Mark A. Lee

Purpose: Different reduction methods and implant choices for subtrochanteric femur fractures with varying fracture patterns have been described. This study aimed to assess the relationship of fracture patterns, reduction methods, and implant selection with radiographic and clinical outcomes. Methods: A retrospective review of patients aged ≥ 18 with traumatic subtrochanteric fractures between 2016 and 2023 at a Level-1 trauma center was conducted. Patient, surgical, and outcome characteristics were collected. Femoral neck-shaft angle , maximum sagittal cortical displacement, and modified radiographic union score of the tibia (mRUST) adapted to the proximal femur were measured on post-operative radiographs. Results: Among 64 patients (mean age 56.1, 70.3% male) with one patient with bilateral injuries, 54 received an intramedullary nail (IMN), 8 a plate, and 3 a nail-plate combination. No differences were observed in AO/OTA fracture patterns between groups. Open reduction was performed in 35 cases and closed or percutaneous reduction in 30 cases. Closed reductions had significantly shorter surgery durations and decreased estimated blood loss (EBL) compared to open reductions ( p = 0.028 and p = 0.049, respectively). Radiographically, maximal cortical displacement on lateral imaging was significantly increased in closed or percutaneously reduced fractures compared to open reductions ( p = 0.025). IMN fixation was utilized in patients with higher BMI ( p = 0.017). IMN fixation resulted in increased maximal cortical displacement on lateral imaging compared to plate and combination nail-plate fixations ( p = 0.041). No differences in mRUST at multiple time points were observed in reduction method or implant type. Our average length of follow-up was 132 days. Post-operatively, no differences existed in pain, independent ambulation, complication or revision rates between implants or reduction methods. Conclusion: Subtrochanteric fractures treated with open reduction and presence of a plate in the fixation can improve sagittal alignment. Closed/percutaneous reduction decreases surgery duration and estimated blood loss. Regardless of reduction type and implant, adequate reduction, high union rates and successful outcomes are possible. Anatomic reduction and stable fixation are essential in surgical treatment, regardless of approach or implant choice.

Introduction: Socioeconomic status has been correlated with clinical and functional outcomes in elective orthopaedic surgery; however, there has been limited application in orthopaedic trauma. The Area Deprivation Index (ADI) uses 17 different metrics to assess disadvantages at the neighborhood level by zip code. The purpose of this study was to examine the relationship between ADI and unplanned return to the operating room (UROR) in the orthopaedic trauma patient population. Methods: A retrospective review of adult orthopaedic trauma patients from 2014 to 2019 at a level 1 trauma center was done. Patient demographics, injury characteristics, and ADI were recorded. ADI was used to describe survival to UROR, and logistic regressions were used to identify factors that increased the odds of UROR. Results: In total, 1,031 patients were included in the study, with a UROR incidence of 14.3%. The average ADI score fell in the minimally deprived category (second quartile). Univariate analysis demonstrated a significant association between UROR and younger age (P < 0.001), higher Injury Severity Score (P < 0.001), ADI > 75 (P< 0.05), osteoporosis (P < 0.001), open fracture (P< 0.05), number of fractures (P < 0.05), and higher fracture complexity (P < 0.001). Multivariate analysis revealed that ADI > 75 (OR 3.486, P = 0.029), younger age (OR 0.982, P = 0.004), Injury Severity Score (OR 1.069, P < 0.001), and osteoporosis (OR 5.086, P < 0.001) was associated with UROR. Kaplan-Meier confirmed increased rates of UROR for the third and fourth ADI quartiles for all cases (P < 0.001) and when controlling for symptomatic implant (P < 0.001). Conclusion: Defined by ADI, patients from severely deprived communities undergoing orthopaedic trauma interventions were found to have a 3.5-fold increased rate of UROR. This study shows outcome disparities in the orthopaedic trauma population when using a comprehensive measure for socioeconomic status even after controlling for other contributing factors. Understanding and addressing the unique challenges facing socioeconomically deprived patient populations has the potential to markedly improve outcomes for orthopaedic trauma patients.

Introduction: Tibial shaft fractures, frequently treated with intramedullary nailing (IMN), are high-risk fractures of nonunion. The effect of intramedullary nail diameter on fracture union reduction remains an area of investigation, with many surgeons anecdotally preferring to place at least a 10-mm tibial nail. We hypothesized that small-caliber nails (SCNs) (diameter ≤9 mm) are safe to use and have no difference in complication rates compared with large-caliber nails (LCNs) (≥10 mm). Methods: A retrospective study was conducted on patients with tibial shaft fractures undergoing reamed IMN at a level 1 trauma center between 2018 and 2022. Patient and injury characteristics, intramedullary nail diameter, surgical details, and postoperative complication rates were recorded. Nail and intramedullary canal width at the isthmus on coronal radiographs determined the nail-canal ratio. Radiographic coronal and sagittal displacement, angulations between fracture segments, and coronal plane tibial mechanical axis were evaluated on latest radiographs. Results: Among 113 patients, 68 received SCN while 45 received LCN. No difference was observed in the nail-canal ratio between the SCN and LCN groups, indicating that smaller nails were used for smaller canals. No significant demographic differences were noted between groups. LCNs were more prevalent in (AO Foundation/Orthopaedic Trauma Association classification) AO/OTA 42C (P = 0.03) and Gustilo-Anderson type III fractures (P = 0.05). The LCN group had higher rates of revision surgery (20% vs. 5.9%, P = 0.03) and wound dehiscence (8.9% vs. 0%, P = 0.02). Gustilo-Anderson IIIA fractures were independently associated with poorer outcomes overall. Radiographic parameters were comparable between groups. Conclusions: Small-diameter and large-diameter reamed intramedullary nails can be effective in treating tibial shaft fractures. Nail-canal ratios and alignment were similar between the two groups, suggesting that surgeons should not feel obligated to ream to a 10-mm nail in a smaller patient with a well-reduced fracture.

Introduction: Staged treatment of high-energy periarticular tibia fractures involves temporization with closed reduction and external fixation, aiming to provide early reduction and stabilization while mitigating soft-tissue complications. Various external fixator configurations exist, including those that use a “multipin” clamp capable of holding multiple pins but limiting pin placement to a single plane. The purpose of this study was to compare clinical and radiographic outcomes and associated costs of standard and multipin outrigger clamp constructs in tibial plateau and pilon fractures treated with temporary external fixation. We hypothesized that use of the multipin clamp may be associated with poorly aligned reductions and increased complication rates. Methods: A retrospective review of 100 patients with periarticular tibial plateau (AO/OTA: 41B/C) or pilon (43B/C) fracture at a Level 1 trauma center from 2014 to 2023 was conducted. Patient, injury, and complication characteristics were collected. Patients were categorized based on the external fixator clamp used: multipin (MP) or standard (S). Clinical outcomes and complication rates were assessed. Radiographic alignment was evaluated by the change in anterior and lateral distal tibial angles, and sagittal plane translation for pilon fractures, and medial and posterior proximal tibial angles for plateau fractures. Results: 70 patients underwent standard (25 pilon, 45 plateau) and 30 multipin (10 pilon, 20 plateau) external fixation. MP and S groups showed no notable differences in demographics or injury characteristics. Both groups demonstrated comparable complication rates and radiological alignment outcomes, with no notable differences observed. MP constructs were more costly than standard systems. Conclusion: In this retrospective study of 100 patients, there was no difference in radiographic or clinical outcomes between the standard frame and multipin frame groups. Typical costs for the multipin frame constructs were $635 to $1249 more than the standard frame constructs.

Purpose: The retrograde femoral nailing advanced (RFNA) system (DePuy synthes) is a commonly used implant for the fixation of low distal femur and periprosthetic fractures. There is concern that the rate of distal interlock screw back-out may be higher for the RFNA compared to other nails (ON). The purpose of this study was to evaluate the incidence of interlock screw back-out and associated screw removal for RFNA versus ON, along with associated risk factors. Methods: A retrospective comparative study of patients who underwent retrograde nailing for a distal femur fracture at an academic level one trauma center was performed. The incidence of distal interlock screw back-out and need for screw removal were compared for RFNA versus a propensity score matched cohort who received other nails. Results: One hundred and ten patients underwent retrograde nailing with the RFNA for a distal femur fracture from 2015 to 2022 (average age: 66, BMI: 32, 52.7% smokers, 54.5% female, 61.8%). There was a significantly higher rate of interlock back-out in the RFNA group compared to the ON (27 patients, 24.5% vs 12 patients, 10.9%, p = 0.01), which occurred 6.3 weeks postoperatively. Screw removal rates for back-out were not significantly different for the RFNA group versus ON (8 patients, 7.3% vs 3 patients, 2.7%, p = 0.12). Conclusion: In this retrospective comparative study of distal femur fractures treated with retrograde nailing, the RFNA implant was associated with an increased risk of distal interlock screw back-out compared to other nails.

In order to determine the impact of COVID-19 on the treatment and outcomes in patients with proximal femoral fracture’s (PFF), we analyzed a national US sample. This is a retrospective review of American College of Surgery’s (ACS) National Surgical Quality Improvement Program (NSQIP) for patients with proximal femoral fractures. A total of 26,830 and 26,300 patients sustaining PFF and undergoing surgical treatment were sampled during 2019 and 2020, respectively. On multivariable logistic regression, patients were less likely to have ‘presence of non-healing wound’ (p < 0.001), functional status ‘independent’ (p = 0.012), undergo surgical procedures of ‘hemiarthroplasty’(p = 0.002) and ‘ORIF IT, Peritroch, Subtroch with plates and screws’ (p < 0.001) and to be ‘alive at 30-days post-op’ (p = 0.001) in 2020 as compared to 2019. Patients were more likely to have a case status ‘emergent’, ‘loss of ≥10% body weight’, discharge destination of ‘home’ (p < 0.001 for each) or ‘leaving against medical advice’ (p = 0.026), postoperative ‘acute renal failure (ARF)’ (p = 0.011), ‘myocardial infarction (MI)’ (p = 0.006), ‘pulmonary embolism (PE)’ (p = 0.047), and ‘deep venous thrombosis (DVT)’ (p = 0.049) in 2020 as compared to 2019. Patients sustaining PFF and undergoing surgical treatment during pandemic year 2020 differed significantly in preoperative characteristics and 30-day postoperative complications when compared to patients from the previous year.