Improved Reduction of the Tibiofibular Syndesmosis With TightRope Compared With Screw Fixation: Results of a Randomized Controlled Study Objective: To compare the rate of malreduction after high fibular fractures associated with syndesmosis injury treated with open reduction and internal fixation, with either 2 screws or 1 knotless TightRope device. Design: Prospective randomized controlled multicenter trial. Setting: Eleven academic and community hospitals including Level 1 and Level 2 trauma centers across Canada. Patients/Participants: One hundred three patients with OTA/AO 44-C injuries with demonstrated radiographic syndesmosis diastasis or instability after malleolar bony fixation were followed for 12 months after treatment. Methods: Open reduction of the syndesmosis was performed in all cases. Fixation was randomized to either TightRope (1 knotless TightRope, group T) or screw fixation (two 3.5-mm cortical positional screws placed across 3 cortices, group S). Surgical techniques and rehabilitation were standardized. All surgeons were trained or experienced in the use of the TightRope device. Follow-up was performed at 2 and 6 weeks, 3, 6, and 12 months. Main Outcome Measure: Rate of malreduction based on bilateral ankle computed tomography scan results at 3 months after fixation. Secondary outcome measures included adverse events, reoperation, and validated functional outcomes including the EQ-5D, the Olerud–Molander Ankle Score, the Foot and Ankle Disability Index, and the Work Productivity Activity Impairment Questionnaire. The estimated sample size required to detect a difference in reduction rate was 72 patients, but the estimated sample size required to detect a difference in functional outcome scores was 240 patients, suggesting the study was adequately powered for radiographic results only. Results: Overall, the rate of malreduction using screw fixation was 39% compared with 15% using TightRope fixation (P = 0.028, χ2). Analysis of computed tomography results was performed using a 2-mm translation or 10-degree rotation threshold for malreduction and included fibular translation (anterior, posterior); syndesmosis distance (anterior, posterior, and mid); medial compression; and rotation (fibular and articular). Patients in group T had greater anterior translation (5.4 ± 1.8 mm) compared with the contralateral limb (4.3 ± 1.3 mm, P < 0.01) or group S (4.6 ± 1.5 mm, P = 0.05). Group T syndesmoses also had greater diastasis compared with control limb (4.1 ± 1.3 vs. 3.3 ± 1.4 mm, P < 0.01) and less fibular medialization compared with group S (1.04 ± 1.8 vs. 0.3 ± 1.8 mm, P = 0.05). Functional outcome measures demonstrated significant improvements over time, but no differences between fixation groups. Foot and Ankle Disability Index scores at each time interval were 44 ± 22 (T) versus 45 ± 24 (S) (6 weeks), 76 ± 14 versus 73 ± 17 (3 months), 89 ± 10 versus 86 ± 13 (6 months), and 93 ± 9 versus 90 ± 14 (12 months) (all P > 0.2). The reoperation rate was higher in the screw group compared with TightRope (30% vs. 4%, P = 0.02) with the difference driven by the rate of implant removal. Conclusions: Based on our results, the TightRope device seems to compare favorably with two, 3.5-mm, 3-cortex screw fixation for syndesmosis injuries. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Early Effects of the Trauma Collaborative Care Intervention: Results From a Prospective Multicenter Cluster Clinical Trial Objectives: To evaluate the impact of the Trauma Collaborative Care (TCC) program's early intervention components on 6-week outcomes. TCC was developed to improve psychosocial sequelae of orthopaedic trauma and includes the Trauma Survivors Network and additional collaborative care services. Design: Prospective, multicenter, cluster clinical trial. Setting: Level I Trauma Centers. Patients: Individuals with high-energy orthopaedic injuries requiring surgery and hospital admission: 413 patients at 6 trauma centers implementing the TCC program and 374 patients at 6 trauma centers receiving usual care. Intervention: TCC early intervention: patient education, peer visits, and coaching calls. Main Outcome Measurements: Pain rating scale, Patient Health Questionnaire—9 depression, Post-Traumatic Stress Disorder Checklist, and self-efficacy for return to work and managing finances. For each outcome, a hybrid Bayesian statistical procedure, accounting for clustering within sites and differences in baseline characteristics between sites, was used to estimate the intention-to-treat (ITT) effect and the effect under full receipt of early intervention components. Results: Sites varied substantially in utilization of intervention components. The posterior estimates of the ITT (full receipt) effect favor TCC for 4 (5) of the 5 endpoints. The posterior probabilities of a favorable (ITT; full receipt) TCC effect were as follows: depression (89%–93%), pain (84%–74%), post-traumatic stress disorder (68%–68%), self-efficacy for return to work (74%–76%), and self-efficacy for managing finances (47%–61%). Conclusions: Results suggest TCC may have a small positive effect on early outcomes, but use of the services was highly variable among sites. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Intramedullary Nails Yield Superior Results Compared With Plate Fixation When Using the Masquelet Technique in the Femur and Tibia Objectives: To determine the optimal fixation method [intramedullary nail (IMN) vs. plate fixation (PF)] for treating critical bone defects with the induced membrane technique, also known as the Masquelet technique. Design: Retrospective cohort study. Setting: Four Level 1 Academic Trauma Centers. Patients/Participants: All patients with critical bone defects treated with the induced membrane technique, or Masquelet technique, between January 1, 2005, and January 31, 2018. Intervention: Operative treatment with a temporary cement spacer to induce membrane formation, followed by spacer removal and bone grafting at 6–8 weeks. Main Outcome Measurements: Time to union, number/reason for reoperations, time to full weight-bearing, and any complications. Results: One hundred twenty-one patients (56 tibias and 65 femurs) were treated with a mean follow-up of 22 months (range 12–148 months). IMN was used in 57 patients and plates in 64 patients. Multiple grafting procedures were required in 10.5% (6/57) of those with IMN and 28.1% (18/64) of those with PF (P = 0.015). Reoperation for all causes occurred in 17.5% (10/57) with IMN and 46.9% (30/64) with PF (P = 0.001). Average time to weight-bearing occurred at 2.44 versus 4.63 months for those treated with IMN and plates, respectively (P = 0.002). The multivariable adjusted analysis showed that PF is 6.4 times more likely to require multiple grafting procedures (P = 0.017) and 7.7 times more likely to require reoperation (P = 0.003) for all causes compared with IMN.” Conclusions: This is the largest study to date evaluating the Masquelet technique for critical size defects in the femur and tibia. Our results indicate that patients treated with IMN had faster union, fewer grafting procedures, and fewer reoperations for all causes than those treated with plates, with differences more evident in the femur. The authors believe this is a result of both the development of an intramedullary canal and circumferential stress on the graft with early weight-bearing when using an IMN, as opposed to a certain degree of stress shielding and delayed weight-bearing when using PF. We, therefore, recommend the use of an IMN whenever possible as the preferred method of fixation for tibial and femoral defects when using the Masquelet technique. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Sagittal Plane Considerations During Long Cephalomedullary Nailing: Optimal Distal Positioning and the Role of Intraoperative Nail Bending Objective: To retrospectively review a large population of long cephalomedullary nails with special attention to distal implant position in the sagittal plane and assess the ability to avoid anterior cortical contact (ACC) by bending the distal tip of the nail intraoperatively. Design: Retrospective review of single surgeon experience. Setting: Single Level 1 trauma center. Outcomes: Radiographic position of the cephalomedullary nail with respect to the anterior femoral cortex and the effects of intraoperative bending of the distal tip of the nail. Patients: A total of 215 patients who underwent long cephalomedullary nailing for peritrochanteric hip fractures between 2007 and 2017 were reviewed. Results: In the period between 2007 and October 2013, ACC of the distal portion of the nail in the sagittal plane was a common finding. Its incidence significantly decreased after intraoperative bending of long cephalomedullary nails was incorporated into practice in cases where sagittal plane impingement was detected (P < 0.0001). ACC was more prevalent if the final nail position was proximal to the level of the patella. Conclusion: Careful attention should be paid to sagittal plane anatomy and distal ACC during insertion of a long cephalomedullary nail. One strategy to prevent anterior impingement or perforation may be intraoperative bending of the distal end of the nail. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effect of Nail Size, Insertion, and Δ Canal-Nail on the Development of a Nonunion After Intramedullary Nailing of Femoral Shaft Fractures Objective: To determine whether intramedullary nail (IMN) diameter, antegrade versus retrograde insertion, or the difference between the canal and IMN diameter affect femoral shaft fracture healing. Design: Retrospective analysis of a prospective database. Setting: Level One Regional Trauma Center. Patients/Participants: Seven hundred thirty-three femoral shaft fractures (OTA/AO 32) treated with an IMN between 1999 and 2017. After exclusion criteria, 484 fractures remained in the final analysis. Intervention: Closed section, cannulated, interlocked, titanium alloy IMN using a reamed insertion technique. Main Outcome Measurements: Nonunion, IMN size (10, 11.5, and 13 mm), antegrade versus retrograde insertion, Δ canal-nail diameter (ΔD) after reaming (<1, 1–2, or >2 mm). Results: IMN diameters used were as follows: 314/10 mm (64%), 137/11.5 mm (28%), and 33/13 mm (8%). Forty-five percent were placed in antegrade versus 55% retrograde. Four hundred fifty-six fractures (94.2%) healed uneventfully. There were no IMN failures. 10/484 IMNs (2%) had broken interlocking screws; only 4 were associated with a NU. Average time to union was 23 weeks (12–119). Twenty-eight (5.8%) developed NU. There was no statistical correlation between (1) the NU rate and IMN diameter: 10 mm, 6.3%; 11.5 mm, 5.1%; 13 mm, 3% (P = 0.8, power = 0.85), (2) the NU rate and ΔD: 7.1% <1 mm, 5.6% 1–2 mm, 20% >2 mm (P = 0.36), (3) the NU rate and fracture location: Prox = 11%, Mid = 5%, Dist = 3% (P = 0.13), or (4) the NU rate and antegrade (7.2%) versus retrograde (4.2%) insertion (P = 0.24). Conclusion: Similar healing rates occurred regardless of IMN diameter, Δ canal-nail diameter after reaming, or insertion site. This indicates that a closed section, cannulated, interlocked, titanium alloy IMN with a diameter of 10 mm can be considered the standard diameter for the treatment of acute femoral shaft fractures, regardless of entry point. This should be associated with less reaming and therefore shorter operative times, and possibly less hospital implant inventories as well. Larger diameter IMN should be reserved for revision surgery. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Maintenance of Compression With a Positional Screw Versus Compression Generated With a Lag Screw Objective: To determine whether a position screw will maintain the interfragmentary compression force obtained by a reduction clamp across an anatomically reduced cortical bone fracture and determine whether this compressive force is equivalent to that generated by a lag screw (LS). Methods: Oblique fractures were created in 6 composite cortical bone models. Interfragmentary compression was measured using force sensors within the fracture after reduction with a clamp. A position screw was then placed perpendicular to the fracture, and force measurements were repeated with both the clamp and the screw. Finally, the clamp was removed, and force measurements were taken with the screw only to measure maintenance of initial compression. After these measurements, the screw was removed, and the near fragment was overdrilled to allow LS placement by technique. Compression force measurements were repeated for clamp only, clamp + screw, and screw only. Results: The mean force of clamp alone across all 12 trials was 139.77 N. Application of an LS increased the compression across the fracture (P = 0.01) which was unchanged when the clamp was removed. The position screw had the opposite effect, reducing compression, and the removal of the clamp further reduced the compression (P = 0.013). Conclusions: A reduction clamp will initially compress a fracture to an average of 139 N. An LS will significantly increase this interfragmentary compression. A position screw will not maintain the compression created by the clamp and in fact will significantly decrease interfragmentary compression.

Commentary Related to: Maintenance of Compression With a Positional Screw vs. Compression Generated With a Lag Screw No abstract available

Underdosing of Prophylactic Enoxaparin Is Common in Orthopaedic Trauma and Predicts 90-Day Venous Thromboembolism Objectives: To determine the feasibility and impact of real-time anti-factor Xa (aFXa) level monitoring and enoxaparin dose adjustment in orthopaedic trauma. To examine the adequacy of standard fixed-dose enoxaparin chemoprophylaxis and to examine whether patient-specific factors influence enoxaparin metabolism. Design: Prospective cohort. Setting: Academic Level-I trauma center. Patients: Postoperative adult orthopaedic trauma patients undergoing acute fracture or nonunion surgery of the pelvis, acetabulum, or lower extremity placed on 30 mg of enoxaparin twice daily. Intervention: Peak steady-state aFXa levels were drawn with a goal range of 0.2–0.4 IU/mL. Patients with out-of-range levels underwent a 10-mg dose adjustment followed by repeat aFXa draws. Main Outcome Measures: Peak and trough aFXa levels, 90-day venous thromboembolism, and bleed events. Results: Of 109 enrolled patients, 43% had inadequate initial peak aFXa levels (aFXa < 0.2 IU/mL) with standard dosing. Higher gross weight, acetabular surgery, and operation length predicted low aFXa levels (P < 0.001, 0.006, 0.004, respectively). Dose adjustment increased the proportion of patients with in-range aFXa levels from 53.2% to 87.8% (P < 0.001). Patients with low aFXa levels during hospitalization or at discharge had significantly higher 90-day deep vein thrombosis and pulmonary embolism rates compared to those with adequate aFXa levels (deep vein thrombosis 12% vs. 1.36%; P = 0.023, pulmonary embolism 8% vs. 0%; P = 0.027). There were no major bleed events. Conclusions: Patients receiving inadequate enoxaparin chemoprophylaxis were at significantly increased risk of 90-day venous thromboembolism. Standard fixed-dose enoxaparin provided inadequate chemoprophylaxis in 43% of postoperative orthopaedic trauma patients, which significantly improved with dose adjustment. Weight, acetabular surgery, and operation length predicted inadequate enoxaparin prophylaxis. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

The Impact of Hemodialysis on Mortality and Personal Independence After Hip Fracture. A Prospective Matched Cohort Study Objective: To determine the cumulative 30-day and 1-year mortality as well as personal independence after hip fracture in patients on hemodialysis. Design: Prospective, observational cohort study with matched controls. Setting: One teaching hospital, one metropolitan trauma center, one peripheral hospital. Patients and Intervention: Study group: a consecutive cohort of 64 patients with end-stage renal disease receiving chronic hemodialysis who had undergone surgery for a trochanteric or femoral neck fracture from June 2008 to November 2016. Control group: subjects without end-stage renal disease who underwent surgery for similar hip fractures. Main Outcome Measure: One-year mortality, activities of daily living, and ambulatory activity. Results: The 30-day and 1-year mortality rate in patients with a hip fracture undergoing hemodialysis was 25.0% and 57.8%, respectively. Hemodialysis was independently associated with increased 30-day (Hazard ratio 2.933; 95% confidence interval 1.270–6.770; P = 0.018) and 1-year (hazard ratio 2.535; 95% confidence interval, 1.494–4.299; P < 0.001) mortality compared with the matched controls. At the 1-year follow-up, loss of personal independence in comparison with the prefracture status was detected. Conclusions: Hemodialysis was associated with increased mortality after hip fracture. A worse prefracture functional status predicted the loss of functional independence at follow-up. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effect of Kidney Disease on Hemiarthroplasty Outcomes After Femoral Neck Fractures Objective: To compare the outcomes of patients with predialysis chronic kidney disease (CKD) or end-stage renal disease (ESRD) with the outcomes of patients with no kidney disease after hemiarthroplasty (HA) for femoral neck fractures (FNF). Design: Retrospective review utilizing the Nationwide Readmissions Database. Setting: National database incorporating inpatient data from 22 states. Patients: Using the Nationwide Readmissions Database, 214,399 patients who underwent HA after FNF between 2010 and 2014 were identified and divided into 3 groups using ICD-9 diagnosis codes: no kidney disease (n = 176,300, 82%), predialysis CKD (n = 34,400, 16%), and ESRD (n = 3,698, 2%). Intervention: HA for FNF. Main Outcome Measurement: Mortality, blood transfusion, and postoperative complications during index hospitalization. Hospital readmission, postoperative dislocation, periprosthetic fracture, and revision surgery within 90 days of surgery. Results: Compared to patients with no kidney disease, ESRD patients had an increased risk of mortality [odds ratio (OR) = 3.76, 95% confidence interval (CI), 2.95–4.78], blood transfusion (OR = 2.35, 95% CI, 2.08–2.64), and postoperative complications (OR = 1.64, 95% CI, 1.45–1.86) during the index hospitalization as well as an increased risk of 90-day hospital readmission (OR = 3.09, 95% CI, 2.72–3.50). Interestingly, even patients with predialysis CKD had an increased risk of mortality (OR = 1.80, 95% CI, 1.59–2.05), blood transfusion (OR = 1.66, 95% CI, 1.59–1.75), and postoperative complications (OR = 2.37, 95% CI, 2.25–2.50) during the index hospitalization as well as an increased risk of 90-day hospital readmission (OR = 1.43, 95% CI, 1.37–1.51). Conclusions: This retrospective cohort study demonstrates that both ESRD and CKD patients have worse outcomes compared to patients with no kidney disease after HA for FNF. Level of Evidence: Prognostic Level III. See instructions for authors for a complete description of levels of evidence.