Open Reduction Internal Fixation Of Fractures Research Articles

Prediction of Short-Term Postoperative Complications Following Open Reduction Internal Fixation of Acute Ankle Fractures

Introduction/Purpose: Acute ankle fractures are a common injury and represent a significant financial burden to the healthcare system. Reimbursement following ankle fractures is complicated by bundled payments within the 90-day global period which do not account for unpredictable complications. Comorbidity indices, such as the American Society of Anesthesiologists (ASA) classification, are often correlated with complications; however, the positive predictive value of these metrics have not been investigated. As insurers continue to transition towards bundled reimbursements, greater attentiveness towards providing efficient care is paramount. The purpose of this investigation is to develop a machine learning (ML) model that is predictive of complications following operative management of acute ankle fractures. This study will also compare ML algorithms to legacy indices to assess the predictive value in predicting complications. Methods: The American College of Surgeons-National Surgical Quality Improvement Program database was queried via Current Procedural Terminology (CPT) from 2015-2018 for open reduction internal fixation (ORIF) cases for ankle fractures, including ORIF of the medial malleolus, posterior malleolus, lateral malleolus, bimalleolar, trimalleolar, syndesmosis. Training and validation sets were created by randomly assigning 80% and 20% of the data set. Included variables were age, body mass index (BMI), operative time, smoking status, comorbidities, diagnosis, and preoperative hematocrit and albumin. Complications included any adverse event, transfusion, surgical site infection, return to the operating room, deep vein thrombosis or pulmonary embolism, pneumonia, urinary tract infection, cerebrovascular accident, cardiac arrest, myocardial infarction. Each ML algorithm was compared with one another and to a baseline model using American Society of Anesthesiologists (ASA) classification. Model strength was evaluated by calculating the area under the curve (AUC) for receiver operating characteristic (ROC) of any adverse event. Results: We identified a total of 28,736 ORIF cases. Mean age and BMI were 32.2 ± 18.6 years, 30.8 ± 7.6 kg/m^2, respectively. The overall incidence of any medical complication was 3.4% (n=975) with surgical site infection (1.3%, n=386) and return to operating room (1.3%, n=367) being the most common. Percentage hematocrit, BMI, operative time, and age were of highest importance in outcome prediction. Logistic regression (AUC: 72%) and gradient boosting (AUC: 72%) ML algorithms outperformed ASA classification (AUC: 69%) for predicting any adverse event following ORIF of ankle fractures. Conclusion: Legacy comorbidity indices are simple metrics that can be easily constructed from patient demographic variables and past medical history. However, the predictive power is limited as they have shown a low positive predictive value for predicting complications. Machine learning algorithms can calculate patient-specific risk for postoperative complications which may adjust perioperative care and site of surgery. These models have the capability to optimize utilization of healthcare resources and minimize excessive expenditure by providing patient-specific care. Receiver Operating Curve-Area under the Curve Analysis for Adverse Events Following ORIF of Ankle Fractures

Immediate Weight-bearing Through Walker or Crutches After Surgical Fixation of Clavicle Fractures in Patients With Lower Extremity Fractures: A Retrospective Cohort Study.

To assess the safety of immediate upper extremity weight-bearing as tolerated (WBAT) rehabilitation protocol after clavicle fracture open reduction internal fixation (ORIF). Retrospective cohort study. Three Level 1 trauma centers. Patients older than 18 years who had ORIF of mid-shaft clavicle fractures and lower extremity fractures who were allowed immediate WBAT on their affected upper extremity through use of a walker or crutches were included. All clavicles were fixed with either precontoured clavicular plates or locking compression plates. Included patients were those who had clinical/radiographic follow-up until fracture union, nonunion, or construct failure. WBAT patients were matched in a one-to-one fashion to a cohort with isolated clavicle fractures who were treated non-weight-bearing (NWB) postoperatively on their affected upper extremity. Matching was done based on age, sex, and temporality of fixation. After matching, treatment and control groups were compared to determine differences in possible confounding variables that could influence the primary outcome, including patient demographics, fracture classification, cortices of fixation, and construct type. All patients were assessed to verify conformity with weight-bearing recommendation. Primary outcome was early hardware failure (HWF) with or without revision surgery. Secondary outcomes included postoperative infections and union of fracture. Thirty-nine patients were included in the WBAT cohort; there were no significant differences with the matched NWB cohort based on patient demographics. Both the WBAT and the NWB cohorts had 2.5% chance of acute HWF that required surgical intervention ( P = 1.0). Additionally, there was no difference in overall HWF ( P = 0.49). All patients despite weight-bearing status including those who required revision ORIF for acute HWF had union of their fracture ( P = 1.0). Our data would support that immediate weight-bearing after clavicle fracture fixation in patients with concomitant lower extremity trauma does not lead to an increase in HWF or impact ultimate union. This challenges the dogma of prolonged postoperative weight-bearing restrictions and allow for earlier rehabilitation. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Low Geriatric Nutritional Risk Index Predicts Early Complications following Distal Radius Fracture Open Reduction Internal Fixation

Abstract Background While previous studies have investigated the association between the Geriatric Nutritional Risk Index (GNRI) and functional outcomes following distal radius fracture (DRF), no large-scale studies have investigated the associations between GNRI and postoperative outcomes following DRFs. Objectives The purpose of this study is to investigate the association between GNRI, a simple multifaceted measure of malnutrition risk, and 30-day postoperative complications following DRF open reduction internal fixation (ORIF). Materials and Methods The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent DRF ORIF from 2015 to 2021. Patients were organized into three groups based on preoperative GNRI: normal/reference (GNRI > 98), moderate malnutrition (92 ≤ GNRI ≤ 98), and severe malnutrition (GNRI < 92). Logistic regression analysis was conducted to investigate the relationship between preoperative GNRI and postoperative complications. Results Severe malnutrition was independently associated with a greater likelihood of any complication (odds ratio [OR]: 3.22, 95% confidence interval [CI]: 2.48–4.17; p < 0.001), sepsis (OR: 15.41, 95% CI: 1.66–143.32; p = 0.016), cardiac arrest or myocardial infarction (OR: 20.58, 95% CI: 1.62–261.26; p = 0.020), pulmonary embolism (OR: 9.40, 95% CI: 1.76–50.11; p = 0.009), surgical site infection (OR: 7.73, 95% CI: 1.99–30.02; p = 0.003), nonhome discharge (OR: 2.55, 95% CI: 1.87–3.49; p < 0.001), readmission (OR: 2.47, 95% CI: 1.47–4.14; p < 0.001), and length of stay > 2 days (OR: 3.51, 95% CI: 2.67–4.62; p < 0.001). Conclusions Malnutrition is an independent significant predictor of early complications following DRF ORIF. Level of Evidence Level III; retrospective cohort comparison; prognosis study.

Leave it Alone: Ulnar Nerve Management in Distal Humerus Fracture Fixation – A Large Database Study

ABSTRACT Objectives: To determine the impact of intra-operative ulnar nerve manipulation during distal humerus open reduction internal fixation (ORIF) on post-operative ulnar neuritis. Methods: This study was a retrospective cohort analysis using the PearlDiver Mariner Database. Patients undergoing ORIF of distal humerus fractures were identified using Current Procedure Terminology (CPT) codes. Concurrent ulnar nerve transposition, neuroplasty, or neurolysis was defined using CPT-64718, occurring on the same day as the index procedure. Patients with pre-existing ulnar neuropathy within one year prior to the index procedure were excluded. The incidence of delayed ulnar neuropathy, occurring at least 2 weeks post-operatively, was compared at 3, 6, 9, and 12 months. Multivariable logistic regression models were employed to evaluate the association between ulnar nerve transposition, neuroplasty, or neurolysis and the development of delayed ulnar neuropathy, adjusting for the effects of age, sex, insurance type, and Elixhauser comorbidity index. Results: 16,881 patients who underwent distal humerus ORIF were identified, of which 2,016 (11.9%) received concurrent ulnar nerve transposition, neuroplasty, or neurolysis. The cohorts differed by age and insurance type (p<0.001). Ulnar neuropathy between 2 weeks and 1 year occurred in 191/2,016 (9.5%) patients who received ulnar nerve transposition, neuroplasty, or neurolysis and 742/14,865 (5.0%) patients who did not (p < 0.001). Ulnar nerve transposition, neuroplasty, or neurolysis was associated with increased odds of delayed ulnar neuropathy at all time points (p<0.001). Conclusion: Ulnar nerve transposition, neuroplasty, or neurolysis at the time of distal humerus ORIF was associated with an increased incidence of delayed post-operative ulnar neuritis.

Total Hip Arthroplasty Following Operative Fixation of Acetabular Fracture: A Contemporary Series

BackgroundTotal hip arthroplasty (THA) is the operation of choice for salvage of post-traumatic arthritis following acetabular fracture. While high failure rates have been reported for these procedures, existing literature reports mainly on historical implant designs and techniques. We aimed to describe implant survivorships, complications, radiographic results, and clinical outcomes of contemporary THA following prior open reduction internal fixation (ORIF) of an acetabular fracture. MethodsWe identified 104 patients undergoing THA following prior ORIF of an acetabular fracture from 2000 to 2015 via our institutional total joint registry. Mean age at THA was 50 years (range, 18 to 79 years), 71% were men, and mean body mass index was 27 (range, 18 to 52). All patients were implanted with uncemented acetabular components, and 89% had uncemented stems. Some hardware from prior fixation was retained in 94% of cases. Mean follow-up was 10 years (range, 2 to 21 years). ResultsThe 10-year survivorships free of any revision and any reoperation were 98% and 97%, respectively. There were 4 revisions: 1 each for psoas tendonitis, dislocation, acetabular aseptic loosening, and periprosthetic joint infection. There were 9 complications that did not lead to reoperation: 5 dislocations, 2 periprosthetic femur fractures, 1 sciatic nerve palsy, and 1 case of symptomatic heterotopic ossification. All unrevised components appeared radiographically well-fixed. Mean Harris Hip Score improved from mean 50 preoperatively to mean 82 at 5 years (P < .001). ConclusionsIn this series of contemporary THAs following prior acetabular fracture ORIF, revision-free survivorship was excellent with only a single case of acetabular aseptic loosening. These results are encouraging and suggest that contemporary implants and techniques have notably improved on historic results. Level of EvidenceTherapeutic, Level IV.

Cost Burden of Rigid Internal Fixation in Craniomaxillofacial Trauma Care in Low‐ and Middle‐Income Countries

AbstractFractures of the craniomaxillofacial (CMF) skeleton cause significant morbidity and mortality in low‐ and middle‐income countries (LMICs). Despite this, quality CMF trauma care is lacking for the majority of the world's population. There is a paucity of literature describing the costs of standard‐of‐care open reduction internal fixation (ORIF) for CMF fractures in LMICs. We consider the cost of a six‐hole plate with six screws (SHPS), standard materials used in ORIF for CMF fractures, as a percentage of gross domestic product (GDP) per capita to ascertain the cost burden to patients. Hospital pricing catalog data at 14 LMIC institutions were queried. On average, the SHPS cost represented 10.2% of the GDP per capita in sampled LMICs. We highlight manufacturing costs, import taxes, and lack of subsidized health care as factors contributing to the significant cost burden of ORIF in these areas. Future work should characterize additional financial and socioeconomic barriers to optimal CMF care.

High return to sports rates after operative treatment of patella fractures

BackgroundPatella fractures are relatively rare fractures and only little is known about the postoperative return to sports after patella fractures.MethodsThis retrospective study presents information on functional outcome after operative treatment of patella fractures as well as time until return to sports and patients’ complaints after open-reduction internal-fixation (ORIF) of patella fractures.ResultsOverall, 39 patients after ORIF of patella fractures were evaluated at our Level-I trauma center with a mean follow-up of 42 months. The mean time until return to sports was 7 ± 3.9 months. No significant difference was found for functional outcome with respect to body mass index (BMI) or age. Fracture consolidation was accomplished after a mean of 6.9 ± 2.9 months besides a relatively low complication rate of 5.1% (n = 2).ConclusionThe results demonstrate a high return to sports rate of 90.3%. However, only 51.6% were able to perform sports on their pre-injury level or above.Trial Registration The study was retrospectively registered at DRKS (No: DRKS00031146).

Adverse Events After Ankle Fracture Open Reduction Internal Fixation Among Patients With and Without Documented Cannabis and Tobacco Use.

Ankle fractures are common orthopaedic injuries that may be indicated for open reduction internal fixation (ORIF). Although the negative impact of tobacco use on perioperative outcomes of ankle fracture ORIF has been described, the potential impact of cannabis use on related outcomes is not as well established. Retrospective database study of adult patients undergoing ankle ORIF for closed, isolated, ankle fractures from the 2010-2021 Q1 PearlDiver M151 data set. Subcohorts without and with cannabis and/or tobacco use were identified based on coding and matched based on patient age, sex, and Elixhauser Comorbidity Index (ECI) scores to yield groups of nonusers, tobacco users, tobacco and cannabis users, and cannabis users. Ninety-day adverse events were assessed between matched subcohorts with multivariable logistic regression controlling for age, sex, and ECI. A total of 149 289 patients met study inclusion criteria for whom tobacco only use was documented for 14 989 (10.0%), tobacco and cannabis use for 2726 (1.8%), and cannabis only use for 867 (0.6%). Matching yielded 823 for each group. On multivariable analyses, isolated tobacco users were at higher odds of 90-day urinary tract infections (UTIs) (odds ratio [OR] 2.64), minor adverse events (OR 2.33), all-cause adverse events (OR 2.17), readmissions (OR 1.85), and severe adverse events (OR 1.84). Tobacco and cannabis comorbid users were at a marginally higher odds of 90-day UTI (OR 2.82), minor adverse events (OR 2.51), readmissions (OR 2.39), and any adverse events (OR 2.22). Cannabis only users were not at greater odds of 90-day adverse events relative to nonusers. Patients with tobacco use (alone or with cannabis) were at greater odds of 90-day adverse events following ankle fracture ORIF, but cannabis only users were not. Level III, Retrospective database study.

Attitudes and Practices Surrounding Opioid Prescriptions following Open Reduction Internal Fixation of Distal Radius and Ankle Fractures: A Survey of the Canadian Orthopaedic Association Membership.

The past two decades have seen a significant increase in consequences associated with nonmedical misuse of prescription opioids, such as addiction and unintentional overdose deaths. This study aimed to use an electronic survey to assess attitudes and opioid-prescribing practices of Canadian orthopaedic surgeons and trainees following open reduction internal fixation (ORIF) of distal radius and ankle fractures. This study was the first to assess these factors following ORIF of distal radius and ankle fractures using a survey design. A 40-item survey was developed focusing on four themes: respondent demographics, opioid-prescribing practice, patients with substance use disorders, and drug diversion. The survey was distributed among members of the Canadian Orthopaedic Association. Descriptive statistics were used to summarize respondent demographics and outcomes of interest. A Chi-square test was used to determine if proportion of opioid prescriptions between attending surgeons and surgeons in training was equal. 191 surveys were completed. Most respondents prescribed 10-40 tabs of immediate-release opioids, though this number varied considerably. While most respondents believed patients consumed only 40-80% of the prescribed opioids (73.6%), only 28.7% of respondents counselled patients on safe storage/disposal of leftover opioids. 30.5% of respondents felt confident in their knowledge of opioid use and mechanisms of addiction. Most respondents desired further education on topics such as procedure-based opioid-prescribing protocols (74.2%), alternative pain management strategies (69.7%), and mechanisms of opioid addiction (49.0%). The principle finding of this study is the lack of a standardized approach to postoperative prescribing in distal radius and ankle fractures, illustrated by the wide range in number of opioids prescribed by Canadian orthopaedic surgeons. Our data suggest a trend towards overprescription among respondents following distal radius and ankle ORIF. Future studies should aim to rationalize interventions targeted at reducing postoperative opioid prescribing for common orthopaedic trauma procedures.

Republication of "Primary Ankle Arthrodesis vs ORIF for Severely Comminuted Pilon Fractures: A Comparative Retrospective Study".

The treatment for highly comminuted pilon fractures remains controversial. The goal of this retrospective cohort study was to compare functional outcomes of primary arthrodesis of the tibiotalar joint (fusion) and open reduction internal fixation (ORIF). Patients who underwent primary ORIF or fusion for pilon fractures at our institution since 2000 were identified by Current Procedural Terminology (CPT) code. Inclusion criteria for the ORIF cohort were patients with an AO/Orthopaedic Trauma Association type C3 pilon fracture. Additional inclusion criteria for the fusion cohort were patients whose fractures were deemed non-reconstructable by the treating surgeon. Outcome assessment was determined by the Foot and Ankle Outcome Score (FAOS) and Short Form 36-item health survey (SF-36), time to radiographic union or fusion, and wound-healing complications at a minimum of 2 years after their surgery. Nineteen ORIF and 16 fusion patients completed the study's outcome assessments. A higher rate of nonunion was observed in patients treated by primary ORIF than primary fusion (5/19 vs 1/16). Posttraumatic arthritis was observed in 11 of 19 primary ORIF patients. Primary fusion patients exhibited increased symptoms, pain, and physical role limits but were equivalent to primary ORIF patients on all other functional metrics examined. Primary ankle arthrodesis achieves a lower rate of nonunion and comparable functional outcomes to ORIF in patients with severely comminuted pilon fractures. The higher rate of nonunion observed in the primary ORIF group suggests that primary fusion should be considered an effective procedure for severe injuries to decrease the need for further operative intervention. Therapeutic Level III, retrospective cohort.

What Is the Effect of Resident Involvement on Short-Term Outcomes after Distal Radius Fracture Surgery?

Background: The objective of this study was to assess whether resident involvement in distal radius fracture open reduction internal fixation (ORIF) affect 30-day postoperative complication, hospital readmission, reoperation and operative time. Methods: A retrospective study was performed using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database by querying the Current Procedural Terminology (CPT) codes for distal radius fracture ORIF from 1 January 2011 to 31 December 2014. A final cohort of 5,693 adult patients who underwent distal radius fracture ORIF during the study period were included. Baseline patient demographics and comorbidities, intraoperative factors, including operative time and 30-day postoperative outcomes, including complications, readmission and reoperations, were collected. Bivariate statistical analyses were performed to identify variable associated with complication, readmission, reoperation and operative time. The significance level was adjusted using a Bonferroni correction as multiple comparisons were performed. Results: In this study of 5,693 patients who underwent distal radius fracture ORIF, 66 patients had a complication, 85 patients were readmitted and 61 patients underwent reoperation within 30 days of surgery. Resident involvement in the surgery was not associated with 30-day postoperative complication, readmission or reoperation, but was associated with longer operative time. Moreover, 30-day postoperative complication was associated with older age, American Society of Anesthesiologists (ASA) classification, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypertension and bleeding disorder. Thirty-day readmission was associated with older age, ASA classification, diabetes mellitus, COPD, hypertension, bleeding disorder and functional status. Thirty-day reoperation was associated with higher body mass index (BMI). Longer operative time was associated with younger age, male sex and the absence of bleeding disorder. Conclusions: Resident involvement in distal radius fracture ORIF is associated with longer operative time, but no difference in rates of episode-of-care adverse events. Patients may be reassured that resident involvement in distal radius fracture ORIF does not negatively impact short-term outcomes. Level of Evidence: Level IV (Therapeutic).

Geriatric Distal Femur Fractures: Equivalent Long-Term Reoperation Rates Between Fixation and Primary Arthroplasty.

Our primary objectives were to 1) determine the rate of requiring conversion to arthroplasty after ORIF of geriatric distal femur fractures and 2) compare 10-year reoperation rates after open reduction internal fixation (ORIF) versus primary arthroplasty for geriatric distal femur fractures. Propensity-matched retrospective cohort study. All centers participating in the California Office of Statewide Health Planning and Development (OSHPD) database.Patients/Participants: All patients 65 or older who underwent operative management of a distal femur fracture between 2000 and 2017. ORIF, total knee arthroplasty (TKA), or distal femur replacement (DFR). Reoperation. A total of 16,784 geriatric distal femur fracture patients were identified, of which 16,343 (97.4%) underwent ORIF. The cumulative incidence of conversion to arthroplasty within 10 years of ORIF was found to be 3.5%, with young age and female sex identified as risk factors for conversion. There was no significant difference in 10-year reoperation free survival rate between propensity matched patients undergoing ORIF versus primary arthroplasty (94.5% vs. 96.2%, p=0.659). There were no differences in short-term complication or readmission rates between matched treatment cohorts, but arthroplasty was associated with a higher rate of wound infection within 90 days (2.0% vs. 0.2%, p=0.011). The 10-year cumulative incidence of conversion to arthroplasty after ORIF was found to be low. There was no significant difference in long term reoperation-free survival rates between patients undergoing ORIF versus primary arthroplasty. Primary arthroplasty was associated with significantly higher rates of acute wound or joint infection. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Scapular Fracture Open Reduction Internal Fixation: How to Approach?

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The Association between Bleeding Disorders and Postoperative Complications Following Operative Treatment of Distal Radius Fracture.

Background While previous studies have investigated the association between bleeding disorders and outcomes with hip or knee surgeries, no studies have investigated the association between bleeding disorders and outcomes in upper extremity surgery. Questions/Purposes The purpose of this study was to investigate if a past history of bleeding disorders is associated with which, if any postoperative complications for patients receiving distal radius fracture open reduction internal fixation. Patients and Methods Patients undergoing operative treatment for distal radius fracture from 2007 to 2018 were identified in the National Surgical Quality Improvement Program database. Patients were stratified into two cohorts: patients with a bleeding disorder and patients without a bleeding disorder. In this analysis, 30-day postoperative complications were assessed, as well as mortality, extended length of stay, reoperation, and readmission. Bivariate and multivariate analyses were performed. Results Of the 16,489 total patients undergoing operative treatment for distal radius fracture, 16,047 patients (97.3%) did not have a bleeding disorder, whereas 442 (2.7%) had a bleeding disorder. Following adjustment on multivariate analyses, an increased risk of postoperative transfusion requirement (odds ratio [OR] 17.437; p = 0.001), extended length of hospital stay more than 3 days (OR 1.564; p = 0.038), and readmission (OR 2.515; p < 0.001) were seen in patients with a bleeding disorder compared to those without a bleeding disorder. Conclusion History of bleeding disorders is an independent risk factor for transfusions, extended length of stay, and readmission. We recommend a multidisciplinary team approach to addressing bleeding disorders before patients receive distal radius fracture open reduction internal fixation. Level of Evidence Level III, retrospective study.

Anemia and Its Severity Is Associated With Worse Postoperative Outcomes Following Open Reduction Internal Fixation of Ankle Fractures.

Ankle fractures are often treated in a nonemergent fashion and therefore offer the chance for treatment of preoperative anemia. Although preoperative anemia has been associated with postoperative morbidity following certain types of orthopaedic procedures, its effect on postoperative outcomes following open reduction internal fixation (ORIF) of ankle fractures has not been evaluated. The purpose of this study was to determine the influence of preoperative anemia on 30-day postoperative outcomes following ankle fracture ORIF. The American College of Surgeons National Surgical Quality Improvement Program (ASC-NSQIP) registry was queried from 2005 to 2019 for patients undergoing ankle fracture ORIF. Patients were stratified into nonanemic, mildly anemic, and moderately to severely anemic. Univariate analyses were used to assess differences in patient characteristics between cohorts. Multivariate logistic regressions adjusting for these differences were performed to assess the effect of preoperative anemia on 30-day postoperative outcomes. We obtained data for 21 211 patients, of whom 14 931 (70.39%) were not anemic, 3982 (18.77%) were mildly anemic, and 2298 (10.83%) were moderately to severely anemic. After adjustment, mild preoperative anemia was associated with higher odds of any adverse event (P < .001), deep surgical site infections (SSIs; P = .013), sepsis (P = .001), 30-day readmission (P < .001), and extended length of stay (LOS) (P < .001). Similarly, moderate to severe anemia in these patients was also associated with increased odds of any adverse event (P < .001), deep SSIs (P = .003), sepsis (P = .001), readmission (P < .001), and extended LOS (P < .001). Both mild (P = .004) and moderate to severe (P < .001) anemia groups had higher odds of requiring a blood transfusion. Preoperative anemia is associated with an increased risk of adverse postoperative outcomes in patients undergoing ORIF for ankle fractures. Future studies should evaluate whether optimization of hematocrit in these patients results in improved outcomes. Level III, comparative study.

Carpal Tunnel Release Performed during Distal Radius Fracture Surgery.

Background Carpal tunnel release (CTR) may be concomitantly performed along with distal radius fracture open reduction internal fixation (DRF ORIF) to prevent carpal tunnel syndrome; however, there is little to no literature investigating the rate, risk factors, and complications associated with CTR. Questions/Purposes The purpose was to determine (1) the rate of CTR performed at time of DRF ORIF, (2) factors associated with CTR, and (3) whether CTR was associated with any complications. Patients and Methods In this case-control study, adult patients who underwent DRF ORIF from 2014 to 2018 were identified from a national surgical database. Two cohorts were analyzed, (1) patients with CTR and (2) patients without CTR. Preoperative characteristics and postoperative complications were compared with determine factors associated with CTR. Results Of the 18,466 patients, 769 (4.2%) had CTR. Rates of CTR in patients with intra-articular fractures with two or three fragments were significantly higher than the rate of CTR for patients with extra-articular fractures. Underweight patients underwent CTR at a significantly lower rate compared with overweight and obese patients. The American Society of Anesthesiologists ≥3 was associated with a higher rate of CTR. Male and older patients were less likely to have CTR. Conclusion The rate of CTR at time of DRF ORIF was 4.2%. Intra-articular fractures with multiple fragments were strongly associated with CTR at time of DRF ORIF, while being underweight, elderly, and male were associated with lower rates of CTR. These findings should be considered when developing clinical guidelines to assess the need for CTR in patients undergoing DRF ORIF. This is a retrospective case control study and reflects level of evidence III.

The Primary Cost Drivers of Outpatient Distal Radius Fracture Fixation: A Cost-Minimalization Analysis of 15,379 Cases.

Background Distal radius fractures are the most common fracture of the upper extremity. While some distal radius fractures can be managed with closed reduction and immobilization, operative treatment is the standard of care, with open reduction internal fixation (ORIF) as a predominant operative method. Questions/Purpose To investigate how patient and surgical characteristics affect the overall costs of internal fixation of distal radius fractures in adults. Patients and Methods The 2014 State Ambulatory Surgery and Services Databases for six states were used to identify cases and surgical characteristics of distal radius fracture ORIF in adult patients. Results Surgical variables that significantly increased cost were postoperative admission within 30 days, regional anesthesia, simultaneous endoscopic carpal tunnel release, and increasing operating room time. Conclusion Substantial contributors to total cost are postoperative hospital admission within 30 days of surgery, use of regional anesthesia, simultaneous endoscopic carpal tunnel release, and longer operative time. Level of Evidence Level III, retrospective cohort study.

Presence of Anemia and Its Severity is Associated with Worse Outcomes Following Open Reduction Internal Fixation of Ankle Fractures

Category: Trauma; Ankle Introduction/Purpose: Preoperative anemia has been associated with significant postoperative morbidity following various types of orthopaedic procedures. However, to our knowledge, there is no study assessing postoperative outcomes following open reduction internal fixation (ORIF) of ankle fractures with varying severity of anemia. The purpose of this study was to determine the influence of preoperative anemia severity on 30-day postoperative outcomes following ankle fracture ORIF. Methods: The American College of Surgeons National Surgical Quality Improvement Program registry was queried from 2005 to 2019 for patients undergoing ankle fracture ORIF. Patients were stratified into 3 cohorts: non-anemic (hematocrit &gt; 36% for women, &gt;39% for men), mildly anemic (hematocrit 33%-36% for women, 33%-39% for men), and moderately to severely anemic (hematocrit &lt;33% for both women and men) based on World Health Organization definitions. Patients with missing hematocrit data were excluded. Univariate analyses were utilized to assess differences in patient characteristics between cohorts. Multivariate logistic regressions controlling for differences between subgroups were performed to assess the effect of preoperative anemia on 30-day postoperative outcomes. Statistical significance was set at P&lt;0.05. Results: In total, 22,413 patients that underwent ORIF for ankle fractures were included. Of these, 15,739 (70.22%) were not anemic, while 4,243 (18.93%) and 2,431 (10.85%) were mildly and moderately to severely anemic, respectively. Multivariate analysis revealed that mild preoperative anemia in patients undergoing ankle fracture ORIF was associated with higher odds of any adverse event (OR 1.62, P&lt;0.001), superficial surgical site infections (SSIs) (OR 1.46, P=0.047), deep SSIs (OR 2.06, P=0.022), sepsis (OR 2.83, P=0.002), 30-day readmission (OR 1.61, P&lt;0.001), and extended length of stay (LOS) (OR 1.56, P&lt;0.001). Similarly, moderate to severe anemia in these patients was also associated with increased odds of any adverse event (OR 1.94, P&lt;0.001), deep SSIs (OR 2.77, P=0.006), sepsis (OR 3.55, P=0.001), readmission (OR 2.07, P&lt;0.001), and extended LOS (OR 2.21, P&lt;0.001). In addition, moderate to severe anemia patients were associated with higher odds of unplanned reoperation (OR 2.31, P&lt;0.001) and progressive renal insufficiency (OR 3.74, P=0.048). Conclusion: Preoperative anemia is associated with an increased risk of adverse postoperative outcomes in patients undergoing ORIF for ankle fractures. This association seems to be dose dependent, as the odds of adverse events increases with increases in anemia severity. Medical optimization of patients with moderate to severe anemia should take precedence.

Risk factors for complications and reoperation following operative management of displaced midshaft clavicle fractures.

Optimal management of a displaced midshaft clavicle fracture remains controversial. This study assessed demographic factors, fracture pattern, and surgical technique as potential predictors of surgical complications. Smoking, diabetes, obesity, polytrauma, high-energy mechanism, inpatient status, transverse or comminuted fractures, and single-plating technique were hypothesized to be associated with an increased risk of complications following clavicle fracture open reduction internal fixation (ORIF). Consecutive patients with minimum 12-week follow-up from the trauma and sports medicine divisions at a single tertiary institution who presented with a midshaft clavicle fracture and underwent ORIF between 2007 and 2020 were retrospectively identified. Patient demographics, fracture pattern, plating technique, and postoperative complications were recorded. Postoperative complications were classified into major (reoperation) and minor (no reoperation) complications. Chi-squared statistics, Fisher's exact test, analysis of variance, Kruskal-Wallis test, and multivariate logistic regression modeling were utilized with a significance level set to P<.05. One hundred ninety-eight patients (average = 39.5±14.6years) were identified with an average follow-up of 9.1±10.7months. The cohort consisted of 155 males (78.3%), 62 smokers (31.3%), and 12 diabetics (6.1%). Injury characteristics revealed 80 transverse fractures (40.4%), 87 oblique fractures (43.9%), and 31 Z-type fractures (15.7%). Seventy-nine patients (39.9%) underwent superior plating, 72 (36.4%) underwent anterior plating, and 47 (23.7%) underwent dual plating. Overall, postoperative complications occurred in 47 patients (23.7%), 29 minor (14.6%) and 18 major (9.1%). Major complications requiring reoperation were symptomatic hardware, nonunion, deep infection, wound dehiscence, and broken hardware. Minor complications consisted of sensory deficit or paresthesia beyond peri-incisional numbness, superficial infections, postoperative pain and/or stiffness, and delayed union. Smoking status (P=.008), obesity (P=.009), and transverse or Z-type fractures (P=.002) were significant prognostic factors for overall complication risk. Only manual labor was predictive of minor complications (P=.019). Transverse or Z-type fractures and single plating were predictive of major complications (P=.004 and P=.008, respectively). No reoperations occurred in patients who underwent dual plating. Smokers (P=.027) with transverse/Z-type fractures (P=.022) were at the highest risk of reoperation with single plating. The overall rate of complications following ORIF of displaced midshaft clavicle fracture was 27.3%, with 9.1% requiring reoperation. Given relatively high complication rates, in instances when nonoperative vs. operative management is equivocal, nonoperative management should be strongly considered in obese patients, smokers, and patients who present with transverse or Z-type fracture. If operative management is indicated, use of dual plating may decrease reoperation rates.

Patients' Opinions on Critical Portions of Surgical Procedures in Foot and Ankle Surgery

Category: Other; Ankle Introduction/Purpose: Over the last decade, simultaneous or overlapping procedures in orthopedic surgery have come under increased media attention and public scrutiny. While little is known about what surgeons consider to be 'critical portions' of the myriad of foot and ankle procedures performed, even less is known about the expectations and opinions of patients themselves. In this study we aimed to elucidate patients' expectations of foot and ankle surgeons regarding their presence at different portions of a given surgery and what portions of a surgery they considered to be 'critical'. Methods: In this survey, data was collected using a questionnaire that was filled out by 49 patients presenting to an orthopedic foot and ankle tertiary referral clinic. The questions were designed around three common foot and ankle procedures: open reduction, internal fixation of fractures (ORIF), Achilles tendon repair, and ankle arthroscopy. For each procedure, the key steps were identified, and the responding patient was asked to characterize each step as 'Always Critical' 'Often Critical' 'Sometimes Critical' 'Rarely Critical' or 'Never Critical.' Additionally, demographics, education level, number of prior surgeries, and profession were also collected from the patients. Data were described using means, ranges, and percentages. Results: Of the 49 patients surveyed, the average age was 52.9 years old; 59% were female and 41% were male; 76% of respondents were college graduates, 8% completed some college, and 12% were high school graduates. Overall, 12% of respondents work in a healthcare related field. The average number of previous surgeries was 2.0, with a minimum of 0 and a maximum of 14. In all three procedures, the steps for which more than 50% of the patients identified as 'Always Critical' were discussion of risks, benefits, and alternatives, marking the surgical site, pre-operative time-out, skin incision for ORIF, soft tissue dissection, reduction of fracture, fracture fixation with hardware, repair of the tendon, and scoping the ankle. Across all three procedures, transferring the patient between operating table and bed, applying a sterile bandage, and applying a splint were categorized as the least critical portions of the procedure (Figure 1). Conclusion: The result of this study offers insight on what the most critical portion of three common foot and ankle procedures from the patient's perspective. Generally speaking, patients perceived initial dissection and even closure to be critical, in addition to procedural elements such as fracture reduction. Ongoing research aims to correlate these findings with the perceptions of foot and ankle surgeons themselves. Nonetheless, it highlights the potential discrepancy in perceptions between clinicians and patients as it pertains to 'critical portions' of a given procedure.