Background: Nitinol staples have been used effectively for stabilization and compression at fracture sites. This study compared yield load, fracture displacement, and load to failure between nitinol staples and superior plating for midshaft clavicle fractures. Methods: Ten pairs of cadaveric clavicles underwent midshaft osteotomy. Each specimen in each pair was randomly assigned to fixation with superiorly placed nitinol staples or with superior plating. Specimens were loaded cyclically with increasing loads to a maximum of 1200 cycles and 60 N. Fracture displacement and construct stiffness were compared at each load. Load to failure was performed at the conclusion of testing. Results: The staple group demonstrated lower yield load and higher median fracture displacement at all levels of force compared to the plate group. Median displacement at physiologic load was 15.3 (IQR 12.8-16.5) mm for the staple construct and 2.9 (IQR 2.5-3.6) mm for plated constructs (P=2.04E-07). Median stiffness of plated constructs was significantly higher than staple constructs at all levels (P<0.05). Median cycles to failure for staple constructs was significantly lower compared to plated constructs (P=0.004). Median load to failure was significantly higher for plated constructs compared to staple constructs (P=2.8E-06). Conclusions: Nitinol staple fixation of midshaft clavicle fractures demonstrated lower yield load, stiffness, increased displacement, and lower load to failure compared to superior plate fixation. However, staple constructs provided adequate stability to maintain reduction of the fracture at physiologic levels of repetitive stress, indicating a potential role for nitinol staples in clavicle fracture fixation.

Background: Rotator cuff tendinopathy is the most common cause of painful shoulder. There is evidence supporting the use of extracorporeal shock wave therapy (ESWT) in the rotator cuff calcific tendinopathy, but evidence supporting its use in non-calcifying tendinopathy is lacking. The current study aimed to compare the clinical effectiveness of corticosteroid injections versus ESWT until 3 mo of follow-up for the management of painful non-calcific rotator cuff tendinopathies. Methods: A total of 33 patients affected by painful rotator cuff tendinopathy were randomly divided into 2 groups of 16 and 17 cases. The first group received corticosteroid injection under ultrasound guidance and the second group received three sessions of shockwave within 3 consecutive weeks consisted of 2000 pulse energy, 5 Hz frequency, and pressure of 4 bar using a radial shock wave device. Two outcome measures of VAS and Quick-DASH were obtained to evaluate patients before treatment, and 2 and 12 wk after treatment. Discussion: Regarding both VAS and the score of the Quick-DASH questionnaire, no statistically significant difference was observed between these 2 therapeutic interventions (ultrasound-guided corticosteroid injection and shockwave). Both interventions reduced the patient’s pain to the same extent (P-value=0.955 for VAS, and P-value=0.865 for Quick DASH questionnaire score). Moreover, within-group changes showed that both groups’ improvements were significant in the time intervals of 1 to 2 and 1 to 3. Conclusions: Corticosteroid injection and radial shockwave, both can be effective to the same extent in reducing pain and improving function in non-calcific shoulder tendinopathy. Level of Evidence: Level I.

Background: Social media is a robust outreach tool that allows programs to outreach with prospective applicants while maintaining social distancing policies. The purpose of this study was to evaluate how the COVID-19 pandemic influenced the social media practices of ACGME accredited orthopaedic surgery residency programs. Methods: An analysis of orthopaedic surgery residency social media accounts was performed to identify changes in practices from July 2019 to December 2020. Social media participation was analyzed with respect to program type, location, size, geographical location, and Doximity ranking. Results: A total of 194 residency programs were included in this study. Twitter accounts increased from 56 (28.9%) in December 2019 to 87 (44.8%) in January 2021 while Instagram accounts increased from 16 (8.2%) to 107 (55.2%). Allopathic programs, programs with a higher Doximity Reputation Ranking, and those with more than 35 residents were significantly more likely to have an Instagram or Twitter account (P<0.05). There was a significant increase in the average number of Instagram posts per month in July and September 2020 (P<0.05) 2020 as compared to the same period in 2019. Conclusions: There was an increase in the prevalence of orthopaedic residency social media accounts during the Covid pandemic. Allopathic programs, programs with a higher Doximity Reputation Ranking, and larger programs were more likely to utilize social media. Social media offers another avenue for programs to communicate with applicants and an increasing number of programs are harnessing this tool to connect with the next generation of orthopaedic surgeons. Level of Evidence: Level IV.

Background: In 2014, the United States Drug Enforcement Agency rescheduled hydrocodone from schedule III to II to mitigate the opiate crisis in America. Hydrocodone has long served as common pain medication after outpatient orthopaedic surgical procedures in the United States. We hypothesize rescheduling of hydrocodone would correlate with an increase in postoperative emergency department visits for pain. Methods: We performed a retrospective review of all outpatient orthopaedic procedures and identified all patients who subsequently presented to our emergency department for postoperative pain for the one calendar year prior to and after the rescheduling of hydrocodone. Results: We identified 2984 orthopaedic procedures and 3193 emergency department visits for postoperative pain across all surgical specialties. 875 orthopaedic procedures occurred prior to hydrocodone rescheduling with 48 postoperative ED visits for pain (5.4%). 2109 procedures occurred after the rescheduling of hydrocodone with 123 ED visits for pain postoperatively (5.8%). 199 patients presented to the ED for postoperative pain, for a total of 345 visits. The median postoperative time to emergency room visit for the pre-rescheduling group was 6.5 days versus 4.0 days post-rescheduling. Conclusions: We identified statistically significant differences in postoperative medication and prescribed amounts. We identified no difference in the proportion of patients that went to the emergency room by timeframe relative to hydrocodone rescheduling, nor did we identify a difference between samples in terms of gender, race, insurance status, and comorbid conditions. Increased restriction on hydrocodone prescribing did not increase emergency department visits for pain after outpatient orthopaedic surgery. Level of Evidence: Therapeutic III.

Background: Pilon fractures are associated with a high incidence of complications, yet there continues to be uncertainty regarding variables associated with adverse outcomes after pilon open reduction and internal fixation (ORIF). This study sought to characterize the rate of arthrodesis and identify risk factors that increase the likelihood of ankle arthrodesis in patients with ORIF pilon fractures. Methods: After institutional review board approval, a retrospective review was conducted to identify patients who underwent ORIF of pilon fractures at an ACS Level I trauma center from 2005 to 2014. Medical records and radiographs were reviewed retrospectively for patient demographics, comorbidities, fracture characteristics, associated injuries, mechanism of injury, and functional activity. Logistic regression analyses were performed to identify risk factors associated with arthrodesis. Results: 282 pilon fractures (279 patients) met inclusion criteria. There were 182 men and 97 women with an average age of 43.8±15.2 yr. Overall, 15 pilon fractures (5.3%) in six male patients and nine female patients were treated with an ankle arthrodesis an average of 1.73±5.15 yr after their initial injury. Following multivariable logistic regression analysis, age greater than 40 yr, tobacco use, and nonunion were identified as independent predictors of arthrodesis. Conclusions: This study found a number of patient-related factors associated with an increased risk of arthrodesis after a pilon fracture was sustained. Multivariable logistical analysis identified age greater than 40 yr, tobacco use, and nonunion as independent predictors of arthrodesis following pilon fracture ORIF. Level of Evidence: Level III

Hussaini, Syed Mohd Esmat MD; Chandirasegaran, Saturveithan MS (ORTHO); Yusof, Mohamad Fauzlie MS (ORTHO); Abdul Wahid, Abdul Muttalib MS (ORTHO) Author Information

Operative treatment of olecranon fractures in the elderly can lead to greater complications with similar outcomes to nonoperative treatment. The purpose of this study was to analyze cost differences between operative and nonoperative management of isolated closed olecranon fractures in elderly patients. Using a United States Medicare claims database, the authors identified 570 operative and 1,863 nonoperative olecranon fractures between 2005 and 2014. The authors retrospectively determined cost of treatment from the payer perspective for a 1-year period after initial injury, including any surgical procedure, emergency room care, follow-up care, physical therapy, and management of complications. One year after diagnosis, mean costs per patient were higher for operative treatment (United States dollars [US$]10,694 vs US$2,544). 31.05% of operative cases were associated with a significant complication compared with 4.35% of nonoperative cases. When excluding complications, mean costs per patient were still higher for operative treatment ($7,068 vs $2,320). These findings show that nonoperative management for olecranon fractures in the elderly population leads to fewer complications and is less costly. Nonoperative management may be a higher-value management option for this patient population. These results will help inform management of olecranon fractures as payers shift toward value-based reimbursement models in which quality of care and cost influence surgical decision making. Level IV.

Murray, Richard D. MDa; Chiaramonti, Alexander M. MDb; Daley, Dane N. MDb Author Information

Background: With the Affordable Care Act (ACA), the challenge of expanding healthcare insurance to Americans without jeopardizing quality of care remains. This study was initiated to evaluate how the timing of MRI completion for shoulder pathology correlates with implementation of the ACA by comparing lag times between the initial visit and the date of MRI completion. In addition, the access to orthopaedic care after ACA implementation was evaluated by comparing shoulder MRI lag times among three cohorts based on insurer status. Methods: All shoulder and proximal upper extremity MRIs between 2009 and 2017 were reviewed, 5 yr before and 3 yr after ACA implementation. Patients were grouped into commercial, Medicare, and Medicaid cohorts. Average lag times for the pre- and post-ACA periods overall and among payor cohorts were calculated. Results: Included were 5900 MRIs, 1997 (33.8%) before and 3903 (66.2%) after ACA implementation. The difference in payor mix before and after ACA implementation was significantly different (P<0.001). Median lag time increased from 23 days pre-ACA to 31 days post-ACA (P<0.001). For commercial insurance, median lag time was 23 days pre-ACA compared with 28 days (P<0.001) post-ACA. Median lag time pre- and post-ACA in the Medicaid cohort was 8 days compared with 30.5 days (P<0.001), respectively. Pre- and post-ACA lag times in the Medicare cohort did not differ significantly (P=0.450). Conclusions: Lag times increased significantly after ACA implementation in patients with commercial and Medicaid insurance. This study provides valuable insight into unintended outcomes associated with the ACA legislation. Level of Evidence: Level III.

Background: Socioeconomic status is known to influence outcomes in healthcare. This study compares hip fracture care in patients of different socioeconomic status. Methods: A retrospective study of hip fracture patients over the age 65 with hip fracture who received operative care by a single surgeon was undertaken at an academic level 1 trauma center (county group, n=47) and two private tertiary care hospitals (private group, n=78). A standardized hip fracture protocol was initiated for all patients upon admission with the goal of operative management in less than 48 hr. Time-to-surgery, length of stay, and short-term postoperative complications were compared between groups. Results: Patients from the county hospital, which serves a low socioeconomic population, were largely nonwhite (93.6%) with 12.8% uninsured, whereas 32.1% of private patients were nonwhite, and all were insured. County patients had a longer time from presentation to surgery compared with private patients (30.5 hr vs 21.7 hr, respectively, P=0.003). Length of stay was equivalent between county and private patients (8.0 days vs 7.2 days, respectively, P=0.060). There was no significant difference in the rate of complications between county versus private groups (21.3% vs. 21.8%, respectively, P=0.946). Difference in 30-day mortality was not statistically significant (8.5% county vs. 3.9% private, respectively, P=0.424). No risk factors were associated with significantly increased risk of complications with logistic regression analysis. Conclusions: There was a similar length of stay, complication rate, and mortality rate after hip fracture surgery despite demographic differences between the groups. A fragility fracture protocol can lead to similar outcomes in patients of differing demographics and insurance payor mixes. Level of Evidence: Level III.