Faculty Bibliography

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.

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.

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.

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.

To determine the functional outcome and complications following dorsal plating for unstable fractures of the distal radius. We searched our IRB-approved Distal Radius Fracture Databases and identified all patients who were treated with a dorsally applied plate. Thirty-four distal radius fractures in 33 patients with a mean age of 50 years and average follow-up of 14 months were treated with a dorsal locking plate from 2007 to 2015. Fifteen and six patients had dorsal shearing fracture pattern and delayed presentation, respectively. There were no loss of reduction, malunion, or nonunion. Average VAS pain score was 2.1/10. Eight patients (23%) required hardware removal, one of which was due to extensor tendon rupture (3%) and five due to extensor tendon irritation (15%). Dorsal locked plating of distal radius fractures with newer low-profile implants is a viable option for particular fractures types, such as the dorsal rim shear type fractures.

OBJECTIVES/OBJECTIVE:To evaluate the causes of 30-day readmissions following orthopedic trauma surgery and classify them based on their relation to the index admission. DESIGN/METHODS:Retrospective chart review. SETTING/METHODS:One large, academic medical center. PARTICIPANTS/METHODS:Patients admitted to a large, academic medical center for a traumatic fracture injury over a nine-year period. INTERVENTION/METHODS:Assignment of readmission classification. MAIN OUTCOME MEASUREMENTS/METHODS:Readmissions within 30 days of discharge were identified and classified into: orthopedic complications; medical complications; and non-complications. A chi-square test was performed to assess any difference in the proportion of readmissions between the hospital-reported readmission rate and the orthopedic complication readmission rate. RESULTS:1,955 patients who were admitted between 2011-2018 for an acute orthopedic trauma fracture injury were identified. Eighty-nine patients were readmitted within 30 days of discharge with an overall readmission rate of 4.55%. Within the 30-day readmission cohort, 30 (33.7%) were the direct result of orthopedic treatment complications, 36 (40.4%) were unrelated medical conditions, and 23 (25.8%) were non-complications. Thus, the readmission rate directly due to orthopedic treatment complications was 1.53%. A chi-square test of homogeneity revealed a statistically significant difference between the hospital-reported readmission rate and the orthopedic-treatment complication readmission rate, p < .0005. CONCLUSION/CONCLUSIONS:The use of 30-day readmissions as a measure of hospital quality of care overreports the number of preventable readmissions and penalizes surgeons and hospitals for caring for patients with less optimal health. LEVEL OF EVIDENCE/METHODS:Diagnostic Level III.

Fracture-related infection (FRI) remains a challenging complication that imposes a heavy burden on orthopaedic trauma patients. The surgical management eradicates the local infectious focus and if necessary facilitates bone healing. Treatment success is associated with debridement of all dead and poorly vascularized tissue. Debridement is, however, often associated with formation of a dead space, which provides an ideal environment for bacteria and is a potential site for recurrent infection. Dead space management is therefore of critical importance. For this reason, the use of locally delivered antimicrobials has gained attention, not only for local antimicrobial activity, but also for dead space management. Local antimicrobial therapy has been widely studied in periprosthetic joint infection, without addressing the specific problems of FRI. Furthermore, the literature presents a wide array of methods and guidelines with respect to the use of local antimicrobials. The present review describes the scientific evidence related to dead space management with a focus on the currently available local antimicrobial strategies in the management of FRI. LEVEL OF EVIDENCE:: Level V.

CASE/METHODS:This report reviews 2 cases of chronic lower extremity pain after traumatic tibial shaft fractures treated with intramedullary nail fixation. After examination and radiographic evaluation, clinical suspicion and pressure manometry were used to identify fascial herniation and indicate patients for fasciotomy, which ultimately relieved pain. CONCLUSIONS:Lower extremity fascial hernias typically present with nonspecific chronic pain. Ultrasonography and magnetic resonance imaging (MRI) can be used to confirm diagnosis. However, in patients with implanted hardware, MRI may be ineffective in detecting hernias because of artifact. Clinical suspicion and pressure manometry are effective ways of identifying patients with this etiology of chronic pain.

INTRODUCTION/BACKGROUND:Total hip arthroplasty (THA) is often used for displaced femoral neck fracture. In this study, institutional hip arthroplasty data were compared with the National American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data for any differences in outcomes between our hospital, with an integrated hip fracture care pathway, and those of the country as a whole. METHODS:Elective THA was compared with arthroplasty performed for acute fracture. Outcomes for both groups included thromboembolic event (VTE), death, and deep prosthetic infection. RESULTS:Institutional data revealed no increased rate of infection after THA for fracture compared with elective. National Surgical Quality Improvement Program analysis revealed higher infection rates in fracture arthroplasty. There was an increased VTE rate in fracture performed for arthroplasty compared with elective in both institutional and NSQIP data. CONCLUSIONS:When performed at an academic medical center with an integrated care program, THA for fracture can have similar infection rates to elective THA. By contrast, national data showed significantly higher rates of infection and VTE for arthroplasty for fracture compared with elective. The contrast in complication rates may be related to well-functioning comprehensive interdisciplinary pathways. Patient-centered care pathways may be optimal for hip fracture patients.