Intramedullary Nailing of Periarticular Fractures

Plate fixation has historically been the preferred surgical treatment method for periarticular fractures of the lower extremity. This trend has stemmed from difficulties with fracture reduction and concerns of inadequate fixation with intramedullary implants. However, the body of literature on management of periarticular fractures of the lower extremities has expanded in recent years, indicating that intramedullary nailing of distal femur, proximal tibia, and distal tibia fractures may be the preferred method of treatment in some cases. Intramedullary nailing reliably leads to excellent outcomes when performed for appropriate indications and when potential difficulties are recognized and addressed

Costs and Complications of Single Stage Fixation Versus Two-Stage Treatment of Select Bicondylar Tibial Plateau Fractures

Objectives: To determine the differences in costs and complications in patients with bicondylar tibial plateau (BTP) fractures treated with one stage definitive fixation compared to two stage fixation following initial spanning external fixation. Design: Retrospective cohort study Setting: Level one trauma center Patients/Participants: Patients with OTA 41-C (Schatzker 6) treated with open reduction internal fixation (ORIF). Intervention: Definitive treatment with ORIF either acutely (one stage) or delayed following initial spanning external fixation (two stage). Main Outcome Measures: Wound healing complications, implant costs, hospital charges, PROMIS outcome measures. Results: 105 patients were identified over a three-year period, of which 52 met inclusion criteria. There were 28 patients in the One-Stage group and 24 patients in the Two-Stage group. Mean follow-up was 21.8 months, and 87% of patients had at least 12 months follow-up. The mean number of days to definitive fixation was 1.2 in the One-Stage group and 7.8 in the Two-Stage group. There were no differences between groups with respect to wound healing or any other surgery-related complications. Functional outcomes (PROMIS) were similar between groups. Mean implant cost in the Two-Stage group was $10,821 greater than the One-Stage group, mostly due to the costs of external fixation. Median hospital inpatient charges in the Two-Stage group exceeded the One-Stage group by over$68,000 for all BTP fractures and by $61,000 for isolated BTP fractures. Conclusions: Early single stage treatment of BTP fractures is cost effective, and is not associated with a higher complication rate than two stage treatment in appropriately selected patients. Level of Evidence: Level III- Retrospective cohort stud

Locking Plate Fixation in a Series of Bicondylar Tibial Plateau Fractures Raises Treatment Costs Without Clinical Benefit

Objectives: To compare outcomes and costs between locking and nonlocking constructs in the treatment of bicondylar tibial plateau (BTP) fractures. Design: Retrospective cohort study. Setting: Level 1 academic trauma center. Patients: All patients that presented with complete articular, BTP fractures (AO/OTA 41-C and Schatzker 6) between 2013-2015 were screened (n=112). Patients treated with a mode of fixation other than plate-and-screw were excluded. 56 patients with a minimum follow-up of 12 months were included in the analysis. Intervention: Operative fixation of BTP fractures with locking (n=29) or nonlocking (n=27) implants. Main outcome measurements: Implant cost, patient reported outcomes (PROMIS physical function and pain interference), clinical, and radiographic outcomes. Results: There were no differences between the two groups with respect to demographics, injury characteristics, radiographic outcomes (change in alignment) or clinical outcomes (PROMIS, reoperation, nonunion, infection). Implant costs were significantly greater in the locking group compared to the nonlocking group (mean L $4453; mean NL$2569; p<0.01). Conclusions: This study demonstrated improved value of treatment (less cost with no difference in clinical outcome) with nonlocking implants for bicondylar tibial plateau fractures when dual plate fixation strategies are performed. Level of Evidence: Therapeutic III. See Instructions for Authors for a complete description of levels of evidence

Objective metric of energy absorbed in tibial plateau fractures corresponds well to clinician assessment of fracture severity

Objectives Determine the agreement between subjective assessments of fracture severity and an objective CT-based metric of fracture energy in tibial plateau fractures. Methods Six fellowship-trained orthopaedic trauma surgeons independently rank-ordered 20 tibial plateau fractures in terms of severity based upon AP and lateral knee radiographs. A CT-based image analysis methodology was used to quantify the fracture energy, and agreement between the surgeons’ severity rankings and the fracture energy metric was tested by computing their concordance, a statistical measure that estimates the probability that any two cases would be ranked with the same ordering by two different raters or methods. Results Concordance between the six orthopaedic surgeons ranged from 82% to 93%, and concordance between surgeon severity rankings and the computed fracture energy ranged from 73% to 78%. Conclusions There is a high level of agreement between experienced surgeons in their assessments of tibial plateau fracture severity, and a slightly lower agreement between the surgeon assessments and an objective CT-based metric of fracture energy. Taken together, these results suggest that experienced surgeons share a similar understanding of what makes a tibial plateau fracture more or less severe, and an objective CT-based metric of fracture energy captures much but not all of that information. Further research is ongoing to characterize the relationship between surgeon assessments of severity, fracture energy, and the eventual clinical outcomes for patients with fractures of the tibial plateau

Predictors of Improved Early Clinical Outcomes After Elective Implant Removal

Objectives: To determine preoperative factors predictive of improvement in pain and function after elective implant removal. We hypothesized that patients undergoing orthopaedic implant removal to relieve pain would have significant improvements in both pain and function. Design: Prospective cohort study. Setting: Level I Trauma Center. Patients/Participants: One hundred eighty-nine patients were enrolled after consenting for orthopaedic implant removal to address residual pain. One hundred sixty-three were available for 3-month follow-up. Main Outcome Measurement: Preoperative and postoperative outcome measures including Patient Reported Outcomes Measurement Information System (PROMIS) scores were compared. Preoperative scores, surgeon prediction of pain improvement, and palpable implants were analyzed as predictors of outcomes. Results: Median PROMIS physical function and pain interference scores and visual analogue scale significantly improved by 6, 8, and 2 points, respectively (P < 0.001 for all). Worse preinjury scores predicted improvement in respective postoperative outcomes (P < 0.001 for all). Surgeon prediction of improvement was associated with improved PROMIS pain interference (P = 0.005), patient subjective assessment of pain improvement (P = 0.03), and subjective percent of pain remaining at 3 months (P = 0.02). Implant superficial palpability was not predictive for any postoperative outcomes. Conclusions: Although the primary indication for implant removal in this population was pain relief, many patients also had a clinically relevant improvement in physical function. In addition, patients who start with worse global indices of pain and function are more likely to improve after implant removal. This suggests that implant-related pain directly contributes to global dysfunction

Potential Benefits of Limited Clinical and Radiographic Follow-up After Surgical Treatment of Ankle Fractures

Introduction: Ankle fractures are one of the most prevalent musculoskeletal injuries, with a significant number requiring surgical treatment. Postoperative complications requiring additional interventions frequently occur during the early postoperative period. We hypothesize that there is a limited need for routine clinical and radiographic follow-up once the fracture is deemed healed. Methods: IRB approval was obtained at four academic trauma centers. A retrospective chart review was done to identify adults with healed unimalleolar and bimalleolar ankle fractures treated surgically with at least 12 months of follow-up. Based on postoperative radiographs, changes in fracture alignment and implant position from radiographic union to final follow-up were documented. The average reimbursement for a final follow-up clinic visit and a set of ankle radiographs were estimated. Results: A total of 140 patients met inclusion criteria. The mean age at injury was 49.5 years, and 67.9% of patients were female. The mean time to healing was 82.2 days (±33.5 days). After radiographic healing, one patient had radiographic changes but was asymptomatic and full weight bearing at their final follow-up. On average, our institution was reimbursed $46 to$49 for a follow-up clinic visit and $364 to$497 for a set of ankle radiographs. Conclusion: Given the average time to healing, there is limited utility in routine radiographic and clinical follow-up beyond 16 weeks in asymptomatic patients. In our series, this would result in a savings of $950 to$1,200 per patient. However, after ankle fractures were deemed healed, 0.7% patients had radiographic evidence of a change in implant position. Documenting this change did not modify the immediate course of fracture treatment. Surgeons will need to balance the need for routine follow-up with the potential economic benefits in reducing costs to the healthcare system

Correction to: Cluster identification, selection, and description in Cluster randomized crossover trials: the PREP-IT trials

An amendment to this paper has been published and can be accessed via the original article

A Liberal Transfusion Strategy Leads to Higher Infection Rates, ORthopaedic Trauma and Anemia: Conservative vs. Liberal Transfusion Strategy (ORACL), a Prospective Randomized Study 30 Day Inpatient Complications

Purpose: There is ongoing debate what level of anemia should be used as a transfusion trigger for asymptomatic trauma patients no longer in a resuscitative phase immediately following trauma. A previous retrospective case-control study by one of the lead investigators showed there was a higher risk of complications with a more liberal strategy, and this appeared to be dose-dependent. Multiple previous studies have shown allogeneic blood transfusion is immunosuppressive and may increase infection rates in surgical patients. This study was completed to determine if a more conservative strategy was safe and might decrease the risk of infection. Methods: The ORACL pilot study randomized 100 patients ages 18-50 to a conservative transfusion strategy of 5.5 g/dL vs a liberal strategy of 7.0 g/dL in asymptomatic patients no longer being resuscitated who required inpatient admission for an associated musculoskeletal injury. Enrollment was performed at 3 level 1 trauma centers from 2014-2021. Ninety-nine patients completed 30 day follow up. Results: There was a significant association between a liberal transfusion strategy and higher rate of deep infection (defined as unplanned return to OR for debridement or admission for IV antibiotics) but superficial infection (defined as oral antibiotics alone needed without admission or debridement) did not reach statistical significance (Table 1). Multiple secondary outcomes or complications that might occur due to anemia or transfusion were not different between the two groups. Conclusion: This study shows a conservative transfusion strategy of 5.5 g/dL in an asymptomatic young Orthopaedic trauma patient leads to a lower deep infection rate without an increase in adverse outcomes