Is surgery for displaced, midshaft clavicle fractures in adults cost-effective? Results based on a multicenter randomized, controlled trial

OBJECTIVES

To determine the cost-effectiveness of open reduction internal fixation (ORIF) of displaced, midshaft clavicle fractures in adults.

DESIGN

Formal cost-effectiveness analysis based on a prospective, randomized, controlled trial.

SETTING

Eight hospitals in Canada (seven university-affiliated and one community hospital).

PATIENTS/PARTICIPANTS

One hundred thirty-two adults with acute, completely displaced, midshaft clavicle fractures.

INTERVENTION

Clavicle ORIF versus nonoperative treatment.

MAIN OUTCOME MEASUREMENTS

Utilities derived from SF-6D.

RESULTS

The base case cost per quality-adjusted life-year (QALY) gained for ORIF was $65,000. Cost-effectiveness improved to $28,150/QALY gained when the functional benefit from ORIF was assumed to be permanent with cost per QALY gained falling below $50,000 when the functional advantage persisted for 9.3 years or more. In other sensitivity analyses, the cost per QALY gained for ORIF fell below $50,000 when ORIF cost less than $10,465 (base case cost $13,668) or the long-term utility difference between nonoperative treatment and ORIF was greater than 0.034 (base case difference 0.014). Short-term disutility associated with fracture healing also affected cost-effectiveness with the cost per QALY gained for ORIF falling below $50,000 when the utility of a fracture treated nonoperatively before union was less than 0.617 (base case utility 0.706) or when nonoperative treatment increased the time to union by 20 weeks (base case difference 12 weeks).

CONCLUSIONS

The cost-effectiveness of ORIF after acute clavicle fracture depended on the durability of functional advantage for ORIF compared with nonoperative treatment. When functional benefits persisted for more than 9 years, ORIF had a favorable value compared with many accepted health interventions.

Hip fracture outcome: is there a "July effect"?

We assessed the differential complications and mortality rates of teaching versus nonteaching hospitals in July against other month-to-month differences in a cohort of 324,988 elderly patients hospitalized for a femoral neck or intertrochanteric fracture (data taken from the 1998-2003 National Inpatient Sample). Demographics were similar between teaching and nonteaching hospitals and across admission months. The overall mortality rate was 3.64% and was slightly higher in teaching hospitals compared with nonteaching hospitals (3.69% vs. 3.61%, relative risk [RR] = 1.0062, 95% CI 0.99-1.02). The adjusted relative risk (RR) for mortality in July/August was significantly higher than the overall adjusted RR and compared with all other month pairs, indicating higher in-hospital mortality rates in teaching hospitals compared with nonteaching hospitals. Intraoperative complications and length of stay were statistically significantly greater in teaching hospitals but did not demonstrate a "July effect." Teaching hospitals had lower perioperative complication rates. Elderly hip fracture patients treated at teaching hospitals had 12% greater relative risk of mortality in July/August (ie, experience a "July effect") compared with nonteaching hospitals during that time period (1998-2003). Although various methods exist for exploring the "July effect," it is critical to take into account inherent month-to-month variation in outcomes and to use nonteaching hospitals as a control group.

Is early internal fixation preferred to cast treatment for well-reduced unstable distal radial fractures?

BACKGROUND

In the treatment of distal radial fractures, physicians often advocate internal fixation over cast treatment for potentially unstable fracture patterns, citing the difficulties of successful nonoperative treatment and a decrease in patient tolerance for functional deficiencies. This study was performed to evaluate whether early internal fixation or nonoperative treatment would be preferred for displaced, potentially unstable distal radial fractures that initially had an adequate reduction.

METHODS

A decision analytic model was created to compare early internal fixation with use of a volar plate and nonoperative management of a displaced, potentially unstable distal radial fracture with an acceptable closed reduction. To identify the optimal treatment, quality-adjusted life expectancy was estimated for each management approach. Data from the literature were used to estimate rates of treatment complications (e.g., fracture redisplacement with nonoperative treatment) and of treatment outcomes. Mean health-state utilities for treatment outcomes of painless malunion, functional deficit, and painful malunion were derived by surveying fifty-one adult volunteers with use of the time trade-off method. Sensitivity analysis was used to determine which model parameters would change the treatment decision over a plausible range of values.

RESULTS

Early internal fixation with volar plating was the preferred strategy in most scenarios over the ranges of parameters available, but the margins were small. The older patient (mean age, 57.8 years) who sustains a distal radial fracture can expect 0.08 more quality-adjusted life years (29.2 days) with internal fixation compared with nonoperative treatment. Sensitivity analysis revealed no single factor that changed the preferred option within the reported ranges in the base case. However, the group of patients sixty-five years or older, who had lower disutility for painful malunion, derived a very small benefit from operative treatment (0.01 quality-adjusted life year or 3.7 days) and would prefer cast treatment in some scenarios.

CONCLUSIONS

Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature. This long-term gain in quality-adjusted life years outweighed the short-term risks of surgical complications, making early internal fixation the preferred treatment in most cases. However, the difference was quite small. Patients, especially those over sixty-four years old, who have lower disutility for the malunion and painful malunion outcome states may prefer nonoperative treatment.

A cost-effectiveness analysis of the arthroplasty options for displaced femoral neck fractures in the active, healthy, elderly population

This study was performed to explore the cost-effectiveness of total hip arthroplasty (THA) compared with hemiarthroplasty (HEMI) in the treatment of displaced femoral neck fractures in active otherwise healthy older patients in whom the optimum treatment is believed to be an arthroplasty procedure. A Markov decision model was used to determine whether THA or HEMI was most cost-effective for the management of a displaced femoral neck fracture in this patient population. Total hip arthroplasty was associated with an average cost $3000 more than HEMI, and the average quality-adjusted life year gain was 1.53. The incremental cost-effectiveness ratio associated with the THA treatment strategy is $1960 per quality-adjusted life year. Currently available data support the use of THA as the more cost-effective treatment strategy in this specific population. The increased upfront cost appears to be offset by the improved functional results when compared with HEMI in this select patient group.

Clinical pathway after hip fracture

PURPOSE

Hip fracture occurs frequently, resulting in considerable morbidity, mortality and utilization of healthcare resources. Technical advances in fracture fixation and surgical treatment have improved outcomes following hip fracture in the elderly. However, further improvement in outcomes of hip fracture patients may be possible with utilization of a clinical pathway designed to enhance outcomes in a standardized, cost-effective manner. This paper presents a clinical pathway for the treatment of hip fractures in the elderly with the above aims.

METHOD

The clinical pathway presented is based on personal experience and literature pertaining to the treatment of the elderly hip fracture patient. It outlines a suggested algorithmic approach to the patient that begins with the initial evaluation, progresses on through pre-operative and operative management, and ends with post-operative rehabilitation and treatment.

RESULTS

The clinical pathway for the hip fracture patient in this paper is a working treatment algorithm that has been successful in personal experience.

CONCLUSION

This treatment algorithm has been utilized successfully in personal experience. Further input from healthcare professionals may prove to enhance outcomes in a cost-effective, standardized manner.

Distal radial fracture treatment: what you get may depend on your age and address

BACKGROUND

Distal radial fractures are common and confer a considerable financial burden on the health-care system; however, controversy surrounds the optimal treatment of these injuries. This study was performed to determine (1) the rate of distal radial fractures in the U.S. Medicare population stratified by hospital referral region and (2) whether the type of fracture treatment is affected by patient age, race, sex, comorbidity, or hospital referral region.

METHODS

A 20% sample of Medicare Part-B claims from the years 1998 through 2004 was analyzed. Procedural codes for nonoperative treatment, percutaneous fixation, and open reduction and internal fixation of distal radial fractures were identified. These codes were then used to determine the overall rate of distal radial fracture. The rates of distal radial fracture were then evaluated according to hospital referral region and patient age, sex, comorbidity, and race. The types of treatment were determined and were also analyzed on the basis of hospital referral region and patient age, sex, comorbidity, and race. Regression analysis was performed with use of the above variables.

RESULTS

We identified 107,190 patients. The rate of distal radial fracture was 125 per 10,000 Medicare beneficiaries. The rate of the fracture in white individuals (136 per 10,000) was more than twice that in non-white individuals (fifty-nine per 10,000), and the rate in women (189 per 10,000) was 4.8 times higher than that in men (thirty-nine per 10,000). The overall fracture rate varied widely across the United States, from forty-seven per 10,000 beneficiaries in New Orleans, Louisiana, to 220 per 10,000 in Spartanburg, South Carolina. Treatment rates were similar across race, with the rate of nonoperative treatment being 84% for white beneficiaries compared with 83% for non-white beneficiaries, the rate of percutaneous fixation being 11% for white beneficiaries compared with 10% for non-white beneficiaries, and the rate of open treatment being 6% for white beneficiaries compared with 7% for non-white beneficiaries. There was variation across the country, with the rate of nonoperative treatment ranging from 60% in San Luis Obispo, California, to 96% in Covington, Kentucky; the rate of percutaneous fixation ranging from 2% in Boulder, Colorado, to 39% in San Luis Obispo, California; and the rate of open treatment ranging from 0.4% in Wilkes-Barre, Pennsylvania, to 25% in Great Falls, Montana. While the rates of percutaneous fixation and nonoperative treatment remained relatively stable, the overall rate of operative fixation nearly doubled from 5% in 1998 to 8% in 2004.

CONCLUSIONS

There is wide variation in the rate of distal radial fractures across sex, age, race, and geographic region in the United States. There is also significant variation in the treatment of these fractures, driven mainly by age and region. Between 1998 and 2004, a strong trend toward more frequent operative fixation was apparent. While white individuals had more than twice as many fractures as did non-white individuals, there did not appear to be significant racial variation in the treatment of this injury.

Return to sports following operatively treated ankle fractures

BACKGROUND

This study investigated which variables influence patients' return to sports after operative fixation of an unstable ankle fracture.

MATERIALS AND METHODS

Over a 5-year period, 488 patients underwent surgical repair of an unstable ankle fracture. 243 patients preoperatively identified themselves as participating in vigorous activity. Clinical evaluation, functional outcome scores, and radiographic findings were reviewed retrospectively.

RESULTS

At 3 months postoperatively, only 3% of all patients had returned to full sports. At 6 months, 14% of patients had returned, while at one year, only 24% of patients had returned. Younger age was predictive of return to sports by 3 months (p = 0.02), 6 months (p = 0.02) and 12 months (p = 0.0001). Males were more likely to return to sports at 6 (p = 0.001) and 12 months (p = 0.040). At 1 year, 88% of recreational athletes had returned to sports, while only 11.6% of competitive athletes had returned to sports (p = 0.043). At 12 months, bimalleolar injuries were more likely to return to sports than unimalleolar ankle fractures (p = 0.042). Furthermore, patients without an associated syndesmotic injury were more likely to return to athletic activities at 12 months (p = 0.011). A patient with an ASA of one or two was ten times more likely to return to sports versus a patient with an ASA of three or four (odds ratio > 10, p = 0.010).

CONCLUSION

Predictors of return to sporting activities at one year include younger age, male gender, no or mild systemic disease, and a less severe ankle fracture. Negative predictors include older age, female gender, and the presence of severe medical comorbidities.

Variation in hip fracture treatment: are black and white patients treated equally?

To examine disparity in race for hip fracture treatment, we identified femoral neck fractures and pertrochanteric fractures from a 20% sample of 1999-2003 Medicare part B claims data and stratified patients by treatment: total hip arthroplasty (THA), hemiarthroplasty (HA), open reduction and internal fixation (ORIF), and nonoperative management (NM). Covariables included patient race, age, sex, and Charlson Comorbidity Index score. The geographic variable was the hospital referral region (306 such US regions are defined in The Dartmouth Atlas of Health Care). Logistic regression was performed to evaluate the independent effect of each variable on treatment received. There were 49,755 femoral neck fractures (94% white patients) and 90,440 pertrochanteric fractures (94% white). For femoral neck fractures, no significant differences were found by race (P=.16) in adjusted mean rates for THA (2.73%), HA (77.8%), ORIF (26.9%), or NM (2.95%). For pertrochanteric fractures, no significant differences were found (P=.09) in adjusted mean rates for THA (0.47%), HA (8.24%), ORIF (94.8%), or NM (2.11%). There were no significant disparities by race across hospital referral regions with regard to type of fracture treatment.

The association of race, gender, and comorbidity with mortality and function after hip fracture

BACKGROUND

Few studies of hip fracture have large enough samples of men, minorities, and persons with specific comorbidities to examine differences in their mortality and functional outcomes. To address this problem, we combined three cohorts of hip fracture patients to produce a sample of 2692 patients followed for 6 months.

METHOD

Data on mortality, mobility, and other activities of daily living (ADLs) were available from all three cohorts. We used multiple regression to examine the association of race, gender, and comorbidity with 6-month survival and function, controlling for prefracture mobility and ADLs, age, fracture type, cohort, and admission year.

RESULTS

The mortality rate at 6 months was 12%: 9% for women and 19% for men. Whites and women were more likely than were nonwhites and men to survive to 6 months, after adjusting for age, comorbidities, and prefracture mobility and function. Whites were more likely than were nonwhites to walk independently or with help at 6 months compared to not walking, after adjusting for age, comorbidities, and prefracture mobility and function. Dementia had a negative impact on survival, mobility, and ADLs at 6 months. The odds of survival to 6 months were significantly lower for people with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and/or cancer. Parkinson's disease and stroke had negative impacts on mobility and ADLs, respectively, among survivors at 6 months.

CONCLUSIONS

The finding of higher mortality and worse mobility for nonwhite patients with hip fractures highlights the need for more research on race/ethnicity disparities in hip fracture care.

Fractures of the distal part of the radius. The evolution of practice over time. Where's the evidence?

BACKGROUND

During the administration of the oral (Part II) examinations for the American Board of Orthopaedic Surgery over the past nine years, it has been observed that orthopaedic surgeons are opting more often for open treatment as opposed to percutaneous fixation of distal radial fractures. Evidence to support this change in treatment is thought to be deficient. The present study was designed to identify changes in practice patterns regarding operative fixation of distal radial fractures between 1999 and 2007 and to assess the results of those treatments over time.

METHODS

As a part of the certification process, Part II candidates submit a six-month case list to the American Board of Orthopaedic Surgery. In the present study, we searched the American Board of Orthopaedic Surgery Part II database to evaluate changes in treatment over time and to identify available outcomes and associated complications of open and percutaneous fixation of distal radial fractures. All distal radial fractures that had been treated surgically over a nine-year period (1999 to 2007) were reviewed. The fractures were categorized according to fixation method with use of surgeon self-reported surgical procedure codes. Comparisons of percentage treatment type by year were made. Utilization was analyzed by geographic region, and open and percutaneous fixation were compared with regard to complications and outcomes as self-reported by candidates during the online application process.

RESULTS

The proportion of fractures that were stabilized with open surgical treatment increased from 42% in 1999 to 81% in 2007 (p < 0.0001). Although the differences were small, surgeon-reported outcomes revealed that a higher percentage of patients who had been managed with percutaneous fixation had no pain and normal function but some deformity as compared with patients who had had open treatment. Patients who had been managed with percutaneous fixation had a higher overall complication rate (14.0% compared with 12.3%; p < 0.006) and a higher rate of infection (5.0% compared with 2.6%; p < 0.0001) than those who had been managed with open treatment. Patients who had had open treatment had a higher rate of nerve palsy and/or injury (2.0% compared with 1.2%; p = 0.001). No other differences in the reported complication rates were found between the two techniques.

CONCLUSIONS

A striking shift in fixation strategy for distal radial fractures occurred over the past decade among younger orthopaedic surgeons in the United States. These changes occurred despite a lack of improvement in surgeon-perceived functional outcomes.

Orthopaedic anesthesia - part 1. Commonly used anesthetic agents in orthopaedics

Anesthesia is a broad discipline; for orthopaedic applications, the type and location of the planned orthopaedic procedure is important in the selection of the most appropriate anesthetic agent and technique. The purpose of this overview is to: 1. highlight the role of several anesthetic agents commonly used in an orthopaedic setting and 2. to familiarize the orthopaedist with those techniques of regional anesthesia that have implications for emergency rooms and other ambulatory settings. Because the subject matter is expansive in scope, it is necessary to address each of the above objectives separately, in two different articles. Part 1 describes anesthetic agents, whereas Part 2 encompasses techniques of administering regional anesthesia.

Predictors of mortality after hip fracture: a 10-year prospective study

The role of medical, social, and functional covariates on mortality after hip fracture was examined over a 16-year period. A total of 1109 patients with hip fractures were included in a prospective database. The inclusion criteria were patients who were age 65 years or older, ambulatory prior to fracture, cognitively intact, living in their own home at the time of the fracture, and had sustained a nonpathological femoral neck or intertrochanteric chip fracture. Data were analyzed using a Cox proportional hazards model. Mortality was compared with a standardized population, and standardized mortality ratios were calculated for 1, 2, 3, 5, and 10 years,respectively. The 1-, 2-, 5- and 10-year mortality rates were 11.9%, 18.5%, 41.2%, and 75.3%, respectively. The predictors of mortality were advanced age, male gender, high American Society of Anesthesiologists (ASA)classification, the presence of a major postoperative complication, a history of cancer, chronic obstructive pulmonary disorder, a history of congestive heart failure,ambulating with an assistive device, or being a household ambulator prior to hip fracture. The increased mortality risk was highest during the first year after hip fracture and returned to the risk of the standard population 3 years postoperatively. Males who are 65 to 84 years had the highest mortality risk.

Orthopaedic anesthesia - part 2. Common techniques of regional anesthesia in orthopaedics

Anesthesia may be considered in terms of two categories: general and regional. The aim of general anesthesia is to induce analgesia, sedation, amnesia, suppression of autonomic reflexes, and relaxation of muscles. Regional anesthesia is more site-specific and is typically divided into three categories based on the location of injection: 1. a central neuraxial block is an injection of an anesthetic drug into the epidural or intrathecal space; 2. a peripheral nerve block is an injection near the nerve or plexus supplying the area under operation; and 3. a field block is an injection into the adjoining tissues with subsequent diffusion into the surgical area (in orthopaedics, it is typically employed for minor procedures of the hand or foot). Of these three categories of regional anesthesia (i.e., neuraxial, peripheral, and field blocks), this article focuses on the latter two. Although neuraxial blocks comprise an important part of regional anesthesia, they are typically performed by anesthesiologists in an operative setting for major procedures of the lower extremities. The intent of this article is to familiarize the orthopaedist with techniques that have implications for emergency rooms and other ambulatory settings in which regional techniques are sometimes favored over general alternatives because they entail less risk of systemic side effects and may involve more cost-effective use of resources.

Does hospital surgical volume affect in-hospital outcomes in surgically treated pelvic and acetabular fractures?

A retrospective evaluation was done to determine the relationship between hospital volume and in-hospital mortality, complications, and length of stay in patients with operatively treated fractures of the pelvis or acetabulum. Patients were divided into three groups based on hospital volume. High volume centers had higher percentages of patients with one or more comorbidities, but who were less severely injured. Mortality rates were highest in small volume centers. Moderate volume centers had the lowest odds of death. Complication rates were similar between small and high volume hospitals. Length of stay was shortest in high volume centers. In-hospital outcomes associated with surgical fixation of the pelvis, acetabulum, or both were not uniformly associated with hospital volume.

Risk of injury associated with the use of seat belts and air bags in motor vehicle crashes

Although air bags have been reported to reduce passenger mortality in frontal collisions, they have also been reported as a cause of injury in motor vehicle collisions(MVCs). The purpose of this study was to evaluate a large cohort of patients involved in MVCs to determine mortality and the pattern of injuries associated with seat belt use and air bag deployment. Information on patients involved in MVCs from 1988 to 2004 was obtained from the National Trauma Data Bank (NTDB). The data was evaluated based on four groups of safety devices: seat belt and deployed air bag (SBAB), seat belt only (SBO), deployed air bag only (ABO), and no safety devices (None). A total of 35,333 patients met study inclusion criteria. Air bags and seat belts used in combination decreased the risk of potentially fatal injuries, but increased the risk of lower extremity injuries (odds ratio, 1.35). The use of any type of restraint led to a decrease in the risk of injury or mortality in MVCs. Only half of all individuals in this study used any type of restraint device, which indicates the need for significant improvements in public health and safety seat belt utilization programs.

The effects of alcohol on in-hospital mortality in drivers admitted after motor vehicle accidents

BACKGROUND

The effects of alcohol on morbidity and mortality following motor vehicle accidents (MVAs) are controversial. This study was performed to address the effect of alcohol on in-hospital mortality for drivers in MVAs admitted to a trauma center before and after controlling for injury severity, safety device use, and patient demographics.

METHODS

A retrospective study was performed using data from the National Trauma Data Bank, version 4.3. The cohort consisted of drivers in an MVA who were 15 years of age or older, had been admitted to the hospital on the same day as the accident, were screened for alcohol, and had no documentation of drugs in their system. Analyses were performed to explore the relationships between patient age, gender, race, presence of head injury, comorbid- ity status, injury severity score (ISS), and presence of alcohol and in-hospital mortality.

RESULTS

The cohort consisted of 67,021 patients, 38.3% of whom were drivers involved in an MVA and, following screening, were found to have alcohol present in their system. Drivers who had alcohol present were more likely to be younger, male, White, not using a safety device, and to have sustained a head injury, than drivers who had no alcohol present in their system (alcohol absent driv- ers) at hospital presentation. After controlling for potential confounding variables, risk factors for in-hospital mortality included male sex, older age, and higher injury severity, while protective factors included the presence of alcohol and use of safety devices. The single strongest predictor of mortality was ISS. Sensitivity analyses to relect the impact of inlation in true ISS scores in the subgroup of patients who had alcohol present as well as a head injury revealed that the protective effect of alcohol diminished and became nonsignificant when the ISS was reduced by 9% and became a significant risk factor for in-patient mortality when the false elevation in ISS was estimated at 21%.

CONCLUSIONS

These results suggest the importance of carefully considering the consequences that falsely inlated ISS scores might have for patients with alcohol present. Future work should evaluate the possible inlation of ISS and attempt to reconcile different interpreta- tions of the effects that the presence of alcohol may have on MVA mortality based by jointly considering crash site and in-hospital data.

The American Orthopaedic Association's "own the bone" initiative to prevent secondary fractures

BACKGROUND

The American Orthopaedic Association initiated its Own the Bone pilot project in 2005 in order (1) to assess current orthopaedic practices for the prevention of secondary fractures in adult patients who have sustained a low-energy fracture (fragility fracture), (2) to pilot quality-improvement tools designed to improve the application of evidence-based strategies for the prevention of secondary fractures, and (3) to identify barriers to the broader implementation of the Own the Bone project and explore how to overcome them.

METHODS

The ten-month pilot project took place at fourteen sites (thirteen inpatient sites and one outpatient site) and involved 635 participants with a median age of seventy-seven years. The primary outcome measures were the percentages of patients who received (1) counseling on calcium and vitamin-D supplementation, weight-bearing exercise, smoking cessation, and fall prevention, (2) bone mineral density testing, and (3) pharmaceutical intervention to prevent or treat osteoporosis. Secondary outcome measures focused on improved information flow and included the percentage of patients whose physicians were sent a letter recommending the evaluation and treatment of the fracture and the percentage of patients who received a letter recommending that they see their primary-care physician for evaluation and treatment of osteoporosis associated with the fracture.

RESULTS

The intervention produced significant improvements (p < 0.0001) in patient counseling on calcium and vitamin-D supplementation, exercise, fall prevention, and communication with primary-care providers and the patients themselves. No improvements were shown in the ordering of bone mineral density testing or the prescription of pharmacotherapy. The most significant improvements (p < 0.0001) were in improved communication with primary-care physicians and in efforts to educate patients about their risk of future fracture.

CONCLUSIONS

The Own the Bone initiative offers tools to improve the prevention of secondary fractures and a structure to monitor physician compliance. The American Orthopaedic Association plans to use these quality-improvement tools to stimulate change in both physician and patient behavior following low-energy fractures.

Does a traction-internal rotation radiograph help to better evaluate fractures of the proximal femur?

BACKGROUND

The standard radiographic series for evaluation of a suspected hip fracture in most centers includes an anteroposterior (AP) radiograph of the pelvis, as well AP and cross-table lateral views of the hip. The natural femoral neck anteversion, as well as the fracture deformity, however, may make accurate fracture classification difficult. We have noted that inexperienced physicians sometimes misclassify hip fractures based on the initial radiographic series, which may lead to errors both in surgical planning and implant choice. At our institution, we routinely obtain a physician-assisted traction-internal rotation radiograph of the affected hip in all fractures of the proximal femur. The purpose of the current study was to examine the usefulness of the traction-internal rotation radiograph for the classification of hip fractures by junior residents in our department.

MATERIALS AND METHODS

Forty-seven sets of complete radiographs (AP pelvis, AP hip, cross-table lateral, traction- internal rotation views) of patients who sustained a proximal femur fracture were identified. Fifteen first year orthopaedic residents (PGY2) individually reviewed the cases and classified them as one of six possible choices: 1. nondisplaced femoral neck fracture, 2. displaced femoral neck fracture, 3. stable intertrochanteric fracture, 4. unstable intertrochanteric fracture, 5. intertrochanteric fracture with subtrochanteric extension, or 6. subtrochanteric fracture. Each fracture case was classified after first reviewing the standard hip series (AP pelvis, AP hip, and cross-table lateral). A traction-internal rotation radiograph was then added to each case, and any changes in the initial classification were noted. The resident's classification was then compared with those of the senior investigators (KJK, KAE), who used all four views for classification.

RESULTS

Reviewing a traction-internal rotation radiograph led to a statistically significant increase in agreement between the resident and senior investigators' classification (71.9% to 77.9%, p value < or = 0.01). The residents were more accurately able to identify fracture patterns as femoral neck (from a prior 98.5% to 99.3% after reviewing a traction-internal rotation view), intertrochanteric (a prior 87.7% to 91.3%), and subtrochanteric (prior 22.9% to 28.9%) after reviewing the additional radiograph. There were a total of 57 (8.1% of all responses) changes in classification after the traction-internal rotation view, 42 of which involved a change from an incorrect to a correct classification. In 50% of the changed responses, the correct classification would have led to a change in implant or surgical procedure choice, or both.

CONCLUSION

The routine addition of a traction-internal rotation radiograph increased the ability to accurately classify proximal femur fractures by junior residents in our department. This has a direct impact in accurate surgical planning and implant choice.

The "Z-effect" phenomenon defined: a laboratory study

The Z-effect phenomenon is a potential complication of two lag screw intramedullary nail designs used for fixation of intertrochanteric hip fractures, in which the inferior lag screw migrates laterally and the superior lag screw migrates medially during physiologic loading. The current investigation was undertaken in an attempt to reproduce the Z-effect phenomenon in a laboratory setting. Sixteen different simulated femoral head and neck constructs having varying compressive strengths were created using four densities of solid polyurethane foam and instrumented with a two-screw cephalomedullary intramedullary nail. Each specimen was then cyclically loaded with 250 N vertical loads applied for 10, 100, 1000, and 10,000 cycles. Measurement of screw displacement with respect to the lateral aspect of the intramedullary nail was made after each cyclic increment. The inferior lag screw migration component of the Z-effect phenomenon was reproduced in specimens with head compressive strengths that were higher than the compressive strengths of the neck. Specimens with the greatest difference in head-neck compressive strength demonstrated the most significant displacement of the inferior lag screw without any displacement of the superior lag screw. Specimens with a femoral neck compressive strength of 0.91 MPa of and a head compressive strength of 8.8 MPa resulted in more than one centimeter of inferior lag screw lateral migration after 10,000 cycles of vertical loading. Models where the femoral head had a higher compressive strength than that of the femoral neck may simulate fracture patterns with significant medial cortex comminution that are prone to varus collapse.

Complications after ankle fracture in elderly patients

BACKGROUND

Controversy exists regarding the risks and benefits of ankle fracture treatment in elderly patients. The purpose of this study was to use the United States Medicare database to determine the complication rate for ankle fractures in elderly patients treated operatively and to compare it to fractures treated nonoperatively.

METHODS

We used the National Medicare Claims History System to study all enrollees who sustained ankle fractures between 1998 and 2001. A total of 33,704 patients were identified and their outcomes at numerous time points were evaluated. These outcomes included mortality, rate of repeat hospitalization, rate of medical and operative complications, and the rate of additional surgery. The predictor variables were either nonoperative or operative intervention. Covariates included patient age, gender, race, medical comorbidity status, and fracture type.

RESULTS

Patients treated nonoperatively had significantly higher mortality (p < 0.05) than those treated operatively at all time periods except for 30 days. However, patients treated operatively had significantly higher rehospitalization rates (p < 0.05) at all time periods studied. The medical and operative complication rates at all time periods were less than or equal to 2% for patients who had either operative or nonoperative treatment. In the group that had operative management, a relatively small number of patients had additional procedures. Eleven percent had removal of hardware. Less than 1% of all patients had revision of the internal fixation, arthroplasty, arthrodesis, or amputation.

CONCLUSION

In properly selected cases, the complication rates of both operatively and nonoperatively treated elderly patients are low.

Does a positive ankle stress test indicate the need for operative treatment after lateral malleolus fracture? A preliminary report

OBJECTIVES

At our institution, a standardized protocol using magnetic resonance imaging (MRI) to evaluate ankle stability and need for surgery following a positive manual stress test for isolated lateral malleolus fractures has been used. The purpose of this study was to evaluate the results using this standardized protocol.

DESIGN

Retrospective review.

SETTING

University teaching hospital.

PATIENTS

: Twenty-one patients who had a positive ankle stress test (>or=5 mm clear space widening) after isolated Weber B lateral malleolus fracture were further evaluated by MRI to determine the status of the deep deltoid ligament.

INTERVENTION

If the MRI showed the deltoid ligament was completely disrupted, the patient was advised to have operative ankle repair. However, if the MRI demonstrated that the deep deltoid was intact or only partially disrupted, the patient was treated nonoperatively in a walking boot with weightbearing as tolerated ambulation.

MAIN OUTCOME MEASUREMENT

Patients were followed until fracture union and contacted at 12-month minimum follow-up to determine outcomes by radiographic evaluation, health related quality of life (HRQOL) based on Short Form (SF)-36 results and functional outcomes based on the American Orthopaedic Foot and Ankle (AOFAS) and patient report of treatment satisfaction.

RESULTS

Twenty-one patients had an MRI after a positive ankle stress test and comprised the study group. There were 12 men and 9 women with an average age of 27 years (range, 16-62 years). Absolute medial clear space measurement on stress testing ranged from 5 to 8 mm. In all, 19 of 21 patients (90%) had evidence of partially torn deep deltoid ligament on MRI and were treated nonoperatively, whereas two patients had MRI findings of a complete deep deltoid injury and underwent surgical treatment. There were no statistically significant correlations between the medial clear space measurements and MRI documentation of complete deltoid ligament rupture. All fractures united without evidence of residual medial clear space widening or posttraumatic joint space narrowing. Of the 15 patients who were available for 1 year minimum follow-up and agreed to come back for clinical and radiographic evaluation, 14 had an AOFAS score of 100, with the remaining patient having a score of 85. HRQOL based on SF-36 results indicated all patients were above or at normal levels, and all patients reported that they were satisfied with their treatment; 93% (14/15) indicated that they would make the same treatment decision again.

CONCLUSIONS

Using our protocol, we were able to identify and provide effective nonoperative care to 19 patients who otherwise might have underwent operative treatment after an isolated lateral malleolus fracture. Further work is needed to identify the subset of patients who could be treated nonoperatively without a need for MRI scanning.

Are outcomes of bimalleolar fractures poorer than those of lateral malleolar fractures with medial ligamentous injury?

BACKGROUND

Recommendations for surgical treatment and expected outcomes differ for two unstable patterns of supination-external rotation ankle injuries. We compared the demographic characteristics and functional outcome following surgical stabilization between the two types of supination-external rotation type-4 fractures: distal fibular fracture with a deltoid ligament rupture and bimalleolar fracture.

METHODS

Demographic data on 456 patients in whom an unstable fracture of the ankle was treated surgically were entered into a database and the patients were prospectively followed. Two hundred and sixty-six of these patients sustained either a bimalleolar fracture or a lateral malleolar fracture with insufficiency of the deltoid ligament and widening of the medial clear space. No medial fixation was used in the patients with a deltoid ligament injury. All patients followed a similar postoperative protocol. The patients were followed clinically and radiographically at three, six, and twelve months after the surgery. Function was assessed with the Short Musculoskeletal Function Assessment and the American Orthopaedic Foot and Ankle Society score.

RESULTS

Bimalleolar fractures were more commonly seen in female patients, in those older than sixty years of age, and in patients with more comorbidities. There was no significant association between the fracture pattern and either diabetes or the length of the hospital stay. At a minimum of one year postoperatively, the patients with a bimalleolar fracture had significantly worse function, even after we controlled for all other variables. The overall complication rate, including elective hardware removal, was also higher in the group with a bimalleolar fracture (seventeen compared with nine patients).

CONCLUSIONS

At one year after surgical stabilization of an unstable ankle fracture, most patients experience little or mild pain and have few restrictions in functional activities. However, the functional outcome for those with a bimalleolar fracture is worse than that for those with a lateral malleolar fracture and disruption of the deltoid ligament, possibly because of the injury pattern and the energy expended.

Does obesity influence the outcome after the operative treatment of ankle fractures?

Many orthopaedic surgeons believe that obese patients have a higher rate of peri-operative complications and a worse functional outcome than non-obese patients. There is, however, inconsistency in the literature supporting this notion.

This study was performed to evaluate the effect of body mass index (BMI) on injury characteristics, the incidence of complications, and the functional outcome after the operative management of unstable ankle fractures.

We retrospectively reviewed 279 patients (99 obese (BMI ≥ 30) and 180 non-obese (BMI < 30) patients who underwent surgical fixation of an unstable fracture of the ankle. We found that obese patients had a higher number of medical co-morbidities, and more Orthopaedic Trauma Association type B and C fracture types than non-obese patients. At two years from the time of injury, however, the presence of obesity did not affect the incidence of complications, the time to fracture union or the level of function.

These findings suggest that obese patients should be treated in line with standard procedures, keeping in mind any known associated medical co-morbidities.

Avulsion fractures of the fifth metatarsal base: a prospective outcome study

BACKGROUND

This prospective study was done to evaluate functional outcomes after acute avulsion fractures of the fifth metatarsal base.

METHODS

Fifty-two patients who sustained an avulsion fracture of the fifth metatarsal base and presented to the outpatient clinic of our hospital system were treated according to a standardized protocol. A total of 49 patients (50 fractures) were available for 1-year followup. There were eight men and 41 women with an average age of 41.9 (range 17 to 81) years. The lower extremity was placed in a hard-soled shoe, and patients were allowed to bear weight as tolerated. Baseline data collection consisted of demographic information, and radiographic, and functional evaluation. Patients were seen at regularly scheduled visits for 6 months and then contacted at 1 year to obtain followup information. A Short Musculoskeletal Function Assessment (SMFA) questionnaire was obtained at 6 months and 1 year. Analyses were performed to determine differences in outcome based on demographics and injury information. A p value of less than 0.05 was considered significant.

RESULTS

An average of 22 days were lost from work, with 23 patients (46.9%) taking up to 10 days, 18 (36.7%) taking 10 days or longer off work, and eight patients (16.4%) losing no days of work. Based on self-reports, 10 patients (20.4%) had returned to pre-injury functional status by 3 months, 42 patients (85.7%) by 6 months, and all 49 patients by 1 year. At six and 12 months, no differences in SFMA were found based on gender, fracture type, or amount of fracture displacement.

CONCLUSIONS

Fracture of the fifth metatarsal base often is a source of lost work productivity. Although patients can be expected to return to their preinjury level of function, recovery may take 6 months or longer.

Tape blisters after hip surgery: can they be eliminated completely?

It was recently reported that use of a perforated, stretchable cloth tape instead of silk tape reduced the incidenc of postoperative blisters around the hip from 41% to 10%. The present prospective randomized study was conducted to determine whether use of spica bandage (vs the cloth tape) could further reduce or eliminate the incidence of these blisters. Patients were randomized to 2 treatmen groups: perforated, stretchable cloth tape (Hypafix; Smit & Nephew, Memphis, Tenn) and elastic spica bandage tha was started at the lower thigh and was extended aroun the hip and abdomen. After surgery, cloth tape or spic bandage was applied over the postoperative dressing, with care taken not to produce skin tension. At the first dressing change, presence or absence of blisters was recorded, along with their number, size, location, and type. All subsequent dressing changes were done much as they wer at surgery, using the assigned type of dressing. Presence or absence of blisters was recorded at each subsequent dressing change. Two hundred ninety-four patients (300 hips) were enrolled. Twenty-two (7.33%) of the 300 hips developed a blister. Risk for developing a blister was 10% with the cloth tape versus 4.67% with the elastic spica bandage (P < .09). Surgery type (arthroplasty vs open reduction and internal fixation [ORIF], P < .03) and surgery duration (P < .05) had more of an effect on postoperative blister formation than dressing type.