Faculty Bibliography

OBJECTIVES: To document the complications among obese patients who underwent surgical fixation for intertrochanteric femur (IT) fractures and to compare with nonobese patients. DESIGN: Retrospective cohort study. SETTING: Four level I trauma centers. PATIENTS: 1078 IT fracture patients. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Patient and fracture characteristics, surgical duration, surgical delay intraoperative and postoperative complications, inpatient mortality, and length of stay. METHOD: A retrospective review at 4 academic level I trauma centers was conducted to identify skeletally mature patients who underwent surgical fixation of intertrochanteric fractures between June 2008 and December 2014. Descriptive data, injury characteristics, OTA fracture classification, and associated medical comorbidities were documented. The outcomes measured included in-hospital complications, length of stay, rate of blood transfusion, change in hemoglobin levels, operative time, and wound infection. RESULTS: Of 1078 unique patients who were treated for an IT fracture, 257 patients had a Body mass index (BMI) of 30 or greater. Patients with a high BMI (>/=30) had a significantly lower mean age (73 vs. 77 years, P < 0.0001), higher percentage of high-energy injuries (18% vs. 9%, P = 0.0004), greater mean duration of surgery (96 vs. 86 minutes, P = 0.02), and higher mean length of stay (6.5 vs. 5.9 days, P = 0.004). The high-BMI group (n = 257) had significantly higher percentages of patients with complications overall (43% vs. 28%, P < 0.0001), respiratory complications (11% vs. 3%, P < 0.0001), electrolyte abnormalities (4% vs. 2%, P = 0.01), and sepsis (4% vs. 1%, P = 0.002). Patients with BMI >/= 40 had a much higher rate of respiratory complications (18%) and wound complications (5%) than obese (BMI: 30-39.9) and nonobese patients (BMI < 30). CONCLUSION: Intertrochanteric hip fracture patients with a BMI of >30 kg/m are much more likely to sustain systemic complications including respiratory complications, electrolyte abnormalities, and sepsis. In addition, morbidly obese patients are more likely to sustain respiratory complications and wound infections than obese (BMI: 30-39.9 kg/m) and nonobese patients (BMI: < 30 kg/m). The findings from this study can help direct surgeons in the counseling to obese patients and their family, and perhaps increase hospital reimbursement for this group of patients. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Advances in medicine and orthopaedic implant technology have dramatically increased the number of patients sustaining interprosthetic, inter-, or peri-implant fractures. For these complex clinical scenarios, there are currently no available treatment algorithms. In this review, we outline the principles, strategies, and techniques to obtain both successful reconstruction and maximum function. LEVEL OF EVIDENCE: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

With the aging population and rising incidence of primary total joint arthroplasty has come the increasing incidence of revision total hip arthroplasties. One challenge in revision total hip arthroplasty is dealing with acetabular defects. The orthopaedic surgeon who chooses to take on these challenges requires a proper method for the evaluation of these defects as well as an evidence-based treatment algorithm. Initial assessment requires appropriate use and interpretation of imaging modalities such as x-rays and computed tomography. Preoperative planning presupposes knowledge of available approaches and implant options, such as porous coated jumbo cups, modular augments, and cup-cage constructs. Surgical execution necessitates experience in the indications for each type of implant for various types of defects. This review will aid in the understanding of each step of the diagnosis and treatment of acetabular defects in revision total hip arthroplasty.

A 67-year-old man presented to orthopaedic care with a painful knee. Workup was consistent with septic arthritis of a native knee, and the patient underwent operative treatment. Cultures from the operating room were speciated to Staphylococcus lugdunensis. To the investigators' knowledge, this is the first reported S. lugdunensis infection in a peripheral joint in the absence of an orthopaedic prosthesis. Although traditionally associated with infectious endocarditis, S. lugdunensis has been identified as a causative agent in many organ systems, including orthopaedic infections. This case report emphasizes the importance of familiarity with this emerging pathogen in the treatment of a septic joint.

Intramedullary nail and plate combination techniques have been described mostly for use in the proximal tibia. However, the nail and plate combination technique can also be used in the distal tibia, to counteract the deforming forces that cause construct failure and nonunion. In this article, we review pertinent anatomy and biomechanics and offer case examples that highlight the indications and applications of the nail and plate combination technique for distal tibia fractures.

Technological advances and improved understanding of functional anatomy about the elbow have lead an evolution regarding operative reconstruction of complex proximal ulnar and coronoid fractures. When treating these complex and challenging fractures, goals of anatomic articular restoration along with balanced soft tissue stability can lead to early range of motion and thus, desired functional outcome. The purpose of this review is to outline and provide tips and pearls to achieve desired results, with a comprehensive update on the most recent literature to support the latest fixation methods and techniques.

INTRODUCTION: Lower patient satisfaction and high rates of plate prominence has led to the use of lower profile, smaller plates in the treatment of midshaft clavicle fractures. Specifically regarding the use of 2.7mm reconstruction plates, there lacks biomechanical comparison to its more robust 3.5mm counterpart. This study was designed to compare the mechanical properties of anteroinferior plate fixation on a clavicle fracture model using either 2.7mm or 3.5mm reconstruction plates. METHODS: Forty-eight synthetic left clavicles were divided into two groups based on the type of fixation: 3.5mm or 2.7mm pelvic reconstruction plate fixed in the anteroinferior position. Fixation was tested on AO/OTA 15B1.3 transverse midshaft fractures. Each specimen underwent the following three mechanical tests: axial compression, torsion, and four-point bending. RESULTS: Significant differences were observed in axial (p=0.016) and torsional (p=0.00097) stiffness between the two groups. The average bending rigidity (EI) was found to be significantly lower for the 2.7-mm plates as compared to the 3.5-mm plates (p=0.03). The loading scenarios performed in the mechanical tests did not lead to failure of any implants. CONCLUSION: While our results show clear mechanical superiority of 3.5-mm reconstruction plates over 2.7-mm plates, superior results in the clinical setting may not necessarily translate. With exceptional mechanical strength also noted for the 2.7mm plate, well above the biomechanical properties of an intact clavicle, these results may obviate the need for robust plates in general.

Dead space is defined as the residual tissue void after tissue loss. This may occur due to tissue necrosis following high-energy trauma, infection or surgical debridement of non-viable tissue. This review provides an update on the state of the art and recent advances in management of osseous and soft tissue defects. Specifically, our focus will be on the initial dead space assessment, provisional management of osseous and soft tissue defects, techniques for definitive reconstruction, as well as dead space management in the setting of infection. LEVEL OF EVIDENCE: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

The use of fluoroscopy has become commonplace in many orthopaedic surgery procedures. The benefits of fluoroscopy are not without risk of radiation to patient, surgeon, and operating room staff. There is a paucity of knowledge by the average orthopaedic resident in terms proper usage and safety. Personal protective equipment, proper positioning, effective communication with the radiology technician are just of few of the ways outlined in this article to decrease the amount of radiation exposure in the operating room. This knowledge ensures that the amount of radiation exposure is as low as reasonably achievable. Currently, in the United States, guidelines for teaching radiation safety in orthopaedic surgery residency training is non-existent. In Europe, studies have also exhibited a lack of standardized teaching on the basics of radiation safety in the operating room. This review article will outline the basics of fluoroscopy and educate the reader on how to safe fluoroscopic image utilization.