Faculty Bibliography

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.

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: 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.

The internet is a popular resource for orthopedic fellowship applicants. We conducted a study to assess the accessibility of orthopedic trauma fellowship (OTF) program websites and to evaluate the content on the sites. We queried the online database of the Orthopaedic Trauma Association (OTA) and the online Fellowship and Residency Electronic Interactive Database (FREIDA) to assess available OTF program links. We used Google to assess how accessible the sites are from outside the databases. We then analyzed accessible sites for content pertinent to OTF applicants. Of the 49 OTF programs identified, 42 (86%) had their websites accessible from Google and FREIDA links. The OTA database had no OTF website links. Analysis of the 42 accessible OTF sites revealed they had an average of 40% (range, 0%-75%) of assessed content, with operative experience on 88% of sites and a program description on 93% of sites. OTF programs with >1 fellow had significantly more education content (48% vs 33%; P = .043) and total content (46% vs 37%; P = .01) on their sites than OTF programs with 1 fellow. Accessibility and content of OTF websites are highly variable and largely deficient. OTF programs should focus on improving their website accessibility and content.

PURPOSE: Posttraumatic bone defects in the setting of severe open injuries of the lower extremity present a significant challenge for orthopaedic trauma surgeons. The induced membrane technique, also known as the Masquelet technique, has been shown to be generally successful in achieving bony union. This video demonstrates the use of the Masquelet technique for a large (18 cm) femoral defect. METHODS: The Masquelet technique is a 2-stage process. The first stage involves debridement of all devitalized tissue, using open reduction and internal fixation, and placement of a cement spacer with or without antibiotics. In the second stage, which is performed at least 6 weeks after the first, the spacer is removed and the resulting void is filled with bone graft. RESULTS: This surgical case video reviews the relevant patient injury presentation, initial management, and indications for the Masquelet technique. The second stage of the Masquelet technique is featured in this video. CONCLUSIONS: The Masquelet technique is a generally reliable method for treating large segmental bone defects. In addition, this relatively simple technique is suitable for both infected and noninfected cases.

PURPOSE: Operative fixation of displaced patella fractures is considered to be standard of care. However, patients with inferior pole patella fractures have limited options in terms of fixation. This video demonstrates the repair of an inferior pole patella fracture using nonabsorbable suture fixation. METHODS: Suture repair of patella fractures is a clinically acceptable technique, yielding similar functional results to patella fractures treated with K-wires or cannulated screws while reducing the rates of removal of hardware after fixation. RESULTS: This video features the repair of a displaced, comminuted inferior pole patella fracture using 5 Ethibond and Fiberwire. Postoperative radiographs confirm bony union. CONCLUSIONS: Suture fixation for pole patella fractures provides reliable fixation and reduces the risk of postoperative complications secondary to hardware irritation. This case highlights the success of this technique.

INTRODUCTION: This video demonstrates the technique of intramedullary nailing for a humeral shaft fracture. METHODS: The patient is a 30-year-old man who sustained a gunshot wound to his right arm. The patient was indicated for humeral nailing given the comminuted nature of the diaphysis and to allow for minimal skin incisions. Other relative indications include soft-tissue compromise about the arm precluding a large surgical exposure. RESULTS: This video presents a case of a comminuted humeral shaft fracture treated with an intramedullary nail. Anatomic reduction and stable fixation was obtained with this technique. CONCLUSION: This case demonstrates a soft-tissue sparing technique of humeral shaft fixation using a humeral intramedullary nail. The technique is easy to perform and has significant benefits in minimizing surgical exposure, decreasing operative time, and decreasing blood loss. In the correct clinical setting, humeral nailing provides an expeditious form of fixation that restores length, alignment, and rotation of the fracture humeral diaphysis.