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Introduction: The purpose of this study was to determine if augmentation of the helical blade with polymethylmethacrylate bone cement decreases the rates of varus cut-out and medial perforation in geriatric intertrochanteric hip fracture fixation. Methods: This was a retrospective comparative cohort study at two urban Level I trauma centers. Patients with an intertrochanteric hip fracture (classified as AO 31A1-3) who were treated with the TFN-Advanced Proximal Femoral Nailing System (TFNA) from 2018 to 2021 were eligible for the study. Medical records and post-operative radiographs were reviewed to determine procedure complications and reoperations. Results: Of the 179 patients studied, cement augmentation (CA) was used in 93 patients (52%) and no cement augmentation (NCA) was used in 86 (48%). There were no significant differences between group demographics and fracture reduction grades. Varus cut-out occurred three times in the CA group and five times in the NCA group (p = 0.48). Medial perforation occurred three times, all in the NCA group (p = 0.11). The most frequent complication was symptomatic blade lateralization from fracture collapse, with eight occurrences in the CA group compared with two in the NCA group (p = 0.10). There were 10 reoperations in the CA group and 9 in the NCA group (p = 0.99). The most common reason for reoperation was varus cut-out and the most common revision procedure was hip arthroplasty. Conclusions: Intertrochanteric hip fractures treated with the TFNA fixation system with and without cement augmentation have similar complication profiles and reoperation rates.

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Introduction: Owing to limited clinical clerkships and travel restrictions related to COVID-19, recent medical student mentorship in orthopaedic surgery has been impacted negatively. The purpose of this quality improvement (QI) project was to determine if medical student awareness of orthopaedics as a possible career field may be improved through a mentoring program designed and delivered by orthopaedic residents. Methods: A five-resident QI team developed four educational sessions aimed at a medical student audience. Forum topics included: (1) orthopaedics as a career, (2) fracture conference, (3) splinting workshop, and (4) residency application process. Pre- and post-forum surveys were administered to student participants to assess changes in their perceptions regarding orthopaedic surgery. Data derived from the questionnaires were analyzed with nonparametric statistical tests. Results: Of 18 forum participants, 14 were men and 4 were women. A total of 40 survey pairs were collected, averaging 10 per session. In the all-participant encounter analysis, there were statistically significant improvements in all outcome measures including interest in, exposure to, and knowledge of orthopaedics; exposure to our training program; and ability to interact with our residents. Those undecided regarding their specialty demonstrated larger increases in post-forum responses, suggesting that the learning experience was more impactful for that subgroup. Conclusions: This QI initiative was a successful demonstration of orthopaedic resident mentorship of medical students, wherein perceptions of orthopaedics were influenced favorably by the educational experience. For some students with limited access to orthopaedic clerkships or formal one-on-one mentoring, forums like these may be an acceptable alternative.

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Introduction: Transitioning from one clinical rotation to the next may be particularly stressful for orthopaedic residents attempting to navigate new work environments with new faculty mentors and new patients. The purpose of this quality improvement (QI) project was to determine if resident stress could be improved by using a handbook to disseminate key rotation-specific data during quarterly rotation transition periods. Methods: A comprehensive electronic handbook was created by residents to describe each rotation in our orthopaedic training program in terms of: (1) faculty and staff contact data, (2) daily clinic and surgery schedules, (3) resident responsibilities and faculty expectations, and (4) key resources and documents. At rotation transition, a session in the academic schedule was dedicated for outgoing residents to update the handbook and to sign-out to incoming residents. Pre- and post-handbook questionnaires were administered to assess resident perceptions of stress or anxiety, preparedness, and confidence before commencing the new rotation. Nonparametric data derived from the surveys were analyzed using the sign test choosing p < 0.05 for a two-tailed test as the level of statistical significance. Results: Most residents perceived improvements in stress/anxiety, preparedness, and confidence understanding rotation expectations after the handbook was implemented. Changes in these three outcome parameters were statistically significant. Conclusions: This rotation transition QI initiative consisting of a resident-authored, rotation-specific electronic handbook and dedicated verbal sign-out session enhanced resident wellness by decreasing stress, increasing preparedness, and improving confidence among residents starting a new rotation. Similar online resources may be useful for trainees in other specialties.

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Introduction: During fracture osteosynthesis, traumatologists may remove screws which are too long, cut the excess length from the screw tip, then reinsert the cut screw (CS) to minimize implant waste. The purpose of this study was to determine if this practice influences screw purchase. Methods: Using an axial-torsion load device, the maximal insertion torque (MIT) required to insert 3.5 mm stainless steel cortical screws into normal and osteoporotic bone models was measured. MIT was determined in three different test conditions: (1) long screw (LS) insertion; (2) LS insertion, removal, and insertion of a normal-length screw (NS); and, (3) LS insertion, removal, cutting excess length from the screw tip, and reinserting the CS. Results: In the normal bone model, mean (± SD) MIT of LS insertion was 546 ± 6 Newton-centimeters (N-cm) compared to 496 ± 61 N-cm for NS reinsertion and 465 ± 69 N-cm for CS reinsertion. In the osteoporotic bone model, MIT of LS insertion was 110 ± 11 N-cm, whereas the values for NS and CS reinsertions were 98 ± 9 N-cm and 101 ± 12 N-cm, respectively. There was no significant difference in MIT between CS and NS reinsertions in the osteoporotic bone analog. Conclusions: Cutting excess length from a 3.5 mm stainless steel cortical screw did not decrease its purchase regardless of bone density. During osteosynthesis, orthopaedists may remove screws which are too long, cut the screw tip, and reinsert the shortened screw as a cost-saving measure without compromising fracture fixation.

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Introduction: Miscommunication during shift change and other handoff events is a common source of malpractice claims and patient-care errors. An efficient patient handoff system is imperative to prevent miscommunication. Owning to limitations with our current handoff system and to an ever-increasing reliance on electronic health information, our residency program sought to modernize our handoff method. Methods: To improve handoff communication, the HIPAA-compliant application Listrunner© was adopted. Members of the orthopaedic trauma team were oriented to the new application. Change-of-shift patient handoff was transitioned from the current email system to List-runner©. After three months of using the new application, a web-based questionnaire was administered to all members of the care team to assess their experiences, including perceived benefits and limitations of the Listrunner© application. Results: Seventeen orthopaedic resident physicians and three orthopaedic trauma attending physicians completed the survey. While almost half of the respondents were satisfied using email as a checkout tool, more than half of study participants indicated that it lacked security and several users believed there was a need for improvement. Most indicated that Listrunner© was easy to use, improved clinical efficiency, and improved patient care and safety. Seventeen of 20 respondents reported that they would like to continue using Listrunner© as a check-out tool. Conclusions: The Listrunner© application was adopted quickly by our orthopaedic trauma team, whose members opined that the application increased the efficiency and accuracy of handoff when compared to the previous secure email system.

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From the casting couch to the board room, the media, and beyond, the topic of sexual harassment and bullying can no longer be ignored. Sexual harassment and bullying in medicine has the potential to be the next big headline on these topics. The culture in medicine and especially the hierarchy in surgery often permit this behavior. To improve the culture in orthopaedic surgery regarding sexual harassment and bullying, education must occur. With education, comes acknowledgment and recognition. This permits an ability to act on and improve the culture. This paper will start the dialogue of this difficult topic and provide a call to action for sexual harassment and bullying to become "Never events".

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We have recently identified a population of cells within the peripheral nerves of adult rodent animals (mice and rats) that can respond to Bone Morphogenetic Protein-2 (BMP-2) exposure or physical injury to rapidly proliferate. More importantly, these cells exhibited embryonic differentiation potentials that could be induced into osteoblastic and endothelial cells in vitro. The current study examined human nerve specimens to compare and characterize the cells after BMP-2 stimulation. Fresh pieces of human nerve tissue were minced and treated with either BMP-2 (750 ng/mL) or a PBS vehicle for 12 h at 37 °C, before being digested in 0.2% collagenase and 0.05% trypsin-EDTA. Isolated cells were cultured in a restrictive stem cell medium. Significantly more cells were obtained from the nerve pieces with the BMP-2 treatment in comparison with the PBS vehicle controls. Cell colonies started to form at Day 3. Expressions of the four transcription factors, namely, Klf4, c-Myc, Sox2, and Oct4, were confirmed at both the transcriptional and translational levels. The cells can be maintained in the stem cell culture medium for at least 6 weeks without changing their morphology. When the cells were transferred to a fibroblast growth medium, dispersed spindle-shaped motile cells were noted and became fibroblast activated protein-α (FAP) positive with immunocytochemistry staining. The data suggest that human peripheral nerve tissue also contains a population of cells that can respond to BMP-2 and express Klf4, Sox2, cMyc, and Oct4-the four transcription factors driving cell pluripotency. These cells are able to differentiate into FAP-positive fibroblasts. In summary, in human peripheral nerves also reside a population of quiescent cells with pluripotency potential that may be the same cells as rodent nerve-derived adult stem (NEDAPS) cells. It is proposed that these cells are possibly at the core of a previously unknown natural mechanism for healing an injury.

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INTRODUCTION: Skeletal traction use generally has decreased over generations and is used most often for temporary fracture stabilization. Proper nursing management of patients in skeletal traction is crucial. A hospital protocol was created and implemented to educate and direct registered nurses (RNs) in the care of patients requiring skeletal traction. METHODS: A skeletal traction management protocol was drafted and implemented as hospital policy. Twenty-nine RNs from an orthopaedic unit at a level 1 trauma center attended a financially compensated, 45-minute, in-person, off-shift educational session. An anonymous pre-test utilizing a 5-point Likert scale was completed to assess RN knowledge and comfort regarding the following topics of traction care: pin care, manual traction, frame assembly, weight application and removal, skin evaluation, neurovascular checks, and reporting issues. The RNs were provided with a copy of the new hospital policy and key points were highlighted and demonstrated. After the demonstration, the RNs were given a post-test to assess their perceived knowledge and comfort with traction care. RESULTS: Statistically significant improvements in RN knowledge and comfort were seen in six of the seven evaluated topics. The greatest increase was seen in the manual traction topic. No significant change regarding neurovascular checks was observed with this topic having the highest pre-test scores. CONCLUSIONS: A hospital protocol was created successfully and implemented that significantly improved the level of RN knowledge and comfort with the management of patients requiring skeletal traction. Future studies should assess the effectiveness of annual education regarding the traction policy.

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Meniscal tears are often seen in orthopedic practice. The current strategy for meniscal repair has only had limited success with a relatively high incidence of re-operative rate. This study evaluates the therapeutic effects of Bone morphogenetic protein-2 (BMP-2) soaked sutures for cartilage repair, using a rat model of xyphoid healing. Vicryl-resorbable sutures were presoaked in BMP-2 solutions prior to animal experimentation. Rat xyphoid process (an avascular hyaline cartilage structure) was surgically ruptured followed by repair procedures with regular suture or with sutures that were pre-soaked in BMP-2 solutions. In vitro assessment indicated that presoaking the Vicryl-resorbable sutures with 10 µg/mL BMP-2 resulted in a sustained amount of the growth factor release up to 7 days. Histological analysis suggested that application of this BMP-2 soaked suture on the rat xyphoid process model significantly improved the avascular cartilage healing compared to non-soaked control sutures. In conclusion, data here confirm that the rat xyphoid process repair is a reproducible and inexpensive animal model for meniscus and other cartilage repair. More importantly, coating of BMP-2 on sutures appears a potential avenue to improve cartilage repair and regeneration. Further study is warranted to explore the molecular mechanisms of this strategy.

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INTRODUCTION: The purpose of this study was to identify additional injuries commonly seen with proximal humerus fractures experienced by patients 65 years or older and to evaluate discrepancies in the management of these patients with regard to provider type. METHODS: A retrospective review was conducted of all patients 65 years or older who sustained a proximal humerus fracture. Patient data collected included demographics, injury details, hospital course, and discharge destination. RESULTS: Patients with a concomitant fracture (45.5%, n = 65) had a slightly higher Injury Severity Score (ISS; 8.3 ± 3.0 vs. 6.4 ± 3.0, p < 0.001) and experienced one additional death than those with an isolated fracture (54.5%, n = 78). Slightly more patients were managed by a trauma provider (51.7%, n = 74) than by a non-trauma provider (48.3%, n = 69). Those managed by a trauma provider sustained the most pelvic fractures (12.2% vs. 2.9%, p = 0.038), were more likely to be injured in a motor vehicle collision (8.1% vs. 0%, p = 0.005), had a higher ISS (8.0 ± 3.3 vs. 6.4 ± 2.8, p = 0.003), and had more imaging performed than those treated by a non-trauma provider. There was, however, no difference in operative rates, concomitant injuries, length of stay, or discharge disposition regarding provider type. CONCLUSION: It is important to recognize proximal humerus fractures as a sign of fragility and to optimize hospital management of these patients.

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INTRODUCTION: Hip fracture is a major cause of morbidity and mortality in older adults. Intertrochanteric hip fractures often are treated surgically using cephalomedullary nails (CMN), in either a short or long length. Their outcomes are documented in the literature; however, outcomes of the intermediate-length CMN have not been well described. METHODS: A retrospective review was conducted of older adults with intertrochanteric hip fractures that were treated with cephalomedullary nail fixation using an intermediate-length (235 mm Synthes Trochanteric Fixation® nail or 240 mm Stryker Gamma 3®) nail. Outcome data were collected during the inpatient stay and 16 months post-operatively. RESULTS: Seventy-seven patients met inclusion criteria and were reviewed during inpatient stay; however, only 42 had documented post-operative outcomes. Of those, two patients died post-discharge and were not included in the 16-month follow-up. Comparison of results to published literature suggested that intermediate-length nails are comparable to short-length nails with regard to time in the operating room and estimated blood loss. The rate of blood transfusion was lower and length of hospital stay was shorter than in comparable studies of both short- and long-length nails. There were no post-operative peri-prosthetic fractures in the 16-month follow-up. This rate was lower than published rates for short and long nails. The hardware failure rate (3/42, 7.1%) of intermediate-length nails was higher than comparison studies of both short- and long-length nails. CONCLUSION: Patient outcomes for intermediate-length nails were similar to outcomes of shorter length nails. Utilization of the intermediate-length nail appears to be an effective treatment option for repair of intertrochanteric femur fractures. However, direct comparison is difficult since peri-prosthetic fracture rate may increase over time and nail length and hardware failure are not defined consistently in the literature. Further study is needed with a larger sample size followed over a longer period of time to confirm our findings.

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INTRODUCTION: The initial treatment for many orthopaedic injuries is splinting. Unfortunately, formal musculoskeletal training is limited in primary care leading to deficiencies in competency and confidence. Suboptimal splints can result in complications such as skin break-down, worsening of deformity, and increased pain. Our orthopaedic surgery clinic often cares for patients who initially present to an emergency department or primary care clinic for their orthopaedic injury. Previous studies have shown that a high number of splints are applied improperly in the primary care setting, which could result in in avoidable skin complications and fracture instability. METHODS: Orthopaedic surgery residents held a splinting workshop for family medicine residents. The workshop involved didactic and skills portions. Pre- and post-surveys were administered using a 10-point scale to assess confidence in applying three common splints. The data were analyzed using student's t-test and qualitative feed-back. RESULTS: Confidence in applying and molding each splint type improved significantly (p < 0.05). Knowledge in splint construction improved significantly as well (p < 0.05). Subjective feedback was positive. CONCLUSION: These results showed inter-residency education can increase residents' confidence in skill-based medical care significantly. The results are encouraging and should facilitate further collaboration between multispecialty residency programs to improve patient care. Further investigation is needed to determine how well skills gained in workshop are retained.

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While it is widely understood that management of hip fractures not only represents clinical decision making dilemmas for the individual orthopaedist, these increasingly common injuries present economic burdens to local and national systems as well. This supplement article looks at current clinical trends, as well as systems-based issues in the United States and Canada.

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INTRODUCTION: Metabolic bone disease is a malady that causes significant morbidity and mortality to a patient who has sustained a fragility fracture. There is currently no protocol to prevent secondary fragility fracture at our institution. The objective of this study was to create an appropriate protocol for implementing clinical pathways for physicians to diagnose and treat osteoporosis and fragility fractures by educating patients. METHODS: A multidisciplinary team created an appropriate protocol that could be implemented in an inpatient setting. A thorough literature review was conducted to evaluate potential barriers and efficacious methods of protocol design. RESULTS: A bone health improvement protocol was developed. Any patient over the age of 50 who sustains a fracture from low energy trauma, such as a fall from standing or less, should be considered to place into this protocol. These patients received education on metabolic bone disease, a prescription for high dose vitamin D therapy, and laboratory testing to determine the etiology of their metabolic bone disease. Continuity of care of these patients with their primary care provider was provided for further management of their metabolic bone disease and evaluation of their disease after discharged from the hospital. DISCUSSION: Comprehensive secondary prevention should consist of osteoporosis assessment and treatment together with a fall risk assessment. With this protocol, secondary fragility fractures potentially could be prevented.

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We compared the durability of 3 different selected composite materials that underwent repeated steam sterilization with the durability of traditional metal materials. Composite materials Tepex, CFR-PPS (carbon-fiber-reinforced polyphenylene sulfide), and HTN-53 (Zytel HTN53G50HSLR NC010) were evaluated for durability and water retention after repeated steam sterilization. These composites were compared with stainless steel and aluminum. The structural properties of these materials were measured (short-beam load-to-failure and cyclic compression loading tests) before, during, and after repeated steam sterilization. The relative radiographic density of these materials was also compared. There was no significant difference in the moisture retention of these composite materials before and after repeated sterilization. The composite materials were significantly more radiolucent than the metals. For all the composite materials, load to failure deteriorated after repeated sterilization. The cyclic compression loading tests showed HTN-53 had the poorest performance, with complete failure after 400 cycles of repeated sterilization. CFR-PPS performed slightly better, with 33% failure at final testing. Tepex had no failures at final testing. Although HTN-53 has shown promise in other orthopedic applications, its performance after repeated sterilization was relatively poor. Tepex showed the most potential for durability after repeated sterilization. Further study is needed to identify specific applications for these materials in the orthopedic industry.

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BACKGROUND: It is a common practice among orthopaedic surgeons to make radiographs at the first outpatient postoperative visit after surgical repair of acute fractures. There is not much literature that investigates the benefits and necessity of such a practice. We hypothesized that the practice of routine postoperative radiographs is unnecessary and increases cost to the patients and the health-care system, increases radiation exposure, and provides no change in patient management. METHODS: A retrospective review of patients sustaining acute fractures requiring operative fixation was done with the goal of determining how often a radiograph made at the first postoperative visit in the surgeon's office resulted in a change in patient management. RESULTS: Fifteen (7.5%) of 200 fractures in 171 patients had a clinical indication for a radiograph because of an abnormal physical examination finding or history of additional trauma. Three (1.5%) of these fractures had a deviation from standard postoperative care; this deviation was a change in postoperative care on the basis of the patient history and physical examination rather than radiographs. One fracture (0.5%) had a radiographic change from the immediate postoperative radiograph to the clinic radiograph, yet did not have a change in treatment. The estimated average radiation exposure per radiograph was 0.164 mSv, and the average charge to the patient per radiograph was $335.13. CONCLUSIONS: The majority of radiographs made at the first postoperative visit in the surgeon's office after acute fracture fixation did not result in a change in patient management and added substantial cost to the health-care system.

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The patient was a 17-year-old female who was referred to a physical therapist by her primary-care physician with a chief complaint of bilateral hip and groin pain. The patient was treated by the physical therapist for 8 weeks, but she was unable to successfully return to playing soccer. The patient was subsequently referred to an orthopaedic surgeon, who ordered a magnetic resonance arthrogram that did not reveal intra-articular pathology. To further evaluate bony morphology, computed tomography with 3-dimensional reconstructions was ordered, which demonstrated findings consistent with cam-type femoroacetabular impingement.

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In the prospective cohort study reported here, we used the Short Musculoskeletal Function Assessment (SMFA) questionnaire to assess rate of return of functional outcome after open reduction and internal fixation of unstable ankle fractures (Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen [OTA/AO] 44B and 44C) at a level II trauma center over the course of 1 year. The entire group of 69 consecutive adults improved significantly (P<.01) on the SMFA Emotional Status and Dysfunction scales from 2 to 4 months and on the Mobility and Daily Activities scales from 2 to 4 months and from 4 to 6 months. There were no significant changes on the Arm/Hand Function and Bother scales. There was a significant effect of age on Mobility, Daily Activities, and Dysfunction, with older patients (> or = 50 years) obtaining higher (worse) scores. There was no significant effect on patient sex on any of the scales. Patients with 44C fractures (vs 44B fractures) had significantly (P = .05) higher mean Bother scores at 6 months. There were no significant differences arising from presence or absence of a fracture of the medial malleolus. Our SMFA data show that older patients (> or = 50 years) and patients with 44C fractures had slower return to maximal function and higher Bother scores at 6 months. All groups reached a relatively stable functional outcome by 6 months after injury, but their mobility did not return to population norms over the same period.

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BACKGROUND: The treatment of femoral shaft fractures in older children and adolescents using rigid intramedullary (IM) nail fixation offers the advantages of decreased soft tissue stripping, low incidence of malalignment, leg length discrepancy, early ambulation, and decreased hospital stay. Recent reports have described the development of osteonecrosis of the femoral head in children after IM nailing through the piriformis fossa and the tip of the greater trochanter. Others have noted secondary proximal femoral valgus and femoral neck narrowing after antegrade IM nailing. Using the lateral aspect of the greater \trochanter as the starting point avoids the tenuous blood supply of the proximal femur and did not seem to produce avascular necrosis or proximal femoral deformity in early reports. METHODS: A retrospective clinical and radiographic review of 78 children and adolescents with 80 femoral shaft fractures who underwent IM nail fixation through the lateral aspect of the greater trochanter, with a mean follow-up of 99 weeks, was performed. Twenty-four fractures were observed until skeletal maturity. Final standing anteroposterior radiographs of both lower extremities were used to assess for evidence of osteonecrosis, limb length discrepancy, fracture alignment, and indices around the hips. RESULTS: All patients went on to union in good clinical alignment without loss of reduction. No nonunions, delayed unions, or malunions were observed. Two patients developed infections postoperatively (2.5%). No patient had evidence of osteonecrosis of the femoral head. There was no significant difference in neck-shaft angle, articulotrochanteric distance, or femoral diameter when compared with the nonsurgical, normal side in these patients. CONCLUSIONS: Intramedullary nail fixation through the lateral aspect of the greater trochanter in children and adolescents is effective. It does not produce clinically important femoral neck valgus or narrowing. We did not observe osteonecrosis of the femoral head. LEVEL OF EVIDENCE: : Level IV, case series.

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Intramedullary fixation as a treatment for adolescent femur fractures has increased in popularity. We investigated the varus stability of 3 fixation techniques--the standard 2-nail configuration (2 retrograde nails), a 3-nail configuration (standard 2-nail configuration plus 1 antegrade nail), and a retrograde/antegrade 2-nail configuration--in synthetic femurs with 2 simulated fracture patterns (transverse, butterfly). A varus moment was applied to the specimens until 20 degrees of varus angulation was obtained. The varus angular stiffness of the construct defined varus stability. The 3-nail configuration had the most varus angular stiffness with both fracture patterns. The varus stability of the 3-nail configuration was statistically higher than that of the standard 2-nail configuration with the transverse fracture pattern only. Adding 1 antegrade nail to 2 retrograde nails significantly increased resistance to varus deformity of reduced proximal-third transverse femur fractures in the synthetic femur model.

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