Background. As cancer survivorship continues to improve, the perioperative morbidity and mortality following surgical treatment of metastatic bone disease become an increasingly important consideration. The objective of this study is to identify risk factors for early postoperative complications and mortality following extremity prophylactic fixation and pathologic fracture stabilization. Methods. A single-centre retrospective review of 185 patients (226 total surgeries) who underwent prophylactic fixation or pathologic fracture stabilization for extremity metastatic bone disease between 2005 and 2020 was performed. Skull, spine, pelvic, and revision surgeries along with diagnosis of primary bone neoplasm were excluded. Univariate, multivariate, and subgroup analyses were performed to identify predictors and independent risk factors for 30-day postoperative morbidity and mortality. Results. Primary cancers included lung (n = 41), breast (n = 36), multiple myeloma (n = 35), prostate (n = 16), lymphoma (n = 11), renal cell carcinoma (n = 10), and other (n = 36). The 30-day postoperative complication and mortality rates were 32.30% (n = 73) and 17.26% (n = 39), respectively. The most common complications were pulmonary-related, cardiac events, surgical site infection, sepsis, and thromboembolism. Pathologic fracture, presence of extra-skeletal metastases, longer surgical duration, and blood transfusion requirements were associated with 30-day postoperative complications overall. A past medical history for cardiac disease was also associated with systemic but not local surgical complications. Pathologic fracture, presence of extra-skeletal metastases, lung cancer, blood transfusion requirements, and increasing pack-year smoking history were predictors for 30-day mortality. In the multivariate analysis, pathologic fracture (p=0.016) and presence of extra-skeletal metastases (p=0.029) were independent predictors of complications. For mortality, pathologic fracture (p=0.014), presence of extra-skeletal metastases (p=0.0085), and increased blood transfusion requirements (p=0.048) were independent risk factors. Conclusions. The findings of this study provide additional guidance for perioperative risk assessment and patient counselling. Additionally, improving clinical assessment tools to identify and quantify patients at risk of pathologic fractures becomes increasingly important given the significant morbidity and mortality associated with pathologic fracture treatment.

OBJECTIVE:To determine the effect of deltoid ligament repair on the development of posttraumatic arthritis in logsplitter ankle injuries. METHODS: DESIGN:Retrospective cohort. SETTING:Academic, Level I trauma center. PATIENT SELECTION CRITERIA:Patients ≥18 years of age with logsplitter injuries (OTA/AO 44B, 44C) treated with open reduction internal fixation (ORIF) with or without deltoid ligament repair from January 2008 to October 2021. OUTCOME MEASURES AND COMPARISON:The rate of posttraumatic arthritis (PTOA) development at the final follow-up (minimum 6 months) after ORIF was evaluated using the Kellgren-Lawrence scale. The achievement of acceptable reduction indicated by articular reduction <2 mm, and a medial clear space ≤4 mm was assessed at 6 weeks postoperatively with weight-bearing radiographs. The effect of deltoid ligament repair on the development of PTOA was investigated. RESULTS:Fifty-nine patients aged 49.1 ± 17.2 years met inclusion criteria with a mean follow-up of 16.6 months (range = 6 to 96). Twenty-six of 59 patients (44%) had developed PTOA at the final follow-up. Acceptable reduction was achieved in 83.1% (49/59) of fractures. The acceptable reduction rate in fractures undergoing deltoid ligament repair was 100% versus 78% in those without deltoid ligament repair (13/13 vs. 36/46, P = 0.017). The rate of PTOA development was significantly lower in patients who underwent deltoid ligament repair (15%) than those who did not (52%), P = 0.026. Patients who underwent deltoid ligament repair had a significantly reduced rate of PTOA development leading to arthrodesis compared with those who did not (0% vs. 17%, P = 0.013). CONCLUSIONS:Logsplitter injuries resulted in a high rate of development of posttraumatic arthritis. An acceptable reduction is required to minimize the risk of development of PTOA and progression to arthrodesis. Deltoid ligament repair during ORIF may facilitate acceptable reduction and decrease the rate of PTOA and progression to arthrodesis in these injuries. LEVEL OF EVIDENCE:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: The safety of outpatient total ankle arthroplasty (TAA), and factors predictive of early complications are poorly understood. The objective of this study was to determine the frequency of early complications in patients undergoing outpatient TAA compared to a matched inpatient TAA cohort. Factors predictive of early complications following TAA are elucidated. Methods: A retrospective review of prospectively collected data from the 2011-2018 American College of Surgeons–National Surgical Quality Improvement Program (ACS-NSQIP) database was performed. An unadjusted analysis comparing complication rates in outpatient, and inpatient TAA was performed followed by a propensity score–matched cohort analysis. A multivariate logistic regression model was then used to identify significant independent predictors for complications, reoperation, and readmission following TAA. Results: A total of 1487 patients (198 outpatient, 1289 inpatient) undergoing TAA were included in the study. Inpatient TAA was associated with increased 30-day readmission compared with outpatient TAA (3.54% vs 0.51%, P = .032) in a matched cohort analysis. Thirty-eight (2.6%) patients had a minor complication, with 16 (1.1%) patients having a major complication after TAR. Nineteen (1.3%) patients underwent reoperation, and 42 (2.8%) patients were readmitted within 30 days of the index TAR. Multivariate analysis identified factors predictive of early complications to include length of stay (LOS) >2 days, smoking, hypertension, bleeding disorders, and diabetes mellitus. Conclusion: From this relatively limited data set, outpatient TAA appears to be safe for management of end-stage ankle arthritis in select patients. Inpatient status was associated with an increased rate of 30-day readmission following TAA. Postoperative length of stay >2 days, smoking, hypertension, bleeding disorders, and diabetes mellitus were identified to be associated with early postoperative complications following TAA in this cohort. Level of Evidence Level III, retrospective cohort study.

Background: Risk stratification of individual patients who are prone to infection would allow surgeons to monitor high-risk patients more closely and intervene early when needed. This could reduce infection-related consequences such as increased health-care costs. The purpose of this study was to develop a machine learning (ML)-derived risk-stratification tool using the SPRINT (Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures) and FLOW (Fluid Lavage of Open Wounds) trial databases to estimate the probability of infection in patients with operatively treated tibial shaft fractures (TSFs). Methods: Patients with unilateral TSFs from the SPRINT and FLOW trials were randomly split into derivation (80%) and validation (20%) cohorts. Random forest algorithms were used to select features that are relevant to predicting infection. These features were included for algorithm training. Five ML algorithms were trained in recognizing patterns associated with infection. The performance of each ML algorithm was evaluated and compared based on (1) the area under the ROC (receiver operating characteristic) curve (AUC), (2) the calibration slope and the intercept, and (3) the Brier score. Results: There were 1,822 patients included in this study: 170 patients (9%) developed an infection that required treatment, 62 patients (3%) received nonoperative treatment with oral or intravenous antibiotics, and 108 patients (6%) underwent subsequent surgery in addition to antibiotic therapy. Random forest algorithms identified 7 variables that were relevant for predicting infection: (1) Gustilo-Anderson or Tscherne classification, (2) bone loss, (3) mechanism of injury, (4) multitrauma, (5) AO/OTA fracture classification, (6) age, and (7) fracture location. Training of the penalized logistic regression algorithm resulted in the best-performing prediction model, with AUC, calibration slope, calibration intercept, and Brier scores of 0.75, 0.94, 0.00, and 0.076, respectively, in the derivation cohort and 0.81, 1.07, 0.09, and 0.079, respectively, in the validation cohort. Conclusions: We developed an ML prediction model that can estimate the probability of infection for individual patients with TSFs based on patient and fracture characteristics that are readily available at hospital admission.

Background: Indications for deltoid ligament repair in bimalleolar equivalent ankle fractures are unclear. This study compared radiographic outcomes in bimalleolar equivalent ankle fractures undergoing open reduction internal fixation (ORIF) +/-deltoid ligament repair.Methods: A retrospective review of 1024 ankle fractures was performed. Bimalleolar equivalent injuries treated with ORIF +/-deltoid ligament repair were included. Radiographic assessment was performed preoperatively, and at three months postoperatively.Results: One hundred and forty-seven ankle fractures met inclusion criteria with 46 undergoing deltoid ligament repairs. There was a significant decrease in medial clear space (1.93 +/- 0.65 mm vs. 2.26 +/- 0.64 mm, p = 0.01), and tibiofibular clear space (3.89 +/- 1.20 mm vs. 4.87 +/- 1.37 mm, p = 0.0001) at 3 months postoperative in the deltoid repair group compared to the no repair group. When syndesmotic fixation was performed, there were no differences between groups.Conclusion: Deltoid ligament repair in bimalleolar equivalent ankle fractures resulted in reduced medial clear space, and tibiofibular clear space in the early postoperative period. These differences were small and remained within established normal limits.Level of clinical evidence: Level III, retrospective cohort study.(c) 2021 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Objectives: In the SPRINT trial, 18% of patients with a tibial shaft fracture (TSF) treated with intramedullary nailing (IMN) had one or more unplanned subsequent surgical procedures. It is clinically relevant for surgeon and patient to anticipate unplanned secondary procedures, other than operations that can be readily expected such as reconstructive procedures for soft tissue defects. Therefore, the objective of this study was to develop a machine learning (ML) prediction model using the SPRINT data that can give individual patients and their care team an estimate of their particular probability of an unplanned second surgery. Methods: Patients from the SPRINT trial with unilateral TSFs were randomly divided into a training set (80%) and test set (20%). Five ML algorithms were trained in recognizing patterns associated with subsequent surgery in the training set based on a subset of variables identified by random forest algorithms. Performance of each ML algorithm was evaluated and compared based on (1) area under the ROC curve, (2) calibration slope and intercept, and (3) the Brier score. Results: Total data set comprised 1198 patients, of whom 214 patients (18%) underwent subsequent surgery. Seven variables were used to train ML algorithms: (1) Gustilo-Anderson classification, (2) Tscherne classification, (3) fracture location, (4) fracture gap, (5) polytrauma, (6) injury mechanism, and (7) OTA/AO classification. The best-performing ML algorithm had an area under the ROC curve, calibration slope, calibration intercept, and the Brier score of 0.766, 0.954, -0.002, and 0.120 in the training set and 0.773, 0.922, 0, and 0.119 in the test set, respectively. Conclusions: An ML algorithm was developed to predict the probability of subsequent surgery after IMN for TSFs. This ML algorithm may assist surgeons to inform patients about the probability of subsequent surgery and might help to identify patients who need a different perioperative plan or a more intensive approach.

OBJECTIVE:To determine if geriatric intertrochanteric hip fracture patients achieve equivalent postoperative functional status after management with either a short (180-200 mm) or a long (260-460 mm) InterTAN intramedullary device.DESIGN:Retrospective review of a prospective randomized control trial.SETTING:Four Level I Trauma Centers.PATIENTS/PARTICIPANTS:One hundred eight patients with OTA/AO classification 31A-1 and 31A-2 intertrochanteric hip fractures were included in the study.INTERVENTION:Internal fixation using an IT device.MAIN OUTCOMES MEASURES:Primary outcomes included Functional Independence Measure and Timed Up and Go. Secondary outcomes included blood loss, surgical time, length of stay, adverse events, and mortality.RESULTS:Seventy-one short and 37 long IT patients met study inclusion criteria. Demographics were similar between groups. There was no difference in Functional Independence Measure or Timed Up and Go scores between the 2 IT groups at any of the time points collected. Mean operative time was lower in the short IT group than in the long IT group (60 vs. 73 minutes; P = 0.021). A higher proportion of long IT patients had reamed constructs (95% vs. 48% short IT, P < 0.001). Postoperative blood loss was significantly higher in the long IT group without a significant influence on the number of patients requiring transfusion (P = 0.582) or average units transfused (P = 0.982). There was no significant difference in the proportion of postoperative adverse events between the 2 cohorts despite a higher number of peri-implant femur fractures in the short IT group than in the long IT group (5 vs. 1, P = 0.350).CONCLUSIONS:Postoperative functional status was not influenced by the length of IT device in the management of geriatric intertrochanteric hip fractures.LEVEL OF EVIDENCE:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: The FAITH trial evaluated effects of sliding hip screws versus cancellous screws in femoral neck fracture patients. Using FAITH trial data, we quantified changes in living status, use of aids, and investigated factors associated with living and walking independently 12 months after fracture. Methods: We conducted a descriptive analysis to quantify patients' changes in living status, use of aids, and used multivariable Cox regression analyses to determine factors associated with living and walking independently after fracture. Results: Of patients who lived independently before hip fracture, 3.07% (50–80 years old) and 19.81% (>80 years old) were institutionalized 12 months after injury. Of patients who were walking independently before injury, 33.62% (50–80 years old) and 69.34% (>80 years old) required a walking aid 12 months after injury. Factors associated with higher chances of living independently included the following: being between 50 and 80 years, having a class I American Society of Anesthesiologists classification, not using a walking aid before fracture, being a nonsmoker or former smoker, and having an acceptable quality of implant placement. Factors associated with higher chances of walking without an aid included the following: being between 50 and 80 years, having a class I American Society of Anesthesiologists classification, living independently before fracture, being a nonsmoker or former smoker, having an undisplaced fracture, and not requiring revision surgery. Conclusions: Femoral neck fracture patients suffer great losses of independence. Identifying factors associated with living and walking independently after hip fracture may help surgeons better identify which patients are at risk and optimize care of patients with this injury. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

This study examined how a hand washing compliance auditing system affects physician hand washing compliance and rates of hospital acquired infections. Ultimately, data collection was significantly impaired by low recruitment and compliance rates. To learn from this project's failure, medical residents were invited to participate in an interview to discuss the project, its merits and shortcomings. Beyond existing resistance to such surveillance, study procedures, confounding contextual variables and insufficient value propositions seem to account for the project's failure. Use of a hand washing compliance auditing system is likely to fail if it is not optimally integrated into existing clinical workflows and hospital infrastructure, or if auditing seems to take the form of surveillance. Beyond the establishment of proof of concept, proof of relevance and value for all stakeholder groups must be established to embed an innovation such as this hand washing compliance auditing system.

The benefit of using a long intramedullary device for the treatment of geriatric intertrochanteric hip fractures is unknown. The InterTAN device (Smith and Nephew, Memphis TN) is offered in either Short (180–200 mm) or Long (260–460 mm) constructs and was designed to provide stable compression across primary intertrochanteric fracture fragments. The objective of our study was to determine whether Short InterTANs are equivalent to Long InterTANs in terms of functional and adverse outcomes for the treatment of geriatric intertrochanteric hip fractures.108 patients with OTA classification 31A–1 and 31A–2 intertrochanteric hip fractures were included in our study and prospectively followed at one of four Canadian Level-1 Trauma Centres. Our primary outcomes included two validated primary outcome measures: the Functional Independence Measure (FIM), to measure function, and the Timed Up and Go (TUG), to measure motor performance. Secondary outcome measures included blood loss, length of procedure, length of sta...

Background: Prescription opioid misuse is a significant issue with multiple consequences for our patients and society. The purpose of this study was to evaluate the role of a postoperative pain guideline pamphlet on patient pain satisfaction, on number of patients seeking a renewal prescription, and on appropriate disposal of leftover prescription medication. Methods: This prospective, randomized controlled trial included patients aged 18 to 65 yr undergoing elective foot and ankle surgery, who were opioid naïve and had no preexisting chronic pain conditions. Patients consenting to participate were divided into low-, medium-, and high-use groups according to anticipated postoperative prescription narcotic usage. Patients in each group were randomized to the control group that received no written discharge instructions, or the intervention group that received written instructions outlining postoperative pain expectations and recommendations for opioid medication usage and disposal. Both groups received equivalent prescriptions targeted to the use group (low, medium, or high). At the 4-week postoperative mark, a telephone interview was conducted to evaluate the primary outcome of pain satisfaction using a modified brief pain inventory. Secondary outcomes included renewal of opioid prescription and disposal method of leftover medication. Results: A total of 80 patients were recruited for this study. Of the 80 patients, 22 were classified as low use, 45 moderate use, and 13 high use. There was no difference among group demographics, other than the surgery being performed. Of the 80 patients, 41 received postoperative pain instructions and 39 did not. On average, pain satisfaction postoperatively was 8.19/10, where 10/10 represented completely satisfied. Interference scores averaged 27.18/70. Interestingly, only seven patients (six moderate use and one high use) used the entirety of their prescription, and only five patients required a renewal of their prescription. Only five patients returned their surplus medication to the pharmacy despite 41 patients receiving direct instructions to do so. Conclusions: Written discharge instructions in this patient population did not appear to improve postoperative pain scores. Interestingly, this study captured that a small percentage of postoperative pain medication prescriptions are completely utilized. Even more concerning is the fact that very little of the leftover pain medication is disposed of appropriately. Overprescribing narcotic medication may contribute to the issue of opioid abuse, and we should consider our role in minimizing opioid prescriptions postoperatively.

Objectives:The purpose of this clinical study is to determine whether the rate of fracture healing and fracture union, repaired with a locked device, will be as good as or better than standard nonlocking bicortical fixation in distal femoral fractures.Design:Institutional review board-approved, multicenter prospective randomized controlled trial.Setting:Seven level 1 trauma centers across Canada.Patients:Fifty-two patients with distal femoral fractures (AO/OTA 33A1 to 33C2) were enrolled in the randomized trial. Twelve AO/OTA 33C3 fractures were excluded from the randomized trial but followed up as a nonrandomized cohort.Intervention:Patients were treated through a standardized minimally invasive approach. Fractures were randomized 1:1 to treatment with the locked Less Invasive Stabilization System (LISS; Synthes, Paoli, PA) or the dynamic condylar screw (DCS). The nonrandomized cohort was treated at the surgeon's discretion.Main Outcome Measurements:Primary outcomes were time to radiological union and number of delayed/nonunions at 12 months. Secondary outcomes were postoperative function and complications.Results:Fifty-two patients were randomized including 34 women and 18 men. The mean age was 59 years. Twenty-eight patients were treated with the LISS and 24 with the DCS. There was no statistically significant difference between the LISS and the DCS in terms of the number of fractures healed, time to union, or functional scores. Complications and revisions were more common in the LISS group. There were 7 reoperations in the LISS group and one in the DCS group. Only 52% of the LISS group healed without intervention by 12 months compared with 91% in the DCS group.Conclusions:There was no advantage to the locking plate design in the management of distal femoral fractures in this study. The higher cost of the locking plates, challenges in technique, and lack of superiority have led the authors to discontinue the use of this lateral unicortical locking device in favor of other devices that allow locked or nonlocked bicortical fixation, articular compression, and bridging of the comminuted fracture segments. The cost-effective treatment for a subgroup or periarticular fractures may be a fixed-angle nonlocked device in patients with reasonable bone quality.Level of Evidence:Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES:To compare outcomes in elderly patients with intertrochanteric hip fractures treated with either the sliding hip screw (SHS) or InterTAN intramedullary device (IT).DESIGN:Prospective, randomized, multicenter clinical trial.SETTING:Five level 1 trauma centers.PATIENTS:Two hundred forty-nine patients 55 years of age or older with AO/OTA 31A1 (43) and OA/OTA 31A2 (206) fractures were prospectively enrolled and followed for 12 months.INTERVENTION:Computer generated randomization to either IT (n = 123) or SHS (n = 126).MAIN OUTCOME MEASUREMENTS:The Functional Independence Measure (FIM) and the Timed Up and Go test (TUG) were used to measure function and motor performance. Secondary outcome measures included femoral shortening, complications, and mortality.RESULTS:Demographics, comorbidities, preinjury FIM scores and TUG scores were similar between groups. Patients (17.2%) who received an IT had limb shortening greater than 2 cm compared with 42.9% who received an SHS (P < 0.001). To determine the importance of preinjury function and fracture stability, we analyzed the subgroup of patients with the ability to walk 150 m independently preinjury and an OA/OTA 31A-2 fracture (n = 70). In this subgroup, patients treated with SHS had greater shortening and demonstrated poorer FIM and TUG scores compared with patients treated with an IT.CONCLUSIONS:Overall, most patients with intertrochanteric femur fractures can expect similar functional results whether treated with an intramedullary or extramedullary device. However, active, functional patients have an improved outcome when the InterTAN is used to treat their unstable intertrochanteric fracture.LEVEL OF EVIDENCE:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

INTRODUCTION:Inadequate sample size and power in randomized trials can result in misleading findings. This study demonstrates the effect of sample size in a large clinical trial by evaluating the results of the Study to Prospectively evaluate Reamed Intramedullary Nails in Patients with Tibial fractures (SPRINT) trial as it progressed.METHODS:The SPRINT trial evaluated reamed versus unreamed nailing of the tibia in 1226 patients, and in open and closed fracture subgroups (N = 400 and N = 826, respectively). We analyzed the reoperation rates and relative risk comparing treatment groups at 50, 100, and then increments of 100 patients up to the final sample size. Results at various enrollments were compared with the final SPRINT findings.RESULTS:In the final analysis, there was a statistically significant decreased risk of reoperation with reamed nails for closed fractures (relative risk reduction 35%). Results for the first 35 patients enrolled suggested that reamed nails increased the risk of reoperation in closed fractures by 165%. Only after 543 patients with closed fractures were enrolled did the results reflect the final advantage for reamed nails in this subgroup. Similarly, the trend toward an increased risk of reoperation for open fractures (23%) was not seen until 62 patients with open fractures were enrolled.CONCLUSIONS:Our findings highlight the risk of conducting a trial with insufficient sample size and power. Such studies are not only at risk of missing true effects but also of giving misleading results.

Purpose: To compare the reoperation rates of three commonly used forms of fixation for distal femur fractures. Method: 89 patients treated between 2002 and 2006 were retrospectively reviewed (mean follow up 28 months).. 40 fractures were treated with an intramedullary nail (IMN), 34 with the LISS internal fixator and 16 with a DCS construct. Patients were reviewed clinically and radiographically. The primary treatment outcome was the rate of secondary surgical intervention; secondary outcomes included radiographic alignment and clinical outcome measures (LEM and SF-36). Results: Reoperation: Reoperation rate for the DCS group was 12.5%, compared to 17.5 % in the IMN group and 44 % in the LISS group. Failure rates were the same when only AO type C fractures were considered. Most concerning in the LISS group was the rate of failure in distal short oblique type A fractures, in which catastrophic failure was observed in 4 of 9 patients. Alignment was similar comparing all three groups; the average radiographic distal femoral articular angle (DFAA) of was 10 degrees valgus in the DCS group, compared to 8 degrees in the IMN group and the LISS patients. Conclusion: Reoperation rate was highest in this study when the LISS fixator was used for distal short oblique fractures of the femur. These fractures may benefit from fixation which achieves direct interfragmentary compression, such as an intramedullary device or compression plating.

Objective: Screw fixation of the injured syndesmosis restores stability but may reduce motion. The purpose of this study is to determine whether functional outcomes and radiographic results after ankle fracture are affected by the status of the syndesmosis screw. Design: Retrospective review of a consecutive clinical series. Setting: Level 1 academic trauma center. Patients: One hundred six adults were reviewed radiographically; mean follow up was 15 months (range, 4-30 months). Seventy-six of the 106 patients completed formal functional testing; mean follow up was 23 ± 13 months (range, 12-32 months). Intervention: Open reduction and internal fixation, including fixation of the tibiofibular syndesmosis. Main Outcome Measurements: Patients with intact, broken or loose, or removed syndesmosis screws were compared. Functional outcomes were measured using the Lower Extremity Measure and the Olerud Molander ankle score. Radiologic review included tibiofibular clear space, tibiofibular overlap, and medial clear space. Results: Functional outcomes were improved in patients with fractured, loosened, or removed screws compared with those with intact screws. The Lower Extremity Measure score for patients with intact screws was 70 ± 6 compared with 85 ± 3 for fractured, loosened, or removed screws (P = 0.01). The Olerud Molander ankle score for patients with intact screws was 47 ± 8.0 compared with 64 ± 4 for fractured, loosened, or removed screws (P = 0.04). There was no difference in outcome comparing fractured, loosened, and removed screws. The tibiofibular clear space was narrowed in patients with intact screws compared with removed, fractured, or loose screws. The tibiofibular clear space for intact screws was 3.1 ± 0.2 compared with 4.1 ± 0.2 for removed, fractured, or loosened screws (P = 0.005). There was no difference in outcome comparing large and small fragment screws. Conclusions: An intact syndesmosis screw was associated with a worse functional outcome compared with loose, fractured, or removed screws. However, there were no differences in functional outcomes comparing loose or fractured screws with removed screws. Screw removal is unlikely to benefit patients with loose or fractured screws but may be indicated in patients with intact syndesmosis screws.

This study is designed to evaluate intra-operative stress testing on detection of syndesmosis injuries. We evaluated forty patients with ankle fractures requiring surgery. Their ankles were subjected to stress examinations after each stage of fixation. These were compared to the contralateral side. Biomechanical criteria were used to predict need for syndesmosis fixation. In 42% of the fractures, intra-operative fluoroscopy found an unpredicted syndesmosis injury. In 8% the syndesmosis was intact despite prediction. Medial malleolar fixation was not adequate for syndesmosis fixation as shown by stress testing. These findings may have implications for future diagnosis and treatment of syndesmosis injuries. This study is designed to evaluate the utility of intra-operative fluoroscopic stress testing in diagnosing tibio-fibular syndesmotic injuries. Forty skeletally mature patients with unilateral external rotation ankle fractures requiring open reduction and internal fixation were prospectively recruited. Intra-operatively the injured ankle was examined fluoroscopically using external rotation, valgus and anterior drawer stress tests, as well as static antero-posterior, mortise, and lateral ankle views. Stress testing was performed using a standardized force of 37.5 N. Stress testing was done after each stage of fixation (lateral, medial, and syndesmotic). The uninjured contralateral limb was examined as a control, and a 1 mm side to side difference was defined as a positive stress examination. Intra-operative fluoroscopy detected unpredicted syndesmotic injuries in 42 % of ankle injuries. In all cases, fixation of the medial malleolus did not restore syndesmotic stability. In 8 % of ankle injuries, a syndesmotic injury was predicted but stress testing revealed the syndesmosis intact. Intra-operative fluoroscopy is a more sensitive modality for detection of otherwise unpredicted syndesmotic injuries compared to criteria based upon static radiographs. Medial malleolar fixation did not add stability to syndesmotic injuries in this study. Injuries involving the distal tibio-fibular syndesmosis are difficult to detect. Previously, the decision to stabilize the syndesmosis in ankle fractures was based upon biomechanical criteria and static radiography. This and other recent studies challenge this, suggesting fluoroscopic stress testing is a better diagnostic method for these poorly tolerated injuries. Funding: Synthes Canada, Smith Nephew Richards Inc.

BACKGROUND The purpose of this study was to assess the functional outcome and causes of persistent disability in patients with isolated femoral shaft fractures treated at an academic level-1 trauma centre. METHODS We prospectively enrolled 40 consecutive skeletally mature patients with isolated, nonpathologic diaphyseal femur fractures. All patients underwent fracture reduction and fixation using an antegrade locked intramedullary nail. We measured functional outcome using the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index and the Short Musculoskeletal Functional Assessment (SMFA). We obtained visual analog scores for pain in the groin, buttock, thigh and knee 6 months after the injury. RESULTS Joint-related and musculoskeletal outcome scores improved gradually from the baseline assessment to the 6-month review. Mean scores (and standard deviations [SDs]) on the WOMAC index improved gradually from 57 (23) to 24 (22) for pain, from 57 (25) to 30 (20) for stiffness and from 70 (21) to 21 (23) for function (p < 0.001). The mean SMFA score (and SD) improved from 64 (13) to 25 (20) (p = 0.024). We noted no further improvements in functional outcome measures from the 6-month to the 12-month assessment (p > 0.21). Patients reported more pain in the knee than in other anatomic locations; the mean pain scores (and SDs) were 3.7 (3.1) in the knee, 2.5 (2.7) in the thigh, 1.7 (2.7) in the buttock and 1.0 (1.7) in the groin (p = 0.003). We noted correlations between knee pain and WOMAC pain (rho = 0.748, p < 0.001), function (rho = 0.701, p < 0.001) and SMFA (rho = 0.733, p < 0.001). We noted weaker correlations between thigh, groin and buttock pain and functional outcomes, with rho scores ranging from 0.2 to 0.55. CONCLUSION Recovery from femur fractures occurs most rapidly in the first 6 months after injury. Residual deficits in functional outcome were still measurable 12 months after injury. Knee pain was the most common and most severe source of patient discomfort 12 months after isolated femur fractures, and demonstrated moderate to good correlation with general and joint-specific functional outcome measures.

Objective: To compare the mechanical performance of 3 fixation techniques for comminuted talar neck fractures. Design: In vitro biomechanical study. Setting: Bioengineering research laboratory. Participants: Thirty previously frozen human cadaveric tali were osteotomized across the talar neck. A wedge of bone 2 cm long and extending 50% of the medial to lateral and superior to inferior dimension of the talus was removed to create an unstable, comminuted fracture. Intervention: The specimens were randomized to one of 3 fixation groups. The first group was fixed with 3 anterior-to-posterior screws. The second group was fixed with 2 cannulated screws inserted from posterior to anterior. The third group was fixed with 1 screw from anterior to posterior and a medially applied blade plate. Specimens were embedded in acrylic cement and mounted on an Instron mechanical testing machine. Loading was applied in the dorsal-medial direction to failure. Main Outcome Measures: For each specimen, the load-displacement curve, yield point, and 3 mm displacement point were recorded in response to controlled dorsal-medial loading to failure. Stiffness was calculated as the linear portion of the slope of the load (kN) versus displacement (mm) curve. Statistical analysis of the data was conducted using analysis of variance. Results: The mean yield point of each of the fixation techniques tested exceeded 1.4 kN. No statistically significant difference was found between the fixation methods, even when variations in age and sex were considered. Conclusions: The mean yield point of the fixation techniques tested exceeds the theoretical stress across the talar neck during active motion. Anterior plate fixation provided equivalent stability to posterior screw fixation.

BACKGROUND:High tibial osteotomy (HTO) is used to treat medial compartment osteoarthritis of the knee in active patients with varus alignment. In this study we review the clinical and radiographic outcomes associated with the Taylor Spatial Frame (Smith & Nephew), and its use in HTOs, and we include an illustrative case report.METHODS:In 7 patients with medial compartment osteoarthritis of the knee and varus alignment, the Taylor Spatial Frame was applied to the tibia in the operating room and a proximal tibial osteotomy was performed. Patients followed a computer-generated turning schedule until the desired correction was achieved. The frame was removed when the osteotomy site had healed. The lower extremity measure (LEM) was used to assess physical function. Clinical outcome measures relating to the Taylor Spatial Frame included latency, time to correction, time in the frame, number of residual corrections and complications. Radiographic outcomes included preoperative Resnick grades of osteoarthritis, pre- and post-correction limb alignment and tibial slope measurements.RESULTS:Average (and standard deviation) LEM grade at a mean 41 (14) months follow-up after correction was 94% (5%). Average latency was 8 days, time to correction was 15 days, time in the frame was 23 weeks and number of residual corrections was 1.3. Complications were similar to those for external fixators. Radiographic correction goals were met in all patients.CONCLUSION:The Taylor Spatial Frame is a valuable asset when using HTO to treat medial compartment osteoarthritis of the knee.