Faculty Bibliography

OBJECTIVES: To assess the presence of fracture site gross motion on physical examination to predict humeral shaft fracture progression to nonunion in patients managed nonoperatively. DESIGN: Retrospective cohort study. SETTING: Single trauma level 1 institutional center. PATIENTS: Eighty-four consecutive patients undergoing nonoperative treatment of a diaphyseal humeral shaft fracture were identified. The average age of the population was 48.3 years, and 50% of the cohort was men. INTERVENTION: Clinical examination for fracture stability was routinely performed on patients by the treating physicians and documented it in the medical record. Patients were followed until union or surgery for persistent fracture mobility. MAIN OUTCOME MEASUREMENTS: Stability was graded if there was motion at the site (1: motion of any kind and 0: moved as a unit). RESULTS: Seventy-three patients (87%) healed their fracture within our study cohort by 6 months postfracture. Of the remaining 11 patients, after discussion with their treating physicians about the option of surgical intervention, 8 chose to undergo open reduction internal fixation at an average of 8 months, 1 proceeded nonsurgical interventions, and 2 were lost of follow-up. If the humeral shaft fracture site was mobile at 6 weeks follow-up visit, it identified future fracture nonunion with 82% sensitivity and 99% specificity (only 1 patient with motion at 6 weeks proceeded to fracture union). CONCLUSION: With a high negative predictive value, clinical examination of fracture motion at 6 weeks should be assessed in every patient to determine which patients should obtain closer follow-up for the risk of nonunion progression. Knowledge of gross fracture motion can be used in the shared decision-making model in counseling about early surgical options. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE: To compare the cost and outcomes of patients treated at orthopaedic teaching hospitals (OTHs) with those treated at nonteaching hospitals (NTHs). DESIGN: Retrospective study. SETTING: The Statewide Planning and Research Cooperative Systems (SPARCS) database, which includes all admissions to New York State hospitals from 2000-2011. PATIENTS/PARTICIPANTS: A total of 165,679 patients with isolated closed hip fracture 65 years of age and older met inclusion criteria. Of them, 57,279 were treated at OTH and 108,400 were treated at NTH. INTERVENTION: Admission for the management of a hip fracture. MAIN OUTCOME MEASURE: Cost, length of stay (LOS), and inpatient mortality. RESULTS: Univariate analysis shows that mean total hospital costs were higher at OTH ($16,576 +/- $17,514) versus NTH ($13,358 +/- $11,366) (P < 0.001); LOS was equivalent at OTH (8.0 +/- 9.0 days) versus NTH (8.0 +/- 7.6 days) (P = 0.904); and mortality was lower in OTH (3.4%) versus NTH (4.0%) (P < 0.001). In the multivariate total cost analysis, in addition to demographic differences, we identified total hospital beds and total ICU beds as significant confounding variables. Interestingly, when controlling for these patient and hospital factors, OTH designation was not a significant predictor of cost. In addition, multivariate analysis found that OTH status decreased LOS by 0.743 days (95% confidence interval: 0.632-0.854, P < 0.001) and mortality by 21% (odds ratio 0.794, 95% confidence interval: 0.733-0.859, P < 0.001), confirming the univariate trends. CONCLUSIONS: While OTH may seem to have higher hospital costs for operative hip fractures on cursory analysis, controlling for patient and hospital factors including hospital bed number negates this effect such that OTH has no additional cost compared with NTH. In addition, OTH status is associated with shorter LOS and lower in-hospital mortality. With the results of this study, health care systems and patients should feel confident that the quality of care at teaching hospitals is no less and potentially better than that at NTH with no added cost. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES: To assess the outcome of patients with hyperextension bicondylar tibial plateau fractures (HEBTPs) and those with other complex tibial plateau fractures. DESIGN: Retrospective cohort design. SETTING: Academic Medical Center. PATIENTS: A total of 84 patients were included in the study. There were 69 patients with 69 knees (82%) that had sustained non-HEBTPs and 15 patients with 15 knees (18%) that had HEBTPs. INTERVENTION: Surgical repair of bicondylar tibial plateau fracture. MAIN OUTCOME MEASURES: Clinical and functional outcomes included knee range of motion, postoperative alignment, numerical rating scale pain scores, and Short Musculoskeletal Functional Assessment (SMFA) scores at long-term follow-up. Complications were recorded for both cohorts including infection and posttraumatic osteoarthritis. RESULTS: There was no difference in knee range of motion at 1-year follow-up between hyperextension and nonhypertension patients. Patients with hyperextension mechanisms did however have higher functional (SMFA) scores and a trend of higher pain scores, indicating worsened functional outcomes and were more likely than their nonhyperextension mechanism counterparts to have associated soft-tissue damage and to develop posttraumatic osteoarthritis. CONCLUSIONS: Non-HEBTP and HEBTP fracture patients have similar outcomes in terms of range of motion at approximately 1 year of follow-up, however, differ significantly in terms of functional recovery and the types of complications associated with their injuries. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

INTRODUCTION: The operative management of tibial plateau fractures is challenging and post-operative complications do occur. The purpose of this study was three-fold. 1). To report complications and unplanned outcomes in patients who had sustained tibial plateau fractures and were operatively managed 2). To report predictors of these post-operative events 3). To report if differences in clinical outcomes exist in patients who sustained a post-operative event. METHODS: Over 11 years, all tibial plateau fractures were prospectively followed. Clinical outcomes were assessed using the validated Short Musculoskeletal Functional Assessment (SMFA) score. Demographics, initial injury characteristics, surgical details and post-operative events were prospectively recorded. Student's t-tests were used for continuous variables and chi-squared analysis was used for categorical variables. Binary logistic regression and multivariate linear regression were conducted for independent predictors of post-operative events and complications and functional outcomes, respectively. RESULTS: 275 patients with 279 tibial plateau fractures were included in our analysis. Ten patients (3.6%) sustained a deep infection. Six patients (2.2%) developed a superficial infection. One patient (0.4%) presented with early implant failure. Two patients (0.7%) developed a fracture nonunion. Eight patients (2.9%) developed a venous thromboembolism. Seventeen patients (6.2%) went on to re-operation for symptomatic implant removal. Nine patients (3.3%) underwent a lysis of adhesions procedure. Univariate analysis demonstrated bicondylar tibial plateau fractures (P<0.001), Moore fracture-dislocations (P=0.005), open fractures (P=0.022), and compartment syndrome (P=0.001) to be associated with post-operative complications and unplanned outcomes. Long-term functional outcomes were worse among patients who developed a post-operative complication or unplanned outcome (P=0.031). CONCLUSION: Orthopaedic trauma surgeons should be aware of complications and unplanned outcomes following operatively managed tibial plateau fractures, along with having the knowledge of factors that are associated with development of post-operative events.

OBJECTIVES: To determine whether racial or economic disparities are associated with short-term complications and outcomes in tibial plateau fracture care. DESIGN: Retrospective cohort study. SETTING: All New York State hospital admissions from 2000 to 2014, as recorded by the New York Statewide Planning and Research Cooperative System database. PATIENTS/PARTICIPANTS: Thirteen thousand five hundred eighteen inpatients with isolated tibial plateau fractures (OTA/AO 44), stratified in 4 groups: white, African American, Hispanic, and other. INTERVENTION: Closed treatment and operative fixation of the tibial plateau. MAIN OUTCOME MEASUREMENTS: Hospital length of stay (LOS, days), in-hospital complications/mortality, estimated total costs, and 30-day readmission. RESULTS: There were no significant differences regarding in-hospital mortality, infection, deep vein thrombosis/pulmonary embolism, or wound complications between races, even when controlling for income. There was a higher rate of nonoperatively treated fractures in the racial minority populations. Minority patients had on average 2 days longer LOS compared with whites (P < 0.001), costing on average $4000 more per hospitalization (P < 0.001). Multivariate logistic regression found that neither race nor estimated median family income were independent risk factors for readmission. CONCLUSIONS: Although nature of initial injury, use of external fixator, comorbidity burden, age, insurance type, and LOS were independent risk factors for readmission, race and estimated median family income were not. In patients who sustained a tibial plateau fracture, race and ethnicity seemed to affect treatment choice, but once treated racial minority groups did not demonstrate worse short-term complications, including increased mortality and postoperative readmission rates. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

PURPOSE: Whether racial differences are associated with function in the long term following surgical repair of lower extremity fractures has not been investigated. The purpose of this study is to compare how race affects function at 3, 6 and 12 months post-surgery following certain lower extremity fractures. METHODS: Four hundred and eighteen patients treated operatively for a lower extremity fracture (199 tibial plateau, 39 tibial shaft, and 180 rotational ankle fractures) were prospectively followed for 1 year. Race was stratified into four groups: Caucasian, African-American, Hispanic origin, and other. Long-term outcomes were evaluated using the short musculoskeletal function assessment (SMFA) and pain scores were assessed at 3, 6 months and 1 year. RESULTS: There were 223 (53.3%) Caucasians, 72 (17.2%) African-Americans, 53 (12.4%) Hispanics, and 71 (17.0%) patients from other ethnic groups, included in our study population. Minority patients (African-American, Hispanics, etc.) were more likely to be involved in high velocity mechanisms of injury and tended to have a greater percentage of open fractures. Although there were no differences in the rate of wound complications or reoperations, long-term functional outcomes were worse in minority patients as assessed by pain scores at 6 months and functional outcome scores at 3, 6 and 12 months. Multivariate analysis revealed that only African-American and Hispanic race continued to be independent predictors of worse functional outcomes at 12 months. CONCLUSIONS: Racial minorities and those on medicaid had poorer long-term function following fractures of the lower extremity. While minority patients were involved in more high velocity accidents, this was not an independent predictor of worse outcomes. These disparities may result from multifactorial socioeconomic factors, including socioeconomic status and education levels that were not controlled in our study. LEVEL OF EVIDENCE: Prognostic Level III.

PURPOSE: The Hoffa fracture is a rare fracture pattern consisting of a unicondylar posterior fracture of the distal femur. This video demonstrates a case of Hoffa fracture repair using headless screw compression. METHODS: Hoffa fractures are intra-articular in nature. Given that isolated Hoffa fractures are rare, there is little information available as to the best management of this injury. However, several small studies have demonstrated good-to-excellent functional results after anatomical reduction and rigid fixation of the Hoffa fracture, followed by early mobilization. RESULTS: This video presents a case of surgical repair of a Hoffa fracture, and contaminant meniscal repair, in a 25-year-old man. Partially threaded, headless compression screws provide for independent compression of the fracture after placement. CONCLUSIONS: The Hoffa fracture is a rare injury typically seen after high-energy trauma. The surgical technique for treatment of the Hoffa fracture as seen in this video provides good stabilization and enables for early range of motion.

INTRODUCTION: This video demonstrates the technique of posterolateral bone grafting with iliac crest bone graft for a distal tibial nonunion. METHODS: The patient is a 42-year-old man who is 6 months status post an open distal tibia-fibula fracture treated surgically, and presents complaints of persistent right ankle pain. The fracture site was tender to palpation, and 3 consecutive plain radiographs spaced 6 weeks apart demonstrated no evidence of callus formation. RESULTS: This patient was indicated for posterolateral bone grafting of his tibia and fibula nonunion with autogenous iliac crest bone graft. The plan was to create a synostosis between the fibula and tibia. Atrophic and oligotrophic nonunions have poor biology at the fracture site to promote bone growth and would therefore benefit from autogenous iliac bone graft, as this technique is osteoinductive, osteoconductive, and osteogenic stem cells. Indications for posterolateral bone grafting of the tibia include atrophic or oligotrophic nonunions, an ipsilateral same level tibia and fibula nonunion, or a tibial nonunion with a large anteromedial soft-tissue injury. CONCLUSION: The technique of posterolateral bone grafting with iliac crest bone graft for distal third tibia and fibula atrophic nonunion provides a reliable method for achieving union. If patients with injuries at high risk of nonunion are followed closely and intervention is performed in a timely manner, additional fixation or revision of fixation is not necessary if the addition of appropriate osteoinductive, osteoconductive, and osteogenic material to the nonunion is performed.

INTRODUCTION: Acute compartment syndrome (ACS) is well known among orthopaedic surgeons. The timely diagnosis and management of ACS is crucial to avoiding its sequelae, including renal failure, ischemic contractures, and limb loss. Despite its relative importance, ACS poses a challenge to many residents and clinicians as diagnosis relies largely on clinical judgment. METHODS: Timely diagnosis and thorough compartment release are essential to optimizing outcomes in ACS. This video highlights a clinical case in which compartment syndrome of the leg was considered, diagnosed, and surgically managed. RESULTS: This video will present the indications for compartment release and a video-guided demonstration of compartment checks using an arterial line transducer, a 4-compartment fasciotomy with 2 incisions, and temporizing vessel loop closure. CONCLUSIONS: Compartment syndrome can be a devastating complication of common fractures. It is essential that orthopaedic practitioners understand the immediacy of intervention. We have a responsibility to provide timely, accurate diagnosis along with expedient surgical management.

PURPOSE: Fracture nonunion is a common problem for today's orthopaedic surgeon. However, many techniques are currently available for the treatment of long-bone nonunion. This video demonstrates the use of iliac crest bone graft and plate stabilization in the setting of a hypertrophic femoral nonunion. METHODS: Treatment of femoral nonunion after intramedullary nail fixation using compression plating and bone grafting is a reliable technique for reducing pain, improving function, and achieving radiographic union. Furthermore, the use of autologous bone graft, in particular iliac crest bone graft, has provided reliable clinical results. RESULTS: In this video, we present the case of a hypertrophic femoral nonunion treated with supplemental bone grafting in addition to plate and screw fixation. CONCLUSIONS: Although femoral nonunions are a relatively rare occurrence, they can be reasonably treated using stabilization and supplemental bone grafting. Iliac crest bone graft provides for excellent results when used for treatment of a fracture nonunion.