Publications by authors named "Daniel S Horwitz"

50 Publications

Potential Benefits of Limited Clinical and Radiographic Follow-up After Surgical Treatment of Ankle Fractures.

J Am Acad Orthop Surg Glob Res Rev 2021 05 11;5(5). Epub 2021 May 11.

From the Geisinger Medical Center, Department of Orthopaedics, MSK Institute, Danville, PA (Dr. Friedman and Dr. Horwitz); the Universidad del Rosario, School of Medicine and Health Sciences, Bogota, Colombia (Dr. Sanchez); the Department of Orthopaedic Surgery, University of California Davis Health System, Sacramento, CA (Dr. Zachos); Department of Orthopedic Surgery, Lahey Hospital and Medical Center, Burlington, MA (Dr. Marcantonio); Department of Orthopaedic Surgery, Beaumont Health, Royal Oak, MI (Dr. Audet); Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH (Dr. Vallier); Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN (Dr. Mullis); University of Miami, Department of Anesthesiology, Jackson Memorial Hospital, Miami, FL (Dr. Myers-White); Department of Orthopaedic Surgery, Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, NC (Dr. Kempton); and Department of Orthopedic Surgery, Cleveland Clinic Akron General Hospital, Akron, OH (Dr. Watts).

Introduction: Ankle fractures are one of the most prevalent musculoskeletal injuries, with a significant number requiring surgical treatment. Postoperative complications requiring additional interventions frequently occur during the early postoperative period. We hypothesize that there is a limited need for routine clinical and radiographic follow-up once the fracture is deemed healed.

Methods: IRB approval was obtained at four academic trauma centers. A retrospective chart review was done to identify adults with healed unimalleolar and bimalleolar ankle fractures treated surgically with at least 12 months of follow-up. Based on postoperative radiographs, changes in fracture alignment and implant position from radiographic union to final follow-up were documented. The average reimbursement for a final follow-up clinic visit and a set of ankle radiographs were estimated.

Results: A total of 140 patients met inclusion criteria. The mean age at injury was 49.5 years, and 67.9% of patients were female. The mean time to healing was 82.2 days (±33.5 days). After radiographic healing, one patient had radiographic changes but was asymptomatic and full weight bearing at their final follow-up. On average, our institution was reimbursed $46 to $49 for a follow-up clinic visit and $364 to $497 for a set of ankle radiographs.

Conclusion: Given the average time to healing, there is limited utility in routine radiographic and clinical follow-up beyond 16 weeks in asymptomatic patients. In our series, this would result in a savings of $950 to $1,200 per patient. However, after ankle fractures were deemed healed, 0.7% patients had radiographic evidence of a change in implant position. Documenting this change did not modify the immediate course of fracture treatment. Surgeons will need to balance the need for routine follow-up with the potential economic benefits in reducing costs to the healthcare system.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-21-00074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8116015PMC
May 2021

Modern Results of Functional Bracing of Humeral Shaft Fractures: A Multicenter Retrospective Analysis.

J Orthop Trauma 2020 04;34(4):206-209

Orthopaedic Trauma Service, Florida Orthopaedic Institute and University of South Florida, Tampa, FL.

Objectives: To evaluate the rate of, and reasons for, conversion of closed treatment of humeral shaft fractures using a fracture brace, to surgical intervention.

Design: Multicenter, retrospective analysis.

Setting: Nine Level 1 trauma centers across the United States.

Patients: A total of 1182 patients with a closed humeral shaft fracture initially managed nonoperatively with a functional brace from 2005 to 2015 were reviewed retrospectively from 9 institutions.

Intervention: Functional brace.

Main Outcome Measurements: Conversion to surgery.

Results: A total of 344 fractures (29%) ultimately underwent surgical intervention. Reasons for conversion included nonunion (60%), malalignment beyond acceptable parameters (24%), inability to tolerate functional bracing (12%), and persistent signs of radial nerve palsy requiring exploration (3.7%). Univariate comparisons showed that females and whites were significantly (P < 0.05) more likely to be converted to surgery. The multivariate logistic regression identified females as being 1.7 times more likely and alcoholics to be 1.4 times more likely to be converted to surgery (P < 0.05). Proximal shaft as well as comminuted, segmental, and butterfly fractures were also linked to a higher rate of conversion.

Conclusions: This large multicenter study identified a 29% surgical conversion rate, with nonunion as the most common reason for surgical intervention after the failure of functional brace. These results are markedly different than previously reported. These results may be helpful in the future when counseling patients on the choice between functional bracing and surgical intervention in managing humeral shaft fractures.

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.0000000000001666DOI Listing
April 2020

Henry Versus Thompson Approach for Fixation of Proximal Third Radial Shaft Fractures: A Multicenter Study.

J Orthop Trauma 2020 Feb;34(2):108-112

Department of Orthopaedics, Louisiana State University, Kenner, LA.

Objective: To compare the volar Henry and dorsal Thompson approaches with respect to outcomes and complications for proximal third radial shaft fractures.

Design: Multicenter retrospective cohort study.

Patients/participants: Patients with proximal third radial shaft fractures ± associated ulna fractures (OTA/AO 2R1 ± 2U1) treated operatively at 11 trauma centers were included.

Intervention: Patient demographics and injury, fracture, and surgical data were recorded. Final range of motion and complications of infection, neurologic injury, compartment syndrome, and malunion/nonunion were compared for volar versus dorsal approaches.

Main Outcome: The main outcome was difference in complications between patients treated with volar versus dorsal approach.

Results: At an average follow-up of 292 days, 202 patients (range, 18-84 years) with proximal third radial shaft fractures were followed through union or nonunion. One hundred fifty-five patients were fixed via volar and 47 via dorsal approach. Patients treated via dorsal approach had fractures that were on average 16 mm more proximal than those approached volarly, which did not translate to more screw fixation proximal to the fracture. Complications occurred in 11% of volar and 21% of dorsal approaches with no statistical difference.

Conclusions: There was no statistical difference in complication rates between volar and dorsal approaches. Specifically, fixation to the level of the tuberosity is safely accomplished via the volar approach. This series demonstrates the safety of the volar Henry approach for proximal third radial shaft 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.0000000000001651DOI Listing
February 2020

Femoral Neck Fractures in Children: Issues, Challenges, and Solutions.

J Orthop Trauma 2019 Dec;33 Suppl 8:S27-S32

Elkerliek Hospital, Netherlands.

Femoral neck fractures in children are rare injuries resulting from high-energy trauma. Different methods of treatment, lack of standard management protocols, and the high risk of complications make this injury one of the biggest challenges that an orthopaedic surgeon can face. This review focuses on the general aspects of the pediatric femoral neck fracture management as well as its complications and possible solutions.
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http://dx.doi.org/10.1097/BOT.0000000000001645DOI Listing
December 2019

Orthopaedic Trauma Association: Trauma Care Forum Connecting the International Trauma Community.

J Orthop Trauma 2019 Dec;33 Suppl 8:i-ii

Department of Orthopaedics, MSK Institute, Geisinger Health System, Danville, PA.

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http://dx.doi.org/10.1097/BOT.0000000000001646DOI Listing
December 2019

Semiextended Tibial Nail Insertion Using an Extraarticular Lateral Parapatellar Approach: A 24-Month Follow-up Prospective Cohort Study.

J Orthop Trauma 2019 Oct;33(10):e366-e371

Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA.

Objective: To analyze the outcomes of tibial shaft fractures treated with a lateral parapatellar approach in the semiextended position for intramedullary nail insertion.

Design: Prospective cohort study.

Setting: Level I trauma center.

Patients And Methods: Seventy patients treated from March 2012 to July 2015 with intramedullary nailing (IMN) using an extraarticular lateral parapatellar approach in the semiextended position were reviewed. Patients were clinically and radiographically checked at a minimum follow-up of 24 months, and the following data were recorded: fracture healing, any residual deformity, nail-apex distance, range of motion of the treated knee together with the contralateral side, knee functional outcome, and residual knee pain.

Results: Twenty-four months after surgery, all patients were clinically and radiographically healed, with 2 cases of malalignment (angular deformity <10 degrees). The average range of motion of the treated knee was 0-130.6 degrees (±8.6 degrees) compared with 0-131.1 degree (±7.9 degrees) of the contralateral. Lysholm knee score was excellent for 57 patients, good for 11, and fair for 2. The mean residual pain was 0.6 (±1.1) according to the visual analogue scale.

Conclusions: The described technique represents an effective option for IMN of tibial fractures. It is suitable for all tibial fractures, including proximal and distal. The results of our series demonstrate the effectiveness of this technique with nearly complete recovery of knee function and negligible incidence of anterior knee pain at a minimum follow-up of 24 months.

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.0000000000001554DOI Listing
October 2019

Minimally Invasive Plate Osteosynthesis for Periprosthetic and Interprosthetic Fractures Associated with Knee Arthroplasty: Surgical Technique and Review of Current Literature.

J Knee Surg 2019 May 28;32(5):392-402. Epub 2019 Mar 28.

Department of Orthopaedics, Geisinger Medical Center, Danville, Pennsylvania.

With the increasing number of total knee arthroplasties (TKAs) being performed, the incidence of periprosthetic fractures adjacent to a TKA is rising. Minimally invasive plate osteosynthesis (MIPO) has proven to be successful for the biological fixation of many fractures. Advances in surgical instrumentation and techniques made MIPO possible for more complex fractures. Periprosthetic fractures are always complicated by problems of soft tissue incisions, scarring, and, of course, the arthroplasty components. MIPO techniques may be particularly suited to these injuries and may make the surgical repair of these fractures safer and more reliable. In this review, case examples are used to define the indications, preoperative planning, implant selection, complications, limitations, and challenges of MIPO for the treatment of periprosthetic fractures about the knee. When considering MIPO for any fracture, we recommend prioritizing an acceptable reduction with biological fixation and resorting to mini-open or open approach when necessary to achieve it. Awareness of the learning curve of the surgical technique, advances in implant designs, the tips and tricks involved, and the limitations of the MIPO is of paramount importance from the orthopaedic surgeon's perspective.
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http://dx.doi.org/10.1055/s-0039-1683443DOI Listing
May 2019

Garden 1 and 2 Femoral Neck Fractures Collapse More Than Expected After Closed Reduction and Percutaneous Pinning.

J Orthop Trauma 2019 03;33(3):116-119

Department of Orthopaedic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA.

Objectives: To report on the final displacement after in situ percutaneous pinning for Garden type 1 and 2 fractures in height, femoral neck fracture collapse, and loss of offset.

Design: Retrospectively reviewed case series.

Setting: Three Academic Medical Centers. Boston University Medical Center (Level 1 Trauma Center), Lahey Hospital and Medical Center (Level 2 Trauma Center), and Geisinger Medical Center (level 2 Trauma Center).

Patients/participants: One hundred thirty skeletally mature patients with 130 fractures (78 garden 1 and 52 garden 2) who were treated between January 2000 and January 2014 at participating hospitals with percutaneous pinning with a cannulated screw system to successful union after sustaining an intracapsular femoral neck fracture without complete displacement.

Intervention: In situ percutaneous pinning with 3 cannulated, partially threaded screws in an inverted triangle orientation.

Main Outcome Measurements: Femoral neck fracture collapse (mm), femoral height shortening (mm), and femoral offset shortening (mm).

Results: A total of 130 patients (81F, 49M), average age 72 years, sustained 78 Garden 1 and 52 Garden 2 femoral neck fractures. Maximal collapse occurred in the plane of the femoral neck. Thirty-three of 78 (42%) Garden 1 fractures and 33/52 (63%) Garden 2 fractures demonstrated >10 mm fracture collapse. The range of displacements was 0-39 mm as measured along the plane of the femoral neck.

Conclusions: Garden 1 fractures collapse less frequently than Garden 2 fractures, but both have high rates of fracture collapse when treated to union with in situ percutaneous pin fixation.

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.0000000000001360DOI Listing
March 2019

Ankle Fractures in Elderly Patients with Osteopenia and Neuropathy.

Instr Course Lect 2018 Feb;67:79-86

Adjunct Professor, Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, University of Nevada, Las Vegas, Nevada.

Ankle fractures are increasingly common in elderly patients given the number of aging individuals who remain active. The already difficult aspects of ankle fixation are amplified by the compromised soft-tissue envelope and bone quality present in elderly patients with an ankle fracture. In addition, elderly patients with an ankle fracture often have compromised neuroprotective mechanisms and are physically unable to follow postoperative protected weight-bearing protocols during ambulation. Surgeons should be aware of strategies to improve fixation and maintain the tibiotalar relationship during ambulation in elderly patients with an ankle fracture.
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February 2018

Is "Early Total Care" a Safe and Effective Alternative to "Staged Protocol" for the Treatment of Schatzker IV-VI Tibial Plateau Fractures in Patients Older Than 50 Years?

J Orthop Trauma 2017 Dec;31(12):e400-e406

Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA.

Objectives: To compare "Early Total Care" (ETC) with "Staged Protocol" (SP) for the treatment of Schatzker IV-VI tibial plateau fractures in patients older than 50 years regarding safety and effectiveness.

Design: Retrospective cohort study.

Setting: An academic level 1 US trauma center.

Patients/participants: Eighty-one patients older than 50 years with Schatzker grade IV-VI tibial plateau fractures were included.

Intervention: Fifty-three patients were treated under SP with immediate external fixation followed by definitive internal fixation. Twenty-eight patients were treated under ETC with immediate internal fixation.

Main Outcome Measurements: Comparison of perioperative findings, time to bony and clinical union, soft-tissue and bony complications, radiological outcome, and secondary procedures.

Results: The 2 groups were comparable without significant difference regarding age, sex, side of involvement, body mass index, smoking status, American Society of Anesthesiologist classification, associated injuries, comorbidities, follow-up duration, and fracture classification. No statistically significant difference was found regarding the perioperative complications, quality of reduction, time to union, Rasmussen score at union or at the final follow-up, soft-tissue/bony complications, and the rate of the secondary procedures.

Conclusion: ETC seems to be a safe, efficacious, and effective alternative to the SP for the treatment of some Schatzker IV-VI fractures in patients older than 50 years.

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.0000000000000995DOI Listing
December 2017

Surgical treatment of osteoporotic fractures: An update on the principles of management.

Injury 2017 Dec 4;48 Suppl 7:S34-S40. Epub 2017 Sep 4.

Department of Orthopaedic Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA, USA. Electronic address:

The treatment of osteoporotic fractures continues to challenge orthopedic surgeon. The fragility of the underlying bone in conjunction with the need for specific implants led to the development of explicit surgical techniques in order to minimize implant failure related complications, morbidity and mortality. From the patient's perspective, the existence of frailty, dementia and other medical related co-morbidities induce a complex situation necessitating high vigilance during the perioperative and post-operative period. This update reviews current principles and techniques essential to successful surgical treatment of these injuries.
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http://dx.doi.org/10.1016/j.injury.2017.08.036DOI Listing
December 2017

Medial Malleoli Fractures: Clinical Comparison Between Newly Designed Sled Device and Conventional Screws.

Foot Ankle Spec 2017 Aug 9;10(4):296-301. Epub 2016 Nov 9.

Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, Pennsylvania.

Background: The Trimed Medial Malleolar Sled is a newer device designed to treat medial malleolus fracture. The purpose of this study was to compare the outcome of medial malleolar fractures treated with the sled and conventional malleolar screws.

Methods: After obtaining an institutional review board approval, we conducted a retrospective study to identify all skeletally mature patients who sustained an ankle fracture with medial malleolar involvement treated with the sled and we identified a matched cohort treated with conventional malleolar screws. The patients were divided into 2 groups: group A included patients treated with malleolar screws and group B included patients treated with the sled device. The outcomes measured included rate of union, implant removal, and pain over the implant site.

Results: Eighty-five medial malleolar ankle fractures were divided into 2 groups: group A included patients (n = 64) treated with malleolar screws and group B included patients (n = 21) treated with the sled device. In group A (n = 64), 62 patients (96.8%) achieved radiological union with a mean union rate of 11 weeks and 10 (15%) patients underwent repeat surgery for implant removal of which 3 patients (4.6%) had pain specifically over the medial implant. In group B (n = 21), all of the patients (100%) achieved radiological union with a mean union rate of 10.8 weeks and 3 patients (14.2%) underwent repeat surgery of which 1 (4.7%) was related to the medial pain. There is no significant difference between the groups for the outcomes measured, including rate of union (  P = .93), visual analog scale score for pain (  P = .07), implant removal (  P = .41), and pain over the implant site (  P = .88).

Conclusion: Based on the data from our study, we conclude that there are no major differences between the sled devices and conventional screws relating to union rate and complications.

Levels Of Evidence: Level III: Observational study.
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http://dx.doi.org/10.1177/1938640016677809DOI Listing
August 2017

Anterior-Inferior Plating Results in Fewer Secondary Interventions Compared to Superior Plating for Acute Displaced Midshaft Clavicle Fractures.

J Orthop Trauma 2017 Sep;31(9):468-471

*Department of Orthopedic Surgery, University of South Florida, Tampa, FL; †Geisinger Medical Center, Orthopaedic Institute, Danville, PA; ‡Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL; §Shoulder and Elbow Surgery Service, Florida Orthopaedic Institute, Tampa, FL; and ‖Department of Orthopaedics, Harborview Medical Center, Seattle, WA.

Objectives: To determine whether a difference in plate position for fixation of acute, displaced, midshaft clavicle fractures would affect the rate of secondary intervention.

Design: Retrospective Comparative Study.

Setting: Two academic Level 1 Regional Trauma Centers.

Patients: Five hundred ten patients treated surgically for an acutely displaced midshaft clavicle fracture between 2000 and 2013 were identified and reviewed retrospectively at a minimum of 24 months follow-up (F/U). Fractures were divided into 2 cohorts, according to plate position: Anterior-Inferior (AI) or Superior (S). Exclusion criteria included age <16 years, incomplete data records, and loss to F/U. Group analysis included demographics (age, sex, body mass index), fracture characteristics (mechanism of injury, open or closed), hand dominance, ipsilateral injuries, time between injury to surgery, time to radiographic union, length of F/U, and frequency of secondary procedures.

Intervention: Patients were treated either with AI or S clavicle plating at the treating surgeon's discretion.

Main Outcome Measures: Rate and reason for secondary intervention.

Statistical Analysis: Fisher exact test, t test. and odds ratio were used for statistical analysis.

Results: Final analysis included 252 fractures/251 patients. One hundred eighteen (47%) were in group AI; 134 (53%) were in group S. No differences in demographics, fracture characteristics, time to surgery, time to union, or length of F/U existed between groups. Seven patients/7 fractures (5.9%) in Group AI underwent a secondary surgery whereas 30 patients/30 fractures (22.3%) in group S required a secondary surgery. An additional intervention secondary to superior plate placement was highly statistically significant (P < 0.001). Furthermore, because 80% of these subsequent interventions were a result of plate irritation with patient discomfort, the odds ratio for a second procedure was 5 times greater in those fractures treated with a superior plate.

Conclusions: This comparative analysis indicates that AI plating of midshaft clavicle fractures seems to lessen clinical irritation and results in significantly fewer secondary interventions. Considering patient satisfaction and a reduced financial burden to the health care system, we recommend routine AI plate application when open reduction internal fixation of the clavicle is indicated.

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.0000000000000856DOI Listing
September 2017

External validation of the clinical indications of computed tomography (CT) of the head in patients with low-energy geriatric hip fractures.

Injury 2017 Jul 26;48(7):1594-1596. Epub 2017 Apr 26.

Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA, USA. Electronic address:

Introduction: On evaluation of the clinical indications of computed tomography (CT) scan of head in the patients with low-energy geriatric hip fractures, Maniar et al. identified physical evidence of head injury, new onset confusion, and Glasgow Coma Scale (GCS)<15 as predictive risk factors for acute findings on CT scan. The goal of the present study was to validate these three criteria as predictive risk factors for a larger population in a wider geographical distribution.

Patients And Methods: Patients ≥65 years of age with low-energy hip fractures from 6 trauma centers in a wide geographical distribution in the United States were included in this study. In addition to the relevant patient demographic findings, the above mentioned three criteria and acute findings on head CT scan were gathered as categorical variables.

Results: In total 799 patients from 6 centers were included in the study. There were 67 patients (8.3%) with positive acute findings on head CT scan. All of these patients (100%) had at least one criteria positive. There were 732 patients who had negative acute findings on head CT scan with 376 patients (51%) having at least one criteria positive and 356 patients (49%) having no criteria positive. Sensitivity of 100% and negative predictive value of 100% was observed to predict negative acute findings on head CT scan when all the three criteria were negative.

Conclusion: With the observed 100% sensitivity and 100% negative predictive value, physical evidence of acute head injury, acute retrograde amnesia, and GCS<15 can be recommended as a clinical decision guide for the selective use of head CT scans in geriatric patients with low energy hip fractures. All the patients with positive acute head CT findings can be predicted in the presence of at least one positive criterion. In addition, if these criteria are used as a pre-requisite to order the head CT, around 50% of the unnecessary head CT scans can be avoided.
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http://dx.doi.org/10.1016/j.injury.2017.04.051DOI Listing
July 2017

Obesity Is Associated With High Perioperative Complications Among Surgically Treated Intertrochanteric Fracture of the Femur.

J Orthop Trauma 2017 Jul;31(7):352-357

*Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA; †Center for Health Research, Geisinger Medical Center, Danville, PA; ‡Department of Orthopaedics, University of Utah, Salt Lake City, UT; §Department of Orthopaedics, Orlando Health, Orlando, FL; and ‖Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY.

Objectives: To document the complications among obese patients who underwent surgical fixation for intertrochanteric femur (IT) fractures and to compare with nonobese patients.

Design: Retrospective cohort study.

Setting: Four level I trauma centers.

Patients: 1078 IT fracture patients.

Interventions: None.

Main Outcome Measures: Patient and fracture characteristics, surgical duration, surgical delay intraoperative and postoperative complications, inpatient mortality, and length of stay.

Method: A retrospective review at 4 academic level I trauma centers was conducted to identify skeletally mature patients who underwent surgical fixation of intertrochanteric fractures between June 2008 and December 2014. Descriptive data, injury characteristics, OTA fracture classification, and associated medical comorbidities were documented. The outcomes measured included in-hospital complications, length of stay, rate of blood transfusion, change in hemoglobin levels, operative time, and wound infection.

Results: Of 1078 unique patients who were treated for an IT fracture, 257 patients had a Body mass index (BMI) of 30 or greater. Patients with a high BMI (≥30) had a significantly lower mean age (73 vs. 77 years, P < 0.0001), higher percentage of high-energy injuries (18% vs. 9%, P = 0.0004), greater mean duration of surgery (96 vs. 86 minutes, P = 0.02), and higher mean length of stay (6.5 vs. 5.9 days, P = 0.004). The high-BMI group (n = 257) had significantly higher percentages of patients with complications overall (43% vs. 28%, P < 0.0001), respiratory complications (11% vs. 3%, P < 0.0001), electrolyte abnormalities (4% vs. 2%, P = 0.01), and sepsis (4% vs. 1%, P = 0.002). Patients with BMI ≥ 40 had a much higher rate of respiratory complications (18%) and wound complications (5%) than obese (BMI: 30-39.9) and nonobese patients (BMI < 30).

Conclusion: Intertrochanteric hip fracture patients with a BMI of >30 kg/m are much more likely to sustain systemic complications including respiratory complications, electrolyte abnormalities, and sepsis. In addition, morbidly obese patients are more likely to sustain respiratory complications and wound infections than obese (BMI: 30-39.9 kg/m) and nonobese patients (BMI: < 30 kg/m). The findings from this study can help direct surgeons in the counseling to obese patients and their family, and perhaps increase hospital reimbursement for this group of patients.

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.0000000000000825DOI Listing
July 2017

Locking Compression Pilon Plate for Fixation of Comminuted Posterior Wall Acetabular Fractures: A Novel Technique.

J Orthop Trauma 2017 Jan;31(1):e32-e36

*Orthopaedic Institute, Geisinger Medical Center, Danville, PA; and †Memorial University Medical Center, Savannah, GA.

Posterior wall acetabular fractures involving a large portion the wall's width and with extensive comminution are difficult fractures to manage operatively. Cortical substitution with a pelvic reconstruction plate and supplemental spring plates has been the traditional means of fixation for these fractures. This option, however, requires the use of multiple, unlinked plates and provides no reliable option for peripheral fixation in comminuted fragments. We describe a novel technique for operative fixation of large, comminuted posterior wall fractures using a single distal tibia pilon plate with the option for peripheral locking screw fixation and report on a series of 20 consecutive patients treated with this method.
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http://dx.doi.org/10.1097/BOT.0000000000000675DOI Listing
January 2017

Osteoarticular allograft reconstruction of post-traumatic defect of distal femur in a pediatric patient: A case report and literature review.

Injury 2016 Nov 6;47(11):2473-2478. Epub 2016 Sep 6.

Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA, United States. Electronic address:

Successful results of osteoarticular allografts in reconstruction of periarticular bone defect after tumor resection encouraged its utilization in post-traumatic defects. Here we describe a case of post-traumatic skeletal defect in a 4 year-old girl treated with osteoarticular allograft reconstruction. Due to severity of the associated soft tissue injury and contamination at presentation staged treatment with antibiotic spacer followed by the reconstruction was carried out. At the end of one year the patient achieved 'Musculoskeletal tumor society' functional score of 27 points and radiographic score of 93%. Reconstruction immediately after healing of soft tissues prevented development of any varus or valgus deformity of the knee. Our case demonstrates utility of osteoarticular allograft in a pediatric post-traumatic skeletal defect.
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http://dx.doi.org/10.1016/j.injury.2016.09.015DOI Listing
November 2016

Improvement in osteoporosis detection in a fracture liaison service with integration of a geriatric hip fracture care program.

Injury 2016 Dec 17;47(12):2755-2759. Epub 2016 Oct 17.

Department of Orthopaedic Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA 17822-2130, USA. Electronic address:

Introduction: Care gaps have been identified in the treatment of osteoporosis after the occurrence of a fragility hip fracture. HiROC (High Risk Osteoporosis Clinic) is a fracture liaison service implemented at our institution. In ProvenCare geriatric hip fracture care program at our institution pre-set orders for the inpatient HiROC consults were prescribed. We hypothesized that there will be a significant increase in the rate of enrollment of patients in the HiROC program after the integration of the pre-set orders.

Patients And Methods: The trauma database at a level-I trauma center was reviewed retrospectively for the charts of patients >50 years of age with fragility intertrochanteric fractures. Patients not treated under the geriatric hip fracture care program and patients treated under the geriatric hip fracture care program were identified and reviewed for the enrollment in HiROC and subsequent follow up.

Results: Out of 589 patients treated before the implementation of ProvenCare, 443 patients (75%) were enrolled in HiROC at the index consult. In comparison, out of 153 patients treated after the implementation of ProvenCare, 131 patients (85.6%) were enrolled in HiROC at the index consult. The difference between the two groups was statistically significant (p=0.008).

Conclusion: Our experience shows that the occurrence of a fragility intertrochanteric fracture can be effectively utilized for the detection and initiation of treatment of osteoporosis. With the implementation of pre-set orders in the geriatric hip fracture care program significantly better enrollment can be achieved.
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http://dx.doi.org/10.1016/j.injury.2016.10.011DOI Listing
December 2016

The Role of Radiographs and Office Visits in the Follow-Up of Healed Intertrochanteric Hip Fractures: An Economic Analysis.

J Orthop Trauma 2016 Dec;30(12):687-690

*Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA; and †Department of Orthopaedics, University of Utah, Salt Lake City, UT.

Objectives: The purpose of this study was to evaluate the role and the necessity of radiographs and office visits obtained during follow-up of intertrochanteric hip injuries.

Design: Retrospective study.

Setting: Two level I trauma centers.

Patients: Four hundred sixty-five elderly patients who were surgically treated for an intertrochanteric fracture of the femur at 2 level I trauma centers between January 2009 and August 2014 were retrospectively identified from orthopaedic trauma databases.

Intervention: Analysis of all healed intertrochanteric hip fractures, including demographic characteristics, quality of reduction, time of healing, number of office visits, number of radiographs obtained, and each radiograph for fracture alignment, implant position or any pathological changes.

Results: The surgical fixation of 465 fractures included 155 short nails (33%), 232 long nails (50%), 69 sliding hip screw devices (15%), 7 trochanteric stabilizing plates (1.5%), and 2 proximal femur locking plates (0.5%). The average fracture healing time was 12.8 weeks and the average follow-up was 81.2 weeks. Radiographs of any patient obtained after the fracture had healed did not reveal any changes, including fracture alignment or implant position and hardware failure. In 9 patients, pathological changes, including arthritis (3), avascular necrosis (3), and ectopic ossification (3) were noted. The average number of elective office visits and radiographs obtained after the fracture had healed were 2.8 (range: 1-8) and 2.6 (range: 1-8), respectively. According to Medicare payments to the institution, these radiographs and office visits account for a direct cost of $360.81 and $192, respectively, per patient.

Conclusion: The current study strongly suggests that there is a negligible role for radiographs and office visits during the follow-up of a well-healed hip fracture when there is documented evidence of radiographic and clinical healing with acceptable fracture alignment and implant position. Implementation of this simple measure will help in reducing the cost of care and inconvenience to elderly patients.

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.0000000000000682DOI Listing
December 2016

The Agreement of Level-of-Evidence Ratings of Articles Submitted to the JOT from 2012 to 2014.

J Orthop Trauma 2016 Jul;30(7):367-9

*Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA †Center for Health Research, Henry Hood Research Center, Danville, PA.

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http://dx.doi.org/10.1097/BOT.0000000000000548DOI Listing
July 2016

Posterior Malleolar Fractures Associated With Tibial Shaft Fractures and Sequence of Fixation.

J Orthop Trauma 2016 Oct;30(10):568-71

*Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA; †Department of Health Research, Geisinger Research Center, Danville, PA; ‡Department of Orthopaedics, University of Utah, Salt Lake City, UT; and §Department of Orthopaedics, Boston University Medical Center, Boston, MA.

Objectives: The purpose of this study was to evaluate posterior malleolar injuries associated with nailed tibial fractures and to determine the quality of reduction based on the sequence of fixation in associated fracture patterns.

Design: Retrospective cohort study.

Patients: 1113 tibia fractures treated with an intramedullary nail at 3 level I trauma centers.

Intervention: Tibial shaft fractures with posterior malleolar injury were analyzed regarding type of fracture, mechanism of injury, energy of injury, fracture characteristic, surgical characteristics including sequence of fixation, obvious intraoperative displacement of the posterior malleolar fragment, and the quality of reduction. One group ("malleolus-first") consisted of patients in whom the posterior malleolus was fixed before tibial nailing and the other group ("tibia-first") included patients in whom tibial nailing was done before posterior malleolus fixation.

Outcomes Measured: Intraoperative displacement, quality of reduction.

Results: Ninety-six of 1113 (9%) nailed tibial shaft fracture patients had a concomitant posterior malleolus fracture (9%). Of the 96 posterior malleolar fracture patients, 70 patients were operatively treated (73%). In the malleolus-first group (54 patients), intraoperative displacement of the posterior malleolar fragment was observed in 1 patient, and 1 case of poor reduction of the posterior malleolar fragment was observed (2%). In the tibia-first group (16 patients), obvious intraoperative displacement of the posterior malleolar fragment was observed in 5 patients (31%), and poor reduction of the posterior malleolar fragment was observed in 7 patients (44%). These percentages of patients with poor quality of reduction were statistically significantly different (p ≤ 0.01).

Conclusion: Many low-energy tibia fractures with a spiral configuration do have an associated posterior malleolus fracture. In order to avoid intraoperative displacement and poor reduction, we recommend fixation of the posterior malleolar fragment before nailing of the tibia in associated fracture pattern.

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.0000000000000629DOI Listing
October 2016

Nail Length in the Management of Intertrochanteric Fracture of the Femur.

J Am Acad Orthop Surg 2016 Jun;24(6):e50-8

From the Department of Orthopaedic Surgery, Geisinger Health System, Danville, PA.

Intramedullary devices are used increasingly to treat intertrochanteric femur fractures, especially those with unstable patterns. In spite of the considerable use of nails in the management of these fractures, opinions differ about the correct length of intramedullary nail. Long nails were developed to address the risk of diaphyseal fracture associated with earlier short nail designs and to extend the indications for use to include diaphyseal and subtrochanteric fractures. Several recent studies, however, have found no differences between modern short nails and long nails with regard to union and complication rates. In the absence of existing guidelines, the treating surgeon's preference and fracture characteristics continue to influence the decision of whether to use short nails or long nails. The surgeon needs to consider the fracture configuration and related factors, including whether osteoporosis is present and the cost and risk of revision surgery, when selecting the appropriate nail length.
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http://dx.doi.org/10.5435/JAAOS-D-15-00325DOI Listing
June 2016

Role of Sonication for Detection of Infection in Explanted Orthopaedic Trauma Implants.

J Orthop Trauma 2016 May;30(5):e175-80

Departments of *Orthopaedic Surgery, and †Infectious Disease, Geisinger Medical Center, Danville, PA; and ‡Center for Health Research, Geisinger Medical Center, Danville, PA.

Objectives: Sonication is a new technology that uses high-frequency sound waves to mechanically dislodge bacteria adherent in biofilms. Unlike arthroplasty, its role in orthopaedic trauma has not been described. The goal of this study was to explore the utility of sonication in orthopaedic trauma.

Design: Retrospective review.

Setting: Level I trauma center.

Patients: One hundred forty-six sonicated metallic orthopaedic devices from September 2010 to May 2013 were included. Patients were divided into 3 groups: clinically infected, elective implant removals, and nonunion.

Intervention: Sonication culture results were retrospectively reviewed for all patients undergoing implant removal.

Outcomes: Sonication results were the primary study outcome and were considered positive for culture growth if equal to or greater than 20 colony-forming units per plate.

Results: In 32 patients with clinical infection, tissue cultures were positive in 30 (94%) and negative in 2 (6%). In contrast, sonication cultures were positive in 19 patients (59%) and did not identify additional organisms. Of the 72 patients who underwent elective implant removal, 52 had pain. Sonication cultures were positive in 5 of these 52 patients (10%) and in 0 of 20 patients with no pain. Sonication culture results were negative in all 42 patients who underwent nonunion surgery.

Conclusions: Sonication of orthopaedic trauma implants in patients with clinically apparent infection or "aseptic" nonunion offered negligible additional information. Sonication demonstrated a positive microbiologic yield in a subset of patients with painful implants; further research is required to better establish the frequency of subclinical infection and to determine the diagnostic role of traditional cultures and sonication.

Level Of Evidence: Diagnostic 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.0000000000000512DOI Listing
May 2016

Knee Injury Associated With Acetabular Fractures: A Multicenter Study of 1273 Patients.

J Orthop Trauma 2016 Jan;30(1):48-51

*Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA;†Orthopaedic Associates of Michigan, Grand Rapids, MI;‡Department of Orthopaedic Surgery, Boston University Medical Center, Boston, MA; and§Department of Orthopaedic Surgery, Lahey Hospital and Medical Center, Burlington, MA.

Objectives: The purpose of this study was to determine the incidence and pattern of the knee injury associated with acetabular fractures.

Design: Retrospective cohort study.

Setting: Three level I and one level II trauma centers.

Patients: A total of 1273 skeletally mature patients treated at 4 trauma centers between November 2004 and December 2013 for acetabular fractures were retrospectively identified from orthopaedic trauma databases.

Intervention: Analysis of all acetabular fractures with knee injury regarding type of acetabular fracture, mechanism of injury, energy of injury, pattern of the knee injury, knee examination findings at initial presentation, intraoperative and on follow-up, requirement for surgery/conservative management, and the associated injuries. The clinical data entered during inpatient stay and office visits were analyzed.

Main Outcome Measures: Incidence and pattern of the knee injury.

Results: One hundred ninety-three of 1273 patients (15%) were found to have ipsilateral knee symptoms within a period of 1 year from the date of injury. The patterns of knee injury included 56 fractures (29%), 49 ligamentous lesions (25%), and 88 miscellaneous (46%) causes including bone bruises, wounds, and swelling. Associated injuries included 85 patients with ipsilateral hip dislocation (45%), 59 pelvic injuries (31%), 61 extremity injuries (32%), 38 head injuries (20%), 37 chest injuries (20%), 23 abdominal and genitourinary injuries (12%), and 7 injuries of the spine (4%).

Conclusion: Based on this study, we conclude that knee injuries associated with high-energy acetabular fractures constitute a significant portion of the patient population. Ligament injuries are frequently overlooked and thorough clinical evaluation and utilization of magnetic resonance imaging in selected cases will help in early detection and prevention of long-term complications.

Level Of Evidence: Prognostic 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.0000000000000425DOI Listing
January 2016

Clinical indications of computed tomography (CT) of the head in patients with low-energy geriatric hip fractures.

Injury 2015 Nov 3;46(11):2185-9. Epub 2015 Jul 3.

Department of Orthopaedic Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA 17822-2130, USA(1). Electronic address:

Objective: To define the role of head computed tomography (CT) scans in the geriatric population with isolated low-energy femur fractures and describe the pertinent clinical variables which are associated with positive CT findings with the objective to decrease the number of unnecessary CT scans performed.

Design: Retrospective review.

Setting: Level I trauma centre.

Patients: Eleven hundred ninety-two (1192) patients sustaining a femur fracture following a low-energy fall.

Main Outcome Measurement: Pertinent clinical variables that were associated with CTs that yielded positive findings.

Results: Two hundred fifty patients (21%) underwent a head CT scan as part of their evaluation. Of these patients, 83% suffered proximal femur fractures, 11% shaft fractures and 6% distal fractures. The majority of the patients were evaluated by the emergency department (ED) with only 18% (44/250) being evaluated by the trauma team. Average patient age was 83 years (range 65-99 years). One hundred seventy-three patients (69%) were on some form of antiplatelet medication or anticoagulation. Of the 250 patients who underwent head CT scan, 16 (6%) patients had acute findings (haemorrhage - 15, infarct - 1), and none of the patients required neurosurgical intervention.

Conclusion: None of the patients with a traumatic injury required a neurosurgical invention after sustaining a low energy fall (0/1192). Head CT scans should have a limited role in the work-up of this patient population and should be reserved for patients with a history and physical findings that support head trauma.

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/10.1016/j.injury.2015.06.036DOI Listing
November 2015

Invited Commentary.

J Orthop Trauma 2014 Aug;28(8):443

Danville, PA.

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August 2014

Percutaneous and Mucocutaneous Exposure Among Orthopaedic Surgeons: Immediate Management and Compliance With CDC Protocol.

J Orthop Trauma 2015 Oct;29(10):e391-4

Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA.

Background: Orthopaedic surgeons are at a high risk of sustaining a percutaneous or mucocutaneous exposure to blood and body fluids. The Center for Disease Control and Prevention recommends a wash with soap and water and notification of the concerned hospital authorities after any percutaneous/mucocutaneous exposure, but a systematic amenability with these guidelines is not always seen. This cross-sectional study was undertaken to determine current knowledge and practices of orthopaedic surgeons in case of a percutaneous sharp injury exposure, emphasizes the immediate first aid steps taken after an exposure, the degree of reporting, and to explore the reasons for noncompliance. Finally, we sought to create awareness about the prevailing Center for Disease Control and Prevention guidelines after any exposure to blood or body fluids.

Materials And Methods: We conducted a cross-sectional survey using an anonymous prepared questionnaire. The study population included exclusively orthopaedic surgeons, including residents, fellows, and attending physicians at 4 US institutions. The questionnaire was also available online on the OTA Web site as a part of survey monkey. The questionnaire comprised 9 multiple choice questions, and more than 1 response could be given for some questions. The questions addressed previous needle stick/sharp injury exposure, number of times that had happened, whether reported to the hospital administration, reason for nonreporting, and risk perception for transmission of blood-borne pathogens (human immunodeficiency virus, HBsAg, and hepatitis C virus). The questions were also asked based on what should be done in four different clinical settings based on respondents risk perception.

Results: Of fifty eight attendings, 7 fellows, 45 residents, and 7 respondents who did not indicate their position participated in the survey for a total of 117 respondents. Out of 99, 24 had sustained it once, 18 twice, 11 three times, and 35 at least 4 times. When questioned about informing the incident to the hospital administration, 38% had always reported the incident, 33% had never reported the incident, and the remaining 29% had not reported it every time. Of note, 87% gave the correct response about the risk of transmission of human immunodeficiency virus after an exposure. On questioning about the risk of hepatitis B transmission, from an HBsAg- and HBeAg-positive source, 13% gave the correct response, whereas from HBsAg-positive and HBeAg-negative source, 30% gave the correct response. Regarding transmission of hepatitis C virus from a positive source, 36% responded correctly. The surgeons seemingly attempted to risk stratify their exposure, and they were more likely to report their exposure in the higher risk scenarios.

Conclusions: This study demonstrates that orthopaedic surgeons of all levels of training are at high risk of occupational exposure to blood-borne pathogens. Moreover, despite the level of training, the majority of surgeons do not follow the recommended steps, although we do not know the reasons for such behavior. Also, there is a low awareness of the significant risk of hepatitis transmission among orthopaedic surgeons treating a population with a high prevalence of undiagnosed hepatitis.
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http://dx.doi.org/10.1097/BOT.0000000000000360DOI Listing
October 2015
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