Faculty Bibliography

Lewis Albert Sayre (1820-1900) is one of the key figures in the history of American orthopedic surgery who left an indelible mark on the field. Sayre dedicated much of his career to teaching and practicing orthopedics in New York City and is considered to be one of the "fathers" of orthopedics in America. Sayre's career was defined by his development of novel, innovative treatments to attempt to improve the lives of his patients. Two of the treatments he is most well-known for developing are "exsection of the hip" for treating "Morbus Coxarius" and the plaster of Paris jacket used for treating spinal deformities caused by Pott's disease or scoliosis. Although Sayre's developments are no longer used today, examining them can help us to reflect on the orthopedic principles he sought to apply in the 19th Century as well as how Sayre's treatments have shaped the interventions that we use to care for patients today.

Purpose/UNASSIGNED:To assess risk factors and associated outcomes of acute kidney injury (AKI) in hip fracture patients. Methods/UNASSIGNED:Risk factors for AKI were identified by multivariate logistic regression. AKI patients were matched to patients who did not experience AKI using a validated trauma triage score. Comparative analyses between matched groups were performed. Results/UNASSIGNED:Risk factors of AKI included increasing Charlson Comorbidity Index and use of anticoagulation medications. AKI was associated with increased likelihood of medical complications and longer, more costly hospital stays. Discussion/UNASSIGNED:

Purpose/UNASSIGNED:To evaluate outcomes for a combined osteoligamentous reconstruction technique for Neer Type IIB clavicle fractures. Methods/UNASSIGNED:Patients with Neer Type IIB clavicle fractures treated with combined clavicular locking plate and coracoclavicular ligament suture reconstruction were identified. Demographics, clinical outcomes, and radiographic outcomes were collected. Results/UNASSIGNED:Twenty-four patients with mean 13 months of follow-up were included. Bony union and normal radiographic coracoclavicular relationship were achieved in 23 (96%) patients. The mean UCLA Shoulder score was 33.3. Three (13%) complications occurred. Discussion/UNASSIGNED:The combined osteoligamentous reconstruction approach as described is a successful option for treating Neer Type IIB clavicle fractures.

OBJECTIVES:To determine the factors associated with successful union and eradication of infection in the setting of staged procedures to treat obviously infected nonunions of long bones. We hypothesize that patients with positive intraoperative cultures obtained at the time of definitive surgery for infected nonunions are more likely to have persistent nonunion than those with negative cultures. DESIGN:Multicenter retrospective review. SETTING:Eight academic Level 1 trauma centers. PATIENTS/PARTICIPANTS:Patients who underwent staged management for obviously infected nonunion of a long bone. MAIN OUTCOME MEASUREMENTS:For each patient, initial fracture management, management of retained implants, number of debridements, grafting, bacteriology, antibiotic course, bone defect management, soft-tissue coverage, and definitive surgery performed were reviewed. RESULTS:A total of 134 patients were treated with staged procedures for obviously infected nonunion of a long bone (mean age 49 years, 60% open fractures, and mean follow-up 22 months). During definitive procedures, 120 patients had intraoperative cultures taken with 43% having positive cultures. For culture-positive patients, 41 patients achieved eventual union and 10 had persistent nonunion. Of 69 culture-negative patients, 66 achieved eventual union and 3 had persistent nonunion. The number of patients with union versus persistent nonunion was statistically significant between culture-positive and culture-negative groups (P = 0.015). CONCLUSIONS:Management of infected nonunion in long bones with staged treatments before definitive fixation are beneficial but ultimately less effective when performed in the setting of positive bacterial cultures at the time of definitive management. LEVEL OF EVIDENCE:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

PURPOSE/OBJECTIVE:The ability to predict contracture development after elbow fracture would benefit patients and physicians. This study aimed to identify factors associated with the development of posttraumatic elbow joint contracture. METHODS:A retrospective review of elbow fractures (AO/Orthopaedic Trauma Association [OTA] type 13 and 21) treated at one institution between 2011 and 2015 was performed. Data collected included demographics, injury information, treatment, and postoperative elbow range of motion (ROM). Multivariate logistic regression analyses were performed to identify factors associated with contracture development. Notable contracture was defined as an arc of motion less than 100° flexion/extension, which has been associated with reduced ability to perform activities of daily living. RESULTS:A total of 278 patients at least 1 8 years of age underwent surgical repair of an elbow fracture or fracture-dislocation during the study period and had at least 6 months of postoperative follow-up. Forty-two (15.1%) developed a clinically notable elbow contracture, of whom 29 (69.0%) developed heterotopic ossification (HO). Multivariate analysis of preoperative variables demonstrated that AO/OTA 13-C fracture classification (odds ratio [OR], 13.7, P = 0.025), multiple noncontiguous fractures (OR, 3.7, P = 0.010), and ulnohumeral dislocation at the time of injury (OR, 4.9, P = 0.005) were independently associated with contracture development. At 6 weeks postoperatively, an arc of elbow ROM less than 50° flexion/extension (OR, 23.0, P < 0.0005) and the presence of HO on radiographs (OR, 6.7, P < 0.0005) were found to be independent risk factors for significant elbow stiffness. DISCUSSION/CONCLUSIONS:Ulnohumeral dislocation, multiple noncontiguous fractures, AO/OTA 13-C fracture classification, limited elbow ROM at 6 weeks postoperatively, and the presence of radiographic HO at 6 weeks postoperatively are associated with contracture development after surgical elbow fracture repair. Patients with these risk factors should receive aggressive physical therapy and be counseled as to the possible development of a contracture requiring surgical intervention.

INTRODUCTION/BACKGROUND:It is important to understand the current characteristics of orthopaedic surgery program leadership, especially in the current climate of modern medicine. The purpose of this report was to describe the demographic, academic, and geographic characteristics of current orthopaedic chairs and program directors (PDs). METHODS:Orthopaedic surgery residency programs were obtained from the Accreditation Council for Graduate Medical Education website and cross-referenced with the Electronic Residency Application Service, identifying 161 residency programs for the 2018 to 2019 cycle. All data were collected in January 2020 to best control for changes in leadership. Demographic and academic information were collected from public websites. For geographic analysis, the United States was divided into five regions, and training locations were categorized as appropriate. RESULTS:A total of 153 chairs and 161 PDs were identified. 98.0% of chairs were men versus 88.8% of PDs (P = 0.001). Chairs had been in practice and in their current position for longer than PDs (26.4 vs 16.8 years [P < 0.005] and 9.1 vs 7.1 years [P = 0.014], respectively). Chairs had more publications and were more likely to be professors than PDs. PDs were more likely to remain at both the same region and institution that they trained in residency. The most common subspecialty was sports among chairs and trauma among PDs, although when compared with national averages orthopaedic trauma and orthopaedic oncology were the most overrepresented subspecialties. CONCLUSION/CONCLUSIONS:Orthopaedic chairs are more likely to be men, have had longer careers, and have more academic accomplishments than their PD counterparts. Geography appears to have an association with where our leaders end up, especially for PDs. Subspecialization does not notably influence leadership positions, although orthopaedic trauma and orthopaedic oncology surgeons are more commonly represented than expected. This report serves to identify the current state of orthopaedic leadership and may provide guidance for those who seek these leadership positions.

OBJECTIVES:To evaluate monetary trends in government (Medicare) reimbursement rates for 20 commonly used orthopedic trauma surgical procedures over a 20-year period. METHODS:The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried for the 20 common Current Procedural Terminology (CPT) codes in orthopaedic trauma, and reimbursement data were extracted. All monetary data were adjusted for inflation to 2020 US dollars (USD) using changes to the US Consumer Price Index. Both the average annual and the total percentage change in reimbursement and in Relative Value Units were calculated for all included procedures. RESULTS:After adjusting for inflation, the average reimbursement for all procedures decreased by 30.0% from 2000 to 2020. Total Relative Value Units during this time increased by 4.4% on average. Procedures about the foot and ankle demonstrated the greatest decrease in the mean adjusted reimbursement at -42.6%, whereas procedures about the shoulder and upper extremity demonstrated the smallest mean decrease at 23.7% during the study period. From 2000 to 2020, the adjusted reimbursement rate for all included procedures decreased by an average of 1.5% each year. CONCLUSION:To the best of our knowledge, this is the first study to comprehensively evaluate trends in procedural Medicare reimbursement for orthopaedic trauma. When adjusted for inflation, Medicare reimbursement for included procedures has steadily decreased from 2000 to 2020. Increased awareness and consideration of these trends will be important for policy makers, hospitals, and surgeons to assure continued access to meaningful surgical orthopaedic trauma care in the United States.

BACKGROUND:Tibial shaft fractures (TSFs) are among the most common long bone injuries often resulting from high-energy trauma. To date, musculoskeletal complications such as fracture-related infection (FRI) and compromised fracture healing following fracture fixation of these injuries are still prevalent. The relatively high complication rates prove that, despite advances in modern fracture care, the management of TSFs remains a challenge even in the hands of experienced surgeons. Therefore, the Fracture-Related Outcome Study for operatively treated Tibia shaft fractures (F.R.O.S.T.) aims at creating a registry that enables data mining to gather detailed information to support future clinical decision-making regarding the management of TSF's. METHODS:This prospective, international, multicenter, observational registry for TSFs was recently developed. Recruitment started in 2019 and is planned to take 36 months, seeking to enroll a minimum of 1000 patients. The study protocol does not influence the clinical decision-making procedure, implant choice, or surgical/imaging techniques; these are being performed as per local hospital standard of care. Data collected in this registry include injury specifics, treatment details, clinical outcomes (e.g., FRI), patient-reported outcomes, and procedure- or implant-related adverse events. The minimum follow up is 12 months. DISCUSSION/CONCLUSIONS:Although over the past decades, multiple high-quality studies have addressed individual research questions related to the outcome of TSFs, knowledge gaps remain. The scarcity of data calls for an international high-quality, population-based registry. Creating such a database could optimize strategies intended to prevent severe musculoskeletal complications. The main purpose of the F.R.O.S.T registry is to evaluate the association between different treatment strategies and patient outcomes. It will address not only operative techniques and implant materials but also perioperative preventive measures. For the first time, data concerning systemic perioperative antibiotic prophylaxis, the influence of local antimicrobials, and timing of soft-tissue coverage will be collected at an international level and correlated with standardized outcome measures in a large prospective, multicenter, observational registry for global accessibility. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov : NCT03598530 .

Introduction: The purpose of this study is to evaluate the relationship between patients"™ own health expectations and treatment outcomes following surgical repair of proximal humerus fractures. Hypothesis: Patients"™ health expectations will correlate with treatment outcomes following surgical repair of proximal humerus fractures. Material and methods: Over a 14-year period, 247 patients with a displaced proximal humerus fracture who underwent ORIF with locking compression plates were prospectively followed at one academic institution. Minimum follow-up period was 12 months. Patient-reported functional outcome data for the latest follow up visit (12 months and greater) was obtained from Disabilities of Arm, Shoulder, and Hand (DASH) questionnaires. Survey responses regarding health expectations were recorded at 3-month follow-up and converted to dichotomous variables. Two groups were identified: the high expectations and the low expectations groups. Statistical analysis comparing the two groups and their functional and clinical outcomes was performed using the independent t-test, using p < 0.05 for significance. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated to further statistically characterize the relationship between health expectations at 3 months and long-term outcomes. Results: 185 (75.0%) patients available for analysis with a mean follow-up length of 24.8 months. The cohort included 124 (67%) females and 61 (33%) males and the average age at time of injury was 59.5 years. Eighty-six (46.5%) patients had low expectations for their overall health and 99 (53.5%) patients had high expectations for their health. No significant differences were seen between groups in regards to age, gender, follow-up length, Charlson Comorbidity Index (CCI), smoking and tobacco use, fracture pattern (OTA and Neer classifications), early complications (p > 0.05), fracture healing, and avascular necrosis. The mean DASH score at the latest follow up for patients with low expectations was 31.42 ± 22.8 whereas the mean for those with high expectations was 16.76 ± 20.2 (p < 0.0005). The mean forward flexion of the shoulder for patients with low expectations was 137.8 ± 31.5 degrees as compared to 148.5 ± 26.3 degrees (p < 0.05). The positive predictive value of good expectations correlating with good outcomes was 71,7%. Discussion: Patients with high expectations for their health early following injury had better outcomes in the long term. These high expectations also appeared to have an optimal influence on range of shoulder motion. This data suggests attitudinal and psychological factors that affect patient health expectations early on in the course of treatment may also influence patients"™ functional and clinical outcomes. Level of evidence: II; Retrospective Study.

BACKGROUND:The number of reverse total shoulder arthroplasties (RTSAs) performed annually has increased, and the indications for RTSA have expanded beyond rotator cuff arthropathy to include treatment of complex proximal humeral fractures. No studies exist comparing clinical, functional, and radiographic outcomes in patients receiving RTSA for the treatment of acute fracture vs. those undergoing the procedure for degenerative conditions. This study was designed to fill the void in this knowledge gap. We hypothesized that patients undergoing RTSA for fracture treatment would experience worse clinical outcomes than those undergoing elective RTSA. METHODS:A prospectively collected database was queried for patients undergoing RTSA between 2007 and 2016. Patients were sorted based on the indication for RTSA: treatment of acute proximal humeral fracture vs. "elective" treatment of degenerative conditions of the shoulder. Baseline demographic characteristics, intraoperative and perioperative complications, and clinical, functional, and radiographic outcomes were collected. Only patients with ≥2 years' follow-up were included. Final outcomes were compared between the fracture and elective groups. RESULTS:In total, 1984 patients met the inclusion criteria, with 1876 in the elective group and 108 in the fracture group. Compared with the elective RTSA group, the group undergoing RTSA for fracture treatment was older, was female dominant, and was less likely to have undergone a previous operation on the ipsilateral shoulder. RTSA for fracture was associated with a longer hospital length of stay and greater intraoperative blood loss. The incidence of postoperative adverse events was 7.1% in the elective group vs. 4.6% in the fracture group. Functional outcomes did not differ beyond 1 year or at mean final follow-up > 40 months. CONCLUSION/CONCLUSIONS:Despite differences in patient demographic characteristics, the outcome and complication profiles are similar between patients undergoing RTSA for acute fracture and those indicated for the treatment of degenerative conditions of the shoulder.