Journal of Orthopaedic Trauma

Journal of Orthopaedic Trauma is devoted exclusively to the diagnosis and management of hard and soft tissue trauma, including injuries to bone, muscle, ligament, and tendons, as well as spinal cord injuries. Under the guidance of a distinguished international board of editors, the journal provides the most current information on diagnostic techniques, new and improved surgical instruments and procedures, surgical implants and prosthetic devices, bioplastics and biometals; and physical therapy and rehabilitation. The Official Publication of: Orthopaedic Trauma Association AO Trauma North America​ Belgian Orthopaedic Trauma Association Canadian Orthopaedic Trauma Society Foundation for Orthopedic Trauma International Society for Fracture Repair The Japanese Society for Fracture Repair
Journal of Orthopaedic Trauma - Current Issue
  1. imageObjectives: To delineate if there were differences in outcomes between definitive fixation strategies in open tibial shaft fractures. Data Sources: MEDLINE, EMBASE, CENTRAL, and OpenGrey. Study Selection: Randomized and Quasi-randomized studies analyzing adult patients (>18 years) with open tibial shaft fractures (AO-42), undergoing definitive fixation treatment of any type. Data Extraction: Data regarding patient demographics, definitive bony/soft-tissue management, irrigation, type of antibiotics, and follow-up. Definitive intervention choices included unreamed intramedullary nailing (UN), reamed intramedullary nailing, plate fixation, multiplanar, and uniplanar external fixation (EF). The primary outcome was unplanned reoperation rate. Cochrane risk of bias tool and Grading of Recommendation Assessment, Development and Evaluation systems were used for quality analysis. Data Synthesis: A random-effects meta-analysis of head-to-head evidence, followed by a network analysis that modeled direct and indirect data was conducted to provide precise estimates [relative risk (RR) and associated 95% confidence interval (95% CI)]. Results: In open tibial shaft fractures, direct comparison UN showed a lower risk of unplanned reoperation versus EF (RR 0.67, 95% CI 0.43–1.05, P = 0.08, moderate confidence). In Gustilo type III open fractures, the risk reduction with nailing compared with EF was larger (RR 0.61, 95% CI 0.37–1.01, P = 0.05, moderate confidence). UN had a lower reoperation risk compared with reamed intramedullary nailing (RR 0.91, 95% CI 0.58–1.4, P = 0.68, low confidence); however, this was not significant and did not demonstrate a clear advantage. Conclusions: Intramedullary nailing reduces the risk of unplanned reoperation by a third compared with EF, with a slightly larger reduction in type III open fractures. Future trials should focus on major complication rates and health-related quality of life in high-grade tibial shaft fractures. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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  4. imageObjectives: To synthesize all-cause reoperations and complications data as well as secondary clinical and functional outcomes, after the management of very distal femur periprosthetic fractures (vDFPFs) in a geriatric patient population with either a distal femoral locking plate (DFLP) or distal femoral replacement (DFR). Data Sources: MEDLINE, Embase, and Web of Science were searched for English language articles from inception to March 16, 2020, in accordance to the PRISMA guidelines. Study Selection: Studies reporting the management of vDFPFs in adults older than 65 years with either a DFLP or DFR were included. To ensure this review solely focused on very distal femoral periprosthetic fractures, only fractures of the following classifications were included: (1) Lewis and Rorabeck type II or III, (2) Su and Associates' Classification of Supracondylar Fractures of the Distal Femur type III, (3) Backstein et al type F2, and/or (4) Kim et al type II or III. Data Extraction: Three reviewers independently extracted data from the included studies. Study validity was assessed using the methodological index for nonrandomized studies (MINORS), a quality assessment tool for nonrandomized controlled studies in surgery. Data Synthesis: Twenty-five studies with 649 vDFPFs were included for analysis. There were 440 knees in the DFLP group (mean age range: 65.9–88.3 years) and 209 knees in the DFR group (mean age range: 71.0–84.8 years). Because of the literature's heterogeneity, the data were qualitatively synthesized. Conclusions: vDFPFs in the elderly treated with DFR underwent fewer reoperations relative to DFLP (0%–45% vs. 0%–77%, respectively). Time to weight-bearing was observably shorter in DFR studies relative to DFLP studies. Functional outcomes and postoperative range of motion indicated a trend for DFLP knees to outperform DFR knees. Future research should include prospective studies and cost-effectiveness evaluations to better understand the utility of DFR for these fractures. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
  5. imageObjectives: To assess the complication rate of hindfoot nailing of acute fractures involving the tibiotalar joint, and mortality, patient-reported outcome measures, and return to preinjury activities. Data Sources: MEDLINE; EMBASE. Study Selection: A systematic literature search for articles in English was completed using MEDLINE and EMBASE databases on April 23, 2020. Original research articles that assessed patients with acute intra-articular fractures of the ankle joint (malleolar ankle fractures and/or pilon fractures) that were treated with a locked hindfoot intramedullary nail, inserted retrograde through the plantar surface of the foot, were selected for inclusion. Case reports (≤4 patients), studies with nonlocked implants, and non-English studies were excluded. Data Extraction and Synthesis: A validated data extraction form was used, which included study demographics (authors, journal, date of publication, and study design), patient characteristics, implant type, and reported outcomes. Risk of bias for each included study was evaluated using the Institute of Health Economics Quality Appraisal Checklist for case series and the Risk of Bias in randomized trials tool, where appropriate. The best evidence was summarized and weighted mean values were provided when appropriate. Results: Ten case series and one randomized controlled trial were included. The overall quality of studies was poor with considerable bias. The majority of studies included elderly patients (weighted mean age 75.5 years) with diabetes (42% of patients). Overall complication rate was 16% with an 8% major complication rate (deep infection, malunion, nonunion, implant failure) and an overall infection rate of 6.2%. Pooled mortality rate was 27% with fracture union rates from 88% to 100%. Mean proportion of patients able to return to preinjury level of activity was 85%. Conclusions: Hindfoot nailing of acute ankle and pilon fractures in elderly patients and patients with diabetes is associated with complication rates comparable with other methods of fixation. Issues with elimination of subtalar joint motion and implant complications secondary to poor implant fixation persist. The literature to date has composed of primarily Level IV studies with considerable bias. Further research is necessary to clarify the role of hindfoot nailing of acute ankle and pilon fractures. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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  7. imageObjective: To compare the early pain and functional outcomes of operative fixation versus nonoperative management for minimally displaced complete lateral compression (LC; OTA/AO 61-B1/B2) pelvic fractures. Design: Prospective clinical trial. Setting: Two academic trauma centers. Patients: Forty-eight adult patients with LC pelvic ring injuries with 10 mm of displacement were treated nonoperatively and 47 with surgical fixation. Sixty percent of participants were randomized. Seventy-three percent of the fractures were displaced 5 mm, and 71% were LC-1 patterns. Intervention: Operative fixation versus nonoperative management. Main Outcome Measurements: The primary outcome was patient-reported pain using the 10-point Brief Pain Inventory. Functional outcome was measured using the Majeed pelvic score. Outcomes were analyzed using hierarchical Bayesian models to compare the average treatment effect from injury to 12 and 52 weeks postinjury. The probability of the mean treatment benefit exceeding a clinically important difference was determined. Results: The 3-month average treatment effect of surgery compared with nonoperative management was a 1.2-point reduction in pain [95% credible interval (CrI): 0.4–1.9] and an 8% absolute improvement in the Majeed score (95% CrI: 3%–14%). Similar results persisted to 1 year. Patients with initial fracture displacement ≥5 mm experienced a larger reduction in pain (2.2, 95% CrI: 0.9–3.5) compared with those patients with less initial displacement (0.9, 95% CrI: 0.1–1.8). Conclusion: On average, surgical fixation likely provides a small improvement in pain and functional outcome for up to 12 months. Patients with ≥5 mm of posterior pelvic ring displacement are more likely to experience clinically important improvements in pain. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
  8. imageObjectives: To determine risk factors for early conversion total hip arthroplasty (THA) after operative treatment of acetabular fractures. Design: Retrospective cohort. Setting: Level I trauma center. Patients and Intervention: We reviewed 685 operative acetabular fractures at our institution from 2011 to 2017, with a median follow-up of 12 months (range, 4–105 months). Main Outcome Measure: Multivariable regression analysis was performed after univariate analysis to identify independent risk factors for conversion THA. Sensitivity analysis was performed with minimum follow-up set at 6 and 12 months. Results: One hundred eight patients (16%) underwent conversion THA, with 52% of conversions occurring within 1 year, an additional 27% within 2 years, and the remaining 21% within 6 years of the index acetabular open reduction internal fixation. The median time to conversion THA was 11.5 months (range, 0.5–72 months). The risk of conversion THA by fracture pattern was 53 of 196 (27%) for transverse posterior wall (TPW), 12 of 52 (23%) for T shaped, 10 of 68 (15%) for posterior column with posterior wall, and 25 of 207 (12%) for posterior wall. Independent risk factors for early conversion included the following: TPW fracture, protrusio, hip dislocation, increased body mass index, increased age, infection, and dislocation after open reduction internal fixation. Independent risk factors for early conversion THA specific to patients with TPW fractures include only increased age and body mass index. Sensitivity analysis showed no change in results using either 6 or 12-month minimum follow-up. Conclusion: Transverse posterior wall fractures have a high risk of early conversion THA compared with other acetabular fracture patterns, especially when in combination with other significant risk factors. Consideration for different and novel management options warrants further study in this subset of acetabular fracture patients. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
  9. imageObjective: To compare the results and complications of a large consecutive series of total hip arthroplasty (THA) performed for acute femoral neck (FN) fracture by adult reconstructive (AR) and trauma (T) surgeons to determine if there is a difference in outcomes. Design: Retrospective chart review. Setting: Level 1 trauma center. Patients: One hundred forty-nine consecutive patients who presented to our institution with displaced FN fractures treated by THA were included in this study. Intervention: All patients were treated with THA. Main Outcome Measurements: Implant survival, 90-day complications, 90-day readmission, 1-year complications. Results: For the group as a whole, the major surgical complication rate (defined as dislocation, deep infection, loosening, fracture) was significantly higher for T surgeons (20%) than for AR surgeons (7%) (P = 0.021). AR surgeons had significantly less radiographic component malpositioning 12% versus 3% (P = 0.024). Mortality and readmission rates were similar between the 2 cohorts at all time points. Implant survivorship was significantly higher at 1 year for AR surgeons (P = 0.05). Conclusions: THA for acute FN fracture performed by AR surgeons demonstrated higher rates of accurate radiographic component positioning, significantly lower major complication rates at 90 days and 1 year, and greater implant survival at 1 year. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
  10. imageObjectives: To compare complications and cost of care in patients with traumatic arthrotomies (TAs) treated with surgical debridement, irrigation, and closure to those treated with nonoperative treatment and local wound care. Design: This is a prospective observational multicenter study. Setting: This study was conducted at multiple Level I trauma centers. Patients: Patients with TAs. Intervention: Patients were treated with operative versus nonoperative management decided by the attending surgeon. Nonoperative treatment of TAs included bedside irrigation, primary closure, antibiotics, and discharge from the emergency department with close follow-up unless admission was otherwise indicated. Main Outcome Measurements: Primary outcomes included adverse outcomes and cost. VR-12 was captured at the time of injury and 3 months postinjury. Results: Of 189 major joint TAs, 64 arthrotomies were treated nonoperatively and 125 operatively. Seventy percent of the arthrotomies in the nonoperative group were small (less than 50 mm in size) and 95% had minimal/no gross contamination, whereas the operative group (OG) had significantly more arthrotomies greater than 50 mm in size and with moderate/severe gross contamination. There was one septic joint in the nonoperative group (1.5%) and 7 in the OG (5.6%). Nonoperative treatment was associated with significantly lower total charges when compared with the OG. Conclusions: Although further study may still be needed, this study suggests that small, minimally contaminated TAs with no associated fracture have a low risk of adverse complications, can safely be treated nonoperatively, and are associated with a significantly decreased cost of care. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
  11. imageObjectives: To identify the ideal distal nail position in the distal tibia, using a computed tomography analysis. Methods: Three-dimensional models of 860 left tibiae were analyzed using the Stryker Orthopaedic Modeling and Analytics software (SOMA, Stryker, Kiel, Germany). The nail axis was defined by 7 center points at the middle of the inner cortical boundary. The point where this line fell relative to the center of the tibial plafond in both the anteroposterior and mediolateral planes was calculated. Results: The mean mediolateral offset of the tibial nail exit path was 4.4 ± 0.2 mm (95% confidence interval) lateral to the center of the tibial plafond. The mean anteroposterior offset of the tibial nail exit path was 0.6 ± 0.1 mm anterior to the center of the tibial plafond. Conclusions: We have presented an anatomic study analyzing the ideal nail exit path using computed tomography scans of 860 tibiae. We defined that the ideal nail exit path of a tibial nail is lateral with respect to the center of the tibial plafond. This is supported by previous clinical studies and has significant implications for preventing malalignment when treating distal tibial fractures with intramedullary nailing.
  12. imageObjective: To compare the outcomes and complications of bone transport over a nail (BTON) with those of bone transport over a plate (BTOP) for segmental tibial bone defects. Design: Retrospective matched study design. Setting: A major metropolitan tertiary referral trauma center. Patients: Thirty-six patients with segmental tibial bone defects of >4 cm were included in this study. Intervention: Either BTON or BTOP was performed on 18 patients. Main Outcome Measurements: We compared the healing of the distraction process and of the docking site between the techniques. Distraction parameters including external fixator (EF) time, external fixation index, and healing index were compared. Bone and functional results were compared according to the Paley–Maar classification. Complications associated with each procedure were compared. Results: Both BTON and BTOP achieved similar rates of primary union (83% vs. 89%) at the distraction or docking site. Significantly less time wearing an EF was needed for BTOP than for BTON (2.8 vs. 5.4 months; P 0.01). The external fixation index was significantly lower for BTOP than for BTON (0.45 vs. 0.94 mo/cm; P 0.01), whereas the healing indexes were similar. The final outcomes and complication incidences were not significantly different. Conclusions: The EF time was significantly shorter for BTOP than for BTON; however, the final outcomes were similar. Therefore, BTOP could be considered an attractive option for bone transport in patients with segmental tibial defects. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
  13. imageObjective: To evaluate femoral growth after placement of retrograde intramedullary nails in the treatment of pediatric femoral shaft fractures. Design: Retrospective case series. Setting: Large urban trauma center in Mongolia. Patients/Participants: Twenty-nine pediatric patients who sustained a diaphyseal femoral shaft fracture were included in the study. Intervention: Retrograde intramedullary nail fixation with the standard, fin, or pediatric fin Surgical Implant Generation Network nail across an open distal femoral physis. Main Outcome Measures: The main outcome measure was the distance traveled by the intramedullary nail with respect to the distal femoral condyles and distal femoral physis from initial surgery to follow-up. Results: The mean age of patients was 10.7 years (range: 7–14 years). Follow-up occurred at a mean of 292 days (range: 53–714 days). Both condyle distance and physis distance were significantly positively correlated with follow-up days, with Pearson R values of 0.90 (P 0.001) and 0.84 (P 0.001), respectively. Multiple regression analysis revealed that follow-up days was the only significant predictor of physis distance, whereas age, sex, percent growth plate violation, and nail fully traversing physis were not significant predictors. The nail completely crossed the physis in 5 patients and no growth arrests were found. Conclusions: This is the first study, to our knowledge, to evaluate treating femoral shaft fractures with a retrograde nail across an open distal femoral physis. In the pediatric population, the use of a retrograde femoral intramedullary nails does not seem to cause growth arrest of the injured femur during the postoperative period and may be a reasonable treatment option when other surgical options are not available. Additional study is necessary to further evaluate the safety profile. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
  14. imageObjectives: The iliac cortical density (ICD) is a critical fluoroscopic landmark for pelvic percutaneous screw placement. Our purpose was to evaluate the ICD as a landmark in pediatrics and quantify the diameter of osseous pathways for 3 screw trajectories: iliosacral (IS) at S1 and transiliac–transsacral (TSTI) at S1 and S2. Methods: Two hundred sixty-seven consecutive pelvic CT scans in children 0–16 years of age were analyzed. ICD and S1 vertebral heights were measured at multiple regions along S1. Their height and corresponding ratios, as well as osseous screw corridor dimensions were compared between age groups and by the dysmorphic status. Results: In the nondysmorphic pelvises, S1 height, ICD height, and the ICD to S1 height ratio increased across age groups for all locations (P 0.001). All 3 screw pathway diameters increased with age (P 0.001). In the dysmorphic group, there was no increase in ICD to S1 height ratio with age. Except for the age 0–2 group, the ICD to S1 height ratios were significantly larger in the nondysmorphic group. In the dysmorphic group, S1 TSTI pathway remained narrow with age, whereas IS at S1 and TSTI at S2 had a significant increased diameter with age (P 0.001). Conclusion: The ICD is a useful fluoroscopic landmark for percutaneous screw placement in the pediatric pelvis. For nondysmorphic pelvises, the ICD to S1 height ratio, as well as osseous corridors for IS, TSTI at S1, and TSTI at S2 screw trajectories increase significantly with age. The margin for safe screw placement in S1 is smaller for younger and dysmorphic pelvises.
  15. imageObjectives: To investigate the association of obesity with fracture characteristics and outcomes of operatively treated pediatric supracondylar humerus fractures. Design: Retrospective multicenter. Setting: Two Level I pediatric hospitals. Patients: Patients (age 18 years) with operatively treated Gartland type III and type IV fractures 2010–2014. Intervention: Closed or open reduction and percutaneous pinning of supracondylar humerus fractures. Main Outcome Measure: Incidence of Gartland IV fracture, preoperative nerve palsy, open reduction and complication rates. Results: Patients in the obese group had a significantly higher likelihood of having a Gartland IV fracture (not obese: 17%; obese: 35%; P = 0.007). There was a significantly higher incidence of nerve palsy on presentation in the obese group (not obese: 20%; obese: 33%; P = 0.03). No significant differences were found between groups regarding incidence of open reduction, compartment syndrome, and rates of reoperation. Conclusions: The present study demonstrates that obese children with a completely displaced supracondylar humerus fractures have an increased risk of Gartland type IV and preoperative nerve palsy compared with normal weight children. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.