Faculty Bibliography

PURPOSE/OBJECTIVE:The purpose of this study is to determine if the radiographic humerus union measurement (RHUM) is predictive of union in humeral shaft fractures treated nonoperatively. METHODS:All patients with long bone fracture nonunion presenting to a single surgeon were enrolled in a prospective registry. This registry was queried to identify patients with humeral shaft fractures treated nonoperatively and developed nonunion. The nonunion cohort was matched to a three to one gender- and age-matched control group that were treated nonoperatively for a humeral shaft fracture and achieved union. Two fellowship-trained orthopedic traumatologists blinded to eventual union scored radiographs obtained 12 weeks after injury using the RHUM. A binomial logistic regression determined the effect of the RHUM on the likelihood of developing union. RESULTS:Nine patients with humeral shaft fractures treated nonoperatively with radiographs 12 weeks after injury that developed nonunion were identified. These patients were matched to 27 controls. Logistic regression demonstrated the RHUM was a significant predictor of healing 12 weeks after humeral shaft fracture treated nonoperatively (p = 0.014, odds ratio 9.434, 95% CI for OR 1.586-56.098). All patients with RHUM below 7 went on to nonunion. All patients with RHUM above 8 healed. Three of seven patients (43%) with RHUM of 7 or 8 healed. CONCLUSION/CONCLUSIONS:The RHUM demonstrated an increased likelihood of achieving union 12 weeks after injury. Orthopedic surgeons can counsel patients that fractures with RHUM scores of 6 or below are in danger of developing nonunion and can target interventions appropriately.

The purpose of this study was to compare the functional outcomes of diabetic patients who were treated for a fracture nonunion against matched controls. Sixty-one diabetic patients (type 1 or type 2) were identified from a prospective database. This cohort was paired with matched controls and univariate analysis was performed to evaluate for differences in complication rates, time to bony union and functional outcomes at 3, 6, 12, and greater than 24 months post-operatively.The diabetic group was composed of 29 females and 32 males, with an average age of 58 years, and 17 upper extremity nonunions and 43 lower extremity nonunions. Time to bony union, complication rate or functional outcomes at any follow-up time point did not significantly differ between groups. The comorbidity of diabetes mellitus does not lead to worse functional outcomes or increased complications following surgical treatment for a fracture nonunion.

CASE/METHODS:Two patients who developed radial nerve palsy at least 6 weeks after injury during nonoperative treatment of humeral shaft fractures. This complication was associated with external bracing, progressive varus angulation during treatment, and excess callus formation. CONCLUSION/CONCLUSIONS:Delayed radial nerve palsy may develop during nonoperative treatment of humeral shaft fractures when functional bracing fails to maintain alignment and stability at the fracture site.

BACKGROUND:The number of individuals turning to cycling for physical activity and commuting has been expanding across the US. However, studies have demonstrated that when compared to motor vehicle accidents, cyclists in major cities have a significantly increased risk of injuries requiring hospitalizations. The purpose of this study was to assess if a correlation exists between the growing cyclist volume in a densely populated metropolitan city and prevalence of clavicle fractures requiring inpatient hospital admissions. HYPOTHESIS/OBJECTIVE:A correlation exists between the increased number of cyclists and the increasing number of clavicle fractures requiring inpatient hospital admissions. METHODS:Patients who sustained a clavicle fracture that required an inpatient admission were identified using the New York Statewide Planning and Research Cooperative System (SPARCS). The location of hospital admission was screened using New York City (NYC) hospital county codes, as only clavicle fractures presenting to NYC hospitals were included in the analysis. This study was exempt from Institutional Review Board (IRB) approval. Public transportation data was available through the Department of Transportation (DOT) and The Decennial Census. These databases are publicly available and are performed to assess if New Yorkers are using cycling as a mode of transportation. The cycling data included the following information in a given year: the number of people in NYC who use a bicycle as their primary mode of commuting to work, the number of daily cycling trips, total bicycle protected bike lane mileage, midtown Manhattan cycling counts and East River Bridge cycling counts. Spearman's correlation analysis was conducted between the numbers of patients with clavicle fractures per year and the described data for that specific year. Additionally, the number of bicycle-share program miles traveled per month and total number of cycling trips that month were obtained from the public bicycle-sharing program database from June 2013 through June 2015. Spearman's correlation analysis was conducted between the numbers of patients with clavicle fractures per month and total bicycle-sharing miles and trips traveled per month. RESULTS:The increasing daily cycling trips in NYC has a strong correlation with the increasing number of clavicle fractures in NYC (rs = .979, p < 0.001). The increasing use of a bicycle as transportation to work has a strong positive correlation with the increasing number of clavicle fractures in NYC (rs = .988, p < 0.001). There was a strong positive correlation between the mileage of bicycle lanes in NYC and the number of clavicle fractures (rs = .867, p = 0.001). A strong positive correlation exists between NYC clavicle fracture number and public bicycle-sharing miles (rs = .819, p < 0.001) and trips (rs = .811, p < 0.001). CONCLUSION/CONCLUSIONS:There are many physical benefits to cycling. Cycling, as a means of transportation, has been encouraged to decrease CO2 emissions from vehicular transportation. These benefits do not come without risks, as this study shows a correlation between increased cycling and clavicle fractures. CLINICAL RELEVANCE/CONCLUSIONS:Physicians and public health officials should be aware of the dangers of cycling in major cities in order to create safer routes for this environmentally beneficial route of transportation.

OBJECTIVES/OBJECTIVE:To develop a tool that can be used preoperatively to identify patients at risk of poor functional outcome following operative repair of fracture nonunion. DESIGN/METHODS:Retrospective analysis of prospectively collected data. SETTING/METHODS:Academic medical center. PATIENTS/PARTICIPANTS/METHODS:Three hundred twenty-eight patients who underwent operative repair of a fracture nonunion were prospectively followed for a minimum of 12 months post-operatively. INTERVENTION/METHODS:After randomization, 223 (68%) patients comprised an experimental cohort and 105 (32%) patients comprised a separate validation cohort. Within the experimental cohort, forward stepwise multivariate logistic regression was applied to 17 independent variables to generate a predictive model identifying patients at risk of having a poor functional outcome [Predicting Risk of Function in Trauma-Nonunion (PRoFiT-NU) Score]. MAIN OUTCOME MEASUREMENTS/METHODS:Functional outcomes were assessed using the Short Musculoskeletal Function Assessment (SMFA). Poor outcome was defined as an SMFA function index greater than 10 points above the mean at 12 months post-operatively. RESULTS:Significant predictors of poor outcome were lower extremity nonunion [odds ratio (OR) = 3.082; P = 0.021], tobacco use (OR = 2.994; P = 0.009), worker's compensation insurance (OR = 3.986; P = 0.005), radiographic bone loss (OR = 2.397; P = 0.040), and preoperative SMFA function index (OR = 1.027; P = 0.001). The PRoFiT-NU model was significant and a good predictor of poor functional outcome (χ(5) = 51.98, P < 0.0005; area under the receiver operating curve = 0.79). Within the separate validation cohort, 16% of patients had a poor outcome at a PRoFiT-NU score below 25% (low risk), 39% of patients had a poor outcome at a PRoFiT-NU score between 25% and 50% (intermediate risk), and 63% of patients had a poor outcome at a PRoFiT-NU score above 50% (high risk). CONCLUSIONS:The PRoFiT-NU score is an accurate predictor of poor functional outcome following fracture nonunion repair. LEVEL OF EVIDENCE/METHODS:Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence description of levels of evidence.

Fracture-related infections (FRIs) are among the most common complications following fracture fixation, and they have a huge economic and functional impact on patients. Because consensus guidelines with respect to prevention, diagnosis, and treatment of this major complication are scarce, delegates from different countries gathered in Philadelphia in July 2018 as part of the Second International Consensus Meeting (ICM) on Musculoskeletal Infection. This paper summarizes the discussion and recommendations from that consensus meeting, using the Delphi technique, with a focus on FRIs. A standardized definition that was based on diagnostic criteria was endorsed, which will hopefully improve reporting and research on FRIs in the future. Furthermore, this paper provides a grade of evidence (strong, moderate, limited, or consensus) for strategies and practices that prevent and treat infection. The grade of evidence is based on the quality of evidence as utilized by the American Academy of Orthopaedic Surgeons. The guidelines presented herein focus not only on the appropriate use of antibiotics, but also on practices for the timing of fracture fixation, soft-tissue coverage, and bone defect and hardware management. We hope that this summary as well as the full document by the International Consensus Group are utilized by those who are charged with musculoskeletal care internationally to optimize their management strategies for the prevention and treatment of FRIs.

The purpose of this study is to determine when functional outcome no longer improves following tibial plateau fracture. A patient series of operatively treated tibial plateau fractures was reviewed. Patients were evaluated using the short musculoskeletal function assessment (SMFA), range of motion (ROM) assessment, and pain levels at visual analog scale (VAS) at 3, 6, and 12 months postoperatively. Fractures were classified by the Schatzker's classification using preoperative imaging. The case series was divided into two groups based on fracture patterns. Friedman's tests were conducted to determine if there were differences in SMFA, ROM, or VAS throughout the postoperative course. A total of 117 patients with tibial plateau fractures treated operatively, with complete follow-up and without complication, were identified. Seventy-seven patients (65.8%) sustained lateral tibial plateau fractures (Schatzker's I-III). Friedman's test demonstrated significant differences in SMFA (p < 0.0005) and ROM (p < 0.0005) at the three time points. Post hoc analysis demonstrated a significant difference in SMFA (p < 0.0005) and ROM (p = 0.003) between 3 and 6 months postoperatively but no significant difference in either metric between 6 and 12 months postoperatively. Friedman's test demonstrated no significant difference in VAS postoperatively (p = 0.210). Forty patients (34.2%) sustained medial or bicondylar tibial plateau fractures (Schatzker's IV-VI). Friedman's test demonstrated significant differences in SMFA (p < 0.0005) and ROM (p < 0.0005) at the three time points. Post hoc analysis demonstrated a strong trend toward significance in SMFA between 3 and 6 months postoperatively (p = 0.088), and demonstrated a significant difference between 6 and 12 months postoperatively (p = 0.013). ROM was found to be significantly different between 3 and 6 months postoperatively (p = 0.010), but no difference was found between 6 and 12 months postoperatively (p = 0.929). Friedman's test demonstrated no significant difference in VAS postoperatively (p = 0.941). In this cohort, no significant difference in function, ROM, or pain level exists between 6 and 12 months after treatment of lateral tibial plateau fractures. However, there are significant improvements in function for at least 1 year following medial or bicondylar tibial plateau fractures.

AIMS/OBJECTIVE:Tibial plateau fractures are serious injuries about the knee that have the potential to affect patients' long-term function. To our knowledge, this is the first study to use patient-reported outcomes (PROs) with a musculoskeletal focus to assess the long-term outcome, as compared to a short-term outcome baseline, of tibial plateau fractures treated using modern techniques. METHODS:-test. RESULTS:Patient-reported functional outcomes as assessed by overall SMFA were statistically significantly improved at five years (p < 0.001) compared with one-year data from the same patients. Patients additionally reported an improvement in the Standardized Mobility Index (p < 0.001), Standardized Emotional Index (p < 0.001), as well as improvement in Standardized Bothersome Index (p = 0.003) between the first year and latest follow-up. Patient-reported pain and knee ROM were similar at five years to their one-year follow-up. In total, 15 of the patients had undergone subsequent orthopaedic surgery for their knees at the time of most recent follow-up. Of note, only one patient had undergone knee arthroplasty following plateau fixation related to post-traumatic osteoarthritis (OA). CONCLUSION/CONCLUSIONS:2020;102-B(5):632-637.