Intramedullary nailing versus sliding hip screw for A1 and A2 trochanteric hip fractures

AIMS: This study evaluated variation in the surgical treatment of stable (A1) and unstable (A2) trochanteric hip fractures among an international group of orthopaedic surgeons, and determined the influence of patient, fracture, and surgeon characteristics on choice of implant (intramedullary nailing (IMN) versus sliding hip screw (SHS)). METHODS: A total of 128 orthopaedic surgeons in the Science of Variation Group evaluated radiographs of 30 patients with Type A1 and A2 trochanteric hip fractures and indicated their preferred treatment: IMN or SHS. The management of Type A3 (reverse obliquity) trochanteric fractures was not evaluated. Agreement between surgeons was calculated using multirater kappa. Multivariate logistic regression models were used to assess whether patient, fracture, and surgeon characteristics were independently associated with choice of implant. RESULTS: The overall agreement between surgeons on implant choice was fair (kappa = 0.27 (95% confidence interval (CI) 0.25 to 0.28)). Factors associated with preference for IMN included USA compared to Europe or the UK (Europe odds ratio (OR) 0.56 (95% CI 0.47 to 0.67); UK OR 0.16 (95% CI 0.12 to 0.22); p < 0.001); exposure to IMN only during training compared to surgeons that were exposed to both (only IMN during training OR 2.6 (95% CI 2.0 to 3.4); p < 0.001); and A2 compared to A1 fractures (Type A2 OR 10 (95% CI 8.4 to 12); p < 0.001). CONCLUSION: In an international cohort of orthopaedic surgeons, there was a large variation in implant preference for patients with A1 and A2 trochanteric fractures. This is due to surgeon bias (country of practice and aspects of training). The observation that surgeons favoured the more expensive implant (IMN) in the absence of convincing evidence of its superiority suggests that surgeon de-biasing strategies may be a useful focus for optimizing patient outcomes and promoting value-based healthcare. Cite this article: Bone Joint J 2021;103-B(4):775-781

Quantitative 3-Dimensional Computed Tomography Measurements of Coronoid Fractures

Purpose Using quantitative 3-dimensional computed tomography (Q3DCT) modeling, we tested the null hypothesis that there was no difference in fracture fragment volume, articular surface involvement, and number of fracture fragments between coronoid fracture types and patterns of traumatic elbow instability. Methods We studied 82 patients with a computed tomography scan of a coronoid fracture using Q3DCT modeling. Fracture fragments were identified and fragment volume and articular surface involvement were measured within fracture types and injury patterns. Kruskal Wallis test was used to evaluate the Q3DCT data of the coronoid fractures. Results Fractures of the coronoid tip (n = 45) were less fragmented and had the smallest fragment volume and articular surface area involvement compared with anteromedial facet fractures (n = 20) and base fractures (n = 17). Anteromedial facet and base fractures were more fragmented than tip fractures, and base fractures had the largest fragment volume and articular surface area involvement compared with tip and anteromedial facet fractures. We found similar differences between fracture types described by Regan and Morrey. Furthermore, fractures associated with terrible triad fracture dislocation ( n = 42) had the smallest fragment volume, and fractures associated with olecranon fracture dislocations (n = 17) had the largest fragment volume and articular surface area involvement compared with the other injury patterns. Conclusions Analyzing fractures of the coronoid using Q3DCT modeling demonstrated that fracture fragment characteristics differ significantly between fracture types and injury patterns. Detailed knowledge of fracture characteristics and their association with specific patterns of traumatic elbow instability may assist decision making and preoperative planning. Clinical relevance Quantitative 3DCT modeling can provide a more detailed understanding of fracture morphology, which might guide decision making and implant development. Copyright (C) 2015 by the American Society for Surgery of the Hand. All rights reserve

Tibial Plateau Fracture Characteristics: Computed Tomography Mapping of Lateral, Medial, and Bicondylar Fractures

Background: Computed tomography (CT) is seen as a useful diagnostic modality in preoperative planning for tibial plateau fractures. The purpose of this study was to characterize patterns of tibial plateau fractures with use of CT mapping. We hypothesized that CT mapping of fractures of the tibial plateau would reveal recurrent patterns of fragments and fracture lines, including patterns that do not fit into Schatzker's original classification. Methods: One hundred and twenty-seven tibial plateau fractures were retrospectively included in this study. Fracture lines and zones of comminution were graphically superimposed onto an axial template of an intact subarticular tibial plateau to identify major patterns of fracture and comminution. This fracture map of the tibial plateau was subsequently divided into lateral (Schatzker types I, II, and III), medial (Schatzker type IV), and bicondylar (Schatzker types V and VI) fracture maps. Results: This study included seventy-three female and fifty-four male patients (average age, forty-seven years [range, seventeen to ninety-one years]) with a tibial plateau fracture. Sixty-four of the fractures were Schatzker type I, II, or III; fifteen were Schatzker type IV; and forty-eight were Schatzker type V or VI. Analysis of the fracture maps suggested patterns in the Schatzker type-IV, V, and VI fractures beyond those described in Schatzker's original classification. The maps of the 127 fractures revealed four recurrent major fracture features: the lateral split fragment (A), found in 75%; the posteromedial fragment (B), seen in 43%; the tibial tubercle fragment (C), seen in 16%; and a zone of comminution that included the tibial spine and frequently extended to the lateral condyle (D), seen in 28%. Conclusions: Tibial plateau fracture maps show recurrent patterns of fracture lines, revealing four major fracture characteristics. An understanding of these recurrent features of tibial plateau fractures can aid surgeons during diagnosis, preoperative planning, and execution of surgical strategie

The posttraumatic stiff elbow: an update

Posttraumatic elbow stiffness is a disabling condition that remains challenging to treat despite improvement of our understanding of the pathogenesis of posttraumatic contractures and new treatment regimens. This review provides an update and overview of the etiology of posttraumatic elbow stiffness, its classification, evaluation, nonoperative and operative treatment, and postoperative managemen

Biomechanical studies: Science (f)or common sense?

It is our impression that many biomechanical studies invest substantial resources studying the obvious: that more and larger metal is stronger. The purpose of this study is to evaluate if a subset of biomechanical studies comparing fixation constructs just document common sense. Using a web-based survey, 274 orthopaedic surgeons and 81 medical students predicted the results of 11 biomechanical studies comparing fracture fixation constructs (selected based on the authors’ sense that the answer was obvious prior to performing the study). Sensitivity, specificity, and accuracy were calculated according to standard formulas. The agreement among the observers was calculated by using a multirater kappa, described by Siegel and Castellan. The accuracy of predicting outcomes was 80% or greater for 10 of 11 studies. Accuracy was not influenced by level of experience (i.e., time in practice and medical students vs. surgeons). There were substantial differences in accuracy between observers from different regions. The overall categorical rating of inter-observer reliability according to Landis and Koch was moderate (κ=0.55; standard error (SE)=0.01). The results of a subset of biomechanical studies comparing fracture fixation constructs can be predicted prior to doing the study. As these studies are time and resource intensive, one criterion for proceeding with a biomechanical study should be that the answer is not simply a matter of common sense

The Effect of Two Factors on Interobserver Reliability for Proximal Humeral Fractures

The purpose of this study was to assess whether training observers and simplifying proximal humeral fracture classifications improve interobserver reliability among a large number of orthopaedic surgeons. One hundred eighty-five observers were randomized to receive training or no training in a simple classification for proximal humeral fractures before evaluating preoperative radiographs of a consecutive series of 30 patients who were treated with open reduction and internal fixation. The overall interobserver reliability of the simple proximal humeral fracture classification system was low and not significantly different between the training and the no training group (κ = 0.20 and κ = 0.18, respectively; P = 0.10). Subgroup analyses showed that training improved the agreement among surgeons who have been in independent practice ≤5 years (κ = 0.23 versus κ = 0.14; P < 0.001), surgeons from the United States (κ = 0.23 versus κ = 0.16; P = 0.002), and general orthopaedic surgeons (κ = 0.42 versus κ = 0.15; P = 0.021). Simplifying classifications and training observers did not improve the interobserver reliability for the diagnosis of proximal humeral fractures. However, training observers improved interobserver reliability of a simple proximal humeral fracture classification system among surgeons from the United States and, in particular, younger and less specialized surgeons. This finding may suggest that our interpretations of radiographic information might become more fixed and immutable with experienc

Tibial Plateau Fracture Characteristics: Reliability and Diagnostic Accuracy

The purpose of this study was to assess the interobserver reliability and diagnostic accuracy for 2-dimensional (2D) and 3-dimensional (3D) computed tomography (CT)-based evaluation of tibial plateau fracture characteristics. We hypothesized that recognition of specific tibial plateau fracture characteristics is equally reliable and accurate in 2DCT and 2D- and 3DCT. Eighty-one orthopedic trauma surgeons and residents were randomized to either 2DCT or 2D- and 3DCT evaluation of 15 complex tibial plateau fractures using web-based platforms to recognize 4 tibial plateau fracture characteristics: (1) a posteromedial component, (2) a lateral component, (3) a tibial tubercle component, and (4) a tibial spine (central) component. Interobserver reliability was evaluated by Siegel and Castellan's multirater kappa measure and kappa values were interpreted according to the categorical rating by Landis and Koch. Diagnostic accuracy was calculated according to standard formulas. Interobserver reliability of tibial plateau fracture characteristics ranged from "fair" to "substantial". The addition of 3DCT reconstructions did not improve agreement between observers or diagnostic accuracy, because kappa values and diagnostic accuracy were significantly better for evaluation of tibial plateau fractures using 2DCT alone. Diagnostic accuracy of fracture characteristics ranged from 70% to 89% and was better for more frequently encountered components (ie, the posteromedial and lateral component). The recognition of tibial plateau fracture characteristics prove accurate and reliable on CT-based evaluation in this study and may be useful besides current classification systems, which do not account for all fracture components, in daily practice to help clinical decision making. Further research is needed to evaluate whether the use of distinct fracture components helps preoperative planning of surgical approach and specific fixation technique

Interobserver variability of radiographic assessment using a mobile messaging application as a teleconsultation tool

Background: To examine whether interobserver reliability, decision-making, and confidence in decision-making in the treatment of distal radius fractures changes if radiographs are viewed on a messenger application on a mobile phone compared to a standard DICOM viewer. Methods: Radiographs of distal radius fractures were presented to surgeons on either a smart phone using a mobile messenger application or a laptop using a DICOM viewer application. Twenty observers participated: 10 (50%) were randomly assigned to the DICOM viewer group and 10 (50%) to the mobile messenger group. Each observer was asked to evaluate the cases and (1) classify the fracture type according to the AO classification, (2) recommend operative or conservative treatment and (3) rate their confidence about this decision. Results: There was no significant difference in interobserver reliability for AO classification and recommendation for surgery for distal radius fractures in both groups. The percentage of recommendation for surgery was significantly higher in the messenger application group compared to the DICOM viewer group (89% versus 78%, P=0.019) and the confidence for treatment decision was significantly higher in the mobile messenger group compared to the DICOM viewer group (8.9 versus 7.9, P=0.026). Conclusion: Messenger applications on mobile phones could facilitate remote decision-making for patients with distal radius fractures, but should be used with caution