We assessed operatively treated closed distal radial fractures to identify independent risk factors for surgical site infection after treatment. A retrospective review was carried out of 531 operatively treated closed distal radial fractures over a 5-year period. Multiple logistic regression was performed with infection as the dependent variable, using a stepwise regression procedure to select variables to construct the final model. In total, 19 (3.6%) fractures were complicated by postoperative surgical site infection. Uncontrolled diabetes with HbA1c >7, the presence of external fixation or external Kirschner wires, and tobacco use were significant independent predictors of infection. Age and time in the operating room were also statistically significant predictors but deemed to be not clinically meaningful.Level of evidence: IV

PURPOSE:Multiple procedures have been described for wrist and finger flexion contractures and spasticity. Fractional lengthening of forearm flexor tendons involves making parallel transverse tenotomies at the musculotendinous junction to elongate the muscle. Currently, there is limited literature to define the biomechanical consequences of this lengthening technique. METHODS:Forty-eight flexor tendons were harvested from eight paired upper limbs including flexor carpi radialis, flexor carpi ulnaris, flexor pollicis longus, and flexor digitorum superficialis tendons. Each tendon that was lengthened was paired with the contralateral tendon as a control. A pair of transverse tenotomies were completed for the fractional lengthening. The first tenotomy was performed at the musculotendinous junction where the tendon narrowed to 75% of its maximal width. The second tenotomy was made 1 cm distal to the first. Tendon length was measured before and after fractional lengthening at a constant resting tension of 1 N. The maximum load at failure of each tendon and the mechanism of failure were each measured and compared with the contralateral side. RESULTS:After fractional lengthening, the mean increase in resting tendon length was 4 mm. When loaded to failure, the mean maximum load of fractionally lengthened tendons was 42% of the mean maximum load of intact tendons. All lengthened tendons failed at the distal tenotomy site. CONCLUSIONS:Fractional lengthening resulted in an increase of 3-6 mm (mean: 4 mm) in tendon length at resting tension. There was a significant loss in tensile strength and load to failure following fractional lengthening compared with an intact musculotendinous unit. CLINICAL RELEVANCE:The reduction in tensile strength following fractional lengthening results in loads at failure that are, in some cases, lower than the estimated forces required to perform basic tasks. Caution during the healing and rehabilitation period is warranted.

PurposeProximal interphalangeal (PIP) joint arthrodesis is a procedure employed to address arthritis, instability, and deformity. Multiple fixation methods are available to maintain stability across the arthrodesis interval, including headless compression screws (HCSs), tension band wiring (TBW), plating, and Kirschner wire constructs. The purpose of this study was to compare the biomechanical properties of the HCS and TBW techniques.MethodsThirty-two nonthumb digits from the paired upper limbs of four fresh frozen cadavers were divided into pairs, matching contralateral digits from the same specimen. One PIP joint of each pair was fused with an antegrade 3.5 mm HCS, and the second was fused with TBW using 0.035 in. Kirschner wires with 24-gauge dental wire. Each construct was then stressed to 10 N in the radial deviation, ulnar deviation, flexion, and extension planes, and stiffness (N/mm) was calculated. The fingers were stressed to failure in extension with the ultimate load and mode of failure recorded.ResultsWhen stressed in extension, the HCS construct had a significantly greater mean stiffness than the TBW construct (16.4 N/mm vs 10.8 N/mm). The stiffness in all other planes of motion were similar between the two constructs. The mean ultimate load to failure in extension was 91.4 N for the HCS and 41.9 N for the TBW. The most common mode of failure was fracture of the dorsal lip of the proximal phalanx (13/16) for the HCS and bending of the K-wires (15/16) for TBW.ConclusionsArthrodesis of the PIP joint using a HCS resulted in a construct that was significantly stiffer in extension with greater than double the load to failure compared to TBW.Clinical RelevanceAlthough the stiffness required to achieve successful PIP joint arthrodesis has not been well quantified, the HCS proved to be the most favorable construct with respect to initial strength and stability.

Purpose Dorsal wrist-spanning plate fixation for comminuted, intra-articular distal radius fractures involves the indirect reduction of intra-articular fractures via ligamentotaxis. The reduction is maintained by application of a bridge plate from the radial diaphysis to either the second or third metacarpal. The objective of this study was to retrospectively compare radiographic outcomes between distal radius fractures managed with bridge plate fixation to the second versus third metacarpal. Methods A single-institution retrospective review identified 50 cases of distal radius fractures that underwent dorsal wrist-spanning plate fixation, with 9 and 41 fractures undergoing fixation to the second and third metacarpals, respectively. Radiographic parameters, such as radial height, radial inclination, volar tilt, and ulnar variance, were measured at 3 time points: immediately after surgery, immediately prior to elective plate removal, and at the final follow-up. Radiographic measurements of the 2 cohorts were compared at the 3 time points. Results Final radiographs showed an average radial height of 8.9 mm versus 9.4 mm for the second versus third metacarpal cohorts, respectively; average radial inclination of 17.4 degrees for both the second and third metacarpal cohorts; average volar tilt of 1.9 degrees versus 1.7 degrees for the second versus third metacarpal cohorts, respectively; and an average ulnar variance of +0.6 mm versus +0.1 mm for the second versus third metacarpal cohorts, respectively. Radiographic parameters of the second and third metacarpal cohorts were similar across all the time points. Additionally, evaluation of the radiographic parameters across the 3 time points (immediately after surgery, immediately prior to elective plate removal, and at the final follow-up) demonstrated little to no loss of radiographic alignment. Conclusions Radiographic outcomes for distal radius fractures managed with bridge plate fixation to the second versus third metacarpal appear similar. The distal plate fixation site can likely be determined on the basis of fracture anatomy and patient-specific features. (J Hand Surg Am. 2023;48(10):1061.e1-e6. Copyright (c) 2023 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV.

Background: The purpose of this study was to identify independent risk factors associated with an increased rate of surgical site complications after elective hand surgery. Methods: This study is a retrospective review of all patients who underwent elective hand, wrist, forearm, and elbow surgery over a 10-year period at a single institution. Electronic medical records were reviewed, and information regarding patient demographics, past medical and social history, perioperative laboratory values, procedures performed, and surgical complications was collected. Surgical site complications included surgical site infections, seromas or hematomas, and delayed wound healing or wound dehiscence. A univariate analysis was then performed to identify potential risk factors, which were then included in a multivariate regression analysis. Results: A total of 3261 patients who underwent elective hand surgery and met the above inclusion and exclusion criteria were included in this study. The mean age was 57 years, with 65% female and 35% male patients. The overall surgical complication rate was 2.2%. Univariate analysis of patient factors identified male sex; number of procedures >1; history of drug, alcohol, or smoking use; American Society of Anesthesiologists (ASA) class III and IV; and serum albumin <3.5 mg/dL to be significantly associated with complications. However, multivariate regression analysis identified that only ASA class III and IV (odds ratio = 3.27) was significantly associated with surgical complications. Conclusions: Patients classified as ASA class III or IV were identified to be at a significantly increased risk of complications following elective hand surgery. Health factors which triage patients into these 2 groups may represent potentially modifiable factors to mitigate perioperative risk in the elective hand surgery population.

Background: There is a paucity of literature exploring the impact of smoking on short-term complications, readmissions, and reoperations after elective upper extremity surgery using a large multicenter national database. We hypothesized that smokers will have an increased rate of complications, readmissions, and reoperations compared with a cohort of nonsmokers undergoing elective upper extremity surgery. Methods: Patient data were collected from the American College of Surgeons National Surgical Quality Improvement Program database between the years 2012 and 2017. Patients were included if they underwent elective surgery of the upper extremity using 338 predetermined Current Procedural Terminology codes. The data collected were divided into patient demographics, comorbidities, perioperative variables, and 30-day complications. Current smoking status was defined as smoking within 1 year prior to surgery. The incidence of surgical complications, reoperations, and readmissions was compared between the 2 cohorts using multivariable regression analysis. Results: Of the 107 943 patients undergoing elective surgeries of the upper extremity, 73 806 met the inclusion criteria. Of these, 57 986 (78.6%) were nonsmokers in the year prior to surgery, and 15 820 (21.4%) were current smokers. Between these groups, current smokers were younger ( P < .001), more often men ( P < .001), had lower body mass index ( P < .001), and more often underwent procedures that involved bone manipulation ( P < .001). Multivariate regression analysis defined current smoking as significantly associated with overall surgical site complications, superficial surgical site infections, deep surgical site infections, reoperation, and readmission. Conclusion: Current smoking was significantly associated with an increase in all surgical site complications, readmissions, and reoperations after elective upper extremity surgery. Surgeons should consider smoking a modifiable risk factor for postoperative complications and appropriately counsel patients on outcomes and complications given the elective nature of upper extremity surgery.

Elbow arthrodesis is a salvage operation designed to relieve pain and enable weight bearing in young patients with painful arthritic joints who have failed all other treatment modalities. Unfortunately, elbow arthrodesis is poorly tolerated by many patients because there is no fusion position that accommodates all activities of daily living. As indications for elbow arthroplasty expand and implant design improves, patients living with elbow arthrodesis may seek conversion to arthroplasty to regain a functional range of motion. Only one case of elbow arthrodesis to elbow arthroplasty conversion has been reported in the English literature to date. We present the case of a 58 year old male, five years status post elbow arthrodesis, unable to perform his ADLs adequately, who was successfully converted to a total elbow arthroplasty. Indications, contraindications, and technical pearls are discussed.

Background: Limited research exists investigating the association between diabetes and glycemic control on complications following elective hand surgery. The goal of this research was to assess the incidence of complications within 30 days of elective hand surgery in a large population of diabetic patients compared to a population of non-diabetics. Furthermore, we sought to examine the relationship of glycemic control, as measured by HbA1c, and postoperative complications. Methods: We performed a retrospective review of electronic medical records at our institution of all patients who underwent elective hand, forearm, or elbow surgery from the dates of January 1st, 2008 to December 31st, 2017. Patients were categorized as diabetic or non-diabetic and most recent HbA1c was documented. Multivariable analysis was employed to compare the incidence of surgical complications within 30 days between the diabetics and non-diabetic populations, adjusting for baseline patient characteristics. Results: A total of 3,261 patients met the inclusion criteria. There were 646 (20%) diabetic patients and 2,615 (80%) non-diabetic patients. No difference was found in the overall rate of complications between the cohort of diabetic and non-diabetic patients. Additionally, statistical analysis found no difference in the complication rate between insulin and non-insulin controlled diabetics. Rates of complications were stratified based on HbA1c level and statistical analysis found no increased risk of complications with increased hemoglobin A1c value. Conclusions: In our present study we were not able to demonstrate any significant difference in the 30 day complication rates between and non-diabetics undergoing elective hand surgery. This study attempted to aid in risk stratification of diabetic patients by evaluating preoperative glycemic indices in the form of HbA1c.

Severe coronavirus disease 2019 (COVID-19) has been complicated by coagulopathy and thrombotic events including venous thromboembolism, pulmonary embolism, and arterial thrombus at a rate higher than has traditionally been seen with sepsis-induced coagulopathy or disseminated intravascular coagulation leading most centers to treat hospitalized patients with prophylactic anticoagulation. We present a case of a patient with thoracic outlet syndrome who presents with brachial artery thrombosis in the setting of infection with COVID-19. Both thoracic outlet syndrome and COVID-19 infection are independently associated with increased risk of thrombotic events. The induced hypercoagulable state from COVID-19 infection may result in acute arterial thrombosis in patients with predisposing anatomic differences consistent with thoracic outlet syndrome. Level of Evidence: V.

Background: The purpose of this study was to determine the rate of short-term complications after total elbow arthroplasty (TEA) and identify predictors of readmission and reoperation. We hypothesized that TEA performed for acute elbow trauma would have higher rates of 30-day readmission and reoperation than TEA performed for osteoarthritis (OA). Methods: Using the National Surgical Quality Improvement Program for the years 2011-2017, we identified patients undergoing TEA for fracture, OA, or inflammatory arthritis. Patient demographic characteristics, comorbidities, reoperations, and readmissions within 30 days of surgery were analyzed. Potential predictors of reoperation and readmission in the model included age, sex, race, body mass index (BMI), diabetes, hypertension, chronic obstructive pulmonary disease, congestive heart failure, smoking, bleeding disorders, American Society of Anesthesiologists classification, wound classification, operative time, and indication for surgery. Results: A total of 414 patients underwent TEA from 2011-2017. Of these patients, 40.6% underwent TEA for fracture; 37.0%, for OA; and 22.7%, for inflammatory arthritis. The overall rate of unplanned readmissions was 5.1% (21 patients). The rate of unplanned reoperations was 2.4% (10 patients). Infection was the most common reason for both unplanned readmissions and reoperations. The rates of reoperations and readmissions were not significantly associated with any of the 3 operative indications: fracture, OA, or inflammatory arthritis. Multiple logistic regression analysis found increased BMI to be associated with lower odds of an unplanned readmission (odds ratio [OR], 0.883; 95% confidence interval [CI], 0.798-0.963; P = .0035) and found wound classification > 3 to be associated with increased odds of an unplanned reoperation (OR, 16.531; 95% CI, 1.300-167.960; P = .0144) and total local complications (OR, 17.587; 95% CI, 2.207-132.019; P = .0057). Patients who were not functionally independent were more likely to experience local complications (OR, 4.181; 95% CI, 0.983-15.664; P = .0309) than were functionally independent patients. Conclusions: The 30-day unplanned reoperation rate after TEA was 2.4%, and the unplanned readmission rate was 5.1%. Low BMI was predictive of readmission. Wounds classified as contaminated or dirty were predictive of reoperation. Dependent functional status and contaminated wounds were predictive of local complications. The indication for TEA (fracture vs. OA vs. inflammatory arthritis) was not found to be a risk factor for reoperation or readmission after TEA. Level of evidence: Level IV; Retrospective Case Series Using Large Database; Treatment Study (c) 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Purpose To investigate the distinguishing morphological characteristics of the upper extremities in children with Mobius syndrome. Methods Twenty-seven involved extremities in 14 patients with a diagnosis of Mobius syndrome were identified at 2 institutions. Medical records, radiographs, and clinical photographs were evaluated. Congenital hand differences were classified according to the Oberg, Manske, and Tonkin classification, and hands with symbrachydactyly were classified by the Blauth and Gekeler classification. The presence of other congenital anomalies was catalogued. Results There was bilateral involvement in 93% of patients with congenital hand anomalies. Twelve patients demonstrated congenital hand anomalies and 2 patients had been diagnosed with arthrogryposis. Among the 12 patients with congenital hand anomalies, 21 hands were classifiable as symbrachydactyly by the Oberg, Manske, and Tonkin classification and could be categorized by the Blauth and Gekeler classification. Short finger type was the most common subtype of symbrachydactyly, present in 13 hands. Eleven of these 13 patients (85%) were primarily affected on the radial side of the hand. Proximal arm involvement was identified in 2 patients with symbrachydactyly, both of whom had Poland syndrome and an absent pectoralis major. Conclusions Symbrachydactyly in Mobius syndrome differs from the typical presentation of symbrachydactyly. Characteristically, there is a bilateral presentation with a strong predilection for radially based brachydactyly. These described characteristics may help the hand surgeon appropriately assess patients, especially those with radial-sided symbrachydactyly. Copyright (C) 2019 by the American Society for Surgery of the Hand. All rights reserved.

Purpose In order to effectively improve value in health care delivery, providers must thoroughly understand cost drivers. Time-driven activity- based costing (TDABC) is a novel accounting technique that may allow for precise characterization of procedural costs. The purpose of the present study was to use TDABC to characterize costs in a high-volume, low-complexity ambulatory procedure (endoscopic vs open carpal tunnel release [CTR]), identify cost drivers, and inform opportunities for clinical improvement. Methods The costs of endoscopic and open CTR were calculated in a matched cohort investigation using TDABC. Detailed process maps including time stamps were created accounting for all clinical and administrative activities for both the endoscopic and the open treatment pathways on the day of ambulatory surgery. Personnel cost rates were calculated accounting for capacity, salary, and fringe benefits. Costs for direct consumable supplies were based on purchase price. Total costs were calculated by aggregating individual resource utilization and time data and were compared between the 2 surgical techniques. Results Total procedural cost for the endoscopic CTR was 43.9% greater than the open technique ($2,759.70 vs $1,918.06). This cost difference was primarily driven by the disposable endoscopic blade assembly ($ 217), direct operating room costs related to procedural duration (44.8 vs 40.5 minutes), and physician labor. Conclusions Endoscopic CTR is 44% more expensive than open CTR compared with a TDABC methodology at an academic medical center employing resident trainees. Granular cost data may be particularly valuable when comparing these 2 procedures, given the clinical equipoise of the surgical techniques. The identification of specific cost drivers with TDABC allows for targeted interventions to optimize value delivery. Copyright (C) 2019 by the American Society for Surgery of the Hand. All rights reserved.

SYNOPSIS We estimate the costs of two substitutable medical procedures in a hospital as reported by a conventional two-stage system and from using TDABC concepts. Comparisons yield insights into the data needs for both systems, and practical issues that arise when implementing TDABC in an organization with a complex cost structure. As “lessons learned,” we list four insights relating to simplifying the data needs of a TDABC system. We also discuss how features of the traditional system influence the differences in the cost estimates from the two approaches. Based on our experience, we offer suggestions on how organizations might be able reap many of the benefits associated with TDABC without an overhaul of the entire costing system. JEL Classifications: M41; I19. Data Availability: Data are proprietary to the research site and are not publicly available.

BACKGROUND:Multimodal analgesia inclusive of periarticular injection with a local anesthetic agent has been rapidly assimilated, with demonstrated safety and efficacy, into the care of patients undergoing elective lower-extremity arthroplasty. The present study was performed to evaluate the efficacy and safety of a surgical-site, multimodal drug injection for postoperative pain control following operative management of femoral fractures. METHODS:There were 102 patients undergoing operative intervention (plate fixation, intramedullary device, or arthroplasty) for a broad range of femoral fracture patterns who were prospectively randomized either to receive an intraoperative, surgical-site injection into the superficial and deep tissues containing ropivacaine, epinephrine, and morphine or to receive no injection. Visual analog scale (VAS) scores were recorded at regular intervals as the primary outcome measure. Narcotic consumption and medication-related side effects were also monitored. RESULTS:The injection group demonstrated significantly lower VAS scores (p < 0.05) than the control cohort in the recovery room and at the 4, 8, and 12-hour postoperative time points. The median score (and interquartile range) was 1.6 (0 to 4.0) for the injection group and 3.2 (1.3 to 5.7) for the control group immediately postoperatively, 1.0 (0 to 3.0) for the injection group and 5.0 (2.0 to 7.0) for the control group at 4 hours, 2.0 (0 to 4.0) for the injection group and 5.0 (2.0 to 6.8) for the control group at 8 hours, and 3.5 (0 to 5.0) for the injection group and 5.0 (2.0 to 8.0) for the control group at 12 hours. Additionally, narcotic consumption was significantly lower (p = 0.007) in the injection group (5.0 mg [1.3 to 8.0 mg]) compared with the control group (9.7 mg [3.9 to 15.6 mg]) over the first 8 hours following the surgical procedure. No cardiac or central nervous system toxicity was observed secondary to infiltration of the local anesthetic. CONCLUSIONS:Surgical-site injection with a multimodal analgesic cocktail provides improved pain control and reduces narcotic utilization over the first postoperative day, with no observed adverse effects attributable to the local injection, across a diverse orthopaedic trauma population undergoing operative intervention for femoral fractures. LEVEL OF EVIDENCE:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To investigate whether aerobic fitness as determined by preoperative metabolic equivalents (METS) better predicts postoperative functional outcomes after open reduction and internal fixation (ORIF) of acetabular fractures than chronologic age. Design: Retrospective review. Setting: Level 1 Trauma Center. Patients/Participants: A total of 157 patients underwent open surgical treatment for acetabular fracture between January 2005 and December 2013 with age ≥18 years and minimum 1-year follow-up inclusive of imaging, functional outcome scores, and complications. Intervention: ORIF of acetabular fracture. Main Outcome Measurements: Final postoperative functional outcomes as assessed with the University of California Los Angeles activity score and the Western Ontario and McMaster Universities Osteoarthritis Index. Results: Multivariate logistic regression analysis demonstrated elevated preinjury METS, female gender, and lower injury severity score (<18) to be significant independent factors predictive of improved functional outcome per the University of California Los Angeles score. Similarly, preinjury METS were identified as significant predictors for improved Western Ontario and McMaster Universities Osteoarthritis Index scores for both the stiffness and physical function components. Chronologic age was not a significant predictor for any functional outcome score. Furthermore, a Pearson correlation analysis demonstrated a weak relationship between preoperative METS and chronologic age (r = −0.346). Conclusions: Pre-operative aerobic fitness as determined by METS may prove to be a superior prognostic factor for predicting postoperative functional outcome after acetabular fracture fixation than chronologic age. Consideration of aerobic fitness, in addition to other established prognostic factors, may be useful to patients and surgeons for injury counseling purposes. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES:To evaluate lactate levels before reamed intramedullary nailing (IMN) of femur fractures treated with early fixation. DESIGN:Retrospective study. SETTING:Three academic, tertiary care trauma centers. PATIENTS:Age ≥18 years, injury severity score ≥17, admission lactate ≥ 2.5 mmol/L, elevated preoperative lactate = preoperative lactate ≥ 2.5 mmol/L. INTERVENTION:Reamed IMN of femur fracture within 24 hours. MAIN OUTCOME MEASURE:Total duration of mechanical ventilation, pulmonary complications (PC) = duration of mechanical ventilation ≥5 days. RESULTS:Four hundred and fourteen patients identified; 294/414 (71.0%) with admission lactate ≥ 2.5 mmol/L. No difference in PC among the groups (86/294, 29.3% vs. 28/120, 23.3%; P = 0.22). Median admission lactate: 3.7 (interquartile range: 3.0-4.6); median preoperative lactate: 2.8 (interquartile range: 1.9-3.5). 184/294 (62.6%) demonstrated an elevated preoperative lactate (≥ 2.5 mmol/L) before fracture fixation. No difference in elevated preoperative lactate and vent days (4.8 ± 9.9 vs. 3.9 ± 6.0, P = 0.41) or PC (50/86, 58.1% vs. 134/208, 64.4%; P = 0.31). There was no difference in PC when preoperative lactate was considered separately for a lactate ≥3.0 (34/123, 27.6% vs. 52/171, 30.4%; P = 0.61), ≥3.5 (21/79, 26.6% vs. 65/215, 30.2%; P = 0.54), or ≥4.0 (14/50, 28.0% vs. 72/244, 29.5%; P = 0.83). Multivariable linear regression modeling demonstrated that admission lactate [coefficient of variation: 0.84, standard error: 0.33, 95% confidence interval (CI): 0.20-1.49] was correlated with duration of mechanical ventilation, after adjusting for emergency department Glasgow Coma Scale, age, chest Abbreviated Injury Scale (AIS) score, abdominal AIS, and admission glucose. Logistic regression demonstrated admission lactate was also significantly associated with PC (odds ratio: 1.26, 95% CI: 1.03-1.53) after controlling for age, admission Glasgow Coma Scale, chest AIS, abdominal AIS, admission pulse and admission glucose; preoperative lactate was not a risk factor (odds ratio: 0.84, 95% CI: 0.65-1.09) for PC. CONCLUSION:Median admission lactate of 3.7 mmol/L was associated with duration of mechanical ventilation ≥5 days, whereas median preoperative lactate of 2.8 mmol/L was not, when multisystem trauma patients with a femoral shaft fracture were treated with reamed IMN within 24 hours after admission. LEVEL OF EVIDENCE:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To investigate the relationship between obesity and distal radius fracture severity after low-energy trauma and to identify patient-specific risk factors predictive of increasing fracture severity. Design: Retrospective review. Setting: Level 1 Trauma Center. Patients/Participants: Four hundred twenty-three adult subjects with a history of fracture of the distal radius resulting from a fall from standing height. Intervention: Demographic data and injury characteristics were obtained. Preoperative wrist radiographs were reviewed and classified by the OTA classification system. Distal radius fractures were categorized as simple [closed and extra-articular (OTA 23-A)] and complex [intra-articular (OTA 23-B or 23-C) or open fracture or concomitant ipsilateral upper extremity fracture]. Multivariate logistic regression was completed to model the probability of incurring a complex fracture. Main Outcome Measurements: Simple versus complex fracture pattern. Results: Average age at the time of injury was 53.8 years (range, 18.9–98.4). Seventy-nine percent of subjects were female. The average body-mass index was 28.1 (range, 13.6–59.5). Two hundred forty-four patients (58%) suffered complex distal radius fractures per study criteria. Obese patients (body-mass index > 30) demonstrated increased fracture severity as per the OTA classification (P = 0.039) and were more likely to suffer a complex injury (P = 0.032). Multivariate regression identified male gender, obesity, and age ≥50 as independent risk factors for sustaining a complex fracture pattern. Conclusions: Obesity is associated with more complex fractures of the distal radius after low-energy trauma, particularly in elderly patients. This relationship may have important epidemiologic implications predictive of future societal fracture burden and severity in an obese, aging population. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Diabetes mellitus increases the risk of complications following operative treatment of lower extremity fractures. There is little published data establishing the impact of diabetes following surgical treatment of upper extremity fractures. This investigation aimed to compare the incidence of short-term postsurgical complications following volar locked plating of distal radius fractures in patients with and without diabetes. Methods A retrospective matched cohort investigation of 33 diabetics matched 1:2 to 66 non-diabetics was performed, accounting for age, gender, fracture type, and smoking status. Electronic medical records and radiographs were reviewed for all major and minor postsurgical complications. Demographic characteristics, postoperative radiographic parameters, and final range of motion were also compared. Mean follow-up was 5.3±8.2 and 5.5±7.8 months for diabetics and non-diabetics, respectively. Results The diabetic cohort had a significantly higher overall complication rate with 24 postsurgical complications affecting 12 patients (36 %) compared to 16 complications affecting 12 patients (18 %) in the non-diabetic cohort. There was no difference in the incidence of major complications requiring operative intervention. Minor complications were significantly more common in the diabetic group and were largely accounted for by peripheral neuritis with an incidence of 30 %. Final radiographic outcomes and range of motion were similar. Conclusions Diabetics experienced a greater incidence of minor postsurgical complications following volar locked plating of distal radius fractures when compared to a matched, control population. The difference in outcomes is largely accounted for by the increased incidence of peripheral neuritis among diabetics. Diabetic patients should be counseled preoperatively regarding their elevated risk profile.

BACKGROUND The evolving surgical skills education paradigm in orthopaedics has generated a strong demand for validated educational tools and methodologies. This study aimed to confirm that a one-on-one faculty coaching review of the head-mounted video recording of a resident's surgical performance on a validated articular fracture simulation trainer would substantially improve subsequent performance. METHODS Fifteen first-year or second-year orthopaedic surgery residents reduced and fixed a standardized intra-articular tibial plafond fracture model under fluoroscopic guidance. Their performances were recorded by a head-mounted video camera. Prior to repeating the procedure six weeks later, eight subjects (the intervention group) reviewed the video of their performance with an orthopaedic traumatologist, and seven subjects (the control group) did not. Cohort performance was compared with respect to task duration, number of fluoroscopic images, and scores on the Objective Structured Assessment of Technical Skills (OSATS) as evaluated by fellowship-trained orthopaedic traumatologists blinded to the residents' year in training and prior surgical experience. RESULTS The initial performance OSATS scores were not significantly different (p ≥ 0.05) between the control and intervention groups. Assessments of their repeat performance showed a significant net interval improvement (p < 0.05) in OSATS scores in the intervention group (mean [and standard deviation], 21 ± 8 points) compared with the control group (6 ± 3 points). The mean fluoroscopy utilization had a significant net decrease (p < 0.05) in the intervention group (-5.4 ± 11.7 points) compared with the control group (5.3 ± 7.0 points). Task duration in the repeat performance was similar between both groups. CONCLUSIONS Personalized video-based feedback improved performance on a standardized articular fracture trainer for first-year and second-year residents. The described technique may further enhance resident surgical skills education.