Faculty Bibliography

OBJECTIVES/OBJECTIVE:To examine the feasibility of a novel anesthetic option for hip fracture fixation with short cephalomedullary nails. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:An urban, academic level 1 trauma center, a tertiary care academic medical center, and an orthopedic specialty hospitalPatients/Participants: 20 recent and 40 risk-matched (1:1:1 by anesthesia type) historical hip fracture patients. INTERVENTION/METHODS:All patients with an OTA 31.A1-3 IT hip fracture presenting from October 1st 2019 - March 31st, 2020 treated with a short cephalomedullary nail (CMN) underwent a new intraoperative anesthesia protocol using monitored anesthesia care (MAC) and soft-tissue infiltration with local anesthesia (STILA). MAIN OUTCOME MEASUREMENTS/METHODS:Intraoperative measures, postoperative pain scores, narcotic and acetaminophen use, hospital quality measures, and inpatient cost. RESULTS:A total of 60 patients (20 each: MAC, general, spinal) were identified. There were differences among the groups regarding mean minimum and maximum intraoperative heart rate with MAC-STILA protocol demonstrating the best maintenance of normal heart rate parameters (60-100 bpm). For the first 3 hours post-operatively, MAC-STILA patients reported consistently lower pain scores (VAS <1) than spinal or general patients (VAS>1). Through 48 hours postoperatively, MAC-STILA narcotic usage was similar to that of the spinal cohort and approximately five times less than the general cohort. There were no differences in procedural time, length of stay, minor or major complications, inpatient and 30-day mortality, or 30-day readmissions, or post-operative ambulatory distance. There was no difference in inpatient cost among cohorts. CONCLUSIONS:This feasibility study demonstrates safety for the MAC-STILA protocol with comparison to spinal and general anesthesia. The MAC-STILA protocol is a viable option for treatment of OTA 13.A1-3 IT fractures with a short CMN, and may be the preferred method for patients with severe medical co-morbidities or relative contraindications to general and/or spinal anesthesia. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

PURPOSE/OBJECTIVE:This study sought to compare postoperative outcomes and complications between patients with distal humerus fractures treated with open reduction and internal fixation (ORIF) of their non-dominant versus dominant arm. METHODS:A retrospective review of all patients who sustained a distal humerus fracture treated operatively with ORIF at one academic institution between 2011 and 2015 was performed. Measured outcomes included complications, time to fracture union, painful hardware, removal of hardware, Mayo Elbow Performance Index (MEPI), and elbow range of motion. Differences in outcomes between patients who underwent surgery of their dominant upper extremity and those who underwent surgery of their non-dominant extremity were assessed. RESULTS:Sixty-nine patients met inclusion criteria. Forty (58.0%) underwent ORIF of a distal humerus fracture on their non-dominant arm and 29 (42.0%) on their dominant arm. Groups did not differ with respect to demographics, injury information, or surgical management. Mean overall follow-up was 14.1 ± 10.5 months, with all patients achieving at least 6 months follow-up. The non-dominant cohort experienced a higher proportion of postoperative complications (P = 0.048), painful hardware (P = 0.018), and removal of hardware (P = 0.002). At latest follow-up, the non-dominant cohort had lower MEPI scores (P = 0.037) but no difference in elbow arc of motion (P = 0.314). CONCLUSION/CONCLUSIONS:Patients who sustained a distal humerus fracture of their non-dominant arm treated with ORIF experienced more postoperative complications, reported a greater incidence of painful hardware, underwent removal of hardware more often, and had worse functional recovery in this study. Physicians should emphasize the importance of physical therapy and maintaining arm movement especially when the non-dominant arm is involved following distal humerus fracture repair. LEVEL OF EVIDENCE/METHODS:Level III.

Introduction/UNASSIGNED:Type II distal clavicle fractures are associated with significant displacement and high rates of nonunion. Due to the risk of nonunion, these fractures are most often managed operatively soon after the injury. Case Report/UNASSIGNED:We present an 84-year-old male who sustained a Type II closed distal clavicle fracture that converted to an open fracture 1 month following initial injury. The patient underwent surgical repair with open reduction internal fixation and coracoclavicular ligament reconstruction. Following surgery, the patient experienced hardware failure with nonunion. He did not have any residual soft-tissue problems. Conclusion/UNASSIGNED:Delaying surgical treatment of significantly displaced Type II distal clavicle fractures may pose a risk of conversion to open fracture. Surgeons should counsel their patients on this potential complication when discussing the risks and benefits of operative versus nonoperative treatment.

INTRODUCTION/BACKGROUND: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/OBJECTIVE:Patients' health expectations will correlate with treatment outcomes following surgical repair of proximal humerus fractures. MATERIAL AND METHODS/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:One hundred and eighty-five (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/CONCLUSIONS: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/METHODS:II; Retrospective Study.

This case presentation and surgical technique demonstrates a complete distal triceps tendon rupture repair with single-row suture anchor fixation through a posterior midline approach to the elbow in a 17-year-old male rugby player. Key procedure points include complete triceps mobilization for adequate excursion to facilitate repair, identification of the ulnar nerve, isolation and sharp debridement of torn tissue to healthy tendon, thorough debridement of the olecranon reattachment site, suture construct, and order of fixation to optimize tendon-bone apposition.

SUMMARY:There are a variety of treatment options available for proximal humerus fractures, including nonoperative management, open reduction internal fixation with screws, locking plates, intramedullary nailing, or suture fixation, and arthroplasty, including hemiarthroplasty and total shoulder replacements. Fracture characteristics, including the number of fracture parts and involvement of the humeral head and glenoid and the patient's functional status and postoperative goals help dictate the optimal choice. Although the indications for hemiarthroplasty as treatment for severe proximal humerus fractures have narrowed, the authors believe that there is a still a place for this technique in practice.

SUMMARY:High-energy tibial plateau fractures are associated with knee fracture dislocations and concomitant ligamentous injury. Both bony and ligamentous injuries can require surgical fixation, often requiring a multidisciplinary team and staged treatment. This article and accompanying video describe the workup and treatment of a Moore type 4 tibial plateau rim compression fracture with posterolateral corner and anterior cruciate ligament rupture that underwent open reduction internal fixation of the tibial plateau with posterolateral corner reconstruction and then staged anterior cruciate ligament reconstruction with quad tendon autograft.

OBJECTIVES/OBJECTIVE:To evaluate the outcomes of patients who underwent soft tissue flap coverage during treatment of a tibia fracture nonunion. DESIGN/METHODS:Retrospective analysis on prospectively collected data. SETTING/METHODS:Academic medical center. PATIENTS/PARTICIPANTS/METHODS:157 patients were treated for a fracture nonunion following a tibia fracture over a 15-year period. Sixty-six had sustained an open tibial fracture initially and 25 of these patients underwent soft tissue flaps for their open tibia fracture nonunion. INTERVENTION/METHODS:Manipulation of soft tissue flaps, either placement or elevation for graft placement in ununited previously open tibial fractures. MAIN OUTCOME MEASUREMENTS/METHODS:Bony healing, time to union, ultimate soft tissue status, postoperative complications, and functional outcome scores using the Short Musculoskeletal Functional Assessment (SMFA). This group was compared to a group of open tibial fracture nonunions that did not undergo soft tissue transfer. RESULTS:Bony healing was achieved in 24/25 patients (96.0%) who received flaps at a mean time to union of 8.7 ± 3.3 months compared to 39/41 patients (95.1%) at a mean 7.5 ± 3.2 months (p > 0.05) in the non-coverage group. Healing rate and time to union did not differ between groups. At latest follow-up, the flap coverage group reported a mean SMFA index of 17.1 compared to an SMFA index of 27.7 for the non-coverage group (p = 0.037). CONCLUSIONS:Utilization of soft tissue flaps in the setting of open tibia shaft nonunion repair surgery are associated with a high union rate (>90%). Coverage with or manipulation of soft tissue flaps did not result in improved bony healing rate or time to union compared to those who did not require flaps. However, soft tissue flap coverage was associated with higher functional scores at long-term follow-up. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

SUMMARY:There are a variety of ways to treat chronic elbow dislocations, including repeat closed reduction and immobilization, transarticular pinning, temporary bridge plating, hinged or rigid external fixation, and internal fixator application. Although each have distinct advantages and disadvantages, avoiding recurrent instability is critical. The internal-fixator is a relatively new option to maintain a stable, concentric reduction and facilitate early range of motion. This article and accompanying video describe the surgical technique of using an internal joint stabilizer for treatment of a chronically unstable ulnohumeral joint.

SUMMARY:A 58-year-old woman with a proximal 1/3 humeral shaft nonunion presented 2 years after initial injury. We present a technique for nonunion repair, including nonunion site preparation, direct compression of the fracture site using plate osteosynthesis, and iliac crest bone graft harvest and utilization. The purpose of this video is to review humeral shaft nonunion literature and describe our management technique.