoming increasingly focused on data-driven quality metrics. Academic performance of a department can be used to motivate individual surgeons, but objective measures are used to define a residency program. Annual in-service examinations serve as a marker of resident knowledge base, and board pass rates are clearly scrutinized. Research productivity, however, has proven harder to objectively quantify. In an effort to improve transparency and better account for conflicts of interest, bias, and self-citation, multiple bibliometric measures have been developed. Rather than using individuals' research productivity as a surrogate for departmental research, we sought to establish an objective methodology to better assess a residency program's ability to conduct meaningful research. In this study, we describe a process to assess the number and quality of publications produced by an orthopaedic residency department. This would allow chairmen and program directors to benchmark their current production and make measurable goals for future research investment. The main goal of the benchmarking system is to create an "h-index" for residency programs. To do this, we needed to create a list of relevant articles in the orthopaedic literature. We used the Journal Citation Reports. This publication lists all orthopaedic journals that are given an impact factor rating every year. When we accessed the Journal Citation Reports database, there were 72 journals included in the orthopaedic literature section. To ensure only relevant, impactful journals were included, we selected journals with an impact factor greater than 0.95 and an Eigenfactor Score greater than 0.00095. After excluding journals not meeting these criteria, we were left with 45 journals. We performed a Scopus search over a 10-year period of these journals and created a database of articles and their affiliated institutions. We performed several iterations of this to maximize the capture of articles attributed to institutions with multiple names. Based off of this extensive database, we were able to analyze all allopathic US residency programs based on their quality research productivity. We believe this as a novel methodology to create a system by which residency program chairmen and directors can assess progress over time and accurate comparison with other programs.

Intraosseous Plating for the Management of Cortical Defects.

The management of fractures with segmental bone loss or abundant comminution on the far cortex is often complicated by deformity or frank hardware failure. Using plate constructs that rely on off-axis loading may not be sufficient to support the limb until healing occurs. There are a number of techniques to mitigate this problem, notably the use of intramedullary nails and bicolumnar plating of the fracture. These techniques are not always possible and do come with the biologic cost of additional surgery. In this article, the authors present a technique along with 2 case examples of using plates in an intraosseous location that was described by Dr Mast in his classic orthopaedic text. By placing these plates in the intramedullary space and then interdigitating fixation from the standard cortical plate, a rigid "I-beam" of fixation can be created to mitigate the eccentric loading placed on extraosseous plates. This technique is especially useful in situations in which intramedullary nails are precluded (comminuted intraarticular and some periprosthetic fractures).

Endosteal Substitution With an Intramedullary Rod in Fractures of the Femur.

BACKGROUND: Morbid obesity and segmental fracture/bone loss are challenging problems in the treatment of fractures and nonunions of the distal femur. The use of an intramedullary rod as an endosteal substitute for a deficient medial cortex along with a lateral locked plate is 1-tool to combat these problems. This article describes the technique used and its results at a single Level 1 trauma center. METHODS: Retrospective chart and radiographic review of all patients treated for acute fractures and nonunions of the distal femur using endosteal substitution with an intramedullary nail and a lateral locked plate. Fixation construct was determined at the surgeon's discretion and was strongly influenced by bone loss and patient body habitus. RESULTS: Seven of 8 acute fractures and 8 of 8 nonunions healed without an unplanned reoperation. There were no cases of secondary displacement after fixation, and only 1 unplanned reoperation in the study group. CONCLUSION: Endosteal substitution with an intramedullary rod and the use of a lateral locked plate provides the stability needed to allow bone healing under prolonged or supraphysiologic loads seen in morbid obesity or segmental bone loss. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Stability of the Syndesmosis After Posterior Malleolar Fracture Fixation.

BACKGROUND: We sought to define the rate of syndesmotic instability after anatomic reduction of the posterior malleolus when posterior stabilization of a trimalleolar or trimalleolar equivalent ankle fracture was chosen vs when a supine position and initially conservative management of the posterior elements was chosen. METHODS: The types of syndesmotic and posterior malleolar fixation used to treat adult patients with ankle fractures involving the posterior malleolus at our level I trauma center were retrospectively assessed (N = 198). Specifically, both bimalleolar and trimalleolar fractures were included. Exclusion criteria included pilon fractures, trimalleolar fractures with Chaput fragments, and neurologic injury. Demographics, fracture classification, initial operative position, medial clear space, and posterior malleolar fragment size were recorded for each fracture. RESULTS: In total, 151 patients (76.3%) were initially positioned supine, 27.2% of whom had syndesmotic instability requiring operative stabilization. Almost 25% of supine patients also underwent posterior malleolar stabilization for posterior instability. Overall, 73 (48.3%) patients who were initially treated in the supine position needed some form of additional stabilization. Forty-seven patients (23.7%) were initially positioned prone. Syndesmotic stability was restored in 97.9% of these patients. This 2.1% rate of instability vastly differs from the 13-fold higher syndesmotic instability rate observed in the supine group ( P < .001). CONCLUSION: Our data demonstrate that the rate of syndesmotic instability was reduced in trimalleolar and trimalleolar equivalent fractures when prone positioning and direct fixation of the posterior malleolus were first performed. Using traditional preoperative estimates of posterior stability to determine the need for posterior malleolar fixation may be inadequate since almost a quarter of patients treated supine received posterior stabilization. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Extent and Morbidity of Lateralization of a Trochanteric Fixation Nail Blade.

This study examined the incidence and risk factors associated with lateral helical blade migration and trochanteric pain with the trochanteric fixation nail. A retrospective review was performed of 141 cases of pertrochanteric femur fracture treated with a trochanteric fixation nail at a level I trauma center over a period of 42 months. Exclusion criteria included follow-up of less than 60 days, preexisting osteonecrosis of the femoral head, and prophylactic trochanteric fixation nail treatment. Patient demographics, operative findings, and radiographic findings were recorded. Medical records were reviewed to identify symptomatic hardware. Overall, 27 patients (19.1%) were symptomatic, and 3 (2.1%) required revision surgery for blade prominence. Of the patients, 42 (30%) had lateralization of greater than 1 cm, and 16 of these (38.1%) were symptomatic (P<.02). A risk factor for lateralization was AO classification, with 46.1% of type A2 fractures showing lateralization of greater than 1 cm. The quality of calcar reduction nearly reached statistical significance, and 44.8% of patients who had inadequate reduction had lateralization of greater than 1 cm compared with 26.4% of patients who had adequate reduction (P=.054). Lateralization of greater than 1 cm was directly associated with the presence of symptoms (P<.001) and removal of hardware because of trochanteric pain (P=.007). Multivariate analysis showed that increasing tip-apex distance, inadequate calcar reduction, and greater fracture severity were predictive of excessive lateralization of greater than 1 cm. Nearly 20% of patients had lateral hip pain associated with cephalomedullary fixation. Final lateralization of the helical blade of greater than 1 cm was a very strong predictor of symptoms. During preoperative counseling, surgeons should caution patients about this relatively frequent and likely underreported complication. [Orthopedics. 2017; 40(5):e886-e891.].

Lower Extremity Fracture Reduction: Tips, Tricks, and Techniques So That You Leave the Operating Room Satisfied.

It can be challenging for surgeons to obtain proper alignment and to create stable constructs for the maintenance of many lower extremity fractures until union is achieved. Whether lower extremity fractures are treated with plates and screws or intramedullary nails, there are numerous pearls that may help surgeons deal with these difficult injuries. Various intraoperative techniques can be used for lower extremity fracture reduction and stabilization. The use of several reduction tools, tips, and tricks may facilitate the care of lower extremity fractures and, subsequently, improve patient outcomes.

The effects of obesity in orthopaedic care.

Obesity is a costly, difficult, and increasingly prevalent challenge facing orthopaedic care. It adds complexity to caring for patients throughout all types and stages of treatment in all orthopaedic subspecialties. There are medical complications to mitigate, anesthetic challenges to meet, and surgical complexities to overcome. The financial implications of treating patients who are obese will continue to challenge surgeons, especially as new payment models are encountered. Research continues to provide more evidence of the unfavorable effects of obesity on outcomes after various orthopaedic procedures. An increasing awareness of the effects of obesity on patients undergoing orthopaedic procedures and educating orthopaedic providers on methods of countering the challenges associated with obesity should ultimately benefit both the provider and the patient.

Prevalence of post-traumatic osteoarthritis in morbidly obese patients after acetabular fracture fixation.

BACKGROUND: Morbid obesity and osteoarthritis are conditions that place a significant burden on the US healthcare system. Acetabular fracture is a known cause of post-traumatic osteoarthritis (PTOA) and morbid obesity contributes to the development of osteoarthritis. This study aimed to determine the prevalence of PTOA in morbidly obese patients who underwent acetabular fracture fixation. METHODS: A retrospective review of morbidly obese patients who underwent acetabular fracture repair was performed. Patient information included demographics, body mass index, patient age, and length of hospital stay. The prevalence of PTOA was determined by radiographic review with a minimum follow-up of 4 years. RESULTS: There were 299 acetabular fracture fixations performed from 2007 to 2012 at our institution and 39 of these were in morbidly obese patients. One patient was excluded due to preoperative osteoarthritis of the hip. Of the 38 patients, 26 (68%) went on to develop PTOA after acetabular fracture fixation. This is significantly higher than previously reported rates of PTOA after acetabular fracture fixation. There was a higher rate of PTOA in morbidly obese males compared with females (P=0.008). CONCLUSION: Morbid obesity appears to pose a significantly increased risk for the development of PTOA after fixation of acetabular fractures.

Modifier 22 for acetabular fractures in morbidly obese patients: does it affect reimbursement?

BACKGROUND: Modifier 22 in the American Medical Association's Current Procedural Terminology (CPT®) book is a billing code for professional fees used to reflect an increased amount of skill, time, and work required to complete a procedure. There is little disagreement that using this code in the setting of surgery for acetabulum fractures in the obese patient is appropriate; however, to our knowledge, the degree to which payers value this additional level of complexity has not been determined. QUESTIONS/PURPOSES: We asked whether (1) the use of Modifier 22 increased reimbursements in morbidly obese patients and (2) there was any difference between private insurance and governmental payer sources in treatment of Modifier 22. METHODS: Over a 4-year period, we requested immediate adjudication with payers when using Modifier 22 for morbidly obese patients with acetabular fractures. We provided payers with evidence of the increased time and effort required in treating this population. Reimbursements were calculated for morbidly obese and nonmorbidly obese patients. Of the 346 patients we reviewed, 57 had additional CPT® codes or modifiers appended to their charges and were excluded, leaving 289 patients. Thirty (10%) were morbidly obese and were billed with Modifier 22. Fifty-three (18%) were insured by our largest private insurer and 69 (24%) by governmental programs (Medicare/Medicaid). Eight privately insured patients (15%) and seven governmentally insured patients (10%) were morbidly obese and were billed with Modifier 22. For our primary question, we compared reimbursement rates between patients with and without Modifier 22 for obesity within the 289 patients. We then performed the same comparison for the 53 privately insured patients and the 69 governmentally insured patients. RESULTS: Overall, there was no change in mean reimbursement when using Modifier 22 in morbidly obese patients, compared to nonmorbidly obese patients (USD 2126 versus USD 2149, p < 0.94). There was also no difference in mean reimbursements with Modifier 22 in either the privately insured patients (USD 3445 versus USD 2929, p = 0.16) or the governmentally insured patients (USD 1367 versus USD 1224, p=0.83). CONCLUSIONS: Despite educating payers on the increased complexity and time needed to deal with morbidly obese patients with acetabular fractures, we have not seen an increased reimbursement in this challenging patient population. This could be a disincentive for many centers to treat these challenging injuries. Further efforts are needed to convince government payer sources to increase compensation in these situations. LEVEL OF EVIDENCE: Level IV, economic and decision analyses. See Instructions for Authors for a complete description of levels of evidence.