Abstract: Femoral neck fractures are a commonly encountered injury in orthopaedic practice and result in significant morbidity and mortality. It is essential that surgeons are able to recognize specific fracture patterns and patient characteristics that indicate the use of particular implants and methods to effectively manage these injuries. Use of the Garden and Pauwels classification systems has remained the practical mainstay of femoral neck fracture characterization that help dictate appropriate treatment. Operative options include in situ fixation, closed or open reduction and internal fixation, hemiarthroplasty, and total hip arthroplasty. Recent reports demonstrate diversity among orthopaedic surgeons in regard to the optimal treatment of femoral neck fractures and changing trends in management. The present discussion focuses on the current indications and methods for femoral neck fracture management to provide direction with respect to appropriate and effective care of these injuries.

Abstract: Objective:To determine the reliability of the Radiographic Union Scale for Tibia (RUST) score and a new modified RUST score in quantifying healing and to define a value for radiographic union in a large series of metadiaphyseal fractures treated with plates or intramedullary nails.Design:Healing was

Abstract: Objectives:To compare the clinical and radiographic outcome after stabilization of an acute syndesmosis rupture with either a static implant (a 3.5-mm metallic screw through 4 cortices) or a dynamic device (TightRope; Arthrex).Design:Multicenter randomized double-blind controlled trial.Settings:Stud

Abstract: Objectives:To compare the outcomes of open reduction and internal fixation (ORIF), closed reduction and percutaneous pinning, hemiarthroplasty (HA), and reverse shoulder arthroplasty (RSA) for proximal humerus fractures.Data Sources:The search was performed on September 9, 2012 using an explicit sea

Abstract: Objectives:To compare patient satisfaction between telemedicine and in-person follow-up appointments for orthopedic trauma.Design:Prospective randomized controlled trial (pilot study).Setting:Level I trauma center.Patients/Participants:Twenty-four patients were enrolled and randomized into 2 groups.

Abstract: Objectives:This study was performed to identify the risk factors for reduction loss after locking plate fixation of proximal humerus fractures.Design:Retrospective study.Setting:University trauma center.Patients and Intervention:We retrospectively evaluated 252 patients who had been surgically treat

Abstract: Successful treatment of periprosthetic femur fractures, like all fractures, requires careful attention to understand the fracture pattern nuances, identifying and executing a rational treatment approach, and providing an appropriate postoperative recovery protocol. Unlike most other fractures, modification of standard techniques is often required to obtain a stable fixation construct, and there is a greater role for revision arthroplasty in the treatment of periprosthetic fractures. Optimal indications for surgical repair versus revision arthroplasty and optimal postoperative weight-bearing protocols remain uncertain. Reported outcomes for patients with periprosthetic femoral shaft fractures are generally good and are relatively consistent. Results for periprosthetic distal femur fractures, however, are less good and more inconsistent. Both periprosthetic femoral shaft and distal femur fractures are associated with relatively high mortality rates, approaching that of patients with hip fractures. This review should provide insight into the current solutions and challenges for the treatment of patients with periprosthetic femur fractures.

Abstract: OBJECTIVES: Non-compliance with postoperative follow-up visits remains a common problem in orthopaedic trauma. The aim of this study was to identify risk factors for loss of follow-up after orthopaedic trauma. DESIGN: Retrospective review. SETTING: Urban level 1 academic trauma center. PATIENTS: A total of 307 (226 male / 81 female) patients undergoing surgical treatment of their orthopaedic injuries were included in this study. The average age was 40.4 ± 17 years. INTERVENTION: All patients were treated surgically for their orthopaedic injuries and were instructed to follow-up in the orthopaedic trauma clinic after hospital discharge. MAIN OUTCOME MEASUREMENTS: Non-compliance with follow-up appointment at six month after injury. RESULTS: Over a six-month postoperative period, a total of 215 patients were non-compliant with at least one of their follow-up appointments between hospital discharge and the six-month follow-up. A logistic regression showed male gender, uninsured or government insurance, and smoker to be statistically significant risk factors for non-compliance with the six-month follow-up (pCONCLUSIONS: Loss of follow-up is a common problem in orthopaedic trauma. Our study suggests different risk factors for non-compliance including male gender, smoker, lack of commercial health insurance, and illicit drug abuse. Health care providers may consider establishing protocols for facilitating follow-up appointments to patients who are at risk for non-compliance. Language: en

Abstract: Objectives To identify factors associated with increased postoperative length of stay (LOS) and readmission after surgical repair of geriatric hip fractures. Methods Patients aged 70 years and older who underwent hip fracture surgery from January 2011 through December 2012 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patient characteristics were tested for association with postoperative LOS and readmission using bivariate and multivariate analyses. Results For the 8434 patients with hip fracture identified, the average age was 83.8 ± 5.9 years (mean ± SD), and 26.9% were male. Average postoperative LOS was 5.6 ± 6.0 days. Ten percent were readmitted within the first 30 postoperative days. Increased postoperative LOS of at least 1 full day was associated with increased time from admission to surgery, non-general anesthesia, and procedure type on multivariate analysis. Readmission was associated with increased age, male sex, body mass index ≥35 kg/m, American Society of Anesthesiologists class ≥3, pulmonary disease, hypertension, steroid use, dependent functional status, and discharge to a facility on multivariate analysis. Conclusions Ten percent of patients were readmitted after hip fracture repair in this national sample. Preoperative time to surgery, anesthesia type, and implant selection are 3 risk factors for increased LOS that can potentially be modified. A clinically significant risk factor for readmission was body mass index ≥35 kg/m, which was not associated with increased postoperative LOS. The identified risk factors illuminate opportunities for optimizing care for hip fracture patients aged 70 and older. Level of evidence Prognostic level II. See Instructions for Authors for a complete description of levels of evidence.

Abstract: Summary:Talus fractures occur rarely but are often associated with complications and functional limitations Urgent reduction of associated dislocations is recommended with open reduction and internal fixation of displaced fractures when adjacent soft tissue injury permits Delayed definitive fixati

Abstract: OBJECTIVES To compare the clinical and radiologic results of conventional open plating (COP) and minimally invasive plate osteosynthesis (MIPO) in the treatment of noncomminuted humeral shaft fractures. DESIGN Randomized prospective study. SETTING Five level 1 trauma centers. PATIENTS Sixty-eight consecutive patients were randomized into 2 study groups: those treated by COP (COP group; n = 32) and those treated by MIPO (MIPO group; n = 36). INTERVENTION Simple humeral shaft fractures (AO/OTA classification types A and B) were reduced by open reduction or closed reduction and fixed with a narrow 4.5/5.0 locking compression plate, metaphyseal locking compression plate, or proximal humeral internal locking system plate to the anterior lateral aspect of the humerus. MAIN OUTCOME MEASUREMENTS Fracture healing time, operative time, radiation exposure time, and intraoperative nerve injury. To assess shoulder and elbow function, we used the University of California, Los Angeles (UCLA) scoring system and the Mayo elbow performance index, including the range of motion and pain. Radiographic measurements included fracture alignment, delayed union, and nonunion. RESULTS Thirty-one fractures (97%) healed in the COP group within 16 weeks, whereas 36 fractures (100%) were healed in the MIPO group by 15 weeks. No significant difference was observed in the operative time or complication rates. In both groups, all fractures achieved union without malunion and with excellent functional outcomes by definition of the Mayo elbow performance index and UCLA scoring system. CONCLUSIONS This study confirmed a high overall rate of union and excellent functional outcomes in both MIPO and COP groups. MIPO is equivalent to COP as a safe and effective method for simple types of humeral shaft fractures when surgery is indicated, and the surgeon is experienced in the technique. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Abstract: Acute fractures, nonunions, and nonunions with bone defects or osteomyelitis often need bone graft to facilitate union. There are several factors to consider when it is determined that a bone graft is needed. These factors include the source of the bone graft (autograft vs. allograft), proper timing for placement of the bone graft, strategies to avoid further complications (particularly in the setting of osteomyelitis), and with the development of a variety of bone graft substitutes, whether alternatives to autograft are available and appropriate for the task at hand. Autograft bone has commonly been referred to as the "gold standard" of bone grafts, against which the efficacy of other grafts has been measured. The best timing for when to place a bone graft or substitute is also somewhat controversial, particularly after an open fracture or a potentially contaminated bed. The treatment of infected nonunions, particularly those that require a graft to facilitate healing, can be quite challenging. Typically, the infection is completely eradicated before placement of a bone graft, but achieving a sterile bed and the timing of a bone graft require strategic thinking and planning. This review outlines the benefits of autografts, the most suitable sites for harvesting bone grafts, the timing of bone graft procedures, the potential risks and benefits of grafting in the face of infection, and the currently available bone graft extenders.

Abstract: OBJECTIVES: To describe the incidence and magnitude of femoral neck fracture shortening in patients age younger than 60 years. Secondarily, to examine predictors of fracture shortening. DESIGN: Retrospective chart review. SETTING: Level I trauma centre. PATIENTS/PARTICIPANTS: Sixty-five patients with a median age of 51 years (interquartile range: 42-56 years) were included. Seventy-one percent were male, 75% were displaced fractures, and 78% were treated with cancellous screws. INTERVENTION: Internal fixation with multiple cancellous screws or sliding hip screw (SHS) + derotation screw. MAIN OUTCOME MEASUREMENTS: Radiographic femoral neck shortening at a minimum of 6 weeks after fixation. RESULTS: Fifty-four percent of patients had ≥5 mm of femoral neck shortening (22% had between ≥5 and <10 mm and 32% ≥10 mm). Initially, displaced fractures shortened more than undisplaced fractures (mean: 8.1 vs. 2.2 mm, P < 0.001), and fractures treated with SHS + derotation screw shortened more than fractures with cancellous screws alone (10.7 vs. 5.5 mm, P = 0.03). Even when adjusting for initial fracture displacement, fractures treated with SHS + derotation screw shortened an average of 2.2 mm more than fractures treated with screws alone (P = 0.03). CONCLUSIONS: The incidence of clinically significant shortening in our young femoral neck fracture population was higher than anticipated, and 32% of patients experienced severe shortening of >1 cm. Our findings highlight the need for further research to determine the impact of severe shortening on functional outcome and to determine if implant selection affects fracture shortening. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Abstract: Objectives To report the rates of osteonecrosis and subtalar arthritis after talar neck fractures and to examine if rates have changed over time. Data sources A systematic review and meta-analysis of the English literature was performed using EMBASE, MEDLINE, CENTRAL, and Cochrane in November 2011 and updated in November 2014. Study selection Inclusion criteria were studies examining talar neck fractures that reported talar body osteonecrosis rates as a primary or secondary outcome. Exclusion criteria included case series with 50% pediatric patients, inability to isolate results of talar neck fractures, primary treatment of talar excision or arthrodesis, mean follow-up of Data extraction Basic information was collected including journal, author, year published, level of evidence, number of fractures, and follow-up length. Specific information collected included fracture classifications, timing of interventions, method of treatment, osteonecrosis rates, subtalar arthrosis rates, and method of diagnosis of osteonecrosis. Data synthesis Fixed-effects models were used for meta-analysis. The overall event rate of osteonecrosis was calculated and stratified based on Hawkins classification of the talar neck fractures. Mean rates of subtalar arthritis were calculated for all studies and for studies including >2 years of follow-up. Conclusions The overall rate of osteonecrosis was 0.312. Rates for Hawkins' types I-IV were 0.098, 0.274, 0.534, and 0.480, respectively. The mean rate of subtalar arthritis was 0.49 but increased to 0.81 in studies with >2 years of follow-up. Complication rates are high in talar neck fractures, and patients should be counseled accordingly.

Abstract: OBJECTIVES The aim of our study was to identify the risk factors associated with the development of acute compartment syndrome (ACS) after a fracture of the tibia. DESIGN Retrospective cohort study. SETTING Orthopaedic trauma unit, university teaching hospital. PATIENTS From our trauma database, we identified all patients who sustained an acute tibial diaphyseal fracture over a 13-year period. A retrospective analysis of 1407 patients was performed to record and analyze the OTA fracture classification, open fracture grade according to Gustilo, soft tissue injury classification according to Tscherne, treatment, development of ACS, and other patient demographics including smoking, occupation, and socioeconomic deprivation. MAIN OUTCOME MEASURE A diagnosis of ACS was made using clinical signs, compartment pressure monitoring, or a combination of the 2. RESULTS One thousand three hundred eighty-eight patients were included with a mean age of 39 (12-98) years, and 957 (69%) were male. One hundred sixty patients (11.5%) were diagnosed with ACS. On initial analysis, age, male gender, blue-collar occupation, sporting injury, fracture classification, and treatment with intramedullary nails were predictive of ACS (all P < 0.05). Age was the strongest predictor of developing ACS (P < 0.001), with the highest prevalence between 12-19 years and 20-29 years. Occupation (P = 0.01) and implant type (P = 0.004) were the only factors that remained significant after adjusting for age. On further subanalysis, implant type was not predictive when stratified by Tscherne class (P = 0.11). CONCLUSIONS We have documented the risk factors for the development of ACS after an acute tibial diaphyseal fracture, with youth the strongest predictor. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Abstract: Objectives:To critically review the outcomes and issues associated with the induced membrane technique in a trauma population.Design:Retrospective case series, Level IV therapeutic study.Setting:Urban Level I trauma center.Patients:Sixty-nine patients aged 18 years or older who underwent treatment o

Abstract: Objective:This study reports the complications and functional outcomes in patients treated acutely with combined open reduction internal fixation (ORIF) and immediate total hip arthroplasty (THA) for displaced comminuted acetabular fractures.Design:Single surgeon retrospective case series.Setting:Le

Abstract: Pilon or tibial plafond fractures usually result from high-energy injuries with rotation and/or axial compression. They occur in an area of relatively poor soft tissue coverage and frequently present a surgical challenge in deciding which incisions will be best for performing open reduction internal fixation. A variety of anterior and posterior approaches have been described based on the ease of fracture reduction and internal fixation with plates. Some of the incisions are fracture specific, that is, planned for a limited approach to the pilon. But in more complex cases, a wider exposure is indicated and thus more extensile approaches, both anterior and posterior, can be valuable. This review article will describe the different surgical approaches, focusing on their indication and technique.

Abstract: Objectives:First, to provide the readership with a summation of the current practice patterns of North American orthopaedic surgeons for venous thromboembolism prophylaxis after musculoskeletal trauma. Second, to establish a set of guidelines and recommendations based on the most current and best av

Abstract: Objective:The objective of this study was to characterize relationships between obesity and initial hospital stay, including complications, in patients with multiple system trauma and surgically treated fractures.Design:Prospective, observational.Setting:Level 1 trauma center.Patients:Three hundred

Abstract: Infection in orthopaedic trauma patients is a common problem associated with significant financial and psychosocial costs, and increased morbidity. This review outlines technologies to diagnose and prevent orthopaedic infection, examines implant-related infection and its management, and discusses the treatment of post-traumatic osteomyelitis. The gold standard for diagnosing infection has a number of disadvantages, and thus new technologies to diagnose infection are being explored, including multilocus polymerase chain reaction with electrospray ionization-mass spectrometry and optical imaging. Numerous strategies have been employed to prevent orthopaedic infection, including use of antibiotic-impregnated implant coatings and cement; however, further research is required to optimize these technologies. Biofilm formation on orthopaedic implants is attributed to the glycocalyx-mediated surface mode of bacterial growth and is usually treated through a secondary surgery involving irrigation, debridement and the appropriate use of antibiotics, or complete removal of the infected implant. Research into the treatment of post-traumatic osteomyelitis has focused on developing an optimal local antibiotic delivery vehicle, such as antibiotic-impregnated polymethylmethacrylate (PMMA) cement beads or bioabsorbable bone substitute (BBS) delivery systems. As these new technologies to diagnose, prevent and treat orthopaedic infection advance, the incidence of infection will decrease and patient care will be optimized.

Abstract: Objectives:The purpose of this study was to evaluate the effectiveness of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunion.Design:Retrospective cohort.Setting:Tertiary referral center.Patients:Forty-six aseptic tibial nonunion sites in 40 patients (2 bilateral a

Abstract: Objective:To analyze the mechanical stability of locked plating in comparison with tension-band wiring for the fixation of fractures of the patella.Methods:Biomechanical tests were performed on artificial foam patella specimens comparing an angular stable plate and monocortical screws with tension-b

Abstract: Objective:To evaluate the ability of the Lauge-Hansen classification to predict ligament injuries in ankle fractures using magnetic resonance imaging (MRI) and intraoperative findings.Design:Prospective evaluation in consecutive patients.Setting:Academic level 1 trauma center.Patients:Three-hundred

Abstract: Objectives:To determine whether interobserver technical variations and errors in the measurement of compartment pressures may affect measurement accuracy.Methods:Four above-knee cadaveric specimens were used to create a consistent model of lower leg compartment syndrome. Thirty-eight physicians exam

Abstract: The accurate reduction of tibial plateau malunions can be challenging without guidance. In this work, we report on a novel technique that combines 3-dimensional computer-assisted planning with patient-specific surgical guides for improving reliability and accuracy of complex intraarticular corrective osteotomies. Preoperative planning based on 3-dimensional bone models was performed to simulate fragment mobilization and reduction in 3 cases. Surgical implementation of the preoperative plan using patient-specific cutting and reduction guides was evaluated; benefits and limitations of the approach were identified and discussed. The preliminary results are encouraging and show that complex, intraarticular corrective osteotomies can be accurately performed with this technique. For selective patients with complex malunions around the tibia plateau, this method might be an attractive option, with the potential to facilitate achieving the most accurate correction possible.

Abstract: Fracture healing is a unique multifaceted process requiring the presence of cells, molecular mediators, and angiogenic factors. The state of inflammation dominates the initial phase, but the ideal magnitude and duration of the process for an optimal outcome remains obscure. Biological response modifiers, such as platelet-rich plasma (PRP) preparations, have been used to reconstitute the desirable early inflammatory state, but the results obtained remain inconclusive. Ongoing research to characterize and quantify the inflammatory response after bone fracture is essential in order to better understand the molecular insights of this localized reaction and to expand our armamentarium in the management of patients with an impaired fracture healing response. Non-steroidal anti-inflammatory drugs frequently administered for analgesia after trauma procedures continue to be a cause of concern for a successful bone repair response.

Abstract: Patella fractures are challenging orthopaedic injuries. Many commonly used fixation techniques can be ineffective and lead to poor clinical outcomes even with satisfactory reductions and fracture healing. In this investigation, we present the technique of cage plate fixation of patella fractures and the clinical outcomes of 9 initial patients surgically treated at our institution. This technique allows direct visualization of the articular reduction, provides multiplanar fixation, effectively stabilizes inferior pole comminution, and reduces the risk of patella vascular disruption. Using this technique, we have achieved excellent functional and radiographic outcomes.

Abstract: Stem cells offer great promise to help understand the normal mechanisms of tissue renewal, regeneration, and repair, and also for development of cell-based therapies to treat patients after tissue injury. Most adult tissues contain stem cells and progenitor cells that contribute to homeostasis, remodeling, and repair. Multiple stem and progenitor cell populations in bone are found in the marrow, the endosteum, and the periosteum. They contribute to the fracture healing process after injury and are an important component in tissue engineering approaches for bone repair. This review focuses on current concepts in stem cell biology related to fracture healing and bone tissue regeneration, as well as current strategies and limitations for clinical cell-based therapies.