Paul Tornetta

OBJECTIVES: To compare the clinical outcomes of open versus closed reduction methods for femoral neck fractures (FNFs) in young patients treated with fracture repair. METHODS: Design: Multicenter retrospective cohort study. Setting: Twenty-six North American Level 1 trauma centers. Patient Selection Criteria: Skeletally mature patients younger than 50 years with displaced FNFs (OTA/AO type 31B) undergoing surgical repair and having minimum follow-up >6 months, except in cases where major complications occurred earlier. Intervention: Open versus closed fracture reduction. Main Outcome Measurements: The primary outcome of “major complication” was defined as nonunion/failed fixation, osteonecrosis, malunion (vertical or femoral neck shortening of ≥15 mm), and/or subsequent major reconstructive surgery was compared by reduction method using chi-squared tests and risk-adjusted binary mixed effects regression models. RESULTS: A total of 290 patients with FNFs were included in the study, 107 treated with closed reduction (average follow-up 27.1 months [range, 4.1–159.5 months]) and 183 treated with open reduction and (average follow-up 22.4 months [range, 3.7–141.3 months], P = 0.105). Sex distribution showed no difference between the groups, with 25.5% of the closed group, and 29.0% of the open cohort being female ( P = 0.615). Patients who received open reduction were younger than patients who received closed reductions (mean age 35.6 ± 8.8 vs. 39.5 ± 8.0 years, P < 0.001) and had fewer cases of cases of diabetes mellitus (2.2% vs. 8.6%, P = 0.027). Overall, adverse events were observed following 57.0% of closed reduction reductions versus 54.1% of open reductions ( P = 0.890). No differences were seen in the frequency of defined failure modes, including failed fixation/nonunion (33.6% closed vs. 35.0% open, P = 0.919), osteonecrosis (21.5% closed vs. 14.2% open, P = 0.151), malunion (17.8% closed vs. 14.8% open, P = 0.611), or major reconstructive surgery (33.6% closed vs. 36.6% open, P = 0.702). CONCLUSIONS: Open and closed reductions of FNFs in patients younger than 50 years were associated with similar rates of repair failure. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: It is unclear whether postoperative pain differs by treatment type for patients with severe open tibial fractures. Methods: We performed a secondary analysis of data from the FIXIT study. Adults with severe open tibial fractures were randomized to undergo definitive modern external ring fixation (n = 122) or internal fixation (n = 132). Primary outcomes were pain intensity and interference at 6 and 12 months, measured by the Brief Pain Inventory. Secondary outcomes were Numeric Pain Rating Scale (NPRS) scores and the incidence of moderate to severe pain. Post hoc subanalysis compared pain in patients with and without pin-site infections and with and without external fixation removal. Results: At 6 months, median pain intensity did not differ significantly between the external fixation group (4.1 [interquartile range (IQR), 2.2 to 5.5]) and the internal fixation group (3.0 [IQR, 1.8 to 5.8]) (p = 0.11); however, patients who underwent external fixation had greater median pain interference (6.0 [IQR, 3.3 to 8.0]) than patients who underwent internal fixation (4.0 [IQR, 1.9 to 7.4]) (p = 0.01). At 12 months, pain intensity, pain interference, and NPRS scores did not differ by treatment type. The overall incidence of moderate to severe pain was 33% at 6 months and 35% at 12 months. At 6 months, pin-site infections were associated with greater pain intensity (p = 0.01) but not greater interference (p = 0.10). At 12 months, the presence of external fixation was associated with greater pain intensity (p = 0.01) and interference (p < 0.01). Conclusions: At 6 months after a severe open tibial fracture, patients treated with modern external ring fixation had greater pain interference than patients treated with internal fixation, partly because of pin-site infections. No differences in pain interference or intensity were seen at 12 months. At 12 months, patients with external fixation in place had greater pain intensity and interference than those whose external fixation had been removed, but this was not the case at 6 months. Approximately one-third of all patients had moderate to severe pain at both time points, highlighting that persistent pain is common, regardless of treatment type. These findings can guide surgeons in choosing ring external fixation or internal fixation for these fractures. Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE: To evaluate the effect of joint preparation and patient factors on outcomes and complications in patients treated acutely with hindfoot fusion nails for ankle and pilon fractures. METHODS: Design: Retrospective chart review. Setting: Thirteen US trauma centers and 2 UK trauma centers. Patient Selection Criteria: Ankle and pilon fractures (AO-OTA types A-C) from 2010 to 2020 acutely treated definitively with hindfoot fusion nail were reviewed. Patients at least 18 years old and with minimum 6 months follow-up or earlier diagnosis of complication were included. Exclusion criteria included nonambulatory at baseline, prior internal fixation that failed and underwent revision, and prior tibiotalar or subtalar arthrodesis. Outcome Measurements and Comparisons: The primary outcome was final postoperative ambulatory status. Secondary outcomes were infectious and fracture-related complications. RESULTS: One hundred forty-nine patients (75 men; 74 women; age 20–99; median 63 years) were treated for ankle (104) or pilon (45; 8A, 13B, 24C) fractures. Eighty-five patients (44%) had open fractures and 55 (37%) had diabetes. Thirty-six patients (24%) had joint preparation at the time of surgery. Forty-five (30%) were made weight bearing as tolerated postoperatively; the median time to mobilize was 1.5 days (0–210) and to full weight bearing was 35 days (0–1462). Fifty-seven patients (85%) returned to their preinjury ambulatory status, which was not affected by joint preparation (50% vs. 59%, P = 0.327). Joint preparation led to higher articular fusion rates (94% vs. 24%; P = 0.001) and fewer hardware removals (19% vs. 42%, P = 0.013), but trended toward a higher fracture nonunion rate (19% vs. 8%, P = 0.053). Forty-five patients (30%) had infectious complications, 60 (40%) had a fracture-related complication, and 67 (45%) had additional procedures. Open fractures did not lead to any differences in superficial or deep infection. Insulin-dependent diabetes was associated with higher rates of infectious complications (31% vs. 15%, P = 0.028) and amputation (17% vs. 4%, P = 0.029). CONCLUSIONS: Hindfoot fusion nails for acute ankle and pilon injuries had high complication rates. More complications occurred in patients with insulin-dependent diabetes. While 95% regained ambulation, only 57% returned to preoperative status. Joint preparation led to higher rates of articular fusion (94% vs. 24%, P < 0.001) but not fracture union (81% vs. 66%, P = 0.106). LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction: The optimal surgical approach for intraarticular calcaneal fractures remains debated. This study compares deep infection rates between the extended lateral (EL) and sinus tarsi (ST) approaches. Methods: A retrospective review was conducted of 782 patients treated surgically for OTA 82B/C calcaneal fractures across 15 institutions. Deep infection was defined as requiring surgical débridement or treatment for osteomyelitis. Risk factors were identified using univariate and multivariate analyses. Results: Of 782 fractures, 444 were treated with EL and 338 with ST. Deep infections occurred in 6.8% of EL and 3.0% of ST cases ( P = 0.017). Multivariate analysis found that surgical approach ( P = 0.03) and age ( P < 0.001) were independent risk factors. EL had more wound complications; ST had more symptomatic implants. Conclusion: The ST approach was associated with lower rates of deep infection and wound complications, even in higher-risk patients.

Background: There has been an increase in diversity initiatives regarding selecting speakers for the American Academy of Orthopaedic Surgeons (AAOS) annual meeting and courses. The purpose of this study was to determine the percentage of female or underrepresented minority (URM) speakers for instructional course lectures (ICLs) and AAOS courses over the past 2 decades including a surrogate for expertise. Methods: For 2002, 2012, and 2022, the academic and demographic information of speakers and the number of publications at the time of their speaking role were obtained and compared by sex and URM status. Owing to the unequal sample sizes between male versus female cohorts and URM versus non-URM cohorts, the Welch t-test was used. Results: The percentage of ICL and AAOS course speakers who were female increased over time (ICL, AAOS courses): 2002 (2.6%, 3.3%), 2012 (3.9%, 6.3%), and 2022 (11.8%, 15.5%) (P < 0.001, P < 0.001). The percentage of female AAOS fellows in these years was 2.9%, 4.7%, and 7.4%, respectively. For ICLs and AAOS course speakers, female presenters had fewer publications than male counterparts (ICL, AAOS courses): 2002 (P < 0.001, P = 0.048), 2012 (P = 0.003, P < 0.001), and 2022 (P < 0.001, P < 0.001). For ICLs in 2022, URM speakers had a similar number of publications compared with non-URM speakers. In 2022, URMs comprised 6.9% of ICL speakers and 4% of AAOS fellows. For 2022 ICLs, there were no significant differences in academic institution, position, or region when compared by sex or URM status. For AAOS courses, the percentage of URM speakers increased over time: 2002 (1.1%), 2012 (4.5%), and 2022 (8.6%). For AAOS courses, URM presenters had similar publications compared with non-URM presenters in 2002 and 2022 but less in 2012 (P = 0.027). Discussion: The percentage of women and URMs presenting ICLs and AAOS courses has increased over the past 2 decades and exceeded the percentage they represent in the AAOS by over 50%. The female cohort has fewer publications, on average, than the male cohort for all years evaluated, indicating no institutional bias against female speakers.

Background: The Short Musculoskeletal Function Assessment (SMFA) is a well validated, widely used patient-reported outcome (PRO) measure for orthopaedic patients. Despite its widespread use and acceptance, this measure does not have an agreed upon minimal clinically important difference (MCID). The purpose of the present study was to create distributional MCIDs with use of a large cohort of research participants with severe lower extremity fractures. Methods: Three distributional approaches were used to calculate MCIDs for the Dysfunction and Bother Indices of the SMFA as well as all its domains: (1) half of the standard deviation (one-half SD), (2) twice the standard error of measurement (2SEM), and (3) minimal detectable change (MDC). In addition to evaluating by patient characteristics and the timing of assessment, we reviewed these calculations across several injury groups likely to affect functional outcomes. Results: A total of 4,298 SMFA assessments were collected from 3,185 patients who had undergone surgical treatment of traumatic injuries of the lower extremity at 60 Level-I trauma centers across 7 multicenter, prospective clinical studies. Depending on the statistical approach used, the MCID associated with the overall sample ranged from 7.7 to 10.7 for the SMFA Dysfunction Index and from 11.0 to 16.8 for the SMFA Bother Index. For the Dysfunction Index, the variability across the scores was small (<5%) within the sex and age subgroups but was modest (12% to 18%) across subgroups related to assessment timing. Conclusions: A defensible MCID can be found between 7 and 11 points for the Dysfunction Index and between 11 and 17 points for the Bother Index. The precise choice of MCID may depend on the preferred statistical approach and the population under study. While differences exist between MCID values based on the calculation method, values were consistent across the categories of the various subgroups presented. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES: To evaluate the timing of definitive fixation of tibial plateau fractures relative to fasciotomy closure with regard to alignment and articular reduction. METHODS: Design: Retrospective case series. Setting: Four Level I trauma centers. Patient Selection Criteria: Patients with tibial plateau fractures (TPF) with ipsilateral compartment syndrome treated with fasciotomy between 2006 and 2018 met inclusion criteria. Open fractures, patients younger than 18 years, patients with missed or delayed treatment of compartment syndrome, patients with a diagnosis of compartment syndrome after surgical fixation, and patients whose plateau fracture was not treated with open reduction and internal fixation were excluded. Patients were divided into 2 groups depending on the relative timing of fixation to fasciotomy closure: early fixation (EF) was defined as fixation before or at the time of fasciotomy closure, and delayed fixation (DF) was defined as fixation after fasciotomy closure. Outcome Measures and Comparisons: Radiographic limb alignment (categorized as anatomic alignment (no varus/valgus), ≤5 degrees varus/valgus, or >5 degrees varus/valgus) and articular reduction (categorized as anatomic alignment with no residual gap or step-off, 5 mm of articular surface step-off) were compared between early and delayed fixation groups. In addition, superficial and deep infection rates were compared between those in the EF and DF cohorts. Subgroup analysis within the EF cohort was performed to compare baseline characteristics and outcomes between those that received fixation before closure and those that underwent concurrent fixation and closure within one operative episode. RESULTS: A total of 131 patients met inclusion criteria for this study. Sixty-four patients (48.9%) were stratified into the delayed fixation group, and 67 patients (51.1%) were stratified into the early fixation group. In the EF cohort, 57 (85.1%) were male patients with an average age of 45.3 ± 13.6 years and an average body mass index of 31.0 ± 5.9. The DF cohort comprised primarily male patients (44, 68.8%), with an average age of 46.6 ± 13.9 years and an average body mass index of 28.4 ± 7.9. Fracture pattern distribution did not differ significantly between the early and delayed fixation cohorts (P = 0.754 for Schatzker classification and P = 0.569 for OTA/AO classification). The relative risk of infection for the DF cohort was 2.17 (95% confidence interval, 1.04–4.54) compared with the EF cohort. Patients in the early fixation cohort were significantly more likely to have anatomic articular reduction compared with their delayed fixation counterparts (37.5% vs. 52.2%; P < 0.001). CONCLUSIONS: This study demonstrated higher rates of anatomic articular reduction in patients who underwent fixation of tibial plateau fractures before or at the time of fasciotomy closure for acute compartment syndrome compared with their counterparts who underwent definitive fixation for tibial plateau fracture after fasciotomy closure. The relative risk of overall infection for those who underwent fasciotomy closure after definitive fixation for tibial plateau fracture was 2.17 compared with the cohort that underwent closure before or concomitantly with definitive fixation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: The objective of this study was to compare the biomechanical properties of locked and nonlocked diaphyseal fixation in a model of distal femur fractures using osteoporotic and nonosteoporotic human cadaveric bone. Methods: A supracondylar osteotomy was created to mimic a fracture (OTA/AO 33A3) in osteoporotic (n = 4) and nonosteoporotic (n = 5) cadaveric distal femurs. The left and right femurs of each pair were instrumented with a distal femoral locking plate and randomly assigned to have diaphyseal fixation with either locked or nonlocked screws. The construct was cyclically axially loaded, and construct stiffness and load to failure were evaluated. Results: In osteoporotic bone, locked constructs were more stiff than nonlocked constructs (mean 143 vs. 98 N/mm when all time points combined, P < 0.001). However, in nonosteoporotic bone, locked constructs were less stiff than nonlocked constructs (mean 155 N/mm vs. 185 N/mm when all time points combined, P < 0.001). In osteoporotic bone, the average load to failure was greater in the locked group than in the nonlocked group (mean 1159 vs. 991 N, P = 0.01). In nonosteoporotic bone, the average load to failure was greater for the nonlocked group (mean 1348 N vs. 1214 N, P = 0.02). Bone mineral density was highly correlated with maximal load to failure (R² = 0.92, P = 0.001) and stiffness (R² = 0.78, P = 0.002) in nonlocked constructs but not in locked constructs. Conclusions: Contrary to popular belief, locked plating constructs are not necessarily stiffer than nonlocked constructs. In healthy nonosteoporotic bone, locked diaphyseal fixation does not provide a stiffer construct than nonlocked fixation. Bone quality has a profound influence on the stiffness of nonlocked (but not locked) constructs in distal femur fractures.

Introduction: The purpose of this study was to evaluate surgeons' ability to perform or supervise a standard operation with agreed-upon radiologic parameters after being on call. Methods: We reviewed a consecutive series of patients with intertrochanteric hip fractures treated with a fixed angle device at 9 centers and compared corrected tip-apex distance and reduction quality for post-call surgeons versus those who were not. Subgroup analyses included surgeons who operated the night before versus not and attending-only versus resident involved cases. Secondary outcomes included union and perioperative complications. Results: One thousand seven hundred fourteen patients were of average age 77 years. Post-call surgeons treated 823 patients and control surgeons treated 891. Surgical corrected tip-apex distance did not differ between groups: on-call 18 mm versus control 18 mm (P = 0.59). The Garden indices were 160° on the AP and 179° on the lateral in both groups. In 66 cases performed by surgeons who operated the night before, the TAD was 17 mm. No difference was noted in corrected tip-apex distance with and without resident involvement (P = 0.101). No difference was observed in pooled fracture-related complications (P = 0.23). Conclusion: Post-call surgeons demonstrated no difference in quality and no increase in complications when performing hip fracture repair the next day compared with surgeons who were not on call.