Faculty Bibliography

INTRODUCTION/BACKGROUND:The purpose of this study is to compare patient outcomes between the Equinoxe® (Exactech, Gainesville, Fla) proximal humerus locking plate and the PHILOS® (Synthes, Paoli, PA) proximal humerus locking plate. METHODS:Two hundred and seventy-one patients with a displaced proximal humerus fracture presented to our academic medical center between February 2003 and October 2020. Functional outcomes assessed included the Disabilities of the Arm, Shoulder, and Hand questionnaire and shoulder range of motion. Radiographs were utilized to determine fracture healing and development of posttraumatic osteoarthritis or osteonecrosis. RESULTS:Overall, 108 Equinoxe® and 87 PHILOS® patients treated by a single surgeon with complete clinical, functional, and radiographic follow-up were included in the study. Demographics were similar between groups. One hundred and eight Equinoxe® patients healed at a mean time to union by 3.7 ± 2.2 months, and 86 PHILOS® patients healed (p = 0.24) by 4.1 ± 2.3 months after surgery (p = 0.31). Shoulder external rotation was greater in Equinoxe® patients by 7 degrees (p = 0.044), and forward elevation was greater by 16 degrees (p = 0.005) at one-year follow-up. DASH scores were similar between patients at the 3-, 6-, and 12-month follow-up (p = 0.86, p = 0.77, p = 0.64). Fewer Equinoxe® patients experienced complications (p = 0.043). CONCLUSION/CONCLUSIONS:Fixation of a proximal humerus fracture can safely be performed with both Equinoxe® and PHILOS® proximal humerus locking plates. Patients fixed with Equinoxe® plates achieved a slightly greater degree of external rotation, forward elevation, and experienced fewer complications. This difference may be due to surgeon experience rather than the implant itself.

A systematic literature search was performed using the PubMed, MEDLINE, and the Cochrane Library databases according to the Preferred Reporting Items for Systematic review and Meta-Analyses guidelines on May 20, 2019. The keywords used were: ankle, distal tibia, distal fibula, fracture, arthroscopic, cartilage, and chondral. The objective of this study is to systematically review the characterization of intra-articular chondral injuries of the talus, tibial plafond, medial malleolus, and lateral malleolus in patients who undergo ankle arthroscopy following ankle fracture. Studies evaluating the incidence of chondral lesions at the time of arthroscopy for ankle fractures within any timeframe were included. The incidence of intra-articular chondral lesions was recorded, the location within the ankle, ankle fracture type, time of arthroscopy, characterization of chondral injury, complications, and outcome if available. Fifteen studies with 1355 ankle fractures were included. About 738 demonstrated evidence of chondral or osteochondral lesion (54.5%). Statistical analyses were carried out with statistical software package SPSS 24.0 (SPSS, Chicago, IL). We compared incidence rates of chondral injury based on Weber classification, malleolar fracture type, and Lauge-Hansen classification, using Pearson chi-square test. For all analyses, p < .05 was considered statistically significant. We found a high incidence of intra-articular chondral lesion in the setting of ankle fractures as demonstrated by arthroscopy.

PURPOSE/OBJECTIVE:To assess outcomes for patients who sustained peri-implant fractures (PIFs). METHODS:Medical records of patients who sustained a PIF were reviewed for demographic, injury, outcome, and radiographic data. PIFs were classified using a reproducible system and stratified into cohorts based on fracture location. Clinical outcomes were evaluated for each cohort. RESULTS:Fifty-six patients with 61 PIFs with at least 6 months of follow-up were included. The mean age of the cohort was 60.4 ± 19.5 years. Twenty-two (36.1%) PIFs occurred in males, while 39 (63.9%) occurred in females. Fifty-two (85.2%) PIFs were sustained from a low-energy injury mechanism. PIFs were most often treated with plate/screw constructs (50.8%). Complications included: 6 (9.8%) nonunions, 5 of which were successfully treated to healing, 5 (8.2%) fracture related infections (FRI), and 1 (1.6%) hardware failure. Sixty (98.4%) PIFs ultimately demonstrated radiographic healing. CONCLUSION/CONCLUSIONS:PIFs are usually treated surgically and have a relatively high incidence of complications, with nonunion in femoral PIFs being the greatest. Despite this, the rate of ultimate healing is quite high.

Nail plate constructs (NPC) have shown promising results in complex lower extremity peri-articular fractures as well as in peri-prosthetic fractures. The combination of both implants allows for improved mechanical stability and immediate weight bearing. The use of NPC has not been described in the upper extremity in the literature. We herein describe potential indications and surgical technique for NPC usage for complex upper extremity trauma and reconstruction.

The advent of value-based care as a component of the United States health care system is part of a broader paradigm shifting away from fee-for-service payment models in favor of alternative reimbursement incentives tied to quality and outcome metrics. Bundled care models, gainsharing agreements, and other cost containment measures, although promising, may induce unintended systemwide consequences for orthopedic trauma surgeons who often specialize in tending to costly multiply injured patients and marginalized populations. This article reviews facets of value-based care applicable to orthopedic trauma surgery with an emphasis on public health and ethical considerations for policymakers and orthopedic surgeons.

By the end of their training, all orthopaedic residents should be competent in understanding musculoskeletal research enough to navigate the literature and base clinical decisions on it. To accomplish this, the Accreditation Council for Graduate Medical Education requires involvement in scholarly activity. For those interested in academics and having additional involvement in research, there can be many benefits including professional achievement and intellectual /personal satisfaction. A number of potential career models exist for those interested in being engaged in musculoskeletal research, so trainees should seek the training and level of involvement in research that will help them achieve their individual academic goals. To that end, trainees should become involved with research early and identify research mentors in their field of interest (at home or from afar). Training programs and faculty members should create a milieu conducive to research productivity and support and equip trainees who have such aspirations.

INTRODUCTION/BACKGROUND:This study compared costs, length of visit, and utilization trends for patients with fractures seen in an immediate care orthopaedic center (I-Care) versus the emergency department (ED) in a major metropolitan area. METHODS:A retrospective chart review of consecutive patients seen on an outpatient basis in the ED and I-Care over a 6-month period was conducted. Patient demographics, procedures done, care category, estimated costs, and disposition information were included for statistical analysis. Within the low-acuity fracture care group, a cost-comparison analysis was conducted. RESULTS:A total of 610 patients met inclusion criteria with 311 seen in I-Care and 299 in the ER. I-Care patients were more likely to have low-acuity injuries compared with ED patients (60.1% versus 18.1%, P < 0.001). The length of visit was longer for patients seen in the ED compared with I-Care (6.1 versus 1.43 hours, P value < 0.001). A cost analysis of low-acuity patients revealed that an estimated $62,150 USD could have been saved in healthcare costs by the initial diversion of low-acuity patients seen in the ER to I-Care during the study period. DISCUSSION/CONCLUSIONS:These results suggest that the I-Care orthopaedic urgent care model is a more cost-effective and more efficient alternative to the ED for patients with fractures requiring procedural treatment and low-acuity patients managed on an outpatient basis.

The method of skin closure and post-operative wound management has always been important in orthopedic surgery and plays an even larger role now that surgical site infection (SSI) is a national healthcare metric for both surgeons and hospitals. Wound related issues remain some of the most feared complications following orthopedic trauma procedures and are associated with significant morbidity. In order to minimize the risk of surgical site complications, surgeons must be familiar with the physiology of wound healing as well as the patient and surgical factors affecting healing potential. The goal of all skin closure techniques is to promote rapid healing with acceptable cosmesis, all while minimizing risk of infection and dehiscence. Knowledge of the types of closure material, techniques of wound closure, surgical dressings, negative pressure wound therapy, and other local modalities is important to optimize wound healing. There is no consensus in the literature as to which closure method is superior but the available data can be used to make informed choices. Although often left to less experienced members of the surgical team, the process of wound closure and dressing the wound should not be an afterthought, and instead must be part of the surgical plan. Wounds that are in direct communication with bony fractures are particularly at risk due to local tissue trauma, resultant swelling, hematoma formation, and injured vasculature.

The dataset presented was collected via retrospective review from an orthopedic trauma database approved by the institutional review board at the author's institution from patients treated at any of the four hospitals serviced by the academic orthopedic surgery department. Femoral neck and intertrochanteric hip fracture patients from low energy mechanisms admitted between October 2014 and February 2020, were selected if they were age 55 or older and had recorded sex, body mass index (BMI), Charlson Comorbidity Index (CCI), American Society of Anaesthesiologists (ASA) physical status classification, Glasgow Coma Score, Abbreviated Injury Severity score for the chest, head and neck, and extremities, and ambulation status prior to injury. The resultant 1,590 subject dataset may be analysed via the supplied R statistical code to determine the frequency of equipoise in baseline and outcome variables from propensity matching via three matching schemes. The code implements three matching schemes including matching by (1) The Score for Trauma Triage in Geriatric and Middle-Aged (STTGMA) (2) CCI alone, or (3) a combination of sex, age, CCI and BMI. The code selects a subset of ten percent of hip fracture patients by a pseudorandom number generator (PRNG). The code matches the remaining patients 1:1 to the selected patients by propensity score generated by logistic regression of STTGMA, CCI, or a combination of sex, age, CCI and BMI using greedy nearest neighbor matching without replacement by the MatchIt package for R software. The code then compares matched cohorts by Chi-square, Fisher, or Mann-Whitney U test with significance level of 0.05 representing a 5% chance of significant differences due to random sampling of subjects. The supplied code repeats the random selection, matching and testing process 100,000 times for each matching method. The resultant code output is the frequency of significantly different demographic or outcome parameters among matched cohorts by matching method. This data and statistical code have reuse potential to explore alternative matching schemes. The supplied baseline variables should be robust enough to derive alternative risk scores for each patient which may be included as a matching variable for comparison. The authors also look forward to unexpected ways that this data may be used by readers.