Raymond Y. Hsu

Operative versus nonoperative treatment of geriatric ankle fractures: a Medicare Part A claims database analysis.

Background: The incidence of ankle fractures is increasing in the geriatric population, and several studies suggest them to be the third most common extremity fracture in this age group. Previous work has reflected relatively low complication rates during operative treatment. Little is known, however, about the association between these injuries and overall mortality, nor whether operative intervention has any effect on mortality. We hypothesized that geriatric ankle fractures would be correlated with an elevated mortality rate and that operative intervention would be associated with a reduced mortality when compared to nonoperative management. Methods: Following Institutional Review Board approval we retrospectively assessed all relevant 2008 part A inpatient claims from the Medicare database. We queried diagnosis codes for ankle fractures, and then excluded any patients whose age was less then 65 or had an admission related to an ankle fracture during the previous year. Operative patients were then identified by their ICD-9 procedure codes occurring within 30 days of their initial diagnosis code; all other patients were presumed to be treated without operative intervention, thereby creating 2 groups for comparison. We then analyzed this database for specific variables including overall mortality, length of stay, age distribution, and other demographical characteristics. Groups were compared with Elixhauser and Deyo–Charlson scores to determine the level of comorbidities in each group. Multivariate logistic regression analysis was used to determine if operative intervention had a protective effect. Results: In all, 19 648 patients with an ankle fracture were identified. Of those, 15 193 underwent operative intervention (77.3% ) and 4455 were treated nonoperatively (22.7% ). The mean ages for nonoperative and operative intervention were 80.9 and 76.5, respectively (P < .0001). The average length of stay for nonoperative management was 4.5 days, while operative intervention resulted in a length of stay of 4.6 days (P = .43). One-year mortality was 21.5% for the nonoperative group and 9.1% for the operative group (P < .0001). The mean Elixhauser score for the nonoperative group was 2.5 and 2.2 for the operative group (P < .0001). The mean Deyo–Charlson score was 1.3 and 1.0 for the nonoperative and operative groups, respectively (P < .0001). Multivariate logistic regression analysis demonstrated an odds ratio of 0.534 of death within 1 year for patients undergoing operative intervention as compared to nonoperative intervention (95% CI 0.483-0.591, P < .0001). Conclusion: The incidence of geriatric ankle fractures continue to increase as our population continues to grow older. A significantly larger number of those patients were treated with operative intervention, at a ratio of approximately 3:1 versus nonoperative management. Despite a relatively low overall reported complication rate with treatment of these injuries, they are associated with substantially increased 1-year mortality in both patient groups. Compared to the operative group, the nonoperative cohort demonstrated a 2-fold elevated mortality rate, although this may be related to them being an arguably more frail population as suggested by both comorbidity indexes. In spite of the difference in comorbidities, logistic regression analysis demonstrated operative intervention to have a protective effect. Level of Evidence: Level III, comparative series.

Neurologic Deficit Associated With Lateralizing Calcaneal Osteotomy for Cavovarus Foot Correction

Background: Lateralizing calcaneal osteotomy (LCO) is a frequently used technique to correct hindfoot varus deformity. Tibial nerve palsy following this osteotomy has been described in case reports but the incidence has not been quantified. Methods: Eighty feet in 72 patients with cavovarus foot deformity were treated over a 6-year span by 2 surgeons at their respective institutions. Variations of the LCO were employed for correction per surgeon choice. A retrospective chart review analyzed osteotomy type, osteotomy location, amount of translation, and addition of a tarsal tunnel release in relation to the presence of any postoperative tibial nerve palsy. Tibial nerve branches affected and the time to resolution of any deficits was also noted. Results: The incidence of neurologic deficit following LCO was 34%. With an average follow-up of 19 months, a majority (59%) resolved fully at an average of 3 months. There was a correlation between the development of neurologic deficit and the location of the osteotomy in the middle third as compared to the posterior third of the calcaneal tuber. We found no relationship between the osteotomy type, amount of correction, or addition of a tarsal tunnel release and the incidence of neurologic injury. Conclusions: Tibial nerve palsy was not uncommon following LCO. Despite the fact that deficits were found to be transient, physicians should be more aware of this potential problem and counsel patients accordingly. To decrease the risk of this complication, we advocate extra caution when performing the osteotomy in the middle one-third of the calcaneal tuberosity. Although intuitively the addition of a tarsal tunnel release may protect against injury, no protective effect was demonstrated in this retrospective study. Level of Evidence: Level III, retrospective cohort study.

The Effect of C-Arm Position on Radiation Exposure During Fixation of Pediatric Supracondylar Fractures of the Humerus

BACKGROUND Closed reduction and percutaneous pinning of a pediatric supracondylar fracture of the humerus requires operating directly next to the C-arm to hold reduction and perform fixation under direct imaging. This study was designed to compare radiation exposure from two C-arm configurations: with the image intensifier serving as the operating surface, and with a radiolucent hand table serving as the operating surface and the image intensifier positioned above the table. METHODS We used a cadaveric specimen in this study to determine radiation exposure to the operative elbow and to the surgeon at the waist and neck levels during simulated closed reduction and percutaneous pinning of a pediatric supracondylar fracture of the humerus. Radiation exposure measurements were made (1) with the C-arm image intensifier serving as the operating surface, with the emitter positioned above the operative elbow; and (2) with the image intensifier positioned above a hand table, with the emitter below the table. RESULTS When the image intensifier was used as the operating surface, we noted 16% less scatter radiation at the waist level of the surgeon but 53% more neck-level scatter radiation compared with when the hand table was used as the operating surface and the image intensifier was positioned above the table. In terms of direct radiation exposure to the operative elbow, use of the image intensifier as the operating surface resulted in 21% more radiation exposure than from use of the other configuration. The direct radiation exposure was also more than two orders of magnitude greater than the neck and waist-level scatter radiation exposure. CONCLUSIONS Traditionally, there has been concern over increased radiation exposure when the C-arm image intensifier is used as an operating surface, with the emitter above, compared with when the image intensifier is positioned above the operating surface, with the emitter below. We determined that, although there was a statistically significant difference in radiation exposure between the two configurations, neither was safer than the other at all tested levels. CLINICAL RELEVANCE In contrast to traditional teaching regarding radiation exposure, neither C-arm configuration-with the image intensifier serving as the operating surface or with the image intensifier positioned above a radiolucent hand table-was shown to be clearly safer for pediatric supracondylar humeral fracture fixation.

Surgical Techniques of Gastrocnemius Lengthening

This article summarizes the various alternatives for direct gastrocnemius lengthening and elucidates the relative strengths and tradeoffs of each as a means of providing balanced perspective in selecting the appropriate procedure for any given patient.

Morbidity and Mortality Associated with Geriatric Ankle Fractures: A Medicare Part A Claims Database Analysis.

BACKGROUND The purpose of this study was to examine the incidence of adverse events in elderly patients who required inpatient admission after sustaining an ankle fracture and to consider these data in relation to geriatric hip fracture and other geriatric patient admissions. METHODS A retrospective cohort study of patients admitted with an ankle fracture, a hip fracture, or any other diagnosis was performed with the Medicare Part A database for 2008. The primary outcome measure was the one-year mortality rate, examined with multivariate analysis factoring for both patient age and preexisting comorbidity. Secondary outcome measures analyzed additional morbidity as reflected by length of stay, discharge disposition, readmissions, and medical complications. RESULTS There were 19,648 patients with ankle fractures, 193,980 patients with hip fractures, and 5,801,831 patients with other admitting diagnoses. Significant differences (p < 0.001) were noted in both age and comorbidity status between the group with ankle fractures and the group with hip fractures. The one-year mortality after admission was 11.9% for patients with ankle fracture, 28.2% for patients with hip fracture, and 21.5% for patients with any other admission. Upon using multivariate analysis to account for both age and comorbidity, the hazard ratio for one-year mortality associated with fracture was 1.088 for patients with hip fracture and 0.557 for patients with ankle fracture. CONCLUSIONS Even after selecting for admitted patients and accounting for both age and comorbidity, geriatric patients with ankle fractures were found to have a lower one-year morbidity compared with geriatric patients who had sustained a hip fracture or alternative admitting diagnoses. Geriatric patients with ankle fractures are likely healthier and more active in ways that are not captured by simply accounting for age and comorbidity. These findings may support more aggressive definitive management of such injuries in this population. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of one-year mortality after geriatric ankle fractures in patients admitted to nursing homes

INTRODUCTION The incidence of geriatric ankle fractures will undoubtedly increase as the population continues to grow. Many geriatric patients struggle to function independently after such injury and often require placement into nursing homes. The morbidity and mortality associated with nursing homes is well documented within the field of orthopaedic surgery. However, there is currently no study examining the mortality associated with nursing home placement following hospitalization for an ankle fracture. Therefore, the purpose of this study was to determine if geriatric patients admitted to nursing homes following an ankle fracture experience elevated mortality rates. METHODS Patients were identified using diagnosis codes for ankle fractures from all 2008 part A Medicare claims, and those admitted to nursing homes were identified using a Minimum Data Set (MDS). The Medicare database was also analyzed for specific variables including over-all one year mortality, length of stay, age distribution, certain demographical characteristics, incidence of medical and surgical complications within 90 days, and the presence of comorbidities. Multivariate logistic regression analysis was used to determine if patients admitted to nursing homes had elevated mortality rates. RESULTS 19,648 patients with ankle fractures were identified, and 11,625 (59.0%) of these patients went to a nursing home after hospitalization. Patients who went to a nursing home had higher Elixhauser and Deyo-Charlson comorbidity scores (p<0.0001). Nursing home patients also had significantly increased rates of postoperative medical and surgical complications. One year mortality was 6.9% for patients who did not go to a nursing home and 15.4% for patients who were admitted to a nursing home (p<0.0001). However, multivariate logistic regression analysis demonstrated no significant difference in one year mortality between patients admitted to nursing homes and those who were not (OR=1.1; 95% CI 0.99-1.24, p>0.05). DISCUSSION Although admission to nursing home was significantly associated with increased mortality in a bivariate statistical model, this significance was lost during multivariate analysis. This suggests that other patient characteristics may play a more prominent role in determining one year mortality following geriatric ankle fractures.

Subtle anterior subtalar dislocation

Subtalar dislocations are uncommon injuries, and anterior subtalar dislocations are extremely rare. Only 7 cases have been reported in detail in the literature, but all were associated with substantial displacement immediately apparent on radiographs. We report a case of a subtle anterior subtalar dislocation that was missed on initial plain films but was subsequently treated successfully with closed reduction.

Novel Posterior Splinting Technique to Avoid Heel Ulcers

Heel ulcers are a costly and preventable complication of lower-extremity immobilization, but they still occur with some regularity. A technique using a short leg posterior splint that suspends the heel away from the splint is described. This modification completely removes pressure the heel to prevent decubitus ulcer formation. This technique is simple, inexpensive, and effective.

Letter Regarding “A Novel Casting Technique for Tongue-Type Calcaneus Fractures With Soft Tissue Compromise”

Dear Editor: We read with interest the December 2017 article by Dr Heintzman et al, “A Novel Casting Technique for Tongue-Type CalcaneusFracturesWithSoftTissueCompromise.” Wewould like to congratulate the authors on the adoption of the technique of offloading the posterior heel to both splints and casts. Greater awareness of this technique will benefit other patients with tongue-type fractures with compromised soft tissue. We published a comparable article, “A Novel Posterior Splinting Technique to Avoid Heel Ulcers” in 2013 in Orthopedics, which describes the same technique with the goal of reaching a wide audience. The recent movement toward more open access orthopedic journals such as Foot & Ankle Orthopaedics will hopefully serve as an additional venue for dissemination of useful techniques to benefit all patients. We hope, however, that the same standards for appropriate citation and peer review continue with the increase in publications.

Lesser Metatarsophalangeal Joint Instability: Advancements in Plantar Plate Reconstruction

The plantar plate and associated collateral ligaments are the main stabilizers of each of the lesser metatarsophalangeal joints. Although clinical examination and plain radiographs are usually sufficient to establish the diagnosis of a plantar plate tear, MRI or fluoroscopic arthrograms may help in specific cases. Recent results with a dorsal approach to plantar plate repair are promising with respect to pain relief and patient satisfaction.