Faculty Bibliography

OBJECTIVE: : To describe the outcomes for patients treated at a single institution, who sustained incomplete bisphosphonate-induced femoral fractures. DESIGN: : Retrospective review. SETTING: : University-based academic medical center. PATIENTS: : Thirty-one patients with 43 incomplete fractures met the inclusion criteria. INTERVENTION: : Nonoperative management or surgical intervention for fractures with refractory symptoms or progression of fracture lucency on radiographs. MAIN OUTCOME MEASUREMENTS: : Radiographic assessments and the Short Musculoskeletal Functional Assessment to gauge functional status. RESULTS: : The cohort was all women with an average age of 69.2 (range: 46-92) years and had been treated with bisphosphonate therapy for an average of 9.1 (range: 5-20) years. The average healing time for all incomplete fractures was 9.4 (range: 1.5-36) months. Forty-nine percent of the fractures (21 of 43 fractures) were ultimately treated with surgery for impending complete fracture or failure of nonsurgical management. Of the incomplete fractures treated with surgery, 81% became pain free and 100% were radiographically healed at a mean of 7.1 (range: 1.5-12) months. In contrast, of the nonoperatively treated incomplete fractures, only 64% were pain free at latest follow-up, with only 18% of fractures demonstrating radiographic evidence of healing at an average of 11 (range: 6-24) months. Standardized dysfunction index from the Short Musculoskeletal Functional Assessment was better (19.7) in the surgical group than in the nonsurgical group (19.7 vs. 25.7, P = 0.0017). CONCLUSIONS: : A higher percentage of patients treated surgically became asymptomatic and demonstrated radiographic evidence of healing earlier than those treated nonsurgically. Surgical intervention is effective for relief of symptoms when treating incomplete bisphosphonate-related femur fractures, and patients should be counseled to the potential benefits of prophylactic surgery. LEVEL OF EVIDENCE: : Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To elucidate the effects of prolonged bisphosphonate (BP) exposure on the development of atypical fragility fractures and to define risk factors.Methods: Approval was obtained from the IRB. A retrospective chart analysis was performed on 51 patients with complete subtrochanteric or diaphyseal femoral fracture(s) from January 2005 to April 2011 while on BP for at least 3 years; 25 patients (mean age 67.52) had all available data. All fractures included in the study were low or no energy fractures. Relevant clinical and demographic data including age, gender, ethnicity, height, weight, comorbid medical conditions, and medications were collected. Imaging and laboratory data including calcium, alkaline phosphatase, 25-hydroxy vitamin D(25-OHD), intact parathyroid hormone(PTH), serum c-telopeptide(CTX), urine n-telopeptide(NTX), bone mineral density, radiography and MRI were obtained in all patients.Results: The majority of patients were Caucasian, on alendronate, had bilateral findings, and almost half had prodromal symptoms. 45.8% had a 25-OHD level that was suboptimal (less than 30 ng/ml). Mean BP duration was 9.84 years and mean bone densities were in the osteopenic, not osteoporotic, range.Conclusion: Certain characteristics in patients with atypical BP-related fracture include relatively young age, long duration of BP use, suboptimal 25-OHD and bone densities in non-osteoporotic ranges. All of these may be significant risk factors for insufficiency fracture development.

Both-bone forearm fractures, also known as concomitant diaphyseal radius and ulna fractures, and distal radioulnar joint (DRUJ) dislocations are each uncommon injuries in adult upper extremity trauma. DRUJ dislocations are more often associated with radial shaft (Galeazzi) fractures. In this article, we report the case of a patient who sustained a both-bone forearm fracture and DRUJ dislocation, and we review the literature on this unique injury pattern.

BACKGROUND: Bilateral ruptures of the extensor mechanism are rare. QUESTIONS/PURPOSE: The purpose of this study was to compare the clinical outcomes of operatively treated unilateral and bilateral knee soft tissue extensor mechanism injuries and to identify risk factors for bilateral disruption. METHODS: All patients operatively treated for a knee extensor mechanism injury were entered into a database and prospectively followed. Postoperative protocol was standardized for all patients. Demographic data, baseline characteristics, range of motion, complications, pain, and functional status were assessed. The main patient-reported outcome measures used in this study were the SF-36 Health Survey and the Lysholm Scale. RESULTS: Patients who sustained bilateral injuries were more likely to have one or more systemic medical conditions. There was no statistical difference between the groups with regard to mechanism of injury or body mass index. The average follow-up was 29 months (range 6-60 months). Patient-reported outcomes, in the form of the SF-36 Health Survey and Lysholm scores, were not significantly different between the two groups at final follow-up. Range of motion and quadriceps strength was also similar between the two cohorts. At latest follow-up, 88% of patients with unilateral injuries and 83% of patients with bilateral disruption were able to return to their pre-injury employment. CONCLUSION: Operatively treated bilateral knee extensor mechanism disruptions fare similar to unilateral injuries with regard to ultimate functional outcome. The presence of one of more preexisting medical conditions was identified as a risk factor for bilateral tendinous disruption.

Iatrogenic vascular injury during hip fracture surgery is a rare complication, with infrequent reports of injury during the procedure of cepahalo-medullary nailing. We describe a case report of injury to the superior gluteal artery which occurred during insertion of a nail for prophylactic fixation of an incomplete femur fracture secondary to alendronate use. We describe the anatomy of the arterial branches, the postoperative course, and the management strategy and hope this will increase awareness of these rare injuries.

Post-traumatic ankle arthritis can be a very disabling condition especially in young patients. Localization of the pain is important to allow appropriate treatment. Non-surgical treatment options include anti-inflammatory medications and use of bracing. Multiple surgical options range from joint sparing procedures for the younger patient to total ankle replacement for the older, less active patient. Arthrodesis remains the gold standard and is the procedure of choice for younger patients who are heavy laborers and in patients with severe arthritis who are not candidates for a total ankle replacement. Joint sparing operations include allograft resurfacing, arthroscopic debridement and osteophyte resection, joint distraction arthroplasty, and supramalleolar osteotomy. In older low demand patients, the surgeon may consider a total ankle arthroplasty as an alternative to arthrodesis.

OBJECTIVES: : The purpose of this study was to compare the outcome after the operative treatment of patella fractures (PFs) as compared with those of quadriceps tendon and patella tendon (PT) ruptures. DESIGN: : This pertains to a retrospective case control. SETTING: : The setting was in academic teaching hospitals. PATIENTS: : Ninety-four patients with 99 extensor mechanism disruptions were treated operatively. Of these, 50 (50%) were PFs; 36 (37%) were quadriceps ruptures; and 13 (13%) were PT ruptures. MAIN OUTCOME MEASURES: : The patients were evaluated at 6 and 12 months and were tested for range of motion, quadriceps circumference and strength, SF36, Lysholm, and Tegner outcome scores by independent observers. Radiographs of the knee were obtained to assess bony healing, posttraumatic arthritis, and heterotopic ossification RESULTS: : A minimum of 12-month follow-up (range 12-81 months) was available for 76 patients (77%). PFs were seen more commonly in women (P < 0.001) and PT ruptures tended to occur in younger males (P < 0.001), with no difference in the body mass index. Thigh circumference was significantly smaller than normal in PFs at 1 year as compared with tendon injuries. At latest follow-up, there were no significant differences noted with respect to knee range of motion, radiographic arthritis, Tegner, Lysholm, or SF36 scores. CONCLUSIONS: : There were no significant differences with regard to outcome in patients sustaining these injuries. LEVEL OF EVIDENCE: : Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES: : To compare postoperative pain control in patients treated surgically for ankle fractures who receive popliteal blocks with those who received general anesthesia alone. DESIGN: : Institutional Review Board approved prospective randomized study. SETTING: : Metropolitan tertiary-care referral center. PATIENTS: : All patients being treated with open reduction internal fixation for ankle fractures who met inclusion criteria and consented to participate were enrolled. INTERVENTIONS: : Patients were randomized to receive either general anesthesia (GETA) or intravenous sedation and popliteal block. MAIN OUTCOME MEASURES: : Patients were assessed for duration of procedure, total time in the operating room, and postoperative pain at 2, 4, 8, 12, 24, and 48 hours after surgery using a visual analog scale. RESULTS: : Fifty-one patients agreed to participate in the study. Twenty-five patients received popliteal block, while 26 patients received GETA. There were no anesthesia-related complications. At 2, 4, and 8 hours postoperatively, patients who underwent GETA demonstrated significantly higher pain. At 12 hours, there was no significant difference between the 2 groups with regard to pain control. However, by 24 hours, those who had received popliteal blocks had significantly higher pain with no difference by 48 hours. CONCLUSIONS: : Popliteal block provides equivalent postoperative pain control to general anesthesia alone in patients undergoing operative fixation of ankle fractures. However, patients who receive popliteal blocks do experience a significant increase in pain between 12 and 24 hours. Recognition of this "rebound pain" with early narcotic administration may allow patients to have more effective postoperative pain control. LEVEL OF EVIDENCE: : Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.