Background: Comminuted inferior pole patellar fractures can be treated in numerous ways. To date, there have been no studies comparing the biomechanical properties of transosseous tunnels versus suture anchor fixation for partial patellectomy and tendon advancement of inferior pole patellar fractures. Hypothesis: Suture anchor repair will result in less gapping at the repair site. We also hypothesize no difference in load to failure between the groups. Study Design: Controlled laboratory study. Methods: Ten cadaveric knee extensor mechanisms (5 matched pairs; patella and patellar tendon) were used to simulate a fracture of the extra-articular distal pole of the patella. The distal simulated fracture fragment was excised, and the patellar tendon was advanced and repaired with either transosseous bone tunnels through the patella or 2 single-loaded suture anchors preloaded with 1 suture per anchor. Load to failure and elongation from cycles 1 to 250 between 20 and 100 N of force were measured, and modes of failure were recorded. Statistical analysis was performed using a paired 2-tailed Student t test. Results: The suture anchor group had less gapping during cyclic loading as compared with the transosseous tunnel group (mean ± SD, 6.83 ± 2.23 vs 13.30 ± 5.74 mm; P = .047). There was no statistical difference in the load to failure between the groups. The most common mode of failure was at the suture-anchor interface in the suture anchor group (4 of 5) and at the knot proximally on the patella in the transosseous tunnel group (4 of 5). Conclusion: Suture anchors yielded similar strength profiles and less tendon gapping with cyclic loading when compared with transosseous tunnels in the treatment of comminuted distal pole of the patellar fractures managed with partial patellectomy and patellar tendon advancement. Clinical Relevance: Suture anchors may offer robust repair and earlier range of motion in the treatment of fractures of the distal pole of the patella. Clinical randomized controlled trials would help clinicians better understand the difference in repair techniques and confirm the translational efficacy in clinical practice.
Fluoroscopy poses an occupational hazard to orthopedic surgeons. The purpose of this study was to examine resident and faculty understanding of radiation safety and to determine whether or not a radiation safety intervention would improve radiation safety knowledge. An anonymous survey was developed to assess attitudes and knowledge regarding radiation safety and exposure. It was distributed to faculty and residents at an academic orthopedic program before and after a radiation safety lecture. Pre- and post-lecture survey results were compared. 19 residents and 22 faculty members completed the pre-lecture survey while 11 residents and 17 faculty members completed the post-lecture survey. Pre-lecture survey scores were 48.3% for residents and 49.5% for faculty; post-lecture survey scores were 52.7% and 46.1% respectively. Differences between pre and post-survey scores were not significant. This study revealed low baseline radiation safety knowledge scores for both orthopedic residents and faculty. As evidence by our results, a single radiation safety information lecture did not significantly impact radiation knowledge. Radiation safety training should have a formal role in orthopedic surgery academic curricula.
Introduction: Given the rapidly increasing population of Spanish-speaking patients in the United States, medical providers must have the capability to effectively communicate both with pediatric patients and their caregivers. The purpose of this study was to query the Spanish language proficiency of pediatric orthopaedic surgeons, assess the educational resources available to Spanish-speaking patients and their families, and identify the barriers to care at academic pediatric orthopaedic centers. Methods: The Web sites of medical centers within the United States that have pediatric orthopaedic surgery fellowships recognized by the Pediatric Orthopaedic Society of North America (POSNA) were accessed. Web sites were investigated for a health library as well as the availability of interpreter services. Profiles of attending surgeons within each Pediatric Orthopaedic Department were evaluated for evidence of Spanish proficiency as well as educational qualifications. Centers were contacted by phone to determine if the resources and physicians who could converse in Spanish were different than what was readily available online and if automated instructions in Spanish or a person who could converse in Spanish were available. Results: Forty-six centers with 44 fellowship programs were identified. The profiles of 12 of 334 (3.6%) surgeons who completed pediatric orthopaedic fellowships indicated Spanish proficiency. Seventeen physicians (5.1%) were identified as proficient in Spanish after phone calls. Thirty-eight pediatric orthopaedic centers (82.6%) noted interpreter service availability online, although services varied from around-the-clock availability of live interpreters to interpreter phones. When contacted by phone, 45 of 46 centers (97.8%) confirmed the availability of any interpreter service for both inpatient and outpatient settings. Sixteen centers (34.8%) had online information on orthopaedic conditions or surgical care translated into Spanish. Twenty centers (43.5%) did not have automated phone messages in Spanish or live operators that spoke Spanish. Conclusions: There is a scarcity of surgical providers in pediatric orthopaedic centers proficient in Spanish, demonstrating a large discrepancy with the growing Hispanic population. Interpreter services are widely available, although there is variability in the services provided. Considerable barriers exist to Spanish-speaking patients who attempt to access care by phone or online.
Introduction: The incidence of geriatric ankle fractures is rising. With the substantial variation in the physiologic and functional status within this age group, our null hypothesis was that mortality and complications of open reduction and internal fixation (ORIF) between patients who are aged 65 to 79 are equivalent to ORIF in patients who are aged 80 to 89. Methods: Patients with ankle fracture were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Patients treated with ORIF were identified using the Current Procedural Terminology codes. Patients were divided into two age cohorts: 65 to 79 years of age and 80 to 89 years of age. The primary outcome studied was 30-day mortality. Secondary outcomes included 30-day readmission, revision surgery, surgical site infection, sepsis, wound dehiscence, pulmonary embolism, deep vein thrombosis, blood transfusion, urinary tract infection, pneumonia, stroke, myocardial infarction, renal insufficiency or failure, and length of hospital stay. Results: Our cohort included 2,353 ankle fractures: 1,877 were among 65 to 79 years of age and 476 were among 80 or older. Thirty-day mortality was 3.2-fold higher in the 80 to 89 years of age group compared with the 65 to 79 years of age group (1.47% versus 0.48%, P = 0.019). However, after controlling for the ASA class, 80 to 89 years of age patients no longer had a significantly higher mortality (P = 0.0647). Similarly, revision surgery rate (3.36% versus 1.81%, P = 0.036), transfusion requirement (2.94% versus 1.49%, P = 0.033), urinary tract infection (1.89% versus 0.75%, P = 0.023), and hospital length of stay (4.9 versus 2.9 days, P < 0.0001) were all significantly higher in the 80 to 90 years of age group compared with the 65 to 79 years old group. However, after controlling for the ASA class, 80 to 89 years old patients no longer had a rate of complications in comparison to the 65 to 79 years old age group. Discussion: After controlling for comorbidities (ie, the ASA class), no increased risk is observed for the 30-day mortality or complication rate between geriatric ankle fracture in the 65 to 79 years old and the 80 to 99 years old age groups. Level of Evidence: Prognostic level III, retrospective study.
Background: Ankle arthroplasty has emerged as a viable alternative to ankle arthrodesis due in large part to recent advancements in both surgical technique and implant design. This study seeks to document trends of arthroplasty and arthrodesis for ankle osteoarthritis in New York State from 2009-2018 in order to determine if patient demographics play a role in procedure selection and to ascertain the utilization of each procedure and rates of complications. Methods: Patients 40 years and older from 2009-2018 were identified using International Classification of Diseases, Ninth and Tenth Revisions ( ICD-9 and ICD-10), Clinical Modification ( CM) diagnosis and procedure codes for ankle osteoarthritis, ankle arthrodesis, and ankle arthroplasty in the New York statewide planning and research cooperative system database. A trend analysis for both inpatient and outpatient procedures was performed to evaluate the changing trends in utilization of ankle arthrodesis and ankle arthroplasty over time. A multivariable logistic regression was used to assess the odds of receiving ankle arthrodesis relative to ankle arthroplasty. Complications were compared between inpatient ankle arthrodesis and arthroplasty using multivariable Cox proportional hazards regression. Results: A total of 3735 cases were included. Ankle arthrodesis increased by 25%, whereas arthroplasty increased by 757%. African American race, federal insurance, workers compensation, presence of comorbidities, and higher social deprivation were associated with increased odds of having an ankle arthrodesis vs an ankle arthroplasty. Compared with ankle arthroplasty, ankle arthrodesis was associated with increased rates of readmission, surgical site infection, acute renal failure, cellulitis, urinary tract infection, and deep vein thrombosis. Conclusion: Ankle arthroplasty volume has grown substantially without a decrease in ankle arthrodesis volume, suggesting that ankle arthroplasty may be selectively used for a different population of patients than ankle arthrodesis patients. Despite the increased growth of ankle arthroplasty, certain patient demographics including patients from minority populations, federal insurance, and from areas of high social deprivation have higher odds of receiving arthrodesis. Level of Evidence: Level III, retrospective cohort.
Background: The Risk Assessment Prediction Tool (RAPT) is a validated 6-question survey designed to predict primary total joint arthroplasty (TJA) patients' discharge disposition. It is scored from 1 to 12 with patients stratified into high-, intermediate-, and low-risk groups. Given recent advancements in rapiddischarge protocols and increasing utilization of home services, the RAPT score may require modified scoring cutoffs. Methods: A retrospective chart review of all patients undergoing primary TJA at a single academic center over 14 months was performed. The RAPT score was implemented during the sixth month. Patients undergoing revision TJA, complex TJA, and TJA after resection of malignancy were excluded. Outcomes before and after RAPT implementation were analyzed with additional subanalysis investigating of post-RAPT data. Results: A total of 1264 patients (624 Pre-RAPT and 640 Post-RAPT) were evaluated. The post-RAPT group (245 total hip arthroplasty and 395 total knee arthroplasty) experienced significant decreases in mean hospital length of stay (2.22 days pre-RAPT to 1.82 days post-RAPT, P < .001) and the proportion of patients discharged to facility (21.8% pre-RAPT to 15.2% post-RAPT, P ¼ .002). The modified system demonstrated the highest overall predictive accuracy at 92% and was found to be predictive of hospital length of stay. Conclusion:Owing to the recent trends favoring in-home services over rehab facility after discharge, previously published RAPT scoring cutoffs are inaccurate for modern practice. Using mRAPT cutoffs maximizes the number of patients for whom a discharge prediction can be made, while maintaining excellent predictive accuracy.
Background: Supination adduction ankle fractures are unique among rotational ankle fractures as plate constructs are more commonly used than independent screws for medial malleolar fixation. The purpose of this study was to compare fracture displacement between plate fixation to a novel screw-only construct using a cadaveric biomechanical early-weightbearing model for the treatment of vertical medial malleolus fractures. Methods: Six nonosteoporotic fresh-frozen cadaver shanks and feet in matched pairs underwent a vertical osteotomy of the medial malleolus to simulate the supination adduction type injury. Osteoporosis was measured using DEXA scans. One specimen from each pair was fixed with a one-third tubular buttress plate and the other with screw-only fixation. The specimens were then axially loaded for 100 000 cycles to simulate protected weightbearing, and subsequently loaded to failure in supination. Stiffness, fracture displacement, and load to failure were recorded. Statistical significance was set at P <.05. Results: There were no measurable differences in displacement between the 2 constructs during axial cyclic loading after 100 000 cycles (plate, 0.74 ± 0.09 mm; screws, 0.79 ± 0.18 mm; P = .225). During supination and axial load to failure, the plate outperformed the screw construct. For load to failure (2 mm displacement) at the fracture site, the plate group failed at 716 ± 240 N, whereas the screw group failed at 567 ± 237 N ( P = .015). During load to catastrophic failure, the plate group outperformed the screw group (plate, 6011 ± 1646 N; screws, 4578 ± 1837 N; P = .002). Conclusion: For vertical medial malleolar fractures, the screw-only construct demonstrated no statistical difference when compared to buttress plating for cyclical axial loading, simulating early weightbearing in a boot. However, buttress plating is 21% to 24% stronger than the screw-only fixation construct in overall strength and prevention of catastrophic failure when loading in a supinated position. Clinical Relevance: The screw-only construct is biomechanically similar to a buttress plate when simulating early protected weightbearing. This suggests that early weightbearing as tolerated in a controlled ankle motion boot beginning 2 weeks postoperatively is mechanically safe for this fracture pattern and does not result in unacceptable amounts of fracture displacement. This construct may be useful as a less invasive treatment modality for the treatment of vertical medial malleolus fractures in select patients.
Category: Trauma; Midfoot/Forefoot Introduction/ Purpose: Primary arthrodesis of Lisfranc and midfoot fracture-dislocations is a reliable treatment option, yet concerns remain about nonunion and dorsiflexion malunion. The use of a new generation of nitinol staples has proliferated in midfoot arthrodesis. The purpose of this study is to examine the use of nitinol staples in primary arthrodesis of acute Lisfranc fracture-dislocations, comparing outcomes to traditional plate and screw fixation. The primary hypothesis is that nonunion rates are lower with constructs that include nitinol staples than those with plates and screws alone. Secondary hypotheses are: 1. Total operative and tourniquet time are shorter using nitinol staples. 2. Reoperation rates are lower using nitinol staples. 3. Dorsiflexion malunion rates are lower using nitinol staples. 4. Functional outcome scores will indicate comparable post-arthrodesis disability. Methods: Midfoot fracture-dislocations treated with primary arthrodesis by seven foot and ankle orthopaedic surgeons at a tertiary referral center from 1/1/2012 to 8/1/2021 were reviewed. Patients with open fractures, fractures managed with external fixation, Charcot arthropathy, neuropathy, previous midfoot surgery, or concomitant hindfoot/ankle fractures were excluded. Of 160 eligible patients, 121 patients met the required 4-month minimum radiographic follow-up. Preoperative records were reviewed, evaluating for associated metatarsal and cuneiform fractures, operative and tourniquet time, joints included, and fixation construct. Outcomes were analyzed at both patient and individual joint levels. Patients (121 total) and individual joints (305 total) were categorized as either staples alone (45 patients, 154 joints), staples plus plates and screws (hybrid) (45 patients, 40 joints), or plates and screws alone (31 patients, 111 joints). Postoperative radiographs were analyzed for union and malunion at each joint fused. Medical records were reviewed for postoperative complications. FAAM, VR-12, and NPRS were collected. Results: When assessed at the individual joint level, the nonunion rate was higher (8.1%, 9/111) among joints fixed with plate and screw constructs than with hybrid (2.5%, 1/40) or staple only constructs (1.3%, 2/154) (P = 0.017). Of the 12 nonunions in the study, 6 had either a metatarsal or cuneiform fracture. Median OR and tourniquet time were both shorter for hybrid (92 & 83 minutes) and staple only (67 & 63 minutes) constructs compared to plate and screw only fixation (106 & 95 minutes) (P = 0.0003 & < 0.0001). There were 15 (12.4%) reoperations including 10 hardware removals, 3 nonunion revisions, and 1 malunion revision. There was no difference in reoperation, malunion (14 total, 11.6%), or patient reported outcome measure between fixation types. Conclusion: Nitinol staples are effective in achieving bony fusion when used alone or in combination with plates and screws. Their use should be considered for primary arthrodesis of Lisfranc and midfoot fracture-dislocations due to lower rates of nonunion and shorter tourniquet and operative time compared to traditional plate and screw fixation. Further studies are needed to determine if staples decrease the risk for dorsiflexion malunion and improve patient reported outcomes.
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