Publications by authors named "Julius A Bishop"

99 Publications

ICD-10 codes do not accurately reflect ankle fracture injury patterns.

Injury 2021 Oct 9. Epub 2021 Oct 9.

Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA 94063-6342, United States of America.

Objective: To determine the accuracy of International Classification of Disease Version 10 (ICD-10) coding for ankle fracture injury patterns.

Design: Retrospective cohort study PATIENTS: 97 adult patients with fractures about the ankle (rotational ankle fracture or distal tibia fracture) from 2016 to 2020, selected by stratified random sampling.

Intervention: Assignment of an ICD-10 code representative of a rotational ankle fracture, pilon fracture, or unspecified fracture of the lower leg.

Outcome Measurements: Injury radiographs were reviewed by three authors to determine the correct code. Agreement between the correct code and the electronic medical record (EMR) assigned code was determined using kappa's statistic in the aggregate as well as percent agreement, sensitivity, specificity, and positive predictive value (PPV) between individual codes.

Results: 59 of 97 cases (60.8%) demonstrated discordance between the existing EMR and surgeon-assigned codes. Aggregate agreement between all codes was fair (K = 0.26). Lateral malleolus fracture codes demonstrated the highest PPV (0.91, 95% CI 0.72-0.99), while the lowest PPV was found for "other fractures of the lower leg" (0.05, 95% CI 0.0-0.24) and "other fracture of the fibula" (0.0, 95% CI 0.0-0.15). Generalized "other fracture" codes comprised 45% of EMR codes compared to only 6% of assigned codes (p < 0.001). EMR codes were specific but not sensitive.

Conclusion: There is substantial discordance between existing EMR and surgeon-assigned ICD-10 codes for ankle fractures. Database research that relies on ICD-10 coding as a surrogate for primary clinical data should be interpreted with caution and institutions should make efforts to increase the accuracy of their coding.
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http://dx.doi.org/10.1016/j.injury.2021.10.005DOI Listing
October 2021

To Fix or Revise: Differences in Periprosthetic Distal Femur Fracture Management Between Trauma and Arthroplasty Surgeons.

J Am Acad Orthop Surg 2021 Jul 20. Epub 2021 Jul 20.

From the Department of Orthopaedic Surgery, Stanford Medicine, Stanford, CA (Van Rysselberghe, Amanatullah, Gardner, and Bishop), the Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY (Campbell), and the Department of Orthopaedic Surgery, Harborview Medical Center, Seattle, WA (Goodnough).

Introduction: This study sought to determine the effect of trauma fellowship training on the surgical decision to fix or revise to distal femoral replacement in periprosthetic distal femur fractures.

Methods: An anonymous online survey including nine cases of geriatric periprosthetic distal femur fractures was distributed through the Orthopaedic Trauma Association website. Respondents were asked whether they would recommend fixation or revision to distal femoral replacement. Fractures were classified by the location relative to the anterior flange (proximal or distal) and the presence or absence of comminution. Recommendations were compared between type of fellowship completed (trauma, arthroplasty, or both), practice setting, and number of periprosthetic distal femur fractures treated monthly.

Results: One hundred fifty-one surgeon survey responses were included. Completion of a trauma fellowship was associated with a higher likelihood of recommending fixation for any periprosthetic distal femur fracture compared with arthroplasty training (odds ratio [OR] 2.55, 95% confidence interval [CI] 1.97 to 3.29; P < 0.0001). Disagreement was significant for comminuted proximal (OR 6.90, 95% CI 3.24 to 14.68; P < 0.0001), simple distal (OR 20.90, 95% CI 6.41 to 67.71; P < 0.001), and comminuted distal fractures (OR 2.47, 95% CI 1.66 to 3.68; P < 0.0001). Dual fellowship-trained surgeons were less likely to recommend fixation than surgeons who completed a trauma fellowship alone (OR 0.60, 95% CI 0.39 to 0.93; P = 0.027) and more likely to recommend fixation than surgeons who completed an arthroplasty fellowship alone (OR 1.70, 95% CI 1.13 to 2.63; P = 0.012). Surgeons who treat three or more periprosthetic distal femur fractures monthly showed a significant preference for fracture fixation compared with lower volume surgeons (OR 2.45, 95% CI 1.62 to 3.68; P < 0.0001).

Discussion: Fellowship-trained trauma surgeons show a notable preference for fracture fixation over distal femoral replacement for periprosthetic distal femur fractures, as compared with arthroplasty-trained surgeons. Additional research is needed to clarify surgical indications that maximize outcomes for these injuries.
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http://dx.doi.org/10.5435/JAAOS-D-20-00968DOI Listing
July 2021

Biomechanically superior treatments do not translate into improved outcomes in randomized controlled trials.

Eur J Orthop Surg Traumatol 2021 Jun 27. Epub 2021 Jun 27.

Department of Orthopaedic Surgery, Stanford School of Medicine, 450 Broadway St, Redwood City, CA, 94063, USA.

Purpose: Significant time and resources are devoted to conducting orthopaedic biomechanics research; however, it is not known how these studies relate to their subsequent clinical studies. The purpose of the present study was to determine whether biomechanically superior treatments were associated with improved clinical outcomes as determined by analogous randomized controlled trials (RCTs).

Methods: A systematic review was conducted to find RCTs that tested a research question based on a prior biomechanical study. PubMed and SCOPUS databases were queried for orthopaedic randomized controlled trials, and full text articles were reviewed to find RCTs which cited biomechanical studies with analogous comparison groups. A random-effects multi-level logistic regression model was conducted examining the association between RCT outcome and biomechanics outcome, adjusting for multiple outcomes nested within study.

Results: In total, 20,261 articles were reviewed yielding 21 RCTs citing a total of 43 analogous biomechanical studies. In 7 instances (16.2%), the RCT and a cited biomechanical study showed concordant results (i.e. the superior treatment in the RCT was also the superior construct in the biomechanical study). RCT outcome was not associated with biomechanical outcome (β = -1.50, standard error = 0.78, p = .05).

Conclusion: This study assessed 21 orthopaedic RCTs with 43 corresponding biomechanical studies and found no association between superior biomechanical properties of a given orthopaedic treatment and improved clinical outcomes. Favourable biomechanical properties alone should not be the primary reason for selecting one treatment over another. Furthermore, RCTs based on biomechanical studies should be carefully designed to maximize the chance of providing clinically relevant insights.
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http://dx.doi.org/10.1007/s00590-021-03051-8DOI Listing
June 2021

Distal Femur Replacement versus Open Reduction and Internal Fixation for Treatment of Periprosthetic Distal Femur Fractures: Systematic Review and Meta-Analysis.

J Orthop Trauma 2021 May 15. Epub 2021 May 15.

Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, CA, USA. Lane Medical Library & Knowledge Management Center, Stanford University, Stanford, California, USA.

Objective: To compare complications and functional outcomes of treatment with primary distal femoral replacement (DFR) versus open reduction and internal fixation (ORIF).

Data Sources: PubMed, Embase, and Cochrane databases were searched for English language studies up to May 19, 2020, identifying 913 studies.

Study Selection: Studies that assessed complications of periprosthetic distal femur fractures with primary DFR or ORIF were included. Studies with sample size ≤5, mean age <55, nontraumatic indications for DFR, ORIF with non-locking plates, native distal femoral fractures, or revision surgeries were excluded. Selection adhered to PRISMA criteria.

Data Extraction: Study quality was assessed using previously reported criteria. There were 40 Level IV studies, 17 Level III studies, and 1 Level II study.

Data Synthesis: Fifty-eight studies with 1,484 patients were included in the meta-analysis. Complications assessed (Incidence Rate Ratio (IRR) (95%CI): 0.78 (0.59-1.03)) and reoperation or revision (IRR (95%CI): 0.71 (0.49-1.04)) were similar between the DFR and ORIF cohorts. Mean knee range of motion (ROM) was greater in the ORIF cohort (DFR: 90.47 vs. ORIF: 100.36, p < 0.05). Mean Knee Society Score (KSS) (DFR: 79.41 vs. ORIF: 82.07, p = 0.35) and return to preoperative ambulatory status were similar (IRR (95%CI): 0.82 (0.48-1.41)).

Conclusions: In comparing complications among patients treated for periprosthetic distal femur fracture with DFR or ORIF, there was no difference between the groups. There were also no differences in functional outcomes, although knee ROM was greater in the ORIF group. This systematic review and meta-analysis highlights the need for future prospective trials evaluating the outcomes of these divergent treatment strategies.

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.0000000000002141DOI Listing
May 2021

Incidence and Management of Articular Impaction in Geriatric Olecranon Fractures.

J Am Acad Orthop Surg 2021 Sep;29(18):805-810

From the Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, CA (Wadhwa, Goodnough, Finlay, DeBaun, Bishop, and Gardner), the Department of Orthopaedic Surgery, Santa Clara Valley Medical Center, San Jose, CA (Hecht and Lucas), and the Department of Orthopaedic Surgery, University of Washington Harborview Medical Center, Seattle, WA (Campbell).

Introduction: Olecranon fractures are common in the elderly. Articular impaction is encountered occasionally, but the incidence and outcomes after treatment of this injury pattern have not been well characterized.

Methods: We evaluated a cohort of geriatric olecranon fractures to determine the incidence of articular impaction and describe a technique for open reduction and internal fixation.

Results: Of the 63 patients in our series, 31 had associated intraarticular impaction (49.2%). Patients with articular impaction did not have significantly different rates of postoperative complications (11/31, 35.5% versus 10/31, 32.3%; P = 1.00) or revision surgery (10/31, 32.3% versus 8/31, 25.8%; P = 0.780) compared with those without articular impaction.

Conclusion: Articular impaction is a common feature of geriatric olecranon fractures. Surgeons must maintain a high index of suspicion and have a surgical plan in place for managing this component of the injury.
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http://dx.doi.org/10.5435/JAAOS-D-20-01293DOI Listing
September 2021

Dual mini-fragment plate fixation for Neer type-II and -V distal clavicle fractures.

OTA Int 2020 Sep 14;3(3):e078. Epub 2020 Aug 14.

Department of Orthopaedic Surgery, Stanford University Medical Center, Redwood City, CA.

Contemporary methods for open reduction and internal fixation of displaced distal clavicle fractures have excellent rates of union and high rates of reoperation for symptomatic implant removal. The authors describe their preferred surgical technique and case series of patients with Neer Type-II and -V distal clavicle fractures treated with lower profile dual mini-fragment plates using interdigitating screws placed into the distal segment to enhance fixation.
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http://dx.doi.org/10.1097/OI9.0000000000000078DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8016599PMC
September 2020

Tranexamic acid does not affect intraoperative blood loss or in-hospital outcomes after acetabular fracture surgery.

Eur J Orthop Surg Traumatol 2021 Apr 23. Epub 2021 Apr 23.

Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA.

Purpose: Tranexamic acid (TXA) reduces need for transfusion in total joint arthroplasty, though findings in acetabular surgery are conflicting. We compared outcomes after acetabular fracture surgery with or without perioperative intravenous (IV) TXA administration.

Methods: We performed a retrospective review of 305 patients with acetabular fractures that underwent open reduction and internal fixation (ORIF). Eighty-nine patients received TXA, and 216 did not. The primary outcome was rates of intraoperative and postoperative allogeneic blood transfusion.

Results: Baseline demographics and characteristics were similar. Time from injury to surgery and estimated blood loss were comparable. Operative time (p < 0.01) and intraoperative IV fluids (p < 0.01) were greater in the non-TXA group. The proportion of patients who received blood transfusion and mean units transfused intraoperatively and postoperatively did not differ. Mean differences in preoperative and postoperative hemoglobin and hematocrit, hospital length of stay, and perioperative complications also did not differ. In a multivariable regression model, age 60-70 years, Charlson Comorbidity Index, Injury Severity Score, and fracture patterns likely to bleed were independently associated with intraoperative transfusion. Anterior surgical approaches and intraoperative transfusion requirement were independently associated with postoperative transfusion.

Conclusion: In this study, perioperative IV TXA did not decrease blood loss, need for transfusion, or improve in-hospital outcomes of acetabular fracture surgery. Age 60-70, CCI, ISS, and fracture patterns likely to bleed were independently associated with intraoperative transfusion. Anterior surgical approach and need for intraoperative transfusion were independently associated with postoperative transfusion. Further prospective trials are warranted to confirm these findings.
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http://dx.doi.org/10.1007/s00590-021-02985-3DOI Listing
April 2021

Hypotensive Anesthesia does not reduce Transfusion Rates during and after Acetabular Fracture Surgery.

Injury 2021 Jul 2;52(7):1783-1787. Epub 2021 Apr 2.

Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, CA, USA. Electronic address:

Background: Acetabular fracture open reduction and internal fixation (ORIF) is generally associated with high intraoperative blood loss. Hypotensive anesthesia has been shown to decrease blood loss and intraoperative transfusion in total joint arthroplasty and posterior spinal fusion. In this study, we assessed the effect of reduction in intraoperative mean arterial pressures (MAPs) during acetabular fracture surgery on intraoperative blood loss and need for transfusion.

Methods: Three hundred and one patients with acetabular fractures who underwent ORIF at an academic Level 1 trauma center were retrospectively reviewed. Patients were separated based on mean intraoperative MAPs (<60 mmHg, 60-70 mmHg, >70 mmHg). Thirteen patients had mean intraoperative MAP <60 mmHg, 95 had MAP 60-70 mmHg, and 193 had MAP >70 mmHg. Rates of intraoperative and postoperative allogeneic blood transfusion were compared.

Results: Mean intraoperative MAPs were significantly different between groups (p < 0.0001). Time from injury to surgery, estimated blood loss, operative time and intraoperative IV fluids were comparable. The proportion of patients who received blood transfusion and mean units transfused intraoperatively and postoperatively were similar between groups. Mean differences in preoperative and postoperative hemoglobin and hematocrit were also similar. There was no difference in hospital length of stay or perioperative complications between the groups. Multivariate logistic regression analysis demonstrated that body mass index > 30 (p < 0.05) and anterior surgical approach (p < 0.01) were independently associated with intraoperative transfusion and an anterior surgical approach (p < 0.001) was independently associated with postoperative transfusion.

Conclusion: Decreased intraoperative MAP during acetabular fracture surgery does not reduce blood loss or need for transfusion. On the other hand, no increased end-organ ischemia was seen with hypotensive anesthesia.

Level Of Evidence: Therapeutic Level III.
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http://dx.doi.org/10.1016/j.injury.2021.03.059DOI Listing
July 2021

Effect of Intrawound Vancomycin Powder in Operatively Treated High-risk Tibia Fractures: A Randomized Clinical Trial.

JAMA Surg 2021 May 12;156(5):e207259. Epub 2021 May 12.

Department of Orthopaedic Surgery, Indiana University Methodist Hospital, Indianapolis.

Importance: Despite the widespread use of systemic antibiotics to prevent infections in surgically treated patients with fracture, high rates of surgical site infection persist.

Objective: To examine the effect of intrawound vancomycin powder in reducing deep surgical site infections.

Design, Setting, And Participants: This open-label randomized clinical trial enrolled adult patients with an operatively treated tibial plateau or pilon fracture who met the criteria for a high risk of infection from January 1, 2015, through June 30, 2017, with 12 months of follow-up (final follow-up assessments completed in April 2018) at 36 US trauma centers.

Interventions: A standard infection prevention protocol with (n = 481) or without (n = 499) 1000 mg of intrawound vancomycin powder.

Main Outcomes And Measures: The primary outcome was a deep surgical site infection within 182 days of definitive fracture fixation. A post hoc comparison assessed the treatment effect on gram-positive and gram-negative-only infections. Other secondary outcomes included superficial surgical site infection, nonunion, and wound dehiscence.

Results: The analysis included 980 patients (mean [SD] age, 45.7 [13.7] years; 617 [63.0%] male) with 91% of the expected person-time of follow-up for the primary outcome. Within 182 days, deep surgical site infection was observed in 29 of 481 patients in the treatment group and 46 of 499 patients in the control group. The time-to-event estimated probability of deep infection by 182 days was 6.4% in the treatment group and 9.8% in the control group (risk difference, -3.4%; 95% CI, -6.9% to 0.1%; P = .06). A post hoc analysis of the effect of treatment on gram-positive (risk difference, -3.7%; 95% CI, -6.7% to -0.8%; P = .02) and gram-negative-only (risk difference, 0.3%; 95% CI, -1.6% to 2.1%; P = .78) infections found that the effect of vancomycin powder was a result of its reduction in gram-positive infections.

Conclusions And Relevance: Among patients with operatively treated tibial articular fractures at a high risk of infection, intrawound vancomycin powder at the time of definitive fracture fixation reduced the risk of a gram-positive deep surgical site infection, consistent with the activity of vancomycin.

Trial Registration: ClinicalTrials.gov Identifier: NCT02227446.
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http://dx.doi.org/10.1001/jamasurg.2020.7259DOI Listing
May 2021

Research methodologic quality varies significantly by subspecialty: An analysis of AAOS meeting abstracts.

J Clin Orthop Trauma 2021 Apr 11;15:37-41. Epub 2020 Nov 11.

Department of Orthopaedic Surgery, Stanford University, Stanford, CA, (JAB), United States.

Background: The purpose of this study was to compare the level of evidence and study type of clinical abstracts accepted to the 2017 AAOS Annual Meeting based on subspecialty.

Methods: All clinical abstracts presented at the 2017 AAOS Annual Meeting were assessed by two independent raters for LOE and study type. Nonparametric statistics and chi-square test were used to compare LOE and study types between subspecialties.

Results: A total of 1083 abstracts met inclusion criteria. There was a significant difference in LOE of abstracts by subspecialty ( < 0.001). Shoulder/elbow, adult reconstruction knee, hand/wrist, and sports had the highest percentage of level I and II studies. The type of study also varied significantly by subspecialty ( = 0.005).

Discussion: Methodologic quality of clinical studies presented at the 2017 AAOS Annual Meeting differed significantly among subspecialties. Orthopedic researchers should look to the fields producing the highest quality studies in an effort to improve methodological quality.
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http://dx.doi.org/10.1016/j.jcot.2020.11.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920098PMC
April 2021

Do-Not-Resuscitate status is an independent risk factor for medical complications and mortality among geriatric patients sustaining hip fractures.

J Clin Orthop Trauma 2021 Mar 22;14:65-68. Epub 2020 Sep 22.

Stanford Medicine, Department of Orthopaedic Surgery, Stanford, CA, 94305, USA.

Background: The purpose of this study was to compare outcomes after hip fracture surgery between DNR/DNI and full code cohorts to determine whether DNR/DNI status is an independent predictor of complications and mortality within one year. A significant number of geriatric hip fracture patients carry a code status designation of DNR/DNI (Do-Not-Resuscitate/Do-Not-Intubate). There is limited data addressing how this designation may influence prognosis.

Methods: A retrospective chart review of all geriatric hip fractures treated between 2002 and 2017 at a single level-I academic trauma center was performed. 434 patients were eligible for this study with 209 in the DNR/DNI cohort and 225 in the full code cohort. The independent variable was code-status and dependent variables included patient demographics, surgery performed, American Society of Anesthesiologists, score, Charlson Comorbidity Index, significant medical and surgical complications within one year of surgery, duration of follow-up by an orthopaedic surgeon, duration of follow-up by any physician, and mortality within 1 year of surgery. One-year complication rates were compared, and multiple logistic regression analyses were performed to analyze the relationship between independent and dependent variables.

Results: The DNR/DNI cohort experienced significantly more surgical complications compared to the full code cohort (14.8% vs 7.6%, p = 0.024). There was a significantly higher rate of medical complications and mortality in the DNR/DNI cohort (57.9% vs 36%, p < 0.001 and 19.1% vs 3.1%, p = 0.037, respectively). In the regression analysis, DNR/DNI status was an independent predictor of a medical complication (odds ratio 2.33, p = 0.004) and one-year mortality (odds ratio 9.69, p < 0.001), but was not for a surgical complication (OR 1.95, p = 0.892).

Conclusions: In our analysis, DNR/DNI code status was an independent risk factor for postoperative medical complications and mortality within one year following hip fracture surgery. The results of our study highlight the need to recognize the relationship between DNR/DNI designation and medical frailty when treating hip fractures in the elderly population.
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http://dx.doi.org/10.1016/j.jcot.2020.09.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920119PMC
March 2021

Late Venous Thoracic Outlet Syndrome After Anatomic Fixation of a Diaphyseal Clavicle Fracture: A Case Report.

JBJS Case Connect 2021 03 10;11(1). Epub 2021 Mar 10.

Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, California.

Case: We report the case of a 29-year-old man with a displaced mid-diaphyseal clavicle fracture that healed in anatomic position without fracture callus after surgical treatment but developed symptoms of late venous thoracic outlet syndrome (TOS) 19 months postoperatively. He was diagnosed with proximal subclavian vein thrombosis and was treated with urgent thrombolysis and staged first rib resection with resolution of symptoms.

Conclusions: Late venous TOS is a potential complication of clavicle fracture, even in the setting of anatomic reduction and primary bone healing. This entity has previously only been described in the setting of nonunion and malunion.
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http://dx.doi.org/10.2106/JBJS.CC.20.00243DOI Listing
March 2021

Cephalomedullary helical blade is independently associated with less collapse in intertrochanteric femur fractures than lag screws.

Eur J Orthop Surg Traumatol 2021 Oct 15;31(7):1421-1425. Epub 2021 Feb 15.

Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Stanford, CA, USA.

Objectives: Excessive fracture site collapse and shortening in intertrochanteric femur fractures alter hip biomechanics and patient outcomes. The purpose of the study was to compare extent of collapse in cephalomedullary nails with blades or lag screws. We hypothesized that there would be no difference in collapse between helical blades and lag screws.

Design: Retrospective cohort study.

Setting: Single U.S. Level I Trauma Center.

Patients: 171 consecutive patients treated with cephalomedullary nails with either lag screw or blade for AO/OTA 31A1-3 proximal femur fractures and minimum 3-month follow-up.

Intervention: Lag screw or helical blade in a cephalomedullary nail.

Outcome Measures: The primary outcome was fracture site collapse at 3 months.

Results: There was a significantly higher proportion of reverse-oblique and transverse intertrochanteric femur fractures (31-A3) in the lag screw group (15/42 vs 25/129). A3 patterns were associated with more collapse. There was significantly less collapse in the blade group (median 4.7 mm, inter-quartile range 2.5-7.8 mm) than the screw group (median 8.4 mmm, inter-quartile range 3.7-11.2 mm, p 0.006). Median collapse was no different between blades and screws when comparing stable and unstable patterns. However, blades were independently associated with 2.5 mm less collapse (95%CI - 4.2, - 0.72 mm, p 0.006) and lower likelihood of excessive collapse (> 10 mm at 3 months, OR 0.3, 95% CI 0.13-0.74, p 0.007), regardless of fracture pattern.

Conclusions: Helical blades are independently associated with significantly less collapse than lag screws in intertrochanteric proximal femur fractures, after adjusting for unstable fracture patterns. In fracture patterns at risk for collapse, surgeons can consider use of a helical blade due to its favorable sliding properties compared to screws.
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http://dx.doi.org/10.1007/s00590-021-02875-8DOI Listing
October 2021

Distal femoral fine wire traction assisted retrograde nailing of the femur.

Eur J Orthop Surg Traumatol 2021 Oct 11;31(7):1529-1534. Epub 2021 Feb 11.

Department of Orthopedic Surgery, Stanford University, 450 Broadway Street, Pavilion C, 4th Floor, Stanford, Redwood City, CA, 94063-6342, USA.

Here we describe the surgical technique for using distal femoral fine wire traction during retrograde femoral nailing and present case examples. This technique allows for hands-free distraction across the fracture site to restore length and alignment, while not interfering with the preparation and insertion of the retrograde femoral nail. Distal femoral fine wire traction is a useful adjunctive technique to restore length and effect an indirect reduction in femur fractures being stabilized with a retrograde nail.
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http://dx.doi.org/10.1007/s00590-021-02897-2DOI Listing
October 2021

Iatrogenic Compartment Syndrome After Delayed Primary Closure of the Tibial Fracture-Related Leg Fasciotomy Wound: A Case Report.

JBJS Case Connect 2020 11 20;10(4):e20.00440. Epub 2020 Nov 20.

Department of Orthopaedic Surgery, Stanford University, Stanford, California.

Case: Compartment syndrome can occur after tibial fracture and requires prompt diagnosis and immediate fasciotomy. Because of post-traumatic swelling, delayed primary wound closure can be difficult requiring significant tension on the skin. Closing the skin in this setting theoretically puts the patient at risk of elevated compartment pressures, although compartment syndrome has never been reported in these circumstances. We describe a case of compartment syndrome that developed after delayed primary skin closure of a single incision 4-compartment fasciotomy wound after tibial fracture.

Conclusion: This is the first published description of compartment syndrome after delayed primary closure of a leg fasciotomy wound.
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http://dx.doi.org/10.2106/JBJS.CC.20.00440DOI Listing
November 2020

Short versus long cephalomedullary nailing of intertrochanteric fractures: a meta-analysis of 3208 patients.

Arch Orthop Trauma Surg 2021 Jan 23. Epub 2021 Jan 23.

Department of Orthopaedic Surgery, Stanford University Hospital, 300 Pasteur Drive, Palo Alto, CA, USA.

Objectives: The purpose of the study was to compare treatment outcomes after short or long cephalomedullary nailing for intertrochanteric femur fractures.

Data Sources: A systematic review of perioperative outcomes after short or long cephalomedullary nailing for intertrochanteric femur fractures was performed. The following databases were used: using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (1980-2019), and MEDLINE (1980-2019). The queries were performed in June 2019.

Study Selection: The following search term query was used: "Intramedullary Nail AND Intertrochanteric Fracture OR "Long OR Short Nail AND intertrochanteric Fracture." Studies were excluded if they were "single-arm" studies (i.e., reporting on either long or short CMN but not both), or did not report at least one of the outcomes being meta-analyzed. Furthermore, cadaveric studies, animal studies, basic science articles, editorial articles, surveys and studies were excluded.

Data Extraction: Two investigators independently reviewed abstracts from all identified articles. Full-text articles were obtained for review if necessary, to allow further assessment of inclusion and exclusion criteria. Additionally, all references from the included studies were reviewed and reconciled to verify that no relevant articles were missing from the systematic review.

Data Synthesis: Short nails were associated with statistically significantly less estimated blood loss and operative time compared to long nails. There were no significant differences in transfusion rates, implant failures or overall re-operation rates between implant lengths. Similarly, there was no significant difference in peri-implant fracture between implant lengths.

Conclusions: Overall, the available clinical evidence supports the use of short cephalomedullary nails for the majority of intertrochanteric femur fractures.

Study Design/level Of Evidence: Meta-analysis; Level III, therapeutic.
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http://dx.doi.org/10.1007/s00402-021-03752-zDOI Listing
January 2021

Gluteus Minimus Debridement During Acetabular Fracture Surgery Does Not Prevent Heterotopic Ossification-A Comparative Study.

J Orthop Trauma 2021 Oct;35(10):523-528

Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, CA.

Objectives: To compare rates of heterotopic ossification (HO) after acetabular fracture surgery, through a posterior approach, with and without gluteus minimus muscle (GMM) debridement.

Design: Retrospective comparative study.

Setting: Single academic Level I trauma center.

Patients: Ninety-four patients in the GMM preserved group and 42 patients in the GMM debrided group met inclusion criteria.

Intervention: GMM preservation or debridement during acetabular fracture surgery through a single-posterior approach.

Main Outcome Measurements: Primary outcomes were incidence and severity of HO. Reoperation for HO excision was assessed. Other risk factors for severe HO (Brooker class III-IV) were secondarily assessed using multivariable logistic regression analyses. Odds ratios (ORs) with 95% confidence intervals were calculated. The significance was set at P-value ≤ 0.05.

Results: There was no difference in the incidence or severity of HO between the debrided and preserved groups. Rates of reoperation for HO excision were comparable. American Society of Anesthesiologists physical status class (OR = 3.3), head injury (OR = 4.6), and abdominal injury (OR = 4.5) were associated with severe HO.

Conclusion: GMM debridement was not associated with a decreased incidence of HO after acetabular fracture surgery. American Society of Anesthesiologists class is a novel risk factor associated with severe HO formation.

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.0000000000002061DOI Listing
October 2021

Orthopaedic Basic Science for the Practicing Physician: Optimizing Mechanobiology of Fracture Healing.

Instr Course Lect 2021 ;70:563-576

The practicing orthopaedic surgeon must understand the relationship between fracture biomechanics and fracture biology to optimize patient outcomes. Patient characteristics, fracture pattern, and desired type of bone healing all drive decision making. The benefits of performing an open approach to a fracture, obtaining an anatomic reduction, and achieving absolute stability must be weighed against the biologic cost to the tissues and the potential to compromise healing. Similarly, the decision to perform a closed fracture reduction; apply a splint, bridge plate, or intramedullary nail; and achieve relative stability requires that the surgeon understand the implications of increased strain at a given fracture site. The purpose of this chapter is to review the basic science of primary and secondary bone healing with special attention given to the clinical implications for practicing surgeons.
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January 2021

Low profile fragment specific plate fixation of lateral tibial plateau fractures - A technical note.

Injury 2021 Apr 2;52(4):1089-1094. Epub 2021 Jan 2.

Investigation performed at the Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA.

Purpose: Precontoured plates used to stabilize lateral tibial plateau (LTP) fractures are limited in their ability to raft particular areas of the reconstructed articular surface. These implants also do not fit every individual's bony anatomy and can lead to soft tissue irritation. The purpose of this study was to evaluate fragment specific plate fixation of LTP fractures using generic small and mini fragment constructs.

Methods: This was a retrospective case series of LTP fractures treated with small fragment tubular and/or mini fragment plate constructs at a single Level I trauma center. Postoperative complications were recorded. Final radiographs were analyzed to determine union and interval subsidence of the articular surface and/or loss of reduction.

Results: All 19 LTP fractures healed without loss of reduction or implant failure. There was minimal interval subsidence of the LTP in all patients. There were no complications or reoperations for symptomatic implant removal within the given follow-up period.

Conclusion: Fragment specific fixation of LTP fractures using small and mini fragment plates creates a lower profile construct that reliably maintains fracture reduction to union.
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http://dx.doi.org/10.1016/j.injury.2020.12.037DOI Listing
April 2021

Management of the posterior wall fracture in associated both column fractures of the acetabulum.

Eur J Orthop Surg Traumatol 2021 Aug 1;31(6):1047-1054. Epub 2021 Jan 1.

Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA.

Purpose: The primary aim of this study was to compare clinical outcomes in patients with associated both column (ABC) acetabular fractures with fracture of the posterior wall (PW), in which the PW underwent reduction and fragment-specific fixation versus those that were treated with column fixation alone. Secondary aims were to assess PW fracture incidence and morphology, as well as to compare radiographic outcomes including fracture healing and interval displacement of the PW in those that did and did not undergo fragment-specific fixation of the PW.

Methods: This was a retrospective series of ABC acetabular fractures treated at a single Level I trauma center. Separate fractures of the PW were identified, and associated features were assessed. Associated both column fractures that underwent reduction and fragment-specific fixation of the PW where then compared to ABC fractures with PW involvement that underwent column reconstruction alone. Radiographic and clinical outcomes were compared.

Results: Fractures of the PW occurred in 55.7% of ABC fractures and were associated with central displacement of the femoral head. The majority of PW fractures were large and involved the acetabular roof. All PW fractures healed without displacement by 3 months, regardless of whether or not reduction and stabilization was performed. Mid-term outcomes at 1-year were similar regardless of whether or not the PW was reduced and stabilized, with regards to Tönnis grade, Merle d'Aubigné-Postel score, and conversion to total hip arthroplasty.

Conclusion: Reduction and fragment-specific fixation of the PW component of ABC acetabular fractures did not improve outcomes in this small comparative study. Posterior wall fractures associated with ABC patterns are frequently large-sized fragments that involve the acetabular roof and are rendered stable after reconstruction of the columns.
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http://dx.doi.org/10.1007/s00590-020-02850-9DOI Listing
August 2021

Artificial Neural Networks Predict 30-Day Mortality After Hip Fracture: Insights From Machine Learning.

J Am Acad Orthop Surg 2020 Dec 10. Epub 2020 Dec 10.

From the Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, CA.

Objectives: Accurately stratifying patients in the preoperative period according to mortality risk informs treatment considerations and guides adjustments to bundled reimbursements. We developed and compared three machine learning models to determine which best predicts 30-day mortality after hip fracture.

Methods: The 2016 to 2017 National Surgical Quality Improvement Program for hip fracture (AO/OTA 31-A-B-C) procedure-targeted data were analyzed. Three models-artificial neural network, naive Bayes, and logistic regression-were trained and tested using independent variables selected via backward variable selection. The data were split into 80% training and 20% test sets. Predictive accuracy between models was evaluated using area under the curve receiver operating characteristics. Odds ratios were determined using multivariate logistic regression with P < 0.05 for significance.

Results: The study cohort included 19,835 patients (69.3% women). The 30-day mortality rate was 5.3%. In total, 47 independent patient variables were identified to train the testing models. Area under the curve receiver operating characteristics for 30-day mortality was highest for artificial neural network (0.92), followed by the logistic regression (0.87) and naive Bayes models (0.83).

Discussion: Machine learning is an emerging approach to develop accurate risk calculators that account for the weighted interactions between variables. In this study, we developed and tested a neural network model that was highly accurate for predicting 30-day mortality after hip fracture. This was superior to the naive Bayes and logistic regression models. The role of machine learning models to predict orthopaedic outcomes merits further development and prospective validation but shows strong promise for positively impacting patient care.
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http://dx.doi.org/10.5435/JAAOS-D-20-00429DOI Listing
December 2020

Lateral Distractor Use During Internal Fixation of Tibial Plateau Fractures Has a Minimal Risk of Iatrogenic Peroneal Nerve Palsy.

J Orthop Trauma 2021 02;35(2):e51-e55

Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, CA.

Objectives: To determine the incidence of iatrogenic peroneal nerve palsy after application of an intraoperative lateral distractor during open reduction and internal fixation of tibial plateau fractures.

Design: Retrospective review.

Setting: Single academic Level I trauma center.

Patients: One hundred forty-seven patients met criteria and were included in the study.

Intervention: Patients with unicondylar and bicondylar tibial plateau fractures underwent open reduction and internal fixation and received application of an intraoperative lateral distractor to aid in visualization and reduction of the impacted lateral plateau.

Main Outcome Measurements: Incidence of iatrogenic peroneal nerve palsy.

Results: There was a 2.0% incidence of iatrogenic peroneal nerve symptoms (3 of 147 patients), most of which were incomplete sensory deficits. There was no association with staged external fixation, regional anesthesia, or tourniquet use.

Conclusion: Use of an intraoperative lateral distractor is safe and has a low incidence of iatrogenic peroneal nerve palsy if applied carefully.

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.0000000000001875DOI Listing
February 2021

Can Upstream Patient Education Improve Fracture Care in a Digital World? Use of a Decision Aid for the Treatment of Displaced Diaphyseal Clavicle Fractures.

J Orthop Trauma 2021 03;35(3):160-166

Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA.

Background: The increasing proportion of telemedicine and virtual care in orthopaedic surgery presents an opportunity for upstream delivery of patient facing tools, such as decision aids. Displaced diaphyseal clavicle fractures (DDCFs) are ideal for a targeted intervention because there is no superior treatment, and decisions are often dependent on patient's preference. A decision aid provided before consultation may educate a patient and minimize decisional conflict similarly to inperson consultation with an orthopaedic traumatologist.

Methods: Patients with DDCF were enrolled into 2 groups. The usual care group participated in a discussion with a trauma fellowship-trained orthopaedic surgeon. Patients in the intervention group were administered a DDCF decision aid designed with the International Patient Decision Aid Standards. Primary comparisons were made based on a decisional conflict score. Secondary outcomes included treatment choice, pain score, QuickDASH, and opinion toward cosmetic appearance.

Results: A total of 41 patients were enrolled. Decisional conflict scores were similar and low between the 2 groups: 11.8 (usual care) and 11.4 (decision aid). There were no differences in secondary outcomes between usual care and the decision aid.

Discussion: Our decision aid for the management of DDCF produces a similarly low decisional conflict score to consultation with an orthopaedic trauma surgeon. This decision aid could be a useful resource for surgeons who infrequently treat this injury or whose practices are shifting toward telemedicine visits. Providing a decision aid before consultation may help incorporate patient's values and preferences into the decision-making process between surgery and nonoperative management.

Level Of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001916DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7887007PMC
March 2021

Delayed Union of a Diaphyseal Forearm Fracture Associated With Impaired Osteogenic Differentiation of Prospectively Isolated Human Skeletal Stem Cells.

JBMR Plus 2020 Oct 31;4(10):e10398. Epub 2020 Aug 31.

Department of Orthopaedic Surgery Stanford University School of Medicine Stanford CA USA.

Delayed union or nonunion are relatively rare complications after fracture surgery, but when they do occur, they can result in substantial morbidity for the patient. In many cases, the etiology of impaired fracture healing is uncertain and attempts to determine the molecular basis for delayed union and nonunion formation have been limited. Prospectively isolating skeletal stem cells (SSCs) from fracture tissue samples at the time of surgical intervention represent a feasible methodology to determine a patient's biologic risk for compromised fracture healing. This report details a case in which functional in vitro readouts of SSCs derived from human fracture tissue at time of injury predicted a poor fracture healing outcome. This case suggests that it may be feasible to stratify a patient's fracture healing capacity and predict compromised fracture healing by prospectively isolating and analyzing SSCs during the index fracture surgery. © 2020 The Authors. published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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http://dx.doi.org/10.1002/jbm4.10398DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7574703PMC
October 2020

Metaphyseal callus formation in pilon fractures is associated with loss of alignment: Is stiffer better?

Injury 2021 Apr 17;52(4):977-981. Epub 2020 Oct 17.

Stanford University Department of Orthopaedic Surgery, 300 Pasteur Dr, Edwards Building, R144, Stanford, CA, 94305, USA.

Objective: To assess the relationship between metaphyseal callus formation and preservation of distal tibial alignment in pilon fractures treated with internal plate fixation.

Design: Retrospective Review SETTING: Academic Level I Trauma Center PATIENTS: Forty-two patients with AO/OTA type C2 or C3 pilon fractures treated with plate fixation.

Intervention: Internal fixation with anterolateral plating, medial plating, or both. Modified Radiographic Union Score in Tibial fracture (mRUST) scores were determined from six-month radiographs.

Main Outcome Measurements: Change in lateral and anterior distal tibial angles (LDTA and ADTA) at six months post-operatively.

Results: High callus formation (mRUST ≥ 11 at six months) was associated with a greater loss of coronal reduction as measured by LDTA compared to low callus formation (mRUST < 11): 3.8 vs 2.1° (p = .019), with no difference in ADTA change between groups. In a multivariable logistic regression controlling for age, smoking, obesity, and open fracture, higher mRUST scores were a predictor of coronal reduction loss of five or more degrees (OR 1.71, p=.039). Dual column plating did not independently predict maintenance of alignment.

Conclusions: Recent literature has popularized dual column fixation for pilon fractures, but it remains unknown whether increased metaphyseal stiffness enhances or impairs healing. In this series, decreased metaphyseal callus formation was associated with maintained coronal alignment, suggesting that a stiffer mechanical environment may be preferable to prevent short term reduction loss in these complex injuries.

Level Of Evidence: III.
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http://dx.doi.org/10.1016/j.injury.2020.10.080DOI Listing
April 2021

Outcomes after locking plate fixation of distal clavicle fractures with and without coracoclavicular ligament augmentation.

Eur J Orthop Surg Traumatol 2021 Apr 19;31(3):473-479. Epub 2020 Sep 19.

Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA.

Background: The need for coracoclavicular (CC) ligament augmentation when performing locking plate fixation of unstable distal clavicle fractures is controversial. The purpose of this study was to compare the results after locking plate fixation for treatment of Neer type-II and type-V distal clavicle fractures with and without suture suspensory augmentation of the CC ligaments.

Methods: This was a retrospective case series of all Neer type-II and type-V distal clavicle fractures treated with locking plates at a single Level I trauma center. Patients were separated into locking plate-only and locking plate with CC ligament augmentation groups. Postoperative complications and fracture healing rates were recorded. Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores were recorded as functional outcomes during follow-up phone interviews. Standard descriptive statistics were performed.

Results: Sixteen patients were treated with locking plate fixation-only, and seven patients were treated with additional CC ligament augmentation. There was a similar distribution of Neer fracture types with each group. All fractures in both groups went onto union without loss of reduction or implant failure. There were no cases of infection or wound complications in either group. QuickDASH scores were comparable between locking plate-only fixation (mean 4.1 ± 3.9) and additional suspensory suture fixation (mean 4.5 ± 3.6).

Conclusion: This comparative study of Neer type-II and type-V distal clavicle fractures demonstrated comparable outcomes after locking plate fixation with and without CC ligament augmentation. CC ligament augmentation may not be necessary when treating unstable distal clavicle fractures if locking plate fixation is used.
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http://dx.doi.org/10.1007/s00590-020-02797-xDOI Listing
April 2021

White-Light Body Scanning Captures Three-Dimensional Shoulder Deformity After Displaced Diaphyseal Clavicle Fracture.

J Orthop Trauma 2021 04;35(4):e142-e147

Stanford University Department of Orthopaedic Surgery, Stanford, CA.

Objective: We sought to determine if white-light three-dimensional (3D) body scanning can identify clinically relevant shoulder girdle deformity after displaced diaphyseal clavicle fracture (DCF).

Methods: Adult patients with DCF (OTA/AO 15A) were prospectively enrolled. Four subcutaneous osseous landmarks were used to measure shoulder girdle morphology of the injured and uninjured shoulder. Measurements were made both manually with a tape measure and digitally with a white-light 3D scanner. Bilateral radiographs were obtained, and clavicle length was recorded. Quick-Disabilities of the Arm, Shoulder, and Hand surveys were administered at injury and at 6 and 12 weeks.

Results: Twenty-two patients were included in the study. At the initial visit, all patients had significant differences in deformity measurements between injured and uninjured shoulders as measured by 3D scanning. There was no difference between shoulders measured using manual measurements. At 6 and 12 weeks, shoulder asymmetry was significantly less in patients treated with surgery compared with nonoperative patients as measured by the 3D scanner alone. Clavicle shortening measured on 3D scanning had weak and moderate positive correlations to radiographs (R = 0.27) and manual measurements (R = 0.53), respectively. Patients treated with surgery had significant functional improvements by 6 weeks, and a similar improvement was not seen until 12 weeks in nonsurgical patients.

Conclusion: White-light 3D scanning was able to identify and monitor clinically relevant shoulder girdle deformity after DCF. This tool may become a useful adjunct to clinical examination and radiographic assessment, when determining clinically relevant deformity thresholds. In the future, quantifying and understanding shoulder deformity may inform clinical decision making in these patients.

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.0000000000001957DOI Listing
April 2021

How are peri-implant fractures below short versus long cephalomedullary nails different?

Eur J Orthop Surg Traumatol 2021 Apr 9;31(3):421-427. Epub 2020 Sep 9.

Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive Room R144, Stanford, CA, 94305, USA.

Background: Cephalomedullary nails are a commonly used implant for the treatment of many pertrochanteric femur fractures and are available in short and long configurations. There is no consensus on ideal nail length. Relative advantages can be ascribed to short and long intramedullary nails, yet both implant styles share the potentially devastating complication of peri-implant fracture. Determining the clinical sequelae after fractures below nails of different lengths would provide valuable information for surgeons choosing between short or long nails. Thus, the purpose of the study was to compare injury patterns and treatment outcomes following peri-implant fractures below short or long cephalomedullary nails.

Methods: This was a multicenter retrospective cohort study that identified 33 patients referred for treatment of peri-implant fractures below short and long cephalomedullary nails (n = 19 short, n = 14 long). We compared fracture pattern, treatment strategy, complications, and outcomes between these two groups.

Results: Short nails were associated with more diaphyseal fractures (odds ratio [OR] 13.75, CI 2.2-57.9, p 0.002), which were treated more commonly with revision intramedullary nailing (OR, infinity; p 0.01), while long nails were associated with distal metaphyseal fractures (OR 13.75, CI 2.2-57.9, p 0.002), which were treated with plate and screw fixation (p 0.002). After peri-implant fracture, there were no differences in blood loss, operative time, weight bearing status, or complication rates based on the length of the initial nail. In patients treated with revision nailing, there was greater estimated blood loss (EBL, median 300 cc, interquartile range [IQR] 250-1200 vs median 200 cc, IQR 100-300, p 0.03), blood product utilization and complication rates (OR 11.1, CI 1.1-135.7, p 0.03), but a trend toward unrestricted post-operative weight-bearing compared to patients treated with plate and screw constructs.

Conclusion: Understanding fracture patterns and patient outcomes after fractures below nails of different lengths will help surgeons make more informed implant choices when treating intertrochanteric hip fractures. Revision to a long nail for the treatment of fractures at the tip of a short nail may be associated with increased patient morbidity.
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http://dx.doi.org/10.1007/s00590-020-02785-1DOI Listing
April 2021

Trochanteric fixation nail advanced with helical blade and cement augmentation: early experience with a retrospective cohort.

Eur J Orthop Surg Traumatol 2021 Feb 17;31(2):259-264. Epub 2020 Aug 17.

Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive Room R144, Stanford, CA, 94305, USA.

Intra-articular screw cut-out is a potential complication of intertrochanteric femur fracture fixation with a cephalomedullary nail. Cement augmentation of fixation in the proximal segment offers the prospect of increased stability and fewer complications, but clinical experience with non-resorbable cement is limited. To determine the handling properties and efficacy of this new technique, we performed a retrospective propensity-matched cohort of forty-four geriatric intertrochanteric femur fractures treated with a cephalomedullary nail with (n = 11) or without (n = 33) augmentation with non-resorbable cement injected into the proximal segment. In the patients treated with cement augmentation, at minimum 3-month follow-up, there were no instances of intra-articular cut-out, and no increase in re-operation compared to conventional fixation. Cement augmentation appears to be safe and effective in geriatric intertrochanteric femur fractures to mitigate risk of cut-out.
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http://dx.doi.org/10.1007/s00590-020-02762-8DOI Listing
February 2021

Is percutaneous screw fixation really superior to non-operative management after valgus-impacted femoral neck fracture: a retrospective cohort study.

Eur J Orthop Surg Traumatol 2021 Jan 24;31(1):65-70. Epub 2020 Jul 24.

Department of Orthopaedic Surgery, 450 Broadway Ave, Pavilion A, Redwood City, CA, 94063, USA.

Purpose: The optimal management of valgus-impacted femoral neck fractures remains controversial. Internal fixation is associated with significant rates of re-operation, while historical non-operative management strategies consisting of prolonged bed rest also resulted in patient morbidity. Our hypothesis was that screw fixation would have comparable failure rates to non-operative treatment and immediate mobilization for valgus-impacted femoral neck fractures.

Methods: Retrospective cohort at a single academic Level I trauma center of patients with valgus-impacted femoral neck fractures (AO/OTA 31-B1) treated with percutaneous screw fixation (n = 97) or non-operatively (n = 28). Operative treatment consisted of percutaneous screw fixation. Non-operative treatment consisted of early mobilization. The primary outcome was a salvage operation. Patient demographics were assessed between groups.

Results: More non-operatively treated patients were permitted unrestricted weight-bearing (WBAT; p = 0.002). There was no increase in complication rates or mortality, and return to previous ambulatory status was comparable between operatively and non-operatively treated patients. 35.7% (10/28) of non-operatively treated patients underwent a subsequent operation, compared to 15.5% (15/97) of patients with screw fixation (p = 0.03). Only WBAT was independently associated with treatment failure (OR 3.1, 95%CI 1.2-8.3, p =0.02). WBAT was predictive of treatment failure only in the non-operatively treated group (64.3%, 9/14 WBAT vs 8.3%, 1/12 partial, p =0.005).

Conclusion: After controlling for weight-bearing restrictions, we found no difference in failure rates between non-operative treatment and screw fixation. Non-operative treatment with partial weight-bearing had low failure rates, comparable complication and mortality rates, and equivalent functional outcomes to operative treatment and is reasonable if a patient would like to avoid surgery and accepts the risk of subsequent arthroplasty. Overall, there were relatively high failure rates in all groups.
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http://dx.doi.org/10.1007/s00590-020-02742-yDOI Listing
January 2021
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