Faculty Bibliography

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.

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.

Introduction/UNASSIGNED:Insufficiency fractures are uncommon injuries, but may occur in the lower extremity due to repetitive stress on abnormal bone tissue. Management of these injuries may include weight bearing restrictions, bracing, or even surgical intervention. In addition, a proper metabolic healing environment is required to encourage healthy bone growth following an injury. Case Presentation/UNASSIGNED:This case report discusses a patient who underwent surgical repair of a closed nondisplaced proximal tibia insufficiency fracture. Several reoperations were required due to hardware failure and bone resorption following operative nonunion repair. It was determined that her elevated PTH due to end-stage renal disease (ESRD) likely inhibited bone regeneration during the course of her treatment. A successful kidney transplant rapidly normalized the patient's PTH levels and permitted bony healing of her tibial stress fracture. Conclusion/UNASSIGNED:Several studies have demonstrated a relationship between metabolic abnormalities and fracture healing. We are the first to present a case where bony union in an ESRD patient with secondary hyperparathyroidism was only achieved following a kidney transplant. Surgeons should be cognizant of the effect that metabolic abnormalities may have in the development of insufficiency fractures and subsequently achieving bony union following such fractures.

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.

BACKGROUND:The purpose of this study is to determine if treated psychological depression is associated with poorer functional outcomes in patients who sustain tibial plateau fractures. METHODS:Patients with a tibia plateau fracture were prospectively followed. Functional status was assessed using the Short Musculoskeletal Function Assessment (SMFA) at baseline (pre-injury), 3 months, 6 months, and 1 year post injury. Clinical outcomes were recorded at each follow up visit and radiographic outcomes were obtained from follow up radiographs. Records were reviewed to identify patients who were being treated for major depressive disorder (MDD). SMFA scores and clinical outcomes were compared between the depression and no depression cohorts. RESULTS:420 patients were treated for a tibial plateau fracture and the mean age was 50.83 ± 15.60 years. Forty-two (10%) patients with 42 fractures were being treated for MDD at the time of their fracture. Patients with MDD were older (p = 0.05) and were more likely female (p < 0.01). At baseline, the clinical depression cohort had worse Total SMFA scores compared to the non-depressed cohort (5.90 ± 14.41 vs. 2.69 ± 8.35, p < 0.01). There were no differences in total SMFA score or any SMFA subscores at 3, 6, and 12 months. The incidence of wound complications, reoperations, and radiographic outcomes also did not differ between the cohorts. CONCLUSION/CONCLUSIONS:Despite patients with MDD reporting higher SMFA (poorer) scores at baseline, MDD was not associated with worse injuries, diminished clinical or poorer functional outcomes following tibial plateau fractures.

INTRODUCTION:The purpose of this study is to determine whether the Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) patients is able to predict fall, fracture, periprosthetic fracture, or dislocation risk after femoral neck fracture arthroplasty surgery. METHODS:Four hundred one patients who underwent hip arthroplasty surgery after a femoral neck fracture at one urban academic medical center were stratified into groups based on their risk scores assigned at femoral neck fracture presentation. The cohort was reviewed for the occurrence of postdischarge falls, secondary fractures, and prosthetic dislocations that resulted in a presentation to the emergency department (ED) after discharge from their hip fracture surgery. The incidence and timing of these complications after discharge were compared between the low-risk and high-risk groups. RESULTS:The low-risk group included 201 patients, and the high-risk group included 200 patients. The high-risk group had significantly more postdischarge falls resulting in ED presentation (49 vs. 32, p = .035) that occurred significantly sooner (12.6 vs. 18.3 months, p = .034) after discharge. CONCLUSIONS:The STTGMA model was able to successfully stratify patients who are at a higher risk of sustaining a fall after an arthroplasty procedure for a femoral neck fracture.

OBJECTIVES/OBJECTIVE:To assess the outcomes of patients who underwent closed reduction and percutaneous pinning (CRPP) with cannulated screws for treatment of a displaced femoral neck fracture (DFNF) as they were deemed too high risk to undergo hemiarthroplasty (HA). DESIGN/METHODS:Prospective cohort study. SETTING/METHODS:One urban academic medical center. PATIENTS/PARTICIPANTS/METHODS:Sixteen patients treated with CRPP and 32 risk-level-matched patients treated with HA. INTERVENTION/METHODS:CRPP for patients with DFNFs who were deemed too ill to undergo HA. The concept being that CRPP would aid in pain control and facilitate mobilization and if failed, the patient could return electively after medical optimization for conversion to arthroplasty. MAIN OUTCOME MEASUREMENTS/METHODS:Complications, readmissions, mortality, inpatient cost, and functional status. RESULTS:The CRPP cohort had a greater incidence of exacerbations of chronic medical conditions or new onset of acute illness and an elevated mean American Society of Anesthesiologist score. There were no differences in discharge location, length of stay, major complication rate, ambulation before discharge, or 90-day readmission rate. Patients undergoing CRPP were less likely to experience minor complications including a significantly decreased incidence of acute blood loss anemia. Three patients (18.7%) in the CRPP cohort underwent conversion to HA or THA. There was no difference in inpatient, 30-day, or 1-year mortality. CONCLUSION/CONCLUSIONS:In the acutely ill patients with DFNFs, "damage control" fixation with CRPP can be safely performed in lieu of HA to stabilize the fracture in those unable to tolerate anesthesia or the sequelae of major surgery. Patients should be followed closely to evaluate the need for secondary surgery. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

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.