Sanjit R. Konda

Older age does not affect healing time and functional outcomes after fracture nonunion surgery.

Introduction: Elderly patients are at risk of fracture nonunion, given the potential setting of osteopenia, poorer fracture biology, and comorbid medical conditions. Risk factors predicting fracture nonunion may compromise the success of fracture nonunion surgery. The purpose of this study was to investigate the effect of patient age on clinical and functional outcome following long bone fracture nonunion surgery. Materials and Methods: A retrospective analysis of prospectively collected data identified 288 patients (aged 18-91) who were indicated for long bone nonunion surgery. Two-hundred and seventy-two patients satisfied study inclusion criteria and analyses were performed comparing elderly patients aged ≥65 years (n = 48) with patients <65 years (n = 224) for postoperative wound complications, Short Musculoskeletal Functional Assessment (SMFA) functional status, healing, and surgical revision. Regression analyses were performed to look for associations between age, smoking status, and history of previous nonunion surgery with healing and functional outcome. Twelve-month follow-up was obtained on 91.5% (249 of 272) of patients. Results: Despite demographic differences in the aged population, including a predominance of medical comorbidities (P < .01) and osteopenia (P = .02), there was no statistical differences in the healing rate of elderly patients (95.8% vs 95.1%, P = .6) or time to union (6.2 ± 4.1 months vs. 7.2 ± 6.6, P = .3). Rates of postoperative wound complications and surgical revision did not statistically differ. Elderly patients reported similar levels of function up to 12 months after surgery. Regression analyses failed to show any significant association between age and final union or time to union. There was a strong positive association between smoking and history of previous nonunion surgery with time to union. Age was associated (positively) with 12-month SMFA activity score. Conclusions: Smoking and failure of previous surgical intervention were associated with nonunion surgery outcomes. Patient’s age at the time of surgery was not associated with achieving union. Advanced age was generally not associated with poorer nonunion surgery outcomes.

Mechanism of Injury Differentiates Risk Factors for Mortality in Geriatric Trauma Patients.

Objectives: To evaluate the relationship between mechanism of injury and mortality in geriatric trauma patients and the ability of existing injury severity indices (ISIs) to assess mortality. Design: Retrospective review. Setting: Urban level 1 trauma center. Participants: Four thousand five hundred forty-five trauma patients age ≥55 presenting between 2008 and 2011. Intervention: Low-energy (LE-GTP) and high-energy (HE-GTP) geriatric trauma patient cohorts were created based on ICD-9 injury codes. Existing ISIs were evaluated for their ability to predict in-hospital mortality using the area under the receiver-operating characteristic curve (AUROC). Main Outcome Measures: Mortality. Results: The Trauma Score–Injury Severity Score (TRISS) was the most predictive ISI for both cohorts and was deemed to have moderate predictive capacity (AUROC: 0.82) in LE-GTP and excellent predictive capacity (AUROC: 0.91) in the HE-GTP. For, HE-GTP each 1-year increase in age was associated with a 12% increase risk of mortality versus 6% for LE-GTP. Preexisting conditions (PECs) were distributed differently between the cohorts with significantly more PECs in the LE-GTP (P < 0.01). Conclusions: Existing ISIs have fair-to-moderate predictive capacity for in-hospital morality in LE-GTPs and moderate-to-excellent predictive capacity in HE-GTPs. LE-GTPs and HE-GTPs are distinct cohorts that should be evaluated separately. Combining the cohorts underestimates both the effect of age on HE-GTPs and the effect of PECs on LE-GTPs while overestimating the effect of PECs on HE-GTPs. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Do Elderly Patients Fare Worse Following Operative Treatment of Distal Femur Fractures Using Modern Techniques

Background: The purpose of this study was to compare the functional outcomes and quality of life of older and younger patients with similarly treated distal femur fractures. Methods: We conducted an assessment of 57 patients who sustained distal femur fractures (Orthopaedic Trauma Association Type 33B, C) and underwent surgical treatment at our academic medical center. Patients were divided into 2 groups for analysis: an elderly cohort of patients aged 65 or older and a comparison cohort of patients younger than age of 65. A retrospective review of demographics, preoperative ambulatory status, radiographic data, and physical examination data was collected from the medical records. Follow-up functional data were collected via telephone at a mean of 2.5 years (range 6 months-8 years) using a Short Musculoskeletal Functional Assessment (SMFA). All patients underwent standard operative treatment of either nail or plate fixation. Results: There was no statistical difference in gender, fracture type, surgical technique, surgeon, or institution where the surgery was performed. The percentage of patients with healed fractures at 6-months follow-up was not significantly different between the cohorts. The elderly cohort had slightly worse knee range of motion at 3, 6, and 12 months postoperatively but there was not a statistically significant difference between the groups. The SMFA Daily Activity, Functional, and Bother indices were significantly worse in the older cohort (P < .01, P = .01, P = .02, respectively). However, there was no significant difference in the SMFA Emotional or Mobility indices. Conclusion: Despite lower quality of life and functional scores, this study suggests that relatively good clinical outcomes can be achieved with surgical fixation of distal femoral fractures in the elderly patients. Age should not be used as a determinate in deciding against operative treatment of distal femur fractures in the elderly patients.

Are Locked Plates Needed for Split Depression Tibial Plateau Fractures

Displaced tibial plateau fractures often require surgical treatment and plate and screw constructs are the most common method of fixation. There has been increased usage of locking plate technology for both complex and simple fracture patterns without any evidence demonstrating their advantage. The purpose of this study was to compare the clinical use of locked versus nonlocked plating for repair of displaced Schatzker type-II (OTA Type 41B) tibial plateau fractures. Seventy-seven consecutive patients treated operatively with one of two types of plate and screw constructs in a nonrandomized fashion for Schatzker type II tibial plateau fractures and they were prospectively followed over a 5-year period. A total of 35 (45.5%) patients were treated using a locked plate and screw construct and 42 (54.5%) patients were treated with a nonlocked plate and screw construct. All patients received the same pre- and postoperative care and there was no difference in plate morphology and length between cohorts. Clinical outcomes were assessed using Short Musculoskeletal Functional Assessment (SMFA) scores, Visual Analogue Score for pain, and knee ranges of motion. Radiographic outcome was assessed with plain radiographs at all follow-up points. Implant costs for both types of constructs were calculated from hospital purchasing records. Patients were assessed at a mean period of 18.5 months (range: 12-72 months). There was no difference in demographic factors, physical examination parameters, radiographic outcomes, and SMFA scores between cohorts. In terms of cost, the cost of locked construct was

Late Intratendinous Abscess of the Achilles Tendon Complicating Surgical Repair: A Case Report

905 more than the nonlocked construct. Based on clinical outcomes and cost per implant, we found no evidence to support the routine use of locked plating for simple split depression fractures of the lateral tibial plateau. The use of standard nonlocked, precontoured implants provides adequate fixation for these fracture patterns.

Open surgical elbow contracture release after trauma: results and recommendations

Level of Evidence: V, Expert Opinion

Comparison of Short-Term Outcomes of Geriatric Distal Femur and Femoral Neck Fractures: Results From the NSQIP Database.

BACKGROUND Post-traumatic elbow contracture is a debilitating complication after elbow trauma. The purpose of this study was to characterize the affected patient population, operative management, and outcomes after operative elbow contracture release for treatment of post-traumatic elbow contracture. METHODS A retrospective record review was conducted to identify all patients who underwent post-traumatic elbow contracture release performed by 1 of 3 surgeons at one academic medical center. Patient demographics, injuries, operative details, outcomes, and complications were recorded. RESULTS The study included 103 patients who met inclusion criteria. At the time of contracture release, patients were a mean age of 45.2 ± 15.6 years. Contracture release resulted in a significant mean increase to elbow extension/flexion arc of motion of 52° ± 18° (P < .0005). Not including recurrence of contracture, a subsequent complication occurred in 10 patients (10%). Radiographic recurrence of heterotopic ossification (HO) occurred in 14 patients (14%) after release. Ten patients (11%) elected to undergo a secondary operation to gain more motion. CONCLUSION Soft tissue and bony elbow contracture release is effective. Patients with post-traumatic elbow contracture can make significant gains to their arc of motion after contracture release surgery and can expect to recover a functional elbow arc of motion. Patients with severe preoperative contracture may benefit from concomitant ulnar nerve decompression. HO prophylaxis did not affect the rate of HO recurrence or ultimate elbow range of motion. However, patients must be counseled that contracture may reoccur, and some patients may require or elect to have more than one procedure to achieve functional motion.

Current Practices Regarding Perioperative Management of Patients With Fracture on Antiplatelet Therapy: A Survey of Orthopedic Surgeons.

Purpose: To compare and contrast postoperative complications in the geriatric population following open reduction and internal fixation (ORIF) for (DF) fractures relative to femoral neck (FN) fractures. Methods: Patients aged 65 years and older in the American College of Surgeons National Surgical Quality Improvement Program database who underwent ORIF for FN fractures or DF fractures from 2005 to 2012 were identified. Differences in rates of any adverse events (AAEs), serious adverse events (SAEs), infectious complications, and mortality between groups were explored using univariate and multivariate analyses. Results: The DF cohort had a higher proportion of females (81.95% vs 71.35%, P < .001), were younger (79.41 ± 7.93 vs 82.11 ± 7.26 years old, P < .001), and had a lower age adjusted modified Charlson comorbidity index score (4.22 ± 1.32 vs 4.49 ± 1.35, P = .02). Cases with DF and FN did not differ in AAE (20.05% vs 20.20%, P = .94), SAE (12.03% vs 13.19%, P = .51), infectious complication (4.26% vs 4.22%, P = .97), hospital length of stay (7.32 ± 6.73 days vs 7.02 ± 10.67 days, P = .59), or mortality rates (4.51% vs 5.99%, P = .23). Multivariate analyses revealed that fracture type did not impact AAE (P = .28), SAE (P = .58), infectious complications (P = .83), or mortality (P = .85) rates. Conclusion: Postoperative morbidity and mortality of geriatric patients who sustain DF and FN fractures treated operatively were comparable. This information can be used when risk stratifying and prognosticating for elderly patients undergoing these procedures.

Results after radial head arthroplasty in unstable fractures

Objective: There continues to be controversy over whether operative delay is necessary for patients on antiplatelet therapy, particularly for elderly patients with hip fractures. This study sought to assess current clinical practices of orthopedic surgeons regarding perioperative management of these patients. Methods: A 12-question, Web-based survey was distributed to orthopedic surgeons via e-mail. Questions regarding timing of surgery assumed patients were on antiplatelet therapy and assessed attitudes toward emergent and nonemergent orthopedic cases as well as operative delay for specific closed fracture types. Responses were compared using unpaired, 2-tailed Student t tests for continuous variables and Pearson chi-square tests with odds ratios (ORs) and 95% confidence intervals (CIs) for categorical variables. Statistical significance was defined as a P value <.05. Results: Overall 67 orthopedic surgeons responded. Fifty-two percent (n = 35) of the respondents described their practice as academic. Thirty-nine percent (n = 25) of the surgeons indicated that no delay was acceptable for urgent but nonemergent surgery, and 78% (n = 50) reported no delay for emergent surgery was acceptable. Sixty-eight percent (n = 46) of respondents felt patients on antiplatelet therapy with closed hip fractures did not require operative delay. Surgeons who opted for surgical delay in hip fractures were more likely to delay surgery in other lower extremity fracture types (OR = 16.4, 95% CI 4.48-60.61, P < .001). Sixty-four percent (n = 41) of the surgeons indicated there was no protocol in place at their institution. Conclusions: There continues to be wide variability among orthopedic surgeons with regard to management of patients with fracture on antiplatelet therapy. Over a quarter of surgeons continue to opt for surgical delay in patients with hip fracture. This survey highlights the need to formulate and better disseminate practice management guidelines for patients with fracture on antiplatelet therapy, particularly given the aging population in the United States.

Does Use of Oral Anticoagulants at the Time of Admission Affect Outcomes Following Hip Fracture

BACKGROUND Whereas most radial head fractures are stable injuries, they sometimes occur as part of complex injury patterns with associated elbow instability. Radial head arthroplasty has been favored in patients with unreconstructable radial head fractures and unstable elbow injuries. The purpose of this study was to review radiographic outcomes, functional outcomes, and complications after radial head arthroplasty for radial head fracture in unstable elbow injuries. METHODS This study was a retrospective review of radial head fractures treated with radial head arthroplasty by a single surgeon during a 15-year period. Demographics of the patients, injury details, operative reports, radiographic and clinical outcomes, and any complications were recorded. Patients were divided into stable and unstable elbow injury groups. RESULTS A total of 68 patients were included. There were 50 unstable fractures that were compared with 18 stable fractures. Patients with unstable radial head fractures with associated elbow dislocation achieved mean flexion and mean forearm rotational arc of motion similar to that of patients with stable radial head fractures. However, supination loss was greater in the unstable group than in the stable fracture group, with a mean difference of 10°. Radiographic outcomes and complication rates did not differ between injury groups. There was no observed decrease in implant longevity in patients with unstable elbow injuries. CONCLUSIONS Radial head arthroplasty is an effective option for treatment of unstable elbow injuries, with recovery of functional elbow range of motion and no difference in complication rate or implant survivorship compared with those patients with stable injuries.