Publications by authors named "Cory Collinge"

93 Publications

Mapping of Vertical Femoral Neck Fractures in Young Patients Using Advanced 2 and 3-Dimensional Computed Tomography.

J Orthop Trauma 2021 Jun 5. Epub 2021 Jun 5.

Objective: To better describe the pathoanatomy of young patients' femoral neck fractures with the goal of improving surgeons' decisions for treatment including reduction and fixation.

Design: This is a retrospective study of patient records, plain radiographs, and the modern computed tomography scans to study the pathoanatomy of Pauwels II and III femoral neck fractures (coronal angle >30 degrees) in young adults.

Setting: One American College of Surgeons Level 1 trauma center.

Patients: All patients 18-49 years of age with a surgically repaired Pauwels' II and III (>30 degrees) femoral neck fracture between 2013 and 2017.

Methods: Fifty-six adult patients younger than 50 years were identified with a femoral neck fracture in the study period, of whom 30 met study criteria. We evaluated plain radiography and computed tomography data including fracture orientation, characteristics of fracture morphology including size, shape, and dimensions, comminution, displacement, and deformity.

Results: Fracture morphology typically included a wide-based caudal head-neck segment (80%) that ends at a variable location along the medial calcar, sometimes as caudal as the lesser trochanter. Comminution was present in 90% of cases mostly located in the inferior quadrant, but anterior or posterior to the void left by the head-neck's caudal segment. The fractures orientations and deformities were reported by means and ranges.

Conclusions: We investigated and reported on the pathoanatomy of high-energy femoral neck fractures in young adults with the goal of increasing understanding of the injury and improving surgeons' ability to provide for improved treatment decisions and quality fracture repair.

Level Of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000002102DOI Listing
June 2021

Exposure Provided by the Gibson Versus the Kocher-Langenbeck Approaches With and Without Trochanteric Osteotomy: A Cadaveric Mapping Study.

J Orthop Trauma 2021 May;35(5):234-238

Department of Orthopedic Trauma, Harris Methodist Fort Worth Hospital, Fort Worth, TX.

Objective: To determine if prevalent approaches in acetabular fracture surgery provide enhanced anterior and cranial exposure in a cadaveric model.

Methods: A Kocher-Langenbeck (K-L) approach (followed by a Gibson approach on the contralateral hip) was performed in the lateral position on 8 cadavers. A Steinmann pin was used to create holes outlining the bony surfaces available for instrumentation before and after a trochanteric osteotomy. All soft tissue was then removed from the pelvis, and a calibrated digital picture was taken. The surface area of the pelvis visualized through each approach was calculated and compared with the contralateral side to assess for a difference in exposure between the Gibson approach and the K-L approach. An increase in exposure of greater than 10% was considered significant. The extent of anterior exposure (with and without a trochanteric osteotomy) was then measured from the greater sciatic notch.

Results: In 2 of 8 cadavers (25%), the Gibson approach yielded an increase in exposure when compared with a K-L approach. The addition of a trochanteric osteotomy yielded on average 1.6 cm (range, 0.7-2.6 cm) of increased anterior exposure in the K-L approaches and 1.5 cm (range 0.9-3.1 cm) in the Gibson approaches.

Conclusion: The Gibson approach did not reliably provide increased anterior exposure compared with a K-L approach in a cadaver model. A trochanteric osteotomy can be expected to add 1-2 cm of increased anterior exposure in both approaches.
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http://dx.doi.org/10.1097/BOT.0000000000001970DOI Listing
May 2021

Radiographic Evaluation of the Tibial Intramedullary Nail Entry Point.

J Am Acad Orthop Surg 2020 Sep;28(18):e810-e814

From the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN (Dr. Maslow, Dr. Joseph, Mr. Hong, Ms. Henry, and Dr. Mitchell), and the Orthopaedic Trauma Surgery, Orthopedic Specialty Associates, Fort Worth, TX (Dr. Collinge).

Introduction: Tibia fractures are common injuries that can often be effectively treated with intramedullary nail (IMN) fixation. The ideal starting point for IMN reaming and nail placement is well described and regarded as a crucial aspect in the technique. The purpose of this study is to determine the accuracy and precision with which the starting point is established and if this is maintained after nail insertion during fracture fixation.

Methods: Fifty consecutive tibia fractures treated by IMN fixation sized 9 to 13 mm through an infrapatellar or medial parapatellar approach and 50 treated with a suprapatellar approach were evaluated. The starting point for reaming and IMN placement was measured using intraoperative fluoroscopy. Postoperative radiographs were used to determine the center of the IMN after placement. The distance between the measured points and the ideal starting point was measured.

Results: Deviation from the ideal entry point on intraoperative fluoroscopy averaged 4.6 ± 4.0 mm medially, 2.9 ± 3.7 mm anteriorly, and 2.7 ± 3.3 mm distally. In 30% of cases, the final IMN position varied from the entry point by greater than one SD in the coronal or sagittal plane. No difference between approaches was appreciated.

Discussion: Although the ideal starting point for tibial IMN fixation is known, this is frequently not the starting point accepted in practice. Final position of the IMN is independent of IMN size or approach and is not markedly different than the obtained starting point.

Level Of Evidence: Therapeutic level III.
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http://dx.doi.org/10.5435/JAAOS-D-19-00557DOI Listing
September 2020

Calcaneal Avulsion Fractures: A Multicenter Analysis of Soft-Tissue Compromise and Early Fixation Failure.

J Orthop Trauma 2019 Nov;33(11):e422-e426

Department of Orthopeadic Trauma, Harris Methodist Fort Worth Hospital, Fort Worth, TX.

Objective: To characterize the presentation and outcomes of calcaneal avulsion fractures.

Design: Case series.

Setting: Two ACS Level I trauma centers.

Patients/participants: Forty-seven calcaneal avulsion fractures isolated from a cohort of 1365 calcaneus fractures treated over a 17-year period.

Main Outcome Measurements: We collected instances of soft-tissue compromise at presentation, evidence of implant failure or fracture displacement after fixation, and reoperation.

Results: Forty-one patients were treated operatively, and 6 were treated without surgery. Twenty-one patients (44.7%) had either soft-tissue compromise or an open fracture necessitating urgent treatment at the time of presentation. Of those patients treated operatively with 3-month follow-up (n = 39), 28.2% of patients (11/39) had evidence of implant failure or fracture displacement. Age was the only predictor of catastrophic fixation failure (P = 0.01). The use of washer(s), suture anchor(s), or addition of soft-tissue procedures (eg, Strayer) did not have a significant effect on failure rate. Neither the number of screws used nor size of screw impacted the failure rate. Fourteen patients (35.9%) underwent a secondary operation.

Discussion: Avulsion fractures of the calcaneus commonly present with soft-tissue compromise and have a significant rate of treatment failure and reoperation. This injury should be identified early and approached thoughtfully, acknowledging that risks are high.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001582DOI Listing
November 2019

Setting Yourself Up for Success: Locked Plating for Vancouver B1 Fractures.

Authors:
Cory A Collinge

J Orthop Trauma 2019 Sep;33 Suppl 6:S5-S9

Orthopaedic Surgery Dvision, Texas Health Physicians Group, Fort Worth, TX.

This chapter discusses principles and controversies surrounding the treatment of periprosthetic fractures around a hip replacement, specifically the Vancouver B1 injury. Evaluation and treatment decisions, as well as surgical tips and tricks, are discussed.
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http://dx.doi.org/10.1097/BOT.0000000000001573DOI Listing
September 2019

Intramedullary Nails Yield Superior Results Compared With Plate Fixation When Using the Masquelet Technique in the Femur and Tibia.

J Orthop Trauma 2019 Nov;33(11):547-552

Florida Orthopaedic Institute, Tampa, FL.

Objectives: To determine the optimal fixation method [intramedullary nail (IMN) vs. plate fixation (PF)] for treating critical bone defects with the induced membrane technique, also known as the Masquelet technique.

Design: Retrospective cohort study.

Setting: Four Level 1 Academic Trauma Centers.

Patients/participants: All patients with critical bone defects treated with the induced membrane technique, or Masquelet technique, between January 1, 2005, and January 31, 2018.

Intervention: Operative treatment with a temporary cement spacer to induce membrane formation, followed by spacer removal and bone grafting at 6-8 weeks.

Main Outcome Measurements: Time to union, number/reason for reoperations, time to full weight-bearing, and any complications.

Results: One hundred twenty-one patients (56 tibias and 65 femurs) were treated with a mean follow-up of 22 months (range 12-148 months). IMN was used in 57 patients and plates in 64 patients. Multiple grafting procedures were required in 10.5% (6/57) of those with IMN and 28.1% (18/64) of those with PF (P = 0.015). Reoperation for all causes occurred in 17.5% (10/57) with IMN and 46.9% (30/64) with PF (P = 0.001). Average time to weight-bearing occurred at 2.44 versus 4.63 months for those treated with IMN and plates, respectively (P = 0.002). The multivariable adjusted analysis showed that PF is 6.4 times more likely to require multiple grafting procedures (P = 0.017) and 7.7 times more likely to require reoperation (P = 0.003) for all causes compared with IMN."

Conclusions: This is the largest study to date evaluating the Masquelet technique for critical size defects in the femur and tibia. Our results indicate that patients treated with IMN had faster union, fewer grafting procedures, and fewer reoperations for all causes than those treated with plates, with differences more evident in the femur. The authors believe this is a result of both the development of an intramedullary canal and circumferential stress on the graft with early weight-bearing when using an IMN, as opposed to a certain degree of stress shielding and delayed weight-bearing when using PF. We, therefore, recommend the use of an IMN whenever possible as the preferred method of fixation for tibial and femoral defects when using the Masquelet technique.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001579DOI Listing
November 2019

Orthopedic Surgeons Have Inadequate Knowledge of the Cost of Trauma-Related Imaging Studies.

Orthopedics 2019 Sep 3;42(5):e454-e459. Epub 2019 Jul 3.

Radiographic imaging is integral to the diagnosis and treatment of orthopedic injuries. Previous studies have shown that orthopedists consistently underestimate the price of implants, but their knowledge of imaging charges is unknown. This study evaluated whether orthopedic residents and faculty could accurately estimate charges of imaging modalities at their respective institutions. A survey with 10 common imaging studies was sent to 8 academic level I trauma centers. Participants estimated the total charge of each imaging modality. This was compared with the actual charge at their institution. Seven centers produced 162 responders: 74 faculty and 88 residents. The differences between the estimated cost and the billing charge were calculated and broken down by training level and imaging modality. Overall, imaging charges were underestimated by 31% (P<.001), with 19.4% of estimates being within 20% of actual charges (95% confidence interval, 19.1-19.9). There was no difference between training levels (P=.69). There was greater than 1000% variation in charges between institutions. Orthopedists across training levels underestimate hospital charges associated with common imaging studies, and there is a large variation in charges between centers. Awareness of charges is important because charges affect clinical decision making and are relevant to practicing both cost-conscious and clinically sound medicine. [Orthopedics. 2019; 42(5):e454-e459.].
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http://dx.doi.org/10.3928/01477447-20190627-04DOI Listing
September 2019

Morphology of the Posterior Malleolar Fracture Associated With a Spiral Distal Tibia Fracture.

J Orthop Trauma 2019 Apr;33(4):185-188

Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN.

Objective: To define the pathoanatomy of the posterior malleolus fracture associated with a spiral distal tibia fracture to guide clamp and implant placement when treating these common injuries.

Design: Retrospective cohort.

Setting: Level I trauma center.

Patients/participants: One hundred twenty-two spiral infraisthmal tibia fractures identified from a cohort of 922 tibia fractures undergoing intramedullary nailing over a 7-year period.

Main Outcome Measurements: We collected instances of intra-articular extension seen on preoperative, intraoperative, or postoperative imaging. For patients with a posterior malleolus fracture and computed tomography imaging, we used an axial image 2-3 mm above the articular surface to create a fracture map.

Results: Intra-articular extension was present in 84 patients (68.9%), with posterior malleolus fractures occurring most commonly (n = 59, 48.4%). Other fractures included plafond fractures (n = 8), medial malleolus fractures (n = 7), anterior-inferior tibiofibular ligament avulsions (n = 5), and other anterior fractures (n = 5). Forty-one of 44 (93%) posterior malleolus fractures with cross-sectional imaging were Haraguchi type I (posterolateral-oblique type) with an average angle of 24 degrees off the bimalleolar axis. The remaining 3 were type II (transverse-medial extension type) fractures. Posterior malleolus fractures were visible 61% of the time on preoperative radiographs.

Discussion: Posterior malleolus fractures occur in approximately half of spiral distal tibia fractures and are consistently posterolateral in their morphology. This study can be used to enhance evaluation of the posterior malleolus intraoperatively (eg, ∼25 degrees external rotation view), and if the typical variant of posterior malleolus is identified, clamps and lag screws might be applied accordingly.
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http://dx.doi.org/10.1097/BOT.0000000000001398DOI Listing
April 2019

Vascular Anatomy of the Medial Femoral Neck and Implications for Surface Plate Fixation.

J Orthop Trauma 2019 03;33(3):111-115

Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO.

Objectives: To describe the inferior retinacular artery (IRA) as encountered from an anterior approach, to define its intraarticular position, and to define a safe zone for buttress plate fixation of femoral neck fractures.

Methods: Thirty hips (15 fresh cadavers) were dissected through an anterior (Modified Smith-Petersen) approach after common femoral artery injection (India ink, blue latex). The origin of the IRA from the medial femoral circumflex artery and the course to its terminus were dissected. The IRA position relative to the femoral neck was described using a clock-face system: 12:00 cephalad, 3:00 anterior, 6:00 caudad, and 9:00 posterior.

Results: The IRA originated from the medial femoral circumflex artery and traveled within the Weitbrecht ligament in all hips. The IRA positions were 7:00 (n = 13), 7:30 (n = 15), and 8:00 (n = 2). The IRA was 0:30 anterior to (n = 24) or at the same clock-face position (n = 6) as the lesser trochanter. The mean intraarticular length was 20.4 mm (range 11-65, SD 9.1), and the mean extraarticular length was 20.5 mm (range 12-31, SD 5.1).

Conclusions: The intraarticular course of the IRA lies within the Weitbrecht ligament between the femoral neck clock-face positions of 7:00 and 8:00. A medial buttress plate positioned at 6:00 along the femoral neck is anterior to the location of the IRA and does not endanger the blood supply of the femoral head. The improved understanding of the IRA course will facilitate preservation during intraarticular approaches to the femoral neck and head.
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http://dx.doi.org/10.1097/BOT.0000000000001377DOI Listing
March 2019

Course of the Femoral Artery in the Mid- and Distal Thigh and Implications for Medial Approaches to the Distal Femur: A CT Angiography Study.

J Am Acad Orthop Surg 2019 Jul;27(14):e659-e663

From the Vanderbilt University Medical Center, Nashville, TN.

Introduction: Unfamiliarity with the location of the femoral artery in the medial thigh has tempered surgeons' enthusiasm for medial approaches to the distal femur. The purpose of this study was to define the relationship of the femoral artery to the mid- and distal femur to assist in safely approaching the femur for fracture care.

Methods: Fifteen patients undergoing CT with angiography (CTA) of the lower extremity (CTA) were evaluated. From three-dimensional CTA images, the distance of the artery at the anterior border, midsagittal line, and posterior border of the femur from the distal femur at both the adductor tubercle and medial femoral condyle was measured.

Results: The average distances of the adductor tubercle to the femoral artery were 23.2 cm (±3.3), 18.8 cm (±3.4), and 14.3 cm (±4.1) at the level of the anterior border, midsagittal line, and posterior border of the femur, respectively. The descending genicular artery (DGA) originated 10.8 cm (±1.3) proximal to the adductor tubercle.

Discussion: A wide safe zone exists in the medial distal femur. The artery crosses the midsagittal axis of the medial femur an average of 18.8 cm proximal to the adductor tubercle.
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http://dx.doi.org/10.5435/JAAOS-D-17-00700DOI Listing
July 2019

Fixation Strategy Using Sequential Intraoperative Examination Under Anesthesia for Unstable Lateral Compression Pelvic Ring Injuries Reliably Predicts Union with Minimal Displacement.

J Bone Joint Surg Am 2018 Sep;100(17):1503-1508

University of South Florida/Florida Orthopaedic Institute, Tampa, Florida.

Background: Examination under anesthesia (EUA) has been used to identify pelvic instability. Surgeons may utilize percutaneous methods for posterior and anterior pelvic ring stabilization. We developed an intraoperative strategy whereby posterior fixation is performed, with reassessment using sequential EUA to determine the need for anterior fixation. Our aim in the current study was to evaluate whether this strategy reliably results in union with minimal displacement.

Methods: This was a multicenter retrospective study involving adult patients with closed lateral compression (LC) pelvic ring injuries treated during the period of 2013 to 2016. Included were patients who underwent percutaneous pelvic fixation based on sequential EUA. Data points included patient demographics, injury and fixation details, and displacement as observed on follow-up radiographs.

Results: Complete documentation was available for 74 patients (mean age, 41 years). The mean duration of follow was 11 months. Fifty-three of the patients had LC-1 injuries, 19 had LC-2 injuries, and 2 had LC-3 injuries. Twenty-five (47.2%) of the 53 patients with LC-1 and 11 (57.9%) of the 19 patients with LC-2 injuries did not undergo anterior fixation on the basis of the algorithm. The 36 LC-1 or LC-2 patients who underwent combined anterior and posterior fixation had no measurable displacement at union. Of the 36 LC-1 or LC-2 patients with no anterior fixation, 27 with unilateral rami fractures had no measurable displacement at union. The remaining 9 LC-1 or LC-2 cases with no anterior fixation had bilateral superior and inferior rami fractures; each of these patients demonstrated displacement (mean, 7.5 mm; range, 5 to 12 mm) within 6 weeks of fixation that remained until union. All patients had protected weight-bearing for 12 weeks.

Conclusions: A fixation strategy based on sequential intraoperative EUA reliably results in union with minimal displacement for unstable LC pelvic ring injuries. Injuries requiring combined anterior and posterior fixation healed with no displacement. Those without anterior fixation and a unilateral ramus fracture healed with no displacement. In the presence of bilateral rami fractures, even with a negative finding on sequential EUA, the pelvis healed with 7.5 mm average displacement. Surgeons may consider anterior fixation to prevent this displacement.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.17.01650DOI Listing
September 2018

Effect of Deformity and Malunion of the Anterior Pelvic Ring.

J Orthop Trauma 2018 Sep;32 Suppl 6:S31-S35

Department of Orthopaedics and Sports Medicine, University of Cincinnati Medical Center, Cincinnati, OH.

Pelvic fractures are common after high-energy trauma and are often associated with ligamentous injury. Treatment is guided by assessing stability of the pelvic ring, and unstable injuries frequently require surgery to achieve a desirable outcome. Assessment of pelvic ring stability is often possible with physical examination and standard imaging studies (plain radiographs and computed tomography); however, these "static" imaging modalities may not adequately identify dynamically unstable pelvic injuries that require surgery. Cadaveric and clinical data suggest that the injured pelvis may recoil significantly from the point of maximal displacement, and some unstable injuries may not be recognized until patients present with clinical symptoms. This article presents the case of a patient who sustained a minimally displaced pelvic ring injury that was stable on bedside examination and static imaging, but ultimately was unstable. She developed a substantial pelvic malunion with significant pain and activity limitations. The patient subsequently underwent successful pelvic ring reconstruction, and she remains asymptomatic at 2 years.
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http://dx.doi.org/10.1097/BOT.0000000000001247DOI Listing
September 2018

Early Comparative Outcomes of Carbon Fiber-Reinforced Polymer Plate in the Fixation of Distal Femur Fractures.

J Orthop Trauma 2018 08;32(8):386-390

Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN.

Objective: To evaluate the early clinical results of distal femur fractures treated with carbon fiber-reinforced polyetheretherketone (CFR-PEEK) plates compared with stainless steel (SS) lateral locking plates.

Design: Retrospective comparative cohort study.

Setting: ACS Level I trauma center.

Patients/participants: Twenty-two patients (11 SS, 11 CFR-PEEK) with closed distal femur fractures treated by a single surgeon over a 6-year period.

Main Outcome Measurements: Nonunion, hardware failure, reoperation, time to full weight-bearing, and time union were assessed.

Results: The CFR-PEEK cohort was on average older (71 vs. 57 years, P = 0.03) and more likely to have diabetes (P = 0.02). Nonunion was diagnosed in 4/11 (36%) patients in the SS group and 1/11 (9%) patients in the CFR-PEEK group (P = 0.12). Hardware failure occurred in 2 SS patients (18%) compared with none in the CFR-PEEK group (P = 0.14). Time to full weight-bearing was similar between groups, occurring at 9.9 and 12.4 weeks in the CFR-PEEK and SS groups, respectively (P = 0.23). Time to radiographic union averaged 12.4 weeks in the SS group and 18.7 weeks in the CFR-PEEK group (P = 0.26). There were 4 reoperations in the SS group and 1 in the CFR-PEEK group (P = 0.12).

Conclusions: CFR-PEEK plates show encouraging short-term results in the treatment of distal femur fractures with a comparable nonunion, reoperation, and hardware failure rates to those treated with SS plates. This data suggest that CFR-PEEK plates may be a viable alternative to SS plates in fixation of these fractures.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001223DOI Listing
August 2018

Sarcopenia Is Predictive of 1-Year Mortality After Acetabular Fractures in Elderly Patients.

J Orthop Trauma 2018 06;32(6):278-282

Florida Orthopaedic Institute, University of South Florida, Tampa, FL.

Objectives: To determine whether sarcopenia is an independent predictor of mortality in geriatric acetabular fractures.

Design: Retrospective cohort.

Setting: American College of Surgeons Level I trauma center.

Patients/participants: One hundred and forty-six patients over the age 60 with acetabular fractures treated at our institution over a 12-year period.

Main Outcome Measurements: The primary outcome was 1-year mortality, collected using the Social Security Death Index. We used the psoas:lumbar vertebral index (PLVI), calculated using the cross-sectional area of the L4 vertebral body and the left and right psoas muscles, to assess for sarcopenia.

Results: Using a multivariate logistic regression model, we found that low PLVI was associated with increased 1-year mortality (P = 0.046) when controlling for age, gender, Charlson Comorbidity Index, Injury Severity Score (ISS), smoking status, and associated pelvic ring injury. Increasing age and ISS also showed a relationship with 1-year mortality in this cohort (P < 0.001, P < 0.001, respectively). We defined sarcopenia as those patients in the lowest quartile of PLVI. The mortality rate of this cohort was 32.4%, compared with 11.0% in patients without sarcopenia (odds ratio 4.04; 95% confidence interval 1.62-10.1). Age >75 years, ISS >14, and sarcopenia had 1-year mortality rates of 37.1%, 30.9%, and 32.4%, respectively. In patients with all 3 factors, the mortality rate was 90%.

Conclusion: Sarcopenia is an independent risk factor for 1-year mortality in elderly patients with acetabular fractures. This study highlights the importance of objective measures to assess frailty in elderly patients who have sustained fractures about the hip and pelvis.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001159DOI Listing
June 2018

Bicondylar Tibial Plateau Fractures: A Critical Analysis Review.

JBJS Rev 2018 02;6(2):e4

Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.

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http://dx.doi.org/10.2106/JBJS.RVW.17.00050DOI Listing
February 2018

Acute Compartment Syndrome: An Expert Survey of Orthopaedic Trauma Association Members.

J Orthop Trauma 2018 05;32(5):e181-e184

Louisiana State University Health Sciences Center, New Orleans, LA.

Objectives: The goal of this study was to describe current opinions of orthopaedic trauma experts regarding acute compartment syndrome (ACS).

Design: Web-based survey.

Participants: Active Orthopaedic Trauma Association (OTA) members.

Methods: A 25-item web-based questionnaire was advertised to active members of the OTA. Using a cross-sectional survey study design, we evaluated the perceived importance of ACS, as well as preferences in diagnosis and treatment.

Results: One hundred thirty-nine of 596 active OTA members (23%) completed the survey. ACS was believed to be clinically important and with severe sequelae, if missed. Responses indicated that diagnosis should be based on physical examination in an awake patient, and that intracompartmental pressure testing was valuable in the obtunded or unconscious patient. The diagnosis of ACS with monitoring should be made using the difference between diastolic blood pressure and intracompartmental pressure (ΔP) of ≤30 mm Hg. Once ACS is diagnosed, respondents indicated that fasciotomies should be performed as quickly as is reasonable (within 2 hours). The consensus for wound management was closure or skin grafting within 1-5 days later, and skin grafting was universally recommended if closure was delayed to >7 days.

Conclusions: ACS is a challenging problem with poor outcomes if missed or inadequately treated. OTA members demonstrated agreement to many diagnostic and treatment choices for ACS.

Level Of Evidence: Therapeutic Level V. See Instructions for Authors for a complete description of the levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001128DOI Listing
May 2018

Pathoanatomy of the Tongue-Type Calcaneus Fracture: Assessment Using 2- and 3-Dimensional Computed Tomography.

J Orthop Trauma 2018 05;32(5):e161-e165

Vanderbilt University Medical Center, Nashville, TN.

Objective: To define the pathoanatomy of the tongue-type calcaneus fracture and assess the appropriateness of percutaneous techniques in addressing all planes of deformity in this injury.

Design: Retrospective cohort.

Setting: ACS Level I trauma center.

Patients/participants: Fifty-six displaced Sanders 2B and 2C tongue-type calcaneus fractures identified from an initial cohort of 1118 calcaneus fractures treated over a 16-year period.

Main Outcome Measurements: We reviewed cross-sectional imaging and documented the presence of a varus/valgus (coronal plane) or adduction/abduction (axial plane) position of the tongue fragment in relation to the intact posterior facet, with greater than 10 degrees of angulation being diagnostic of displacement.

Results: When assessing for displacement and angulation in the coronal plane, 98% of tongue fragments were either in a position of valgus (77%) or neutral (21%), with a mean valgus angulation of 17.3 degrees. In the axial plane, 98% of tongue pieces were in a position of adduction (64%) or neutral (34%), with an average angulation into adduction of 15.0 degrees. Sanders 2B fractures were more likely to be in a position of valgus and adduction than those of 2C fractures.

Discussion: The tongue-type calcaneus fracture most often displaces into a position of plantarflexion, valgus, and adduction. Knowledge of this deformity may aid in achieving successful closed reduction when using the Essex-Lopresti maneuver or other less invasive techniques.
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http://dx.doi.org/10.1097/BOT.0000000000001113DOI Listing
May 2018

Increased Anterior Column Exposure Using the Anterior Intrapelvic Approach Combined With an Anterior Superior Iliac Spine Osteotomy: A Cadaveric Study.

J Orthop Trauma 2017 Nov;31(11):565-569

*San Antonio Military Medical Center, Fort Sam Houston, TX; and †Vanderbilt Orthopaedics, Nashville, TN.

Objective: To determine whether the addition of an anterior superior iliac spine (ASIS) osteotomy to the lateral window, when combined with the anterior intrapelvic (AIP) surgical approach, would improve visualization of the iliopectineal eminence and allow for predictable and safe clamp application.

Methods: Ten lateral window approaches to the iliac fossa were developed in conjunction with the AIP approach on 10 fresh-frozen cadaveric pelvi. A calibrated digital image was taken from the surgeon's optimal viewing angle to capture the visualized osseous surface of the false pelvis with emphasis on the iliopectineal eminence. An ASIS osteotomy was then performed and an additional calibrated image was obtained to identify any increased visualization of the iliopectineal eminence. Using ImageJ software (NIH, Bethesda, MD), the additional surface area afforded to the surgeon was calculated. An AIP approach was then performed to confirm complete exposure of the anterior column and whether a Weber clamp could safely be placed across the iliopectineal eminence.

Results: The lateral window, osteotomy, and AIP approach were successfully accomplished in all 10 specimens. Before performing an ASIS osteotomy, a mean of 20.3 cm (range: 14.5-25.6 cm) of the false pelvis adjacent to the pelvic brim was visualized. After completion of the osteotomy, the mean visualized surface area increased significantly to 28.4 cm (range: 14.6-45.6 cm) (P < 0.0168). Clamp placement through the lateral window was unsuccessful in all 10 specimens. After completion of the AIP approach, complete visualization of the iliopectineal eminence was confirmed and safe clamp application through the lateral window possible in all 10 specimens.

Conclusion: ASIS osteotomy through the lateral window significantly improved visualization and access to the iliopectineal eminence in this cadaveric model, which suggests that it may be a suitable alternative to the traditional ilioinguinal approach for select fracture patterns when combined with an AIP approach.
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http://dx.doi.org/10.1097/BOT.0000000000000964DOI Listing
November 2017

Risks to the Superior Gluteal Neurovascular Bundle During Iliosacral and Transsacral Screw Fixation: A Computed Tomogram Arteriography Study.

J Orthop Trauma 2017 Dec;31(12):640-643

Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN.

Objectives: Iliosacral (IS) and transsacral (TS) screws are popular techniques to repair complicated injuries to the pelvis. The anatomy of the superior gluteal neurovasculature (SG NV bundle) is well described as running along the posterior ilium, providing innervation and perfusion to important abductor muscles. The method of pelvis fixation least likely to injure the SG NV bundle is unknown.

Methods: Twenty uninjured patients with a contrasted computed tomogram of the pelvis and lower extremities (CTA) were evaluated. Starting points for an S1 IS screw and S1 and S2 TS screws were estimated on the "ghost" lateral CTA image for those pelvi with safe corridors (>9 mm diameter). The distance from the projected screw to the SG artery was measured. A distance of <3.65 mm (half of a 7.3-mm screw's diameter) was considered likely for NV bundle injury.

Results: Of 40 pelvi CTAs (single sides), 10 pelvi (25%) were determined to be inappropriate for an S1 TS screw. The average distances from the screw starting point and the artery were 25.3 mm (±9.2) for S1 IS, 12.4 mm (±9.0) for S1 TS, and 23.5 mm (±10.7) for S2 TS screws, respectively. Ten S1 TS screws (25%) and no S1 IS or S2 TS screws were projected to have caused injury to the SG NV bundle (P < 0.001).

Conclusions: Inserting S1 IS and S2 TS screws put the SG NV anatomy at significantly less risk than S1 TS screws. This information may aid in choosing the "best" fixation option for patients with pelvic ring trauma requiring surgery.
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http://dx.doi.org/10.1097/BOT.0000000000000996DOI Listing
December 2017

Proper Distal Placement of Tibial Nail Improves Rate of Malalignment for Distal Tibia Fractures.

J Orthop Trauma 2017 Dec;31(12):e407-e411

Campbell Clinic Orthopaedics, Memphis, TN.

Objectives: We hypothesize that the anatomic center of the distal tibia is just lateral and anterior to the center of the distal tibia articular surface in the coronal and sagittal planes, respectively, and that placement of the nail along this axis results in improved rates of malalignment when treating distal tibia fractures.

Design: Retrospective study.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Setting: One Level I and one Level II trauma center.

Patients/participants: Two hundred three distal tibia fractures treated with intramedullary nailing (IMN) (primary cohort) whose main fracture line extended within 5 cm of the plafond to evaluate the rate of malalignment with distal nail placement. Additionally, we retrospectively reviewed a secondary cohort of 15 patients with proximal tibia fractures treated with intramedullary nailing for evaluation of passive anatomic distal nail position.

Main Outcome Measures: Primary malalignment ≤5 degrees on the anteroposterior (AP), mortise, and lateral planes were evaluated in distal tibia fractures on perioperative radiographs.

Results: Primary Cohort: 85 patients met inclusion criteria for evaluation in the coronal plane. Overall malalignment in the coronal plane was 17.6%. There was a 2.9% (1/34) fracture malalignment rate when the nail was placed lateral to the center of the joint versus 27.5% (14/51) when placed medial to the center of the joint, with all occurring in valgus. This achieved statistical significance (P = 0.04). Correlation was highest when measuring the trajectory on mortise view using the talus as reference point. When evaluating the sagittal plane, there were 64 patients that met inclusion criteria with a 48% malalignment rate. Malalignment was greatest when the nail was placed in the anterior quadrant 100% (4/4), versus 50% (22/44) in the anterior middle, and 31.3% (5/16) in the posterior middle quadrant. This achieved statistical significance (P = 0.05). No nails were placed in the most posterior quadrant. Secondary Cohort: 15 patients met inclusion criteria for distal nail placement. The position of the nail in the coronal plane was measured on both the anteroposterior and mortise ankle radiographs using both the plafond and talus as a reference, whereas sagittal nail placement was measured on the lateral ankle radiographs. In the coronal plane, the mean passive distal position of the nail when referenced from the lateral cortex was 45.2% of the tibia plafond and 45.5% the width of the talus, or just lateral to the center of each. In the sagittal plane, passive nail placement was 40% the sagittal width of the joint measured from the anterior cortex, or just anterior to the center of the joint.

Conclusions: This is the first patient series that defines optimal tibial nail placement in the treatment of distal tibia fractures. Distal placement of the nail just lateral to the center of the talus and plafond, or along mechanical axis of the tibia, results in significantly reduced rates of malalignment on the coronal plane when compared to nail placement medial to the center of the talus or plafond. Fluoroscopic judgment of distal nail trajectory was improved on the mortise view using the talus as a reference when compared to using the anteroposterior view. On the sagittal plane, anatomic passive nail placement is just anterior to the center of the plafond. However, nonanatomic nail placement just posterior to the center of the plafond had a lower incidence of malalignment compared with nails placed anterior to the center of the plafond. Further study of appropriate nail positioning on the sagittal plane is needed.
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December 2017

Interprosthetic and Peri-Implant Fractures: Principles of Operative Fixation and Future Directions.

J Orthop Trauma 2017 May;31(5):287-292

*Division of Orthopaedic Trauma and Complex Adult Reconstruction, Department of Orthopaedic Surgery Jersey City Medical Center, Jersey City, NJ; and †Division of Orthopaedic Trauma, Harris Methodist Fort Worth Hospital, Fort Worth, TX.

Advances in medicine and orthopaedic implant technology have dramatically increased the number of patients sustaining interprosthetic, inter-, or peri-implant fractures. For these complex clinical scenarios, there are currently no available treatment algorithms. In this review, we outline the principles, strategies, and techniques to obtain both successful reconstruction and maximum function.

Level Of Evidence: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.
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May 2017

Proximity and Risks of the Anterior Neurovascular and Tendinous Anatomy of the Distal Leg Relative to Anteriorly Applied Distal Locking Screws for Tibia Nailing: A Plea for Open Insertion.

J Orthop Trauma 2017 Jul;31(7):375-379

*Department of Orthopedic Surgery, Vanderbilt University, Nashville, TN; and †Campbell Clinic/University of Tennessee Health Science Center, Memphis, TN.

Purpose: To determine the proximity and potential risks to distal leg anatomy from anterior to posterior (A-P) applied distal tibia locking screws for tibial nailing.

Design: Retrospective.

Setting: ACS level I trauma center.

Patients/participants: Twenty consecutive adult patients undergoing computed tomograms with intravenous contrast (computed tomography angiograms) on uninjured legs.

Main Outcome Measurements: Simulated 5-mm distal interlocking screws placed in the A-P axis of an ideally placed tibial nail at 10-mm increments from the tibial plafond (10-40 mm) were studied in relation to the distal leg's anterior anatomy.

Results: All A-P screws (80/80, 100%) impacted the tibialis anterior tendon, extensor hallucis longus tendon, and/or anterior tibial neurovascular (NV) bundle between 10 and 40 mm cranial to the plafond. The NV bundle was impacted in 53% of cases. The medial extent of the tibialis anterior tendon was greatest 10 mm cranial to the plafond and averaged 27 degrees (95% confidence interval, 22-33 degrees) medial to the A-P line. The maximum lateral border of the foot's common extensors, found 40 mm cranial to the plafond, averaged 71 degrees (95% confidence interval, 62-80 degrees) lateral to the A-P line.

Discussion: The anterior tibial NV bundle and foot and ankle extensor tendons are at high risk from A-P-directed distal locking screws. The tendinous anatomy of the distal leg is at risk between 33 degrees medial and 80 degrees lateral to the A-P axis of a tibial nail. Distal locking screws placed from the A-P direction should be thoughtfully applied and an open approach should be strongly considered.
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http://dx.doi.org/10.1097/BOT.0000000000000818DOI Listing
July 2017

Negative Stress Examination Under Anesthesia Reliably Predicts Pelvic Ring Union Without Displacement.

J Orthop Trauma 2017 Apr;31(4):189-193

*University of Wisconsin School of Medicine and Public Health, Madison, WI; †Orange Park Medical Center, Jacksonville, FL; ‡University of Cincinnati, Cincinnati, OH; §University of South Florida, Tampa, FL; ‖University of Maryland School of Medicine, Baltimore, MD; ¶Vanderbilt University, Nashville, TN; **University of Washington, Seattle, WA; and ††Florida Orthopaedic Institute, Tampa, FL.

Objectives: To identify the negative predictive value of examination under anesthesia (EUA) for determining pelvic ring stability and union without further displacement.

Design: Retrospective cohort study.

Setting: Two academic Level 1 trauma centers.

Patients/participants: Thirty-four adult patients with closed pelvic ring injuries treated over a 5-year period.

Interventions: Pelvic stress EUA.

Main Outcome Measures: Pelvic ring union and pelvic ring displacement at final follow-up.

Results: Thirty-four patients with closed pelvic ring injuries who underwent pelvic EUA during the study period and had a negative examination (indicating a stable pelvis) were identified. Mean age was 38 years (range 16-76), and 19 patients (55.9%) were male. Twenty-two patients (64.7%) had Young-Burgess lateral compression (LC)-1 injuries with complete sacral fractures, 4 patients (11.8%) had LC-2 injuries, and 8 patients (23.5%) had anteroposterior compression (APC)-1 injuries. Eight patients (23.5%) had associated injuries requiring restricted weight-bearing on one or both lower extremities and were excluded from the analysis. Immediate weight-bearing as tolerated was permitted bilaterally in the remaining 26 patients. Mean pelvic ring displacement at the time of injury was 3.8 mm (range 1-15 mm) for LC injuries and 9.1 mm (range 2-20 mm) for APC injuries. Patients were followed for a mean of 8 months (range 3-34 months). At final follow-up, mean displacement was 3.7 mm (range 0-17 mm) for LC injuries and 7.1 mm (range 2-19 mm) for APC injuries. Mean change in displacement from injury to union was -0.1 mm for LC injuries and -2.0 mm for APC injuries, indicating decreased pelvic ring displacement at union. All patients were able to tolerate full weight-bearing bilaterally with no pain, and there were no instances of delayed operative fixation after negative EUA.

Conclusions: Negative pelvic EUA after closed pelvic ring injury accurately predicts pelvic stability and union without displacement after nonoperative treatment with full weight-bearing bilaterally. Unless otherwise dictated by associated injuries, immediate weight-bearing as tolerated seems safe in patients with pelvic ring injuries who have had a negative EUA.

Level Of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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April 2017

No Incidence of Postoperative Knee Sepsis With Suprapatellar Nailing of Open Tibia Fractures.

J Orthop Trauma 2017 Feb;31(2):85-89

Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN.

Objective: To evaluate the incidence of knee sepsis after suprapatellar (SP) nailing of open tibia fractures.

Design: Retrospective; Setting: ACS level 1 trauma center.

Patients/participants: We reviewed 139 open tibia fractures that underwent SP nailing as definitive treatment over a 5-year period (January 1, 2011 to January 1, 2016). Most patients (90%, n = 126) underwent intramedullary nailing at the time of their initial surgery. We defined knee sepsis as intra-articular infection requiring operative debridement, either open or arthroscopically, within 1 month's time.

Intervention: Open tibia fractures treated with an SP tibial nail.

Main Outcome Measurements: Demographic data, fracture characteristics, Gustilo and Anderson classification of open fractures, and occurrence of knee sepsis.

Results: In 139 open tibia fractures, there were no cases of knee sepsis in the 30 days after treatment with an SP intramedullary nail. Eighty-seven percent of our cohort had Gustilo and Anderson type II (41%) or type III (46%) open fractures. Most open fractures (83%) underwent primary wound closure during the index procedures. Twenty-five limbs (18%) had evidence of infection at the open fracture site of their open fracture necessitating operative intervention and/or antibiotics: none, however, developed knee sepsis.

Conclusions: Although the SP approach carries intra-articular risks, we found a low risk of knee sepsis using this technique in the treatment of open tibia fractures. Our data suggest that there is no greater risk of intra-articular infection using an SP portal as compared with an infrapatellar one.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000000725DOI Listing
February 2017

Corrigendum to "Adverse cardiac events in 56,000 orthopaedic trauma patients: Does anatomic area make a difference?" [Injury 47 (2016) 1856-1861].

Injury 2016 12 5;47(12):2838-2840. Epub 2016 Oct 5.

Vanderbilt Orthopaedics Institute Center for Health Policy, Vanderbilt University Medical Center, Nashville, TN, United States. Electronic address:

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December 2016

Higher Charlson Comorbidity Index Scores Are Associated With Increased Hospital Length of Stay After Lower Extremity Orthopaedic Trauma.

J Orthop Trauma 2017 Jan;31(1):21-26

*The Vanderbilt Orthopaedic Institute Center for Health Policy, Nashville, TN; and †Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY.

Objectives: The purpose of this study was to explore the relationship between preoperative Charlson Comorbidity Index (CCI) and postoperative length of stay (LOS) for lower extremity and hip/pelvis orthopaedic trauma patients.

Design: Retrospective.

Setting: Urban level 1 trauma center.

Patients/participants: A total of 1561 patients treated for isolated lower extremity and pelvis fractures between 2000 and 2012.

Interventions: Surgical intervention for fractures MAIN OUTCOME MEASUREMENTS:: The main outcome metric was LOS. Negative binomial regression analysis was used to examine the association between CCI and LOS while controlling for significant confounders.

Results: One thousand five hundred sixty-one patients met the inclusion criteria, 1302 (83.4%) of which had lower extremity injuries and 259 (16.6%) experienced hip/pelvis trauma. A total of 1001 (64.1%) patients presented with a CCI score of 1 and stayed an average of 7.9 days. Patients with a CCI of 3 experienced a mean LOS of 1.2 days longer than patients presenting with a CCI of 1, whereas patients presenting with a CCI score of 5 stayed an average of 4.6 days longer. After controlling for age, race, American Society of Anesthesiologists score, sex, anesthesia type, and anesthesia time, a higher preoperative CCI was found to be associated with longer LOS for patients with lower extremity fractures (Incidence Rate Ratio: 1.04, P = 0.01). No significant association was found between CCI and LOS for patients with hip/pelvic fractures.

Conclusions: This study demonstrated the potential utility of the CCI as a predictor of hospital LOS for lower extremity patients; however, the association may be small given the smaller Incidence Rate Ratio value. Further studies are needed to clarify the predictive value of the CCI for different types of orthopaedic injuries.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete.
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January 2017

Stress Modulation of Fracture Fixation Implants.

J Am Acad Orthop Surg 2016 Oct;24(10):711-9

From the Department of Orthopaedics, San Antonio Military Medical Center, Fort Sam Houston, TX (Dr. Beltran), the Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN (Dr. Collinge), and the Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, CA (Dr. Gardner).

Stress modulation is the concept of manipulating bridge plate variables to provide a flexible fixation construct that allows callus formation through uneventful secondary bone healing. Obtaining absolute stability through the anatomic reduction of all fracture fragments comes at the expense of fracture biology, whereas intramedullary nailing, which is more advantageous for diaphyseal fractures of the lower extremity, is technically demanding and often may not be possible when stabilizing many metaphyseal fractures. Overly stiff plating constructs are associated with asymmetric callus formation, early implant failure, and fracture nonunion. Numerous surgeon-controlled variables can be manipulated to increase flexibility without sacrificing strength, including using longer plates with well-spaced screws, choosing titanium or stainless steel implants, and using locking or nonlocking screws. Axially dynamic emerging concepts, such as far cortical locking and near cortical overdrilling, provide further treatment options when bridge plating techniques are used.
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http://dx.doi.org/10.5435/JAAOS-D-15-00175DOI Listing
October 2016

Geographic variations in orthopedic trauma billing and reimbursements for hip and pelvis fractures in the Medicare population.

J Orthop 2016 Dec 25;13(4):264-7. Epub 2016 Jun 25.

The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Ave S, Suite 4200, Medical Center East-South Tower, Nashville, TN 37232, United States.

We investigated geographic variations in Medicare spending for DRG 536 (hip and pelvis fracture). We identified 22,728 patients. The median number of charges, discharges, and payments were recorded. Hospitals were aggregated into core based statistical (CBS) areas and the coefficient of variation (CV) was calculated for each area. On average, hospitals charged 3.75 times more than they were reimbursed. Medicare charges and reimbursements demonstrated variability within each area. Geographic variation in Medicare spending for hip fractures is currently unexplained. It is imperative for orthopedists to understand drivers behind such high variability in hospital charges for management of hip and pelvis fractures.
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http://dx.doi.org/10.1016/j.jor.2016.06.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4925899PMC
December 2016

Adverse cardiac events in 56,000 orthopaedic trauma patients: Does anatomic area make a difference?

Injury 2016 Aug 8;47(8):1856-61. Epub 2016 Jun 8.

Vanderbilt Orthopaedics Institute Center for Health Policy, Vanderbilt University Medical Center, Nashville, TN, United States. Electronic address:

Purpose: Postoperative cardiac events in orthopaedic trauma patients constitute severe morbidity and mortality. It is therefore increasingly important to determine patient risk factors that are predictive of postoperative myocardial infarctions and cardiac arrests. This study sought to assess if there is an association between anatomic area and cardiac complications in the orthopaedic trauma patient.

Patients And Methods: From 2006-2013, a total of 361,402 orthopaedic patients were identified in the NSQIP database using Current Procedural Terminology (CPT) codes. Of these, 56,336 (15.6%) patients were identified as orthopaedic trauma patients broken down by anatomic region: 11,905 (21.1%) upper extremity patients (UE), 29,009 (51.5%) hip/pelvis patients (HP), and 15,422 (27.4%) lower extremity patients (LE) using CPT codes. Patients were defined as having adverse cardiac events if they developed myocardial infarctions or cardiac arrests within 30days after surgery. Chi-squared analysis was used to determine if there was an association between anatomic area and rates of cardiac events. Multivariate logistical analysis was used with over 40 patient characteristics including age, gender, history of cardiac disease, and anatomic region as independent predictors to determine whether anatomic area significantly predicted the development of cardiac complications.

Results: There were significant differences in baseline demographics among the three groups: HP patients had the greatest average age (77.6 years) compared to 54.8 years for UE patients and 54.1 years in LE patients (p<0.001). HP patients also had the highest average ASA score (3.0) (p<0.001). There was a significant difference in adverse cardiac events based on anatomic area: 0.27% (32/11,905) UE patients developed cardiac complications compared to 2.15% (623/29,009) HP patients and 0.61% (94/15,422) LE patients. After multivariate analysis, HP patients were significantly more likely to develop cardiac complications compared to both UE patients (OR: 6.377, p=0.014) and LE patients (OR: 2.766, p=0.009).

Conclusion: There is a significant difference in adverse cardiac events following orthopaedic trauma based on anatomic region. Hip/Pelvis surgery appeared to be a significant risk factor in developing an adverse cardiac event. Further studies should investigate why hip/pelvic patients are at a higher risk of adverse cardiac events.
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August 2016

Posterior to Anteriorly Directed Screws for Management of Talar Neck Fractures.

Foot Ankle Int 2016 Oct 23;37(10):1130-1136. Epub 2016 Jun 23.

Department of Orthopaedic Surgery, Vanderbilt University, Nashville, TN, USA

Background: Screws placed from posterior to anterior have been shown to be biomechanically and anatomically superior in the fixation of talar neck and neck-body fractures, yet most surgeons continue to place screws from an anterior start point. The safety and efficacy of percutaneously applied posterior screws has not been clinically defined, and functional outcomes after their use is lacking.

Methods: After institutional review board approval, we performed a retrospective review of 24 consecutive talar neck fractures treated by a single surgeon that utilized posterior-to-anterior screw fixation. Clinical, radiographic, and functional outcomes were assessed at a minimum follow-up of 12 months. Functional outcomes including the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, Olerud-Molander Scores, and the Short Form 36 (SF-36) measurement were collected and reviewed. Average patient follow-up was 44 months.

Results: According to the classification system of Canale and Kelly, there were 4 type I fractures, 15 type II fractures, 4 type III fractures, and 1 type IV fracture. Four patients had open fractures. One superficial wound infection occurred, 1 patient reported FHL stiffness, and 6 complained of numbness or paresthesias in the distribution of the sural nerve (5 transient, 1 permanent). One reoperation was required to exchange a screw impinging on the talonavicular joint. Radiographically, 44% developed a positive Hawkins sign, and the specificity of this finding was 100% for talar dome viability. Avascular necrosis developed in 43% of patients, with 33% revascularizing and none going on to collapse. Subtalar arthrosis developed in 62% of patients.

Conclusion: Screws placed from posterior to anterior are a useful technique in the treatment of talar neck fractures. Functional outcomes following their use appear favorable compared with recent reports with minimal risk to local structures.

Level Of Evidence: Level IV, retrospective case series.
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http://dx.doi.org/10.1177/1071100716655434DOI Listing
October 2016