Faculty Bibliography

INTRODUCTION: Difficulty determining anatomic rotation following intramedullary (IM) nailing of the femur continues to be problematic for surgeons. Clinical exam and fluoroscopic imaging of the hip and knee have been used to estimate femoral version, but are inaccurate. We hypothesize that 3D c-arm imaging can be used to accurately measure femoral version following IM nailing of femur fractures to prevent rotational malreduction. METHODS: A midshaft osteotomy was created in a femur Sawbone to simulate a transverse diaphyseal fracture. An intramedullary (IM) nail was inserted into the Sawbone femur without locking screws or cephalomedullary fixation. A goniometer was used to simulate four femoral version situations after IM nailing: 20 degrees retroversion, 0 degrees version, 15 degrees anteversion, and 30 degrees anteversion. In each simulated position, 3D c-arm imaging and, for comparison purposes, perfect lateral radiographs of the knee and hip were performed. The femoral version of each simulated 3D and fluoroscopic case was measured and the results were tabulated. RESULTS: The measured version from the 3D c-arm images was 22.25 degrees retroversion, 0.66 degrees anteversion, 19.53 degrees anteversion, and 25.15 degrees anteversion for the simulated cases of 20 degrees retroversion, 0 degrees version, 15 degrees anteversion, and 30 degrees anteversion, respectively. The lateral fluoroscopic views were measured to be 9.66 degrees retroversion, 12.12 degrees anteversion, 20.91 degrees anteversion, and 18.77 degrees anteversion for the simulated cases, respectively. CONCLUSION: This study demonstrates the utility of a novel intraoperative method to evaluate femur rotational malreduction following IM nailing. The use of 3D c-arm imaging to measure femoral version offers accuracy and reproducibility.

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.

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.

OBJECTIVE: The purpose of this study was to determine whether the finding of failed fracture implants in association with lower extremity long bone fracture nonunion portends worse clinical or functional outcome following surgical nonunion repair. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Academic Medical Center. PATIENTS: One hundred eighty-one patients who presented to our institution over a 10-year period and underwent surgical repair of a lower extremity fracture nonunion. INTERVENTION: Surgical repair of lower extremity fracture nonunion. MAIN OUTCOME MEASUREMENTS: Time to union, postoperative complications, VAS pain scores, and Short Musculoskeletal Function Assessment (SMFA) scores following lower extremity nonunion repair. Data was analyzed to assess for differences in postoperative outcomes based on the integrity of fracture implants at the time of nonunion diagnosis. Implant integrity was defined using 3 groups: broken implants (BI), implants intact (II), and no implants (NI). RESULTS: There was no significant difference in time to union following surgery between the BI, II, or NI groups (mean 8.1 months vs 7.6 months vs 6.2 months, respectively). Fourteen patients (7.7%) failed to heal, including 5 BI patients, 7 II patients, and 2 NI patients. One tibial nonunion patient in each of the 3 groups underwent amputation for persistent nonunion following multiple failed revision attempts at a mean of 4.8 years after initial injury. There was no difference in postoperative pain scores, the rate of postoperative complications, or functional outcome scores identified between the 3 groups. CONCLUSION: The finding of failed fracture implants at the time of lower extremity long bone nonunion diagnosis does not portend worse clinical or functional outcome following surgical nonunion repair. Patients who present with failed fracture implants at the time of nonunion diagnosis can anticipate similar time to union, complication rates, and functional outcomes when compared to patients who present with intact implants or those with history of nonoperative management. LEVEL OF EVIDENCE: Prognostic Level IV.

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.

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.

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: Nonunion of long bone fractures is a serious complication for many patients leading to considerable morbidity. The purpose of this study is to elucidate factors affecting continued pain following long bone nonunion surgery and offer better pain control advice to patients. METHODS: Patients presenting to our institutions for operative treatment of long bone fracture nonunion were enrolled in a prospective data registry. Enrolled patients were followed at regular intervals for 12 months using the Short Musculoskeletal Function Assessment (SMFA), visual analog scale (VAS), physical examination, and radiographic examination. The registry was reviewed to identify patients with a tibial or femoral nonunion that went on to union with complete follow up. Univariate analyses were conducted to identify patient characteristics associated with postoperative pain. Identified patient factors with univariate p-values <0.1 were included in multivariate linear regression models in order to identify risk factors for pain 3 months, 6 months, and 12 months after nonunion surgery. RESULTS: Ninety-one patients with tibial or femoral nonunion who went on to union and had complete follow-up were identified. A Friedman test revealed mean pain score decreased significantly by 3 months postoperatively (p<0.0005). Univariate analyses demonstrated age (p=0.016), days from injury to nonunion surgery at our institution (p=0.067), smoking status (p<0.0005), wound status at time of injury (p=0.085), anesthesia (p=0.045), and nonunion location in the bone (p=0.047) were associated with postoperative pain in at least one time point postoperatively. These were included in multivariate models that revealed nonunion location (p=0.035) was predictive of pain 3 months postoperatively, smoking status was predictive of pain 3 months (p=0.012) and 6 months (p<0.0005) postoperatively, and days from injury to nonunion surgery at our institution was predictive of pain 6 months (p=0.024) and 12 months (p=0.004) postoperatively. CONCLUSION: Healed patients have improved pain levels after lower extremity nonunion surgery. Orthopedic surgeons should stress smoking cessation programs and minimize delay to nonunion surgery, in order to maximize pain relief in this patient cohort.

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.

Pelvic ring injuries can result in significant morbidity and mortality. New techniques, technologies, and research have led to the development of various algorithms to guide the initial diagnosis and management of these injuries. These include treatment with antibiotics and operative debridement in the case of open fractures and temporary stabilization in certain cases with sheets, binders, or external fixators. Yet even after successful completion of the initial treatment phase, identifying and implementing the optimal definitive treatment of pelvic ring injuries remains a challenge. Various classification schemes have been proposed and contribute in different ways to an understanding of pelvic ring injuries. The current paper will review the definitive management of pelvic ring injuries, ultimately using the Young and Burgess classification as a guide, with a focus on current practice and the supporting evidence.