In Memoriam: Arsen Pankovich, MD (1930–2019) No abstract available

Short Versus Long Cephalomedullary Nails for Pertrochanteric Hip Fractures: A Randomized Prospective Study Objective: To compare functional and clinical outcomes in patients with pertrochanteric hip fractures treated with either a short (SN) or long (LN) cephalomedullary nail. Design: Prospective, randomized. Setting: Clinical investigation was performed at the Mayo Clinic's Level 1 Trauma Center in Rochester, MN. Patients/Participants: Two hundred twenty patients with intertrochanteric fractures were prospectively randomized to an SN or LN cohort. A total of 168 patients (SN, n = 80; LN, n = 88) had a mean follow-up of 13.9 months. Fifty-two patients did not meet the minimum 3-month follow-up. Demographics were comparable between the cohorts. Main Outcome Measures: The primary outcome measurement was functional outcome evaluated by Short Form (SF-36) and Harris Hip scores (HHS) at 3 months. Secondary outcomes included implant failure, peri-implant fracture, mortality, operative time, estimated blood loss, and reoperation. Results: SN and LN cohorts were comparable in all aspects of the SF-36. There was a clinically insignificant difference in the HHS between cohorts. Patients treated in the SN cohort experienced shorter operative times but did not differ in tip-to-apex distance or subtrochanteric fracture extension. There was no difference in implant cutout, deep surgical site infection, or peri-implant fractures. Conclusions: Patients treated with SNs or LNs for pertrochanteric femur fractures experienced comparable functional outcomes as measured by SF-36 and HHS. When compared with the LN cohort, SN patients experienced no difference in peri-implant fracture or lag-screw cutout and tolerated up to 3 cm of subtrochanteric fracture line extension. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Femoral Neck Shortening After Hip Fracture Fixation Is Associated With Inferior Hip Function: Results From the FAITH Trial Objective: To describe the distribution of femoral neck shortening after internal fixation and to determine whether shortening is associated with inferior hip function at 24 months after a hip fracture in patients 50 years of age or older. Design: Retrospective cohort study. Setting: A secondary analysis of data from 81 clinical centers included in the Fixation using Alternative Implants for the Treatment of Hip Fractures (FAITH) trial. Participants: Three hundred fifty patients, 50 years of age or older, who had an isolated femoral neck fracture and underwent timely operative fixation of the fracture. Intervention: Femoral neck shortening was measured as a categorical variable and classified into one of the following groups, as determined by the Central Adjudication Committee: no shortening, mild shortening (≤5 mm), moderate shortening (6–10 mm), or severe shortening (>10 mm). Main Outcome Measurement: The primary outcome for the current analysis was hip function, as measured by the Western Ontario & McMaster Universities Osteoarthritis Index questionnaire, at 24 months after injury. Results: Two-thirds of patients had no or mild shortening (≤5 mm), whereas one-third of patients had moderate or severe shortening (>5 mm). After adjusting for surgical treatment, a greater amount of femoral neck shortening was found to be associated with poorer hip function (P < 0.01). Conclusions: We found that increasing femoral neck shortening was associated with inferior hip function. Although internal fixation often results in successful union, patients who heal in a shortened position report poorer functional outcomes. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The Predictive Value of the Clinical Frailty Scale on Discharge Destination and Complications in Older Hip Fracture Patients Objectives: To determine whether the Clinical Frailty Scale (CFS), a validated frailty tool, was associated with discharge destination. Secondary objectives were to determine whether the CFS was associated with in-hospital complications and length of stay. Design: This is a 5-year retrospective cohort study. Setting: The study took place at an academic Level 1 trauma center. Patients/Participants: All patients 65 years of age and older admitted with an isolated hip fracture were included (N = 423). Intervention: Preadmission CFS was determined as part of routine clinical care prospectively and abstracted from the chart. Main Outcome Measurements: We collected demographic and process data associated with adverse outcomes (age, sex, time to surgery, and mode of anesthesia) and used multivariable logistic regression to determine the association between CFS with discharge destination, in-hospital complications, and length of stay. Results: Preadmission frailty was independently associated with adverse discharge destination (adjusted odds ratio 23.0; 95% confidence interval, 3.0–173.5) and in-hospital complications (adjusted odds ratio 4.8; 95% confidence interval, 2.1–10.8) in greater magnitude than traditional risk factors such as age, male sex, time to surgery, and mode of anesthesia. There was a dose–response relationship between increasing frailty and length of stay (P < 0.001). Conclusions: Preadmission frailty as quantified by the CFS is associated with discharge destination, in-hospital complications, and length of stay. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Accurate Prediction of Antegrade and Retrograde Femoral Intramedullary Implant Length From Patient-Reported Height Objective: To determine whether patient height correlates with implant length selection of antegrade or retrograde femoral intramedullary implants. Design: Case–control Study. Setting: A single level 1 trauma center. Patients/Participants: All patients with operatively treated femoral shaft fractures from 2011 to 2017. Intervention: All fractures were treated with an intramedullary nail. Retrograde or antegrade insertion was decided at the discretion of the surgeon and fracture location. Main Outcome Measurements: Length of femoral implant and patient height. Results: Five hundred sixty-seven operatively treated fractures were reviewed, 322 antegrade and 245 retrograde. The correlation between patient height and actual nail length was 0.55 for antegrade implants (P < 0.01) and 0.59 for retrograde implants (P < 0.01). Separate prediction equations for nail length based on patient height were estimated for antegrade and retrograde implants and found accurate prediction of length 86% and 88% of the time, respectively. Conclusions: Intramedullary nail length can be accurately predicted based on patient height and the technique using the equations below. This is the first study to establish a simple equation to serve as an adjunct for selecting the most appropriate length implant. This equation can be used in cases of bilateral femur fractures, templating to have appropriate sized implants in close proximity to the odds ratio, and in remote environments where surgical planning is critical for determining implant needs.

A Predictive Score for Determining Risk of Surgical Site Infection After Orthopaedic Trauma Surgery Objectives: To determine factors predictive of postoperative surgical site infection (SSI) after fracture fixation and create a prediction score for risk of infection at time of initial treatment. Design: Retrospective cohort study. Setting: Level I trauma center. Patients/Participants: Study group, 311 patients with deep SSI; control group, 608 patients. Intervention: We evaluated 27 factors theorized to be associated with postoperative infection. Bivariate and multiple logistic regression analyses were used to build a prediction model. A composite score reflecting risk of SSI was then created. Main Outcome Measures: Risk of postoperative infection. Results: The final model consisted of 8 independent predictors: (1) male sex, (2) obesity (body mass index ≥ 30) (3) diabetes, (4) alcohol abuse, (5) fracture region, (6) Gustilo–Anderson type III open fracture, (7) methicillin-resistant Staphylococcus aureus nasal swab testing (not tested or positive result), and (8) American Society of Anesthesiologists classification. Risk strata were well correlated with observed proportion of SSI and resulted in a percent risk of infection of 1% for ≤3 points, 6% for 4–5 points, 11% for 6 to 8–9 points, and 41% for ≥10 points. Conclusion: The proposed postoperative infection prediction model might be able to determine which patients have fractures at higher risk of infection and provides an estimate of the percent risk of infection before fixation. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Diabetic Control Predicts Surgical Site Infection Risk in Orthopaedic Trauma Patients Objectives: (1) To determine the incidence of surgical site infections (SSIs) in diabetic orthopaedic trauma patients and (2) to establish a protocol for managing diabetes mellitus (DM) in orthopaedic trauma patients. Design: Retrospective cohort study. Setting: Level 1 Trauma Center. Patients: All diabetic orthopaedic trauma patients who underwent surgical intervention with at least 1 month follow-up. Patients were classified as poorly controlled or controlled diabetic patients based on admission hemoglobin A1c and blood glucose (BG) levels. Interventions: Orthopaedic surgical intervention in accordance with fracture type and a standardized diabetes management protocol with internal medicine comanagement. Main Outcome Measurement: SSI incidence. Results: There were 260 patients during the study period. Two hundred two (77.7%) were included in the final analysis. Seventy-five (37.1%) patients met the criteria for poorly controlled DM. The overall rate of SSI was 20.8%; 32.0% for poorly controlled diabetic patients, and 14.2% for controlled diabetic patients (P < 0.01). The admission blood glucose level (BG, P = 0.05), but not discharge BG, was associated with SSI incidence. Conclusions: Trauma patients with poorly controlled DM have a higher rate of SSIs than patients with controlled DM. Perioperative diabetes control does not seem to decrease infection rates in these patients. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical Site Infections in Elderly Fragility Hip Fractures Patients Undergoing Warfarin Treatment Objectives: Surgical site infection (SSI) is a devastating complication of proximal femoral fracture surgery, related with an increased morbidity and mortality. As warfarin treatment has been described as a risk factor for SSI, we aimed to compare patient and SSI characteristics in warfarin and nonanticoagulated patients. Design: Retrospective cohort study. Setting: Level-1 trauma center. Patients: Individuals 65 years of age and older with fragility hip fractures. Intervention: Patients were divided into 2 cohorts: warfarin treated (n = 85) or nonanticoagulated (n = 771). Demographics, in-hospital characteristics, laboratory data, prior hospitalizations, recent antibiotic use, and 1-year incidence of SSIs and their characteristics were gathered. Main Outcome Measures: Postoperative SSIs. Results: Twelve patients (14.1%) from the warfarin group and 21 patients (2.7%) from the noncoagulated group had SSI (P < 0.001). Both groups were comparable in terms of demographics and Charlson comorbidity score. Warfarin-treated patients had reduced white blood and neutrophils counts (10.1 ± 3.2 vs. 11.6 ± 4.0 cells/mm3 and 8.1 ± 3.2 vs. 9.6 ± 3.9 cells/mm3 for both comparisons respectively; P < 0.001 for both). They were more likely to be admitted to a geriatric ward than to orthopedics ward and were delayed to theater (58.5 ± 44.5 vs. 30.6 ± 27.4 hours; P < 0.001). Following surgery, there was no difference in blood transfusions required, in-hospital complications, or time to infection. Rates of prior hospitalizations, antibiotic use, or type of bacteria did not differ. Conclusions: Warfarin treatment in fragility hip fracture surgery is correlated with an increased risk for SSI, regardless of in-hospital complications, and hospitalizations before surgery or to the infection itself. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Using Trauma Triage Score to Risk-Stratify Inpatient Triage, Hospital Quality Measures, and Cost in Middle-Aged and Geriatric Orthopaedic Trauma Patients Objectives: To investigate the efficacy of a novel geriatric trauma risk assessment tool [Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA)] designed to predict inpatient mortality to risk-stratify measures of hospital quality and cost of care in middle-aged and geriatric orthopaedic trauma patients. Design: Prospective cohort study. Setting: Academic medical center. Patients: One thousand five hundred ninety-two patients 55 years of age and older who were evaluated by orthopaedic surgery in the emergency department between October 1, 2014, and September 30, 2016. Intervention: Calculation of the inpatient mortality risk score (STTGMA) using each patient's demographics, injury severity, and functional status. Patients were stratified into minimal-, low-, moderate-, and high-risk cohort groups based on risk of <0.9%, 0.9%–1.9%, 1.9%–5%, and >5%. Main Outcome Measurements: Length of stay, complications, disposition, readmission, and cost. Results: One thousand two hundred seventy-eight patients (80.3%) sustained low-energy injuries and 314 patients (19.7%) sustained high-energy injuries. The average age was 73.8 ± 11.8 years. The mean length of hospital stay was 5.2 days with a significant difference between the STTGMA risk groups. This risk stratification between groups was also seen in complication rate, need for Intensive Care Unit/Step Down Unit care, percentage of patients discharged, and readmission within 30-days. The mean total cost of admission for the minimal-risk group was less than one-third that of the high-risk cohort. Conclusions: The STTGMA tool is able to risk-stratify hospital quality outcome measures and cost. Thus, it is a valuable clinical tool for health care providers in identifying high-risk patients in efforts to continue to provide high-quality resource conscious care to orthopaedic trauma patients. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Are Routine Postoperative Computer Tomography Scans Warranted for All Patients After Operative Fixation of Pelvic Ring Injuries? Objective: To evaluate the efficacy of routine postoperative computed topography (CT) scan after percutaneous fixation of unstable pelvic ring injuries. Design: Retrospective chart review. Setting: Level I Trauma Center. Patients/Participants: A total of 362 consecutive patients underwent operative fixation of unstable pelvic ring injuries during the study period. Intervention: Postoperative CT scan of the pelvis was obtained in 331 (91%) of the 362 patients treated operatively for unstable pelvic ring injuries. Main Outcome Measurements: Revision surgery based on routine postoperative CT scan. Results: Two patients (0.55%) returned to the operating room on the basis of postoperative CT scans due to malpositioned implants. There were no significant differences of age, sex, body mass index, Injury Severity Score, mechanism of injury, smoking status, or diabetes status between those who did and did not undergo revision surgery. A dysmorphic pelvis was identified in 154 (47%) patients. Both patients undergoing revision surgery were determined to have a dysmorphic pelvis while no patients with normal pelvic anatomy returned to the operating room based on postoperative CT (2/154, 1.3% vs. 0/177, 0%, P = 0.22). Conclusions: Although there remains a role for postoperative CT scans in the appropriately selected patient, in the hands of experienced orthopaedic traumatologists, patients with adequate intraoperative fluoroscopy and a nondysmorphic pelvis may not require routine postoperative three-dimensional imaging. Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.