Faculty Bibliography

This video demonstrates a displaced radial shaft fracture repaired through a dorsal (Thompson) approach to the forearm. The patient is an 18-year-old man who sustained a left elbow dislocation and ipsilateral radial shaft fracture (OTA/AO: 22-B2) while playing basketball. The patient underwent a closed reduction of the elbow joint and was indicated for operative repair of the radius. Ultimate fixation included a compression plate and nonlocking screws through a dorsal approach to the radius. Anatomic reduction and stable fixation was obtained. The posterior interosseus nerve was identified and protected throughout the procedure. A dorsal (Thompson) approach to a radial shaft fracture is advantageous for fractures involving the proximal and middle-third of the radius. This approach can also be used when there is soft tissue damage (open wounds) on the dorsal aspect, which require debridement.

INTRODUCTION/BACKGROUND:Students seek gap years to enhance knowledge and improve chances of professional success. Although many institutions offer research opportunities, no studies have examined outcomes after these experiences. This study evaluates a dedicated year of orthopaedic research on a cohort's ultimate orthopaedic surgery match rate. METHODS:From 2001 to 2018, 129 learners spent a year with our Department of Orthopedic Surgery at a major academic medical center. The students were either completing a gap year after college, during or after medical school, or after an unsuccessful match. Participants were asked to respond to a survey, which included demographics, educational information, and metrics related to the program. For the subcohort of students who ranked orthopaedic surgery, the match rate was compared with the mean for the US orthopaedic surgery match rates from 2006 to 2018 using a chi-square analysis. In addition, a Mann-Whitney U test was used to compare the number of publications before and after the year. RESULTS:One hundred three students (80%) returned completed questionnaires. Of all learners who applied to and ranked orthopaedic surgery, 91% matched into an orthopaedic surgery residency program. These results compared favorably with the US orthopaedic match from 2006 to 2018 (67.9%; P < 0.001), despite a 4-point lower United States Medical Licensing Examination (USMLE) Step 1 score for the research cohort. Finally, the research cohort had a greater percentage of women (23%) and minorities (40%) than the proportion of woman and minority practicing orthopaedic surgeons. CONCLUSION/CONCLUSIONS:Students who completed a gap year in research matched into orthopaedics at a higher rate than the national average, despite a lower Step score. Mentors may also target traditionally underrepresented groups to help increase the pool of diverse applicants.

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 examine one health system's response to the essential care of its hip fracture population during the COVID-19 pandemic and report on its effect on patient outcomes. DESIGN/METHODS:Prospective cohort study SETTING:: Seven musculoskeletal care centers with New York City and Long Island. PATIENTS/PARTICIPANTS/METHODS:138 recent and 115 historical hip fracture patients. INTERVENTION/METHODS:Patients with hip fractures occurring between February 1, 2020 and April 15, 2020 or between February 1, 2019 and April 15, 2019 were prospectively enrolled in an orthopedic trauma registry and chart reviewed for demographic and hospital quality measures. Patients with recent hip fractures were identified as COVID positive (C+), COVID suspected (Cs) or COVID negative (C-). MAIN OUTCOME MEASUREMENTS/METHODS:Hospital quality measures, inpatient complications and mortality rates. RESULTS:Seventeen (12.2%) patients were confirmed C+ by testing and another 14 (10.1%) were suspected (Cs) of having had the virus but were never tested. The C+ cohort, when compared to Cs and C- cohorts, had: an increased mortality rate (35.3% vs 7.1% vs 0.9%), increased length of hospital stay, a greater major complication rate and a greater incidence of ventilator need postoperatively. CONCLUSIONS:COVID-19 had a devastating effect on the care of hip fracture patients during the pandemic. Although practice patterns generally remained unchanged, treating physicians need to understand the increased morbidity and mortality in hip fracture patients complicated by COVID-19. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

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.

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.

OBJECTIVES/OBJECTIVE:To determine whether a validated trauma triage tool can identify which middle-aged and geriatric trauma patients with tibial shaft and plateau fractures are at risk for costly admissions and poorer hospital quality measures. DESIGN/METHODS:Prospective cohort study. SETTING/METHODS:Level 1 trauma center. PATIENTS/PARTICIPANTS/METHODS:64 patients over the age of 55 hospitalized with isolated tibial shaft or plateau fractures. INTERVENTION/METHODS:Patients with either isolated tibial plateau fractures or tibial shaft fractures over a three year period were prospectively enrolled in an orthopedic trauma registry. Demographic information, injury severity, and comorbidities were assessed and incorporated into the STTGMA score, a validated trauma triage score that calculates inpatient mortality risk upon admission. Patients were then grouped into tertiles based on their STTGMA score. MAIN OUTCOME MEASUREMENTS/METHODS:Length of stay, complications, discharge location, and direct variable costs. RESULTS:64 patients met inclusion criteria. 33 (51.6%) patients presented with tibial plateau fractures and 31 (48.4%) with tibial shaft fractures. The mean age was 66.7 ± 10.2 years. Mean length of stay was significantly different between risk groups with a mean of 6.8 ± 4 days (p<0.001). While 19 (90.5%) of minimal risk patients were discharged home, only 7 (33.3%) and 5 (22.7%) of moderate and high-risk patients were discharged home, respectively (p<0.001). Higher risk patients experienced a significantly greater number of complications during hospitalization but had no differences in the need for ICU level care (p=0.027 and p=0.344, respectively). The total cost difference between the lowest and highest risk group was nearly 50% ($14070 ± 8056 vs $25147 ± 14471, mean difference $11077; p=0.022). CONCLUSION/CONCLUSIONS:Application of the STTGMA triage tool allows for prediction of key hospital quality measures and cost of hospitalization that can improve clinical decision-making. LEVEL OF EVIDENCE/METHODS:Prognostic Level III.

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.