Akhil Tawari

What makes an intertrochanteric fracture unstable in 2015? Does the lateral wall play a role in the decision matrix?

Summary: Intertrochanteric (IT) fractures pose a tremendous burden to the healthcare system. Although consistently good results are obtained while treating stable IT fractures, treatment failure rates with unstable fractures are much higher, and hence, it is imperative to identify unstable patterns. Presently, the conventionally classified unstable configurations (fracture with posteromedial comminution, reverse oblique, IT with subtrochanteric extension) and the recently added fracture patterns (IT fractures with avulsed greater trochanter and lateral wall breach) qualify as unstable IT fractures; however, the list is certainly not exhaustive. Disruption of lateral wall converts an IT fracture into a reverse oblique fracture equivalent and should be given a strong consideration in the decision matrix.

Posterior Malleolar Fractures Associated with Tibial Shaft Fractures and Sequence of Fixation.

Objectives: The purpose of this study was to evaluate posterior malleolar injuries associated with nailed tibial fractures and to determine the quality of reduction based on the sequence of fixation in associated fracture patterns. Design: Retrospective cohort study. Patients: 1113 tibia fractures treated with an intramedullary nail at 3 level I trauma centers. Intervention: Tibial shaft fractures with posterior malleolar injury were analyzed regarding type of fracture, mechanism of injury, energy of injury, fracture characteristic, surgical characteristics including sequence of fixation, obvious intraoperative displacement of the posterior malleolar fragment, and the quality of reduction. One group (“malleolus-first”) consisted of patients in whom the posterior malleolus was fixed before tibial nailing and the other group (“tibia-first”) included patients in whom tibial nailing was done before posterior malleolus fixation. Outcomes Measured: Intraoperative displacement, quality of reduction. Results: Ninety-six of 1113 (9%) nailed tibial shaft fracture patients had a concomitant posterior malleolus fracture (9%). Of the 96 posterior malleolar fracture patients, 70 patients were operatively treated (73%). In the malleolus-first group (54 patients), intraoperative displacement of the posterior malleolar fragment was observed in 1 patient, and 1 case of poor reduction of the posterior malleolar fragment was observed (2%). In the tibia-first group (16 patients), obvious intraoperative displacement of the posterior malleolar fragment was observed in 5 patients (31%), and poor reduction of the posterior malleolar fragment was observed in 7 patients (44%). These percentages of patients with poor quality of reduction were statistically significantly different (p ⩽ 0.01). Conclusion: Many low-energy tibia fractures with a spiral configuration do have an associated posterior malleolus fracture. In order to avoid intraoperative displacement and poor reduction, we recommend fixation of the posterior malleolar fragment before nailing of the tibia in associated fracture pattern. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Obesity Is Associated With High Perioperative Complications Among Surgically Treated Intertrochanteric Fracture of the Femur

Objectives: To document the complications among obese patients who underwent surgical fixation for intertrochanteric femur (IT) fractures and to compare with nonobese patients. Design: Retrospective cohort study. Setting: Four level I trauma centers. Patients: 1078 IT fracture patients. Interventions: None. Main Outcome Measures: Patient and fracture characteristics, surgical duration, surgical delay intraoperative and postoperative complications, inpatient mortality, and length of stay. Method: A retrospective review at 4 academic level I trauma centers was conducted to identify skeletally mature patients who underwent surgical fixation of intertrochanteric fractures between June 2008 and December 2014. Descriptive data, injury characteristics, OTA fracture classification, and associated medical comorbidities were documented. The outcomes measured included in-hospital complications, length of stay, rate of blood transfusion, change in hemoglobin levels, operative time, and wound infection. Results: Of 1078 unique patients who were treated for an IT fracture, 257 patients had a Body mass index (BMI) of 30 or greater. Patients with a high BMI (≥30) had a significantly lower mean age (73 vs. 77 years, P < 0.0001), higher percentage of high-energy injuries (18% vs. 9%, P = 0.0004), greater mean duration of surgery (96 vs. 86 minutes, P = 0.02), and higher mean length of stay (6.5 vs. 5.9 days, P = 0.004). The high-BMI group (n = 257) had significantly higher percentages of patients with complications overall (43% vs. 28%, P < 0.0001), respiratory complications (11% vs. 3%, P < 0.0001), electrolyte abnormalities (4% vs. 2%, P = 0.01), and sepsis (4% vs. 1%, P = 0.002). Patients with BMI ≥ 40 had a much higher rate of respiratory complications (18%) and wound complications (5%) than obese (BMI: 30–39.9) and nonobese patients (BMI < 30). Conclusion: Intertrochanteric hip fracture patients with a BMI of >30 kg/m2 are much more likely to sustain systemic complications including respiratory complications, electrolyte abnormalities, and sepsis. In addition, morbidly obese patients are more likely to sustain respiratory complications and wound infections than obese (BMI: 30–39.9 kg/m2) and nonobese patients (BMI: < 30 kg/m2). The findings from this study can help direct surgeons in the counseling to obese patients and their family, and perhaps increase hospital reimbursement for this group of patients. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Medial Malleoli Fractures: Clinical Comparison Between Newly Designed Sled Device and Conventional Screws:

Background. The Trimed Medial Malleolar Sled is a newer device designed to treat medial malleolus fracture. The purpose of this study was to compare the outcome of medial malleolar fractures treated with the sled and conventional malleolar screws. Methods. After obtaining an institutional review board approval, we conducted a retrospective study to identify all skeletally mature patients who sustained an ankle fracture with medial malleolar involvement treated with the sled and we identified a matched cohort treated with conventional malleolar screws. The patients were divided into 2 groups: group A included patients treated with malleolar screws and group B included patients treated with the sled device. The outcomes measured included rate of union, implant removal, and pain over the implant site. Results. Eighty-five medial malleolar ankle fractures were divided into 2 groups: group A included patients (n = 64) treated with malleolar screws and group B included patients (n = 21) treated with the sled device. In group A (n = 64), 62 patients (96.8%) achieved radiological union with a mean union rate of 11 weeks and 10 (15%) patients underwent repeat surgery for implant removal of which 3 patients (4.6%) had pain specifically over the medial implant. In group B (n = 21), all of the patients (100%) achieved radiological union with a mean union rate of 10.8 weeks and 3 patients (14.2%) underwent repeat surgery of which 1 (4.7%) was related to the medial pain. There is no significant difference between the groups for the outcomes measured, including rate of union ( P = .93), visual analog scale score for pain ( P = .07), implant removal ( P = .41), and pain over the implant site ( P = .88). Conclusion. Based on the data from our study, we conclude that there are no major differences between the sled devices and conventional screws relating to union rate and complications. Levels of Evidence: Level III: Observational study

Improvement in osteoporosis detection in a fracture liaison service with integration of a geriatric hip fracture care program

INTRODUCTION Care gaps have been identified in the treatment of osteoporosis after the occurrence of a fragility hip fracture. HiROC (High Risk Osteoporosis Clinic) is a fracture liaison service implemented at our institution. In ProvenCare geriatric hip fracture care program at our institution pre-set orders for the inpatient HiROC consults were prescribed. We hypothesized that there will be a significant increase in the rate of enrollment of patients in the HiROC program after the integration of the pre-set orders. PATIENTS AND METHODS The trauma database at a level-I trauma center was reviewed retrospectively for the charts of patients >50 years of age with fragility intertrochanteric fractures. Patients not treated under the geriatric hip fracture care program and patients treated under the geriatric hip fracture care program were identified and reviewed for the enrollment in HiROC and subsequent follow up. RESULTS Out of 589 patients treated before the implementation of ProvenCare, 443 patients (75%) were enrolled in HiROC at the index consult. In comparison, out of 153 patients treated after the implementation of ProvenCare, 131 patients (85.6%) were enrolled in HiROC at the index consult. The difference between the two groups was statistically significant (p=0.008). CONCLUSION Our experience shows that the occurrence of a fragility intertrochanteric fracture can be effectively utilized for the detection and initiation of treatment of osteoporosis. With the implementation of pre-set orders in the geriatric hip fracture care program significantly better enrollment can be achieved.

Percutaneous and Mucocutaneous Exposure Among Orthopaedic Surgeons: Immediate Management and Compliance With CDC Protocol.

Background: Orthopaedic surgeons are at a high risk of sustaining a percutaneous or mucocutaneous exposure to blood and body fluids. The Center for Disease Control and Prevention recommends a wash with soap and water and notification of the concerned hospital authorities after any percutaneous/mucocutaneous exposure, but a systematic amenability with these guidelines is not always seen. This cross-sectional study was undertaken to determine current knowledge and practices of orthopaedic surgeons in case of a percutaneous sharp injury exposure, emphasizes the immediate first aid steps taken after an exposure, the degree of reporting, and to explore the reasons for noncompliance. Finally, we sought to create awareness about the prevailing Center for Disease Control and Prevention guidelines after any exposure to blood or body fluids. Materials and Methods: We conducted a cross-sectional survey using an anonymous prepared questionnaire. The study population included exclusively orthopaedic surgeons, including residents, fellows, and attending physicians at 4 US institutions. The questionnaire was also available online on the OTA Web site as a part of survey monkey. The questionnaire comprised 9 multiple choice questions, and more than 1 response could be given for some questions. The questions addressed previous needle stick/sharp injury exposure, number of times that had happened, whether reported to the hospital administration, reason for nonreporting, and risk perception for transmission of blood-borne pathogens (human immunodeficiency virus, HBsAg, and hepatitis C virus). The questions were also asked based on what should be done in four different clinical settings based on respondents risk perception. Results: Of fifty eight attendings, 7 fellows, 45 residents, and 7 respondents who did not indicate their position participated in the survey for a total of 117 respondents. Out of 99, 24 had sustained it once, 18 twice, 11 three times, and 35 at least 4 times. When questioned about informing the incident to the hospital administration, 38% had always reported the incident, 33% had never reported the incident, and the remaining 29% had not reported it every time. Of note, 87% gave the correct response about the risk of transmission of human immunodeficiency virus after an exposure. On questioning about the risk of hepatitis B transmission, from an HBsAg- and HBeAg-positive source, 13% gave the correct response, whereas from HBsAg-positive and HBeAg-negative source, 30% gave the correct response. Regarding transmission of hepatitis C virus from a positive source, 36% responded correctly. The surgeons seemingly attempted to risk stratify their exposure, and they were more likely to report their exposure in the higher risk scenarios. Conclusions: This study demonstrates that orthopaedic surgeons of all levels of training are at high risk of occupational exposure to blood-borne pathogens. Moreover, despite the level of training, the majority of surgeons do not follow the recommended steps, although we do not know the reasons for such behavior. Also, there is a low awareness of the significant risk of hepatitis transmission among orthopaedic surgeons treating a population with a high prevalence of undiagnosed hepatitis.

Nail Length in the Management of Intertrochanteric Fracture of the Femur.

Intramedullary devices are used increasingly to treat intertrochanteric femur fractures, especially those with unstable patterns. In spite of the considerable use of nails in the management of these fractures, opinions differ about the correct length of intramedullary nail. Long nails were developed to address the risk of diaphyseal fracture associated with earlier short nail designs and to extend the indications for use to include diaphyseal and subtrochanteric fractures. Several recent studies, however, have found no differences between modern short nails and long nails with regard to union and complication rates. In the absence of existing guidelines, the treating surgeon’s preference and fracture characteristics continue to influence the decision of whether to use short nails or long nails. The surgeon needs to consider the fracture configuration and related factors, including whether osteoporosis is present and the cost and risk of revision surgery, when selecting the appropriate nail length.

The Role of Radiographs and Office Visits in the Follow-up of Healed Intertrochanteric Hip Fractures: An Economic Analysis

Objectives: The purpose of this study was to evaluate the role and the necessity of radiographs and office visits obtained during follow-up of intertrochanteric hip injuries. Design: Retrospective study. Setting: Two level I trauma centers. Patients: Four hundred sixty-five elderly patients who were surgically treated for an intertrochanteric fracture of the femur at 2 level I trauma centers between January 2009 and August 2014 were retrospectively identified from orthopaedic trauma databases. Intervention: Analysis of all healed intertrochanteric hip fractures, including demographic characteristics, quality of reduction, time of healing, number of office visits, number of radiographs obtained, and each radiograph for fracture alignment, implant position or any pathological changes. Results: The surgical fixation of 465 fractures included 155 short nails (33%), 232 long nails (50%), 69 sliding hip screw devices (15%), 7 trochanteric stabilizing plates (1.5%), and 2 proximal femur locking plates (0.5%). The average fracture healing time was 12.8 weeks and the average follow-up was 81.2 weeks. Radiographs of any patient obtained after the fracture had healed did not reveal any changes, including fracture alignment or implant position and hardware failure. In 9 patients, pathological changes, including arthritis (3), avascular necrosis (3), and ectopic ossification (3) were noted. The average number of elective office visits and radiographs obtained after the fracture had healed were 2.8 (range: 1–8) and 2.6 (range: 1–8), respectively. According to Medicare payments to the institution, these radiographs and office visits account for a direct cost of

Nonunion Tibia Shaft Treated with IMN/Bone Grafting

360.81 and

The Agreement of Level-of-Evidence Ratings of Articles Submitted to the JOT from 2012 to 2014.

192, respectively, per patient. Conclusion: The current study strongly suggests that there is a negligible role for radiographs and office visits during the follow-up of a well-healed hip fracture when there is documented evidence of radiographic and clinical healing with acceptable fracture alignment and implant position. Implementation of this simple measure will help in reducing the cost of care and inconvenience to elderly patients. Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.