Faculty Bibliography

INTRODUCTION: This study sought to assess and compare long-term functional and clinical outcomes in patients with tibial plateau fractures that are treated nonsurgically. METHODS: Over a period of 8 years, 305 consecutive tibial plateau fractures were treated by three surgeons at a single institution and followed prospectively in an Institutional Review Board-approved study. Overall, 41 patients (13%) were treated nonsurgically and 37 were available for follow-up. Indications for nonsurgical management were minimal fracture displacement or preclusion of surgery because of comorbidities. A series of univariate retrospective analyses were used to identify individual risk factors potentially predictive of Short Musculoskeletal Functional Assessment scores. RESULTS: Thirty-seven patients were included with a mean follow-up of 21 +/- 14.9 months. Overall, 59% of patients (n = 22) attained good to excellent functional outcomes. In patients for whom surgery was precluded because of comorbidities, outcome scores were significantly poorer (38.8 +/- 23.0 versus 12.7 +/- 14.2; P = 0.001). Surgery precluded by a factor other than minimal fracture displacement predicted poor outcome (P = 0.002). DISCUSSION: Carefully selected patients with minimally displaced tibial plateau fractures can expect good to excellent outcomes when treated nonsurgically. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

BACKGROUND: Patellar tendon rupture is rare in the general population. Typically, failure occurs proximally or at the mid-substance. Distal avulsion from the tibial tubercle in adults is rare and not well described in the orthopedic literature. METHODS: We present the largest series of patients with distal patellar tendon injury with associated multi-ligamentous disruption of the knee. A series of six patients with distal patellar tendon avulsion were identified at a single institution. The cases were reviewed and are presented. RESULTS: Each case of distal patellar tendon rupture was associated with high-energy trauma to the knee. There was multi-ligamentous disruption in all cases, associated tibial plateau fracture in one case, and a compartment syndrome diagnosed in another. We propose that distal patellar tendon avulsion is a distinct pathology of the extensor mechanism in healthy adults. When present, it should prompt clinicians to assess patients for occult knee dislocation, monitor their neurovascular status, and obtain an MRI to evaluate for associated multi-ligamentous injury. CONCLUSION: We propose a modification to the Schenk classification to include extensor mechanism injury to help guide steps of operative intervention.

The purpose is to identify risk factors of functional outcome following proximal humerus open reduction and internal fixation. Patients treated for proximal humerus fractures with open reduction and internal fixation were enrolled in a prospective data registry. Patients were evaluated for function using the Disability of the Arm, Shoulder and Hand score for 12 months and as available beyond 12 months. Univariate analyses were conducted to identify variables associated with functional outcome. Significant variables were included in a multivariate regression predicting functional outcome. Demographics and minimum of 12 month follow-up were available for 129 patients (75%). Multiple regression demonstrated postoperative complication (B=8.515 p=0.045), education level (B=-6.269p<0.0005), age (B=0.241p=0.049) and Charlson Comorbidity Index (B=6.578, p=0.001) were all significant predictors of functional outcome. Orthopaedic surgeons can use education level, comorbidities, age, and postoperative complication information to screen patients for worse outcomes, establish expectations, and guide care.

BACKGROUND: With an expected doubling of the geriatric population within the next thirty years it is becoming increasingly important to determine who among the elderly population benefit from orthopaedic interventions. This study assesses post-operative outcomes in patients aged seventy or greater who sustained a proximal humerus fracture and were treated surgically as compared to a younger geriatric cohort to determine if there is a chronologic age after which post-operative outcomes significantly decline. METHODS: A retrospective chart review was conducted for 201 patients who sustained fractures of the proximal humerus (OTA 11A-C) and were treated operatively by open reduction and internal fixation. Data from 132 independent, active patients aged fifty-five or older was identified and analyzed. Forty-seven patients age 70 or older were compared to 78 patients aged 55-69. Average length of follow-up was 19.5 months. All complications were recorded. Univariate and multivariate analysis was conducted to assess for differences between groups. RESULTS: 95% of patients achieved fracture union within 6 months. No significant differences were found between cohorts with regard to gender, fracture severity, or CCI (p = 0.197, p = 0.276, p = 0.084, respectively). Functional outcome scores, shoulder range of motion, and complications rates for patients aged 70 and older were not significantly different from patients aged 55-69. There were 10 complications in the older elderly cohort (21%), 6 of which required re-operation and 13 complications in the young elderly cohort (17%), 8 of which required re-operation. CONCLUSIONS: Operative fracture repair using locked plating of the proximal humerus in septuagenarians and octogenarians can provide for excellent long-term outcomes in appropriately selected patients. These patients tend to have long term functional outcome scores, post-operative range of motion, and complication rates that are comparable to younger geriatric patients. Physicians should not exclude patients for repair of proximal humerus fractures based on chronological age cutoffs.

AIMS: To evaluate whether an ultra-low-dose CT protocol can diagnose selected limb fractures as well as conventional CT (C-CT). PATIENTS AND METHODS: We prospectively studied 40 consecutive patients with a limb fracture in whom a CT scan was indicated. These were scanned using an ultra-low-dose CT Reduced Effective Dose Using Computed Tomography In Orthopaedic Injury (REDUCTION) protocol. Studies from 16 selected cases were compared with 16 C-CT scans matched for age, gender and type of fracture. Studies were assessed for diagnosis and image quality. Descriptive and reliability statistics were calculated. The total effective radiation dose for each scanned site was compared. RESULTS: The mean estimated effective dose (ED) for the REDUCTION protocol was 0.03 milliSieverts (mSv) and 0.43 mSv (p < 0.005) for C-CT. The sensitivity (Sn), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) of the REDUCTION protocol to detect fractures were 0.98, 0.89, 0.98 and 0.89 respectively when two occult fractures were excluded. Inter- and intra-observer reliability for diagnosis using the REDUCTION protocol (kappa = 0.75, kappa = 0.71) were similar to those of C-CT (kappa = 0.85, kappa = 0.82). Using the REDUCTION protocol, 3D CT reconstructions were equivalent in quality and diagnostic information to those generated by C-CT (kappa = 0.87, kappa = 0.94). CONCLUSION: With a near 14-fold reduction in estimated ED compared with C-CT, the REDUCTION protocol reduces the amount of CT radiation substantially without significant diagnostic decay. It produces images that appear to be comparable with those of C-CT for evaluating fractures of the limbs. Cite this article: Bone Joint J 2016;98-B:1668-73.

INTRODUCTION/BACKGROUND:This study aimed to develop a tool to quantify risk of inpatient mortality among geriatric and middleaged trauma patients. This study sought to demonstrate the ability of the novel risk score in the early identification of high risk trauma patients for resource-sparing interventions, including referral to palliative medicine. MATERIALS AND METHODS/METHODS:This retrospective cohort study utilized data from a single level 1 trauma center. Regression analysis was used to create a novel risk of inpatient mortality score. A total of 2,387 low energy and 1,201 high-energy middle-aged (range: 55 to 64 years of age) and geriatric (65 years of age or odler) trauma patients comprised the study cohort. Model validation was performed using 37,474 lowenergy and 97,034 high-energy patients from the National Trauma Databank (NTDB). Potential hospital cost reduction was calculated for early referral of high risk trauma patients to palliative medicine services in comparison to no palliative medicine referral. RESULTS:Factors predictive of inpatient mortality among the study and validation patient cohorts included; age, Glasgow Coma Scale, and Abbreviated Injury Scale for the head and neck and chest. Within the validation cohort, the novel mortality risk score demonstrated greater predictive capacity than existing trauma scores [STTGMALE-AUROC: 0.83 vs. TRISS 0.80, (p < 0.01), STTGMAHE-AUROC: 0.86 vs. TRISS 0.85, (p < 0.01)]. Our model demonstrated early palliative medicine evaluation could produce $1,083,082 in net hospital savings per year. CONCLUSION/CONCLUSIONS:This novel risk score for older trauma patients has shown fidelity in prediction of inpatient mortality; in the study and validation cohorts. This tool may be used for early intervention in the care of patients at high risk of mortality and resource expenditure.

OBJECTIVE: To identify variables that predict mortality in geriatric patients with trauma. DESIGN: Retrospective review. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: A total of 147 geriatric patients with trauma (age >/=65) with a predicted probability of survival of 10%-75% based on the Trauma Score-Injury Severity Score (TRISS). MAIN OUTCOME MEASUREMENTS: Patients were divided into 2 cohorts: survivors and nonsurvivors. The following variables available at presentation were analyzed: age, mechanism of injury, temperature, systolic blood pressure, pulse rate, shock index, respiratory rate, Glasgow Coma Scale (GCS) score, base deficit, and hematocrit (HCT). The Injury Severity Score (ISS) and TRISS were calculated for both cohorts. RESULTS: Of the 147 patients analyzed, 84 (57%) died during the index hospitalization and 63 (43%) survived. The mean age of nonsurvivors was significantly higher than that of survivors (78.6 vs. 76.1 years; P < 0.04). A greater number of nonsurvivors (72.6%) sustained injuries as a result of a low-energy mechanism compared with survivors (54%; P = 0.02). GCS, temperature, and respiratory rate were significantly lower for nonsurvivors, whereas base deficit was higher (P < 0.05). The TRISS was predictive of survival (TRISS 0.27 vs. 0.53, P < 0.001), but the distinguishing capacity of the TRISS to predict mortality was limited (area under the receiver operator curve; 0.67; 95% confidence interval 0.58-0.76; P < 0.0001). CONCLUSIONS: Older age, lower GCS, and a low-energy mechanism of injury are associated with a higher mortality rate in this at-risk geriatric trauma population. Early identification of predictors of mortality may help care providers more accurately assess injury burden in geriatric patients. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Displaced tibial plateau fractures often require surgical treatment and plate and screw constructs are the most common method of fixation. There has been increased usage of locking plate technology for both complex and simple fracture patterns without any evidence demonstrating their advantage. Purpose The purpose of this study was to compare the clinical use of locked versus nonlocked plating for repair of displaced Schatzker type-II (OTA Type 41B) tibial plateau fractures. Methods Seventy-seven consecutive patients treated operatively with one of two types of plate and screw constructs in a nonrandomized fashion for Schatzker type II tibial plateau fractures and they were prospectively followed over a 5-year period. A total of 35 (45.5%) patients were treated using a locked plate and screw construct and 42 (54.5%) patients were treated with a nonlocked plate and screw construct. All patients received the same pre- and postoperative care and there was no difference in plate morphology and length between cohorts. Clinical outcomes were assessed using Short Musculoskeletal Functional Assessment (SMFA) scores, Visual Analogue Score for pain, and knee ranges of motion. Radiographic outcome was assessed with plain radiographs at all follow-up points. Implant costs for both types of constructs were calculated from hospital purchasing records. Results Patients were assessed at a mean period of 18.5 months (range: 12-72 months). There was no difference in demographic factors, physical examination parameters, radiographic outcomes, and SMFA scores between cohorts. In terms of cost, the cost of locked construct was $905 more than the nonlocked construct. Conclusion Based on clinical outcomes and cost per implant, we found no evidence to support the routine use of locked plating for simple split depression fractures of the lateral tibial plateau. The use of standard nonlocked, precontoured implants provides adequate fixation for these fracture patterns.

Extensor mechanism disruptions are relatively uncommon injuries involving injury to the quadriceps tendon, patella, or patellar tendon. Patellar tendon avulsions from the tibial tubercle in adults are rare; as such, little technical information has been written regarding surgical management of this injury in the adult. Transosseous-equivalent repairs have been described in the management of several types of tendon ruptures, including rotator cuff and distal triceps tendon ruptures, but not previously in patellar injuries. We present a technique for repairing an avulsion injury of the patellar tendon from the tibial tubercle using suture anchors in a transosseous-equivalent manner. This technique for treating distal patellar tendon avulsion injuries likely increases contact area at the repair site while potentially improving fixation strength.